Chronic Diarrhoea.
Etiology.—The chronic form of diar rhoea is met with either as the result of a previous acute attack or arising in an in sidious manner from prolonged irrita tion of the intestinal canal by ill-digested and more or less fermenting food.
In the majority of those cases in which it follows an acute attack we have to deal with more or less definite organic lesions present in the alimentary tract. In some the persistent diarrhoea is due to ulcer ation of the intestinal wall, generally follicular, but occasionally catarrhal, in character. In others a more or less atrophic condition of the tubular glands and villi in the small intestines, associ ated with marked cell-proliferation in the adenoid tissue of the mucosa (Holt), is present. In a few instances the consti tution of the infant has been so pro foundly impaired during the acute attack that the various systemic functions are re-established with difficulty. Digestion continues to be imperfectly performed; and fermentation with development of toxins takes place to an irregular extent. This slight, but continued, systemic in toxication manifests itself in anemia, de fective general nutrition, and an irritable nervous system.
Symptoms.—The cases of chronic diarrhoea form a considerable proportion of the diarrhceas met with during the autumn. In such, the symptoms of acute inflammation have to a great extent sub sided; the temperature remains for the greater portion of the day normal, and sometimes falls even below the normal line: and pain and tenderness have al most entirely passed away; but the mo tions still remain too frequent; their odor is offensive; blood is occasionally seen in the form of minute dark specks; and mucus of a greenish or brownish color is still present in considerable amount. The consistence and color of the stools is variable. At one time they are of nearly normal consistence and fairly homo geneous; at other times they are quite fluid. They are usually associated with much flatulence. Prolapse of the bowel
occurs only occasionally.
The infant's appetite appears very variable, but a fair amount of nourish ment is generally taken during the twenty-four hours. Vomiting is infre quent. Nevertheless the infant remains pale and weak, and lies in a helpless and apathetic manner. As the disease pro gresses nutrition steadily fails. The in fant ceases to grow. A gradual loss in weight occurs through wasting of the subcutaneous tissues till the inelastic skin hangs in folds over the shrunken limbs. In many cases the abdomen may be some what distended, but in others it is soft and retracted. The liver and spleen are found of normal size. The mesenteric glands, although in post-mortem exami nations they are seen to be enlarged, are not palpable. Occasionally petechial spots are seen either on the abdominal wall or on the extremities. The circula tion in these infants is very feeble. The extremities are always cold, sometimes cyanotic, and occasionally oedematous. The urine is scanty. The nervous system suffers with the general failure in nutri tion. The infant is peevish, easily dis turbed, and sleeps badly at night.
The progress of these cases is by no means uniform. Some weeks may show a slight gain; but trivial causes, a chill to the surface of the body, or a slight irregularity in feeding, may bring, on a relapse, and the gain is usually soon lost.
Complications frequently arise. Bron chitic or pneumonic symptoms may ap pear in the lungs. Bachitis frequently develops. Sometimes we have a general adenitis, or a still more distressing furun culosis. Only very rarely is nephritis en countered.
A fatal termination is frequently has tened by some intercurrent disease; at other times it advances very slowly and the ending comes so gently that the ex act moment of death is unascertainable. In a few cases, however, the appetite gradually returns, the stools become more normal, nutrition gradually im proves, and at last convalescence is thoroughly established.