6491 THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY CLINICAL LECTURES ON INFANT FEEDING 'Boston Methods by LEWIS WEBB HILL, M.D. Junior Assistant Visiting Physician, Children's Hospital, Boston; Alumni Assistant in Pediatrics, Harvard Medical School Chicago Methods by JESSE ROBERT GERSTLEY, M.D. Instructor in Pediatrics, Northwestern University Medical School; Associate Attending Pediatrician, Michael Reese Hospital, Chicago W. B. SAUNDERS COMPANY 1917 Copyright, 1917, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA ---- .! ' u/s rf/7 PREFACE As these lectures represent a somewhat new method of post- graduate medical education in this country, the history leading to their development may be of interest. The plan originated with Dr. W. S. Rankin, Secretary of the Board of Health of the State of North Carolina. He conceived the idea of bringing the medical school, in the person of a traveling lecturer, to the doors of the physician, enabling the latter in this way to con- tinue with his practice instead of being compelled to leave it for several months while he sought postgraduate education in one of the large medical centers. Upon hearing of this scheme, President E. K. Graham, of the University of North Carolina, gave it his enthusiastic support, and courses were arranged under the joint auspices of the University and the State Board of Health. Two sections of six classes each were organized, one in the eastern part of the State, one in the western. Each of us had six towns in his circuit, and traveled each day to a new town, returning to the first one at the beginning of each week. One of us was trained in the methods used in Boston, the other in Chicago, with postgraduate work in Europe. As a result of this dissimilarity in our training the lectures differ a good deal, and it occurred to us that it might be of value to combine the two sets in one volume, so that the teachings of two somewhat different schools of infant feeding may be compared. Each of us has prepared and presented his course of lectures independently of the other and without knowledge of the other's methods and plans. It is with a spirit of cooperation rather than rivalry, of construction than destruction, that we offer them to the profession. LEWIS WEBB HILL JESSE R. GERSTLEY September, 1917 11 624304 CONTENTS CLINICAL LECTURES ON INFANT FEEDING (BOSTON METHODS) BY LEWIS WEBB HILL, M.D. LECTURE I INTRODUCTION TO FEEDING IN GENERAL 17 Breast Feeding 21 Artificial Feeding 27 LECTURE II THE MODIFICATION OF MILK 31 LECTURE III THE FEEDING OF NORMAL INFANTS 41 THE PROPRIETARY FOODS 49 PREMATURE INFANTS 56 LECTURE IV DIFFICULT FEEDING CASES 59 Disturbances of Digestion 61 The Various Types of Indigestion 61 THE STOOLS IN INFANCY 70 CONSTIPATION 73 LECTURE V DIARRHEAS OF INFANCY 76 Nervous Diarrhea 77 Mechanical Diarrhea 77 Fermentative Diarrhea 77 Infectious Diarrhea 83 LECTURE VI PYLORIC STENOSIS 91 PYLORIC SPASM 93 INTUSSUSCEPTION 95 ACIDOSIS 98 13 14 CONTENTS LECTURE VII PAGE RICKETS 104 SCURVY 107 SPASMOPHILIA Ill CLINICS 116 CLINICAL LECTURES ON INFANT FEEDING (CHICAGO METHODS) BT JESSE R. GERSTLEY, M.D. LECTURE I INTRODUCTION 151 Milk 152 LECTURE II DIGESTION OF MILK 163 ENERGY OF FOODS 176 LECTURE III MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 178 LECTURE IV FAILURE TO GAIN . 193 205 LECTURE VI DECOMPOSITION 224 LECTURE VII PARENTERAL AND ENTERAL INFECTIONS 242 LECTURE VIII ARTIFICIAL FEEDING OF THE NORMAL INFANT . 256 LECTURE IX BREAST FEEDING 270 LECTURE X DISTURBANCES IN THE BREAST FED 280 CLINICS 293 CONCLUSION 366 INDEX . . .369 CLINICAL LECTURES ON INFANT FEEDING Boston Methods BY LEWIS WEBB HILL, M.D. CLINICAL LECTURES ON INFANT FEEDING (BOSTON METHODS) LECTURE I * INTRODUCTION TO FEEDING IN GENERAL Pediatrics, or the study of diseases of children, is naturally divided into a number of sections, of which the most important is the feeding of infants and the treatment of the diarrheal dis- eases of infancy. My lecture today is somewhat of an introductory lecture, taking up breast feeding and a short introduction to artificial feeding. It is my purpose to make these lectures as practical as possible, and to touch upon theory and chemistry only so much as is absolutely necessary as I am fully aware that you are a practical group of men, dealing every day with sick people, and not with theories, chemical names, and formulae. It is, however, necessary for us to consider a few fundamental chemi- cal facts upon which modern infant feeding is based before we can go on to the more practical portion of the subject. I am going to teach you "percentage feeding," which is used more in Boston than in any other city. In the old days of infant feeding there was no science of any sort ; a little milk and water was mixed and fed to the baby, without knowing what he was getting of food value; of fat, sugar, and protein. Some babies got along very well on this, but as you know some will get along on almost anything, whereas some need the utmost care. Dr. T. Morgan Rotch, of Boston, about twenty-five years ago, devised the so-called percentage method. This means that in a baby's milk certain elements have to be recognized. The * Sixteen lectures were given in the course. The other nine lectures dealt with the general diseases of children. 17 18 INFANT FEEDING (BOSTON METHODS) food elements of milk are, as you know, fat, sugar, and protein, and it is desirable to know how much of each the infant is get- ting, because digestive disturbances of all sorts are likely to be due to too much or too little of one element or the other in the milk. These ideas simplify the whole matter of feeding because the physician can tell so easily with what he is dealing. There is no reason why a baby should not have its milk made up in just as accurate a way as a prescription is made up. With adults it is not necessary to regulate the food so carefully, because an adult's digestion is stronger, and small things will not upset it so easily. The percentage method of feeding consists simply in writing a prescription for the baby's milk according to the in- dications, knowing approximately how much of each food ele- ment the prescription contains, the most convenient way of expressing the quantity of these elements being in percentages. As an introduction, I think I cannot do better than to read a few lines written a short time ago by Dr. Ladd, of Boston : "Now, whatever our method of making a food for infants, in which milk is the basis, we are making a modified milk containing certain percentages of the elements. Percentage feeding presupposes that these alterations have been made by the physician with design and with a definite knowledge of the end-result of his changes. By the old method milk was modified quite as much as by modern methods, but with this fundamental difference: that the physician had not the slightest conception of the composition of his mixture, and hence no check upon his results. Without a knowledge of the percentage composition of the milk it is next to impossible to give a lucid and intelligent expression of its food value. A mixture expressed as so many ounces of cream, milk, lime-water, sugar, and water may exactly fulfil the requirements of an individual infant, but unless I can express such a formula to a student in percentages or calories, or both, my exposition of the principles on which I have acted in prescribing such a formula is vague and indefinite. "Whatever we may feel about the relative values of fats and sugars and proteins, and the proportions best suited to individual conditions, the per- centage method of thinking, writing, and prescribing should not and does not complicate the question. In fact, it simplifies it enormously, for it furnishes us the means for accurate estimation of food values, and only by such knowledge can we intelligently check up our results when struggling with the problem of adapting a food to the individual requirements of an infant. "If one will grasp this simple idea of percentage feeding, one will dis- abuse one's mind of the conception, so erroneously held, that percentage feeding is ultra-scientific, very mathematical, complex, and impractical for the average practitioner. "I wish to emphasize the fact that the purpose of percentage feeding is, on the contrary, to simplify the sometimes very difficult question of finding INTRODUCTION TO FEEDING IN GENERAL 19 a food which the infant will digest and upon which it will gain normally in development. The mathematics involved in the calculation of percentages are of the simplest a mere matter of proportions. If properly presented, anyone of half a dozen in vogue-is easily mastered and perfectly practical. It does not matter by whose methods one works to gain this fundamental knowledge of how to calculate the percentage elements of the food, so long as that method is thoroughly mastered. Some methods are simpler to understand than others, and any method requires some study and practice, but this hardly offers an excuse for ignorance of the subject. Any third- year medical student may in two hours be taught a practical way of calcu- lating percentages and estimating the caloric value of any mixture. Such knowledge is rudimentary but fundamental. Any physician who pretends to feed scientifically should not shun the task of acquiring this knowledge, any more than he should avoid the labor involved in grasping the technic of simple surgical or bacteriological procedures, in order to become more skilled in the practice of modern medicine. Too much is written of the difficulties of these methods of calculation by men who have been too lazy or indifferent to learn them; too little has been written about the responsi- bility of the physician to master them in order to become a more efficient worker along the lines of modern infant feeding." That is a very good summing up of the question of percent- age feeding. In a nutshell, it is necessary to know, in any milk mixture which is being fed to a baby, approximately how much fat, how much protein, and how much sugar it contains. In order to do this it is necessary to know the composition of milk. Human milk contains 4 percent of fat, 7 percent of sugar, 1.6 percent of protein, and about 0.2 percent of salts. Cow's milk contains 4 percent of fat, 4.5 percent of sugar, 3.2* percent protein, and 0.7 percent salts. Now, different specimens of human milk vary a great deal. Different cows' milks also vary a great deal, but these are the average figures. Besides the quantitative differences, there are also certain qualitative differences. The fat in the milk is in the form of an emulsion; the sugar, protein, and salts are in solution. The globules of fat in cow's milk are much larger than in human milk. The sugars are exactly the same. In all milks there are two kinds of proteins casein and al- bumin or whey protein. In human milk there is more whey protein than casein. The ratio is about three to one. In cow's milk there is more casein than whey, and this is one reason why * These figures are not absolutely correct, but are near enough for practi- cal purposes. 20 INFANT FEEDING (BOSTON METHODS) cow's milk is so much harder to digest, because the casein pro- tein is coagulated in the stomach into tough curds. The whey protein is not. The salts are qualitatively about the same in both milks, the most important being salts of sodium, potas- sium, magnesium, calcium, iron, phosphorus, and sulphur. The salts are of extreme importance in the nutrition of every baby, but we cannot take them into practical quantitative consideration in feeding a baby, so let us consider the three elements fat, sugar, and protein. It is very important to bear in mind this composition of milk. Now I want to run over very briefly the digestion of the different food elements. First, the fat it is not acted upon to any great extent in the stomach. Chemically it consists of a fatty acid in combination with glycerin, forming a so-called "neutral" fat. After leaving the stomach it enters the intes- tine, where it is split by the pancreatic juice into glycerin and a fatty acid. The fatty acid combines with an alkali in the in- testine, forming a "soap." This is acted upon by the bile, which emulsifies it, and it is then absorbed. The absorption of fat is usually very good. Often 90 or 95 percent of the fat taken in will be absorbed by a well baby. In other cases as little as 30 or 40 percent will be absorbed, and most of the fat will come out in the stool in the form of "soaps." The sugar is acted upon very little in the stomach. Milk- sugar is what is known as a disaccharid, that is, a complex sugar. In the intestine it is split into simpler sugars and absorbed as such. The absorption of sugar is usually extremely good, and it is very rare to find any in the stools of infants. Sugar may sometimes remain in the intestine, and may be broken up by the bacteria in the intestine into acids, as acetic acid and butyric acid. Fats may also be broken up in this way. Next comes protein. Protein is partly digested in the stom- ach, where it is coagulated by the gastric juices. Digestion is carried on further in the intestine by the pancreatic juice and the secretions of the intestine, and the end-products are ab- sorbed as salts of the amino-acids. An important point which I wish to emphasize is that in the intestine of every infant there are always two forces working against each other. That is, the end-products from the breaking down of fat and sugar are acid INTRODUCTION TO FEEDING IN GENERAL 21 in reaction; those from the breaking down of protein are alka- line in reaction, from the ammonia which is formed. The normal reaction of a child's stool is slightly alkaline, slightly acid, or neutral, and if there is too great acidity or too great alkalinity, trouble results. It is very important to have such a balance between the fat and sugar and the protein in the food as not to have too great acidity or too great alkalinity in the intestine. You have all probably heard a good deal of discussion about "calories." What is a calorie? Of course, all food is fuel. The different elements of food have different fuel value, and we measure this fuel value by calories. A calorie is the amount of heat that is necessary to raise one liter of water one degree centi- grade. This is a "large" calorie, which is the one we use in infant feeding. The average baby needs about 50 calories per pound of body weight in order to thrive. The different food elements, produce different amounts of these calories. Fat pro- duces 9.3 calories per gram; protein and sugar each produce 4.1 calories per gram. That covers the bare essentials of the theoretical part of our subject, and although it may sound rather complicated and not very practical, it is necessary to understand the scientific ground- work upon which rests the practical superstructure of our ideas of infant feeding. BREAST FEEDING In regard to breast feeding, it is an axiom that every baby should be fed upon the breast if possible. Of course, there are a good many women who cannot nurse their babies, but it should be insisted upon that every woman who is able should nurse her baby through the first year. Breast milk produces the big, robust babies, and babies who are breast fed have very little chance of developing the gastro-intestinal troubles of various sorts which bottle-fed babies are so likely to have, especially in the summer. Of course, in some cases a baby must be weaned, but these cases are comparatively few. Persist in breast feed- ing, and do not take the baby off the breast merely because it perhaps vomits once or twice or does not gain on the breast milk. If a mother has not enough milk, try to find out why. Look after 22 INFANT FEEDING (BOSTON METHODS) her habits, see that she leads a reasonable, quiet life, that she is not worried or nervous about anything, and that she gets a proper diet. Another thing: sometimes the milk is late in coming into the breast. Normally, after a baby is born it comes into the breast in from twenty-four to forty-eight hours. Sometimes it is delayed for four or five days. However, don't take the baby off the breast because the milk is late in coming. How is a new-born baby to be fed? It may be put to the breast six hours after birth. This may not furnish much nour- ishment, but it teaches the baby to suck, and it stimulates the breast to produce milk. For the first twenty-four hours the 'baby should be nursed every six hours; for the next day, every four hours; for the first few weeks after that, every two hours. There is a great deal of discussion in all the pediatric centers about the intervals between nursings, but I really think most of the intervals that is, two, two and one-half, three, or four- hour intervals are reasonable. Most normal babies get along well on any of those intervals. Personally, I think it is best to have a normal baby nursed every two hours during the first month ; for the next three months every two and one-half hours ; after this, every three hours. It is a good thing to have the baby take one bottle a day. This gives the mother more time to get out and take exercise than if it has to be nursed every time. If the bowels of a new-born baby have not moved well soon after birth, it is wise to give a small dose of castor oil, because the meconium may undergo decomposition and make the baby ill from toxic absorption, so it is important to clean it out artificially if it has not cleaned itself out naturally. It is important to have the baby nursed regularly, and not every time it cries. Have this distinctly understood by the mother. If the baby is asleep at the time of nursing, it should be waked. It is better to give the baby alternate breasts each feeding rather than a little out of one and a little out of the other, for if one is used for each nursing it will be emptied, and thus stimulated to the production of more milk. An average baby will empty the average breast in about fifteen minutes; of course this time may vary, but that is usually the average. A baby does not take the same amount of milk from a INTRODUCTION TO FEEDING IN GENERAL 23 breast at each nursing, and at some feedings it will take only one or two ounces, at others six or seven. This is not very impor- tant, however, because most babies get the same amount every twenty-four hours. If little is taken at one feeding, it will be made up at another. The twenty-four-hour amount is the im- portant thing to consider. Sometimes it is important to know if a baby is getting enough milk in a day, and the best way to learn this is to weigh the child before and after each nursing. Take the difference between the weights before and after nurs- ing, add them all together, and the result will be the number of ounces the baby is getting in a day, as an ounce of milk weighs about an ounce. It is true that every baby should be fed on the breast, but it is also true that there is abnormal breast milk bad breast milk. There are four kinds of bad breast milk. The first kind is too rich it has too much of every food element. This type of milk is found in certain women of the upper classes usually, who eat too much rich food and who do not take enough exercise. The second type is one in which the fat and sugar are low and the protein high. This sort of milk is seen in the poorer classes of women who do not get enough to eat and who have to work too hard. The third type of milk is one in which the fat and sugar are very low and the protein very high. This type of milk is usually found in excessively neurotic women. The fourth type of milk is that in which, by repeated chemical analyses, it is found that every one of the elements is in perfect proportion; but which, for some reason or other, the baby can- not take. I do not know the cause, but it is unquestionably true that in the milk of some nursing women a toxic substance is secreted, and this upsets the baby. In one case I analyzed the milk three times and found it perfectly normal, but the baby could not take it at all and had to be weaned. Of course, in considering this type of milk it must be taken into account that the trouble may be in the baby and not in the milk, and that the milk might be perfectly suitable for some other baby. This type of milk is not common, but it is certainly seen some- times. It ought not to be assumed, however, that a milk is of this sort until the nursing mother has been given a very thorough trial and until the milk has been analyzed, if possible. Never 24 INFANT FEEDING (BOSTON METHODS) give up nursing until every means has been tried of modifying the mother's milk and making it better. How may the chemical composition of a nursing mother's milk be modified? When a woman has too rich milk, the important things are to take her outdoors, make her exercise, keep her bowels open, cut down on her diet, and make her drink plenty of water. In the other type, where the milk is too thin, ease up the woman's home life, have her arrange to get some one to do part of her work, and have her eat more, especially fatty and starchy food. If the quantity of milk, on the other hand, is too little, have her drink plenty of fluid. I have many of my nursing mothers take corn-meal gruel at night before going to bed. It is of no use, however, to give more than three or four pints of fluid a day; anything over this does more harm than good. Another thing, and probably the most important of all : use the breast. There is nothing which will stimulate milk production so well as a com- plete emptying at each nursing. If the baby is weak and small and does not empty the breast, pump it out. There is no drug with which I am familiar that will increase milk secretion. As to the diet of the mother : I think the best thing to tell a nursing mother in average circumstances is to eat exactly what she would if she had no baby at all, provided she is taking a reasonable diet. Undoubtedly there are certain things which may be eaten by a nursing mother that will influence the milk and upset the baby. Cabbage, strawberries, and certain other fruits and vegetables sometimes do this. Babies generally get on well, however, if the mother is healthy and eats an average ordinary diet. How much should a normal breast-fed baby gam? It should be weighed every week, so that its progress can be followed, and the food corrected, if necessary. The normal breast-fed baby should gain six to eight ounces a week for the first five months of its life; For the rest of the first year it should gain four to six ounces a week. If it does not gain as much as this, there is something wrong. The weight of a baby is one of the best indices we haye to determine whether or not it is thriving, and the weighing of babies is neglected in altogether too many cases. INTRODUCTION TO FEEDING IN GENERAL 25 The breast-fed baby usually has three or four rather loose, golden-yellow, sour-smelling movements a day. Those fed on cow's milk usually do not have so many. Certain babies may have more than others and the stools may be green in color and smell bad. The baby may vomit a little. But if it is getting on well in every other way and is gaining weight, it is best not to pay too much attention to this. Let us take up the abnormal breast-fed baby, the baby who is not gaining on the breast, who has a good deal of colic, who does not sleep at night, who vomits often, who has bad movements; and the thin, poorly nourished, breast-fed baby who does not get enough to eat. These troubles may be due to a number of causes. If a baby does not gain, but has no symptoms of in- digestion, the milk may not be rich enough or there may not be enough of it. In cases like this substitute feedings should be given after a trial has been made to increase the amount and richness of the milk. Modified cow's milk can be given after each breast feeding, or it can be substituted in alternate feedings with the breast. It is a little better to give it after each breast feeding, because cow's milk is better taken care of in the stomach when it is mixed with human milk. When a baby has colic, when it is fussy most of the time and does not gain, the milk is probably too rich, or too much is taken at a feeding. It may contain too much fat or protein. The sugar in human milk gives very little trouble. The symptoms of fat indigestion are vomiting of creamy, thick, sour-smelling material, diarrhea, failure to gain, and fussiness. The symp- toms of protein indigestion are the same, except that the vomi- tus is not quite so thick and creamy. Treat these conditions by treating the mother in the first place, by taking her outdoors, having her walk, take exercise, and by getting her to drink plenty of water. In the second place, keep the baby quiet after each nursing. Do not let the mother shake it up and down, as so many do. Also, it is a very good idea to give a tablespoonful of boiled water to dilute the milk. Again, it is well not to let the baby nurse too long. It may be getting too much milk. Sometimes if the intervals between nursings are increased, it will help these cases. As to colic, the treatment is to prevent it, if possible, by regu- 26 INFANT FEEDING (BOSTON METHODS) lating the feeding. The best thing to do during the attacks is to give a suds enema, hot applications to the abdomen, half a soda- mint tablet, a few drops of gin or aromatic spirits of ammonia, or peppermint water. A very common cause of disturbance in breast-fed babies is irregular feeding intervals. Many mothers nurse their babies every time they cry, and thus they are fed sometimes every half-hour, sometimes every three hours. Such feeding as this is bound to cause trouble; the usual symptoms are failure to gain, fussiness and sleeplessness, colic, vomiting, and the passage of an increased number of loose stools, which may be green. Oftentimes it is surprising to see how much may be done for babies of this sort simply by regulating the nursing periods. Many babies have the same sort of symptoms because the mother is upset or worried about something or because the household is in confusion. A nervous mother and a nervous household make a nervous and unstable baby, and many babies may have severe symptoms of indigestion and may fail to gain in weight for a number of weeks until calm and quiet conditions are restored in the household. The mother should be in a quiet room, without any noise or confusion around if possible, when she is nursing her baby; and after the nursing, it should be put into its bed and left alone for half an hour. Some babies may swallow a good deal of air when they nurse, and with these babies it is a good idea for the mother to interrupt the nursing every two or three minutes and hold the baby up against her shoulder, slapping its back gently, to give it a chance to get rid of this swallowed air, which may cause colic. There are certain indications for weaning. Many mothers have the idea that if menstruation starts the baby should be weaned. This is not so. Sometimes menstruation in the mother does upset the baby temporarily, but it will probably be right again in a day or two. If a nursing mother becomes pregnant, however, the baby should be weaned immediately in most cases. Women with any wasting disease, such as tu- berculosis, cancer, or chronic nephritis, in most cases should not be allowed to nurse their babies. It is also best to wean the baby if the mother develops any severe acute illness, such as typhoid fever or pneumonia. If the mother has a "cold" or INTRODUCTION TO FEEDING IN GENERAL 27 slight tonsillitis, it is best to discontinue nursing for a day or two, or perhaps in some cases not to discontinue it entirely, but to substitute bottle feedings for half of the breast feedings. If a mother cannot nurse her baby, it is often a very great advantage to get a wet-nurse. What are the qualifications of a wet-nurse? In the first place, how is the wet-nurse's own baby? If it is doing well, the chances are that the other baby will do well. No one should be taken whose own baby is over eight or nine months old, because after this period the milk becomes thin and poor in quality. Every nurse should have a thorough physical examination to exclude tuberculosis and syphilis. A Wassermann should be done on the blood of every wet-nurse if possible. ARTIFICIAL FEEDING In artificial feeding, what kind of milk is to be used? There is another axiom in pediatrics, and that is that no milk is too good for a baby. Get the very best milk possible. Get it from a good dairy, from a farmer who takes care of his barns and his cattle and who is interested in producing good milk. There is nothing that causes so many babies to die as unclean milk. Milk is really one of the dirtiest things in the world, because of the conditions under which it is produced and the ease with which bacteria grow in it. A handful of dirt may be thrown into a bottle of milk and it cannot be seen. What looks like clean milk may be centrifuged and a large amount of dirt may be found as a sediment. An Ayrshire, Holstein, or plain ordinary "cow" is usually the best cow from which to procure the baby's milk. Many of the laity prefer a Jersey, but Jersey milk is too rich. The fat may often run up to 6 or 7 percent, and the baby may get into a great deal of trouble on account of this high fat percentage. A baby may be fed on raw milk or on pasteurized or sterilized milk. I have no hesitation in saying that every milk fed ; o a baby should be pasteurized or sterilized, especially in a warm climate like this, unless it is what is called "certified" milk. Certified milk composes less than 1 percent of the milk supply of great cities. It is produced under the greatest precautions. The cow is washed off before milking, the milkers wear white 28 INFANT FEEDING (BOSTON METHODS) gloves, the barns are sanitary, and every possible precaution is taken to produce good milk. But, of course, such milk is only a very small proportion of the milk supply, and the milk that babies get should in practically all cases be sterilized or pas- teurized. Insist upon this. I do not know much about the milk supply of North Carolina, but I think it would be a great deal better if it were pasteurized or sterilized before being fed to babies, and I hope that you will all feed all your babies on pasteurized or sterilized milk this summer. There has been a great deal of objection to pasteurized milk because some people think it is harder to digest. This is not so. Some people say that it tends to constipate the baby. But what if it does? A slight amount of constipation is better than dysentery. Some people say, too, that it is too much work to pasteurize milk, but it is really not very much more trouble. The greatest objection is that pasteurized and, more especially, sterilized milk may produce scurvy; but this is not much of an objection. Scurvy can be cured in a few days by the use of orange-juice, and it can be prevented by the use of two table- spoonfuls of orange-juice a day. In Boston nearly all milk fed to babies is pasteurized except the certified milk. The latter costs twenty cents a quart, and is therefore out of the question for most people. Pasteurization is not an excuse for bad milk. Milk, whether pasteurized or not, should be good milk to start with, if possible. What is the difference between pasteurization and steriliza- tion? They are two different processes. Pasteurization con- sists of heating milk to 145 F. and keeping it at that tempera- ture for thirty minutes. This does not kill the ferments in the milk, but it does kill almost all the bacteria except the spore- bearing bacteria, of which the gas bacillus is the most important. Sterilizing milk, on the other hand, consists in boiling it, which kills all the bacteria. A great many devices for pasteurizing milk have been put on the market, which are convenient, but not at all necessary. Milk may be very efficiently pasteurized with a simple home- made apparatus as follows: Put the milk bottles and some warm water into an ordinary tin pail and heat until the temperature of the water is 145 F. INTRODUCTION TO FEEDING IN GENERAL 29 Then take the pail off the stove, put a small doubled-up blanket over it, and let it stand for half an hour. Pour off the hot water and fill the pail with cold water in order to cool the milk as quickly as possible, as spores develop very readily in luke- warm milk. Sterilization consists in boiling the milk for four or five min- utes. Whether or not sterilization or pasteurization should be employed depends largely upon the sort of people one is dealing with. If they will take the trouble to do it, pasteurization is better. If a baby is fed on pasteurized or sterilized milk, it should be given orange-juice as a prophylactic against scurvy. The best way to give this is in two doses, a tablespoonful morning and night. It is best given about an hour before feeding. I have mentioned a number of times the "modification" of milk. Just how is milk to be modified? The modification of milk consists in adding water or other substances to cow's milk to change it to suit the digestion of the individual baby that is being treated. What is of the utmost importance to remember is to fit the milk to the individual baby. There are no definite rules or laws that can be laid down, because babies vary so much in what they will take and in their digestive capacities, but there are certain broad principles which may be followed in a general way. There is no question but that the average practitioner feels helpless when it is a question of milk modification, and the reason for it is this. Every man who writes a text-book of pediatrics has a different method of milk modification, and usually gives complicated formulae and long tables which he himself understands perfectly, but which are usually hopeless for the average practitioner to carry in his mind. Thus great confusion has arisen: there are so many different methods. I feel very strongly that tables showing how much milk, water, etc., should be mixed to feed a baby of a given age should be used as little as possible. In the methods I am going to teach you one remembers about what percentages should be fed to a baby of a given age ; then he figures by the aid of certain data which can be easily carried in the head the amounts of milk, cream, water, and sugar to use to make up the desired formula. Thus multitudinous formula and tables are largely done away with. 30 I am going to teach you two slightly different methods of modi- fying milk, which I am sure you will find very simple of applica- tion: the "gravity" cream and skimmed-milk method and the "whole" milk dilution method. Top or "gravity" cream is all the cream that is visible in a quart of milk in an ordinary milk bottle after the milk has stood for about six hours. It is usually about six ounces of cream, and the composition is about 16 percent fat, 4.5 percent sugar, 3.2 percent protein. There are various methods of taking off this cream, which we will discuss later. What is left behind, after taking it off, is skimmed milk, which consists of no fat, 4.5 percent sugar, 3.2 percent protein. These figures are not exact, but they are what we use in calculating our milks. The skimmed milk, cream, water, and sugar are mixed in such pro- portions as to secure the percentages of food elements that are desired to feed the baby. The other method of modifying milk consists in diluting whole milk with water and adding milk-sugar to secure the desired percentages. This method of whole milk dilution has one dis- advantage, which is that if the milk is diluted enough to reduce the protein percentage to the amount which the baby can digest the fat is reduced too much, and the food does not contain a sufficient number of calories for the baby's nutrition. How- ever, a great many babies do very well on this method, but others do not. Most normal babies will do perfectly well on whole milk and water dilutions, but not many difficult feeding cases can be fed by this method. In each case the circumstances and the people have to be sized up. Some people will not take the trouble to take off the cream and to go through the various steps in a cream and skimmed-milk modification. The other method is easier, and if I am dealing with ignorant people I tell them to use this method of whole milk dilution. In feeding a baby, six things have to be decided : 1. What percentages of the food elements is it to take? 2. How much food is to be given in the twenty-four hours? 3. How much food at each feeding? 4. How often are the feedings? 5. What method of milk modification is to be used? 6. How many calories is the baby getting? Does the food prescribed furnish enough calories to make it gain weight? As an introduction to the lecture today, which deals with the modification of milk and the calculation of percentages and calories, I can do no better than to quote some words of Dr. John Lovett Morse, of Boston: "In approaching the subject of artificial feeding, it must be remembered that there are only a few food elements. A baby's food may contain all these elements; it must contain some of them, it cannot contain any other elements. These food elements are fat, carbohydrate, protein, and salts. It must also be remembered that a baby, in order to thrive and gain, must have a sufficient amount of food. The amount of food, in considering its fuel value, is not calculated, however, in ounces or pints of food, but in food values or calories. A baby must receive a sufficient number of calories in proportion to its body weight, otherwise it cannot gain. It is not sufficient, however, for a food to contain a sufficient number of calories; it must also contain a sufficient amount of protein to cover the nitrogenous needs of the baby. It must further be remembered that a food may contain enough calories and enough protein to cover the caloric and protein needs of the baby, and yet not be a suitable food for any baby, or if suitable for one baby, not for another. "It is absolutely necessary to fit the food to the digestive capacity of the individual infant. These fundamental principles must be always borne in mind in feeding babies artificially. If they are forgotten, the result is likely to be failure rather than success." You will remember that I said at our last lecture that there were two methods of milk modification we were going to con- sider : 1. The "gravity" cream and skimmed-milk method. 2. The "whole" milk dilution method. I also said that there is more trouble to the first method, but that it is likely to give better results in difficult feeding cases, and that the second method is a good deal simpler to use and more applicable for most patients, especially when they are not intelligent enough to carry out the first method. Gentlemen, I know that the figures and formula? we are going 31 .32 INFANT FEEDING (BOSTON METHODS) to talk about may seem complicated to you, but I want to say now, before we go any further, that infant feeding is fussy, and that if a man wishes to have any success whatever with it he must be willing to go into considerable detail and take as much pains with his feeding cases as he would take with the most difficult surgical or obstetrical case. First, let us consider the gravity cream and skimmed- milk method. Gravity cream is all the cream that is visible on .a quart bottle of milk that has stood about six hours. This amounts usually, in an average milk, to about 6 ounces. Skimmed milk is what is left behind after the gravity cream has been removed. Gravity cream has the following composition: Fat .- 16.0 percent Sugar 4.5 " Protein 3.2 Skimmed milk has the following composition: Fat 0.0 percent Sugar 4.5 Protein 3.2 " These percentages are not absolutely correct, but are the ones we use in our calculations, and for practical purposes are near enough. I am not going to speak of the way in which to take care of the utensils used in milk modification, you can get this from any text-book, but will merely say that the thing of greatest im- portance is to have all utensils as clean as possible. There are a number of ways of separating the cream from the skimmed milk, the most practical of which are pouring and dipping. Pouring is the simpler, but not very accurate, and if one is deal- ing with a family who will take the trouble, it is best to have them remove the cream with a small dipper. The dipper de- vised by Dr. Chapin, of New York, and known as the "Chapin dipper," is the best, and can be obtained at most drug-stores. Now suppose we want to prepare a certain formula, let us say: Fat 3 percent Sugar 6 " Protein . 2 " THE MODIFICATION OF MILK 3$ The amount to be 32 ounces, and the lime-water in the mixture to be 25 percent of the skimmed milk and cream used: how much cream do we need? We want 3 percent of fat all the fat is coming from the cream; the fat content of our cream is 16 percent, therefore yV of our mixture will be cream: T^ of 32 = 6. Therefore 6 ounces cream will go into our mixture. How much protein did we put in with the cream? Cream con- tains 3.2 percent protein, so if we had made up our complete mixture of 32 ounces with cream alone, we would have put in 3.2 percent protein. But we are putting into our 32-ounce mixture only 6 ounces of cream. Therefore we have put in -fz of 3.2 percent = 0.6 percent protein. But we want 2 percent of protein in our mixture. We want 1.4 percent more protein. This is to come from the skimmed milk. We want 1 4 ^-5 of 32 = 14 ounces. 9we Then we put into our mixture 14 ounces of skimmed milk, giving us so far 20 ounces of cream and milk in all. How much sugar did we put in with this cream and skimmed milk? If we had put into our 32-ounce mixture 32 ounces of cream and skimmed milk, we would have put in 4.5 percent of sugar; but we put in only 20 ounces, 20 80-57; of 4.5 = 3 percent sugar. iSIfi We need 3 percent more sugar, as we wanted 6 percent of sugar in our formula. The deficit is made up with dry milk- sugar. What we want is yfir (3 percent) of 32 ounces. This equals 1 ounce. A rounded tablespoon of milk-sugar equals }/2 ounce. Then we put in two rounded tablespoons of milk- sugar. We wanted our lime-water to be 25 percent of the milk and cream used. 25 percent of 20 = 5. Then we need 5 ounces of lime-water. Gravity cream 6 ounces Skimmed milk 14 Lime-water 5 " Water 7 " Milk-sugar 2 rounded table- spoonfuls 3 34 INFANT FEEDING (BOSTON METHODS) I know that all this seems very complex, but you will not have to figure out all your modifications this way, as I can show you some short cuts which will simplify matters greatly. It is very important, however, to know how to use this long method of calculation, even if you do not use it much. The calculation is just the same for any formula, and any desired formula may be calculated by using this one as a model. The advantage of knowing this method of calculation is that no tables whatever are necessary : all that is necessary is to remember the percent- age composition of the milk and cream and the various steps used in the calculation, and when it is once learned, it is not for- gotten. / wish to emphasize particularly that not one of you can learn to figure formula; by hearing me talk about it: you must give the mutter a little thought yourselves and take a pencil and paper and figure a few. If you are willing to give the matter an hour of your time some day, I am sure that you can all learn to calcu- late these formulae very quickly and readily, and that you will find this of great value in your practice. A great many practi- tioners have objected to percentage feeding on the ground that the calculation of the formulae is too complicated. It is more a question of laziness than anything else; any man can learn these methods if he is willing to take a little trouble, but he cer- tainly never can learn them by reading this over superficially or by hearing some one else talk about them; he must do a little thinking for himself. It is often of importance to calculate backward; that is, if it is known that a certain number of ounces each of skimmed milk, gravity cream, and milk-sugar are being used, how can it be determined what percentages are being obtained? Let us say we are using this formula: Gravity cream 8 ounces Skimmed milk 20 Water 20 Milk-sugar 4 tablespoons Total mixture equals 48 ounces. Then: A of 16.0 = 2.6 percent fat ft of 3.2 = 1.8 percent protein || of 4.5 = 2.8 percent sugar, went in with the skimmed milk and cream THE MODIFICATION OF MILK 35 Four rounded tablespoons (2 ounces) of sugar equal about 4.00 Then we have, Fat, 2.60; sugar, 6.8; protein, 1.8. Short Method. The method of calculation which we have been discussing is of value because when it is once learned no tables are necessary. But it is rather long; it is a good deal of trouble to go to all this figuring every time a modification is prescribed, and it is usually not necessary, for there are certain short cuts which simplify matters greatly, and which enable one to figure formulae much more quickly than is possible with the "long method." There are two simple tables which must be remembered if this short method is used, but these are not complicated and they can usually be carried in the head. I think this short method is the one you will want to use in feeding your babies, rather than the long one. It is as follows : In a 16-ounce mixture the number of ounces of 16 percent (gravity) cream that is needed always equals the fat percentage desired, and the number of ounces of skimmed milk and cream needed always equals five times the percentage of protein de- sired. Thus, let us say that a mixture of 16 ounces is wanted, containing: Fat 3 percent Sugar 6 " Protein 1 " Then 3 ounces of gravity cream is needed 1.8 (protein percent desired) X 5 = 9 ounces skimmed milk and cream This means 6 ounces skimmed milk, for 9 3 = 6. We have put 9 ounces of skimmed milk and cream into a 16- ounce mixture : how much sugar have we put in with this? j^ of 4.5 percent of sugar = about 2.5 percent sugar. We need 3.5 percent more sugar. How much dry milk-sugar are we going to need? This can be very easily calculated from the following sugar table, or it can be figured out by ounces, as we did in the long method. 36 INFANT FEEDING (BOSTON METHODS) SUGAR TABLE One level tablespoon of sugar raises the sugar percentage 2.40 percent in a 16-ounce mixture 2.00 percent in a 20-ounce mixture 1.60 percent in a 24-ounce mixture 1.20 percent in a 32-ounce mixture 1.00 percent in a 40-ounce mixture .95 percent in a 42-ounce mixture .80 percent in a 48-ounce mixture In this 16-ounce mixture we are dealing with we have figured that we need 3.5 percent more sugar. Then, dividing 3.5 by 2.4 to get the number of tablespoons, we get 3. 5 -r- 2.4 =1.4, or about 1% level tablespoons of sugar. Water, of course, is added up to 16 ounces. This method of calculating simplifies the whole procedure a great deal, as you can easily see. The sugar table is easily remembered after it has been used a number of times. In a 16-ounce mixture, you will remember, the figure to mul- tiply the desired fat percentage by to secure the required num- ber of ounces of cream is 1, and the number to multiply the protein percentage by to secure the number of ounces of milk and cream is 5. There are similar figures for different mixtures, which are as follows: 20 ounces: Fat factor, 1.25 Protein factor, 6.2 24 ounces: Fat factor, 1.50 Protein factor, 7.5 32 ounces: Fat factor, 2.00 Protein factor, 10.0 40 ounces: Fat factor, 2.50 Protein factor, 12.5 42 ounces: Fat factor, 2.60 Protein factor, 13.1 48 ounces: Fat factor, 3.00 Protein factor, 15.0 You will see that it is a great deal easier to figure modifications by this table than to calculate them by the "long method" which I first spoke of, and if a little card is carried in the pocket with the different fat and protein factors on it, it is a simple matter to figure any modification in a very short time. The mixtures most frequently used are 16-, 32-, and 48-ounce mix- tures, and it is very easy to remember, without any card, that the fat factors are 1, 2, and 3 respectively, for these mixtures, and the protein factors 5, 10, and 15. This covers the gravity cream and skimmed milk method of milk modification. THE MODIFICATION OF MILK 37 Now let us turn to the whole milk method; that is, simple dilutions of whole or skimmed milk with water and addition of sugar. This is the method which is best to use with people who are too ignorant fcc handle the skimmed milk and cream method, and most normal babies will get along fairly well with it. As I have said before, its disadvantages are that the fat in the milk is usually too much reduced, and it is impossible to secure by this method certain combinations of percentages of the food elements which can be obtained by the use of the gravity cream and skimmed milk method, which might be needed in feeding cer- tain abnormal babies. It depends a great deal upon what com- bination of percentages is desired whether the gravity cream and skimmed milk or the whole milk dilution method should be used, and it is simpler, if one can get the percentages one wants by it, to use the latter method. Also, normal babies over eight or nine months old can be fed very well on whole milk dilutions, as what we are driving at at this period of the baby's life is to get it gradually onto whole milk and a baby of this age needs comparatively little diluent in its milk, so the fat is not reduced too much by dilution. These are some of the considerations which should be taken into account in the choice of a method. In using whole milk dilutions it is best not to say to oneself that one wants certain percentages in the formula, and then to calculate it out, for in many cases one will have picked out an impossible combination of fat and protein percentages. One can, of course, obtain any sugar percentage desired (provided it is not too low), whether the cream and skimmed milk or the whole milk method is used. In using whole milk dilutions either one of two procedures may be employed: 1. Use the desired amounts of milk, water, and sugar, and then calculate what the percentages are, so that the modifica- tion can be checked and the approximate composition of the mixture determined, so that the baby does not get too strong or too weak a formula. As a matter of fact, after a person has fed babies for a while this way, he knows almost auto- matically about what the percentages are in any dilution, and does not need to stop and calculate them. It is not accurate or at all advisable, except in the case of babies who are nearly on 38 INFANT FEEDING (BOSTON METHODS) whole milk, or in those who have infectious diarrhea, and who are being underfed any way, to simply mix milk, water, and sugar and pay no attention to the percentages; one is likely to get into trouble if this is done, and the percentages should al- ways be figured as a check to this method of feeding. Let us say that a baby is being fed on whole milk and water dilution, and one wants to know what percentages it is getting. Say it is taking a 48-ounce mixture: Whole milk 36 ounces Water 12 " Milk-sugar 4 level table- spoons Then, as whole milk contains: Fat 4.0 Sugar 4.5 Protein. . . 3.2 ff of 4.0 = 3.0 percent fat in the mixture |f of 4.5 = 3.3 percent sugar in the mixture || of 3.2 = 2.4 percent protein in the mixture A level tablespoonful of milk-sugar added to a 48-ounce mixture raises the sugar percentage 0.8 percent. Therefore the sugar percentage in this mixture has been raised 3.2 percent, which, added to the sugar that has already been put in with the milk (3.3 percent), gives 5.5 percent sugar in the mixture, and the baby is getting Fat 3.0 Sugar 5.5 Protein 2.4 The same method is used in figuring any whole or skimmed milk and water dilution. 2. Another way that one can use whole milk dilutions is with the aid of a table, which is perhaps easier. In any whole milk and water mixture if y% of the mixture is milk, that is, 5 ounces milk in a 16-ounce mixture, and the rest water, the per- centages are: Fat 1.25 Sugar 1.40 Protein. . . .1.00 THE MODIFICATION OF MILK 39 Similarly, if more milk is added: 6 T5 2 -K; A 1 H = Fat 1.50 = Fat 1.75 = Fat 2.00 = Fat 2.25 = Fat 2.50 = Fat 2.75 = Fat 3.00 Sugar 1.70 Sugar 2.00 Sugar 2.25 Sugar 2.50 Sugar 2.80 Sugar 3.00 Sugar 3.30 Protein 1.20 Protein 1.40 Protein 1.60 Protein 1.80 Protein 2.00 Protein 2.20 Protein 2.40 The amount of sugar necessary to add can be determined by referring to the sugar table given above, which I will repeat again for the sake of clearness : One level tablespoonful of sugar raises the sugar percentage 2.40 in a 16-ounce mixture 2.00 in a 20-ounce mixture 1.60 in a 24-ounce mixture 1.20 in a 32-ounce mixture 1.00 in a 40-ounce mixture .95 in a 42-ounce mixture .80 in a 48-ounce mixture The table of whole milk dilutions is calculated on the basis of sixteenths. Of course, if one is dealing with a 32-ounce or a 48-ounce mixture, the fraction fir or fV> etc., is multiplied through by 2 or 3, as the case may be ; that is, fV is the same as Morif. _ Proportionate calculations can be made for 24-ounce or 40- ounce formulae, that is, in a 24-ounce mixture the amount of each ingredient would be f times what it would be for a 16-ounce mixture, or in a 40-ounce mixture it would be f what it would be for a 32-ounce mixture. Thus we can accurately figure from this table 16-, 24-, 32-, 40-, and 48-ounce mixtures, which are the most common ones used. So much for the calculation of percentages. The "whole milk" method is considerably simpler to use than the gravity cream and skimmed-milk method, and it will probably be the more practical one for you gentlemen to use most of the time in feeding many of your normal babies. Now for the calculation of the calories. There may be very accurately calculated percentages of the food elements in the mixture, but if the baby is not getting enough to eat, they do not do him much good. Most babies require about 50 calories per 40 INFANT FEEDING (BOSTON METHODS) pound of body weight in order to thrive. This varies a good deal, of course, in different babies. If a baby is gaining weight steadily and is doing well, there is not much use in calculating the calories in its food. It is self-evident that it is getting enough to eat from the simple fact that it is gaining weight. If it is not gaining, however, or if the weekly gains are too small, it is advisable to calculate the caloric value of the food, and it can be done very easily by the following simple formula: (2F + P + S) X l l /i Q = total calories F = The fat percentage of the food P = The protein percentage of the food S = The sugar percentage of the food Q = The twenty-four-hour quantity of the food To a man who has not been brought up in the method the use of so many figures and calculations may seem extremely compli- cated; but, as I have said before, the feeding of a baby who is not doing well is a very delicate task, which requires a great deal of painstaking care, and much time and thought must be given to it if good results are to be obtained. I am perfectly sure that after you have used these methods for a while you will have no trouble whatever with them. / wish to emphasize particularly that in using the percentage method it is not necessary to calculate the percentages too accurately, for any chain is only as strong as its weakest link, and it is non- sensical to try to get greater accuracy in the calculating than there is in the percentage of the milk to start with, or in the methods of mixing it. The idea of great accuracy in calculation is one that has been a stumbling-block to many beginners in percentage feeding. At the next lecture we will take up the feeding of the premature and normal baby and a discussion of the various proprietary foods. LECTURE m THE FEEDING OF NORMAL INFANTS -THE PROPRIE- TARY FOODS -PREMATURE INFANTS THE FEEDING OF NORMAL INFANTS I am going to take up today the feeding of normal babies and children, then a discussion of the various proprietary foods, showing their advantages and disadvantages. After that, if there is time, I shall discuss the care and feeding of premature infants. Breast milk contains 4 percent fat, 7 percent sugar, 1.6 per- cent protein a food relatively rich in fat and sugar and poor in protein. It is reasonable to suppose that as this is the type of food nature intended for infants, the best artificial food for them is a food which somewhat approximates breast milk in its composition, and in which, especially, the proportion of one ele- ment to another is somewhat the same as it is in breast milk. We do not try to exactly imitate breast milk, however. Rather do we try to fit the milk to the digestive capacity of the individual baby, determining this capacity by watching the baby's symptoms, its weight, and by carefully examining its stools. The feeding of any baby is more or less experimental for the first few feedings. The digestive capacity of average babies of similar size, age, and weight is known ; but the digestion of any particular baby is at first an unknown quantity, until the physi- cian becomes better acquainted with it, so the baby is given a milk which it ought to be able to take, and if it cannot digest that, the food has to be altered to suit the capacity of its diges- tion. It is very important in all artificial feeding to fit the food to the baby. The baby, and not rules and tables, ought to be followed in artificial feeding. Remember the individual baby and certain broad general principles which apply to all babies. The feeding of sick babies is a different proposition from feed- ing well babies. Often a sick baby cannot take a milk that is 41 42 INFANT FEEDING (BOSTON METHODS) anything like the milk a well baby would take. More than ever, dealing with these abnormal cases, does the food have to be fitted to the particular digestive and absorptive power of the individual baby. How often is a baby to be fed, how strong a food is it to take, how much of it in the twenty-four hours, and how much at each feeding? As I said last time, this varies a great deal for different babies. Two babies of the same age, size, and weight may take entirely different amounts and strengths of food and may need entirely different intervals. Especially is it true that two babies of the same size and weight, but of different ages, will need different foods. The older baby will need a great deal more food and stronger food than the younger baby. In general, an older baby needs more calories per pound of body weight than a younger baby of the same size and weight. Now, if we were feeding a baby rather small amounts of food, we would naturally give these small amounts more often. If a large feeding is given each time, the intervals should be lengthened. This table shows what most well babies will take and the most usual intervals employed : AGE Iwk. . 4 wks. 4 mos. 6-mos. 9 mos. TWENTY-FOUH- HOUB AMOUNT . 10-12 ounces 20 " . 32 " .36-42 " 48 " NUMBER OF FEEDINGS, AMOUNT AND INTERVALS 10 feedings of 1 ounce every 2 hours l}/2 GUI 2H 3 4 VA 6-7 8 ices \P\N \^> C<1 f / 2 0/0 4 o/ > Fig. 2. (From Langstein and Meyer.) This child, with only 2 percent sugar in his diet, may have had a subnormal temperature for several days. If we increase the sugar to 4 percent, the temperature may rise to normal. MINERAL MATTER Gentlemen, the mineral matter in baby's food has long been overlooked. Indeed, even now the door has barely opened, but visions and dreams perhaps, begin to suggest the coming im- portance of mineral metabolism. One may almost say that physiologists are learning from the pediatricians. The baby is the simplest of all organisms to study. He is untouched by disease; his food is the simplest of all foods can be analyzed and absolutely controlled ; and to get correctly the total urine and daily stools in twenty-four hours is not a very difficult task. Hence the study of the baby has increased our knowledge de- cidedly in some of the fields of physiology. Of mineral matter, breast milk has 0.2 percent; cow's milk, DIGESTION OF MILK 169 0.76 percent. You see that cow's milk has almost four times the salt content of breast milk. Strange that in our studies we have so long overlooked these differences. The splendid researches of Ludwig F. Meyer only relatively recently have been responsible for bringing them to our attention. Like other foods, salts are absorbed chiefly from the intestines. In the body they perform many functions, and then leave through the kidney and bowel. Through the kidneys most are excreted; through the intestines calcium, magnesium, and iron leave. Of course, we cannot say whether the calcium, magnesium, and iron found in the stool have been absorbed into the body and thrown out again, or whether they have simply passed unabsorbed along the child's digestive tract; but we do know that we find these salts in the stool. In passing, let me call your attention to the calcium: ONE QUAKT Breast Milk Cow's Milk Calcium 0.42 gram Calcium 1.72 grains This preponderance of calcium in cow's milk is an important factor in making the intestine alkaline. In the normal baby salts have a relation to protein, and for every definite amount of protein that the child absorbs a corre- sponding amount of salt is retained. This relation is far more definite in the baby on the breast than in the one on the bottle, and in disturbances of the latter often far more mineral is lost than is nitrogen. This improper relation of salt to protein in the artificially fed baby may feature in some of the disturbances. Gentlemen, I don't want to bother you too much with chem- istry, but let me give you one little glimpse into the possibilities of salt metabolism. Suppose we take a simple salt like calcium ^ -^ chlorid; suppose that salt is in- troduced into the intestine. In the intestine it is split up into Uy . j^ "^^ Stool calcium and chlorin. We just p- 3 have learned that chlorin is excreted chiefly in the urine; calcium, in the stool. We may picture this by the accompanying illustration (Fig. 3). 170 INFANT FEEDING (CHICAGO METHODS) Chlorin cannot leave the body alone, but must leave in com- bination with some other salt, usually sodium. The calcium makes other combinations in the intestines. Thus, feeding a simple substance like calcium chlorid forces sodium out of the body through the urine. This is a simple conception, but see what tremendous possibilities open to us! Just picture to your- selves all the different salts of the baby's diet pursuing their individual courses through his body. See these possibilities! We barely are beginning to grasp them. How utterly in the dark are we as to the actual effects upon the child's organism of the complicated mixtures that we are wont to prescribe! We Fig. 4. Drop in weight and temperature following salt withdrawal. (From Langstein and Meyer.) are barely at the beginning of understanding the true effects of our simple combinations, and you can see what enormous differences absolutely unknown to us must there be in the effects upon the child's body of the markedly different salt contents of breast milk and of cow's milk. Like protein, water, and carbohydrates, minerals are essential to life, and removal of them results in rapid death. The fasci- nating experiments of Jacques Loeb show that not only are minerals absolutely essential to life, but, if they are not present in the body in certain proportions, they may exert toxic in- fluences. The surgeons make use of these principles in their so-called balanced salt solutions. Like carbohydrate, salts DIGESTION OF MILK 17 J seem to have definite relation to body weight and temperature (Fig. 4). The removal of salts at A results in a drop of temperature and a marked loss of weight. The most important of all salts in causing these effects is sodium. Again, in chronic undernutri- tion, with deficiency of salt in the diet, the temperature may be consistently subnormal, and feeding a child in this stage about a dram of sodium chlorid may cause a marked rise in temperature with fever. WATER METABOLISM The child's tissues are somewhat richer in water than the adult's. In a quart of breast milk a day, a quart being equal to 1000 c.c., he drinks 885 c.c. of water. Just see the percentage of water in baby's diet, 885 parts to every 1000, or, to put it differently: an adult uses approximately one-half ounce of water for every pound that his body weighs, while the- child uses between two and three about four times the quantity of the adult. Like the other food-stuffs, water is ab- sorbed chiefly from the small intestine. It is stored mainly in the muscles and normally leaves the body about 60 percent through the urine and about 40 percent through the lungs and skin. Like carbohydrate, salts have a definite relation to water (Fig. 5). If, at A, we add a teaspoon of salt to the diet, the baby's weight rises sharply. The inexperienced physician and the happy mother might exclaim: "At last we have found the proper diet ! The child finally is gaining !" But, unfortunately, the excretion of this salt is accompanied by just such a precipi- tate loss as there was previously a gain. The weight comes down exactly to where it was before the salt was added, and now we rather ruefully learn that this great gain was not in true tissue substance, but was only in the water-content of the body. MILK IN THE GASTRO-INTESTINAL TRACT Gentlemen, we have considered the individual elements of the milk. We have studied them in the gastro-intestinal tract; we have followed them through the body; we have seen them 172 INFANT FEEDING (CHICAGO METHODS) in their excretion. Let us pause for a moment and look at the milk as a whole. Fig. 5. Gain in weight following addition of salt to diet. (From Lang- stein and Meyer.) In the stomach two important changes take place: the pro- tein, due to the rennet, coagulates, and the milk separates into DIGESTION OF MILK 173 curd and whey. You remember that the curd consists of the casein, which, in its formation, ensnares some fat. In this process much of the calcium is dragged out of the whey and joined in chemical combination to the casein; so casein in con- nection with the base calcium becomes a powerful agent for making the intestine alkaline. The whey, you will remember, represents the water-soluble elements of the milk; i. e., the water, salts, sugar, and the albumins and globulins. This quickly leaves the stomach. The casein curd with the en- trapped fat may remain several hours to be thoroughly digested. This interesting little point in physiology explains the useless- ness of following the tables which older scientists with great pride and perseverance built for us, viz., feeding the child at definite ages, food in proportion to the capacity of his stomach. As a matter of fact, because the whey leaves the stomach so rapidly we often feed the baby more than one might imagine, and we may disregard entirely these older tables. You see we have at hand a means for hastening or retarding the emptying of the stomach. A mixture high in whey will leave the stomach rapidly; a mixture high in casein and fat will leave slowly, and so, by altering our mixtures, we can greatly influence gastric motility. In the intestine the milk meets the various digestive fer- ments. The bile makes the fat soluble. Then the feqments of the pancreas and the intestinal glands, aided by the bile, seize all the fat, carbohydrate, and protein, and tear them down to their fundamental elements. These then leave the intestine. THE STOOLS The above in a very superficial way describes the digestion of the milk. Just what remains in the stool? In the stool are a. Great quantities of bacteria. I put these bacteria first to impress you with their importance. Up to the present, in infant feeding, these bacteria have bee"n almost overlooked although they may constitute 16 to 18 percent of the stool. You see the possibilities for bacterial action existing in the intes- tine. Normally, the organisms live only in the large intestine, 174 INFANT FEEDING (CHICAGO METHODS) the upper intestine being sterile; but, under conditions of which we shall hear later, they leave their home, extend up to the small intestine, and flourish there. Why they normally remain only in the large intestine and do not thrive in the upper bowel is not absolutely known. Some men claim that the duodenum, either by its juices or by the properties of its cells, is able to exert a strong bactericidal influence. Kendall has suggested to me that, due to the rapid absorption of food-stuffs, bacteria may not thrive in the upper intestine, as no food remains for them. Prob- ably both factors are of importance. In the large intestine two different groups of bacteria exist: those living chiefly on protein, attacking this protein, and caus- ing putrefaction and alkali formation; those living chiefly on carbohydrate, attacking the sugars and causing fermentation and acid formation. Gentlemen, in the last lecture you heard of the importance of these two processes, fermentation and putrefaction. Just as readily as in the milk that stands at the doorstep, do these activities proceed in the child's intestinal tract; but here we have them perfectly under control. Feeding protein calls forth the putrefactive organisms; feeding carbohydrate calls those producing fermentation. Remember that putrefaction, with resulting alkaline change, slows down intestinal peristalsis and leads to an alkaline, foul-smelling stool. On the other hand, fermentation with resulting acid formation leads to increased peristalsis and to watery, greenish, sour-smelling diarrheal stools. I urge you under no circumstances to forget that protein putre- fies; carbohydrate ferments. b. Besides bacteria, the stool consists of unabsorbed food- stuffs. (1) Protein, we learned, rarely appears normally in any appre- ciable quantity unless raw milk is given. (2) Fat is concerned somewhat in the actual structure of the stool. Feeding skimmed milk may result in thin bowel move- ments with mucus and small amounts of solid material ; increas- ing the fat in the diet may give rise to a formed stool. It is the fat in the form of soaps which has most influence on stool structure. (3) Like protein, little carbohydrate is found normally except DIGESTION OF MILK 175 in those cases where much starch is fed, this starch passing down the intestinal tract undigested. (4) The salts are of great importance. Calcium, for instance, by its insolubility in water, gives bowel movements of dry, alkaline nature. c. Besides bacteria and food substances, there are secondary products. Protein, as you remember, calls forth alkaline intes- tinal juice rich in albumin. Secondly, any protein that remains in the intestine unabsorbed will be attacked by the putrefactive bacteria, with resulting alkaline products. In the same way any unabsorbed carbohydrate will ferment into acid products. The amount of fermentation of this carbohydrate we can influence markedly by the nature of carbohydrate we use. Bacteria do not attack readily the complicated carbohydrates, such as starches and dextrins. When we feed starch or dextrin to a baby, this carbohydrate is changed by the digestive processes slowly to the simpler sugars, and these simpler sugars; as they are formed in small amounts, are absorbed through the upper intestine before the bacteria attack them. Thus complex carbo- hydrates, such as starch and dextrin, are normally rather con- stipating. The lower carbohydrates, such as milk-sugar and glucose, are readily attacked. When a child receives a large quantity of one of the latter some of the sugar may reach the region where intestinal bacteria are flourishing, and fermenta- tion, acid formation, and diarrhea result. Clinical observation suggests that the fermentation of these sugars is influenced by different factors: (a) Feeding the baby whey of cow's milk seems to increase the degree of fermentability of the sugar. (6) An increased amount of protein with its putrefying alka- line-forming properties makes the sugar less fermentable. (c) The condition of the intestine is of great importance: (1) A perfectly healthy, intact mucous membrane will be able to keep bacterial growth under control and prevent a marked degree of fermentation. (2) A diseased intestine may not be able to combat a fermen- tation induced by high sugar feeding. You see, gentlemen, why I am dwelling upon these subjects. The condition of the baby's stool depends absolutely upon you. 176 INFANT FEEDING (CHICAGO METHODS) You have at your disposal the means of making the stool alka- line, constipated, and hard, or acid, diarrheal, and watery. There is no mystery about the process; the explanation is simple; the means are at hand. Feeding a baby high protein, by inducing putrefactive change, by calling forth large amounts of alkaline intestinal juices, by bringing down large amounts of the base, calcium,* in connection with the casein, produces constipated, hard, soapy stools. Feeding large amounts of sugar, by inducing fermentation, with the resulting formation of various irritating acids, leads to diarrheal acid stools. Don't forget these important factors. Just one word about the energy of foods. ENERGY OF FOODS In the science of physics the term "calorie" is used. This is purely scientific, and means the amount of heat or energy re- quired to raise 1 gram or 1 kilogram of water one degree (30 grams are an ounce). The older physicists investigated the energy content of various food-stuffs, and in their investiga- tions learned 1 ounce of protein represents about 120 calories. 1 ounce of carbohydrate represents approximately 120 calories. 1 ounce of fat represents approximately 270 calories. This is pure physics. It was due to the investigations of the children's specialist, Heubner, in connection with the physiol- ogist, Rubner, that these physical studies were applied to infant feeding. They showed that a normal baby, to thrive and gain, requires for the first six months approximately 45 calories for every pound of his body weight. For example, a baby weighing six pounds requires about 270 calories. From these studies has * Since delivering these lectures the writer has read the fascinating work of C. H. Clowes, Jour, of Phys. Chern., 1916, xx, 407, in regard to emul- sions. He has shown that the addition of salts of calcium to a mixture of oil in water, as, for example, cream, will promote the change of this mixture to an entirely different type, namely, an emulsion of water in oil, as butter. The author does not know if these studies have as yet been applied to nutri- tional disturbances. This effect of calcium salts may possibly be equally important, as regards causing constipation, as the effect of calcium as an alkali. ENERGY OF FOODS 177 developed the caloric system of feeding first advocated by Heub- ner and later adopted by many pediatricians. We shall speak of it again. In conclusion, what points of this lengthy discourse are going to be of value to you in the feeding and treatment of nutritional disease? Remember, first and foremost, the great differences in putrefaction and fermentation; that any protein remaining unabsorbed leads to putrefaction and alkali formation, with resulting hard, constipated stools; that any carbohydrate re- maining unabsorbed in the intestinal tract leads to fermentation and acid formation, with diarrhea and watery stools. Remember, fermentation of the carbohydrate is greatly increased by the whey elements of cow's milk and by any diseased or weakened condition of the child's intestine. Normally, due to their gradual digestion, starch and dextrin ferment less readily than simple sugars. Remember, in a general way, the stool content, and that fat in the form of alkaline soaps gives structure to the stool. This is the fat in combination chiefly with calcium and mag- nesium. Remember that in the stools normally no carbohydrate is present, and that when milk is boiled, no undigested protein is found, thus disproving in a rather general way the previously held idea of indigestibility of cow's milk casein. Remember the functions of the different elements of the food. Protein and salts make up the tissues of the body. Remember what we said about carbohydrate, and that carbohydrate and salts seem to be important factors in pulling water into and out of the baby's tissues. LECTURE HI MODERN CONCEPTION OF DISTURBANCES OF NUTRITION Gentlemen, in the last two lectures we concerned ourselves with the subject of milk and with the subject of milk and the baby. Today let us start the most fascinating of all studies, the study of the baby. We wish to consider that great, bewilder- ing group of ailing, non-thriving, sick children, some with diar- rhea, some with constipation, described by the various terms atrophy, marasmus, malnutrition, inanition, indigestion, gastro- enteritis, ileocolitis, cholera infantum, and dysentery. You probably are conversant with the methods and teachings of the eastern schools. My purpose is now to give you the view- point of the middle West. In a general way we follow the European ideas. Wishing information from the very source, our younger men have sought foreign clinics, and it is informa- tion thus obtained which I wish to convey to you. After you have thoroughly mastered our methods you will be in a posi- tion to survey comprehensively the entire field and to make an intelligent decision for yourselves. A little review of history will be of great aid in understanding the modern developments. Let us return for a moment to the autopsy room in Vienna some twenty or thirty years ago. Vienna, as you know, is almost the home of pathology. Post- mortem examination is conducted with the same rigid care and exactness as is clinical investigation. Every patient who dies in the Vienna hospital must come to postmortem. It is natural that with such facilities, the whole Vienna teaching should follow pathological-anatomical lines. Even the clinicians made pathology the foundation of their diagnoses, and it was only logical to attempt to divide this great group of sick children into classes according to pathological findings. In Vienna one might say the conception was as follows: 178 MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 179 The well baby was in a The sick baby might be group exclusively by him- affected with self. a. Dyspepsia. b. Entero-catarrh. c. Cholera infantum. d. Follicular enteritis, etc. This was the consensus of opinion of the great Viennese pedia- tricians and pathologists. To them a well baby was a child to be neglected, not to be considered by medical men. The well baby might play in his nursery; be of no interest until he as- sumed one of the types of disease. These types were described as local pathological-anatomical changes in the gastro-intestinal tract. In other words, if the baby vomited, he had gastritis. If he vomited and had a slight diarrhea, he had a gastro-enteritis. If he had a diarrhea with bloody stools, he had ileocolitis or possibly follicillar enteritis. You see, then, that such a viewpoint made a sharp distinction between the well baby and the sick baby. The well baby was uninteresting, but the sick baby, by showing local changes in his gastro-intestinal tract, became very attractive and an object of much study. When it came to putting this classification into clinical practice, however, great difficulties arose, and when these clinical pathological diagnoses had been established, autopsy frequently failed to confirm them. Clinical pictures often changed. What one day was diagnosed entero-catarrh became the following day cholera infantum. Not even in sharp pictures, such as follicular enteritis, could the ulcerated intes- tine always be demonstrated. And in many cases showing the severest clinical symptomatology, as, for instance, cholera in- fantum, postmortem examination not rarely showed absolutely no change in the digestive tract other than perhaps a slight reddening of the mucous membrane. Slowly the pathologists became discouraged. Gradually they lost their interest in seeking pathological foundations, and now, if one goes to Vienna and stands in the great autopsy room, the lack of interest shown in the postmortem examination of infants is impressive. While great groups of men crowd around the tables seeking knowledge from the carefully, accurately con- 180 INFANT FEEDING (CHICAGO METHODS) ducted autopsies of adults, dead infants are often absolutely neglected not even examined. When one asks the busy pro- fessor why such and such a child is not autopsied, the answer is a shrug of the shoulders and " What's the use? We never find anything." This mute evidence from the anatomy room of Vienna speaks for the utter failure of pathology to provide a classification for these disturbances. The next attempt was made by the great Vienna pediatrician, Escherich. Not satisfied with pathology, he and his assistants sought etiological factors in pathogenic bacteria. Numerous and valuable researches were conducted, but in vain, for no specific microorganisms seemed to produce these clinical entities. When I say "He failed," gentlemen, I do not mean that he failed. His service was of tremendous importance, because negative evidence is as valuable as positive, and we could proceed only after having learned that our classification could not be founded upon bacteriology. The next step was taken by that almost romantic figure in pediatrics, Adalbert Czerny, the brilliant Austrian clinician who occupied the chair of children's diseases at Breslau. His great mentality, aided by keen clinical observation, has given the pediatricians of the world the most novel and most useful conception we have yet received. We must forever be indebted to him for introducing the new term, "disturbance of nutrition." In employing this term we already have a premonition of changes that will affect our therapy. This term implies that the child as a whole is affected, rather than exclusively his gas- tro-intestinal tract. Even though the trouble originates in the digestive organs, even though symptoms may entirely be those from stomach and intestine, still every organ in the body is af- fected. What a thought is this, gentlemen, to guide us in our therapy! If the child as a whole is affected, we must admit that changes take place in his bones, in his muscles, in his skin, in his complete organism; and already our keen interest in the stool must wane. The stool becomes no longer our sole guide to therapy but merely one of many symptoms. Czerny was one of the first to doubt the indigestibility of cow's-milk casein. With the doctrine, "Protein can do no MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 181 harm," the very antithesis of former teaching, his skeptical brain cast the pediatrics world into furor Realizing the failures of pathology and bacteriology as aids in classification, he directed his studies from the viewpoint of etiology and gave us the famous Czerny classification. The grouping of "disturbances of nutrition" is according to etiology. 1. Disturbances on the basis of infection. These may be of two types: (a) Direct bacterial infection of the child. (6) Milk or food spoiled by bacterial action. 2. Disturbances on the basis of constitution. 3. Disturbances on the basis of food. Of these, Czerny de- scribed two clean-cut clinical entities: (a) The condition which he called "milk injury," namely, a rather pasty, flabby child, not very sick, but not thriving, and very constipated. Czerny thought the etiology of this condi- tion to be high fat feeding; and so, though he gave the name "milk injury," he really meant "fat injury." (6) The condition he called "starch injury," a little ema- ciated, weak, undernourished baby, who has received an exclu- sively one-sided starch diet. Czerny's immeasurable contribution in this classification was the introduction of food factors, in the causation of a clinical picture. For the very first time we hear and think of a sharply defined, clearly described disease being due to nothing other than the food we offer the baby perfectly good wholesome food, but mixed in improper proportions. What a tremendous differ- ence in our viewpoint results as regards our conception of the well baby! What Czerny has done is to impress upon us that the well baby is not necessarily well, but by a little one-sided feeding can be brought right over into the group which we had reserved entirely for the sick. Like this (Fig. 6) : Sick Baby From Const itut ion. From Infection. From Food, Fig. 6. 182 INFANT FEEDING (CHICAGO METHODS) In this study Czerny limited to two the clinical types which improper feeding could produce, namely: the pasty, consti- pated child resulted from fat, and the emaciated, undernour- ished one from exclusive starch. The diarrheal diseases he be- lieved due either to definite intestinal infection or to milk spoiled by bacterial action. Contemporaneous with Czerny, Finkelstein in Berlin was making remarkable clinical studies. Perfectly independently these two men worked, Czerny seeking the causes of disease and Finkelstein describing clinical pictures. Not by theorizing, not by hypothesis, but by careful observation at the bedside, sitting with his little patients by the hour, studying them with the care of a scientist in his laboratory, did Finkelstein arrive at conclusions which threw the already perturbed scientific world into chaos. The opportunities for clinical investigation in Berlin are enormous. Many great institutions care for the large number of illegitimate children that exist in that city. Finkelstein's alone has over 300 beds for infants under two years of age. Studying and observing such infants are, of course, much simpler than in private practice, or even in ordinary hospital work. Many great men are in charge of these institu- tions, many have had the same opportunity as Finkelstein; but none had the great clinical insight and judgment to ac- complish what he has. His studies were of a purely clinical nature. He saw that some children had diarrheas; some had constipation; some had fever, some subnormal temperature. In some the pulse was markedly accelerated; in others it was slow, feeble, and ir- regular. In some respiration was increased, rapid, and deep; in others it was slow and weak. In some the urine was full of sugar, albumin, and casts; in others it was perfectly normal. Varying from the velvety pink of the normal to the inelastic, flabby, mud-colored tint of the child in disease, the skin seemed subject to infinite variations and change. So was it with the muscles, some being normal, some rigid, some flabby. In one type of child with evidence of great cerebral involve- ment consciousness was markedly disturbed, and in another the sensorium was perfectly free. MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 183 In these clinical studies Finkelstein brought out one fact, the importance of which long had been overlooked; namely, the child's weight curve (Fig. 7). To make a weight curve one must weigh the baby every few days, preferably every day, and plot out a curve upon a tabulated sheet, as one does for temperature, pulse, and respiration, or just as simply conceive it in the mind. These studies showed that weight curves were diagnostic of definite clinical entities. He called atten- tion to the curve of the healthy breast-fed baby, gaining steadily, the gain each day being like the one previous. He Bays 4 4 1 I 1 t i < i 13 02 11 OX 9 oz 7 oz 5 oz 8 oz 1 OB S* fS ^ ^ ^ ^ ^ S* ^ s* S* s* / ; s / / \ / / *^ ^N f / f ^ s* ^ ^ Fig. 7. reminded us of the zigzag curve of the bottle baby, and sug- gested that this irregularity was due to the irregular retention and excretion of salts. You remember that cow's milk is richer than breast milk in mineral matter, and that being concerned in the retention of water in the baby's body, salts markedly in- fluence the weight. 184 INFANT FEEDING (CHICAGO METHODS) He showed a curve characterized by cessation of gain. He showed a curve characterized by gradual loss. He showed a curve characterized by acute severe loss. And, lastly, he showed the curve of a chronically sick baby, sick for weeks or months. These four curves (Fig. 8) are typical and practically diag- nostic of four distinct types of cases, each one of which might be produced through improper feeding. His entire classifica- tion is a comprehensive one, but for the present let's confine Days Weeks 1011 10 11 Fig. 8. ourselves to this group which Czerny first introduced and Finkelstein so greatly enlarged, namely, "Disturbances of Nu- trition" on the basis of food. Why Finkelstein was not satis- fied with etiology as a means of classification he explains in his modest way by saying: "We are still in such a maze that it might perhaps be wiser, as a guide to us in further study, for the present to content outselves with clinical pictures. The truth is always to be found at the bedside." His classification of food disturbances is as follows: MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 185 1. Failure to Gain. Infants who, though not very sick, are not thriving nor gaining as they should. They usually have constipated, soapy stools and are subject to infections. 2. Dyspepsia. Here the picture is that of a mild diarrhea. The child is not very sick, but is a little peevish and irritable the type which you gentlemen would call a mild gastro-enteritis or a mild summer complaint. 3. Intoxication. This is a very sick child. Diarrhea is marked; loss of weight, rapid and severe. Consciousness is dis- turbed, and the temperature high. It is much the same picture that you gentlemen, I presume, would call a very severe gastro- enteritis or a cholera infantum. 4. Decomposition. In this condition the child has been chronically ill with feeding difficulties. Nothing has agreed with him for weeks. He shows the great emaciation and under- nourishment of which the terms atrophy, malnutrition, and marasmus are descriptive. Not only are we indebted to Finkelstein for this beautiful new clinical classification, but we owe him everlasting gratitude for introducing into the study of disease a new food factor. Czerny introduced fat, and thought overfeeding in fat brought on milk injury, with its associated constipation. Finkelstein, with this same viewpoint, studied sugar, and it was his idea that over- feeding in sugar produced diarrhea. What a startling new con- ception this was! When he described to us the severe picture of intoxication, which you would call cholera infantum, and laid the cause of this hitherto deadly, often mysterious disease, simply to excess of sugar in the feeding, the interested profession was stunned, amazed, and unbelieving. In rapid succession, from all parts of the world, seeking to confirm or to disprove this view, innumerable new investigations and experiments were started, and although many of the original theories have been modified, the infinite value of this fundamental observation impresses us ever more and more. The third invaluable contribution of Finkelstein was the grouping of these four types under the head of "disturbances of nutrition." Like Czerny, when Finkelstein studied diarrheal disease and noted the changed pulse-rate, the changed respira- tion, the changed temperature, the disturbed consciousness, 186 INFANT FEEDING (CHICA.GO METHODS) and, above all things, the variable and impressive weight re- actions, we readily can imagine his reasoning: "Certainly this disturbance must be one involving more than the digestive canal. No matter, even though the origin be purely gastro- intestinal, if every function of the body is involved and affected, we must think of the child as one in whom the entire nutrition is changed, and certainly such change must have great influence upon our treatment. Under no circumstance must we think of the gastro-intestinal tract alone." This viewpoint has been inestimable in directing our therapy away from the child's stool to that of the child's body. We believe that the stools are valuable symptoms of disturbance of the gastro-intestinal tract; but viewing our little patients from the broad conception of "disturbance of nutrition," after having noted the symptom of the stool, we often neglect it entirely, considering it only in its relation to the entire clinical picture. According to the viewpoint of Finkelstein, the grouping of diarrheal diseases as "disturbances of nutrition" must make stool examination absolutely incidental to the examination of the entire baby. The symptom of the stool sinks into insig- nificance beside the symptom of the baby as a whole. The one symptom representing the baby is the weight. The stool is a symptom to be considered, it is true, but not to be followed blindly. The weight becomes our index for treatment. -4 Finkelstein did not deny as a factor the influence of constitu- tion, which Czerny had suggested, nor the importance of in- fection; but he believed, first and foremost, that most disturb- ances were due not so much to constitution, not so much to infection, as to food; and when we say food we mean perfectly wholesome, good fresh cow's milk, given to the child, however, in improper dilutions. Whether one follows Czerny or whether one follows Finkelstein is immaterial. Both men have done the world a service for which generations to come must be grateful. From the point of view of the clinician the Finkelstein classi- fication is perhaps more practical. A crude illustration might make clearer the methods of these two men. Suppose we lived two hundred years ago, when dis- ease was considered due to evil spirits, to witchcraft, and to demons. Suppose at that time that out of the bewildering mass MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 187 of ailments some great mind had become inspired with an idea of infectious disease, and to the eager world had exclaimed: "Some of these conditions are in a distinct group. They are 'infectious diseases/ and exist as three types: "Those from pneumococcus. Those from streptococcus. Those from meningococcus." This is what Czerny did some ten years ago when, out of the bewildering mass of ailing infants, he saw "disturbances of nutrition" and said they could be divided into three groups: Those due to constitution. Those due to infection. Those due to food. Finkelstein, on the other hand, had he lived two hundred years ago, when the above hypothetical individual had discovered "infectious disease," would have said: "I certainly agree that there is a great group of diseases due to infection. We know so little about them, however, that I think we had better stick to the clinical pictures and later we can worry about the causes." He then might have described, for example: Pneumonia. Meningitis. Septicemia. Rheumatism. He would have agreed that these pictures might each one be due to the pneumococcus, streptococcus, or meningococcus, but wouldn't have committed himself definitely. In the same way the Finkelstein classification recognizes "disturbances of nu- trition" and shows four clinical pictures: 1. Failure to gain. 2. Dyspepsia. 3. Intoxication. 4. Decomposition. He accepts the etiological factors offered by Czerny con- stitution, infection, and food; but the advantage of his view- point is that he leaves the field more easily opened for further additions as to etiology. 188 INFANT FEEDING (CHICAGO METHODS) Either classification is correct. It makes no difference which you follow; but from the clinical aspect the Finkelstein idea is perhaps more practical, for it resembles our clinical classification of infectious disease. As clinicians, what we seek first is a clinical picture. When we go to the bedside we do not ask ourselves, "Is this a disturbance due to pneumococcus or strep- tococcus or meningococcus?" but we do ask, "Is this a pneu- monia or a septicemia or a meningitis?" And having estab- lished that, then we seek the etiological factors. The beauty about a clinical classification is that it is true. Theories may be altered, ideas changed, new explanations advanced, but "in the clinic lies the truth." Having clean-cut clinical pictures, we are in, a better position to seek causative factors. Just as in septicemia we have learned that much the same picture may be due to pneumococcus, strep- tococcus, or influenza, so can we amplify these clinical types of Finkelstein. This classification I, myself, do not believe to be the last word. I doubt if it will stay with us permanently; but it will be of invaluable help in further study. Having recognized these four clinical types, Finkelstein him- self began to seek causes to fill in the subheadings. Stimu- lated by Czerny's description of fat injury and by his own dis- covery of the diarrheal effect of sugar, he attempted to place all four of these clinical pictures upon a food basis. In a crude way one might say his first idea was as follows (Fig. 9) : Intoxication *^- ' Decomposition.. Fig. 9. Failure to gain was due either to insufficient food or to over- feeding with fat. The latter was the very same condition that Czerny described as "milk injury," Finkelstein's term, how- ever, for reasons which we will discuss later, was "disturbed balance." Continuance of the overfeeding with fat led to the decomposition stage. Overfeeding with sugar led to the stage MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 189 of dyspepsia. If the overfeeding with sugar were continued in the stage of dyspepsia, intoxication resulted. If the mistake was overfeeding with fat in the stage of dyspepsia, decomposi- tion resulted. This viewpoint has been greatly modified. The hundreds of studies all over the world, stimulated by the novel idea, have brought great light. The all-important result of this first idea of Finkelstein was to bring the well baby and the sick baby closer together. The well baby can now no longer be secluded in his nursery, independent of all interest, only to come to notice when he shows abnormal symptoms. The well baby may at any moment, due to a little improper feeding, enter the group of sick babies. Let me impress upon you gentlemen, that Finkel- stein did not deny infections as a factor, did not deny constitu- tion as a factor; but of all things he did impress upon us the very, very great importance of food, and he attempted to show that many of the clinical pictures of even the very worst diar- rhea were due, not to external influence, but to the milk mixtures which we ourselves were feeding the baby. This, of course, has been of unspeakable importance in guiding our therapy and stimulating us to deeper thought. Finkelstein's idea as to the importance of food has under- gone, during recent years, considerable revision. Continued studies from all parts of the world have introduced new and reemphasized old factors. Now we recognize many influences other than food. Finkelstein's latest classification is as follows : A. FOOD. I. Perfectly good, wholesome food, i.e., pure, fresh cow's milk, (a) Overfeeding. This may be of two types: 1. Too great quantity. 2. A preponderance of one of the elements of the milk, too much fat or too much sugar the group which Czerny and Finkelstein called so strik- ingly to our attention. (6) Hunger. This may be: 1. Insufficient total quantity. 2. Insufficiency of one or more elements of the milk, as protein and salt deficiency in prolonged use of barley water and gruel. 190 INFANT FEEDING (CHICAGO METHODS) II. Spoiled milk and food. The factor to which Czerny ascribed diarrheal disease, the one which Finkel- stein considered unimportant as compared to sugar in the diarrhea of nurslings. Both observers admit the importance of spoiled food in diarrheas of older children. B. UNDERLYING WEAK CONSTITUTION, or any factor weakening the constitution, such as heat, is an influence of no small importance. C. MILDER INFECTIONS, such as coughs and colds, bronchitis, and cystitis, are important predisposing agencies. D. NURSING injuries may be of two types: I. The failure of the individual nurse in allowing her charge to suffer from improper care, from uncleanliness, from overclothing, overheating, or exposure. II. A weakness inherent to our hospitals is the infant ward. Here one nurse, no matter how efficient, is in charge of several babies. She cannot give each child the necessary individual care. She cannot take proper interest in the preparation of the bottles, nor give personal attention during feedings. The children, suffering from lack of exercise, resemble plants rather than animals, and each day approach more closely the danger of a disturbance of nu- trition. DIAGNOSIS How do we diagnose a nutritional disturbance? Besides care- ful physical examination, we have two valuable aids: 1. A careful history. Information of frequent digestive dis- turbances, of frequent infections, improper care, a weak consti- tution, or backward development, would lead us to think strongly of nutritional disturbance as a factor in the present complaint. 2. Above all things, gentlemen, never neglect, and learn to know, the reactions to food and to hunger. (a) In one child with severe diarrhea the addition of a full bottle of food may be fatal, the child dying, with a rapid loss of weight and with the severest symptoms of intoxication. In MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 191 this same child, the complete withdrawal of food for twenty-four hours seems to effect a rapid, striking improvement. It was, in a way, this so-called paradoxical reaction that first led Finkel- stein to the careful study of food in these diarrheal conditions. Addition of food kills : withdrawal of food saves. What better clinical evidence can we demand of the vital importance of food? (6) In some children complefe withdrawal of food for twenty- four hours leads, with all symptoms of collapse, to rapid loss of many ounces of weight and death. Of these clinical pictures, of these weight curves, of these food reactions, we shall hear more. To conclude, we have learned this morning that in the great group of non-thriving children, the children with diarrhea, the children with constipation, pathological, examination of the intestinal tract as a means of classification is of little aid. We have learned that the science of bacteriology helps us but little. Czerny, with the conception of "disturbance of nutrition," takes our attention away from the intestinal tract, makes us think of the baby as a whole, and Czerny does us an infinite service by doubting the danger of protein and first calling to our attention the importance of food (of fat) in the production of the clinical picture of non-thriving, constipated children. Finkelstein, in a way following the footsteps of Czerny, arriving at these conclusions through careful clinical observation, im- presses us with the importance of all foods in causing these dis- turbances, agreeing with Czerny in some respects as to the effects of fat, and doing us immeasurable good in calling to our attention the diarrheal effects of sugar. Laying lesser stress upon constitution and infection in the production of these dis- eases, he believes disturbances of nutrition almost exclusively to be due to food perfectly good, wholesome milk, but given in improper amounts and diluted in improper proportions. We can never be sufficiently grateful to him for placing diarrheal diseases also under the term "disturbance of nutrition." This magnificent conception is of inestimable value to us in the treatment of our children. From this viewpoint the stool be- comes a symptom, the baby as a whole becomes the important consideration. The stool becomes absolutely subservient to the whole clinical picture. Just think what this means! This 192 INFANT FEEDING (CHICAGO METHODS) means we must never devote ourselves to the intestine alone, but only the intestine in relation to the whole body. In our deeper interest in the child's body we may be forced to do what seems to be worst for the intestinal tract. This viewpoint impresses upon us finally, irrevocably, the tremendous importance of the weight curve. The weight curve expresses the condition of the baby as a whole; the stool, only that of intestinal tract. With this conception of the fundamental importance of food, the well baby becomes a sick baby. The well baby may assume any clinical picture by varying his feeding. Gentlemen, if you will remember this, if you will only see your well babies more often, if you only will think of them as sick babies, will treat them with the same care and consideration that you would a patient with infectious disease, I can assure you that you will have little trouble with the babies, little trouble with the moth- ers, and the feeding cases in your practice will become a pleasure rather than a burden. LECTURE IV FAILURE TO GAIN Gentlemen, you remember in our last lecture we spoke of the viewpoints of the various great pediatricians. We told of the failure of the Vienna school to place nutritional disease upon a definite pathological-anatomical basis. We spoke of the failure of Escherich to find specific bacterial causes. Don't misunder- stand me, gentlemen; the ideas failed. The men succeeded. Patient, conscientious perseverance cleared away the obstacles that otherwise would have prevented the advent of newer con- ceptions. You remember it was Adalbert Czerny, the skeptic, the keen observer, the deep philosopher, who gave us newer thoughts. You remember he no longer spoke of disease of the gastro-intestinal tract. To him these disturbances were "dis- turbances of nutrition." The baby no longer was diseased solely in his stomach and intestines, but changes were effected in every sinew and fiber of the body. It was Czerny who, for the first time, cast doubt upon the orthodox idea of the in- digestibility of cow's-milk casein. It was Czerny who, for the first time, called to our attention the factor of food in the pro- duction of definite clinical entities. With two clean-cut clinical pictures he brought to our notice fat and starch. Too much fat was the causative factor in non-thriving, constipated in- fants; too much starch produced another clinical entity. It was Czerny who gave an etiological classification. You re- member the classification? Nutritional disturbances were those a. On the basis of constitution. b. On the basis of infection; these were the diarrheal diseases. Two factors might be concerned: (1) True infection of the gastro-intestinal tract with germs of specific diseases, such as dysentery or cholera. 13 193 194 INFANT FEEDING (CHICAGO METHODS) (2) Poisoning, resulting from the drinking of spoiled food food which had not properly been cared for and had become a great culture-medium for the common every-day organisms. c. Disturbances due to food: (1) Milk injury. (2) Starch injury. So, if we follow Czerny, we no longer speak of gastritis, gastro- enteritis, and cholera inf antum ; but rather of a disturbance due to constitution, due to infection, or due to food. In a and b he gave us etiological factors; in c he gave us an etiological factor with two beautifully described clinical pictures. You remember while this epoch-making work was being evolved, Finkelstein, in Berlin, was making great studies from a purely clinical viewpoint. In today's lecture I wish to discuss with you Czerny's "milk injury" and show how this has been modified by clinical obser- vation. Czerny's description roughly is as follows: A mother brings her infant, complaining that he is not thriving and that he is very constipated; she doesn't regard him as being sick: just wants a little advice. You, doubtless, have seen many such cases. Upon examination you find a rather pasty, not badly nourished, somewhat anemic-looking child. He is a little flabby. You think of a beginning rickets ; you place him upon the table and he flops over, showing a somewhat flaccid mus- culature. His weight is slightly below normal. Upon ques- tioning the mother you learn that he is not gaining as he used to; that he is a little peevish and fretful; he is subject to mild infections; and, above everything else, the mother dwells upon the constipated, dry, crumbly, soap-like stools, which charac- teristically do not adhere to the diaper, but easily can be brushed away. To the mother the chief trouble is constipation. You think the child is undernourished; you increase his diet; but he doesn't gain. Possibly he becomes more peevish and irritable, and the constipated stools more persistent. In seeking the cause of this condition, Czerny focused his attention sharply upon these abnormal bowel movements, and here he made a great discovery. You remember in our second lecture we spoke of the way in which fat normally leaves the FAILURE TO GAIN 195 intestine ; that a certain amount of it a rather small percent combines with alkalis, such as calcium and magnesium, and leaves in the form of soap. To Czerny's great interest, these stools contained a much greater percentage of soap than stools of normal babies. If the soap in a normal baby was perhaps 20 percent of the fat of the stool, in these babies it might be 50 percent. Czerny's reasoning was clear and simple. If a soap consists normally of fat combined with calcium or magnesium ; if the stools of these children contain an increased amount of soap, then from these children there must be an excessive ex- cretion of mineral matter, of calcium and magnesium, and the general symptoms might be explained as a disturbance of nu- trition in which loss of mineral matter plays a prominent part. If the mineral matter combines with fat to form soaps, then by reducing the fat in the diet we should decrease soap formation and thus lessen mineral loss; by increasing fat in the diet, we should enhance soap formation and increase mineral loss. True enough, Czerny's assistants, by offering these children increased quantities of fat, were able to increase soap formation and cause greater mineral excretion. The solution to the question was now simple. All that was necessary was to diminish the amount of fat in baby's bottle, substitute some food of equal caloric value, and the child should thrive. To accomplish this, Czerny used a mixture known as Keller's Malt Soup, which is made as follows : (a) To one-third of a quart of milk add 1 ounce of ordinary flour. (6) In another mixture, to two-thirds of a quart of water add about 3^ ounces of malt soup extract. In this country the latter is put up by Borcherdt or the "Maltine" concern. (c) Add the two mixtures together, boil, and you have in the resulting food an absolute cure, a perfectly ideal treatment. The baby's constipation subsides, the stools become normal, he gains in weight, and in every way becomes brighter and happier. The following curve, taken roughly from the text of Czerny and Keller, illustrates Czerny's idea (Fig. 10). This child is five months of age. From birth he got nothing but milk and water, and was brought to the clinic for typical symptoms 'of milk injury. He did not sleep well, was restless, 196 INFANT FEEDING (CHICAGO METHODS) and showed the constipated, fat-soap stools. During the first half of February he received one-third milk; during the latter half, half milk, and during March, full milk. Notice here a slight rise in the curve, but it is not sustained. In April Keller's Malt Soup resulted in the astonishing rise. This Czerny at- tributed to reduction of fat. In taking up this subject I hesitated somewhat. Would it be wiser to go into detail, showing you the reasoning of these observers, or to state simply that "The symptoms are so and so, the treatment so and so." Upon consideration, however, I thought I should like to show you the fundamental "why" at Month Feb. March April May 13 Ibs. 12 Ibs. 11 Ibs. 10 Ibs. a& /r 1-1 1-1 '+ * a a !/ /* if ^ w CM it H 2 A y -^^ 7 ^ / 10 E 5 S Fig. 10. the basis of these observations, because if you master the under- lying principles, you will have the key not only to the treatment of this particular condition, but also to many of the cases of constipation which perplex you in your daily children's practice. While these brilliant experiments were being conducted in Breslau, Finkelstein, in his institution in Berlin, was attacking the problem by careful study at the bedside, by accurate clinical observation. Perfectly independently he studied a great group of children, many of whom apparently were not very ill, all of whom showed a "failure to gain." In some, marked constipa- tion was present ; in others, bowel movements were more nearly normal. In these studies, Finkelstein and the men influenced by FAILURE TO GAIN 197 his teaching, showed that there were many factors featuring in the etiology. (1) Some children who showed the typical picture of Czerny's "milk injury" were getting insufficient food; increase of quan- tity brought correction of the intestinal symptoms and speedy cure. This, strictly speaking, does not belong to the group we are discussing. I place it here, however, as did Finkelstein, for from a clinical standpoint in your practice you frequently meet such cases. In true "milk injury," as described by Czerny, in- crease in total food volume does not result in gain. (2) Some children recovering from ordinary infections showed this very same symptomatology. They had been thriving perfectly until taken ill with a cough or cold or mild cystitis, and upon recovery, with absolutely no change in diet, spon- taneously developed this disturbance. Here, then, fat alone or even the food, could not be blamed, for the baby previously had been gaining on the very same mixture. (3) In another group improper care of the baby, whether in the home or in the hospital, in some mysterious way seemed to predispose. The explanation is not as yet clear. You remem- ber we are confining ourselves to clinical observation. (4) A group of children who suffer with a weak constitution, congenital heart disease, or other hereditary anomalies easily progress to this condition. (5) Lastly, the group in clean-cut, definite form in which too much milk, or, as Czerny would have it, too much fat, seemed to be the important factor. Gentlemen, you already see what tremendous influence clinical observation exerted upon our interpretation of this condition. Czerny gave us the wonderful conception of disturbance of nutrition; then temporarily forgot it in his intense interest in the baby's stool, and overlooked other factors, perfectly inde- pendent of food, which might have been concerned. Finkel- stein and his students, in adhering to the broader conception, the original idea of Czerny, regarding the stool purely and simply as a symptom and not as a cause, were able to add much to our knowledge. Let us return for a moment to group (5), the cases in which both Czerny and Finkelstein noted a rather high amount of fat in the 198 INFANT FEEDING (CHICAGO METHODS) diet. The many observations and experiments stimulated by Czerny's novel conception began to bear fruit, but as time pro- gressed these observations and experiments gradually began to speak against the primary influence of fat. First was shown that in some cases, in spite of a high fat diet, in spite of the fat- soap stool, there was no total mineral loss to the body. True, the mineral matter in combination with fat was increased, but the' mineral matter excreted in combination as salts was de- creased, and so the sum total was not above normal. A second argument against the primary importance of fat was the brilliant metabolic work of young Hans Barth, whose tragic death in the present war has been such a sad blow to modern pediatrics. He and his coworkers showed that in many cases the total amount of mineral matter lost in the form of calcium and magnesium was infinitely greater than could be ex- plained by the soap formation in the stool. And, lastly, comes the ever-valuable, unexplainable clinical evidence that children with well-developed, perfectly typical milk or fat injury can be cured in striking fashion by the use of breast milk. Breast milk, as you remember, contains the very same amount of fat as cow's milk. This is an unan- swerable argument. If a baby showing the picture of milk injury on cow's milk feeding can be cured at once by the use of breast milk, then fat exclusively, by itself, can scarcely be the sole factor in the etiology. We, blindly groping for explanation, must conclude that fat alone cannot be responsible, but fat plus some invisible mysterious element contained in cow's milk and not in breast milk. During the furor accompanying Czerny's discovery and the battles waged by his supporters and his critics, Freund was making brilliant, almost conclusive, experiments in his own in- stitution. He fed babies showing the typical picture of milk injury various foods, such as starch. This had little effect upon the stool. He fed them sugar of milk and malt ex- tract. Lo and behold! under the influence of the latter articles of diet the soaps disappeared ; the fats were excreted in other combinations, and constipation was cured. This observation seemed uncanny full of mystery. What could be the under- lying principle? Freund explains it in what seems very beauti- ful, simple reasoning. FAILURE TO GAIN 199 Gentlemen, you remember in our previous lectures we dwelt upon the processes of putrefaction and fermentation. We spoke of the alkali-forming protein, of the rather non-fermenting higher carbohydrates, and the fermenting acid-forming lower carbohydrates. The substances which were of great influence in correcting the constipated stool were those aiding fermenta- tion, those tending to make the intestinal contents acid; and now Freund reminds us of a simple little chemical process which previously had been overlooked, viz., that fat does not readily form soaps in the presence of acids, but in a way combines with them to form the so-called fatty acids. Soaps in the presence of acids are completely split up, just as if they were salts. Gen- tlemen, do you grasp the importance of this contribution of Freund? Think of it carefully for a moment. If this be true, soap formation is a result arid not a cause. Soap formation is simply a symptom of the intestinal reaction and not a factor affecting it. Feeding substances like protein, which alkalinize the intestine, favor soap formation and constipation. Feeding substances like carbohydrate, which make the intestine acid, break up the soap formation, and cause the looser type of bowel movement. Gentlemen, I urge you to give this matter careful consideration, to hold the principle before you at all times, because in mastering it you have mastered one of the great causes of constipation in infants. "Fat in an alkaline intestine forms soaps; in an add intestine, fatty acid." And now, if this great mass of careful observation and scien- tific experiment proves to us that the constipated soapy stool is an effect and not a cause, are we any closer to a clearer under- standing of the picture of milk injury? With true American lack of respect for dignity and title one day I assailed Finkel- stein in a corner of his great institution, from which the modest little man could not escape, and asked him to make the matter clear to me. I never left him until, filled with wonder and ad- miration, I had obtained his own personal viewpoint. He re- minded me that in feeding a baby we must consider the food, the intestine, and by all means that factor which so frequently and at such tremendous cost is overlooked by men speaking exclusively of " gastro-intestinal disease" rather than "dis- turbance of nutrition, " the needs of the child's whole body. He re- 200 INFANT FEEDING (CHICAGO METHODS) minded me that in feeding Keller's Malt Soup one reduces the fat, but at the same time increases markedly the carbohydrate. Simple reasoning, simple skepticism, forces the question, "How does one know that this gain, that this recovery, was due to the reduction of fat? Is it not just as reasonable to assume that the increase of carbohydrate was a factor of equal or even greater importance? Is it not likely that children with weak constitu- tions, children recovering from infections, children suffering from neglect, need more carbohydrate, more energy, than does the normal baby? Is not the primary consideration in these cases the demands of the child's body rather than the condition of his digestive tract?" Have you forgotten the striking statement of Naunyn, "The fat burns in the fire of the carbohydrate"? With such a remarkable viewpoint, the condition of the digestive tract fades into insignificance before the primary consideration of the child's body. The child's vigor and strength depend upon the amount of carbohydrate offered, and are perfectly inde- pendent of the reaction of the intestinal tract. Whether the fat in the stool is excreted in the form of soap or whether it is excreted as fatty acid depends upon the reaction of the intestinal contents. If the contents are alkaline, soaps are formed; if acid, fatty acids result. In Keller's Malt Soup we have a mixture ideal for creating an acid condition in the intestine. Low protein from the dilution of the milk lessens alkali forma- tion; high carbohydrate favors acid. Due to this acid, the fat soaps are split up and constipation corrected; but the great benefit to the child the gain in weight, the improved tone of the muscles, the returning elasticity to the skin depends not upon the correction of the stool, but upon the increased supply of carbohydrate offered to the needy tissues. It was for this reason that Finkelstein introduced the term "disturbed balance." He meant to imply that the primary fault was not one of fat injury, was not one of chronic fat in- digestion, as is the viewpoint of so many men, but that the trouble lay in a disturbed balance between carbohydrate and fat, perhaps carbohydrate and protein, the body not receiving enough carbohydrate to satisfy its wants, probably not receiv- ing enough carbohydrate to perform successfully the metabolism of the fat. This viewpoint in a striking way makes clear to us FAILURE TO GAIN 201 the brilliant success from feeding of breast milk. Breast milk offers the body high carbohydrate; breast milk, with its high carbohydrate and low protein, establishes processes of fermen- tation in the intestinal tract and cures the constipation. This viewpoint, perhaps, does not explain every case; perhaps some cases really are due to primary fat indigestion; but at any rate we learn much from this conception, and a great group of cases becomes clear. Probably in the majority of cases, as shown by the results with breast milk, the fat is indeed only a secondary factor. Gentlemen, now you see why I have tried to go into detail. If you have followed me carefully; if you have understood the principles which I am trying to make clear, you have the key to the majority of cases of constipation which you meet. You see also how modern clinical medicine can never be separated from chemistry, physiology, and the allied sciences. The physician needs them all for complete understanding. The diagnosis of this condition is easy. In practice you will have to distinguish it only from inanition, i. e., hunger; in the latter, an increase of a half-ounce or an ounce to each feeding will result in rapid cure. In the true case of disturbed balance no improvement follows. Treatment. For the young baby breast milk, which is always the ideal food, is the best treatment. In offering breast milk, let me warn you of a little complication, simple in physiology, ignorance of which, however, may lead to unpleasant results. To illustrate (Fig. 11): 7 ox 6 oz 5 oz 4 oz 3 oz Z oz 1 oz s* ** A / / / \ \ / N / / V ^H ^ ~-- Fig. 11. 202 INFANT FEEDING (CHICAGO METHODS) At A we have changed the mixture of cow's milk to one of breast milk. A loss of several ounces occurs, lasting several days. What is the explanation? Can any of you grasp why a loss of weight should result from feeding breast milk? The answer is found in the simplest physiology. In our first lecture we told you that cow's milk was much richer in mineral matter than breast milk. In our second lecture we told that minerals, particularly sodium, were important in binding water to the tissues. If our baby had been getting a mixture of three-quar- ters of a quart of cow's milk, he would be getting 5.7 grams of salt over a teaspoon. The change to three-quarters of a quart of breast milk reduces his salt intake to \ l /% grams. You see what reduction occurs in the mineral matter of his diet. For this reason, until he gets properly adjusted, water leaves the body, with the resulting drop of several ounces in the weight curve. This loss is not due to poor breast milk, is not due to insufficient breast milk, but to perfectly normal breast milk, and a knowledge of the simple explanation will save the mother, the wet-nurse, and incidentally you, much worry. If artificial feeding is to be employed, what shall be our pro- cedure? Do we need Keller's Malt Soup? No; but we do need the principles upon which it is based. We wish to offer more carbohydrate, more energy to the baby's tissues; we wish and must do this without injuring the intestinal tract. In our next lecture we shall learn that mixtures of high carbohydrate in connection with high fat, particularly in connection with concen- trated whey of cow's milk, are dangerous from the intestinal viewpoint. We, therefore, dilute our milk, not with the idea of diluting the fat exclusively, but of simply making up a mixture which will enable us to offer to the tissues higher carbohydrate without causing intestinal complications. We dilute to one- third, adding two-thirds water, and then gradually increase carbohydrate until we get the improvement of the general con- dition and the more normal stool. Ordinary cane-sugar is the simplest and cheapest carbohydrate to use. One word of warn- ing, however, in employing it. It may become necessary to add more than six or eight teaspoons to a quart of the mixture in order to get the physiological results. Under such circum- stances the mother and babe rebel at the sweet taste; therefore, FAILURE TO GAIN 203 if it becomes necessary to increase over six to eight teaspoons, it is wise to add some easily fermentable carbohydrate less sweet to the taste. This can be done in the form of the above-said malt soup extract. Don't make the mistake, however, of order- ing pure malt extract. This does not mix so readily with the milk, and you may get into difficulties with the mother; but show your superior knowledge by impressing her with the neces- sity of getting malt soup extract. Several concerns put this up. In children over two or three months of age, remember that one-third milk is not sufficient to provide for continued growth. After a short time one cautiously must increase the concentra- tion of the milk. The increased protein temporarily may cause an alkaline reaction to the intestine with a renewal of soap for- mation and constipation. This can be combated readily by additional increase of carbohydrate. One point in the treatment, let me impress you, is what you should not do. Now that you understand the underlying prin- ciples, you see how utterly unreasonable, how absolutely with- out scruple, is the physician who drugs these patients, treating their constipation with calomel, castor oil, and other cathartics. At our hospital at home Dr. Abt and his associate, Dr. Jampolis, some years ago made interesting observations on perfectly normal babies. Feeding a fine healthy baby a therapeutic dose of these drugs caused the appearance of blood in the stool not in large quantities, but easily detected chemically. Just think of that, gentlemen; feeding a perfectly healthy, normal infant medicinal doses of calomel produces such irritation in the in- testine as to make blood appear in the stool! What a crime is it, then, to offer a little child suffering from a condition of dis- turbed balance these strong intestinal irritants; to try to over- come constipation, not by reason and principle, but by brute force! What this baby needs is not medicine: he needs sugar. Gentlemen, we are now temporarily going to leave Czerny. Remember his great service to us his service in giving us the conception of disturbance of nutrition; his service in casting doubt upon the indigestibility of protein; his service in recog- nizing food as an important factor in nutritional disease. What have we learned from this lengthy, perhaps complicated, dis- cussion? We have learned to think. Only the light shed by 204 INFANT FEEDING (CHICAGO METHODS) time, by distance, by laboratory experiments, stimulated by the keenest clinical observations, could make us change alle- giance to Czerny's first idea. Every great pediatrician who was able to read these writings and comprehend them was in- fluenced. The very foundation of pediatrics was shaken. Now, from across the space separating us by years from Czerny's first work we ask ourselves, "Did we not all err alike? Did we not all make the same fundamental error?" We were stirred by the brilliant conception of disturbance of nutrition; we temporarily lost sight of this in our keen interest in one symp- tom the stool. In focusing our attention upon the stool we lost all sense of proportion in the discovery of the soap. In this maze of thought we lost sight of the relation of fat to the other elements in the milk; we lost sight of the fact that fat in an acid intestine makes fatty acids; in an alkaline intestine, makes soaps. Not that our observations were without value or interest: much good has resulted. But they were in entire disproportion to the great clinical picture. Only careful, fre- quently repeated, accurate bedside study resulted in putting us again upon the right path. Just as we had forgotten to note the relation of the fat to the other elements of the milk, so had we forgotten to note the relation of the symptom the consti- pated stool to the main clinical picture. Just as our exclusive attention to the fat had led us astray, so did our exclusive at- tention to the stool divert us from our original broad conception of disturbance of nutrition. Gentlemen, what have we learned? We have learned that if we wish to err only slightly, if we wish to have an anchor that will hold us secure, let us never forget that first, foremost, above everything else, the fundamental truth is to be found in careful, conscientious clinical observation and study. What is the practical significance of this lengthy discourse? If a constipated baby is not gaining upon a well-regulated diet, carefully increase it. If he still does not gain, make up a mix- ture with a higher percentage of fermentable carbohydrate than was contained in the original formula, and increase gradu- ally this carbohydrate until improvement occurs. LECTURE V THE STATES OF DYSPEPSIA AND INTOXICATION Gentlemen, if our last lecture was important from a stand- point of therapy, today's lecture is vital, for it concerns life. You remember at our last meeting we spoke of Czerny's new viewpoint, "disturbance of nutrition." We showed how he introduced food as a factor in causing disease and how he laid particular importance on fat. He doubted the indigestibility of protein; he gave us an etiological classification; due to this etiological classification, to this concentration, perhaps, on one causative factor, we became side-tracked and focused too care- fully upon one symptom the stool. Finkelstein, you re- member, accepted the viewpoint of "disturbance of nutrition," agreed that infection and constitution were factors, but enlarged greatly the importance of food. To him most disturbances, including even the diarrheas, were due not to infections, but practically entirely to food alone. Clinical pictures to be brought about by improper feeding were four: The picture of milk injury he saw just as did Czerny, but for reasons which we stated he changed the name to "disturbed balance." His tremendous contribution in this realm was in- cluding diarrheal disease in this group. To him the majority of diarrheas do not belong to the infectious group of Czerny; do not belong either to (a) those caused by specific bacterial in- fection of the intestine or to (6) those resulting from milk spoiled by bacterial growth, but do belong to the group of dis- turbances arising from the feeding of good, wholesome, pure milk made into improper mixtures. The history of the observation and development of the food basis for diarrhea is fascinating. The first stimulus came to Finkelstein and his assistants with the appearance, in their great institution, of a number of cases of severe diarrhea gastro-enteritis, as they might then have been called, or dis- 205 206 INFANT FEEDING (CHICAGO METHODS) turbances of nutrition on the basis of infection, as Czerny would have said. Perhaps, in a way, it was Czerny's conception of food disturbance that led them to investigate carefully condi- tions in the diet kitchen. To their interest and amazement they discovered that by an error, many mixtures contained unusually high quantities of sugar. Could the sugar be a causa- tive factor? Full of curiosity, they fed babies large quantities of sugar, produced severe diarrheal disease, and gave to the pediatrics world one of our most wonderful contributions. Not only could high fat and low sugar produce a condition of disturbed balance, but high sugar, on the other hand, could produce severest diar- rheal disease. For the moment we see Finkelstein following the same error of Czerny, focusing too carefully upon the stool, upon one symptom, forgetting the big clinical picture and laying blame for almost every case of bad diarrhea on too much carbo- hydrate in the food. Not long, however, before he saw his error. The same objection applied to this view as did to the original idea of Czerny. Breast milk, the ideal food, contains a large quantity of carbohydrate, easily fermentable carbohydrate, but children when fed breast milk do not develop these deadly diseases. There must be some other factor some other in- fluence. This is simple reasoning, simple common sense. Care- ful clinical study again guides us along the right path. At this time Ludwig F. Meyer, Finkelstein's first assistant, made an important contribution. While his experiments are open to great criticism; while in the light of our present knowl- edge they can be attacked from all sides, nevertheless, in their day they served their purpose. He took cow's milk and breast milk, separated them each into curd and whey, as, for example (Fig. 12), Breast Milk Casein Xnn&y nruAt* Cow's Milk Casein' -*Whey Fig. 12. and after having divided these mixtures, he crisscrossed, adding the casein of cow's milk to the whey of breast milk, and the THE STATES OF DYSPEPSIA AND INTOXICATION 207 casein of breast milk to the whey of cow's milk. Offering these mixtures to children sick with diarrheal disease resulted in sharp differences. Those getting the mixture containing the whey of breast milk made good recoveries; those getting the mixture with the whey of cow's milk did not do so well. Gentlemen, although this experiment is open to great criti- cism, it served its purpose. It called to our attention, for the very first time, the whey of cow's milk. Now we hear of the whey as a factor in producing disturbance. We have heard of protein, fat, carbohydrate, and now we hear whey; and, after all, is it not strange that for so many years we have neglected this portion of the milk? Is it not likely that whey, with almost four times the salt content of breast milk, also could exert harm- ful influences upon the intestine, perhaps due to osmotic con- ditions or to who knows what? To Ludwig F. Meyer, then, are we indebted for this new inspiration. While these observations were going on, clinical study again was bringing Finkelstein toward the ultimate truth. Increasing carbohydrate in some milk mixtures resulted in diarrhea. In- creasing carbohydrate in others, to his mystification, had no such effect. What could be the explanation? The solution was discovered in combining the above two clinical experiments. When carbohydrate is added to mixtures of cow's milk rich in whey, diarrhea results; when carbohydrate is added to mixtures poor in whey, no diarrhea results. The more concentrated the whey, the worse the diarrhea! Thus, you see, adding carbo- hydrate to buttermilk or to skimmed milk will make a laxative combination these mixtures containing all the whey elements of the milk. Adding carbohydrate to pure whey would cause an intense diarrhea. I should advise you not to try this. What factor in the whey causes these symptoms I do not know. Per- haps it is the salt. As I have said so frequently, "This is clinical observation." It is human, however, to wish things clear; to have a picture to hold before us, a guide for our thoughts. I can offer the explanation that has been given by our teachers. Do not take it as an absolute truth, but simply as an illustration of the processes of modern reasoning. How can a mixture of whey and carbohydrate produce these results? 208 INFANT FEEDING (CHICAGO METHODS) Normally, billions and billions of bacteria live in the large intestine. The small intestine is relatively sterile. Only at times when food is digested are bacteria found in any amount in the upper tract. With the disappearance of food, with its absorption through the intestinal wall, the bacteria rapidly go back to their home, to their normal environs in the large in- testine. Those left in the upper tract are killed, probably by the intestinal cells and by the digestive juices. Postmortem examination in many cases of severe diarrhea, however, reveals the upper intestine swarming with micro- organisms not abnormal ones, but simply those which normally live in the lower bowel. Gentlemen, what has happened? Normally the upper intestine is able to keep its contents sterile. Something must have impaired this function. Is it not possible that the digestive juices and the activities of the epithelial cells have been handicapped by the high salt content, perhaps by the changed salt relations of the cow's-milk whey? Moro's experi- ments would tend to confirm this hypothesis. In carefully conducted researches he and his assistants showed that the in- testinal cells are more efficient when active in a medium of breast-milk whey than of cow's-milk whey. Once injured, these intestinal cells cannot suppress bacterial growth. Bacteria will thrive and prosper, and now, when car- bohydrate is introduced, before the intestinal digestive enzymes can alter it, prepare it for assimilation, and carry it through the intestinal wall, the hungering bacteria have seized it, fermented it, and changed it to the irritating lower fatty acids, such as acetic, butyric, and formic. Gentlemen, do you remember that in the first lecture and in the second, also, we tried to impress upon you that when bacteria attack carbohydrate the process is known as fermentation and acid results? Now you under- stand why. The injured intestinal epithelium can no longer exercise control and fermentation proceeds rapidly. A tremen- dous quantity of irritating products results, and causes a severe, acid, watery diarrhea. Such is what we reasonably may be- lieve. Clinical observation has painted a picture in abnormal physiology. To return to the bedside. Diarrheas are of two types: THE STATES OF DYSPEPSIA AND INTOXICATION 209 (a) A mild attack, with symptoms described as mild gastro- enteritis or mild summer complaint. (6) An intense attack, often deadly in nature, described as severe gastro-enteritis, severe ileocolitis, or cholera infantum. The first of these conditions Finkelstein called dyspepsia; the second, intoxication, not because he had isolated any toxin, but because from a clinical point of view the little patient appeared poisoned. This, you remember, is a clinical classification. The picture is constantly before us. Explanations will be varied, causes amplified, new factors discovered; but the clinical picture remains unchanged. DYSPEPSIA This is one of the most frequent ailments you meet. The mother brings the babe mainly for relief of intestinal symptoms. The child has mild diarrhea five, six, or eight watery, green, sour-smelling stools with mucus; vomits occasionally and has colic. Careful history shows nothing of importance other than per- haps a slight cold. Baby's sleep is disturbed, and for a few days he has not been gaining. Fig. 13. Examination (Fig. 13) shows that he is not very sick he is slightly undernourished, pale, and restless, perhaps peevish and irritable. Consciousness is not affected. There may be shadows 14 210 INFANT FEEDING (CHICAGO METHODS) under the eyes and the abdomen distended. Temperature, pulse, and respiration, other than possibly a slight fever, reveal no important change. Gentlemen, we have spoken about the reactions to food and to hunger. Addition of food or increase of diet to this patient will have little effect. His diarrhea may become worse, his general symptoms a little increased, but he will show no radical change. Withdrawal of food absolute hunger causes a marked improvement. Diarrhea ceases and he becomes better, brighter, and happier. There may be a moderate loss of a few ounces of weight for a day or so, but then the curve rapidly swings to normal. If we study such a child from a standpoint of metabolism; if we analyze carefully the amount of food taken in twenty-four hours and the end-products excreted in the urine and the stool for twenty-four hours, we find the following changes: a. Protein excretion is slightly increased. b. Fat is not changed unless the child has been receiving some quantity in his bottle. Then considerable is found in the stool. c. Starch may be found in the stool, particularly if baby has been receiving a starchy diet. d. There may be a slight loss of mineral matter, chiefly of sodium and potassium. e. Most striking is the increased excretion of the irritating volatile lower fatty acids, such as acetic, butyric, and formic. What is the source of these acids? Czerny would have said that they come from bacterial infection of the milk outside of the body; Finkelstein, that these acids are produced by the normal bacteria of the intestine attacking the carbohydrates of the milk under the accelerating influence of the whey. The splendid studies of the younger men, such as Barth, Edelstein, and others, stimulated by these controversies, have shown that acid formation in the stool is infinitely greater than acid formation in spoiled milk. Thus they must be created in the body. Just as clinical study enlarged Gzerny's idea of fat injury, so did it enlarge Finkelstein's idea of whey-sugar injury. New points added as etiological factors are: THE STATES OF DYSPEPSIA AND INTOXICATION 211 I. From the Standpoint of Food. A. As regards good, wholesome, pure milk, the factor which Finkelstein so emphasized: (1) Simple overfeeding is a frequent cause. (2) Particularly is overfeeding with sugar-whey mix- tures a factor. This was Finkelstein's first great con- tribution. (3) In a medium of cow's-milk whey, high sugar plus fat causes these diarrheas. Many men lay primary emphasis upon the latter, for the stools show great quantities of undigested fat. We do not wish to be dogmatic. Undoubtedly high fat, particularly if not properly digested, can produce irritating products and diarrhea. We believe, however, the more important process is the primary fermentation of the carbohy- drate, which whisks out the fat in the resulting diar- rhea, the fat appearing as a neutral secondary element. We believe that probably the fat suffers secondarily as the acids from sugar fermentation interfere with the digestive enzymes. These, you know, work best in an alkaline medium. B. As Regards Spoiled Food. From the viewpoint of Czerny, spoiled milk undoubtedly at times provides irri- tants to the intestine sufficient to cause these symptoms particularly in older children, during the summer months, are spoiled foods of all sorts important agents. II. We have relearned the value of constitution. The weaker the baby, the more is he predisposed. III. Frequently repeated mild infections, as coughs and colds, are of extreme importance. IV. Heat and improper nursing must meet with our consider- ation, and, of course, time will add new influences to the list. Probably all of these in some way or another will increase fermentation in the intestines. From this viewpoint you see how relatively unimportant is examination of the stool I mean, relatively unimportant as a strict indication for therapy. Jn any of these dyspeptic stools, had the baby been fed starch, the starch-granules would have been whisked through by the increased peristalsis; had he 212 INFANT FEEDING (CHICAGO METHODS) received high fat, the fat would have appeared in large quanti- ties. Had we focused our attention exclusively upon the stool, forgetting the more general considerations, we would have said, "This is a disturbance due to starch; this is a disturbance due to fat"; but now, as Ludwig F. Meyer in his pointed way once said to me, "When you find high fat in the stool, seek the carbo- hydrate." Treatment. The treatment based upon these opinions must be self-evident and simple. If the whey is a factor injuring the intestine and permitting bacteria to flourish in the upper tract, it must be diluted. If carbohydrate ferments, we must give it in a non-fermentable form. The more we dilute the whey, the more we reduce the factor injuring the intestine, the safer is it to give carbohydrate. Non-fermentable carbohydrates, we told you, are composed of mixtures of dextrin and maltose and can be offered as Mead's Dextri-maltose. More fermentable are MeUin's Food, Horlick's Malt Food (not Malted Milk), etc. Remember, these substances are carbohydrates, and under no circumstances baby foods. Dextri-maltose, copied from Soxh- let's Nahrzucker, contains most dextrin, and is therefore the least fermentable. Borcherdt also puts up a similar prepara- tion. Our treatment then for these milder conditions would be: 1. Hunger for twelve to twenty-four hours, not forgetting, however, to keep up a sufficient supply of water. During this hunger period the baby's vomiting and diarrhea empty his digestive tract of all irritants. It is not necessary to give calo- mel and castor oil, unless, perhaps, foreign substances have been eaten; for the baby, as a rule, can well take care of himself. If you suspect that the trouble is due not to milk, but to corn or cucumbers or watermelon, a dose of castor oil and a mild colonic flushing may do no harm, if given once. 2. . After this hunger period we start food. To dilute the whey, we give one part milk, two parts water. To this mixture we add 1 or 2 percent of non-fermentable carbohydrate. We boil these together and in six feedings give a total of six to ten ounces in twenty-four hours, always keeping up the supply of water. We gradually increase about three ounces to the total every day or two until we have reached the maximum, depending upon the THE STATES OF DYSPEPSIA AND INTOXICATION 213 baby's age. Then gradually we increase the carbohydrate to 5 percent. In all this treatment our guide must be not so much the stool as the baby's weight curve (Fig. 14). 10 11 12 oz 8 Oz 4 oz \ Fig. 14. At A we have withdrawn food; a loss of perhaps seven to eight ounces results during the next few days. At B, after twelve to twenty-four hours' hunger, we give a day's total of six to ten ounces. We make no change until at C the curve has straightened, and then we cautiously increase. Remember, the curve is the index of the general nutrition, and although this dyspepsia is almost exclusively a local intestinal affair, still the loss of weight resulting from improper treatment proves that the general nutrition also can and does suffer, and if we keep this broad picture before us we shall less likely err badly. In some cases physicians, instead of giving water during the first day, give cereal waters barley gruel, etc. This often is fully as efficient as plain water. The dangers, however, are two: a. The physician, in his carelessness, the mother not knowing that barley water is a starvation diet, forgets to add food, and allows the baby to remain on barley water for days. After a period of four, five, or six days the child rapidly develops the condition of Czerny's starch injury, or, as we shall call it, "decomposition." 6. Sometimes, after the baby has been on barley water, for 214 INFANT FEEDING (CHICAGO METHODS) reasons which are not clear, upon the addition of milk to the diet, fermentation again becomes active in the intestine and diarrhea returns. For dyspepsias in older children the same principles hold good. We shall refer to them later. Gentlemen, suppose we are ignorant of the food factor in this dyspepsia; suppose we have attributed the condition to some- thing else-; suppose we have quieted the child with opiate and allayed the mother's fears; suppose we have thoroughly cleaned out the child with calomel and castor oil ; and then suppose, in our folly, thinking the baby must have food, we offer the child one of those mixtures high in the whey elements of the milk and rich in fermentable carbohydrate, such as buttermilk with sugar or skimmed milk with sugar can you grasp the result? Shortly we are called to see a desperately sick baby. The child is feverish and lies in semi-stupor. The sunken cheeks, the sharp nose, the ashen, mud-colored, wrinkled skin, the cold extremities, all show great loss of weight and great prostration. Intense watery diarrhea drains the body of its food, pulls out the very building-blocks of the tissues. The pulse is rapid and weak. Lying apathetically, our little patient takes not a par- ticle of interest in his surroundings. The unclosed lids show the glassy eyes fixed unintelligently upon one corner of the room. Occasionally he wakes for a moment, looks at us, cries fretfully, and again wanders off into apathy. The breathing is charac- teristic, deep, tireless, rapid, unceasing, like the air-hunger of diabetic coma. Occasionally one of the almost limp extremities moves slightly. Sometimes it takes a cataleptic attitude. The arms, particularly, are apt to assume the position typical of a prize-fighter. The urine may show sugar, albumin, and casts. Examination reveals an enlarged liver. What have we done? We have produced a wonderful, a terri- ble, clinical picture. We have produced the " alimentary intoxi- cation" of Finkelstein. Gentlemen, we spoke about the importance of food reactions. Listen carefully: If in this stage we offer our patient a full bottle; if we offer him any large quantity of food, his weight curve sinks precipitately, vertically, downward to rapid death. We have killed him. No surer way have we of doing this than THE STATES OF DYSPEPSIA AND INTOXICATION 215 by offering food; no surer way have we of saving him than by removing food (Fig. 15). Days : j A I ' 5 1 $ Ib 12 oz 8 oz 4 oz 6 Ib 12 oz 8 oz ~ \ fc t \ \ \ \ \ \ \ v ( Fig. 15. In the period of his dyspepsia, if at point A we have mis- treated our patient, so that steady progression has thrown him into the stage of intoxication, at B addition of food brings the fatal drop; withdrawal of food straightens out the curve and the child is saved. What more beautiful illustration has one .of the effects of food than this clinical observation than this so- called "paradoxical reaction of Finkelstein"? The food which would cause a normal baby to gain, causes destruction; the hunger which causes a normal baby to lose, is salvation. What processes are involved in this radical change, in the progress of the mild dyspepsia to the deadly intoxication? Lis- ten carefully: This progress is one of transition from a mild, local, intestinal disturbance to the severest "disturbance of nutrition." In the dyspepsia, constitutional symptoms are mild. The acids formed slightly irritate the mucous membrane and cause diarrhea, but nutrition is not badly affected, as shown by the relatively slight loss of weight. Now note the progress. 216 INFANT FEEDING (CHICAGO METHODS) Increasing acid formation injures the intestinal wall. The acids become sufficient to interfere with the digestive enzymes. Fat no longer is properly digested, and its split products aid in in- creasing the damage. In this acid medium new types of bac- teria nourish bacteria which can attack the fat, producing intense irritants. Before these combined "assaults the intestinal wall begins to fail. The membrane remains no longer impermeable to attack. Its weakened strength cannot be detected by the microscope: it can be by physiological experiment. Now for the first time undigested food-substances pass the membrane into the body. We have not seen these substances enter, but our examinations have found them as they leave. We feed children in this con- dition lactose, and lactose appears in the urine. We feed foreign protein, and foreign protein reappears. Gentlemen, the process of digestion is to prepare food-stuffs for the use of the tissues. Undigested food circulating in the body fluids is poison. See the possibilities of this conception. The mild dyspepsia has progressed so that now the entire body has become severely and dangerously involved. We can paint any picture. We see undigested protein and poisonous products of the fat taken into the circulation. We see the tissues bathed in strong solutions of sugar and of salt. We see innumerable products of bacterial activity rapidly enter- ing the system. We see chaos where we should see order. Small wonder at the multitude of clinical symptoms. Con- vulsions, strabismus, and cerebral cry may suggest meningitis. Gastro-iritestinal effects may be great enough to resemble cholera. But in all cases remember that certain symptoms will be constant : the rapid loss of weight, the acidosis breathing, the disturbed consciousness. The examination of the intake and the total excretion of these children, in contrast to the mild dyspepsia, shows considerable loss of body substance. Protein, fat, and minerals are thrown out by the rapid intestinal movements. The urine shows the most profound changes of metabolism. There is a tremendous loss of water, due, perhaps, not so much to the increased bowel movements, for this loss is compensated by the decreased urine, but to the tireless, rapid, deep respiration. In this condition, THE STATES OF DYSPEPSIA AND INTOXICATION 217 then, we are dealing with an infinitely more important problem than local intestinal disease. As tonsillitis results in endocar- ditis ; as the insignificant wound ends in deadly tetanus, so may the simple dyspepsia lead to a profound "disturbance of nutri- tion " "alimentary intoxication." Diagnosis. The history, in a way, makes the diagnosis. Im- proper feeding, followed by a disturbance, such as we have described, almost invariably is "alimentary intoxication." How- ever, we have learned from more recent studies not to focus our history too carefully upon feeding alone, but to recognize new factors, which, by their effect upon the baby's general condition, also predispose. To these we referred in dyspepsia, viz., age, constitution, infections, poor nursing, and heat. We have learned that this condition never develops primarily in a well child. There must have been a preceding state of dyspepsia or decomposition. The latter we consider in the next lecture. The diagnosis is definitely established upon withdrawal of food (Fig. 16). Days I 1 4 t 9 Ib 12 oz 8 oz 4 oz 8 Ib \ \ \ \ ^ \ , \ \ N^ ^*~ ^ Fig. 16. If, after twenty-four hours of hunger, frie loss of weight ceases, the temperature drops to normal, the diarrhea improves, the latter, however, not being absolutely essential, we make a positive diagnosis of alimentary intoxication. 218 INFANT FEEDING (CHICAGO METHODS) Treatment. 1. Gentlemen, during the first twenty-four hours the child must hunger. During this day the diarrhea and the vomiting will empty the intestinal tract of irritants. 2. Under no circumstances shall we give calomel, castor oil, or any other irritating drug. Just think! The intestines are acting as rapidly as possible to rid themselves of irritants. They are moving just as quickly as they can; you can't make them move any more quickly; all that you are doing with these drugs is to increase injury. What the intestine needs is not stimula- tion: it needs a rest. For this same reason we would not injure the stomach and intestines by getting a big pump and repeatedly washing out the stomach and flushing out the bowels. Let them alone! They will take care of themselves if you give them only half a chance. If your aim in using these drugs is intestinal asepsis, your hope is in vain! No drug is known which will make the intestine sterile. Indeed, animals raised with sterile intestinal tracts live only a short time. Barrels of medicine haven't nearly the effect of a slight change in diet. In addition to the great principle of physiologic rest during these twenty-four hours we can aid our little patient in other ways: 3. He is suffering greatly from loss of water: we must supply fluids. Give him all the water he wants. 4. The use of a little salt will aid him in retaining water in his body. Simply take a little surgical salt solution physiological salt solution, made by adding a teaspoon of salt to a pint of water; dilute this to half-strength, sweeten it with a little sac- charine, and offer the baby three to four ounces by mouth during the first twenty-four hours. Don't give over this amount, or you will produce edema and throw too great a strain upon the heart. Edema readily results. 5. Our little child may need to be stimulated. Under these conditions, brand}' in doses of 10 to 15 drops every few hours; caffein citrate, in doses of % grain, may be given by mouth. Infinitely more effective is the hypodermic use of 10 to 15 minims of a 10 percent solution of camphor in oil, repeated, when necessary, every few hours. Personally I have come to place more and more confidence in adrenalin. One hears very little of this in medical discussions; but, from my own observations, THE STATES OF DYSPEPSIA AND INTOXICATION 219 I am absolutely convinced that in the failing pulse and sinking blood-pressure of this condition, just as in surgical shock, hypo- dermic injections of two to three minims, repeated every two or three hours, are of great value. In my own studies I have found that the blood-pressure is raised and maintained for periods of one-half hour following injection, probably by the gradual absorption resulting from subcutaneous rather than intravenous use. 6. During this first day, treatment of the mother is an impor- tant consideration. She, in her maternal anxiety, demands that we do something. The substitution of tea for water is a great help. From our standpoint, children take it well, like it, and we supply fluid to the tissues. We can explain to the mother, however, that in tea we have caffein, which is a great stimulant; tannic acid, which will tend to combat the diarrhea, and we can make the matter more impressive by adding a little sac- charine tablet for sweetening. We can busy the mother, during the first day, with the general care of the baby, keeping him warm, offering with a medicine-dropper small doses of salt solution and perhaps a little medicine at regular intervals, but under no circumstances shall we diverge radically from our prin- ciples. 7. What medication shall we use for the intestine? Gentle- men, if you have understood the principles of this disturbance, you see that a little alkali can be reasonable and logical. Chalk mixture, with its calcium, can be given in doses of several tea- spoons every few hours. It is interesting to see how the older men empirically arrived at this remedy; but, gentlemen, under no circumstances place your faith in medicine; medicines are simply insignificant aids in our treatment, compared to the enor- mous influence exerted by food. 8. While in the stage of simple dyspepsia, ordinary dilution of the milk and reduction of carbohydrate suffice for a cure, in intoxication we are reduced to the use of two foods only. These are breast milk or, if this is not obtainable, "Eiweiss Milch/' or albumin milk of Finkelstein and Meyer. The principles of this food depend upon ordinary common sense. If carbohydrate ferments, it must be reduced. If whey so injures the intestine as to enhance fermentation, the whey 220 INFANT FEEDING (CHICAGO METHODS) must be diluted. If casein, by calling forth alkaline intestinal juice, by aiding putrefaction, by combining with calcium, over- comes fermentation and makes the intestine alkaline, protein must be increased. With this object in view Finkelstein and Meyer set about making the albumin milk. It was originally made as follows: (a) To one quart of raw milk add enough ferment to cause coagulation and formation of large casein curds. Any milk- coagulating ferment will do. In Chicago we use chymogen in amounts of one dram to a quart of milk, put up by Armour & Co. (6) In order to separate the curd from the whey we filter, letting the mixture hang in a cloth bag for an hour. During this process all the whey drips off and the pure casein curd remains. (c) This is put through a fine hair sieve, the wire meshes of which must be finer than a window-screen. You understand if the casein is fed in large pieces it will not exert its physiological effects, for only a small amount of it will be exposed to the intes- tinal juices and to the bacteria and less calcium can be efficient. The center of the curd will be untouched. The success of the mixture, then, depends upon a very fine division of the casein. It must be put through the sieve two or three times. (d) To the finely divided curd we add one pint of buttermilk. Buttermilk supplies salts, and a baby must have salts to live. You ask why a pint of whole milk or skimmed milk will not suffice. Whole milk, you remember, contains fat, which we are glad to reduce in these severe cases. Whole milk and skimmed milk both contain lactose, which is very fermentable. Butter- milk not only has no fat, but also has very little lactose, and possibly even the lactic acid may be of aid. (e) Enough water is added to make one quart. The mixture is boiled, stirred with a cutting motion to prevent the reforma- tion of large curds, and divided into bottles. Upon offering them to the baby, these bottles must not be heated above body temperature or large curds again will form. You see now what this mixture contains: (a) The casein of one quart of milk plus that of one pint of buttermilk. THE STATES OF DYSPEPSIA AND INTOXICATION 221 (6) The whey of one pint of buttermilk; thus the whey has been reduced to one-half. (c) Almost no lactose. Everything in this mixture speaks for alkali formation speaks against acid formation. What a curious world! In the olden times we threw away the curd and used the whey; now we throw away the whey and use the curd. This mixture is ideal to overcome the fermentative stool, to neutralize the intes- tinal reaction, and to stop the diarrhea. Shall we feed this mixture to the baby? What an ideal mixture this is to kill our little patient! You look surprised. You have made just the same mistake as Finkelstein and his assistants. Reports of pro- test came rapidly from all over the world. Not long, however, before 4 the error was detected. Finkelstein and Meyer had made the same mistake that we have seen repeated time and time again. They focused too carefully upon the stool and forgot the baby! True enough, the intestinal condition was cured; the stools became alkaline and constipated, but the baby died! Gentlemen, the baby died from lack of carbohydrate! In our intense desire to treat the diarrhea we forgot the baby. The child must have carbohydrate to live, and this baby was getting an amount insufficient for life. Without going too much into detail, it was learned that in albumin milk it is perfectly safe to give at least 3 percent carbohydrate. If this is given in the form of non-fermentable carbohydrate, such as dextrin-maltose prepar- ations, no harm will result ; so in making albumin milk, never commit the fatal error of omitting 3 percent carbohydrate. In offering albumin milk, instruct the mother to use a nipple with a large hole, as some of the casein curds may stick in a small one. You may also add a little saccharine for sweetening, for when the child gets stronger, he may object to the taste of the butter- milk. In offering the baby breast milk or albumin milk, shall we give a full bottle? Gentlemen, to do so means death. Even if a wet-nurse be obtainable, if we, thinking that breast milk is an ideal food, recklessly allow the child to nurse, we probably shall lose him in a few hours. With such an intense degree of fermen- tation existing in the intestine, the large amount of sugar in 222 INFANT FEEDING (CHICAGO METHODS) breast milk, even though it be in the healing breast-milk whey, may ferment and increase the damage. In all cases our technic must be extremely rigid and exact. 1. Keeping up the same general treatment of the first day, stimulation and fluids in the form of tea, we offer ten feedings of about Yi ounce each of food. 2. The next day we increase to ten feedings of %j ounce. 3. The following day we may increase to ten feedings of 1 ounce, then to 1% or 1^ ounces. Here we wait and note the reaction of our weight curve (Fig. 17): UUc 1 6 1 ! ! i 11 1 2 \ 3 4 9 lb \ 12 oz \ \ 8 oz \ ft > S 4 ox V X X x X * S ' ' V --' y^ * 6 1* \ ^ , \ ^ ^ 12 ox *^- > ^ ' ' \ *~^ -Si, N r-l ,_, ._, ^ f rH N X J X X X n X X X M 7 Fig. 17. We hold the food perfectly constant at 10 x 1^, independent of the stools, until the weight curve has straightened out. If the weight curve still sinks; if the diarrhea continues, undei no circumstances make any change in the food. The danger of a change is greater than the danger of leaving it as it is. When, however, the weight curve has become horizontal, we continue to increase gradually to the maximum quantity; that is, about three ounces of the mixture for every pound of the baby's weight. Then we cautiously increase the carbohydrate to 5 percent. After a few weeks we return to an ordinary milk mixture. It THE STATES OF DYSPEPSIA AND INTOXICATION 223 is not good policy at any time to make any change while the baby is gaining. I have gone into such detail, gentlemen, not because I want you to remember the technic exactly of making albumin milk, but because I want you to remember the principles. If you have these principles, then, no matter where you are or what means are at your disposal, simply make up a combination of high protein, low whey, and non-fermentable carbohydrate. Never commence with large doses, but, following a hunger period, guided by your weight curve, offer gradually increasing amounts. These principles you can apply to your older children chil- dren of one to three years of age : 1. Hunger with tea and fluids for the first day. 2. Reduce the whey by removing milk or diluting it to one- third or one-half. 3. Increase the protein by giving egg, scraped meat, cottage cheese, and curds of milk. 4. Give non-fermentable carbohydrates, zwieback, mashed potato and cereals, such as corn-starch, Cream of Wheat, and arrowroot. 5. Supply salts best as vegetable purees. Don't forget the hunger period ; don't forget fluids, and, above all things, in the beginning of the treatment, don't forget the tiny doses of food. Gentlemen, if you are thoroughly conversant with these principles, no matter where you are, no matter how primitive the home, you will always be completely master of the situation. LECTURE VI DECOMPOSITION Gentlemen, in the previous lectures we discussed three types of nutritional disturbance. You remember it was Finkelstein who, for the first time, clearly and emphatically laid importance upon factors of nutrition and food, in the production of what we previously had called "the diarrheal diseases of infants." That many of his first explanations were incomplete; that many of his views again will be amplified, there can be no doubt. But his service has been immeasurable. In the lectures on dis- turbed balance, dyspepsia, and intoxication we described the clinical pictures as he saw them. Today we concern ourselves with the last of the four, the subject of decomposition. You gentlemen have known this condition as atrophy, marasmus, or malnutrition. It is familiar to you all. Finkelstein, however, did not think that these terms described accurately the compli- cated processes being evolved in the child's body, and so sug- gested a term of his own. Names, of course, are immaterial. If you prefer the older terms, well and good. The essential, however, is that you understand the changes taking place in the child. There is an actual disintegration of body substance. Finkelstein thought the usual terms misleading and so spoke of decomposition, which in German means destruction. It is hardly necessary to describe the picture. Doubtless you have seen it often. A tiny, undernourished infant, weight far below normal, lies restless and crying in his bed or in his mother's arms. Simultaneously one notices the pallid, blue, wrinkled, tissue-paper-like, fat-free skin, and the whole bony skeleton that seems to protrude through it. The face is that of a .tired old man. The large, deep-seated eyes move restlessly about, then fix upon you with an uncanny stare. The large mouth, with its thin lips opened wide in a never-ceasing fretful cry, is in striking disproportion to the small, weazened face, or is hidden com- 224 DECOMPOSITION 225 pletely by the fists which the child chews greedily in a vain attempt to relieve his pitiful hunger. The peevish tones reveal perpetual misery. The emaciated skin of the thorax reveals the bony framework in all its detail, and the thin covering of the abdomen cannot conceal the outlines and movements of the Fig. 18. Fig. 19 viscera. On the extremities the skin hangs in large folds right over the bones (Figs. 18 and 19). In sharp contrast to intoxication, consciousness is undis- turbed. If anything, it is excited. You remember how the child with intoxication lies drowsily, eyes fixed apathetically on 15 226 INFANT FEEDING (CHICAGO METHODS) one corner of the room, arouses himself with a short cry, and again lapses into semi-consciousness. This child is on the alert, cries pitifully, incessantly, and never seems to sleep. You remember the child with the intoxication had rapid, tireless respiration. This child has the slow, feeble, irregular type. In intoxication the pulse is rapid. In decomposition the pulse is slow and weak. Normally in an infant the pulse ranges around 120. Here it may be 80 or below. In intoxication the temper- ature usually is elevated. In decomposition it is subnormal the more subnormal, the worse the disturbance. In contrast to the albuminuria, glycosuria, and casts of intoxication, the urine of this child is negative. Intoxication suggests acute poisoning; decomposition, chronic collapse. Symptoms from the gastro-intestinal tract vary with the food. Vomiting is not unusual. Stools, however, depend to a large extent upon the diet. When this is large, particularly if high in carbohydrate, intestinal fermentation becomes active, with resulting diarrhea. This is very easy to understand when we consider that the intestinal tract suffers in its general nutrition as much as does every other organ of the body. It is perfectly rational, then, to assume that the functionally injured intes- tinal cells of the upper digestive tract do not suppress bacterial growth as they do in the normal infant. Consequently any improper combination of food, especially mixtures rich in whey and carbohydrate, stir these bacteria to growth, and in the resulting fermentation are formed the irritating acid products which lead to dyspepsia and intoxication. In such a condition, if much fat is fed, it will be carried out in the stool. We do not mean to be too dogmatic. It is perfectly reasonable and logical, and there is also good evidence to show that the digestive ferments are not very active, and we can readily understand the appearance of fat in the stools, due to its improper digestion and assimilation. We believe, however, that in the majority of cases fat appears passively, being secondary to the primary fermentation of the carbohydrate. On the other hand, if the restricted diet is high in protein, low in carbohydrate and whey, the stool becomes alkaline and hard. Now less undigested fat appears. This observation again supports the premise that fat is really the secondary factor. DECOMPOSITION 227 Again, the smaller the diet, the less likely will the stool be diarrheal. Perhaps no better illustration can be afforded of the danger of being guided in treatment by the condition of the stools. Many of these babies go down and die in collapse, with typical consti- pation. No greater or more terrible mistake can be made than of focusing all one's attention upon the character of the stool (treating the stool so as to change it from a diarrheal to a con- stipated type) and forgetting the baby in the meantime : allow- ing the baby to go down and die in the collapse of hunger. This danger can be avoided if one remembers what we have repeated again and again, that the stools are simply indications of what has been put into the intestinal tract, of the way that food has been handled, and are only a tiny guide to us simply a symptom of scarcely more importance as an absolute indication for therapy than is the condition of the skin, than the condition of the baby's heart and pulse, than the condition of the baby's breathing. They constitute simply one of the many important symptoms of the condition. As the weakened pulse points to the failing circulation, so do the abnormal stools point to an inefficient digestive tract. This latter not the stool is one of the objects of our therapy. In these conditions we have dwelt upon the fundamental importance of the weight curve and the food reactions (Fig. 20). If at A, the child being in a state of decomposition, and hav- ing lost weight for months, we give a bottle adapted to a normal child, he loses steadily three to five ounces a day, and dies not infrequently with symptoms of intoxication. On the other hand, withdrawal of food for twenty-four hours produces a sharp drop in weight, the child dying in acute collapse. Gentlemen, no more terrible mistakes are made than allowing children in this condition to hunger. They are so susceptible to all influences that a period of hunger of twenty-four hours, which scarcely would be noticed by a normal baby other than by his loud protests, results in rapid death. In addition to the above clinical symptoms the child shows great change in reactions to external influences. He is particu- larly susceptible to heat and to cold. He is susceptible to all forms of violence, readily injured by improper nursing and care, particularly likely to be attacked and carried away by the infec- 228 INFANT FEEDING (CHICAGO METHODS) tious diseases. Ludwig F. Meyer says aptly that these children sicken from causes of nutrition and die from infection. Fatal infections frequently are overlooked, even by the most experi- enced, because the child is so weakened in his reactions that the most virulent infections may give no clinical signs. The baby is too weak to react with temperature, too weak to show acceler- ation of the pulse or of the breathing, and only postmortem examination reveals how frequently our little patients have been carried away with terminal pneumonias. Months. I j I t ! i Da y. i \ 12 Ibs, 11 10 9 e 7 6 6 Iba, \ \ \ ^ \ S \ \ \ \ \ \ \ \ \ \ ~~~, \ f ^^ --^ >--~. \ Fig. 20. Often we find masked types of decomposition. Upon hasty clinical examination, we may think our little patient is only in a state of dyspepsia or disturbed balance. We become suspi- cious, however, on learning of a previously irregular weight curve, and noting deficiency of fat in the subcutaneous tissues and skin of muddy color. Our opinion will be confirmed when, upon treating this child for a dyspepsia, withdrawal of food pro- duces not the usual slight reaction of the weight curve, but a DECOMPOSITION 229 sharp, severe drop of many ounces, associated with subnormal temperature (Fig. 21). Days. S I 10 Ib. 12 oz, 8 4 9 Ib. 100 99 98 97 96 _- i < ^ \ --i ^ \ \ \ ^> \ \ Fig. 21. Gentlemen, whenever you find a child upon withdrawal of food reacting with symptoms of collapse and subnormal tem- perature, no matter how slight you considered the disturbance, beware of one of these masked types of decomposition. Remem- ber that that child is particularly susceptible to external influ- ences to hunger, to heat, to cold, to infections, to poor nurs- ing, to improper food and look upon him as a very sick baby. Metabolism. Having studied the clinical picture carefully, we now must investigate the causes. Don't misunderstand me, gentlemen ; it has long been known that this picture can be pro- duced by tuberculosis, syphilis, wasting diseases, and other con- ditions; but it remained for Finkelstein to show that a great, great number of these cases cases in which the etiology pre- viously had been mysterious or unknown was based upon and resulted from the same fundamental errors in nutrition of which we have spoken so frequently. For the first time we see in careful clinical examination, this condition also studied from the broad viewpoint of nutritional disease. Such a child, when placed upon a metabolism bed, shows a sharp contrast to dys- pepsia or disturbed balance, for he suffers actual loss of protein from the body, the body losing more protein than is taken in. 230 INFANT FEEDING (CHICAGO METHODS) The same holds true for mineral matter; more salts are lost than are contained in the food. Indeed, much of the clinical picture may be simulated by mineral hunger. Such investigations are very difficult, are few in number, but are of tremendous value. It was due to this conception, to this idea, that actual destruc- tion was taking place that Finkelstein changed the term from atrophy to decomposition. The fat metabolism depends upon the way fat is administered. If it is given in a mixture rich in carbohydrate and whey, the fat is lost in the resulting diarrhea. If a reasonable quantity is given in a mixture high in protein, low in carbohydrate and whey, the fat is well assimilated. As regards carbohydrates, the body itself seems to need and use them well. The great difficulty, however, is to get them into the body, for with the weakened condition of the upper intestine permitting bacteria to flourish, carbohydrates, unless given very carefully, are apt to ferment and cause diarrhea, with pictures varying from the slightest dyspepsia to the severest intoxication. Diagnosis. The diagnosis is easy. A freshman medical student, a novice, a beginner, can recognize such a picture at a glance. It makes absolutely no difference what name we give, the clinical picture is there; and it remains for us as medical men not to be content with a mere diagnosis, but to insist upon a diagnosis of the cause. We have spoken of tuberculosis, syphilis, and wasting disease; these are well known ; but of new factors from the viewpoint of nutrition we are learning more and more. 1. We have learned that this condition never comes in the midst of health. The child must have been sick for weeks or months, with a history of ailing, of digestive disturbance, and of not thriving. 2. We have learned the importance of age. The younger the child, the more susceptible he is. 3. We have learned the importance of diarrheas, not only those from improper feeding, the dyspepsias, but also those resulting from true pathogenic bacterial infection. In each of these attacks the child probably loses a little mineral matter, and if the diarrhea is not handled properly, the loss eventually may be so great as to bring on decomposition. DECOMPOSITION 231 4. We have learned that long-continued undernourishment is an important factor, the baby not getting for a sufficient time a great enough total quantity of food. 5. Hunger is a tremendous factor, particularly hunger applied too long to a sick child (Fig.. 22) . TteyR 1 I 5 I 9 Ib 12 or 8 oz 4 oz \ \ \ \ 3 * \ \ 8 Ib \ \ Fig. 22. You remember in intoxication when the weight curve was drop- ping rapidly, if we removed food at A for twenty-four hours the drop of weight ceased and the curve straightened out. If at the end of twenty-four hours, at B we had not started to feed that baby perfectly independent of the number or condition or appearance of the stools, if instead of feeding him we had prolonged the hunger period, guided only by the condition of the stools, the weight curve would have swung down, taken another sharp drop, and we would have been responsible for the additional calamity of decomposition. 6. Important as is absolute hunger, partial hunger is perhaps even a more frequent cause. By partial hunger I mean one- sided feeding, such as feeding with barley water or condensed milk. Due to the fault of the physician or the carelessness of the mother, children are kept for days on a diet of barley water. This, as you know, is largely carbohydrate, and after four, five, or six days, the child suffering in the meantime from insufficiency 232 INFANT FEEDING (CHICAGO METHODS) of protein, salts, and fat, decomposition develops. This type was the one that Czerny described as starch injury. Condensed milk perhaps is the most frequent cause. It is very high in sugar, low in other elements, as protein and salts. You remember in our second lecture we spoke about the property of sugar to bind water in the tissues. Due to the high sugar of condensed milk, a great deal of water is retained in the tissues of these children. They gain for some weeks, and the doctor and mother are delighted, because they think the baby is doing so well. As a matter of fact, however, the baby is starving, his tissues are being filled with water, and his body-cells are dying from lack of protein and salt. Only the severe reaction following a slight infection, following a little exposure to heat or a slight error in diet (such as feeding a little too much or letting him hunger too long), shows that we are handling a child who really is in the stage of decomposition. Too long exclusive feeding with breast milk belongs to this class. This sounds like heresy, gen- tlemen ; but nevertheless it is true. This is no infrequent factor. As you remember, breast milk is very low in protein and very low in mineral matter. After a child is nine months or more of age the demands of his body are greater than those answered by the breast. Kept too long exclusively upon this food, with- out the addition of other substances to cover these wants, or without an enormous supply of breast milk, the body-cells suffer from lack of protein and salts, and the child gradually develops decomposition. 7. The most frequent factor of all is probably the fault of the physician, the one for which you largely are to blame, I don't mean you personally; I mean you, me, all physicians, namely, the improper treatment of mild dyspepsias. The development is as follows: The child gets a slight dyspepsia; the physician, not recognizing the food nature of the disturbance, cleans him out with calomel and castor oil; gives him a little paregoric to check the bowels, and makes no change in the food. Repetition occurs in perhaps two or three weeks. Again the child is cleaned out, again is he subjected to the irritating effect of calomel, and again the bowels are drugged with paregoric; but the food is unchanged. Maybe the factor of hunger is introduced. A recurrence of diarrhea leads to the same treatment. Now the DECOMPOSITION 233 physician says: "We certainly will give these bowels a rest. We are going to let this baby hunger a good long time." No factor, gentlemen, is more important in bringing these children to this condition than is the frequent combination of improper therapy of dyspepsia plus the improper use of hunger. Remem- ber, gentlemen, the longer the hunger, the greater the danger. Remember, the more frequently repeated the hunger, the greater the danger; and remember, the closer together the hunger periods, the greater the danger. This combination of improper treatment of dyspepsia plus the improper use of hunger periods is the most important of all the nutritional factors in producing decomposition. Besides the above errors in nutritional technic, we must never forget that the same influences are effective that were concerned in the production of dyspepsia and intoxication, influences which are independent of our skill, and for which we are not to blame; namely, constitution, infection, and improper care. A baby with a weak constitution, a baby who repeatedly has had infec- tions, a baby who is improperly cared for, is far more susceptible to a nutritional error than is a healthy strong child. Treatment. Gentlemen, let me urge upon you that the most important treatment by far is prophylaxis. If we handle dys- pepsias properly; if we realize the importance of the state of disturbed balance; if we see that the well baby is properly nursed and cared for, properly dressed and properly fed, the number of cases of decomposition arising from nutritional sources will be very few indeed. Once developed, however, the condition is difficult to treat, and requires careful, definite routine. Only upon two foods can we rely. Just as in intoxication, we have absolute confidence only in breast milk or albumin milk. During the first day, if a bad diarrhea is present, the child may hunger six, to at the very most twelve, hours; never under any circumstances longer. Preferably, he should miss only one or two bottles, and none if the stools are few in number. During this period the general treatment is that of intoxication; that is, the use of stimulants, the use of water and tea, the use of a little salt. Following the hunger period, or if no diarrhea be present at 234 INFANT FEEDING (CHICAGO METHODS) once, we start food. The first day we offer ten feedings, with a total in twenty-four hours of ten ounces. Gradually we increase, adding two to three ounces to the twenty-four-hour total every other day. Our maximum with albumin milk is three ounces for each pound of body weight; that is, a baby weighing seven pounds shall get a total of 21 ounces, a baby of nine pounds a total of 27 ounces. During this increase our guide is solely the weight curve. Gentlemen, let me impress upon you that no graver mistakes can be made than letting the condition of the stools influence your treatment. We are interested in saving the baby. The baby is infinitely more important than his gastro-intestinal canal. If to save the baby it becomes neces- sary to neglect all symptoms of impaired digestion, we must do so. The gastro-intestinal tract is simply a means of introducing nourishment. We absolutely must give food. If we let this one symptom, the stool, sway us from our course, though we correct the condition of the stool, we frequently lose our patient. Our guide to increase shall be the weight curve. To illustrate (Fig. 23) : Weeks i i , j Da ye ! j ! ( ' 10 Ib \ \ 6 02 X s s \ 9 Ib 12 oi \ H s s 8 o: \ / 4/v Nj ^ / 8 Ib X, * , -^. J r ---' **" ^ A ^ "-^ "-^ ^ i i Fig. 23. The baby has been sick for weeks, the curve constantly com- ing downward. At A he is in the state of decomposition. We allow him to hunger or offer small quantities of food, a total in twenty-four hours of ten ounces. Due to the hunger or due to the small quantities of food he continues to lose slightly. We DECOMPOSITION 235 make no change until at B his curve has straightened out. A continuation downward at C shows that the destructive process is continuing; under these circumstances we are in no condition to increase the diet, nor to change nor to withdraw it. If we wish to save the baby, we must hold the quantity constant and steady, independent of the stools, until the curve has straightened and shown that destruction is ceasing and that the baby now is in a position to assimilate nourishment. This is the time to start a gradual, cautious increase according to the schedule just given. If the baby is breast fed, under no circumstances put him to the breast the first few days. The mother must express the milk from her breasts and give these quantities exactly from a bottle or medicine-dropper. When the curve finally has straightened out, a matter of a few days, we sigh with relief, for the battle is won; and now, after the child has gained slightly, it is safe to put him again gradually to the breast. In the last lecture I gave in detail the technic of making albu- min milk. I wanted you to know the original process, so as to emphasize the principles of the mixture. You remember they were low whey and low carbohydrate to reduce the factors caus- ing fermentation; high protein to increase the factors causing alkalinity and overcoming fermentation. Today I want to give you a simpler technic quoted by Langstein and Meyer, one which you may use in the humble home, where ignorance of the mother or lack of facilities renders impossible the more compli- cated mixture. One takes one quart of buttermilk and one quart of water, mixes them well, lets them boil a few minutes, and allows them to stand for at least half an hour. During this period the casein curd settles to the bottom and the clear whey-water mixture rises to the top. You see, by the addition of water we have diluted the whey one-half. Without disturbing the casein curd lying below, we pour into another jar as much whey as possible. This separates curd from whey. In this process we boiled the milk. In the original we used it raw. If we had boiled it in the original technic the curds would have been too fine to be separated from the whey, being able to pass during the filtration through the meshes of the muslin bag. To the casein curd we add four ounces of boiled cream. This is done because in the original 236 INFANT FEEDING (CHICAGO METHODS) mixture, during precipitation of the casein, considerable fat is ensnared in its meshes, the fat content of albumin milk be- ing 2 to 3 percent. Accordingly, we add cream to this mixture. We then add the usual 3 percent of a dextrin-maltose. Not having "dextri-maltose," we can use foods of somewhat similar nature, such as Mellin's Food or Horlick's Malt Food. Our mixture now contains high protein, a certain amount of fat, a certain amount of carbohydrate in a non-fermentable form, and to add salts we fill up to a total of one quart with the original water-whey mixture in our second jar. You see in this process we have reduced the whey to one-half. In cases where the child does not take albumin milk well it can be sweetened with a little saccharine. And now, gentlemen, before concluding, let me call your attention to a most fascinating study, one to which this treat- ment with albumin milk has directed us (Fig. 24). Di Y s 5 & 1 B 1 10 Ib e 02 9 lb 8 ox 8 Ik \ \j / \ / \ / \ / \ / \ s I / s' ] -^ ^ ^ ^ * " 3 o/ ) 1 o/ 9 \ A E | | 1 3 8 02 6 02 4 oz 2 oz fi_Vb / Ii ifei ,ti< >n / / / j / / j J / / i / / / Fig. 27. the child becomes infected. The accompanying fermentation is severe enough to produce a mild dyspepsia. The change in the weight curve shows that baby's nutrition is beginning to suffer. Shall we change the diet in this case? Let the baby alone! Again see the picture! The fault was not primarily with the food. It lay in the infection of the nose, throat, or bladder. A mild secondary disturbance of nutrition has arisen, but if we simply wait a few days, the cough and cold will disappear, and after the injuring factor has gone, the intestine corrects itself at B, the weight curve starts to ascend and diarrhea disappears. In these two instances treat the mother as you will, but unless he begins to lose weight, don't treat the baby. Let him take as much food as he will. He drinks less than his normal amount, and so spontaneously prevents the occurence of a secondary distur- bance. PABENTERAL AND ENTERAL INFECTIONS 247 Fundamentally different is a third type (Fig. 28), occurring in babies fed on one-sided carbohydrate mixtures. The baby on condensed milk or barley gruel, the baby with a masked type of decomposition, shows a sharp and severe reaction. With the onset of the infection diarrhea commences. The stools may not vary markedly from those of the other children. How misled we would be by focusing exclusively upon them! But the child reacts with a marked disturbance, varying from a mild dyspepsia to the severest intoxication or decomposition. In these cases forget the primary factor. From his cough and cold the mother may think the baby is very sick, but you know that death is Days 8 oz 6 o 4 o 6 Ib Fig. 28. going to occur not from the infection, but from the severe sec- ondary disturbance of nutrition. First and foremost, the latter must receive your immediate attention, and you treat it, de- pending upon its nature, according to the principles laid out in previous lectures. Two symptoms arising in the course of a parenteral infection may need treatment: 1. Vomiting. If the vomiting be due to a primary food dis- turbance, the child recovers upon removal of the primary cause, namely, the food. If, however, the condition arises from a parenteral infection, change of food will have no effect, and unless we stop the vomiting we have trouble. In these cases 248 INFANT FEEDING (CHICAGO METHODS) gentle stomach washing is of value, as are also mildly anesthetic drugs, such as novocain, in doses of ^V grain before each meal. 2. Anorexia. If the loss of appetite is due to food, removal of the cause will cure the condition. If the cause of anorexia, however, is the parenteral infection, change of food will have no influence. In these cases physicians often make fatal errors. One often hears, "If the baby won't eat, we'll starve him to it." No graver error can be made than this. The cause of the baby's loss of appetite is not the food, but is the product of the paren- teral infection, and you may starve him and starve him, but his appetite will not return. What you accomplish, however, by introducing the factor of hunger is to throw him into the state Da-vs i i j i 8 tt> 12 oz 8 oz 4 oz 7 Ib \ / \ \ \ \ \ V \ \ \ 3 Fig. 29. of decomposition (Fig. 29). Many of the deaths occurring during mild infections are due not to this cause, but to the fac- tor of decomposition developing from the associated anorexia. Gentlemen, the baby must have food. If he takes it in no other way, use a stomach-tube. I don't mean, now, that you must get a pump and pump gallons into his stomach, but you must introduce small quantities, enough to keep him alive, and of such proportions as to avoid the dangers of a secondary dyspep- sia or intoxication. The factors of heat, of food, of parenteral infection, and of care usually are all concerned in these dyspepsias and intoxica- PARENTERAL AND ENTERAL INFECTIONS 249 tions. In recognition Finkelstein suggests classifying them etiologically as follows: I. Purely alimentary or food type. II. Mixed type (in which all influences are concerned). INFECTIOUS DIARRHEAS Gentlemen, we have now finished the "Disturbances of Nu- trition." I want to take you far away for a moment to view an entirely different group of diseases. While the success of high protein, low whey,- non-fermentable carbohydrate was attested by the consensus of opinion of the whole world; while in the Finkelstein clinic a great international assemblage of men had collected, men from America, England, Austria, Russia, Japan, Bulgaria, Rumania, Switzerland, Portugal, and other coun- tries, all testifying to the great influence of these teachings, a communication came from A. I. Kendall, of the Boston Floating Hospital, saying that the treatment of severe diarrhea was low protein and high carbohydrate. Could anything be more tan- talizing, more aggravating? Just at the moment when we thought the problem of diarrhea in children forever solved, when we thought the infallible remedy for all diarrhea was high protein, low whey, non-fermentable carbohydrate, we must read that the proper treatment is low protein, high carbohy- drate, and carbohydrate in a fermentable form, such as lactose. The first inclination was to do as always, when some one dis- agrees with us to question the writer's sanity. Careful study of the publication, however, showed that Kendall was speaking of a group of diseases entirely different from those we were studying. His work had to do with the true infectious diar- rheas those due to specific microorganisms; the type of case we did not see. The communication was so interesting that I resolved, upon my return to this country, to try to meet Ken- dall. To my great pleasure I learned that he had been called to take charge of the Department of Bacteriology at Northwestern University Medical School, the institution with which I was to be connected. He, with the true interest of the bacteriologist, was concerned mainly with the deadly infectious diarrheas: I chiefly with the question of nutrition. To settle the point as 250 INFANT FEEDING (CHICAGO METHODS) regards the nature of material in Chicago, we made a study during the summer of 1914. Dr. Alexander Day, one of Kendall's associates on the Boston Floating Hospital, examined bacteriologically all cases of severe diarrhea in our wards. He cultured carefully all the stools, while I studied the cases from the standpoint of "nutritional disturbance," looking at them clinically and noting their weight and food reactions. Our results showed that, during this sum- mer, in our wards in Chicago, one or two cases of diarrhea showed the gas bacillus in the stools; two cases showed reactions to food typical of the primary food disturbances, and the remainder were those associated with coughs and colds the so-called parenteral infections. During a study made the following year we found two cases of severe dysentery sent to the hospital from out of town cases entirely different in nature from our own, and showing symptoms identical in every respect to the dysentery infection which Kendall had noted in Boston. In the stools Dr. Day discovered the true organisms of dysentery. Why is it that in Boston infectious dia'rrheas and in Chicago nutritional disturbances prevail? The failure to discover in- fectious diarrheas in Chicago could not have been due to technic, as the investigations were conducted by the same men. We must regard these results as conclusive. Day and I offered the explanation that, in the sense of Brennemann, the difference may be due to the fact that in the East raw milk had been used, and in Chicago, boiled milk. Isn't it reasonable to assume that in the East, with raw milk, infectious diarrheas prevail; in the middle West, where these organisms have been removed by boiling, nutritional disturbances only are seen? Gentlemen, in this part of the country probably many of your patients use raw milk. When you are called to see a baby with diarrhea, you are at once confronted with the problem, "Is this an infectious diarrhea or is it one of the nutritional type?" To distinguish between these is of fundamental importance. We have several means. History. The acute infectious diarrhea starts suddenly in a previously well baby and prostrates him at once. The nutri- tional disturbance comes more gradually. In the latter we get a history of improper feeding, of previous nutritional dis- PARENTERAL AND ENTERAL INFECTIONS 251 turbance, of parenteral infection. It is more gradually pro- gressive. Stools. These are of considerable aid in our diagnosis. In the infectious diarrhea, particularly dysentery, they are very fre- quent, small, and chiefly blood-stained mucus. They contain barely any solid material, and the microscope reveals pus. They may be identical to the evacuations in intussusception. The reaction in dysentery is alkaline. In nutritional distur- bance the stools are green, usually acid, and watery. They con- tain increased solid material and some mucus; rarely blood or pus unless the case has long been neglected. The reaction to food is of value. If, after twenty-four hours of tea, the temperature continues high, the weight curve sinks, the diarrhea continues, with small, bloody, mucous stools, then some factor other than food must be at hand. If careful physical examination rules out parenteral infection, such as pneumonia or sepsis, the diagnosis, by exclusion, will be enteral infec- tion. Treatment. Gentlemen, what I have to tell you about the treatment of true infectious diarrheas will be disappointing. All that I can do is to expose our ignorance. The treatment de- pends just as absolutely upon definite bacteriologic diagnosis as that of diphtheria depends upon throat culture. How to treat cases of infectious diarrhea in this part of the country I do not know, for I have absolutely no idea what types of infection you meet. If it is a gas bacillus, one food must be given; if it is a dysentery bacillus, radically the opposite treatment must be instituted. Bacteriologic methods of diagnosis are difficult a trained bacteriologist is necessary. An agglutination reaction in dysentery, such as the Widal in typhoid, can be of service. All that I can do, gentlemen, is to urge you, in connection with your medical society, to cooperate with the State Board of Health or with the State University in attempting to discover what types of infection exist here. I won't bother you with the technic for isolating the dysen- tery organisms. The gas bacillus, however, can be detected relatively simply: To get a sterile specimen of the baby's stool, round the ends of a piece of sterile glass tubing about the thickness of a lead- 252 INFANT FEEDING (CHICAGO METHODS) pencil, and insert it into the rectum as you would a thermometer. Usually a little fecal material enters. If the rectum is empty, repeat in an hour. Then inoculate a small quantity of the stool, about the size of a pea, into a test-tube of milk. This is heated to 180 F. for half an hour. All bacteria are killed except the spores, which resist heat, and, when the milk is incubated at body temperature, grow rapidly. If they be those of the gas bacillus, they split sugar into acetic and butyric acids, and char- acteristically give the odor of rancid butter. Secondly, the acid causes the casein to coagulate. This precipitates in large curds, but, due to the growth of the gas bacillus, has the appear- ance of being completely "shot to pieces." Lastly, the micro- scope shows the large Gram-positive bacillus. The treatment for gas bacillus infection, according to Kendall, is based upon the observations that the organism grows well in sugar and does not grow well on high protein or lactic acid. In such an infection, therefore, the treatment is buttermilk. Al- bumin milk, due to its high protein, low carbohydrate, and lactic acid, would also be ideal. Kendall made the interesting sug- gestion that perhaps some of the cases that Finkelstein treated so successfully with albumin milk were really those of gas bacil- lus infection. This is a very interesting suggestion, but I don't believe will prove true as a general rule. The treatment of true infectious dysentery is based upon entirely different principles. Here great ragged ulcers line the intestine. In these the dysentery organisms live and produce toxins, just as do diphtheria bacilli, from their location in the throat. Death occurs in dysentery largely from toxemia. You see then, gentlemen, how hopeless is drug therapy. We may give calomel. We may give medication to flush out the intes- tine. With small quantities we may do no harm. -To me, however, giving cathartics in such cases suggests reaching in with a forceps and tearing out the membrane of diphtheria. What folly! If our sole therapy in diphtheria is physical injury, we kill the baby. Our treatment lies in antitoxin ; and so it is with dysentery. Our ultimate success must lie in the adminis- tration of antitoxin if we can give it in time. In speaking of calomel, gentlemen, I understand that it is used considerably down here and that you place great faith in it. PARENTERAL AND ENTERAL INFECTIONS 253 It may be very efficient. I do not know, because I do not know the existing types of infection. May be you have organisms to which calomel is deadly. That remains to be seen. After all, the wisest is to establish means for obtaining definite diagnosis. The general treatment of dysentery must be that of all in- fectious disease. Keep up the fluids, provide proper nursing and care, stimulate if necessary. Opium is of great value. In nutritional diarrheas opium, by disguising the symptoms, might lull us into an insecure, dangerous self-satisfaction. In dysen- tery, however, where the bacillus and not the food is the cause, we disguise no symptoms with opium, but quiet our little pa- tient and relieve the pain and tenesmus. Give as much as you can with safety. As regards medication, quinin tannate, in doses of 3 to 5 grains three times a day, is highly recommended; but, as I have said so frequently, do not put too much confidence in drugs. The dietetic treatment is radically different from that of nutritional disturbance and from gas-bacillus infection. Theo- bald Smith, the great American bacteriologist, years ago ob- served that if the diphtheria bacillus be grown on carbohydrate it will not produce toxin, but if grown on protein, it produces the typical toxin of diphtheria. Kendall, working from this viewpoint, experimented with dysentery and found that if it be grown on carbohydrate, no poison is produced, while if grown on protein, the deadly dysentery toxin results. This explains, then, why in dysentery he advocated high carbohy- drate feeding. He wished to get carbohydrate to the organisms growing .in the intestine, thus preventing the formation of toxin. Two forms of dietetic treatment may be employed: 1. Breast Milk. Breast milk with low protein and high car- oohydrate is a food ideal for Kendall's requirements, and at the same time does not endanger the child from a nutritional stand- point. 2. The Frank Treatment. This is the most successful of artificial feedings. I give it as recommended: (a) Tea for twenty-four hours, except in cases of decomposi- tion. (6) On the second day start with five feedings, each of which is composed of two ounces of whey and two ounces of gruel. 254 INFANT FEEDING (CHICAGO METHODS) (c) Gradually increase by the fourth or fifth day to five feed- ings of 2^ ounces each. (d) On the fifth to the eighth day, in teaspoonful doses, slowly replace the whey by milk. See the importance of diagnosis! We have ordered a mixture of sugar, salts, and barely any pro- tein for five days. This would have been the worst possible in nutritional disturbance or gas-bacillus infection. (e) On the twelfth to fourteenth day, perfectly independent of the stools, the patient must be getting 13 to 14 ounces of gruel, 13 to 14 ounces of milk, and 6 to 7 ounces of broth. He also may receive a little cereal, as rice, farina, Cream of Wheat, etc., and, if over one year of age, a little meat. This is the most successful up-to-date treatment for infection with true dysentery. How complicated, how long, often how unavailing! Why not with one stroke save your patients and yourselves all this wearisome treatment and danger, practise a little prophylaxis, and boil the milk? We have now finished the subject of nutritional diseases. We have given you some of the viewpoints developed in the great European clinics and adopted in the middle West. You may have wondered at the hours given to nutritional conditions, and have been disappointed in the few words given to infection. Time prevents a thorough consideration of everything. I laid most emphasis upon the former, with the idea of preparing you for the future. I believe that if you boil your milk, disturbance of nutrition will be the type preeminent, the picture which will become more and more apparent in your practice. I have spoken chiefly of our ideas in Chicago. Other view- points you may obtain from the many excellent American text- books on the subject. We prefer the clinical classification be- cause we believe the broad conceptions in it will aid us in further study. We like the term "disturbance of nutrition," rather than that of gastro-intestinal disease, because we believe this conception prevents our focusing too closely upon the stool. Even though the primary causative factor lay in the intestinal canal, we believe the baby's general condition far more im- portant than his gastro-intestinal tract. Our whole plan of feeding and therapy depends not upon the stool, but upon the weight curoe. We believe the latter, if controlled by conscientious PARENTERAL AND ENTERAL INFECTIONS 255 history and physical examination, gives the best index of the baby's general condition, of the combined influences exerted by "food," by "intestine," and by "demands of the body." Just one word more. A recent communication of 1916 from Dr. Louis W. Hill, of Boston, who is conducting so successfully the sections in the East, divides diarrheas into three groupls, namely : 1. The infectious type. 2. The nervous type. 3. The fermentative type. Regarding the latter, he goes into some length, showing the antagonistic effects of protein and carbohydrate, laying emphasis upon carbohydrate fermentation in the production of the irri- tating lower fatty acids, and recognizing carbohydrate as a primary factor even in some cases where much fat is excreted. There must then be very little difference between the opinions of the East and middle West. Why have we disputed? Powers of observation do not depend upon geographical location. There must be some deeper factor, some truer explanation. One thought constantly repeats itself in my mind: Cannot the whole difference be explained upon the basis of boiled milk? Isn't it possible that conditions in the East are undergoing evo- lution; that during the period of raw milk, pictures of the spec- tacular, deadly infectious diarrheas exclusively prevailed? But now, as I understand it, boiled milk is coming into its own. Isn't it possible that for the first time, the gradual waning of infectious diarrhea reveals the rise of disturbances of nutrition? We eagerly shall await new developments. LECTURE VIQ ARTIFICIAL FEEDING OF THE NORMAL INFANT Gentlemen, artificial feeding in the middle West has developed from the studies we have described. We never start with a preconceived idea as regards a definite and exact formula, but by knowledge of the various disturbances arising from improper combinations we select mixtures to avoid them. The funda- mental requisite in infant feeding is a little good common sense. Before going into detail, it might be well to rid ourselves of a few conceits. A young animal, even if starved, nevertheless continues to grow. He will not gain in weight, but he will in size. So it is with the baby. Don't for a moment think that you are responsible for the baby's growing. You simply offer him bricks and mortar for his tissues, but you certainly are not responsible entirely for his growth. Don't take yourselves too seriously. You are an outside factor, an external influence important, it is true, but by no means the sole cause of baby's thriving. Remember that the mother does not feed the baby at the breast. The baby feeds himself. The mother does not start with the preconceived idea of how much, of how many ounces, she is going to give the baby. She simply puts him to the breast, he takes what he wants, and when satisfied, stops. Gentlemen, get the idea out of your head that you are going to feed the baby. Leave a litttle of the responsibility to him ! Remember, by all means, that the baby is human. Think of yourselves, for instance; your appetite varies depending upon the weather, upon your mood, upon the nature of the food. On a hot day you eat less; on a cold day, more. Amounts vary daily. Some of you are vegetarians; some of you meat eaters; some of you not particular. So it is with the baby. Remember that he is human, that his appetite will vary, that no two babies 256 ARTIFICIAL FEEDING OF THE NORMAL INFANT 257 are alike; meet him half-way, and rather than expect all con- cessions from him, make a reasonable attempt to adjust your mixtures to his demands. Remember that when we eat our fundamental worry is "will this food agree with us?" If we take our meal without digestive trouble; if we get the food past the intestinal tract into the body, our troubles largely are over. The body uses what it needs and throws out the excess. Why should the baby be different? Any food which easily and harmlessly passes the intestinal tract into the body, and at the same time contains enough bricks and stones and mortar for the body tissues, will provide for the baby's growth. He retains what he needs and casts out any excess, whether it be breast milk or cow's milk. Thus, you see, many systems of feeding may be successful. There is no one system which is exclusively right many meth- ods are right. Our main concern is simplicity. We must ans- wer the body requirements and employ the intestine simply as an agent for introducing food-stuffs. How often shall we offer food? Opinion varies from two to four hours. Czerny advises adhering rigidly to the four-hour schedule five feedings in twenty-four hours: at 6, 10, 2, 6, and 10 o'clock, and from 10 at night to 6 in the morning the baby to receive nothing. He insists upon this schedule for all babies, and undoubtedly this method is attended with much success. The claims in favor of it are: first, it is scientific (based upon physiological reasoning), and second, it is a great help and con- venience to the mother. From my own experience, I find many children do well on four-hour nursings, but it seems to me also that many of those under two to three months do not seem satisfied when made to wait so long and do better on a three- hour schedule. And so, as a matter of routine, I order for all children under two to three months seven feedings at 6, 9, 12, 3, 6, and 9 o'clock and once during the night. Undoubtedly, however, many of these would do just as well on the Czerny system, and when they do, it is a great convenience to the mother. Recently the very interesting experimental work of Professor A. J. Carlson, of the University of Chicago, who has done so much to clear up the physiology of hunger, goes to show that 17 258 INFANT FEEDING (CHICAGO METHODS) perhaps, after all, the three-hour system is based upon more scientific principles than the four-hour one. The number of feedings varies somewhat with locality. I believe in the East they feed more frequently than we do. A simple experiment which we made in the Finkelstein Clinic might explain these differences. Babies in some wards we fed according to the percentage method; babies in others we fed according to the methods I am about to teach you. All were given five feedings in twenty-four hours. The percentage babies vomited more than did the others. As the percentage method frequently requires more fat than does ours, we rea- soned that this vomiting might possibly be due to the fat, i. e., to the irritating lower fatty acids contained in cow's milk fat. Empirically we controlled this vomiting by feeding smaller quantities more frequently; so in a short time all the percentage babies received several more feedings a day than did the others, and all thrived beautifully. This may help explain the differ- ence in the various feeding schedules. What shall we offer? Almost any system of feeding has its ardent advocates. The possibilities of the normal child's in- testinal tract are immense. The normal baby thrives upon a great number of mixtures. Therefore it's easy to understand how many different systems have arisen, each with its enthusias- tic adherents. The French, for instance, have at times recom- mended full boiled milk. Many children do well on this; some don't. Biedert, one of the older German pediatricians (he it was who first described casein curds in the baby's stool), recom- mended the dilution of whole milk to lower the protein. To make up for the loss in strength he added cream and sugar. The resulting combination resembled somewhat a percentage mixture. Some children thrived beautifully; some did not. Heubner brought calories to our notice. He first advocated feeding 45 calories per pound body weight for children under six months. This system is not ideal, as you readily see. A child's bottle may contain the proper number of calories, but they may be only in fat or in sugar, and will not satisfy the de- mands of his body tissues. Again, newer studies show that mysterious invisible substances, called vitamins, play important roles in growth. The excellent work of the men at the Uni- ARTIFICIAL FEEDING OF THE NORMAL INFANT 259 versity of Wisconsin already has subdivided this new group into fat-soluble substances found in butter, and water-soluble sub- stances found in wheat embryo, both of which are absolutely essential to an animal's growth. These, of course, cannot be measured by caloric value. We of the Middle West do not follow rigidly, but we value the caloric system chiefly as a check upon us, and when a baby is not gaining, we occasionally run over the formula and estimate approximately how many calories it represents. But let me emphasize that we do not advocate this as a method of feeding. It is simply a check upon the fuel value of food that we are offering. An ingenious advance was the percentage system, used by our friends in the East. It was first devised for the purpose of making the relations of protein, fat, and carbohydrate in cow's milk similar to those in breast milk, but, as I understand it, now is offered simply "as a method of calculation and a means of attaining relative accuracy in the preparation of infant's foods." For such a purpose we welcome it heartily. We of the Middle West do not use it, not because we object to accur- acy, but because we find the percentage formula? somewhat cumbersome and because we accomplish excellent results with methods which to us seem simpler. Ludwig F. Meyer once said to me: "What an ideal combina- tion would result if one would take your percentage method of feeding, striving as it does for accuracy, and adapt it to the principles we are attempting to develop!" Gentlemen, I think tliis would be a step in the right direction. In this entire course I have attempted to teach you not rules, but principles. You know that in infants fed with boiled milk we consider most dis- turbances due to fermentation of carbohydrate, induced either primarily by improper relation to the whey, or to the fat and whey; or secondarily to one of many parenteral factors. In all cases, however, we pay far more attention to the baby as a whole than to his intestinal tract. Gentlemen, don't forget these principles. With them you may face any nutritional distur- bance with equanimity. Make up your mixtures as you will. By all means strive for accuracy. If you find the percentage method of calculation of value as a check, use it. From our system of feeding, however, has developed, I believe, the simplest 260 INFANT FEEDING (CHICAGO METHODS) technic for answering the above requirements. But any simpler method of calculation which will enable us, while still being true to our principles, to make up mixtures with even greater accuracy, we shall always be glad to adopt. METHODS OF THE MIDDLE WEST Our system is prophylactic from the start. We have learned that the fault does not lie exclusively with one element of the milk: that it depends upon improper relations of the different elements. Thus, if we give much sugar in concentrated whey, diarrhea results; if we give the same sugar in highly diluted whey, the chances of disturbance are decreased. If we give fat in combination with high carbohydrate in a medium of cow's milk, we frequently have trouble. The fat may be involved either primarily or secondarily. If, however, we give this very same fat in combination with albumin milk, viz., with high pro- tein, low whey, and non-fermentable carbohydrate, the fat becomes harmless. Fat in an acid intestine enhances diarrhea; in an alkaline intestine, enhances constipation. Again, we may offer rather concentrated whey, even as full milk, which the French have done, and experience no difficulty whatsoever until carbohydrate is added. In our feeding we attempt to dilute all elements of the milk and to make our additions with only one. In the baby's intestine high fat and high sugar in cow's milk are not agreeable companions. Prophylaxis is our motto, and we proceed as follows: 1. To protect our baby from dysentery and other virulent infections, and to prevent the formation of tough casein curds, we boil the milk. 2. To prevent the accusation that we are predisposing to scurvy we add, at the end of the first month, orange-juice in doses of a teaspoonful each day. Dr. Alfred Hess, of New York, has shown this to be extremely important. 3. To prevent the danger of overfeeding, we are careful as to the total quantity of food. How much do we offer? Naturally, the amount in each bottle must depend upon the fuel value of the food and the number of feedings: the more frequent the feedings, the less the individual quantity. But don't try to ARTIFICIAL FEEDING OF THE NORMAL INFANT 261 follow any hard and fast outline. Remember, we are treating babies, not manufacturing rules. In a general way the first time we see a child we guide ourselves as follows : (a) By the end of the second week an infant will drink in twenty-four hours a total of roughly 15 ounces, increasing to 20 ounces by the end of the first month. (6) During the second month he increases this total to 25 ounces. (c) During the third month he drinks a quart This is no rigid routine. Some babies take more; some less. Try the baby on this amount and see how he reacts. The first formula is really a feeding experiment. 4. To protect the child from nutritional disturbances arising from improper relations of the various ingredients, we bear the following picture in mind. I do not believe you will find it formulated just as I give it, but in a way it represents our point of view (Fig. 30). Dyspepsia & Intoxication This illustration shows the well baby included in the group of sick babies, and suggests that this very same well baby can be made to assume any one of four clinical types. The factors concerned in these changes are the improper usage of carbohy- drate and whey and the improper understanding of the role of fat as a secondary factor. The conditions on the right develop from too high carbohydrate in concentrated whey; the condi- tions on the left arise, as Czerny would have said, from too much fat; as Finkelstein would say, from too little sugar. Of course, constitution, infection, etc., are important accessory agents. What is the purpose of this scheme? It suggests that our attitude must be identical to that, for example, in typhoid fever. In typhoid we don't treat the disease: we simply try to guide our patient through the difficulties that lie in his path; and so it is with infant feeding. We don't feed the baby : we simply guide 262 INFANT FEEDING (CHICAGO METHODS) him. In ordinarily diluted milk we try to avoid the dangers of excessive carbohydrate, on the one hand, and of insufficient car- bohydrate, on the other. 5. The next step in our scheme of prophylaxis requires a care- ful history and physical examination of the patient. If he be a weak child; if he have dyspepsia; if he have a parenteral infec- tion; if he be suffering from poor care, we must be careful as to ordering a high percent of carbohydrate never over 3 percent to begin with. If the examination suggest a condition of disturbed balance, or if the child be recovering from an infection, he needs increased carbohydrate or at any rate increased energy. Our prob- lem in the latter case is to offer the increased carbohydrate to the body in such a way as not to endanger the intestine. How shall we make mixtures to avoid intestinal complication? Gentlemen, this sounds complicated, but it is extremely simple. There is nothing to it. You may banish from your minds any worries regarding the difficulties of infant feeding. It's the simplest branch of pediatrics! Simplicity is our motto, and, indeed, so simple is our method that any novice can use it suc- cessfully. To illustrate: In our stomachs a great quantity of hydrochloric acid is secreted daily, but this acid is very dilute. The same total quantity in concentrated form would be deadly. So it is with milk. Train yourselves to think in terms of con- centrations the more dilute the mixture, the less injurious to the intestinal tract and to the body tissues after its absorption. 1. For the first four weeks we use one part milk and two parts water one-third milk. 2. During the second month we use equal parts of milk and water one-half milk. 3. From the beginning or middle of the third month we use two parts milk and one part water two-thirds milk. In these mixtures, as the strength of the milk is weakened, we must offer additional food, and preferably one element rather than two. This is done best by adding carbohydrate in non- fermentable form, such as dextri-maltose, etc. We use ap- proximately 3 percent the first time we see the child, and, de- pending upon the reaction, increase gradually to 5. To illustrate : Suppose we saw for the first time a normal baby of one month. We would say: This child shall receive a con- ARTIFICIAL FEEDING OF THE NORMAL INFANT 263 centration of one-half milk. He drinks roughly 20 ounces a day, so we'll order Milk 10 ounces Water 10 " Add 3 percent of dextri-maltose or, roughly, five teaspoons. Boil for one minute, and divide into seven bottles of about 2J^ ounces each. If the child were three and one-half months old, we'd say: He can tolerate a concentration of two-thirds milk and drinks a quart a day, so we'll order Milk 20 ounces Water 11 " Add 3 percent of dextri-maltose, or about eight teaspoons. Boil and divide into five bottles of six ounces each. Don't take these mixtures as final; simply make up one on such principles and then adapt it to the baby. Some of our Chicago pediatricians make practical application of these prin- ciples in a slightly different way. During the first few months they order slightly greater concentrations of milk than the above and avoid disturbance from the concentrated whey by keeping the carbohydrate low, i. e., 1 to 2 percent. The writer prefers the more dilute mixtures with higher carbohydrate, however, for two reasons: (a) Constipation of an obstinate nature is less likely to result with the higher carbohydrate diet. The concentrated mixtures with low sugar lead to putrefactive processes in the intestines, and, although the babies thrive perfectly, probably using the protein for energy, the mothers are never satisfied. (b) On the more concentrated mixtures with lower carbo- hydrate children often drink greater total quantities than those on the less concentrated, higher carbohydrate diets. While in private practice and infant welfare work, where children receive individual attention, they thrive perfectly, in hospital wards these larger quantities frequently induce vomiting. During these first months, what shall be our guide? How shall we know that the baby is doing well? Gentlemen, under all circumstances let the weight curve, controlled by history and 264 INFANT FEEDING (CHICAGO METHODS) physical examination, be your index. If the baby is gaining an average of five to seven ounces per week, and at the same time seems clinically well, let him alone. No matter though his stools be a little dyspeptic ; no matter if he have a slight colic or slight diarrhea: if he is gaining in weight, let him alone. Your main difficulty will be in treating the mother, particularly the mother of the first baby. She sits at the bedside ; in one hand she clasps "Mother So and So's Guide to Infant Feeding," "based upon forty years' experience." She searches each stool, seizes with enthusiasm upon any slight abnormality, as a tiny curd of fat or a little mucus, and tells you, with gloomy joy, that the food is not agreeing with her baby. Under these circumstances treat her as you will. Tell her that the condition is normal; that Mother So and So's book is old-fashioned. Do anything you wish: but let the baby alone. In a few conditions gain of weight may be deceptive. High sugar mixtures, as condensed milk, and particularly mixtures rich in both sugar and salt, may cause water-logging of the body and not an increase in true tissue substance. Salt in itself may do this in certain types of nephritis. In fever there is often acute retention of water, with a corresponding gain in weight, and again we know that a child may be gaining nicely and at the same time develop rickets. But history and physical exami- nation easily will preclude such errors, and knowing the dangers in advance, you will avoid them. During the first months you must see the baby or hear from the mother every few weeks, and you will be called to meet several indications. (a) The child may vomit. This we will discuss under Breast Feeding. But remember not to get excited. If the baby is gaining, tell the mother the vomiting is of no significance, is normal, and make no change unless vomiting is very severe, when you might reduce the day's total feeding by a few ounces. If the baby is not gaining, it might be better to make no change in the day's total, and give a greater number of feedings, thus decreasing the amount in each bottle. (6) The child may not gain, and the weight curve become straight or begin to drop. The stools are not more than two or three per day. Under these conditions take the mother into ARTIFICIAL FEEDING OF THE NORMAL INFANT 265 your confidence many mothers really have more intelligence than we imagine; ask if the baby seems hungry; does he cry directly after finishing his bottle, put his fingers into his mouth between feedings, fret before the next bottle, seize it with avidity and drain it rapidly? If so, increase the total quantity of food by a few ounces, making no change in the proportions. How- ever, if he seems satisfied with the quantity, one could increase the milk exclusively an ounce or two, or the carbohydrate ex- clusively by 1 to 2 percent, but not both together. (c) If he is not gaining, does not seem extremely hungry, and is suffering from constipation, then it is perfectly safe to in- crease the proportion of carbohydrate in the diet to 4 or 5 per- cent. In this increase we have a true means of winning mother's affection. If our increase is in non-fermentable carbohydrate, gain in weight may result, but the constipation will persist. If we increase with fermentable carbohydrate, such as milk- sugar, or, more simply, cane-sugar, not only will gain in weight result, but the resulting fermentation corrects constipation. So, by striking the proper balance between dextrin-maltose, on the one hand, and fermentable carbohydrate, on the other, we have a means of regulating absolutely the condition of the intes- tine and of bringing joy to the anxious mother's heart. (d) If the weight curve straightens out, but at the same time the stools are four to five daily and fermentative, we are con- fronted with the one problem that may arise in this system of feeding. Dyspeptic stools may be a symptom of underfeeding or beginning dyspepsia. History and physical examination aid us greatly. If the child shows definite symptoms of hunger; if questioning shows the mother has not of her own accord made changes in the mixture, and if examination shows that the child looks well, then it is safe cautiously to increase slightly the amount of food, noting the reaction. Here one never would increase the proportion of carbohydrate, but simply the 'total quantity, not changing the relations of the different elements. If, on the other hand, the child shows a tendency to avoid food, these little children often are so much wiser than we, if examination shows him not looking well, slightly feverish, rings under his eyes, and, above all things, that mysterious change in the skin (the rosy pink becoming an ashen gray), we know we 266 INFANT FEEDING (CHICAGO METHODS) are dealing with a case of beginning dyspepsia. Now, an in- crease of food will make the disturbance worse. Give the baby only the quantity he wishes and await results. Daya 1 > i i i i i < i ( 4 ox 2 03 , y^ i >- . - . S ^ ^ 1 "^ ^ 'v. 8 Ib 7 *V ^ / Fig. 31. (e) If, in connection with the fermentative stool and the child's change of appearance, the weight curve definitely starts to drop, then we are dealing with dyspepsia, beginning intoxica- tion, or decomposition, and treatment must be instituted ac- cordingly (Fig. 31). (/) If the baby isn't gaining, we rarely increase the day's total much over a quart. Many men give 40 ounces or more. The reason I do not is that on the breast the baby doesn't get much over a quart. A larger quantity throws an excess of water into the system, and why burden the baby's metabolism with taking care of this excess of fluid? We know that from birth on the body becomes relatively poorer and poorer in water. If at the fifth month the baby ceases to gain, offer more food in the form of cereal and a slowly increasing mixed diet. My own impres- sion is that when once on a mixed diet, children are more im- mune to infections and to nutritional disturbances than those on large quantities of fluid. In all cases, by watching our weight curve and by studying our little patient carefully, we can check most disturbances be- fore they develop, and the severe conditions will be few indeed. What is the advantage of our method over the others? Per- haps its extreme simplicity. Any method used by one trained in its application will be successful. Our method, 'however, we believe easiest for the untrained man the man who has not had time to work up his own technic. ARTIFICIAL FEEDING OF THE NORMAL INFANT 267 As an example of this let me quote my experiences in the Chicago Infant Welfare Society. This organization was founded by private subscription some six or seven years ago. Its object was not charity, but education. The idea was to reduce infant mortality, not by medical treatment, but by prophylaxis; not by curing the sick baby, but by keeping the well baby well. With this end in view one station was organized in our poorer districts. A physician attended twice a week. A salaried nurse was in charge. Mothers were urged to bring their well babies for advice as to feeding, and during the intervals between conferences the nurse went into the home and gave simple in- struction as to the technic of making the mixtures. No medi- cine was given ; no milk supplied. The mothers could buy their milk where and from whom they chose. At the station they got nothing but advise. Gentlemen, the success of this new experiment was astound- ing. The swarms of mothers flocking to the first station, the immediate lowering of infant mortality, were all the evidence necessary to show the success of this new departure. Under the able leadership of Dr. H. F. Helmholz and Dr. Walter Hoffmann, the organization has grown in the last few years from the origi- nal one station to 21. The numbers of infants seen in an after- noon average about 30, but often reach 50. Wherever a station is opened, in that district infant mortality drops. This exper- ience was in a way very humiliating to me. I served the Society for several years as assistant medical director. During that time I had ten or eleven stations under my charge and visited them each once a month. I saw many men for the first time come to take charge; saw these men instructed in the above simple methods of feeding, and saw these men in a very few weeks' time obtain just as successful results as I did with a much wider experience. They had never read Finkelstein or Czerny or Heubner; but the results accomplished were all that were necessary. Nothing speaks more for the simplicity of our feed- ing than the success of the Infant Welfare Society. True distur- bances of nutrition rarely arise. The children become simply " feeders." In this work, gentlemen, one fact has impressed me most strongly. That is the fundamental, the previously unrecog- 268 INFANT FEEDING (CHICAGO METHODS) nized, but indispensable, services of our nurses. We, in the stations or in the dispensaries, see the baby for a moment and write out a formula for the milk mixture; the nurse, however, goes into the home and meets the true condition. She sees all the great influences which are at work, the accessory aiding influences, the influences which constantly are undermining the baby's constitution and upsetting our plans. She instructs the mother as to proper clothing; she teaches that on a warm summer's day it is unwise to wrap the baby up in thick layers, surround him with a pillow, or place him near the kitchen stove. She informs the mother about the dangers of flies, and attempts in a simple way to protect the child from these pests. She shows how to bathe the baby. She dwells upon the importance of regularity of feeding; she demonstrates the proper care of the bottle and the cleansing of the rubber nipple; she shows how to keep the milk cool if no ice-box is available, by placing the bottle in a tub of cool water; in short, she fulfils the indications which Schlossman so pointedly expressed when he said, "A good nurse can always overcome the mistakes of any poor physician." Gentlemen, those of you who are interested in infant feeding, those who wish wider experience in dealing with nurslings, those who wish to do inestimable good in the poorer districts, should attempt to establish an Infant Welfare Society; and, in your own practice, profit by the lessons that we have learned. Where these splendid nurses are not available, be yourselves a little more the nurse, a little less the physician. Explain clearly to the mother that she is not doing her duty simply by mixing the milk in the proportions you have suggested, but that she must fulfil all the other requirements which are so essential to the baby's general health, and without which any system of feeding will fail. If you will only lay sufficient emphasis upon the nursing care of your infants, the feeding will almost take care of itself. Have we spoken the last word? Is our method going to last? I do not think so. New advances constantly will be made ones we shall adopt, no matter what their source. I believe that we have mastered the art of guiding food past the intestinal tract into the body, but rather than rest upon our laurels we must arise to attack newer and more intricate problems ones ARTIFICIAL FEEDING OF THE NORMAL INFANT 269 which loom ominously before us. Are our combinations those best adapted to meet the demands of the body? In years to come we may learn that boiled milk has produced some hidden, undiscovered damage. We have learned that high carbohy- drate, fed exclusively or in combination with high salts, fills the tissues with water but does not satisfy their hunger. Some evidence shows that children fed with no fat in the diet may at times possess a decreased immunity to infection. We may learn in time that our moderate reduction of fat, our slight in- crease of carbohydrate, though passing the intestine easily and safely, may not have been a combination best adapted for the body tissues. Only years of study and observation will an- swer these questions. The physiologist, Friedenthal, recently has devised a mixture in which the salt proportions are identical to those of breast milk. In this mixture fat and carbohydrate may be given in the same relations as in breast milk, with little evidence of intestinal disturbance. This is again a splendid step: a means of introducing fat and carbohydrate into the tissues in the same proportions as they exist in breast milk, and with no danger to the intestinal tract, but is as yet somewhat impracticable. Until these indications can be met practically and simply; until we can introduce to the tissues food-stuffs in the same pro- portions as they exist in breast milk without in any way im- pairing digestive and assimilative functions, we believe that our method of feeding is the most feasible. It is easily employed, seems to satisfy the mothers, seems to provide for the growth of healthy, thriving, happy babies, who look well and strong and appear smiling and contented, and, first and foremost, it answers the requirements of simplicity. LECTURE IX BREAST FEEDING I have neglected the subject of breast feeding until now be- cause often it becomes necessary to supplement the breast with the bottle. If we have mastered the art of prescribing artificial mixtures, then difficulties with supplementary feeding will be very slight indeed. It is not necessary to emphasize the importance of breast feeding. You know that breast milk is the natural food. You know that the breast-fed infant is more immune to infectious disease than is the artificially fed. You know that mortality is much less among breast fed than among bottle babies. When- ever there is any possibility of offering breast milk, by all means do so. General contraindications to breast feeding are few. As you know, tuberculosis in the mother almost unanimously is agreed a distinct one, but even against this some voices have been raised. Tubercle bacilli have never definitely been dem- onstrated in human milk, and some men claim if the mother, during nursing, will protect the baby from her coughing, that tuberculosis is a contraindication only from her own standpoint and not from that of the child. This, however, is the opinion of a few, but I give it to show that even against the most ortho- dox of all contraindications objections have been filed. I be- lieve, though, that the consensus of opinion makes tuberculosis of the mother a contraindication to nursing, not only from her own standpoint, but also from that of the child. Severe constitutional diseases, such as malignancy and epi- lepsy, are, of course, contraindications. As regards acute infectious disease, such as typhoid, scarlet, diphtheria, etc., opinion, particularly in European clinics, is becoming more and more tolerant. The newborn has consider- 270 BREAST FEEDING 271 able immunity to infectious disease. Again, very few patho- genic bacteria have been demonstrated in breast milk, and the theoretical objection that toxins are excreted may be met with the theoretical answer that antitoxins also will pass to the child. Even in diphtheria, if the child be properly immunized, breast feeding is permitted. These opinions of the European men may seem rather radical to you. I give them, however, to emphasize the importance in which breast feeding is held, and to show that most contraindica- tions are those raised in consideration of the mother rather than the infant. Even in erysipelas, where a superficial infection of the breast makes it possible for organisms to pass to the milk, this may be drawn off, boiled, and then offered to the baby. Syphilis, as you know, is an indication, rather than a contra- indication. Whether the syphilitic woman be mother of an apparently well baby, or whether an entirely well woman be mother of a syphilitic baby, in all cases we should insist upon breast feeding, for in both these conditions we believe that mother and child are alike infected. Some difficulties arise, however, from local changes in the mother's breasts. Perhaps two are important: 1 . Retracted nipples make much trouble, cause great anxiety to the mother, and to considerable extent handicap the nursing. In many cases, however, if the mother practises patience, these difficulties can be overcome. Instead of surrendering in des- pair, simply tell her, "Yes, it's going to be hard for the baby to nurse, but if you practise patience and perseverance, after a week or two he may learn to take the breast." Patience and perseverance are the requisites necessary, and after a week or two of conscientious work the mother may be able to educate her child to nurse from nipples that previously seemed hopeless. Application of a breast-pump between nursing periods aids in drawing them out. 2. Erosions and fissures are extremely disagreeable. By the pain inflicted upon the mother they make nursing a very, great burden indeed. The variety of treatments offered is of itself sufficient evidence of the inefficiency of any particular method. Medicaments suggested are: - (a) The use of a cotton swab saturated with 1 to 2 percent 272 INFANT FEEDING (CHICAGO METHODS) silver nitrate solution, and laid upon the fissure for a minute once during the day. (6) The following prescription of the French is one highly rec- ommended by Langstein and Meyer. Personally, I have had no experience with it, but I give it upon their recommendation. The technic is as follows: Wash the nipple after nursing, and apply the following mixture on sterile gauze: Tincture of benzoin 12.0 Sodium borate 8.0 Glycerin 20.0 Rose-water 40.0 Cover with oiled silk or gutta-percha and bandage. Before the next nursing wash off with lukewarm boiled water. A valuable point in treating these fissures is the use of a mild local anesthetic ointment. A 5 percent salve of anesthesin applied to the fissures just before nursing is a great relief to the mother. Anesthesin is not poisonous to the child, and is very acceptable to the mother on account of the relief from the severe pain. In order to give the painful nipple as much rest as pos- sible, longer feeding intervals should be employed; indeed, one might substitute a bottle for one nursing. Nipple-shields too are of great value. The very best of these is a large one, made of pure rubber, covering almost the entire breast. Difficulties with nursing from the standpoint of the child are not many. A cleft-palate or harelip is to be considered. These handicaps, like the retracted nipple, often can be overcome by patient, conscientious work of the mother. Many cases which seem hopeless at first, after a week or two of devoted care may learn in some way to. obtain milk from the breast. Other difficulties, such as a neuropathic constitution of the child, we shall consider in the next lecture. As regards the entrance of milk into the breast, this occurs between the first and eighth days usually about the fourth. Often, however, it is delayed, and you are asked by all con- cerned, "Can we hasten it?" Gentlemen, there is one, and only one, lactagogue you may use with any degree of assurance, and that is the nursing infant. The only stimulus to a breast is one arising from this source. BREAST FEEDING 273 Wet-nurses in European clinics sometimes nurse four or five babies, and often secrete two to three quarts of milk a day: the greater the stimulus to the breast, the greater the response. And so, gentlemen, to hasten the entrance of milk into the lagging breasts, urge the frequent and regular application of the infant. Of course, if the mother believes that any particular medicine or any particular drink is going to help her, or does help her, by all means don't discourage her. Do anj r thing you can to put her mind at ease, and at the same time to keep her in the best physical condition. If the baby does not nurse very vigorously, you may use a breast-pump also; but this, in con- nection with massage, electricity, and all other artificial aids, is infinitely less efficient than the normal natural method. If, in spite of frequent, regularly repeated applications of the babe to the breast, the milk still delays, how long shall we wait? Safely, a few days. During this time we must be very careful not to entirely appease the baby's appetite with artificial food. We must keep him hungry. We want him to tug good and hard at the breast, and therefore, during this time, we offer only a little water or weak tea. By this method we can accelerate the appearance of the milk. However, gentlemen, don't focus your attention so carefully upon the mother that you forget the child. Don't let your zeal for hunger lead you into the greater error of letting the child suffer from too much hunger. In all these cases, as I have repeated over and over, our index is the baby's weight curve. The physiologic loss of weight during the first few days amounts to from one-half to one pound. If the child shows no tendency to recover, or if he continues to lose, we must heed this danger-signal and direct our attention more to the babe and less to the mother. We must put him to the breast more frequently, using both breasts if necessary, or if this is impossible, add a bottle to the diet. We must never for a moment allow the hunger to develop weakness, for if the child becomes too weak to nurse properly, we defeat our own purpose. Among the laity the general opinion is that breast milk is influenced, as regards quantity and quality, by many different factors by diet, by medication, by nervous influence". As a matter of fact, accurate, scientific experiments showing changes in breast milk are very few indeed. You must remember that 18 274 INFANT FEEDING (CHICAGO METHODS) the amount of the individual ingredients secreted during the individual nursing varies. Fat is in small amount at the begin- ning, and increases toward the end. To get experiments not subject to criticism one must analyze twenty-four-hour speci- mens of breast milk. Experiments which will withstand searching criticism are few, but those that have been made suggest that nervous and psychic factors, pregnancy and menstruation, positively have no effect upon the quality of the breast milk. Undoubtedly children show disturbance at such times, particularly during the menstrual period, but our present observations tend to show that these disturbances are due to changes in quantity rather than quality of breast milk. Less milk is secreted, the child is hun- gry, becomes peevish, irritable, and fretful, and the natural conclusion is that the quality of the milk is changed that the milk is not agreeing with him. As far as we know now, how- ever, there is only one definite change, and this usually a dimi- nution of the total secretion. As regards the influence of diet, we despair more and more. No one in experiments devoid of criticism has shown that he can control at will the quantity or quality of breast milk by change of diet. Many of the statements you read as to the efficiency of diet are based upon only the most superficial investigations. There is one exception, perhaps, this being with fat. In under- fed, badly nourished women, high fat feeding at times seems to increase the fat in the milk secreted. There is some doubt, however, as to whether this influence is exerted also in well- nourished women. Probably it will hold absolutely true only in the undernourished. We are in the same position as regards medication. Every drug in the pharmacopoeia at some time or other has been tried. Every one in turn has been given up. The latest is pituitrin. This, in definite physiological experiment, will increase the amount of milk excreted in a given time, but again must we be disappointed. Most recent observations show that it acts upon the smooth muscle-fibers, causes them to contract, thus forcing the milk more rapidly from the breast, but that it in no way affects the total secretion. There are two ways by which we may affect the supply of BREAST FEEDING 275 breast milk. Undoubtedly one is by building up the general nutrition of the mother good hygiene, good food, fresh air, and plenty of exercise. Many nursing mothers are lax in this respect. Besides hygiene, there is the aforesaid suggestion, namely, the use of a hungry, healthy, strong child. So much difficulty, however, attends this in private practice that it is really just as satisfactory to add a supplementary bottle after each feeding from the start. As a matter of fact, in most disturbances upon the breast the following scheme is satisfactory. Make up your mind that breast milk is always all right in quality. Make up your mind that the only difficulties arising from breast feeding are those of quantity. Treat the mother as you will to put her mind at rest, but from your own standpoint conduct your treatment along the lines of correction of the amount, and if you keep your child on four-hour feedings, this correction will be one usually for underfeeding, rather than overfeeding. You see why in relatively well-nourished babies who are not gaining on the breast I like to wait a week or so without the supplementary bottle. I reason that may be from nervous fac- tors or constitutional change there has been a temporary dimi- nution in the secretion, and that, after a week or two, this will right itself. However, where the condition has lasted longer, out of consideration for the child we are justified in no further delay. Just a few words about the technic of nursing, because errors in technic sometimes are responsible for many disturbances. Some men would not place the newborn to the breast at all during the first twenty-four hours; others would every six hours. As long as one keeps up the supply of fluid, these dif- ferences in technic are of slight importance. Personally, I believe application to the breast is better, as it stimulates secre- tion of milk and possibly also uterine contractions. Question (by Dr. Summerell of China Grove). Doctor, have you had enough experience in the country to have seen new- born pigs? Answer. No; my personal experience in that direction is limited. Question. Well, the minute pigs are born they make for the 276 INFANT FEEDING (CHICAGO METHODS) breast and nurse right away. Don't you think it's a good idea in our treatment to follow the lead of nature? Answer. Yes, that's an interesting point. I think if we physicians had more experience with country life it would be better for us. I should consider that observation as valuable evidence in favor of putting the child to the breast during the first day. As regards rigid disinfection of the breasts, our ideas are changing more and more. Where the mother practises ordi- nary cleanliness, application of strong chemicals to the nipple is absolutely uncalled for. Of course, in very poor districts, where the breasts are caked with dirt, they must be washed thoroughly; but in ordinary private practice cleansing with a little cotton and lukewarm water is all that is necessary. If the mother be of the modern, scientific type and wishes something more fashionable and antiseptic, use a little boric solution. Personally, however, I believe the use of strong antiseptics a frequent cause of painful, fissured nipples. Question by Dr. Summerell. In the cases of our poor patients, where the mother's work keeps her all day long in the fields, where underclothing is changed infrequently, and where cloth- ing is, of course, saturated with perspiration, where absolutely no care of the body is taken before the baby nurses in such cases, doctor, do you advise some sort of application to the nipples? Answer. Where the breasts and nipples are dirty, of course they should be cleaned, but the best means for this process is ordinary soap and water. Question. Do you believe the offensive odor of the clothes in such cases would interfere with the baby's appetite or pre- dispose to disturbance? Answer. The influence of bad odors and bad air upon a nursling's appetite is open to dispute. I believe, however, that most men think this influence unimportant. How often shall we put the baby to the breast? The same rules apply as to the bottle baby. How long shall we allow the baby to nurse? Until he is satisfied, and this requires from fifteen to twenty minutes. The first five are the most important, for in these five the baby BREAST FEEDING 277 gets the greatest amount of milk. You easily can tell, gentle- men, when he is satisfied by the cessation of the swallowing sound. When he is hungry, he nurses and swallows constantly. When he ceases to swallow and lies playing idly with the nipple, he has had enough. If he has emptied the breast thoroughly and still is not satisfied, we either order an increase in the num- ber of feedings or put him to both breasts. But in the latter case we must be perfectly sure that the first breast has been emptied thoroughly. A child is easily spoiled, and if the second breast awaits him, often will not thoroughly empty the first. Of course, thfe reduction of the stimulus will cause reduction of the amount of milk secreted. One little point of technic often is overlooked a point of considerable value, even though used by our grandmothers. You remember our grandmothers used to interrupt the nursing at intervals to place the baby so that the abdomen was against grandmother's shoulder. Then she would pat him on the back until he belched up some air. In the younger days of pediatrics any practice interfering with the quiet of nursing was rejected. Recently, however, we are learning that there is much truth in grandmother's advice. If you hold a baby when nursing in front of the fluoroscope, you will see that he frequently swallows air. A large bubble collects in the upper part of the stomach. This interferes with the proper filling of the stomach, prevents his getting sufficient food, often makes him vomit, and may cause colic. If you break the nursing interval every few min- utes and pat the child upon the back, as our grandmothers did, he belches up air, the tension in his stomach is relieved, and he nurses with renewed vigor. Many perplexing difficulties with breast feeding are overcome by this simple bit of advice. In instructing the mother as to nursing, tell her the baby does better if he has not only the nipple, but also a little of the areola in his mouth. How do we know when the baby is doing well if he is getting sufficient food? The best index, gentlemen, is his weight. If he gains on an average of about six ounces a week, no fault can be found with his nutrition. Dr. Swnmerell asks how often it is advisable to weigh the baby as a routine. 278 INFANT FEEDING (CHICAGO METHODS) Answer. The oftener the better. I should say at the very least once or twice a week. Dr. Summerell. That is all right, doctor, but in our country practice the parents have no scales. Have you any idea as to the feasibility of a portable scales? Answer. One of the men of the Children's Memorial Hospital at home (Dr. Spicer)* has devised an ingenious scales. I have had no experience with it myself, but from his description it sounds quite practicable. What shall be the diet of a nursing mother? As far as we know the nursing mother may eat absolutely anything that makes her happy and contented. We may disregard totally in this respect the mandates of our grandmothers. If the nursing mother likes vinegar and it agrees with her, let her have it. Whatever she craves, whatever she can digest, whatever pleases her and makes her happy and contented, she shall have. Our sole desire in regulating her diet shall be to fulfil three require- ments : (a) She must have enough food. Many a poor woman does not secrete a good supply of milk because she herself is starving. (6) The food must be digestible. The nature of the food de- pends upon the mother's social condition and her tastes, but anything that she can digest she may eat. (c) Lastly, we must gratify her thirst. Langstein and Meyer dwell upon this point, which seems to me a very important one. The mother normally secretes about a quart of milk a day. Thus she excretes almost a quart of water more than normally. You see, then, that she has every reason to be thirsty. Here is where many mistakes, even by well-educated physicians, are made. The physician takes advantage of this thirst to force extra food. The mother does not need extra food at this time, her appetite is taking care of that,- but she needs fluid. This should be given as water, tea, broth, or thin soup. How wrong it is to take advantage of her need of fluid by throwing into her body a great excess of starches, such as are contained in thick soups and gruels. She does not need this excess of food pro- vided she is getting her meals normally : she needs simply water. Question by Dr. Gilmer. Doctor, if a baby is four months old, * Amer. Jour. Dis. Children, January, 1915, p. 70. BREAST FEEDING 279 could you offer him milk from a mother of a newborn? What is the present idea as regards feeding children milk of a mother whose child is so much younger? Answer. As far as we know now, such considerations are im- material. Breast milk is the ideal food, and is infinitely better than any other food that can be offered, no matter how young or old the other baby may be. LECTURE X DISTURBANCES IN THE BREAST FED Gentlemen, disturbances of the breast fed also, we prefer to consider as disturbances of nutrition. Just as in the artificially fed child, the symptoms arising are many more than those of simply local gastro-intestinal irritation. The skin, the nervous system, the decreased immunity to infections, above all, the weight curve, show that involvement is general. Just as in the artificially fed baby, we find vomiting, diarrhea, or constipation. When these exert no influence upon the weight curve, we are acting wisely if we let the baby alone. However, as you once took me to task as regards the practical importance of these subjects, just a few words about them. VOMITING If the babe is brought for vomiting, the first thing to establish is the duration of the symptom. Is it an acute attack or has it been present for a long time? Acute vomiting may be due to infections, enteral or parenteral, may be associated with dis- turbances of nutrition or metabolic disorders, may be due to nervous factors which are, as yet, not clear to us, and, of course, in older children may follow the conventional cucumber-water- melon mixture. Often it is due to too much fat. Chronic vomiting may be associated with chronic disturbances of nutrition, such as decomposition, may occur even in inanition, may be associated with a so-called neuropathic constitution (which we shall discuss in a moment), and may be due to pyloro- spasm or pyloric stenosis. Treatment. In our treatment, however, we must adopt the same attitude that we have to the stool. Vomiting is simply a symptom and must be made subservient to the condition of the baby as a whole. If the baby is gaining; if he is well and happy and contented, by all means let him alone. Keep your eyes open for errors in technic of nursing, such as overfeeding, irregular 280 DISTURBANCES IN THE BREAST FED 281 feeding, neglect of patting him on the back, and too rapid feed- ing; but frequently vomiting persists in spite of perfect and un- impeachable routine. If so, the disturbance is due probably to the baby, the fault lying with a hyperesthetic mucous mem- brane or to faulty reflexes. No matter what be the underlying cause, if the baby is thriving, if he is happy, contented, and satis- fied, take the mother into your confidence : tell her this condition occurs so frequently as to be considered almost normal; and explain that from the third to the sixth month it will disappear. On the other hand, if the baby's nutrition is suffering, we must take notice. Acute attacks will disappear upon treat- ment of the underlying cause, and require little actual treatment of the vomiting except in older children who have devoured im- possible food-mixtures. For them a good stomach washing and a dose of castor oil will be a cure. In the chronic vomiting also we attempt to treat the funda- mental cause, as in nutritional disturbances. Pyloric stenosis may require operation. The spastic vomiting of neuropaths, usually considered a pylorospasm, may be influenced by (a) Increasing the number of feedings and thus decreasing the quantity in each. (6) Reduction of the fat, and offering as a substitute Keller's Malt Soup or a buttermilk mixture. (c) Anesthesin or novocain, 1/60 grain before meals. (d) Tincture of belladonna, one or two drops with a few drops of paregoric before meals. I have found this very satisfactory. (e) Sodium citrate, 1 to 2 percent; one dram in each bottle has been recommended by the French. Prolonged boiling of the milk for some minutes may be very successful. But in all cases don't do too much. Sometimes all that is necessary is to reduce the total quantity and make up for the decrease of food value by an increase in concentration. ABNORMAL BOWEL MOVEMENTS (a) In reading text-books you learn that the stool of the nor- mal breast-fed baby is soft, homogeneous, pasty, yellow, and smooth. This undoubtedly is a normal stool. But, gentle- 282 INFANT FEEDING (CHICAGO METHODS) men, if you examine a great number of breast-fed babies you find that the stools are green, slightly watery, somewhat acid, and contain mucus and curds. These occur more frequently, or at any rate fully as frequently, as those described in the text. In spite of this apparent abnormality the baby thrives, gains persistently, is happy, contented, and satisfied. Under such circumstances, why these stools are not to be considered normal I do not know. The cause of them is not certain. It may be intestinal fer- mentation; it may be a neuropathic constitution probably both. But as long as the baby is happy, contented, and gain- ing, let him alone, and instruct the mother that this stool is absolutely normal. Tell her that it will correct itself by the third to sixth month. If it does not, we can be of service in a way to be mentioned later. (6) Constipation. In discussing the constipation that occurs independent of nutritional disturbance, let me present an idea of my own. I present this to you purely as an idea, not as a fact one which you may in your leisure moments consider, but not necessarily believe. For my own purpose I divide con- stipation into two types: these you probably will not find in text-books; but this arbitrary classification has been of great value to me. (1) The first I call pseudo-constipation. Here the baby is perfectly happy, contented, and thriving. Bowel movements occur perhaps once in two days. They are normal, soft, and homogeneous. The mother complains to you bitterly. She has read in her guide book, or has been instructed by the family physician, that unless the bowels move once a day the baby won't sleep, will be restless, will have colic. As a matter of fact, gentlemen, these symptoms exist only in the mother's mind. They are in the guide book, or in the advice obtained from outside sources, but in the baby they rarely exist. He goes sailing along perfectly independent of the anxiety he is causing. Has it ever occurred to you to question the authority which states that a baby must have one bowel movement a day? Frequently I have asked myself, "By what right has this author to state definitely that a child must have a bowel movement daily." We do not lay down definite rules as to the frequency of DISTURBANCES IN THE BREAST FED 283 urination. We know that this depends upon many different factors. The text-books make the statement, but where is their author- ity? It comes, I presume, from books written in previous times. These books, when written, were founded upon more previous observations; and ultimately, I presume, we should find the statement, like so many we read, to have originated in those medieval, mysterious ages when knowledge was dogma and wisdom superstition. In such cases I tell the mother, "For this baby this condition is normal; don't worry. The intestine is so strong that he is absorbing almost all his food. Very little remains in the bowel, and two days are required for residue to accumulate sufficiently to cause a normal bowel movement." As I say, gentlemen, this idea may be wrong, but it gives good practical results. (2) True constipation requires more definite treatment. Here the stools are hard and soapy; i. e., truly constipated. They do not adhere to the diaper, and the baby may strain and have pain. No matter how well the child may thrive, if he strains, woe be to you if you tell the mother to let him alone! If you wish to retain your practice, you must suggest definite therapy. How shall we proceed? First, make a careful examination to rule out any organic cause, such as tumor or a congenitally di- lated colon. Shall we give physics? This is not reasonable. Physics simply flush out the bowel but do not correct the funda- mental cause. Enemas often do more harm than good. When these are repeated daily, the child's rectum becomes sore and he voluntarily restrains himself to prevent the pain. Thus we de- feat our own purpose. If the mother insists upon active treat- ment, an enema of one ounce or more of olive oil may be intro- duced into the rectum once or twice a week, just before the baby goes to sleep. Instruct the mother to hold the buttocks to- gether, so that the oil remains in the intestine all night, and in the morning, either spontaneously or from a mild suppository, the child will have a soft bowel movement. As regards correcting the underlying cause, we must attempt, as closely as possible, to simulate the normal. In the intestine of the normal breast-fed child a state of mild fermentation exists. As you remember from the lectures on artificial feeding, such a 284 INFANT FEEDING (CHICAGO METHODS) condition may easily be produced by the use of fermentable carbohydrate. Offer your patient, after each nursing, an ounce or more of cereal water with 5 percent to 10 percent lactose, or else add from one-half ounce to an ounce after each nursing of a 10 percent watery solution of malt soup extract. In addition, use fruit-juices, and after the third or the fourth month a little apple-sauce. With such simple procedure, these cases respond readily. So much for isolated symptoms where the babe as a whole has been unaffected. Now for those which affect the weight curve. INANITION The first of these, as in the artificially fed, we might call "failure to gain." In the normal breast fed failure to gain almost invariably is due to insufficient milk, and so usually is inanition. As regards gastro-intestinal symptoms, the stools are of the truly constipated type, being infrequent and hard; but, gentlemen, let me urge that in some cases stools are green, watery, and contain mucus and curds. No worse mistake can be made than diagnosing such cases, as so frequently is done, gas- troenteritis from overfeeding. Symptoms of general involvement are cessation of the normal gain in weight, pallid, inelastic skin, lost agility, and sunken abdomen. The nervous system is affected. The child may cry continuously, showing neurotic tendencies by scratching the skin of the face and body. Crying, however, may be entirely absent. Dr. Woodson asks: What difference do you draw between inanition and decomposition? Answer. That is rather a fine point, but perhaps rather a practical one, too. Inanition is a condition arising from insufficient food. When a child is in a state of inanition, increase his diet and he will gain. When, however, the inanition has proceeded to an ex- treme degree, then we speak of decomposition. Now if we add food to the diet, a paradoxical reaction will result and the weight curve goes down. DISTURBANCES IN THE BREAST FED 285 By simple inspection we scarcely can say whether the child is in a state of simple inanition or whether this has proceeded to a mild decomposition. We can tell only by the reaction to food. As a matter of experience, however, children on the breast, although they may suffer considerable inanition, rarely proceed to decomposition as do bottle babies. It is on the basis of this experience, knowing that the breast baby, perhaps due to the better condition of his tissues, never proceeds to such a severe stage as does the bottle baby, that I am not so careful with their bottles in supplementary feedings. In the etiology of inanition several factors are to be con- sidered : (1) Insufficient milk may be due to failure of the supply of the mother; to retracted nipples; or to fissured nipples. (2) The child may be unable to obtain sufficient milk, due to cleft-palate or harelip. What so frequently is overlooked is weakness in the child. Small twins or prematures may be unable to obtain sufficient nourishment simply from lack of strength. (3) A so-called neuropathic constitution may be the basis of the trouble, resulting in a distracted physician and a perturbed household. The mother's breast may be abundantly supplied; the slightest pressure may cause milk to gush forth. The child, however, when put to the breast, takes one or two swallows, then seems to show an absolute lack of interest in anything con- nected with his food, and lies disinterestedly playing with the nipple. How deceptive is this contentment! Were we guided in our feeding solely by the baby's disposition we would com- pletely overlook the warning given by the stationary weight curve. In the newborn this neuropathy manifests itself by some difficulty in swallowing. The nervous system is incompletely developed, and the child's swallowing reflexes are not as they should be. The child makes clumsy, awkward attempts. Dur- ing the third or fourth month, however, this constitution shows itself in more persistent form; that is, in a prolonged loss of appetite. Do what you will, the little fellow takes no interest in his food. He smiles and is happy, but will not nurse. In- variably the distracted mother insists, "My milk is no good; 286 INFANT FEEDING (CHICAGO METHODS) the baby absolutely refuses it." The unfortunate innocent physician gets a wet-nurse. Added to his worries now are not only the complaints of the mother, but also the domestic in- felicity arising from the new acquisition to the family. The baby refuses the breast of the first wet-nurse and she is dis- charged. Sometimes four or five are employed before the un- happy, by this time well-nigh insane, physician realizes that fundamentally the fault did not lie with the breast milk, but did lie with the baby. 4. The failure of the child to gain may in another way be due to insufficient breast milk. He may obtain enough, but lose it again by vomiting. As a general rule, mild vomiting does not produce any marked inanition. The vomiting of the neuro- pathic child may be severe, however. It is usually associated with a spasm of the pylorus and is spastic in nature. A mother in one of our poorer districts described it best to me by saying, "John vomits the way his pa spits tobacco." In this and in true stenosis of the pylorus, disturbance is grave and severe. 5. Lastly, and not to be classified as inanition, failure to gain may be a temporary affair, resulting from an acute dyspepsia. Diagnosis. First, is this a case of inanition, or if the stools be dyspeptic, is it a case of overfeeding? Instead of wasting time speculating, simply weigh the baby for a twenty-four-hour period before and after each nursing, and estimate the day's total intake. This simple procedure rather than stool exami- nation makes a definite diagnosis. Equally important is it to diagnose the cause. Retracted or fissured nipples speak for themselves. If the fault be an in- sufficient supply, the baby, after five or ten minutes, ceases nursing and cries irritably. Examination of the breast shows it to be empty, or if the nursing be interrupted, one finds that the milk oozes from the nipple simply drop by drop. If the fault lies with the child, observation of the nursing process makes the diagnoses. The clumsy swallowing of the newborn points to undeveloped reflexes. The lack of interest in the older child shows the neuropathic loss of appetite. Vomiting is recognized by the history and the examination. Prognosis. In the breast-fed this is relatively good. Rarely does the breast-fed child progress to the stage of decomposition DISTURBANCES IN THE BREAST FED 287 so easily reached by the bottle baby. Decomposition results only in extreme cases. Treatment. Treatment depends upon the cause. (1) If the fault lies with insufficient milk, the child may be put to the breast more frequently or else both breasts may be used. If the weight curve does not rise after a few days of this treatment, a bottle may be added after each nursing, the amount depending upon the amount of milk obtained from the breast. As children wean themselves rapidly, never give the child the bottle until the breast has been thoroughly emptied. (2) When the fault lies with the child: (a) If it be due to the undeveloped reflexes of the newborn, we must be patient for a few weeks. However, during this time don't allow the baby's nutrition to suffer; and insist that the breast be emptied after each nursing, so that the supply does not fail. (6) If the fault lies with loss of appetite, correction is more difficult. Sometimes a few drops of pepsin with dilute hy- drochloric acid, given before each meal, stimulate the appetite. A daily stomach washing may be of value. A lukewarm bath, followed by a cool spray, occasionally gives striking results. In the latter be careful not to shock the child. Babies are very susceptible to cold. Make the spray just cool enough to be mildly stimulating and to make the child breathe deeply; to make him cry perhaps, but under no circumstances to shock him severely. If this is done once or twice a day, a few minutes before meal-times, often the child nurses with considerably more vigor. During this period of treatment the child's nutrition must by no means be neglected. Here great errors are made. The physician too frequently says, "If this child won't nurse, we'll let him get so hungry that he will have to." Such treatment accomplishes nothing. The child's loss of appetite is not due to his having obtained sufficient food. It is due to the con- dition of his nervous system. Whether you give food more frequently or less frequently, his appetite will not change unless the underlying fault can be corrected. Under these circum- stances, as the baby takes only the slightest amount of food at each nursing, put him to the breast oftener, and then, if his 288 INFANT FEEDING (CHICAGO METHODS) weight curve doesn't ascend, use forced feeding, because there is no reason for his nutrition's suffering during the period that you are trying to overcome his nervous tendencies. The use of a stomach-tube may accomplish a marvelous cure. Lastly, as this neuropathy is inherited from nervous parents, as the baby makes the mother nervous, and the mother in turn makes the baby nervous, at times the only thing we can do is to order a change of environment. If you can get a good wet-nurse, a sane woman who takes a perfectly disinterested sort of interest in the child, results are very gratifying. (3) In all cases, no matter what be the cause of the inanition, don't neglect the child's water supply. ' Children suffer griev- ously from lack of water. In getting small quantities of breast milk naturally they reduce markedly their water intake. In your treatment don't neglect to make up this deficiency. The other marked disturbance is dyspepsia, which is much like that arising on the bottle. DYSPEPSIA Gastro-intestinal symptoms are vomiting, regurgitation, diar- rhea, anorexia, flatulence, tympanites, and colic. General symptoms other than gastro-intestinal are cessation of gain, change in the quality of the skin, slight fever, nervous reactions, as sleeplessness and unrest, and decreased immunity to infection. Etiology. Several factors may be concerned: (1) Alimentary influences up to the present have been con- sidered most important. Alimentary Influences. (a) Overfeeding is given the first place. Gentlemen, I don't want to be too radi- cal, but I believe that more and more we are beginning to doubt the importance of overfeeding. As the im- portance of constitution grows in our mind, as we recog- nize the neuropathic type .of child and other types, too, as we recognize fundamental differences in the baby himself, just so much are we decreasing our emphasis on the outside factors. Irregularity of feed- DISTURBANCES IN THE BREAST FED 289 ing in our mind is perhaps much more important than is overfeeding, and let me remind you that ir- regularity of feeding is due frequently to underfeeding rather than to overfeeding. Indeed, we are beginning to doubt whether many cases do result from over- feeding. So great is the adaptability of the mother's breast to the baby's demands, when the baby wants more, more milk is secreted; when the baby wants less, less is secreted, so great is this adaptability that if the child be nursed regularly every four hours it is a question whether many mothers can overfeed their babies. Perhaps overfeeding is a factor when an undernourished infant is put to the breast of a fine, healthy wet-nurse. Before the baby has adapted it- self to the breast, and vice versa, often too much milk is taken. Such statements are, of course, heresy, gentlemen, but weigh the baby before and after nursing and see for yourselves. (&) Of alimentary factors, we believe irregularity of nursing to be most important, but don't forget inani- tion may produce a picture identical to dyspepsia. (c) Foreign substances secreted in breast milk and causing this dyspepsia we believe very rare indeed. (d) Shifting proportions of the different elements, as, for example, too much fat, are described. Undoubt- edly some breast milk contains more fat than the average. As the stools of many of these children, however, are typically fermentative, frequently do I wonder whether perhaps too much sugar is not being secreted. In all cases very little scientific evidence proves that disturbances arise from these sources. We may learn more later. As I mentioned in our last lecture, one will make fewest grave errors if, for the present, he considers that invariably breast milk is perfect in quality and disturbances are due only to changes in quantity. (2) Infections. The more dyspepsias we see on the breast, the more do we realize the fundamental influence of in- 19 290 INFANT FEEDING (CHICAGO METHODS) fection. A baby has been thriving, becomes infected with a nasopharyngitis, a bronchitis, an otitis, or a cystitis, and a dyspepsia results. When the infection has run its course, the intestinal tract corrects itself, fermentation ceases, and the stools become normal. In this type, frequent errors are made. The mother says the milk is not agreeing with the baby. The physician may prescribe a wet-nurse; may take the baby from the breast; may order medicine for the child; may diet the mother; and in spite of all treat- ment, improvement occurs. Why? Improvement does not result from the therapy; it occurs because the child has recovered from the infection. In all cases of dyspepsia on the breast don't neglect search- ing for parenteral infections. (3) Our old enemies, overclothing, overheating, improper care, overcooling, are, of course, never to be overlooked. The symptoms depend to some extent upon the cause. Those due to alimentary factors develop gradually. Nervous changes, with disturbed sleep and restlessness, manifest themselves first. Later symptoms of the gastro-intestinal tract develop. General symptoms and fever are, as a rule, not severe. The type due to infection appears rather suddenly in the previously thriving child. General symptoms and fever are more in evidence than in the former. The severity of the reaction and the course depend upon the child's constitution the better the constitution, the less the reaction. The alimentary type is progressive and often ends in anorexia. The infectious type is short and ends in a cure, with recovery from the infection. Diagnosis. The diagnosis is made from the history. Treatment. The treatment is relatively easy where ali- mentary factors can be corrected. Where infection is the basis of the disturbance, wait. In all cases, and in that mentioned at the beginning of the lecture, powdered casein is of value, Formerly this could be obtained as a powder. Since the war I doubt if it is obtainable, but we may make it by getting the curds of milk and putting them through a sieve. You remember that casein makes the intestine alkaline, and as most of these DISTURBANCES IN THE BREAST FED 291 diarrheas are of a fermentative nature, casein is ideally suited to our requirements. Give it in doses of one or two teaspoonfuls after each nursing, and increase until you obtain the desired results. Albumin milk may work wonders in small doses after nursing. One must never neglect the general care of the child, and in- quire earnestly into the conditions in the household, clothing, and general hygiene. One danger leads to serious complications. The mother or the physician, not recognizing that an infection is the cause, lays great emphasis upon the importance of the breast milk. Some- thing must have affected its quality. Therefore we take the baby from the breast and starve him until the milk has corrected itself and until the stools become normal. Gentlemen, all that we have accomplished is to add to our patient's troubles the damaging influence of hunger. Frequently he gets better with this treatment, but this change is due to cessation of the infection. Don't make unnecessary use of hunger. Children have so much intelligence, often so much more than we, if you weigh the baby before and after nursing you will find that instinctively he cuts down his diet. You will find that he drinks far less during these few days than ordinarily. It is my custom simply to put the child to the breast, allow him an in- terval shorter than usual, five minutes, for example, and to repeat this at the regular feeding time, but never let him hunger markedly. By this procedure you will find that during these few trying days the baby's general nutrition is maintained. From the above you see how unnecessary in many cases is a wet-nurse. The fault lies so frequently with the baby, rather than with the .milk, so frequently with outside factors, such as infections, rather than with the mother herself. Just one word about severe diarrheas occurring in the breast fed. Breast-fed children, rarely it is true, but still definitely, do develop symptoms almost identical to the alimentary in- toxication of the bottle baby. Our previous ideas were that a toxin was secreted by the breast milk. I believe this has been disproved. I doubt if people ever find human breast milk definitely poisonous to the child. However, we are learning to recognize other factors. We are learning that parenteral in- 292 INFANT FEEDING (CHICAGO METHODS) factions; true intestinal infections, such as dysentery; or over- heating may be the basis of the trouble, and, lastly, we have learned that children in states of severe decomposition, when given large quantities of any breast milk whatsoever, go down and die with the severest alimentary symptoms. The treatment is identical to that of the alimentary intoxica- tion or true infections of the artificially fed. This finishes, gentlemen, infant feeding. There are many, many more phases of this interesting subject which I should like to discuss with you. Time, however, forbids. If you have followed me carefully you will perhaps have obtained some idea of the methods of our Middle West, as I understand them. I do not urge these exclusively upon you. I trust that you have become interested and will investigate the teachings of the great men all over this country of ours. After you have obtained a comprehensive view of the whole field, select the method which pleases you most, or, better yet, you may be in a position to select from the different teachings many points of value, and I trust that you will use them all, no matter what their source, to aid sick and suffering children. CLINICS CLINIC I Gentlemen, I asked you to bring normal babies to the clinic today for two reasons: First, no satisfactory work in infant feeding can be accomplished without a thorough understanding of the normal infant, who represents the ideal for which we are striving. Second, you have learned that from the viewpoint of infant feeding it is wiser to consider the artificially fed baby as a sick baby. For this reason, no matter how well he may seem, before you prescribe feedings you must obtain an accurate history and a careful physical examination. (Normal children are brought by Dr. J. W. Long (Greens- boro), Dr. F. Raymond Taylor (High Point), and Miss Powers (Winston-Salem) . Dr. Long's patient demonstrated. Gentlemen, just step up and feel the texture of this skin. Put your hand on it and notice its delicacy, its velvety softness. The first touch, more than the first glance, diagnoses the breast- fed baby. Notice the fineness, the elasticity, and the fullness. Note the smoothness, the splendid state of nutrition, the delicate pink color. Feel the subcutaneous tissue. Strange that the first thing we see in looking at any patient is the skin, and yet in our examination it's the most neglected of all organs. In future clinics we shall learn what marked changes in elasticity, fullness, softness, and color it undergoes during the development of disturbances of nutrition. Indeed, with eyes blindfolded practically by palpation we can diagnose such disturbances. In this normal baby notice the well-developed muscles their normal tone, neither too rigid nor too flaccid. Note the abdo- men, not retracted, not bulging, just about the level of the thorax. We haven't this baby's weight, but he looks approxi- mately 16 to 18 pounds, which would be normal for a baby of about six months. Above all things, notice his contentment, his happy smile, 293 294 INFANT FEEDING (CHICAGO METHODS) his fearlessness. Note how he reaches for my watch and wants to play (Figs. 32 and 33). Fig. 32. Fig. 33. Fig. 34. CLINICS 295 Note how joyfully he stamps and kicks and waves his arms. I clap my hands; he looks at me with a somewhat inquisitive, rather pained expression; he's disappointed in me; but he's normal (Fig. 34). He doesn't shriek with terror as would a baby with a neuropathic constitution. Having satisfied ourselves as to the state of his nutrition, we ask, "Has he developed normally?" I see by Dr. Long's expression that he thinks we have abused his protege sufficiently; so let's persecute this one of Dr. Tay- lor's. I wish you gentlemen would come up and examine him, and then go to your seats and write on a slip of paper your esti- mate of his age. Well, for such a superficial examination, you have done better than you deserve. In estimating a child's age, you must take into consideration many points. We reason as follows : First, is he a newborn? No. The skin has not the characteristic bright-red color of an Apache Indian; it is not covered with vernix caseosa, and baby's size, of course, contradicts such an assumption. Again, the skin of the newborn desquamates for about ten days. This skin shows no trace of desquamation. The breasts in all normal children secrete during the first week, sometimes a few days longer. When these breasts are compressed, no trace of fluid exudes. Again, in normal babies the cord falls off within four days. In this child not only has the cord disappeared, but the navel has also healed perfectly. This shows him to be over three weeks. Has he reached the normal development of a child of two to three months? Question. Mother, does he recognize you? Does he smile when he sees you? We don't need an answer. That smile speaks for itself. Question. Does he notice things? We'll try him. See how the eyes follow my flashlight! See the interest he takes! He follows not only with the eyes, but with the whole head. All this confirms our opinion that he is at least two to three months of age. Interesting, is it not, that when a baby first starts to notice external affairs he follows with only one eye, and so dur- ing the first four to eight weeks strabismus is normal? By the 296 INFANT FEEDING (CHICAGO METHODS) end of the second month, however, he follows with both, and with the head too. So this baby easily has passed eight weeks (Figs. 35 and 36). Fig. 35. Fig. 36 CLINICS 297 Is he over three months of age? Does he hold up his head? He does this very well, either when raised by the shoulders from the table or when lying on his stomach. So he is three months or more. At three months tears appear for the first time, as does drooling, and coordinate movements of the ex- tremities show a beginning of voluntary muscular control. Question. Mother, does he recognize familiar noises? Answer. Yes, he knows my voice and also his father's. That shows he must be four months or more. Does he sit up yet? Well, he's making a brave attempt, but I guess it's too heroic a task. And he has no teeth either. At six months a baby begins to sit up, shows two lower central incisors, and has doubled his birth weight. From this. child's size he must be almost six months. But he doesn't sit up, and so I judge him to be perhaps five months, or a little more. Question. Is that right, mother? Answer. (Proudly.) He is four months and three weeks. Well, here we have not only a baby normal in every respect, but also one who is a little ahead of time; so, mother, you may be proud of him. It will be very interesting to watch the development of this young man. When he reaches the dignified age of nine months, if supported, he will attempt to stand, and his vocabulary will include such choice words as "pa," "ma," and "goo." Nine to twelve months may find him attempting to walk. At the end of the first year he will treble his birth weight and will have six to eight teeth. The large anterior fontanel will close be- tween twelve and eighteen months. The posterior, as you know, is closed at or shortly after birth. You may wonder what all this has to do with infant feeding. Simply this: If the baby is not normal as regards his physical and mental development, you must make allowance in your formulas. If you limit yourselves to rules and regulations which concern themselves only with baby's age or his weight, you will meet with unavoidable failure. Baby's tolerance to food is the vital factor, and this you estimate by careful history and by con- scientious physical examination. As a rule, the more deficient the child's physical development, the less will be his tolerance. 298 INFANT FEEDING (CHICAGO METHODS) If we do our work thoroughly, we should examine every nor- mal baby as carefully as we do a sick one. Time prevents this morning, but, nevertheless, I am going to take just a moment to examine the heart. I advise you in all cases, in addition to general inspection, no matter how healthy or normally devel- oped the child may seem, never to neglect this. You will find congenital heart lesions not uncommon, and from my own ex- perience I believe more and more that these lesions are impor- tant factors in influencing the baby's nutrition and predisposing him to disturbances. I think we have abused this child's good nature sufficiently. Let's see the next. CLINIC I. BABY 1 Brought by Dr. W. T. Meadows (Greensboro) Question. Doctor, is this baby to be demonstrated as a well baby or as a sick one? Answer. He has been breast fed until the present, and up to three weeks ago had been doing nicely. Since then he's not been thriving. I saw him for the first time yesterday, and sug- gested that the mother bring him to the clinic. Discussion. Good! Here then we can demonstrate the methods of history taking. I'll go over this one in detail to show the procedure. After this I'm going to ask you gentlemen to take these histories in advance, so as to save time. Before starting, however, let me impress upon you that in all our work we are going to adopt the attitude of the pediatrician, the chil- dren's specialist, rather than that of the general practitioner. We are not simply going to say, "What's the matter with this baby?" and offer a little medication, but we must use every means at our disposal to find out with "just what sort" of child we are dealing. We cannot hope for success in our feeding unless we know something of the general make-up of our patient, and this knowledge we obtain first by careful history, and sec- ond by conscientious physical examination. Question. Doctor, will you please take this card and fill it out as follows: On the upper left-hand corner write the baby's name; on the upper right, his age. CLINICS 299 Question. Mother, how old is the baby? Answer. Just four months and one week. The first questions in this history are those concerning the family. The influence of heredity must never be overlooked. Doctor, will you kindly write: Family History. Question. Mother, are you in good health? Answer. Yes; I didn't feel very strong just before the baby came, but I'm all right now. I'm always pretty well. Question. Is the baby's father in good health? Answer. Yes, he's never been very sick in his life except once. Question. What did he have? Answer. Typhoid fever. Question. Are there any nervous sicknesses in your family? Have any relatives your father, mother, brothers, or sisters, or your husband's brothers and sisters or parents ever been in any institution for any nervous sickness? Answer. No; there have been no such sicknesses in the family, or at any rate none that I know of. Discussion. The reason I asked this is that many children are predisposed to nervous trouble by heredity. It's hardly necessary to mention that severe nervous disease, or alcoholism in the parents, often leads to epilepsy or nervous degeneracy in the child, and this latter, in its turn, frequently gives rise to nutritional disturbance. Question. Have you or your husband, or any of your rela- tives, or any of your husband's relatives, ever had any lung sickness? Answer. There has been no severe lung sickness in our fam- ily. Both my husband and I at times have had severe coughs, but they have been of short duration, and the doctor said they were simple bronchitis. Discussion. We are particularly interested in lung diseases because we know tuberculosis in the parent is a frequent cause of feeble, poorly developed offspring, and, secondly, even though these children may not be born with tuberculosis, in such an environment they readily become infected. Of course, tubercu- losis is a great factor in predisposing to nutritional disturbance. The next points to be considered in the family history are the 300 INFANT FEEDING (CHICAGO METHODS) number of children, the health of these children, and the num- ber of miscarriages. Question. How many children have you? Answer. This is the only one. Discussion. Gentlemen, look out. Keep your eyes open for the only child; he's always exceedingly difficult to examine. Usually excuse me, mother he's just a little bit spoiled. He likes his own way, and looks upon the doctor as a decided enemy. See! He's preparing for the battle. We must handle him with great care and discretion. Question. Have you lost any children? Answer. I lost two of colitis. Question. How old were they? Answer. One was nine months and one two years. Question. Have you had any miscarriages? Answer. None. Discussion. We're glad to know that, because miscarriages make us at any rate think of syphilis. By no means has every mother who suffers from miscarriage syphilis, but if we should get a history of miscarriages as follows: for instance, one, say, at four months, another one a little later, say, at six months, a third one a little later, for example, at eight months, and then perhaps a baby born dead, we are justified in being very sus- picious of congenital syphilis, and, as I tried to emphasize be- fore, in infant feeding we must try to keep our eyes open for every influence that possibly can have been exerted upon the baby. This child seems to have a perfect family history. Nothing from this standpoint will influence our feeding orders. We next ask if any factors in his past life are of importance. Past History. Question. Mother, were you well before the baby was born? Answer. I suffered from headaches and backache and felt a little weak, but never had any serious complaint. Question. No kidney trouble or convulsions? Ansiver. No. Question. Is this a full-term baby, or did he come too soon? Answer. He was full-term. Discussion. We are interested in knowing this because pre- CLINICS 301 matures are far more susceptible to nutritional disturbances than are full-term babies, and must be handled with special care. Of particular importance is the next subject: Question. Was the labor difficult? Was there any serious complication? Was it necessary to use any instruments? Answer. The doctor told me my case was normal. Question. Did the baby cry as soon as he was born, or did the doctor have any trouble with him? Did the doctor tell you that he was suffocated, or blue, or that he was almost like dead? Answer. No, he cried right away and seemed all right. Dr. Brown said he was a fine baby. Discussion. These are important questions. I ask about difficult labor and about instruments because these complica- tions may cause direct cranial injury with a resulting menin- geal hemorrhage, or by producing a great rise in blood-pressure from asphyxia may indirectly cause the hemorrhage. Such a hemorrhage injures the brain. As a result, the child does not develop properly, and although he may show no marked symptoms at first, by the time he reaches five or six months of age he presents a grave and most distressing picture. He is very backward, his mentality is deficient, his limbs are rigid, and often crossed like scissors. In the clinics which are to come I haven't the slightest doubt that we shall see such cases of so- called Little's disease, and you will learn how this condition affects the general nutrition of the child. Children with mental defects are very difficult to feed, and many of them suffer ex- treme inanition from loss of appetite. Question. How much did he weigh at birth? Answer. We had no scales at home, but Dr. Brown esti- mated him at 11 pounds. Discussion. He certainly was a fine youngster. Most babies average about 6 to 8 pounds at birth. Answer. All our North Carolina babies are larger than that. Question. W T hat sicknesses has the baby had? Answer. He's had nothing but an occasional cold. Question. Has he ever had measles or whooping-cough? Answer. No. Question. Does he get very sick with these colds? Answer. No. He doesn't get sick at all. 302 INFANT FEEDING (CHICAGO METHODS) Discussion. In this way we learn first the diseases which have influenced this child's life. We are particularly interested in measles and pertussis because they so often predispose to tuberculosis. Secondly, we learn the nature of his resistance. The better the condition of nutrition, as a rule, the more perfect is the resistance. Question. Has the child developed in the right way? Discussion. This is hardly a question that mother can answer. We can learn this more satisfactorily in our examina- tion. Inspection of this apparently normal baby and the his- tory of the well-developed resistance to infection make us think that he either has been breast fed or has been fed perfectly on the bottle. This brings us to the subject of feeding. Feeding History. Question. How has the baby been fed? Answer. He has been breast fed up to the present. Question. How often have you been nursing him? Answer. I was giving him the breast every two or three hours. Question. Was he satisfied with it? Was he gaining? Answer. He seemed going nicely until about two or three weeks ago. For the last two weeks, however, he has been pee- vish and irritable. He hasn't been gaining, and has been very constipated. He won't take the breast any more, and I've given him a little sugar water between meals. He likes that pretty well, but he vomits a lot. Question. How often do his bowels move? Answer. Well, they don't move every day unless I give him an injection. Question. When they move, are they hard or soft? Answer. They are usually soft. Question. Let's see if this is correct. Here is a baby who was well up to some weeks ago. Then he became cross, irri- table, constipated, stopped gaining, didn't nurse as well as previously, and didn't seem contented. Is that right, mother? Answer. Yes. Discussion. Now, gentlemen, following the feeding history, we take the present complaint to learn if the child has been feverish, has been coughing, sneezing, or showing any other abnormal symptoms. CLINICS 303 Present Complaint. In this case the feeding history probably will be synonymous with the present complaint. Question. Does he show any other symptoms, like fever, or have you noticed anything else the matter with him? Answer. No, that is all we noticed. Physical Examination. Question. Mrs. Peck, what is the baby's weight? Answer. Eleven pounds two ounces. Temperature, 98 F. Discussion. This would be a good weight for a baby who weighed six or seven pounds at birth. But if he weighed almost eleven pounds he certainly hasn't gained very much. Gentlemen, I'm going to examine him very carefully to show the methods. No matter how convinced we are that it's simply a feeding case, we never should establish a diagnosis before making a thorough examination. We must rule out every other possibility and arrive at feeding more by exclusion than in any other way. Always remember, before confining yourself to any local examination, to look at the baby as a whole. Here we see a fairly nourished infant. He doesn't look so very sick; he doesn't look unhappy you notice he smiles at us, but the smile is a little feeble. Notice this somewhat flabby, inelastic skin; the color, too, isn't that of the normal children we just have examined; it has the slight muddy tinge which we know to be an important symptom. I pick it up and it wrinkles rather easily. It seems softer than the skin of the other children. The subcutaneous tissue is less firm and allows the skin unusual motility. Notice the lack of tone of the muscles. They feel flabby. All these findings are suggestive of a disturbance of nutrition. As a routine, however, we examine every part of the body. The osseous system, you know, is very important in infants. We feel the large fontanel, which, of course, is widely open, but it's neither sunken nor under tension. We feel for softness in the bones behind the ears craniotabes. We find none. We feel for beading of the ribs where they join the sternum the rosary. This, too, is absent. Both of these symptoms are very suggestive of rickets. As a routine, we examine all the lymph- nodes the cervical, the axillary, the cubital, and the inguinal. 304 INFANT FEEDING (CHICAGO METHODS) We find nothing except a few the size of a pea in the posterior portion of the neck. The more children we examine, the less significance we lay upon a few palpable nodes. Next we seek abnormalities about the head. The eyes, ears, and nose show nothing. Everything is normal. You notice we let the mouth and throat go for the present, because this child is so good we don't want to make him cry. It's a good routine to leave the mouth and throat examination for the last. We feel for rigidity of the neck it's absent. We carefully percuss the heart and lungs and auscultate. Everything is nega- tive. We feel for an enlarged liver and spleen. The flaccidity of the abdominal muscles makes this easy. I don't feel the spleen. The liver reaches one finger below the costal margin. This is of no significance. There are no other abnormalities. We examine the reflexes the triceps, knee-jerk, Achilles, and abdominal reflexes. They are all brisk, equal, and show no definite findings. So in this case our physical examination is absolutely negative. Gentlemen, by no means does this finish the examination. In every case where anything in the family history makes us in any way suspect lues we never must be satisfied until we have a Wassermann, and that means a Wassermann on the mother as well as the baby. The Wassermann of the parent is perhaps the more accurate. Again, where the child in any way has been exposed to tu- berculosis, we must demand a Von Pirquet test. Where anything, such as extreme pallor or enlarged spleen, suggests blood dis- eases, we examine the blood, and the stool for hook-worm, and, of course, as a matter of routine, where there is the slightest suggestion of trouble, or even the slightest possibility, never omit a urinalysis. Cystitis is very common, but frequently overlooked. As to methods of obtaining urine. In a boy it is simple. Simply attach a bottle or rubber glove with adhesive. In a little girl it's more difficult. Sometimes a cool bath will be followed by urination. An enema often causes the child to pass water, but, of course, this may be mixed with the stool. Letting the child sit upon something cold, as a saucer or plate, may cause her to urinate. Massage over the bladder is fre- CLINICS 305 quently successful. A rubber glove may be used. An in- genious apparatus by Dr. James Leach, one of the fellows at our hospital (Fig. 37). End View Nipple Shaped for Glass Tubing Application Fig. 37. This device consists of a rubber nipple from a nursing bottle, a suitably curved piece of glass tubing, about three feet of soft rubber tubing, and some adhesive plaster. The nipple, preferably an old discarded one, because of its softness, is cut curved, forming a concave end, with the lower portion forming a tongue-shaped cup. The other end is fastened to the glass tubing. This tubing is curved so as to fit between the thighs, and rests on the bed, preventing dragging, forming a ready exit for the urine, and preventing backing up and leakage. The rubber tubing carries the urine to a receptacle attached at the side of the bed, and the whole is held in place by means of adhesive plaster. In applying the apparatus the labia majora are retracted, the lower cup-shaped portion is applied just within the fourchet, and the' rest is brought up, inclosing the labia minora and ure- thral orifice within the nipple. The labia majora are then closed over this and held together with adhesive plaster. The whole device is further secured to the vulva by means of a flange- shaped piece of adhesive wrapped around glass tubing. Diagnosis. -Time, this morning, prevents our going into an extensive discussion of the diagnosis. I believe the great ma- jority of men will tell you that babies fed every two to three hours are suffering from overfeeding. Personally, as regards this point, I am somewhat of a heretic. Understand, however, 20 306 INFANT FEEDING (CHICAGO METHODS) that many pediatricians will not agree with what I'm about to tell you. I believe, nevertheless, that many children who are nursed every two to three hours really are underfed. I believe that they are nursed so frequently because the mother hasn't sufficient breast milk, and tries to ease the child's discomfort by placing him more frequently to the breast. I believe, in these cases, if we add food rather than reduce it, we get better results. The first thing, however, is to determine definitely whether the child is receiving too little or too much. The his- tory of discomfort, the failure to gain, the constipation, the refusal of the child to take the breast, all point to insufficiency of the supply of milk, and we make a tentative diagnosis of inanition. Treatment. Mother, I wash you would place this baby to the breast regularly every three hours seven times in twenty-four hours: First at 6 o'clock in the morning, then at 9, 12, 3, 6, 9, and once during the night. If the baby won't nurse, give him absolutely nothing until the next nursing time. Let him nurse for twenty minutes. Under no circumstances give him any more sugar water. Bring him back to us next week. We'll weigh him accurately, and then shall know just exactly what he is doing on your breast milk. Be very careful to give him nothing in addition to the breast, and be absolutely sure to come next week. Good-by! Discussion. Gentlemen, in private practice we wouldn't wait so long for the reaction, that we could determine within a few days, but as these clinics are held only once a week, I think it will be desirable to wait to demonstrate the changes. I feel quite confident that this baby will not gain and that we shall have to add something to the diet in addition to the breast milk. In all children who are to come we necessarily must wait one week for the reaction, but remember, in private practice don't wait over two or three days. CLINIC H. BABY 1 Age. Four months two weeks. Mother says the baby is no better. He frets after each nurs- ing, seems peevish all the time, and very hungry. He suffers greatly with colic and is constipated. CLINICS 307 Question. After he has finished nursing does he still fret? Answer. Yes; he never seems satisfied at the breast, and I have a terrible time making him wait until the full three hours are up, but when he gets to the breast he doesn't like it. Question. Have you kept him regularly on the three-hour schedule? Answer. Yes; but it's been very difficult. Weight. Eleven pounds two ounces. No gain during the week. Temperature $8 F. Examination. He presents just exactly the same appearance as last week. He's a little flabby and pale and apparently undernourished. Discussion. As he hasn't gained this week, and in the ab- sence of any factor other than food, we feel sure of our diagnosis of inanition. I should add a bottle right now, but just to be absolutely sure that mother is secreting an insufficient supply of milk let's wait a few days longer. You remember that this child drank sugar water between meals. Possibly he was so spoiled, due to the sweet taste of the water, that for this reason he has refused the breast. Directions.^ Let's try him just one week more, and then, if he doesn't gain, we certainly shall be justified in adding a bottle. There is a bare possibility, though, that by adhering rigidly to our routine the child will nurse vigorously enough to increase the supply of breast milk. Be sure to come back next week, mother. Question by Mother. But doctor, what shall I do for the colic? Shall I have my breast milk examined? Answer. All right, mother, give Dr. Meadows a specimen of your breast milk. Discussion. Gentlemen, you have heard about qualitative changes in breast milk, but examination will make mother feel easier. Personally, I'm convinced that this colic is due to hunger, as the child hasn't gained the required amount. How- ever, to make sure, let's wait another week and see exactly what he's doing. To Mother. I think we can aid the baby greatly if you'll just follow our instructions for this next week. See if you 308 INFANT FEEDING (CHICAGO METHODS) can't put up with his crying for a few days and then we'll fix him. Question by Dr. SummerelL Have you any babies of your own, doctor? Answer. No; but I see by your smile that you think my ideas will change. Dr. Woodson. Doctor, it's all very well in clinic to tell these mothers, " If baby is crying, let him alone," but we can't do that in practice. When we are called up at 3 A. M. and father says, wearily, "I never knew I could walk ten thousand miles in one evening," we've got to say something more to him than simply "weigh the baby." Answer. Gentlemen, I accept the reproof. The reason I didn't lay much stress upon the colic is my earnest desire to teach you to put the welfare of the baby above the relief of any individual symptom. As regards the immediate relief of colic, an enema may save the day, or, rather, the night. The enema can be given in the form of salt solution, a teaspoon of salt to a pint of water, or, if this is not satisfactory, as a soapsuds enema. One drop of essence of peppermint in a teaspoonful of sweetened water, by causing internal warmth, will sometimes satisfactorily relieve pain ; or you may give a few drops of pepsin. Apply hot- water bags or hot flannels to the abdomen, and lastly, if the child must be relieved, give him a few drops of paregoric, and repeat in an hour or so. But, gentlemen, the point to be remembered is this: While advising this treatment, always ask yourselves, " Is this truly a case of intestinal colic?" Don't neglect to apply a little pressure to the ear; don't neglect to ask for a urinalysis as soon as possible. The colic, after all, may be simply an otitis media, a cystitis, or a meningitis. Second, ask yourselves, " Is this truly a case of colic from indigestion, or is it simply the pain of hunger?" For this latter reason I lay so much emphasis on the weight. Lastly, if it's a digestive affair, is it due to too much perfectly good food or is it due to an excess of one individual element of a food? We think that some colic in the breast fed is due possibly to excessive carbohydrate in the breast milk. So, gentlemen, although the relief of the immediate pain in a child is important and not difficult, don't forget that, after all, CLINICS 309 the essential thing is to arrive at the underlying factor and make a proper diagnosis. Question by Dr. F. Raymond Taylor (High Point). Doctor, as long as we are on the subject, would you mind telling us just what is three months' colic? Answer. Three months' colic is a term applied by the laity to the colic which occurs in breast-fed babies who seem thriv- ing, however, in every way. It lasts usually from three to six months, the baby suffering apparently from considerable in- digestion, and snowing green, watery, fermentative stools. The etiology is not definitely known. I don't know of much scientific work upon it, as the condition is not of grave signifi- cance; the children all outgrow it. Two factors may be con- cerned: First, some evidence points to the fact that it occurs in nervous children that it is due not to the milk, but to the baby. These neuropathic children, for some reason or other, do not seem able to control fermentative processes in the intestine as do normal children. The second factor, although not proved, might lie in an excess of sugar in the mother's milk. Certainly the stools of these children point to fermentation. The practical treatment of the colic, in which you gentlemen have shown yourselves so interested, is along the lines just laid out. To strike at the cause, however, we attempt to overcome intestinal fermentation. This can be done by giving a little powdered casein or powdered curds of milk after each nursing, or, by what sometimes works wonders, namely, a little albumin milk with no sugar, after the breast. This food, with its high protein, low salt, and low carbohydrate, by tending to stimu- 'late putrefaction in the intestine, sometimes accomplishes sur- prising results. In this case I'm positive that the crying is from hunger. In private practice I should have added a bottle to the diet several days after first seeing the child, but, unfortunately, the clinics come only weekly, and I'm very anxious to show you the differ- ent reactions of the weight curve uninfluenced by treatment. In this case the curve has remained horizontal, so we'll make mother put up with the noise just one week more. 310 INFANT FEEDING (CHICAGO METHODS) CLINIC IE. BABY 1 Age. Four months three weeks. Mother says the child has not improved in any way, is still fretful, peevish, irritable, and doesn't take the breast well at all. No additional symptoms or complications have been noted. Bowels are constipated. Mother says that she hasn't much milk, and the baby cries all the time. In addition, the child shows some aversion to the breast and is not nursing well. Weight. Ten pounds fourteen ounces, showing a loss of four ounces during the week. Temperature 97.8 F. Question. Mother, do you notice that your supply of milk is much less than it used to be? Answer. Yes, indeed, the baby doesn't get much from the breast any more. Directions. To confirm our diagnosis of inanition, this loss is by no means sharp enough to suggest any of the graver dis- turbances, we'll add a bottle after each nursing. Let's figure that the baby will drink about two ounces, and so if he's four and one-half months old we'll be absolutely safe in ordering a mixture of Milk 9 ounces Water 6 ounces Sugar 4 teaspoonf uls Seven bottles. To Mother. Mother, have you ever fixed up any feedings before? Answer. No. Well, then, let me tell you just exactly how to proceed: In one corner of the kitchen put up a shelf, or else set aside a corner of the kitchen table. Use this exclusively for baby's food uten- sils, and don't mix them with anything else in the kitchen. First, get as many bottles as there are feedings during the day, or even a few more. Next take some whole milk, shake it thoroughly so that the cream is well mixed, and in your case pour out nine ounces. Add six ounces of water and four tea- spoons of sugar. Boil thoroughly for a minute and pour at CLINICS 311 once into seven bottles. This makes about two ounces in each. If you let the mixture stand in an open pitcher for any length of time, it will spoil. Get a few cents' worth of sterile cotton and cork the bottles, keeping the unused cotton in its original package. Then you are through for the day. Of course, you must keep the bottles cool, either in the ice-box or, if you haven't one, in the well or in the stream. Nurse the baby for ten to fifteen minutes and then give a bottle. Let him have this five or ten minutes. If he takes it and is satisfied, well and good; but if he doesn't finish it in ten minutes, take it away from him. By all means nurse him first and give the bottle afterward, because if you give the bottle first, he will wean himself more easily. This way will be more likely to keep up your milk supply. Put the nipple on the bottle only at feeding time. Those not in use can be kept in a covered jar of boiled water with a little boric acid or soda. As regards washing the bottles : you may do so either at once or the next morning. If the latter, because milk sticks to the inside, get a bottle brush, scrub them with yellow soap, and rinse them thoroughly afterward. If you wash them directly after using, keep the clean bottles in a jar with sterile water and a little soda. When you clean the nipples, be sure to invert them. It goes without saying that if the baby drops his bottle on the floor you must take out another nipple. When you give the baby his bottle, be sure to see that he really gets it. Don't leave him all alone to go to sleep, but do your best to hold it and give it to him with the same care that you would if you were nursing him. Hold the bottle so that he really gets milk, not air. Warm the bottle just before giving it to him by putting it in a little warm water, but if you take the baby out for the day, don't make the mistake of heating the bottle before you go. Wait until feeding time or else the milk will spoil. You can do a good deal toward keeping the bottle cool by wrapping it thoroughly in a newspaper before you go out. Let's see him again next week, and when you come back tell us how he is. We'll weigh him and see how he has responded. 312 INFANT FEEDING (CHICAGO METHODS) Question. Have you understood everything, mother? Mother. If I am to give seven bottles with two ounces, should I add five or six ounces of water? Answer. Six ounces, because about one will be lost during the boiling. Discussion. It's always a good idea to add more water than you need on account of the boiling. You notice the simplicity of the formula? It required no calculation on my part what- soever. It consists simply of two-thirds milk and one-third water, with a little sugar. In cases such as this I prefer to add a bottle after each nursing, but when such order works hardship on a mother who is weak or who must work, we may give breast and bottle in alternate feedings. Whenever I order a bottle I start orange-juice. You may dilute it with water, or give half a teaspoon of the pure juice. In either case the baby may vomit the first dose or have a little colic. Don't pay any attention to these symptoms, but give it again the next day, and in a short time you'll find baby taking it nicely. CLINIC IV. BABY 1 Age. Five months. Baby is very much better. He takes his bottle after each nursing and likes it ever so much. He vomits just a little bit, but sleeps through the night now. He is quiet for three hours and seems a different baby. Weight. Eleven pounds eight ounces, a gain of ten ounces in a week. Temperature 98 F. Examination. The child certainly looks better and happier and begins to have the contented look of the normal baby. Discussion. With such a nice response of the weight we ig- nore absolutely the vomiting. The baby's general nutrition, which is the point in which we are interested, has certainly im- proved. Directions. Mother, keep up this treatment and let's see him again in a week. CLINICS 313 CLINIC V. BABY 1 Age. Five months one week. Mother says the baby is doing nicely, but that he is a little hungry; that no sooner does he empty his bottle than he cries for the next one. Weight. Eleven pounds fifteen ounces, showing a gain of seven ounces during the week. Temperature. 98.6 F. Examination. Child looks bright and happy. Discussion. I don't think we can complain of that gain in weight, and I should advise the mother to let him absolutely alone. He is gaining really faster than he should. Mother says: "That is all right, doctor, but I have no breast milk. For the last week my breast milk has gone entirely, and to tell the truth, I have given him more of the bottle myself." Directions. Well, that's different. We'll put him on regular bottle feedings for a baby of his age. He's over four months old, so we'll order Milk 20 ounces Water 11 ounces Sugar 6 teaspoonf uls Five feedings and start a little cereal. CLINIC VOL BABY 1 Age. Six months. Mother says the baby did all right for a week, but for the last two has been hungry and not gaining. Weight. Twelve pounds eight ounces, showing a gain of nine ounces in three weeks. Temperature. 98.6 F. Examination shows him to be in good condition. Directions. Mother, baby is now six months old; so you gradually may offer a greater variety of food. Very slowly add a little soup or vegetable or chicken broth. Give an occasional Graham cracker or a little zwieback, which is the same as hard, dry, doubly baked bread. If you can't get it, take some toast and bake it thoroughly until very hard and dry. Give the 314 INFANT FEEDING (CHICAGO METHODS) zwieback or Graham cracker mashed up with a little broth, or soaked in .the soup or the bottle, or baby may like to take it in his hand and chew it. In addition to these, start a variety of cereals, such as farina, corn-starch, Cream of Wheat, or arrow- root. We can begin with vegetables : you may use almost any that can be boiled to soft consistence, put through a sieve, and made into a pure"e. This includes mashed potatoes. Perhaps the best at first is spinach or carrots. Carrots are best given if cooked and then grated right into the soup. Of course, the baby must have fruit-juices, such as orange- juice, prune-juice, and also a little apple-sauce or baked apple. A six-months-old baby may have a strip of bacon. Bacon directly from the shop is a little salty; so it's a good idea to soak it first in water to rid it of this excess, and then broil it rather crisp. You may start, too, with beef-juice. Question by Mother. How shall I cook the cereal? Answer. If you are using farina, take a tablespoonful to a cup of water; boil this over the fire for half an hour. As the water boils away, of course, add fresh water. In the last few minutes add about half a cup of milk. You must stir this con- stantly; if you use a double boiler, you won't need to use so much care, but you must cook it for over four hours. Add a pinch of salt and enough sugar to sweeten slightly. In making corn-starch I would use perhaps a little less than a tablespoonful because the corn-starch thickens easily. Question by Mother. We don't have farina down here; I never heard of it, but could we use hominy or a little mush in- stead? Answer. Yes, those would do exactly as well. Question by Mother. How about oatmeal? Answer. Some children take oatmeal very well at six months, but to some it seems rather laxative. Of all cereals, oatmeal seems most likely to ferment and cause diarrhea in children of this age. Question by Mother. How shall I prepare the beef -juice? Answer. Cut the beef into tiny cubes, throw them into a hot pan to sear the outside, and then squeeze out the juice. You may give a teaspoonful or more a day. CLINICS 315 Question by Dr. Meadows. Would you use fresh or canned vegetables? Answer. If possible, I would certainly use the fresh. By the way, if you have any trouble in making pure"e, we have a little apparatus in the hospital at home which is of great value. It's a little grinding mill put up by the Enterprise Manufactur- ing Co., of Philadelphia, called the "Nixtamal Mill." It's in- expensive, costing only a few dollars, and certainly is very satis- factory. Dr. Abt introduced it into our hospital, trying it as a means for pulverizing casein and curds in the making of albu- min milk. Of course, in starting the baby out don't give him a banquet the very first day. You must use considerable discretion and care. I think I should start out perhaps like this: Tomorrow, after the 10 o'clock bottle, add a half teaspoonful of the farina or corn-starch. This being a new food, may be vomited; don't pay any attention to this vomiting, but repeat the next day. Gradually, day by day, increase the dose, so that by the end of two or three weeks he gets the whole quantity. A few days after giving the cereal start, in addition, one of the other foods, as a little broth or a teaspoonful of vegetable puree after the 2 o'clock bottle. A few days later, having increased the quan- tity of broth to an ounce or more, try a few crumbs of zwieback broken into the broth. In two or three weeks, when you have learned which foods baby prefers, give him at 2 o'clock a little dinner of broth, zwieback, a little vegetable and beef-juice, or bacon. Then, of course, he won't take so much of his bottle; but remember, it's essential to start gradually and increase very slowly. As baby is getting small amounts of food the first few days, he won't gain much, and we must tell mother in advance, so that she won't be discouraged if there isn't a marked gain next week. Question by Dr. Brown. Don't you think, doctor, this is a pretty full diet for so young a baby? Answer. I suppose it seems that way; I doubt if you will find it prescribed in many texts. On the other hand, if you will only try it as I have outlined, I am sure you will agree with me that it is very successful. I have had many discussions and been forced to overcome many objections, particularly from the 316 INFANT FEEDING (CHICAGO METHODS) nurses, but I believe you will find that such a diet will be adopted more and more. Certainly the brilliant results we get at home are sufficient evidence in its favor. From my own point of view I believe that our fear of overfeeding babies has carried us .to the other extreme, and that many babies of this age really are underfed. Of course, I don't mean that you should cram food into a child and stuff him : simply give him what he wants and you will find that upon the four-hour schedule he adjusts his diet to his own needs and practically never overfeeds him- self. Of course, you must remember that as he takes more solid food he drinks less of his bottle; so don't force the bottle upon him. And remember that his daily diet shouldn't contain everything in this list, but just should be selected from it. Question by Mother. Can I add an egg? Answer. No, I should not advise this as yet. It is true that some children, as early as the eighth or ninth month, take a soft- boiled egg and tolerate it well, but it is wiser, with the majority of children, to wait until they are somewhat over a year. CLINIC VH. BABY 1 Age. Six months one week. Mother says the diet is causing diarrhea. She has given a little spinach, and he likes it very much. He seems happy and sleeps well, but has a diarrhea, with four or five watery stools daily. Weight. Twelve pounds ten ounces, a gain of two ounces in a week. Temperature 38.6 F. Examination. Well, gentlemen, he looks well, doesn't he? Notice he seems happy, contented, smiling, and he kicks and stamps and waves his arms. He's interested in everything about him, so no matter what mother tells us about his bowels, the baby looks all right, and the gain in weight, though slight, proves this. Probably he hasn't eaten enough to cause a greater gain. Discussion. In many cases diarrheas occurring upon addi- tion of solid food, though attributed to the diet, depend upon absolutely other factors. CLINICS 317 Question. Mother, have you been feeding the baby as we told you? Answer. I started in very slowly and carefully, and he is getting just a little cereal, broth, and yesterday some spinach. Question.- How long have the bowels been loose? Answer. Three days. Question. Have you given any medicine? Answer. Yes. I was afraid he wouldn't digest the cereal very well, and so I gave him three teaspoons of castor oil for the last three days. Discussion. No more explanations are necessary, gentlemen. The castor oil explains the diarrhea. A nice illustration of diarrhea occurring upon change of diet is one I saw yesterday. The baby, one year old, was brought for feeding. He had been breast fed until three weeks before. We ordered a soft diet and a milk mixture of Milk 20 ounces Water 11 ounces Five feedings, We told mother to wean him gradually. On his return mother reported a diarrhea, which she ascribed to the soft diet. Questioning revealed that in trying to wean the baby she had put salt on her nipples to make them distasteful. The baby liked this addition and took to it eagerly; so the in- genious mother added pepper. This combination proved too much, and the diarrhea resulted. CLINIC Vin. BABY 1 Age. Six months two weeks. Mother says 'the baby is well in every respect the bowels move two to four times a day. He likes his vegetables, and is content and happy. Weight. Thirteen pounds one ounce, a gain of seven ounces in the week. Discussion. You see, gentlemen, what one accomplishes by judicious use of a soft diet. Let's let him alone. Mother, you might bring him back in two or three weeks. 318 INFANT FEEDING (CHICAGO METHODS) CLINIC I. BABY 2 Dr. J. D. Williams (Greensboro) Age. Five weeks. History. Negative. Mother has no breast milk and comes for feeding advise. Temperature. 98.8 F. Weight. Seven pounds three ounces. Examination. Normal baby. Directions. Milk 11 ounces Water 11 ounces Sugar 4 teaspoonfula Seven feedings. Don't omit orange-juice. Let's see the baby next week. CLINIC H. BABY 2 Age. Six weeks. Mother says the baby is not doing well ; that he cries, doesn't want to eat, has colic, and is awfully constipated. The food doesn't agree with him. He doesn't even empty his bottles, and his mouth is very sore and all white. Temperature. 99.4 F. Weight. Seven pounds four ounces, showing a gain of one ounce in the week. Examination. Negative, except for white patches all over gums and mucous membrane of the cheeks. Discussion. Gentlemen, you see the value of our scales. This week the child gained only one ounce an insufficient gain, of course. Can this be due to an acute disturbance from overr feeding? No, because there is no acute loss in weight simply failure to gain. There is no diarrhea; indeed, the baby is very constipated. It's more likely that the pain is that of hunger, and that the failure to gain is from insufficient food. Diagnosis. We diagnose mild inanition, and ask, " Why isn't he drinking his full bottle?" Is it because he doesn't like it? Is it because he has bronchitis, or something interfering with his CLINICS 319 drinking? Our examination has answered this question at a glance. Question. Mother, you've been washing .out the baby's mouth. What have you used? Answer. The druggist recommended some silver nitrate to me. Discussion. See how a little disturbance absolutely inde- pendent of food may arise, and lead you, if not careful, to diag- nose improper feeding! Here is an excellent illustration of thrush and the improper way of treating it. Thrush, you know, is an infection by a fungus. The fungus never attacks an in- tact mucous membrane, but only one that has been injured. The surest way of predisposing the child to infection is to wash the mouth with any strong solution or with sufficient mechanical violence to cause injury. Remember, the intact mucous mem- brane is immune. During my experience in the Finkelstein clinic we could tell at a glance from which maternity hospital our patients came. All those who had thrush came from an institution where it was routine to wash the babies' mouths. Those without thrush came from one where the mouths were let alone. There is no surer way of inviting thrush than to wash out the mouth roughly. Better let it go unwashed. Directions. Mother, for the next few days let the baby's mouth absolutely alone. Once or twice a day saturate a little cotton with half peroxid and half water, and just touch the white spots on the gums and cheeks. Don't rub them or scrape them, but touch them as gently as if you were taking up a blot with a piece of blotting-paper. When his mouth is healed and it doesn't hurt to drink, I think he'll take his bottle better. For the next few days, as his mouth is so sore, feed him with a spoon or a medicine-dropper. CLINIC m. BABY 2 Age. Seven weeks. Mother says the baby is drinking the bottle with renewed vigor, but that he's hungry. Weight. Seven pounds five ounces, showing a gain of one ounce in a week. 320 INFANT FEEDING (CHICAGO METHODS) Temperature 98.6 F. Examination shows the mouth in much better condition. Discussion. As this gain is insufficient, and as the baby now is taking his entire food as offered, the failure to gain must be due to insufficient amount. Directions. We'll order an increase to Milk '. 13 ounces Water .12 ounces Sugar 6 teaspoonf uls Seven bottles. CLINIC IV. BABY 2 Age. Eight weeks. Mother says baby is doing nicely; that he drinks well and seems satisfied. Until yesterday he had been quite constipated, but yesterday his bowels moved three times and she noticed a lot of white, hard curds in the stool. The other day he had a little cold. Weight. Seven pounds fourteen ounces, showing a gain of nine ounces in the past week. Temperature. 98.8 F. Examination. Negative, other than coryza. Discussion. Gentlemen, as he gained nine ounces in the past week, we're not going to worry, about the bowel trouble. Un- doubtedly it resulted from the coryza, with secondary fermen- tation in the intestine, but you see for yourselves, from the happy appearance of the child and from the decided gain, his nutrition is in no way affected. Question. Mother, are you boiling the milk? Answer. No, doctor, I thought it would be better to give it raw. Directions. Mother, if you will boil the milk the hard curds will disappear from the stool. Use a little liquid vaselin for the nose, and when the cold is better his bowels will correct them- selves. If they don't in a day or two, the doctor will order some chalk mixture. CLINICS 321 CLINIC I. BABY 3 Dr. C. S. Gilmer (Greensboro) Age. Seven weeks. History. Mother lost her milk and has never nursed any of her babies over a few weeks. She comes for advice. Temperature. 98.6 F. Weight, seven pounds fifteen ounces. Examination shows a happy baby. Everything negative. Discussion. He has been getting Milk 14 ounces Water 14 ounces Sugar 6 teaspoonfuls Seven feedings. This seems a perfect formula. You notice it's half milk and half water, and approximately 3 percent carbohydrate. The total quantity is a little above the average for babies of this age, but if he's taking it well and not vomiting, I don't believe it needs to be changed. Directions. Continue this formula. Don't forget to shake the milk thoroughly before making up the mixture, and don't forget the orange-juice. CLINIC II. BABY 3 Age.Eight weeks. The baby is fine, happy, and contented in every way. Weight. Eight pounds four ounces, showing a gain of five ounces. Temperature. 98.8 F. Examination. Negative. Directions. Baby is doing well, but you had better bring him next week. Discussion. Gentlemen, I like to have the babies return as often as possible. It's the best means to keep a check on them. Those who don't return, puzzle us: may be the diet didn't agree with them. On the other hand, may be it agreed with them so well that the mother thinks her troubles are over a dangerous conclusion, however. As I have tried to emphasize, any baby upon the bottle is to be regarded as sick, and I urge 21 322 INFANT FEEDING (CHICAGO METHODS) you to impress this upon your patients and have them return as frequently as possible. CLINIC m. BABY 3 Age. Nine weeks. Mother says the baby seems to be doing pretty well but is hungry. He had a croupy cough for the last two or three days. His bowels are constipated, with hard stools. Weight. Eight pounds two ounces. Loss of two ounces in the week. Temperature. 99.2 F. Examination. Very slight bronchitis. Question. Mother, does the baby vomit when he coughs? Answer. No. Question. Is his cough worse at night or in the daytime? Answer. It's worse in the daytime. Question. Does he whoop at all? Answer. No. Discussion. Gentlemen, in all cases of coughing in children, don't overlook pertussis. In this case we're glad to hear that the stool is constipated, although the mother looks shocked. Children, especially the young ones, when they develop coughs or colds, show severe diarrheas and nutritional disturbances. The fact that this child hasn't reacted shows, first, that his intestinal tract is unaffected, and, second, that we needn't fear increasing his diet. Mother says he's hungry and would like more. If, however, he were having a diarrhea associated with this cough, we certainly shouldn't order an increase. The weight shows a loss of two ounces this week, yet the mother says he empties all his bottles. If he were having a diarrhea at this time, we might diagnose a mild dyspepsia. The fact that he's constipated ; that he empties all the bottles and still is hungry, makes us believe that his failure to gain is not due to any com- plication but simply to insufficient food. Directions. We'll order Milk 16 ounces Water. 16 ounces Sugar 7 teaspoonf uls Seven bottles. CLINICS 323 I warn you this is rather daring for children suffering with in- fections, but the fact that he looks and acts perfectly well notice his rosy color and his pleasant smile and that he is hungry, warrants, I believe, this increase. CLINIC IV. BABY 3 Age. Ten weeks. Mother says the baby is in fine condition. His bowels move once a day, sometimes twice. Weight. Eight pounds nine ounces, showing a gain of seven ounces in the last week. Temperature. 98.6 F. Examination. Negative. Directions. As long as he is gaining we'll make no change. CLINIC V. BABY 3 Age. Eleven weeks. Mother says the baby is in good condition, but thinks he is a little hungry. Weight. Nine pounds one ounce, showing a gain of eight- ounces during the week. Temperature. 98.6 F. Examination. Negative. Directions. As the gain is surely normal, better make no change in the feeding, except from seven to five feedings, with- out altering the total quantity. CLINIC VI. BABY 3 Age. Three months. Mother says the baby is hungry. Weight. Nine pounds four ounces, showing gain of only three ounces in the week. Temperature. -98.6 F. Examination. Negative. Directions. As he gained only three ounces this week, I think we are justified in ordering a slight increase in diet. He's now three months old. We either may increase the amount and 324 INFANT FEEDING (CHICAGO METHODS) thus the concentration of the milk exclusively, or we may in- crease the total quantity, leaving the concentration unchanged. As I like to limit the total to a quart, I'd suggest Milk 18 ounces Water 13 ounces Sugar 8 teaspoonf uls Five bottles. CLINIC VH. BABY 3 Age. Three months one week. Mother says the child has been crying all the time, that his bowels are "running off" about seven or eight times, with lots of mucus and curds. She thinks the increase in the diet was too much. He has severe colic and is not gaining. He doesn't want the bottle and vomits sometimes. Weight. Nine pounds four ounces. No gain this week. Temperature. 101 F. Examination reveals nothing except this notice how pressure on the tragus of the right ear makes him wince and cry. Discussion. Gentlemen, in 90 percent of cases by this method you can diagnose complications in the auditory canal or the middle ear. Don't attempt to penetrate the cranial cavity, but just exert the mildest sort of pressure. A perfectly normal baby will pay no attention. A baby who is crying, will con- tinue, but will do nothing else. This child, however, not only cries, but winces and jerks his head away sharply. We have, then, either a furuncle in the auditory canal or an otitis media. Examination. The otoscope reveals an inflamed ear-drum. Directions. This baby should see the ear doctor. And now we have a dyspepsia and colic, not directly from food, but secondary to otitis media. Shall we change the diet in this case? Not at all, because although there has been a fermenta- tion in the intestinal tract, this fermentation has not been severe enough to interfere markedly with the child's nutrition. He is not losing any weight; so, mother, for the present let the baby alone as regards his diet let him take what he wishes, feed him regularly, and see an ear doctor. He won't want much for a few days because he has fever; so don't try to force him. Use a few drops of a 5 to 10 percent solution of carbolic CLINICS 325 acid in glycerin in that ear every three to four hours for a day or two until you see the ear doctor. Use a few drops of pepsin in a teaspoonful of water for "the colic. CLINIC VIII. BABY 3 Age. Three and one-half months. Mother says the baby seems well. The ear trouble and dyspepsia have disappeared, and he is satisfied and happy. Weight. Nine pounds nine ounces, showing a gain of five ounces in the week. Temperature. 98.6 F. Examination. Negative. Directions. No change. CLINIC I. BABY 4 Dr. D. A. Stanton (High Point) Age. Eighteen months. History. Negative, other than that the child has been suffer- ing for six months from repeated attacks of otitis media. Temperature. 98.6 F. Weight. Twenty-three pounds. Physical Examination. This shows a pasty, pallid, rachitic child, who looks anemic and water-logged, although there is no edema. There are no adenoids nor large tonsils. Right ear discharging. Discussion. Gentlemen, I am no ear specialist. However, the child's general nutrition in a way might account for this condition. Of course, in such a child we must rule out tubercu- losis, syphilis, hookworm, nephritis, blood diseases, etc. Let's see if the feeding is a factor. Question. Mother, how have you been feeding the baby? Answer. I give him mostly milk. Question. Don't you give him anything else? Answer. Well, sometimes I give him a little hominy or mush or toast. Question. Anything else? No vegetables, eggs; anything like that? 326 INFANT FEEDING (CHICAGO METHODS) Answer. No, that is all he gets; sometimes a few Graham crackers. Discussion. I think that explains part of the difficulty. The diet of milk and carbohydrate, you remember, is the one caus- ing water-logging of the body, and you remember we spoke of the fact that children such as these seem to have a lessened im- munity to disease. I am glad of the opportunity to demon- strate such a case to you, because here we have a disturbance of nutrition not following a parenteral infection, but really pre- disposing to one. Directions. Let's refer the child to the ear doctor, but in the meantime get him on a well-regulated diet, and try to increase his general resistance and immunity. Of course, we'll order cod-liver oil with phosphorus. CLINIC I. BABY 5 Dr. A. C. Whitaker (Julian) Age. Six months two weeks. Weight. Thirteen pounds one ounce. Temperature. 100.6 F. Examination shows coryza, slight bronchitis, and a mud- colored skin. History. Negative up to the present. Baby has gotten the breast and a mixture of Milk 6 ounces Water 7 ounces Sugar 3 teaspoonfuls Six bottles. For two weeks he has had a soft diet. Mother thinks the feedings are not agreeing with the baby, who for the last few days has vomited, had diarrhea, with six or seven stools a day, and refused food. The baby has lost seven ounces during the week. Discussion. This sounds like a true dyspepsia. Of course, the loss of weight could arise from insufficient food, but we ques- tion whether a child who has been gaining normally up to the present would, all of a sudden, drop back seven ounces in one week. Vomiting, except in extreme cases, is rarely associated CLINICS 327 with underfeeding. Diarrhea may be present in inanition, as well as in other conditions, but from the general symptomatol- ogy, the loss of weight, the vomiting, the diarrhea, and the anorexia, we diagnose dyspepsia. The cause of the dyspepsia surely can't be the food upon which the child up to the present has been thriving, and we must seek it in other factors. Question. When did you start the soft diet? Answer. About a week ago. I gave a little cereal. Question. How long has he been coughing? Answer. He got sick about five days ago. Question. When did the diarrhea start? Answer. It started three or four days ago. Question. Are his cough and cold better or worse? Answer. The cough, I think, is better. Discussion. Here we have a parenteral infection occurring with the change in diet. The mother blames the diet. We believe, however, that the cough and cold predisposed the child to a mild fermentation in the intestinal tract, and that the re- action was just severe enough to make us careful. In a baby of this age on a soft diet secondary disturbances are not severe. In a study some time ago* we found that the best dietetic treat- ment for these secondary diarrheas in children on a soft diet is to let them alone and not to vary the diet too dogmatically. Directions. In this case the doctor will treat the cough and cold as he sees fit, and we'll leave the diet unchanged. Let the baby eat what he wishes. He won't eat very much for a few days, and by no means force him. To please the mother, let's order a little chalk mixture every three or four hours. CLINIC H. BABY 5 Age. Six months three weeks. Mother says the baby still has coryza, a bad cough, and won't eat. The diarrhea is better, but yesterday he had four rather loose movements. Weight. Thirteen pounds one ounce. No gain. Temperature. 100.2 F. Examination. Coryza and bronchitis. * "Studies on Parenteral Infections," Archives of Pediatrics, 1916, 671. 328 INFANT FEEDING (CHICAGO METHODS) Discussion. Gentlemen, the child has not gained during this past week. Probably he hasn't eaten as much as usual. The persistency of the bronchitis, with the associated fermenta- tion in the intestine, however, makes us hesitate about urging any forced feedings, particularly as mother says baby is not hungry. Let's wait another week until he gets over this cold. CLINIC m. BABY 5 Baby much better. Cough improved. Appetite returned. Weight. Thirteen pounds ten ounces. Gain of nine ounces. Examination. Negative. CLINIC I. BABY 6 Dr. A. F. Fortune (Greensboro) Age. Seven months. History. Family history negative. The child was breast fed up to one month, then received malted milk for five months, but didn't do well; was hungry and had diarrhea all the time. Came to the doctor yesterday for advice. He's better now. Temperature. 37 .8 F. Weight. Eleven pounds eight ounces. Examination shows baby only fairly nourished, with inelastic, mud-colored, thin skin which wrinkles easily, and flaccid muscu- lature. Discussion. As the doctor has ruled out tuberculosis and is positive there is no trace of lues in the family, and as an exami- nation has ruled out anything of a constitutional nature, the findings, with this history of improper feeding, establish the diagnosis of mild decomposition of the alimentary type. Directions. Just to contrast different methods of treatment, let's order a simple milk mixture and omit temporarily the soft diet. Mother give the baby Milk 20 ounces Water 11 ounces Sugar 3 teaspoonfuls Boil this, divide it into five bottles of six ounces each, feed the CLINICS 329 baby regularly once every four hours, and be sure to return next week. Discussion. Gentlemen, personally for all children over six months of age I prefer a soft diet, but I'll order this milk mixture so that you may compare the result here with those of Baby 1. CLINIC V. BABY 6 Age. Eight months. Mother says she didn't bring the baby back before because he gained so well for a few weeks she thought it wasn't necessary. For the last few days his bowels moved five or six times a day, he has vomited, and looks very puny again. No blood in the stools. Weight. Ten pounds, showing a loss of one and one-half pounds in four weeks. Temperature 97 .2 F. Examination. Negative as to causes other than feeding. Discussion. The reason for this loss in weight easily is ex- plained. You know the great importance of carbohydrate. We withdrew sugar for just a few days, intending to supplement it with cereals, zwieback, and other non-fermentable carbo- hydrates. However, mother didn't bring baby back, and now for four weeks, due to lack of carbohydrate, and of course to other food elements, too, he has been developing a severe de- composition. The onset of the diarrhea a few days ago shows the beginning intolerance to food, and he now is in worse condition than when we first saw him. Directions. We'll put him then on regulation treatment for decomposition. We'll reduce the concentration of the milk to about half- Milk 15 ounces Water 15 ounces Five bottles. We'll add non-fermentable carbohydrate to the mixture, approximately four teaspoonfuls of dextri-maltose, and to sweeten a little, I think it safe to add one or two teaspoonfuls of sugar. We'll give four ounces every three hours, and very care- 330 INFANT FEEDING (CHICAGO METHODS) fully start zwieback and cereal once or twice a day. We may also offer carbohydrate in the form of a little mashed potato. Return in a week. Question by Dr. Woodson. Did I understand you to say mashed potatoes for a baby of seven months in this condition? Answer. Yes, if very thoroughly cooked and mashed and given in small doses this is a convenient way of giving non- fermentable carbohydrate. Discussion. This was the child in whom we treated the condition of decomposition by an ordinary milk mixture instead of a soft diet. If the mother had returned, as she should have, the result would certainly not have been so unsatisfactory. Don't think that one will accomplish such poor results by the exclusive use of mik mixtures, but at any rate, on a soft diet, such an unfortunate occurrence could not have happened, for the child's demand for carbohydrate would have been covered by the cereals, potatoes, zwieback, and Graham crackers. CLINIC VI. BABY 6 Age. Eight months one week. Mother says the child is much improved; he is eating zwie- back and cereal, and she is keeping the milk formula as directed. Bowels move two or three times daily and are almost normal. Weight. Eleven pounds four ounces, representing a gain of one pound four ounces in a week. Temperature 98.4 F. Examination. Child better and brighter. Directions. No change in feeding is necessary. CLINIC Vm. BABY 6 Age. Eight months three weeks. Mother says the baby is doing nicely. Weight. Twelve pounds, showing a gain of twelve ounces in two weeks. Temperature. 98.6 F. Examination. Doing nicely. Directions. No change. CLINICS 331 CLINIC I. BABY 7 Dr. Thomas Anderson (Statesville) Age. Eight and one-half months. History tells us he is a premature, weighing three pounds at birth. After a few months of breast feeding mother lost her milk and gave Milk 10 ounces Water 12 ounces Sugar > . . 6 teaspoonf uls Seven bottles. He is hungry and suffers frequently from diarrhea. Temperature. 97 .6 F. Weight. Six pounds twelve ounces. Examination. Having ruled out tuberculosis and syphilis, examination shows nothing more than an extremely rachitic, anemic, undernourished child in a state of decomposition. Directions. You see the importance of a careful history. The fact that he is decidedly premature makes us very careful indeed, particularly as he is also in a state of decomposition. Let us wait a week and see what he is doing, except let's use dextri-maltose instead of sugar. CLINIC H. BABY 7 Age. Eight months three weeks. Mother says the baby shows no change that he still frets considerably. Bowels move three times a day. Weight. Six pounds twelve ounces, showing no gain. Temperature. 97.6 F. Examination. No change. Directions. Increase very carefully to Milk 14 ounces Water 12 ounces Dextri-maltose 6 teaspoonfuls Seven bottles. Discussion. In feeding prematures there are a few points to be considered: First, remember that in every case you should suspect lues not that you will find it, but you always must consider it. 332 INFANT FEEDING (CHICAGO METHODS) Next, if you are working with calories, prematures need more than do normal babies. Dr. Julius H. Hess, of our city, made a nice study recently, showing this higher requirement. This is easily understood, for the premature must gain not only as does a normal baby, but must make up back losses. An interesting point in feeding is brought out by Langstein. Up to this time the mortality of his prematures was very high. In many instances, when put to the breast, due to their great weakness, they tired before getting sufficient food, and from the resulting inanition, developed decomposition and death. Lang- stein found that, by forcing feedings either with a medicine- dropper or a stomach-tube, by getting more food into them, the mortality was greatly reduced. Gentlemen, if your pre- mature on the breast isn't gaining, don't waste time. Put him to the breast more frequently. If he still doesn't gain, force more food into him, either with a medicine-dropper or, if that fails, with a stomach-tube. In this baby we won't waste any time, but as his curve shows no gain, we increase at once. A valuable point is the following : Often the amount of breast milk necessary, overloads the stomach, causes vomiting, and defeats our purpose. This we readily may obviate by offering small quantities of buttermilk mixture a mixture of boiled buttermilk with 5 percent dextri-maltose. This is food of high concentration, and is indicated particularly in prematures, who seem to need especially protein and salts. However, remember that this combination is one of concentrated whey with carbo- hydrate, and is likely to induce intestinal fermentation and nutritional disturbances; so under no circumstances offer more than one-third or one-half of the total amount of breast milk given. Clinical observation has taught that prematures and many twins develop, almost invariably, during the third or fourth month, severe anemias and bad rickets. It was Czerny who first offered an explanation. Just consider for a moment the composition of breast milk. In one quart there is eV grain of iron and little over 7 grains of calcium. There is insufficient iron, barely enough calcium, to cover the needs of the child. Czerny suggested that during the last three months of intra- uterine life storage-warehouses of iron develop in the body. CLINICS 333 The main one seems to be in the liver. During the first months of life, while baby is on the breast, he doesn't live on the iron of breast milk but upon that in the body. In a like manner, Czerny suggested calcium warehouses, although the latter are not quite so well established as the former. Now you see, gentlemen, why prematures develop anemia and rickets. They have come into the world before these deposits have been developed, and the supply of iron and calcium in breast milk is insufficient for their needs. In a like way, twins suffer because they have to share their supply with each other. It is a good idea, as a prophylactic, in all cases of twins and prematures, to add, after the first few months, a little calcium, some cod-liver oil, and often some iron. If you practise these methods of prophylaxis, you will be gratified with your success. Severe anemias rarely develop, and rickets appears only in its milder forms. The same conditions exactly develop in those children fed too long on the breast. Don't think for a minute that breast milk is the ideal food for a baby over six to nine months of age. There is nothing wrong with breast milk, but it doesn't supply suffi- ciently, the ingredients necessary. Of course, some children cover their demands by taking a larger quantity of milk from the breast, particularly if the mother has an abundant supply, but you'll find that most normal children, if kept exclusively on the breast after nine months of age, will develop anemias and rickets, just as do prematures and twins. From these studies of physiology, you will understand why I have always insisted upon a mixed diet for every child of six months of age. The purpose is to provide for these known defi- ciencies, and also for some of those, perhaps, whose existence, though now unknown, may be revealed in future observation and experiment. In regard to calcium, how we give it is unimportant, provided we give it in the form the baby likes. I should suggest a mixture of Calcium lactate 1 H drams Syrup of orange, to make 4 ounces Two teaspoonfuls three times a day. This gives about six grains of calcium three times daily. 334 INFANT FEEDING (CHICAGO METHODS) The addition of cod-liver oil can be as follows: Ol. morrhuae Syiij Ol. phosph 3j SIG. Teaspoonful thrice daily after meals. As each teaspoonful contains one drop of oil of phosphorus, and as one drop of oil of phosphorus contains yiir grain of phosphorus, a teaspoonful of this mixture contains Tff grain of phosphorus. You also may use mixtures of cod-liver oil and malt. These mixtures aren't delicious, but if you persist, children take them well. As they sometimes impair the appetite, it is a good idea to give them after the feeding. On the other hand, if baby vomits, give before the feeding. Then, if the baby vomits, it makes no difference. Don't pay any attention to the vomit- ing, but keep up the treatment, and the majority of children learn to take it readily. In some cases it may be wise to start with 10 to 15 drops and slowly increase to a teaspoonful. CLINIC m. BABY 7 Age. Nine months. Mother says child is still hungry. Weight. Seven pounds, showing a gain of four ounces dur- ing the week. Temperature 98 F. Examination. No change. Still peevish. Directions. Milk 18 ounces Water 10 ounces Dextri-maltose 8 teaspoonfuls .Seven bottles. Continue calcium and cod-liver oil. CLINIC VI. BABY 7 Age. Nine months three weeks. Mother says baby is much better. Weight. Eight pounds four ounces, showing a gain of one pound four ounces in three weeks. Temperature. 98.8 F. Examination. Child better. CLINICS 335 CLINIC Vn. BABY 7 Weight. Eight pounds twelve ounces, showing a gain of 8 ounces during the week. Better. CLINIC Vm. BABY 7 Weight. Nine pounds, showing a gain of 4 ounces during the week. Directions. Give a little cereal and continue calcium and cod-liver oil. Slowly start a soft diet. Examination. A fine baby. No signs of rickets other than a slight rosary. CLINIC I. BABY 8 Dr. S. F. Pfohl (Winston-Salem) Age. Four and one-half months. History. Family and past history are negative, except that during the first two days of life the child had fourteen hemor- rhages from the bowels. These stopped upon injections of horse-serum. Since then he has been on the breast, but is gaining slowly and is very pale. Mother now has no milk and is giving Milk 10 ounces Water. 9 ounces Sugar 5 teaspoonfuls Six bottles. He is not gaining on this and is very constipated. Temperature. 97.6 F. Weight. Seven pounds three ounces. Examination. Rachitic baby of the decomposition type, with extreme pallor. Discussion. Gentlemen, here is an example illustrating in another way the points of the previous case. This child suf- fered at birth a great loss of iron from his system, and the feed- ings since are insufficient to make up this great loss. Directions. We'll increase his food slightly: Milk 14 ounces Water 8 ounces Sugar 6 teaspoonfuls Six bottles. 336 INFANT FEEDING (CHICAGO METHODS) We also will offer iron, as we would to prematures and twins; here, however, not as a prophylactic, but as actual treatment. The most convenient form is the saccharated carbonate. The ordinary dose is three to four grains, but for practical purposes it is sufficient to tell the mother to take as much as she can put on the end of an ordinary knife. Give this to the baby in a teaspoonful of water about three times a day. Children take it well. CLINIC II. BABY 8 Age. Four months three weeks. Mother says the baby is much better, but she is dissatisfied with the stools, which are green, watery, and contain curds. Three movements a day. The baby himself is happier and more contented. Weight. Seven pounds ten ounces, representing a gain of seven ounces in a week. Temperature. 98 F. Examination. Color hasn't changed much. Directions. As we are more interested in the baby than in the stools, and as he has gained more than we anticipated, we'll let him alone. Forget about the stools, and feed him just as you are doing. Return in a week. Continue the iron. CLINIC m. BABY 8 Age. Five months. Mother says baby is better and brighter in every way. Stools are normal. Weight. Seven pounds fourteen ounces. Gain of four ounces in a week. Temperature -98.2 F. Examination. No change except a bit of color in baby's cheeks. CLINIC IV. BABY 8 Baby improving nicely. Is now hungry again and consti- pated. Weight. Eight pounds one ounce. Gain, three ounces in the week. This is not sufficient and is an indication for more food. Temperature. 98 F. CLINICS 337 Examination. Child looks fresher. More color to cheeks. Directions. Continue iron. Increase diet to Milk 16 ounces Water 9 ounces Sugar 7 teaspoonf uls Six bottles. CLINIC I. BABY 9 Dr. R. E. L. Flippen (Pilot Mountain) Age. Four months. History. Family and past history negative. As regards feeding: He received condensed milk during the first two and one-half months. The mother couldn't nurse him, and at that time he suffered severe dysentery, with sixteen stools a day. These showed blood infrequently. For the most part they were thin and watery, with mucus probably not of the infec- tious type. From then until the present the child got Mellin's Food and barley water. He doesn't seem doing well, cries incessantly, and apparently the food is not agreeing with him. He is suffer- ing from no cough, fever, or other disturbance. The only symptoms seem to be indigestion, occasional vomiting, and frequent attacks of diarrhea. At present stools are about four to six a day green, watery, with mucus and curds. Temperature. 98 F. Weight. Ten pounds nine ounces. Examination. Almost the first glance tells us that he belongs to the disturbances of nutrition. You notice the flabby, in- elastic skin, its peculiar muddy color particularly about the .eyes and cheeks, and the bluish rings around the eyes. The sore buttocks suggest acid stools. Notice how he. puts his fist in his mouth. He doesn't cry, but he doesn't look happy. Notice the tenseness and rigidity of the muscles. This occurs often in children on one-sided carbohydrate diets. Of course, we must not jump to such a conclusion without ruling out diseases, as meningitis or birth paralyses, but examination, excepting for a few cervical glands of pea size, is absolutely negative. Diagnosis. We have here a mild decomposition. This child, however, is also in a condition of dyspepsia, and I am glad he 22 338 INFANT FEEDING (CHICAGO METHODS) came today, because he illustrates nicely the subject of the lecture. Treatment. Mother, in order to give his stomach and in- testines a rest, for the remainder of the day give him absolutely nothing but a little weak tea. You may sweeten it with a pinch of sugar, but just enough to sweeten it slightly. Question by Mother. How shall I give it? Answer. At his regular feeding hours, 6, 10, 2, 6, and 10 o'clock. Give him as much as he wants at these times, and nothing whatsoever between meals. Question by Mother. What kind of tea shall I give? Answer. Any tea at all that you use at home, green or black, provided you make it weak. Tomorrow start with a mixture of one-third milk: Milk 10 ounces Water 20 ounces Sugar 3 teaspoonf uls Five feedings. Keep him on this for two days, and then push him up gradu- ally by the end of the week to Milk 15 ounces Water 16 ounces Sugar 5 teaspoonf uls Five feedings. The doctor will see you during the week. To Doctor. You see, we started the baby on one-third milk, and ordered the mother to increase it in a few days. I think it would be a good idea to run in and judge how the baby is doing before the mother makes this increase. Let your index, to the best of your ability, be the weight curve, and if the baby ceases losing weight and seems better, make the increase. On the other hand, if he should lose rapidly and the diarrhea con- tinue, better wait for a day or two. If you have no access to scales, perhaps it would be wiser to go by the number of stools in this case, and not increase unless the stools have decreased to approximately three or four a day. In all our treatment we are influenced far more by the number of the stools than by the appearance of the individual stool. CLINICS 339 CLINIC H. BABY 9 Age. Four months one week. Mother says the baby is better and happier in every way. He is very, very hungry and not satisfied with the bottle he wants more he can't wait four hours; indeed, she gives him a little in between. The stools have diminished to three daily. Weight. Eleven pounds one ounce, showing a gain of eight ounces. Temperature. 98 F. Examination. Child looks fresher. Discussion. Gentlemen, we are far happier with the gain in weight than we are with the diminished stools, although, of course, both are very gratifying to us. We now have the child in such condition that his general nutrition is improving. Directions. I think, in such a condition, we can pay heed to the appeal of the mother and the baby and order an increase, as his present diet is, of course, insufficient. We '11 do this very carefully; but as the baby is gaining and happier in every way, I think we're justified. Let's increase to Milk 18 ounces Water 13 ounces Sugar 6 teaspoonfuls Five bottles. I risk this, gentlemen, because the baby is over four months of age, and the older the child, of course, the less susceptible, but you notice we keep the concentration of milk still not much over one-half. CLINIC m. BABY 9 Age. Four months two weeks. Mother says the baby is much improved. The stools vary from three to four a day. He is hungry. Weight. Eleven pounds four ounces, showing a gain of three ounces in one week. Temperature. 98.2 F. Examination. As before. Directions. As he cries considerably; as the scales show in- 340 INFANT FEEDING (CHICAGO METHODS) sufficient gain and the intestinal tract is in better condition, we increase to Milk 20 ounces Water 11 ounces Sugar 6 teaspoonf uls Dextri-maltose 3 teaspoonf uls Five bottles. We add dextri-maltose, as it is not so sweet as cane-sugar and because it is less fermentable. CLINIC V. BABY 9 Age. Five months. Mother says the baby is doing nicely, but for the last week he has been crying considerably. He doesn't vomit; has no colic; but just cries all the time. He has no cough, fever, diarrhea. He stops crying if she picks him up. Weight. Twelve pounds one ounce, showing a gain of thir- teen ounces in the last two weeks. Temperature. 98.8 F. Examination. As regards temperature, foci of infection, otitis, pharyngitis, and urinalysis, negative. Discussion. Gentlemen, we have here a baby who seems to cry all the time. Organically there is nothing wrong. Can it be the cry of hunger? No, for the child has gained thirteen ounces in two weeks. Can it be the cry of indigestion or over- feeding? No, for there has been no vomiting and the stools have been normal. The crying is not related to meals. We are tempted to believe the following : He is an only child. Ex- perience has taught that the mother of an only child usually is an exceedingly nervous individual. She fusses continually, carries him more than he should be carried, and often excites him. Is that true, mother? Mrs. Jones (nurse) states : I guess we'll have to admit that the mother is really very anxious, and certainly the baby has stopped crying whenever she picks him up. Discussion. Gentlemen, listen to that crying. It is not that of pain; it is characteristically that of temper. See the value of the weight curve! It is a greater guide to us even than baby's CLINICS 341 disposition, though of course the latter is of value also. If we were guided in our feeding mainly by the child's temperament, we should have changed the diet in this case. Mother, pick up the baby and show us how to cure him. Treatment. Mother instructed not to worry about the baby's crying; told that the cry is one of temper, and urged to let him cry to his heart's content for a few days. CLINIC VIL BABY 9 Age. Five months two weeks. Mother says the baby is better. He cries much less, but she finds it difficult to restrain herself from picking him up. Weight. Twelve pounds fifteen ounces, showing a gain of fourteen ounces in two weeks. Temperature -98.8 F. Examination. Negative. Directions. No change. CLINIC I. BABY 10 Dr.. F. Raymond Taylor (High Point) Age. Four months. History. Negative, other than that he is a condensed milk baby ; but since taken to Dr. Taylor last week he has received half milk and half water, with 3 percent dextri-maltose, a total of 24 ounces a day. Previously he had considerable diarrhea, but now his stools seem normal. He's much better, and the mother says there is nothing acute the matter with him simply he isn't thriving. Temperature. 97 .6 F. Weight. Nine pounds. Examination. A pale, flabby child. Notice the emaciation. Peristalsis can be seen through the abdominal wall. See how he puts his fingers into his mouth ! However, we have one good sign here. Although he's a puny little fellow, he smiles. Here again, as long as we have ruled out tuberculosis, syphilis, nephri- tis, and cystitis, and as physical examination is absolutely nega- tive, particularly as the history is one of improper feeding, this child belongs to the group described as decomposition. 342 INFANT FEEDING (CHICAGO METHODS) Question. Mother, is he hungry? Answer. Yes, he certainly would take more. Directions. Well, let us give him a little larger quantity. Remember, though, it is wiser to offer a mixture not so concen- trated as for a normal child. Understand, gentlemen, for such children the ideal mixture is albumin milk, but as we can't obtain it, we have to use an ordinary milk mixture. This is much less efficient. Let us order: Milk 15 ounces Water 16 ounces Dextri-maltose 8 teaspoonf uls Seven bottles. CLINIC H. BABY 10 Age. Four months one week. (Does not return to Clinic.) The nurse says the baby is gaining satisfactorily according to an outside scales, and his stools are normal, but he seems hungry, and asks if she may increase the diet. Weight. Not obtained. Temperature. Not obtained. Discussion. Gentlemen, whenever a baby is gaining it is unwise to increase, especially in these cases of marked decom- position, if you cannot see the baby personally. Directions. I don't believe I'd make any change, except possibly a slight increase in carbohydrate. As the stools are normal, we might give nine teaspoonfuls of dextri-maltose in- stead of eight. But let us keep the concentration of the milk unchanged. As he's better, we might ease the mother's work by ordering five feedings, but under no circumstances change the total quantity in twenty-four hours. This means the baby will get five feedings of approximately six ounces each. CLINIC IV. BABY 10 Age. Four months three weeks. Mother says the baby is very sick. He's had "running off " of the bowels, seven or eight movements a day, and has been vomit- ing a lot. She is sure he lost weight. His food for the past three days is not agreeing with him at all, and she wishes some- thing else. CLINICS 343 Weight. Eight pounds fourteen ounces, showing a consider- able loss, for the child weighed nine pounds three weeks ago, and had been gaining considerably. Temperature. 97 F. Examination. One glance shows a severe nutritional dis- turbance. The skin, which three weeks ago showed returning elasticity, fulness, and color, again is inelastic and wrinkly. The child has shrunken in every way. There are circles under the eyes. The smile is no longer present. He appears anxious and miserable. The cheeks are sunken, and generalized rigidity is marked. There is no coryza, no bronchitis, no tenderness over the ears, no redness in the throat. There is no evidence of parenteral infection. Here we have a decomposition baby in the state of dyspepsia, almost verging on intoxication. Discussion. Mother says the food is not agreeing with him. This statement I am not prepared to admit, for a food upon which a child is thriving will not all of a sudden become in- jurious without the introduction of some other factor. Here our scales are a check, and they told us definitely that up to a few days ago baby had been gaining. We must seek some other factor, because the very slight change in the diet we made two weeks ago would not have had such a marked effect and cer- tainly not ten or eleven days after it had been ordered. Indeed, we ordered a slight change only, feeling we wouldn't be justified in anything more radical without seeing the baby. Question. Mother, has he coughed or sneezed or had a cold, or has he been putting his hands to his ears during the last week before his trouble started? Answer. No, I haven't noticed that. He coughed once or twice and he cried a lot. Question. Did he cry before or after the trouble started? Answer. He cried after. Discussion. Gentlemen, we are strongly tempted to lay the blame to this little cough, but I don't think we are justified. It was too mild. Still I don't want to censure the milk mixture. What other outside factors might be important? Question. The weather hasn't changed much. Are you dressing the baby any differently than you did? 344 INFANT FEEDING (CHICAGO METHODS) Answer. No, during these hot days he wears just his shirt and diaper. Discussion. Heat retention, then, can't be a factor. Pos- sibly the mother has misunderstood instructions. Let's see if she is following the technic of feeding accurately. Question. Mother, tell us exactly how you are feeding the baby. Answer. Well, I did just as you told me. I increased the food, and gave him six ounces in each bottle as I was directed. That is just what we ordered. Question. How often did you give it? Answer. Every three hours. Question. How often? Answer. Every three hours. Discussion. Well, there's the trouble. You remember, gentlemen, last week we changed to the four-hour schedule so as to make it easier for the mother. We increased the amount to six ounces in each bottle, but we did not increase the total quantity in twenty-four hours. Mother has been feeding six ounces every three hours, which means a total of forty-two ounces of food, and we ordered only thirty ounces. So we have a severe dyspepsia developing from overfeeding in a decomposi- tion baby. There is nothing wrong with the food itself. The trouble was too much food. Now we must treat a decomposition baby plus a case of severe dyspepsia. I wish we had albumin milk. We give nothing but tea until tonight; then one-third milk, as Milk 10 ounces Water 20 ounces Dextri-maltose 4 teaspoonf uls Divide this into seven bottles of four ounces each. Now, mother, don't give over four ounces at a feeding. In a day or two we shall increase the concentration, so that by four or five days he'll get Milk 15 ounces Water 15 ounces Dextri-maltose 6 teaspoonfuls Seven feedings. CLINICS 345 Remember this means four ounces every three hours for seven feedings in a day. Question by Mother. In a day do you mean day and night? Answer. Seven feedings in twenty-four hours. CLINIC V. BABY 10 Age. Five months. Mother is dissatisfied; she says the baby is better, but still vomits. Stools are three or four daily. Weight. Nine pounds one ounce, showing a gain of three ounces in the week. Temperature. 98 F. Examination. Absolutely no change. Discussion. The child has gained three ounces this week. The bowel movements have improved; the child looks better. The fact that the weight curve is rising proves that this gastric disturbance is not affecting his nutrition. As we get no history of parenteral infection, and as our examination is negative, we ask again, " can it be possible that the mother still is not follow- ing directions?" Question. Mother, tell us exactly how you are feeding the baby. Answer. I make double the amount you told me. Question. How much did we tell you? Answer. Milk, 15 ounces; water, 15 ounces; dextri-maltose, 6 teaspoonf uls, in seven feedings of four ounces. Question. That's right; but why twice the amount? Answer. I've got two babies at home, and so it is easier. Question. Has this child been satisfied with four ounces? Answer. No, he wants more. Question. Don't you sometimes give him a little of his brother's bottle, mother? Answer. Well, sometimes I do. Question. How much? Answer. For the last few days I gave him five ounces? Discussion. Gentlemen, here you have the same trouble over again. Last week we treated this dyspepsia by food with- drawal, and then, as the child was in a state of decomposition, 346 INFANT FEEDING (CHICAGO METHODS) we were particularly careful about increasing. The baby evi- dently improved on this treatment, for he gained weight. Now, however, mother is pushing the quantity too rapidly, and this vomiting is a symptom of another beginning overfeeding dys- pepsia. In this case it is unnecessary to withdraw food entirely because the baby is gaining. I think if we limit the amount and lessen it just sufficiently to stop the vomiting, the result will be satisfactory. So, mother, if you want the baby to get well you simply must follow our instructions. We told you to give seven feedings of four ounces, and no matter how much he cries, under no circum- stances give him any more. Come next week. CLINIC VI. BABY 10 Age. Five months one week. Mother says the child still vomits, but somewhat less than last week. For three days he's had diarrhea, with seven or eight watery stools a day, cries, and has colic. Weight. Nine pounds, showing a loss of one ounce in the week. Temperature. 99.4 F. Examination. Coryza. Discussion. The weight curve has remained almost hori- zontal. The stools show intestinal fermentation. So here we have a mild dyspepsia. Question. Mother, how long has the baby had this cold? Answer. For four days. His nose runs all the time. Question. Did he have fever? Answer. Yes, I think he had a little fever. Question. Is he better now? Answer. Yes, he's some better. Discussion. Gentlemen, the history here is typical, i. e., a decomposition baby, susceptible as he is to every external in- fluence, to heat, to cold, to infections, being attacked with a slight coryza. One day later he reacts with diarrhea. Such children are usually very sick and develop severe nutritional disturbances. Here, however, our weight curve makes a rela- tively good prognosis. The very slight drop shows us that we CLINICS 347 have a milder disturbance, only a dyspepsia, and not a severe form of that. A loss of one ounce in a few days is of no grave significance. In such a case, two courses are open. If we could see the patient every day, we might leave the milk as it is, or even in- crease it slightly, and at the same time withdraw the carbo- hydrate. This would give us high protein and low sugar in the intestinal tract, i. e., factors favoring putrefaction and overcom- ing fermentation. The stools would become constipated, but the child would react with a considerable loss of weight, for his tissues would feel the loss of the carbohydrate. The same result could be accomplished with the use of buttermilk. Then, in a day or two, we'd carefully and gradually increase the sugar to answer the tissue requirements. In this case, however, co- operation in the home is none of the best. We may not see the child for two weeks. Total withdrawal of sugar for so long would probably be fatal; and again an injudicious and too rapid increase, with some fermentation already present in the intes- tine, might produce an intoxication. I think the alternative, though apparently somewhat reckless, will be safer in this in- stance. Let's take into consideration that we may not see this patient for some days, and by that time his body tissues will need, roughly, three percent carbohydrate. Let's avoid the possibility of any error in the home and so order that much at once. From this amount, however, some intestinal fermenta- tion will doubtless arise, and so we'll try to provide for it by ordering putrefactive, alkali-forming reagents, in the hope of preventing intestinal damage. Let us add to the above mix- ture, curds of one pint of milk, ground very thoroughly through a sieve; in addition, a few teaspoonfuls of chalk mixture every few hours, and I believe with these alkali-forming agents we may increase the dextri-maltose to eight teaspoonfuls, thus attempting to give the body tissues the carbohydrate which they need. This child is on the border line, however. If at all possible, the doctor should see him every few days, and any evidence of a further drop in the weight curve must be taken as diagnostic of a severer dyspepsia, and typical treatment insti- tuted. 348 INFANT FEEDING (CHICAGO METHODS) CLINIC VH. BABY 10 Age. Five and one-half months. Mother says the baby is much improved. Bowels three a day and still loose, but he seems happy and much more content. Weight. Nine pounds six ounces, showing a gain of six ounces in the week. Temperature -98.8 F. Examination. Looks better. Directions. No change. In a short time we'll add cereals. CLINIC I. BABY 11 Dr. J. H. Boyles (Greensboro) Age. Nineteen months. History. Family and past history are negative. He's been a bottle baby since two months of age, when mother lost her milk. Eagle Brand Condensed Milk was given, and he did well for some time. For several months he has received cow's milk and Graham crackers, potatoes, and soup. For some time he hasn't been doing well. He's not thriving; has frequent in- digestion, and is very puny. The mother brought him three days ago because of severe diarrhea, with 15 to 20 watery stools a day. There was no blood in these stools; they were green, smelled sour, had mucus and curds. He was feverish, seemed losing weight, vomited considerably, and lay in a stupor most of the time. He was very sick. The doctor ruled out all constitutional disease, parenteral infections, tuberculosis, and syphilis. Due to the long history of improper feeding and the absence of blood and pus in the stools, he thought definite enteral infection unlikely. Urinaly- sis was negative, and he made the diagnosis of alimentary in- toxication complicating a condition of decomposition. Examination. This shows a child in a miserable state of nutrition; feeble, peevish, and irritable. The skin is dry, wrinkled, and thin. The musculature is atrophied and rather rigid. Weight. Sixteen pounds six ounces. Temperature -98 F. CLINICS 349 Discussion. Gentlemen, although diarrheas in children of this age more frequently are due to watermelon, raw sweet potatoes, peanuts, anything the child may lay hands on, I think the diagnosis in this instance is absolutely correct. Here is a history of decidedly improper feeding, leading to decomposi- tion. The primary gain on condensed milk was due, of course, to the sugar, and additional feeding of Graham crackers and potatoes furnished still more carbohydrate. There has been nothing to cover the child's demand for protein, for salts, pos- sibly for fat. Soups, you know, have no food value other than the salts they contain. Question by Dr. Beal. Do you mean to say that soups are not nourishing? Answer. The ordinary soup which we offer has no food value; it contains simply the extractives of the meat and leaves the nourishing part behind. We feed soups to supply salts and to stimulate the appetite. Children like them, but as regards food value, they are unimportant. The treatment the doctor ordered in this case seems absolutely perfect. He ordered tea for twenty-four hours. Following this, in the absence of albumin milk, and because a child of this age, and even as sick as this child was, unquestionably can tol- erate mixtures of cow's milk, the doctor ordered a mixture of Milk 15 ounces Water 15 ounces Dextri-maltose 6 teaspoonfuls On this treatment the child is better and happier and the diarrhea has improved greatly. But, gentlemen, notice how he keeps his hands in his mouth; notice his puny size, his thin, flabby, inelastic skin. Notice the extreme emaciation and rigidity of the muscles characteristic of these children on one-sided carbohydrate diets (this is a typical picture of Czerny's starch injury). See how the emacia- tion reveals general adenopathy, as in tuberculosis! The rig- idity is so marked as to make us think of Little's disease. These conditions the doctor has ruled out, and the weight of sixteen pounds six ounces shows the miserable state of nutrition, and confirms our diagnosis of decomposition. Here, then, we have 350 INFANT FEEDING (CHICAGO METHODS) a child in the state of decomposition who, for some unknown reason, developed an intoxication. This complication has been successfully treated, and now it is up to us to correct the state of decomposition. As the acute disturbance is past, let us give more food. Directions. We'll keep the milk in dilute concentration. Then we safely can give more carbohydrate in a non-ferment- able form: as farina, corn-starch, arrow-root, mush, tapioca, or Cream of Wheat. We may give a little mashed potato. I think I'd omit oatmeal, which is the most easily fermentable cereal. To supply salts we add vegetable purees. To supply protein, and in this case also to keep the intestine alkaline, we add pure cottage cheese, or, if this is not obtainable, simply the curds of milk. In a baby of this age we may offer finely scraped meat, such as a chicken or lamb-chop. We may add custard and zwieback. I think I would feed this child a little oftener than the normal schedule, namely, every three hours, seven feedings in twenty-four hours, and remember, increase very slowly and cautiously. By no means give him everything in one day, or large quantities of any particular food. CLINIC H. BABY 11 Mother says the child is much better and happier. His bowels move only three times daily. Weight. Seventeen pounds ten ounces, showing a gain of one pound four ounces in the last week. Temperature. 98.8 F. Examination. Looks better, brighter, and happier. Discussion. Considering the above gain in weight, we don't need to complain about the therapeutic results ,in this case. The child now is eating a little egg, potato, meat, Graham crack- ers, cereals, and milk, and seems on the road to complete, re- covery. Directions. Put him on five feedings. CLINIC HI. BABY 11 Mother sends in report that baby is doing nicely. CLINICS 351 CLINIC I. BABY 12 Dr. H. H. Ogburn (Greensboro) History. Baby is three months old. Family and past his- tory negative. The baby was breast fed every two hours since birth; was always hungry, always fretful, never thriving; he has no diarrhea, but is puny and not gaining. Temperature. 97.4 F. Weight. Six pounds twelve ounces. Examination. This shows a baby of the typical decomposi- tion type, with wrinkled skin and cold hands and feet. Diagnosis. Although the appearance is that of decomposi- tion, we have learned in breast-fed children to establish the diagnosis rather of inanition. Directions. Having, by examination and tests, ruled out conditions other than feeding, we'll treat this child as a case of inanition. We'll order seven nursings in twenty-four hours, the mother to allow the child five minutes for the breast and then ten minutes for the bottle. We don't know how much this child will take in each bottle, but, as a guess, two ounces. This would make a formula of, roughly Milk 7 ounces Water 8 ounces Dextri-maltose 4 teaspoonfuls Seven bottles. CLINIC H. BABY 12 Age. Three months one week. Mother says the child is better, cries less, and seems happier. The bowels are still loose, however about three a day. Weight. Seven pounds four ounces. Gain of eight ounces in a week. Temperature .97 '.8 F. Examination. Looks better. Directions. As this is such an excellent gain in this puny child, we'll make no change. 352 INFANT FEEDING (CHICAGO METHODS) CLINIC m. BABY 12 Age. Three months two weeks. Mother says the baby has four or five green, watery bowel movements each day. He doesn't desire much food and has been peevish and irritable. Weight. Seven pounds four ounces, showing no gain this week. Temperature -98.2 F. Examination. Negative. There is no parenteral infection, and the child doesn't look unhappy. The skin, however, isn't quite as fresh looking as last week, and there are suggestions of rings under the eyes. Discussion. Gentlemen, here we have one of the conditions in which perplexity may arise. Are these watery, green bowel movements of significance or are they not? The weight curve during this week is perfectly straight. Is this due to under- feeding, and will the curve and stools improve upon increase of diet, or have we a beginning dyspepsia? The fact that he doesn't desire food makes us cautious, and I think it wiser to hold him as he is. The fact that he gained well last week eight ounces makes us in no particular hurry, and if this be an incipient dyspepsia, due to some outside factor, possibly a cystitis, it is wiser to make no change for a few days and note the reaction. Meanwhile we await urinalysis. Directions. Mother must be very careful to feed the baby just exactly as we directed, and if he doesn't want all his food, take the -bottle from him. Don't force it! Bring him next week. CLINIC IV. BABY 12 Age. Three months three weeks. Mother says baby is much better but seems hungry. Stools are three a day and a little loose. Weight. Seven pounds twelve ounces, showing a gain of eight ounces in the last week really in two weeks. Temperature. 98 F. Examination. Child looks fresher. Urine reported negative. Directions. As there was no gain in the previous week, and CLINICS 353 as he seems hungry and is well in every other respect, I think we are justified in increasing slightly. Let's give, in addition to the breast, Milk 9 ounces Water 9 ounces Mellin's Food (as the mother cannot get dextri-maltose) 6 teaspoonfuls Seven feedings. CLINIC VI. BABY 12 Age. Four months one week. The baby is happy in every way and doing nicely. Weight. Eight pounds eight ounces, showing a gain of twelve ounces in two weeks. Temperature. -98.6 F. Examination. Child looks bright, happy, and contented. Directions. No change. CLINIC I. BABY 13 Dr. Ed. King (Statesville) Age. Three months. History. Family and past history negative. Twelve other children living and well. The baby is brought for vomiting, which has persisted since birth. He gets the breast every half- hour. Temperature -97 .6 F. Weight. Nine pounds. Examination. A fine, healthy, happy baby. Discussion. Persistent vomiting since birth makes us think of pyloric stenosis. However, if such were the case, the child's nutrition would be markedly affected. One look rules this out. Vomiting from parenteral infections wouldn't have persisted so long. I'm inclined to think the vomiting is due to the improper technic of feeding. Perhaps the baby is underfed and mother puts him to the breast every half-hour to appease him. Of course, continual insult to the stomach makes it rebel. Directions. Let us put him on regular nursings twenty minutes every three hours, seven feedings in twenty-four hours and await the reaction. 23 354 INFANT FEEDING (CHICAGO METHODS) CLINIC H. BABY 13 Age. Three months one week. Mother says baby has ceased vomiting, but is very consti- pated, fretful, and peevish. Weight. Nine pounds, showing no gain this week. Temperature. 97.6 F. Examination. No change. Discussion. Failure to gain, with no vomiting, no diarrhea, and with constipation, establishes .the diagnosis of inanition. Directions. Add after nursing : Milk 4 ounces Water 4 ounces Sugar 1 teaspoonf ul Seven bottles. CLINIC m. BABY 13 Age. Three months two weeks. Baby still hungry no vomiting. Weight. Nine pounds two ounces, showing a gain of two ounces in a week. Directions. Increase diet to Milk 8 ounces Water 8 ounces Sugar 3 teaspoonf uls Seven bottles. CLINIC IV. BABY 13 Mother sends in report that baby is doing very well indeed and seems satisfied and contented. CLINIC I. BABY 14 Dr. A E. Bell (Mooresville) Age. Four months. History. Family and past history negative. Baby was breast fed for one month. Mother lost her milk and gave Mellin's Food with cow's milk. Due to work in the fields, she has never given him proper care, leaving him to grandmother, CLINICS 355 who doesn't know definitely the details of the diet. The baby was brought to Dr. Bell a few days ago on account of severe diarrhea, with green, watery, sour-smelling stools containing mucus and curds. Although this was an acute attack, the child had been ailing for a long time. He is better now, but still very weak. Weight. Seven pounds less than when he was born. Temperature. 97 F. Examination. Physical examination other than extreme emaciation and weakness is negative. Pirquet and urinalysis are negative. The family history gives no reason for suspecting lues. It is a case of marked decomposition. Directions. In such an extreme case we prefer infinitely breast milk or albumin milk. An ordinary milk mixture is far less efficient. Indeed, I doubt whether we shall accomplish much. Question. Grandmother, is there any possibility of getting any breast milk from your neighbors? Answer. Yes, Mrs. Miller just had a new baby and I might get a little from her. Question. Do you suppose that you could get an ounce every two hours? Answer. I think so. Well, then, give the baby an ounce at 6, 8, 10, 12, 2, 4, 6, 8, 10 o'clock and once or twice during the night. Be sure to warm the milk to body temperature before using, and feed the baby absolutely regularly. Don't let him have the bottle over ten or fifteen minutes. Discussion. Gentlemen, this child is sick enough to need stimulation. He would* be better in a hospital. Failing such,' I doubt if we'll be able to accomplish much in the home. We know that proper care and proper nursing are equally as important as certain formulae. I haye grave fears, as you yourselves probably have, after noticing grandmother's hostile demeanor, that our instructions may not be carried out. When- ever grandmother looks skeptical, she probably intends intro- ducing methods of her own. I don't believe she approved of our advice. * 356 INFANT FEEDING (CHICAGO METHODS) CLINIC H. BABY 14 Age. Four months one week. Grandmother states baby is better, that his bowels are all right and his appetite good. Weight. Seven pounds four ounces, showing a gain of four ounces in one week. Temperature 98 F. Examination. No change. Discussion. Gentlemen, you remember last week we dis- cussed the importance of care in the home, and wondered how frequently our directions really were carried out. It always is interesting to learn if baby really has improved on our feedings, or if some change of diet which the nurse never admits is the fundamental reason. Question. Grandmother, tell us just exactly what you gave the baby. Answer. Well, doctor, to tell the truth, I was able to get more breast milk from Mrs. Miller than I thought; so I gave the baby four ounces instead of one. Question. How often did you give this, grandmother? Answer. Well, I tried to give it every two hours. Question. You don't mean that you gave the baby four ounces every two hours? Answer. Perhaps not every two hours, but somewhere near there. Question. How much are four ounces? Answer. I didn't measure exactly, but Mrs. Miller said she thought there were four ounces. It quarter filled my glass. Discussion. Gentlemen, you see how many factors come into infant feeding, and how often we draw absolutely false conclu- sions. In this instance grandmother says she offered four ounces, but probably the baby got only two. One fact remains, how- ever, the baby gained. For this let us be grateful ; so, as long as he's gaining, we'll be justified in violating dogmatic routine and continuing the amounts which grandmother offers. I believe you will agree with me that in this case it is impossible to demand an exact routine. So, grandmother, as long as the baby is gain- ing, feed him as you are doing, but try to be regular, and measure CLINICS 357 in the bottle just how much you are giving, because that will help us greatly. Try to feed him every three hours 6, 9, 12, 3, 6, 9 o'clock, and once during the night, and tell us next week how many ounces he takes, as you measure it in your bottle. CLINIC m. BABY 14 Age. Four months two weeks. Grandmother says the baby is better. Weight. Eight pounds, showing a gain of twelve ounces in the week. Temperature 98.4 F. Examination. Negative. Notice how much fresher and^ hap- pier he looks, and, above all things, notice the returning elas- ticity to the skin and the decided change in color. This child is doing nicely. Question. Grandmother, how are you feeding the baby? Answer. I am feeding him just exactly as you told me. He seems satisfied, and I think he's much better. He gets three ounces each feeding. CLINIC IV. BABY 14 Age. Four months three weeks. Grandmother says the baby is doing as well as can be ex- pected. He seems more cheerful, but she can't see much change in his weight. Bowels move two or three times a day. Weight. Eight pounds four ounces, showing a gain of four ounces. Temperature. 98.6 F. Examination. Baby looks better. Discussion. Well, gentlemen; we didn't expect a very notice- able change in such a tiny baby, but the scales show a gain of four ounces. This isn't bad. Question. Grandmother, what have you been giving this week? Answer. Well, I can only get breast milk once in a while, and so I gave five ounces whenever I could get it, and the rest of the time condensed milk. 358 INFANT FEEDING (CHICAGO METHODS) Question. How much breast milk did you give him in twenty- four hours? Answer. I don't think I got much more than five or ten ounces. Question. And the rest of the feeding was condensed milk, was it? Answer. Yes. Question. How much in each bottle? Answer. I guess about five ounces. Discussion. You see how careful we must be at all times. If we hadn't learned this, we should have attributed this gain to breast milk and would have been pleased. You remember the dangers of condensed milk how a child gains temporarily from the high amount of carbohydrate, but that this gain repre- sents water-logging of the body rather than true gain in tissue substance. So, although he apparently put on four ounces, we're not satisfied. If we must use artificial food, let us use a regular milk mixture. Doctor, will you explain to grandmother during the week the dangers of condensed milk feeding and let us figure on a milk mixture of Milk 10 ounces Water 22 ounces Dextri-maltose 8 teaspoonf uls Seven bottles. This will make seven feedings in twenty-four hours, of four and one-half ounces each a little more than I ordinarily would order, but as grandmother has been giving five ounces every three hours, I think we're safe. I'd give just as much breast milk as possible at each feeding. Then offer a bottle for ten minutes. Let him take as much as he wishes, and after ten or fifteen minutes, if he hasn't finished, take it away and make him wait until the next feeding time. CLINIC V. BABY 14 Age. Five months. Grandmother says he is better, but hungry. CLINICS 359 Weight. Eight pounds eight ounces, showing a gain of four ounces in the week. Temperature 38.4 F. Examination. No marked change. Discussion. Gentlemen, in a child as poorly nourished as this one we mustn't push feedings too rapidly, particularly where we're not sure of the nursing "cooperation in the home. I believe as long as he's gaining we should leave him for two or three days, and then, if he seems very hungry, we might in- crease to perhaps Milk 13 ounces Water 19 ounces Dextri-maltose 8 teaspoonfuls L_ Seven bottles. and perhaps toward the end of the week Milk 15 ounces Water 17 ounces Dextri-maltose 8 teaspoonfuls Seven bottles. CLINIC VI BABY 14 Age. Five months one week. The baby had a diarrhea this week, but now bowels move only once or twice a day. Careful questioning shows that grand- mother overfed the baby, and of herself removed food, thus treating successfully the resulting dyspepsia. Weight. Eight pounds four ounces, showing loss of four ounces during the week. Temperature 98 F. Examination. No change. Directions. Continue to feed the baby as ordered, giving Milk 15 ounces Water 17 ounces Mellin's Food (as grandmother can't get dextri- maltose) 1 ounce Seven bottles. 360 INFANT FEEDING (CHICAGO METHODS) CLINIC VH. BABY 14 Age. Five months two weeks. The diarrhea has gone, and the bowels move once a day and are hard. The baby is hungry, however. Weight. Eight pounds three ounces, showing a loss of one ounce during the week. Temperature -98 F. Examination. No change. Directions. Increase the feeding to Milk 18 ounces Water 16 ounces Mellin's Food 9 teaspoonfuls Seven feedings. CLINIC VIE. BABY 14 Child much better. Weight. Eight pounds twelve ounces, showing a gain of nine ounces in the week. Directions. No change. In a few days start cereal. CLINIC I. BABY 15 Brought by Dr. W. P. Knight (Greensboro) Age. Two years two months. History. Family and past history negative. The complaint is very marked constipation. The child wouldn't have a bowel movement oftener than every three or four days if castor oil or enemas weren't given continually. Weight. Not taken. Temperature. 98.8 F. Examination. Negative. Discussion. Gentlemen, in trying to diagnose the cause of this"condition let us think of the simplest things first. Let us see exactly what baby has been eating. Question. Mother, how do you feed the baby? Answer. I give him meat, one and sometimes two eggs a day, a little broth, some toast, once in a while some corn-starch or Cream of Wheat, and once or twice a week a baked apple. CLINICS 361 Question. Don't you give him anything'else? Answer. No. Question. Don't you give him any vegetables? Answer. No, my book on feeding said I shouldn't use any vegetables until he was over two years of age. Discussion. Gentlemen, you see how simply we meet many of the problems in pediatrics? You see the value of a little simple physiology? Remember, in the early lectures we spoke of fermentation and putrefaction. Meat and eggs, which form a large part of this baby's diet, are protein and cause an alkaline intestinal reaction. The carbohydrate which the baby gets is of the starchy type, and normally will not produce much fer- mentation. Again, there are no vegetables not enough cellu- lose to leave a residue in the intestines. I think the treatment is to put this child on a perfectly full diet, perhaps reducing the meat and eggs slightly, giving more cereal, particularly oatmeal. By all means give plenty of vegetables, even the coarser ones, such as mashed cabbage and turnips. Give baked apple or apple-sauce every day, all kinds of stewed fruits, and, in short, feed the baby almost everything that you would feed an adult, with the exception, of course, of the very heavy things, and with the provision that whatever you give must be cut up fine. I would lay particular emphasis upon vegetables and stewed fruits. Graham crackers are considered laxative. Now, of course, this baby won't react tomorrow, and so, until we get him adjusted, he will be constipated. Under these cir- cumstances let him go for perhaps two days, and then give an oil enema. Under no circumstances give him any more pur- gatives. A valuable aid in children of this age is a combination of raw prunes, dates, figs, and raisins. These are put through a meat- grinder, or finely chopped in a chopping bowl, and formed into little candy balls. Roll them in a little powdered sugar and they look like candy. In this case we may need some malt soup extract and may be some mineral oil also. 362 INFANT FEEDING (CHICAGO METHODS) CLINIC I. BABY 16 Brought by Dr. C. W. Woodson (Salisbury) Age. Fifteen months. History. Negative except for the following: The child re- ceived the breast for fourteen months, plus a mixed diet from the eighth. After thriving until ten months he developed measles and whooping-cough. During the following weeks he lost weight and became puny, but his bowels were all right. Then he got a severe diarrhea, with some blood in the stool. The family physician treated him with broth and albumin water for five days. Although the diarrhea stopped, he got much worse on this diet. Another physician was called, who ordered a full diet. The child again grew worse, vomited, had severe diarrhea, and lost rapidly. The parents, in desperation, took him to a neighboring city. Here for four days the doctor ordered large quantities of oatmeal water and buttermilk. He received noth- ing else during that time and gained rapidly. Two or three days ago another doctor was called. Although the child had gained at an enormous rate, he was very, very sick. He was suffering severe diarrhea, temperature was 97 F., and the whole body was edematous. The last physician ordered albumin milk. On this he has lost much of what he gained. Temperature. 97 F. Weight. Ten pounds. Examination. This shows a terribly emaciated child the worst we have seen. Diffuse rales are present throughout the chest. Discussion. Gentlemen, is this a case of decomposition due to various factors, or is it miliary tuberculosis? In favor of tuberculosis is the history of measles and whooping-cough and the clinical picture, with the rales throughout the entire chest. Against this diagnosis are the absence of an enlarged liver and spleen and the absence of dulness upon direct percussion over the spine from enlarged bronchial glands. A Pirquet here would not help us because, if this is tuberculosis, it is of the miliary type and would give a negative reaction. The only sure way is to introduce a cotton swab into the larynx, obtain sputum when the child coughs, and make smears. CLINICS 363 In favor of decomposition of the mixed type we have the history of all sorts of irregularities in feeding, improper diets, starvation, recently one-sided carbohydrate feeding, plus the secondary influences of parenteral infections, as measles and whooping-cough, and even possibly definite enteral infection when blood appeared in the stools. The cough might simply be a bronchitis secondary to the child's weakened condition. The subnormal temperature doesn't help us, for it may be present in either alimentary decomposition or in the collapse of a miliary tuberculosis. In either case, however, whether it is a decomposition due to tuberculosis or to alimentary factors, the child must be fed. Our feeding technic will be the same as in decomposition. Directions. Let us keep him on albumin milk with 3 percent dextri-maltose. Let us offer protein in the form of soft-boiled egg, cottage cheese, curds of milk. Let us offer carbohydrate, as mashed potato, zwieback, and corn-starch. Of course, remember to be very, very careful as regards quan- tity, and certainly not- start more than one new food on the same day. I believe he is so sick we might try three-hour feedings. Give the child all the water he wants to drink, and you may have to stimulate him. Let us see him next week if he is still with us. CLINIC IL BABY 16 Present Age. Fifteen months one week. Present Weight. Twelve pounds nine ounces, a gain of two pounds nine ounces in one week. Mother says the child is improved in every way. He is brighter, happier, his voice is stronger, and sometimes he smiles. She has noticed his great gain. He likes his food and wants more. Examination. Shows a decided improvement. There is a suggestion of returning elasticity to the skin, and the muscles, too, begin to feel more like the normal. Doctor reports smears negative for tubercle bacilli. Discussion. Gentlemen, from the standpoint of our course, this case makes a most excellent conclusion. Within the last 364 INFANT FEEDING (CHICAGO METHODS) months has arisen almost every complication possible in the course of infant feeding. Let us picture the course of this child by the following curve (Fig. 38) : Fig. 38. He was doing nicely until he suffered a parenteral infection. Due to this, his nutrition suffered and he ceased to gain. A severe diarrhea complicated the picture. We can't say whether this was an infectious diarrhea or one resulting from the paren- teral infection. The presence of bloody stools makes us suspect the former. The weight curve suffered. The physician treated the stool and ordered nothing but a starvation diet for five days. The stool improved, but the factor of severe hunger, added to the previous injuries, undoubtedly was sufficient to reduce the child to a condition of decomposition. Now, the physician not recognizing the fundamentals of the case, ordered a full unre- stricted diet. This additional insult reduced the child still fur- ther and he was taken out of town. In .a neighboring city, a mixture high in water, carbohydrate, and salt was ordered. The gain in weight was phenomenal, but, gentlemen, this gain in weight was not one of true tissue substance, but was one of water. The condition of decomposition was not cured, but was masked. The water-logging of the body was extreme great enough to produce a marked edema. The water, however, was bound only very loosely to the tissues. The baby was in a criti- cal condition, with subnormal temperature and slow, feeble CLINICS 365 pulse. The feeding then ordered, i. e., albumin milk, a mixture low in salts, low in sugar, just the reverse of the previous, caused a complete reversal of the reaction. The organism squeezed out the excess of fluid with which it previously had been filled, and the baby was in a condition identical to that when he left town. The feeding instituted last week, taking into consideration the needs of the body tissues, answering them with a combination not injuring the intestinal tract, has apparently worked wonders. I believe this child will recover. I am very proud of this result, gentlemen, and I should advise you to copy this curve and study it carefully. In it you have a summary of our entire course. Question by Dr. Flippen. Before concluding this part of the course, would you mind stating precisely once more just what significance you place upon stool examination? Answer. Gross examination of the stool will aid us, first, in distinguishing the infectious from the nutritional types of diar- rhea. The infectious types usually are associated with blood, mucus, pus, and rather small, solid contents of the stool. The nutritional types only rarely show blood or pus. Dysentery causes alkaline stools; nutritional diarrheas, usually acid. Hav- ing ruled out infectious disturbances, the condition of the stool, whether constipated or diarrheal, is of value. The constipated stool in many cases may mean insufficient food or insufficient fermentable carbohydrate, allowing putre- factive processes to predominate, or may mean simply insuffi- cient residue in the intestinal tract from excessive resorption of the food. It must be considered only in connection with the child's weight curve. If the child is gaining, the stool has little significance. The diarrheal stool usually signifies excessive fermentation in the child's intestinal tract. Whether this fermentation be due to a high carbohydrate-whey mixture, to parenteral infec- tions, to heat, to overfeeding, or to o'ther factors, our history and examination will disclose. I believe I've made the com- parison of diarrheal stools to coughs. If the baby coughs once or twice a day, we accept this as evidence of irritation of the re- spiratory tract, but don't get excited. If he coughs more fre- quently but has no fever and is still subjectively well, we assume that the respiratory irritation is worse, but still are not alarmed, 366 INFANT FEEDING (CHICAGO METHODS) because the child himself is not suffering. However, when he not only coughs severely, but also shows other reactions, as fever and general disturbance, then we know that the infection is sufficient to affect the baby as a whole. So it is with these diar- rheal stools. When the child's weight curve is unaffected, when the child clinically is well, we pay little attention. Indeed, we know these stools may be symptoms even of underfeeding, but if the child, on the other hand, appears sick, shows changes in his general behavior and conduct, is fretful, and, above all things, shows changes in the weight curve which are so significant of the baby's general condition, then we know that the conditions in the intestinal tract are sufficient to affect the baby as a whole. So, gentlemen, stool examination in these conditions is of importance, but it is of importance only as a symptom, and must be studied not by itself, but only in connection with baby's history, present condition, general conduct, and, by all means, in connection with his weight curve. CONCLUSION Gentlemen : This concludes the main chapters of the course. These lectures and clinics have leaned possibly a little more to the scientific, a little less to the practical. This was absolutely intentional on my part. To attempt to teach you, with your years of experience the practice of medicine would be absurd. You know better than I the little devices, the various forms of psychotherapy, that sustain and satisfy anxious patients. In inanition, if the mother thinks her breast milk not good, satisfy her by obtaining a specimen for examination. In a case of overfeeding, if the child vomits, give a little placebo, besides correcting the diet. In dyspepsia order a mild mixture for the bad stools. Only in families of the highest type can you practise your profession without some sort of a prescription. In the city, as well as in the country, patients want medicine. In this course, however, I have omitted all these details because I wanted to show you the clear, distinct reactions. The disap- proving glances of our good nurses, the disappointment of the parents, and even your own criticisms have not escaped me, CLINICS 367 but I paid no heed, for I wanted to teach you what I consider the truth. I wanted to feel that after the conclusion of this course no one would be justified in completely overlooking some of the essentials in diet and saying, " Such and such a result was due to a stomach washing, a colonic flushing, a dose of castor oil, or what not, given coincidentally with the change of food." We have attempted, one might say, a laboratory course, un- trammeled by any factors which might cloud the pictures. Usually a haze separates us from our patients, a haze made of false conclusions derived from superficial examinations and from blind adherence to antiquated texts; a haze invoked by superstitious grandparents, and, as I understand it, even by some of your newspapers and by some of your clergy in their unthinking recommendation of proprietary and secret remedies. I have tried to clear away this mist; to reveal the patient clear and distinct before you; to show you the truth, as I see it. Having mastered the science and truth of medicine, you may, if necessary, adopt the various devices of practice with impunity. Use them, but don't let them blind you. INDEX ABNORMAL breast-fed baby, 25 breast milk, 23 Absorption, 20 toxic, 22 Acetic acid, 20 Acetone, 99 in urine, conditions in which found, 99 test for, 99 Acetonuria, 99 Acid, acetic, 20 butyric, 20, 156 intoxication, acidosis in, 100 lactic, 153 Acidity in intestine, 20, 21 Acidosis, causes, 98 definition, 98 etiology, 101 in acid intoxication, 100 in diarrhea, 79 treatment, 101-103 types peculiar to children, 100 usual symptoms, 101 Acids, fatty, 164 Adrenalin, 218 Adulteration of milk, 154 Agar-agar, 75 Albumin in milk, 19 milk in treatment of decomposi- tion, 233 of intoxication, 219 preparation of, 220 technic of Langstein and Meyer, 235 Albumins, 153 Alimentary intoxication, 214 Alkali as prevention of curd forma- tion, 47 in treatment of acidosis, 102 Alkalinity in intestine, 20, 21 Alkalis, 164 Amino-acids, 163 salts of, 20 Apple, 54 Artificial feeding, 27 certified milk in, 27 modification of milk in, 29 gravity method, 30 whole method, 30 of normal infant, 256 pasteurized milk in, 28 sterilized milk in, 28, 29 BABCOCK quantitative test for fat in milk, 154 Baby, average, caloric needs of, 21 premature, 56-58 Bacillus, dysentery, 83 gas, 83 streptococcus, 83 Bacteria, action of, upon carbohy- drates, 208 in intestine, 20, 208 in stools, 173 Bacterial growth in milk, 156 Barley jelly, 46 water, 45 Beef-juice, 53 Bile, 20 Bismuth in diarrhea, 81, 87 Boiled milk, 160, 162, 250, 254, 255 42 369 370 INDEX Bowels of new-born baby, 22 Breast and bottle feeding mixed, case illustrating, 142 feeding, 21, 270 amount taken in twenty-four hours, 23 appearance of milk, 272 contra-indications for, 26, 270 difficulties in, from local changes in breast, 271 from standpoint of child, 272 during menstruation, 26, 274 during pregnancy, 26, 274 first few weeks, 22 of newborn baby, 22 twenty-four hours, 22 intervals for, 22 modification of milk, 24 quantity of milk, 24, 274, 275 regularity of, 22 second day, 22 stimulation of breasts, 24, 273 swallowing of air during, 26, 277 weaning, 26 weight in, 23 wet-nurse, 27, 273 milk, abnormal, 23 calcium in, 169 composition of, 41, 155 in alimentary intoxication, 221 in nutritional disturbances, 198, 201 modification of, 24 quantity of, 24, 274, 275 scarcity of, 24 stimulation of production of, 24, 273 time of appearance, 22, 272 Breast-fed baby, abnormal, 25 abnormal bowel movements in, 281 colic of, 25 treatment of, 26 Breast-fed baby, constipation in, 282 dyspepsia in, 288 etiology, 288 symptoms, 288, 290 treatment, 290 inanition in, 284 diagnosis, 286 etiology, 285 prognosis, 286 treatment, 287 irregular feeding intervals, 26 normal, gain in weight of, 24 nutritional disturbances of, 25, 280 stools of, 25 substitute feedings for, 25 undernourishment of, 25 vomiting in, 280 Bulgar tablets, 82 Buttermilk, 220 composition of, 48 Butyric acid, 20, 156 CALCIUM, 112, 114, 164 chlorid, 114, 115 in breast milk, 169 in cow's milk, 169 lactate, 114 Calomel, 75 in infectious diarrheas, 252 Caloric needs of average baby, 21, 176 production of fat, 21 of protein, 21 of sugar, 21 value of foods, 176 formula for calculating, 40 Calorie, 39 definition, 21 Cane-sugar, 44 Carbohydrates, caloric value of, 176 INDEX 371 Carbohydrates, digestion of, 165 forms of, 165 functions performed by, 166 in milk, 153 need of, in nutritional disturb- ances, 200 relation of, to water in body, 167 Care of nursing mother, 21 Carpopedal spasm, 113 Casein, 45, 46, 153 breast-milk, 19, 156 cow's milk, 19, 156 Castor oil, 22, 75 Certified milk, 27, 159 Chapin dipper, 32 Chicken soup, 53 Chloral in diarrhea, 87 Chvostek's sign in spasmophilia, 113 Clinics, 116-144; 293-367 Colic, 25 Composition of milk, 19 Condensed milks, 50, 51 Constipation, 72, 194, 195, 196 causes of, 72 diet in, 74 drugs in treatment, 74, 203 in disturbances of breast-fed, 283 laxatives in, 74 sugar in treatment, 202, 203 Convulsions in spasmophilia, 113 Craniotabes, 106 Cream, gravity, composition of, 32 Curds, 156 casein, 46 in stool, 160 methods for preventing, 47 DECOMPOSITION, clinical picture, 224 diagnosis, 230 gastro-intestinal symptoms, 226 infection in, 227, 228 Decomposition, metabolism in, 229 treatment, 233 in older children, 239 Dextrins, 44, 45, 165 Diacetic acid in urine, test for, 99 Diarrhea, acidosis in, 100 causes, 205, 208 chronic fermentative, feeding of eighteen-months-old baby with, case illustrating, 128 difference between infectious and fermentative, 88 fermentative, 77 diet in, 80 due to protein, 82, 83 in small baby, case illustrating, 134 stools in, 78 treatment, 80 gas bacillus type, 87 diet in, 87 test for, 88 high sugar diet as cause of, 185, 206 infectious, 83, 249 bacilli in, 83 calomel in, 252 case illustrating, 85, 136 dysentery type, 84 diet in, 84 treatment, 84 reaction to food in, 251 stools in, 251 treatment, 251 mechanical, 77 nervous, 77 of infancy, 76 starvation in, 88 summer, 78 types of, 208, 209 whey of cow's milk in, 207 Diet in constipation, 74 in fermentative diarrhea, 80 372 INDEX Diet in infectious diarrhea, 84 in pyloric spasm, 94 in pyloric stenosis, 92 list at thirteen months, 55 Children's Hospital, Boston, 54 for eighteen months' baby, 54 sixteen to eighteen months, 55 twenty to twenty-two months, 55 of nursing mother, 24 Difference between cow's milk and breast milk, 155 Difficult feeding cases, 59 Digestion, disturbances of, 61 of different food elements, 20 of milk, 163. See also Milk, di- gestion of. Disaccharid, 20, 165 Disturbances in breast-fed, 280 of digestion, 61 too much food as cause, 61 of nutrition, modern conception of, 178 Drugs in constipation, 74, 203 in diarrhea, 81, 86 in spasmophilia, 114 Dysentery, 83 treatment, 253 dietetic, 253 Frank, for infection with true, 253, 254 Dyspepsia, 209 causes, 211 in disturbances of breast-fed, 288 metabolism in, 210 starvation in treatment of, 210, 212 states of, 205 treatment of, 212 weight curve in, 213, 214, 215 whey in, 207 EGGS, 53 Eisenzucker, 74 Eiweiss, 48, 64, 219 Electrical reactions in diagnosis of spasmophilia, 113 End-products in intestine, 20, 21 Enemas, 75 suds, 26 Energy of foods, 176 Enteral and parenteral infections, 242 Eskay's Food, 50, 52 Evaporated milks, 51, 52 FAILURE to gain, 193 carbohydrates in, 199, 200 constipation in, 194, 195 diagnosis, 201 disturbed balance in, 200 milk injury in, 194 case illustrating, 194 treatment, 201 Fat, absorption of, 20 caloric production of, 21, 176 digestion of, 20, 164 in milk, 153 Babcock's quantitative test for, 154 in stool, 164 indigestion, acute, 61 chronic, 61 stools in, 71 symptoms, 25 intolerance, case illustrating, 68 in older children, 67 treatment, 62 in older children, 67 scrambled-egg stool type, 63 soapy stool type, 62 neutral, 20, 164 of cow's milk, 156 percentage of, for normal infant, 43 INDEX 373 Fat, test for, in stools, 72 Fat-soap stools, 195 Fat- soaps, 164 Fatty acid, 20, 164 Feces, 173. See also Stools. Feeding, percentage, 17, 18 Fermentation, 157, 174, 199 Food, caloric value of, formula for calculating, 40 composition of, 42 different elements of, 43 digestion of, 20 fat, 43 milk, 18, 153 protein, 46 starch, 45 sugar, 44 table for normal infant, 42 Foods, energy of, 176 malted, 44, 45, 50 proprietary, 49 solid, for infant, 53 Frank treatment for infection, with true dysentery, 253, 254 Fruit, 54 GAS bacillus in diarrhea, 83 Globulins, 153 Glucose, 165 HARRISON'S grooves, 106 Horlick's Malt Food, 212, 236 Malted Milk, 50, 52 Hunger in alimentary intoxication, 218 in decomposition, 227, 231 in dyspepsia, 210, 212 ILEOCOLJTIS, 83 Imperial Granum, 50, 52 Inanition, 284 Indigestion, chronic sugar and fat, case illustrating, 125 fat, acute, 61 chronic, 61 from nervous influences, case illus- trating, 118 in older children, 67 protein, acute, 65 chronic, 66 starch, chronic, 66 sugar, acute, 64 chronic, 65 too much food as cause, 61 various types, 59 Infant, normal, feeding of, 41 premature, 56-58 Welfare Society, 267 Infections, parenteral and enteral, 242 anorexia in, 248 as cause of increased intestinal fermentation, 244 diagnosis, 245 treatment, 245 vomiting in, 247 Infectious diarrheas, 249. See also Diarrheas, Infectious. Intestinal antiseptics in diarrhea, 82,87 Intestine, acidity in, 20, 21 alkalinity in, 20, 21 bacteria in, 20, 208 end-products in, 20, 21 Intoxication, alimentary, 214 diagnosis, 217 treatment, 218 in older children, 223 states of, 205 whey in, 207 Intussusception, cases illustrating, 96,97 definition, 95 374 INDEX Intussusception, stools in, 95 treatment, 96 tumor in, 95 Iron, 68, 73 KELLER'S Malt Soup, 195, 200, 281 Kindolac, 50, 53 LACTAGOGUE, 272 Lactic acid, 153 bacillus, 49 milk, 49 Lactose, 44, 153 Larosan, 48 Laxatives in constipation, 74 Lime-water, 33, 47, 48 Loeflund's Malt Soup Extract, 45 MAGNESIA, milk of, 75 Magnesium, 164 Malt soup extract, 203 Malted foods, 44, 45, 50 Maltine Malt Soup, 45 Maltose, 44, 45, 165 Malt-sugar, 44, 45 Meade's Dextri-maltose, 45 Meconium, decomposition of, 22 Mellin's Food, 45, 50, 52, 212, 236 Metabolism of salt, 169 of water, 171 Milk, 152 adulteration of, 154 Babcock test, 154 albumin in, 19 bacterial growth in, 156 boiled, 160, 162, 250, 254, 255 breast, 23. See Breast milk. casein in, 19 certified, 27, 159 composition of, 19, 153 breast, 155 Milk, composition of cow's, 155 cow's, breast, difference between, 155 digestibility of, 20 protein in, 46 digestion of, 163, 171 carbohydrates in, 165 fat in, 164 protein in, 163 salts in, 169 sugars in, 165 evaporated, 51, 52 food elements of, 18 homogenized, 44 in gastro-intestinal tract, 171 injury, Czerny's, case illustrating, 194 lactic acid, 49 mineral matter in, 168 modification of, 31. See also Modification of milk. of magnesia, 75 pasteurized, 28, 159 proteins in, 19 skimmed, composition of, 32 sterilized, 28, 29 sugar of, 20, 44, 153 whole, composition of, 38 Milk-borne diseases, .157 Mineral matter in baby's food, 168 Modern conception of disturbances of nutrition, 178 Modification of milk, 29, 30, 31-40 gravity method, 31, 32 long method, 33 preparation of formula, 32, 33 short method, 35 sugar table for, 36 whole method, 37 NERVOUS influences, indigestion from, case illustrating, 118 INDEX 375 Neutral fat, 20 New-born baby, bowels of, 22 first feeding of, 22 Nipples, erosions and fissures of, medicaments for, 271 Normal infant, feeding of, 41 artificial, 256 interval for, 257 methods of Middle West, 260 prophylactic method, 260 diet lists, 54, 55 fat percentage in, 43 food table for, 42 fruit in, 54 intervals for, 42 night feedings, 43 number of, 42 olive oil in, 44 protein in, 46 solid food, 53 sugar in, 44, 45 twenty-four-hour amount, 42 vegetables in, 54 Nurse, wet-, qualifications of, 27 Nurses, 268 Nursing, breast. See Breast feeding. mother, care of, 21 diet of, 24, 278 fluid for, 278 menstruation of, 26 nervous, 26 pregnancy in, 26 Nutrition, disturbances of, bacterio- logical classification, 180 Czerny's etiological classifica- tion, 181 diagnosis, 190 fat injury in, 181 Finkelstein's classification of food disturbances, 184, 185 latest classification, 189 milk injury in, 181 Nutrition, disturbances of, modern conception of, 178 pathological classification, 179 secondary, due to parenteral in- fections, 243, 244 starch injury in, 181 sugar injury in, 185 Vienna conception of, 178, 179 weight curve in, 183, 186, 192 Nutritional disturbances of breast- fed baby, 25, 26 Nux vomica, 68, 73 OATMEAL jelly, 46 Olive oil, 44 Opium in diarrhea, 81, 87 Orange-juice, 28, 29, 53, 54, 160 in treatment of scurvy, 110 Overfeeding, 288, 289 PANCREATIC juice, 20 Parenteral and enteral infections, 242 Pasteurization, 158 Pasteurized milk, 28 Peptonization of milk, 47 Percentage feeding, 17, 18, 259 calculation of formulae, 34 principles of, 89, 90 Peristalsis, increased causes of, 76 Phenolphthalein, 75 Pigeon-breast, 106 Potato, 54 Premature babies, 56-58 breast milk for, 56 cow's milk for, 57 indigestion of, 58 water for, 58 Proprietary foods, 49 Protein, absorption of, 20 caloric production of, 21, 176 content of breast milk, 155 of cow's milk, 155 376 INDEX Protein, digestion of, 20, 163 in food for normal infant, 46 in milk, 19, 153 in urine, 164 indigestion, acute, 65 chronic, 66 stools, in 66, 72 symptoms, 25 Prune-juice, 53 Purgatives in diarrhea, 81, 86 Putrefaction, 157, 174, 199 Pyloric spasm, definition, 91, 93 physical signs of, 93 treatment, 94 stenosis, definition, 91 symptoms, 91 treatment, 92 Pylorospasm, 93 RACHITIS, 104. See also Rickets. Rickets, 104 acute, case illustrating, 139 causes, 105 definition, 104 general appearance, 106 pathology, 104 symptoms, 105 treatment, 106 Ridge's Food, 50 SACCHARATED oxid of iron, 74 Saccharose, 165 Salt metabolism, 169 Salts, digestion of, 169 in breast milk, 156 in cow's milk, 156 in milk, 20, 153 in stool, 169 of amino-acids, 20 relation of, to water in body, 171 Scrambled-egg stools, 62, 63, 71 Scurvy, 28, 29 Scurvy, diagnosis, 109 pathology, 108 symptoms, 109 treatment, 110 vitamins in, 107 Skimmed milk, 32 Soap in intestine, 20 in stool, 20 stools, 62, 63, 71 Soaps, fat-, 164 Sodium bicarbonate, 47, 48 bromid in diarrhea, 87 citrate, 47, 48 Spasmophilia, definition, 111 diagnosis, 112, 113 etiology, 111 prognosis, 113 treatment, 114 Trousseau's symptom in, 113 Starch in food for normal infant, 45 indigestion, chronic, 66 stools in, 66, 72 intolerance in older children, 70 test for, in stools, 73 Starvation, 59 in treatment of alimentary in- toxication, 218 of dyspepsia, 210, 212 Sterilized milk, 28, 29 Stomach, digestion in, 20 Stools, 173 abnormal, types of, 71 bacteria in, 173 curds in, 160 fat in, 164 in constipation, 74 in decomposition, 226, 227 in disturbances in breast-fed, 281- 283 in fat indigestion, 71 in fermentative diarrhea, 78 in infancy, 70 in infectious diarrheas, 251 INDEX 377 Stools in protein indigestion, 66, 72 in starch indigestion, 66, 72 intolerance, 70 in sugar indigestion, 72 microscopic examination of, 72 oily, 71 of breast-fed baby, 25 salts in, 169 scrambled-egg, 62, 63 secondary products in, 175 soapy, 62, 63, 71 unabsorbed foodstuffs in, 174 Streptococcus bacillus in diarrhea, 83 Sucrose, 44 Suds enema, 26 Sugar, 44 absorption of, 20 caloric production of, 21 child's need of, 166, 167 complex, 20 diet, high, as cause of diarrhea, 185,206 digestion of, 20, 165 forms of, 165 in food for normal infant, 44 in stools, 20 indigestion, acute, 64 chronic, 65 stools in, 66, 72 of milk, 20, 44, 153 relation of, to temperature, 168 table, 36 Suppositories, 75 TEMPERATURE, relation of sugars to, 168 Tetany, 111. See also Spasmophilia. Toasted bread, 53 Toxic absorption, 22 Trousseau's symptom in spasmo- philia, 113 UNDERNOURISHMENT of breast-fed baby, 25, 26 Urine, acetone in, 99 diacetic acid in, 99 in acidosis, 100 protein in, 164 VEGETABLES, 54 Vitamins, absence of, as cause of scurvy, 107 Vomiting from irregular feeding, case illustrating, 116 in disturbances of breast-fed, 280 obstinate, from feeding too quickly, case illustrating, 121 projectile, 91 recurrent, acetone in urine in, 100 WATER and carbohydrates, 167 barley, 45 content of whole milk, 38 gain in weight from, 167 in body, relation of salts to, 171 in milk, 154 metabolism, 171 supply in inanition, 288 Weaning, 26 Weight curve in nutritional dis- turbances, 183 in parenteral infections, 245 gain in, from water, 167 in disturbances of nutrition, 186 of normal breast-fed baby, 24 Wet-nurse, qualifications of, 27 Whey, composition of, 46 in dyspepsia, 207 in intoxication, 207 of cow's milk, in nutritional dis- turbance, 206, 207 preparation of, 47 Whole milk, 38 ZWIEBACK, 53 SURGERY and ANATOMY W. B. SAUNDERS COMPANY West Washington Square Philadelphia 9, Henrietta Street Covent Garden, London The Surgical Clinics of Chicago These new Clinics consider all departments of surgery from the clinical side, giving particular emphasis to differential diagnosis and treatment. They will give you the actual word-for- word clinics of jo great teacher-surgeons of Chicago, representing all the important hos- pitals of that great center of postgraduate instruction. You get the day-in and day-out teachings of these men. You get their tried and proved methods of diagnosis, their operative technic, and their plans of management. The first number appears February, 1917. ILLUSTRATIONS BY TOM JONES The instruction here is case-teaching of the most practical sort. The cases presented are the kind you and every active man meets. They do not present the symptoms tradition has taught you to expect. They pre- sent the symptoms you actually see in your practice. They demanded the same prompt attention your cases demand the same efficient treatments your patients seek and which these teacher-surgeons detail for you. Surgical Clinics of Chicago. By leading Chicago Surgeons. Issued serially, one num- ber every other month (six numbers a year). Each number about 225 octavo pages, illus- trated. Per Clinic Year (February to December): Cloth, $14.00 net; Paper, $10.00 net. SAUNDEKS' BOOKS ON Albee's Bone-Graft Surgery Bone-graft Surgery. By FRED H. ALBEE, M. D., Professor of Orthopedic Surgery at the New York Post-graduate Medical School. Octavo of 417 pages, with 329 text-illustrations and 3 colored plates. Cloth, $6.5 net. ORIGINAL TECHNIC This book presents Dr. Albee's original applied technic for bone-graft work. The successful outcome of any procedure to restore the skeletal archi- tecture depends not only upon a proper operative technic, but in many cases in a greater decree upon the skill with which the postoperative external fix- ation dressing is applied and in the convalescent management of the case. Dr. Albee here gives you his own successful technic and his own methods of dressing and management, all illustrated with original pictures. This is the only book going fully into this important question of bone surgery, a field that is attracting pronounced attention over the entire surgical world. Smithies and Ochsner's Cancer of the Stomach Cancer of the Stomach. By FRANK SMITHIES, M. D., Gastro-enterologist to Augustana Hospital, Chicago. With a chap- ter on the Surgical Treatment of Gastric Cancer by ALBERT J. OCHSNER, M. D., Professor of Clinical Surgery, University of Illinois. Octavo of 525 pages, illustrated. Cloth, $5.75 net. RECENTLY ISSUED This work gives you the information gleaned from a study of 921 oper- atively and pathologically demonstrated cases of gastric cancer. It is the first complete monograph upon this subject for more than a decade, and represents some ten years' study. The wonderful advances made within this time are of the greatest importance to the clinician, the pathologist, and the surgeon. Dr. Smithies presents these advances in a most practical way. The chapter on Operative Treat- ment, by Dr. Ochsner, gives you the most approved and successful technic, illustrating the various operations with original pictures. SUKGERY AND ANATOMY Hornsby and Schmidt's The Modern Hospital The Modern Hospital. Its Inspiration ; Its Construction; Its Equipment ; Its Management. By JOHN A. HORNSBY, M. D., Secretary, Hospital Section, American Medical Association ; and RICHARD E. SCHMIDT, Architect. Large octavo of 644 pages, with 207 illustrations. Cloth, $7.00 net; Half Morocco, $8.50 net. ADOPTED AT ONCE BY THE U. S. GOVERNMENT AS "THE LAW" "Hornsby and Schmidt" tells you just exactly how to plan, construct, equip, and manage a hospital in all its departments, giving you every detail. It gives you exact data regarding heating, ventilating, plumbing, refrigerating, etc. and the costs. It tells you how to equip a modern hospital with modern appliances. It tells you what you need in the operating room, the wards, the private rooms, the dining room, the kitchen every division of hospital house- keeping. It gives you definite diets for the patients and the hospital house- hold. It gives you hundreds of valuable points on the business management of hospitals large and small. Allen's Local Anesthesia Local Anesthesia. By CARROLL W. ALLEN, M. D., In- structor in Clinical Surgery at Tulane University of Louisiana. Octavo of 625 pages, illustrated. Cloth, $6.00 net. ILLUSTRATED This is a complete work on this subject. You get the history of local anesthesia, a chapter on nerves and sensation, giving particular attention to fain what it is and its psychic control. Then comes a chapter on osmosis and diffusion. Each local anesthetic is taken up in detail, giving very special attention to cocain and novocain, pointing out the action on the nervous system, the value of adrenalin, paralysis caused by cocain anesthesia, control of tox- icity. You get Crile's method of administering adrenalin and salt solution, the exact way to produce the intradermal wheal, to pinch the flesh for the inser- tion of the needle all shown you step by step. You get an article on anoci- associalion, the production of local anesthesia in the various regions, spinal analgesia, and epidural injections. There is a large section on dental anesthesia. SAUNDERS 1 BOOKS ON Moynihan's Abdominal Operations Abdominal Operations. By SIR BERKELEY MOYNIHAN, M. S. (LON- DON), F. R. C. S., of Leeds, England. Two octavos of 500 pages each, with 385 illustrations, 5 in colors. Per set: Cloth, $11.00 net. THIRD EDITION, RESET This new edition has been issued after a most thorough revision so thorough that the work had to be reset and issued in two handsome volumes. Over 150 pages of new matter and 80 new illustrations were added. Two new chapters arc those on excision of gastric ulcer and complete gastrectomy. Some p5 illustrative cases are dis- tributed throughout the work, giving every detail, history, examination, operation, complications, results. These are extremely instructive. Moynihan's definite, didactic style, together with the Urge number of practical illustrations and the illustrative cases make this work the most useful abdominal surgery published. Each volume has stamped on its back the subjects treated therein, thus facilitating quick consultation. Moynihan's Duodenal Ulcer DUODENAL ULCER. By SIR BERKELEY MOYNIHAN, M. S. (LON- DON), F. R. C. S., of Leeds, England. Octavo of 486 pages, illus- trated. Cloth, $5^00 net. " Easily the best work on the subject ; coining, as it does, from the pen of one of the masters of surgery of the upper abdomen, it may be accepted as authoritative." The London Lancet. Moynihan on Gall-stones GALL-STONES AND THEIR SURGICAL TREATMENT. By SIR BERKELEY MOYNIHAN, M. S. (LONDON), F. R. C. S. Octavo of 458 pages, illus- trated. Cloth, $5.00 net. " He expresses his views with admirable clearness, and he supports them by a large number of clinical examples, which will be much prized by those who know the difficult problems and tasks which gall-stone surgery not infrequently presents." British Medical Journal. SURGERY AND ANATOMY Crandon and Ehrenfried's Surgical After -treatment Surgical After-treatment. By L. R. G. CRANDON, M. D., Assistant in Surgery, and ALBERT EHRENFRIED, M. D., Assistant in Anatomy, Harvard Medical School. Octavo of 831 pages, with 265 original illustrations. Cloth, $6.00 net. THE NEW (2d) EDITION This work tells how best to manage all problems and emergencies of sur- gical convalescence from recovery-room to discharge. It gives all the details completely, definitely, yet concisely, and does not refer the reader to some other wont perhaps not then available. The postoperative conduct of all operations ; s given. There is an elaborate chapter on Vaccine Therapy, Im- munization by Inoculation, and Specific Sera, by Dr. George P. Sanborn. Therapeutic Gazette " This book is one which can be read with profit by the active surgeon and practitioner and will be generally commended." Mayo Clinic Papers Mayo Clinic Papers. By WILLIAM J. MAYO, M. D., CHARLES H. MAYO, M. D., and their ASSOCIATES at The Mayo Clinic, Rochester, Minn. Papers of 1905-09, 1910, 1911, 1912, 1913. Each, $5.50 net. Papers of 1916 preparing. A Collection of Papers (published previous to 1909). By W. J. and C. H. MAYO. Two octavos of 525 pages each, illus- trated. Per set: Cloth, $10.00 net. SAUlVDERS' BOOKS ON Keen's New Surgery Surgery : ITS PRINCIPLES AND PRACTICE. Written by 82 eminent specialists. Edited by W. W. KEEN, M. D., 'LL. D., HON. F. R. C. S., ENG. AND EDIN., Emeritus Professor of the Principles of Surgery and of Clinical Surgery at the Jefferson Medical College, Philadelphia. Six large octavo volumes of over 1050 pages each, containing 3100 illustrations, 157 in colors. Fer volume: Cloth, $7.00 net; Half Morocco, $8.00 net. VOLUME VI GIVES YOU THE NEWEST SURGERY In this sixth volume you get all the newest surgery both general and special from the pens of thu^e same international authorities who have made the success of Keen's Surgery world-wide. Each man has searched for the new, the really useful, in his particular field, and he gives it to you here. Here you get the newest surgery, and fully illustrated. Then, further, you get a complete index to the entire six volumes, covering 125 pages, but so arranged that reference to it is extremely easy. If you want the newest sur- gery, you must turn to the new " Keen " for it. Moorhead's Traumatic Surgery Traumatic Surgery. By JOHN J. MOORHEAD, M. D., Adjunct Professor of Surgery, New York Post-Graduate Medical School and Hospital. Octavo of 760 pages, with 520 original line-drawings. Just Ready. Cloth, $6.50 net. WITH 522 ORIGINAL LINE-DRAWINGS This work has a wide appeal. It appeals to the surgeon, the prac- titioner, the mining, railroad, and industrial physician, those having to do with Compensation Law, accident insurance and claims, and legal medicine. But its greatest appeal is to the general practitioner the man in general prac- tice anywhere because practically the entire work is devoted to Minor Sur- gery those traumatic conditions that form a part of every doctor's daily prac- tice. The work is original in text, illustrations, arrangement, and method of presentation. Only those treatments are given which Dr. Moorhead has found successful. SURGE R Y AND ANA TO MY Scudder's Fractures WITH NOTES ON DISLOCATIONS The Treatment of Fractures : with Notes on a few Com- mon Dislocations. By CHARLES L. SCUDDER, M. D., Surgeon to the Massachusetts General Hospital, Boston. Octavo volume of 735 P a S es > w ith I0 57 illustrations. Polished Buckram, $6.00 net. THE NEW (8th) EDITION, ENLARGED OVER 35.000 COPIES Seven large editions of this remarkable book is a decisive indication of the value of Dr. Scudder's work. For this new edition numerous ad- ditions have been made throughout the text and a large number of new illustrations added, greatly enhancing the value of the work. In every way this edition reflects the very latest advances in the treatment of fractures. J. F. Binnie, M. D., formerly University of Kansas. " Scudder's Fractures is the most successfnl book on the subject that has ever been published. I keep it at hand regularly." Scudder's Tumors of the Jaws Tumors of the Jaws. By CHARLES L. SCUDDER, M. D., Surgeon to the Massachusetts General Hospital, Boston. Octavo of 395 pages, with 353 illustrations, 6 in colors. Cloth, $6.50 net. WITH NEW ILLUSTRATIONS Dr. Scudder in this book tells you how to determine in each case the form of new growth present, and then points out the best treatment. As the tendency of malignant disease of the jaws is to grow into the accessory sinuses and toward the base of the skull, an intimate knowledge of the anatomy of these sinuses is essential. Dr. Scudder has included, therefore, sufficient anatomy and a number of illustrations of an anatomic nature. Whether gen- eral practitioner or surgeon, you need this new book because it gives you just the information you want. SAUNDERS' BOOKS ON Cotton's Dislocations and Joint Fractures Dislocations and Joint Fractures. By FREDERIC JAY COTTON, A. M., M. D., First Assistant Surgeon to the Boston City Hospital. Octavo volume of 654 pages, with 1201 original illustrations. Cloth, $6.00 net. TWO PRINTINGS IN EIGHT MONTHS Dr. Cotton's clinical and teaching experience in this field has especially fitted him to write a practical work on this subject. He has written a book clear and definite in style, systematic in presentation, and accurate in state- ment. The author is himself the artist, so that the illustrations show just those points he wished to emphasize. Boston Medical and Surgical Journal "The work is deliehtful. spirited, scholarly, and original. It brings the subjects up to date a feat long neglected." Diagnosis and Treatment of Surgical Diseases of the Spinal Cord and its Membranes. Octavo of 330 pages, with 158 illustrations, 3 of them in colors. By CHARLES A. ELSBERG, M. D., Professor of Clinical Surgery, New York University and Bellevue Hospital Medical School. Cloth, $5.00 net. INCLUDING USE OF X-RAYS There is no other book published like this by Dr. Elsberg. It gives you in clear definite language the diagnosis and treatment of all surgical diseases of the spinal cord and its membranes, illustrating each operation with original pictures. Because it goes so thoroughly into Symptomatology, diagnosis, and indications for operation this work appeals as strongly to the general prac- titioner and neurologist as to the surgeon. The first part of the work is de- voted to anatomy and physiology of the spinal cord, and to the symptomatology of surgical spinal diseases. The second part takes up operations upon the spine, the cord, and nerve-roots. The third part is given over to surgical dis- eases of the cord and its membranes their diagnosis and treatment. In- cluded also are chapters on hematomyelia and spinal gliosis, because in these diseases much harm is done to the fiber tracts by compression. SURGER Y AND ANA TO MY Kelly and Noble's Gynecolog'y and Abdominal Surgery Qynecology and Abdominal Surgery. Edited by HOWARD A. KELLY, M. D., Professor of Gynecology in Johns Hopkins University; and CHARLES P. NOBLE, M. D., formerly Clinical Professor of Gynecology, Woman's Medical College, Philadel- phia. Two imperial octavos of 950 pages each, with 880 illustra- tions. Per volume : Cloth, $8.00 net ; Half Morocco, $9.50 net. WITH 880 ILLUSTRATIONS BY BECKER AND BRODEL This work possesses a number of valuable features not to be found in any other publication covering the same fields. It contains a chapter upon the bacteriology and one upon the pathology of gynecology, and a large chapter devoted entirely to medical gynecology, written especially for the physician engaged in general practice. Abdominal surgery proper, as distinct from gynecology, is fully treated, embracing operations upon the stomach, intes- tines, liver, bile-ducts, pancreas, spleen, kidneys, ureter, bladder, and peri- toneum. American Journal of Medical Sciences "It is needless to say that the work has been thoroughly done ; the names of the authors and editors would guarantee this, but much may be said in praise of the method of presentation ; and attention may be called to the inclusion of matter not to be found elsewhere." Crile and Lower's Anoci-Association Anoci-Association is the new way of anesthetizing. It pre- vents shock, it robs surgery of its harshness, it diminishes post- operative mortality, it lessens the likelihood of nausea, vomit- ing, gas-pains, backache, nephritis, pneumonia, and other post- operative complications. You get anoci-association and blood- pressure and the technic of nitrous-oxid oxygen anesthesia. Octavo of 275 pages, illustrated. By GEORGE W. CRILE, M. D., Professor of Surgery, and WILLIAM E. LOWER, M. D., Associate Professor of Genito-Urinary Surgery, Western Reserve University. Cloth, $3.00 net. 10 SAUNDERS' BOOKS ON Mumford's Practice of Surgery The Practice of Surgery. By JAMES G. MUMFORD, M. D., formerly Lecturer on Surgery, Harvard Medical School. Octavo Of 1032 pages, with 683 illustrations. Cloth, $7.00 net. SECOND EDITION This is a clinical surgery, giving those methods and operations which the author has personally followed for the past twenty years. The plan of the work is somewhat off the conventional lines, the diseases being taken up in loeir order of interest, importance, and frequency. John B. Murphy, M. D., Northwestern Medical School, Chicago " This work truly represents Dr. Mumford's intellectual capacity and scope, and pre- sents in a terse, forceful, yet pleasing manner, the live surgical topics of the day. It is in every particular up to date." DaCost&'s Modern Surgery Modern Surgery GENERAL AND OPERATIVE. By JOHN CHALMERS DACOSTA, M. D., Samuel D. Gross Professor of Sur- gery, Jefferson Medical College, Philadelphia. Octavo of 1515 pages, with 1085 illustrations. Cloth, $6.00 net; Half Morocco, $7-5 n et. SEVENTH EDITION A surgery, to be of the maximum value, must be up to date, must be com- plete, must have behind its statements the sure authority of experience, must be so arranged that it can be consulted quickly ; in a word, it must be practical and dependable. Such a surgery is DaCosta's. Always an excellent work for this edition it has been very materially improved by the addition of much new matter and many additional illustrations. Rudolph Matas, M.D., Professor of Surgery, Tulane University of Louisiana. " This edition is destined to rank as high as its predecessors, which have placed the learned author in the fore of text-book writers. The more I scrutinize its pages the more I admire the marvelous capacity of the author to compress so much knowledge in so small space." SURGERY AND ANATOMY Cullen's Diseases of the Umbilicus Embryology, Anatomy, and Diseases of the Um- bilicus ; together with Diseases of the Urachus. By THOMAS STEPHEN CULLEN, M. B., Associate Professor of Gynecology in the Johns Hopkins University. 8vo of 680 pages, with 269 illus- trations. Cloth, $7.50 net; Half Morocco, $9.00 net. ILLUSTRATED BY MAX BRODEL This new monograph appeals to the anatomist, pediatrician, surgeon, genito-urinary specialist, and practitioner. Conditions of the umbilicus have always been more or less the "X" of general practice. This book ex- plains these unknown conditions, presenting thoroughly every disease in any way associated with the umbilicus, and making the entire subject strikingly clear. Crile's The Kinetic Drive Recently issued THE KINETIC DRIVE. By GEORGE W. CRILE, M. D., Professor of Surgery, Western Reserve University, Cleveland. Octavo of 71 pages, illustrated. Cloth, $2.00 net. In this book Dr. Crile analyzes the mechanism by which the present-day industrial and commercial "speeding" is accomplished, and relates it to the speeding due toother stimuli, such as infections, auto-intoxication, physical injury, etc. The work is timely. Montgomery's Care of Surgical Patients CARE OF PATIENTS: Before, During, and After Operation. By E. E. MONTGOMERY, M. D., LL. D., Professor of Gynecology in Jefferson Medical College. 12010 of 149 pages, illustrated. Cloth, $1.25 net. This book gives you many hints and suggestions acquired during many years of operative work. Its use will lessen the anxiety of the surgeon, promote better work, facilitate the labor of nurses and interns, and add to the comfort and satisfaction of the patient. R^y soon MANUAL OF ANATOMY. By HENRY E. RADASCH, M. D., Assistant Professor of Histology and Biology, Jefferson Medical College. Octavo of 500 pages, profusely illustrated. Dr. Radasch's new handbook is complete in both text and illustrations. Every effort has been taken to make the study of anatomy both easy and interesting the many illustrations contributing markedly to this end. SAUNDERS' BOOKS ON Cushing's Tumors of the Brain Tumors of the Nervus Acusticus and the Syndrome of the Cerebellopontine Angle. By HARVEY CUSHING, M. D., Surgeon-in-Chief, Peter Bent Brigham Hospital, Boston. Octavo of 350 pages, fully illustrated. A FULLY ILLUSTRATED STUDY Dr. Gushing presents here an exhaustive study of tumors of the acoustic nerve. He gives you his own technic, and the results of study and ob- servation of some thirty cases. These tumors, despite the fact that they are comparatively common, are imperfectly understood, and the present volume is a thorough presentation of the subject, embracing history, ana- lysis of symptoms, physical examination, morphology, histology, and opera- tive technic in short, every aspect of the cases clearly and completely covered. You are given not only the surgical aspects, but the historical, symptomatic, and pathologic as well. The illustrations are particularly noteworthy; they are plentiful, practical, and definitely valuable. Many- show the successive steps in operation, demonstrating as nothing else can the exact technic that makes for the successful outcome. Owen's Treatment of Emergencies The Treatment of Emergencies. By HUBLEY R. OWEN, M. D., Surgeon to the Philadelphia General Hospital. 12010 of 560 pages, with 249 illustrations. A COMPLETE TREATMENT Dr. Owen's book gives you not only the actual technic of the pro- cedures, but, what is equally important, the underlying principles of the treatments, and the reason why a particular method is advised. You get chapters on fractures of all kinds, going fully into symptoms, treatments, and complications. You get treatments of contusions, of wounds, both lacerated and incised. Particularly strong is the chapter on gun-shot wounds, which gives the new treatments that the great European War has developed. You get the principles of hemorrhage, together with its con- stitutional and local treatments. You get chapters on sprains, disloca- tions, burns, sunburn, chilblain, asphyxiation, convulsions, hysteria, apo- plexy, exhaustion, opium poisoning, uremia, and electric shock. You get sections on bandages, and a complete discussion of artificial respiration, including mechanical devices. The book is complete; it is thorough; it is practical. SURGERY AND ANATOMY 13 D&nnreuther's Emergency Surgery MINOR AND EMERGENCY SURGERY. By WALTER T. DANNREUTHER, M. D., Surgeon to St. Elizabeth's Hospital and to St. Bartholomew's Clinic, New York City. I2mo of 225 pages, illustrated. Cloth, $1.25 net. Fowler's Operating Room Third Edition THE OPERATING ROOM AND THE PATIENT. By RUSSELL S. FOWLER, M. D., Chief Surgeon, First Division, German Hospital, Brooklyn, New York. Octavo of 61 1. pages, illustrated. Cloth, $3.50 net. Keen's Addresses and Other Papers ADDRESSES AND OTHER PAPERS. Delivered by WIU.IAM W. KEEN, M. D., LL.D.. F. R. C. S. (Hon.). Professor of the Principles of Surgery and of Clinical Sureerv. Jefferson Medical College, Philadelphia. Octavo volume of 441 pages, illustrated. Cloth, $2-75 net. Keen on the Surgery of Typhoid THE SURGICAL COMPLICATIONS AND SEQUELS OF TYPHOID FEVER By WM. W. KEEN, M. D., LL.D., F. R. C. S. (Hon.), Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia, etc. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. American Text-Book of Surgery Fourth Edition AMERICAN TEXT- BOOK OF SURGERY. Edited by W. W. KEEN, M. D., LL. D., HON. F. R. C. S., ENG. and EDIN.; and J. WILLIAM WHITE, M. D., PH. D. Octavo, 1363 pages, 551 text-cuts and 39 colored and half-tone plates. Cloth, $7.00 r.et ; Half Morocco, $8.50 net. Nancrede's Essentials of Anatomy 8th Edition ESSENTIALS OF ANATOMY, including the Anatomy of the Viscera. By CHARLES B. NANCREDE, M. D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Crown octavo, 430 pages, 155 cuts. Based on Gray's Anatomy. Cloth, $1.25 net. In Sanndcrs' Question Competids. Whiting's Bandaging Recently Issued This new work takes up each bandage in detail, telling you and shmoing you by original illustrations just how each bandage should be applied, each turn made. Dr. Whiting's teaching experience has enabled him to devise means for overcoming common errors in applying bandages. izmo of 151 pages, with 117 illustrations. By A. D. WHITING, M. D.. Instructor in Surgery at the University of Pennsylvania. Cloth, $1.15 net. 14 SAUNDERX BOOKS ON American Illustrated Dictionary New (gth) Edition THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY. With tables of Arteries, Muscles, Nerves, Veins, etc. ; of Bacilli, Bacteria, etc. ; Eponymic Tables of Diseases, Operations, Stains, Tests, etc. By W. A. NEWMAN DORLAND, M. D. Large octavo, 1137 pages. Flexible leather, $4.50 net; with thumb index, $5.00 net. Howard A. Kelly, M. D., Professor of Gynecology, Johns Hopkins "Dr. Borland's dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." Golebiewski and Bailey's Accident Diseases ATLAS AND EPITOME OF DISEASES CAUSED BY ACCIDENTS. ByDn. ED. GOLEBIEWSKI, of Berlin. Edited, with additions, by PEARCE BAILEY, M.D. Cloth, $4.00 net. /;/ Sounders' Hand- Atlas Series. Helferich and Bloodgood on Fractures ATLAS AND EPITOME OF TRAUMATIC H RACTURES AND DISLO- CATIONS. By PROF. DR. H. HELFERICH, o: ; Greifswald, Prussia. Edited, with additions, by JOSEPH C. BLOODGOOD, M.D., Asso- ciate in Surgery, Johns Hopkins University, Baltimore. 216 colored figures on 64 lithographic plates, 190 text-cuts, and 353 pages of text. Cloth, $3.00 net. /// Sounders' Atlas Series, Sultan and Coley on Abdominal Hernias ATLAS AND EPITOME OF ABDOMINAL HERNIAS. By PR. DR. G. SULTAN, of Gottingen. Edited, with additions, by WM. B. Coley, M.D. Cloth, $3.00 net. In Sounders' Hand- Atb& Series. Fenger Memorial Volumes COLLECTED WORKS OF CHRISTIAN FENGER, M. D. Edited by LUDWIG HEKTOEN, M. D., Professor of Pathol- ogy, Rush Medical College, Chicago. Two octavos of 525 pages each. Per set: Cloth, $15.00 net. Zuckerkandl and DaCosta's Surgery ATLAS AND EPITOME OF OPERATIVE SURGERY. By DR. O. ZUCKERKANDL, of Vienna. Edited, with additions, by J. CHALMERS DACOSTA, M. D., Samuel D. Gross Professor of Surgery, Jefferson Medical College, Philadelphia. 40 col- ored plates, 278 text-cuts, and 410 pages of text. Cloth, $3.50 net. In Sounders' Atlas Series. SURGERY AND ANATOMY 15 Martin's Essentials of Surgery 7th Edition ESSENTIALS OF SURGERY. Containing also Venereal Diseases, Sur- gical Landmarks, Minor and Operative Surgery, and a complete des- cription, with illustrations, of the Handkerchief and Roller Bandages. By EDWARD MARTIN, A. M., M. D., Professor of Clinical Surgery, University of Pennsylvania, etc. Crown octavo, 338 pages, illus- trated. With an Appendix on Antiseptic Surgery, etc. Cloth, $1.25 net. In Sounders' Question Compends. Metheny's Dissection Methods DISSECTION METHODS AND GUIDE. Octavo of 131 pages, illustrated. By DAVID GREGG METHENY, M. D., L. R. C. P., L. R. C. S. (EDIN.), L. F. P. S. (GLAS. ), Associate in Anatomy at Jefferson Medical College, Philadelphia. Cloth, $1.25 net. American Pocket Dictionary New (9th) Editior THE AMERICAN POCKET MEDICAL DICTIONARY. Edited by \f. A. NEWMAN DORLAND, A.M., M.D. 693 pages. Full leather, limp, with gold edges, $1.25 net; with patent thumb index, $1.50 net. Bryan's Surgery PRINCIPLES OF SURGERY. By W. A. BRYAN, M. D., Professor of Surgery and Clinical Surgery at Vanderbilt University, Nashville. Octavo of 667 pages, with 224 original illustrations. Cloth, $4.00 net. Dr. Bryan here discredits many fallacious ideas, giving you facts instead. He shows you in a most practical way the relations between surgical pathology and the resultant symptomatolgoy, and points out the influence such information has on treatment, Meyer & Schmieden's Bier's Hyperemic Treatment Second Edition BIER'S HYPEREMIC TREATMENT in Surgery, Medicine, and the Special- ties. By WILLY MEYER, M. D., Professor of Surgery, New York Post- Graduate Medical School and Hospital; and Prof. Dr. VICTOR SCHMIE- DEN, Assistant to Professor Bier, University of Berlin, Germany. Octavo of 280 pages, illustrated. Cloth, $3.OO net. Morris* Dawn of the Fourth Era in Surgery DAWN OF THE FOURTH ERA IN SURGERY AND OTHER ARTICLES. By ROBERT T. MORRIS, M. D., Professor of Surgery, New York Post- Graduate Medical School and Hospital. I2mo of 145 pages, illustrated. $1.25 net. UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. NOV 2 3 1955 DECS APR 1 8 lib. BIOMED LIB. KNMBV9 75 NOV6 REC'O SEP 04REC'D BIOMED NOV10'7|9 Form L9-42m-8,'49(B5573)444 BIOMEO DEC 15 '83 BIOMED LIB. DEC 15 REC'O THE LIBRARY UNIVERSITY OF CALIFORNIA LOS ANGELES 3 1158 00445 7098 000375245 8