Summer Complaint: A Clinical 
Contribution to the 2Eti- 
ology, Pathology, and 
Treatment of the 
Disease. 
/BY 
H. ILLOWAY, M. D., 
Lecturer on Diseases of Children, 
Cincinnati College of Medicine and Surgery. 
REPRINTED FROM THE 
Neto York fHetocal journal. Reprinted from the New York Medical Journal. 
SUMMER COMPLAINT: 
A CLINICAL CONTRIBUTION TO THE ETIOLOGY, PATHOLOGY, 
AND TREATMENT OF THE DISEASE. 
By II. ILLOWAY, M. D., 
LECTURER ON DISEASES OF CHILDREN, 
CINCINNATI COLLEGE OF MEDICINE AND SURGERY. 
Despite all that has been written of late years upon this 
subject, our knowledge of the intimate nature of this mala- 
dy, the great scourge of infantile life, has not made great 
progress, and the treatment being therefore vacillating and 
uncertain, directed now to one special symptom, now to an- 
other, is not attended by any greater success, as is clearly 
shown by the mortality statistics of our health offices, than 
it was formerly. 
I use the term " summer complaint " as I know of no 
other more applicable, and certainly none that would better 
indicate the nature of the malady and the therapeutic meas- 
ures necessary for its relief. 
I hold this disease to be a morbid entity entirely dis- 
tinct from the gastro-intestinal catarrhs produced by errors 
in feeding or diet or by toxic agents developed in the food, 
and most certainly distinct from cholera infantum, a term 
so frequently applied to it. 
In order that the subject of this paper may be still more 
Copyright, 1892, by D. Appleton and Company. 2 
SUMMER COMPLAINT. 
clearly defined, a symptomatic description is here appended 
at the outset: " A malady of the infantile period of life, a 
disease essentially of hand-fed children, affecting more espe- 
cially those passing through their second summer." 
It is a disease that prevails more particularly among the 
poorer class-those living in crowded tenement-houses and 
in close, badly aired apartments. It usually makes its ap- 
pearance with the first days of July, though sometimes with 
the middle of June if that month be already very hot, as 
has happened in the last few years, and lasts until the early 
part of September, when, the nights having become cool, it 
rapidly disappears. 
Symptoms.-The symptoms of this malady are restless- 
ness, vomiting, diarrhrea, fever, emaciation. 
(a) Restlessness.-After two or three hot days and nights 
the infant, which previously had slept well, becomes rest- 
less. The sleep is fitful and disturbed; there are frequent 
paroxysms of crying, these crying spells lasting from ten 
minutes to half an hour and even longer. The child is 
peevish; wants to be carried around on the arm; it will 
not rest in the cradle or bed. This restlessness, which is 
most marked at night, is also present in the day-time. 
When, however, the infant is taken out in the wagon or 
upon the arm into the cool morning air, or, if it be night, 
into some open space where the breeze has free play, it will 
sleep a nice, pleasant, quiet sleep that may continue unin- 
terrupted for hours. As soon, however, as it is taken back 
into the house the restlessness and peevishness return. 
With the increase in severity of the malady the restless- 
ness increases. The infant gets but very little sleep, and 
only then, as already mentioned above, when out in the 
open air, or when under the influence of whisky or of some 
hypnotic. It will not stay in the cradle or bed; wants to 
be carried upon the arm continually; will cry for hours, till SUMMER COMPLAINT. 
3 
exhaustion compels it to stop. It kicks its legs, moves its 
body, rolls its head. This restlessness is generally greatest 
at night. 
(6) Vomiting.-After a restless night or two, as already 
described, it will be observed that the child does not feed 
naturally; it will either not take all of its bottle or it will 
drink it down very greedily as if it had great thirst. After 
feeding, eructations of wind or sour-smelling material are 
apt to occur; or, if the food has been taken very greedily 
and hastily, some of it, perhaps the larger part, may be 
vomited. With the continuance of the conditions produc- 
ing these phenomena the vomiting becomes more frequent, 
until, when the malady has reached its climax, nothing at 
all in the form of food will be retained upon the stomach ; 
it will be ejected almost as soon as taken. 
With the increase in the frequency of the vomiting 
there is also an increase of thirst and of hunger, and the 
infant will take its bottle or its drink greedily only to eject 
again what it has taken. The great thirst is one of the 
marked features of the malady. 
(c) Diarrhoea.-With the setting in of the restlessness 
and of the vomiting there occurs also an increase in the 
number of the stools. At the outset there may not be more 
than three to six stools in the twenty-four hours ; at a little 
later period they may go up to ten, and at the climax to 
fifteen to twenty in the same period of time. 
At first they are semi-solid, homogeneous, yellow in 
color, and neutral in reaction; then they become more 
liquid in consistence, green in color, and acid in reaction. 
Or they may be semi-fluid, heterogeneous, and green, with 
fragments of yellowish-white casein, and acid in reaction ; 
or quite watery, with numerous flakes of yellowish or green- 
ish matter, and acid in reaction. Or the stool may contain 
a large quantity of mucus mixed up with the greenish or 4 
SUMMER COMPLAINT. 
yellowish matter, almost like that of a mucous diarrhoea. 
Or it may be entirely white in character, like a deposit of 
casein coagulated in small lumps, as if the casein had been 
expelled from the intestines just as it had come from the 
stomach, without undergoing any change in them. Usually 
there is considerable mucus mixed in with the lumps of 
casein. Sometimes the stool is half white and half green. 
The character of the stools is not constant, changing 
from day to day; and this inconstancy is marked from the 
outset of the disease. Nevertheless, it is considerably de- 
pendent upon the food that is administered. Thus the 
white or half-white stool mentioned above is only observed 
in children fed with cows' milk that has undergone no 
other preparation than boiling and dilution with water. 
The odor of the stools is at first faecal, then it may be 
either acid or sour-smelling, or offensive and putrid. Or 
we may have the three odors in the following order: First, 
the ordinary faecal; then the sour-smelling; and, last, the 
offensive or putrid. Occasionally we also find a moldy or 
musty odor. The putrid stool is alkaline in reaction. 
The act of defecation is preceded by pain, manifested 
by the expression of the face, by crying, by twisting of the 
trunk, and drawing up of the legs. When this diarrhoea 
has continued for any length of time there may be tenes- 
mus, and there is very frequently prolapse of the rectum 
with the stool. Under these circumstances a minute quan- 
tity of blood in the shape of a bright, red streak will be 
noted in the stool. 
Sometimes great exhaustion follows it, and the child 
will lie back on the arm or on its bed with its face pale 
and eyes closed and very near to a syncope. 
The abdomen is distended with flatus. Undoubtedly 
this is the source of the frequent colicky attacks observed. 
Tenderness of the abdomen I have never noted. SUMMER COMPLAINT. 
5 
(d) Pyrexia.-With the setting in of the restlessness it 
will be found that the hands of the infant are warmer than 
usual, but the increase of temperature is especially well 
marked on the head, over the verto-occipital region, which 
is hot to the touch. A thermometer placed in the axilla 
will indicate an increase of from 2° to 3°. Usually the 
highest temperature is noted at the outset, and sometimes 
also just before death. This increase of temperature con- 
tinues throughout the whole period of the disease, with 
variations therein. However, when the diarrhoea becomes 
very profuse and the exhaustion thereupon marked, the 
temperature may fall to, and even below, the normal. It is 
a rather noteworthy feature that even then yet the head 
does in many cases feel hot, or at least warmer than natu- 
ral, to the hand applied to it. 
The pulse is increased in rapidity, beating 130 to 150 
per minute. It is weak. 
(e) Emaciation.-It is one of the noteworthy features of 
the malady that emaciation sets in very early and may reach 
an extreme degree. And it is but natural, as, from the fre- 
quent vomiting and the diarrhoea, but very little food is 
carried into the system to supply the deficit. The face be- 
comes pale; the eyes are surrounded by dark circles; the 
nasal lines appear; the fontanelle is depressed. The fat 
disappears from the body; the muscles grow soft and 
flabby. This diminution of the fat continues until the in- 
fant is a mere skeleton. Its face then presents a peculiar 
appearance-an appearance characteristic of the disease : the 
face of advanced old age. The skin is dry and wrinkled. 
The buttocks and inner surfaces of the thighs are reddened 
by the acid stools and concentrated urine. There is great 
feebleness and languor, but the voice usually maintains its 
vigor up to a late period; and an infant too feeble to hold 
up its head will cry lustily for a considerable time at a 6 
SUMMER COMPLAINT. 
stretch. Toward the end of the malady, when the drain 
upon the system has almost completely exhausted the vital 
forces, the voice becomes weak and piping. 
The urine, as might be expected, is diminished in quan- 
tity and passed only three to four times daily ; frequently 
at longer intervals-as much as twelve hours. 
It is a noticeable feature that with a remission of the 
heat-i. e., with a little fall in temperature, with a little 
cooling of the atmosphere, as occasionally occurs during the 
summer-all the symptoms ameliorate and the infant ap- 
pears much better, only to relapse again with the next rise 
in temperature. 
When death approaches, all the phenomena are usually 
exaggerated: the pyrexia is greater; the restlessness is 
greater, the infant rolling around and moaning and emit- 
ting, occasionally, shrill cries; the vomiting is incessant; 
that is, everything administered by the mouth is imme- 
diately ejected. The discharges from the bowels are either 
entirely arrested or passing involuntarily, and small in quan- 
tity, almost continually. There is frequently strabismus; 
if not that, indolent pupils. Occasionally convulsions set in 
shortly before death. 
Sometimes the phenomena are just the reverse : A sub- 
normal temperature ; a cool skin ; a dull, drowsy state verg- 
ing on stupor; an apathetic refusal of food and drink; a 
cessation of vomiting, even though a little drink, as of cool 
water, be put into the mouth and swallowed; arrest of diar- 
rhoea ; coldness of the extremities. 
When the malady tends to recovery, the vomiting stops 
-that is, food and drink begin to be retained; the stools 
decrease in number and become more normal in character 
and appearance ; the fever disappears; the skin becomes 
moist; the restlessness grows less pronounced and disap- 
pears and the sleep thus becomes sound, uninterrupted, and SUMMER COMPLAINT. 
7 
refreshing. The eyes grow brighter, and the infant be- 
gins to manifest interest in its surroundings. It takes 
its food better and rapidly regains flesh and strength. 
Micturition becomes more frequent, more in accordance 
with the normal state; the urine normal in quantity and 
character. 
Summer complaint is a disease of comparatively long 
duration, lasting from four to six weeks, and I have seen 
cases that have lasted eight weeks.* This applies more 
particularly to hand-fed infants. Infants nursed at the 
breast-and these are but very rarely attacked-generally, 
if appropriate measures are instituted, quickly recover. 
Death is most frequently due to the extreme exhaustion 
of the vital forces, f 
There is one special feature of this disease which, 
though rarely observed, merits some attention here, as but 
few text-books make mention of the same. This feature 
is a peculiar exanthem which makes its appearance usually 
at a late period in the disease. Small, roseola-like spots 
appear upon the arms, upon the legs, or upon the whole 
body, and it looks very much as if the child were going to 
have an attack of measles. When very abundant, it is 
very likely to be mistaken for measles by the laity, and the 
poor little patient, who is already burning with fever and 
consumed with thirst, is swathed in heavy flannels and 
dosed with warm saffron tea J until either compassionate 
Death relieves him or the intelligent physician saves him 
from further torture. The spots remain isolated, or not 
more than three coalesce. The skin between them retains 
* See report of eases further on. 
f See Diseases of Children, by J. Lewis Smith, edit. 1890. Dis- 
eases of Digestive Organs in Children, by Louis Starr, 1886. 
| This is no exaggeration; it happened in a case under my obser- 
vation. 8 
SUMMER COMPLAINT 
its normal color. The eruption lasts from two to five days, 
gradually paling in that period, and then disappears with- 
out desquamation. The very few instances in which I ob- 
served this exanthem were cases of summer complaint that 
had either not been treated at all or only indifferently up 
to the period of eruption. Baginski * says that in the few 
cases in which he observed the exanthem it was not of bad 
import; in the cases under my observation it heralded a fatal 
issue. 
Occasionally, and still more rarely, another form of ex- 
anthem is observed. This, as Baginski f rightly observes, 
can hardly be called anything but an erythema multiforma. 
It appears in the form of pale or bright-red patches, of 
greater or lesser extent, and with more or less infiltration 
of the cutis. This also disappears in a few days. 
In the years 1871, 1872, 1873, 1874, and 1875, while 
connected with a colleague in medical practice in a tene- 
ment-house quarter of this city, I had occasion to see many 
cases of thij disease during the summer months of each 
year. From the setting in of the hot weather it was noth- 
ing but summer complaint day after day, almost ad nau- 
seam. 
In the course of this large experience I had occasion to 
try almost every method of treatment recommended and 
every remedy that up to that time had been advised : bis- 
muth, chalk, oxide of zinc, calomel, hydrargyrum cum creta, 
pepsin, lactopeptin, tannic acid, haematoxylon, opiates, vari- 
ous kinds of infant foods, the raw-beef treatment imported 
from Russia and so highly lauded by Trousseau. 
The results of all and the several methods were mostly 
nil. The children whose parents were not of the poorest, 
* Berliner klin. Wochenschrift, 1889. No. 49. 
f Ibid. SUMMER COMPLAINT. 
9 
whose habitations were not of the worst, and who had suffi- 
cient vital powers to carry them through the long siege, 
dragged through a miserable existence until the setting in 
of the cooler nights, when the disease began to abate, and 
the infant that had been worn down to skin and bone gradu- 
ally revived, gained in vigor, and lived, while those not so 
endowed died, despite all and everything that was done for 
them. This experience was further verified by the obser- 
vations made, though not in such numbers, in subsequent 
years. 
In view of this unsuccess in treatment with all the 
remedies at command, even with such as had been heralded 
at one time or another as veritable specifics; in view of the 
fearful mortality attendant upon this disease, it became evi- 
dent to me that the nature of the malady was not yet at all 
understood, that the supposed pathology of the disease, as 
taught by post-mortem section, was erroneous, and hence 
this failure. 
This conclusion arrived at, I began the study of the 
subject anew. With this purpose in view, I carefully re- 
viewed the mass of notes taken and the histories of cases 
kept during the past years. From a careful collation of 
these, the following facts stood forth prominently : 
a. Nursing infants may be attacked by the malady. 
b. That even in families where the most scrupulous care 
was exercised as to feeding, bottles, and milk, such cases 
would occur. 
c. That infants were affected who received no milk at all, 
but were fed with different kinds of infant food. 
d. That even the most restless and sleepless child in the 
house became quiet and slept when kept out in the open air. 
I have seen mothers keep their little patients out till two 
and three in the morning. 
e. That the infants that were quiet and slept while out in 10 
SUMMER COMPLAINT. 
the street (that is, in the parks and open spaces, away from 
the large brick houses) would be but a short time in the 
house when they again became restless, noisy, and fretful, 
and had to be carried around upon the arm until morning, 
when, usually from sheer exhaustion, they would fall into 
a short, fitful slumber. 
f. That the infants that vomited and purged at short 
intervals in the house would, while out in the street (in the 
open places above described), be able to retain food and 
have rest from the diarrhoea for as much as three to four 
hours and even longer. As soon as they returned to the 
house, or rather a short time thereafter, the vomiting and 
diarrhoea recurred with their previous frequency. 
To these points I added the already well-established 
facts laid down in all text-books and corroborated by my 
notes : 
1. That this disease always prevailed at one and the 
same season-to wit, the hot months of the year. 
2. That it was chiefly among the tenement-house popu- 
lation that lives in apartments that are hot and stuffy and 
which are still further heated by the cooking, washing, 
ironing, etc., and by the burning of lamps at night, that the 
disease manifested itself. 
A careful consideration and weighing of all these facts- 
and they are facts that will be verified by all who have Irad 
sufficient opportunity for observation in the homes of the 
people-led me to the inevitable conclusion that heat was 
the principal, if not the sole, factor in the Aetiology of this 
malady. 
The therapeutic indication, the logical sequence of such 
a conclusion, was clearly this: that we must address our- 
selves to the modification of the aetiological factor, heat or 
its effects, if we desired success for our therapeutic inter- 
vention-remotus causa tollitur effectus. But how to do SUMMER COMPLAINT. 
11 
this ? It is true that I might have advised removal to the 
country, to the mountains, to the sea-shore; but, unfortu- 
nately, it is mainly those, as already said, who do not pos- 
sess the necessary means to get away whose children are 
thus afflicted. I determined, therefore, as 1 could not change 
the temperature, to resort to such a measure as would do 
for the time being what is accomplished by removal to the 
country, to the mountains, or sea-shore-i. e., remove the 
child from the heated atmosphere, and at the same time re- 
move any effects already produced by it-a measure that 
had proved of greatest service in heat stroke *-viz., the wet 
pack. 
The opportunity for testing the correctness of my views 
did not present itself to me, owing to absence from home 
during several summers and for other reasons, till the sum- 
mer of 1887, which was an exceedingly hot one, and cases 
of summer complaint were numerous. As the treatment 
was very nearly alike in all cases, I shall report here only a 
few, selected from the whole number treated by me after 
the new method for some special feature that each pre- 
sented : 
Case I.-Sammy F.. aged nine months, tenth child, bottle-fed 
with Nestle's milk food since his third week, rather stout, always 
a very good child, giving his mother but little trouble, is now 
in a period of dentition. The family occupy a small house of 
eight rooms on one of the best streets in the city. Some years 
previous they lost two children with summer complaint. 
In the early part of July the child became very restless, 
cried all night, was very fretful through the day, and wanted to 
be carried around constantly upon his mother's arms. Diar- 
rhoea has set in and continues to grow worse. He is nauseated, 
* Heat Stroke (Thermic Fever) in Infants. By H. Illoway, M. D. 
Medical News, August 8, 1891 ; Cincinnati Medical News, September, 
1891.. 12 
SUMMER COMPLAINT. 
gags, and when he takes food be vomits. He usually sleeps up 
stairs, in a rather small bedroom, in a bed with one or two 
adults. As the nights were exceedingly hot, I advised the 
mother to keep the child down stairs, even throughout the 
night, in a rather roomy parlor and much cooler than the upper 
Hoors. For the sickness at tbe stomach I prescribed a weak solu- 
tion of cocaine, a dose of which was but eight drops, and given 
at intervals of from two to three hours. For some reason or 
other the mother did not take my advice with regard to keep- 
ing the child down stairs, and the cocaine was of but tempo- 
rary benefit. For the time being the nausea was allayed, tore- 
turn in a little while after the administration of the medicine. 
The diarrhoea continued, the number of stools increasing in fre- 
quency despite the usual mixtures that were given to check 
them-in short, the child grew very much worse. Though I 
had hesitated at first, I determined now to follow out tbe thera- 
peutic indication above mentioned. I therefore directed the 
mother to wrap the child in a wet pack (as already described in 
my paper on Hydrotherapy and my paper on Heat Stroke), to 
renew it when warm, and to continue this process for two to 
three hours ; then, when the child was quiet, to leave it off, and 
resume again as soon as he manifested any signs of irritability. 
The mother did as I directed, and the effect was marvelous. 
The infant went to sleep and slept very quietly and nicely, and 
even the renewal of the pack did not disturb him much. As 
soon as tbe process was completed he fell asleep again. This 
continued thus nearly the whole of the first day. The nausea 
disappeared, the diarrhoea was very much improved, and the 
child every way better. The mother continued the application 
of the wet pack every day-that is, two to three in the morning 
from about 10 a.m., and three to four in the evening-for two 
months, and the marked improvement obtained at the outset con- 
tinued. His appetite was fair. The food (Nestle's) was fairly 
well borne, though not quite as it should be, and not in the usual 
quantity. A little red wine (claret or Ives's seedling) and water, 
with a biscuit broken in it, was given twice daily and very much 
relished. The diarrhma was almost completely arrested, not more 
than three to four stools a day, and frequently not more than one SUMMER COMPLAINT. 
13 
or two, and these of good character ; when the stools were more 
than the latter figure they usually contained some undigested 
masses. He slept well at night and did not disturb his mother 
much. When the cooler weather set in, the infant, which had 
weathered the great heat of the season and had gone through 
the process of cutting four teeth, was in excellent shape, some- 
what thinner, it is true, but very fat in comparison to other chil- 
dren similarly affected that I had seen in my former experience. 
It took but a very few days until he began to eat again his usual 
quantities, and very rapidly regained his fat. 
His mother, who had had the sad experience with this mala- 
dy above mentioned, said to me, when the child had fully re- 
covered, that she would not have believed it possible to accom- 
plish so much with so little medication had she not witnessed 
it herself. 
Case II.-Baby R., aged eleven months; well developed, 
well nourished, and nursing at the breast. 
The family occupied the lower floor of a house, the front 
half of which was occupied by them as a store and the rear half 
divided off into living-rooms. The bedroom was thus in the 
center, a small compartment without any windows and no 
ventilation except what came from above, the partitions not 
reaching to the ceiling. The family is well to do, and every- 
thing is kept scrupulously clean. 
Was called to see the baby in the morning and learned that 
it had been seized with vomiting and diarrhoea, whether in the 
night or in the early morning hours the mother was not posi- 
tive. Temperature, 102° ; it is extremely restless, tosses about 
in its cradle, and cries constantly. I prescribed a febrifuge mixt- 
ure (spirits of Mindererus, sweet spirit of niter, and a minute 
quantity of tincture of aconite), but this was vomited every 
time, and about 1 p. m. I was hurriedly called to see it again. I 
now directed the mother to wrap the child in the wet pack, and 
this to be continued till night; then to discontinue it for a 
while and to resume it again when the child became restless. 1 
also directed that it be not given the breast, but that a tea- 
spoonful of equal parts of lime water and milk, cold, be given 
every half-hour to allay thirst. This was done; the diarrhoea 14 
SUMMER COMPLAINT. 
and vomiting ceased at once, and after four hours the mother 
again gave it the breast, which it nursed; the milk was re- 
tained ; the lime water and milk were then discontinued. The 
wet pack was continued for two days, with intervals of absten- 
tion, and the infant then discharged well. 
Case III.-Baby L., aged fifteen months; weaned; well- 
developed child ; eats, and is evidently well nourished. The four 
incisors, both upper and lower, cut for some time already. Is 
now in the developmental period of another group-the an- 
terior molars. 
The family lives on the third floor (top) of a tenement house, 
occupying two large rooms, separated, however, from each 
other by a stairway. There are not more than three families in 
the house proper, the lower floor-separated from the others 
altogether-being occupied by a store. The apartments of the 
family are scrupulously clean and fairly well aired, the rooms 
having three and two windows respectively. Nevertheless, the 
heat in them, especially in the large front room-the best room- 
is exceedingly great; at times it seemed to me like a bake-oven 
and this though no fire, for any purpose, was made in this 
room. The heat poured down from the ceiling and was so great 
that when I came to visit my little patient, despite the perspi- 
ration rolling down, I kept my hat on to shield my head from 
it. The infant is exceedingly restless, tosses about in its cradle, 
cries constantly, and is especially bad at night. The mother is 
almost distracted. It vomits and has some diarrhoea; the evacu- 
ations are of a greenish color. 
I directed the mother to wrap the infant in the wet pack 
and continue its application for three hours; then to intermit 
and resume again as soon as the child again became restless. 
For the thirst, to give it lime water and milk, equal parts, a tea- 
spoonful every half-hour. The effect was excellent. The 
vomiting ceased at once; that is, the milk and lime water ad- 
ministered were retained. The diarrhoea was arrested. The 
child fell into a slumber and slept quietly and peacefully for 
quite a time. After the condition of the child had been greatly 
improved under this treatment I advised taking it out and 
keeping it out of the house even at night. As long as it was SUMMER COMPLAINT. 
15 
kept out it rested well, but when taken in it was but a little 
while till the child was again restless, tossed about, cried, until 
wrapped in the wet pack, when it at once became quiet and 
went to sleep. 
However, after a while the mother, perhaps owing to multi- 
farious duties incumbent upon a poor woman with a large 
family of small children, somewhat relaxed in her attention to 
the baby, and one morning early I was hastily summoned to 
see it, as it was very bad, as the messenger said. I went at 
once and found the child almost wild, as one might say. At 
times it almost stood upon its head, the head and feet resting 
upon the bed and the body forming an arch between these two 
points. There was marked rise of temperature, but it could not 
be ascertained by the thermometer, as the child could not be 
kept quiet or in one position for two minutes at a time. There 
was great thirst. I at once had the child wrapped in the wet 
pack and had some sherry wine brought, which I poured into 
a tumbler upon a lump of ice, and gave the child four to five 
small teaspoonfuls of it-two drachms and a half perhaps in all. 
The child quieted down in a very little while, and went into a 
refreshing sleep. Anxious to learn if possible what had caused 
this sudden change, I inquired of both father and mother as to 
their treatment of the child since the day before. The father 
told me that the child had been very comfortable the day be- 
fore ; it had been in the wet pack twice. In the evening he 
had taken it out and kept it out till 1 a. m., and it had slept, 
well and even soundly, and had taken its milk and lime water. 
Feeling tired himself, he had then gone into the house and put 
the child into bed. It had slept till about 3 a. m., and then be- 
gan to cry and toss around and stand upon its head; it had also 
vomited some milk that they had given it. When asked why 
he had not put the child in the pack, he said that he really could 
not say whether it was forgetfulness, owing to fatigue, or whether 
they were frightened by the child standing upon its head. 
As the infant seemed to me to suffer considerable pain-and to 
this I attributed the remarkable positions it would take-and as 
it displayed some nervous symptoms (slight twitchings), I pre- 
scribed a mixture of chloral hydrate in lac asae fcetidae, to be 16 
SUMMER COMPLAINT. 
administered by rectal injection if needed; but so soothing was 
the effect of the pack that it was not required. 
The plan of treatment pursued was this: Twice in the day, oc- 
casionally three times, the child was wrapped in the wet pack and 
kept therein for an hour and a half to two hours. In the even- 
ing it was taken out and kept out the greater part of the night, 
except on the rare occasions when it rained, and then the house 
was much cooler-sufficiently to permit of the child being 
kept in. 
The food which it received was milk-plain, ordinary milk 
-mixed with a little more than one third lime water. 
This treatment was carried out faithfully by the parents for 
two long months, I visiting the patient occasionally to keep 
myself fully informed as to the progress made, and for the pur- 
poses of history. When the cooler weather set in the child did 
not show any evidences of suffering; it had weathered that 
frightfully torrid summer in excellent condition; it was reduced 
somewhat, it is true, but not more so than other children that 
had kept well, and it was but a very short time till it had re- 
gained its previous weight and vigor. It had also cut, during 
the period referred to in this history, the four anterior molars 
and two lower canines. 
Case IV.-Baby II., aged ten months; partly nursed at 
breast, but chiefly bottle-fed with milk and lime water. A 
large child. The family occupied a large, airy house in an ex- 
cellent part of the city. They had just come from New York 
city, where the baby had been taken sick with summer com- 
plaint and a rather bad prognosis made for it. The child was 
restless day and night; wanted to be carried upon the arm, and 
cried almost incessantly. Both father and mother seemed dis- 
tracted. It vomited, no matter what was given it, and had a 
marked diarrhoea, using a great number of diapers daily. It 
was very much emaciated. 
For the purpose of assisting the stomach in digesting any 
material that might remain in it, and for the purpose of allaying 
its irritability, as also that of the intestinal tract, I prescribed a 
powder of- SUMMER COMPLAINT. 
17 
R Bismuth, subnitrat gr. viij ; 
Pancreatin (F. & R.) gr. iv; 
Sodii bicarbonat gr. j. 
M. Make one powder. 
One such powder to be given three times a day. For the 
great thirst, which was evident, a little good sherry to be 
poured upon ice, and two or three half-teaspoonfuls to be given 
every two or three hours. To wrap the child in the wet pack 
and allow it to remain for two hours and a half and then to leave 
off; to resume again as soon as the child became restless. To 
abstain from bottle feeding. 
Two days afterward I was sent for again to call and see the 
child, as it was worse. I called and made inquiry and found 
that my orders had not been carried out with regard to the wet 
pack. The powders had been given, so also the sherry, and it 
had been fed but little. The vomiting and diarrhoea continued 
as before, and the restlessness was as marked-greater, if such 
a thing was possible. On learning this, 1 asked the mother why 
she had not fully carried out my orders. She made answer that 
it was too much trouble, and that the child would not live any- 
how ; her physicians in New York had said so. All she wanted 
was something to quiet the child so that it would not cry so. I 
gave her a sound lecture upon the duties of a mother, with 
rather vigorous denunciation of her conduct, and told her to get 
whom she pleased, but that 1 would not treat her child any 
longer. She begged me to continue, and promised faithful com- 
pliance. The effect of the pack was as excellent in this as in the 
previous cases. The child became quiet and slept well while in 
the pack, and even when out of it. Already, after the first few 
days, it was much quieter than previously. The vomiting and 
diarrhoea ceased. 
The treatment as described was continued (under careful 
supervision), and under it, despite the hot weather, the child 
began to gain. To still further assist recovery of vital power, 
embrocations of cod-liver oil, twice daily, into the axilla 
were added to the treatment, and as the mother did not have 
sufficient milk, a little strained oatmeal was allowed morn- 
ing and evening. The child continued to do well and to gain 
2 SUMMER COMPLAINT. 
18 
in flesh, and after a week of cooler weather it was as fat as 
hutter. 
Case V.-Baby M., aged ten months, partly nursed, partly 
fed-mostly fed, however, as the mother says she has but little 
milk. A large child. The family live in the attic of a five- 
story tenement-house and are exceedingly poor. The child be- 
coming sick, it was taken to a college dispensary for treatment. 
The physician in attendance gave her some medicine, but at the 
same time informed the mother that the child was in a dangerous 
state, and that its death might be looked for in two or three 
days. Upon hearing this, she brought the child to my office for 
treatment. The baby presented the usual symptoms-rest- 
lessness, vomiting, and diarrhoea, and, superadded to all this, a 
state of feebleness that I ascribed to previous insufficient feed- 
ing. I reassured the mother and allayed her fears. I then di- 
rected her to wrap the child in the wet pack (she had witnessed 
the procedure in Case III) and to continue this at intervals for 
two days, then leave off; but always thereafter to keep the 
child well cooled off either by the cool sponge bath, cool bath, 
or, if it became very restless at any time, by means of the wet 
pack. To keep it out of the house most of the time; to give it 
every three hours (later on four hours) ten drops of good 
whisky in a teaspoonful of cold water. Not to feed it at all for 
the day, and not to nurse it oftener than every three hours and 
a half. Directed the mother to nourish herself better. Five 
days afterward the mother again brought the child to my office 
to show me how nicely it had done. It was apparently in 
good health, and kept so throughout the whole summer. 
Case VI.-Baby M., aged twelve months, a well developed 
child and apparently well nourished ; weaned since tenth month. 
The two central incisors, both upper and lower, already cut. 
The family live on the ground floor of a frame barrack, in two 
miserable back rooms, one of which is used as a kitchen 
and dining-room, the other as a bedroom for the family-two 
adults and three children. The rooms are rather dirty. Child 
is very restless ; cries day and night; vomits everything given 
it; diarrhoea. Temperature 101'5°; considerable emaciation. 
Treatment: The wet pack, as already described in the other SUMMER COMPLAINT. 
19 
cases; to abstain from feeding the child for the next twenty- 
four hours, and to give it during that time nothing but lime 
water and milk, equal parts-one drachm every half-hour. 
Under this treatment improvement was rapid. Vomiting and 
diarrhoea airested; temperature normal; child quiet. I now- 
advised the mother to see that the child was kept cool by spong- 
ing with cold water, the cool bath, or by occasional application 
of the wet pack ; to feed it for a time on nothing else but boiled 
milk, with an addition of one third its bulk of lime water. The 
child kept well, despite the great heat, and after a time a 
regular dietary was prescribed for it. 
Summarized, the results obtained with this treatment 
were: 
1. It at once calmed the restlessness and fretfulness of 
the child and gave it rest and refreshing sleep. The value 
of sleep-quiet and invigorating sleep-to the sick infant 
need not be expatiated upon, as it is patent to all who have 
treated children with any attention. 
2. Cessation of the vomiting. 
3. Arrest of the diarrhoea, or at least such decidedly 
beneficial modification of it that it ceased to be a source 
of danger. 
4. Improvement of the digestion. 
5. The children were maintained in very good condi- 
tion, and when the cooler weather, especially the cooler 
nights, set in they rapidly and in brief time regained their 
former weight. 
These results were certainly most remarkable in their 
excellence and far'superior to any that I had ever obtained 
with any other plan of treatment or that I had seen ob- 
tained. 
However, in a certain number of cases there was still 
room for further improvement in a certain special direc- 
tion-viz., the digestion of the infant. Though the vomit- 20 
SUMMER COMPLAINT. 
ing ceased and the diarrhoea was arrested, or at least so 
greatly modified that it did not constitute any more a 
source of danger, and though the children picked up, still 
the fact remained that the digestive power of the infant 
was enfeebled, and its feeding required the greatest tact 
and attention. It suffered from some form of dyspepsia; 
undigested particles were occasionally found in the stools; 
and any neglect of the mother in the matter of food was 
followed by an increase in the number of discharges and 
the development of considerable flatus. The question that 
naturally presented itself to me was therefore this: In 
what especial manner is the digestive function of the 
stomach affected by the a?tiological factor, heat ? 
An answer to this was readily found in the investiga- 
tions and experimental studies made upon this point by 
others. It is now a well-established fact, demonstrated by 
numerous clinical investigations, that in all febrile states 
there is a diminution which may amount to a total sup- 
pression of the hydrochloric acid secreted by the stomach. 
And it is not requisite that we have a very high degree of 
temperature; even a moderate elevation will have this 
effect. This has been well shown by the investigations of 
Gluzinski.* As is seen from Table I of his paper, his 
patient (typhoid fever-exanthem, typhoid.), with a tem- 
perature of not more than 102° F., had no hydrochloric 
acid in his gastric secretion, as was shown by careful ex- 
amination of the stomach contents; this absence of free 
1IC1 continued even at 99°+ F. It was only when the 
temperature had descended to the normal that 11C1 was 
clearly demonstrable in the stomach contents. Even 
Sasseckif and Edinger, who oppose this statement as too 
* Gluzinski. Deutsch. Archie f. k/in. Med., 1888, p. 484. 
| St. Petersburger Mediz. Wochenschrift, 1878, No. 19; Deutsch. 
Archie f. klin. Med., loc. tit. SUMMER COMPLAINT. 
21 
broad, acknowledged that in all febrile states where dys- 
pepsia is present, this dyspepsia is due to the absence of 
or deficiency in IIC1. 
It might, perhaps, be claimed by some that this defi- 
ciency was due rather to the effect of the malady upon the 
economy in general than to the pyrexia eo ipso. This 
point has also been very clearly established by the experi- 
mental studies of Manassein.* This investigator found 
that in animals put into a febrile state by artificial over- 
heating, the stomach secretion showed a marked deficiency 
in IIC1 and a consequent diminution of its digestive capa- 
city. Furthermore, his experiments have shown that such a 
deficiency of IIC1 may occur even when the pepsin con- 
stituent of the gastric juice is normal in amount. " Auf 
Grund des eben angefiihrten halte ich mich zum Schlusse, 
dass bei fiebernden Thieren die Sauremenge in dem Magen- 
safte der Quantitat des Pepsins unentsprechend sei, berecht- 
igt." 
The conclusion was therefore necessarily this : that the 
dyspeptic condition was due to a deficiency of IIC1 in the 
gastric secretion. 
The further results of this study were an additional ex- 
planation of the marked beneficial action of the wet pack 
and the further therapeutic indication : To assist the digest- 
ive function where it still remains enfeebled by the adminis- 
tration of hydrochloric acid. 
I determined, should the opportunity offer, to carry out 
in my treatment of summer complaint, in addition to the 
measure that had given me previously such favorable re- 
sults, the last-mentioned therapeutic indication. However, 
the material, so far as 1 am concerned, has been very 
scant, but a small number of cases that would come under 
the category of summer complaint, as described at the out- 
* Manassein. Virchow's Archiv, vol. Iv, p. 423. 22 
SUMMER COMPLAINT. 
set, having come under my observation since. Of these, I 
shall report in detail but three. 
Though I was fully convinced of the correctness of my 
conclusions, and though 1 had administered pepsin and hy- 
drochloric acid in certain cases of infantile dyspepsia, I had 
not the courage, when the time arrived, to break at once 
with the received traditions and to strike out in a course 
directly the opposite to that recommended by all the 
authorities in paediatrics; and that is the explanation for 
the apparently halting manner in the treatment of the first 
case to be reported. 
Case I.-R. F., aged four months, a stout and healthy child, 
that I have known since its birth. It was nursed at the breast 
for about five weeks, and then the mother's milk gave out and 
it was given the bottle with Nestle's food. This is the sister of 
Sammy F. reported as Case I, ante, who is now a big fat boy. 
The surroundings of the child are the same as reported above. 
August 1st.-The night previous, of July 31st, was excess- 
ively hot. The baby was restless and irritable, and had, as 
the mother, a very intelligent lady, reported, a marked eleva- 
tion of temperature. The mother, recollecting the previous 
practice, had wrapped the child in the wet sheet, but only 
once, as she was in doubt as to its applicability in so young a 
child. For the time being it did good, however, and the child 
rested and had some sleep. The next day, August 1st, was 
equally hot and close. The child was restless, crying continu- 
ally; it vomited; diarrhoea set in, and till evening the child 
had eight stools, when I was sent for to see it. It presented 
the characteristic shriveled appearance, had considerable eleva- 
tion of temperature, and great thirst. I advised that the child 
be put in the wet pack and that this be kept up for at least two 
hours; forthethirst, that it be given a teaspoonlul of lime 
water and milk, equal parts, cold, every half-hour. 
August 2d.-This was done. The baby went to sleep in the 
pack, and slept well even after its discontinuance; it did not 
vomit any more. The child is brighter this morning; does not SUMMER COMPLAINT. 
23 
vomit; and has had but two stools since last evening. This 
treatment was kept up till the next day, and then the child be- 
ng much better, it was given its bottle, though in smaller quan- 
tity and at longer intervals. The applications of the pack were 
repeated at various times for the next few days, and the benefi- 
cial effect maintained ; still the digestion of the infant left much 
to be desired. I finally mustered up courage to abandon the 
beaten track and follow out the therapeutic indication last 
mentioned-viz., to administer hydrochloric acid. 
Being somewhat at a loss as to the best manner of adminis- 
tering this remedy in this case, 1 took advantage of a formula 
given by Jacobi* and credited to Dr. J. Rudisch, which is as 
follows: 
" 7b one pint of water one half teaspoonfid of official di- 
lute muriatic acid is to be added. To this mixture add one 
quart of raw, cold milk; mix the two liquids thoroughly, and 
then boil for ten or fifteen minutes.'1'1 
I instructed the mother in the details of preparation of the 
above nutriment, adding to the formula that only water that 
had been thoroughly boiled previously and cooled should be 
used, and gave explicit directions as to the quantity to be given 
at a time and as to the intervals -namely, three ounces every 
two hours and a half. For further precaution I had but half 
the quantity prepared at a time. The child took the milk thus 
prepared very well and throve nicely upon it. 
It was about the 2d or 3d of September when an incident 
happened which was rather unpleasant. The child was seized 
in the afternoon with a profuse diarrhoea, and till evening, 
when I saw it, it was more dead than alive. I directed 
the following treatment: Subnitrate of bismuth, two grains 
every two hours. A mild sinapism-equal parts of wheat 
Hour and mustard stirred into a paste with cold water-to 
be applied over the abdomen and to be shifted till the whole 
belly was reddened. To give it eight drops of whisky in 
a teaspoonful of cold water every two hours. In place of its 
* Am. Jour, of Obst., vol. xii, No. 3. Treatment of Infant Diar- 
rhoea and Dysentery. By A. Jacobi. Reprint, p. 10. 24 
SUMMER COMPLAINT. 
food, which was inhibited, I gave half a teaspoonful of Reed & 
Carnrick's liquid peptonoids* every two hours. In three days 
under this treatment the child recovered, and was again able 
to take its bottle with Nestle's food, to which the mother 
recurred again; but, as it did not tolerate it well, it was again 
given milk (obtained from a cow kept by a private family, and 
therefore rich) diluted with boiled water, at first one half and 
then one third. The cooler nights setting in, the baby was soon 
as fat as ever. 
I can only explain this incident in one of two ways: either 
it was due to carelessness in the preparation of the milk-and 
there is good ground for this belief, for the mother, seeing the 
child doing well, became somewhat lax in her supervision, and 
allowed her daughters, very young girls, to prepare the food; 
and every physician knows how difficult it is to get an accurate 
history of things if the family are at fault-or it may have been 
possible that the IIC1 mixture was continued too long and a state 
of gastric hyperacidity created, and thus the diarrhoea produced 
by the exaggerated peristalsis to which this state gives rise. 
This can be readily understood when the fact is kept in mind 
that in the infant the stomach and intestinal tube are very 
nearly one organ. 
Case II.-Baby R., aged seven months, bottle-fed with 
condensed milk since the second month; family live in a tene- 
ment-house, occupying three rooms on the third door. The 
apartments are clean and have fair ventilation. 
August 3d.-Called to see the child. The history of the 
child's illness the same as in the foregoing case-restlessness; 
crying, especially marked at night; vomiting; diarrhoea; some 
elevation of the temperature. 
Treatment.-The wet pack as already described. To allay 
thirst, a teaspoonful of milk and lime water, equal parts, cold, 
every half-hour. In the place of food, to give it-that is, be- 
* This preparation is an excellent one and has done me good service 
in many cases of infantile dyspepsia and gastric catarrh due to over- 
feeding, in which I desired to withdraw for a short time the usually 
given food. SUMMER COMPLAINT. 
25 
ginning not earlier than the afternoon-half a teaspoonful of 
Reed & Carnrick's liquid peptonoids every two hours. 
Jfth.-The child is in good condition ; has slept well the 
night previous; no more vomiting, and diarrhoea arrested ; but 
three stools since my last visit. I instructed the mother to re- 
peat the wet pack whenever the necessity therefor arose, and 
to look carefully to the child's feeding. 
10th.-I was sent for again. The child, though doing fairly 
well, had occasional recurrence of the diarrhoea, and the mother 
desired something for that. Believing that this recurrence of 
the diarrhoea was due to indigestion, I instructed the mother in 
the preparation of Rudisch's milk, and directed her to give no 
more than five ounces and a half at a time, and not oftenerthan 
every three hours. To let me know then how the child got 
along. 
About six weeks after this last mentioned visit, having occa- 
sion to be in the house, I inquired of the mother how the milk 
had acted. She informed me that it had done very well; that 
she had continued it for two weeks, and, the child doing well and 
gaining, she returned to her ordinary food, as the preparation 
of the milk required too much of her time-more than she could 
spare, as she was engaged in work that she could not neglect 
any longer. 
Case HI -Baby B.. aged seven months, apparently a well- 
nourished infant, nursed at the breast and also fed somewhat. 
Of good size for its age; cutting its upper incisors. 
The family live in two back rooms, opening upon a porch, 
of a tenement-house in a narrow street-one that is generally 
not over clean. The child is very irritable and fretful through 
the day, and cries the greater part of the night. It has a pro- 
fuse watery diarrhoea ; considerable thirst, as it takes water 
with great avidity; slight elevation of temperature above nor- 
mal, 99'6° F. Ordered chalk mixture with syrup of ginger. 
Two days thereafter the child was again brought to the office; as 
its father said, it was no better; he also brought a soiled diaper 
along to show me the character of the stool. It was white and 
consisted principally of unchanged flocculi of casein. I ordered 
the baby a cool sponge bath-ordinary hydrant water, to which 26 
SUMMER COMPLAINT. 
a little warm water had been added-twice daily. Sponging of 
the abdomen especially with cold water. Inhibition of artificial 
food and proper regulation of breast feeding. 
Medicine.-Acid, hydrochloric, dilut., gtt. j, in a teaspoonful 
of slightly sweetened water every two hours. I also advised a 
measure which I had found useful in other cases and to which 
I shall recur again-viz., the mother to sponge herself with cold 
water, at least the upper part of the body to below the breasts, 
twice daily-in the morning before nursing the child, and 
at night before retiring. 1 saw the child no more: but a 
short time thereafter I met the father and he told me that 
they had given the medicine for three days, and the child ap- 
pearing well, they had discontinued it. The child has remained 
well since. 
As already stated, the cases of summer complaint that 
came under my observation from the summer of 1888 to 
the present time were but few in number-ten; of these, 
there were six in which a persistence of a certain degree of 
indigestion led to the administration of hydrochloric acid 
in one or the other described form. The result of such ad- 
ministration in these few cases was very satisfactory; the 
digestion improved rapidly, and in consequence thereof 
the appetite became better, and the stools normal in 
character. Furthermore, in children fed with the bottle, 
the milk prepared according to Rudisch's formula solved 
in a satisfactory manner the question of what to feed for 
the time. 
The accident that occurred in Case I of the second 
series can not be regarded as testimony strongly contra- 
dicting the assertions here made; for, as already stated in 
the history, there were several factors that may have tended 
to produce it; but the most important of all, perhaps, was 
my lack of precise notions as to the length of time for 
which the acidulated milk should be administered. SUMMER COMPLAINT. 
27 
Total number 
of cases. 
Recoveries. 
Deaths. 
First series, 1887 
Second series 
25 
10 
25 
9 
1 
Total 
35 
34 
1 
Summary of Results. 
Though the number of cases is comparatively small, it 
can nevertheless be safely maintained that the results ob- 
tained by me, as illustrated by the table, are far superior to 
what have ever been obtained with any of the other meth- 
ods of treating summer complaint. And even the case 
which died strongly illustrates the value of the therapeutic 
measures here indicated, as can be seen from the following 
history: 
Baby F., aged five months, bottle-fed with condensed 
milk; had received the breast for about four weeks; puny. 
Sister of baby F., referred to above. When the mother discov- 
ered about the second month that she was again pregnant, she 
was disconsolate. She bad already had fourteen children and 
several miscarriages, and the hard work and suffering that she 
had gone through with them had told on her frame, producing a 
scoliosis. She therefore resorted to various drugs-ergot, quinine, 
cotton root, pennyroyal, and to patent nostrums-to rid herself 
of the impediment, without avail, however. When about five 
months gone she had a recurrence of an old middle-ear catarrh ; 
she became greatly debilitated and had attacks of syncope ; she 
had to be kept in bed for a week at a time, and stimulants free- 
ly administered became requisite. To cap the climax, financial 
difficulties overtook the family shortly after her confinement, 
and though no direct suffering ensued, it entailed great mental 
distress upon her and put upon her a great amount of work that 
was generally attended to by the husband. Family living in a 
small, narrow house adjoining a livery stable, in a very excel- 
lent street, however. 
May 29, 1890.-The weather is very hot. Called to see the 28 
SUMMER COMPLAINT 
baby. The mother said that the baby had had a greater num- 
ber of stools than usual since the 10th. but that she bad not 
given the matter much attention. To-day the infant had 
ten stools. I asked to see the diapers, but there was none 
to show just then. The mother described the stools as green- 
ish. I ordered a mixture of bismuth subcarbon, with some 
aromatics. 
June 5th.-The bismuth did not do any good. A couple of 
diapers were shown me; the stools were of a greenish color. 
There is some elevation of temperature; the child is peevish, 
restless, and rather haggard in appearance. Vomits occasion- 
ally. I called the mother's attention to the necessity of apply- 
ing the wet pack, as she had done in the other two children, 
and of frequent sponging after the temperature had been re- 
duced. 1 also directed that the child be fed with milk prepared 
with hydrochloric acid, with which she was already familiar. 
6th.-Child is better. 
7th.-Continues to improve; stools not more than eight in 
the twenty-four hours and rather small; still greenish in color, 
with the addition of some mucus. To-day the stool was but a 
few hard lumps of casein. As, in my opinion, this clearly 
pointed to either an inefficient preparation of the milk or to 
the administration of plain milk, I called the mother's attention 
thereto, and urged upon her a little more care upon this point. 
The child had slept much better the night previous, and pre- 
sented a much better appearance. 
15th.-Stools still of the same frequency-eight in twenty- 
four hours. Directed bismuth subnitrate, gr. ij, every three 
hours. 
20th.-Stools still as frequent. Child is bright, has a fair ap- 
pearance ; in no way the aspect peculiar to children with sum- 
mer complaint. It appeared to me, however, that the rules laid 
down for the care of the child were not very strictly observed, 
neither in the matter of the wet pack and spongings nor in the 
preparation of the food; but more especially in the latter. I 
therefore advised the substitution of Reed & Carnrick's pepto- 
genic milk powder, and impressed upon them the necessity of 
sponging the child ; furthermore, I directed that whenever the SUMMER COMPLAINT. 
29 
head got warm to put upon it a towel wrung out of cold water, 
and I instructed the sister, a girl of fourteen, and the little nurse 
girl, upon whom the care of the child principally devolved, in 
this last point. 
23d.-The milk powder preparation disagreed with the child, 
and the milk with hydrochloric acid was resumed. The child 
strained somewhat at stool, and for this I directed a small 
rectal injection of a strong decoction of peppermint with the ad- 
dition of a few drops of paregoric-gtt. vj. This relieved the 
trouble at once. 
July 31st.-Since last report the child did well. Once about 
the middle of the month during the hottest part the child had 
a slight recurrence of the trouble, but the same measures, pre- 
viously employed, soon relieved it. This evening was called to 
see the child. The weather is extremely hot and has been so 
for the last three days. The mother states that the child had 
some diarrhoea, but the injection of peppermint decoction, as 
above described, soon relieved this. However, the child is rest- 
less, whines, and seems rather feeble. Some tendency to vomit. 
Body cool, but the head, especially about vertex and occiput, is 
hot. I directed the child to be immediately taken out of the 
house, which was frightfully hot. The cold applications to be 
applied to the head. As a stimulant and to relieve the evident 
nausea, I prescribed a few drops of spirit, amnion, aromat. to 
be given every three to four hours. The child was taken out in 
its wagon, a cold compress applied to the head, and in a very 
few minutes thereafter it was enjoying a sound sleep. 
August 2d.-The hot weather continues; atmosphere sultry. 
Called to see the baby. Bowels loose; stools have a moldy odor. 
The mother gave it last evening an injection of peppermint and 
put it in the wet pack. As long as it is kept in the wet pack 
the bowels are checked, the child ceases to moan, and seems to 
feel much better. It did not take the bottle so well through the 
day, but takes it much better this evening. Four stools to-day; 
while I was in the house the child had a stool; it was of the 
consistence of pap and light yellow in color. It takes ten drops 
of whisky with a little cold water every three to four hours. 
10th.-Child doing well; looks bright; has a fair appear- 30 
SUMMER COMPLAINT. 
ance ; thin, but not a wrinkle in its face. Sleeps fairly well, 
though occasionally it may wake up two to three times in the 
night, cry a little, and go to sleep again. 
16th. -The child is very bad; it has lost its good color; face 
is wrinkled; body much emaciated; is very feeble; extremities 
cool; lies in a sort of stupor. 
I ascribed this sudden change for the worse to a sudden and 
remarkable fall in temperature that occurred at this time-a fall 
so great that the houses actually felt cold and chilly. Coming 
on so suddenly, it had a very depressing effect upon my little pa- 
tient. 
^Oth.-Child died this morning. 
That, despite the great difficulties the child labored under-a 
constitution undoubtedly already prenatally enfeebled, deprived 
of mother's milk, a mother rendered almost indifferent by amul- 
titude of troubles and worries and sickness (she suffered from 
menorrhagia and pains in the back during the. whole period em- 
braced in the history of the child's illness), almost wholly de- 
pendent for the necessary attentions upon the two little girls, 
children themselves-it should have withstood so long and so 
well the ravages of the torrid summer of 1890, and that with 
but trivial medication, as can be seen from the history, I regard 
as a triumphant demonstration of the great value of the thera- 
peutic measures here advocated, and ergo of the position here 
assumed as to the true nature of summer complaint. I said, with- 
stood so long and so well. The history certainly proves this; and 
I am furthermore of the positive conviction that had it not been 
for the very great depressing effect upon a system already im- 
paired in vitality by the long struggle, of the sudden cold spell, 
the child would have survived. 
It can not be denied that the proposition here laid down 
as to the aetiology of summer complaint is opposed by emi- 
nent paediatric authority in this country. But upon what 
grounds ? 
J. Lewis Smith, in his treatise The Diseases of Infancy 
and Childhood, edit. 1890, in the chapter Intestinal Catarrh SUMMER COMPLAINT. 
31 
of Infancy (Entero-colitis), page 788, says : " The fact is 
therefore undisputed and is universally admitted that the 
summer season, stated in a general way, is the cause of this 
annual recurring diarrhoea. That atmospheric heat does not 
in itself cause the diarrhoea is evident from the fact that in 
the rural districts there is the same intensity of heat as in 
the cities, and yet the summer complaint does not occur." 
Louis Starr, in his very excellent book The Diseases of 
the Digestive Organs of Children, makes a similar statement, 
edit. 1886, chapter Entero-colitis, page 178. He says : 
" There must be another factor at work here besides the ele- 
vated temperature, since in the open country immediately 
surrounding affected cities, where the thermometer ranges 
nearly as high, the disease is of exceptional occurrence." 
Shattuck, the translator of Strumpell, in the chapter on 
cholera infantum, in a paragraph in brackets, repeats this 
argument. 
To anyone who has lived both in the city and the coun- 
try the fallaciousness of the argument will be at once ap- 
parent. What are the facts I 
1. It is true that the intensity of heat is the same in the 
country as in the city, but only in the open plain and only 
part of the day. 
2. The dwellings in the country are much cooler, even 
throughout the day, than those of the city, and certainly 
much more so than those occupied by the urban, middle, 
and poorer classes. 
3. There is a vast diifcrence between the night atmos- 
phere of the country and that of the city. The night at- 
mosphere of the country is cool even to chilliness; that of 
the city is hot. 
Though for part of the day there may be the same in- 
tensity of heat in the country as in the city, nevertheless 
the houses, not alone in the farming districts but also in 32 
SUMMER COMPLAINT. 
the small villages, are cool. They are generally built apart, 
and whatever of breeze is blowing finds but little obstruc- 
tion to penetrating them, while the shaded windows keep 
out the hot rays of the sun. Then the shade trees which 
usually surround these habitations still further tend to keep 
them cool and comfortable. 
What the houses in the large cities are-especially in the 
crowded districts with their narrow streets, the cramped and 
crowded habitations swarming with living beings, and their 
cooking and washing, and the multitude of lights at night 
-is so well known that it need not be expatiated upon 
here. 
But the greatest difference is in the atmosphere of the 
night. In the country the air is cool and pleasant, and re- 
freshing sleep waits upon tired Nature. But how is it in 
the great city ? While the heat was great throughout the 
day, it is stifling at night. With the setting of the sun and 
the fall of darkness the immense mass of brick and stone of 
house and pavements gives forth the heat absorbed through- 
out the day, and an atmosphere is created very much like 
that of a furnace. Here poor tired humanity seeks in vain 
for a cool spot to woo sleep, and house-tops and porticoes 
and cellar doors and hallways are turned into sleeping apart- 
ments. But the poor little infant is kept in the room which 
is too hot for every one else, in its cradle with feather pil- 
lows, perhaps a feather bed to lie on. Furthermore, a light 
is usually kept burning all night and adds its share to ren- 
der the atmosphere still more intolerable. 
And it is really not so much the heat of the day as it is 
the great heat of the night of the large cities, which de- 
prives the little children of their much-needed rest, that is 
the factor in the production of summer complaint. The 
proof of this lies in the fact that the children are attacked 
after the first hot nights ; that the children are much more SUMMER COMPLAINT. 
33 
restless and seem to suffer more at night than in the day- 
time ; in the repeatedly verified observation that though the 
days be hot, as long as the nights remain cool summer com- 
plaint does not occur ; in the generally admitted fact that 
with the beginning of September summer complaint ceases 
-and certainly we still have hot days in September ; but 
the nights are cool. 
It is this continuous heat, day and night, of the city that 
causes summer complaint. It is the coolness of the coun- 
try at night, the coolness of the early morning hours, the 
coolness of the dwellings, that gives it exemption from this 
really dread disease. 
It is for these same reasons that the children taken to 
the country do so well. These are facts patent to all and 
can not be gainsaid. 
Foul odors, decaying vegetation, domestic filth, and the 
like have been set down by these authors as the direct causes 
of summer complaint. Any such aetiology, however, can be 
at once excluded for the following reasons : 
(a) Summer complaint occurs in dwellings whose sur- 
roundings are clean, that are themselves kept perfectly clean, 
wherein the children are kept clean, wherein clothing and 
bedding are kept perfectly clean. 
(6) It occurs among the rich in their fine mansions in 
the broad streets as well as among the poor. 
(c) Localities with noisome odors are, comparatively, 
not in any way more afflicted than localities free from them. 
It is true, as has been said and as I have stated, that 
the disease is more prevalent in the densely populated dis- 
tricts of the large cities, which are usually characterized 
by high tenement-houses and narrow streets; but it is not 
because of any such fancied aetiological factors as were just 
mentioned above, for in many instances-aye, in the ma- 
jority of instances-they are absolutely wanting. But it is 
3 SUMMER COMPLAINT. 
34 
because in these parts the heat is positively greater, both 
day and night, than in the less crowded districts, or, better, 
in the newer districts, with their wide streets. Each house 
in the populous district is much hotter for the further rea- 
son that so many families dwell therein, usually large ones, 
and each one cooks, bakes, and washes; at night each one 
has one or more lights burning. Furthermore, in these, 
usually the oldest parts of the cities, the streets are short 
and crooked, and the free access of air to them is cut off 
by other piles of masonry that block the street at either 
end. 
A careful scrutiny of the histories here given clearly 
shows that in but two out of the ten cases reported was 
there any ground for the assumption of such an aetiology, 
and even here it was but slight. 
That the disease does not occur among the poor only 
these gentlemen themselves indirectly admit. In the chap- 
ters on the therapeutics of the disease they recommend re- 
moval to the mountains or to the sea-side as the best of 
remedies. Now, such advice can certainly only be given to 
the richer class who possess sufficient means, and they must 
be quite considerable for compliance therewith. And cer- 
tainly such people do not, as a rule, live among stenches, 
decaying vegetation, and tilth. 
But we have more direct proof. It is a well-known 
fact that if these factors are anywhere present it is in the 
quarter inhabited by the negro population of a city. The 
squalid, rickety dwellings, densely populated-almost a 
family to a room-reek with a thousand odors from decay- 
ing animal and vegetable matter. The streets in which 
these dwellings are situated-usually alleys or abandoned 
streets-teem with tilth, being the receptacle for the gar- 
bage, etc., from the houses on it. The street-cleaning de- 
partment visits these places only in times when a pestilence SUMMER COMPLAINT. 
35 
threatens; otherwise they remain undisturbed, year in and 
year out. Now, if these factors are so potent, the mor- 
tality among the colored children should be something 
frightful. How is it in reality ? The following table will 
show: 
Deaths from Cholera Infantum.* 
White. 
Colored. 
1889, June 
18 
" ' July 
42 
1 
" August 
27 
1890, June 
56 
1 
" ' July 
45 
2 
" August 
22 
This table loudly proclaims the contrary of what, upon 
this theory, we should have expected. Not alone that, but 
it also clearly indicates that summer complaint is of exceed- 
ingly rare occurrence among colored children. 
If foul odors, decaying vegetation, and tilth are the chief 
factors in the production of summer complaint, then this 
table is certainly a riddle the solution of which is as yet 
to be found. It can not be claimed that the colored race 
has an immunity against such agents, for there are no 
grounds upon which to base such an assumption; more- 
over, the much greater mortality of the race, as shown by 
Southern statistics, clearly indicates the contrary. 
If heat, however, is the chief aetiological factor in its 
production, as is maintained here, the exemption of colored 
children from this disease is perfectly clear. I say exemp- 
tion, because I firmly believe that, if the cases were thor- 
oughly sifted and summer complaint separated from the 
cases in which the vomiting and diarrhoea were due to 
* This table was prepared for me by the registrar of vital statistics 
from the records of our city, by the kindness of the present able health 
officer, Dr. Pendergrast. 36 
SUMMER COMPLAINT. 
the ingestion of decaying animal substances, stale meat, 
stale fish, etc., and these cases are not so rare, the mortality 
under the head of cholera infantum would, so far as col- 
ored children are concerned, have been nil. It is readily 
explained upon the ground of the much greater tolerance 
of the colored race for heat-a fact well established and 
not needing further elucidation here. 
As additional proof the following brief mortality table 
is adduced. It is taken from the official records of the 
health office, giving the mortality by wards for the year 
1890 : 
Wards. 
June. 
July. 
August. 
Total. 
14 
2 
1 
3 
16 
3 
3 
1 
7 
Deaths from Cholera Infantum* 
In Ward 14 are located slaughter-houses, soap factories, 
tanneries, melting houses, factories for sausage casings, and 
other like odoriferous institutions. A thousand smells, 
dense and strong, assail the passer through this portion of 
the city. Ward 16 is one of the best wards of the city, 
free from any odors and smells, nothing more formidable 
than retailers of meat, and these not many, being located 
therein. And, still, see what the table says. The ward with 
the numerous smells had the smallest mortality, and conse- 
quently must have had a much smaller number of cases 
than the other. 
The facts here adduced clearly show, I believe, that 
foul odors, decaying vegetation, etc.-the factors to which the 
authors mentioned above attach so much importance-really 
play no role at all in the production of summer complaint. 
* This table was prepared for me by the registrar of vital statistics 
from the records of our city, by the kindness of the present able health 
officer, Dr. Pendergrast. SUMMMER COMPLAINT. 
37 
We have also the weight of opinion with us. The well- 
known Dr. Parrish, of Philadelphia, speaking of summer 
complaint, says of it: " It begins with the hot weather, 
increases and becomes more fatal with the rise of the ther- 
mometer, and declines with the cool weather in autumn. 
During its continuance it may be observed to vary with every 
prominent change of temperature* A few very hot days 
in succession in the month of June are sufficient to call it 
into action, and during the length of its prevalence a spell 
of cold weather will diminish if not suppress it." 
" Let any one take a walk in a summer morning through 
the thickly-built lanes and alleys of Philadelphia; he will 
be struck with the appearance of the children, reclining 
their heads, as if exhausted, upon the breasts of their 
mothers, with a pale, languid countenance and clammy skin, 
a shrunken neck, and other signs of debility arising from 
their confinement during the night * to close and hot apart- 
ments." f 
Dr. Joel Shew, the author of an excellent treatise on 
The Hydropathic Management of Children in Health and 
Disease, referring to the disease under consideration, says 
thus : 
"Effects of Heat.-High atmospheric temperature is 
manifestly a great cause of this disease. It is aptly termed 
summer complaint. It commences with the hot weather, 
etc." J 
Dr. T. Clark Miller, in an article entitled Cholera Infan- 
tum and the Weather, says : "Observation also justifies the 
belief that a continuance of high temperature, for a more 
or less definite period of six to ten days, is necessary to the 
* Italics mine. 
f Children, their Hydropathic Management in Health and Disease. 
By Joel Shew, M. D., Philadelphia, 1852. 
t Ibid. 38 
SUMMER COMPLAINT. 
development of the disease, in an epidemic form, in the 
early part of the hot season, while, as the season advances, 
the number of days of continued high temperature neces- 
sary to inaugurate new epidemic outbreaks becomes less. 
This being true, it is not at all strange that unprofessional 
grandmothers, as well as physicians, have associated the 
disease with the continued high temperature as effect and 
cause, not ignoring the existence of co-operating causes, 
nor the varying degrees of susceptibility in children." * 
Finkelnburg f has expressed himself in this sense, and has 
set forth more especially that it is not so much the high 
temperature per se as it is its continuance, and particularly 
its continuance in the dwellings even at night, that is the 
aetiological factor in the production of the disease and its 
great mortality. 
Dr. A. Seibert, in a graphic study entitled Cholera In- 
fantum and the Weather, has demonstrated for some of the 
largest cities of the United States what had been already 
graphically shown by Baginski for Berlin-that the disease 
prevails in the hot months, that the greatest prevalence is 
in July, that it diminishes in August and ceases in Sep- 
tember. 
It is true that, though compelled by his charts to admit 
the direct and decided influence of the weather upon this 
disease, he does not regard a high temperature as the neces- 
sary factor. He says: " Now, then, we have found so far 
that, though the temperature evidently has some decided 
relation to the frequency of cholera infantum, yet we have 
no right to accept our first impression that the higher the 
more, the lower the temperature the less, frequent do we 
find this complaint; on the contrary, we must admit that 
comparison of monthly means of temperature during the 
* Med. Record, July 21, 1888. 
f Berlin, klin. Wochenschrift, No. 49, 1889. Quoted by Bagin ski. SUMMER COMPLAINT. 
39 
summer months shows that the frequency of summer com- 
plaint (like its mortality) is independent of the rise and fall 
of atmospheric temperature." * 
This conclusion, which is contrary to the direct obser- 
vation of every practitioner, is based upon an erroneous 
method of study, as has already been pointed out by Dr. 
Clark Miller, who very truly says : " A monthly record does 
not satisfy the requirements, from the fact that there may 
be two or even three weeks of low temperature, giving the 
month a low mean, and yet enough of days of high tem- 
perature to give the month a high mortality record from 
cholera infantum; or, from a succession of hot days at the 
end of the month, the cumulative effects show on the mor- 
tality records of the following month of perhaps low 
mean." f 
But we have most striking proof to demonstrate that a 
study of the " monthly means of temperature during the 
summer months " is erroneous and leads to false conclu- 
sions. In his summary Dr. Seibert says: 
2. Warm weather (either dry or moist) showing mini- 
mum daily temperature of not less than J 60° F. brings on 
the epidemic appearance of cholera infantum invariably in 
every year irrespective, etc. 
3. Summer complaint loses its epidemic character as 
soon as the daily minimal temperature remains below J 60° F., 
as in the latter half of October of nearly every year. 
Dr. Turner,* in bis report upon the Sanitary Condition 
of Portsmouth, studied the statistics of epidemic infantile 
diarrhoea (summer complaint) in sixteen towns in England 
for the ten years from 1867 to 1876. Admitting the influ- 
* Med. Record, March 24, 1888. 
f Ibid., July 21, 1888. 
| Italics mine. 
# Lancet, July 13, 1878. 40 
SUMMER COMPLAINT. 
ence of meteorological conditions, he finds, by a study of 
the monthly means of temperature during the summer 
months for the period given, that a continued minimal tem- 
perature of 50° F. is necessary to produce epidemic infantile 
diarrhoea. 
If further proof were necessary, it could be brought in 
the fact that summer complaint was never observed at a 
steady temperature of 60° F., and certainly not at 50° F. 
Schoppe,* in a study of cholera infantum, expresses him- 
self plainly and unmistakably to the effect that high tem- 
perature is essentially the setiological factor of this disease. 
Dr. A. Baginski, that eminent and painstaking investi- 
gator of the diseases of the digestive organs of jchildren, is 
very explicit upon this point. In an address delivered be- 
fore the Berliner medicin. Gesellschaft, after referring to the 
graphic study of this disease made by him for Berlin, and 
published in his Verdauungskrankh. der Kinder, 1884 he 
says: "Vergleicht mann nun die Thatsachen, die wir fiir 
Berlin gefunden haben, mit den Thatsachen aus anderen 
Stadten, so hat mann die eigenthiimliche Wahrnehmung, 
dass in den verschiedensten Grossstadten sowohl Europa's 
als auch Amerika's die Erscheinung ganz dieselbe ist, und 
es ist vom hbchsten Interesse die Curven welche aus Ameri- 
ka verblfentlich werden f mit unserer Curve zu vergleichen. 
Es ist fast als ob die Amerikaner die Berliner Curve ab- 
gezeichnet batten, so genau decken sich die Curven, etc. 
Under solchen Verhaltnissen ist es begreifich wenn mann die 
Hohe der Temperatur fur die Mortalitat an Kinderdiarrhoen 
verantwortlich macht." J Further on he says : " Wenn mann 
* Schoppe. Der Brechdurchfall der Sauglinge a. seine Behandlung, 
Bonn, 1887. 
f I believe reference is here made to the charts of Dr. Seibert, men 
tioned above. 
| Italics mine. SUMMER COMPLAINT. 
41 
sich mit dieser Frage so weit abgefunden hat dass mann, 
ganz allgemein ausgedriickt, die Hbhe und lange Dauer der 
hohen Sommertemperatur als massgebend betrachtet, so," 
etc.* 
The general effect of this continuous high temperature, 
with its attendant heating up of the dwellings, is the pro- 
duction of a state of fever in the infant. 
This needs no demonstration here. It is sufficiently 
proved by experimental investigation and clinical study.f 
The aetiological factor having been clearly determined 
and its general effect upon the organism of the child being- 
evident and well understood, the next question, the logical 
one, that presented itself was this: What special effect is 
produced upon the digestive tract ?-the system pointed to 
by the symptomatology as specially involved in this disease. 
And first as to the stomach. 
The question of organic lesion required no considera- 
tion. It was excluded by the aetiology, by the rapidity of 
the involvement, and most positively by the many necrop- 
sies which have been made and which have shown the 
stomach free from such lesion. There remained therefore 
but functional disturbance-a dyspepsia-to account for the 
symptomatology. 
That it is but a functional disturbance has apparently 
never been doubted. Upon this point there is a consensus 
of medical opinion, demonstrated by the general use of 
pepsin, lactopeptine, malt, pancreatized preparations, etc., 
and by the many different nutritive preparations introduced 
by manufacturers, and all recommended as a panacea for the 
dyspepsia of summer complaint. It has been clearly and 
* Berliner klinische Wochenschrift, No. 46, 1889. 
f Litten. Ueber die einwirkung Erhohter Temperaturen etc., Vir- 
chow's Archiv, Band 70.-Heat Stroke in Infants, by H. Blow ay, Med- 
News (Phila.), August 3, 1891; Cin. Med. News, September, 1891. 42 
SUMMER COMPLAINT. 
definitely expressed by Dr. L. Emmet Holt. In an article 
entitled The Antiseptic Treatment of Summer Diarrhoea he 
says : " One conclusion has long been forcing itself upon 
my mind with increasing strength every summer-viz., that, 
excepting the rare cases of pure cholera infantum, nearly 
all the diarrhoeas and intestinal catarrhs of young children 
are essentially dyspeptic in their origin." * 
What is the precise nature of this functional disturb- 
ance ? This was the point to be determined, and in only 
one way, by taking into consideration the well-established 
factors in this disease-the setiological factor, heat, and the 
morbid condition produced by it, the pyrexia-and ascer- 
taining what special effect they have upon the stomach. 
What this effect is has been sufficiently demonstrated in 
the foregoing-namely, an inhibition or marked restriction 
of the secretion of hydrochloric acid in the gastric juice. 
In addition to the theoretical considerations which led 
to this conclusion, and which are amply sufficient in them- 
selves, being based upon incontrovertible and well-estab- 
lished facts, we have direct testimony from the malady 
itself. 
(a) Leo,f in his studies upon the infantile stomach in 
health and disease, investigated the condition of its con- 
tents in one hundred and four children, laboring under 
various maladies. Of these, twenty-two were cases of 
cholera infantum-summer complaint. In all these cases 
there were found, in large quantities, the volatile fatty 
acids, butyric, acetic, and lactic acids. 
Now, the presence of these acids in any quantity in the 
stomach contents is due, as has been amply shown by care- 
ful investigation, to the absence of IIC1 in the gastric se- 
* N. K Med. Jour., July 29, 1887; 
f Ueber die Functionen des normalen u. kranken Magens, etc., ini 
Sauglingsalter. Berliner klinische Wochen., 1888, No. 49. SUMMER COMPLAINT. 
43 
cretion.* This is to-day an established fact. The explana- 
tion thereof is this : All fermentative processes occurring in 
the digestive tract (and these acids are the results of such) 
are due to the activity of micro-organisms which abound 
therein. It is a characteristic of these micro-organisms 
that a strongly acid medium inhibits their activity. The 
presence, therefore, of hydrochloric acid, which is a very 
energetic and strong acid, prevents any and all fermen- 
tation. f 
(6) The microscopical examinations of the faeces of 
summer complaint have shown therein a great number of 
bacteria, a greater number than are found in the infantile 
intestinal canal in a state of health. Baginsky, J in his 
latest discourse on this subject, enumerates eleven different 
species that he has found therein. 
It is an established fact that the greater number of bac- 
teria that are taken up with the food, the drink, the air, are 
destroyed in the stomach,* and though a few may pass it 
unharmed-e. g., as is claimed by Lesage || for his green- 
coloring bacillus-nevertheless, their activity is inhibited, 
as the effect of the admixture of the hydrochloric acid to 
the chymus continues even in the small intestine. A 
It is furthermore an established fact that it is the 
hydrochloric acid in the gastric secretion Q that is the 
* Boas. Allgemeine Diagnost. a. Therap. der Magenkrankh.-Ewald 
Klinik der Verdauungskrankh., vol. ii, p. 26. 
f Boas. Loe. cit.-Maefadyen, Nencki u. Sieber. Archiv f. ex- 
periment. Path. u. Pharmacolog., B. 28, II. 1, 2. 
| Ueber Cholera Infant. Berl. klin. Woehen., 1889, No. 46. 
* Some New Bacterial Poisons, etc. Victor A. Vaughan. Med. News 
(Phila.), August 16, 1890. 
|| Archives de phgsiologie normale et path., 1888, No. 2. Le- 
sage, etc. 
A Maefadyen, Nencki u. Sieber. Archiv f. experiment. Path. u. 
Pharmac., loc. cit. 
Q Ibid., and Boas, loc. cit. 44 
SUMMER COMPLAINT. 
guardian at the portal of the stomach and destroys or ren- 
ders harmless the invaders that come from without. 
The presence, therefore, of such great numbers of bac- 
teria of varied form demonstrates an inhibition or marked 
diminution of the (IIC1) acid constituent of the gastric 
juice. 
We have corroborative evidence from analogous patho- 
logical conditions. 
(c) Boas,* in his clinical investigations, has found that 
in the majority of cases of chronic intestinal catarrh there 
is anacidity (absence of HC1) of the stomach. 
Troitzky,) in a recent article on the gastric disturbances 
in children, says that the majority of gastric dyspepsias in 
children are caused by the deficiency of HC1 in the gastric 
juice. 
The large quantities of gas J ami the acids, especially 
the volatile, fatty acids, developed in the stomach as a re- 
sult of the fermentation therein set up, are the direct cause 
of the nausea and of the vomiting. 
The Bowels.-The bowels are not affected at the out- 
set ; after a period, however, a catarrhal condition super- 
venes, excited by the constant passage of irritating material 
over the intestinal mucous membrane. The diarrhoea is the 
direct result of the dyspepsia. The food not being properly 
digested in the stomach and undergoing abnormal changes 
therein is thus thrown in an improper state into the intesti- 
nal canal; it acts as an irritant therein, and provokes fre- 
quent and abnormal peristalsis and its own more or less 
early expulsion. 
These fermentative changes begun in the stomach are 
* Boas. Loe. cit. 
f Troitzky. Jahrb. f. Kinderheilk., xxxii, 4; Archives of Paedi- 
atrics, November, 1891. 
| Leo. Loe. cit. SUMMER COMPLAINT. 
45 
continued in the intestinal canal, and still others originated 
there de novo ; there is consequently a still further devel- 
opment of flatus (additional to that which has passed from 
the stomach), readily recognizable by the tympanitic condi- 
tion of the belly; and this, by the distention it produces 
and the irregular peristalsis it excites per se, is the chief 
source of the pain. Diarrhoea and flatulence as a result of 
indigestion-dyspepsia-are so firmly established in pa- 
thology that they need no further demonstration here. 
The variegated color of the stools in this disease, as set 
forth in the symptomatology, is readily explained. The 
preen stools, which predominate, derive their color from the 
presence of a special bacillus, first described by Lesage. * 
This bacillus is found in greatest abundance in the upper 
two thirds of the intestinal canal, is very rare in the lower 
third, and altogether absent in the colon. These green 
stools constitute that part of the intestinal chymus which 
is expelled from the small intestine and passes to the ex- 
terior without previous sojourn in the colon. The yellow 
stool consists of material which has undergone a more nor- 
mal digestion, and has taken the course usual in the healthy 
state. Or it may be that the natural color is due to the 
fact that the previous evacuations had so thoroughly re- 
moved the chromogenic bacilli that none were present when 
this special portion passed their habitat.f If it turn green 
on exposure to the air, it is owing to the presence of this 
bacillus of Lesage, but so thoroughly concealed in the cen- 
tral portion of the mass as to have been occluded from the 
air. On reaching the exterior, and exposure to the greater 
atmosphere, the bacillus, which is decidedly aerobic, is at 
once roused into activity, and produces its special effect- 
the green color. The white stool (only found in milk-fed 
* Lesage. Loe. dt., also Bulletin medical, 1887. 
f On this point see Baginski, loc. cit. 46 
SUMMER COMPLAINT. 
infants) is due to this, that the food is expelled too quickly 
for any change, except curdling, to take place therein * ; 
perhaps also due, in part, to a previous clearance of the in- 
testinal tract of everything except mucus, a considerable 
quantity of which is found in all stools. 
The abundance of the mucus is due to the catarrh of 
the intestinal mucous membrane. 
The acid stool is accounted for, as will have been al- 
ready surmised from the foregoing, by the fermentation 
developed in the carbohydrate elements of the food and 
by non-sojourn, or lack of sufficient sojourn, in the large 
bowel. 
The putrid stools are due to putrefactive fermentation 
of the albuminoid constituents of the chymus. I believe 
that there are two important factors concerned in the de- 
velopment of this form of fermentation - namely, high 
fever and lesions of the mucous membrane of the large in- 
testine. In support of this belief may be adduced the fact, 
-a fact so far at least as my observation goes-that putrid 
stools are not observed until a late period in the disease,) 
at a time when we have both high fever and destructive 
lesion of the mucous membrane of the large bowel. 
The inhibition of the acid fermentation is undoubtedly 
a necessary preliminary to the development of the putre- 
factive process. This is accomplished by the high fever 
which, at the period referred to, reaches 103° F. and more. 
The lesions in the mucous membrane of the colon, by ar- 
resting the normal secretion of this portion of the digestive 
tract, favor the activity of Bienstock's bacillus, and of other 
bacilli that may be concerned in putrefactive fermentation. 
* Beale. Slight Ailments, their Nature, etc., 1882, p. 49. 
f I hold that the cases called foudroyante are not summer com- 
plaint. They are cases either of heat stroke (see my paper already re- 
ferred to, Heat Stroke in Infants) or of true cholera infantum. SUMMER COMPLAINT. 
47 
My reason for believing that the lesions in the large bowel 
are more responsible for the putrid stool than those of 
other parts of the intestinal tract is this: Under normal 
conditions the albuminoid constituents of the chymus are 
not affected in the small intestine; it is only after they 
have entered the large bowel that their decomposition be- 
gins, and it is only therein that the results of such decom- 
position as indol, skatol, etc., are found.* It is evident 
therefrom that this part of the digestive tract is the place 
specially adapted for the breaking up of the albuminoids 
into their ultimate elements. 
It is possible that 1 am mistaken upon this point; how- 
ever, there is this additional in favor of it: Bienstock main- 
tains that it is his special bacillus only and solely that 
effects the decomposition of the albuminoids,! and, accord- 
ing to the observations of Macfadyen, Nencki, and Sieber, 
this bacillus is not found anywhere in the organism but in 
the large bowel. Putrid stools are of rare occurrence, at 
least in my experience, and when they do so occur, it is 
only at a late period, as has been stated in the foregoing. 
Exceptionally we meet with them at an early period in the 
malady, and then it is only in children who have been fed 
strongly nitrogenous food, such as eggs, meat, etc. J 
Epitomizing the foregoing, we have the following as the 
natural history of the malady under consideration : 
Summer complaint is a disease produced by the high 
temperature usually prevalent in the summer months, espe- 
cially July and August-a high temperature that is con- 
tinuous day and night. 
This high temperature produces in the infant a state of 
pyrexia. 
* Macfadyen, Nencki, and Sieber, loc. cit. 
| Ztxchrft. f. kiln. Medizin, 8, 1884. 
| For explanation of this difference, see Bienstock's article, loc. cit. 48 
SUMMER COMPLAINT. 
As an effect of this pyrexia we have an inhibition of 
the secretion of hydrochloric acid, or at least a marked 
diminution in the quantity secreted, and therefore an in- 
ability on the part of the stomach to properly perform its 
functions, consequently a dyspepsia. 
As a result of the dyspepsia we have the diarrhoea and 
subsequent intestinal catarrh. 
Two important conclusions force themselves upon us as 
a result of this study. 
1. Summer complaint is not an entero-colitis, as has been 
hitherto assumed, and as it has been up to the present 
designated. 
2. The treatment with alkalics is unscientific, and not 
alone that, but positively injurious. 
In further support of the first conclusion, we have the 
results of post-mortem examinations of recent date made 
by so competent an observer as Dr. L. Emmett Holt.* 
These necropsies demonstrate that- 
(o) Well-marked lesions are found only at a late period 
of the disease. Dr. Holt, in concluding his report, says: 
" We may be pretty certain that at the end of three weeks 
lesions of a good deal of importance exist in the intestines." 
(6) The lesions are the results of a catarrh of the intes- 
tines. 
As to the origin of this catarrh there can be no ques- 
tion. It is a well-established fact in pathology that dys- 
pepsia, vddh its attendant consequences, is the most frequent 
cause of intestinal catarrh. Ziegler, in his Lehbruch der 
path. Anat., is very explicit upon this point. He says: 
" Chronische Katarrhe koinmen namentlich bei anhaltender 
Einfuhr reizender Substanzen in dem Darmkanal und bei 
abnormer Zersetzung des Darminhaltes &c. vor." f 
* Medical News (Phila.), June 9, 1888. 
f Ziegler. Lehrb. der speciell. path. Anatomic, p. 536. SUMMER COMPLAINT. 
49 
We have also the evidence of Boas, already quoted 
above, that in most cases of chronic intestinal catarrh there 
is anacidity of the stomach (lack of HC1). 
It is therefore clearly evident that the entero-colitis 
found at a late date is not the true pathology of summer 
complaint; it does not in any way constitute the disease, 
but is itself only a secondary result of a primary patho- 
logical condition elsewhere located-to wit, the dyspepsia. 
The correctness of the second conclusion is demonstrated 
by the results of late physiological investigations. It can 
not be doubted that the alkaline plan of treatment, which 
has been handed down to us by a former generation, was 
based upon an erroneous idea as to the normal condition of 
the chymus in the intestinal tract. It is not so long since 
that we were taught that the function of the bile and of the 
intestinal secretions was to render alkaline, or at least neu- 
tralize, the acid mass coming from the stomach. Further- 
more, the fermentative processes, the bacteria (and their 
nature) that induce them, were altogether unknown. 
To day, however, we know better. The investigations 
of Ewald * have shown us that the chymus in the small in- 
testines is normally acid, and this has been fully corrobo- 
rated by the extensive studies of Macfadyen, Nencki, and 
Sieber, already referred to here. We are also familiar with 
the fermentative processes occurring in the digestive tract 
and with the nature of the bacteria inducing them. We 
know that to correct the hyperacidity of the chymus-i. e., 
to inhibit the fermentative process-it is not an alkali that 
is required but an acid. 
The correctness of the views enunciated here is very 
strongly attested by this: that upon the basis of this ex- 
position all the numerous contradictions that have hitherto 
existed between observed facts and accepted theories dis- 
* Ewald. Klinik der Verdauungskrankh. 
4 50 
SUMMER COMPLAINT. 
appear, and all facts, symptomatology, pathology, and 
therapeutics are united into one harmonious whole. 
We understand readily why this disease prevails only in 
the summer months. 
Why it occurs only in cities. 
Why the country is exempt. 
Why it is more common among the poor than among 
the rich. 
We understand readily why it is principally hand-fed 
children that are affected by this malady. 
The investigations of Einhorn* as to the time required 
for the digestion of various artificial foods have shown that 
in hand-fed children the stomach is always taxed to the ut- 
most to properly perform its function. Now, it is well 
known to all familiar with gastric pathology that a stom- 
ach that is always working under a high pressure, as it 
were, is very easily functionally disabled and very difficult 
to restore to its normal state. In these children, therefore, 
dyspepsia is very easily induced, and, owing to the fact 
that even the blandest of artificial foods is rather hard of 
digestion for them, difficult to overcome. 
Why it is that breast-fed infants are but rarely affected, 
and when so affected quickly recover. 
We understand readily why removal to the farm, to the 
mountain, to the sea-shore, is so efficient in curing this dis- 
ease. The child being removed from the sphere of influ- 
ence of the aetiological factor heat, is naturally relieved of 
its effects. The fever ceases ; as a result, hydrochloric acid 
is again secreted and the stomach soon recovers its func- 
tional power. That this is the modus operandi is very 
strikingly illustrated by a case reported by Dr. Boardman, 
* N. Y. Medical Journal, July 20, 1889. The Time required in the 
Stomach Digestion of Different Foods in Infants. SUMMER COMPLAINT. 
51 
of Atlantic City. In this case, despite all the advantages 
of the sea-shore, the disease continued, because the stomach 
was kept disabled by the continuous administration of a 
strongly opiated mixture which the parents had brought 
with them. As soon as this was stopped the child began 
to recover.* 
Why removal even at a late period of the disease is 
beneficial and effective. 
We understand readily why the treatment with alkalies 
has been unavailing; why all the remedies like pepsin, pan- 
creatin, bismuth, etc., have proved more than useless, and 
why even antiseptics-e. g., naphthol, sodium salicylate- 
are of but little benefit. Consequently, why the disease 
has been hitherto attended by so great a mortality. 
Why opium, to any extent, is not orly ineffective but 
positively injurious. 
We understand readily why any sudden cool spell oc- 
curring amid the torrid summer weather should be attended 
with immediate improvement of the children sick with this 
malady. Why such measures as excursions upon the water 
for a day (as are arranged by various charitable organiza- 
tions of New York city) should be attended with striking 
benefit to the sick children. 
We understand readily how lavage of the stomach, in- 
troduced into paediatrics by Epstein f and highly lauded by 
Seibert, J should prove of benefit, especially if it be aided 
by enemata of cool water, as seems to be the practice of 
Seibert. 
Why rectal injections of cold, * even of ice, water should 
be beneficial. Cold enemata have a marked cooling effect 
* Med. Record, Oct. 4, 1890. 
f Prager med. Wochenschr., Band 45, 1880. 
| Archives of Paediatrics, April, 1889. 
* Annals of Gynaecol, and Paid., December, 1890. 52 
SUMMER COMPLAINT. 
upon the organism; this lias been very clearly shown by 
Dr. Cantani.* 
The Treatment.-The therapeutic indications are very 
plain. They may be summed up as follows: 
1. Obviation of the aetiological factor, heat. 
2. Cure of the dyspepsia. 
Of course, where removal to the farm, to the mountain, 
to the sea shore is possible, it is the best measure that can 
be advised, as it fulfills in itself both therapeutic indica- 
tions. Where, however, this is impossible, and it is so in 
the majority of cases, I know of no better way of fulfilling 
indications than by the wet pack as described in the clinical 
histories. 
The advantages of the wet pack are many. It accom- 
plishes rapidly a removal of the heat effects. It invigo- 
rates the system. It promotes the cure of the dyspepsia by 
favoring the secretion of IIC1. It is easily applied, and 
even the dullest mother learns readily its mode of applica- 
tion and the indication therefor. Its use can be kept up 
through the whole hot season, if necessary; two or three 
or more applications in the morning, two or three in the 
afternoon, and, if the indication therefor manifest itself, a 
repetition at night. There is no danger connected with its 
use; not the least harm can be done. 
I have never found a mother who did not at once con- 
sent to its application and who, seeing its beneficial effects, 
did not carry out faithfully and intelligently the instruc- 
tions for its use, which were simply to apply the wet pack 
whenever the child's skin, especially of the head, felt over 
warm to the touch-a condition usually indicated by marked 
fretfulness and irritability. 
In cases of breast-fed infants, entirely or partially, be- 
* Berl. klin. Wochensehr., No. 31, 1890. SUMMER COMPLAINT. 
53 
sides the measures above described, I direct certain hygi- 
enic regulations for the mother-viz.: 
1. She shall sponge herself (at least the whole upper 
half of the body, from the root of the neck to the last rib) 
with cool water (the ordinary hydrant water suffices) twice 
daily-on rising in the morning and before she nurses the 
infant, and at night before retiring. 
2. That she shall not nurse the child at any time 
throughout the day when overheated from cooking, wash- 
ing, etc. She shall wait until she has cooled off and rested 
herself. 
It is a well-established and well-known fact, set forth in 
numerous treatises, that morbid states affecting the mother 
have a decided influence upon the milk, and thence upon 
the child. The importance of these regulations for the wel- 
fare of our little patients and their rationale will be there- 
fore readily understood without further elucidation. 
If the dyspepsia has not been completely relieved by 
the wet pack, we can aid Nature to a rapid cure by («) medi- 
cation and (6) regulation of diet. 
As regards medication, there is only one remedy indi 
cated, and that is hydrochloric acid. The value of the 
acid in all cases where the natural secretion is deficient 
therein (malignant disease excepted) is fully established. 
Its usefulness in the malady under consideration was already 
long ago attested by Jacobi.* Lesage f advises an acid as 
the remedy par excellence for green diarrhoea. 
It is remarkable to observe how quickly the dyspepsia 
and its symptoms disappear under the use of the acid. 
The green or white stools give place to stools of normal 
color and consistence, all offensiveness disappears, the de- 
velopment of flatus is inhibited, the appetite becomes good, 
and the child regains its bright and cheerful look. 
* Loe. (if. 
f Loe. tit 54 
SUMMER COMPLAINT. 
Mode of Administration.-The acid may be adminis- 
tered combined with milk according to Rudisch's formula, 
which has been detailed above, or it may be given in doses 
of two drops in a teaspoonful of water every two to three 
hours at first; later on, as the dyspepsia improves, at longer 
intervals-three to four times daily. I have found this 
method very effective in many cases of infantile dyspepsia 
due to deficient secretion of 1IC1. I generally prefer this 
latter method, but where the child is very much enfeebled, 
either from neglect or improper treatment, I should employ 
Rudisch's method for the first few days, and as soon as the 
child gained in strength give the acid in the ordinary way. 
The preparation I employed and still usually employ is 
the acidum hydrochloric dilutum of the U. S. P. 
Tn exceptionally severe cases that had already lasted 
some time-two weeks and over-before coming under treat- 
ment, the administration of two to three grains of the bis- 
muth subnitrate (in powder) every two to three hours (for 
one or two days) proved an excellent adjuvant to the treat- 
ment above described. 
For the flatulence and the pain thereby caused, 1 found 
the rectal injection of a small quantity of a strong decoc- 
tion of peppermint, or the administration of lac asae foetidae, 
in half-drachm doses, of excellent service. The regulation 
of the diet is of the greatest importance in the treatment 
of dyspepsia. The quantity of food (and 1 usually advise 
no other than plain cow's milk from a reliable dairy, boiled 
and kept in a closed vessel, though I have occasionally 
found some artificial foods and condensed milk well borne) 
for each feeding should be somewhat less than the normal 
quantity. 
The number of feedings must not be beyond the ac- 
cepted standard; better less, but never more. The child 
must not take a bottle to bed with it (a very common prac- SUMMER COMPLAINT. 
55 
tice among people). As it need not be fed more than twice 
in the night, a fresh bottle should be prepared for it about 
11 p. m. and 3 a. m. When milk is badly tolerated in any 
form, 1 have found nothing better than the decoction of 
barley, prepared according to Jacobi's* directions. With 
all this there must be enjoined upon the mother an observ- 
ance of the most scrupulous cleanliness of all clothing of 
the child, of its bedding, and of all its feeding utensils. It 
is almost superfluous to say here that an abundance of fresh 
air is insisted upon ; the child to be taken out of doors in 
the early morning hours and later in the evening, if possi- 
ble to a park. This is of special importance to those liv- 
ing in rather cramped and close apartments, that are gen- 
erally more like bake-ovens. 
Of the many measures otherwise proposed for the treat- 
ment of this disease, but two require any consideration 
here-lavage of the stomach and intestinal irrigation. 
To lavage there are many serious objections. It re- 
quires the skilled hand of a physician for its application. 
This alone would be an insuperable obstacle to its general 
use. The poor can not pay a physician for frequently re- 
peated and long-continued visits, and but very few physi- 
cians will burden themselves with such a task where there 
is no prospect of remuneration. 
It is true that it has been maintained that one, or at 
most two, applications suffice for the cure.f Experience, 
however, has not substantiated this allegation. A moment's 
consideration will show that it can not be so. The aetiologi- 
cal factor being constantly active, the pathological condition 
that necessitated the lavage is reproduced, and such repro- 
duction certainly makes requisite a repetition of the reme- 
dial measures. 
* Loe. cit. 
f Seibert. 
Archives of Pcedia'rics, lot. cit. 56 
SUMMER COMPLAINT. 
It is not by any means so harmless and simple a meas- 
ure as we have been led to believe. In an article on the 
Treatment of Diarrhoea in Early Life, Dr. H. C. Chapin re- 
ports the occurrence of fatal syncope from introduction of 
the tube and distention of the stomach with water. * But 
lately a case was reported in which longitudinal rupture of 
the mucous coat near the pyloric extremity and death re- 
sulted from lavage of the stomach. 
It does not fulfill the therapeutic indications in the meas- 
ure requisite. This needs no further elucidation here, for 
it will be at once apparent to all that, if the views as to the 
aetiology and pathology of summer complaint as set forth 
here be correct (and they undoubtedly are), lavage of the 
stomach is a very inadequate remedy-too inadequate to be 
employed when simpler and much more effective measures 
are at our command. 
As a matter of fact, despite the glowing accounts from 
Epstein's clinic and the high recommendations of Seibert, 
lavage of the stomach has found but little favor in the eyes 
of practitioners and is but rarely resorted to, undoubtedly 
for reasons as set forth above. 
Intestinal Irrigation.-I believe I am keeping within 
the bounds of truth when I say that no such process is at 
all resorted to (generally); the injection of a little cool wa- 
ter into the rectum is not intestinal irrigation-not at all as 
understood by its author. 
Rectal injections of cold water are not sufficiently ef- 
fective in any way. The same objection, therefore, holds 
good here also: They do not fulfill the therapeutic indica- 
tions in the measure requisite. Taking all things into con- 
sideration, it can be safely maintained that the plan of 
treatment as outlined and advocated here is far superior to 
any that has been devised. It answers thoroughly all the 
* A. K A fed. Record, June 21, 1890. SUMMER COMPLAINT. 
57 
therapeutic indications furnished by a careful study of the 
aetiology and pathology of the disease. It is simple, and, 
once instructed as to its purposes, any person of ordinary 
intelligence can carry it out. It is economic, it is cheap, 
and therefore within reach of the poorest of the poor. 
Note.-As will be seen, I have made no mention in the section on 
treatment of sterilization of milk, now regarded as one of the most im- 
portant factors to recovery. This, from my standpoint, becomes un- 
necessary. I seek to accomplish and do accomplish, as the cases here 
set forth show, a restoration of the normal antiseptic qualities of the gas- 
tric juice. This I hold a far superior method, as it effects not alone the 
destruction of bacteria introduced from without, but also the inhibition 
of the activity of the bacteria that normally inhabit the digestive tract. 
And this superiority is still further enhanced by the knowledge afford- 
ed us by the valuable investigations of Leeds and Davis, that the nutri- 
tive value of milk is destroyed by sterilization.* 
My directions as to milk used for infant food are: That it shall be 
obtained from a reliable dairy; that it shall be gotten twice daily, 
morning and evening; that it shall be boiled as soon as received for 
half an hour in a vessel kept solely for that purpose; that it shall be 
kept covered, not allowing the cover to be off at any time longer than 
necessary to take therefrom the modicum of milk needed for each 
feeding; that it shall be kept in a cool place; if that is impossible, 
and it frequently is among the poor, I direct that it be put in a large 
vessel containing cool water, to which a piece of ice is from time to 
time added. 
* Am. Jour, of the Med. Sei., June, 1891. ® a REASONS WHY 
Physicians Should 
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