(G) RECURRENT VOMITING WITH ACETON/EMIA I make use of the name given by Giliberti to this disease, which has been the subject of thorough study in recent years, because this writer has described most vividly the character of the illness and is not prejudiced in regard to its nature. Single Ciltie.ti have been described in the last century. The accurate knowledge and understanding of the disease as a peculiar symptom-complex, dates front the works of a series of American and French writers, in addition to which, lately, there is also a publication by Misch from Iieuhner's Clinic.
The illness manifests itself by violent vomiting which occurs in a condition of perfect health, or after short prodromata of various kinds. In children, after the first year of age, the vomiting, which can persist for several hours or even days or weeks, ceases suddenly, and is followed by no well marked convalescence because of the immediate comfortable condition of the patient. Acetone in fairly definite quantities is found in the urine during the paroxysms of vomiting, which are repeated at various intervals, and which occur occasionally throughout the whole period of childhood up to puberty. Acetone is present also before the at tack, and as a rule some time after it, and the characteristic acetone odor of the expired breath is noticed in the patient. Marfan strikingly says the odor is a ndxture of the aroma of chloroform and acetic acid and may be so strong that it is noticed on entering the patient's room.
Boys are more frequently attacked (of thirty-four cases collected by Comby twenty-four occurred in males); the greatest frequency conies between two to eight years of life. The cases observed in infants (Rachford) I think are somewhat doubtful, and after puberty this malady is exceptional. 3Iost of the French writers emphasize the suddenness of this illness which sets in without any warning, out of a clear sky- and quickly reaches its climax, or appears after a short period of malaise consisting of headache, dizziness anti nausea. Observers in other coun tries, however (Northrup and others), have claimed that symptoms antecedent to the intestinal disturbance, such as loss of appetite, clay colored stools, often diarrhcca. and the like are not infrequently present, and state that these conditions may occur also in the interval between two attacks of vorniting.
The symptom of the vomiting remains in the foreground. It is produced without especial accompanying nausea, with little effort and copiously (projectile as in tuberculous meningitis). At the beginning, the vomitus consists of food and then becomes mucous and watery, and later, blood-stained in consequence of the straining, while a bilious content indicates, according to Giliberti, that the crisis is near its end. The children whose appetite is not particularly impaired, and who in consequence of the great loss of water, produced through the incessant vomiting, suffer greatly from thirst, retain absolutely nothing. Even a small swallow of ice-water, and every change in position brings on the act of vomiting, so that the little patients lie on their backs in bed in a state of the greatest lassitude. Their pinched features, the eyes sur rounded with dark rims, the over-anxious mien, the dry tongue, and the great exhaustion, caused by the continual contractions of the stomach which finally bring up no further material, produce a pathetic picture. At the same time, the tongue appears more or less thickly coated, the breathing is quickened and occasionally irregular (after the type of so-called agicl respiration in diabetic eoma, Edsall); the pulse is small, frequent, seldom retarded, although never arrhythmieal. The tempera ture is normal, slightly or highly febrile. 1Rachford, has observed elevations of temperature to -10.5° C. 1104.9° F.)].
The abdomen is usually sunken, scaphoid, seldom distended; it inay- be soft or sensitive. The stools during the whole duration of the attack are restrained, exceptionally loose. The swelling of the liver is oeeasionally demonstrable; moderate ieterus has been de,scribed toward the end. So the attack persists, sometimes interrupted by intermissions in which the vomiting stops and more fluid ean be borne for several hours, more often for three to five days, seldom for a week. In several observations, the vomiting returned after fourteen to twenty clays, or only after intervals of weeks or months, or it may be after a year or more before it comes baek. The attacks may be repeated frequently, as already mentioned, and the condition may persist throughout the whole period of infancy.