Differential count of leueoeytes in a series of twenty-five eases. In the blood of normal children under two years of age it shows a relative increase in the small mononuclear elements and a de crease in the polymorpbonuelears as compared with the adult. In the sum mer diarrhceas there is usually an in crease of the lencoeytes, but the•count varies within such wide limits that a high or a low leueoeytosis cannot be re garded as of diagnostic value. On the other hand, the differential count is of more importance. A relative increase in the polynuclears is an indication of an intoxication with decomposition products in the intestine or of the toxins of pathological bacteria; the in crease is, as a rule, in proportion to the severity of the infection. Knox and Warfield (Bull. Johns Hopkins Hosp., July, 1902).
Diarrhceal Disorders.
Classification.—Attempts have been made at a classification of diarrhceal dis orders, based either upon the changes found. post-mortem in the intestinal canal or upon the bacteriological condi tions met with in the discharges, but in both respects our knowledge is still too imperfect to permit us from it to draw dividing lines in a thoroughly satisfac tory manner. As physicians we are able also to recognize clinically certain types of the disease, which to sonic extent cor respond with the groups that patholo gists have attempted. Nevertheless we, too, must admit that our clinical types have no sharp dividing lines, but, both in the group and in the individual patient, show a tendency to pass from the milder into the more severe form.
Two recent classifications, which rest partly on a pathological and partly upon a clinical basis, are worthy of mention. One is that of Lesage, who, in a very in teresting article recently issued from the press, groups the acute eases of infantile diarrhcca into three classes.
In the first he includes all those which are due to the presence in the infant's food, whether breast-milk or cows' milk, of irritant substances not the result of fermentation in the milk. These diar rliceas are generally of a mild type and quickly controlled. In a second group are placed those cases where the disturb ance is due to fermentation in the stom ach or intestinal canal of indigestible but, at the same time, more or less sterile food. The constitutional intoxication in these cases is due to the abnormal de velopment of bacteria previously exist ing in the canal (endogenous). These cases, although sometimes severe, gen erally run a comparatively mild course. The third and largest group contains all those cases in which the diarrhoea is due to fermental changes in the milk admin istered as food to the infant. The poison
producing bacteria are thus introduced from without (exogenous). The consti tutional symptoms met with in this class are frequently of the severest type.
This classification, although interest ing, is scarcely as satisfactory as that made by Booker, who also groups the acute cases of diarrhoea met with during summer into three classes. In the first he places all cases of a dyspeptic and non inflammatory character. In these the stools are lumpy and acid and contain no leucocytes or epithelial cells; the bac teria are only those of normal healthy motions; and the diarrhoea is of a milder form and for the most part easily con trolled; but, if neglected, it shows a tend ency to take on the characters of one of the two succeeding classes. The sec ond group is characterized by symptoms of only moderate inflammation, but there is present a well-marked toxic condition of the system; the stools are numerous, of a watery or pasty character, and con tain few, if any, leucocytes, hut bacilli in iistinctly predominating numbers; sel dom. however, is any one variety so greatly in excess as to exclude the influ ence of other forms. In the third group of cases we meet with a distinctly inflam matory diarrhoea associated with symp toms of a general infection; the stools are frequent and slimy and contain many leucocytes; streptococci arc found in predominating numbers, although other forms of bacteria are also present. In the more severe cases an invasion of the tissues of the intestinal wall by the strep tococci takes place, and in many in stances more or less extensive ulceration of a suppurative character may be found post-mortem. There is, according to Booker, a considerable difference in the clinical course run by the individual cases in this group; some patients respond readily to treatment, while others are little influenced and steadily grow worse, until the disease terminates fatally. Booker thinks that this may possibly be due to the fact that the streptococci met with are of more than one variety.
Of this classification, Booker says that in typical instances the three forms may be easily recognized, but there are many transitional cases which do not fall into any one of the three groups and are prob ably due to a more mixed infection in which no one bacterium is especially pre dominant. This classification of Booker's corresponds clinically very closely with that of Holt, who, however, lays more emphasis on the anatomical post-mortem changes.