In the course of the acute and chronic nutritional disturbances that have just been outlined, new and startling symptoms are apt to appear commonly quite suddenly, less often more gradually. The baby that has seemed only moderately sick becomes alarmingly so. It becomes feverish, listless, drowsy, stuporous, heavy-eyed, in severe cases even comatose, and all bowel symptoms are aggravated. The child looks as if poisoned - i. e., intoxicated by a drug. This condition has been variously designated as catarrhal enteritis, gastro-enteric intoxication, entero-catarrh, summer complaint, because of its greater frequency during the summer months, and cholera infantum. To these conditions Finkelstein has given the name of alimentary (i.e., food) intoxication, because his investigations have seemed to establish very convincingly that the food itself given in excessive amounts is the intoxicating agent, and not a bacterial toxin as has been believed hitherto. According to this view, we have in the intoxication not the introduction of a new outside element, but simply the culmination of an unbroken series of events that lead step by step, in accordance with certain fundamental laws, from the mildest disturbance of nutrition to the severest intoxication. While these changes lead almost imperceptibly from a less to a more severe condition it will be necessary for the sake of clearness, and also to include in the discussion the conditions commonly described separately as indigestion, dyspepsia, marasmus, etc., to divide this process into stages in which a whole symptom-complex can be designated by a name.

(A) The Normal Healthy Infant In Its Relation To Food

In every nutritional disorder there are certain definite departures from what we may consider attributes of the normal thriving baby. These normal conditions may be enumerated for this purpose as follows:

I. The infant makes a regular, steady gain in weight that is normal for its age, that is neither excessive nor too little. If fed more it gains more; if fed less it gains less.

II. It has a definite temperature - 98° to 99° F. - a monothermia that is remarkably uniform, and any considerable deviation from which is pathological.

III. It has a wide tolerance for food, both in general and for individual food elements.

IV. It has bowel movements that are normal for the food it is taking.

V. It is contented, easily goes four hours without feeding, sleeps well, is bright and active, and smiles a good deal.

VI. It has a good color and firm tissue.

The bearing of this is evident in the following consideration of:

(B) The Pathogenesis Of Food Disorders Of Infancy. - I. Stage Of Disturbance Of Balance

In this earliest stage that results from the administration of food beyond the infant's limit of tolerance we find irregularities chiefly in the weight and temperature. The weight fluctuates widely from day to day without apparent cause, instead of increasing steadily. The temperature likewise fluctuates abnormally, and readings above 99° F. and under 98° F. are always significant. The baby at times appears normal, and again may be uncomfortable, restless, and sleep less soundly. The bowel movements still appear normal or nearly so, and the baby is only a little paler than before. Even at this early stage there is present a paradoxical reaction that is characteristic throughout - namely, increasing the food causes a failure to gain normally in weight, or even a loss, while lessening the food, will cause a return to normal, and even an increase in weight. This is especially true of the fat. The tolerance for sugar is still high, and that for protein is unaffected. If the condition is not relieved, and especially if, on a mistaken diagnosis that is easy to understand, still more food is given, particularly cream (i. e., fat), there is ushered in:

II. The Stage Of Dyspepsia Or Indigestion

This corresponds to the various "gastric" and "intestinal"indigestions that always occur inseparably. The weight may increase again for a short time with the added food, but commonly becomes stationary, or shows a steady loss. The temperature is still unsteady and frequently goes considerably over normal, though this may be only for a short period of the day. The child is still more restless and fretful, cries a great deal of the time, seems hungry, and sucks its hands. The face is drawn, and even in sleep is not placid, but twitches and moves as if in pain. The baby becomes pale and flabby. The chief characteristic of this stage is the well-marked evidence of indigestion as shown in the bowel movements. There is commonly vomiting, abdominal distention and colic, an increased frequency of bowel movements, with mucus and curds, and an abnormal color and odor. They may be brownish, sour, frothy, and irritating, especially if the carbohydrates are in excess; or they may be dry, pale, hard, and offensive - i.e., the typical soap stool, or, later, frequent, cheesy, whitish or gray, slimy, and excessively foul, or greenish, curdy, strong and watery, if the fat is the chief disturbing element. Various combinations occur, and it is not always easy or possible to pick out the exact cause. The condition may become subacute or chronic. The tolerance for fat is so reduced that frequently only a small amount is consistent with return to normal. The carbohydrates are better tolerated, as a rule, but much less so than before. The peculiar form of indigestion would, of course, to some extent influence the relative tolerance for these two elements. The protein alone is still apparently tolerated perfectly. Two conditions may now arise that are successive stages of severity in one way, and yet are in many ways antithetical - that is, a stage of marasmus, or one of intoxication.

III. Stage Of Decomposition

As the term implies, in its German meaning, we have here an actual beginning of disintegration of tissue. The typical clinical counterpart to this condition is marasmus, atrophy, or athrepsia. These babies may remain stationary in weight for weeks and months, or may even lose steadily; we have, finally, the hungry, emaciated, pale, fretful, weakly baby, with its shriveled, wrinkled, old-looking face, bony body, and large, distended abdomen. With this low vitality there is a strong tendency to subnormal temperatures that rarely reach 98° or even 97° F., and often sink to 95° or even 93° or 92° F. The bowel movements often appear nearly normal, but are commonly formed and constipated, especially in the chronic cases of milk overfeeding that are peculiarly typical of this stage. In other cases they may be continually dyspeptic, or alternating with periods of constipation. Tolerance for cow's milk fat is here reduced to a minimum, and in severe cases life can hardly be maintained with its continued administration. The tolerance for carbohydrates is likewise greatly reduced, but less so than for fat, that for starch remaining higher than for sugar. The protein is still well borne, except, perhaps, in the severest cases. Such cases are wholly unnourishable, and death is inevitable. In any of the severer cases a single dietetic error may reduce the child beyond recall. In the preceding stages human milk acts as a specific, and can be given freely. Here for the first time tolerance for human milk is lowered, and in extreme cases even absent. While it still forms the specific food, it must be given with extreme caution, or there will be either a severe paradoxical reaction or else an intoxication. The stage of decomposition may last for months and result in extreme marasmus, or only for a very short time. A dietetic error, increasing the fat or sugar too rapidly, will readily bring on an intoxication. Mixed conditions in which the stage of decomposition is at one time predominant, and at another time that of intoxication, are frequent.