. Types of normal breast- and bottle- fed infants. 1. Baby Y 14 months. Bottle-fed from birth. 2. B. J. S., 11 months. Bottle-fed after 4th month. 3. E. S., 6 months. Breast-fed. A PRACTICAL TREATISE 1L o ON ^ INFANT FEEDING AND ALLIED TOPICS! FOR PHYSICIANS AND STUDENTS BY HARRY LOWENBURG, A.M., M.D. Assistant Professor of Pediatrics, Medico-Chirurgical College of Philadelphia; Pediatrist to the Mt. Sinai Hospital; Pediatrist to the Jewish Hospital; Pediatrist to the Jewish Maternity Hospital; Consulting Pediatrist to the Hebrew Orphans' Home; Assistant Pediatrist to the Medico-Chirurgical Hospital and to the Philadelphia General Hospital; Formerly Instructor of Pediatrics, Jefferson Medical College. Illustrated with 64 Text Engravings and 30 Original Full- page Plates, 11 of which are in Colors. PHILADELPHIA F. A. DAVIS COMPANY, PUBLISHERS ENGLISH DEPOT STANLEY PHILLIPS, LONDON 1916 2 VJS19-G COPYRIGHT, 1916 BY F. A. DAVIS COMPANY Copyright, Great Britain. All Rights Reserved, Philadelphia, Pa., U. S. A. Press of F. A. Davis Company 1914-16 Cherry Street DEDICATION IN REVERENT AND AFFECTIONATE MEMORY OF MY MOTHER HENRIETTA LOWENBURG PREFACE. THE author's purpose in publishing a work upon "Infant Feeding and Allied Topics" is to meet the many requests received from his students and from 1 his medical colleagues who have honored him with! their confidence. The con- tents will be found to be largely clinical and practical, and to embody the author's personal experience with the prob- lems presented. Theorizing and the presentation of a medley of views of different authorities have been studi- ously avoided. Credit has not always been given for views expressed which are not original, although the attempt has been made to do so where the fact stated is eminently new and, as yet, has not become a part of common medical knowledge. Quotations and references have been avoided as much as possible, as they are time-consuming and gen- erally annoying, distracting the mind of the reader from the text. In not a few instances the author has indulged in the repetition of certain facts and statements. This has been done largely for the sake of emphasis and to insure the individual completeness of the presentation of the par- ticular topic under discussion, and also to avoid references and cross-references. A serious attempt has been made to emphasize the im- portance of breast feeding and the digestive problems which present themselves in this class of patients. The influence of the German school of pediatrics has been presented in a conservative way, and simply includes (v) vi PREFACE. the author's personal experience with the ideas promul- gated by this brilliant coterie of workers. Adherence to the percentage idea, in its broader sense, has been maintained, as furnishing a valuable method of thinking, and not as a "conditio, sine qua non," the idea being that individualization is the basic principle of suc- cessful infant feeding. The advantages and disadvantages of the caloric system have been discussed. As a means of adapting milk to the individual require- ments the top-milk methods and the miilk-and L cream mixture methods have been abandoned as being too cumber- some, and often incomprehensible to both the physician and to the caretaker. The dilution of whole or of skimmed milk is advocated as simple and efficient. Where their use has given good results the author recommends a few pro- prietaries, not as substitutes for, but as adjuvants to cows* milk. The author's thanks are due, and are hereby gratefully acknowledged, to Prof. John B. Deaver, who has written the article upon "Surgical Treatment of Infantile Pyloric Obstruction." To his sister, Miss Sara Lowenburg, the author wishes to express his appreciation for her assistance while the work was passing through the press. To Robert A. Schless, senior student at Jefferson Medical College, and to Malvin H. Reinheimer, Esq., for their unselfish and enthusiastic assistance in reading proof, and preparing the index, the author is likewise gratefully indebted. The majority of the Rontgenograms were made by Dr. Geo. Rosenbaum, of Mt. Sinai Hospital, Philadelphia. HARRY LOWENBURG. 1927 N. BROAD ST., PHILADELPHIA, PA. CONTENTS. CHAPTER I. PAGE BREAST FEEDING 1 CHAPTER II. ARTIFICIAL FEEDING 49 CHAPTER III. ARTIFICIAL FEEDING (continued) 118 CHAPTER IV. INFANTILE ATROPHY ISO CHAPTER V. RICKETS 185 CHAPTER VI. SCURVY 222 CHAPTER VII. VOMITING 232 CHAPTER VIII. CONSTIPATION 247 CHAPTER IX. DIARRHEA 260 (vii) viii CONTENTS. CHAPTER X. PAGE SPASMOPHILIA 276 CHAPTER XI. EXUDATIVE DIATHESIS 297 CHAPTER XII. PYLORIC OBSTRUCTION 313 CHAPTER XIII. SPECIAL TOPICS 350 IXDEX . 375 LIST OF ILLUSTRATIONS. FIG. PAGE 1 The mammary gland (Gray.) 3 2 Artificial nipple or nipple-shield 7 3 Breast-pump. (Physician's Supply Co., of Phila.) 9 4 Massaging breast 11 5 Abscesses not interfering with breast feeding 12 6 Microphotograph of colostrum 13 7 Microphotograph of human and of cows' milk 15 8 Stripping of breast for sample 18 9 Lactometer. (Physician's Supply Co., of Phila.) 19 10 Creamometer for estimating percentage of fat. (Holt) 22 11 Babcock's centrifuge tube for estimating fat. (Arthur H. Thomas Co.) 22 12 Babcock's pipette for estimating fat 23 13 Eschbach's albuminometer used in protein test. (Arthur H. Thomas Co.) 23 14 Types of good nursing breasts 31 15 How to hold an infant while at the breast 39 16 Proper can used in milking cows. (Dairyman's Supply Co., Philadelphia, Pa.) 64 17 Freeman's pasteurizer 92 18 Apparatus used in mixing formula 95 19 Nursing bottle 96 20 A good type of nipple 96 21 Bottle-brush (Physician's Supply Co., of Phila.) 97 22 Showing correct rapidity of flow of formula through nipple . . 98 23 Nursery refrigerator. (Courtesy of Gimbel Bros., Phila.) 99 24 Home buttermilk churner. (Gimbel Bros., Phila, Pa.) 122 25 Flour ball 134 26, 27 Essential marasmus 156, 157 28 Marasmus 158 29 Frog appearance in essential marasmus 159 30 Marasmus complicated by edema 161 31 Atrophy or marasmus due to chronic cerebrospinal meningitis . 167 32 Square outline of head in rickets 193 33 Rachitic kyphosis 197 34 Rickets 198 35 Rachitic rosary 199 (ix) x LIST OF ILLUSTRATIONS. FIG. PAGE 36 Rachitic scoliosis 201 37 Tubercular kyphosis 203 38 Pot belly and bow-legs 204 39 Rickets. Anterior bowing of tibia and pot belly 205 40 Rickets. Pot belly and protruding umbilicus 207 41 Double congenital dislocation of hip 212 42 Scurvy 227 43 Same child after recovery from scurvy 229 44 Constipation due to dilated colon. (Hirschsprung's disease.) . . 253 45 Massage balls. (Physician's Supply Co., of Phila.) 258 46 Percussion hammer 283 47 Lingua geographica 306 48 Showing pyloric obstruction 313 49 Weight curve in a case of complete or surgical pyloric ob- struction 317 50 Effect of posterior gastroenterostomy on weight curve 318 51 Visible gastric peristalsis 319 52, 53 Weight charts of two cases of incomplete non-surgical pyloric obstruction 326 54 Weighing the baby 328 55 From combined weight of baby and towel subtract the weight of towel to obtain result 329 56 Apparatus for stomach washing, etc 351 57, 58 Stomach washing 354, 355 59, 60 Colonic irrigation with the catheter 357, 358 61 Giving a colonic irrigation or a high enema without inserting the catheter 359 62 Nasal feeding 362 63 Hypodermoclysis 371 64 Necrosis and ulceration from the subcutaneous injection of car- bonate of soda and sodium chlorid solution . 372 LIST OF PLATES. PLATE FACING PAGE Types of normal breast- and bottle- fed infants. .Frontispiece I. Meconium (colored) 16 II. Normal breast stool (colored) 28 III. Normal stool of artificially fed baby (colored) 32 IV. Stool of indigestion in the breast-fed (colored) 36 V. Stool of dyspepsia (colored) 40 VI. Constipated, greasy stool of artificially fed infant, due to administration of too much fat (colored) 64 VII. Hard, constipated, calcium-soap stool due to adminis- tration of too much fat (colored) 80 VIII. Hard, dry, whitish, constipated, crumbly stool, consist- ing of undigested protein, occurring in a bottle-fed baby (colored) 104 IX. Stool of a case of diarrhea discolored by bismuth (colored) 128 X. Same case as Plate IX. Diarrhea more advanced (colored) 144 XL Tubercular kyphosis 200 XII. The appearance of the gums in a case of infantile scurvy (colored) 224 XIII. Showing stomach-tube in situ in a case of intense gas- tric dilation 316 XIV. Practically complete obstruction 320 XV. Same case as Plate XIV. One hour after the adminis- tration of the bismuth 320 XVI. Same case as Plate XIV. Three hours later. No bis- muth has left the stomach 320 XVII. Same case as Plate XIV. Six hours later 320 XVIII. Same case as Plate XIV. The next day, about nineteen hours later 320 XIX. Comet-like appearance of the bismuth shadow at the pylorus in cases of complete obstruction 320 XX. Non-surgical incomplete pyloric obstruction 336 (xi) Xll LIST OF PLATES. PLATE FACING PAGE XXI. Same case as Plate XX. Two hours later 336 XXII. Same case as Plate XX. Bismuth still in stomach, four hours after administration 336 XXIII. Same case as Plate XX. Much bismuth still in the stomach, but also seen in descending colon and sigmoid 336 XXIV. Same case as Plate XX. Eighteen hours later 336 XXV. Case of incomplete but surgical pyloric obstruction 336 XXVI. Same case as Plate XXV. Bismuth in stomach, two hours later 336 XXVII. Same case as Plate XXV. Four hours later 336 XXVIII. Same case as Plate XXV. Eight hours later 336 XXIX. Same case as Plate XXV. Sixteen hours later . . 336 CHAPTER I. BREAST FEEDING. MATERNAL AND MEDICAL RESPONSIBILITY. PHYSICIANS have long recognized that the best food for an infant is human milk. In spite of this, thousands' of children continue to be placed upon artificial feeding, some to thrive, some to live and to suffer from nutritional dis- eases, and some to die. The responsibility for the failure to conserve the maternal milk-supply, while dual, rests with greater weight upon the physician, who, while realizing the value of natural and the dangers and uncertainties of arti- ficial feeding, has failed to become fired with that enthu- siasm which the subject demands. Consequently many mothers are lacking in enthusiasm. It must be stated, first, that the majority of women, providing they are disease-free, can nurse their young. The physician should, therefore, from the day that his pa- tient comes under his charge for her expected confinement, point out to her at every opportunity the advantages of maternal nursing and the dangers of bottle feeding. It is a grave error, too often committed, to discontinue the breast at the first sign of indigestion in the newborn, an occur- rence so common that it may almost be regarded as normal. A mother, on the other hand, will frequently believe that her baby is not getting sufficient nourishment or that her milk is too weak or too rich, and that altogether she is unfit, both from her own and the standpoint of her infant's health, i (1) 2 BREAST FEEDING. to suckle her babe. The psychic element, represented by fear and uncertainty in the mother's mind, is a very potent cause for the discontinuance of maternal feeding and is ex- ceedingly difficult and sometimes impossible to overcome. In fact, fear and anxiety may cause a temporary suspension of the lacteal flow, just as oft the other secretions, saliva, for instance. The physician here again fails in his func- tion if he thoughtlessly coincides with the mother's ideas without investigation. True it is that there are contraindi- cations to maternal feeding, but these will really be found to be few. In our zeal to secure some substitute for or imitation of human milk, we have been carried away from the truism that nothing is quite so good as the real article, and that, if we would but have it, there is plenty of it at hand ; and that the study of its conservation is perhaps the most urgent duty of the pediatrist and of the practitioner. The best guide as to a particular woman's ability to nurse is the physical condition of her babe. Ifi its weekly gain equals from 5 to 7 ounces or even a little less, then nothing else need be considered. In spite of this, on the plea that the milk is insufficient in quantity and quality, although the simple process of weighing the infant before and immediately after nursing for a few times was not practised; or that the infant failed to gain weight (even in the absence of a milk analysis) ; or that it suffered from digestive disturbances, physicians are daily sacrificing the human milk-supply. Granted that these conditions are realities, one may pertinently ask "Do they constitute a suffi- cient reason to stop breast feeding?" Certainly not! As will be pointed out later, there are methods of conserva- tion and of correction whereby the milk can be increased in quantity or whereby any or all of the various elements MAMMARY GLAND. may be augmented or diminished. These it is the physi- cian's duty to know and to practise. The mother, on her part, should look to her medical advisor alone, and not de- pend upon the gratuitous advice of well-meaning but poorly informed friends. Breast feeding may be done either by the mother (ma- ternal nursing) or by a wet-nurse (wet-nursing). The Fig. I. The mammary gland. (Gray.) former is by far the more satisfactory. The latter is useful in emergency. As the milk is secreted by the mammary glands, the construction and function of these organs should be understood. MAMMARY GLAND. The mammae, or breasts, secrete the milk and are two, large, hemispherical eminences situated on the lateral aspect of the chest, between the third and the sixth or seventh ribs, and between the sternum and the axilla (Fig. i). They 4 BREAST FEEDING. vary in size in different women and in the same woman, depending upon the physiologic activity of the uterus. The left breast is a trifle larger than the right. Before puberty they are insignificant, but increase in size as the generative organs develop. During pregnancy they enlarge and re- main so during* active lactation. The shape of the organ, as a rule, changes from a circular convex outline to a large, pendent mass. The nipple is a small, conical eminence placed just below the centre of the gland. The skin cover- ing the nipple and surrounding its base contains pigment, the amount and character of which depend upon the type of woman (blonde or brunette) and upon the activity of the gland. This pigment, called the areola, in the virgin is of a delicate rose tint. As pregnancy advances it becomes darker and spreads over a larger area, extending from the base of the nipple over the surface of the gland (secondary areola). In brunettes of pronounced type this secondary pig- mentation may be black. The skin covering the surface of the gland, besides being pigmented, also becomes striated much after the fashion of the skin of the abdomen. The nipple contains involuntary muscle-fibre, which, under sex- .ual excitement or the irritation produced by the infant's lips, contracts, causing the nipple to become erect. The nipple is perforated at its tip by the numerous orifices of the galacto- phorous ducts. Around the base of the nipple are found several sebaceous glands which serve to keep the skin in a pliable condition (glands of Montgomery). Numerous nerves find their endings in the cutaneous papillae of the nipple. Histologically the mammae are tubo-racemose glands (Piersol), containing fifteen to twenty lobes, which are MAMMARY GLAND. 5 separated and supported by masses of adipose tissue and by fibrous septa, which divide the lobes into lobules and these again into acini. These acini are lined by a low columnar epithelium, which varies in character, depending- upon the functional activity of the gland. These cells, resting upon a membrana propria, rapidly multiply and oil-droplets appear within them. These gradually increase in amount and coalesce until they occupy almost the entire content of the cell, crowding the nucleus and the protoplasm to one side. As the amount of oil increases the cells become distended and finally rupture, the oil being discharged into the lumen of the acinus, where, becoming mixed with an albuminous secretion and epithelial debris, constitutes the secretion of the gland, or milk. The cells near the centre of the acinus undergo fatty degeneration and are discharged for a few days following the establishment of lactation. These cells constitute the large colostrum corpuscles (Fig. 6) which persist for a week or ten days, and the first secretion is known as colostrum. The milk is carried off by means of ducts which extend from each acinus. These are called lactiferous ducts, and they unite with those from other acini and form the lobular duct which joins with those from other lobules, and finally this union terminates into the lobar duct or galactophorous duct, which passes as a single tube, ununited, from each lobe and opens by a separate outlet into the apex of the nipple. Just before it reaches the apex of the nipple, each duct dilates into a pouch or ampulla. These ampullae act as reservoirs for the milk. The ducts are lined with low columnar epithelium which rests upon a membrana propria, and each duct possesses a fibrous coat which contains elastic tissue and some unstriped muscle-fibre. As the ducts approach the surface of the 6 BREAST FEEDING. nipple the lining- epithelium becomes stratified and con- tinuous with that of the epidermis. The internal mammary, the thoracic branches of the axillary, and the intercostal arteries supply these organs with blood, and their branches penetrate the entire gland, even surrounding the acini in a capillary network. The venous blood from the interior of the gland is carried by venules to the circulus venosus surrounding the nipple. Thence large branches carry the blood to the circumference, terminating in the axillary and the internal mammary veins. The lymphatics empty for the most part into the anterior axillary glands and some few into the anterior mediastinal glands. During lactation the vascular supply to the mam- mae is increased and the veins become decidedly prominent. The anterior and lateral nerves of the thorax supply the mammae with innervation. HYGIENE OF THE BREAST AND NIPPLES. After each nursing, the nipples are gently cleansed with a piece of absorbent cotton moistened with boric acid solu- tion and gently dried. The infant's mouth is cleansed in a similar manner with a mild antiseptic alkaline solution. Be- fore nursing the nipples should also be cleansed. No milk should be permitted to dry or to sour upon the nipple, as digestive disturbances are likely to follow as well as mam- mary infection. Excoriations and fissures of the nipples may cause excruciating pain. They can often be prevented by bathing the parts during the entire period of gestation with a solution of alum in alcohol, thereby rendering the epithelium tough. When present, temporary suspension of breast feeding may become necessary for a few days, or the artificial nipple may be employed (Fig. 2). Experience HYGIENE OF BREAST AND NIPPLES. 7 with this instrument is not always satisfactory. It may annoy the mother, and the infant may not take to it kindly. A better method is to withdraw the milk by manual manipu- lation, and to feed it to the baby through a bottle or by means of a spoon. The application of some sedative dusting powder, as equal parts of bismuth and boric acid, is often Fig. 2. Artificial nipple or nipple-shield. serviceable. Before nursing, the powder should be care- fully wiped away. Indolent fissures are stimulated to heal- ing by touching them with a stick of silver nitrate. Com- presses wet with a 10 per cent, solution of.argyrol or ichthyol are also useful. Better than all these is a paste made from equal parts of bismuth subnitrate and castor oil. An ointment of calendula, prepared by homeopathic phar- macies, applied to the sore places, has often yielded good results. 8 BREAST FEEDING. ECZEMA OF NIPPLES DURING PUERPERIUM. Eczema of the nipples and of the neighboring integu- ment is a troublesome complication of the puerperium and may seriously interfere with nursing. Water should be kept away from the parts. The condition usually yields to the combination of castor oil and bismuth. If there be present indurated fissures, salicylic acid gr. x and lanolin 3j will usually cause them to heal. DEPRESSED NIPPLES. The nipples may be depressed below the surface of the gland, or they may be inverted or even absent. The de- pression may disappear under the stimulus of sexual excite- ment or of the infant's lips. Depressed or inverted nipples may be a serious handicap to maternal feeding. For this reason throughout the puerperium, the mother should be taught to daily draw the nipple out with her fingers or with the breast pump. It is surprising, on the other hand, to note, in some cases wherein the galactophorous ducts open directly upon the surface of the glands with practically no nipple, with what ease the infant seizes the breast and maternal feeding is successfully accomplished. CAKING AND ABSCESS OF THE BREAST. If the milk enters the breast too rapidly, or if it fails to be withdrawn, by proper nursing, it collects in the lac- tiferous tubules and in the acini of the mammary gland, causing them to distend. This is known as caking. The breast becomes exceedingly painful and, especially in the dependent portions, are felt the hard and tender lobes of the gland. Caking is best prevented by regular and steady nursing. If in spite of this an excess of milk is secreted, CAKING AND ABSCESS OF BREAST. 9 the breast pump (Fig. 3) may be used to remove the excess, and the breasts are gently massaged with warm oil several times a day, care being exercised to make the stroke in the direction of the ducts, from the base toward the nipple (Fig. 4, A andB). Abscess of the breast is a preventable as well as a lament- able accident. It results directly from mammary infection. Infection may be carried into the lobules of the glands through cracks in the nipple, through eczematous excoria- Fig. 3- Breast-pump. (Physician's Supply Co., of Phila.) tions, by the mouth of the infant, and by the decomposition of milk left to dry upon an imperfect nipple. The nurse or physician may carry infection to the breast by undue manipulation. Symptoms. Abscess may appear at any time during the nursing period. It is more common during the earlier weeks. There may be few if any constitutional symptoms. On the other hand, the general reaction may be severe, the patient complaining of chilly sensations or suffering a real rigor. The temperature rises to 101 F. or to 103 F. (rarely higher), and the pulse is proportionately increased. Ano- rexia and nausea, as well as headache and neuromuscular pains occur. The tongue is coated and the bowels become constipated. 10 BREAST FEEDING. Locally there appears a small or a large, circumscribed spot of induration which is tender and which varies in size from a marble to a walnut. More than one such area may thus appear. The overlying skin becomes bright red. It is .not at first adherent, but later becomes so. The color dark- ens, the area softens, often increasing to an enormous size, spreading not only superficially, but deeper into the substance of the gland. The skin is hot, the pain intense, and fluctua- tion is made out with ease or difficulty, depending upon the depth of the infection. Spontaneous rupture may occur with a disappearance of general symptoms, to be followed by slow healing and perhaps one or more remaining sinuses, which may or may not intercommunicate. These sinuses may persist for months. Treatment. Aside from incision and drainage, as soon as fluctuation manifests itself, the effect of mammary abscess upon the future ability of the mother to nurse her babe must be seriously considered. At first thought it would appear that a mammary gland, once infected, is lost to the infant forever. While true in most cases, one must discriminate and determine each case individually. The size and the posi- tion of the abscess, and also 1 whether or not pus is being secreted at the nipple, largely influence the decision. This may be recognized by the naked eye ; or bacteria, pus cells, and perhaps blood may be discovered by the microscope. If the other breast be healthy it may yield sufficient milk. At least partial breast feeding should be employed. If on the other hand, as in a case in point, in which the abscess was as large as a marble and in which no pus appeared at the nipple by reason of the fact that the galactophorous duct leading to it, between it and the abscess, was obliterated by an adhesive inflammation, the infant will not receive any CAKING AND ABSCESS OF BREAST. A 11 Fig. 4. Massaging breast. The motion starts at the base of the organ (A) and, by a circular or spinning movement of the hands, ends at the nipple (B). 12 BREAST FEEDING. infected material, there is no reason why, after incision and drainage, nursing should not go on, provided the nipple can be protected (Fig. 5). Incision into a mammary abscess should be made in a manner radiating from the nipple, and not encircling it, in order to prevent severing of the healthy ducts. Internally the mother should receive a gentle laxative, as cascara, or a small dose of castor oil. An enema may Fig- 5- Abscesses not interfering with breast feeding. suffice to open the bowels. The diet is limited to fluids, and in order to combat toxemia a daily enema of normal salt solution (to be retained) or continuous rectal proctoclysis are valuable adjuncts. Head and body pains and fever may be relieved by small doses of aspirin, codein and extract of aconite root. If the mother feels too ill to nurse the infant, it may be temporarily withdrawn from; the breasts for from twenty-four to seventy-two hours. In the mean time it should be placed upon a weak mixture of condensed milk and water. The healthy breast should be massaged and the pump applied to prevent caking. When healing COLOSTRUM. 13 is slow search should be made in the mother for tuber- culosis or for some depressing diathesis. Change of air, good food, Basham's mixture or iron citrate, with other tonics, hypodermically, should be used. Autogenous or stock vaccines should also be employed as adjuvants. B Fig. 6. Microphotograph of colostrum. A, the large nucleated and granular colostrum corpuscles ; B, oil globules. COLOSTRUM. About the third day of the puerperium milk makes its appearance in the mother's breast. This first lacteal secre- tion is not really milk, but consists largely of water and is comparatively rich in protein. It is known as colostrum and microscopically contains large, granular, corpuscular bodies, about five times the size of milk-corpuscles. They are known as colostnwi corpuscles, and probably represent desquamated epithelial cells which line the acini of the mam- 14 BREAST FEEDING. mary gland (Fig. 6). Colostrum also contains globules of oil. Its composition is variable, as indicated by the table of Harrington, quoted by Rotch : Fat I 1.40 II 0.68 III 2.40 IV 5-73 V 4.40 Milk-sugar and pro- teins 9-44 H-53 11.15 10.69 11.27 Ash 0.17 0.31 0.25 0.16 0.21 Total solids II.OI 12.52 13.80 16.58 15-88 Water 88.99 87.48 86.20 83.42 84.12 IOO.OO IOO.OO IOO.OO IOO.OO IOO.OO As indicated, the quantity of fat is comparatively low; while the percentages of milk-sugar and of proteins are high and uniform. The function of colostrum is but little under- stood. It probably does not contribute to the nutrition of the infant. In fact, the reverse is true, for during the first week of life the infant's weight is diminished. Its effect is probably that of a laxative, ridding the bowel of meco- nium. Colostrum disappears in about one week to ten days, and is replaced by true milk. CHEMISTRY AND PHYSICS OF HUMAN MILK. Human milk, as well as cows' milk, is an emulsion. It is an opaque fluid, bluish white in appearance, and has a sweet, palatable taste. Its reaction is alkaline or amphoteric when freshly drawn. The specific gravity varies between 1029 and 1030. Under the microscope the milk is seen to consist of a fluid portion and of corpuscular elements (Fig. 7, A). These corpuscles are minute, evenly divided, fat globules, which are held in suspension. When milk is acted upon by rennin and slightly warmed it coagulates. The coagu- CHEMISTRY AND PHYSICS OF HUMAN MILK. 15 O c -- - - ~>v O< c Z " P ri'o ' - K^-x P . . -A Fig. 7. Microphotograph of human and of cows' milk. I. Normal human milk showing uniformity in size of fat globules (A). The apparent smallness in the size of those in the centre is due to the focusing. Note the absence of epithelial cells and leucocytes. The presence of the latter would indicate in- flammation of the breast, probably beginning abscess. II. Cows' milk showing the comparative irregularity in the size (larger) and shape of the fat globules (A) with reference to human milk. Also note the absence of epithelial cells and leucocytes, showing the teat to be free of inflammation. !6 BREAST FEEDING. kirn consists of calcium paracasein (casein) or principal protein constituent of the milk, in the meshes of which are contained the fat globules. In the normal state this protein exists as calcium casein (caseinogen). From the coagulum exudes a clear, watery fluid called whey. Whey contains the soluble and non-coagulable proteins, 1 lact- albumin and lactoglobulin. The former is coagulated by heat; the latter is not. Whey also contains the salts and sugar of milk in solution and a small amount of fat. Two- thirds of the protein in human milk are lactalbumin and lactoglobulin. In cows' milk but one-fourth of the total protein is composed of these constituents. The chemical composition of human 1 milk varies. It varies in different women and in the same woman at differ- ent periods of the same nursing and at different times throughout the entire period of lactation. The composition varies as to the number of daily feedings and the length of each feeding. It also depends upon the character and quantity of the mother's food, her environment, tempera- ment, the care she has received during her accouchement, and the amount of physical exercise. The nearer to nature a woman lives, the more normal iinll be her milk-supply. The percentage of fat is the most variable constituent. It is the lightest element in milk, and, if the milk be per- mitted to stand, it rises to the surface and constitutes cream. Cream does not consist entirely of fat, but contains the other chemical substances found in milk. According to Holt, the ratio of the fat to the cream is as 3 is to 5. The fats of milk are composed of stearin, olein, and palmitin, and are in fixed combinations, the amount of volatile fatty acids be- ing decidedly less than in cows' milk. 1 Non-coagulable with reference to renin. PLATE I Meconium. BACTERIOLOGY OF HUMAN MILK. 17 The percentage of carbohydrates (milk-sugar) rises rapidly after the first few days of lactation and gradually increases to the end. The sugar of milk, lactose, is a white, crystalline substance obtained by the evaporation of whey. The proteins are plentiful in the beginning, but gradu- ally diminish as lactation draws toward the close. The same is true of the salts, which consist principally of the phosphates of sodium, potassium, calcium, and magnesium, and the chlorids of potassium and sodium and a trace of organic iron. The average composition of human milk is represented by the following table: ANALYSIS OF HUMAN MILK. Proteins 1.5 to 2% Fat 3-5 to 4% Sugar 6 to 7% Ash . 0.2 to i% Total solids 1 1.2 to 14% Water . . 88.8 to 86% 100% 100% Reaction Alkaline or amphoteric. Specific gravity 1029 to 1030 BACTERIOLOGY OF HUMAN MILK. Human milk is practically sterile. The only organisms which are found under healthy conditions are those which normally, or rather for the time being, as non-pathogenic germs, inhabit thd skin. These represent the Staphylo- cocci epidermidis albus, and Pyogenes albums, citreus and aureus. In the presence of disease of the gland all vari- eties of pathogenic bacteria have been found. The typhoid bacillus and the pneumococcus have been recovered in cases 18 BREAST FEEDING. of typhoid fever and of pneumonia, as well as the tubercle bacillus in the presence of local tubercular disease. Roger and Carrier report the presence of tubercle bacilli in breast milk in a patient who died of pulmonary and laryngeal tuberculosis. ANALYSIS OF HUMAN MILK. Sample. A sample of milk for analysis is obtained by a breast pump, or, better, by stripping the ducts gently and Fig. 8. Stripping of breast for sample by running the thumb and index-finger from the periphery to the base of the nipple, where pres- sure is exerted. The stream thus produced is caught in a glass until a sufficient amount (about an ounce) is obtained for analysis. receiving the milk into a glass (Fig. 8). The first milk may be discarded. The sample should consist of portions taken throughout the day at different times of the nursing period, and should be secured from both breasts. This gives an average of the milk received by the baby. Breast pumps are of several kinds, the one pictured in the cut (Fig. 3) being the most familiar, simple in construction, and easily cleansed. As a rule, however, the use of these ANALYSIS OF HUM AX MILK. 19 instruments is tedious and unsatisfactory. The pump and the bottle which is to receive the sample should be sterilized. The color of human milk is bluish white in appearance. It has no characteristic odor. A B Fig. 9. Lactometer. (Physician's Supply Co., of Phila.) Reaction. This is tested by litmus-paper. Specific Gravity. This is determined by an ordinary urinometer or a special lactometer (Fig. 9). The milk is put into a small cylinder, A, and the instrument, B, is lowered into the former with a slight spin to avoid sticking to the 20 BREAST FEEDING. sides. When it has come to rest the graduation on the neck is read. The temperature of the milk should be 60 F. The specific gravity furnishes crude but valuable compara- tive data for clinical purposes. Thus the fat, being the lightest constituent of milk, when in excess would cause the specific gravity to be low, provided the other solid con- stituents were normal. Conversely, under the same condi- tions a high specific gravity would indicate that the per- centage of fat must be low. If the percentage of fat is normal and the specific gravity is high, this would indicate that the remaining solids were high. The reverse means that there is a deficiency of the other solids. Therefore, too, if the specific gravity be normal and the fats are high, the other solids are high. If the fat be low and the specific gravity is normal, then the other solids are low. TABLE SHOWING RELATION OF KNOWN PERCENTAGE OF FAT AND SPECIFIC GRAVITY TO REMAINING SOLIDS. High fat and normal specific gravity = High remaining solids. Low fat and normal specific gravity = Low remaining solids. High fat and high specific gravity = High remaining solids. Low fat and high specific gravity = Low remaining solids. High fat and low specific gravity = Low remaining solids. Low fat and low specific gravity = Low remaining solids. Daily Quantity Secreted. This is with difficulty deter- mined, and can only be estimated by weighing a baby which is gaining steadily, before and after each feeding through- out the entire twenty-four hours. From several such daily assays an average can be struck. The following table from Holt 1 gives approximate quantities which may serve as a guide : 1 Holt, "Diseases of Infancy and Childhood," page 130, 6th edition. ANALYSIS OF HUMAN MILK. 21 Ounces. Grams. At the end of the first week 10 to 16 300 to 500 During second week 13 to 18 400 to 550 During third week 14 to 24 430 to 720 During fourth week 16 to 26 500 to 800 From the fifth to thirteenth week 20 to 34 600 to 1030 From the fourth to sixth month 24 to 38 720 to 1150 From the sixth to the ninth month 30 to 40 900 to 1220 Determination of Fat. The simplest method is by the cream gauge devised by Holt (Fig. 10). The only objec- tion to its use is that it requires twenty-four hours. The instrument is graduated into 100 parts and is fitted with a ground-glass stopper. It is filled to the zero mark with milk, and is allowed to stand for twenty-four hours at room temperature. The volume occupied by the cream is then read off. The percentage of fat to the cream is as 3 is to 5. This mathematical formula is arbitrary. The results, how- ever, are useful for practical purposes, as it is possible to learn whether an increase or a diminution has taken place, provided a record of each examination is kept. A simple and accurate method is the test of Babcock. Place in the special percentage centrifuge tube (Fig. n), by means of a graduated pipette (Fig. 12), 17.6 c.c. of milk. Clean the pipette and add 17.6 c.c. of strong sulphuric acid, holding the percentage tube in an inclined position. The acid sinks to the bottom. Mix the two liquids by means of a rotary motion. The mixture becomes dark brown or black, and hot. The sulphuric acid dissolves the calcium paracasein, and the heat generated is sufficient to liquefy the fat. Place the percentage tube and contents in a centri- fuge and rotate 1200 times a minute for six minutes. Now, by means of the pipette, run enough hot water into the per- centage tube to bring the level of the fluid up to the highest graduation. Rotate again in the centrifuge for two minutes. 22 BREAST FEEDING. Note on the graduated neck the volume occupied by the fat. Each unit division indicates one unit per cent. Fig. ii. Babcock's centrifuge Fig. 10. Creamometer for estimating tube for estimating fat. (Ar- percentage of fat. (Holt.) thur H. Thomas Co.) Readings can be made to one-fourth of I per cent. (0.25 per cent). Determination of Proteins. If the specific gravity and the percentages of fat, sugar, and salts be known, the per- ANALYSIS OF HUMAN MILK. 23 centage of proteins may be calculated from the percentage of total solids. The total solids equal the sum of one- Fig. 12. Babcock's pipette for estimating fat. Fig. 13. Eschbach's albuminometer used in protein test. (Arthur H. Thomas Co.) fourth of the last two figures of the specific gravity, plus six-fifths of the percentage of fat, plus 0.14. This may be expressed as follows: 24 BREAST FEEDING. Last two figures of S. Gr. (% of fat X 6) Total solids = + -+.14 4 5 This result minus the sum of the percentages of fat, sugar, and salts equals the percentage of proteins. Example. The specific gravity is 1030. The percentage of fat, sugar, and salts is, respectively, 4, 7, and 0.2. 30 (4 X 6) Total solids = + - + .14= 12.44% 4 5 Percentage of proteins = 12.44% (4% + 7% + 0.2%) = 12.44% 11.2% = 1.24%. A more accurate method is that described by Kjeldahl, but is too complicated for practical purposes. The following method provides accurate comparative data. The solution required consists of Phosphotungstic acid, 25 Gm. Distilled water, 125 c.c. After thorough solution is obtained, add Hydrochloric acid, concentrated, 25 c.c. Distilled water, 100 c.c. The solution if kept in a blue bottle will remain stable for a long while. Human milk is diluted I to 10, or, if the protein is thought to be very low, I to 5. The diluted milk is poured into an Esbach tube such as is used for the estima- tion of albumin in urine (Fig. 13) to the mark U. The solution is added to the mark R; the tube corked and slowly inverted 12 times. It is allowed to remain upright for twenty-four hours, and the percentage of protein is read at the level of the precipitate. Estimation of Lactose. The calcium casein is precipi- tated by acidulating the milk with acetic acid, and the INDICATIONS FOR MILK ANALYSES. 25 lactalbumin by boiling the acidulated mixture. Filter. Wash the precipitate with a measured quantity of distilled water, which is added to the nitrate. When cool, place in a burette and titrate with Fehling's solution, as when examining urine. The reduction factor for lactose differs from that of glucose, 10 c.c. of Fehling's solution being equivalent to 0.06 Gm. of lactose, instead of 0.05 Gm. of glucose. Microscopic Appearance. Human milk contains great numbers of small fat globules of uniform size floating in the watery portion of the milk (Fig. 7, I). Thus, it is seen to be a perfect emulsion. No other cellular elements aside from an occasional epithelial cell or a leucocyte are seen. The last two appearing in excess indicate an abnor- mality, usually inflammation or abscess. INDICATIONS FOR AND INTERPRETATION OF MILK ANALYSES. For clinical purposes it is proper to inquire "When do conditions arise that demand or which would be benefited by a careful analysis of the milk which the infant is re- ceiving, and boiw are these results to be interpreted?" Unless there be a distinct indication, the interest attached to such an examination is purely academic, and serves no practical purpose. On the other hand, if the infant is not thriving, or if there be evidences of indigestion and colic, or if the mother doubts the good quality of her milk, analyses are of use. "If the analysis shows the milk to be poor in all its constituents, does this mean that it is an unfit food for the particular baby receiving it?" Not necessarily. The best guide is the condition of the baby itself, and not infrequently is it seen that an infant will gain steadily on 26 BREAST FEEDING. what appears to be a weak milk, while another will not thrive on a rich one. If, however, there exists a combina- tion of an undernourished babe together with a poor milk, the indication is clear to improve the quality of the mother's milk or to try mixed feeding, or, as a last resort, artificial feeding alone. The value of a milk analysis, in determining which of the food elements of the breast milk are responsible for the symptoms of indigestion, is incalculable, and often is the means of saving to the infant the maternal milk. The in- formation thus obtained frequently permits the physician to speedily correct the trouble through treatment of the mother. Psychic influences exert a tremendous effect upon the secretion of breast milk, and if a milk analysis will con- vince a doubting, fearful, though willing woman, that her milk is of good quality, the time consumed and the expense will have been well worth while. ADVANTAGES OF BREAST FEEDING. In his daily contact with his patients the general practi- tioner meets no question with more frequency than that deal- ing with the nutrition of the infants under his charge. His responsibility has been indicated already with reference to the necessity of attempting the conservation of the human milk-supply. The question may very properly be asked, "What are the advantages of breast feeding?" They in- volve both the mother and the infant, and if the physician has the facts ready at hand, many converts to the ranks of those who suckle their young, and thereby serve as a potent instrument in lowering infant mortality, will be gained by him. ADVANTAGES OF BREAST FEEDING. 27 Gastrointestinal and nutritional diseases are responsible for 55.5 per cent, of all the deaths which occur in infants during the -first year (Holt}. Practically all of these are artificially fed. This should be sufficient argument to en- courage both physician and mother to conserve the milk- supply, and should at once take the right from both or either to arbitrarily decide whether the infant should re- ceive the breast or not. It makes the obligation mandatory. Too frequently the breast is sacrificed because, without investigation, carelessly and heedlessly the physician or the mother, or the former yielding to the wishes of the latter, decides that the milk is unfit food for the baby. A woman may declare for a whim that she does not want to nurse her infant; that it will interfere with her social duties; that it is not aesthetic; that Doctor So-and-So knows how to feed babies artificially, and that she will put her infant under his care; that she has a friend who reared a baby on a popular patented food, and that she will do the same. These and many others are the reasons for withdrawing the breast. Neither physician nor layman possesses an inherent right to destroy a helpless babe's means of sustenance. The obligation of marriage and motherhood carries with it to the healthy woman the obligation of maternal nursing for nine months at least. Digestive disturbances occur with less frequency and with less severity in the breast-fed. They are usually of no consequence, and seldom are associated with nutritional disturbance. Breast milk possesses antirachitic and anti- scorbutic properties not found in any other food. In human milk there probably exists certain substances which confer upon the infant a natural immunity against the acute infectious diseases, as these occur with extreme rarity dur- 28 BREAST FEEDING. ing the first year, especially in the breast-fed. On the other hand, their incidence in this class of patients is marked by less severe symptoms and recovery is the rule. In the breast-fed dentition is rarely troublesome. Breast babies gain regularly in weight, sleep well, and are happy. The so-called dreaded second summer does not exist for the naturally fed infant, and danger of milk infection is absent. The food is always practically sterile, of the proper temperature, and requires no preparation. From the mother's standpoint the knowledge of having a healthy child should be sufficient compensation for any material inconvenience which she fears she might have to endure. Some women honestly think they cannot nurse their infants or that their food is insufficient, consequently they discontinue nursing or use other foods in conjunction with it. It is difficult to convince these women as to the fallacy in their idea, and they go from one physician to another until they find one who> places the baby upon "modified" milk. This usually disagrees, and when the infant has passed the gamut of all the patent foods and summer diarrhea it is returned to the specialist, dyspeptic and marantic, to be remodeled. If feeding be conducted with system and regularity, the nursing mother will not be prevented from attending to her other duties. Between nursings she may rest, and go out, and after three months the baby may be trained to sleep from 8 P.M. until 6 A.M. The mother should not, on the other hand, be permitted to deceive herself with the idea that bottle feeding is easier than breast feeding. Aside from the uncertainty and dangers associated therewith, the former requires considerably more time on account of the necessity of preparation. This, taken in connection with PLATE II Normal breast stool. INDICATIONS OF UNSUCCESSFUL FEEDING. 29 the inconvenience caused by sickness, places artificial feed- ing at a decided disadvantage. INDICATIONS OF SUCCESSFUL FEEDING. A baby thriving on the breast up to the first six months should gain from 5 to 7 ounces a week. It may be a little less or a little more. After this, while progressive, the weekly increase is less. The normal stool of a breast-fed infant is yellow, smooth, mushy, and free of particles and of mucus (Plate II). It has a pleasant, slightly acid odor, and is weakly acid in reaction. The bowels move from one to four times a day. Vomiting does not occur. The infant may regurgitate a little food just after feeding or when unduly handled. Unless viciously trained, it is happy, contented, does not cry, sleeps peacefully between feedings, and awakens regularly at feeding time. INDICATIONS OF UNSUCCESSFUL FEEDING. If the infant does not thrive, if its gain in weight is small or unsteady, or it does not gain at all; if it vomits, has indigestion, is fretful and sleeps poorly, the cause will rarely lie in the mother's milk. More commonly there will be found some error in training, or the infant has received other food in addition, or is suffering from some organic disease of the gastrointestinal canal. Very commonly breast babies may be constipated, and the mothers are in the habit of daily using an injection or a suppository. Not only is this unnecessary, but in many instances is directly respon- sible for the inauguration and continuance of constipation. The mother should be taught to allow the infant to go thirty-six hours before resorting to laxatives, suppositories, or injections. At the end of this time, and usually before, 30 BREAST FEEDING. the baby will have had an evacuation. Before the breast is withdrawn as the cause of trouble, every other possible etiologic factor must be investigated. MOST COMMON CAUSES OF FAILURE OF MILK-SUPPLY AND HOW TO PREVENT THEM. From the day that she places herself under her physi- cian's care the prospective mother must not only be taught the importance of breast feeding, but more forcibly still must she have impressed upon her her ability to accomplish the act. Psychic phenomena, doubt and fear, especially, that the milk-supply is insufficient in quality oM - 6 ' 8 ' I0 , Two. P.M. 12, 2, 4, 6, 8 2 to 4 mons. 2^ hours A>M ' 6 ' 8>3 ' " One. P.M. 1.30, 4, 6.30, 9 4 to 8 mons. 3 hours ^ 9 ^ ^ ^ None. 8 to 10 mons. 3^ hours A>M> 7> IO-3 None. 10 to 12 mons. 4 hours A>M- 7 ' ll None. P.M. 3, 7, 10 A healthy infant, after receiving its nourishment, passes into a sound sleep. After the child has had its meal it should not be carried around nor shaken, but quietly laid in its crib. Otherwise regnrgitation of food will occur. Under special conditions the feeding interval may, even during the very early periods of life, be lengthened to three or to four hours. These will be pointed out as we proceed. PLATE V ' Stool of dyspepsia. Occurs in both the breast-fed and bottle-fed baby. In the former its significance can often be disregarded, if the weight remains unimpaired, or the mother's diet may be regulated as in Plate IV. In the bottle-fed, institute a hunger period for twenty-four hours. Then reduce the fat and the sugar in the formula, and at the same time administer the protein mechanically and chemically modified. (See text.) CONTRAINDICATIONS TO MATERNAL FEEDING. 41 CONTRAINDICATIONS TO MATERNAL FEEDING. A woman's milk may be insufficient in quantity and of poor quality. The quality may be good, but the quantity may be small. Any or all of these conditions may con- stitute a contraindication against maternal feeding if they cannot be corrected or if they interfere with the infant's nutrition. Painful fissures may cause a temporary suspen- sion of nursing. Abscesses of the breast usually contraindi- cate breast feeding, as do painful and septic conditions of the infant's mouth. Mothers who suffer from, epilepsy, nervous exhaustion, chorea, idiocy, profound anemia, tuber- culosis, the acute infectious diseases, syphilis contracted after delivery, and profuse hemorrhage, should not suckle their young. A woman who has become pregnant while nursing her infant should cease doing so, as the strain of supplying nourishment to both fetus and child, besides her- self, is too great. Menstruation, also, is regarded by some as a contraindication to breast feeding. This is altogether a question of the individual, and, if the child's nutrition and digestion are not disturbed, menstruation, per se, should not prevent the infant from nursing. A woman suffering from puerperal eclampsia or Bright's disease should not nurse her child. Malignant disease contraindicates maternal feeding. The breast should be withdrawn, temporarily, from a nursling suffering from acute alimentary intoxica- tion. The physician should hesitate long before he advises the withdrawal of the breast. Each case is a law unto< itself and must be decided on its merits. Tuberculosis and chronic valvular disease, with broken compensation, prevent nursing. An infant born of a syphilitic mother should be nursed by that mother even if it shows no external evidences of 42 BREAST FEEDING. syphilis. It cannot be infected, not on account of immunity, but because the child probably has latent syphilis, as would be shown by a positive Wassermann reaction (Pro- f eta's law). So, too, a woman apparently free of syphilis should nurse her babe if it be markedly infected. She will not become infected (Golles's law). The reason of this is because she, too, has latent syphilis, as shown by a posi- tive Wassermann reaction. Thus a scientific explanation for both these laws is available. In the first instance, if she contracts syphilis after the birth of her babe, nursing must necessarily be discontinued. The susceptibility of the infant under such circumstances is apparent. HYGIENE OF THE NURSING MOTHER. Many women who object to nursing do so from the belief that they thereby surrender themselves for a period of twelve months to a lonely existence, devoid of all pleas- ure and social intercourse. This is an erroneous idea, and it becomes the physician's duty to make plain to the mother her obligation to her child. From the day of conception, or from the time she comes under her medical advisor's care, every prospective mother should have inculcated within her a desire to nurse her infant. Mother-love, often absent during the first period of gestation, gradually develops in most women as the day of labor draws near. To this the physician should appeal, and make known to his patient the dangers and vicissitudes of artificial feeding even at its best. Many women resort to bottle feeding through igno- rance, or through the enticing advertisements to; be found in medical journals and upon the labels of proprietary foods. These make infant feeding an easy matter, setting at naught HYGIENE OF THE NURSING MOTHER. 43 the work of some of the best minds of the profession; and the eager mother, in her zeal to raise her infant with the least care, discovers her mistake when it is too late, when her child, with a fatal pneumonia, or a mortal attack of summer diarrhea, or other acute infectious disease, suc- cumbs because it did not have the vital force to resist the disease because it was not breast-fed! The physician should, therefore, preach the gospel of maternal nursing day in and day out. By doing so, he not only fulfills his duty to his patient, and stands as the defender of helpless infancy, but renders invaluable service to his State. By doing less he fails in the fulfillment of his mission. Between the nursing periods the mother should spend her leisure in useful and healthful recreation. She should indulge regularly in gentle outdoor exercise. Reading and participation in any desirable pastime should be en- couraged. Rest is essential to her well-being, and mental excitement, fear, and worry are to be avoided. She should partake freely of easily digestible and nutritious foods, and, if accustomed to a glass of beer or light wine with her mid- day meal, this should be permitted. Intemperance, how- ever, in all things must be interdicted. Daily bathing and a perfect digestion are conducive to a sufficient and nutri- tious supply of milk. Care should be exercised in administering drugs to the nursing woman. Certain medicines are eliminated in the milk, and exert their physiologic effect upon the infant. Therefore such drugs as the saline purgatives, morphin, colchicum, belladonna, arsenic, antimony, mercury, and the iodids should be administered cautiously, if at all, to the lactating mother. The care of the nipple, as indicated else- where, should also engage the attention of the physician. 44 BREAST FEEDING. BREAST FEEDING DURING ILLNESS OF MOTHER OR CHILD. Whether or not breast feeding is to be continued under these circumstances is largely a problem that must be de- cided upon the merits of the individual case. The attitude of the physician, however, had best be conservative in most instances. Undue haste by needlessly sacrificing the milk- supply and hazarding the health and life of the infant may lead to disaster. Reference is here made especially to the beginning of an acute illness in the mother, in which the milk, as a rule, should not be withdrawn until the diagnosis has been made, or if an acute infectious disease be reason- ably anticipated. The child's safety then demands imme- diate removal. The maternal illness may last but a day or two, and keen disappointment will follow hurried advice to feed the baby otherwise than by the breast. If it be advis- able for instance, if a surgical operation of minor impor- tance must be performed to withhold maternal milk for twenty-four or forty-eight hours, then the infant may be placed upon a weak milk mixture or condensed milk. After a day or two it is an easy matter to rehabilitate the flow by the administration of fluids, cornmeal soup, and Maltropon. It is especially in cases of this type, and in the harmless digestive disturbances of the breast-fed, that the physician can rise above the ordinary level by recognizing and meet- ing his opportunity for conserving the maternal milk- supply, while his colleagues of less discernment will thoughtlessly sacrifice it. Illness in the infant is rarely a cause for stopping the breast. Septic conditions of the mouth and throat, or an acute infectious disease may be a good cause to remove the WET-NURSING. 45 infant from the breast, but not from the breast milk. It should be pumped out and fed by the bottle or dropper. WET-NURSING. Xext to maternal feeding, the milk of a healthy wet- nurse is undoubtedly the safest food for an infant under i year of age. The selection of a wet-nurse should be left to the medical attendant, who must subject her to a rigid physical examination before she is accepted. Her family history should be carefully scrutinized and her past and present medical history examined. A woman, the off- spring of tuberculous, syphilitic, or cancerous parents, must be rejected. Her health should be perfect. She should have sound teeth, normal mucous membranes, good diges- tion, healthy lungs, and a sound heart and normal kidneys. Her skin must be free of all suspicious rashes, and her venereal and child-bearing history carefully examined. A Wassermann test must be performed on every applicant for the position of wet-nurse. If she has frequently aborted, or has given birth to many stillborn children, she should be rejected. Her milk should be analyzed 'in order to estab- lish its nutrient qualities. This is not always necessary, as the health of her own infant will usually give sufficient in- formation as to the quality of her milk. Her breasts should be normal and well developed, free from rhagades, ulcers, and malignant disease. A nurse who is suffering from any form of infectious or suppurative disease, however slight it may be, should not be engaged. The same applies to one who is irritable, nervous, epileptic, or choreic. She should have a just appreciation of her duty and a sincere love for chil- dren. She need not be especially intelligent. Probably the 46 BREAST FEEDING. best test for a wet-nurse is the condition of her own child, which should be healthy and thriving. If possible, other things being equal, a multipara should be given preference, although a primipara need not be rejected for this fact alone. As a rule, however, young women of 17 or 18 make poor wet-nurses. In the family who has engaged her, a wet-nurse oc- cupies a peculiar position. If a good nurse, her services are often invaluable, a fact which should not be too strongly impressed upon her or she may turn tyrant. She should be treated with kindness and courtesy, be well-housed, well- fed and well-clothed, in addition to the ordinary compensa- tion which she receives. The same care should be accorded her as to a nursing mother, and she should be made to adopt the same hygienic and prophylactic measures which pertain to the mother, taking sufficient rest, outdoor exercise, and diversion. Should her milk disagree with the infant, either in its digestibility or in its capacity to' supply sufficient nourishment, as evidenced by the infant's weight and strength, she should be discharged and another nurse sub- stituted. A syphilitic baby should not be permitted to nurse a healthy wet-nurse. Care should be exercised that she does not slight her charge by giving all her milk to her own infant. Indications. Wet-nursing is urgently useful in the care of premature infants, in cases of very weak infants with whom no modification of cows' milk will agree, and who are threatened with, or are already suffering from, inanition. Should the mother die suddenly the outlook for a very young though healthy infant becomes brighter, as the result of a few months of wet-nursing. WEANING. 47 WEANING. By weaning is meant the withdrawal of breast milk and the use of stronger food. In reference to babies who have been reared without the breast, the change means the grad- ual cessation of bottle feeding 1 and the addition of solids to the diet. Weaning, to be done successfully, must be done gradually in most cases. In others, as the result of the death of the mother, failure of the milk-supply, maternal ill-health, or other cause, it must be accomplished rapidly. \Yith wasted infants, who, at the age of 20 to 24 months w r ith many teeth, are still at the breast, no time should be lost. Ordinarily weaning should take place between the ages of 10 months and 12 months. Some practitioners com- mence to give an occasional bottle at 6 months. This, as a general practice, is unnecessary. It is best to wean after the child has cut several teeth. This is an indication, in itself, that the gastrointestinal glands have reached a more ad- vanced stage of development, and are capable of digesting stronger food. The infant should not be weaned while cutting a tooth. It should, under no circumstances, if pos- sible, be weaned during the summer months. The fall and the winter are the best times of the year. The entire time occupied before the breast is finally relinquished, under ordinary conditions, is about two to four weeks. At first one breast feeding is omitted a day and its place is taken by a bottle, the composition of the contained milk being similar to that of the mother's milk. The infant is kept on this for three or four days or a week before another change is made. At this time another bottle feeding is substituted for a breast feeding, provided the digestive organs of the child have not been deranged. The same rule is followed and no change is made for another few days. This method 48 BREAST FEEDING. j is continued until the bottle feedings entirely displace the breast. Now follows the change in the character of the milk mixture fed. As the child gains in weight and strength and the digestive organs remain normal, the strength of the milk mixture is gradually increased from week to' week until the formula corresponds to undiluted cows' milk. At this period, about the age of 12 to 14 months, the use of the bottle is gradually discontinued, and the milk is fed by a spoon or drunk from a cup. The child has now from 8 to 14 teeth, and soft, farinaceous substances are gradually added. Milk-toast, well-cooked rice, oatmeal, mashed baked potatoes, tapioca, cream of wheat, farina, meat- juice, the wing of a spring chicken, baked apple, stewed prunes, soft- boiled eggs, and egg-custard are some of the substances which may slowly be added to the diet toward the close of the first or at the beginning of the second year. The meals are gradually reduced to three a day, with milk or some other form of light nourishment given between. The fullest meal is given at noon and the lightest at 6 P.M. After dentition is complete, other substances may be carefully added and the child be permitted to sit at the table with the family. Such articles, however, as pastries, candy, nuts, pork, veal, rich gravies, fancy dressings, bananas, fresh bread, hot cakes, muffins, turnips, cabbage, radishes, corn, salt and smoked fish and meats are to be carefully eliminated. The child should be taught to chew its food slowly and well, and not to overeat. By watchful care and judicious management it can be easily taught to relish those things which are wholesome, and to refuse those which are indigestible. The diet presented in Chapter III, page 140, may now be used to great advantage. CHAPTER II. ARTIFICIAL FEEDING. EXPLANATORY AND HISTORICAL. THE textbook presentation of this subject is most diffi- cult inasmuch as long experience is of immense importance. Especially is this so at the present time, since the matter is by no means settled. The development of the scientific artificial feeding of infants, up to within a few years ago, was essentially American. Since then the teachings of the German school of pediatrists, represented by Czerny, Keller, Finkelstein, Meyer, Heubner, Rubner, Monti, Escherich, and others, have made their influence felt on the medical mind. At first, analyses of human milk and of cows' milk were made and the marked quantitative and qualitative differ- ences between the coagulable protein of these two milks were noted. Under the initiative of Pepper and Meigs in America the simple diluting of cows' milk, so that the vari- ous percentages resembled those of human milk, was ad- vised and practised. To this diluted milk were added milk- sugar and cream to make up for their deficiency incident to the dilution of the cows' milk. These mixtures were soon found wanting in many cases, because the dilution and additions were not sufficient to overcome certain intrinsic biologic and physical differences, many infants failing to thrive upon a milk which nature primarily intended for cows, even though the percentages fed accurately equaled those of the accepted analyses of human milk. It was 4 (49) 50 ARTIFICIAL FEEDING. found, for instance, that a child could digest 4 per cent, of fat of human milk, but that the same percentage represented by cow-fat often caused disturbance. This fact being recog- nized, it was decided, under the leadership of Rotch, of Bos- ton, that the basic principle was to< recognize digestive dis- turbances as dependent upon the fat, protein, or sugar, as the case may be, and to feed to the infant certain definite per- centages of each ingredient and to increase or diminish them at will according to the indications. From this was evolved the idea of the laboratory method, or the percentage method, or the American system of infant feeding. From this sprang into existence the Walker-Gordon laboratory, which sought to fill the physician's prescription for any combination of percentages which he might desire. This, however, was soon found to be impracticable for the reason that the laboratories were confined to large cities, and that the cost of the production of definite percentage mixtures was beyond the means of the poor, who> needed it most. The idea behind the percentage method seemed to be a good one, i.e., to feed gradually increasing amounts of the vari- ous ingredients as the individual case required, and to increase or diminish any special ingredient as the indication arose. For this reason the so-called home modification of milk was devised, and in this connection the work of Chapin, Holt, Baner, and others is representative. This embraced the so-called' top milk and the milk-and-cream mixture methods. They are of immense practical value when in- telligently applied, and serve a useful purpose in the evolu- tion of scientific feeding. Many physicians seem, however, to be unable to thoroughly grasp the details of these methods, and experience has shown that as good results can EXPLANATORY AND HISTORICAL. 51 be obtained by the simple dilution of whole or of skimmed milk. This method will be described as we proceed. Later it developed that any modification which failed to recognize the physical difference between the calcium para- casein (curd) of human and that of cows' milk would likely fail unless something were done to render the curdi of the latter more pregnable to the digestive juices by causing it to be broken up into, particles resembling the coagulated flocculi of human milk. Jacobi years ago, and Chapin more re- cently, advocated the addition of cereal decoctions or thin gruels made from barley, oatmeal, rice, etc., to dilute the milk instead of plain water. Chapin recommended that these cereal waters be dextrinized. Since then other meth- ods of dealing with the coagulable protein, which will be described later, have been evolved. Still, in spite of care- ful percentage manipulation and the attempted adaptation of the milk to the individual's digestive capacity, failures were numerous. It now came to pass that the micro-organisms were regarded as the important causes of mischief, and that every percentage formula might fail unless the basis of it was germ-free milk. From this arose in succession the advocacy of sterilized, pasteurized, and of certified milk. Under the impetus given by Coit, milk commissions exist in nearly all the large cities and towns of America, and clean milk (certified milk) is regarded as an essential of successful feeding. More recently, the Germans have adopted the so-called caloric method of feeding. This seeks to provide a suffi- ciency of heat units as required by the weight of the child. At least 45 calories for every pound of weight are regarded as necessary. The Germans ignore the percentage composi- 52 ARTIFICIAL FEEDING. tion of the mixture. In this their proposal is weak, since it fails to attempt to recognize the particular ingredient which may be at fault in an individual case. It has been well said that the number of calories necessary may be rep- resented by a ham sandwich, and yet the infant could not digest it. The German school also denies the etiologic influence of the curd as a factor in indigestion, and of microorganisms as the cause of summer diarrhea. They regard the fat as a chief offender, the protein as harmless, and look upon the fermentation of milk-sugar as the chief cause of this frequently fatal disorder of the heated season. While the German idea in a sense simplifies the problem, many of their claims have not been substantiated clinically, at least in America, and their plan of feeding can be made as dogmatic and unindividual as it is claimed that the per- centage method of feeding is. The points of advantage and of disadvantage will be emphasized in the text as the problems present themselves. It can be readily realized that 'the subject is far from settled, that no textbook outline of it can make a successful feeder of the novice. What is necessary in each instance is individualization and experience. The former is absolutely the keynote of success. "What is meat for one is poison for another" applies nowhere with such force as in the artificial feeding of infants. In the following presentation no claim is made to originality. Facts will be stated as they have been learned from personal clinical observation ob- tained in an extensive hospital experience here and abroad, and in private work and from contact with eminent authority. In some instances it may be necessary to plead guilty of being ultra-conservative and, perhaps, even un- scientific. The other's right to his view is recognized, nor CHEMISTRY AND PHYSICS OF COWS' MILK. 53 is it denied that other methods are productive of as good results in the hands of their advocates. Liberality of views, however, and the elastic interpretation of facts and, above all, absolute individualization which the two former insure whatever the method employed, are claimed to be essentials, if the physician would become a successful feeder. SUBSTITUTES FOR HUMAN MILK. For this purpose the milk of lower animals has been appropriated, and means sought to adapt it to human needs. The choice of animal depends considerably upon circum- stances and the environmental influences of the country. Almost universally cows' milk has been employed, although use has also been made of the milk of goats, asses, and mares. Of the last three, the first alone is used with any great frequency, and largely in rural districts and among the foreign population. The composition of goats' milk follows : Jrer cent. Fat 4-50 Sugar 400 Protein 4-50 Mineral matter 0.60 Total solids 13-60 Water 86.40 This approaches the character of cows' milk and, like the latter, is deficient in sugar and richer in protein than human milk. The curd is finer than that of cows' milk. CHEMISTRY AND PHYSICS OF COWS' MILK. Like human milk, the composition is not uniform. It varies in the same cow at different periods of the milking, and varies in the different udders. Thus the composition of the milk of a single cow might differ considerably from that 54 ARTIFICIAL FEEDING. of an entire herd. The practical uniformity in composition of herd milk makes it more preferable for general purposes than that of a single cow. However, the danger of tuber- cular infection, for obvious reasons, is less from the milk of a single cow, properly examined. The composition also varies with the type of cow. Some cows are better adapted to infant feeding than others. Thus the Jersey and the Guernsey furnish milk rich in fat (over 5 per cent.) and one in which the fat emulsion is less perfect than in the milk derived from a Holstein-Friesian or the Ayrshire. The former furnishes milk relatively low in fat (less than 3 per cent.) and protein as well (less than 4 per cent.). The milk from the latter is rich in protein (over 4 per cent.) and weaker in fat (slightly under 4 per cent.). The milk from both these types is well adapted to infant feeding. The Devon and Durham cows resemble each other in fur- nishing a milk of good average richness. Cows' milk, like human milk, is an opaque emulsion of fat in a solution of albuminous material, lactose, and mineral matter. The color is white or yellowish white. The odor is said to be characteristic, and is also determined by disease or by the diet of the cow. Thus, in the spring of the year, the odor of grass or garlic is common. The specific gravity at 60 F. varies from 1029 to 1034. Its oscillations de- pend upon the composition of the milk. The reaction is amiphoteric, leaning toward acid. It becomes acid a few hours after milking, the acidity increasing with age. The addition of preservatives increases the alkalinity. The fat of cows' milk contains olein, stearin, and pal- mitin. It exists in considerable proportion as volatile fats which are readily decomposed. If milk be allowed to stand, CHEMISTRY AND PHYSICS OF COWS' MILK. 55 the fat being the lightest portion of it, rises to the surface and is known as cream. Cream, therefore, is simply superfatted milk. If the cream be removed by skimming after it has risen to the surface it is known as gravity cream, and the remaining portion is called skimmed milk. Gravity cream varies in strength, depending upon the length of time permitted for the fat to rise to the surface and the depth of the layer which is removed. Thus, if a quart of milk be allowed toi stand for from three to four hours, the upper n ounces will contain approximately 10 per cent, of fat, while if the upper 16 ounces, or half of the quart, be removed, this superfatted milk or cream will contain about 7 per cent, of fat. Cream may be removed by the centrifuge (centrifugal cream}. This cream is much richer, contain- ing from 20 per cent, to 35 per cent, of fat. The amount of fat in whole milk is not constant. Its variability has been noted in the different breeds of cows. Good milk averages about 4 per cent. The range of variability allowed by most milk commissions is between 3/ / 2 per cent, and 4^ per cent. Microscopically the oil globules of the fat of cows' milk are seen to be large (Fig. 7, II). The caloric value of the fat is 9. The protein exists in solution as calcium casein (for- merly caseinogen) and as lactalbumin and lacto globulin. Other protein substances of less importance are present, but have no general practical interest. If cows' milk be acted upon by rennin or by the gastric juice in the presence of body temperature it coagulates into a solid mass. From this mass will exude a perfectly clear, colorless fluid, and the mass will contract into a tough curd. The colorless fluid is known as whey, and contains principally the so-called 56 ARTIFICIAL FEEDING. whey-proteins or soluble proteins lactalbumin and lacto- globidm, as well as the salts of milk and the sugar of milk- lactose. During the process of separating from the curd some little fat is carried along. Although, theoretically, whey should contain no fat, practically it does. The com- position of whey is variously given by chemists. An average analysis follows: Per cent. Protein 0.94 Fat 0.96 Lactose 549 Salts 0.48 Water 1 92.13 100.00 Thus it may practically be regarded as a 5 per cent, solu- tion of milk-sugar containing I per cent, of whey-proteins and i per cent, of fat. Lactalbumin and lactoglobulin constitute about one-third or one-fifth of the total protein. The former resembles serum albumin and the latter serum globulin. The coagulable portion of the protein remaining is known as the -curd, or calcium paracasein (formerly casein), and constitutes the large part of the albuminous content (about two-thirds or four-fifths). When coagulation occurs the curd, which is tough, leathery, and dense, con- tains within its meshes fat globules, some lactose, and mineral salts. The amount of combined protein, as the fat, is variable, but in good milk it averages about 4^2 per cent. A variation of from 3 per cent, to 4 per cent, may be regarded as within the normal limits. The caloric value of the combined protein is 4. Lactose constitutes the main carbohydrate. It is a di- saccharid. It is readily changed to< lactic acid by the lactic CHEMISTRY AND PHYSICS OF COWS' MILK. 57 acid bacillus. It crystallizes into hard, white prisms. It is less sweet than cane-sugar (weight for weight) and is soluble in 6 parts of cold water. It is not fermented by yeast. It reduces Fehling's solution. When acted upon by dilute mineral acids it is changed to dextrose and galactose. The lactose of commerce is obtained as a by-product in the manufacture of cheese by the evaporation of whey. It is identical in composition to the lactose of human milk, but it is unclean and requires sterilization. Cows' milk contains about 4 per cent, of lactose, which has a caloric value of 4. The mineral constituents consist principally of the phosphate of potassium, sodium, calcium, and magnesium, together with the chlorids of potassium and sodium. Iron is found in less quantity than in human milk. It is in organic combination with nuclein. Milk contains about 0.75 per cent, of mineral matter. Bacteria. Some of the bacteria found in milk are patho- genic and others are not. Of the former the more common are the tubercle bacillus, the bacillus of typhoid fever, and the bacillus of diphtheria. Epidemics of scarlet fever have not infrequently been traced to a contaminated milk-supply. Local disease of the udder may cause the entrance of the different varieties of streptococci, staphylococci and more rarely of anthrax bacilli. The commoner non-pathogenic varieties found are those belonging to the lactic acid and the colon groups. The total solids, including fat, protein, lactose, mineral constituents and bacteria, average about I 3/ / 2 per cent. The remainder is water. ' The microscopic appearance shows the fat globules toi be large and floating in an opaque fluid. Some epithelium and a few leucocytes may be present and are to be regarded as normal (Fig. 7, II). Any increase in these indicates 58 ARTIFICIAL FEEDING. disease, usually inflammation of the udder, and renders the milk unfit for food. Bacteria are readily recognized by staining, or they may be seen in the fresh specimen. For positive identification they must be cultured, colonized, isolated, and stained. Sources of Adulteration and Contamination. Milk oc- cupies the dual position of being the bottle babies' best friend and worst enemy. The latter is brought about by con- tamination and adulterations, either accidental or intentional. The initial source of contamination occurs at the time of milking, and one of the most important is the dust-laden air of the stable. Anyone who has ever visited a farm and watched the ordinary farmer milk his cows and then, when through, to see him strain it through a coarse strainer and then note that left in the latter are particles of straw, manure, dust, and hair, will be able to> appreciate how readily milk may become a carrier of disease. The cows are usually kept in poorly ventilated stables, in stalls provided only with straw beds, and with no means of collecting the manure, which becoming entangled in the straw and, drying, is thrown into the air, by the kicking and shuffling of the animal. Flies are not excluded, and the udder too is covered with dry manure and milk. The farmer does his milking into an open, perhaps unwashed, bucket or one rinsed in spring-water. The atmosphere is dust-laden and his hands are probably unclean. The cow may have an ulcerated, inflamed, or even tubercular udder. From his bucket the milk' is placed into an indifferently cleansed can, after straining as indicated the gross par- ticles having been removed, but the micro-organisms all passing through. The cans are placed in the spring-house, in which the temperature, while low, is not sufficiently so to CHEMISTRY AND PHYSICS OF COWS' MILK. 59 prevent bacterial growth. Before being placed in the cans,- if the farmer be unscrupulous, the milk may be watered or preservatives introduced, or chalk added to whiten it. It is now transported to the railway station, where it awaits the early train. In the mean time bacterial growth can con- tinue. It reaches the city, where, on the unloading plat- form, it may be exposed to the sun for hours. This again favors the further development of micro-organisms. Ex- posure again occurs in the milk-house where it must be bottled, and, unless the establishment is run in a hygienic manner, the improperly washed bottles and the hands of the workmen may be a further source of contamination. In the early morning it is delivered on the doorstep of the consumer, where it remains exposed for a few hours to a gradually rising temperature, and in summer months to a very high degree of heat. In the home the soiurces of additional infection are many. Danger may arise from improper icing, improperly sterilized receptacles, bottles, nipples, and the water used to dilute may be unfit for this purpose. The formula, even if properly made, may not be carefully iced, and bacterial growth continues uninterrupted. In some cases the milk is not bottled, but sold direct to grocery stores and thence to the consumer, being clipped from the can into a pitcher. Infection readily occurs in this manner. Milkmen have been seen to drink milk from the lid of the can while en route in the city streets, and to return what they did not want to the can. This, not alone filthy habit, is exception- ally dangerous in that the likelihood of tubercular contami- nation is imminent. Another unclean habit is for the mother or nurse to suck the milk from the nursing bottle in testing the temperature before feeding it to the baby. 60 ARTIFICIAL FEEDING. It is readily seen, therefore, that from the time the milk leaves the cow until it reaches the consumer it is exposed to many and varied sources of infection. Analysis of Milk and Detection of Chemical Adulter- ation. Analyses for the various normal constituents of cows' milk are conducted as for human milk (Chapter I). The average corn-position of normal milk may be stated as follows : REACTION, AMPHOTERIC OR ACID. Specific gravity 1029 to 1034 Protein 3-5o% to 4.50% Fat 4.00% Water 4.00% Mineral matter 75% Total solids 12.25% to 13.25% Water 87.75% to 86.75% Watering of Milk. Water is added to< milk by dis- honest dairymen and dealers, to increase the volume. Aside from the moral aspect of the procedure, this is a very dangerous practice. It dilutes the various chemical con- stituents, thereby destroying the nutritive qualities of the milk. Besides it adds to the milk millions of micro- organisms, many of which may be pathogenic. In the same class belong those cases where skimmed milk is sold for pure cows' milk. An easy and simple method of detecting these practices, aside from noting the physical character of the milk, is by the use of a small hydrometer. Skimmed milk, when allowed to stand, will collect no cream on the surface. It is paler than pure milk and has a higher specific gravity, because the cream, the lightest constituent, has been removed. Watered milk is pale bluish in color and of a low specific gravity. Milk may be both skimmed and watered at the same time, exhibiting a normal specific gravity. These adulterations can usually be detected with CHEMISTRY AXD PHYSICS OF COWS' MILK. 61 the naked eye or are discovered by chemical analysis. For practical purposes the lactometer (ordinary hydrometer) is very convenient, and is a rapid means of detecting a good from a bad milk (Fig. 9, page 19). Preservatives. Preservatives are added to milk to keep it fresh, to prevent the growth of micro-organisms, and to save, to the dealer, the expense of extensive icing. Among the preservatives, formaldehyd is the most extensively em- ployed. Boric acid, benzoate of soda, borax, bichromate of potassium, and salicylic acid are used, but to a much less extent. Chalk is added at times, to color the milk white after it has been watered. Formaldehyd is usually employed in the form of for- malin, which is a 40 per cent, solution of formaldehyd gas in water. Only a few drops of this solution need be added to a pint of milk to keep it sweet. Formalin is rarely added in sufficient quantity to be tasted. It may be detected by two principal tests : (a) Dilute a small quantity of milk with an equal amount of water. Pour this gently upon some strong sulphuric acid in a test tube. If formaldehyd be present, there will appear a violet color at the line of con- tact. If formaldehyd be absent, a greenish or brownish ring will be formed. Hydrochloric acid causes the casein of milk to appear yellow in the presence of formaldehyd. (b) Distil a small quantity of milk and to> the distillate add a drop of a weak solution of carbolic acid in water. Gently pour this over some strong sulphuric acid. If for- maldehyd be present a red ring is formed at the line of contact. Borax and boric acid are detected, qualitatively, in the following manner: (a) A small quantity of milk is diluted with an equal amount of distilled water, and then slowly 62 ARTIFICIAL FEEDING. evaporated to dryness. The residue is shaken with alcohol and filtered. The filtrate is then ignited and burns with a green flame. (6) If a piece of tumeric paper be immersed in a solution containing boric acid, upon drying it turns to a reddish-brown color. To detect salicylic acid mix a small amount of the sus- pected milk with an equal quantity of water. Add a few drops of acetic acid, and apply , gentle heat to the boiling point, but do not boil. Add an excess of pure mercuric nitrate. The casein is coagulated. Filter. Evaporate the filtrate. Agitate the residue with ether. Evaporate the ethereal extract. Touch the residue with a few drops of tincture of ferric chloride. If salicylic acid be present there occurs a violet color. Potassium bichromate may be detected by coagulating the milk with a few drops of acetic acid and gentle heat. Filter. To the filtrate add a few drops of a solution of lead acetate. A yellow precipitate of lead chromate indi- cates the presence of the preservative. Milk containing chalk is alkaline in reaction and effer- vesces upon the addition of hydrochloric acid, setting free carbon dioxid gas. The crystals of calcium carbonate may be detected by the microscope. Hygienic Care of Cows. While not attempting to deal with this subject in the comprehensive manner which it merits, a work of this kind that failed to emphasize the great importance of it would be incomplete. All cows should be tested with tuberculin and mallein. The cow- barns must be made sanitary. The stalls must be kept clean and free of all dust and manure. The food must be selected and clean and regularly given to prevent indiges- CHEMISTRY AND PHYSICS OF COWS' MILK. 63 tion. The animals should be regularly watered. The udders are to be kept clean, especially before milking, which should be done in a separate dust-free room. Plenty of rest, and exercise in the green pasture are essential. Under no circumstances should the cows be frightened or teased. In winter they are to be housed in such a manner that they do not suffer from cold. Collection and Care of Milk for Marketing. Cows must all be free from tuberculosis and glanders. The cow-stable should be well ventilated. The floors should be boarded. The cows should be curried and groomed daily. The fecal and urinary discharges should be removed from the stall at once. Attendants should be free of disease, and scrupu- lously clean in person and of good disposition. Persons who have just recovered from typhoid fever should not be employed. Privies and urinals receiving human excrement must be far removed from the cows or the milk-room. If possible the milking should be done in a separate compart- ment, into which the cow is taken after the udder has been thoroughly cleansed with soap and water, rinsed and dried. The milker's hands are prepared by thorough scrubbing and immersion into an antiseptic solution. The milking is done into the spout of a covered can upon which the milker sits (Fig. 1 6). In the spout is a metal filter. Previous to use, the can, and especially the filter, should be scrubbed with soap and water, rinsed, and scalded with live steam. The milk is at once carried into the cooling room, where it is placed into a special, previously sterilized cooling apparatus, which permits it to flow into sterilized quart bottles. The bottles are closed with sterile caps and at once iced. The milk has not been touched by human hands and has reached a refrigerating temperature within half an hour after leav- 64 ARTIFICIAL FEEDING. ing the cow's body. It is shipped to the city iced and kept so until it readies the door of the consumer. This it should do in not less than twenty-four hours. It may even be delivered iced in small individual boxes. Care of the Milk in the Home. On the doorstep of the consumer great damage may often be done to the very cleanest milk. What organisms have entered at the time of milking may rapidly increase if the bottle be permitted to remain long exposed to the sun. It should be immediately Fig. 16. Proper can used in milking cows. (Dairyman's Supply Co., Philadelphia, Pa.) taken into the house and iced until needed. When making modifications every possible means of cleanliness and sterilization with reference to apparatus and diluents should be carefully managed, otherwise a perfect milk may be- come contaminated. After the formula has been made, care- ful and continuous icing are essential. In other words, the requirements necessary to secure a good milk, aside from its proper hygienic care in the home, are perfect dairy hygiene and healthy cows, quick refrigeration and ship- ment to the city, or, as someone has said, it is important to "shorten the time between the cow and the baby." PLATE VI Constipated, greasy stool of artificially fed infant. This stool is due to the administration of too much fat. It is foul-smelling (like Lim- burger cheese), and is commonly accompanied by a stationary weight and an ammoniacal urine. Reduce or omit the fat in the formula or practice the other methods for treating fat intolerance. (See text.) ORDINARY, NURSERY, AND CERTIFIED MILKS. 65 Clean milk is an essential to successful infant feeding, and it matters not how well may be adjusted the percentage or caloric requirements of the food, it will not only fail in its purpose, but it will accomplish serious damage as well, unless this is actually secured. Consumable milk as marketed today may be readily classified under three types : ORDINARY MILK, NURSERY MILK, AND CERTIFIED MILK. Ordinary Milk. This is milk that is sold from cans in the shops, or from wagons, or may be bottled at the city distributing station after shipment in large cans. It is con- stantly exposed to contamination and is scarcely a fit food for infants. The bacterial count is high. It should never be given unboiled. It sells for 8 cents a quart in Philadelphia. Nursery Milk, so called, represents an attempt to pro- duce a higher grade or cleaner milk. \t is bottled on the farm and usually contains a smaller number of bacteria than ordinary milk. It should never be fed unpasteurized or un- sterilized. It costs about 12 cents a quart. Certified Milk represents an attempt at the production of a perfectly clean milk. Coit, of Newark, was the first to conceive the idea of a milk commission in conjunction with the County Medical Society, or independent of it. The milk commission has in its employ a chemist and a bac- teriologist whose duties are to visit the dairy of anyone who may enter into an agreement with the commission. At stated, but unannounced, intervals the chemist and bac- teriologist inspect the dairy and examine the milk. If it be up to the standard as decided upon by the milk commission, 66 ARTIFICIAL FEEDING. the dairyman receives a certificate hence certified milk, which simply means the purest and most wholesome milk obtainable. If the requirements are not met the certificate is withheld, after giving the dairyman ten days in which to correct the error. The milk commission requires perfect dairy hygiene and demands a certain bacterial standard. This has not been uniform with all commissions, some allowing 10,000 bacterial colonies 1 and some 20,000 or more per cubic centimeter. The American Association of Medical Milk Coimmissioiiers has adopted 10,000 as the maximum number allowed. As far as possible the nature of these organisms should be determined, as the presence of a few pathologic ones (typhoid fever, for example) would d)o more damage than many non-pathogenic bacteria. In order to keep the number as low as possible the milk must not be over 30 hours old before it is received by the consumer. Besides the bacteriologic requirements, the milk must contain not less than 3^/2 per cent. o>f fat and preferably 4^ per cent.; cream not less than 18 per cent. From 3 per cent, to 4 per cent, of protein must be present. There must be no preservatives, and the specific gravity is re- quired to be between 1029 and 1034. The commission also supervises the health of the employes. It will be seen, therefore, that the cost of production of certified milk is greater than under ordinary circumstances. For this reason this milk sells from 16 to 24 cents a quart. "May certified milk be fed raw?" is a common query. 1 The terms "bacteria" and "bacterial colonies" are commonly used interchangeably. This is an error, as the colonies are counted and not the bacteria. This distinction is important, as it can be readily ap- preciated that there is quite a difference between 10,000 bacteria and 10,000 bacterial colonies. HOW COWS' MILK DIFFERS FROM MATERNAL. 67 Theoretically it should be perfectly safe and is so during eight months of the year. During June, July, August, and September, in order to make assurance more certain, it is recommended that even certified milk should be pasteurized or sterilized in the home. HOW COWS' MILK DIFFERS FROM MATERNAL MILK. The proper adaptation of cows' milk entails a knowl- edge of the biologic, chemical, and physical differences be- tween it and human milk. The reaction of cows' milk to litmus-paper is amphoteric or acid. By the time it reaches the consumer it is acid, owing to the formation of lactic acid. That of human milk is amphoteric, leaning toward alkaline. The specific gravity of cows' milk is 1029 to 1034, that of human milk 1031. The greatest difference between these two milks is in the character and the quantity of the protein. When cows' milk is acted upon by rennin or pepsin, at body temperature, the coagulable portion (calcium paracasein) derived from cal- cium casein (caseinogen) clots in large, lumpy, tough curds. The liquid portion contains lactalbumin and lacto- globulin. It has been shown that the calcium casein, of human milk is changed by rennin into fine, flaky curds of calcium paracasein. The amount of combined protein found in cows' milk equals about 4.5 per cent., two-thirds of which is coagulable by rennin. The total amount in human milk is 1.5 per cent., of which but one-fourth is coagulable by rennin. The fats existing in the two milks are about equal in amount, but those of cows' milk are more volatile and irritating. There exists in cows' milk only about one-half as much lactose. Cows' milk is practically never sterile. It may be sterile in the cow's udder, but as 68 ARTIFICIAL FEEDING. soon as it strikes the air or the surface of the teat it be- comes contaminated. It also receives micro-organisms from the hands of the milker, sores upon the udder, the milk cans and, sometimes, from the water which is added to dilute the milk by dishonest dealers. The organisms gain entrance into the milk by the medium of flies, stable dust, and manure. They may be pathogenic or non-patho- genic, depending upon their source. They multiply rapidly and may, equal 20,000,000 colonies per cubic centimeter. They constitute a dangerous factor when cows' milk is em- ployed as an infant food, playing an important role in the production of the summer diarrheas and other gastroin- testinal complaints. The following table shows the differ- ences detailed above: Cow's MILK. HUMAN MILK. Amphoteric or acid Reaction Alkaline. 1029 to 1034 Specific gravity .1029 to 1031. 4.5% Proteins 1.5 to 2%. Clots in large lumpy curds. .Effect of rennin Clots in fine curd. 4.0 % Fats 3.50 to 4%. 4.0 % Lactose 6.0 to 7%. 0.75% Salts 0.20 to i%. 13.25% Total solids 1 1.20 to 14%. 86.75% Water 88.80 to 86%. Never sterile Bacteria Practically sterile. THEORY OF MILK ADAPTATION. The term "milk adaptation" is better than "milk modification" for the reason that it at once defines the principle upon which the problem 1 of infant feeding and of milk manipulation rests, viz., individualization. A success- ful feeder of infants must individualize and not feed by rule of thumb. The importance of this one's or that one's method of feeding is fast disappearing in so far as it would describe a fixed way of feeding all infants. As a means THEORY OF MILK ADAPTATION. 69 toward an end, any method that will permit of the manipu- lation of milk, so that it will fit the requirements of the in- dividual infant, will live and continue to be a means of considerable help. One may not feed an infant percentages of fat, protein, and lactose suitable to its age on calories said to be required by its weight, but one must feed per- centages of these ingredients that it can digest and calories that will cause it to gain in weight whether these be less or more than the fixed requirements. The best judge of the suitability of any formula is the infant itself. If it ex- hibits a continuous and regular gain in weight and has a good digestion (normal stools and little or no vomiting), that is the correct formula for it regardless of its composi- tion as to quantity or quality. The weight and the digestion are, therefore, the guides as to the suitability of any food for the individual. The first formula prescribed by the most eminent dietitian is an experiment. We may start out with the idea that we wish to give an individual baby, say, 2 per cent, of fat, 6 per cent, of sugar, and i l / 2 per cent, of protein, and we proceed to< calculate this in ounces of milk, cream, sugar, and water. "Is there absolute accuracy of these various percentages in the finished product?" We do not know. The chances are against it. Any one of the various ingredients may, and probably does, vary from one-fourth to one-half of I per cent, too much or too little. The feeding of absolutely accurate percentages is impossible and unnecessary. Any conception of percentage feeding that regards this as one of the possible advantages to be' gained is fallacious and mischievous. What percentage feeding should mean and afford is an easy way whereby any one of the ingredients of the formula fat, protein, or 70 ARTIFICIAL FEEDING. sugar may be increased or diminished, and it is the physi- cian's province to determine which of these is at fault by studying the symptoms of the individual. What these symptoms of the different forms of indigestion are will be stated under their respective headings. Recognizing that element which is at fault, the physician simply applies whatever method of milk adaptation he may favor to the case, and increases or diminishes the ingredient, using the figures which represent percentages simply as a guide, not caring whether those figures accurately represent the exact amount or not. One cannot say that the fat of cows' milk is the cause of all digestive disturbances in infancy, any more than one can proclaim that infants will tolerate incal- culable amounts of the curd of cows' milk ; nor can one lay all digestive disturbances to protein or to sugar, or to ex- cessive caloiry feeding. One cannot affirm that all infants must be fed every two hours, nor yet every four hours, nor that quantities must be regulated by set figures for the age. Here again it is necessary to individualize and to be guided by the digestion and the appetite. A glance at the foregoing table will indicate certain intrinsic differences between cows' milk and human milk, and it appears patent that these must be considered in any scheme that would provide nourishment for the individual baby. The most striking feature is that, as it exists in its native state, the protein of cows' milk exceeds in amount by about three times that found in human milk, and differs intrinsically in the nature of the curd. Any system of feeding that does not recognize this as an indication to feed to an infant in its early weeks, an amount of cows' curd less than that found in human milk, and at the same time to change its physical character, must necessarily fail. Milks THEORY OF MILK ADAPTATION. 71 are suited to the species, and it is undoubtedly true that the curd determines the future character of the gastrointestinal tract and prepares it for the food which it will receive in adult life. Intestinal development, therefore, depends upon the nature of the curd (Chapin). The curd of cows' milk is intended to develop the gastrointestinal tract of a calf into that of a cow, and therefore 1 is suited to- the digestion of a calf, while that of human milk is intended to develop the guts of an infant into those of a man, and is therefore suited to the digestive powers of early life. Hence) the cows' curd must be fed in small amounts at first and modified in nature, either mechanically or chemically, until tolerance is established. The extent of this modification again depends upon the digestive capacity of the individual, some infants at an early age being able to tolerate larger amounts of protein than others which are older. The curd of bovine milk may be dealt with in several ways. The processes employed will be described later, they simply being named here. In the first place the coagulable protein (calcium paracasein) may be eliminated entirely by the feeding of whey in instances wherein protein intoler- ance exists. The curd may be attenuated, i.e., be made to coagulate in the stomach in finer flocculi by the use of cereal waters or gruels, plain (Jacobi) or dextrinized (Chapin), flour ball, or by malt soup. It may further be acted upon so as to pass through the stomach without coagulation by the addition of sodium citrate (Poynton). Predigestion, or pancreatization, and sterilization are other means of render- ing the curd digestible. Lastly, mechanical division of the curd may be secured by feeding Finkelstein's eiweissmilch or buttermilk. Unchanged cow-protein is therefore fed in gradually 72 ARTIFICIAL FEEDING. increasing amounts until a quantity is reached that about equals or slightly exceeds that found in human milk. One must always, however, be guided by the digestive powers cxf the individual. By the time the infant reaches 9 months or a year it may receive, if it be healthy, whole cows' milk, which means about 4^ per cent, of combined protein. I have met a few instances in which this was safely tolerated at 5^2 months. While occurring in about the same amounts, in both human and in cows' milk, it is nevertheless true that the fat of the latter is less easy of digestion. The same rule, applicable to the protein, therefore applies here. The amount of fat fed must be gauged by the individual's ability to appropriate it. It is best to start with small amounts and tq gradually increase, as a rule never exceeding 4 per cent. In most instances infants do better if kept within this amount from 2,y 2 to 3^2 per cent. Certain infants cannot tolerate fat at all. These must be fed skimmed milk, butter- milk, eiweissmilch, or the formula may be pancreatized. The necessity for fat, however, is urgent, as it provides heat and energy and conserves the proteins of the body. As this is also done by the carbohydrates, in instances wherein fat intolerance occurs, the deficiency may be made up by the addition of starches and sugar. The carbohydrates of these two milks are identical in chemistry, but differ in amounts. The milk-sugar of com- merce requires sterilization. How are we to> deal with the carbohydrates? Personal experience would conclude that infants bear sugar well. Physiologically this is substan- tiated by the high sugar content of human milk. Sugar provides heat and energy. The German idea that milk- sugar, per se, is responsible for the initiation of all cases of THEORY OF MILK ADAPTATION. 73 summer diarrhea appears to be overdrawn, although the withdrawal of sugar in the presence of summer complaint undoubtedly does good. So long as micro-organisms infest milk, so long will their role, either by causing toxic changes in the milk itself or in the intestines of the infant, be quite potent. Milk-sugar is not the best carbohydrate to add to milk, for the reasons stated, that it is unclean, and because it re- quires sterilization and readily ferments. For years Jacobi advocated cane-sugar, which is cheaper, cleaner, more easily accessible, and ferments less readily. Its use is attended by very little digestive disturbance, and has given universally good results. Least irritating of all sugars, and more readily digested and quickly absorbed, is maltose. It is added in about the same amounts as the other sugars (Chapter III, page 137). Immediately after birth, most in- fants can tolerate from 4 to 5 per cent, of sugar. This usu- ally may be speedily increased to 6 or 7 per cent, and at about 9 months is gradually reduced until at a year 4 per cent, is reached. This guide may require variation, as the individual digestion may indicate. 'Those infants which bear sugar badly may be fed upon simple dilutions of whole milk, without the further addition of carbohydrate, or upon buttermilk or eiweissmilch. If the absence of sugar makes the food unacceptable to the infant, the sweet taste may be supplied by the addition of saccharin, i grain to the quart. Every ounce of sugar equals about 120 calories. Cows' milk is deficient in those mineral substances in which human milk is rich. To this latter quality and to the antibodies, derived from the mother, human milk probably owes its antiscorbutic, antirachitic, and immunizing quali- ties. In the artificially fed it is necessary to make up for 74 ARTIFICIAL FEEDING. these deficiencies by feeding to the infant, between nursings, fruit-juices and beef-juice. These are rich in organic sub- stances and materially increase the content of chlorid of soda. This has a stimulating effect upon the gastric secre- tion, thereby aiding digestion. It is good practice to add a few grains of common salt therefore to each bottle as well (Jacobi). This has been my personal practice for years. Human milk is sterile; cows' milk is not. This differ- ence must be overcome by securing as clean a milk as is possible. This is accomplished by using certified milk or by pasteurization or sterilization (pages 91-94). The reaction of cows' milk by the time it reaches the consumer is often acid. Alkalies are to be added with a purpose in view, but not routinely. Sodium citrate, sodium bicarbonate, and lime-water are employed. Their special indications will be detailed as we proceed. Summary. The various percentages of fat, protein, and lactose, as well as the caloric requirements, are to be adapted to the individual. In addition, animal and vegetable juices are necessary. Micro-organisms must be eliminated or destroyed. Alkalies may be required. METHODS OF MILK ADAPTATION. Percentage Feeding. The various methods of adapting cows' milk to the needs of the infant have multiplied so rapidly that considerable confusion exists as to which is the best. Having stated the basic principle of percentage feed- ing, it follows that any method will be suitable that affords an easy means of increasing or diminishing the ingredients of the milk. Two ways of handling this problem are open to practitioners of American cities the Laboratory Method and the Home Method: METHODS OF MILK ADAPTATION. 75 Laboratory Method. This is the easiest from the practi- tioner's viewpoint, and yet in practice is the least satisfac- tory. The physician studies his patient's needs, and writes the percentages of the different elements in the milk as he determines will supply those needs and be acceptable to his patient's digestion. The prescription also states the number of feedings and the amount of each feeding, together with the nature of the diluent. This is sent to the laboratory. The completed formula, either in a single container or in individual bottles, containing sufficient food for one feeding, properly iced, is delivered to the patient's home each day. The physician may change his prescription at any time. Laboratories have been established in many of the large cities in America by the Walker-Gordon firm, under the impetus given accurate percentage feeding by Rotch, of Boston. The disadvantage of this method is that it is not available in rural districts. It is costly and beyond the reach of the middle classes and the poor, who most need clean milk. Further, as good results, and perhaps better, can be obtained by careful home modification. The following represents a prescription form that may be used in laboratory feeding: Name Age Address Date B Protein % Fat % Sugar % Alkali % No. of feedings Amount of each feeding Character of diluent Maltose, saccharose, lactose Lime-water Pasteurize ? Sodium bicarb '. , Sodium citrate ..M.D. 76 ARTIFICIAL FEEDING. Home Method of Milk Adaptation. That system of milk modification or, better, of milk adaptation is correct which gives correct results. The simpler the means by which good results are obtained, the better is the method; for it is more readily adopted by practitioners, is more easily taught to the mother, and is best for the infant. It has therefore appeared to me, after fifteen years of experience with nearly all the methods proposed, that the simple dilu- tion of whole or of skimmed or of partly skimmed milk will yield as good results as the use of top-milks or of those formula derived from some highly complicated algebraic equation. By means of the simple dilution of whole or o>f skimmed milk we need not, nor indeed we should not, dis- card the percentage nor even the caloric idea. Both are founded upon sound scientific reasoning, and both are o-f use provided they do not cause one to become narrow and dogmatic. Percentages should simply be regarded as rep- resenting certain degrees of strength, and the numbers employed to represent the percentages should never be con- sidered to mean absolutely the exact amount of fat, sugar, or protein, as the case may be, as is stated. This is impos- sible ; likewise it is unnecessary. The numbers employed to represent percentages might just as well be indicated by a letter. Thus P. i per cent, and P. 2 per cent, could be written Pa, Pb, each advancing letter standing for a degree of strength of protein stronger than the preceding letter. The same applies to the varying strengths of fat and of sugar which may be desired. The idea is not to feed accu- rate percentages of each ingredient, but to have a means of increasing or of diminishing any particular substance which the clinical condition may indicate. The same is true with reference to the caloric requirements of the individual. Any METHODS OF MILK ADAPTATION. 77 formula may be checked, and thus one will be able in the individual case to note whether the particular baby is receiving a sufficient number of heat units. From the foregoing it must be realized that without the use of common sense one need not expect to become a successful feeder of infants. The keynote of the whole situation is that the individual must be studied from the standpoints of his appetite, his strength, his caloric require- ments, above all, from the standpoint of his digestive capabilities. He who would be successful must therefore be a good reader of stools, and must be able to interpret the macroscopic appearance of the excreta properly, and to de- termine the individual's ability to take care of the fat, sugar, and protein. These points have just been detailed on pages 32-34. It may, however, again be emphasized that the main indices as to the value of any particular food are a con- tinuous and substantial weekly gain in weight and normal stools. If the latter are present and the infant is receiving a sufficient quantity of food, the former must follow as a natural consequence. It is inevitable. Therefore the first formula would be written about as follows : Skimmed milk 2.5 oz. Diluent 17.5 oz. Sugar I .o oz. Salt I pinch. As stated previously, this is an experiment, as all first formulae are, even in the best of hands. Upon this the in- fant may not immediately gain. Skimmed milk is employed in the beginning simply to "play safe." Fat is a common disturber of digestion, and therefore, at the outset, fat is temporarily omitted or reduced to a minimum. Our guides the stools and the weight are now consulted. As just 78 ARTIFICIAL FEEDING. stated, one would not as yet expect a gain. However, it is assumed that the stools appear normal and that the infant does not vomit. We now proceed cautiously. We employ half-skimmed milk in the same proportions as we employed the wholly skimmed milk. The mother is instructed to remove all the cream, and then to pour back into the bottle half of that which was removed. The whole is well shaken up and the second formula is made up as follows : Half-skimmed milk 2.5 oz. Diluent 17.5 oz. Sugar i.o oz. Salt I pinch. It is again assumed that this slight addition of fat causes no disturbance. In a day or two the mother is instructed to shake up well the whole quart of milk and to employ a formula as follows: Whole milk 2.5 oz. Diluent 17.5 oz. Sugar i.o oz. Salt i pinch. No disturbance occurring, in daily succession we speedily change the formula as indicated : Whole milk 4 oz. Diluent 16 oz. Sugar i oz. Salt i pinch. And then too: Whole milk 5 oz. Diluent 15 oz. Sugar i oz. Salt i pinch. From this point onward if the digestion be good the baby should commence to gain from % to i ounce a day or from 5 to 7 ounces per week. The questions to be answered now METHODS OF MILK ADAPTATION. 79 are: "When shall the strength of the formula be changed again?" and "When shall the amount of each feeding be in- creased?" The safest rule to follow in my own experience is to make no change until the infant ceases to gain on its food. Let a stationary weight or a slight loss therefore be our index for action in a case that has been continuously gaining and digesting well. We may now do one of three! things, viz., (a) Increase the strength of the milk in the formula, (b) Increase the amount of each feeding, (c) Do both. The last is bad practice. It is unwise to- increase the amount of the feed when the strength of the formula is increased, i.e., it is bad to do both simultaneously. The latter should be done a day or two after the former, when it is seen that the increase in the strength of the formula has caused no disturbance. "What should be the size of the increment in the milk content of the formula ?" and "What should be the size of the increment of the bulk of the meal ?" The latter will be answered first. The quantity added to each meal should never exceed i ounce, and it had better be not more than l / 2 ounce. Thus, if 10 meals were given daily, this would mean the increase of from 10 to 5 ounces in the total bulk of the food per diem. The strength of the formula may be increased as follows, meanwhile making daily inspections of the stools : Whole milk 6 oz. Diluent 14 oz. Sugar i oz. Salt i pinch. Whole milk 7 oz. Diluent 13 oz. Sugar i oz. Salt i pinch. 80 ARTIFICIAL FEEDING. Whole milk 8 oz. Diluent 12 oz. Sugar '. . i oz. Salt I pinch. And so on, the guide to change from one strength to a higher concentration meanwhile being a cessation in the continuous weekly gain, as previously stated. Weighing should never be practised oftener than twice weekly, and preferably but once weekly, fof 3 months weighing 7 pounds would receive a much weaker mixture as the total amount of food would be greater than an infant of I week weighing 7 pounds. In the latter instance the strength of the food would probably be too great, as the total daily bulk would be less, and therefore the milk would not be sufficiently diluted. Caloric feeding completely ignores the digestive capacity of the individual baby, taking cognizance alone of the heat units required. Further, in order to receive the number of calories necessary, the entire amount of the milk mixture provided for twenty-four hours must theoretically be con- sumed within that space of time. As a practical proposition this is often impossible, due to the vagaries of the infant's appetite as well as to other unpreventable causes. Experience seems to show that in order to make the baby gain in weight it is necessary to provide more calories than 45 per pound of body weight. Often one and one- half and even twice this number must be given. If one adopts calory feeding as his method of nourishing infants, he may become as dogmatic in his statements as one who adheres entirely to- percentage feeding. In order to- be suc- cessful it is necessary to individualize as in any other method. METHODS OF MILK ADAPTATION. 85 In ordering a milk mixture, whether percentage or calory, the following form has proved to be useful when handed to the child's caretaker. Name Date Weight Age Fat per cent. Sugar per cent. Protein per cent. Daily Amount (Make fresh daily.) Calories required Milk oz. Skimmed milk oz. Cream oz. Whey oz. Barley-water oz. Oatmeal-water oz. Boiled water oz. Rice-water oz. Lime-water oz. Sugar oz. Salt. ( Soda cit Medicine J. Saccharin ( Other Pancreatized minutes. Feed oz. every hours, giving oz. in twenty-four hours. Diluents. Of the diluents employed with cows' milk, water probably enjoys the largest field of usefulness. Aside from its diluting properties, it is a valuable thera- peutic agent when used intelligently. It is essentially a food and is necessary for the digestion and assimilation of all other foods. Without it the physiologic activity of the economy would cease. It not only allays thirst, but in physiologic quantities, administered regularly, it increases the flow of gastric juice. It renders soluble the salts of the gastric contents and prepares them for absorption. By in- creasing the fluidity of the intestinal contents it acts as a laxative and prevents constipation. It dissolves and dilutes 86 ARTIFICIAL FEEDING. toxins, favoring their elimination through the skin and kid- neys. It maintains blood-pressure. It forms the main component part of every secretion and excretion of the body. It favors the deposition of fat. As a. diluent therefore in milk mixtures it forms an invaluable addition as a nutritive agent. While its action is to dilute all the ingredients of the milk, it does not, to any considerable extent, change their physical characters. The curd formed by rennin with milk, diluted with water, is almost as tough and dense as that obtained with undiluted cows' milk. To overcome this Jacobi, many years ago', first devised the use of cereal decoctions, for which he claimed the power of mechanically dividing the tough curd of cows' milk into a fine, flocculent, porous curd. For this purpose he recommended the use of barley-, wheat-, oatmeal-, and rice- water. Barley-, wheat-, and rice- water are to be employed when diarrhea exists, and oatmeal-water is added as a diluent with constipated children. Dextrinized gruels are advocated as a diluent, especially by H. D. Chapin and Keller. They go a step farther in the use of plain cereal decoctions. Instead of using the plain cereal-water or thin gruel, they submit the latter to the action of some diastatic agent, thereby changing the starch to dextrin. The efficacy of dextrinized gruel, made from wheat- flour, has been tested in a number of feeding cases in the Medico-Chirurgical and in the Philadelphia General Hos- pitals. It was added to the milk mixture, as a diluent, in the same amount as the formula called for water, the gruel taking the place of water. The first case did remark- ably well, the child gaining in weight on an average of i l / 2 METHODS OF MILK ADAPTATION. 87 ounces a day, curds disappearing from the stools, which became normal in appearance. Other children, all infants under I year of age, showed varying results. Some grew fat and strong, others showing no change either in weight or in the character of their stools. In the test-tube the addition of dextrinized gruel certainly causes the milk to coagulate in fine, feathery, flocculent curds, when acted upon by rennin. In the stomach of some infants the effect is decidedly different. One case of miliary tuberculosis, which came to autopsy, showed a large, dense, tough curd in the stomach after having been fed four hours before death with a mixture which contained only 0.25 per cent, of protein. This may have been due to insufficient gastric motor power or to large doses of subgallate of bismuth which was ad- ministered to control intestinal hemorrhage. Koplik has made use of dextrinized gruels in about 50 cases of subacute and chronic enteric catarrh associated with marasmus. He believes this method of feeding to be of service in older children who refuse milk. He quotes Keller's experience as finding the amount of ammonia in the urine diminishing in marantic infants who suffer from an acid intoxication of the gut. Barley-water. Scald one tablespoonful of white pearl barley and throw away the water. One quart of water is then poured over the barley. It is allowed to boil down to one pint and is strained. Barley-water is useful for a short time in the treatment of the summer diarrheas as a substi- tute for milk. It contains a small amount of nourishment and is constipating. It is a useful vehicle for the adminis- tration of stimulants. It is also added to milk as a sub- stitute for water to attenuate the curds in the presence of protein indigestion. 88 ARTIFICIAL FEEDING. Barley-gruel or Barley-jelly. Two to three ounces o,f barley-flour, either Robinson's or that prepared by the Cereo Company of Tappan, N. Y., are rubbed into a smooth paste with water and then sufficient water added to make one pint. Boil with constant stirring 1 for twenty minutes, add suffi- cient hot water to make up for the amount evaporated, salt to taste. When cool the substance sets into a thick jelly. In making the gruel a little less barley-flour is used. Oatmeal-water. This is of service in the attenuation of the curd of cows' milk when used as a diluent in place of plain water, especially in the presence of constipation. Add one tablespoonful of oatmeal to one pint of boiling water. Simmer for thirty to sixty minutes. The bulk is again brought up to a pint by the addition of boiling water. Strain. Salt to taste. Oatmeal-gruel or Jelly. This may be made either from the plain oatmeal or from Cereo oat-flour. In the latter instance the preparation is similar to barley-gruel or barley- jelly. In the former three to four ounces of oatmeal are added to one pint of water. Boil for three hours, prefer- ably in a double boiler. Water is added in the mean time to make up for evaporation. Strain. Salt to taste. When cool it jellies. It may be fed in this way or added to' milk in varying amounts to attenuate the curd. Wheat-flour Water. This may be used as a diluent of milk in the presence of diarrhea. One to two teaspoonfuls of wheat-flour are added without lumping to one pint of water. Boil thirty minutes. Stir constantly. Add suffi- cient water to a pint. Strain. Salt to taste. Arrowroot- water. Rub one teaspoonful of arrowroot into a smooth paste with a little cold water. Add to one pint of hot water. Boil five minutes with, constant stirring. METHODS OF MILK ADAPTATION. 89 Rice-water. This is used as a milk diluent in cases of diarrhea, or may be given plain to the infant. One table- spoonful of clean rice is covered with a quart of warm water and permitted to stand for one hour. Boil until the volume is reduced to one pint. Strain. Salt to taste. Dextrinized Gruels. Dextrinized gruels are made either from wheat-, barley-, oatmeal-, or rice- flour in the follow- ing manner: One to two tablespoonfuls of any of these flours is stirred into a thin, smooth paste with a little water. This is added to one pint and a half of water and boiled for fifteen or twenty minutes with constant stirring, using a long-handled spoon. The gruel is then removed from the fire and allowed to cool. When cool enough to taste, one teaspoonful of a preparation of diastase is added and mixed well with it. Upon the addition of diastase the gruel at once becomes thin- and watery; 5; to 10 grains of taka- diastase may be dissolved in a teaspoonful of water. Use may be made of any preparation of malt, as Liebig's malt extract or of Cereo, which is a glycerite of diastase. Malt Soup. In 1898 Keller published reports of his experiments at the University Childrens' Clinic in Breslau. The preparation of choice is Loeflund's malt soup. It is a thick, syrupy substance of brownish color and pleasant odor. It contains potassium carbonate, the purpose of which is to overcome the acidity of the malt. It is employed as follows : From i to 2 ounces of malt soup are added to i pint of warm water (solution No. i). From I to 3 ounces by measure of wheat-flour are smoothly mixed with i pint of milk and strained (solution No. 2). The two solutions are mixed and slowly brought to a boil with con- stant stirring. Cool and bottle. The amount of malt soup and flour may be varied as indicated. If diarrhea or vomit- 90 ARTIFICIAL FEEDING. ing occur, less malt is employed; if abdominal distention, less flour. On the other hand, the proportions of milk and water may be adjusted to suit any desired percentages. The effect of mixing these solutions is to provide a dex- trinized cereal dextrin and maltose. Milk prepared in this way has undoubtedly a large field of usefulness in marantic infants whose digestive organiza- tion is so delicate that it is next to impossible to secure a food that will agree or produce a gain in weight. Cases of essential marasmus often gain with tremendous strides when placed upon this food. Cases which have difficulty in digesting the 1 curd, but show' a tolerance for starch, are benefited, while those that vomit and have diarrhea do not thrive upon this food. The addition of malt soup should not be permanent, but is only to be employed for the pur- poses indicated especially protein indigestion and grad- ually discontinued when the bowels 1 are normal or the weight ceases to increase. It is especially useful in cases which show acidosis as the ammonium output is decidedly lessened. Alkalies. Although, as stated, by the time that cows' milk reaches the consumer it is slightly acid, alkalies are not to be employed routinely, but for a; distinct indication. This indication is to overcome hyperacidity, to assist in pro- tein indigestion, and to overcome the effects of acidosis attendant upon too much fat in the food, as indicated by an ammoniacal urine. Of alkalies lime-water is the most com- monly employed in the amount of from 5 per cent, (com- mon) to as much as 20 to 30 per cent, of the milk mixture. Besides overcoming acidity, it causes the curd to become attenuated and improves the flavor of the milk. METHODS OF MILK ADAPTATION. 91 Sodium citrate finds its greatest advocates in Wright and Poynton, of England, and Vaderslice and Cotton, of Chicago. It is added to milk in the strength of from I to 3 grains for every ounce of milk and cream in the mixture. It prevents, if in sufficient strength, coagulation of the milk in the stomach, thereby entirely eliminating gastric diges- tion. As can readily be appreciated, this is not desirable as a routine measure, weak digestion would be an indication, especially where the motor function is impaired or in cases of pyloric obstruction. The addition of sodium citrate, gr. 10 to gr. 30, before each feeding, either in the breast- or bottle- fed, is a valuable means of seeking to allay vomiting by permitting the milk to pass more readily into the duodenum on account of its unclotted condition. The exact manner of the action of sodium citrate is un- known. It is assumed that the citric acid liberated combines with the lime-salts of the milk, forming citrate of calcium. The calcium being thus bound, the free sodium unites with the free casein to form sodium paracasein, which, in con- tradistinction to the curd, calcium paracasein, is in solution. Sodium bicarbonate is not commonly employed, but is indicated in hyperacidity, and is used in the strength of from i to 5 grains/ for every ounce of milk and cream in the mixture. Pasteurized Milk. This means the process by which the milk is subjected to a temperature of 155 F. for a period of about thirty minutes to an hour, after which it is rapidly cooled to 68 F. The best means of pasteurizing is by the Freeman instrument (Fig. 17). This consists of a metal bucket or pail which has a removable lid (A} and a groove encircling it about one-third from the bottom. In this bucket fits a metal rack (B), which is made to hold bottles 92 ARTIFICIAL FEEDING. (C). Two sizes are made: one holding 10 bottles, the capacity of which is 6 oz., and one holding 7 bottles, the capacity of which is 8 oz. The rack has a wire crosspiece (/}) by means of which it can be raised when the cross- piece is made to rest on a metal support (E) which projects into the bucket. Fig. 17. Freeman's pasteurizer. A, cover; B, metal rack; C, bot- tles; D, crosspiece; E, support; F, separate compartments. (Physi- cian's Supply Co., Phila., Pa.) The pasteurizer is filled to the groove with water and placed over a hot fire. When the water boils, each bottle, after being sterilized and having been filled with the desired quantity of milk mixture, is stoppered with sterile cotton and placed in its own compartment (F) in the metal bracket, and cold water is allowed to run into each compartment. Any compartments that do not contain milk formulas are occupied by bottles filled with water. The rack is then placed in the pail containing the boiling water. The lid of the pasteurizer is now adjusted and the apparatus is taken METHODS OF MILK ADAPTATION. 93 from the fire. It is left undisturbed for from thirty minutes to one hour, when it is carried under a faucet of cold water, the lid removed, and the rack raised so the crosspiece (D) rests on the metal support (E) which projects into the bucket, and cold water is permitted to run into' the pail, thus rapidly displacing the hot water. The bottles are now removed from the rack, stoppered with sterile cork stop- pers, and placed on ice. Before feeding they are slightly warmed by being placed in warm water. While it is true pasteurization does not make a dirty milk clean nor a fit food for infants, it is the best and safest procedure we at present possess. It is, perhaps, a good rule to pasteurize all milk, even when the method' of its production is known to be the best, during four months of the year (June, July, August, and September). Some dealers sell pasteurized milk. This is a delusion and a snare, as it has been clearly shown that pasteurized milk is a better culture medium than raw milk. Hence the home product is best, as it is not kept sufficiently long toi be exposed to contamination. A rough method of pasteurization applicable to cases wherein expense is a desideratum,, that is efficient, is to place the milk or formula into a sterilized Mason jar. The latter is then placed into a vessel containing cold water which reaches at least two-thirds up the sides of the jar. The water is brought to the boil, at which time it is removed from the fire, the lid placed upon the Mason jar, and the whole allowed gradually to cool off. The formula is now bottled. In summer this method is better than none at all, and is decidedly superior to' sterilization, since the tempera- ture of the milk, while rising higher than when using the Freeman apparatus, is considerably less than the boiling 94 ARTIFICIAL FEEDING. point, a fact of much importance if the process is to be continued over a long period of time. Sterilization. By sterilization is meant the destruction of germs by boiling. It may or may not include the destruction of the bacterial toxins. This depends upon the character of the toxin and its power to resist a temperature of 212 F. Boiling is usually continued for fifteen to twenty minutes. It is a fact that this milk can be kept for many months. It is further a fact, well established beyond dispute, that such milk fed to infants, over a long period of time, will produce scurvy and perhaps rickets. This is due to the chemical changes which occur in the milk. The boiling temperature coagulates the lactalbumin which rises to the surface, entangling the fat. It forms the so-called "skin" of boiled milk. Sterilized milk should not be fed to infants ordinarily. However, in some cases it may be the choice between two evils as a temporary measure. Thus, in the summer months, it may be the safer plan to tell the slum mother to boil her milk before feeding it to her infant, than to assume the risk of a severe intestinal infection. It is further borne out by clinical experience that boiling the milk for a short period (five minutes) greatly assists in rendering the curd digestible. Pancreatized Milk or Pancreatized Formula. This is sometimes poorly named peptonized milk. Predigested milk, which is synonymous, is a better term than the latter. Dissolve the contents of one of Fairchild's peptonizing tubes in i ounce of water. Add this to a pint of the completed formula. Mix. Place the vessel containing this in water of 115 F. for as many minutes as directed to do so. At the end of the required time, either divide into the number of needed bottles and place at once on ice, or bring the METHODS OF MILK ADAPTATION. 95 mixture to a sudden boil. Either method will stop the pan- creatization. If the formula or milk becomes bitter, the process has been carried too far. Uses. Pancreatized milk is useful in cases of indiges- tion where the baby cannot digest the curd or fat of the milk. It does well in some cases of essential marasmus. Fig. 18. Apparatus used in mixing formula. Pitcher, 16-02. glass graduate, sugar measure, large spoon, nursing bottle, glass or agate funnel, corks. (Physician's Supply Co., Phila, Pa.) The combination of i teaspoonful of pulverized flour ball to each bottle of pancreatized formula often forms a useful addition in curd dyspepsia. How to Prepare Formula. The preparation of the for- mula in the home must be done with care, especially with regard to cleanliness. This bears reference not only to the proper icing of the milk, but to everything else, including the hands of the nurse or mother, all utensils, water or 96 ARTIFICIAL FEEDING. diluents, bottles and nipples that may come in intimate con- tact with the milk. The number of ounces of milk or skimmed milk required are placed in a large sterile pitcher made of glass or agate (Fig. 18). Into this is measured, by means of a i6-ounce glass graduate, the required amount of diluent. To this is added the sugar, salt, or any other solid ingredient required. A druggist will furnish a small receptacle or box marked to measure an ounce of Fig. 19. Nursing bottle. Fig. 20. A good type of nipple. sugar by weight. The whole is thoroughly mixed with a large sterile spoon. It is now placed in bottles by means of a glass, agate, or tin funnel, previously steril- ized. The bottles are preferably stoppered with sterile corks. If no further manipulation is required, the bottles are well iced after cooling, and placed preferably in a special nursery refrigerator (Fig. 23). Under no circumstances are they permitted td come in contact with food. If it be necessary to pasteurize, while in the pasteurizer the bottles must be closed with cotton which is later replaced by corks. Hygiene of the Bottle and Nipple. The successful feed- ing of artificially reared infants, aside from the chemical METHODS OF MILK ADAPTATION. 97 composition of the milk mixture, necessitates the strictest attention to details. Of these the selection and care of the nursing bottle and nipple are matters of importance. Gen- erally speaking, that bottle and nipple are the best which are simplest in construction and are the most easily cleansed. Bottles with many curves and angles are harmful. The use of nursing bottles with long rubber tubes is an abomina- tion and should be prohibited by law. They are germ car- riers, cannot be cleansed, and favor decomposition of the milk. The best bottle is one r holding about 6 or 8 ounces, and which consists essentially of a graduated straight tube, Fig. 21. Bottle-brush. (Physician's Supply Co., of Phila.) tapering slightly as it reaches the top (Fig. 19). The bottle should be thoroughly cleansed with Castile soap and hot water, using a stiff brush (Fig. 21) on a long handle. It is then thoroughly rinsed with plain, boiling water and filled with sterile borax-water when not in use. Before using, it is again thoroughly scalded. The brush used to clean the bottle must also be sterile. The best nipples are those which allow the milk to flow easily but not too rapidly. When the feeding bottle is in- verted, the milk should drop from the nipple and not run from it (Fig. 22). Nipples which permit, the milk to flow rapidly produce colic. Those which flow too slowly may vex and irritate the infant. One of the best nipples is known as the Mizpah. The Davidson Health nipple is also a good 98 ARTIFICIAL FEEDING. one (Fig. 20). Any nipple) which is simple in construction and easily cleansed may be recommended. The nipples made from red rubber contain lead, therefore only the black- Fig. 22. Showing correct rapidity of flow of formula through nipple. . rubber ones are to be employed. A nipple should not be used longer than a week, as the rubber becomes poor and is not easily sterilized. The same treatment should be accorded the nipples as the bottles, except that they should METHODS OF MILK ADAPTATION. 99 not be boiled. They are turned inside out and well scrubbed with Castile soap and hot water. Afterward they are rinsed in hot, sterile water. When not in use they are kept in a solution of sterile borax-water or boric acid solu- tion. Immediately before use they are immersed in sterile water. Blind nipples are purchaseable and are convenient Fig. 23. Nursery refrigerator. (Courtesy of Gimbel Bros., Phila.) when it is impossible to secure nipples with sufficiently small holes. The latter are made by passing a fine, red-hot needle through the apex of the nipple. A great incon- venience, difficult to overcome, is the collapse of the nipple while the infant is sucking. In order to obviate this, a nipple and bottle called the Novae have been placed on the market and are of some value. Diet-kitchen; Refrigerator. If available, a small room especially set aside as a diet-kitchen, devoted entirely to 100 ARTIFICIAL FEEDING. the preparation of the infant's food, is desirable. In hos- pitals this is essential. Among the poor, however, the physician, if he will but interest himself, can do 1 much to improve the hygienic surroundings, so that the preparation of the food may be accomplished with safety. Ice is essen- tial to the preservation of the formula. A very convenient and hygienic arrangement is the nursery refrigerator, to which reference has already been made (Fig. 23). These refrigerators come in two sizes and may be purchased for from $1.50 to $3.00. The sides are packed with mineral wool. They are divided into two compartments, one in which the bottles may be kept surrounded with ice and another in which such things as the milk, barley-water, and beef-juice may be kept. Icing the milk or formula is a serious problem with the poor and ignorant, especially during hot weather. Very often a bottle half-finished will be permitted to lie around for several hours, to be again offered to the infant. This practice is exceedingly danger- ous and must be prevented. How to Tell when Formula Agrees. The best evidence that the proper food has been selected for the infant is fur- nished by the condition of its digestion and its weekly weight record. The stools may not at once become normal. The change is usually gradual. Too frequent alterations in the composition of the food are not to be made. The individual digestive apparatus must be given an opportunity to become accustomed to the new food. This only applies to minor disturbances. Severe gastrointestinal derange- ments call for radical changes. A gain of from 5' to 7 ounces a week is normal. Less than this, in the beginning of the use of a new food, until the proper strength is reached is satisfactory. The infant's disposition while awake, and METHODS OF MILK ADAPTATION. 101 its ability to secure a proper amount of sleep, are first-hand guides as to the success of the feeding, unless the baby be hampered and viciously trained. Feeding Routine ; Amounts to be Fed ; Feeding Interval ; Diurnal Feeding ; Nocturnal Feeding. No fixed rule can or should be given. The demands of the individual must be met. As the student requires some guide upon which to base his original advice which may be adjusted by future observation, the following, as representing the result of practical experience, is suggested. Up to 6 months the number of ounces of each feeding may approximately be representel by the infant's age expressed in months. After this the progression is somewhat slower, s& that at i year it receives about 10 ounces. The feeding interval should be every two hours until after 3 months, with two night feedings after midnight. The infant is to be awakened regularly for its meals during the day on the exact feeding hour, timing from the com- mencement of the last meal and not from, the finish. Be- fore feeding, the food is to be properly warmed by im- mersing the bottle in hot water. The formula will be of the proper temperature when it can be comfortably dropped upon the back of the hand. The bottle must be held for very young infants. The infant is not permitted to suck air. The neck of the bottle is always kept full. The infant may not sleep with the nipple in its mouth. The meal should be finished within from fifteen to twenty-five minutes. The food must not be given too rapidly. This may be guarded against by having a nipple which does not permit too rapid a flow, and by removing the nipple from the infant's mouth at the end of every third or fourth suck. The meal should be given with the infant lying down. 102 ARTIFICIAL FEEDING. After feeding, its mouth is gently cleansed! with boric acid solution and the infant must not be picked up. From the third to the end of the sixth month the feeding interval is lengthened to two and one-half hours ; from the seventh to the end of the ninth month, every three hours; from' this time to 12 months, every three and one-half hours. After the fourth month, and sooner if feasible, no night feedings are to be given unless under exceptional circum- stances. (See Vomiting, Chapter VII.) The adoption of some such routine has an excellent effect upon the patient's nervous development and its digestion. Good feeding habits are as easy to inculcate as vicious ones, and make for the comfort of the infant and the general good morale of the entire household. The infant should, if possible, be in a room by itself and left immediately as soon as its meal is finished and its general wants attended. Soon it will be found that the baby will respond to this scheme of regularity. It may take a week or more to accustom some infants to it, but the trial is worth the effort on account of the future comfort which ensues. FEEDING TABLE. Age. Amounts to be fed. Feeding interval. Daily quantity. Night feedings. Up to 3 weeks i to 2 oz. 2 hours n to 22 oz. 2 Up to 2d month 2^2 td 3 oz. 2 hours 25 to 33 oz. 2 Up to end of 3d m. 3 to $y 2 oz. 2 hours 25 to 35 oz. I During 4th month 4 to 5 oz. 2 l / 2 hours 32 to 40 oz. I During 5th month S to 6 oz. 2 l /2 hours 35 to 42 oz. Up to end of 6th m. 6 to 7 oz. 2 l / 2 hours 42 to 45 oz. O During 7th month 7 to 8 oz. 3 hours 42 to 48 oz. o During 8th month 7 to 8 oz. 3 hours 42 to 48 oz. Up to end of 9th m. 8 to 9 oz. 3 hours" 45 to 50 oz. During loth month 9 oz. 3Y 2 hours 45 to 50 oz. During nth month 9 oz. 3*/ 2 hours 50 to 55 oz. o Up to end of I2th m. 10 oz. 3^ hours 50 to 55 oz. METHODS OF MILK ADAPTATION. 103 Individual peculiarities or digestive disturbances may necessitate a radical change in the feeding routine as to feeding interval and qwwtity to be fed. No absolute routine may be prescribed for all babies. Here as elsewhere in- dividualization must be the basic keynote of practice. Thus the advocates of a regular four-hour interval may be as dogmatic as they desire to be regarded as progressive. Reference to the indications for shorter or longer intervals and for larger or smaller amounts to be fed will be found in their proper place -with in the body of the text. Bottle Feeding Among the Poor. Milk Stations. Among the poor, the artificial feeding of infants who are deprived of breast milk, is a problem that touches the ques- tion of infant mortality and concerns the State as well as the individual. Economic conditions underlie the entire sit- uation. The conservation of the human milk-supply is vital, and it does not seem to be Utopian to express the hope that the nursing mother of the poor may some day become the ward of the State during the lactating period, or be paid outright for her services in nursing an infant so that she may be relieved of all other material responsibility during this time. Where the infant is artificially reared, accurate adjust- ment to the individual's digestive peculiarities is just as possible, with some exceptions, if the physician takes the trouble to teach the mother, as among the better classes. The greatest difficulty is, however, to secure pure milk at a reasonable price and to keep the formula properly iced until used. Good milk cannot be secured if purchased from cans in the open market. For this reason milk stations have been established to provide it at cost or, in worthy cases, free. These milk stations, in conjunction with the visiting nurses, 104 ARTIFICIAL FEEDING. have accomplished much in the reduction of infant mortality. It appears, however, to be a useless expenditure of funds where much more good could be done by sustaining the mother during the nursing period, as previously stated. Pasteurization if feasible and, if not, sterilization should be practised during the summer months. The latter is easier and more certain, and should always be advised without thought as to the future development of scurvy. This may be combated by the simultaneous administration of fruit- juices. Condensed milk, being sterile, is a valuable makeshift when added to boiled water, and may be successfully used in many instances throughout the summer months. Feeding while Travelling. If the journey be short, occu- pying twenty-four hours or less, a day's supply of a formula may be prepared and placed in a sterilized Thermos bottle, or be bottled and put into a small receptacle, as a bucket, and properly iced. Where a journey of some distance is to be taken, as a sea-voyage, reliance may confidently be placed upon condensed milk or Ramogen. THE DIGESTIVE DISTURBANCES OF THE BOTTLE-FED AND HOW TO TREAT THEM. Pediatrists are agreed as to the frequency of the diges- tive disturbances of the artificially reared, as well as to the serious and often fatal effects these may have upon the nutrition of the infant. Difference of opinion, however, exists as to the etiologic basis of these digestive upsets. The controversy as to which of the food elements, fats, pro- tein, or sugar, of cows' milk, is responsible still continues, although the German contention, that most of the trouble depends upon a relative excess (for the individual) of fats PLATE VIII Hard, dry. whitish, constipated, crumbly stool, consisting of undi- gested protein, occurring in a bottle-fed baby. These movements are passed with much straining. (See text for treatment of protein intol- erance.) DIGESTIVE DISTURBANCES OF BOTTLE-FED. 105 and sugar, and rarely upon a relative excess of protein, seems to possess at the present time the predominant influ- ence upon the medical mind. An active feeding experience of fifteen years does not permit entire accord with this view. It is patent that the feeding of an excessive relative amount of any or all of the food elements may cause trouble, but the attempt to harness the responsibility upon one or more to the exclusion of the rest appears dogmatic and futile. The researches of von Pirquet clearly demonstrate that the infant thrives best when fed the food optimum (an amount just within the limit of the greatest quantity of food that the organism can assimilate, i.e., the limit of food tolerance), and that loss of weight results from exceeding the food maximum as quickly as when the infant receives less than the minimum. In the second instance the loss of weight occurs because the food tolerance becomes lowered from the burden placed upon the digestive apparatus. Conse- quently assimilation becomes poor and the infant is prac- tically in the same position as if he were receiving less than the minimum. He starves from overfeeding because non- digestion means non-assimilation. In the last instance weight falls because not enough nourishment is provided. The digestive organs, however, having been given a chance to rest, the limit of food tolerance is increased as evidenced by our ability to gradually increase the strength and amount of the food. Reference will again be made to this fact. Thus, while these statements, based upon von Pirquet's work, indicate that the digestive disturbances depend upon the fact that the food maximum has been exceeded, they do not mean that any one particular ingredient is respon- sible in all instances. A clinical fact of importance is that it is often possible to feed large relative amounts of one 106 ARTIFICIAL FEEDING. food element while, if all are relatively large, trouble will ensue. Thus, a high fat may be tolerated when fed alone, but when exhibited with a high protein or a high sugar, or both, may be responsible for fat indigestion. To exclude proteins as an etiologic factor of indigestion is a fallacy. Cases of this type do occur and are marked by definite symptoms. They are as common today as they were ten years ago, when, to the exclusion especially of sugar, nearly all digestive disturbances were laid at the door of this element. All so-called present-day curds in the stools are not fat. Clinical experience, very frequently, in spite of the researches of modern investigators, recognizes them as calcium paracasein, and they may be readily demon- strated to be protein by the xanthoproteic test. It is as impossible today to feed relatively or absolutely as high percentages of chemically or mechanically unmodified cow- curds as it was years ago, and to teach otherwise is danger- ous and cannot but lead to disaster. PROTEIN INDIGESTION OR INTOLERANCE. When an excess and by excess is meant an excess for the individual, which in reality may be a small amount of protein is fed to an infant, tolerance may persist for a brief period, to be followed by digestive disturbances and inter- ference with the nutrition. Protein excess is rarely marked by vomiting unless the amount be so large that its speedy coagulation is followed by ejection from the stomach in the form of a tough, leathery mass within a short time after feeding. The main features of disturbance are confined to the intestinal tract. The stools are usually loose and green (Plate V). They have an unpleasant, but rarely foul odor, and contain considerable mucus and white or PROTEIN INDIGESTION OR INTOLERANCE. 107 whitish-yellow masses of undigested calcium paracasein (curd). These masses may exist in an otherwise normal stool. This is not indigestion, but non-digestion of rela- tively too much curd. In this instance the curds act as a foreign body, and if their presence persists they may cause serious intestinal irritation. These symptoms resemble the dyspepsia of Finkelstein, described by him as due to exces- sive fat or sugar. As before stated, the masses may be dis- tinguished as being protein by the xanthoproteic test. The babies have colic and are very irritable. In other instances, where too much protein is being fed, constipation exists, and the movements are hard, whitish, dry, and readily crumble (Plate VIII). They are passed with considerable effort, as a single mass covered with mucus, which may be blood-stained. Stationary weight or a loss is recorded in both these types of protein intolerance. The urine is often scanty, highly acid, and deposits of uric acid and urates are noted on the diaper. The temperature range in these cases is between 99 F. and 100^2 F. or may be normal. Treatment. An initial purgative of from I to 2 drams of castor oil should be given. An excellent substitute con- sists of equal parts of castor oil and the aromatic syrup of rhubarb. Of this substance double the dose just indicated is to be prescribed. Initial purgation is followed by barley- water or whey feeding for twenty-four to forty-eight hours, or by weak tea sweetened with saccharin. In protein intol- erance initial purgation is valuable and without danger. (See "Diarrhea," Chapter IX, page 267.) Whey is practically a 5 per cent, solution of milk-sugar containing i per cent, of fat and i per cent, of soluble proteins. To the whey, properly heated to 150 F. in order to destroy 108 ARTIFICIAL FEEDING. any remaining ferment, may now be gradually added small amounts of plain milk or cream (split proteins). These, as tolerance is established, may be cautiously increased. In mild cases it may be unnecessary to entirely eliminate the coagulable protein by whey feeding, 1 or whey feed- ing may not be continued long, a gradual return being made to the formula, starting with a weak mixture and gradually increasing. In this case it is advisable, for a short period at least, to pancreatize the formula (page 94). The time of pancreatization is gradually reduced and finally it is entirely omitted. After this the addition of some efficient digestive ferment to each bottle, just before feeding, is an excellent aid until the digestive function has been completely re-established. The early teaching of Jacobi 1 advocating the use of cereal decoctions still holds good as an excellent means of rendering the paracasein easily digestible, and has received more recent emphasis from the work of Chapin, who em- ploys dextrinized gruels (page 86). The cereal decoctions provide a certain amount of starch, which, according to the investigations of Kerley, 2 can be digested and assimilated by infants as young as 19 days. Ordinarily barley-water made from the grain is to be preferred, either full strength or diluted one-half with boiled water. If constipation be present, oatmeal-water makes an excellent substitute. In this connection the old-fashioned flour ball has rendered excellent service. It may be baked to a bread brown and, after being pulverized and sifted, added to each bottle just before feeding. At the same time a few grains of the very best extract of pancreatin 1 Jacobi, A., "Therapeutics of Infancy and Childhood," p. 29. 2 Kerley, C. G., "The Treatment of Diseases of Children," p. 126. PROTEIN INDIGESTION OR INTOLERANCE. 109 may or may not be employed. If the pancreatin is not pure, the stools may become foul. Flour ball may also be used as follows: 2^2 to 5 per cent, of the total quantity of milk mixture is made to represent the amount of flour ball used. To this may be added 5 to 10 grains of pure pan- creatin, or the pancreatin may be omitted. A portion of the completed formula is rubbed while cold with the flour ball so that. a smooth paste results. The remainder of the for- mula is brought just to the boiling point in a double boiler. It is poured over the moistened flour ball and, if pancreatin has been added, it is maintained at this temperature for fifteen minutes, when the mixture is again raised! to the boiling point, allowed toi cool, and is bottled and iced. If no pancreatin has been added, immediately after adding the hot formula it is allowed to cool and iced without the second heating. The use of flour ball in this manner is, in the vast majority of cases, immediately followed by normal stools and a progressive gain in weight. A preparation oin the market known as Benger's Food consists practically of pulverized flour ball and extract of pancreatin. It may for convenience be employed instead of the home-made flour ball. It gives excellent results as a curd modifier. I un- hesitatingly commit the heresy of recommending it. Both of these preparations are gradually reduced and finally omitted. Sometimes the simple boiling of the formula will ren- der the protein digestible, but must not be continued too long without the addition of fruit and animal juices to the dietary. Sodium citrate, gr. j to gr. iij, added to the formula for every ounce of milk and cream in the mixture, may render the curd digestible by causing it to remain fluid until it HO ARTIFICIAL FEEDING. reaches the small intestine. Its effects are not immediate and are usually revealed clinically within a few days. It is continued for some weeks, after which the amount is grad- ually reduced. As a further means to overcome the indigestibility of protein, the use of mechanically divided curd is of great service and permits of the feeding of unusually large amounts. For this purpose, buttermilk and eiweissmilch (pages 121 and 126), especially the former, serve admirably as temporary foods or "pick me ups." As already mentioned, Loeflund's malt soup as advo- cated by Keller is of service in removing protein masses from the stools in some cases. To epitomize, therefore, the following may be stated as the means of dealing with protein intolerance: 1. Eliminate curd by whey feeding. 2. Split protein whey and cream or whey and milk mixtures. 3. Pancreatization. 4. Cereal decoctions plain or dextrinized. 5. Flour ball alone or pancreatized. 6. Benger's Food. 7. Plain boiling. 8. Sodium citrate. 9. Buttermilk. 10. Eiweissmilch. 11. Loeflund's Malt Soup. FAT INDIGESTION OR INTOLERANCE. This, by Finkelstein, has been designated "weight dis- turbance" when occurring in its milder form. When of a more severe type, he calls it "dyspepsia," the symptoms of FAT INDIGESTION OR INTOLERANCE. HI which have been practically described as protein indigestion. No two babies can digest the same amount of fat. Diffi- culty is therefore experienced in attempting to arrange any set rule for the proper amounts of this ingredient to be fed. When intolerance occurs, the infant commences to vomit. The vomitus is sour, smelling like rancid butter, and occurs from an hour to an hour and a half after feeding. The bowels are often loose and just as often constipated. In the former instance they are acid, green, or green and yellow, and greasy, containing mucus and lumps of un- digested fat, that may be mistaken for protein curds (Plates IV, V, and VI). These "curds," or masses, are softer, soluble in ether, burn when dried, are blackened by osmic acid, and are stained characteristically by Sudan III. The addition of a solution of Sudan III causes the fat par- ticles and oil globules to appear red under the microscope. When placed in water, oil droplets are found floating on the surface. When constipation occurs, typical soap stools (Plate VII) are found. The constipated stools are quite often solid, greasy, foul-smelling, and whitish or grayish white, or they may have a pinkish tinge (Plate VI). They fre- quently contain large or small granular masses of hard calcium soap, sometimes covered with mucus which may be blood-tinged (Plate VII). These stools result from the formation of fatty acids in the stomach and intestines. These acids combine,' with the mineral substances of the body and intestinal mucus. Thus a process of deminerali- zation obtains. The direct result of this is a profound effect upon the whole nutrition. The weight remains stationary or a slight loss is noted. The infant becomes anemic, weak, and the bones commence to show evidences of poor 112 ARTIFICIAL FEEDING. ossification, and enlargement of the epiphyseal junctions (incipient rickets). The urine, on account of the large excess of fatty acids entering the blood and being there neutralized, be- comes highly alkaline and emits a decided ammoniacal odor. If this condition of acidosis continues, the digestive processes are all disturbed and intolerance for all food may ensue, to be followed by marasmus or decomposition (Finkelstein). As a rule the temperature remains normal or is only slightly elevated at times. Treatment. An initial purgative of castor oil may or may not be valuable, depending upon the severity of the symptoms. In mild cases it should be withheld ("Diarrhea," Chapter IX, page 267. The temporary course of barley- water or whey feeding may be of service. However, where the diagnosis is certain, all fat had better be at once eliminated following a period of starvation. This is accom- plished by the use of dilutions of fat-free milk (completely skimmed milk). These may be made half and half, or, better, i part of milk and 3 of water. Gradually, as tolerance is established, the dilution is made less and finally small quantities of cream may be added, or plain whole milk may be fed, at first well diluted. From 2^ to 5 per cent, of extra carbohydrate (sugar) is added. The fat is gradually increased, keeping well within the border of tolerance. . Where great acidity exists, marked by sour eructations, alkaline urine and soap stools, lime-water in quantities ranging from 5 to 25 per cent, should be added to all formulas. This seeks to prevent alkalinization of the fatty acids by the tissues of the body, thereby preventing de- mineralization and acidosis. Fresh buttermilk forms an SUGAR INDIGESTION OR INTOLERANCE. 113 excellent substitute in fat intolerance. If made at home by the simple addition of lactic acid tablets, all cream should have been at first removed. The deficiency of caloric value, as the result of this, is made up by the addition of cane- sugar and wheat-flour in gradually increasing quantity (Chapter III, page 123). Pancreatization may overcome fat intolerance without necessitating a great reduction in the amount of fat fed. It must not be continued too long, or the very purpose for which it was used will be defeated. SUGAR INDIGESTION OR INTOLERANCE. Sugar has come into prominence as a great, if not the greatest, factor in the digestive disturbances of infancy. For reasons previously stated, personal experience does not permit of entire accord with this view. It has rarely been a source of trouble. The reason for this may be that routinely, following the teachings of Jacobi, cane-sugar, instead of the commercially impure lactose, has been em- ployed. Frequent, watery, acid stools that excoriate the buttocks, associated with a sour, watery vomitus which irritates the esophagus and causes the infant to cry, together with flatulency and colic, are indicative of sugar indiges- tion. The urine may contain sugar; the baby may develop a high temperature and pass into a state of collapse on account of the frequent evacuations. A rapid loss of weight occurs, intoxication (Finkelstein). There are some infants who receive an excess of sugar and who do not suffer from indigestion, but grow fat. They are. however, flabby, anemic, and often develop rickets and scurvy at the same time, being subject to colds and to eczematotis rashes. 114 ARTIFICIAL FEEDING. Treatment If the condition be acute and the symp- toms of intoxication severe, castor oil and starvation for twenty-four hours are indicated. In mild cases initial pur- gation is unnecessary and does harm. During this time cereal-waters or weak tea sweetened with saccharin, gr. j to the quart, are employed. If not acute, this preliminary treatment may be omitted. In this condition Finkelstein's eiweissmilch finds its greatest field of usefulness. It is, unfortunately, very difficult to prepare, except in institu- tions, and hence may be impracticable. A good substitute consists of equal parts of buttermilk and of a wheat-flour solution (Chapter III, page 123). Both this and the eiweissmilch may be sweetened with saccharin, gr. j to the quart. The infant may be kept upon the buttermilk mix- ture for some time, and will gain, especially if gradually increasing amounts of cane-sugar or Dextri-Maltose are added. As far as the addition of extra carbohydrates to milk formulas is concerned, increasing experience with it seems to demonstrate the value of maltose. This is found on the market as Mead-Johnson's Dextri-Maltose or as Loeflund's Food Maltose. Both are mixtures of dextrin and maltose. The latter is the more expensive, as it is an imported product. Both are used in the same manner as cane-sugar or lactose. A similar preparation is Soxhlet's Nahrzucker. Normal breast and bottle stools are shown in Plates II and III. DEFICIENCY OF FOOD ELEMENTS. This is marked by slow growth, stationary or losing weight, irritability, and usually by a subnormal temperature, FOOD IN IMPROPER QUANTITIES. 115 unless the point of starvation is reached, when fever may occur. Constipation is the rule and the stools are normal in appearance, but of small bulk. Deficiency of food ele- ments may not mean deficient bulk. In fact, this most often is excessive, but then the milk mixture is weak. It must be remembered that, aside from the characteristic digestive disturbances, the same features of nutritional impairment may be brought about by unduly strong mixtures, the excess causing digestive disturbances which may} prevent proper assimilation. The patient actually receives a defi- ciency of all the elements. Rickets and scurvy may follow a deficiency in fat, protein, and mineral substances. FOOD IN IMPROPER QUANTITIES. The average quantities of food have been stated pre- viously (page 102). A formula may be suitable to the digestion of an individual, and yet be fed to him too fre- quently and in too large amounts. This is just as often the cause of digestive disturbances as excessive amounts of any special ingredient. It is noted in breast-fed children who are nursed every time they cry. These babies are always irritable, vomit, have bad bowels, and often lose weight. This is true, especially of bottle babies. On the other hand, insufficient amounts of a correct formula may be given. These babies are always irritable, do not rest well, and, immediately after receiving the bottle, are unsatisfied, cry, and do not fall asleep at once as most babies do*. They usually have a stationary weight or lose a few ounces. Increase in the quantity of the food is im- mediately followed by a gain in weight. 116 ARTIFICIAL FEEDING. FEEDING OF DELICATE AND SICK INFANTS. That this is a difficult problem gives no information, and yet in the handling of delicate babies who are not act- ually ill, but only below par, general rules may be given to be applied to the individual case as the indications demand. The digestion of these infants must be carefully watched, and at the first sign of trouble it is wise to immediately lessen the strength and quantity of the formula, or, perhaps, withdraw it entirely for twenty-four hours. Not a bad practice is to have the mother make the formula as here- tofore, but just before feeding to pour out of the bottle one-half or three-fourths or one-fourth and replace it by water. A gradual return is then made to the full strength. Quantities to be fed must be regulated according to the tolerance of the stomach and the appetite. While it is desirable to give the stomach absolute rest, many cases do better when fed small amounts frequently. Here the peculi- arities of the individual case must be studied. Infants sick, of diseases other than those depending upon feeding or disorders of the stomach and intestines, must have their food carefully watched, as they are excep- tionally prone to digestive upsets. Such an event may be the cause of a fatal outcome. In no disease is this better illustrated than in pneumonia, wherein an extensive and persistent tympanites often closes the issue. In acute illness food should be withdrawn for twenty-four hours, and a return to the original strength not be made until after the crisis, or the main symptoms have subsided. If digestion is sluggish, the formula should be pancreatized and fed in small amounts. Overfeeding should never be permitted, and the infant is not to be disturbed too frequently, either FEEDING DELICATE AND SICK INFANTS. 117 for food, medicine, or other attention. It is frequently advisable, when gastrointestinal symptoms arise, to with- draw milk altogether during the entire course of the illness, and keep the patient upon animal broths or juices, alone or in combination with cereal decoctions, thin gruels, or albumin-water. For a more detailed description of this topic see Chapter XIII. CHAPTER III. ARTIFICIAL FEEDING. (Continued.) IDIOSYNCRASY TO COWS' MILK. THIS is an actual condition. The smallest amount of cows' milk may, in susceptible individuals, cause symptoms of gastrointestinal derangement, sometimes accompanied by skin rashes. Though rare, the physician should be suffi- ciently familiar with the symptoms to recognize them. Kerley has reported a case. The history of the following case is of sufficient interest to warrant a somewhat detailed report : This was a healthy infant, nursed from the begin- ning by a wet-nurse. The fat in the nurse's milk ran as high as 8 per cent., causing frequent attacks of fat intoler- ance, which were always overcome by treating the nurse with purgatives and by restriction of her diet. It became necessary to dismiss the wet-nurse. A carefully adapted formula, a little weaker than her milk, was prepared. The infant refused it and cried persistently whenever the bottle was offered. It was impossible to make him close his lips about the nipple. On one occasion the nipple was held in his mouth for an hour and a half, the patient crying con- stantly. He finally took 2 or 3 ounces. Within five or six hours he had diarrhea, vomiting, an urticario-erythem- atous rash on his abdomen and legs, and a temperature of 101 F. The symptoms speedily subsided after the ad- ministration of castor oil and the withdrawal of the milk. The wet-nurse had to be recalled. After this any attempt (118) SUBSTITUTES FOR MILK FORMULAS. 119 to feed cows' milk was resisted and, when forced, was always followed by a rash and gastrointestinal symptoms. Weaning had to be finally accomplished by the direct feed- ing of solid foods and broths without milk. He is now 3 years of age, and each time he partakes of cows' milk or of foods cooked with milk he is troubled with digestive dis- orders and an eczematous eruption. These cases are probably anaphylactic in character, and represent an example of so>-called allergia to cow-protein. Whenever an infant vigorously refuses cows' milk, this in itself should be definitely considered before pushing the food. In Kerley's case the first symptoms also followed the forcing of the milk upon the infant. Laboratory investigations may later disclose a method whereby this type of protein intolerance can be recognized by a skin test done after the manner of the von Pirquet reaction. SUBSTITUTES FOR MILK FORMULAS. Whey. Whey is made by coagulating milk with ren- nin or essence of pepsin. To i pint of sweet or skimmed milk is added either 2 teaspoonfuls of liquid rennet or Fairchild's essence of pepsin. The milk is then placed upon the fire and gently heated to blood heat. It is then removed from the source of heat and permitted to clot. The clot is now broken up with a fork or a spoon, and the whole is filtered through 5 or 6 layers of narrow-mesh cheese- cloth, without pressure. Whey, when correctly made, is almost transparent and should be free from oil globules and flocculi of curd. When it is desired to feed a child upon a food in which casein is entirely eliminated, whey feeding may be etn- ployed. It is easily digested and forms an admirable 120 ARTIFICIAL FEEDING. vehicle in which to administer stimulants. It is an excel- lent substitute for milk in the management of some of the gastrointestinal disorders of infancy. It may be given plain or diluted with milk, barley-water, or cream (see below). Whey-and-Cream Mixtures (Split Proteins). In the feeding of artificially reared children, the use of a whey- and-cream mixture may be of advantage. Before whey is added to cream or milk it should be subjected to a tempera- ture of 150 F. in order to destroy the action of the ren- nin or pepsin. Otherwise the cream will curdle. The whey should not be subjected to 1 a temperature higher than this, otherwise the lactalbumin will be coagulated. The mix- tures of whey and cream may be of service in instances wherein milk or milk formulas are not tolerated at all. The good effects are shown by a gain in weight and normal stools. These mixtures are only to be regarded as substi- tutes, and a return to milk should be gradually made as tolerance is indicated. The cream is added in gradually increasing amounts, starting with f3ss to f3j to each bottle of 4 or 5 ounces of whey. Where it is desired to lessen the 1 amount of calcium casein and to increase the whey- protein (lactalbumin and lactoglobulin), instead of whole milk in full strength, one may use sweet or skimmed milk diluted with varying quantities of whey. The proteins of whey equal about i per cent. Thus, if equal parts of whey and skimmed milk are added together, the resulting mixture would contain about 0.75 per cent, of whey-proteins and about 2 per cent, of calcium casein. These mixtures are also of use where plain diluted cows' milk is not toler- ated. For practical purposes it is neither necessary nor useful to accurately calculate the percentages of split pro- SUBSTITUTES FOR MILK FORMULAS. 121 teins being fed. The guides are the infant's digestion and its weight. Wine Whey. Four ounces of sherry wine are added to i quart of milk and the mixture boiled. Strain through cheesecloth. It is useful as a stimulant fed in small amounts, plain or diluted with milk or cereal-water. Albumin-water. Add the white of i fresh egg to a pint of water. Shake well. Strain. Salt and sugar to taste if desired. Feed plain or dilute with cereal water, or employ as a vehicle for fresh beef-juice, orange-juice, or brandy. When all milk is withdrawn, albumin-water, plain or modified, as above, serves as an excellent substitute article of diet, in the treatment of diarrhea cases or other types of indigestion. Sour Milk or Acidified Milk; Lactic Acid Milk; Butter- milk. Milk to which lactic acid bacilli have been added, accidentally or intentionally, undergoes a process of fer- mentation whereby the different varieties of bacilli, of which the Bulgarian type is the most common, change the lactose to lactic acid. This process is partial or complete as the time of fermentation is short or long. Accidentally soured milk should rarely if ever be employed, as there is great danger of pathologic bacterial infection being present, as well as obscure chemical processes which may cause serious trouble. Depending upon the amount of fat desired in the sour milk, whole sweet milk or skimmed milk, sometimes previously sterilized, is employed. Previous sterilization is usually to pro-long the souring for too great a length of time. To the milk is added i or 2 of the many varieties of lactic-acid-bacilli tablets to be found upon the market. These are previously dissolved in a little milk or water. Of these the Lactone Tablets of Parke Davis & Co., or those 122 ARTIFICIAL FEEDING. prepared by Fairchild Brothers & Foster, or the Bulgarian Tablets of Hynson & Westcott, have given satisfaction, although all of them, at times, may be found to be inert. The milk is kept at room temperature overnight, after the tablet has been added. By morning, coagulation has oc- Fig. 24. Home buttermilk churner. (Gimbel Bros., Phila., Pa.) curred. It is then beaten up, and is ready for use. If whole milk or cream has been used, after souring, it may be placed in a churner (Fig. 24) to remove the fat in the shape of butter, and the remainder, or the buttermilk, is decanted. Whole milk soured and simply beaten up, is erroneously designated as buttermilk. Soured skimmed milk more SUBSTITUTES FOR MILK FORMULAS. 123 closely approximates buttermilk which contains very little fat. The souring may be very conveniently brought about by simply adding to a quart of sweet milk a teaspoonful or two of sour milk. This is called a "starter," and takes the place of the tablet. Thus each day a little of the soured milk of the day previous may be used for this purpose. The composition of these milks varies in fat content, depending upon whether they are made from whole sweet milk or skimmed milk. They contain approximately the same amount of protein as plain whole milk, and identical quantities of lactose which is considerably reduced by the fermentation. The composition of buttermilk varies, and depends whether it be made by simply souring skimmed milk or whole milk; or whether it is churned from sour cream or sour whole milk. It is poor in sugar and contains rela- tively more protein than fat. The protein exists in a finely divided state. AVERAGE COMPOSITION. Protein 3.0 per cent. Lactose 1.5 per cent. Fat 2.5 per cent. Salts 0.5 per cent. Prepared Buttermilk. A preparation of buttermilk much used at the Philadelphia General Hospital (Blockley mixture) follows : Depending upon whether the living lac- tic acid organisms shall enter the infant's gastrointestinal tract or not, one of two methods may be employed : i. Three and three-fourths teaspoonfuls of wheat-flour are rubbed into a smooth paste with a little water, and suffi- cient water added to make a quart; 15 24 teaspoonfuls of cane-sugar are dissolved in this. The whole is boiled for twenty minutes with constant stirring, the water of 124 ARTIFICIAL FEEDING. evaporation being replaced. Allow it to cool. Add i quart of soured whole or soured skimmed milk, or buttermilk. 2. After mixing as above, the mixture is again brought to the boiling point. The flame must be low and, as soon as heat is applied, vigorous stirring- is commenced and con- tinued until the boiling point is reached with but momentary interruptions ; otherwise, the curd will unite into a thick, tough, solid mass. At the end of the process sterile water is added to make the entire bulk equal 2 quarts. In this preparation the lactic acid bacilli are destroyed. The amount of cane-sugar added may be varied as the condition of the infant's digestion indicates tolerance or otherwise. It may be often advantageously omitted en- tirely, when the mixture can be sweetened with saccharin gr. j to the quart. Used in this manner, especially if sub- jected to the second boiling, it may form' a good substitute for eiweissmilch, which it closely resembles. The purpose of the addition of the flour is to take the place of the defi- cient fat and. assist in the formation of a finely divided curd. The additional sugar also supplies heat and energy to sup- plant that of the sugar lost by fermentation, and also' of the fat removed by churning. Indications. These different varieties of lactic acid milk are useful in disturbances of digestion where diffi- culty is experienced in taking care of the curd, or where a decidedly lessened amount of sugar is desirable. On account of the fine state of mechanical division in which it is found, the curd is rendered easily digestible. If fed raw, the additional effect of the lactic acid bacilli is secured. This may be of considerable assistance in tubercular enteritis. In one case the acid-fast bacilli were made to disappear. The more commonly useful mixture is the one SUBSTITUTES FOR MILK FORMULAS. 125 to which flour and sugar have been added. It finds its special sphere in intestinal conditions marked by protein and fat intolerance. Green stools, curds, diarrhea, and mucus, associated with loss of weight and, at times, tem- perature, often speedily disappear after the use of this food. If they persist, before the mixture is discontinued it should be tried without the addition of cane-sugar. In either in- stance the cessation of symptoms and the gain in weight, which may be a pound or more the first week, are at times only short of marvelous. Sugar may be cautiously added and slowly increased, after the stools become normal. Buttermilk milk mixture must not, however, be regarded as a permanent food. A time comes when the gain in weight is quite small or does not occur at all; at the same time the infant seems to take a great dislike for the mixture which previously he had relished. A change must therefore be made to other food. This is done promptly, usually after omitting one feeding in order to allow the stomach to become completely empty. Either diluted skim milk (preferable at first) or diluted whole milk, with or without flour ball or Benger's Food, is substituted. Throughout the period of buttermilk feeding the infant receives from i to 2 drams of expressed beef -juice three times a day, as well as from i to 2 daily inunctions of codliver or olive oil. Two great advantages of the buttermilk mixture are its cheapness and the ease of its preparation. It therefore has a great field of usefulness among the poor and among the ignorant. Buttermilk Conserve. This comes in tin cans and re- sembles closely the mixture of buttermilk, wheat-flour, and sugar. It is thick and must be removed from the can as soon as the latter is opened. It is diluted with water. It 126 ARTIFICIAL FEEDING. is a little more convenient therefore, especially while travel- ling, than the home-made mixture. Personal experience with it has been limited. The analysis provided by Biedert and Selter shows: Proteins 9.6 per cent. Fat 0.6 per cent. Sugar 30.0 per cent. Salts 2.0 per cent. Lactic acid 1.7 per cent. Wheat-flour 4.5 per cent. Where cane-sugar seems to< cause disturbance, use may be made of a buttermilk conserve containing Dextri-Maltose, marketed by Louis Hoos, of Chicago. Eiweissmilch (Albumin Milk, Finkelstein's Milk, Pro- tein Milk.) The following method of preparing eiweiss- milch is practised by Finkelstein in his well-equipped diet kitchen in the Waisenhaus u. Kinderasyl in Berlin : i tea- spoonful of any milk coagulant, as rennin or pepsin, is added to i litre of whole milk. This is thoroughly mixed and the vessel containing the material is placed in a water bath, the temperature of which is! about no F. This raises the milk to about 100 F. Within a short period coagulation occurs and the entire mixture becomes solid. The mass is then incised by a complete crucial incision. This facilitates the escape of the whey. The coagulum is now placed in a suspension bag (made of either 4 or 5 layers of cheesecloth or of a porous material resembling a thin, unbleached muslin) for a period of four hours. This permits all the whey to escape, carrying with it the major portion of the salts and the sugar of milk. The tough curd is then pushed through a hair-mesh sieve in order to com- pletely comminute it. This process is accomplished with a wooden spoon, or with a druggist's pestle, or with a wooden SUBSTITUTES FOR MILK FORMULAS. 127 instrument resembling a potato masher. It is repeated four or five times, adding about X ntre f water to facilitate the passage through the fine sieve. One-half litre of good buttermilk is added to the finely divided coagulum, and the entire mixture is again passed through the sieve. The bulk of the product should equal I litre, and, should it not, the deficiency is supplied by adding sufficient water. The mixture is now brought to the boiling point, meanwhile stirring thoroughly and constantly from the moment that heat is applied. This maneuver is crucial in its effect upon the perfection of the finished product. If it is not employed, the finely divided curd will become one solid mass. This accident seems to occur with great frequency in America, while in Finkelstein's kitchen it rarely ever happens. Whether this be due to the use of a special coagulant originally (Labessenz, made by Simon, Berlin c. Spandauer- strasse 17), or whether to the special and rather complicated apparatus which is employed to stir the mixture while it is being heated, is not quite clear, although I incline to the view that the latter is the case. In questioning the Sister in charge of the kitchen, on this point I could receive no definite information, chiefly, I believe, because she never experienced the difficulty. This special apparatus has a device which resembles an egg-beater, and for this reason I have employed one of the latter with which to do> the stirring while the mixture is being heated. The stirring must be continued during the process of cooling, which is accomplished more rapidly by permitting cold water to run over the containing vessel. Many American authors,, in giving their directions as to the manufacture of eiweiss- milch, omit the final boiling. This is incorrect and does not represent Finkelstein's views. In my own experience I have 128 ARTIFICIAL FEEDING. been able, almost without exception, to prevent this coagula- tion en masse by adding a dram of raw wheat-flour to the mixture before applying heat. While this practice too is irregular, it does not seriously interfere with the correct composition of the eiweissmilch, and certainly does not hamper the clinical results. Composition. Eiweissmilch is fat-poor, sugar-poor, and protein-rich. An average analysis follows: Fat 2.5 per cent. Protein 3.0 per cent. Milk-sugar .' 1.5 per cent. Ash 0.5 per cent. The calcium paracasein, or curd, is in a finely divided state. The milk is sterile. Eiweissmilch contains less sugar than buttermilk. The difficulty experienced in preparing eiweissmilch in the home has caused its manufacture to be undertaken on a large scale, in Germany. In America and also in Germany it may be found upon the market in powdered form; 90 grams of this preparation are added to 1000 cubic centim- eters of previously boiled and cooled water, and thoroughly mixed. Larosan is also' a substitute product. It is eiweiss cal- cium, or a combination of the protein of milk and lime. About 2 per cent, is added to l / 2 litre of water. To this is added y 2 litre of whole milk and the entire mixture is boiled. It is employed to correct dyspeptic stools before resorting immediately to eiweissmilch. Additional carbo-- hydrate in the form of cane-sugar or of Dextri-Maltose may be added if desired. (See Diarrhea, Chapter IX.) Uses. Although usually employed full strength, eiweiss- milch may be diluted. On account of its deficiency of PLATE IX Stool of a case of diarrhea discolored by bismuth. Notice absence of fecal matter and the excess of mucus. Artificially fed baby: stool commonly seen in intoxication. (See text for treatment of sugar intolerance and diarrhea.) SUBSTITUTES FOR MILK FORMULAS. 129 sugar, it may be rejected by some infants. In order to overcome this I grain of saccharin may be added to a quart. To increase its caloric value the addition of sugar in the form of Loeflund's Maltose or Mead- Johnson's Dextri- Maltose is usually made. At first 2.y 2 per cent, and then 5 pel" cent, is added, four or five days after starting the feeding, or when the bowels become normal. Eiweissmilch undoubtedly finds its greatest field of use- fulness in the treatment of summer diarrhea and next in cases of infantile dyspepsia, wherein difficulty is experienced in the proper digestion of the protein or fat, or both. It is by no means to be regarded as anything but a tem- porary food, although some children gain slightly on it. Its effect on the diarrhea and character of the stools is almost immediate. From 8 to 10 or more movements a day the number is speedily reduced and their appearance be- comes whitish or brownish yellow, and constipated (calcium soap stools, caseate of lime). This change is so constant that it cannot be regarded as accidental. Maltose is not added to the milk until the stools are normal. From, eiweissmilch the change is made to the required dilution of whole or of skimmed milk immediately, as with buttermilk, but one feeding being omitted to allow the stomach to empty itself. Ramogen, a conserve, marketed in cans, represents a condensed form of Biedert's creami-and-whey mixture, the basic idea of which is to seek a combination of protein and fat acceptable to the infantile digestive apparatus. The relative proportions of protein, fat, and sugar in Ramogen are based upon the principle of the amount of food neces- sary for growth. The fat is rendered easily digestible by a process of emulsification. The proteins are not predigested. 130 ARTIFICIAL FEEDING. The conserve is obtained by condensation at a low tempera- ture. It is sterile. Cane-sugar is added as a preservative. The reaction of Ramogen is slightly alkaline. Its com- position represents: Proteins 7-Q per cent. Fat 16.5 per cent. Sugar 34-6S per cent. Salts 1.5 per cent. This substance is especially useful in some cases of delicate digestion associated with marked disturbance of the nutri- tional balance. Cases of decomposition (marasmus) which have passed the gamut of patented foods and do* not seem able to digest cows' milk fo'rmulas, however manipulated, have shown a remarkable gain in weight and passed on to complete recovery when placed upon this food. It also* does well in many cases of summer diarrhea after the acute symptoms have subsided, following the period of barley- water or weak-tea feeding before milk formulas are again resumed, and where sugar is well tolerated. Ramogen is employed by diluting it either with water (to be preferred) or with milk. The following dilutions are suggested : Age. Mixture. Calories Percentages of Ram. Water. in 100 c.c. Proteins. Fat. Carbhd. First 3 weeks i 13 25 52 1.23 2-7 3 to 6 weeks i 11-12 27-26 56-.S3 1.36-1.3 3-2.8 6 to 9 weeks i IO 30 63 1.48 3-1 9 to 15 weeks i 9 33 7 1.65 346 15 to 18 weeks i 8 35 77 1.81 3-8 18 to 21 weeks i 754 38 .81 1-93 4.0 21 to 24 weeks i 7 4i .87 2.06 4-3 24 to 27 weeks i &/2 43 93 2.19 4-7 27 to 33 weeks i 6 45 .98 2.31 4.8 33 to 49 weeks i 5 1 A 50 1.07 2-54 5-3 39 to 44 weeks i 5 54 MS 2.72 5-7 SUBSTITUTES FOR MILK FORMULAS. 131 Age. Mixture. Calories Percentages of Ram. Water. Milk, in 100 c.c. Proteins. Fat. Carbhd. 4 to 6 weeks I l2l/ 2 2 30 .92 1-39 2-5 6 to 9 weeks I 12 3 33 17 1-54 2.8 9 to IS weeks I u'A z l A 35 29 1.64 2.88 15 to 18 weeks I II 4 37 .42 1-74 3-0 18 to 21 weeks I lO l /2 4/2 39 54 1.83 3.12 21 to 24 weeks I 10 5 4i .66 1.92 3-24 24 to 27 weeks I 9/ SY* 43 1.78 2.01 3.36 27 to 30 weeks I 9 6 45 1-92 2.1 1 3-5 30 to 33 weeks I sy 2 654 47 2.0 2.19 3-6 33 to 36 weeks I 8 7 49 2.18 2.24 3.76 33 to 30 weeks I 7/2 7# 5i 2.3 2.4 3-9 Somatose Milk. This contains: Proteins 8.8 per cent. Fat . . : 16.5 per cent. Carbohydrates 34.6 per cent. Salts 1.5 per cent. It is practically Ramogen containing lactosomatose, which is an albumose of casein and contains 5 per cent, tannin in firm chemical combination. Its purpose is supposed to take the place of the soluble lactalbumin in mother's milk, which plays an important factor in the easy digestibility of the curd. It is very readily assimilable. Indications. It is useful in all cases of weak digestion, in acute, subacute, and chronic inflammation of the intes- tinal tract, and in wasting diseases, as essential marasmus, scurvy, and rickets. It is employed in the same dilutions as Ramogen. Condensed Milk. Milk evaporated in vacuo, after sterilization, constitutes condensed milk. It may be sweet- ened or unsweetened, fresh or sold in cans. The last is the product commonly used. It contains a large amount of carbohydrate, mainly in the shape of cane-sugar, which is added as a preservative. When the can is opened the con- 132 ARTIFICIAL FEEDING. tents should be poured into a china or glass pitcher. It is kept covered on ice, and should not be used after the second day. Its composition, according to the manufac- turer, is as follows: p a t 9.61 per cent. Protein 8.01 per cent. Carbohydrate (42.91 per cent, cane-sugar, 12.03 per cent, lactose) 54-94 P er cent. Salts 1.78 per cent. Water 25.66 per cent. 100.0 per cent. Condensed milk is rich in sugar and poor in fat, protein, and mineral salts. It has been a very much unjustly con- demned food and, at the same time, a very much overused one. Infants fed. exclusively on, condensed milk grow fat, but have poor resisting powers, readily succumb to* the acute infectious diseases and pulmonary trouble, and fre- quently develop rickets and, less often, scurvy. They are often anemic. Nevertheless condensed milk, properly diluted to the digestive capacity (about I part in 12 or 16 of water at the outset, increasing the strength up to about i in 6), is a valuable adjunct to our feeding armamen- tarium. It is best given diluted with a cereal-water. Where protein or fat intolerance exists, this food is often valuable. Especially has it been found useful in some cases of summer diarrhea as a go-between, as it were, between the starvation period and the time when a return is made to fresh milk formulas. Condensed milk should only be employed in those cases of summer diarrhea where it can be proven that the condition is not> dependent upon sugar intolerance. After the acute symptoms have subsided a weak dilution of condensed milk is made with barley-water. This is grad- ually strengthened, and one bottle of the condensed-milk CURD MODIFIERS. 133 feeding is daily or bidaily replaced by a weak freshr-milk formula, until all are replaced. The fresh-milk mixtures are then slowly strengthened. Condensed milk is cheap. It therefore must often be considered when feeding the poor, especially in rural or semirural districts, and also in summer, as it is practically sterile and requires only the addition of a sterile diluent. When travelling for a long distance, it, alone, may be depended upon. When continued over any length of time, it must always be supplemented by the feeding of fresh fruit- or vegetable- and beef- juice. Soya Bean. This has been much advocated by Ruhrah. The bean is made into a flour by the Cereo Company of Tappan, N. Y., and contains 44 per cent, protein, 20 per cent, fat, 10 per cent, cane-sugar, and a trace of starch. In infancy it has been recommended as a gruel: 4 to 8 level tablespoonfuls and a pinch of salt are added to i quart of water. Boil fifteen minutes. Strain. Add water to a quart. Cool. It may be used in this manner or added to milk. In order to prevent the gruel from settling, i to 2 teaspoonfuls of barley-water may be added. This adds 0.6 per cent, to 1.2 per cent, of starch. CURD MODIFIERS. The following substances, useful as additions to or sub- stitutes for cows' milk, merit special mention as mechanical modifiers of the curd of cows' milk: Flour Ball (Plain). One pound of clean wheat-flour is tied in the shape of a ball in a bag made of unbleached muslin or balbriggan. The foot of a new, white stocking, size 10, will answer. It is placed in water and boiled con- tinuously for eight hours. At the end of this time it is removed from the bag and placed on a plate in an oven and 134 ARTIFICIAL FEEDING. slowly but completely dried out. It will appear with an outer skin, as shown in Fig. 25. It is now cracked, opened, and the inside is grated or pulverized and sifted. The pul- verized flour ball is added to each bottle just before feeding, in the amount of from ^ to I teaspoonful, or it may be used as detailed in Chapter II, page 108. Flour Ball (Dextrinized or Browned). This is made as just described, except that after breaking open the ball is baked to a "bread brown" and this portion is grated and Fig. 25. Flour ball. One is cracked open into three pieces. The inside () is pulverized and sifted. The hard shell (A) is discarded. sifted. This baking process is repeated as often as neces- sary. Flour ball will keep indefinitely, provided it is kept perfectly dry and in an air-tight container. This is to pre- vent the growth of mold. Uses. This, an old-fashioned, time-honored "grand- mother's remedy," has, unfortunately, been almost for- gotten and passed into disuse. It is an excellent agent to add to the formula where the infant cannot digest the curd of the milk. It is especially healing and soothing when this condition is associated with diarrhea. When constipa- tion supervenes, the amount of flour ball should be grad- ually lessened and finally omitted. Browned or dextrinized CURD ^MODIFIERS. 135 flour ball should be used in those cases where the plain flour ball produces too much gas, as it may in infants wiho cannot digest starch very well. In addition, in these in- stances, when the simple browning is insufficient, i or 2 grains of Fairchild's extract of pancreatin may be added to each bottle. Benger's Food. Though a proprietary, as a curd modi- fier this food may justly find a permanent place in the dietetics of infancy. It consists simply of extract 'of pan- creatin and of pulverized flour ball, and may be conveniently used as a substitute 5 for it, as the long time required for the preparation of the latter is thus omitted. This food is used in the proportion of 5 per cent, of the total formula or less, usually less (2.^/2 per cent.). The ingredients of the for- mula, with the exception of the Benger's Food, are mixed in the usual manner. A small quantity of the mixture, about an ounce or two, is rubbed into a smooth paste with the Benger's Food. The remainder of the formula is brought to the boiling point in a double boiler. 1 This is then poured over the paste. Mix well; allow to stand fifteen minutes without fire, but covered. Heat quickly a second time to the boiling point in a single boiler placed over a low flame. Stir the mixture constantly to prevent burning. Cool. Bottle. Ice. The effect upon green stools is almost immediate, chang- ing them to a smooth yellow, with a normal or slightly acid reaction. The amount of Benger's Food is gradually re- duced and finally omitted. The only objection toi the use of this preparation is that the milk must be boiled. In sum- 1 It must be remembered that substances do not actually boil in a double boiler. They simply steam and bubbles are seen about the edges ; or the temperature may be taken with a thermometer. 136 ARTIFICIAL FEEDING. mer this is an advantage. If the necessity for its prolonged use exists, fruit- and meat- juices must be fed to the infant. Imperial Granum. From I to 2 tablespoonfuls of Im- perial Granum are added to I pint of milk and boiled one- half hour. At the end of this time the addition of a suffi- cient quantity of water is made to bring the total volume up to a pint. As a cereal-water Imperial Granum is a use- ful curd modifier, and adds materially to the nutrition of the formula on account of the extra starch, which most infants are able to digest at a very early age (Kerley). This preparation must also be reinforced by the feeding of meat-, vegetable-, and fruit- juices. SUBSTITUTES FOR MILK-SUGAR. For reasons previously stated the milk-sugar of com- merce frequently forms a poor substance with which to* pro- vide extra carbohydrate. For this purpose other sugars have been employed. Cane-sugar (Saccharose) in many instances is an excel- lent substitute. Experience with it has verified all that is claimed for it by Jacobi. One ounce equals about 120 calories. Mead's Dextri-Maltose and Loeflund's Food Maltose. Malt-sugar, or maltose, is more rapidly absorbed than either lactose or saccharose. The degree of assimilability of these three sugars is indicated as follows: Maltose 7.7 grams + per kilogram (Ruess). Lactose 3.1 to 3.6 grams per kilogram (Gross). Saccharose About the same as lactose (Ruess). The power to assimilate maltose is therefore double that of the other two. It has been further shown that larger amounts of maltose can be taken by the infant than either SUBSTITUTES FOR MILK-SUGAR. 137 of lactose or saccharose, without sugar appearing in the urine. This is probably due to the fact that maltose, ab- sorbed as such into the body, is acted upon by a special ferment found in the muscles, blood, and other tissues. Maltose causes a more rapid gain in weight. Its combina- tion with dextrin increases this power. It does not readily ferment in the intestinal tract. For dietetic purposes, how- ever, pure maltose is inaccessible on account of its expense. It therefore appears on the market in combination with dextrin in the shape of Mead- Johnson's Dextri-Maltose and as Loeflund's Food Maltose. These resemble each other closely; the latter being imported, is therefore more ex- pensive. They are each added to the formula in any extra percentage desired, from I to 5 per cent. ; i ounce to a 20 ounce mixture equals 5 per cent, extra carbohydrate. When maltose is employed the stool is often characteris- tically brown or brownish yellow. One ounce of either of these preparations approximates 120 calories. Composition of Dextri-Maltose. This practically con- sists of starch converted by malt diastase, the percentage of maltose and dextrin being respectively regulated by the temperature at which the process is stopped and the length of time of exposure to this temperature. It contains neither cellulose, protein, nor fat : Maltose 51.0 per cent. Dextrin 42.7 per cent. Salts 2.0 per cent. Moisture 4.3 per cent. Composition of Loeflund's Food Maltose. Loeflund's Food Maltose contains, approximately: Dextrin 60.0 per cent. Maltose 40.0 per cent. Salts 0.3 per cent. 138 ARTIFICIAL FEEDING. Soxhlet's Nahrzucker. This preparation is marketed by the Arcady Farms of Lake Forrest, 111. It is added as extra carbohydrate in the amounts of i to 5 per cent, of the milk formula. It is called nutrient sugar, and was elab- orated by Prof. Dr. Soxhlet. It is dissolved in boiling water. The milk and other ingredients of the formula are added and the whole sterilized. Its composition is similar to Dextri-Maltose and Food Maltose. FEEDING AFTER THE FIRST YEAR. At 12 months an infant should be receiving whole, un- diluted, cows' milk. At this time additions should be made to the dietary in the shape of cereals, and other foods to be detailed. This statement bears modification in so far as some .infants are able to digest whole milk at an earlier age, and, at the same time, to receive foods that require chewing. Others, again, may not be able to take care of strong food at this time. It is clearly a problem of the individual. Many children beyond a year of age are seen whose nutrition has suffered for the want of strong food, and who are weak and undernourished. In these cases a change in diet to solids is productive of marvelous results. On the other hand, it must not be forgotten that malnutri- tion results as well from overfeeding as feeding an infant things which it cannot digest. How are we to judge, and what are the guides to indicate that the gastrointestinal tract is ready for the digestion of food that requires com- minution? Aside from the condition of the general health and of the digestion, the one single thing that would indi- cate digestive strength is the presence of several teeth. This is a safe indication to commence the feeding of solids FEEDING AFTER FIRST YEAR. 139 and semisolids irrespective of the age, provided the infant is not suffering from indigestion. The use of the bottle should not be permitted beyond 12 months in most instances, and promptly at this time the infant may be taught to take its milk from a cup. Some babies take and relish other food, especially thin cereals and rusk or zweiback, as early as 6 months, but as a general proposition the end of 12 months is the best time to commence extra feeding. A practical point of importance is the statement frequently volunteered by the mother, that her baby will not take this or that food. The acceptance of foods other than the bottle is a matter of education, and the baby must get used to the new substances. Thus, an infant may refuse an egg. It should not be forced, but one should be offered to it again in a few weeks or a month. The additions to the food should be gradual and should consist primarily of well-cooked cereals, as oatmeal, cream of wheat, and cornmeal. These should be cooked at least two hours, with or without milk, and served either with milk and sugar or with butter or meat-juice. Rice is a useful cereal at this time, but must be cooked at least three hours. Mashed baked potato (page 147), with milk and butter or beef -juice, is of value. Bread and butter may also be allowed. For desserts, junket or rice-, sago-, or other pud- ding, or mashed baked apple, or the inside of prunes, may be used. At this age infants should receive not more than five, and better but four, meals a day, so arranged as to give plenty of rest for the stomach, and that the heaviest meal should be given in the middle of the day and the lightest at night. The schedule appended has given uniform satisfaction : 140 ARTIFICIAL FEEDING. DIET No. i. Diet for Age Date Breakfast (6.30 to 7 A.M.). (i) Glass of milk and stale bread broken in it. (2) Cereal, as oatmeal, arrowroot, rice, grits, cooked at least two hours (rice, three hours), and covered with milk. If desired, can be sweetened to taste. (3) Soft-boiled egg and bread and glass of milk. Second Meal (10 A.M.). Milk. Third Meal (2 P.M.). (i) Beef-blood, beef-tea, or fat-free gravy containing stale bread broken in it, and a glass of milk. (2) Rice and grits cooked three hours or mashed baked patato with beef-tea or beef- blood or gravy. (3) Soft-boiled egg, buttered stale bread, and glass of milk. Rice-, sago-, or other pudding, or junket, can be given for dessert; mashed baked apple. Fourth Meal (5 P.M. to 6 P.M.). Glass of milk or milk 'and crackers. Fifth Meal (9 to 10 P.M.). Glass of milk. This diet should not be used beyond the age of 18 months. The fifth meal may preferably be omitted and the time of feeding indicated may be adjusted to fit the routine of the household. If an infant has been kept on the breast up to the age of 12 months or longer, the change to this diet may be made at once, except that, where it calls for milk, diluted milk may be given at first. If an egg be given for breakfast, it should not be given at the midday meal, one a day being ample. At the age of 18 months, further additions may be made, especially at the midday meal. Soups made from mutton, fish, or chicken, either plain or containing a cereal or vege- table, are valuable. The most important addition is meat in the shape of finely cut, rare, broiled steak; lamb-chop, roast beef, boiled fish, or white meat of chicken. Desserts may include custard and bread-pudding. Only three prin- FEEDING AFTER SECOND YEAR. 141 cipal meals a day are given, with a very light lunch between, at 10 A.M. and at 4 P.M. : DIET No. 2. Diet for Age Date Breakfast (7 to 8 A.M.). (i) A slice of bread and butter or soda or graham cracker, or shredded-wheat biscuit with a glass of milk. (2) Soft-boiled egg, glass of milk, bread and butter. (3) Oatmeal, arrow- root, wheat-grits, hominy, cream of wheat (farina), cooked at least two hours with milk; glass of milk. Lunch (10 A.M.) Glass of milk with stale bread, zweiback or cracker, buttered if preferred. Dinner (2 P.M.). (i) Rice boiled three hours, with meat-gravy or milk, or mashed baked potato moistened with butter or beef-juice; glass of milk. (2) Clear vegetable soup or soup made from mutton, lamb, fish, or chicken, clear or containing rice, celery, sago, farina, or stale bread or crackers broken in it; bread and butter, and rice-, sago-, or bread- pudding; custard, junket, apple-sauce, or stewed prunes (pulp), as dessert. (3) Soup, small piece of finely cut white meat of chicken, broiled lamb-chop, tender steak, roast beef, or boiled fish, bread and butter, and dessert. Afternoon Meal (4 P.M.). One to three lady fingers, or piece zweiback. Evening Meal (6 P.M.). Bread (plain or buttered) and milk. This diet is not to be used beyond 2 years. FEEDING AFTER THE SECOND YEAR. The diet now commences to assume more of the char- acteristics of that of the adult, in that a greater variety of food is allowed. The afternoon luncheon is often omitted. Occasionally a little pure ice-cream and a lady finger are allowed. Between 7 and 8 A.M. breakfast is served and con- sists of orange- juice, scraped raw apple, raw ripe or stewed peaches, apple-sauce, California grapes freed of skin and seed, baked apple or stewed prunes, cereal as oatmeal, 142 ARTIFICIAL FEEDING. hominy, wheaten grits, cream of wheat, or other porridge; a small portion of finely cut beefsteak (broiled) or lamb- chop, and bread and butter and a glass of water. If meat be omitted, and it should be if fed at noon, an egg and a glass of milk may be substituted in the morning. At 10 A.M. the child may receive its bath, to be followed by a small glass of milk and a cracker, or a small cup of broth. Its morning nap follows. Dinner is served at 1.30 or 2 P.M., and consists of soup, a meat, two vegetables, bread and butter, dessert, and a glass of moderately cold, pure water. The varieties for selection are noted below. At 6 P.M. a supper consisting of bread and butter and milk, or bread and butter and apple-sauce and water, is given: DIET No. 3. Diet for Age Date . Breakfast (7 to 8 A.M.). (i) Orange-juice, scraped raw ripe apple, raw ripe or stewed peaches, apple-sauce, grapes freed of skin and seeds, baked apple or stewed prunes, oatmeal, hominy grits, wheaten grits, cream of wheat, or other cereal porridge, well cooked and served with plenty of milk and sugar to taste ; small portion of finely cut broiled beefsteak or lamb-chop, with bread and butter. (2) Cereal and fruit as above, with soft-boiled or poached egg, with bread and butter and a glass of milk. Second Meal (10.30 A.M.). (i) Glass of milk, with bread and but- ter, or soda cracker. (2) Bread and milk or graham crackers and milk. Chicken- or mutton- broth, with bread or crackers. Dinner (1.30 P.M.): Clear soup made from beef, chicken, lamb or fish, or soups containing well-cooked rice, barley, farina, celery, or noodles, or oyster- or clam- broth ; roasted or broiled or stewe'd chicken, turkey, squab, beef, lamb, fresh fish cut fine ; mashed baked potato with butter or beef-blood on it; stewed celery; asparagus tips; spinach (German style) ; stewed noodles with milk dressing ; stewed onions ; skinned and mashed peas and lima beans ; creamed squash ; bread and butter. As dessert, rice-, sago-, tapioca-, farina-, or plain bread- pud- DIFFICULT FEEDING AFTER FIRST YEAR. 143 ding; junket, egg-custard, or cornstarch, or any of the fruits mentioned above. (Selection for dinner should consist of a soup, one meat, not more than two vegetables, bread and butter, and dessert.) Supper (6 P.M.). Bread and butter and milk, or crackers and milk, Diet not to be used for child under 2 years. If absolute regularity is practised at this time and no departure is made from the foods contained in the list appended, there will be no digestive derangements. Over- feeding or yielding to the importunities of the child will only bring disaster to it and sorrow to the household. Tea, coffee, pastries, and an undue amount of sweets, a piece of chocolate being allowed each day, fresh bread, beer, alcohol in all forms, made dishes, smoked or pickled foods, cheese, bananas, an excessive amount of cakes and ice- cream should find no place in the child's dietary, even up to the age of 5 or 6 years. It is just as easy to train a child to eat and to relish the correct foods as it is toi allow it to eat indigestibles. The gain to its digestion and nutrition is increased many fold. DIFFICULT FEEDING CASES AFTER THE FIRST YEAR. In those children who' cannot take whole milk, Diet No. i may be given with the breast or with diluted milk, or with no milk at all. These cases often follow an attack of summer diarrhea late during the first year, or during the first half of the second year. A return to milk means a renewal of symptoms, and main reliance must be placed upon mutton- or beef- broth, cereals as rice and farina, and stale bread, and eggs. A diet of this kind will often cause the stools to become normal without the use of medi- cation. The return to milk must be made with the utmost caution, using it boiled at first and well diluted. 144 ARTIFICIAL FEEDING. Again, cases of delicate digestion occur, in which it is impossible to place one's finger exactly on the cause. All that can be said is that the children are delicate. Here individual experience and experience with the individual child, alone can be our guide. The dietary must be carefully scrutinized, and each article that seems to disagree must be eliminated. The stools must be carefully studied in order to learn what substances pass undigested. As a rule, highly seasoned or overfatty foods cause disturbance. In no instance should the evening meal be large, and great care to prevent overfeeding should at all times be taken, the preferable idea being to give several small meals. Where vomiting occurs as a frequent symptom, proteins are to be avoided, as they may be responsible for an increased acidosis, as shown by acetonuria, and the acid fruits and carbohydrates are to be especially pushed. Where night- terrors occur, with febrile attacks and indicanuria, reduce the proteins and sugars and increase the supply of water. During an attack of fever all food had better be withdrawn, or at best the diet reduced to simple liquids (Chapter XIII). FOOD RECIPES. Beef-tea No. i. To i pound of lean chopped beef, free of fat, add i quart of water. Boil one hour, renewing the water from time to time. Strain. Cool. Remove fat. Salt to taste. Warm before feeding. Fresh daily. Beef-tea No. 2. To i pound of lean chopped beef add i quart of boiling water. " Keep warm one-half hour. Strain. Place on ice. Remove fat Salt to taste. Warm before feeding. Fresh daily. This is more rapidly made than No. i. Both may be used as substitute articles of diet, plain or PLATE X Same case as Plate JX. Diarrhea more advanced. Note blood and mucus: some green and discoloration by bismuth. Very little milk feces present. FOOD RECIPES. 145 in combination with white of egg, egg-water, cereal-water, or a small amount of the cereal itself may be added. For older children celery or onion flavoring may be used. Expressed Beef-juice. Cut into squares one-fourth to one-half pound of fresh lean beefsteak. Rump or round will do. Place in a clean pan without fat or butter, and heat until the pieces of meat are just "whitened" on all sides. Express the beef "juice" or blood with a clean lemon-squeezer. Salt to taste. Keep on ice. Remove fat. Give infant from foss to f3ij three times a day on an empty stomach. Exactly one-half hour before feeding is tot be preferred. Before feeding it, heat by placing the desired amount in a spoon and holding the latter over some steam. If the juice changes color and becomes brown it has been heated too much and must be discarded for other. The purpose of heating is to warm it not to cook it, otherwise the purpose for which it was given will be lost. Expressed beef -juice should be fed to all bottle babies after the second or third month, and should be continued until after the nursing period. Most infants enjoy it. It prevents, and assists in curing rickets and scurvy. Mutton-broth. To I pound of fresh, lean, chopped mutton add i quart of water. Boil one hour. Renew water as it evaporates. Strain. Cool. Remove fat. Salt to taste. Fresh daily. Warm before feeding. Useful in cases of diarrhea, alone or in combination with egg-albumin, cereal-water, or the whole cereal. Veal-broth. Made as above, substituting veal. Useful in constipation. Chicken-broth. To every pound of chicken add i quart of water. Proceed as under mutton-broth. A useful sick- room delicacy, alone or in combination as above. 10 146 ARTIFICIAL FEEDING. Squab-broth. To one freshly killed and thoroughly cleaned and washed squab, add sufficient water to cover, and a handful of washed celery tops. Boil fromi twenty minutes to> one-half hour. Strain. Cool. Remove fat. Salt. An excellent stimulant to the appetite. Useful as a change. May be used plain or in combination with cereals, especially well-cooked rice. Vegetable-broth. Thoroughly wash i beet, i carrot, a handful of spinach, and some celery tops. Add i quart of water. Boil until vegetables are tender. Strain. Add sufficient boiled water to make a quart. Salt to taste. Use- ful as a laxative, antacid, antiscorbutic, antirachitic, or antiexudative. Creamed Broths. Any of the broths above detailed may be creamed or thickened. Rub i mediumhsized tablespoon- ful of wheat-flour into a smooth paste with a cupful of the cold broth. Add remaining portion of the quart. Bring to boiling point with constant stirring. Cool. Salt to taste. Warm before using. This adds to the bulk and nourish- ment of the broth and assists in its constipating effect. Burnt-flour Soup. Brown i tablespoonful of wheat- flour in a clean pan, with or without butter. Add.i quart of water and bring slowly to boiling point with! constant stirring. Salt to taste. Very useful in diarrhea in older children. Fed cool or warm. Beef-jelly. To i pound of fresh, lean, chopped beef add i pint of water. Boil one hour. Renew water. Strain. Salt to taste. Allow to cool, when it jellies. A sickroom delicacy. Rice. Wash a cupful of best rice several times with warm water. Add sufficient water to cover it. Boil three hours. Renew water from time to time as needed. Strain. FOOD RECIPES. 147 Salt to taste. Rice should be mushy. Taken with milk, mutton-broth, butter, salt, meat-juice, or sugar and cinna- mon. May be mixed with apple-sauce. Cornstarch. Rub 2 tablespoonfuls of cornstarch into a smooth paste with milk. Heat what remains of I quart of milk. Beat up 2 eggs well. Add the hot milk, the eggs, and 2 ounces of sugar and a little salt, to the cornstarch paste. Mix well. Bring to a boil, stirring constantly. Cornmeal-gruel. One-half cupful of selected yellow cornmeal is sprinkled into I pint of hot water or hot milk. Salt is added. Cook for one hour in a double boiler. Arrowroot. Rub I teaspoonful of best arrowroot into a smooth paste with little milk. Add y 2 pint of boiling milk, meanwhile stirring. Cook five minutes without burning. Sweeten and salt to taste. It may also be flavored with vanilla or cinnamon, etc. Arrowroot-water. Add, without lumping, I teaspoonful of arrowroot to I pint of water. Boil one-half hour. Re- new water to a pint. Salt to taste. Useful as a drink plain or flavored with vanilla or added to milk as a diluent to attenuate the curd. Cream of Wheat, or Farina. Made as cornmeal-gruel. Stewed Squab. See squab-broth, page 146. Baked Potato. \Yash a large potato clean. Dry. Punch full of holes with a fork. Dampen the outside and cover with salt. Put in a hot oven in a pan in which salt has been placed; Bake quickly. Break open at once. Mash and' serve with milk, butter, or beef-juice. Salt to taste. Spinach. Wash spinach ten times with cold water, re- moving all grit and worms. Cover with water to which a little salt has been added. Cook until tender. Place in a 148 ARTIFICIAL FEEDING. collander to remove all water. Chop very fine on a clean board. Brown a little flour with butter, in a pan. Stir in the spinach until hot. A little milk or cream may be added if desired. Stewed Celery. Separate stalks of celery. Thoroughly wash. Cut stalks into small pieces. Cover with slightly salted water. Stew until tender. Pour off water. Add a little plain milk or milk to which a little flour has been added. Add a small piece of butter, dash of salt and pep- per. Heat to boiling. Stewed Onions. Pare young onions of medium size, then prepare as celery. Coddled Eggs. Place a fresh egg in boiling water. Remove from fire. Allow egg to remain immersed two minutes. Open at once. Egg-water. The white of I fresh egg, beaten slightly, is added to i pint of cool water. Shake well. Strain. Salt and sweeten, if desired, to taste. Feed plain or with cereal-waters, or beef -juice. Toast-water. Pour I pint of boiling water over I large piece, of well-browned toast made of stale bread. Stand five minutes. Strain. Salt to taste. Useful in diarrhea, given cold or hot. Lime-water. Piece of unslacked lime size of a walnut. Cover with water and mix well until thoroughly slacked. Allow to stand twenty-four hours. Decant. Filter. Junket. Warm i pint of milk, flavored with vanilla, if desired, to about 100 F. Divide into small' glasses or cups. Stir quickly into each l / 4 teaspoonful of liquid rennet or Fairchild's essence of pepsin, If it be desired not to divide into glasses, the milk, sugar, flavoring, and ferment (f3j to fSij to the pint) may be mixed together FOOD RECIPES. 149 and the whole heated to 100 F. in a double boiler. Re- move and place on ice as soon as clotting 1 occurs. Baked Apples. Wash apples well. Core them. Fill holes with sugar, and, if desired, a small piece of butter. Place in a pan, with a little water. Bake until soft. Serve plain or with cream and sugar. A useful dessert. Orange-juice. Slice an orange in half. Remove juice by hard pressure or lemon-squeezer. Strain to remove seeds and pulp. Given cold on an empty stomach. Anti- scorbutic and laxative. Prune-water. Wash a pound of prunes clean. Cover with water. Boil one hour. Renew water of evaporation. Add no sugar. Strain. Laxative, antiscorbutic. Sugar may be added if desired. The prune-pulp is also a good laxative for older children. Acacia-water. Pour i pint of boiling water over I ounce of gum arabic and agitate until dissolved. Strain. May be used plain, cool, or be flavored with sugar, salt, orange- or lemon- juice. A small amount of brandy may also be added. Demulcent, febrifuge, thirst quencher. Gelatin. Soak the contents of I small package of Knox's gelatin for one hour in just enough water to cover it. Add i quart of boiling water. Stir until dissolved. Pinch of salt. Flavor with sherry wine, vanilla, or fruit- juice. Add sugar to the proper degree of sweetness. Set away to cool and thicken. A useful, cooling dessert. Has no nutritive value, but is filling and satisfying. Zweiback may be made by rebaking stale bread or cake, or it may be purchased. It is a useful, easily digestible foodstuff, and is slightly laxative. It may be served dry or with butter, or, more commonly, with hot water and sugar. Holland Rusk may be used as zweiback. CHAPTER IV. INFANTILE ATROPHY. Synonyms. Marasmus, Essential Marasmus, Decom- position, Infantile Wasting, Baby Consumption, Athrepsia. Definition. Marasmus should include only those cases of gradual but progressive loss of weight which depend upon the faulty assimilation of a food, faulty for the in- dividual and administered over a comparatively prolonged period of time. All other instances of wasting occurring in infants are symptomatic of more or less tangible causes. PATHOLOGY. In essential or dietetic marasmus there are neither gross nor microscopic demonstrable lesions which account for the symptoms. A further discussion as to the findings in a case dead from this disease would be time consuming and of no practical value. Those cases which exhibit tuberculosis, syphilis, chronic suppuration, acute sepsis of the newborn, obstructive pyloric disease or chronic meningitis, are not essential marasmus, but simply instances of wasting which are dependent upon any one of the factors aforementioned. ETIOLOGY. Predisposing Causes. Improper artificial feeding is re- sponsible for the majority of cases. It usually follows the causeless withdrawal of the breast. Marasmus is rarely, if ever, met in the breast-fed. Personally I have never seen a case. Diarrheal diseases in the artificially reared, especially in those cases encountered in the summer months, often are (150) ETIOLOGY. 151 responsible for such an impaired nutritional state that the degree of food tolerance does not again extend beyond the minimum quantity, or at least does not reach the optimum amount necessary to sustain life and to prorvide for gain. Many of these cases develop marasmus because the func- tional activity of the glands of the gastrointestinal tract has been so perverted that no food could subsequently be found which could again properly activate them to produce normal ferments. Hence normal digestion could not occur and assimilation of improper end-products was the final result. Recovery cannot ensue unless the proper food is found to normally activate these perverted glands. Poverty and improper hygienic surroundings, vitiated atmosphere, personal neglect, and overcrowding are predis- posing factors of prime importance, especially when com- bined .with impro'per and irregular nourishment. Infants upon the breast will stand a wonderful amount of abuse and neglect. Remarkable specimens of babyhood are fre- quently encountered in the slums. These infants thrive in spite of filth and poverty, retaining in many instances the one human heritage of which a perverted and selfish social system cannot rob them the milk from their mothers' breasts. Complete the theft deprive these poverty-stricken babies of human milk and the joined forces of artificial feeding and squalor will produce numberless cases of marasmus and fill many unnecessary graves permanent monuments of disgrace to our present-day, much-vaunted, but barbaric civilization ! It is not, however, to be assumed that marasmus is not met among the rich. Here idleness, indolence, indifference, hysteria, selfishness, and ignorance, as surprising as it is common, deprive many an infant of the 152 INFANTILE ATROPHY. better class, so called, of its rightful heritage of breast feeding. The baneful results of overcrowding and of artificial feeding are nowhere better illustrated than in hospitals for infants. These babies do not receive a sufficient comple- ment of fresh air. It is an impossibility for a nurse in charge of five or six babies, however willing she may be, to attend promptly to the personal and physical wants of her charges. Many of these babies do not receive their food properly warmed or the bottle is not held for them, and con- sequently the food becomes cold or the infant falls asleep with the meal unfinished, and the fact is not discovered until the time for the next feed arrives. The attending physi- cian either can not or does not study carefully the individual nutritional demands or the peculiar digestive capacities of his charges. In a word, these babies lack mothering and detailed care, and they cease to gain. They lose, and speedily there is developed marasmus. Ignorance as to the adaptability of the individual diges- tive apparatus to the various food elements may, on the part of the would-be dietitian, lead to serious digestive dis- orders which will eventuate in a perverted metabolism and marasmus. Thus, one infant may exhibit protein intoler- ance, another will be disturbed by fat, and yet another by sugar. Starch, fed in excess or over a prolonged period or exhibited without the additional food elements (protein, fat, sugar), may lead to such injury of the gastrointestinal mucosa as to prevent the proper assimilation of food. This is especially noted after summer diarrhea, where patients are for long periods kept upon cereal-waters (barley, rice, oatmeal) without the addition of milk (Mehlnahrschaden Czerny and Keller) . Scrutiny of the stools and the charac- ETIOLOGY. 153 ter of the symptomatology presented by the digestive organs will enable the practitioner to decide, in most instances, upon the mischief -making factor. (See Chapter II, page 104.) Age in itself has no direct influence on the incidence of this disease, although most cases begin under i year. After dentition has proceeded to the appearance of five or six teeth the possibility of marasmus, unless unusual circum- stances obtain, is extremely rare. Sex and race have no influence. Prematurity, usually associated with an unde- veloped gastrointestinal mucosa and a deficient glandular system, leads to digestive difficulties, at times insurmount- able, and upon these depends the development of marasmus. Exciting Cause. This is at present unknown. Many theories have been advanced, but none has received univer- sal acceptance. The depressed nutritional state and dimin- ished food tolerance probably result from a perverted body chemistry a disturbed metabolism wherein the calories can- not be supplied to the individual in a digestible form so as to provide for growth as well as to maintain body tempera- ture and tissue balance. Hence downtear exceeds upbuild, and the individual commences to feed upon his own stored tissues to 1 furnish sufficient calories to sustain life. This perverted metabolism may be produced by an initially per- verted activation of the salivary glands by a food improper for the individual. Thus results successively perverted activation of all the glands of the gastrointestinal tract. This idea may be amplified as follows : When the adult sees, thinks of, or tastes wholesome food, the functional activity of the salivary glands is inaugurated. This phenomenon, commonly known as "mouth watering," occurs as the result of stimulation of the nervous mechan- ism of the glands as the result of psychic or physical impulses 154 INFANTILE ATROPHY. transmitted through the sympathetic or sensory system. It may be assumed that this normal stimulation results in the elaboration of a saliva normal in every respect and capable O'f acting normally upon a normal food. The food thus prepared is swallowed. As the result of normal salivary digestion upon normal food, end-products, themselves nor- mal in every respect, are formed. The entrance of these normal end-products into the stomach is responsible in turn for the normal activation of the glands of the gastric mucosa. These therefore produce a gastric secretion also normal. This, acting upon the partially digested food, and end-prod- ucts of the salivary digestion, converts the whole into still further normal end-products characteristic of this stage of the digestive process. These, entering the duodenum, nor- mally activate the pancreas and the liver, causing these glands to elaborate their secretions in no way perverted. These now continue their normal action upon the remaining food and end-products normal to this stage of digestion. The final whole now enters the intestines, the glands of which are normally stimulated likewise to produce a normal secre- tion which, again acting upon normal end-products, finally completes the process of digestion by the conversion of all remaining food and normal end-products into normal final products, which, absorbed by the normal intestinal mucosa, eventually reach the blood and tissues via liver and thoracic duct, and these, being normal in every way, not only pro- vide for tissue upbuild and downtear, but for growth as well. Now let us consider the reverse. The mere sight or smell, not alone the taste, of abnormal or unwholesome food (abnormal or unwholesome for the individual), not only perverts the salivary secretion, causing an inhibition, but ETIOLOGY. 155 may even cause serious gastric and intestinal disturbances resulting at times in vomiting and diarrhea. In other words, if we substitute the word unwholesome for wholesome and abnormal for normal in the statements of the preceding paragraph, we may assume an hypothesis not at all unlikely in its applicability to the etiology of infantile atrophy. Primary abnormal stimulation by an unwholesome food produces the initial abnormal secretion and resulting abnor- mal end-product which, acting upon the whole line of gastric and intestinal glands, are the essential factors causing the production of abnormal secretions and end-products at each stage of the digestive process. Each abnormal end-product is responsible for the initiation of the abnormal glandular activation in each step following. The final product, when the end of the digestive process is reached, is abnormal for the individual does not nourish him, i.e., not only is down- tear and upbuild not secured, but growth is not inaugurated. Therefore the individual feeds upon his own tissues, loss ensues atrophy, malnutrition, marasmus decomposition becomes apparent. That this is theory cannot be combated. That it may be sustained by clinical facts and circumstantial data is also true. One common clinical experience is sufficient to war- rant its consideration. These cases of atrophy present neither a gross nor a microscopic anatomy as stated. No perverted or diseased state of the gastrointestinal mucosa is discernible. Therefore the productive element must reside in the food itself. In fact, it must be the food itself ! This is substantiated by many cases which have run the gamut of formulas, food mixtures, and a score of physicians and pedi- atrists, reduced to actual skin and bone, are commonly re- vived by the substitution of proper food (proper for the 156 INFANTILE ATROPHY. individual). In the majority of instances this food is breast milk or a fortunately thought-out milk adaptation. In other words, the cause and cure of the condition have been determined on the instant from which the infant commences to thrive the proper food has been substituted to produce normal activation of the salivary glands initially, from which will follow in succession normal activation of the stomach, the pancreas, liver, and intestines. The end-product is cor- rect and upbuild exceeds downtear. The tide is turned and the infant thrives. In other words, the etiology of infant Fig. 26. Essential marasmus. atrophy is the continuous use of a food faulty for the indi- vidual, and its successful therapy consists in finding the proper food for the individual a responsibility often more readily stated than accomplished, and yet withal, the con- ditio sine qua non. SYMPTOMS. The clinical picture of infantile marasmus is typical and, when once seen, is indelibly impressed upon the memory. It must be remembered, however, that other conditions will bring about a state of wasting identical in all appearances to that which we now understand as essential dietetic maras- mus. These infants (Figs. 26, 27, and 28) appear senile, SYMPTOMS. 157 weazened, and shrunken. The entire face, including the forehead, is wrinkled. The wrinkles are intensified by crying and surrounding the mouth they assume the form of a parenthesis. The features are pointed. The cheek-bones are prominent. The eyes commonly appear large and bright. There is an absence of fat in the orbit. This causes the eyeballs to recede. Later the eyes may be covered by a thick scum of mucus. The tongue is often clean and pre- sents a bright-red surface with swollen papillae. It may be Fig. 27. Essential marasmus. covered with milk-curds, or thrush. The buccal mucosa is pale. The sucking pads remain after every other vestige of subcutaneous fat is lost. The skin hangs in folds upon the arms and legs, especially at the axillae and on the inner aspects of the thighs. The skin may be muddy and dark, or may be unusually transparent. The skin over the but- tocks may be intact, but is often excoriated. These infants move their arms and legs slowly, sometimes appearing to do so with deliberation. On the other hand, they may lie quietly in their cribs, unless disturbed. In the beginning the cry is strong. Later it becomes whiny and, in fatal cases, just preceding dissolution, it may be hoarse and weak. The skin of the abdomen is loose and may be 158 INFANTILE ATROPHY. readily wrinkled when gathered between the thumb and forefinger, on account of the loss of subcutaneous fat. The belly is often distended. If these infants are laid naked upon their backs and their legs extended, they give the appearance of a frog wide abdomen, narrow hips, and skinny legs (Fig. 29). The temperature is subnormal. This is an important diagnostic point. The pulse is normal. It may become weak and rapid. Fig. 28. Marasmus. Characteristic attitude and appearance. Poor circulation shown by cyanosis of feet. Vomiting is a rare symptom. It is not an essential feat- ure of the nosology of marasmus. It may result from an acute digestive disturbance or indicate the effect of a tangible etiologic factor, viz., excessive fat or sugar feeding (exces- sive for the individual). The bowels move from once to five times a day. The movements usually appear well digested. Often they are green and contain mucus and curds. This follows a dietary indiscretion. If fat has been fed in excess, they are greasy. The fat is recognized by its response to its various tests (Chapter I, page 33). The movements may be constipated and greasy, loose and greasy, SYMPTOMS. 159 Fig. 29. Frog appearance in essential marasmus. Note the wide and prominent belly, the narrow hips and skinny legs. This descrip- tion is original with the author and has been of material assistance to him in teaching. 160 INFANTILE ATROPHY. hard and friable, or may contain soap (Plate VII). If the curds be protein they respond readily to the tests for this substance (Chapter I). The stool is neutral or alkaline. Where excessive quantities of sugar are fed, the movements are watery and usually acid and excoriate the anal region. The urine in most cases is normal. It may be concen- trated and deposit urates and uric acid upon the diaper. In some constipated cases receiving too much fat it is ammoni- acal. The blood exhibits the evidences of a symptomatic ane- mia, and may appear unduly concentrated, the clotting time being shortened. These babies often have a voracious appetite, sucking vigorously upon whatever is placed within their mouths. They frequently suck constantly upon the hand until the fingers become macerated and sore (Fig. 27). The stomach is dilated and may present undue miotility. The heart and lungs present no> abnormalities. Where excessive starch (for the individual) causes the injury to the gastrointestinal mucosa (see Etiology, page 152), a peculiar type of atrophic infant is presented. The muscles are hypertonic. The tissues are dry and atrophied. The bowels are loose, the abdomen is distended, and anemia is marked. The etiologic factor, as provided by a history of prolonged starch feeding, must in this instance be known in order to conclude a proper diagnosis and to provide a proper therapy, viz., the exhibition of breast milk or of properly adapted cows' milk, and the exclusion of starch, at least for the time being. It must be remembered, however, that there are cases wherein an excessive starch diet is associated with an unusual increase in weight, due to the retention of water in the system. These babies are fat, SYMPTOMS. 161 doughy, and present a tendency to secondary infection, cornea! ulceration, bronchopneumonia, and skin lesions. Edema, unassociated with nephritis, is not uncommon, and depends upon hydremia (Fig. 30). If starch is withdrawn and milk added to the feeds, these infants lose weight. In the first instance, however, the loss is only temporary. A second and permanent gain is inaugurated finally when the gastrointestinal mucosa assumes its normal state. Those Fig. 30. Marasmus complicated by edema. Note the pits from pressure on the lower leg and thigh and also the edema of the de- pendent portion of the abdomen and of the face. cases which present corneal ulcerations are frequently fatal (Czerny). In yet another type, where atrophy is associated with hypertonicity, the physical appearance is not unlike that of tetany. The muscles are rigid and boardlike and the electrical excitability is materially increased. The head is often retracted. The stools frequently respond to the starch test with iodine. The weight curz>e exhibits a gradual depression in all cases of marasmus. From 5 to 6 ounces per week is the 11 162 INFANTILE ATROPHY. usual record of loss. At times there may be a week or two when the weight does not fall, bait remains stationary, or there may be a gain of an ounce or two. Sudden losses are not common unless there occurs an attack of diarrhea or some other complication. Where edema is present, espe- cially in moribund cases, a sudden rise in weight may be recorded. This should always be borne in mind, so> that the mistake may not be made of regarding it as a turn for the better. In cases which do not recover, the loss in weight usually proceeds to the point where the infant averages be- tween 6 and 7 pounds. It is also noted in some cases that when once the proper food is found, or a change is made from one formula to- another, a rapid gain of from 6 to 10 ounces may be recorded within forty-eight or seventy-two hours. The infant shows marked evidences of improve- ment in every way. After a week or two, however, the usual gain is from 3 to 8 ounces per week. COMPLICATIONS. Sudden and unexpected death may occur in these little babies when their condition seems to be no worse than it had been for some weeks previously. The spark of life has been fluttering foil some time when, unexpectedly but quietly, the supply of fuel having been exhausted, without struggle, it gradually ceases to burn and life is extinct. This fre- quently happens during the night, and the infant is found dead in bed in the morning. Hypostatic pneumonia may develop as a terminal evidence of feeble circulation and of lying in the prone position for a long time. These infants are susceptible to cold, chilling of the surface, and to sudden changes in temperature. Hence colds, rhinitis, bronchitis, and bronchopneumonia occur. All are poorly borne and COMPLICATIONS. 163 frequently determine a fatal outcome. Purpura, affecting the skin of the lower thorax and abdomen, and appearing as a thickly scattered, fine eruption, occurs from two to three weeks before death, in many cases. I have never seen a re- covery in which this symptom appeared. Should these cases develop an acute diarrheal condition, accompanied by severe straining, inguinal hernia may appear. In one case under my care, strangulation of a hernia occurred, and was successfully operated upon by Dr. Stillwell C. Burns. From the same cause prolapsus ani develops, and may be a troublesome though) usually not a dangerous issue. Anal excoriation and severe irritation of the entire buttock may seriously incommode the infant and interfere with its quiet. Stomatitis and thrush are usually directly dependent upon faulty technique in the antiseptic toilet of the mouth. Der- mal irritations of all varieties, bed-sores, macerations, inter- trigo, furunculosis, acute dermatitis and erysipelas are avoidable, troublesome and sometimes dangerous occur- rences in poorly kept cases. Edema occurs without nephritis and is an exceptionally interesting phenomenon, since its etiology is obscure (Fig. 30). It has been already re- ferred to as being responsible for a sudden increase in the weight. It appears first in the extremities and is a terminal state. It spreads upward and may involve the abdominal wall or the entire body. The temperature is very much below no'imal and the urine is clear, limpid, and free of casts and albumin. Its supposed association with injury of the intestinal mucosa by starch (Mehlnarschaden) has been previously noted. Its dependence upon the retention of fluid within the tissues, on account of the presence of sugar and salt in them, has been maintained by some authors. Although in most instances indicating a fatal 164 INFANTILE ATROPHY. outcome, I have seen this symptom, contrary to the fore- going view, entirely disappear following the daily injection, subcutaneously, of warm normal-salt solution. Sclerema and sclerodcrma may occur as prelethal conditions. Scurvy and rickets may be met as the result of carelessness in feed- ing proprietary foods or boiled preparations over too long a period of time without taking proper precautions. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. This must be made entirely by the exclusion of all other causes of wasting. There is usually a history of the groundless discontinuance of the breast, and the feeding in rapid succession of various milk formulas and a host of proprietary foods, some of which may agree and cause a temporary gain in weight. The mere presence of wasting does not, as we now understand it, necessarily mean marasmus. In my experience, the most common error in this connection is to regard wasting dependent upon hid- den chronic suppuration and wasting dependent upon pyloric obstruction as marasmus. As an instance of the first circumstance there appeared at my clinic at the Lebanon Hospital, some years ago, an infant 16 months of age, wasted to skin and bone, in whom the diagnosis of marasmus had been made. The age of the child 16 months and the presence of teeth led to the thought that some factor other than a dietetic error 1 was operative. Fever and leucocytosis were absent. A careful physical examination led to the diagnosis of encysted empyema, which was verified by exploratory puncture. Operation was followed by complete recovery within three months, In this case the absence of fever and of leucocytosis, and also of a careful examination, in all probability caused the DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 165 empyema to be ignored. The two former were absent no doubt on account of the fact that the infant's strength and resisting power had been so vitally reduced that neither the heat centres nor the leucocytes could any longer be stimu- lated by the toxins of the invading organisms; or the sys- tem had become immune to this particular bacterium, for the condition had in all probability lasted for months. The age of the child, presence of teeth, and the previous history of a pneumonia should have led to a careful physical ex- amination, if to nothing else. I have seen wasting due to other forms of chronic sup- puration double otitis media of long standing, chronic mastoid disease, pulmonary abscess diagnosed as simple marasmus and treated by formula. In one instance, in which death ensued, a fatal issue could have been avoided if the importance of the primary underlying factors had been appreciated. The mere mention of these facts should be sufficient to prevent the careful practitoner from falling into error. I have seen 24 or more cases of pyloric obstruction of one type or another, and in each instance save 2 was the diag- nosis of marasmus made. This is a grievous error, since non-surgical or surgical treatment will save the majority of these cases if they are promptly recognized. In maras- mus, vomiting is rare. In pyloric obstructive disease, it is a prominent and early feature, propulsive in character, and occurring without apparent cause. It is especially sugges- tive in breast-fed babies, occurring immediately or a few weeks after birth. This vomiting is usually responsible for taking these babies from the breasts, and this fact in itself should always arouse suspicion. In pyloric disease, inquiry will determine that the bowel movements are constipated, 166 INFANTILE ATROPHY. exceedingly small, infrequent, or entirely absent. Visible gastric peristaltic waves are present. The pylorus is fre- quently palpable. The administration of 10 grains of char- coal is followed by its delayed or non-appearance in the anal discharges and its recovery in the water following stomach wasting twenty-four hours later. The X-ray gives valuable information not only as to the presence of obstruc- tion, but also as to the degree of patency of the pyloric orifice, although this examination is not essential to an accurate clinical diagnosis. In conclusion it may be stated that the only symptoms which pyloric disease has in com- mon with marasmus are the progressive wasting and the subnormal temperature. Tuberculosis may be a cause for wasting. The term "babies' consumption" may, with propriety, be applied to this condition, but not to' "marasmus." Both terms are regarded by many of the laity as synonymous and, conse- quently, this idea is responsible not only for much con- fusion, but also for much unnecessary fear. Tuberculosis will be discovered by careful investigation of the lungs, glands, and bones in particular. Fever is a common possi- bility, but may be absent. A careful rontgenographic ex- amination of the bronchial nodes may determine these to be tubercular and a cause for the wasting. The abdomen should also be thoroughly palpated for enlargements, and the result of a carefully performed von Pirquet or Moro test should not be ignored in coming to a correct conclusion. Syphilis, without skin lesions, especially in the very young, causes not a few infants to rapidly shrivel and in outward aspect they closely resemble marasmus. At pres- ent the Wassermann test is of much value in detecting these cases. In other instances, where this cannot be made, re- DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 167 liance must be placed upon the history of frequent miscar- riages, lesions upon the mother or father or both, or the appearance upon the infant of copper-colored eruptions, mucous patches around the anus or in the mouth, or of rhagades (cracks) about the corners of the mouth, and a chronic nasal discharge (snuffles), together with the com- mon enlargement of one or both epitrochlear glands. Acute but sluggish sepsis of the newborn, manifesting itself by slowly forming metastatic abscess e.g., infection 1 Fig. 31. Atrophy or marasmus due to chronic cerebrospinal meningitis. of the umbilical stump, retroumbilical abscess, peritonitis in the newborn following navel infection is often associated with a shrivelling up process that gives to the infant a dis- tinctly marantic appearance. Cases of cerebrospinal meningitis (Fig. 31) frequently pass into a state of extreme emaciation when they do not succumb in the acute stage. This is especially true of basilar meningitis. Of course, in children beyond the stage of infancy the distinction from marasmus need not be made. In fact, if one bears in mind the history of the case, even in the very young, a mistake is hardly likely to occur, and the condition is mentioned merely to make the list of possibili- ties complete. 168 INFANTILE ATROPHY. Finally it must be stated that malignant disease of any form affecting the young will be recognized by the pres- ence of a growth, and the emphasis of local symptoms will direct the attention to the seat of the trouble. PROGNOSIS. Many cases of marasmus recover completely, no vestige of the disease remaining in after-life. No case of maras- mus should be regarded as hopeless until it is dead. Many marvellous transformations are wrought if the proper food can be quickly found. It may be said that the prognosis depends entirely upon the ease and facility with which the practitioner is able to adjust the food to the digestive capacity and to the nutritional demands of the individual. This responsibility is not always discharged without diffi- culty. Favorable signs are: a speedy change in the stools for the better, if they have been abnormal ; a small but ap- preciable gain in weight; a rise in temperature to normal or to a few tenths of a degree above this point. Unfavor- able signs are: frequent digestive disturbances, vomiting, diarrhea; a persistence of the subnormal temperature; sta- tionary weight or a loss in weight, and the appearance of edema or purpura. Complications, however trivial, espe- cially respiratory or infectious, are badly borne. Speaking generally, it can be stated that the nearer the age approaches a year and the shorter the duration of the condition, the better is the prognosis. Environmental conditions and attention to details also materially influence the outcome in individual cases. The results of treatment in private cases are therefore better than in institutions. TREATMENT. 169 TREATMENT. Preventive. Disease will largely disappear when pov- erty and ignorance are no more ! The incidence of maras- mus will share in this general decadence of misery when society ceases to rob man of his right to toil and to share justly in the products of his labor, and no longer denies to his offspring the right to suck its mother's breast. So too, when physicians and mothers cease to advance their arti- ficial and false ideas as to the feeding of infants, and dis- continue to condemn without reason the human milk- supply in individual cases, and when manufacturers of patented foods cease in their efforts to dictate to physicians how to feed the infants of the land, the cases of marasmus will disappear. Baby-saving shows, mothers' clubs, neigh- borhood talks by competent nurses and physicians, and educational propaganda of every variety should be en- couraged to instruct the motherhood of the country as to the necessity of conserving the human milk-supply, and as to the means of accomplishing it. Hospitalism should stop. The moment an infant has recovered from an acute infec- tion, if this be the cause of its presence in the hospital, it should be removed therefrom to its home or to the country, and to its mother's breast. I am in full accord with the teachings of Henry Dwight Chapin on this point. If pos- sible, during its stay in the hospital it should be nursed by its mother. When for a sufficient reason an infant is de- prived of its mother's milk, every means should be exerted to provide it with clean cows' milk so adapted as to meet its digestive capabilities, and to provide it with sufficient calories to meet its nutritional requirements. Active Treatment. Marasmus should not, if possible, be treated in a hospital. From the preceding it may be cor- 170 INFANTILE ATROPHY. rectly inferred that the mortality in institutions is higher than in private practice. Especially if the infant be under 6 months of age, every effort should be made to secure breast feeding. If its mother's milk is not available the milk of another woman should be provided. This is not always possible, however, among the poor, unless a volun- teer be secured. If one woman does not supply sufficient milk, the milk of many healthy women, if obtainable, may be mixed together and fed whole or diluted by dropper or bottle. If all breast-milk feeding cannot be had, if it be at all possible, one or more feeds of human milk should be given in twenty-four hours. A case recently seen with Dr. J. Cohen illustrated the almost specific effect of breast milk. The marantic infant, 4 months of age, was one of twins. The patient was receiving cows' milk, diluted, and the other twin was upon the breast. This baby was fat and healthy ; the other was in a dying condition. It was placed upon the breast and the healthy infant, having had a good start, was put upon carefully adapted cows' milk. The sick infant made a complete and brilliant recovery and the healthy in- fant was not harmed by the change. Among the well-to-do, wet-nurses, carefully examined, may be secured at various prices. Their services are often invaluable in turning the tide toward recovery. Even though the wet-nurse's milk is excellent, it must be stated that the employment of these women does not always bring peace and contentment into the home. On the contrary, the practice of wet-nursing is far different from the theory. Temperamental differences between the wet-nurse and the mother, together with house- hold and domestic problems, often bring disaster to the arrangements when everything seems serene. Good results, too, may be secured; by artificial feeding. TREATMENT. 171 Every effort should be made to study thoroughly the pecul- iarities of the individual infant, and to determine the food element or elements which may be the causative factor or factors. The essential thing is to individualize, and not to treat infants by the same routine or by one method or sys- tem of feeding. Another essential is to secure clean milk and to keep it clean. With this in view, careful attention should be given to nipples and bottles, proper refrigeration, amount to be fed, feeding interval, the time consumed in taking the meal, and to the use only of sterile diluents. As a general procedure I do not favor the recent fad of long- interval feeding, for the reason that my experience with the older method of every two hours up to 3 months, with from one to two feedings during the night; every two and one-half hours up to 6 months, and one or no feeding dur- ing the night ; every three hours up to 9 months and every three and one-half hours after this time has demonstrated satisfactory results to me. I see no reason to change unless, in individual cases, where vomiting might be benefited by a prolongation of the interval. During the day an infant should be fed by the clock. It should be awakened for its food, the feeding interval being counted from the time it started its meal, not from the time at which it finished it. During the night it should not be disturbed at all for food unless it be very weak. The meal should not be given hurriedly at least from fifteen to thirty minutes being con- sumed, depending upon the amount fed. The nipple should be removed from the mouth at the end of every third or fourth suck. The food should be kept warm and the bottle should be held for the baby, and it should not be permitted to sleep while being fed. The habit of regularity will soon be formed, and the little patient will regularly awaken for 172 INFANTILE ATROPHY. its meal. The quantity fed varies as the appetite, the toler- ance, and the digestive capacity. Some cases do well on small amounts frequently administered. This is true of cases which vomit, especially where the longer-interval feeding fails. Roughly, the quantity may be regulated according to the rules given in Chapter II, page 102. It is well to calculate the caloric value of the daily quan- tity of food, for in this way we may know whether we are feeding above or below the food optimum. Thus may we in a sense prognosticate as to whether or not the food toler- ance permits of the administration of sufficient calories. Not infrequently, in very wasted infants, a larger number of calories are required to secure a gain in weight than the somewhat arbitrary standard would indicate. (See Chap- ter II, page 82.) Cases which exhibit protein intolerance may be handled in several ways. At the outset I wish to make it plain that my experience does not permit me to subscribe to the German view, that unmodified cows' curd is not only never harmful, but can be fed in almost incalculable amounts. I believe that mechanically divided cows' curd, or curd that has previously been predigested or, both, is not only harm- less in individual cases, but of great value. The coagulable protein may be entirely eliminated by the use of whey. With this method I have had little experi- ence, and therefore can neither condemn nor praise it. It has never appealed to me, although some authors recom- mend its use and report very good results. It cannot be continued as a permanent food, as it is lacking in con- structive elements. As soon as improvement is noted, addi- tions of cream, from */ 2 to I dram at a time, should grad- ually be made. As tolerance is noted these quantities may TREATMENT. 173 be increased. Instead of cream, slowly increasing amounts of whole milk may be added. It must be remembered that cream is but superfatted milk, and that whey contains some of the ferment which was used in its making. There- fore, unless the whey is previously heated to 150 F. to kill the ferment, either the cream or the milk will become coagulated. This may not cause any inconvenience as far as the infant is concerned, but may alarm the mother or the nurse, or the curds may not pass readily through the nipple. The whey must not, however, be heated above this or the lactalbumin will become coagulated. As soon as gain is inaugurated or it is seen that the whcy-and-cream or the whey-and-milk mixture is tolerated, a gradual change should be made to dilutions of milk. These should be weak at first and later strengthened. In selected cases I have had success with Ramogen manufactured by Prof. Biedert (Chapter III, page 129). It has been employed as a temporary food, and in some in- stances the results have been nothing short of brilliant. This is likewise true of Somatose milk, which resembles Ramogen, and also of condensed milk in selected cases of protein and fat intolerance. All of these preparations, how- ever, are but temporary foods and must be safeguarded by antirachitic and antiscorbutic remedies as fruit- and animal- juices. The character o>f the coagulable protein may be changed by simple boiling of milk, whole or diluted. The experi- mental work of Brennerman 1 and of Ibrahim seems to prove that the action of the gastric juice upon boiled milk is toi cause the formation of curds distinctly softer and finer and more closely resembling those of human milk than the 1 Journal A. M. A. 174 INFANTILE ATROPHY. curd which is formed as the result of the action of the gas- tric juice upon uncooked milk. In most cases, however, the simple boiling of the milk, without other means of modifica- tion, in cases of cow-curd intolerance is insufficient to over- come the difficulty. In any case, boiling should not be too long continued on account of the possibility of scurvy or, if it must be continued over a reasonable length of time, fruit-juices and beef-juice should be administered. The addition of cereal-waters or gruels made 1 from arrowroot, barley, oatmeal, rice, or wheat-flour, plain, as advocated by Jacobi or dextrinized as advocated by H. D. Chapin, is an excellent means of causing the curd to become comminuted in the stomach and to materially assist in its digestion. Where there is a tendency to looseness of the bowels arrowroot, barley, rice or wheat may be used, but where costiveness predominates oatmeal should be the choice. If starch intolerance exists, as manifested by much flatulence, dextrinization of these waters or gruels may be employed. This is accomplished by the addition of some preparation of malt or by the use of Cereo, which is a glycerite of diastase and is made by the Cereo' Company of Tappan, N. Y. This Company also manufactures a fine grade of cereal flours from which these waters or gruels may be made, but I have for years employed, with satisfac- tion the simple grains (Chapter II, page 87). In cases of difficult protein digestion the use of Keller's Malt Soup is said to give brilliant results, especially where the atrophy is associated with an intensely antmoniacal urine. South- worth's recent experience with this substance, especially in hospital cases, has been extremely encouraging. Malt Soup closely resembles the dextrinized gruels as recommended by Chapin. Malt Soup preparations made in America by the TREATMENT. 175 Maltine Company are now available. For a number of years, in cases where starch intolerance appeared con- spicuous, I have diluted the completed cereal-water with 50 per cent, plain boiled water. Where I have wished to impress the character of the stools, I have employed these waters full strength as the diluent, entirely excluding plain water from the formula. Sodium citrate will promote protein tolerance in some cases, especially where vomiting is present (Chapter II, page 109). Of value in many instances is pancreatization. Other cases do not do so well upon milk or milk formulas ordi- narily pancreatized. Of another form of pancreatization and curd modification that has given me much satisfaction I will speak presently. The feeding of pancreatized for- mulas must not be continued too long, as the digestive ap- paratus may be permanently weakened. The food is sub- jected to the action of the ferment for a period of from twenty to thirty minutes. If too long continued, excessive formation of peptone results and the preparation is made bitter. The time of pancreatization is gradually diminished and finally omitted (Chapter II, page 108). In treating marasmus proper parental intelligence and co-operation are as essential as proper food manipulation. The necessary means to purchase the best milk or access to a free milk station are items of no mean importance. Un- fortunately ignorance and poverty often prevail, and the physician must do the best he can with the means at hand. Under these conditions in particular, but also, among the well-to-do, where protein intolerance was present, and yet, where I felt it was necessary to feed protein in rather large amounts, I have had most happy results from buttermilk 176 INFANTILE ATROPHY. mixtures. It requires very little intelligence for the mother to learn how to make the food. Another consideration of prime importance is its cheapness. My method of using this preparation is as follows: I first place the baby upon the buttermilk-and-flour mixture (Chapter III, page 123), omitting the sugar until the movements become normal. This is practically an eiweissmilch with the exception that it lacks the curd of an extra litre of milk and it contains flour. I now commence to add cane-sugar, running the amount up to fifteen and three-fourths teaspoonfuls to the two-quart mixture. If everything goes well, and usually the gain in weight is inaugurated after the addition of the sugar, I gradually add cream, first a half-dram to every other bottle, then to every bottle, and gradually increase the amount as long as tolerance is maintained. I am forced, from my results, to regard buttermilk feeding as an ex- ceptionally valuable dietetic measure in marasmus. I have learned to depend upon it, as in many instances I am sure that it has saved lives. The mixture is, as before stated, easily made, but directions must be carefully followed. This is particularly true with reference to the constant stirring of the mixture during the second boiling (if it is employed in this manner, which I believe gives better re- sults than when the second boiling is omitted), i.e., after the buttermilk and flour and sugar solutions or the flour solution alone have been mixed together. Unless it is thoroughly stirred from the minute it is placed upon a low fire, unmanageable lumping will ensue. An infant may be kept on buttermilk for months provided antiscorbutic reme- dies, as beef-juice and vegetable broth or fruit-juices, are administered at suitable intervals. In conjunction codliver oil is valuable, especially when adminstered by inunction. TREATMENT. 177 As soon as a substantial gain is recorded (3 to 5 pounds) gradual or instantaneous transference may be made to properly adapted formulas of whole milk. I cannot recom- mend this substance too highly if it be intelligently employed. Instead of buttermilk and flour without sugar, eiweiss- milch answers an admirable purpose in causing the stools to become constipated and normal in aspect. Gradually carbohydrate, in the form of cane-sugar or Dextri-Maltose, is added. After five to six weeks a prompt return is made to whole-milk dilutions. Eiweissmilch may not be con- venient and may be difficult to make. The dried prepara- tion of eiweissmilch on the market known as Larosan is extensively employed by Finkelstein himself, and gives good results. Personally I have had a limited experience with it. I have observed its use in Finkelstein's clinic in Berlin. There I witnessed some good effects in the exuda- tive diathesis (vide Chapter XI, page 309) and in maras- mus. The stools in diarrhea in which sugar is the active etiologic factor are also favorably influenced. Asked to name one method of treating marasmus, where either protein or fat or both have given, trouble, which I favor most or rather which has given me the best results, aside from buttermilk, I should unhesitatingly recommend the use of some simple milk formula ivherein the curd had been modified by the old- fashioned Hour ball, with or without the addition of pancreatin, or by the use of Benger's Food, which is flour ball containing pancreatin. While this is a proprietary its; composition is clearly stated, and it is recommended as a milk modifier and not as a food. It simply represents an easy way of using flour ball without having to go to the trouble of making it. Either one of 12 178 INFANTILE ATROPHY. these preparations may be added in the amount of from 2.y 2 to 5 per cent, of the total quantity of the formula. I find the former percentage to answer most purposes. The heating to which the milk is subjected also materially assists in the digestion of the curd. I have never seen a case of scurvy develop oin account of the heating except in one instance where an unruly infant (Plate XI) refused to take fruit- or animal- juices. I believe this to be due to the fact that it has not been continued over too long a period and because fruit- juices, vegetable broth, and meat- juice are always used in conjunction with the milk feeding one of them or all. The method) of using flour ball or Benger's Food is described in Chapter III. The effect of both of these preparations upon the stools is rapid. The latter are changed within twenty-four to forty-eight hours into a light or golden-yellow mass of smooth, mushy consistency, with the characteristic slightly acid, not un- pleasant odor of normal breast-milk stools. This effect is continuous. Vomiting is usually checked, although it may continue and be without serious significance, and a gain in weight is inaugurated. Both the Benger's Food and the flour ball, as soon as the indications permit, are gradually reduced and finally omitted. The heating, however, is con- tinued for a week or so and then stopped. The quantity and quality of the formula are increased as the appetite and digestive processes warrant. If constipation persists it may be materially lessened by the use of from 10 to 40 drops of Philip's Milk of Magnesia in each bottle, or in every other bottle, or but once daily according to the result obtained. Of late I have been favorably impressed by the use of the liquid paraffin preparations (Chapter VIII, page 254). TREATMENT. 179 As to the character of the formula itself, experience and personal equation count for much. This statement is not made to sidestep the issue or on account of a desire to deny to the practitioner a clear exposition of the details of for- mula manipulation, but simply because it is a fact learned from large experience. It must, however, be stated as a truism that as good results may be obtained by the simple dilution of whole milkt or of skimmed milk as with any other method. One should start with a strength of about one-fourth milk and three-fourths diluent and gradually in- crease the quantity of milk. The key to the entire situation is provided by a careful study of the stools, and the adapta- tion of the strength of the formula to the digestive capacity. The method of dilution or of modification is really a matter of secondary importance. The physician must simply be able to increase or diminish the coagulable protein or any other of the food elements according to the indication. It cannot be too strongly emphasized that success depends upon the ability to individualize. If the cause of the digestive disturbance be fat intoler- ance (Chapter II, page no), whey may be employed for a short time. It contains a little less than I per cent, of fat. To it may be added gradually increasing amounts of skimmed milk. In other instances signal success has been achieved by the use of diluted whole milk or diluted skimmed milk. In all cases where skimmed milk is employed, it should be obtained by skimming the best obtainable whole milk, at home, after the cream is permitted to thoroughly rise. As tolerance is established one-fourth, one-half, and then three-fourths of the cream, which has been removed, may be poured back into the jar and the whole well shaken and 180 INFANTILE ATROPHY. then diluted to any strength, or any of these preparations may be pancreatized or modified by flour ball and pancreatin or by Benger's Food. The pancreatin in each instances acts upon the fat by reason of the steapsin which it contains. In using pancreatin only the best possible product should be employed and pains should be taken to see that it is strictly fresh. That manufactured by Fairchild Bros, and Foster has given me satisfaction. Buttermilk with flour and sugar or eiweissmilch with additional carbohydrates are also exceptionally valuable in cases of fat intolerance, especially the former, since both are weak in fat. If cane-sugar be employed to supply the extra carbo- hydrate, rarely will any disturbance attributable to> this source be demonstrable. Jacobi for years has advocated the use of this chemical in preference to milk-sugar, and my experience bears out the validity of his teachings. Of late, the malt-sugar preparations have come into 1 prominence by reason of the impetus given them by the German school of pediatrists. They owe their popularity to< the fact that they often cause a rapid and permanent increase in weight because maltose, which they are all said to contain in about the proportion of 50 per cent., is readily absorbed and rapidly assimilated by the tissues. The muscle and body juices contain a maltose-splitting ferment, and therefore any mal- tose absorbed as such is converted after it leaves the intes- tinal canal and is not again eliminated as maltose. On the other hand, lactose and saccharose, when fed in excessive amounts, are eliminated in the urine, not being converted in the tissues. Maltose is said to be twice as assimilable as either of these two. Mead- Johnson's Dextri-Maltose, Loeflund's Food Maltose, and Soxhlet's Nahrzucker are practically identical in composition. The first is more avail- TREATMENT. 181 able on account of its comparative cheapness. These prep- arations are used in the same strength as either lactose or saccharose, being added in the strength of from i to 5 per cent. If sugar is not borne well at all, buttermilk plain, or buttermilk with flour, but without sugar, or eiweissmilch furnishes the means of giving nutriment with a minimum of this substance. Additional sweetness may be secured by adding i grain of saccharin to the quart. Gradually, extra carbohydrate is added. Cases which do not tolerate sugar well suffer especially from a subnormal temperature when deprived of this element, and therefore must receive extra care by being protected with proper clothing and external heat. Where the history provides the evidences of starch injury, I. A. Abt 2 recommends milk containing a moderate amount of fat and the withdrawal of carbohydrate food, especially buttermilk mixtures, malt-soup, and cereal de- coctions. If possible to secure it, breast milk offers the greatest chance for recovery. It is administered first in small quantities. The primary withdrawal of starch may, especially in the hydremic types, cause an initial loss in weight. Next to breast milk undiluted cows' milk, at first in small and then in gradually increasing amounts, is recommended. Tea or water sweetened with saccharin (gr. j to the quart) may be administered to supply fluid. Care should be taken not to exceed the infant's tolerance for fats or, in fact, protein and sugar as well, as it must be remembered that the injury produced by the prolonged feeding of starch has impaired the tolerance for all the food elements. 2 Journal A. M. A., October 4, 1913, p. 1276. 182 INFANTILE ATROPHY. Food Preparations Other Than Milk. Useful in the treatment of marasmus are beef -juice, freshly made as directed on page 145, Chapter III, or Valentine's meat-juice, fruit-juices from oranges, grapes, or prunes stewed with- out sugar. Vegetable broths and olive oil are also useful. Meat-juices or fruit-juices are best administered, in small amounts, exactly one-half hour before feeding time. This permits the juice to enter the stomach after it is empty. The previous meal has, under normal conditions, practically passed out and entered the duodenum; hence there is no admixture of meat and milk a scientific adaptation of the Mosaic law which finds modern verification for its originally physical, though Biblical, basis. Vegetable broth (Chapter III, page 146) is used as a drink. It is usually acceptable to the infant. Sometimes it is not. It is a valuable antiscorbutic, antirachitic, antiexu- dative, antacid, and laxative remedy. Its use, however, should not be forced. In fact, this is true of any remedy or any food. Olive oil in doses of ^ to i fluidram is sometimes! well tolerated where the fat of cows' milk cannot be digested. It is best given one-half hour after feeding, especially where skimmed-milk preparations are used as food. Rectal alimentation with small amounts of pancreatized milk, and whisky nix to m.xx, administered once or twice in twenty-four hours high into the bowel, and previously wanned and following a cleansing 1 enema, may be useful in cases of extreme asthenia as a life-saving agent. Hypodermoclysis with normal saline solution, properly warmed and administered in amounts varying from 2 to 5 ounces and under strictly aseptic conditions, and not oftener than once in twenty-four hours, is a useful remedy (Chap- DRUG THERAPY. 183 ter XIII). This is especially so in those cases of atrophy which have followed an attack of summer diarrhea (milk intoxication) and in which the onset has been rather abrupt. The tissues have been speedily dehydrated and demineralized by the tremendous loss of water per rectum. HYGIENIC MANAGEMENT. These babies do better in a warm atmosphere of pure air. As before stated, they should not be kept in hospitals. If orphans are deserted, they should be placed in homes, if possible, especially if the caretaker can at the same time give them the breast. The municipality should thus provide home shelter wherever possible for its infant charges rather than maintain them in almshouses. Regularity in feeding, feeding proper quantities, neither too fast nor too slow, proper warming of the bottle and attention to the minutest detail, which may be included in the expression "intelligent and wholesome care," should be provided. DRUG THERAPY. Drugs occupy a position decidedly subordinate to the dietetic and hygienic management of these cases. There are no specifics. Extract of thyroid has been recommended as well as extract of thymus. I have had little experience with the former and none with the latter. Thyroid, in my hands, has given no indication of its usefulness. On the other hand, Henry Heiman, in a personal communication, recommends its use empirically in certain cases which can- not be classified. He administers it in the dose of from y 2 to i grain three times a day. It is my belief that the physi- cian who leans upon any drug therapy in this condition, to 184 INFANTILE ATROPHY. the exclusion of the application of his knowledge of dietetic detail- and individualization, will have poor results. Tinc- ture of nux vomica in mj to mij doses t i. d., a, c., may be useful to increase the appetite and the motor function of the gastrointestinal tract. Extract of pancreatin and taka- diastase, alone or in combination, and rubbed up with 5 grains of white sugar may assist in protein and fat diges- tion. Paraf JavaTs solution of strontium, bromid may re- lieve colic, vomiting, and flatulency. A peaceful night may be secured by a single or double dose of 3?! - 1 ! ' Ifc Sodii bromidi gr. ij. Tr. opii camph., TH.ij. Syr. simpl., Aquae menthae pip., or Aquae camph., or Aquae anisi aa q. s. ad fSj. A few drops of HC1 dil. niiij-v may assist in the diges- tion of curd and prevent fermentation. An initial dose of castor oil and spiced syrup of rhubarb, equal parts, will cleanse the bowels, relieve fermentative diarrhea, and is often of service. Later it may be followed by small doses of aromatic cascara for its tonic effect. Constipation may further be relieved by suppositories, enemas of olive oil or glycerin-and-soap water, and by the use of liquid paraffin preparations as before stated. Likewise it may be repeated that codliver oil, by inunction, is a valuable agent. CHAPTER V. RICKETS. Synonyms. Rachitis, English Disease. Definition. Rickets is a general disease occurring as the result of a perverted metabolism, the exact nature of which is not at present entirely understood. It manifests itself clinically by changes in the osseous, muscular, nerv- ous, and digestive systems. PATHOLOGY. While rickets depends upon some form of toxemia or metabolic disturbance which involves primarily the nervous, digestive, muscular, and osseous systems, the lesions char- acteristic of the disease are found only in the bones. Whether these changes are inflammatory or not is still a matter for discussion. The most marked changes are in the long bones and occur in the bone-forming centers, i.e., in the cartilage between the shaft and the epiphysis, and in the bone-forming or inner layer of the periosteum, and in the inner layers of bone which lie next to the medullary canal. In all these situations except in the neighborhood of the medullary canal, in health there occurs proliferation of cells which are later replaced by bone. This is accomplished by the deposition of inorganic substances. In this way the long bones grow in length and in thickness. The medullary canal is widened by the absorption of the layers of bone found in this situation. In rickets there occurs increased activity in the prolif- eration of cells in the hyaline cartilage between the epiph- (185) 186 RICKETS. ysis and the shaft and in the inner layer of the periosteum. There also occurs absorption in the medullary region, but decidedly less rapidly than in health. In addition there is an intense increase in the vascularization of the parts and there is a diminution in the deposition of inorganic matter, i.e., the quantity of organic matter far exceeds the inorganic. Thus the process occurring in health is reversed. The medullary canal becomes filled with rapidly proliferating cells that resemble granulation tissue. It can be seen, there- fore, that as a result of this increase in cell proliferation and in the lack of inorganic matter the epiphyses will become enlarged and thickened. Also the surface of the long bones will become irregular and the bones will readily yield to the effects of muscular traction, gravity, and atmos- pheric pressure. These bones also readily bend or, if frac- ture occurs^ it will not be complete, but will be of the "green stick" variety. The same process of cell proliferation and of increased vascularization, together with a scarcity of mineral con- stituents, takes place in the centers of ossification of the flat bones. This is especially true of the cranial bones. This gives rise to the formation of areas of thickness, or bosses. In those areas where the formation of bosses is absent, absolute or relative thinning of the bone results in craniotabes. The rachitic processes may become arrested at any time and complete absorption with perfect restoration to the nor- mal will occur. In fact it may be impossible to recognize that the present adult was a rachitic infant. The deposition of inorganic substances may proceed to such a degree as to cause the bone to become unusually hard or ivorylike (ebonization). ETIOLOGY. 187 ETIOLOGY. This disease is confined almost exclusively to infants who are artificially fed. When it occurs in the breast-fed it does not appear until late in infancy. Its incidence in these babies is evident beyond the first year, i.e., in infants who have been kept upon the breast too long and who are therefore receiving food deficient usually in the elements which are essential to a vigorous metabolism. Just what exists in breast milk that prevents, and what is absent or present in cows' milk which permits or causes the symp- toms of rickets to appear, has not been clearly defined. It may be that the frequent disturbances of digestion to which artificially reared babies are prone, give rise to the develop- ment of enteric fermentation and the subsequent formation of toxins which, circulating in the blood, exert their dele- terious effects upon metabolism and nutrition, preventing the normal development of nervous, muscular, and osseous tissue. Certain it is that clinical experience emphasizes the frequent occurrence of rickets in individuals who receive a deficiency of fat and protein either by accident or through intention, the latter necessitated by the fact that the digest- ive powers are deficient in their ability to take care of these substances. Thus, where mixtures low in fat or low in protein are fed over a long period 1 of time, rickets is likely to develop. Therefore infants who are continuously fed upon condensed milk, which is notoriously deficient in these substances and in mineral constituents as well, containing at the same time an excessive amount of carbohydrate (sugar), are frequently victims of this disease. Without protein and fat, normal development of bone, muscle, and nervous tissues cannot occur. In rickets these are uni- formly affected and exhibit a physical weakness and irri- 188 RICKETS. tability that cannot be readily accounted for in any other way. Fat and protein deficiency may occur not only, as just stated, as the result of a food mixture weak in these sub- stances, but may supervene as well where the formula for some reason disagrees and at the same time contains not only a sufficiency of the food elements, but an excess. In the first instance they may be deficient for the individual. The personal equation therefore or the individual's idio- syncrasy must be considered in coming" to* a correct con- clusion. In the latter instance the deficiency depends upon some digestive disturbance due to the excess per se, or upon intolerance of some other element, notably carbohydrate. In either instance the resultant is malassimilation an amount of fat or protein deficient for the individual's proper metabolism, being absorbed. A deficiency of lime salts in the diet could readily account for the state of hyperirritability of the nervous system in rickety infants who are so eminently liable to convulsion. Lime is a nerve sedative. The salts of sodium and potassium are responsible frequently for nervous ex- citability. Therefore any food lacking a sufficient amount of calcium may predispose to this disease. The deficiency of lime in the tissues, theoretically at least, may be produced as in the case of fat and protein, by its absence or deficiency in the food, or by the failure of the organism to assimilate it sufficiently, or by its increased elimination from the body. The last depends upon the ease with which it could combine with the active agent, presuming this to be an acid, respon- sible for the disease; or it may be due) to the untoward influence of diseased or functionally perverted parathyroids upon the maintenance of a proper calcium balance. ETIOLOGY. 189 The frequent association of rickets! with tuberculosis or, rather, the common occurrence of tubercular lesions in rachitic children, is an ordinary clinical experience that re- quires no special emphasis. However, the degree of inter- dependence of these two diseases is not clear except in so far as it is a matter of common knowledge that all infec- tions are not only more likely to occur in the rachitic, but that they are marked by greater severity. Consequently, under these circumstances, these diseases offer a graver prognosis. In a word, the resistance is lowered in rickets and it is readily understood that the vitality may speedily be vitiated by a deficiency, especially of protein and of fat as well. A factor of prime importance in its bearing upon the development of rickets is provided by faulty hygiene. Overcrowding, improper clothing, deficient aeration and sunshine are peculiarly common to those in whom this dis- ease appears with the greatest frequency. It may be that the frequent association of rickets and of tuberculosis finds its origin in the single etiologic factor) of faulty hygiene, and this symbiosis, as it were, may represent nothing more than a coincidence in that the same factor provides a com- fortable habitat for the exciting cause of each. Race has its influence too. The disease in America is met decidedly most often in the Negro and next in the Italian immigrant. The filth and poor rearing of the former, and both these factors together with the excessively starchy diet of the latter, evidently provide sufficient reasons for the development of this disease. From this, however, it cannot be concluded that the rich are immune to rickets, although its incidence is decidedly less where material assets are suffi- cient to provide for the ordinary and the extraordinary requirements of existence. 190 RICKETS. Sex has no bearing on the frequency of rickets and heredity is without influence. The occurrence of several subsequent cases of this disease in all or in a part of the children of one family can be explained by the continuous presence of the same predisposing and exciting factors. As to age, it must be stated that we are dealing here with rickets as we commonly see it in practice, and not with those questionable types of the disease (achondroplasia, fetal rickets) which depend upon some obscure uterine influence. Nor do I intend to dwell upon the rickets of puberty, but to confine the description to a consideration of the disease as it is met in infancy and in childhood. It is rare in very early infancy. It may appear at 3 months. It is more likely to occur after 6 months and to manifest itself more frankly after I year of age. It is important to remember that the initial symptoms of the disease, to' which reference will again be made, frequently appear quite early. These symptoms are mild at first and are therefore fre- quently unrecognized. My purpose in emphasizing this fact depends upon a desire to insist upon our ability to abort the further development of this disease. If the proper hygienic and dietetic measures are inaugurated as soon as the significance of these initial features are recognized and appreciated, this statement becomes a truism,. If the infant escapes, it is rarely possible that the condition will begin in childhood, i.e., after 2 years. Among predisposing factors of important moment, in fact regarded by some authors as sufficiently influential to be included among the most important exciting causes, is a deficiency of sunshine, fresh air, and the presence of damp surroundings, in a word, as before stated, a vicious hygienic environment. While it is true that the whole SYMPTOMS. 191 economy is depressed and vitiated by such influences and therefore predisposed to any disease, infectious or other- wise, we cannot help but recognize the presence of some other factor as the active agent. All children subjected to such influences do not develop rickets and many acquire the disease who are not so surrounded. While the disease occurs with greater frequency among the poor, it is also found quite commonly among the rich, and in the former instance its more frequent incidence is perhaps relative. Rickets is undoubtedly a disease of metabolism and diet. All other etiologic influences are predisposing and not active. SYMPTOMS. The most apparent symptoms of a well-developed case of this affection are referred to the osseous system. If, how- ever, careful investigation be made, certain other features may be detected early and protective measures be instituted to prevent the further development of the disease. This statement needs qualification, as it is possible that the process may be spontaneously arrested at any time. It is not always safe therefore to conclude that the cessation of symptoms depends upon any therapeutic or dietetic meas- ures which have been instituted. Nevertheless it is a clinical fact readily demonstrable by extended experience that, if certain precautionary measures, which will be pointed out later, are thrown about individual cases of artificial feeding, rickets need not and does not develop. Among the earliest evidences of a rachitic tendency, headsweating occurs with much frequency. It is not pathognomonic in itself, as it may occur in healthy babies, but when associated with other conditions is eminently suggestive. The sweating may be confined to the forehead 192 RICKETS. or it may involve the occipital portions as well. It com- monly occurs during the act of nursing and especially dur- ing sleep. It may be so profuse as to cause a corona of dampness to surround the spot where the head comes in contact with the pillow. Seasonal influences have no bearing upon its presence. It is continued well into childhood and may, in conjunction with draughts and sud- den exposures, be responsible for some of the congestive and infectious accompaniments or sequences of the disease (colds, pneumonia, bronchitis, etc.). Craniotabes, or the thinning of the skull in spots, ap- pears in some instances as early as the third month and is said, in a so-called congenital form, to even precede this age. Of this variety of rickets I have met but few instances. Craniotabes may affect the parietal and frontal bones, but more commonly involves the perpendicular portion of the occiput. This is often flattened by the pressure of the head upon the pillow, and over the flattened area the hair is commonly worn away. This flatness must be distinguished from family resemblances and, before it is said to be due to rickets, the head of the mother and especially that of the father, should be visualized. This symptom appears early, but is continued throughout the attack. When associated with an increase in the parietal and frontal eminences, which occurs as the result of an actual deposition of bone, and which does not appear, as a rule, until after 6 or 8 months, the head assumes the characteristic square appear- ance which is distinctive of the disease (Fig. 32). The circumference of the skull is increased. In young infants it is well to remember, especially after severe labor or in instrumental cases, that the shape of the head may become irregular or flattened as the result of SYMPTOMS. 193 molding or of pressure of the forceps. This change in contour, also, may persist for some weeks or months. In fact in non-rachitic breast-fed babies of vigorous develop- Fig. 32. Square outline of head in rickets. ment, I have noted it as late as 8 months, and I have an impression that it may be permanent without causing any harm to the brain. This should be borne in mind when 13 194 RICKETS. deciding individual instances as to their rachitic or non- rachitic origin, and a careful history of the character of the labor should therefore be elicited. During early infancy and also throughout the attack, digestive disturbances are common. In themselves they present nothing characteristic of the disease, and whether they appear as a part of rickets or as interloping symptoms, or as a consequence of it or even if they possess an etiologic influence, is not clear in the nosology of this affection. Certain it is, however, that rarely is there met a case of rickets in which, at some time during or throughout the milk-feeding period at least, that digestive orders of one type or another are absent. Constipation is the more com- mon type of trouble, or this may alternate with diarrhea in which the stools present features of fermentation and non- digestion. Vomiting is rare. The stools are often fetid. If constipated, they may appear hard and nodular. As has been stated, it cannot be determined with positiveness that these digestive crises possess an etiologic influence. There is no doubt, however, that, at least in a measure, they are responsible for the evidences of toxemia which are com- mon to rickets and which show themselves, as will be de- tailed later, by nervous hyperirritability with a tendency toward convulsive seizures. The liver and spleen are quite commonly enlarged. More significance attaches to the latter than to the former. It is difficult to determine whether splenic enlargement is an essential feature of the disease. My impression is that it is not, but that it depends upon toxemia, probably of intes- tinal origin, or it may be secondary to a tuberculous process to which rachitic children are so frequently subject. Poly- glandular enlargement occurs, too, with considerable fre- SYMPTOMS. 195 quency. The postcervical glands are palpable, as are the glands of the axillae and those in the region of the groin. Undoubtedly, in many instances, the enlargements are tubercular, but not infrequently they represent simply the evidences of general toxemia. Dentition is delayed in those cases in which the rickets appears before the time usually recognized as the physio- logic period at which teething should be inaugurated (6 to 8 months). If the disease appear after this time the two lower central incisors may already have erupted. This must not be taken as a sign that 1 rickets does not exist. This important diagnostic point receives emphasis from Zappert. The subsequent dentition is delayed. Dentition is often irregular and rickety children may although care must be exercised in coming to this conclusion, which should be reached only after every other possible etiologic influence has been eliminated suffer from reflex disturb- ances directly due to teething, on account of the hyper- excitability of the nervous system. The slight irritation may be sufficient to produce irritability, nervousness, changes in disposition, rises in temperature, slight conges- tions, as coughs, otitis, and conjunctivitis. I know this is a dangerous dictum to put into the hands of the general practitioner and am conscious that it has been combated by much eminent authority. I feel, however, convinced, from cases which I have carefully studied, that, at times at least, dentition) and rickets produce a combination of etiologic factors which may be responsible for the conditions noted. At least no other factor was demonstrable and recovery was hastened, if not produced, by gum lancing. Muscular weakness, to which reference will again be made, manifests itself early. There is lacking: a feeling of 196 RICKETS. tone, and this is evidenced by the inability of the baby to support its head upon the shoulders and by the backward curvature (rachitic kyphosis) of the spine when the infant is held in the sitting posture (Fig. 33). Ordinarily an infant should be able to support its head by the end- of the second or third month. While the absence of the power so to do is not pathognomonic of rickets, it occurring in other conditions (hydrocephalus and amaurotic family idiocy), its association with the other symptoms enumerated forms a highly suggestive phenomenon. An ammoniacal urine is a common occurrence in arti- ficially reared infants. It results, in all probability, from the excessive feeding of fats and sugars whereby these sub- stances are but partly transformed by the digestive glands. This results in the formation and absorption of fatty and other acids which combine with the alkaline bases of the body, producing an alkaline reaction of the urine and an increase in the ammonium output. This condition is espe- cially common in infants who show the other symptoms of early rickets. This statement must not be taken as a con- tradiction of the theory which emphasizes the possible etiologic effect of the deficiency of fat. On the contrary it accentuates its possible truth, viz., an excessive amount of fat may be fed to the infant and yet its economy may re- ceive a minimum amount on account of its perverted trans- formation in the gut. The following symptoms, therefore, characterize the symptom-complex of early rickets, and may be nominated the premonitory features of the disease, not that it has not been already inaugurated, but that the progress may, in a sense, be halted by proper management. They are : head- sweating, craniutabes, digestive disturbances, constipation, SYMPTOMS. 197 F'g- 33. Rachitic kyphosis. 198 RICKETS. late dentition, nervous irritability, muscular weakness, and ammoniacal urine. Craniotabes alone is characteristic. The rest, individually, signify nothing, but the entire en- semble constitutes an entity of convincing interest. Fig. 34. Rickets. Bulging forehead, enlarged radii, pot belly, skinny legs, weak muscles (notice child cannot stand), flat-foot. OSSEOUS CHANGES. Other changes in the skull besides craniotabes occur. Great interest attaches to the anterior fontanette. In rachitic infants, up to a certain age, this progressively in- OSSEOUS CHANGES. 199 creases in size with the growth of the head. Ordinarily it should be closed by the eighteenth month. Ossification in rachitic children is delayed beyond this period, sometimes extending well into the second year. While the membrane does not budge, the cranial pulsation may be distinctly felt. The sagittal and frontal sutures likewise remain open. The forehead at times bulges and the frontal eminences are prominent (Fig. 34). The facial bones are also involved, Fig. 35. Rachitic rosary. especially the superior maxilla. The palate consequently presents a highly arched appearance. Chest. The clavicles frequently present abnormal cur- vatures. The sternum is not uncommonly depressed below the surface, causing the characteristic "chicken-breast" ap- pearance or it may be unduly prominent, when the child is said to be "pigeon-breasted." The ribs show changes which possess considerable diagnostic import. At the costochondral junction enlargements appear which may not only be palpated, but which are distinctly visible. This is called "beading" o put the prac- titioner on his guard, as I have on five or six occasions seen this error made both by myself and others. VOMITING IN OLDER CHILDREN. The more common causes for vomiting in older chil- dren are the acute infectious diseases, pneumonia, dietary indiscretions, ivith or urithout acute gastritis, acute indiges- tion, poisons, acute abdominal disease, uremia, brain dis- ease, acidosis (cyclic vomiting, so called), renex causes, and ocular conditions. Vomiting is an important initial symp- tom of scarlatina, smallpox, meningitis, and less so of measles. It may replace the chill of pneumonia. The direct origin of vomiting in these conditions, with the ex- ception, perhaps, of meningitis, is toxic. By far the vast majority of cases of vomiting in young children is due to dietary indiscretions. Included within VOMITING IN OLDER CHILDREN. 243 this term are those cases due to chemical or food (ptomaines) poisons, or medicines ingested by accident or otherwise. These cases may or may not have the added element of gastritis as a causative factor. The treatment of this class of cases may be embraced within a general plan. The greatest element is prevention. It is a grave mistake not to supervise the food of a young child up to at least 4 or 5 years, and even after this vigilance should not be relaxed. Up to the age of i year, in most instances, the infant should receive very litle besides milk, and that preferably maternal. A certain amount of latitude can perhaps be permited in this direction, depending upon the individual. Many physicians are in the habit of per- mitting a certain variety of dried bread called zweiback, at a very early age. I have never seen any harm therefrom, but in the majority of American children I feel that an exclusive milk diet is best, at least up to 9 or 10 months, or until the infant has cut several teeth. After this the diet should be regulated according to the directions given under Chapter III, page 140. "Bring up a child in the way it shall go and when it is old it will not depart therefrom" applies to diet as well as to morals, and an adherence to a simple diet of wholesome foods, with absolute regularity, will prevent as many and more cases of vomiting and indigestion as the vicious habit of continuous nibbling and overfeeding of improper foods will produce. Frequently children are brought to the physician by an anxious mother with the tale that they have no appetite. Careful inquiry will invariably elicit the his- tory that the day is occupied by one continuous meal of small quantities of sweets and indigestibles. The active treatment, after eliminating the cause of this 244 VOMITING. condition, consists in the administration of an emetic, if too much time has not elapsed since the ingestion of the sub- stance. If the stomach has not been actively irritated or inflamed, lavage should be practised. This is a very diffi- cult procedure in young children and should only be employed if urgent. Following this a purgative, preferably iced castor oil, or if this is not tolerated, calomel, triturated well with sugar of milk, should, in small dose, be placed dry upon the tongue. Food should be omitted for twenty- four hours and, when resumed, should be of the mildest kind and given often, but in small quantities. Ice by mouth and a mustard paste upon the epigastrium may be of service, while, of medicaments, cocaine gr. 1 / 30 , bismuth gr. x, and strontium bromide gr. iij are the best. In acute abdominal disease, especially in appendicitis and in peritonitis, as mentioned before, the interest attached to vomiting is purely academic and diagnostic. In 1 peri- tonitis the vomitus may become fecal in rare instances and indicates a fatal outcome. Rarely these cases are benefited by extensive lavage. The insidious onset of nephritis and uremia is often announced by an unexpected attack of nausea and vomiting. This is especially true when occurring during the third or fourth week of an attack of scarlet fever, and such an occurrence should always lead to a urinary analysis. In this disease, therefore, vomiting becomes a symptom of much diagnostic import. Its treatment consists in the treatment of the underlying cause and is entirely elimina- tive, this being accomplished by diaphoresis, diuresis, and catharsis. Vomiting when associated with or rather due to brain disease, especially tumor, abscess, meningitis, less often VOMITING IN OLDER CHILDREN. 245 hydrocephalus, is also of diagnostic importance. It is pro- jectile in character and occurs without nausea. There is no special treatment. Of greater interest, perhaps, than all these, in that it is peculiarly a condition of childhood, is periodic or so-called cyclic vomiting. Children, apparently otherwise well, but of delicate mold, the former subjects of scurvy, marasmus or rickets perhaps, without any apparent cause, certainly without any indiscretion in diet, are seized with severe attacks of vomiting. First the stomach contents are ejected and then, with severe straining and retching, a large quantity of bile-stained material is thrown off. There may .or may not be associated fever. Usually, however, the temperature does not go much higher than 100 F. Jaundice does not occur, but the skin becomes muddy. Soon the attack ceases spontaneously and the child is as well as ever and hungry, and remains so until the next attack occurs within a few weeks. Preceding the attacks the child becomes languid, pale, loses interest in its play, and has dark rings under its eyes. By these signs the care- taker can, if observant, foretell an attack by twenty-four hours. These children are usually anemic, have a hemc*- globin percentage of below 60, and are sometimes the sub- jects of purpura. There is usually a slight leucocytosis up to 15,000. The etiology of this interesting condition is obscure, although the researches of Edsall and others would point to an acidosis or an acidemia. Many of these cases present a highly acid urine containing large amounts of acetone, diacetic and oxybutyric acids. Treatment is unsatisfactory. The attack is self-limited and remedial measures are of no avail. Between attacks all efforts should be directed toward building up the general 246 VOMITING. strength, improving the nutrition, and overcoming the acidosis. With this end in view the diet should contain starches and only a moderate amount of protein. Digest- ants should be given if needed, and large doses of sodium bicarbonate over a long period of time are regarded as specific by Edsall and do good in many cases as a preventive. Iron citrate or sodium cacodylate, alone or combined, and administered hypodermically, may be useful in combating anemia. . Reference has elsewhere been made to those cases of periodic vomiting which are not due to acidosis, but which depend upon pylorospasm, which originally developed in infancy and which has not entirely recovered. These cases can be recognized if sought and especially if they are studied by the X-ray (Chapter XII). CHAPTER VIII. CONSTIPATION. THIS will be discussed largely from the standpoint of treatment. The term itself is more or lessl comparative. The movements may be sufficiently frequent but small in bulk. They may be both sufficiently frequent and of nor- mal bulk, but too dry in consistency. When constipation is complete it is said to be obstipation. This usually depends upon an organic basis. An intelligent therapy can only be arranged after considering the etiology in some detail. ETIOLOGY. Two factors are operative more or less in nearly every case of costiveness, viz., diet and habit. This is true of infants as well as of children. Many babies are made constipated because the caretakers do not give them an opportunity to evacuate their bowels spontaneously. This results in the routine administration of drastic purgatives and local irritants, as suppositories and injections. The bowels shortly cannot empty themselves unless they are so stimulated. A diet poor in sugar and fat or one rich in protein is particularly harmful in this respect. Food which is com- pletely digested also predisposes. Habit is especially potent in older children. The re- sponse to nature's call is delayed, with the result that atony of the bowel and gaseous distention ensue. In cases of rickets in which the involuntary musculature of the small (247) 248 CONSTIPATION. intestines is decidedly at fault, this state of affairs also exists. Constipation in the Breast-fed. A great many mothers complain that their babies are constipated. I find in most instances that these women do not give their children a chance to move their bowels naturally. They proceed to administer purgatives and injections very early, usually as soon as the infant exhibits a little colic. Most of these babies consequently do become constipated from such treat- ment. If the mothers are reassured and are instructed to leave the babies severely alone, the fear of constipation speedily passes, as soon as a few natural evacuations occur. Occasionally, before the habit is fully re-established, use may be made of a glycerin suppository. This treatment must not be continued over too great a period of time, for the fear of establishing the habit. It is only employed to help out, and not more than once or twice a week. I always advise the mother to allow her infant to go thirty-six hours before she attempts to bring about a movement. Usually before this period of time has elapsed, a spontaneous evacu- ation will have taken place. At times something may be accomplished by a milk analysis and by attempting through the mother's diet to so influence the composition of her milk as to make up for the visible deficiency. Thus, the amount of sugar, fat, and protein may be varied according to the directions already given under Chapter I, page 35. While, of course, quick results cannot be expected from this method alone, it should always be pursued as a very important adjuvant. It is often of service to administer to these babies, just before feeding, a small quantity of either oatmeal or ETIOLOGY. 249 Granum water. Between feeding, under any circumstances, boiled water should routinely be offered to all breast babies. Constipation in Artificially Reared Infants. Constipa- tion is not uncommon in this type of baby. The stools are often hard, dry, and crumbly (Plate VIII), and are expelled by the infant with great straining. Much may be accom- plished by dietetic manipulation. I find it to be of great service to change the diluent of the milk to oatmeal-ivater. This is especially effective if barley-water or a wheat-flour gruel has been employed previously. In some other cases, where the formula has been boiled, feeding it raw will cor- rect the trouble. Hardly to be recommended as a routine procedure and yet decidedly effective, is the feeding of the formula cold instead of warm. In other cases the result is favorably influenced by increasing the amount of food if this has been found to be unusually small in bulk. I have noted instances wherein the concentration of the food, was insufficient, i.e., the amount of diluent was greater than the digestive powers of the infant demanded, and entirely too great to permit a sufficient residue to provide for the neces- sary normal peristaltic stimulus. Thus a very low protein may be responsible for constipation. On the other hand a very high percentage of protein, especially if the formula be weak in fat and sugar and if the protein be highly com- minuted, as in eiweissmilch or in buttermilk, or if the pro- tein be otherwise influenced, as chemically by pancreatiza- tion or by boiling, may cause constipation with hard, dry stools. Unchanged coagulable cow-protein, on the other hand, when fed in excessive quantities, may cause diarrhea on account of the irritant effect of the undigested masses which result. In these instances a starchy diluent, as bar- ley-water or a thin, well-cooked wheat-flour' water, is of 250 CONSTIPATION. service in checking- the diarrhea. The curd may also be influenced by boiling, pancreatization, or by the other methods detailed under Protein Intolerance (Chapter II, page 1 06). Infants whose formulas are especially weak in fat are commonly constipated, and the condition can be favorably influenced by the addition of cream in gradually increasing amounts. Care, however, must be exercised not to exceed 3^ to 4 per cent, (even this may be too much for certain individuals), otherwise fat intolerance may ensue, with the discouraging evidences of weight disturbance. Not all cases are benefited by increasing the fat. Some are made worse, especially if the fat be split up into fatty acids, which in the presence of lime-salts causes the for- mation of calcium-soap stools, which are constipated (Plate VII). Excessive fat may cause the formation of a greasy, foul-smelling, constipated stool (Plate VI). These stools contain much fatty acid and often present the odor of overripe cheese. Lime-water should therefore, unless it be used for a special indication, as hyperacidity, rarely enter into the composition of any formula. Personally I have practically discarded it for years, and have not felt the necessity of employing it in any instance except, very occa- sionally, in cases of pyloric obstruction. These cases of constipation due to an excess of fat are benefited by diminish- ing the fat or by predigesting it (pancreatization). Constipation in the bottle-fed is often materially im- proved by increasing the amount of sugar or by changing from milk-sugar to cane-sugar or, still better, to some of the malt preparations, as Dextri-Maltose. The effects of low fat and of low protein, even though 1 the sugar be high, are seen in babies fed upon condensed milk. Many of them ETIOLOGY. 251 suffer from constipation. The ideal for which to strive is a food combination in which all the elemnets (fat, protein, and sugar) are reasonably represented and in which no one element far exceeds the others. This will not only insure a normal state of the intestinal juices, but will provide a proper nutritional balance. Elsewhere I have stated that almost routinely I employ cane-sugar to provide extra car- bohydrate. These cases of constipation constitute one of the exceptions in which I make use of one of the malt preparations. A diet rich in starch is constipating. In fact, this is not at all a bad way in which to favorably influence a state of diarrhea. Many of the patented foods are constipating. The milk diluent may contain too much starch. I have seen constipation result, too, from the use of buttermilk into which an excess of wheat-flour had been incorporated. Therefore the starch must be reduced and the diluent made weaker. In some instances favorable influences are noted where the diluent is dextrinized after the method of Chapin, who adds some diastatic agent, as cereo (glycerite of dias- tase) or a dram or two of one of the many malt preparations upon the market. In yet other infants, good results are obtained by changing the diluent completely to oatmeal-water. This is quite laxative in its effect and should in all cases be tried. Many babies will show surprisingly good results from the use of this simple maneuver by itself. Fruit-juices serve an admirable purpose in the bottle- fed, not only on account of their antiscorbutic effect, but also for their influence upon the stools. I prefer prune- juice made by boiling a pound of prunes in a quart of water without sugar. This is palatable, antiscorbutic, and laxa- 252 CONSTIPATION. tive. Usually from 2 to 3 teaspoon fuls are given once or twice a day on an empty stomach. Other juices, as of the orange, grape, apple, etc., may be employed. A broth made from vegetables (Chapter III, page 146) is useful in this connection and may be given ad libitum. As the infant grows older and articles other than milk are added to the diet, other things being equal, the tendency toward constipation is often materially lessened. Therefore, if digestive disturbances are absent and two of three teeth have been erupted, such foods as oatmeal, Graham crackers, whole-wheat bread, and tender vegetables may prove to be eminently useful. Scraped apple may also" be fed in tea- spoonful doses once or twice daily. From earliest infancy the habit of regular evacuations should be established. The infant's buttocks are brought into contact with a small chamber at definite intervals dur- ing the day. As soon as the baby can sit up it should be placed in a chair in the same regular way. Later the habit of having a daily bowel movement should be made an object of pride on the part of the child, who should be early taught that nothing must be permitted to interfere with its response to nature's demands. Rewards, if necessary, should be offered to encourage this, and mild punishment inflicted for failure to obey. Older Children. Children must be taught to crave wholesome food. It is just as easy to do this as it is to allow them to crave those foods which cause digestive and metabolic disturbances. Vegetables in abundance are not only wholesome, but laxative in their effects. Stewed and seasonable, raw, ripe fruits are valuable adjuncts, but apples must be scraped or very thoroughly chewed. Well- cooked coarse-grained cereals, especially oatmeal, are valu- ETIOLOGY. 253 able. Cereals which are eaten uncooked, witW milk and sugar, are not to be recommended. An abundance of Fig. 44. Constipation due to dilated colon (Hirschsprung's disease). butter and olive oil, if they cause no digestive or metabolic disturbances, is valuable. 254 CONSTIPATION. Sweets and meats are constipating and, therefore, they are to be largely curtailed. I have, however, met instances wherein diet has no influence at all in relieving the condi- tion. One patient, a little boy, recently came under my observation, who consumed seven or eight apples a day without any effect whatever upon his stools. Such obstinate instances require the use of drugs. MEDICINAL TREATMENT. Where dietary measures fail, the cause of the consti- pation probably depends upon functional atony or upon anatomical twists, kinks or tortuosities or upon congenital dilatation of the colon (Fig. 44). In addition to drugs mechanical manipulation, which will be discussed later, is often valuable. To rehearse the entire list of purgatives would be time-consuming and useless. I shall only mention those agents which have been useful in my own experience. I have obtained very encouraging results from the use of some form' of Russian mineral oil. I have employed the preparation known as Interol or Rusol, marketed by Van Horn & Sawtell, or Squibb' s preparation, or Olo. They all act the same and one is as good as the other. This is true as well of the American mineral oils to be found upon the market. These oils are not digested. They are passed as they are taken. They simply lubricate the intestinal wall and cause the contents to slip along easily. They have the great advantage of being tasteless. They are administered from a spoon or placed upon a little water which the child drinks without knowing that the oil has been added. A very small amount of sugar may be added for fastidious children, and the dose offered to them as "sugar-water." Infants receive from i to 2 fluidrams once or twice a day, on MEDICINAL TREATMENT. 255 an empty stomach. Older children are given about half an ounce. The idea is to administer just enough to secure the proper lubrication which will insure from one to three movements daily. There are no ill-effects. Nor is there any danger of establishing a habit. The only inconve- nience noted is that the oil will leak through the anus and soil the clothing, if too much is taken. There is no relaxing effect upon the bowels, and of all permanent agents to be employed for the relief of constipation I firmly believe that one or another of these preparations is by far the best. Olive Oil. This may also be classed as one of the valu- able semimedicinal agents. It is administered per oram or per rectum. It also possesses valuable food qualities, and is especially useful in marantic children of over I year of age. By mouth from y 2 fluidram to 2 fluidrams are administered t. i. d. after meals. It is often more readily accepted if given with grape-juice. It rarely disturbs the digestion. It must then be given per rectum. By this method valuable results are commonly obtained if the remedy is properly administered and continued over a sufficiently long time. Three to four ounces of the oil are deposited high into the bowel each evening, or every other evening, as the 1 infant is put to bed for the night. A soft-rubber catheter is anointed and gently passed into the bowel for a distance of about eight inches. An ordinary small, infant's, hand rectal syringe is now filled with the warm oil, and the hard- rubber tip is connected with the free distal end of the catheter, and the contents of the rubber bulb are gently com- pressed through the catheter into the intestine. One or two syringefuls are sufficient (Chapter XIII, Fig. 56, #). The baby is diapered and usually, the next morning, there will be found a substantial movement. In some cases this 256 CONSTIPATION. occurs immediately. Gradually the frequency of these in- jections may be lessened if the movements show a tendency toward becoming spontaneous, as they frequently do. This treatment is also valuable in older children, a little more oil being employed as well as a slightly thicker catheter, which may be inserted about ten or twelve inches. Agar-agar as such, or* employed as Regulin after the method of Prof. Dr. Otto Schmidt, is useful in some cases. It acts by absorbing moisture through the intestinal mucosa and thereby, as the agar-agar swells, increases not only the bulk of the intestinal contents, but makes them more liquid. As a rule I prefer the ordinarily powdered agar-agar as purchased in the shops, to the Regulin, as it is tasteless, the latter being impregnated with cascara sagrada, which makes it bitter. Either, however, is administered in stewed fruit or cereal in I- or 2- dram doses once or twice daily. The results are not always satisfactory, although in some cases decided benefit is experienced. The material must be mixed with the food during the child's absence. Milk of Magnesia. This in no sense cures constipation. It is, however, often of value in assisting, especially the bottle baby, across a troublesome period. Thus, until the proper-strength formula is found, many infants are con- stipated. Often, as previously stated, the condition is remedied by changing the diluent to oatmeal-water. Until this is done or has a chance to act, 15 to 20 to 30 or more drops of Philip's Milk of Magnesia are added to each bottle or to every other bottle, or, perhaps, but once or twice a day, according to effect. The dosage, both in amount and in frequency, is gradually reduced to a nicety simply to obtain the desired result. It may also be given to breast- fed babies. It is finally omitted. MEDICINAL TREATMENT. % 257 Castor Oil is mentioned simply to impress upon the mind of the student that, while it causes looseness of the bowels, it must never be considered as a remedy to cure constipation. When indicated it is one of the best remedies in the treatment of diarrhea. Its secondary effect is relax- ing 1 and constipating. It is simply employed to effectively sweep out the intestinal tract. To this it owes its use in diarrhea and also in cases of constipation where the bowels have not moved for several days and it is desired to cleanse the intestines and to relieve acute or chronic toxemia. Its use must always be followed by tonic laxatives, of which Cascara Sagrada is the best example. The great objec- tion to it, however, is its taste. This may be more or less disguised by employing the aromatic fluidextract in doses ranging 1 from 15 to 45 drops once or thrice daily. Or it may be disguised as follows: IJ Liquid extract of cascara (B. P.), Liquid extract of liquorice (B. P.), Syrup of orange-peel, Chloroform-water aa n\xv. Or as follows : Ifc Sodium sulphate gr. v. Liquid extract of cascara (B. P.) n^iiss. Glycerin n\_v. Cinnamon-water q. s. I have seen the good effect of both of these formulas in the wards and in the out-patient department of the Hospital for Sick Children, Great Ormond Street, London. The latter prescription is slightly more stimulating than the former. Through experience in the same institution I have obtained good results from the following combination of tonic laxatives : 17 258 CONSTIPATION. U Tr. nucis vomicae TT\. ss. Tr. zingiberis niij. Tr. hyoscyami v\.v. Tr. aloes m iv - Syrupi sennae nixv. Dill-water (B. P.) q. s. This is carminative as well as laxative. A small quantity of the fluidextract of cascara could readily be added with advantage. Phenolphthalein is a useful laxative in some cases. It is found upon the market in various pleasant combinations with other laxatives, or alone. The dose varies from y 2 to 2 grains. Fig. 45. Massage balls used by the author in the treatment of constipation. (Physician's Supply Co., of Phila.) MECHANICAL TREATMENT. No case of constipation is properly handled unless mechanical means have been given a trial. Of these abdominal massage is of considerable value. In my own experience this is best accomplished by the systematic em- ployment of a massage ball (Fig. 45). It is made in sizes Nos. i, 2, and 3. They consist of iron covered with leather and weigh, respectively, % lb., 1^2 Ibs., and 2 Ibs. They resemble baseballs. They are made for me by the Physi- cian's Supply Company, of Philadelphia. The size of the ball is selected according to the age and' size of the patient. SPONDYLOTHERAPY. 259 No. I is for infants, No. 2 is for children from i l / 2 to 2 years of age, and No. 3 for older children. Morning and evening, before the child arises and before it retires, the bladder being at first emptied, the ball is rolled by the palm of the hand in a circular motion, slight pressure being used in addition to the weight of the ball, along the course of the colon, up the right side, across and down the left. This is continued for from ten to fifteen minutes, after which a cir- cular motion is continued for five minutes over the center of the abdomen, over the small intestines. I find that many babies are benefited to no small degree. The treatment must continue for two or three months. SPONDYLOTHERAPY. Albert Abrams, of San Francisco, recommends that in atomic constipation, the most common variety, concussion or sinus oidilization of the spines of the forehead are com- monly involved and the latter may therefore be wrinkled. The mouth may be puckered ( Karpf enmund, or carp's mouth). Eclampsia, or convulsions, occurs in infants as a com- mon clinical experience. This must never be regarded as a distinct disease, but merely as a symptom of an underlying cause or diathesis. Where organic and inflammatory dis- ease of the nervous system, kidney lesions, and epilepsy can be excluded, careful investigation will frequently reveal the presence of the spasmophilic diathesis. As will be detailed later, this fact is of immense importance in the treatment of convulsions, especially in its relation to their prevention, and sheds much new light upon this frequently fatal con- dition. The convulsions are clonic and nearly all the cases which ordinarily occur in childhood must be included under this caption. Hard Edema. A peculiar swelling of the hands and feet is a frequent, although not a constant, accompaniment of tetany. It is not a true edema, as pitting does not occur. It is probably a vasomotor disturbance of the skin. The hyperextensioti of the feet already referred to assists in causing the cushion-like appearance of the dorsum of the feet. Other Symptoms. Where very severe generalized in- volvement obtains, retention of urine and obstinate consti- 19 290 SPASMOPHILIA. pation may ensue from intense spasm of the sphincters. In the latter instance the abdomen may become much, dis- tended. As the spasm relaxes there occurs a discharge of feces and of gas, and the distention may thus suddenly dis- appear. Lingual and esophageal spasms have been noted. The pupils are contracted and do not respond to light. Nystagmus and strabismus may also occur. Spasm of the bronchi may appear independently of all other features of the disease. The clinical picture may assume, therefore, the ap- pearance of pneumonia (Lederer). The absence of physical signs, temperature, leucocytosis, and the presence of the electrical reactions of spasmophilia or of the facial or other reflex phenomena, will permit of a correct differ- entiation. In manifest tetany, we may encounter vosomotor dis- turbances involving the skin, and resulting* in urticaria, ery- thema, profuse sweating, and intense, though evanescent, edema locally situated or of the entire body. The latter, upon superficial examination, may be mistaken as due to nephritis. Digestive disturbances occur both in cases of latent and of manifest spasmophilia. Irregular Forms. Ihe first symptoms may appear be- fore the fourth month. The order of the appearance of the symptoms may be reversed, i.e., the features of manifest tetany, laryngospasmus, and of the electrical reactions or the other phenomena, which indicate the spasmophilic basis, may appear before the characteristic features of the di- athesis are in evidence. Sooner or later, however, these appear, as does the facial phenomenon of Chvostek. The diagnosis is sometimes, therefore, made 1 with difficulty, and must depend upon the results of antispasmophilic therapy. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 291 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. The diagnosis depends upon the typical symptoms just detailed. Of greatest importance are the Chvostek sign and positive electrical reactions. The detection of latent spasmophilia depends largely upon a study of these two features and of the reflex phenomena. The discovery of the latent diathesis really constitutes the crux of the dagnosis, for it is distinctive of this condi- tion alone and serves to properly catalogue the symptoms of manifest tetany, which so closely resemble Qther diseases. These need but be mentioned, for in all a study of the re- flexes and of the electrical reactions will render the diag- nosis clear. They are epilepsy, cerebrospinal meningitis, tetanus, and any other disease in which irritative or con- vulsive symptoms are prominent features. Reference has been made to the occurrence of a positive Chvostek in menr ingitis. However, this need cause no confusion, as other symptoms and the information provided by lumbar punc- ture will permit of a correct conclusion. It is especially difficult, in some cases, where a knowledge of the character- istic symptoms of spasmophilia is lacking, to say that a particular child has or has not epilepsy. This is particularly true of those brief convulsive attacks associated with momentary loss of consciousness, and which are commonly precipitated by anger, fright, or stubbornness, and which so closely resemble petit mal. Stridor inspiratorius has already been considered. Laryngospasmus must not be confused with the convulsive stage of pertussis, laryngeal diphtheria, and retropharyngeal abscess. Many cases of thymic death, so called, where no enlargement of the thymus is demonstrable, are undoubtedly due to laryngospasmus. 292 SPASMOPHILIA. PROGNOSIS. Where recognized and promptly treated, the outlook for permanent and perfect recovery from this disease is ex- cellent. This is not only true of the manifest variety but, with equal emphasis, of latent spasmophilia. Death may unexpectedly ensue, in an otherwise apparently healthy child, from laryngospasmus or from eclampsia. Even in mild cases, which are untreated, complete effacement of all evidences of the diathesis may occur. On the other hand, in these, and also in those energetically treated, remains of the condition may persist into adult life. This is particu- larly true of Chvostek's sign. It must not be forgotten that, under any exciting factor, the latent spasmophilia which has for years persisted undetected, may be speedily transformed into any one of the dangerous expressions of the manifest type, and with a fatal outcome. For this reason each child should routinely be studied at least for the facial phenomena, if search for the electrical reactions be impossible. TREATMENT. Prophylaxis. As the disease is not found in breast-fed infants it logically follows that every effort should be made to conserve the maternal milk. If this fails, properly directed artificial feeding should be instituted and great care exercised to prevent overfeeding and consequent digestive disturbances. Active Treatment. This is directed toward (a) treat- ment of the diathesis or of latent spasmophilia and (b) treatment of the symptoms o>r of manifest spasmophilia. (a) Treatment of Diathesis. This is accomplished by proper diet and carefully directed medicinal treatment. TREATMENT. 293 Most cases will recover if placed upon breast milk. Where dependence must be had upon artificial feeding it is necessary to distinguish between those babies which are being overfed and those which are underfed. Overfed Babies. A hunger period should be instituted for from six to twelve hours. The metabolic processes are thereby rested and a readjustment of the infant's organism is permitted. During this time weak tea, sweetened with saccharin (gr. j to I quart), alone may be given. Following this a 5 per cent, solution of some form of cooked flour wheat, barley, rice, oatmeal, or arrowroot is administered for eight days. Small quantities of whole milk are now judiciously added, commencing with about 50 grams per diem. This is mixed with the flour solution. An initial loss of weight usually occurs and is of no consequence if not too long continued. Therefore the daily amount of milk is cautiously increased, care being exercised not to provoke an acute digestive disturbance, as this may be responsible for the appearance of an attack of acutely fatal manifest tetany, for instance, laryngospasmus. Underfed Babies. A hunger period is here decidedly contraindicated. In an underfed infant an acute alimentary disturbance must be overcome as quickly as possible. Where gray, constipated stools are in evidence (Bilanzstoe- rung), carbohydrate is lacking in the diet, and its addition favorably influences the progress of the case. For this reason, these cases speedily improve on malt-soup or butter- milk to which sugar and flour have been added (Chapter III, page 123). If the stools and weight curve indicate chronic dyspepsia, sugar is omitted. Each case must be individual- ized. Intestinal intoxication calls for eiweissmilch and a 294 SPASMOPHILIA. decomposition must be treated with suitable milk mixtures or breast milk. Medicinal Treatment. The best remedy, acting prac- tically as a specific, is codliver oil combined with phos- phorus : 5 Phosphorus I centigram. Codliver oil 100 grams. M. Sig. : f3j administered over twenty-four hours and in- creased to f3iij. This is best administered one-half hour after meals, If the stools become dyspeptic the oil must be temporarily withheld. The good effect of this treatment is usually manifest after the eighth day. Cure is often effected within three to four weeks, although continuous administration of the oil and phosphorus must be practised for from three to four months. This is true also of cases placed upon the breast, for the latter alone may not be sufficient to produce a disappearance of the manifestations of latent spasmophilia. In some very mild cases which are receiving cows' milk, it is sufficient simply, in conjunction with the oil and phos- phorus treatment, to reduce the daily amount of cows' milk which the infant is receiving. Thus, if this be 800 grams per diem, it may be reduced to 400 grams and the calories thus lost are supplied by flour-gruels. (6) Treatment of Manifest Spasmophilia. The most important symptoms which require active treatment are: (a) convulsions, (&) laryngospasmus. Convulsions. Chloroform is not recommended by the German authorities, although in America it is almost routinely employed. When judiciously handled it produces beneficent results and its administration mav be continued TREATMENT. 295 cautiously over a prolonged period of time. Of late the best Continental physicians employ calcium bromid: B Calcium bromid 10 grams. Aquae destill 200 grams. M. Sig. : From 2 to 3 grams ( l / 2 to ^ dram) to be administered daily. If the soporific effect be too persistent, less may be employed or the drug may be temporarily suspended. Though not as valuable, chloral hydrate may be substi- tuted for calcium bromid if this chemical is not to be had : Chloral hydrate 2 grams. Aquae destill 100 grams. Ten grams of the solution are equivalent to 0.2 gram of chloral hydrate. This is administered by mouth every two hours or ^ gram of chloral hydrate may be employed per rectum as follows: Chloral hydrate i gram. Gum-arabic 5 grams. Aquae destill q. s. ad 50 grams. This represents two doses. Personally I favor, and have obtained prompt and permanent effects from, the adminis- tration of morphin: Morphinae sulph I centigram. Aquae destill 50 grams. One fluidram of this solution equals 3 milligrams, which is the dose. The best effects, however, are probably secured by administering the drug hypodermically in the dose of from V 2 oo to Vso grain. Gastric lavage should be practised if the history indi- cates a recent dietary indiscretion, especially if sufficient time has not elapsed to permit the food to have passed from 296 SPASMOPHILIA. the stomach. While the tube is still in place, if the child be unconscious, a dose of castor oil may be administered in this manner. On the other hand, a dose of bromid and chloral may also be given in this way. Colonic irrigation should be practised at least once. In other words, by mechanical and medicinal means it should be positively ascertained that the gastrointestinal tract has been thor- oughly cleansed. The treatment of an attack of laryngospasmus differs in no important essential from that of convulsions. CHAPTER XI. EXUDATIVE DIATHESIS. Definition and Nature. To the German pediatrists, especially to Czerny (Berlin), belongs the credit of crystal- lizing, under this term, which clearly represents a disturb- ance of metabolism, an ensemble of familiar clinical phe- nomena occurring with great frequency in infants and children. The condition isi characterized by the frequent incidence of fibrinotis or exudative inflammatory processes i^'liich attack principally the skin and mucous membranes. These processes appear as eczema, and as catarrhal involve- ment of the respiratory and gastrointestinal tracts, respect- ively. Many of these patients suffer from nervous dis- turbances as well. The lymphoid tissues may exhibit chronic enlargement. Decided interference with the bodily nutrition may be noted in some cases. ETIOLOGY. Predisposing Factors. Although not manifesting itself immediately after birth, in all cases the condition is, in all likelihood, congenital. The exudative diathesis itself is a latent process. It is, as it were, a foundation upon which in- fection is easily implanted and rapidly develops. Thus, while the various evidences of inflammatory disease of the skin and mucosse constitute an essential portion of the clinical picture of the condition, they in themselves are not entirely due to the diathesis. Without infection brought to the parts by carelessness, accident, or filth, they could not occur. It is maintained, however, that without the presence of the (297) 298 EXUDATIVE DIATHESIS. underlying diathesis, the infection would not develop. Thus, a reciprocal relation existing between the diathesis and the infection brings the manifestations of the disease into existence. To further elucidate this point it may be stated that, according to the German idea, infections of the human body occur in two ways, viz., (a) enteral infection and (b) par enteral infection. The former means the en- trance of the infective agent through the intestines and is represented by typhoid fever, amebic dysentery, etc. The latter represents the entrance of the infection through avenues other than the intestinal tract; for instance, through the skin, as represented by eczema and erysipelas, and through the respiratoiry tract, as represented by laryngitis, bronchitis, and pneumonia. It is largely through these parenteral infections that the exudative diathesis becomes manifest. In other words, it is the predisposing factor. Some parenteral infections may even cause other manifestations of the diathesis, already present, to improve, while others intensify the symptoms. Of the first instance we have an example in the beneficent effect of an attack of measles upon eczema, and, of the second, it is well known that vaccinia and varicella will accentuate the symptoms of this disease. Therefore, unless the circumstances be un- usually urgent, an infant with eczema should not be vac- cinated. It may be surmised, correctly, that there exists a resemblance between the clinical behavior of the exudative diathesis and that of spasmophilia. The latter, as we have seen, may be latent and becomes manifest only as the result of some eotciting factor. The association of the exudative diathesis with spas- mophilia occurs with some frequency in the same patient. The relationship is not clear. The event is probably a co- ETIOLOGY. 299 incidence, although the underlying factor in each instance is metabolic. Heredity undoubtedly plays a role of importance. Many children of the same parents present the symptoms of this diathesis. The parents themselves, more or less constantly, present evidences of perverted metabolic proc- esses. They are frequent victims of neurasthenia or of some neurotic manifestation, or suffer from lithemia, the so-called uric acid diathesis, rheumatism, diabetes, asthma, acidosis, indicanuria, or chronic skin affections. Environ- mental influences, however, may explain these results as well as heredity, as the disturbances, evident in the parents, may be due to dietetic and other determining factors which are permitted to operate constantly in the case of the offspring. The disease is not confined to those artificially reared, the evidences of eczema, especially, occurring, with much frequency, in the breast-fed. Unhygienic surroundings, as already intimated, consti- tute a predisposing factor of no mean importance. There- fore poverty, ignorance, overcrowding, and filth in every form must be considered. For this reason, too, the disease is more common in the city than in the country. Exciting Factor. The exact cause is not known. Be- tween pediatrists and dermatologists there exists a differ- ence of opinion as to whether the skin manifestations are constitutional or local. The latter view is held by the der- matologists, who proclaim the futility of any but local treatment. The proper solution will, no doubt, determine that both local and constitutional causes are operative. There undoubtedly exists a reciprocal relation between the underlying diathesis and infection. Upon what does the 300 EXUDATIVE DIATHESIS. diathesis depend? As yet this has not been clearly defined. Czerny regards a disturbance in the fat metabolism as the underlying factor, but is unable to exactly describe the nature of this disturbance. On the other hand, Finkelstein inclines toward the view that the error lies with the water and with the salts. This finds some confirmation in the fact that certain breast-fed babies, who are gaining but slowly and who have eczema intertriginosum, are benefited by feeding to them the finely comminuted, coagulated pro- tein of cows' milk, with salt, in addition to giving them the breast. In this instancei the fat will not have been removed from the diet. Finkelstein also suggests, as a possible cause, a disturbance in the nitrogen metabolism in which too little nitrogen is absorbed. In any event it may be stated that somewhere in a perverted metabolism lies the cause and somewhere in diet lies the cure, because all cases are decidedly benefited by changes in the food andl in the ex- ternal surroundings. Because of the enlargement, of the lymphatic glands, not infrequently met, the relationship existing between this condition and the status lymphaticus has been considered, but the connection is not clear. SYMPTOMS. In order to attempt some form of classification these will be discussed under (a) body weight, (b) skin manifes- tations, (c) respiratory phenomena, and (d) digestive symptoms. It is important to emphasize that both treated and untreated cases vary in their severity throughout the course of the attack, and apparently without the influence of external agencies. One set of symptoms will often SYMPTOMS. 301 ameliorate while another set, hitherto quiescent, will become intensified. The occurrence, therefore, of substitution phenomena is a part of the natural clinical picture of the disease. Thus, the skin symptoms may entirely disappear, to be followed by an attack of asthma or digestive disturb- ance, and these in their turn will be succeeded by an attack of eczema. Body Weight. Two types of patients are affected : Underfed babies and overfed babies. It is important to dis- tinguish these two types, as experience has shown that, originating from this premise, two different lines of die- tetic management are necessary to secure good results. Reference will again be made to this classification. In general it may be stated that the underfed baby is thin, puny, and "transparent," is stationary in weight, and likely to suffer from digestive disturbance and diarrhea. It often suffers from eczema seborrhceicum universale, with intertrigo. The overfed infant appears fat and robust. These babies are, however, commonly anemic, have poor resist- ance, and exhibit the wet forms of eczema, especially of the face and head. They also have more or less digestive dis- turbance and may be constipated. Skin. The dermal phenomena may be classified as neuropathies, eczemas, pruriginous inflammations, and strophnhis. The first are seen as increased vasomotor irritability and exhibit themselves, not uncommonly, as alternate flushing and paling of the surface, without apparent cause. This gives rise, at times, to the diagnosis of anemia (pseudo- anemia), an examination of the blood showing its hemo- globin content to be normal. Fugitive erythemas, itching, 302 EXUDATIVE DIATHESIS. exanthemas, pruritus, urticaria, and dermographia consti- tute the more common remaining skin neuropathies. The eczemas are usually found during the first year. Frequently they develop during the first weeks and even days of life. They rarely last beyond the end of the second year. Two principal types, of which there are sev- eral variations, exist: Eczema seborrhoische universale, or universal seborrheic eczema, and eczema of the face and head. The latter may occur with the universal type. Eczema Seborrhoische Universale. This develops as a consequence of increased epidermal desquamation, and ex- hibits white or yellow scales which are more or less filled with inspissated sebaceous matter. It may appear upon the head and forehead and about the temples and eyebrows, or it may become diffuse and cover the entire body with scaling plaques. The oily nature is best noted upon the scalp on account of the abundance of oil-glands in this situation. On the body cracks or fissures -occur, and from these exude serum and blood which dry and form crusts. The covering of the scalp may be a complete mask in which the hair is matted in an untangleable mass (gneisz). A form, in which the scalp is simply covered with more or less oily scales, but in which the underlying skin is not inflamed, also occurs. Removal of the crust reveals only a pale surface and there is no bleeding. This is known as seborrhea capitis. Itching is slight. On the other hand, should the skin beneath be red and angry, and itching be intense, then true seborrheic eczema is present. This is a dry type of eczema, and rarely is severe. Intertrigo, or eczema intertriginosum, in nearly all cases follows or accompanies eczema seborrhceicum. It is the same process except that it is found in the folds of the skin, SYMPTOMS. 303 particularly at the joints, in the front part of the neck, and in the groins and behind the ears. The last is an especially common situation. In the groin it must not be confounded with simple maceration and slight irritation of the skin re- sulting from acid stools and urine and carelessness. This type is moist, while eczema intertriginosum is frequently dry and the skin is always infiltrated or thickened and readily cracks. It may be mild or severe. These infants are often weak and under weight, and have mild, dyspeptic stools. Closely resembling this type of eczema is erythrodermia desqiiamativa, or Leiner's disease (Vienna). Finkelstein and Moro regard them as identical. Rarely eczema inter- triginosum becomes infected with the diphtheria bacillus, when it assumes the clinical features of this disease. Eczema of Face and Head. This type occurs most commonly after the fourth month. Careful observation will detect its presence almost at its inception. All infants with "red cheeks" should be objects of suspicion. Nor- mally the cheeks of infants are not red. They possess the healthy skin color. This is true also out-of-doors. In this type of eczema there is seen a more or less circumscribed area of redness on one or both cheeks. At first glance, and always to the untrained eye, it may appear as the blush of health. The skin, however, will be observed to be somewhat inelastic, at times shiny, and to be covered with very fine scales. It itches but slightly, as a rule. The process may be stayed in its further development. Later papules may appear and itching may become so intense that the infant unmercifully tears its own flesh, causingi it to bleed. Crusts are formed and infection is not uncommon. Many of these 304 EXUDATIVE DIATHESIS. babies are transformed into pitiful sights, and suffer in- tensely from the scratching and tearing and crust formation. If their hands are tied they bury their heads into the pillow or nib them against any object in their frenzy to secure relief. Removal of the crusts (milk crusts, or crustalactea} is followed by bleeding. The skin of the rest of the body may appear quite normal. Sometimes, instead of papules, vesicles appear (eczema vesiculosum} or their place may be taken by pustules (eczema vacciniformis). This differs from eczema vac- cinatum, which is due to, and occurs around the area of, vaccination. Phlyctenular conjunctivitis and keratitis impetiginosum are regarded by Czerny as eczema of the cornea, They occur in weak, anemic, underfed infants, and place a grave prognosis upon the final outcome of the disease. Heubner and Finkelstein deny the relationship of this condition to the exudative diathesis. Pruriginous Inflammations. The staphylococci which normally inhabit the skin may become pathogenic, as a re- sult of the lowered resistance due to the exudative diathesis, and thus be responsible for pruriginous inflammatory proc- esses. The most common expressions of this condition are furtmculosis, ecthyma, and infected pemphigus. Strophulus. This appears in older infants and children as a rule. It resembles urticaria in the sense that the lesions may appear as wheals. They are not as evanescent, how- ever. More often they occur as simple small papules on the apices of which appear minute, deep-seated vesicles. The lesions occur anywhere on the body, most often, however, on the extremities and buttocks. They itch intensely and seriously interfere with the child's rest. If the minute SYMPTOMS. 305 vesicle is punctured the degree of itching is decidedly ameliorated. They are made decidedly worse by filth. Respiratory Symptoms. Catarrhal involvement of the respiratory mucosa is a cardinal feature of the exudative diathesis. A tendency toward recurrence of these attacks is their most significant characteristic (the so-called "re- current sibilant bronchitis" of American writers). Rhinitis is common as well as pharyngitis and follicular tonsillitis and chronic tonsillar cnlarge^nent. Bronchitis, which not only, as just stated, frequently recurs, but which is likely to become subacute or chronic, is constantly seen. These frequent infections are no doubt responsible for the many children who present enlargements of the submaxillary and cervical lymphatic nodules. The majority of these enlarge- ments are probably tubercular. This is true also of the enlargements so commonly found at the roots of the bronchi. Infection in both instances is the result, undoubt- edly, of the frequent "colds" to which patients with the exudative diathesis are subject. This disease therefore be- comes one of considerable importance in the consideration of the prophylaxis, not only of glandular, but of pulmonary and of all other types of tuberculosis. "Bronchial asthma," or recurrent sibilant bronchitis, to which reference has already been made, a disease but little understood as to its etiology and certainly less so as to its therapeutics, is regarded by the Germans as being, especially in infants and young children, a neuropathic expression of the exudative diathesis affecting the bronchial mucosa. Right or wrong, it matters little as long as a new thought with reference to this vicious and puzzling malady is suggested. The diet therefore, as indicated later, should be intelligently handled. Perhaps, then, this disease may 20 306 EXUDATIVE DIATHESIS. offer another example of a serious affection yielding to a simple remedy which has long been close at hand, but which has remained unrecognized. Digestive Symptoms. Lingua geographica (-Fig. 47) is a dominion occurrence and is prima facie evidence of the presence of the diathesis. It is a thickening of the epithelium covering the tongue, and assumes the form of a whitish elevation which changes in shape from day to day. Oral Fig. 47. Lingua geographica. infections, as stomatitis and canker, likewise occur. The breath is heavy and often has a sweetish odor. The bowels are commonly normal, but may be constipated. The thin, dyspeptic stools of the newborn, breast-fed baby are re- garded by Czerny as due to this diathesis. My own experi- ence would lead me to believe that this is not so in the majority of instances. The intestinal mucus may reveal eosinophiles (eosinophilous stools). Dyspeptic stools are commonly met in the weak, underfed infants who suffer from eczema intertriginosum. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 307 The Blood and Nervous System. Some of these, babies exhibit symptomatic anemia. In most all, the cosinophiles arc increased to as high as from 20 to 30 per cent. Espe- cially is this noted in cases with eczema. The connection is not clear. Whether the eosinophilia depends upon the eczema, or both the eczema and the eosinophilia depend upon the underlying factor, has not been determined. Various nervous symptoms appear from time to time, as night- terrors, chorea, urinary incontinence, etc. These are not to be regarded as the direct manifestations of the diathesis, but occur from other exciting factors operating upon a weakened system. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. From all that precedes, the physician will immediately recognize that he has seen, and is seeing daily, many of these infants and children. In the past he has failed to classify them, failed to recognize that, without a correct conception of the underlying diathesis, his attempts to thoroughly cure these babies of eczema and other infections have been sig- nally fruitless. On the other hand, he has succeeded blindly, applying his remedies empirically, but without the stimulat- ing effect upon himself which comes from doing things for a reason. Granting that, even with the recognition of the exudative diathesis as a clinical entity, much concerning its intimate nature remains lacking, we are at least provided with a basis for correct reasoning. Consequently with an attempt toward a correct therapeutic regime we are rewarded in some very obstinate cases with brilliant results. There remains nothing from \vhich it is necessary to distinguish this diathesis. 308 EXUDATIVE DIATHESIS. PROGNOSIS. As before stated, the severity of the manifestations of the diathesis varies constantly without the influence of external agencies. The substitution phenomena already mentioned must be borne in mind. Eczemas are rarely fatal, although they may be, especially in the presence of severe secondary infection. I have seen fatal pyemia result. The outlook in respiratory conditions depends on their severity and fre- quency and the general condition of the patient. The pos- sibility of tubercular infection must be remembered. Fre- quent attacks of follicular tonsillitis lead to chronic hyper- trophy and cardiac disease. The possible extension o>f the effects of the diathesis into adult life, in the shape of rheu- matism, eczema, gout, 1 diabetes, asthma, and other affec- tions of undoubted metabolic origin, is not at all unlikely. TREATMENT. Prophylaxis. A change from the city to the seashore or to the country is of supreme value in hastening the cure. The utmost cleanliness should be observed in handling the eczemas. Even without any evidences of skin involvement the latter should in every way be thoroughly cleansed, properly dried, and protected from infection and filth. The proper care of anal and urinary discharges is particularly important. I have learned to appreciate the value of daily inunctions of cold cream for purposes of cleanliness, instead of water, in cases where the skin exhibits the least irritation or is already involved. Underfed Infants with Eczema Intertriginosum and Eczema Universale. In the breast-fed it is necessary to add protein and salt to the diet. For this purpose, while continuing the breast, either plain sodium, chlorid, 15 TREATMENT. 309 grams daily, are given, or the same amount of "emsersalz" (equal parts of NaCl and NaHCO 3 ). This is given with Larosan or Nutrose. The former, as previously stated, is calcium casein and the latter is sodium casein. These prep- arations are added to water or diluted milk, in which the salt is also placed. They may be sweetened if necessary with saccharin. They are given for every other feeding. Locally fullers' earth is applied to the skin lesion with very good effect. In artificially fed children who are under weight, reduce the fat and feed the child with eiweissmilch or Larosan made up with milk, whole or diluted. After the dyspeptic stools become normal a formula low in fat and containing starch- or a cereal- water or gruel may be substituted. Locally if the lesions are at all moist the application of fullers' earth is followed by a happy effect. On the other hand, the preparations of tar serve well in many instances. In seborrhcea capitis nothing does quite so well as a thor- ough cleansing with tincture of green soap, each morning, subsequent to the application of the following for twenty- four hours : Ac. salicylic gr. vj-x. Ung. aquae rosae or lanolin Sj. Under the influence of this simple ointment the cracks of eczema seborrhceicum and of eczema intertriginosum speed- ily disappear and the infiltrated areas are made softer, less thick, and more pliable. Overfed Children with Eczema of Head and Face. In these cases the total amount of food must be reduced as well as the quantity of fat and carbohydrate. These chil- dren should be fed almost exclusively on a diet consisting of vegetables, cereals, and eggs. Some children exhibit an 310 EXUDATIVE DIATHESIS. intolerance for egg-albumin and are made worse thereby. This may be determined in some cases by performing a test upon the skin exactly as the von Pirquet tuberculin reaction is done, except that egg-white is rubbed into the scarifica- tion instead of tuberculin. If the child is sensitive to this form of protein an area of erythema will surround the scari- fication upon which the substance was deposited (Allergy). Very little, if any, milk should be given. With some babies, even eggs must be omitted. If milk is used at all, it is best given skimmed. In the dry forms of eczema the ointment above detailed is of service. The wet types of eczemas do well on eczema soup, which must be administered for from four to eight weeks. This soup is made as follows: Coagulate i litre of milk. Allow the whey to thoroughly drain off. Finely comminute the curd by pushing it through a hair-mesh sieve. Add it to 200 grams of whey and further add sufficient water to make i litre, and sweeten with i tablespoonful of cane-sugar or i grain of saccharin. Marked amelioration is invariably noted after the ad- ministration of this preparation for just one week. It is well now to make use of additional carbohydrate and some vegetables and a cereal. Spinach, mashed carrots, stewed celery, stewed onions, oatmeal, farina, and cream of wheat are examples of the types of food to be allowed. The extra carbohydrate should consist of either cane-sugar or some preparation of malt-sugar. Locally, when the eczema becomes dry, a tar ointment should be employed. Czerny, besides recommending a change in climate, orders the 1 following regime for a child weighing 8 kilograms : TREATMENT. 311 A.M. A simple biscuit cooked in 100 grams of milk. Forenoon. 200 grams of whole milk and thin oatmeal- gruel, half and half. Xoon. Soup and vegetables. Afternoon. 200 grams of whole milk and thin oatmeal- gruel, half and half. P.M. 100 grams of whole milk, thickened with cereals. In severe cases the milk may be still further reduced. Recurrent Bronchitis. It has been possible in several instances to cure and to> prevent a recurrence of attacks of bronchitis, associated with dyspnea and sibilant rales, by adopting the following routine: In the beginning milk, butter, and sugar are entirely excluded from the diet. Dependence is placed entirely upon vegetables, cereals, and meats ivi-thout fat. Raw and stewed fruits are not "per- mitted. Sweetening is obtained by the use of saccharin. The bowels are kept regular by enemas and by mineral oil. All external sources of irritation, whether physical or psychical, are avoided. An open-air existence must be secured, and regular bathing, provided there be no eczema, must be practised. Very gradually the forbidden articles of food are added to the diet, one at a time. At the first suggestion of a recurrence, however, they are again rigidly excluded. It has been possible to demonstrate almost abso- lutely the influence of. diet upon the recurrence of attacks, in several instances, and in others it has been possible to demonstrate the negligible effect of season. Certain chil- dren who have each winter suffered from recurrent bron- chitis have been kept entirely free when the diet has been rigidly enforced. 312 EXUDATIVE DIATHESIS. Supposing that the metabolic disturbance results in an acidosis from the effects of which the bronchitis arises, the use of from i to 2 drams of bicarbonate of soda, scattered throughout the food each day, has been practised with good effects. Other alkalies, like potassium or sodium acetate or citrate or sodium salicylate, are commonly administered in conjunction with the dietary treatment. During an attack, use is sometimes made of small doses of tincture of bella- donna, with good effect. CHAPTER XII. PYLORIC OBSTRUCTION. Synonyms. Congenital pyloric stenosis, Congenital hy- pertrophic pyloric stenosis, Pylorospasm, etc. Fig. 48. Showing pyloric obstruction. Nature. In order that this affection may be the better understood it appears to me that the synonyms above should be omitted from medical literature and that the disease should be known as (a) infantile pyloric obstruction com- plete and (b) infantile pyloric obstruction incomplete. In all cases there is an obstruction at the pyloric ring (Fig. 48). This prevents the onward movement of the gastric contents into the duodenum from taking place, either completely or incompletely, depending upon the degree of (313) 314 PYLORIC OBSTRUCTION. obstruction. With this conception, a better understanding of the clinical phenomena is available and a more rational therapeutic classification is also possible, as we shall see. PATHOLOGY AND ETIOLOGY. Predisposing Factors. Age, sex, neurotic parental tem- perament have all been studied statistically as to their bear- ing on this condition, but they serve no purpose in either prevention or in cure, and will not, therefore, be further discussed. Active Factors. The cause of the obstruction in every case is a narrowing or a practical obliteration of the lumen of the pylorus by (a) hypertrophy of the pyloric muscle or (6) spasm of the pyloric muscle or (c) a combination of both hypertrophy and spasm. The last is, ini all likelihood, most commonly present. Bearing these underlying anatomic features in mind, it is perfectly easy to understand the suc- cession of symptoms characteristic of the two types of this affection, which are met clinically. Reference will again be made to this point. Much as a clear understanding as to the ultimate direct cause of the hypertrophy or of the spasm, would assist in adopting perhaps antenatal or postnatal preventive meas- ures or even curative ones, at present, no definite data bear- ing on this point are available for practical purposes, although many theories, ingenious and otherwise, have been offered. These I shall not discuss, for a medley of diverg- ent opinions cannot possibly serve any useful purpose and will only yield confusion. My view, based upon the obser- vation of two dozen or more cases, is that in essentially all of them the initial condition was spasm, and that hyper- trophy followed as the result of intense, continuous muscular PATHOLOGY AND ETIOLOGY. 315 activity, and I am beginning to feel that perhaps something, either in the mother's milk or in the intestinal and gastric juices or in the resultant of the activity between these juices and the milk, is responsible for the initial spasm. There- fore T believe that our investigations in the future as to the fundamental cause of the primary spasm will have to be sought in this direction. My reasons for this belief are: (a) most cases do not show symptoms immediately after birth, but perhaps anyivherv from two to four ^veeks; (b) the degree of spasm is not always the same in a single case, indicating that the local irritant of the nervous mechanism of the pylorus varies in its intensity; (c) complete non- operative recovery is possible, the symptoms of obstruction sometimes subsiding with comparative suddenness and this, in some cases, has been hastened by a change in diet. For our purpose, at present, it is sufficient to remember that the pylorus is either completely or partially obstructed, and that either one of these conditions may be brought about by spasm, hypertrophy, or both. Thus it is conceivable that the spasm may be so intense and permanent as to cause complete obstruction, just as well as one may imagine a partial ob- struction due to hypertrophy alone (rare) if the hyper- trophy were not sufficient to> entirely occlude the lumen. Hypertrophy per se may cause complete obstruction. So, too, the spasm may be intermittent when either alone or combined with hypertrophy, causing the obstruction to be intermittently complete and incomplete. Clinically we shall see that this is well borne out. Thus any combination erf spasm and hypertrophy may exist. The essential thing, however, as far as subsequent treatment is concerned, is to study these cases clinically, disregarding in a sense the pathology, and to determine in the individual case whether 316 PYLORIC OBSTRUCTION. the obstruction be complete or incomplete and, if the latter, whether enough food passes to sustain life and to warrant a continuance of non-surgical treatment. Reasoning from these data, the symptomatology may be rationally discussed as follows: SYMPTOMATOLOGY. A. Complete Obstruction. This is the less common of the two varieties. Vomiting results directly from the ob- struction. The food cannot get through the obstructed pylorus, so it is ejected through the cardia, after remaining in the stomach a variable length of time. It is the latter phenomenon which often causes confusion and error. One might imagine that if the pylorus is completely occluded the vomiting must occur after each feeding. This is not so because the stomach becomes dilated and its capacity may become enormous (Plate XIII). Thus vomiting may occur but three to four times or less, per diem. Especially is this true after the condition has existed some weeks. Therefore, the amount vomited is important. It may represent three or four or five or more feeds, and be sour and bad-smelling. Vomiting may, however, occur after each feed. The manner in which the food is ejected is characteristic. It is forceful, propulsive, projectile! The vomitus literally shoots out of the mouth, and often through the nostrils as well. If very acid it may cause the infant to cry or set up a coryza. The stream may reach a foot or more beyond the crib. It occurs without nausea, gagging, or any apparent effort on the part of the infant. Vomiting may commence immediately after birth. More often it is delayed until the second or third week. It is one of the prominent causes for removing the infant from the breast when the fault lies not PLATE XIII H Showing stomach-tube in situ in case of intense gastric dilation. The tip of the tube is opposite the right superior spine of the ilium and the lower border of the stomach is at the brim of the pelvis. This case made a complete non-operative re- covery. SYMPTOMATOLOGY. 317 with the maternal milk, but depends upon an unrecognized obstruction at the pylorus. The further history of these babies usually is that they are placed upon an indifferently Fig. 49. Weight curve in a case of complete or surgical pyloric obstruction, a-b, continuously downward course (char- acteristic of this type of obstruction), resembling the crisis of pneumonia temperature curve ; b-c, upward course (gain) after posterior gastroenterostomy. (Original case. Operation by John B. Deaver, M.D.) modified cows' milk or upon a patented food without any relief from the vomiting 1 . Such a history, obtained in a breast-fed baby, should always create the suspicion of 318 PYLORIC OBSTRUCTION. pyloric obstruction. In my experience it has been so con- stant that I have come to regard it almost as a part of the clinical picture of the disease. Constipation. Think again of the pylorus completely occluded, either from spasm, hypertrophy, or both. All the Months Weeks < 3 a 7 11 13 t! 17 19 21 23 25 21 20 P 33 3S 37 3 9 41 4! 45 47 r\ j 13 ' _. z &J yjt J Ir/.I " ^ ^ - - > afj. l_ ^Sfl 11 - & j ~l L fe --2 -_ ^__ L. J ^ ^oC- J ' .^t> -- r 7 7 i Birth H r j 3 \ t~ f r^ i ^ " A " ^ 1 z f 35 3 ._ C i. > ^ . . 2 _ _ i > ,-. s lossc ._! L _, "{ icient eonount of no i i M i i i i i urishment I i \1 ~ Insu .J- i W*ks 135 7 9 11 13 IS 17 19 21 a3 2S Z7 Z9 31 S3 35 37 39 41 41 45 47 Loss of Weight during period of observation for four days just preceding operation Fig. 50 shows effect of posterior gastroenterostomy on weight curve in a case of complete pyloric obstruction. Note continuously downward course of weight curve before opera- tion, as in Fig. 49. Original case. Operation by Francis T. Stewart, M.D. (H. Lowenburg, N. Y. Medical Journal, Feb- ruary 11, 1911.) food is vomited. None passes into the duodenum and thence into the intestines. The reason for constipation is clear. It is complete absolute. It is obstipation. The bowels move rarely, it is true. The movements consist of a discharge of bile-stained mucus. They have no bulk. They SYMPTOMATOLOGY. 319 contain neither curds nor digested-milk feces, because none can come through. IVeiglii and Strength. From the very onset of symp- toms the weight curve tends progressively downward. It is Fig. 51. Visible gastric peristalsis. continuously depressed. There is no hesitation, no retrench- ment, no stationary weight. The loss may not be suddenly great. It is rarely so. It is, however, continuously down- ivard. Thus an infant weighing 7^2 pounds at birth, for instance, may lose y 2 or Y\ pound by the end of the first week after the onset of symptoms. If this is repeated dur- 320 PYLORIC OBSTRUCTION. ing the second and third week, the possibility of complete obstruction or practically complete obstruction becomes a certainty. The weight curve in these cases resembles in a sense the curve seen in the crisis of pneumonia (Figs. 49 and 50; compare with Figs. 52 and 53). The effect of edema on the weight curve will be considered later. The infant's strength for obvious reasons becomes pro- gressively less. Its movements become weak; its cry lacks force and it lies quietly in bed unless disturbed. Visible Gastric Peristalsis (Fig. 51). This is the most interesting as well as the most important symptom from a diagnostic viewpoint. Bearing in mind ag'ain the obstruc- tion at the pylorus (Fig. 48), its method of production is readily understood. The stomach endeavors, as it were, to pass its contents onward into the duodenum. It cannot do so. This causes the peristalsis of the stomach to become exaggerated. The involuntary muscle is stimulated in an effort to overcome the obstruction. The waves of contrac- tion become greater and are seen in the epigastrium, pass- ing from left to right. A globular mass which can be pal- pated will appear under the lower left costal margin. It will lazily pass across the epigastrium. Before it progresses very far another will form at the original site and slowly follows the first, which gradually disappears under the right costal arch, while perhaps yet a third is forming under the left border. So it will be seen that two or three globular masses are slowly following one another from left to right across the epigastrium. The appearance has been likened to the rolling of two or three balls under the skin. The masses represent sections of the contracting stomach. The gastric peristalsis is not constantly visible. In the beginning it may not be seen at all because emaciation has PLATE XIV Practically complete obstruction. Operation. Recovery. Imme- diately after the administration of the bismuth. PLATE XV One hour after the administration of the bismuth. Xone of the chemical has left the stomach. PLATE XVI Three hours later. Xo bismuth has left the stomach. Note the thickened pylorus (P) and how the bismuth shadow stops abruptly there. PLATE XVII Six hours later. Xo bismuth has left the stomach. Note the stomach was photographed while undergoing contraction (C). Note the lower border of the stomach to be opposite the brim of the pelvis. Xo bismuth has passed beyond the thickened pylorus (P). PLATE XVIII The next day, about nineteen hours later. Bismuth still in the stomach. Very little in the small intestines and sigmoid. The amount is practically negligible. Infant has vomited some of the bismuth. PLATE XIX Comet-like appearance of the bismuth shadow at the pylorus in cases of complete obstruction. This appearance is almost constant and is very characteristic of this type of obstruction. SYMPTOMATOLOGY. 321 not become sufficiently advanced to permit the movement to alter the normal appearance of the surface of the upper abdomen. It may also be invisible when the stomach is empty, as immediately following 1 a severe spell of vomiting-. Just preceding this event, however, it is commonly accen- tuated. It is often present during sleep. It may be in- augurated by tlie giving of food or drink or by tapping lightly upon the epigastrium ztrith tJie back of the middle- finger. A few moments may elapse before the contractions commence to appear. Therefore, when searching for this symptom it is unsafe to conclude that it is absent unless the maneuvers above are employed and unless the epigastric area be visualised at least for from ten to fifteen minutes. In some cases the pain associated with the contractions is so intense as to cause the infant to cry. Rarely the movement of the visible gastric peristalsis is seen to be reversed, i.e., it passes from right to left. All these instances, however, must be carefully distinguished from visible peristalsis due to contraction of the transverse colon. This is occasionally met in thin subjects and in cases of obstinate constipation or of organic obstruction of the large intestines. Dilated Stomach. At first the muscle-fibres undergo hypertrophy. Later they become thinned and the degree of gastric dilation may become enormous (Plate XIII). As a rule the lower border of the stomach may be readily seen through the thin abdominal wall. At first it does not reach below the umbilicus, and the upper abdomen alone is dis- tended while the lower portion of the belly is flat on account of the collapsed condition of the intestines, into which no food has entered. Later as the dilation increases the lower border of the stomach reaches far below the navel. In fact 21 322 PYLORIC OBSTRUCTION. it may reach the pelvic brim (Plate XIII). This is readily determined by inspection and can be confirmed by palpation and X-ray studies. In this enormous degree of gastric dilation is found the explanation why, in advanced cases especially, vomiting need not and does not occur after each feeding and may appear but a few times each day. Palpable Pylorus. The pylorus is thick and hard (Fig. 48) ; whether from hypertrophy or from spasm or both, matters not. The abdominal wall is thin. Therefore it is possible to palpate the pylorus. It is commonly felt as a hard object, about the size of a small olive, a little above and to the right of the umbilicus. It is best felt by placing the warm hand gently upon the abdomen, employing the middle-finger as a searcher by gently but firmly pressing it into the abdominal wall. If the abdominal muscles are made rigid by crying or straining, palpation cannot be suc- cessfully accomplished. In order to overcome this the ex- amination should be made while the infant is placed at the breast, or while it is receiving other food or drink, or some- times during sleep. The abdominal wall must be thoroughly relaxed. In some cases of complete obstruction it is impossible to palpate the pylorus during the early stages of the case on account of the comparatively thick layer of adipose tissue, only slight or no loss of weight having occurred. The position of the pylorus is not always constant. It is occa- sionally found close to the lower border of the liver, near the median line, but above the umbilicus. Where a great amount of gastric dilation has ensued it may be found low down and close to the pelvic brim to the right of the median line. SYMPTOMATOLOGY. 323 X-ray Studies. These should be made in all cases. While unnecessary for a clinical diagnosis of obstruction, per se, they aid materially in distinguishing complete from incomplete cases, and are often of lvalue in assisting to determine whether the treatment shall be surgical or non- surgical. For making these studies only bismuth subcar- bonate should be employed, and should be administered through a tube. In cases of complete obstruction it will be found that no bismuth leaves the stomach to enter the in- testines, after a period of twenty-four hours. During this time a series of no less than eight or ten exposures should be made, commencing immediately after the administration of the drug and ending not less, in any case, than sixteen hours after this time. This will insure sufficient time to permit the smallest amount of bismuth to pass (Plates XIV, XV, XVI, XVII, and XVIII). In cases of complete obstruction I have noticed that the bismuth shadow assumes a "comet"-like appearance almost immediately after administration. I regard this as highly significant (Plate XIX) of this type of obstruction. Charcoal Test. Administer 10 grains of either animal or wood charcoal through the stomach-tube, to the near end of which is attached a syringe which contains the charcoal suspended in an ounce or two of water. Slowly inject it. Make a note of the hour of injection. Have the nurse do the same, each time she changes a soiled diaper. In cases of complete obstruction no charcoal will appear upon the diaper. In the mean time considerable charcoal will be lost each time the infant vomits. At the end of twenty-four hours wash out the stomach. The washings will contain charcoal showing conclusively gastric retention and the non-entrance of aliment into the intestinal canal. 324 PYLORIC OBSTRUCTION. Temperature. This speedily becomes subnormal unless external heat is employed. If infection occur it becomes elevated. These infants become readily infected (see Com- plications) . When starvation becomes marked the tempera- ture rises and may reach 104 F. before death. I have also witnessed a sudden rise which I cannot explain follow immediately after stomach washing-. It speedily disappears, however. The poor resistance of these babies is frequently emphasized by their death from pneumonia just about at the end of the disease or immediately after recovery. The temperature rises very high and death may ensue before the signs of consolidation become evident. Urine. The urine exhibits no changes of interest except toward the end in cases which have remained un- treated and in which vomiting has been unduly severe. The tissues become parched for the want of water. The urine then is scant, dark, highly concentrated, sharply acid, and excoriating. Urates may be deposited upon the diaper. A faint trace of albumin is present and microscopically kidney debris and other organized substances are found. Therefore, other things being equal, it may be correctly sur- mised that a free flow of normal limpid urine is a favorable sign. Edema. This is not directly a part of the clinical pic- ture of pyloric obstruction. It may, perhaps, be better classified as a complication. It is emphasized here, how- ever, because its onset is so insidious and because it fre- quently passes unnoticed, but principally because it is responsible^ for a more or less abrupt increase in weight which is erroneously regarded as a favorable sign. The additional weight is not fat, but water. I have seen this error made and a favorable prognosis recorded when death SYMPTOMATOLOGY. 325 was but a few days away. It is a very unfavorable symp- tom. It occurs along toward the end of severe cases in which vomiting has been unusually constant. The insteps and the lower legs are first affected and gradually it spreads upward, rarely, however, passing above the knees. Its method of production is little understood, notwithstanding an overabundance of theorizing. B. Incomplete Obstruction. This type is more common than that of complete obstruction. There are, however, all grades of this form which clinically must be differentiated. Many of them approach in severity cases of complete ob- struction, as we shall see, and must, like them, be treated surgically. Therefore, the distinction betw r een complete and incomplete obstruction must not be regarded as final, but, therapeutically, at least, the classification of surgical and of non-surgical must be made as well, for many cases of incomplete obstruction require operation. In fact, I believe the number of this type of case is daily increasing, as the mortality from operations is steadily becoming less and as the cases are receiving" closer clinical study. Vomiting. This partakes of the nature of the vomiting in cases of complete obstruction, except in very mild in- stances wherein the spasm occurs with some intermittency. Here the intervals between attacks may at times be more than a day or two, to be renewed again with intense vigor, when the degree of spasm increases. Constipation. Bearing in mind again the obstruction at the pylorus and that it is not complete, one can readily understand that some of the aliment passes and that there- fore constipation, while present, is not absolute. The size and the frequency of the movements vary directly as the degree of obstruction, which also determines the severity of 326 PYLORIC OBSTRUCTION. SYMPTOMATOLOGY. 327 the two symptoms vomiting and wasting. These, in com- mon with constipation, form a trinity of symptoms which are closely interrelated, and which possess considerable prog- nostic import. The movements are usually small and dry. Not being of sufficient size to stimulate peristalsis, they lie in the lower bowel so long that they become inspissated. The bowels move, on the average, once every three or four days, a suppository or the clinical thermometer being necessary to secure an evacuation. The movements consist of milk feces and mucus, and often contain small curds which in themselves are conclusive evidence that the pylorus is not entirely occluded. Weight and Strength. A common clinical type o>f in- complete obstruction presents a weight curve which is radically different from that of complete obstruction, For developing this fact, I believe that I may claim originality, for I have no knowledge of its description having been pro- posed by any other author. Before describing this curve it is necessary to state that there is one type of case, however, of incomplete obstruction of which this is not true, viz., those instances in which the passage through the pylorus is so small that but little aliment passes, and for all intents and purposes, clinically at least, the case presents the fea- tures of complete obstruction, and must be so regarded therapeutically. It would perhaps be better to say that this latter type of weight curve belongs to surgical cases rather than to a certain type of incomplete obstruction, because all cases which present it must be operated upon and under it are included as well all cases of complete obstruction, as has been already indicated (Figs. 49 and 50). Figs. 54 and 55 represent the correct manner of weighing an infant. The curve in typical, non-operative, or non-surgical 328 PYLORIC OBSTRUCTION. incomplete cases suggests the line of a continuous fever with slight remissions and elevations (Fig. 53; compare with Figs. 49 and 50). Thus the infant loses a few ounces, say, two or three. The next day he gains one or two ounces. The day following neither loss nor gain is recorded. This may continue for a day or two. Again a slight gain or a slight loss occurs, so that at the Fig. 54. Weighing the baby. First ascertain the weight of the towel. (Fairbank's scale, No. 554.) end of a week the weight is the same or there is noted the loss or the gain of an ounce or two. The curve may remain stationary for two or three weeks, with slight losses or gains recorded in the daily estimations. These have a direct relation to the severity of the vomiting and the con- stipation. If spasm is worse for a few days, these are in- creased and with them is recorded a loss. As the obstruc- tion relaxes vomiting and constipation are less, and the lost weight is partially or wholly regained, with an ounce or so to spare. Therefore it can be appreciated how at the SYMPTOMATOLOGY. 329 end of five or seven weeks after birth the weight has changed but little, being somewhere between six and seven pounds, or there may be noted but a slight loss of about a half to three-quarters of a pound. A careful study of Figs. 50 and 53 will be of value in emphasizing this crucial clinical point of difference between operative and non- operative cases. Fig- 55- From combined weight of baby and towel subtract the weight of towel to obtain result. Visible Gastric Peristalsis. The description of this symptom under complete obstruction applies here, except that at times the intensity of the waves may be temporarily suspended only to return again with increased vigor. Dilated Stomach. The degree of dilation is somewhat less than in complete cases, although in severe types it may reach to enormous proportions. After recovery, in non- operative cases too, the normal outlines of the stomach are commonly recovered except in those cases which extend into childhood and to which reference will again be made. 330 PYLORIC OBSTRUCTION. Palpable Pylorus. The same causes which at times in- terfere with the successful palpation of a completely oc- cluded pylorus apply here. In addition, in those cases which depend entirely upon spasm and in which this phenomenon is intermittent, even when the abdominal wall is quite thin, the pylorus will not be palpable when it is relaxed. There- fore should this finding be reported negatively it does not exclude the diagnosis of either pyloric obstruction, com- plete or incomplete. In the latter instance it may be posi- tive the next day or within a few hours or even minutes. It may occur as the visible, gastric peristalsis, directly after the giving of food or drink or after tapping over the epi- gastrium, to disappear again. The fed of a pylorus, in spasm is just as hard as of one thickened by hypertrophy, only it may not be so constant. For this reason I do> not believe, as some authors teach, that every case in which the pylorus is palpable should be operated upon. I have had several non-surgical recoveries in such instances. This intermiittency is very common in partial cases and is sug- gestively diagnostic of them. Where hypertrophy is present or where spasm is intense and permanent, this intermittency of palpability may be absent and the hard, olive-like pylorus may be easily and constantly felt. X-ray Studies. These indicate that more or less rapidly, depending upon the degree of obstruction, varying amounts of bismuth pass from the stomach into the intes- tines. The quantity which does pass and the time occupied furnish valuable data in assisting to determine the necessity for or against operation (Plates XX, XXI, XXII, XXIII, XXIV, XXV, XXVI, XXVII, XXVIII, and XXIX). A careful study of these plates will indicate that cases of in- DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 331 complete obstruction, may be either surgical (Plates XXV to XXIX) or non-surgical (Plates XX to XXIV). Charcoal Test. Charcoal passes through the pylorus and is therefore found in the feces. The stomach washings contain not any, little, or much charcoal, twenty-four hours after administration, depending upon the degree of obstruc- tion and the severity of the vomiting. Immediately after administration the caretaker is instructed to save and mark the time of each soiled diaper. In this way an idea is ob- tained as to the degree of obstruction and the rapidity of the peristalsis. Therefore the X-ray findings and the charcoal test are valuable in permitting of an intelligent separation of the surgical from the non-surgical cases. Temperature. ^"here the degree of emaciation is ex- treme, the temperature is subnormal. However, it is less difficult to maintain a rectal temperature of 98 2 / 5 to 99 F. than it is in complete cases. Urine and Edema. Neither of these possesses the same interest as in cases of complete obstruction unless the degree of impatency be unusually severe. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. A. In General. Pyloric obstruction is not recognized because the average physician does not include it in the range of possibilities in reference to every case of wasting with which he comes in contact. He does not think of it at all. Its clinical features are so unique that it cannot be mistaken for anything else and cannot be passed by if it is at all considered. Nearly every case of unrecognized pyloric obstruction which I have seen in consultation has been called marasmus. The differentiation has already been dis- cussed under the description, of the latter (Chapter IV, 332 PYLOR1C OBSTRUCTION. page 165). It is of sufficient importance, however, to em- phasize here that these two conditions resemble each other only in so far that in both wasting is a prominent feature. Wasting in infancy., however, must simply be regarded as a symptom and not as a disease, and the underlying cause must always be diligently sought. In this connection pvloric obstruction must always be considered as a very potent and probable factor -of the nutritional bankruptcy. A very common occurrence is to consider that the vomiting is due to the breast milk. The infant is then promptly removed from it and a medley of formulas and patented foods are employed before the real cause of the disturbance is discovered. The practical constancy of this error, as forming a part of the clinical history of this disease, has already been considered. For ordinary purposes it may be stated that mother's milk never causes vomiting, per se, unless the amount of fat is unusually high for the individ- ual. More often among benign causes of vomiting in the suckling it will be found that too frequent feeding, pro- longed nursing, nervous influences, improper training, and bad hygiene, singly or combined, are operative. Besides, the character of the vomiting is never propulsive. There- fore the following may be stated as a truism: That every case of persistent vomiting, especially if projectile, occurring in a breast-fed baby, must be regarded as due to obstructive pyloric disease until it can be proven that it is not. The only other factor responsible for projectile vomit- ing is cerebral disturbance. Here a history of dystocia or forceps pressure or visible head trauma will be in evidence, together with the results of cerebral pressure or irritation, as coma, palsies, or convulsions. An exception to the last occurred in a case seen at the Mt. Sinai Hospital, in which, DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 333 following a history of forceps delivery, the infant suffered one or two attacks of convulsions. Vomiting soon super- vened, but a careful physical examination revealed all the characteristics of pyloric obstruction incomplete. This merely emphasizes the need of bearing pyloric obstruction in mind in every case of vomiting as well as in every case of wasting. Cyclic Vomiting. I have proven to my awn satisfac- tion, at least in one case in which the diagnosis of cyclic vomiting had been made, that the cause of the periodic emesis depended upon the persistence of a mild intermit- tent pyloric obstruction. The child was 2*4 years of age. The history of incomplete pyloric obstruction in infancy was clear and X-ray studies, as well as the retarded passage of charcoal, made the diagnosis certain. Therefore, the suggestion is offered that all cases of so-called cyclic vomit- ing in young" children should be studied from this stand- point before they are regarded as being idiopathic, reflex, or metabolic. The case to which reference has been made re- covered completely under lavage. Obstipation or constipation, occurring as the result of congenital or other defects, may cause some confusion, espe- cially if there be associated reflex vomiting, so called. Bearing in mind the essential symptomatology of pyloric disease, an intelligent discrimination will readily be per- mitted. B. Complete Obstruction. Depending directly upon the complete obstruction at the pylorus, the following ensemble of symptoms constitutes a definite clinical picture: Propul- sive vomiting, obstipation, loss of weight and strength (persistent}, visible gastric peristalsis, dilated stomach, pal- pable pylorus; non-passage of bismuth subcarbonate from 334 PYLORIC OBSTRUCTION. the stomach into the intestines, as sho^mi by the X-rays; the non-passage of charcoal through the gastrointestinal canal and its recovery the next day in the stomach washings. C. Incomplete Obstruction. This is characterized by propulsive vomiting; a variable degree of constipation; a gradual loss in iveight, which may become stationary; visible gastric peristaltic waves of variable intensity; per- manently or intermittently palpable pylorus; dilated stom- ach; the retarded but final passage of bismuth through the pylorus into the intestines; the passage of charcoal and its non-return or in variable but small amounts in the gastric it-askings, depending upon the degree of obstruction. By noting the amount of bismuth and of charcoal which passes, one is often permitted to judge of the quantity of aliment which gets through, and is therefore able to con- clude roughly whether this is sufficient to sustain life. This materially assists one to properly catalogue the individual case as surgical or non-surg'ical. The differential data be- tween these two types of cases are systematically presented under the prognosis, page 338. COMPLICATIONS. Pneumonia may occur, rarely, as a direct result of stom- ach washing, due to inspiration of foreign material. These cases all do poorly. High temperature, difficult to explain, may follow stomach washing. As has been mentioned, it speedily disappears. Edema has been noted. These in- fants, o be followed by albumin- \vater, broth, and similar substances are allowed. If the condition continues favorable, diluted milk formula, pre- digested or not, may be given. As the child continues to improve the milk formula is strengthened and a larger quantity given. If the stomach is not retentive, or if there is vomiting irrespective of taking nourishment, the stomach is to be washed out. In fact, this is the only thing that accom- plishes any good. In my experience, to give medicines, as AFTER-TREATMENT. 349 bismuth, cocaine, oxalate of cerium, and such other agents believed to be of some use in controlling- nausea, is abso- lutely of no use in cases of this character. It not infrequently happens that a few hours after operation the child will vomit some old blood which emits a disagreeable odor, and, if so, lavage should be immediately practised. It is my practice to give these children enteroclysis for two or three days. At the end of the fourth day the bowels are opened by enema. Rarely it is necessary to give an aperient or purgative. If the condition is at all favorable for operation these cases should get well with little or no anxiety on the part of the surgeon. Procrastination, in surgical cases, in the hope that the child will be better with- out operation, until the condition becomes alarming, causes operation to become a matter of much moment, and the con- sequent responsibility of the surgeon to be correspondingly greater. The incision is made through the middle of the right rectus muscle. In closing, the peritoneum is apposed by a continuous iodin-catgut suture. Two or more interrupted silkworm-gut sutures are passed through all tissues, down to the peritoneum. The sheath of the rectus is made to overlap and is fixed by a continuous iodin suture. The skin is closed with silkworm gut or horsehair. The interrupted stitches should not be removed for nine! or ten days, the child being strapped with adhesive plaster. The plaster ex- tends completely around the abdomen. When the stitches are removed too early, the edges of the wound may separate, causing ventral hernia. I have met this accident, but have corrected it by immediate replacing. CHAPTER XIII. SPECIAL TOPICS. DESCRIPTION OF APPARATUS. SHOULD his practice bring him into frequent contact with children, the physician should have the apparatus pictured in Fig. 56 always at hand, in good condition and ready for use. A consists of a small glass funnel ( i ) holding not less than 2 ounces and preferably 3. The funnel is attached to a piece of rubber tubing (2) about 6 to 8 inches in length. To this is connected a piece of glass tubing (3) 2 to 3 inches in length, and to this is finally attached a soft, red-rubber catheter (4), No. 22 to No. 26 French. An extra eyelet is cut into the catheter about ^2 inch from the end. B consists of a small, rubber, hand-bulb syringe (5) with a hard-rubber tip (6). In the figure it is con- nected with a soft, red-rubber catheter, No. 22 to No. 26 French (7). C is a glass syringe which may be employed instead of the hard-rubber syringe, and is especially useful in nasal feeding. D is a rubber fountain syringe holding 2 quarts (8). To the hard-rubber tip at the end is attached a No. 22 to No. 26 soft, red^-rubber catheter (9). It may be remarked that it is not necessary for the physician to possess more than one catheter, as it can be readily removed and be attached to that apparatus being employed at the time. (350) DESCRIPTION OF APPARATUS. 351 E is a sharp-pointed, hollow, steel needle (10) con- nected to a piece of rubber tubing (n). If the catheter (4) be removed in A and this rubber tubing with the needle be connected to the glass tubing ( 3 ) , a convenient apparatus for hypodermoclysis or for intravenous injection (by gravity) is secured. Fig. 56. A, glass funnel (i), rubber tubing (2), glass connecting tubing (3), catheter No. 22 to No. 26 French (4). B, small, rubber, hand-bulb syringe (5), small, hard-rubber connecting tip (6), catheter No. 22 tq No. 26 French (7). C, glass syringe. D, fountain syringe (8), catheter No. 22 to No. 26 French (9). E, hollow needle (10), rubber tubing (n). F, smallest caliber catheter. F is the very smallest red-rubber catheter obtainable, employed in nasal feeding. It will thus be seen that with this apparatus the phy- sician is equipped to perform such useful maneuvers as stomach washing; feeding by stomach-tube; nasal feeding; the administration of medicine via the tube, if the patient cannot swallow ; bowel irrigation ; the giving of a nutrient 352 SPECIAL TOPICS. or medicinal enema (high or low), and to administer saline or other medicinal solutions by hypodermoclysis or intra- venously. STOMACH WASHING (LAVAGE). Solutions Employed. Plain faucet- water will do. Sterile water is better. Normal saline soluton is still better. A solution containing i dram of sodium chlorid and i dram of bicarbonate of soda to the pint is best for routine purposes. For special occasions tannic acid ( i per cent, to 2 per cent.), potassium permanganate i : 8000, silver nitrate i : 10,000, may be of service in the presence of bleeding, morphin or other alkaloidal poisoning, or gastric ulceration or catarrh. For the control of the bleeding in gastric ulcer of adults Rodman recommends filling the stomach with hot water, the temperature being as high as is endurable by the patient. For ordinary purposes the temperature of the solution should be that of the body 98 to 1 00 F. The quantity employed depends upon the indication for which the washing is done. The washing is continued until the indication is overcome or mitigated. Ordinarily from i to 2 quarts are employed. As a rule, but i washing a day is allowed, although if much benefit follow, as in some cases of pyloric obstruction, it may be repeated two, three, and even four times within twenty- four hours. Technique. Apparatus A is employed. The patient is placed flat upon the back and wrapped in a small sheet or blanket in order to secure the arms. The head is steadied in the median line by an assistant. The catheter is made moist with the solution to be used. The tip of the catheter is passed along the dorsum of the tongue until it touches STOMACH WASHING (LAVAGE). 353 the postpharyngeal wall. Pressure is continued and the catheter will glide directly into the esophagus, through which it enters the stomach. The funnel is then held in a vertical position to allow gas to be expelled. This does not always occur, but some of the gastric contents commonly appear at the glass connecting-tubing or shoot into and sometimes out of the funnel. The fluid is now poured into the funnel and, unless the infant struggles, it will gradually enter the stomach. As it disappears from the funnel the latter is again filled. Just as the fluid is about to disappear for the second or the third time, depending upon the age of the baby, the funnel is depressed below the level of the patient and the gastric contents are siphoned into a recep- tacle. This maneuver is again repeated. This refilling and siphoning are continued until the fluid returns clear (Figs. 57 and 58). If the patient struggles, and in older children, the task becomes less easy. The patient cries and compresses its abdominal muscles, and the fluid will not enter the stomach, but moves up and down in the apparatus. If the indication for the washing is urgent, the funnel must be patiently held in the vertical position until the infant relaxes or in some cases the operation must be abandoned. The straining may be so great as to cause the tube to be forcibly expelled through the mouth. Under these circumstances the tube is to be replaced two or three times before the attempt is abandoned. Straining may cause the fluid to gush out of the infant's mouth. This does not interfere with the accom- plishment of a successful result. The stomach is cleansed whether the fluid is returned through the apparatus or via the infant's mouth. In yet other instances the catheter may become blocked by tough mucus or curds, or both. 28 354 SPECIAL TOPICS. Under these circumstances the tube may be withdrawn and an extra eyelet may be cut into its side, or the apparatus may be filled with the solution to 1 be employed before pass- Fig- 57- Stomach washing. The funnel is held erect to allow the fluid to enter the stomach. ing the catheter. The tubing is pinched until the catheter enters the stomach. When release of pressure is made the fluid will flow because, the apparatus being filled, in view of STOMACH WASHING (LAVAGE). 355 the law of the impenetrability of matter (two things cannot occupy the same place at the same time), no curd nor mucus can enter the catheter. The entrance of the fluid Fig. 58. Stomach washing. The funnel is depressed to filter away the stomach contents, which flow into the bowl. itself into the stomach will cause the curd or mucus to be broken up, and thus also the probability of the one or the other blocking the apparatus is materially lessened. 356 SPECIAL TOPICS. Enemata. Apparatus B is employed. An enema may be either high or low. A low enema is given below the internal sphincter, its purpose being to empty the rectum. A high enema is given above the internal sphincter. In giving the low enema the small, rubber, hand-bulb syringe is employed. In giving the high enema this apparatus with the catheter attached is used. The purpose of the high enema may be to cleanse the rectum and sigmoid or to place medicine or nutriment into the lower bowel. For cleansing purposes plain simple water or saline solution, or a mixture of soap and water with the addition of a small amount of turpentine and glycerin, may be employed. A high enema should always be preceded by a low enema, thus avoiding blocking of the catheter by feces. The catheter is anointed and passed within the bowel for a distance of from 4 to 6 or 8 inches, care being taken that the catheter does not curl upon itself. After being properly placed the solution to be employed is injected into the bowel through the catheter by means of the small, rubber, rectal syringe, or by means of gravity, use being made of a funnel or a fountain syringe. A high enema may also be introduced purely by gravity without the use of the catheter. The patient is simply placed in the knee-chest position and the tip of the fountain syringe in apparatus D is anointed and gently inserted into the rectum. The bag containing the fluid is held or hung about 2 or 3 feet above the patient, and the fluid is allowed to gently enter the intestinal canal by the practice of inter- mittent compression upon the rubber tube. Not more than 5 or 6 ounces of fluid should be permitted to enter the bowel (Fig. 61). Within a few minutes the patient will expel the enema and a large amount of feces. COLONIC IRRIGATION. 357 COLONIC IRRIGATION. Indications. When properly employed, colonic washing constitutes a useful therapeutic asset. It is, however, not Fig. 59. Colonic irrigation with the catheter. The tip is intro- duced and the buttocks are seen to be pressed together (so that no water can escape) in order to balloon the rectum. without danger, especially when continued without reason over a long period of time. A distinct indication must exist 358 SPECIAL TOPICS. and the washings must cease as soon as this is overcome, or it appears clear that they will accomplish no good. In Fig. 60 Colonic irrigation with catheter. The catheter has been pushed in for its entire length and the water is seen escaping along- side of it and over the buttocks. chronic constipation a single irrigation is useful to unload a crowded bowel. In this condition it should not be em- ployed more than once within a fortnight. It is also indi- COLONIC IRRIGATION. 359 cated in eclampsia, summer complaint (intoxication), intes- tinal parasites, intestinal putrefaction, dyspeptic diarrhea, Fig. 61. Giving a colonic irrigation or a high enema without in- serting the catheter. The infant is placed in the knee-chest posture and the hard-rubber tip of the syringe is simply placed within the anus and the water flows by gravity. and in dysentery. It is one of the most powerful means of reducing high temperature. 360 SPECIAL TOPICS. Technique. Plain sterile water, normal salt solution, or medicated fluids may be employed. In intestinal ulceration a weak solution of silver nitrate i : 10,000 or a i or a 2 per cent, solution of tannic acid may prove beneficial. The tem- perature of the fluid varies as to the indications to be met. In all instances, except in fever, it should be between 98 and 1 00 F. If the patient has fever, cold water or, better, gradually cooled water, or even ice-water, is valuable. Apparatus D is employed. The irrigation is preceded by a low enema. The child is placed on its left side and under its buttocks is arranged a suitable piece of rubber or a small Kelly pad, which drains the fluid intoi a bucket. The catheter is oiled. The stop-cock is released and the flow of fluid expels all air from the catheter. The flow is now shut off and the tip of the catheter inserted just beyond the internal sphincter. The fluid is again allowed to flow and the buttocks closely pressed together without compres- sing the catheter (Fig. 59). No fluid can escape and the lower bowel is ballooned. After a minute or two the catheter is gently pushed in for its entire length. As the colon fills, the belly is gently massaged. The fluid escapes in spurts from the anus along the sides of the catheter (Fig. 60). The irrigation is continued until the fluid returns clear. The irrigation may be accomplished without the use of the catheter, as in giving a high enema, the child being placed in the knee-chest posture (Fig. 61) and the refilling and the emptying of the bowel being continued until it is cleansed. At intervals the child may be placed upon its back with its buttocks elevated while the abdomen is massaged upward along the left side across and down the right. This insures the fluid reaching the ascending colon. NASAL FEEDING. 361 Accidents. In experienced hands nothing more than an interference with the easy flow of the fluid due to the bend- ing of the catheter upon itself occurs. As the physician pushes the instrument into the bowel the tip of the catheter reappears again at the anus. This may best be avoided by thoroughly ballooning the lower gut, or by passing the index-finger into the rectum and thus guiding the tip of the catheter past any obstruction. If the catheter becomes ob- structed from any cause, this fact may be determined by disconnecting it from the apparatus temporarily, when no fluid will flow through it from the bowel. There is some slight danger of rupturing an ulcerated bowel if the rubber bag be elevated too high above the child. NASAL FEEDING. Indications. Unconsciousness. If the child for any other reason cannot swallow, as in inflammatory and infec- tious conditions of the mouth and throat and after certain operative measures upon these parts, and in cases of tetanus. Technique. The infant's hands and arms are secured by a towel wrapped around its body. The head is steadied in the median line. Apparati F and C are employed. The calibre of the catheter must be the smallest obtainable. The catheter is anointed with oil. It is passed toward the posterior nares, along the floor of the nose. The index- finger of the free hand is passed into the fauces to guide the tip into the esophagus, otherwise, striking the prominence of a cervical vertebra, it may become impinged here and the bulk of the tube accumulate in the throat, or the tip may come out of the mouth. After the tip has entered the stom- ach, as is evidenced by the appearance of gastric contents at the outlet of the tube projecting from the nose, the food, 362 SPECIAL TOPICS. previously warmed, may be slowly injected by means of the glass syringe- (C). Instead of using the syringe the food Fig. 62. Nasal feeding. may be permitted to slowly gravitate by connecting a small glass funnel (A, i) with the projecting end of the catheter and into this the food is emptied. FEEDING BY STOMACH-TUBE (GAVAGE). 363 \Yhere necessary the stomach may be washed out through the nose before the food is allowed to enter, and medicine may also be administered in this fashion. The maneuver of nasal feeding is usually easily accomplished, and without inconvenience to the infant. FEEDING BY STOMACH-TUBE (GAVAGE). Indications. When the patient will not or can not swallow. This may be due to inflammatory conditions of the throat or mouth, to paralytic phenomena, as after diphtheria or in cases of ascending paralysis, or in tetanus. Inability to swallow is a part of the clinical picture of coma, as seen in convulsions, meningitis, infantile paralysis, after head trauma, and during nephritis. Gavage is a valuable adjunct in some cases of forced feeding or in anorexia, or in cases of persistent vomiting associated with acute intestinal intoxication. Food given in this manner is often retained when it would be vomited if taken in the ordinary way. To the careful clinical observer gavage will suggest itself in many other conditions, not necessary to be enumerated. It should be discontinued the moment the necessity for it ceases to exist. Technique. The same apparatus (A) is employed as in stomach washing, and the same method of introducing the tube is followed. The food, adapted to the needs of the individual case, but always liquid and previously warmed, is allowed to slowly enter the stomach by the attendant making regular but intermittent compression upon the tube. On the other hand, one may dispense with the funnel and the aliment may be slowly injected through the catheter by means of a glass or other syringe, as in nasal feeding. During withdrawal the tube must be compressed and re- 364 SPECIAL TOPICS. moved with one swift stroke, between gags. Otherwise the gastric contents may be shot out around, with and after the tube. FEEDING BY BOWEL. Nutrient Enemata. The purpose of this method of feeding is to sustain life over critical periods of acute food intolerance or anorexia, and to reinforce mouth feeding when the stomach is non-retentive. It may also be employed during coma from any cause. While it should be tried as a dernier ressort, in my opinion it rarely renders signal service in saving life. It may also be employed after opera- tions upon the stomach or upon the other organs of the upper abdomen. It cannot be depended upon as the sole source of introducing nourishment for any great period of time. Technique. The lower bowel should previously be emptied by a suppository or preferably by a cleansing high enema of simple saline solution. After this the patient should rest at least one-half hour in order to permit any rectal irritation to pass away. Apparatus B is employed. The rubber catheter is well anointed with oil and introduced into the bowel, for a distance of from 4 or 5 inches. This is accomplished with a variable degree of ease in different individuals. The infant is placed on its left side and the buttocks are slightly elevated. The enema heated to 100 F. is slowly injected by means of the soft-rubber, hand-bulb syringe or by means of a glass syringe, or it is allowed to flow in by gravity, by connecting apparatus A at the glass tubing (3) to the free end of the catheter. From ten to fifteen minutes should be consumed in getting the fluid into the bowel, whatever method be employed. When all has FEEDING DURING INFECTIOUS DISEASES. 365 entered, the catheter is pinched and swiftly withdrawn. The infant is permitted to lie on its left side with its but- tocks elevated, or it is placed for a few moments in the knee-chest posture while the colon is massaged upward on the left side, across, and down the right. The bulk of the enema should never exceed 4 to 5 ounces in a child and in an infant never more than I to 2 ounces. Not more than 2 nutrient enemata should be given within twenty-four hours, and they should be at least twelve hours apart. Any attempt to increase the bulk or the frequency of administra- tion will defeat the purpose for which they are given, for the rectum speedily becomes irritable and expulsion occurs. Composition. Various formulae have been given. All are perhaps good. None appear to me to possess any special advantage. The following is offered as being suit- able in most instances: One egg 4 oz. of completely pancreatized milk (at least 30 minutes). I oz. of water. Deodorized tincture of opium, i to 5 drops. Ex. of pancreatin, 10 grains. Sodium bicarbonate, 10 grains. This may be given in whole or in part. If desired, from i o to 60 minims of whisky may be added. FEEDING DURING THE ACUTE INFECTIOUS DISEASES. The burden of an infectious process is shared by all the vital organs. From this depression of function the alimentary canal does not escape. Hence the tolerance for food, i.e., the power for digestion and for assimilation, is variously diminished, depending upon the resistance of the individual and upon the severity, character, and duration 366 SPECIAL TOPICS. of the infectious disease. This diminished digestive power is commonly seen when, during the course of an acute in- fection, the bowel movements, which previously were nor- mal, now show the evidences of dyspepsia, curds, mucus, greenish discoloration. So much so is this the case that not infrequently the mistake is made of overlooking the in- fection, which may be more or less obscure, and o