U.C. 
 
 LIBRARY 
 
 77b 216 
 

 
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 HUNGER IN THE INFANT 
 
 Thesis Submitted to the Faculty of the Graduate School 
 of the University of Minnesota 
 
 BY 
 ROOD TAYLOR, M.D. 
 
 In Partial Fulfillment of the Requirements for the Degree of Doctor of Science 
 
 1917 
 

HUNGER IN THE INFANT* 
 
 ROOD TAYLOR, M.D., Sc.D. 
 Mayo Clinic 
 
 ROCHESTER, MINN. 
 
 Cannon and Washburn, 1 and Carlson and his colaborers have given 
 us a proved method for studying hunger objectively; its time of occur- 
 rence, its intensity, its effects, and the means by which it may be pro- 
 duced or inhibited. They have shown that contractions of the so-called 
 empty stomach cause the hunger sensation. These contractions depend 
 in part on vagus tonus. They can be increased by chemical changes 
 in the blood, but are primarily due to a gastric mechanism as purely 
 automatic as is that of the heart. 
 
 Impulses set up by these contractions and carried to the higher 
 centers are, in the normal consciousness, recognized as hunger. These 
 impulses produce secondary effects such as restlessness and irritability. 
 They increase the reflex excitability of the central nervous system, the 
 heart beats faster, and there are changes in the vasomotor mechanism. 
 Well fed, sedentary adults seldom experience hunger. The prime fac- 
 tor in their desire for food depends not on the basis of distress due to 
 the contractions of a hollow viscus, but on "the memory processes of 
 past experience with palatable foods." This psychic factor is appetite, 
 and its absolute distinction from the physical factor, hunger, must be 
 kept in mind. 
 
 Working on dogs, Patterson, in 1914, showed the gastric hunger 
 contractions to be much more frequent and vigorous in young than in 
 older animals. In 1915, Carlson and Ginsburg described the great 
 intensity of hunger contractions in the human new-born. Previous to 
 that year no productive analytic studies of the hunger sense in the 
 human infant had been made. Appetite and hunger were not dis- 
 tinguished, and the sucking mechanism alone had been analyzed. 
 
 In 1888, Auerbach distinguished the infantile type of sucking from 
 the voluntary inspiratory type employed by the adult, and in 1894 
 Basch, disproving the older theory of Preyer that sucking is instinctive, 
 showed it to be entirely reflex. 
 
 * From the Department of Pediatrics, University of Minnesota. 
 
 1. All references to the literature will be found at the end of the article. 
 
 377 
 
Czerny, in 1893, observed that an infant awakened a short time 
 after taking his fill from the maternal breast, would again suck vigor- 
 ously if placed on it, and concluded that sucking per se could not be 
 considered as a sign of hunger. A few years later (1900) Keller wrote 
 that, since the normal infant sleeps three hours after nursing, although 
 its stomach is empty in two hours, the emptying of the stomach cannot 
 be considered a positive criterion of need for food. Pies, in 1910, con- 
 sidered the reddening and eczema of the lower lip which occurs in 
 undernourished infants as a sign of hunger, and referred it directly to 
 the infant's fruitless sucking. In 1913 Schlossmann concluded from 
 extensive observations on semistarved infants that the sensation of 
 hunger exists only in the imagination. 
 
 Meyer and Rosenstern studied the results of starvation in the dif- 
 ferent types of alimentary disorder, recording particularly the pulse, 
 temperature, respiration and weight changes. Rosenstern later (1911- 
 1912) wrote extensively on the general subjects of hunger and inani- 
 tion in infancy. These studies are all defective in that they do not 
 distinguish the various factors concerned. Neumann, Pfaundler, 
 Cramer, Siiszwein, Earth, and Kasahara have discussed the subject of 
 disturbances in the food urge largely from the point of view of imper- 
 fections in the sucking mechanism. 
 
 The present studies are concerned particularly with the gastric fac- 
 tors in the urge for food. The major of these, the hunger contrac- 
 tions, was studied by means of apparatus similar to that used by 
 Carlson. A rubber balloon of about 20 c.c. capacity attached to one 
 end of a small soft rubber catheter is inserted into the stomach and 
 inflated, the catheter is attached to a bromofonn manometer with a 
 cork float and a writing pennant which records the gastric movements 
 on smoked paper. 
 
 The material investigated included 5 premature infants weighing 
 from 1,200 to 2,500 gm., 40 full term new-borns under 3 weeks of age, 
 and 11 older babies, 5 between 1 and 2 months, 2 between 3 and 4 
 months, 3 between 4 and 6 months, and 1 boy of 2 years with a sur- 
 gically induced gastric fistula made necessary by the effects of corro- 
 sive in the esophagus. The gastric movements of some of the infants 
 were recorded only once ; on others as many as twenty observations 
 were made. 
 
 Carlson and Ginsburg refer to the readiness with which most 
 infants accept and retain the tube and balloon. It is naturally impos- 
 sible to secure a graphic record of the stomach movements of a raging 
 infant. Carlson and Ginsburg did their work on full term new-borns. 
 These infants, as a rule, sleep quietly when not disturbed. The present 
 work was carried on in a dimly lighted, quiet room. I had less diffi- 
 culty when the infant was left undisturbed in his crib than when I 
 
attempted innovations, such as threading a pacifier on the tube or 
 having the infant held in the nurse's arms. 
 
 The older babies resent the presence of the tube, and with them it 
 \va> often necessary to make repeated attempts to secure tracings. 
 Some infants finally became accustomed to the presence of the tube 
 and slept quietly, particularly if the experiments were conducted in 
 the evening. Most of the tracings on the 2-year-old boy with the 
 gastric fistula were made when he was awake. The greatest problem 
 was to keep him sufficiently interested to prevent crying and restless- 
 ness and at the same time to prevent riotous hilarity. In his case the 
 balloon was introduced directly through the fistula. 
 
 It is said that passage of the stomach tube in infants is apt to cause 
 aspiration pneumonia. Xo ill results followed the procedure carried 
 out in these studies. 
 
 Does the presence of the balloon in the stomach act mechanically 
 to produce gastric contractions ? Carlson states definitely that it does 
 not, and gives the following reasons for his belief : 
 
 1. The presence of the distended balloon in the stomach between the con- 
 traction periods does not induce these contractions. 
 
 2. In Mr. V. [his gastric fistula case] the gastric contractions can be observed 
 directly through the large fistula without any balloon in the stomach. 
 
 3. The contraction periods come on just as frequently without any balloon in 
 the stomach and produce the same effect (hunger). 
 
 4. In pigeons the periodic strong contractions of the empty crop can be seen 
 directly through the skin, and a balloon in the crop does not alter their frequency 
 or intensity. 
 
 The results of this work fully confirm Carlson and Ginsburg's 
 report that the stomach of the new-born infant exhibits greater hunger 
 contraction than does that of the adult. The intervals between the 
 contraction periods are often less than five minutes and usually not 
 longer than from ten to twenty minutes. The first contraction period 
 after a nursing is apt to consist of from five to twenty separate con- 
 tractions and to last from two to eight minutes. The succeeding con- 
 traction periods frequently endure from thirty minutes to an hour or 
 even longer. The duration of each contraction is about twenty seconds. 
 In many of the infants the contraction time of the more powerful con- 
 tractions, especially in those periods ending in partial tetanus, was 
 about eighteen seconds. Except in the first contraction period after a 
 nursing, endings in partial tetanus were frequently observed. Partial 
 tetanus is sometimes present before the close of the period. With the 
 apparatus used, the force of the single contractions usually sufficed to 
 raise the column of bromoform 2 to 3 cm. During partial tetanus the 
 bromoform may be raised 5 cm. 
 
 Patterson found practically continuous hunger contractions in pre- 
 mature pups. It is particularly easy to obtain graphic records of the 
 
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hunger contractions of the somnolent, prematurely born infant. The 
 stomach of such an infant is in a state of nearly continuous contraction. 
 The individual contractions require about the same length of time for 
 their completion and are as powerful as those of the full term infant. 
 In a tracing begun forty minutes after a feeding of 15 gm. of breast 
 milk to a premature baby (Baby 5) weighing 1,510 gm., the record 
 appears very like that obtained by Rogers from the crop of a pigeon 
 in the second day of starvation. The periods of contraction last two 
 or three minutes, with intervening periods of quiescence of about the 
 same length. The individual contractions last twelve to fifteen seconds 
 and raise the bromoform column 3 to 4 cm. Partial tetanus is fre- 
 quent. Xine days later, when the infant was receiving more food, in 
 spite of the fact that he had not gained in weight and that the tracing 
 was begun five hours after his last feeding, the record obtained was 
 similar to those from other infants. 
 
 Are the hunger contractions more frequent or more powerful in 
 cyanosed infants? May they furnish a stimulus for crying with con- 
 sequent better aeration of the lungs? In two such cases no significant 
 increase or decrease in the hunger contractions could be observed. No 
 records were taken from any cyanosed premature infants, although 
 such infants are frequently slightly blue for the first few days. 
 
 Carlson, working on the adult, was unable to produce hunger con- 
 tractions by any sort of stimulus acting directly in the mouth or in the 
 stomach, except that he occasionally could, by suddenly distending the 
 stomach, produce a few transitory contractions. He found, uniformly, 
 that the only effect of such local stimulation was inhibitory. In gen- 
 eral, the taste of salt, sour, bitter, or sweet ; or the chewing of agree- 
 able, disagreeable, or indifferent substances, all produce temporary 
 inhibition of the gastric contractions. Chewing palatable foods by the 
 adult when hungry causes an inhibition, made more lasting by the flow 
 of appetite juice in the stomach. 
 
 Carlson found that acid and alkaline solutions, food and liquids 
 in the stomach, all inhibit the hunger contractions. Inhibition from 
 the stomach is less transitory than that from the mouth. Boldyreff 
 showed that the periodic contractions of the empty stomach were 
 inhibited by the presence of acid in the intestine. Brunemeier and 
 Carlson completed and enlarged this work. They demonstrated inhibi- 
 tion from the presence of gastric juice or acid chyme in the small 
 intestine. This inhibition from the stomach and intestine is reflex, 
 partly through Auerbach's plexus, but mainly through the long reflex 
 arc with the efferent path to the stomach muscles through the 
 splanchnics. 
 
 Inhibition from the mouth is not present in the frog (Patterson). 
 Carlson, who suspects that such inhibition involves conscious cerebral 
 processes, has suggested experiments in infants to settle the point. 
 
Repeated trials with breast milk, sugar water, common salt, quinin, 
 and lemon juice in the mouths of premature and new-born infants in 
 my study failed to produce inhibition of hunger contractions. 
 
 In general I obtained the same results in an infant of 8 weeks. A 
 transitory inhibition occurred occasionally when sugar water was 
 placed in his mouth. In none of the infants did chewing or sucking 
 on the thumb or tube produce inhibition. Nor did such movements 
 or the presence of sugar, breast milk or other substances in the mouth 
 induce hunger contractions. 
 
 The boy of 2 years showed inhibition when sugar or protein milk 
 (his diet at the time) was placed in his mouth. Quinin, dilute hydro- 
 chloric acid, small amounts of sugar water, table salt in crystals or 
 solution, did not inhibit. Benzosulphinidum solution inhibited twice. 
 It was not used subsequently. The sight of sugar did not inhibit. He 
 began to cry when he saw his bottle if the latter were not given him 
 immediately. Conseqeuntly the effect of his seeing the bottle on the 
 hunger contractions could not be registered. During the periods of 
 quiescence the sight of the nurse who fed him did not induce hunger 
 contractions, although he began to whine and tease when she entered 
 the room. 
 
 Apparently inhibition from the mouth was produced by those sub- 
 stances only which the child regarded as food. Quinin very evidently 
 made a profound sensory impression, but did not inhibit the contrac- 
 tions. Dilute hydrochloric acid did not inhibit, while unsweetened 
 protein milk (which is slightly sour) did. 
 
 Carlson's hypothesis as to the need of conscious cerebration for the 
 production of inhibitory reflexes from the mouth would appear to offer 
 the correct explanation. It seems to be agreed that the new-born 
 infant leads a subcortical reflex existence (Soltmann-Cramer). Kuss- 
 maul and Thiemich note that the new-born infant accepts sugar and 
 rejects salt, food that is sour and bitter action which is almost cer- 
 tainly purely reflex on the part of the infant. 
 
 My work shows that when 20 c.c. of water or milk are introduced 
 into the stomach during a contraction period inhibition follows invari- 
 ably. This was found true in infants of all ages. With small amounts 
 of water the inhibition often lasted only three or four minutes, when 
 the contraction period would be resumed. 
 
 On the other hand, it was not unusual to recover from 15 to 40 cm. 
 of clotted milk through the stomach tube even an hour after vigorous 
 hunger contractions had begun. This is a considerable portion of the 
 infant's meal, and in these cases would represent from one-sixth to 
 one-fourth of his total intake at the previous feeding. Soltmann 
 showed that the inhibiting nervous mechanism of the heart is much less 
 effectual in the new-born infant than in later life. It seems possible 
 
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that the nervous apparatus for the inhibition of the gastric hunger 
 movements may likewise be immature. Or the tissue hunger may be 
 so great as to overcome any but the strong inhibition of a heavily laden 
 stomach and duodenum. 
 
 The vagi form the sensory pathway from the stomach to the brain. 
 The first reflex centers are the sensory nuclei of the vagi in the medulla. 
 A second center, possibly that for conscious hunger, is located in the 
 optic thalami. Rogers has shown that the picking reflex in the pigeon 
 (analogous to the sucking reflex in the babe) is abolished on removal 
 of the thalami. 
 
 The reflex irritability (as indicated by the knee jerk) is increased 
 synchronously with each hunger contraction (Carlson). No observa- 
 tions have been made on the infant's knee jerks during the hunger 
 state ; but Zybell has shown that the electrical irritability increases 
 during the first eighteen hours of starvation. 
 
 Let us summarize the events from the close of one meal till the 
 end of the next. The infant sleeps. The upper stomach musculature 
 maintains a tonic grasp on the contained food. The pyloric antrum 
 is traversed by peristaltic waves (Cannon). The stomach gradually 
 empties. The point of origin of the peristaltic waves rises higher and 
 higher. The tonus rhythm of the fundus begins. The stomach empties 
 itself more completely, the tonus rhythm becomes more intense, and 
 the first hunger contractions appear (Rogers and Hardt). 
 
 The first contraction period is apt to be short. After a wait of 
 perhaps twenty minutes a longer and more intense hunger period 
 arrives ; then another and another. The infant's sleep becomes lighter. 
 He is more easily awakened by external stimuli or by gastric discom- 
 fort. He is put to the breast, nurses vigorously, becomes fatigued 
 (Schmidt, Cramer, Pfaundler), or experiences satiety from distention 
 (Neisser and Brauning) and again goes to sleep. 
 
 What constitutes the hunger state? Does it result from the sum- 
 mation of impulses with an increasing psychic and reflex irritability? 
 The evidence is to the contrary. The increase in the reflex excitability 
 is synchronous with the contraction phase of the stomach, and is absent 
 in the intervals between the contractions. In the infant who has been 
 some hours without food the hunger contractions are nearly continu- 
 ous, and it would be expected that the reflex excitability would be 
 nearly continuously high. 
 
 In the absence of hunger contractions the infant often sucks vigor- 
 ously on the tube attached to the balloon. The receptive mechanism for 
 the institution of the sucking reflex is so delicate that it is impossible 
 to provide, artificially, a minimal stimulus. During the hunger state, 
 when presumably a rapid succession of hunger contractions maintains 
 a low reflex threshold, there may often be observed a succession of 
 
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11 
 
 automatic sucking movements involving the lips, tongue and lower jaw, 
 each movement providing the necessary stimulus for its successor. 
 
 The lay mind is prone to think that the crying infant is hungry. 
 Comby and Czerny and Keller believe that hunger is a minor cause of 
 crying. Rosenstern notes that in hunger young babies are usually 
 quiet, but that the older infants cry more. Schlossmann remarks that 
 the normal infant endures hunger well. 
 
 Observations on this point extending over sixteen months of study 
 of the hunger sensation lead me to believe that in normally thriving 
 breast fed infants, except when more than three or lour hours have 
 elapsed since the last feeding, neither the hunger contractions them- 
 selves nor the increased irritability due to them are ordinarily immedi- 
 ate factors in the production of crying. Young infants sleep through- 
 out strong contraction periods. Older infants often do the same, and 
 are frequently quiet even from twelve to sixteen hours after a feeding. 
 Mental factors produce crying at a very early age. And the fact that 
 crying ceases when food or water is administered may only mean that 
 the infant's attention is diverted to the performance of a pleasur- 
 able act. 
 
 It may be noted in this connection that the 2-year-old boy was 
 happier when allowed to take food into his mouth, and that his outlook 
 on life was much more cheerful on days when he could take nourish- 
 ment by mouth than on other days when the esophageal constriction 
 increased, and it became necessary to introduce the food through the 
 gastric fistula. This feeding through the fistula was without pain, and 
 the child submitted to it with some pleasure. 
 
 What is the time interval between feeding and the first appearance 
 of gastric hunger contractions? Ginsburg, Tumpowsky and Carlson 
 studied this point in thirty normal breast fed infants under 4 weeks of 
 age. They gave no data as to gain in weight and did not determine 
 the amount of food taken, but stated that the babes nursed till satisfied. 
 They found the average time between nursing and the appearance of 
 hunger contractions to be two hours and forty minutes, with a mini- 
 mum of two hours and twenty minutes and a maximum of three hours 
 and thirty minutes. My observations on twelve new-born infants 
 under like conditions yielded these results ; a minimum of one hour and 
 thirty minutes, a maximum of three hours and thirty minutes, and an 
 average of about two and one-half hours. 
 
 Many infants in the first two weeks do not receive a sufficient supply 
 of breast milk. This is particularly apt to be true of the time the babe 
 and the mother remain in the hospital. Consequently, observations 
 made under the conditions so far outlined may be misleading. Table 1 
 (A, B and C) gives the results of all satisfactory tracings obtained 
 from normally thriving babies on whom sufficient data as to food 
 intake and weight gain were obtained. 
 
TABLE 1. INTERVAL FOR DEVELOPMENT OF HUNGER 
 
 A. PREMATURE INFANTS 
 
 Name 
 
 Age, 
 Days 
 
 Food 
 
 Feeding 
 Interval 
 
 Quan- 
 tity at 
 Feeding 
 
 Interval Time for 
 Before Development 
 Tracing of First Hun- 
 ger Period 
 
 Remarks 
 
 Sw. 
 
 7 
 
 Breast milk 
 
 4 hours 
 
 35 c.c. 
 
 None 40 min. 
 
 Premature Wt. 2,140 gm. 
 
 
 
 
 5 times a day 
 
 
 
 
 Sw. 
 
 11 
 
 Breast milk 
 
 4 hours 
 
 SOc.c. 
 
 20min. lhr.,20min. 
 
 Wt. 2,240 gm. 
 
 
 
 
 5 times a day 
 
 
 
 
 Sw. 
 
 20 
 
 Breast milk 
 
 4 hours 
 
 90 c.c. 
 
 52 min. 2 hours 
 
 Wt. 2,470 gm. 
 
 
 
 
 5 times a day 
 
 
 
 
 Sw. 
 
 25 
 
 Breast milk 
 
 4 hours 
 
 75 gm. 
 
 38min. 1 hr., 50 min. 
 
 Wt. 2,565 gm. 
 
 
 
 
 5 times a day 
 
 
 
 
 St. 
 
 13 
 
 Breast milk 
 
 4 hours 
 
 30 c.c. 
 
 None 1 hour 
 
 Premature "Wt. 2,270 gm. 
 
 
 
 
 5 times a day 
 
 
 
 
 St. 
 
 14 
 
 Breast milk 
 
 4 hours 
 
 SOc.c. 
 
 None 40 min. 
 
 Wt. 2,280 gm. 
 
 
 
 
 5 times a day 
 
 
 
 
 St. 
 
 25 
 
 Breast milk 
 
 4 hours 
 
 SOc.c. 
 
 1 hr., 13 min. 1 hr., 15 min. 
 
 Wt. 2,450 gm. 
 
 
 
 
 5 times a day 
 
 
 
 
 St. 
 
 28 
 
 Breast milk 
 
 4 hours 
 
 90 c.c. 
 
 38 min. 1 hour 
 
 Wt. 
 
 
 
 
 5 times a day 
 
 
 
 
 St. 
 
 36 
 
 Breast milk 
 
 4 hours 
 
 100 c.c. 
 
 32 min. lhr.,50min. 
 
 Wt. 2,720 gm. 
 
 
 
 
 5 times a day 
 
 
 
 
 Fre. 
 
 9 
 
 Breast milk 
 
 4 hours 
 
 45 C.C. 
 
 Ihr., 38 min. 1 hr., 38 min. Premature Wt. 1,380 gm. 
 
 
 
 
 6 times a day 
 
 
 
 Fre. 
 
 15 
 
 Breast milk 
 
 4 hours 
 
 45 C.C. 
 
 1 hr., IS min. 1 hr., 18 min. Wt. 1,530 em. 
 
 
 
 
 6 times a day 
 
 
 
 
 Fre 
 
 16 
 
 Breast milk 
 
 4 hours 
 
 45 C.C. 
 
 23 min. 1 hr., 15 min. 
 
 Wt. 1,535 gm. 
 
 
 
 
 6 times a day 
 
 
 
 
 Fre 
 
 21 
 
 Breast milk 
 
 4 hours 
 
 65 c.c. 
 
 2 hours 2 hr., 20 min. 
 
 Wt. 1,710 gm. 
 
 
 
 
 6 times a day 
 
 
 
 
 B. FULL TERM NEW-BORN INFANTS 
 
 H. 
 
 8 
 
 Breast milk 
 
 4 hours 
 
 1 
 
 1 hr., 22 min. 
 
 3 hr., 50 min. 
 
 Wt. 3,590 gm.; gain in 4 
 
 
 
 
 5 times a day 
 
 
 
 days, 90 gm. 
 
 Day. 
 
 8 
 
 Breast milk 
 
 3 hours 
 
 75 gm. 
 
 1 hr., 55 min. 
 
 2 hr., 25 min. Wt. 4,l(iO gm.; gain in 5 
 
 
 
 
 8 times a day 
 
 
 
 days 200 gm.; 10 c.c. of 
 
 
 
 
 
 
 
 
 milk clot removed from 
 
 
 
 
 
 
 
 
 stomach 1 hr. after be- 
 
 
 
 
 
 
 
 
 ginning of hunger con- 
 
 
 
 
 
 
 
 
 tractions 
 
 Day. 
 
 9 
 
 Breast milk 
 
 4 hours 
 
 1 
 
 2 hr., 30 min. 
 
 2 hr., 30 min. i Wt. 4,200 gm.; gain In 6 
 
 
 
 
 (for preceding 
 
 
 
 days, 300 gm.; V4 c.c. 
 
 
 
 
 24 hours) 
 
 
 
 
 thick mucus removed 
 
 
 
 
 5 times a day 
 
 
 
 
 from stomach V4 hr. 
 
 
 
 
 
 
 
 
 after beginning of hun- 
 
 
 
 
 
 
 
 ger contractions 
 
 Wes. 
 
 8 
 
 Breast milk 
 
 4 hours : 100 gm. 
 
 1 hr., 30 min. 
 
 3 hr., 10 min. 14 hours fast previous to 
 
 
 
 
 5 times a day 
 
 
 last feeding 
 
 A. 
 
 9 
 
 Breast milk + 
 
 3 hours 
 
 70 gm. 
 
 1 hr., 45 min. 
 
 2 hr., 10 min. Wt. 3,610 gm.; gain in 6 
 
 
 
 cow's milk)__ 
 
 8 times a day 
 
 
 
 days 230 gm.; 2o c.c. of 
 
 
 
 8% lactose) 
 
 
 
 
 
 thick soft milk clot re- 
 
 
 
 
 
 
 
 
 moved from stomach 50 
 
 
 
 
 
 
 
 
 min. after beginning of 
 
 
 
 
 
 
 
 
 hunger contractions 
 
 A. 
 
 10 
 
 Breast milk + 
 
 
 70 em. 
 
 1 hr., 52 min. 
 
 2 hours 
 
 15 c.c. of fluid and curds 
 
 
 
 cow's milk? 
 
 
 
 
 removed from stomach 
 
 
 
 8% lactoses 88 
 
 
 
 ; 30 min. after beginning 
 
 
 
 
 
 
 
 of hunger contractions 
 
 Wai. 
 
 10 
 
 Breast milk 
 
 4 hours 95 gm. 
 
 1 hr., 30 min. 
 
 4 hours 
 
 Wt. 3,240 gm.; gain in 6 
 
 
 
 
 5 times a day 
 
 
 
 days, 260 gm. 
 
 D. 
 
 12 
 
 Breast milk 
 
 4 hours 
 
 115 gm. 
 
 2 hr., 30 min. 
 
 2 hr., 30 min. 
 
 Wt. 3,720 gm.; gain in 7 
 
 
 
 
 5 times a day 
 
 
 
 days, 400 gm. 
 
 C. NORMAL INFANTS OVER TWO WEEKS OF AGE 
 
 Gor. 
 
 18 
 
 Breast milk 
 
 4 hours 
 
 85 gm. 
 
 2 hr., 23 min. 
 
 4 hours Wt. 3,500 gm.; gain in 13 
 
 
 
 
 5 times a day 
 
 
 days, 70 gm. 
 
 Gor. 
 
 19 
 
 Breast milk 
 
 4 hours : 110 gm. 
 
 1 hr., 58 min. 
 
 3 hr., 25 min. 
 
 
 
 
 5 times a day 
 
 
 
 
 Mos. 
 
 
 
 
 
 Way. 
 
 3.5 
 
 Buttermilk + 
 
 4 hours 
 
 150 c.c. 
 
 2 hr., 27 min. 
 
 3 hr., 12 min. Wt. 4,960 gm.; gain in 7 
 
 
 
 flour + 5 times a day 
 
 
 days, 440 gm. 
 
 
 
 saccharose 
 
 
 
 Way. 
 
 3.5 
 
 Buttermilk + 4 hours 150 c.c. 
 
 57 min. 
 
 3 hr., 20 min. 40 c.c. of thick white 
 
 
 
 flour + 5 times a day 
 
 
 materal removed from 
 
 
 
 saccharose 
 
 
 
 
 
 stomach 20 min. after 
 
 
 
 
 
 
 
 
 beginning of contrac- 
 
 
 
 
 
 
 
 
 tion period 
 
 Way. 
 
 3.5 
 
 Buttermilk + 4 hours 150 c.c. 
 
 2 hr., 3 min. 
 
 4 hr., 35 min. 
 
 
 
 
 flour + 5 times a day 
 
 
 
 
 
 
 saccharose 
 
 
 
 
 Herm. 
 
 4 
 
 Breast milk 2 or 3 hours 
 
 1 
 
 2 hr., 45 min. 
 
 3 hr.. 30 min. Well nourished; gaining 
 
 
 
 irregular 
 
 
 
 in weight; normal baby; 
 
 
 
 
 
 
 cared for at home; not 
 
 
 
 
 
 
 
 in hospital 
 
 J. 
 
 4 
 
 Breast milk 
 
 5 times a day 
 
 1 
 
 2 hr., 15 min. 
 
 3 hr., 30 min. Well nourished; gaining 
 
 
 
 
 
 
 in weight; normal baby; 
 
 
 
 
 
 cared for at home; not 
 
 
 
 
 
 in hospital 
 
 Ad. 
 
 4 
 
 Malt soup 4 hours 125 c.c. 
 
 2 hr , 37 min. 
 
 3 hr., 30 min. 
 
 Wt. 3,500 gm.; gain in 2 
 
 
 
 
 5 times a day 
 
 
 
 
 weeks, 200 gm.; prema- 
 
 
 
 
 
 
 
 
 turely born; l.UOOgm. at 
 
 
 
 
 
 
 
 birth 
 
13 
 
 The time required for the development of hunger in the premature 
 infant is noticeably short. In the case of the full term ne\v-borns the 
 figures obtained agree fairly well with those given by Ginsburg, Tum- 
 powsky and Carlson, but are definitely greater than those obtained by 
 me (mentioned in a preceding paragraph) from infants whose food 
 intake was net accurately known. 
 
 The time required for the development of hunger in any one infant- 
 is fairly constant over a short period of time, provided the amount and 
 kind of food is not changed. This conclusion rests not only on the 
 results shown in Table 1, but on a dozen other observations on infants 
 whose feeding conditions remained constant during the time in which 
 studies were made. 
 
 With the older infants difficulty in maintaining quiet, after the 
 insertion of tube and balloon, limits the number of observations which 
 give positive evidence as to the first appearance of hunger contractions. 
 Many less successful observations on healthy, normally developing 
 infants yield this negative evidence that in such infants more than a 
 month old I did not observe the development of hunger before the end 
 of three hours. 
 
 It should be noted further that the contraction period, the first 
 appearance of which is recorded in Table 1, is the first one to develop 
 after feeding. This period is usually short and is not made up of 
 forceful contractions. With Infants J. and A. more intense and more 
 nearly continuous contractions did not begin for four and four and a 
 half hours, respectively. 
 
 Habits as to feeding interval affect the time required for the devel- 
 opment of hunger chiefly as they influence the emptying time of the 
 stomach. It has been shown that the speed of gastric emptying is pro- 
 portional to the length of time during which the individual has been 
 without food (Tobler, Haudek and Stigler), and that large feedings 
 are emptied with relatively greater rapidity than small ones (Tobler 
 and Bogen). Habits undoubtedly exert a more powerful influence or. 
 the mental factors associated with appetite than on hunger itself. 
 
 Tables 2, 3 and 4 illustrate the shorter time required for the devel- 
 opment of hunger in infants with chronic nourishment disturbance, 
 and indicate that the presence of hunger contractions is not in itself 
 evidence that the stomach is ready for food. 
 
 In the columns headed "Remarks" in Tables 1, 2, 3 and 4, there are 
 notes as to material recovered with the stomach tube after the onset 
 of gastric hunger contractions. In normal babies, however, there prob- 
 ably does exist a relation between the emptying time of the stomach 
 and the interval for the development of hunger. 
 
 Observations on the emptying time in infants, so far reported, have 
 been made either with the relatively stiff catheter, the stomach tube. 
 
15 
 
 or the Roentgen ray. The flexible tube introduced by Rehfuss should 
 replace the catheter for this purpose ; it was used in my work. The 
 literature contains no reports of the time required for gastric digestion 
 in the premature infant. The emptying time in normal breast-fed 
 infants under 1 week is usually less than one hour (Leo). The 
 Roentgen-ray observations of Ladd and of Tobler and Bogen would 
 indicate that in normal breast-fed infants the stomach is frequently 
 not empty until after two to three hours. The figures obtained with 
 the use of the stomach tube by Epstein, Czerny, Keller and Cassel indi- 
 cate a delayed emptying time in gastro-intestinal disease. 
 
 TABLE 2. HUNGER IN ATROPHY RESULTING FROM CONTINUED STARVATION 
 
 N. N., aged 2 years; gastric fistula; weight fluctuating between 6.SOO gm. and 7,200 gm.; typhoid fever 
 Dec. 1 until Dec. 14, 1916. 
 
 Date 
 1916 
 
 Food 
 
 Time of Beginning 
 Last of 
 Feeding Ttracing 
 
 
 10/19 
 
 Diluted cow's milk + 
 
 6a.m. 10:15 a.m. 
 
 Practically continuous hunger periods until 10:50 a. m. 
 
 
 general diet 
 
 
 
 10/20 
 
 Diluted cow's milk + 
 
 10 a. m. ; 2:12 p. m. 
 
 Practically continuous hunger periods until 3:15 p. m. 
 
 
 general diet 
 
 
 
 III 1 
 
 
 10 a. m. 2:16 p. m. 
 
 Ono hunger period at 2:45 p. m. to 2:50 p. m. Hunger 
 
 
 
 
 contractions practically continuous after 3 p. m. 
 
 
 
 
 until 4:50 p. m. 
 
 11/10 
 
 160 c.c. cow's milk at 
 
 2 p. m. , 2:45 p. m. 
 
 Observations continued until 5:10 p. m. No hunger 
 
 
 preceding feeding 
 
 
 periods, but child cried or was restless over half 
 
 
 
 
 of the time 
 
 10/11 
 
 160 c.c. cow's milk at 
 
 2p.m. 9:00 p.m. 
 
 Practically continuous contractions until 11 p. m. 
 
 
 preceding feeding 
 
 
 
 11/11 
 
 200 c.c. protein milk + 
 
 5p.m. 10:12 p.m. 
 
 Practically continuous contractions until 11 p. m. 
 
 
 7% dextrimaltose 
 
 
 
 11/12 
 
 200 c.c. protein milk + 
 
 5 p. m. 8:41 p. m. 
 
 First hunger period at 9:30; practically continuous 
 
 
 7% dextrimaltose 
 
 
 from 9:45 on until 10:44 p. m. 
 
 11/29 
 
 200 c.c. protein milk + 
 
 1 p. m. 4:02 p. m. 
 
 First hunger period began at 4:35 p. m.; practically 
 
 
 7% dextrimaltose 
 
 
 continuous from 5 p. m. on until 5:42 p. m. 
 
 12/27 
 
 200 c.c. protein milk + 
 
 9a.m. 12:34 p.m. 
 
 Hunger periods practically continuous until 1:30 p. m. 
 
 
 7% dextrimaltose 
 
 
 
 
 + cereals 
 
 
 
 12/28 
 
 200 c.c. protein milk + 
 
 9 a. m. ; 12:22 p. m. 
 
 Hunger periods began about 12:50; hunger periods 
 
 
 7% dextrimaltose 
 
 
 became continuous after 1:20 p. m. 
 
 
 + cereals 
 
 
 
 12/30 
 
 200 c.c. protein milk + 
 
 5a.m. 10:13 a.m. 
 
 Practically continuous hunger periods until 11:20 a.m. 
 
 
 7% dextrimaltose 
 
 
 
 
 + cereals 
 
 
 
 Major, using the Roentgen ray, finds the emptying time delayed in 
 dyspepsia, but accelerated in decomposition. With the same method 
 Pisek and LeWald found the emptying time to be shorter in infants 
 with chronic disturbances of nutrition. 
 
 These last findings, taken in conjunction with the already quoted 
 reports of Tobler, and of Haudek and Stigler, that the emptying time 
 is shortened by hunger, are suggestive of the results here obtained 
 experimentally ; that is, the greater gastric hunger contraction in infants 
 with chronic nourishment disturbance. 
 
 Not only is the interval for development of hunger shorter in such 
 infants, but the contractions become much more intense. Nov. 10, 
 
17 
 
 1916, the 2-year-old boy (Table 2), whose weight in spite of a calori- 
 cally sufficient intake had remained stationary, and whose temperature 
 had been irregular, developed fever and diarrhea. After eight hours 
 of starvation, with temperature normal, the graphic record of his gas- 
 tric activities resembled those of the starving pigeon and of the pre- 
 mature infant already mentioned. The contractions were continuous 
 and required only twelve seconds for their completion. Next day the 
 child was put on protein milk and thereafter improved. 
 
 It is generally agreed that mixtures with high fat content leave the 
 stomach most slowly, while those with low fat and high carbohydrate 
 
 TABLE 3. HUNGER IN EXUDATIVE DIATHESIS 
 Aus., 1 weeks old, Dec. 19, 1916. Feeding interval 4 hours, 5 times a day. 
 
 
 Food: Breast 
 
 
 
 
 
 Milk + Butter- 
 
 Time ol 
 
 Beginning 
 
 
 Date 
 
 Weight, milk + Flour 
 
 Lust 
 
 of Tracing 
 
 
 
 Gm. 
 
 + Saccharose, 
 
 Feeding 
 
 
 
 
 
 C.c. 
 
 
 
 
 12/19/16 
 
 4.450 
 
 100 
 
 1 p. m. 
 
 3:28 p. m. 
 
 Hunger contractions began at 3:30 p.m. 
 
 
 
 
 
 
 Hunger contractions continuous from 
 
 
 
 
 
 3:55 to 4:37 p. in. 
 
 12/22/16 
 
 4,460 100 
 
 9 a. m. 
 
 11:49 a. m. Hunger contractions present at 11:49 
 
 
 
 
 
 a. m. Hunger contractions continu- 
 
 
 
 
 
 ous until 12:50 p. m. 
 
 12/22/16 
 
 4,460 
 
 150 
 
 1:15 p. m. 
 
 3:34 p. m. Hunger contractions began at 5:45 p. m. 
 
 I/ 6/17 
 
 4,640 
 
 125 
 
 8 a. m. 
 
 10:55 a.m. Hunger contractions began at 10:55 
 
 
 
 
 
 a. m. Hunger contractions continu- 
 
 
 
 
 
 ous until 12:21 p. in. 
 
 I/ 8/17 
 
 4,640 
 
 125 
 
 8:40 a. m. 
 
 11:51 a.m. Hunger contractions began at 12 m. 
 
 
 
 
 
 Hunger contractions strong and con- 
 
 
 
 
 tinuous after 12:18. Babe was restless 
 
 1/11/17 
 
 4,650 125 
 
 8:45 a. m. 
 
 11:11 a. m. Hunger contractions present by 11:45 
 
 
 
 
 a. m. Hunger contractions continu- 
 
 
 
 
 ous until 1:35 p. m. 
 
 1/13/17 
 
 4,740 
 
 150 
 
 8:20 a. m. 
 
 11:03 a. m. Hunger contractions began at 11:45 
 
 
 
 
 
 a. m. Hunger contractions continu- 
 
 
 
 
 
 ous Irom 12 to 1 p. m. 
 
 1/15/17 
 
 4,770 ! 150 
 
 8:45 a. m. 
 
 11:01 a.m. Hunger contractions present at 11:20 
 
 
 
 
 
 a. m. Hunger contractions continu- 
 
 
 
 
 
 
 out from 11:30 a. m. until 12:50 p. m. 
 
 1/15/17 
 
 4,770 
 
 150 
 
 12:50 p. in. 
 
 3:21 p. rn. 
 
 Babe cried a large part ol time; no 
 
 
 
 
 
 
 evidence ol hunger periods until 5 p. m. 
 
 leave most rapidly. In Infants A. and W. the time interval for the 
 development of hunger contractions was much longer when they 
 received low fat and high carbohydrate, and shorter when they 
 received high fat and low carbohydrate. This would be paradoxical 
 if the gastric hunger contractions depended exclusively on the empty- 
 ing time. 
 
 It is, then, only in normal babies, receiving well tolerated food in 
 sufficient quantity, that the development of hunger waits on the empty- 
 ing of the stomach. 
 
 The interval necessary for the development of hunger depends in 
 part on the form of nourishment and is shortest with that food which 
 least satisfies the infant's tissue need (Table 4). The question as to 
 whether the rapid development of hunger in qualitatively poorly 
 
19 
 
 nourished infants depends on the administration of food deficient in 
 carbohydrate in particular, or on the giving of food poorly tolerated 
 in general, is not answered. Records of the gastric contractions in 
 infants suffering from the chronic nourishment disturbance due to long 
 continued carbohydrate overfeeding (the "Mehlnahrschaden" of 
 Czerny) would help to settle this point. 
 
 TABLE 4. INTERVAL FOR DEVELOPMENT or HUNGER IN INFANTS WITH CHRONIC 
 
 DISTURBANCE OF NUTRITION AND SHOWING INFLUENCE OF 
 
 CHANGE IN FORM OF NOURISHMENT 
 
 Name 
 and 
 Date 
 
 Age, 
 Mo. 
 
 Diagnosis 
 
 Weight, 
 Gm. 
 
 Food 
 
 Interval 
 Before 
 Tracing 
 
 Time for 
 Develop- 
 ment of 
 First 
 Hunger 
 Period 
 
 Remarks 
 
 Til 
 
 
 
 Sta- 
 
 
 
 
 
 Ad 
 
 4 
 
 
 tionary 
 4,080 
 
 3300 
 
 -f 7% dextrimaltose 
 5 times a day 
 
 150 c.c. ty milk + 
 
 
 
 tial tetanus less than 3 
 hours after feeding 
 
 2/26/17 
 Ad 
 
 4 
 
 disorder due to 
 overfeeding with 
 milk 
 
 3 500 
 
 10% saccharose 
 5 times a day 
 
 
 
 present in 2 hours and 
 20 minutes 
 
 S/ 8/17 
 
 3 
 
 disorder due to 
 overfeeding with 
 milk 
 
 
 5 times a day 
 
 
 
 hunger contractions 
 first appear in 314 hrs. 
 
 4/14/17 
 
 
 ment disturbance 
 with eczema 
 
 4,200 
 
 8% fp.t. Feeding in- 
 tervals short and 
 irregular. After en- 
 trance to hospital 
 fed 5 times a day 
 150 c.c. l fa cow's milk 
 
 2hr., 
 
 2hr., 
 
 14, 1917 
 
 4/23/17 
 
 
 
 4,510 
 
 + 10% saccharose 
 
 7 min. 
 2br., 
 
 7 min. 
 2hr., 
 
 after feeding; ^ c.c. of 
 mucus and thick curd 
 obtained 
 
 5/ 1/17 
 
 
 
 4,960 
 
 + 10% saccharose 
 150 c.c. buttermilk + 
 
 10 min. 
 2hr., 
 
 10 min. 
 4hr., 
 
 of clotted milk and 
 clear thin fluid recov- 
 ered from stomach 3 
 hours and 25 minutes 
 after feeding 
 Eczema has disappeared 
 
 5/ 2/17 
 
 
 
 4,960 
 
 flour + saccha- 
 rose 
 
 3 min. 
 2hr., 
 
 35 min. 
 3 hr., 
 
 
 5/ 3/17 
 
 
 
 4,960 
 
 flour + saccha- 
 rose 
 
 27 min. 
 57 min. 
 
 12 min. 
 3 hr.. 
 
 
 
 
 
 
 flour + saccha- 
 rose 
 
 
 20 min. 
 
 terial removed from 
 stomach 20 minutes 
 after beginning of first 
 contraction period 
 
 Attention has already been called to the heightened electrical reac- 
 tions found by Zybell in hungry infants. I also wish to mention the 
 findings of Finklestein, Thiemich and Japha that the electrical irrita- 
 bility is frequently heightened in artificially fed infants, and of Czerny 
 and Moser that there is an increase in the electrical irritability of 
 infants suffering with "Mehlnahrschaden." It is possible that the 
 heightened electrical irritability in all depends on the increased hunger 
 contractions due again in part to the constant chemical stimulation 
 reaching the stomach from the semistarved tissues. 
 
20 
 
 Most premature infants and many young infants nurse poorly. 
 The consequent effect on lactation and on the babe's nourishment is 
 serious. An extensive literature on this subject has been developed 
 in German, but there is surprisingly little in French and in English. 
 
 In 1888 Auerbach described the infantile manner of sucking, which 
 depends on the chewing muscles, and Escherich showed its teleologic 
 importance. The reflex paths and center in the medulla were demon- 
 strated in 1894 (Basch). Cramer, Suszwein, Finklestein, Rott, Rosen- 
 stern, Barth and Kasahara have further studied the question and report 
 results which in general support the theory that the inability to nurse 
 well is to be attributed primarily to an imperfect nervous mechanism 
 and not to muscular weakness. 
 
 For further elucidation of the question, tracings of the movements 
 of the empty stomach were taken in two infants who were extreme 
 examples. 
 
 The first baby (Baby M.), weighing 2,700 gm. at birth and pre- 
 senting no anatomic peculiarities, took very little from the mother's 
 breast during the first three weeks, although sufficient milk was 
 expressed therefrom to feed the baby and to complement the feedings 
 of other babies. 
 
 The second infant (Baby T.), aged 3 months, had weaned himself 
 from the breast, had developed dyspepsia and atrophy on artificial 
 feeding, and could be made to take his food from the bottle only with 
 great difficulty. He seemed able to fix his attention on anything other 
 than the act of feeding. 
 
 In these infants as well as in the five prematures, and in one typical 
 case of congenital myxedema, hunger contractions of at least normal 
 force and duration were present. At the time they were studied, none 
 of the infants was able to nurse successfully. In all, the sucking reflex 
 was qualitatively present. 
 
 This study does not solve the problem as to the causation of feeble 
 nursing, but does limit the field of possibilities by excluding derange- 
 ments of the primitive hunger apparatus. 
 
 Carlson reports Rupp's finding that hunger contractions persist 
 during the fever excited by the administration of typhoid vaccine. 
 The boy with the gastric fistula contracted typhoid fever from a 
 carrier. Tracings taken while his rectal temperature ranged between 
 104.4 F. and 105 F., show the presence of hunger contractions. 
 
 Carlson and Ginsburg found hypertonicity and hypermotility in the 
 stomachs of two infants with pylorospasm and stenosis. From a six 
 weeks' old infant (Baby S.) with pyloric stenosis, I obtained records 
 which agree with Carlson and Ginsburg's description of periods of 
 tetanus lasting several minutes interspersed with vigorous contractions 
 of normal duration. 
 
21 
 
 Carlson suggests that pylorospasm and stenosis may be an expres- 
 sion of gastric hypermotility. His cases were seen late, as was the one 
 here reported. In the absence of tracings taken at the beginning of the 
 disease, it is likely that the hypermotility results from the inanition 
 following the obstruction at the pylorus. And without definite knowl- 
 edge that the stomach was washed empty, the long periods of tetanus 
 observed may represent the so-called visible gastric peristalsis. 
 
 SUMMARY 
 
 The study of fifty-six infants from birth to 2 years of age gives 
 the following results : 
 
 1. Confirmation of previous work, that hunger contractions are 
 greater in the new-born infant, with description of these contractions. 
 
 2. Determination of the still greater hunger contraction in the 
 stomachs of prematurely born infants, with description of these con- 
 tractions. 
 
 3. There is no relation between cyanosis and hunger contractions. 
 
 4. Inhibition of the hunger contractions from the mouth does not 
 occur in young infants. 
 
 5. Inhibition of the hunger contractions from the mouth in older 
 infants is present only as the result of stimuli, which the babe has 
 learned to recognize as food. It does not occur with substances pro- 
 ducing equally strong sensory impressions, but which are not con- 
 sidered by the infant as food. 
 
 6. Inhibition from the mouth is psychic in character. 
 
 7. Reflex inhibition from the presence of food in the stomach is 
 present in infants of all ages. 
 
 8. This reflex inhibition from the stomach may be only partially 
 developed in young infants. 
 
 9. Successive automatic sucking movements each sucking act 
 serving as the stimulus for its successor are present during the 
 hunger state, when the reflex threshold is kept almost constantly low 
 by a rapid succession of hunger contractions. 
 
 10. In normally developing breast fed babes, hunger is not ordi- 
 narily an immediate cause of crying. 
 
 11. The average time required for the development of hunger in 
 healthy infants gaining in weight and receiving a known sufficient 
 amount of food is, in prematures, under one month, one hour and 
 forty minutes, with a maximum of two hours and twenty minutes and 
 a minimum of forty minutes; in full term infants under two weeks, 
 two hours and fifty minutes, with a maximum of four hours and a 
 minimum of two hours; in infants from two weeks to four months. 
 
22 
 
 three hours and forty minutes, with a maximum of four hours and 
 thirty-five minutes and a minimum of three hours and twelve minutes 
 (Table 1). 
 
 12. The time required for the development of hunger in any one 
 infant is fairly constant over a short period of time provided the 
 amount and kind of food is not changed (Tables 1, 2, 3 and 4). 
 
 13. The time required for the development of hunger in infants 
 with chronic nourishment disturbance is shorter than in normal infants 
 (Tables 2, 3 and 4). 
 
 14. The time required for the development of hunger is shorter 
 when the infant receives food which is poorly tolerated (Table 4). 
 
 15. Hunger contractions occur in these infants long before the 
 stomach has emptied. Consequently their presence is not in itself an 
 indication that the stomach is ready for food. 
 
 16. The feeble nursing exhibited by most prematures and by many 
 older infants is not due to derangement of the primitive hunger 
 apparatus. Hunger contractions are present and of normal intensity 
 in such infants. 
 
 17. Hunger contractions were present in one infant with congenital 
 myxedema. 
 
 18. Hunger contractions were present in a 2-year-old boy with 
 typhoid fever when the rectal temperature ranged between 104.4 F. 
 and 105 F. 
 
 19. Confirmation of previous findings of increased hunger con- 
 tractions in infants with pyloric stenosis. 
 
 I wish to express my sincere thanks to Dr. A. J. Carlson of the University of 
 Chicago for suggestions which aided materially in carrying out these studies; 
 to Dr. E. P. Lyon and Dr. A. D. Hirschf elder for the loan of apparatus from 
 the departments of physiology and pharmacology ; to Dr. F. H. Scott and Dr. 
 F. B.. Kingsbury for advice and assistance in the construction of apparatus ; to 
 Dr. F. W. Schultz for the use of material from the Infant Welfare Clinic; to 
 Dr. N. O. Pearce, teaching fellow in pediatrics, and to head nurses Barber and 
 Wenck, who cheerfully assisted in preparing the little patients for examination. 
 
 To my chief, Dr. J. P. Sedgwick, who first suggested this problem, and who 
 allowed the free use of his material in the service at the university hospitals, I 
 wish to express my grateful appreciation for constant stimulating interest and 
 helpful suggestions. 
 
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24 
 
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25 
 
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HUNGER AND APPETITE SECRETION OF GASTRIC 
 JUICE IN INFANTS' STOMACHS* 
 
 ROOD TAYLOR, M.D., Sc.D. 
 Mayo Clinic 
 
 ROCHESTER, MINN. 
 
 There is apparently a gastric element in appetite. The contractions 
 of the stomach institute hunger. Its profuse and rich secretion causes 
 an entirely different sensation not painful, but pleasant. Carlson 
 concludes that the appetite or psychic gastric juice described by Paw- 
 low 1 stimulates sensory nerve endings in the gastric mucosa. The 
 resulting sensation resembles that which follows the first few mouth- 
 fuls of good food at a meal to which one has come hungry, and directs 
 the flow of consciousness toward the matter of taking food. 
 
 Pediatric literature contains many references to this secretion. 
 Bauer and Deutsch found no gastric juice in the baby's stomach after 
 it had reached eagerly for its bottle. Pfaundler noted that in babes 
 who nursed actively the stomach emptied sooner, and the degree of 
 acidity attained was higher than in babes who were fed passively or 
 through the tube. Cohnheim and Soetbeer, working with gastrotomized 
 new-born pups, obtained juice containing hydrochloric acid even when 
 the pups nursed on nonlactating breasts. A. H. Meyer found a great 
 variation in gastric acidities in the same child and conjectured that the 
 variations might depend on the presence or absence of Pawlow's appe- 
 tite juice. Schmidt writes that the infant on the breast works and 
 stimulates the secretion of gastric juice. Meisl advocates the use of a 
 pacifier before meals to cause the flow of appetite juice. Bogen, whose 
 material included a 31/2-year-old boy with a stenosed esophagus and 
 gastric fistula, concludes that psychic secretion of gastric juice does 
 occur. Nothmann, in 1909, formally investigated the question of the 
 secretion of appetite juice by the infant's stomach, and concluded that 
 it took place even immediately after birth. Rosenstern advised the use 
 of pepsin and hydrochloric acid to stimulate the appetite of infants 
 who nurse poorly. Bonniger could find in pups no relation between 
 the kind of food and the secretion of gastric juice. 
 
 With the exceptions of the work done on pups, and Bogen's work 
 on a S^-year-old boy, the foregoing is all brought into question because 
 it relies on the use of the ordinary catheter or stiff stomach tube, which 
 
 * From the Department of Pediatrics, University of Minnesota. 
 
 1. References to the literature will be found at the end of the article. 
 
27 
 
 does not permit accurate quantitative studies. A still more serious 
 criticism, and one which leaves the whole subject open, is that in none 
 of the quoted work is the possibility of a continuous secretion of gastric 
 juice sufficiently taken into account. 
 
 In 1888 Leo found free hydrochloric acid in the stomachs of unfed 
 new-born babes, and noted that in older infants the stomach was rarely 
 entirely empty, so that he could usually recover a few drops of thick, 
 yellowish acid fluid. He washed out the stomach and again inserted 
 the tube and then obtained only wash water from the preceding wash- 
 ings. Consequently Leo concluded that the acid juice obtained by him 
 from the "empty" stomach was the gastric juice remaining from the 
 last meal, concentrated by the absorption of water. Wohlmann 
 reported that the secretion of the infant's empty stomach is viscid, 
 colorless, glassy, and without free hydrochloric acid. Wohlmann took 
 his specimens from one to two hours after feeding. The teachings of 
 Pawlow that gastric secretion depends on appetite or on food or other 
 stimuli in the stomach impressed the medical mind so deeply that until 
 the present decade all gastric secretion was interpreted in the light of 
 his investigations. A. H. Meyer concluded that the passage of the 
 stomach tube does not excite the secretion of acid gastric juice. Paw- 
 low's published work supports the same conclusion. Engel reports a 
 4-week-old babe with pyloric stenosis and a jejunal fistula. From this 
 infant, who was fed through the fistula, Engel obtained by way of the 
 esophagus from 60 to 200 c.c. of gastric juice daily. The total acidity 
 of this juice ranged from 60 to 70 and was nearly entirely made up of 
 free hydrochloric acid. Engel was unable to explain his findings except 
 on the basis of a pathologic hypersecretion, which he thought might 
 have caused the pyloric stenosis. Alfred F. Hess, in 1913, showed that 
 the stomach of the unfed new-born babe secretes a highly acid juice, 
 and he concluded further that saliva does not act as a stimulus to the 
 production of such juice. He was unable to determine a relationship 
 between the amount of sucking and the amount of juice secreted. 
 Sedgwick recovered acid stomach and duodenal contents three and four 
 hours after nursing. In 1905 Boldyreff reported continuous secretion 
 of the gastric glands in starving dogs. Ten years later Fowler, Rehfuss 
 and Hawk concluded that, in man, the gastric glands are never idle, 
 while Carlson demonstrated the continuous secretion of gastric juice 
 in the empty stomach of normal adults. Referring to its secretion 
 during the hunger state, Carlson calls it hunger juice. 
 
 It is evident that the determination of the secretion of an appetite 
 juice in the infant's stomach must be made in conjunction with the 
 determination of its continuous secretion. 
 
 The flexible tube with the slotted weight at the tip described by 
 Rehfuss, combined with any simple syringe for gentle aspiration, makes 
 
28 
 
 an excellent instrument for the study of the physiology of the stomach 
 of the infant. A smaller tip can be made for those infants who cannot 
 swallow the ordinary tip. With this apparatus I have repeatedly 
 recovered from the infant's stomach the entire 30 to 50 c.c. of water 
 introduced into it and never have lost more than 2 c.c. in the washing. 
 Furthermore, large, thick, gelatinous clumps of mucus and curd are 
 removed without difficulty. 
 
 In order to avoid, as far as possible, contaminating the gastric juice 
 with saliva, and to permit the carrying out of sham feeding, I converted 
 a No. 21 F. soft rubber catheter into an outer casing for the Rehfuss 
 tube. When in place this outer casing terminates internally in the 
 esophagus, and externally with a suction apparatus. The whole is 
 explained in the accompanying illustration, which is one-half actual size. 
 
 Bulb | or collection 
 of saliva, milk etc 
 
 To Syringe |or 
 
 collection o 
 gastric iuice 
 
 Lnd o| outer casing 
 
 tip 
 n stomach 
 
 Author's apparatus for removing gastric contents from infants; one-half 
 actual size. 
 
 The experimental procedure was as follows: If the babe fasted all- 
 night, he was given water at 5 a. m. in quantity equivalent to his usual 
 feeding. When the stomach was examined a few hours later, milk 
 remains were never found. If the period without food were shorter, 
 his stomach was thoroughly washed out and observations begun an 
 hour later. 
 
 If no aspiration is applied to the stomach tube during the half hour, 
 the amount obtained is usually less than 1 c.c. The usual procedure 
 was to insert the tube, exert suction to empty the stomach of any con- 
 tent, then allow the tube to remain one-half hour without suction, and 
 
29 
 
 collect the specimen, if any. Repeat the procedure, exerting gentle 
 suction every two and one-half minutes and collect the specimen. 
 Exert suction in the same way during a third half hour while the sham 
 feeding progresses. The final two specimens only are listed in the 
 accompanying table. 
 
 As a rule, no secretion was obtained for five minutes after the inser- 
 tion of the tube. On one occasion gastric juice containing free hydro- 
 chloric acid was obtained within two minutes of the time at which 
 introduction of the tube began (Baby A.). This is less than the latent 
 time usually required by the gastric glands (Carlson, Pawlow) and is 
 further evidence that the secretion here obtained was not produced 
 artificially by the apparatus. 
 
 To stimulate an appetite secretion, the babe was given a pacifier 
 threaded over the tube, or, the food to which he was accustomed was 
 administered by a medicine dropper, or, with the artificially fed babes, 
 from their usual nursing bottle. The infant always sucked vigorously 
 during this procedure. If the babe sucked before sham feeding began, 
 it has been noted in the table. As a rule, the babes slept or were quiet 
 and did not suck, except after the beginning of the sham feeding. The 
 presence of the tube seemed to discommode these babes very little. 
 There certainly was no psychic excitement to depress the action of the 
 gastric glands while the babes were smacking and sucking over their 
 food. 
 
 In three cases only, as noted in the table, did food reach the stom- 
 ach. Strictly speaking, neither these instances nor the specimens which 
 contained blood should be considered as offering evidence on either the 
 subject of "hunger" or "appetite" gastric juice. The only demon- 
 strable effect of the blood, which was never present in more than a 
 trace, was to lower the acid titration values. On the three occasions 
 on which milk reached the stomach, larger amounts of secretion was 
 obtained. 
 
 The titrations were done against tenth-normal sodium hydroxid, 
 using di-methyl-amino-azobenzol and phenolphthalein as indicators. 
 The hydrogen-ion concentrations were done by the gas chain methoG. 
 I wish to thank Dr. J. F. McClendon for his courtesy in allowing the 
 use of his apparatus. 
 
 The "appetite" gastric juice is characterized by its relatively pro- 
 fuse secretion and high acidity. Neither characteristic was present in 
 the juice obtained after sham feeding in these infants. On the con- 
 trary, the juice obtained differed little in character and quantity from 
 that obtained before sham feeding was begun. 
 
 It will be seen that the empty stomach of the infant continuously 
 secretes a juice which at times is as acid as that of the adult, and that 
 the infant's stomach does not secrete an "appetite" or psychic juice. 
 
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31 
 
 This accords with the absence of psychic inhibition of the hunger con- 
 tractions. 
 
 As indicated by the digestion of egg white in Mett's tube, the 
 infant's hunger juice contains pepsin. 
 
 Reiche has demonstrated the absence of a duodenal reflux into the 
 infant's stomach. The present findings support his conclusion. What, 
 then, becomes of this continuous secretion under circumstances such as 
 enforced therapeutic starvation from twenty-four to forty-eight hours? 
 Pfaundler has conjectured that at the close of digestion the alkaline 
 secretion of the pyloric glands gradually neutralizes the acid content 
 of the stomach. I cannot support this view. The finding of a greater 
 quantity of juice when a more continuous suction is maintained, the 
 frequent absence of juice when the tube is first inserted, and Sedg- 
 wick's finding that the young infant's duodenal contents are acid, favor 
 the conclusion that at least a portion of this juice makes its way into 
 the intestine. 
 
 It seems probable, therefore, that the secretion of the alkaline pan- 
 creatic and intestinal juices, which in the adult regurgitate into the 
 stomach, as demonstrated by Boldyreff, and lower the acidity of the 
 juice in the stomach (Carlson, Rehfuss and Hawk and Boldyreff), is, 
 in the infant, relatively deficient. 
 
 The hunger juice is delivered through the tube intermittently. The 
 most profuse secretion is, as a rule, associated with the higher acidities ; 
 this is also true in the adult (Carlson). The largest amounts were 
 obtained from one of the unfed new-born babes and from the older 
 infants. It is readily seen that the stomach of the starving infant can 
 secrete from SO to 200 c.c., or more, of highly acid juice daily. This 
 equals the amount Engel obtained from his case of pyloric stenosis, 
 which has served as the clinical basis for the theory that hyperacidity 
 or hypersecretion of the gastric juice is an etiologic factor in that dis- 
 ease. 
 
 Furthermore, this demonstration of the capacity of the infant's 
 stomach to secrete a highly acid juice, makes it probable that the low 
 acid values found during gastric digestion of milk are in part due to its 
 binding power for acid (Aron), and in part due to the relatively slight 
 stimulation which it exerts on the gastric glands (Pawlow, Moore and 
 Allanson). Huenekens found a hydrogen ion concentration of 174 X 
 10' r ' in a 9i/2-months-old infant after a meal of soup and vegetables. 
 Most of his results were lower, however. No such studies have been 
 made in younger infants. 
 
 Experience in the clinic of the University of Minnesota and in 
 other clinics (Rott) has proved the advantage which is gained in feed- 
 ing the premature infant by tube. Theoretical objections to the use of 
 
32 
 
 the tube have been based principally on the assumed existence of an 
 appetite gastric juice (Pfaundler). 
 
 The amount of saliva collected during the experiments on gastric 
 secretion was measured in six cases. 
 
 W. 7 days No sham feeding 7 c.c. in 40 minutes 
 
 H. 17 days Sham feeding 14 c.c. in 2 hours 
 
 P. 1 mo Sham feeding 25 c.c. in 1.5 hours 
 
 Ne. 11 days Sham feeding 15 c.c. in 1.5 hours 
 
 P. 9 days Sham feeding 8 c.c. in 1.5 hours 
 
 S. 12 days Sham feeding 10 c.c. in 1.5 hours 
 
 The saliva collected was the thick viscid product of the submaxil- 
 lary glands, which Schilling has noted as being preponderant during 
 early infancy. 
 
 Allaria points out the chemical and mechanical advantages of 
 having the milk well mixed with saliva, and estimates that the infant 
 secretes an amount equal to from 10 to 20 per cent, of the ingested 
 food. The tube-fed infant may do without this secretion in part or 
 altogether, but there is no evidence that his gastric secretion is less than 
 that of the actively nursing babe. 
 
 What light does this study throw on deprivation of food as a thera- 
 peutic agent? In infancy such a measure finds its chief field in acute 
 alimentary disorders and summer diarrheas. The significant fact is 
 that in hunger the infant's stomach secretes continuously, but with 
 intermittent intensity, a highly acid juice, which at least in part flows 
 into the small intestine where it may play a disinfecting or detoxicating 
 role. 
 
 SUMMARY 
 
 1. Description of an apparatus by which sham feeding can be 
 carried out and gastric juice collected under conditions which give 
 positive evidence of the amount secreted. 
 
 2. There is no appetite or psychic secretion of gastric juice in the 
 young infant. This disproves the present view, which is based on 
 insufficient experimental evidence. 
 
 3. The empty stomach of the hungry babe secretes a gastric juice 
 which often is as acid as that found in the adult's stomach. 
 
 4. The more profuse this secretion, the higher is its acidity. It 
 contains pepsin. 
 
 5. This secretion is not neutralized in the stomach, but flows out 
 into the small intestine. Regurgitation through the infant's pylorus 
 does not occur. 
 
 6. The theoretical objections to tube feeding in prematures because 
 of the lack of stimulation of an appetite gastric juice are not valid. 
 However, a disadvantage may lie in this : that such feeding precludes 
 the usual admixture of the milk with saliva. 
 
.53 
 
 Therapeutic starvation in acute alimentary disorders and in summer 
 diarrheas may owe its success in part to the heightened tonus of the 
 alimentary tract, and in part to the pouring out of highly acid detoxi- 
 cating and disinfecting gastric juice into the small intestine. 
 
 I wish to acknowledge my indebtedness to Dr. J. P. Sedgwick for the use 
 of material from his service in the University of Minnesota Hospital. 
 
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 2. Aron, H.: Das Salzaurebindungsvermogen von Frauen und Kuhmilch. 
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 3. Bauer, L., and Deutsch, E. : Das Verhalten der Magensaure, Motilitat und 
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34 
 
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 24. Schmidt, A. Von : Brustsaugen und Flaschensaugen. Miinchen. med. 
 Wchnschr., 1904, 51, 2141. 
 
 25. Wohlmann, L. : Ueber die Salzaureproduktion des Sauglingsmagnens im 
 gesunden und kranken Zustande. Jahrb. f. Kinderh., 1891, 32, 297. 
 
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