A system of practical medicine. By American authors. Vol. 2

by Unknown

Emesis occurring at a late stage of the summer complaint is often due to commencing spurious hydrocephalus, which is not an infrequent complication, as we will see, of protracted cases. Perhaps when a late symptom it may sometimes have an uræmic origin, for the urine is usually quite scanty in advanced cases. It seems probable, however, that deleterious effects from non-elimination of urea are to a considerable extent prevented by the diarrhoea.

The fecal evacuations may remain nearly uniform in appearance during the disease, but in many patients they vary in color and consistence at different periods. In the same case they may be brown and offensive at one time, green at another, and again they may contain masses of a putty-like appearance, the partly-digested casein or altered epithelial cells. The stools sometimes consist largely of mucus, with or without occasional streaks of blood, indicating the predominance of inflammation in the colon. This is the mucous diarrhoea of Barrier. The stools are sometimes yellow when passed, but become green on exposure to the air from chemical reaction due to admixture with the urine.

The character of the alvine discharges is interesting. In addition to undigested casein I have found epithelial cells, single or in clusters (sometimes regularly arranged as if detached in mass from the villi), fibres of meat, crystalline formations, mucus, and occasionally blood, as stated above. In one instance I observed an appearance resembling three or four crypts of Lieberkühn united, probably thrown off by ulceration. If the stools are green, colored masses of various sizes, but mostly small, are also seen under the microscope.

The pulse is accelerated according to the severity of the attack. The heat of the surface is at first apt to be increased, though but slightly in ordinary cases; but when the vital powers begin to fail from the continuance of the diarrhoea the warmth of the surface diminishes. In advanced cases approaching a fatal termination the face and extremities are pallid and cool, and the pulse gradually becomes more frequent and feeble. The skin is usually dry, and, as already stated, the urinary secretion diminished. In severe cases attended by frequent alvine discharges the infant does not pass urine oftener than once or twice daily. The imperfect action of the skin and kidneys is noteworthy.

Protracted cases of the summer complaint are apt to be complicated by two cutaneous eruptions—erythema extending over the perineum and frequently as far as the thighs and lower part of the abdomen, due to the acid and irritating character of the stools; and boils upon the forehead and scalp. The latter sometimes extend to the pericranium, and in case of recovery leave permanent cicatrices. This furuncular affection of the scalp has seemed to me useful in consequence of the external irritation which it causes, since it occurs at a time when, on account of the feeble heart's action and languid circulation, passive congestion of the vessels of the brain and meninges is liable to be present.

Patients who are weak and wasted in consequence of protracted diarrhoea, remaining almost constantly in the recumbent position, often have an occasional dry cough which continues till the close of life. It is due to hypostatic congestion in the lungs, usually limited to the posterior and inferior portions of the lobes, extending but a little way into the lungs. It is the result of prolonged recumbency with feeble heart's action and feeble pulmonary circulation. Infants reduced by chronic diseases, lying day after day in their cribs with little movement of their bodies, are very liable to this passive congestion of depending portions of their lungs, toward which the blood gravitates, and into which but little air enters in consequence of their distance and position and the feeble respirations. The hyperæmia which results is of a passive character, a venous congestion, and the affected lobules have a dusky-red color. This congestion, continuing, soon results in pneumonitis of the catarrhal form, subacute and of a low grade, for pulmonary lobules in which the blood remains stagnant soon exhibit augmented cell-proliferation, perhaps from the irritating effects of the elements of the blood now withdrawn from the circulation.

I have made or procured a considerable number of microscopic examinations in these cases of hypostatic pneumonia, and the solidification of the pulmonary lobules has been found to be due to the exaggerated development of the epithelial cells in the alveoli, together with venous congestion. The affected lobules, whether in the stage of hypostatic congestion or the more advanced stage of hypostatic pneumonitis, when examined at the autopsy, were somewhat softer than in health, of dark color, and many of the lobules could be inflated by strong force of the breath; but in protracted cases the alveoli in central parts of the inflamed area resisted insufflation. The lung in hypostatic pneumonia, even when it is inflated, still feels firmer between the fingers than normal lung.

Hypostatic pneumonia is so common in hospitals for infants that some physicians whose observations have been chiefly in such institutions have almost ignored other forms of pulmonary inflammation. Billard, many years ago, wrote: "... The pneumonia of young children is evidently the result of stagnation of blood in their lungs. Under these circumstances the blood may be regarded as a kind of foreign body." Of all the chronic and exhausting diseases of infancy, no one has, according to my observations, been so frequently complicated by hypostatic pneumonia as the disease which we are considering, although it does not usually give rise to any more prominent symptom than an occasional cough. Limited to a small and almost immovable part of the lung, it does not ordinarily accelerate respiration or render it painful, and the cough is also apparently painless.

When progressive loss of flesh and strength has continued several weeks, and the patient is much exhausted, another complication is apt to occur, known as spurious hydrocephalus or the hydrocephaloid disease, the anatomical characters of which will be described in the proper place. The commencement of spurious hydrocephalus is announced by gradually increasing drowsiness, perhaps preceded by a period of unusual fretfulness. Vomiting and rolling the head are occasional early symptoms of this complication. As the drowsiness increases the pupils become less sensitive to light than in their normal state, and are usually contracted. When the drowsiness becomes profound and constant, the pupils remain contracted as in sound sleep or in opium narcotism. The functional activity of the organs is now also diminished, the vomiting ceases, the stools become less frequent, the buccal surface dry, and the urine more scanty, while the pulse is more frequent and feeble. Spurious hydrocephalus either continues till death, or by stimulation the patient may emerge from it. When profound the usual result is death.

Although the summer complaint in its commencement may be promptly arrested by proper hygienic and medicinal treatment, if it continue a few weeks the anatomical changes which occur are such that recovery, if it take place, is necessarily slow and gradual. Improvement is shown by better digestion, fewer stools and of better appearance, less frequent vomiting, a more cheerful countenance, and the absence of symptoms which indicate a complication. Many recover after days of anxious watching and perhaps after many fluctuations.