Collapse.—This state—the cold pointed nose, eool bluish extremities, the dry skin hanging in folds about the buttocks and lower extre mities— stands in direct relationship with the intensity of the gastro-intestinal symptoms and develops in accordance with the severity of the vomiting and diarrhoea.
Gastro-intestinal Symptonts.—Early in the disease these symptoms are placed in the foreground. They are not always severe and may not surpass the limit which is notable in dyspepsia. When they are severe and accompanied by the loss of large amounts of water, the fontanel is depressed, the bones of the head overlap, the face becomes pale and pointed, the cornea is shrivelled, and the dryness of the buccal mucous membranes indicates the drying up of all tissues.
Kidneys.—(G. Neuman has made observations of value on the ap pearance of the kidneys ill alimentary intoxication.) The appearance of the kidneys varies according to the severity of the disease and to the sever ity of the gastro-intestinal symptoms. The urine may be greatly re duced in quantity and the specific gravity be high (up to 1032). The limit of the albumin content is as a rule per cent. Hyaline casts may be present in the sediment, but they disappear as the urine increases in quan tity. There are no leucocytes or epithelial cells, thereby denoting that it is a question of toxic irritation and not one of inflammation of the kidneys.
Loss in weight may reach several hundred Gm. in a clay (1 lb.). Such sudden and intense loss dem onstrates the severity of the gastro intestinal symptoms.
The leucorylosis is constantly present, as has been shown by ex aminations of cases in a large in stitution (Finkelstein). This leu coeytosis is regular and seldom exceeds 30,000.
These symptoms as a whole show the picture of alimentary in toxication. It may appear suddenly as an acute breakdown or it may appear slowly assuming a lingering form. For these reasons it is neces sary to observe t he cases closely so as to understand its nature.
The development of these acute cases shows certain types. The best known is the "cholera" type in which the gastro-intestinal symp toms stand out prominently. The "hydrocephalic" form with which nervous symptoms are associated, because of its irritative and para lytic stages, is similar to tuberculous meningitis. The "seporose" form
is distinguished by a great desire to sleep which eventually deepens until there is stupor and coma. This is similar to a diabetic coma. In the "respira(ory" type there are repeated apucea-like attacks which finally result in collapse.
The types occur in frequency in the following order: The "soporose," "cholera," " hydrocephalic," and lastly the "respiratory" type.
Attention has already been called to the importance of making an early diagnosis. It is extremely difficult to determine the initial stage. In this stage there are noticed a desire to sleep, a relaxation of the body, a peculiar bluish color of the skin, beginning disturbances of respiration, and a fixed staring expression. These symptoms may be made to dis appear if the child is startled (Finkelstein).
Another noticeable condition, especially in very young infants and prernature babies, is a gradually developing coma; there are often with this an expression of distress, great relaxation of the muscles, local and general convulsions as well as other evidences of meningeal irritation, difficult and irregular breathing, and collapse. Diarrhcea and profuse vomiting do not always accompany this stage. It is a credit to the older writers that a correct diagnosis has been made in these eases and that they have not been mistaken for cholera sieca or cholera typhoid.
The important diagnostic points are the so-called "grosse" breath ing and glycosuria. These are the first symptoms even in mild eases.
The intoxication usually results in acute or chronic digestive dis turbances or infection of the intestines and may be complicated by acute catastrophes or be associated with a stupor.
The nature of this disease consists in a lessening of the normal protective powers of the intestines and consequent disturbances in metabolism. The function of sugar combustion and the fat absorption is checked or altered, and this also contributes to disintegration of the tissue albumins which is proven by the low amount of nitrogen. The gastro-intestinal symptoms play but a minor part, and these severe metabolic disturbances produce the condition, which is similar to the coma of diabetes, urtemia, ete.