Types of Gastro-Intestinal Dis- ease prevalent in New York. BY FLOYD M. CRANDALL, M. D. REPRINTED FROM JEbe Neto ¥ork fHeUical journal for October 21, ISOS. Reprinted. from the New York Medical Journal for October 21, 1893. TYPES OF GASTRO-INTESTINAL DISEASE PREVALENT IN NEW YORK * FLOYD M. CRANDALL, M. D. No region or country is exempt from the gastro-intes- tinal diseases of young children. In rural districts, where breast feeding is the rule, or where artificial food is obtained fresh and pure, they are at a minimum. In the crowded centers of population where the people are herded together in most unhygienic surroundings; where weak and puny children are born by the thousand in homes of poverty and vice; where artificial feeding is common ; where milk is contaminated and many hours old when first received, they reach their maximum. In New York over thirty thou- sand young children have died of diarrhoeal diseases during the last decade. From June to October the dispensaries are crowded with these little patients. The physician who practices among the well-to-do sees less of these disorders, for his families flee from the city and its dangers during the hot weather. But no general practitioner who remains in town escapes them entirely. * Read before the Section in Diseases of Children of the First Pan- American Medical Congress. Copyright, 1893, by D. Appleton and Company. 2 GASTRO-INTESTINAL DISEASE IN NEW YORK. It is not my purpose to discuss the aetiology of the gas- tro-intestinal diseases, but rather to study their prevailing types as they present themselves in New York. The char- acter and type of diarrhoea is modified by three factors- climate or season, social conditions, and food. It is not now the common belief that heat per se causes diarrhoea. That it is a powerful factor indirectly is undoubted, for it lowers the vitality of the patient, and favors fermentative changes in milk and the growth of pathogenic germs. Di- gestive disorders occur during every month of the year, but they do not become prevalent or very serious until June. There is occasionally considerable hot weather in May, but diarrhoea does not prevail to a serious degree. It frequently happens that no case appears in the large dispensaries be- fore the 10th of June. The first case seen at the Poly- clinic developed one season on June 10th, the next season on June 7th, while this year the first case did not appear until June 19th. Serious development of the disease does not as a rule occur before June 20th. It is most prevalent during the first ten days of July, the numbers being but slightly diminished during the next ten days. After July 20th the number of new cases decidedly diminishes. During the six weeks between July 20th and September 1st the development of new cases is remarkably uniform, being less than half that of early July, although the difference of the average tem- perature of these periods is but one or two degrees. Dur- ing the first half of September the number of new cases is remarkably diminished, but during the latter half of the month there is a decided increase. The accompanying chart shows the date of onset of diarrhoea from June to November. It would be an error to conclude that these variations were due to heat alone. Observations have abundantly proved that when the mean temperature has reached a cer- GASTRO-INTESTINAL DISEASE IN NEW YORK. 3 tain point (about 60° F.) an increase of temperature is not of necessity followed by an increase of the gastro-intes- tinal diseases. Numerous factors contribute to the results shown by the chart. One of the most important, it seems to me, is the fact that large numbers of feeble, marasmic babies are ready to succumb as soon as the hot weather produces the conditions favorable to the development of diarrhoea. It is simply the working of the law of natural selection. The unfit are the first to perish. It must not be supposed that the chart shows the actual number of pa- tients under treatment at any one time. Many children who sicken in July continue ill in August. The actual number of children under treatment in August is greater than would be indicated by the chart. The chart is especially interesting in our present study as it maps out very clearly marked changes in the type of 4 GASTRO-INTESTINAL DISEASE IN NEW YORK. disease. During June and early July the prevailing types are those of acute dyspeptic diarrhoea. In grouping these cases I use Dr. Holt's classification in Keating's Cyclo- paedia. In recording the histories careful observations were made of the character of the stools and their exact number. Until July 20th, twenty or even more stools in twenty-four hours are common. After that date it is rare to find that number. Serous diarrhoea marked by numer- ous profuse, thin, watery passages is common in June and July. In August the prevailing disease is marked by thicker grumous stools much less frequent in number. Acute dyspeptic diarrhoea prevails in July, entero-colitis in August, but in August even dyspeptic diarrhoea shows less tendency to assume a serous type than it does in July. Early in September diarrhoea markedly decreases, but later in the month there is a decided increase. There is now a third and very radical change in type. The pre- vailing disease is the so-called dysentery. I am well aware that the term dysentery is not, from a pathological stand- point, proper. The term dysenteric diarrhoea expresses, however, the type of the prevailing disease. The passages are very frequent and small. They consist chiefly of thick mucus and blood and are accompanied by true tenesmus, high fever being present as a rule. These cases are fre- quently found grouped in certain tenement houses or in cer- tain streets, and are apparently due to some contagious in- fluences. A chart for 1889 would show the September rise far more marked than the one before you. Observa- tion during the past four summers confirms the view, which I expressed in a paper read in 1890, that there are three quite distinct periods. The first begins about the middle of June and terminates about the middle of July, in which diarrhoea is more prevalent than at any other time, the serous type being common. The second extends from the GASTRO-INTESTINAL DISEASE IN NEW YORK. 5 last of July to the middle of September, during which comparatively few cases develop. The number of cases under treatment, however, is large, for entero-colitis is common, dating back in many instances to a dyspeptic diarrhoea in July. The third period occurs during the lat- ter part of September, in which the cases are largely of a dysenteric type. I have been unable to demonstrate that age has any material effect upon the type of disease. The statement that very young children are especially prone to serous diarrhoea has not been borne out. Of patients suffering from dysenteric diarrhoea, over eighty per cent, were under fourteen months. That form of disease seems prevalent chiefly among infants and children of ten or twelve years. As an aetiological factor, age is very important. I showed in the paper referred to that in three thousand cases occur- ring in New York 84T per cent, of the patients were under two years of age, and 53'2 per cent, were between six months and eighteen months. The following observations were made upon five hun- dred and forty-one patients during the four years begin- ning with 1889. A history of disordered digestion pre- ceding the diarrhoea-as slight diarrhoea, constipation, or indigestion-was obtained with certainty in forty-one per cent, of the dyspeptic cases. In a very large number of cases the previous condition could not be ascertained with certainty. Entero-colitis was almost invariably preceded by diarrhoea more or less continuous for a period ranging from a few days to several weeks. Well-defined entero- colitis developed with extreme rarity in perfectly healthy children. The onset was sudden in seventy-two per cent, of the dyspeptic cases. It was frequently so definite that the mother could state the day and hour at which the first 6 GASTRO-INTESTINAL DISEASE IN NEW YORK. symptom appeared. In the remaining cases the onset was gradual or uncertain. In entero colitis the exact date of onset or transition from dyspeptic diarrhoea could be de- termined in but twenty per cent, of the cases. The onset of well marked dysenteric diarrhoea was sudden and definite in over ninety per cent. A curious fact was developed in this connection in studying the cases of two years. The interval between the onset of the diarrhoea and the first visit to the physician was found to be in June, 4'3 days; in July, 3'8 days; in August, 2'9 days. Hence, in August the child was brought for treatment almost a day and a half earlier than in June. This is perhaps explained upon the ground that mothers did not appreciate the dangers of diarrhoea in June. In August, warned by personal experience or that of their friends, they seek medical aid earlier. The number of passages per day was noted in four hun- dred and thirty-eight cases. In dyspeptic diarrhoea they varied from two or three per day to twenty, thirty, or more, the common range being from six to fifteen. In entero- colitis the extremes were about the same, but the usual number was more constant, ranging from eight to twelve. In dysenteric diarrhoea the extremes were from eight to forty, the average number being large-twelve to twenty. Within certain limits the number of passages is not a cri- terion of the seriousness of the disease. Some of the most serious and fatal cases which confront us are those in which the passages are large but not watery, of excessively offen- sive odor, and occur only at intervals of several hours. There may be but two or three in a day. They show a tendency to group themselves. An interval of five or six hours, or even longer, will pass with no passage. Then three or four will occur in quick succession, to be followed by another long interval without passages. The tempera- GASTRO-INTESTINAL DISEASE IN NEW YORK. 7 ture in these cases ranges high and the constitutional dis- turbance is profound. The natural tendency is to termi- nate in death by toxaemia. This type is not uncommon in New York. It illustrates very forcibly the fact that diar- rhoea is, strictly speaking, a symptom, not a disease. Here we have excessive decomposition of the intestinal contents with grave constitutional disturbance, with very slight diar- rhoea. The physician whose sole object in the treatment of these disorders is to check diarrhoea would lose cases of this character. The diarrhoea is a conservative process and is to be encouraged. Allied to these cases are those in which the symptom of diarrhoea appears late. The child is fretful, restless, and apparently ill, with more or less fever. The condition con- tinues for several hours-sometimes twelve hours or more -the bowels being constipated. When at last they do act, either naturally or as the result of a cathartic, the physician suddenly finds that he has a fully developed dyspeptic diar- rhoea to deal with. The temperature is sometimes very high and the diagnosis is uncertain until large grumous, foul-smelling passages indicate the nature of the disease. The temperature usually falls when the bowels act, but, as a rule, unless active measures are taken, recovery does not occur. Diarrhoea of the serous type is common early in the season, as we have already seen. It is not, however, true cholera infantum. It seems to me unwise to apply that term to ordinary summer diarrhoea. Cholera is a disease characterized by certain peculiar symptoms, and the term cholera infantum should be restricted to a well-marked but rather rare type of disease simulating cholera. I have seen in New York but five or six well-marked and typical cases of this class. In the western part of the State of New York it is somewhat more common than in the city. I 8 GASTRO-INTESTINAL DISEASE IN NEW YORK. would restrict the term to a disease which appears suddenly and is marked by frequent and profuse watery passages, which quickly drain the fluids from the body and reduce a strong child in a few hours to a state of extreme danger. The temperature ranges high. Constitutional disturbance is profound. Prostration is alarming. The whole aspect of these cases, as I have seen them, is entirely different from that of ordinary dyspeptic diarrhoea, even when the stools are large and serous in character. The color of the passages varied from the clear watery colorless stools of cholera infantum, and yellowish watery serous passages to yellow, green, brown, and black. Green, more or less decided, appeared at some period in seventy- one per cent, of all the cases. Blood was present in the passages at some period in twenty-nine per cent, of the inflammatory cases not includ- ing the dysenteric, but was rarely profuse. It appeared in at least thirteen per cent, of two hundred and seventy-four dyspeptic cases, usually at the outset, and was several times profuse. The idea that blood is a symptom of inflamma- tion, or of lesions, has no foundation in fact. In several instances the blood appeared in the first passage, but soon ceased, and the patient recovered without any symptoms of inflammation. Vomiting was present in sixty-three per cent, of the dyspeptic cases. It usually occurred early and frequently disappeared after the first day or two, but was often per- sistent. It was more common in cases marked by watery passages and not infrequently preceded the diarrhoea. Vomiting appeared in forty-three per cent, of the inflam- matory cases. It was not often persistent or continuous, nor as troublesome as in the preceding type. Pain is a somewhat uncertain symptom in young chil- dren. In dyspeptic diarrhoea it was sometimes abdominal GASTRO-INTESTINAL DISEASE IN NEW YORK. 9 and griping, but more commonly seemed to be of a bearing- down or straining character. There was frequently ab- dominal tenderness, but this was by no means a constant symptom. Pain was evidently present to a greater or less degree in most of the inflammatory cases. It was com- monly of a bearing-down nature, and was sometimes a true tenesmus, accompanied not infrequently by a partial or complete prolapse of the rectum. Abdominal tenderness was, as a rule, present, usually in the umbilical or right iliac region, but distention or tension of the abdomen was not constant. Temperature records in dispensary cases are necessarily imperfect. In seventy-two per cent, of the dyspeptic cases there was a history of fever or feverishness usually at the outset. Only twenty-one per cent, of the whole number of patients, however, showed a temperature of more than 100° at their first visit. It was frequently normal. In the septic type already described-marked by infre- quent, offensive passages-the temperature, ranged high throughout, occasionally reaching 105° or 106° in fatal cases. Inflammatory diarrhoea was almost invariably marked by some elevation of temperature ranging usually from 99'5° to 103°. Except in cases of a dysenteric type, it was rarely very high. A slight, somewhat intermitting, but persistent temperature was the rule in entero-colitis. From these studies we are able to present the following general description of the gastro-intestinal diseases com- mon to young children in New York. The dyspeptic form is commonly preceded by a disordered state of digestion. The onset may be gradual, but is usually definite and often sudden. Fever is generally present in the early stages, but thereafter is not constant. Two general forms are com- mon, but are not sufficiently distinct to be classed as dif- ferent varieties. One is characterized by watery, brown- 10 GASTRO-INTESTINAL DISEASE IN NEW YORK. ish, greenish, or light-colored passages occurring from ten to twenty or more times a day, accompanied frequently by vomiting, which is sometimes persistent. This is the so- called serous or choleraic diarrhoea. Classical cholera in- fantum is a rare disease. The other class, much more com- mon, is characterized by semisolid passages, composed of ftecal matter, white curdy masses or undigested food, min- gled with serum, mucus, or blood, and of a variable color, but more often green. Fever, pain, and vomiting are fre- quent. The first form is rarely well defined, but usually originates from the second or merges into it, the same pa- tient presenting at different times symptoms referable to each. Entero-colitis, as a rule, develops gradually from a dys- peptic diarrhoea. The passages are usually green and fre- quently contain blood, mucus, and pus. Pain and abdominal tenderness are commonly present and not infrequently true tenesmus. Vomiting is common but not persistent. Fever to a slight degree is invariably present, but. being in some instances intermittent, single thermometric observations may fail to detect it. The course of the disease is ex- tremely variable. 113 West Ninety-fifth Street. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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