In extreme and advanced cases one often sees tea-colored stools, indicating blood. Such children usually urinate frequently, and aside from indican the urine is normal. Toward the end, partly from the com plications and partly- from the toxtemia, the urine may show sugar, albumin and formed elements. The changes in the pulse are of diagnostic importance. It becomes small and frequent, but gradually falls from 110 to SO and later sinks to 90. The respirations show important modi fications. The expirations are lengthened. _Later it becomes irregular, hnd in certain cases is of the Cheyne-Stokes type.
The temperature frequently remains subnormal (39.S degrees C. or lower) (97° F.). As a result of the toxtemia in the advanced stages, it may rise rapidly and then suddenly drop.
The picture of alimentary decomposition is directly opposed to that of alimentary intoxication,—irritability, with clear mind, subnormal temperature, slow pulse, irregular breathing, and normal urinary' findings, while in intoxication there is fever, rapid pulse, deep and "hunted" breathing, albumin, sugar, and casts in the urine. This condition does not last long, and with the advanced stages of decomposition the evi dences of intoxication soon appear. These are manifested by temporary, then continuous changes in the pulse-rate and temperature, cyanosis, deep breathing, anil positive findings in the urine. Sometimes these are accompanied by dropsical conditions. varying from moderate puffiness to severe cedema, cyanosis of varying intensity, and before the end septic infectious complications of various natures.
This condition, as has been stated, is very serious, and in its ad vanced stages all therapeutic measures, even nourishment from the breast , prove futile. The child may die suddenly from syncope or a fatal termination may be indimted by respiratory changes. There may be decided losses in the weight, with rapid pulse, subnormal temperature, total relaxation and a sudden collapse. This most often occurs in very young or weak infants. A small percentage clic from infections such as pneumonia, otitis, meningitis, and peritonitis, there not being the neces sary amount of resistance in the body.
What is the nature of this disease? It is a reversal of the natural condition. Instead of the nutrition of the food being used to maintain life, the necessary nutrition is taken from the various organs. This decomposition first affects the fats, more vitality is required and the digestive organs are overtaxed. At first small amounts of fat may bc
tolerated, but this tolerance is limited to a short time so that eventually even the smallest amounts are dangerous. (Finkelstein has demonstrated the direct effect of fat on the pulse and respiration.) Even in cases with limited degree of fat assimilation there may- be a fair tolerance to carbo hydrates, so that a fat-free and a carbohydrate diet might be tolerated. But in most cases the carbohydrate tolerance is limited, and only small amounts may be used to avoid going over to this stage of decomposition.
A still more intense form of the disease is characterized by the fact that small amounts of carbohydrates cause a loss in the weight. There are certain cases of the more severe grades which are not checked by a withdrawal of the fats and a reduction in the carbohydrates.
Aside from the free nitrogen in cow's milk the nitrogen-containing compounds favor this decomposing state. This is especially true of casein and albumin. Only in especially severe eases are favorable results obtained from tbe use of whey, and this in cases which have been nour ished before with skim milk.
The progress of unfavorable cases as observed from the therapeutic viewpoint shows itself in this way: the tolerance for food gradually diminishes until all forms of food are involved and in the end even human milk is not tolerated. As the condition progresses the loss in weight becomes more and more marked. In the beginning and in mild cases the influence of this sickness on the number and character of the stools is very early shown. In the severe grades this is complete.
Finkelstein considers three grades of decomposition, depending on the gastro-intestinal symptoms and the reaction of the patient when feeding is re-established.
First grade: This resembles dyspepsia. A reduction of the food results, after three to six clays with the weight remaining stationary, in a gradual improvement of the stools—the condition will be benefited by proper artificial feeding.
Second grade: A curtailment of the food leads to a decline in weight. The condition of the stools slowly returns to normal when more nourish ment is given but a reaction sets in before the nourishment can be raised to the point of normal necessity (60 to 70 calories per kilo.). Such chil dren stand a poor chance of recovering.