ClassIELiXiia Book iki GopyiigMN?- COFOaGIlT DEPOSm I \ FRONTISPIECE The normal infant at eight months. PRACTICAL INFANT FEEDING By LEWIS WEBB HILL, M. D. Junior Assistant Physician to the Children's Hospital, Boston Assistant in Pediatrics, Harvard Medical School ILLUSTRATED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1922 ^"^ Copyright, 1922, by W. B. Saunders Company lADE IN U. S. PRESS OF W. S. SAUNDERS COMPANY PHIUAOEI-PHI A CLA659358 To My Friend and Chief John Lovett Morse, A. M., M. D. A Truly Great Practical Clinician and Teacher PREFACE I HAVE tried to write a book on infant feeding which will be practical without being superficial, scientific without being tiresome. Its paramount purpose is to attempt to help the practitioner not only to treat but to understand feeding cases as they occur in his daily practice. It is absolutely essential, and not too much to ask, for the general practitioner, or anyone else who is feeding babies, to have a considerable knowledge of the chemistry of metabolism in normal and abnormal babies before they can feed them intelligently, and before they can be said to have a satisfactory working knowledge of infant feeding. This is what too many practitioners lack. They must know the processes that are going on in the digestive tract, and must understand what the difi'erent food elements do under various conditions, but so many conflicting views are held by various investigators in this country and abroad that it would be of little value in a text-book to attempt to give a review of the literature which forms the corner-stone of scientific infant feed- ing without setting any definite interpretation upon it. To my mind a text-book of infant feeding should consist of a clear pres- entation of what is generally believed on the subject, seen and interpreted through the eyes of the author, and largely supple- mented by his own practical experience. It should serve at the same time as a working guide for the general man and as a reference book for the pediatrist. I have tried in this book to effect a common-sense combina- tion of science and practice, to apply scientific principles to practice as much as possible, to go into a good deal of detail concerning certain scientific investigations which are of prac- tical importance, and to omit others which are not. It has not been my purpose to follow any one "school" of infant feeding, 12 PREFACE but rather to amalgamate the best points taught in this country and abroad into what I hope is a homogeneous whole. It is desirable, of course, to make any subject as simple and as easily understandable as possible, and infant feeding need not be made complicated, but, on the other hand, any presenta- tion which does not explain underlying processes and the basis of symptoms is not enough for the thinking practitioner of today. As I heard an eminent Philadelphia pediatrist say not long ago, there is at present a tendency to try to make infant feeding so easy for the physician that there is a chance of for- getting whether or not the methods used may be suitable for the baby. The general standard of infant feeding in America has, however, improved greatly in the last ten years owing to the increased interest that general practitioners have taken in it, which is shown by the continually increasing numbers coming for instruction to the large post-graduate schools, such as the Harvard Graduate School of Medicine and the New York Post-Graduate School. To such men as this I respectfully offer this book, and sincerely hope that they may find it of value and interest. I wish especially to thank Dr. W. W. Howell for so kindly consenting to write the chapter on Premature Infants; Dr. R. W. Lovett and other members of the staff for permitting me to use several pictures and Roentgen-ray plates taken from their cases in the Children's Hospital; Mr. J. V. Footman for kindly making the prints and taking many pictures, and the publishers for their many courtesies. Lewis Webb Hill. 483 Beacon Street, Boston, Mass., March, 1922. CONTENTS CHAPTER I PAGE The Physiology and Pathology of Digestion and Nutrition 17 The Newborn Infant 17 The Physiology of the Digestive Tract 22 The Bacteriology of the Digestive Tract and the Relation of Bacteria to Food 28 Fermentation and Putrefaction 32 The Metabolism of the Food Elements 34 Protein 34 Fat 38 Sugar 45 Starch 56 Salts 56 The Vitamins 65 Energy Requirements 69 CHAPTER II The Stools in Infancy 75 CHAPTER III Human Milk 90 CHAPTER IV Breast Feeding 100 The Normal Breast-fed Infant 104 Difficulties Arising During Lactation Ill The Abnormal Breast-fed Infant 116 CHAPTER V The Development of Modern Artificial Feeding 124 Biedert 125 Meigs 128 Rotch 129 Widerhofer 132 Escherich 133 Czerny and Keller 134 Finkelstein 137 CHAPTER VI Cow's Mn.K 145 Chemistry 145 Bacteriology 149 The Production of Certified Milk 157 Pasteurization and Sterilization 170 The Essential Differences Between Cow's Milk and Human Milk . . 176 14 CONTENTS CHAPTER VII PAGE The Modification of Milk 180 Whole Milk Dilutions 181 Top Milk Mixtures. 186 Gravity Cream and Skimmed Milk Mixtures 188 CHAPTER VIII Special Preparations Used in Infant Feeding 201 CHAPTER IX The Artificial Feeding of the Normal Infant 228 First Nutritive Period 231 Second Nutritive Period 232 Third Nutritive Period 233 Mixed Diet During the Second Year 246 CHAPTER X Digestive and Nutritional Disturbances in the Bottle Fed .... 252 Underfeeding 256 Acute Fat Indigestion 258 Acute Sugar Indigestion 259 Acute Protein Indigestion 263 Acute Starch Indigestion 264 Chronic Fat Indigestion (Type 1) 268 Chronic Fat Indigestion (Type 2) 272 Chronic Sugar Indigestion 274 Marasmus 275 General Suggestions for Difficult Feeding Cases 286 CHAPTER XI Idiosyncrasy to Cow's Milk 289 CHAPTER XII The Diarrheal Diseases 293 Mechanical Diarrhea 295 Fermentative Diarrhea 296 Infectious Diarrhea 309 Prophylaxis of Diarrheal Diseases 319 CHAPTER XIII Chronic Intestinal Indigestion in Older Children 321 CHAPTER XIV The Physiology, Care, and Feeding of Premature Infants 340 By WILLIAM W. HOWELL, M. D. CONTENTS 15 CHAPTER XV PAGE Constipation in Infancy 356 CHAPTER XVI Habitual Loss of Appetite 360 CHAPTER XVII Rickets 367 CHAPTER XVIII Spasmophilia , 402 CHAPTER XIX Scurvy 419 CHAPTER XX The Treatment of Eczema in Infancy 438 CHAPTER XXI Pyloric Stenosis and Spasm 452 Index 467 Practical Infant Feeding CHAPTER I THE PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND OF NUTRITION THE NEWBORN INFANT Von Reuss^ (Vienna) gives the average weight of the normal full term infant as 7 lbs. 2 oz. for boys and 6 lbs. 9 J oz. for girls. Ramsey and Alley^ (Minnesota) in a series of 300 newborn babies found that the average weight was 7| lbs. for boys and 7 lbs. 3 oz. for girls. In Curry's^ series of 521 cases (San Fran- cisco) the average was 7 lbs. 3 oz. for females and 7 lbs. 11 oz. for males. Hecker of Munich (quoted by Von Reuss) in a large series of cases observed the following weights: 5 lbs. 8 oz. (2500-2999 gm.), 25.8 per cent, of cases 6 lbs. 8 oz. (3000-3499 gm.), 44.4 7 lbs. 11 oz. (3500-3999 gm.), 24.7 8 lbs. 12 oz. (4000-4499 gm.), 4.6 9 lbs. 15 oz. (4500-4999 gm.), 0.48 " 11 lbs. (5000-5499 gm.), 0.02 " Every baby loses normally a certain amount of weight during the first few days of life. This loss, according to Talbot,^ is of two kinds: (1) mechanical, (2) physiologic. The mechan- ical loss is due to the passage of urine and meconium (70-90 gm.), 1 Die Krankheiten des Neugeboren, Berlin, 1914. 2 Amer. Jour. Dis. Chil., vol. 15, 1918. 3 Quoted by Yerington, Jour. Amer. Med. Assoc, vol. 71, September 28, 1918. < Amer. Jour. Dis. Chil., vol. 13, 1917. 2 17 l8 PRACTICAL INFANT FEEDING the loss from the removal of vernix caseosa and other secretions, and possibly sometimes the vomiting of allantoic fluid, which the baby may have swallowed before birth. The "physiologic*' loss of weight is that caused by actual oxidation of body sub- stance. For a few days, during the colostrum period, the baby is in a state of partial starvation, and the energy to supply his fuel needs has to come from oxidation of his body substance instead of from ingested food. The glycogen of the liver and tissues is first used, and when this is exhausted the body fat is burned. "Infants without a good layer of body fat should re- ceive food at the earliest possible moment" (Talbot). The colostriun period usually lasts about three days, and it is not until about the fourth day in most cases that the milk secretion is established. Colostrum is a concentrated food, but there is very little of it. According to the analyses of Camerer and Soldner, very early colostrum contains fat 4.08 per cent., lactose 4.09 per cent., protein 5.80 per cent., ash 0.48 per cent; according to those of Bailey and Murlin,^ fat 2.9 per cent., lactose 7.1 per cent., protein 2.3 per cent. The amount of colostrum is usually estimated at about 20 c.c. on the first day, increasing somewhat on the second and third days. Loss of water from the body is also of considera"ble impor- tance, according to some authorities the most important factor in causing loss of weight. Birk and Edelstein^ found that the amount of water lost from the infant's body was 28.12 gm. per kilo for the first twelve hours, and 40.74 gm. and 53.6 gm. respectively for the next two twenty-four-hour periods. Von Reuss gave a considerable amount of water from the first day to a series of newborns, and noticed that there was much less loss of weight than in those babies to whom no water was given. The loss of weight continues for about three days, and on the third or fourth day the minimum is reached. The loss usually varies between 150 and 300 gm. (5-10 oz.), but occasionally may reach 400 to 500 gm. in babies who are apparently normal. 1 Amer. Jour. Obstet., vol. 1, 1915. 2 Monatschr. f. Kinderh.. vol. 60. 1910. I 1>HYSI0L0GY AND PATHOLOGY OF DIGESTION AND NUTRITION 1 9 If the breast milk is late in coming in, or if it is lacking in quality or quantity, the initial loss of weight may be considerably more. The loss is proportional to the absolute body weight, and is usually about 6 to 9 per cent, of it. There is less likely to be a large loss of weight if the baby is nursed on the first day, and at frequent intervals; babies nursed or fed artifically at four-hour intervals almost always lose more weight than those fed at 2- or 2|-hour intervals. According to Benestad^ babies suffer a greater loss of weight, both relatively and absolutely, the greater the birth weight is. Most of the loss occurs during the first twenty-four hours, and according to various authors as much as 125 gm. may be lost in this time. Most authorities are agreed that nothing can stop the initial loss of weight, but Schick^ in 9 cases was able to prevent it by frequent forced feedings with a mixture of colostrum and breast milk. An excessive loss can be practically always prevented by proper feeding. According to Camerer the birth weight is regained by the eighth or tenth day, while according to Ramsey and Alley only about 25 per cent, of all cases regain the birth weight by the tenth day. Bergman,^ in a series of 1000 hospital cases, found that 11.4 per cent, regained their birth weight by the tenth day, 21.7 per cent, by the fourteenth day, and 24.1 per cent, had not regained it by the twenty-first day. All these babies were fed at four-hour intervals, however, and, moreover, were hospital cases. It is hardly fair, then, to accept these figures as a standard, and in most cases the average breast-fed baby in a private house, looked after carefully and fed at 2J- or 3-hour intervals will regain the birth weight by the fourteenth or fifteenth day. In the case of bottle-fed babies, however, the situation is far dif- ferent, and many normal babies who have had to be fed entirely on the bottle from the day of birth may fail to regain their birth weights before the end of the third or fourth week. Body Temperature. — ^At birth the body temperature is 1 Jahrhb. f. Kinderh., vol. 80, 1914. 2 Ztschr. f. Kinderh., vol. 13, 1916. « Ibid., March. 1916. 20 PRACTICAL INFANT FEEDING relatively high (99,8°-100.8° F.), but during the first few hours of life a newborn baby loses a considerable amount of heat, and it is not unusual to record rectal temperatures of 95° F. in healthy full-term infants a few hours after birth. If the baby is kept warm the temperature soon comes up to normal, however. The first bath usually depresses the temperature from 1 to 1| degrees, and in the first week of life the daily variations are much greater than in older children (1° to 2° F.) (Von Reuss). The heat-regulating mechanism during the newborn period is very unstable, and newborn babies are likely to react differ- ently than older babies to infection. Severe infections, such as erysipelas, may in some cases cause only a slight rise of tem- perature, while in other cases the temperature may be very high from relatively slight causes. Transitory Fever of the Newborn. — Not a few normal infants show a rise of temperature to 101° or 102° F., most com- monly on the third, fourth, or fifth days. In many cases it is not accompanied by symptoms, while in others the baby may be restless and irritable, with mild toxic symptoms. Marked toxic symptoms are unusual, but may occur. The temperature usually lasts from twenty-four to forty-eight hours, and then rapidly subsides. It is difficult to estimate how frequently this transitory fever occurs, as it is undoubtedly often overlooked. CrandalP found at the Sloane Maternity Hospital in New York that it occurred in 135 of 500 consecutive newborns, a rather high percentage, while at the Nursery and Child's Hos- pital only 20 babies out of 200 showed it. Heimann^ found that if the baby was not put to the breast until twenty-four hours after delivery, from 2.3 to 4.2 per cent, had transitory fever, while if the nursing was begun 12 hours after delivery only 0.6 to 1.3 per cent, showed it. Von Jaschke^ in 1000 newborns found only 31 with transitory fever. The etiology of the con- dition is not well understood. It has been usually called "inani- 1 Arch. Ped., vol. 16, p. 174, 1899. 2 Monatschr. f. Geburtsh. u. Gynakol., Bd. 51, 1920. 3 Ztschr. f. Geburtsh. u. Gynakol., 78, 119, 1915. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 21 tion" or "exsiccation" fever, and has been supposed to be due to the desiccation of the tissues during the first few days of the newborn period, when but little fluid has been taken. It has also been supposed to occur especially in babies who lose an excessive amount of weight, which is somewhat borne out by the fact that it is seen most commonly on the third to fifth day, when the weight has usually reached its lowest point. These views have, however, been recently disproved by Grulee and Bonar,^ who found that there was no regular relationship be- tween the occurrence of fever and the amount of fluid taken, or the weight loss. They believe that it is best explained by the absorption of some protein products, bacterial or otherwise, from the intestine, probably from putrefaction of the meconium, which is relatively high in protein and low in sugar. As soon as the breast milk comes in, and the high protein meconium is replaced by the high lactose breast milk, putrefaction stops, and the fever subsides. It is probable, however, that many factors are operative, and an excellent summary of them is given by Von Reuss^: "The replacement of meconium flora by milk flora in the intestine; the irritant effect of bacterial products of decom- position or toxins, and of nutritive ingredients on the intestinal cells, the presence of products of the breaking down of tissue such as occurs during the fiirst days of life; the deficiency of water, due partly to an inadequate external supply of fluid, and partly to internal causes, and the resulting concentration of tissue fluids and restriction of diuresis; and finally, the back- wardness of the mechanism of heat regulation." Diagnosis. — This is not ordinarily difficult, but it must be remembered that there are other causes of temperature in the first few days. Sepsis does not ordinarily have to be con- sidered, as it occurs very rarely before the fifth day. "Tran- sitory" fever practically always occurs before the fifth day. Furthermore, if sepsis is present, the focus can be found. Naso- 1 Amer. Jour. Dis. Chil., vol. 22, No. 1, July, 1921. 2 Diseases of the Newborn, London, 1920, p. 475. 22 PRACTICAL INFANT FEEDING pharyngitis, otitis media, and pyelitis occur occasionally in newborns, and must be ruled out. I have recently seen a baby of three days with an otitis media which gave rise to a high temperature, and subsided as soon as the ear drmn was incised, and a considerable amount of bloody serum was evacuated. The ears should always, therefore, be examined in any newborn baby with an imexplained fever. With otitis media the baby is usually a good deal sicker than is the case with "transitory" fever. Pyelitis is very rare in the newborn, but has been reported. The diagnosis is made by an examination of a catheter specimen of the urine. Treatment. — One-half teaspoonful of castor oil should be given at once, and fluid and food forced. If the breast milk is late in coming in, as it very frequently is, a few ounces of breast milk should be secured from some other woman, and should be given In small, frequent feedings. If breast milk is not available, a weak cow^s milk modification is given, with a very low fat and protein and relatively high sugar. Water should be given fre- quently in as large amounts as possible between the feedings. The condition is not a dangerous one, and the fever practically always subsides in a day or two, without further symptoms. Its chief importance in most cases is that a good deal of alarm is unnecessarily experienced. In a few cases, however, toxic symptoms are marked, but usually subside after catharsis and free fluid and sugar intake. THE PHYSIOLOGY OF THE DIGESTIVE TRACT The Mouth. — ^Mouth digestion is relatively unimportant until the baby possesses ten or twelve teeth. Even then it is not as important as in adults, as babies ordinarily chew very little. The habit that many babies have of holding food in their mouths for some time before swallowing probably aids somewhat in the digestion of the starches, even if only a few teeth are present. The quantity of saliva in the first week of life is very small, but it has been shown to contain ptyalin. When PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 23 the teeth begin to appear the secretion of saliva becomes more abundant. The weight of the saHvary glands at three months is double that at birth, and at a year is quadrupled.^ The stomach of the infant is placed more vertically than that of the adult, which accounts partly for the ease with which babies regurgitate. The pylorus lies slightly to the right of the midline between the umbilicus and the xiphoid. The average anatomic capacity of the stomach in newborn babies, according to Scammon and Doyle,^ is 25 c.c. The anatomic capacity, or size of the stomach, is however, not a good index of the physio- logic capacity, or amount of food that may be taken at one time, as a good part of it passes out through the pylorus before the last part has entered the stomach. The stomach increases rapidly in size during the first few days of life. According to Scammon and Doyle, the following average amounts of breast milk were taken at each feeding by a large series of normal breast-fed babies during the first ten days: Day. Amount taken at each feeding. 1 7c.c. 2 13 « 3 27 « 4 46 " 5 57 « 6 64 " 7 68 « 8 71 « 9 76 " 10 81 " The table below, showing the size of the stomach at different ages, is from Pfaundler and Schlossmann: Size of the Stomach at Various Ages 1 month, 3 oz. 4 months, 4 oz. 7 months, 1\ oz. 2 months, 3| " 5 " 6 « 8 « H « 3 « 31 « 6 " 6f « 9 « 9 « 1 year, 9f « * Gundobin, Die Besonderheiten des Kindesalters, Berlin, 1912. 2 Amer. Jour. Dis. Chil., vol. 20, No. 6, 1920. 24 PRACTICAL INFANT FEEDING Secretions of the Stomach, — The stomach secretes four sub- stances of importance: pepsin, rennin, hydrochloric acid, and a fat-splitting enzyme. In breast-fed babies free HCl is found about 2 hours after the meal in a concentration of about 0.10 per cent. In bottle-fed babies it is found later, or not at all, on account of the greater powers of the cow's milk (casein) to com- bine with the acid. Inasmuch as free hydrochloric acid is a strong antiseptic agent, and undoubtedly destroys a good many of the bacteria which are introduced into the stomach, the stomach contents of a bottle-fed baby are less antiseptic than those of a breast-fed baby. This may be of considerable prac- tical importance in causing digestive disturbances by allowing the bacteria which have not been killed off to attack the food in the digestive tract. Stomach digestion proceeds somewhat as follows (Tobler): Soon after the milk enters the stomach it is coagulated by the rennin. The curd and whey are separated, and in the first part of the digestive period the liquid portion of the chyme is passed into the duodenum. Most of the casein and fat remain behind in the stomach and is slowly digested and liquefied by pepsin and hydrochloric acid digestion. The products of this (protein) digestion are albumoses and peptones. The fat also undergoes a certain amount of digestion by the action of the gastric lipose. Sugar is not acted upon, and most of it leaves the stomach in the whey. It is probable that even in babies with severe digestive or nutritional disturbance there is little or no deficiency of the gastric digestive ferments. There is very little absorption of either water or food material from the stomach. Motility and Emptying Time of the Stomach. — Peristalsis begins soon after taking food. The peristalsis of the stomach mixes the food thoroughly with the gastric juice, in the pyloric portion especially. At certain intervals the pyloric sphincter relaxes and the contraction wave squeezes some of the fluid into the duodenum (HowelP). According to Maynard Ladd,^ who * Text-Book of Physiology, Philadelphia, 1915. 2 Amer. Jour. Dis. Chil., May, 1913, vol. 5. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 2$ has extensively studied gastric motility in infants by means of the Roentgen ray, "There is a curious lack of peristalsis to be seen in infants' stomachs as compared with adults. "The stomach empties itself of the greater part of its contents in from one to two and one-half hours. This time varies con- siderably, however, in different babies. After the greater part of the stomach contents has passed into the small intestine, a considerable residue remains, which is emptied very slowly, after remaining for from four to seven hours, in both bottle- and breast-fed babies." In most cases Ladd found that the stomach was nearly empty after two hours. A new feeding tends to stimulate per- istalsis and to push out ahead of it the residue of the previous feeding. There is a very great difference in the emptying time in dif- ferent babies, as Ladd found that with 3 infants of the same age on the same formula, 2 J, 3|, and 4| hours were required to empty their respective stomachs. The sort of food taken is, of course, important, and one infant in Ladd's series required on differ- ent occasions, with different formulas, 2^, 4i, 6, and 7| hours to completely empty his stomach. Sugar, either lactose or maltose, up to 7 per cent, has apparently no influence upon gastric motility. If the protein in the food is kept low even the fat fails to show any constant tendency to prolong the emptying time, and if the percentage of fat influences the motility at all the effect is not striking.^ Casein is the most important food element concerned in the emptying time; its effect in this respect depends considerably upon the form in which it is given. Pro- tein in high percentage without the addition of alkali retards the emptying time; if it is converted into a non-coagulable form by the addition of alkali, the stomach empties much more quickly. Sodium citrate does not influence the empt3dng time as much as do soda bicarbonate or lime-water. The duodenum secretes a not inconsiderable amount of alkaline juice, alkaline on account of its carbonate content. ^ According to Tobler, fat delays the emptying time. 26 PRACTICAL INFANT FEEDING This juice is not especially important in digestion (Burton- OpitzO. It contains invertin, which inverts cane-sugar, and also erepsin. Its chief importance is that it contains entero- kinase, a substance which has the power of activating the pancreatic juice so that it is more efficient in the digestion of protein. The Intestines. — ^Both the small and large intestines are relatively longer in the iafant than in the adult, which is prob- ably necessary on account of the relatively large amount of food taken by the infant. The small intestine secretes large quantities of alkaline juice, the succus entericus. It is light yellow in color, and its chief function is to break down carbohydrates, specially sugar, by the two sugar-splitting ferments which it contains, maltase and invertase, whose functions are to change disac- charids to monosaccharids. It also contains erepsin, which converts proteoses to polypeptids and amino-acids. The most import phases in the digestion of milk are carried on in the upper portion of the small intestine by the pancreatic juice and the succus entericus. The digestion of the various food elements are very delicately adjusted processes, which need a certain optimum reaction (not too acid or alkaline) in order to proceed satisfactorily. If there is an excessively acid or alkaline reaction in the small intestine where the digestion and absorption of food is taking place, these processes cannot proceed cor- rectly. The ordinary cause of excessively alkaline or acid reactions in the small intestine is the action of bacteria on foods there, and it can therefore be easily seen how important it is for the small intestine to be relatively free from bacteria. In the large intestine there is practically no digestion car- ried on, and probably little absorption, except of water. Nearly all the food that is going to be absorbed is absorbed before the ileocecal valve is reached. The large intestine is swarming with bacteria of many kinds, which live on the undigested or unab- sorbed food residue entering from the small intestine. If this residue is not too great in amount, excessive fermentation or ^ Text-Book of Physiology. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 27 putrefaction will not take place; if it is large in amount, one or the other of these processes becomes excessive, and diarrhea results. The liver in the infant is much larger in relation to the rest of the body than it is in the adult. In a newborn baby the liver is 4.33 per cent, of the body weight, in an adult, 2.85 per cent. The functions of the liver are to change starches, sugars, protein, and possibly fat into glycogen, to produce bile, and to neutralize and destroy poisons arising from the intestines. The liver is frequently enlarged in nutritional disorders, especially those arising from overfeeding with carbohydrate. The Bile. — Fresh bile is reddish-brown in color. Upon oxi- dation it changes to green, or upon reduction it may be color- less. Bile is what gives the color to the stools, and this color depends upon whether oxidation or reduction processes are taking place in the intestine. In the putrefaction that occurs when soap stools are produced the bile undergoes reduction and assumes a colorless form, so that the stools are nearly white. When sugar is fermenting, however, oxidation is taking place, and bilirubin is changed to biliverdin, which gives the character- istic green color to the stools. The chief function of bile is to aid in the digestion and absorption of fat. In the presence of bile the steapsin of the pancreatic juice is much more active in splitting fats than without it. Fat digestion is best in a nearly alkaline solution, and very poor in a strongly alkaline or especially in a strongly acid solution. Bile in a strongly acid solution is easily decomposed and rendered inefficient. It is able under the right conditions to dissolve large amounts of fatty acids, and also probably aids in absorption by emulsifying soaps. The Pancreas. — ^The juices of the pancreas are the most important and powerful of all the digestive juices. The pancreas has about the same significance in the infant as in the adult. It produces a strongly alkaline secretion in large amounts, which contains trypsin, amylopsin, and steapsin. These ferments digest protein, starch, and fat respectively, and are all present 28 PRACTICAL INFANT FEEDING in the pancreas at birth. Pancreatic digestion cannot go on in a strongly acid medium. Summary. — From a practical point of view we are chiefly interested to know what part if any a lack of digestive ferments plays in the various digestive and nutritional disturbances of babies. The evidence here is conflicting, some investigators have found that certain ferments, particularly the fat-splitting ferment of the pancreas, are present in very small quantity or are lacking entirely in severe nutritional disorders, such as marasmus. It is probable, however, that this deficiency is not the cause but the result of the condition, and most investi- gators have found that in most cases of digestive disturbances in babies a deficiency of the digestive ferments plays little if any part. Thus the artificial digestants are of small practical value in the treatment of digestive disorders in infants. THE BACTERIOLOGY OF THE DIGESTIVE TRACT AND THE RELATION OF BACTERIA TO FOOD Importance. — The bacteriology of the gastro-intestinal tract is intimately concerned with problems of practical infant feeding, as there is normally always a slight bacterial decomposition of food going on in the lower portions of the bowel. If this decom- position becomes excessive, owing to poor digestion of food or overfeeding, large amounts of irritating substances are formed, which immediately get the baby into trouble, evidenced espe- cially by looseness of the bowel movements. The intestinal bacteria act on the host not directly, but through the intermediate agency of food, and its decomposition products. They are not ordinarily true parasites, but sapro- phytes; they live not on the tissue of the gastro-intestinal tract, but on the food within it. The intestinal contents at birth are sterile, and the first specimens of meconium passed usually fail to show bacteria. Infection takes place, in all probability, mostly through the mouth, but also probably partly through the anus, so that bacteria are ordinarily found in the meconium twenty-four PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 29 hours after birth.^ "As a rule the proliferation of these first infecting organisms is limited, partly because the intestinal contents at this time are inadequate to support a large bac- terial population, partly because a majority of the bacteria are unable to accommodate themselves to gastro-intestinal con- ditions. "About the third day postpartum the alimentary canal of the infant becomes permeated with breast milk in place of the colostrum, and a marked change is discernible in the intestinal flora at this time. The heterogeneous, irregularly staining mi- crobes disappear to a remarkable degree, and coincidently large numbers of long, slender. Gram-staining bacilli appear. A majority of these belong to the group of Bacillus bifidus, and they usually persist in dominant numbers during the nursing period." The infecting bacteria come partly from the air, partly from the bath-water, or perhaps from the vagina of the mother. The initial bacterial flora is independent of the sort of food that there is in the intestine, but after the first two or three days is dependent upon the type of food that is present. According to Czerny and Keller it is not advisable to give sugar-water during the first day or two before the breast milk comes in, as is com- monly done, because fermentation might be started which would be injurious to the child. "If we feed the newborn in the first few days with foreign substances, we must remember that we may hinder or disturb the normal processes of invasion. It is best to give nothing but sterile water or water plus saccharin during the first twenty-four hours to a newborn baby."^ Bacteriology of the Stomach. — Many bacteria enter the stomach in the food of bottle-fed babies, but the gastric juice possesses strong antiseptic powers, and destroys a great many of them. The stomach, therefore, acts as a protection to the rest of the gastro-intestinal tract in this respect, and is on 1 Kendall, Amer. Jour. Med. Sci., No. 2, vol. clvi, August 7, 1918. ^ Czerny and Keller, Des Kindes Ernahrung, etc., 1906. 3© PRACTICAL INFANT FEEDING account of its antiseptic power relatively free from bacteria in comparison with the lower portions of the digestive tract. From a practical point of view bacterial decomposition of the food in the stomach is not of much importance, except possibly in condi- tions of stasis, such as would exist with pyloric stenosis. Bacteriology of the Small Intestine. — The small intestine, especially in the upper portions, is also relatively free from bac- teria. The necessity of this is apparent, for if many bacteria were present and were continually attacking the food while digestion and absorption were taking place no proper digestion could occur. ''The bacterial poverty of the upper part of the intestine, which, as long as physiologic conditions are maintained in the intestine, is reasonably constant, and guarantees a nonnal digestion process by the ferments alone without the interference of bacteria and bacterial decomposition products."^ The intestinal secretions (bile, pancreatic juice, succus enter- icus) have little if any bactericidal power, so the small intestine depends very largely upon the bactericidal power of the stomach to keep it from being overrun with bacteria. The epithelial cells of the small intestine, when functionally and anatomically intact, als6 probably possess a certain degree of antibacterial power^ and when these are injured in any way by inflammatory proc- esses, or their function is depressed by chemical agencies, a marked overgrowth of bacteria may take place. Roily and Leibermeister^ were able to increase the bacterial content of the small intestine by feeding large doses of soda bicarbonate or chlorid of iron. It has also been thought that the concentrated salt content of cow's milk may depress the antibacterial powers of the epithelial cells of the small intestine in such a way as to allow a greatly increased bacterial population to be present there, with a consequent decomposition of any food present. This has been given great importance by the Finkelstein school 1 Tobler and Bessau, Allegemeine Pathologische Physiologic der Ernah- rung, etc., Wiesbaden, 1914. 2 Cited by Tobler, p. 75. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 3 1 especially. In the lower part of the ileum bacteria begin to increase in numbers, and conditions to approach those of the large intestine. Bacteriology of the Large Intestine. — The large intestine is swarming with bacteria of many varieties, maintained there by the food residue which comes from above. There are three probable reasons why the large intestine should be so rich in bacteria: The antiseptic action of the gastric juice does not reach so far down. Peristalsis is much slower than in the small intestine, and food, therefore, stays there a longer time. The epithelial cells of the large intestine possess no anti- bacterial power. Under normal conditions the amount of food present in the large intestine is not sufficient for enough decomposition to take place to cause trouble. Under abnormal conditions, when too large a residue of undigested food is present, the bacterial content may be enormously increased, and food decomposition, with its resulting irritating products, excessive. Blinds of Bacteria Present. — The flora of the breast-fed baby's intestine is remarkably uniform, and consists largely of the Bacillus bifidus, an organism living chiefly upon sugar, and forming lactic acid from it. The colon bacillus and the Bacillus lactis aerogenes are also numerous, and many other less impor- tant forms are present in smaller numbers. The fecal flora of the breast-fed baby is especially characterized by the fact that it is Gram-positive. In the bottle-fed baby conditions are not so uniform. *'The changes are, generally speaking, a substitu- tion of Gram-negatively staining bacteria of the colon type for a considerable proportion of the Gram-positively staining organisms so distinctive of the flora of the normal nursling, as well as the appearance of large bacilli (many of the spore- forming), cocci, and variable numbers of microbes that vary from time to time and from individual to individual."^ 1 Kendall, Amer. Jour. Med. Sci., vol. clvi, No. 2, 1918. 32 PRACTICAL INFANT FEEDING Dependence of the Type of Bacteria on the Food Supply. — Escherich was the first to show (1886) that the type of bacterial flora in the intestine is dependent upon the sort of food ingested and that changes in it can be produced at will by alterations in the food. As the food is changed those organisms which cannot adapt themselves to the new conditions die out, and others, of more adaptable type, take their place (Kendall). Escherich divided the intestinal bacteria into two broad groups, the putre- factive, which live upon protein food, and the fermentative, which live upon carbohydrate.^ If a food containing large amounts of protein and relatively small amounts of carbohy- drate is ingested, the putrefactive bacteria will flourish, and the fermentative tend to die out; if a high carbohydrate food is offered, the reverse is true. The reason why the flora of the breast-fed baby's intestine is so uniform is that his food is uniform; a high carbohydrate, low protein food, which encourages the growth of the characteristic bifidus flora (fermentative) and inhibits putrefaction. In the bottle-fed baby the conditions of food-supply are not so uniform, his food may be rich or poor in carbohydrate or protein, as the case may be, and his intestinal flora may change from time to time on account of the changes made in the food. In general, the feeding of cow's milk calls forth a putrefactive flora on account of the relatively large amount of casein it contains. These truths are of great practical impor- tance, and one uses them every day in his clinical feeding work. FERMENTATION AND PUTREFACTION In the breast-fed baby's large intestine conditions of fermen- tation normally obtain, owing to the high lactose content and relatively low casein content of breast milk, which maintains a fermentative flora and inhibits putrefaction. This gives rise to an acid reaction of the large intestine, as the products formed from fermentation of sugar are acid in character (largely lactic acid in the breast-fed baby). In the bottle-fed baby the question of whether fermentation * Some types may live upon either. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 33 or putrefaction will predominate depends upon the character of the food; if large amounts of sugar are given, with little protein, fermentation results, with an acid large intestine; if large amounts of protein with little fermentable carbohydrate are given, putre- faction, with an alkaline reaction results, the end-products of protein putrefaction being alkaline in character. Within cer- tain limits these two processes can take place together, and ordinarily do so, but if one becomes markedly predominant, the other recedes. Under normal conditions a slight putrefaction exists in the lai^e intestine of a bottle-fed baby; if more protein and less carbohydrate is fed, this becomes increased. Normally, in the bottle fed, neither putrefaction nor fermentation should be too markedly predominant; if either process becomes so, trouble results due to the consequent overgrowth of bacteria and the irritating end-products formed. A sugar which is completely absorbed in the small intestine has little influence on fermenta- tive processes in the large intestine, but if it is absorbed with difliculty, and a considerable portion of it finds its way into the large intestine, it acts as a food for the ever-ready fermentative bacteria, and conditions of fermentation quickly result. As long as neither fermentation nor putrefaction is excessive, the reaction of the large intestine is either neutral, weakly alkaline, or weakly acid. If excessive fermentation or putrefaction results the re- action becomes too strong one way or the other, and diarrhea is caused by the irritant effect upon the intestinal mucosa of either the strongly acid or alkaline end-products. Under normal con- ditions the fermentation or putrefaction of food takes place in the large intestine only. Under abnormal conditions it may take place in the small bowel as well, these abnormal conditions being brought about usually by one of three agencies, or a combination of the three: 1. The introduction of so many bacteria in spoiled milk that too many of them get through the stomach into the intestine in a viable condition. 2. A depression of the antibacterial power of the epithelial cells of the small intestine from inflanmiation, from excessive 3 34 PRACTICAL INFANT FEEDING external temperature, debilitated condition of the baby^ or other agencies. 3. The swallowing of infected mucus from rhinitis, bronchitis, or any upper respiratory infection. Types of Bacteria which Produce Fermentation or Putre- faction. — ^As fermenting organisms the following are the most important: the enterococcus, which is similar to the ordinary Streptococcus lacticus, the Bacillus bifidus and acidophilus, the coli aerogenes group, and the Bacillus aerogenes capsulatus, or "gas bacillus" (in pathologic cases especially). Some of these organisms cause lactic acid fermentation, some acetic or butyric acid fermentation. The colon, the butyric acid bacillus, and proteolytic bacteria are the most important putrefying organ- isms. The colon bacillus may attack either carbohydrate or protein, but if carbohydrate is present, grows upon this in preference. When the colon bacillus acts as a putrefier it attacks albumoses and peptones; it is probably not capable of attacking undigested protein. The proteolytic bacteria, on the other hand, have the power of breaking down undigested protein. Summary. — Most of our practical procedures in infant feed- ing, as regards intestinal conditions, are founded upon our knowl- edge of what causes fermentation, what putrefaction, the an- tagonism between the two, and a knowledge of how to dimin- ish one or the other by changing the type of food offered. A knowledge of the principles of intestinal bacteriology, the processes of fermentation and putrefaction, and the chemical changes involved is indispensable to a thorough understanding of infant feeding. These principles will be referred to many times in the course of the following pages. THE METABOLISM OF THE FOOD ELEMENTS 1. The Metabolism of Protein. — Protein in the food has a threefold function (Rowland^): 1. Part of it replaces tissue waste (desquamated cells, secretions, etc.). 1 Amer. Jour. Dis. Chil., vol. 5, 1913. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 35 2. Part of it is retained by the body to build up tissue. 3. Part of it is burned and acts as a source of energy. For the infant the most important function of protein is the second — as a tissue builder. The infant retains a considerable amount of protein each day, often as much as 55 per cent, of that which has been absorbed. Sugar and fat (the fuel part of the diet) act as nitrogen sparers, and when they are given in sufficient amounts to furnish adequate fuel for the body only a small portion of the protein need be burned, and most of it is available for purposes of growth. This is illustrated by the metabolism experiment of Talbot and Hill,^ who found that increasing the amount of carbohydrate in the food markedly increased the retention of nitrogen. Thus, in a three-day metabolism period, their baby (J. P.) retained 2.06 gm. of nitrogen, corresponding to about 13 gm. of protein, when the carbohydrate intake was 216 grams. In the next three-day period the carbohydrate intake was 417 grams, and the retention of nitrogen was 3.16 grams, corresponding to about 20 grams of protein, which was nearly a third of the total amount of protein absorbed. Minimum Protein Needs. — Chittenden's well-known work has shown that the minimum protein needs for the adult, in order to keep the body in nitrogenous equilibrium and to replace cell *Vear and tear," are not high, and that it is possible to keep in nitrogenous equilibrium on about 0.73 gm. of protein per kilo- gram of body weight, provided adequate amounts of carbohy- drate and of fat are given. One would naturally expect that the figures would be considerably higher for babies and children on account of the relatively large amounts of protein needed for growth. Such is indeed the case, although in babies and children it has not been possible to carry out any such extensive or ac- curate investigations as those of Chittenden for adults. About the only standard we have to go by is breast milk. We know that this is relatively low in protein, that most of its fuel value is furnished by the fat and sugar, that little of the protein in 1 Amer. Jour. Dis. Chil., vol. 8, 1914. 36 PRACTICAL INFANT FEEDING breast milk is used for fuel, and that probably the amount which it contains represents the optimum amount to furnish nitrogen for growth. It is true that the biologic value of the protein of breast milk is somewhat greater than that of cow's milk pro- tein on account of its constitution, being made up as it is of the most suitable amino-acids for cell growth. This difference is not great enough, however, to invalidate the use of the pro- tein content of breast milk as a rough standard of comparison in artificial feeding. A breast-fed baby of 8 kilograms (17| lbs.) would take as a maximum not over 1000 c.c. of breast milk per day, containing about 12.5 grams of protein. This would furnish about 1.5 grams of protein per kilogram of body weight. Inasmuch as about 20 per cent, of the nitrogen of human milk is unavailable for use, being in the form of extractives, as Rowland^ has pointed out, this would mean only about 1.20 grams of protein per kilogram of body weight. The breast-fed baby can and does thrive then on this amount. The usual amount that has been considered necessary in feeding with cow's milk is 1.5 gm. per kilogram. According to Hoobler,^ if 7 per cent, of the total calories are given as protein calories, the nitrogen needs will be amply provided for. Or, as others have said, the protein contained in 1.5 ounces of whole milk per pound of body weight per day meets the protein re- quirement. As a matter of fact, there is little danger of going below the minimum protein need in any of the ordinary milk modifications used, and almost always considerably more than this is given, especially if whole milk dilutions are used, under which conditions the baby uses a considerable part of the protein intake for fuel. In practical infant feeding, therefore, it is rarely necessary to calculate the protein requirements if at all reasonable con- centrations of milk are employed. If condensed milk or certain of the proprietary foods are used, however, the protein intake is often too low. 1 Loc. cit. 2 Amer. Jour. Dis. Chil., vol. 10, No. 3, 1915. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 37 The Digestion and Absorption of Protein. — The casein of cow's milk is coagulated in the stomach into large tough curds; the whey protein does not undergo coagulation. The casein of human milk is precipitated in soft flocculent curds. The mechanism of the coagulation of casein is somewhat as follows: The gastric enzyme, rennin, acts upon the casein and converts it to paracasein. This paracasein then reacts with the calcium salts of the milk, and forms an insoluble curd consisting of a combination of paracasein and calcium (calcium caseinate). The fat of the milk is mechanically combined with the casein curd, probably by becoming entangled in its meshes. A considerable portion of the calcium caseinate is broken down in the stomach by the pepsin, and hydrochloric acid into albumoses and peptones. The digestion is then carried on further by the trypsin of the pancreatic juice and the erepsin of the succus entericus, trypsin digestion being the more important. These ferments break down the albumoses and peptones into polypeptids and finally amino-acids, which are absorbed free or in combination with various salts. Trypsin is capable of attack- ing protein before it has been changed to albumoses and peptones, and probably normally does so, as some of the milk leaves the stomach so quickly after ingestion that there has been no time for digestion to take place. The absorption of protein in health is good, from 90 to 95 per cent, of the intake being absorbed, and is equally good in both bottle- and breast-fed babies. The absorption is likewise good in most nutritional disturbances unless there is an asso- ciated diarrhea, under which conditions it is always poor. Action of Protein in the Intestine. — ^The unabsorbed residue of protein food is alkaline in reaction, partly owing to the ammonia which may be formed, partly due to the large amount of calcium always ingested when high concentration of milk (with a high protein content) are fed, partly due to the fact that high protein feeding causes an increased pancreatic and intes- tinal secretion, both of which are alkaline in character. If small amounts of protein are ingested, together with large amounts of 38 PRACTICAL INFANT FEEDING carbohydrate, there will be little if any putrefaction in the intestine owing to the fact that in general the intestinal bacteria attack sugar in preference to protein, when plenty of sugar is offered, and the fermentation thus taking place inhibits putre- faction. If large amounts of protein and small amounts of car- bohydrate are taken, the unabsorbed carbohydrate residue is small, and is insufficient to support a fermentative flora, so the proteolytic forms gain the upper hand, and the facultative forms, which can live upon either carbohydrate or protein, attack the protein, as there is no carbohydrate for them. The reaction of the intestinal contents when putrefaction is in the ascendancy is always alkaliue (as in the normal bottle-fed baby). This is normal provided it is not excessive; if it becomes excessive the smooth, slightly foul, yellow, normal "high protein" stools change to the loose, brown, more foul stools of abnormal protein putrefaction. 2. The Metabolism of Fat. — Fat forms an important part of the food as regards calories, for 1 gram of fat furnishes 9.3 calories as against the 4.1 calories furnished by an equal amount of carbohydrate or of protein. It is not, however, so necessary to life as carbohydrate, provided an adequate caloric intake is furnished by the other food elements, and a baby may be fed over a considerable period on a fat-free diet without injury,^ Fat as it exists in milk is in the form of neutral fat, a com- bination of glycerin and higher fatty acids. During the process of digestion the neutral fat is split into these two component parts. The stomach contains a ferment capable of splitting a certain portion of the fat, but this is probably of relatively little importance, and most of the fat digestion takes place in the upper portion of the small intestine, where the steapsin of the pancreatic juice splits it into glycerin and fatty acids. The ^ Recent work has shown that prolonged feeding on a diet containing an inadequate amount of fat may bring about arrested growth, and various disturbances of nutrition, probably on account of the lack of the fat-soluble vitamin. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 39 fatty acids combine with alkaline carbonates in the intestine (Ca, Mg, Na, K) to form soaps, which are emulsified and made soluble by a combination with the bile and then absorbed. The soaps during their passage through the intestinal wall are res)mthesized into neutral fat by ferments contained probably in the epithelial cells. The soaps formed are largely of the higher fatty acids (palmitic, stearic, oleic) ; the calcium soaps, especially that of palmitic acid, are relatively insoluble and are absorbed with difficulty. The sodium and potassium soaps are more easily absorbed. According to Bosworth, Bowditch, and Giblin^ 100 gm. of butter fat when saponified yields 3S per cent, of palmitic acid, the calcium soaps of which are relatively insoluble. When the fat of human milk is saponified less palmitic and more oleic acid is produced, the soaps of oleic acid being more soluble than those of palmitic. In general, the lower the melting-point of a fat or fatty acid, the easier is its absorption. The melting- point of palmitic acid is high (62 degrees), that of oleic acid low (14 degrees). The importance of the bile for fat absorption is shown by Parker's case, a girl with a biliary fistula of such a nature that no bile whatever reached the intestine.^ In a three-day metab- olism period he found that only 64 per cent, of the fat intake was split and only 55 per cent, was absorbed. The absorbed fat enters the lacteals, is carried to the circulation largely by way of the thoracic duct, and is used by the body as fuel, the end- products being carbon dioxid and water, or is deposited in various organs and tissues. Percentage of Fat Intake Absorbed. — Fat absorption in health is remarkably good both in breast- and in bottle-fed babies. The most complete investigation of the subject is by Holt, Courtney, and Fales,^ and the following data are taken from their publications: Normal breast-fed infants were found to absorb an average 1 Amer. Jour. Dis. ChiL, vol. 15, No. 6, 1918. 2 Ibid., vol. 5, 1913. 3 Ibid., vol. 17, April and June; vol. 18, August and September, 1919. 40 PRACTICAL INFANT FEEDING of 95 per cent, of the fat ingested. The figures of other authors vary from 92 to 99 per cent. In 3 breast-fed infants who were not doing well (2 with diarrhea) the fat absorption was 79, 62, and 52 per cent. Constipated bottle-fed babies were found to absorb an average of 90 per cent.; bottle babies with normal stools, 91 per cent. If the stools were slightly softer than normal the absorption sank to 88 per cent. ; if they were loose, to 84 per cent., and if there was an actual diarrhea, the absorption was only 79 per cent. According to all writers the lowest fat absorption occurs in diarrhea, and in severe cases may fall as low as 50 per cent, of the intake. The cause of the diarrhea need not be an excessive fat intake; apparently the low absorption is mostly due to the fact that the increased peristalsis hurries fat through the bowel so quickly that it cannot be absorbed, and partly to the changed chemical conditions that are present in the intestine with any diarrhea, whatever its cause. In the stools of any bottle-fed baby there is a considerable amount of insoluble soap, but this does not necessarily mean a poor fat absorption. With typical, light colored, dry, alkaline soap stools there is probably always a poor fat absorption, although some of the earlier writers found it normal. This was probably due to faulty methods of analysis. Bahrdt,^ who in 1910 made an exhaustive study of soap stools, found that the fat absorption varied between 82 and 86 per cent, when typical soap stools were passed, which is a con- siderable difference from the normal average absorption. The chemistry of soap stools has been for years a subject of pains- taking study, but the exact processes concerned in their formation are as yet not well understood. Dry, whitish-gray, crumbly stools occur in the condition, which was called by Czerny "Milchnahrschaden," by Finkelstein "Bilanzstorung," and has been usually called in America chronic fat indigestion (see Chapter XI). 1 Jahrb. f. Kinderh., 1910, Ixxi, 249. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 4 1 Soap stools, according to Howland/ are formed when three conditions are present in the food: 1. A moderate or a large amount of fat. 2. A large amount of calcium and of casein. 3. A lack of carbohydrate. On account of the large amount of casein and of calcium present in the food and the lack of fermentable carbohydrate the intestine becomes alkaline and peristalsis is slowed. This favors the formation of insoluble calcium soaps, in just what way is not certain. The fat absorption becomes poor, as so much of the fat is changed into insoluble calcium soaps, which are absorbed with relative difficulty. There is also a very poor retention of calcium and magnesium, with a consequent relative acidosis and an ammoniacal urine. The subsequent impairment of nutrition, which may be severe if the process is unchecked, cannot be due to the loss of fat calories alone, as in most cases not more than 30 or 40 calories a day would be lost in this way over the normal amount. Fat must have something to do with the condition, however, as it is not seen except when there is a considerable amount of fat in the diet, and a baby may be fed on a fat-free food, no matter how rich in calcium or casein it may be, or how poor in carbohydrate, without developing this typical nutritional picture. It is probable that the poor calcium retention is the most important single factor in producing the nutritional change which occurs, which is borne out by the fact that a good many of these babies develop rickets or spasmophilia, both conditions which are dependent upon poor calcium retention. The reason why the calcium retention should be poor is obscure, and cannot be accounted for entirely by the combination of calcium with unabsorbed fatty acids to form soaps, as Bahrdt^ has shown that there is not enough fatty acid present to bind all the calciimi that is excreted. According to many authorities there is a primary deficient 1 Amer. Jour. Dis. ChiL, vol. 5, 1913. 2 Loc. cit. 42 PRACTICAL INFANT FEEDING calcium absorption dependent upon increased excretion, and the formation of soap stools is a secondary matter. Whatever the exact cause of soap stools may be, it seems to us that the process which brings them about is simply an exag- geration of that which occurs in the intestine of any normal baby fed on dilutions of cow's milk rich in casein and calcium and relatively low in carbohydrate. The normal stool of a bottle-fed baby is like a soap stool in a good many ways, it is alkaline, formed, slightly foul in odor, and contains a good deal of calcium soap. If the relations of the elements in the food are changed still further, so that the food is still lower in carbohy- drate and higher in calcium and casein or fat, typical soap stools result, which differ essentially from the normal stools of a bottle-fed baby only in that they are very light colored, more constipated, and contain more calcium. The process is in no sense different in kind from that which produces the characteristic bottle-baby stools — ^it is different only in degree, and all grada- tions may occur between the yellowish-brown, formed normal stool, to the more constipated, larger, grayish-white soap stool. For this reason it is not always easy to tell what is a pathologic soap stool and what is not. The color, the large amount of fat seen under the microscope, and the condition of the baby are the most important criteria. Fat Partition in the Stools. — Fat in the stools exists as neutral fat which has not been acted upon at all by the digestive juices, as fatty acid, representing fat which has been split, but not saponified, and as soap, which has been both split and saponified. The total fat normally forms a large proportion of the dried weight of the stool. According to Holt, Courtney, and Fales,^ in normal stools from breast-fed infants 42 per cent, of the dried weight consists of fat. Stools which were green and contained a good deal of mucus were found to contain only 23 per cent, of fat, on account of the relatively large amount of other material present (bacteria, mucus, etc.). In normal bottle-fed babies 1 Loc. cit. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 43 who were taking ordinary mixtures of cow's milk 36 per cent, of the dried stool consisted of fat, and in older children fed on a mixed diet the figure was 18 per cent. These lower figures for artificially fed babies and for older children are to be expected, as in bottle-fed babies there is a comparatively large residue of unabsorbed casein and calcium, and in children fed on a mixed diet, of cellulose. Most of the fat present is in the form of soap, especially if the stools are alkaline in reaction. If the stools are strongly acid there is a decrease in the percentage of soap and an increase in the fatty acid. Fat in an alkaline intestine tends to form soap; in an acid intestine, fatty acid; soaps tend to produce constipation; fatty acids, diarrhea. Thus it is that the effect of fat upon the intestine and upon the metabolic processes depends largely upon the reaction of the intestine, which, in its turn, depends upon the relative proportions of sugar and protein in the diet. When the sugar and protein are weU balanced, and there is neither a strong alkaline or strong acid reaction in the intestine, large amounts of fat when ingested are more likely to produce acidity than alkalinity, on account of the fatty acids formed during digestion of the fat. It is also probable that bacteria attack undigested fat and break it down into fatty acid. The fatty acids which are formed from the breaking down of fat are higher members of the fatty acid group (oleic, stearic, and palmitic), are solid at ordinary tem- peratures (with the exception of oleic), non- volatile, and not particularly irritating to the intestinal mucosa. The lower members of the fatty acid group (acetic, butyric) are liquid, volatile, and extremely irritating to the intestine. It is theo- retically possible that the lower members could be produced from the higher by still further splitting, and it is probable that this occurs to a certain extent when fermentative bacteria are active. It is probable, however, that this splitting does not take place to any great extent, and that when butyric and acetic acids are found in the stools they come from the sugar rather than from the fat. A diarrhea from sugar is likely, there- fore, to be more irritating and profuse than one from fat, on 44 PRACTICAL INFANT FEEDING account of the greater irritating effect of the lower fatty acids arising from sugar decompostiton. Fat splitting is almost always good except when diarrhea occurs, or excessively large amounts of fat are fed, therefore only a small portion of the stool fat ordinarily consists of neutral (unsplit) fat. If a large amount of neutral fat is found in the stools microscopically a severe fat incapacity is indicated. In most cases of "fat indigestion" the trouble is not an "indigestion" at all, but is a failure of absorption of the fat which has been digested. Table I, from Holt/ shows the distribution of the fat in the stools of normal and abnormal bottle-fed babies, and of children on a mixed diet; Table II compares normal breast and bottle babies. TABLE I Total fat per cent, of dried weight of stools. Soap. Per cent, of total fat as Type of stools. Free fatty acids. Neutral fat. Constipated 36.0 36.2 31.9 32.7 30.2 33.4 40.7 18.0 73.8 72.8 59.8 44.6 30.6 12.4 8.8 45.1 17.6 16.5 24.5 19.3 16.6 30.4 38.1 27.4 9 Normal 9 4 Softer than normal Not homogeneous Loose 11.9 22.5 55 1 Diarrheal Severely diarrheal Older children on mixed diet. Normal stools.. 61.6 56.4 27.5 TABLE II Type of stools. Total fat per cent, of dried weight of stools. Soap. Per cent, of total fat as Food. Free fatty acids. Neutral fat. Cow's milk Breast milk Normal Normal 36.2 42.1 72.8 57.8 16.5 26.3 9.4 15.9 Loc. cit. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 45 The most striking thing about this series of figures is the gradual diminution in the percentage of soap, and the rise in fatty acid and neutral fat as the stools become diarrheal. It will be seen that the stools of the bottle-fed baby contain a higher percentage of soap and less fatty acid than those of the breast-fed baby. This goes back to the principle of "soap in an alkaline medium, fatty acid in an acid medium." The stools of a breast-fed baby are strongly acid on account of the relatively large amoimt of lactose and small amount of casein and calcium in breast milk. Those of a bottle-fed baby are likely to be alkaline on account of the relatively large amount of calcium and of casein in the food. Summary. — The chemistry of fat in the intestine is perhaps the most complicated and the most important of that of any of the food elements. It is complicated on account of the three different sorts of fat that are present (neutral fat, fatty acids, soaps) and on account of the variations in the action of these substances according to the conditions present, and the quanti- ties of the other food elements in the diet. It is important, because clinically failure of fat absorption represents one of the most important group of cases we are called upon to treat. There are so many theories concerned in the question of fat metabolism, so many varying views, and so much that we do not as yet understand clearly, or only half understand, that I have not attempted to give any extensive review of the literature, and the foregoing is only a brief outline of the subject. It should be enough, however, for a practical working knowledge. 3. The Metabolism of Carbohydrate. — In contradistinction to fat, carbohydrate is necessary to life: if a baby is fed on a carbohydrate-free diet for any length of time he dies from acid- osis, on account of the abnormal and incomplete combustion of body fat with the resulting acetone bodies — diacetic acid, beta-oxybutyric acid, and acetone. A certain amount of car- bohydrate is necessar}'- to insure proper fat combustion. The exact minimum necessary for babies of different weights and ages is not known. Sugar is of great importance as a nitrogen 46 PRACTICAL INFANT FEEDING sparer, and has more power in this regard than does an iso- dynamic amount of fat. When carbohydrate (sugar) is given in the diet it is possible to establish nitrogen equilibrium at a much lower level than when protein alone or when protein and fat alone are ingested. Thomas^ showed that a diet containing the large amount of 18.4 gm. nitrogen did not suffice to keep the adult body in nitrogen equilibrium when no carbohydrate was given. The reason for this is that the protein food is drawn upon so heavily for fuel in the body that not enough is left for the needs of growth and repair. This holds even more for infants than it does for adults, as the nitrogen needs of infants per kilogram of body weight are considerably greater than those of older persons. The importance of sugar for fuel is shown in breast milk, in which 48.7 per cent, of the calories is furnished by the sugar. The Relation of Sugar to Gain in Weight and the Retention of Nitrogen and Salts, — The feeding of large amounts of sugar may cause a rapid increase in weight, provided the sugar is well digested. This is partly due to water retention, and high sugar feeding is particularly likely to bring this about because the deposition of glycogen in the body cells, which may be con- siderable after high sugar feeding, is possible only when accom- panied by a retention of two or three times its amount of water. The considerable salt retention with high sugar feeding may also account for a part of the water retention. Thus we see many babies who have been fed on a one-sided high sugar diet who appear fat, and are perhaps above normal weight. The apparent robust health and weight in these cases is deceptive because it does not consist of healthy fat and muscle, but of water which has been retained in the body cells. Condensed milk babies are likely to be of this type. Sugar is not without a good deal of influence upon the reten- tion of the other food elements; up to a certain point the more sugar that is fed, the greater is the retention of nitrogen and salts, particularly of nitrogen. If the tolerance for sugar is 1 Arch. f. Physiol., Suppl., 1910, p. 249, PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 47 1 ^ ormed, but much softer than before. Very large. One green stool. e, watery, en, with ny small soft ds, and con- jrable mucus. ^8 li II |i^ j-p .• 4^*?.^ .£3 Mfe & tC H g u !3.Sl J3.5I J J fc h4 I^JJO^ Xi Q° s^.S 1/5 VD fo fs 3 "J a ^o.S O.Hi i2 10 rn C rnU, 10 . 00 m + + + " 00 00 so >r) f^ j c VO ■*' + + + c ii « (^ Pi (S 00 CM (S ^ ;^ s J z|« 00 00 ^" i ^ < . 00 o> ISfcfl 0. « 0. feajj 00 6 d •*' 00 OS Os t^ - 1- ^. ^. Os r°i vO (T) •^' U1 f^ 00 10 »o fS 0) •"J* t^ r- r- fO < i/> >o tA t>. A >/5 .5S so •^_ (x! gM ^ d •^ CN ll1^ fO •* '** a ^^^ d d '-" SO l-SSI OS 00 ^. c^«42^ *-■ VO 10 00 „ CO t^ fN so iS^ ro SO "* 0. 00 t^ SO ■* h-i (N ■* so cs f^ ■* ■rt g So 5"i VO J^' t^ so i ?^ •* -l tH t^ TH ;::^,4os',h' >^"o:^' fedo; fedfe tcido^ fedo^ 48 PRACTICAL INFANT FEEDING overstepped, and fermentation results, the retention of nitrogen, and especially of salts, may be greatly diminished. This is of considerable importance in practical infant feeding and is illustrated in Table III, from some investigations carried out by Dr. Fritz Talbot and myself in 19 14.^ The effect on the retention and absorption of the other food elements of gradually increasing the amounts of sugar in the diet of a six months' old baby was studied in several metabolism periods of three days each. In the first three periods the baby was doing well, his absorption was good, and as the sugar in his diet was in- creased there was an increasing retention of nitrogen and gain in weight. In Period IV his sugar tolerance was overstepped, and he reacted with loose, green, acid stools, causing a poor absorption of all the food elements, a great increase of neutral fat in the stools, and a negative ash and nitrogen balance. Digestion and Absorption of Sugar, — ^The three common sugars used in infant feeding — lactose, sucrose, and dextrin — maltose preparations, are disaccharids of complex formula, and must undergo splitting in the intestinal tract before being absorbed. Glucose is a monosaccharid, and is absorbed as such without further digestion. It is probable that sugar is normally acted upon very little in the stomach. It is broken down in the small intestine by the intestinal ferments into two molecules of a monosaccharid, and is absorbed as such. For each sugar there is a specific ferment: for lactose, lactase; for maltose, maltase; and for sucrose, invertin. The absorption of sugar in health is excellent, and most investigators have been imable to find sugar in the stools of normal babies. In cases where sugar is not being well absorbed, it is broken down by bacterial action into acid end-products, and thus, even in sugar indiges- tion, it is not usual to find sugar in the stools. If there is excess- ively vigorous intestinal peristalsis, and large amounts of sugar are ingested, the sugar may be hurried through so quickly that the unabsorbed residue may not have time to be completely fermented, and small amounts may be found in the stools. 1 Amer. Jour. Dis. Chil., vol. 8, September, 1914. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 49 Normal Action of Sugar in the Intestine. — In the breast-fed baby there is always a certain amount of sugar fermentation going on in the large intestine caused by the fermentative acidophilus and bifidus flora. Lactic acid and to a certain extent acetic and other volatile acids are the end-products of the fermentation, and serve to promote peristalsis and consequent evacuation of the bowel. In the large intestine of the bottle-fed baby, however, putrefactive processes predominate, and under normal conditions sugar fermentation is not so extensive. It has been shown that a slight amount of sugar fermentation in the large intestine is beneficial, and that the absorption and retention of the other food elements is aided by it. Large amounts of sugar in the food are likely to cause loose stools; the lack of sugar favors constipation. Assimilation Limits of Different Sugars. — ^A baby takes rela- tively much more sugar than does an adult, and the assimilation limit, or the amount of sugar ingested per imit of body weight before sugar appears in the urine, is much higher in infancy than it is in later life. A breast-fed baby of 4 gm. would nor- mally take perhaps 120 gm. of milk at a feeding, containing, roughly, 8.4 gm. of lactose, or 2.1 gm. per kgm. of body weight.^ An adult usually shows sugar in the urine after taking about 1 gm. of sugar per kilogram of body weight. Langstein and Meyer have calculated that an adult of 150 pounds would take about 800 gm. of sugar per day if he took as much in proportion to his weight as a 12-pound breast-fed baby. Practically speaking, it is difficult to exceed the assimilation limit of a baby before sugar fermentation and diarrhea occur. Porter and Dunn^ in a series of cases fed large amounts of sugar to babies (from 7 to 18 per cent., or 90 to 225 gm. in twenty-four hours) with the purpose of determining how much sugar could be taken without digestive upset and also if the assimilation limits could be exceeded before diarrhea occurred. > Langstein and Meyer, Sauglingsernahrung und Sauglingsstoffwechsel, Weisbaden, 1910. 2 Amer. Jour. Dis. Chil., vol. 10, No. 2, 1915. 4 50 PRA.CTICAL INFANT FEEDING They found that surprisingly large amounts could be taken without digestive disturbance, and although sugar occurred in the urine in some cases during the course of sugar diarrhea, its occurrence bore no relationship to the amount of sugar ingested. They conclude that much larger quantities of sugar can be taken without the development of intolerance than has been ordinarily supposed, and that it is not possible to exceed the sugar assimila- tion limits, so that sugar occurs in the urine before symptoms of sugar indigestion have occurred. The assimilation limits of the different sugars vary some- what, that of lactose and sucrose being about equal, from 3.1 to 3.6 gm. per kilogram of body weight, that of maltose con- siderably higher, about 7 gm. Sugar Fermentation. — It is now generally granted that bac- terial fermentation of sugar in the intestine plays a very impor- tant part in digestive and nutritional disturbances. A number of different agencies may bring this about, but the end-result is the same: excess of acid from the breaking down of the sugar, with consequent irritation of the intestinal mucous membrane. The production of acid is the first step in the chain of processes which may occur, and which may produce mild or severe con- ditions in the baby, depending upon how far they are allowed to go. It is probable that the unchanged sugar molecule is with- out much influence, and that it must be broken down into volatile acids before harmful results are brought about. This chemical change is produced by the action of bacteria upon sugar, and it is probable that it cannot be done in any other way. Let us consider for a moment the chemistry of sugar fer- mentation, and the products that are formed. Lactose is a disaccharid, a rather complex chemical substance, with the formula C12H22O11, containing many carboxyl and some aldehy3 groups which may be very readily changed over into acid radicals. It will be seen from this that there is possibility for the formation of a considerable number of end-products when the molecule is torn apart, and that from the chemical con- PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 5 1 stitution of sugar acids are the substances which are most likely to be formed. Two different groups of acids may result from the breaking down of sugar: the so-called volatile "fatty" acids and the non-volatile acids. The non-volatile acids are lactic and succinic acids and probably do no harm. It is the volatile fatty acids with which we are chiefly concerned. There are thirteen members in this acid series, as follows: Name of acid.^ Formula. Formic HCOOOH Acetic CH3COOH Propionic CsHeOa Butyric C4H8O2 Valeric C6H]o02 Caproic C6H12O2 Heptylic C7H14O2 Caprylic C8H16O2 Nonylic C9H18O2 Capric C10H20O2 Palmitic C16H32O2 Margaric C17H34O2 Stearic C18H36O2 The lower members are liquids; the higher ones, beginning with Cio, are solids at ordinary temperature. It is the lower members of the group which are most important, and it is unlikely that the higher ones are formed by the breaking dowa of sugar. The higher acids are formed by the breaking downi of fat, and it is also theoretically possible that the lower acids (formic, acetic) may be likewise formed from fat destruction. Probably always when there is a fermentation of sugar going on in the intestine there is also a secondary fermentation of fat, and it is quite impossible to tell how much of the acid formed comes from the one, how much from the other. The modern German school is inclined to attach very little importance to fat fermentation; they believe that it is practically always secondary to sugar fermentation and does little harm. Salge, in his important monograph in 1906, believed, however, that all the trouble came from the fat, and none from the sugar. 1 Holleman, Text-book of Organic Chemistry. 52 PRACTICAL INFANT FEEDING Chemically, both substances can form acids very easily, and it is probable that in many cases the sugar and the fat both play an important part. Bokai^ found that the acids were irritating to the intestine in the following order: caprylic, caproic, acetic, propionic, formic, butyric, valeric. Bahrdt and Bamberg^ believe that acetic is the most irritating. Increased amounts of volatile fatty acids in the intestine may bring about the following harmful changes: 1. Increase peristalsis by irritating the intestine, with diarrheal stools as a result; these loose stools may carry out a good deal of imdigested fat and protein which have not had time for absorption. 2. Injure the mucous membrane of the small intestine in such a way that it is unable to exert its normal antibacterial powers. Also, the functionally injured mucous membrane may allow the passage of harmful substances (lactose (?), salts, acids, or bacterial endotoxins) into the system, which would not be able to pass the healthy intestine. This may lead to severe intoxication, 3. Draw upon the alkali reserve of the body in an attempt to neutralize the excessive acidity. This may help to cause an acidosis. 4. Upset the normal chemical processes of digestion, most of which cannot go on satisfactorily in an excessively acid intestine. Conditions Which Bring About Sugar Fermentation. — ^Two things are necessary for sugar fermentation: imdigested sugar free in the intestine and bacteria in sufficient quantity to attack it. It must be remembered that there is no specific bacterium which accomplishes this; it may be done by a number of differ- ent organisms, either the normal inhabitants of the intestine or harmful organisms introduced from without. The place of fermentation is of a good deal of importance; in the breast-fed baby fermentation in the large intestine is normal; in the bottle- fed baby who is sick on account of sugar fermentation the process 1 See Tobler, ref. 566. 2 Ztsch. f. Kinderheilk., 3, 322, 1911, 1912. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 53 may be taking place in the small as well as in the large bowel. A difficult problem in artificial feeding is to keep down excessive intestinal putrefaction, with the formation of constipated alkaline calcium soap stools, without going to the extreme of excessively acid sugar fermentation. These two conditions are largely controlled by the relation between the different food elements in the mixture offered to the baby. (See section on Bacteriology.) The following seven conditions may produce abnormal sugar fermentation. I shall discuss in this section only the last one — high sugar in combination with high salts — and will take up the others in subsequent chapters. 1. Bacteria introduced from without in bad milk. 2. Overfeeding with sugar. 3. Overheating of the baby's body. 4. "ParenteraP' infections. 5. Nervous influences. 6. Constitutional weakness. 7. High sugar in combination with high salts. The German school has contended that perhaps the most important cause of sugar fermentation is a depression of the antibacterial powers of the epithelial cells of the small intestine by the salts of the cow's milk, particularly those salts which are left behind in the whey after the curd has formed. This lowering of resistance allows bacteria to flourish in the small intestine where they would not normally be able to exist except in very small nimibers. It is an ingenious attempt to explain many little understood phenomena, but does not rest upon a firm enough substratimi of observation and investigation to be unconditionally accepted as the truth. The importance ascribed to the whey salts is based largely upon Meyer's investigation, in which he separated breast milk and cow's milk each into curds and whey, and then added the whey of breast milk to the curds of cow's milk, and vice versa. He found that the mixtures containing the cow's whey caused diarrhea when fed in con- junction with a high sugar; those containing the whey of breast milk did not. 54 PRACTICAL INFANT FEEDING There is no question that cows' whey is rich in salts. It con- tains about 0.80 to 0.90 per cent, salts, in the form of chlorids, citrates and phosphates of sodium, potassium, and calcium. About half of the calcium of the original milk is present in the whey; probably nearly all of the sodium and potassium.^ There is a certain amount of evidence to show that strong solutions of salts may depress the functions of living cells, but the salt con- centration of cow's whey, although higher than that of human whey, corresponds to a physiologic saline solution only. It is hard to see how a concentration of salts which is thus practically isotonic with the body fluids can act in an injurious manner to the intestinal cells. Again, we know that plain whey, undiluted, is usually borne very well by even the smallest babies, and often is fed to them with great success during gastro-intestinal dis- turbances of various sorts, when the casein and fat of cow's milk, perhaps, cannot be borne at all. Also when we add sodiiun citrate in the strength of 1 or 2 grauis to the ounce of milk and cream in the mixture, to modifications to favor the digestion of the protein, we are adding a large amount of sodium and of citrate ions, which does not seem to upset the baby. Again, when we add calcium chlorid to a baby's milk in order to lessen nervous irritability in spasmophilia, we add much more than is ever present in whey. Neither does this ordinarily upset the baby. One of the chief purposes of the famous "Eiweissmilch" was to dilute the whey salts, but in eiweissmilch we have all the salts of the buttermilk used in its preparation, which in the finished eiweissmilch would correspond approximately to a salt concentration obtained by dilution of cow's milk one-half with water. Eiweissmilch works; there is no question of that; but is not its beneficial effect due rather to a very low sugar content (1.5 per cent.) than to a low salt content, which it does not contain? Let us suppose a baby was having dyspepsia on a dilution of one-half milk with added sugar; we would feed him eiweissmilch, and it would probably arrest the sugar fermenta- 1 Bosworth: Personal communication. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 55 tion, but we would not have decreased the salt content of his food at all. The work of Courtney and Fales/ under the direction of Dr. Holt, is interesting in this connection: "Protein milk contains a higher ash and higher amount of all the different salts than are ordinarily given to infants artificially fed. As compared with woman's milk, not only are the total salts of the ash in great excess, but the amount of calciiun is nearly five times and the phosphorus nearly seven times as great. The soluble salts, also, are nearly twice as abundant in protein milk as in human milk. As used at the Babies' Hospital extensively for three years, with most satisfactory results, eiweiss- milch has contained, owing to the addition of sodium chlorid to the buttermilk used, an amount of Na and CI nearly as great as in undiluted cow's milk, and much greater than in woman's milk. The following table shows the salt content in percentages of protein, cow, and human milk": Total ash. CaO. MgO. P2O8. K2O. Na20. CI. Protein 648 .201 .021 .222 .109 .032 .061 Cow 743 .176 .020 .206 .189 .050 .111 Human 206 .047 .008 .034 .057 .014 .035 It can be seen from these few suggestions that the question of the harmfulness of the whey salts is not at all a clear one, and that Meyer's original suppositions can be by no means uncon- ditionally accepted. There is no question that breast milk, even with its high sugar content, can often be fed with beneficial results to babies who are suffering from sugar fermentation. Sugar fermentation must, therefore, be due in these cases to sugar plus some indeterminate factor present in cow's milk and not present in breast milk. There is evidently some property of breast mUk which allows its high sugar content to be handled by the baby without undue fermentation; whether this is due to the relatively low salt content of breast milk or to other factors is by no means certain. 1 Amer. Jour. Dis. Chil., vol. 10, 1915, p. 172. 56 PRACTICAL INFANT FEEDING Starch is a polysaccharid, a more complex fonn of carbo- hydrate than the sugars, and must be broken down into sugar before it can be absorbed. Its absorption is, therefore, slower than that of the sugars. It is probable that mouth digestion of starch is very slight in young babies, although the saliva has been shown to contain active ptyalin. The amylopsin of the pancreatic juice breaks down the starch first into dextrins, then into maltose, and the maltose is in turn changed to dextrose by the maltase of the succus entericus, and is absorbed as such. All the starch-splitting ferments have been found at birth, although their power is feeble during the first few months, and they do not become strongly developed until the end of the first year. Absorption of starch when given in moderate amounts, as cereal gruels to young babies, is good, and it is probably true that starch in this form could be used with advantage a good deal earlier than it usually is. If starch is not well digested, it either comes through the stools as a foreign body, partly or entirely digested, or may be attacked by the intestinal bacteria and slowly fermented, with resulting end-products consisting mostly of volatile acids. 4. The Metabolism of the Mineral Salts. — ^The salts are of very great importance in the normal and abnormal processes of infant nutrition, and in the last fifteen years especially an enormous literature has grown up regarding them. So much has been written, so varying have been and still are many of the opinions held and the figures given, so complicated is the ques- tion of the metabolism of any individual miaeral element, to say nothing of its relations to the other salts and the organic elements of the diet, that it is hard indeed to separate the wheat from the chaff, and to present in a clear and non-tedious way what seem to be the main facts of the subject that are of interest to practical medical men. It is probably true that the clinical pictures produced by many "food injuries" are due very largely to disturbed salt metabolism, and in certain instances it is possible to know with a fair degree of accuracy what has brought about this perversion, PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 57 and how to correct it by changes in the diet, but in general there are far more theories concerned in discussions of disturbances in salt metabolism than well ascertained and universally accepted facts, and it is not ordinarily possible in practical infant feeding to vary the amounts of the various mineral elements in the food offered to the infant with the same degree of accuracy that we vary the organic constituents. Cow's milk contains a much larger quantity of mineral material than does human milk, about 7.8 gm. to the liter for the former, 2 gm. to the liter for the latter. The salt metab- ohsm of the bottle-fed infant is, therefore, on an entirely different plane from that of the breast fed. The salts are in much the same relative proportions in cow's milk as in human milk, with the exception of phosphorus and iron. According to Holt, Courtney, and Fales- 100 gm. of ash contain the following: CaO. MgO. P2OJ. NazO. K2O. Cl. Human milk . . 23.3 gm. 3.7 gm. 16.6 gm. 7.2 28.3 16.5 Cow's milk. . . . 23.5 « 2.8 « 26.5 « 7.2 24.9 13.6 Iron is the only mineral element that is present in smaller quantities in cow's than in human milk. There are three especial points which must be borne in mind in reviewing the question of salt metabolism: 1. The analytic methods that have been used have often been faulty (especially for calcium and iron), and, therefore, many of the older figures are not accinrate. 2. Often reports have been made on the salt metabolism of one infant over a relatively short period of time, and these figures have been used as liie standard, being passed on from book to book. 3. A large portion of the intake of mineral salts (especially calcium) is re-excreted in the intestine after absorption; there- fore it is not possible to get any accurate figures as to the amounts which have actually been absorbed. This must be 1 Amer. Jour. Dis. Chil, vol. 10, 1915. 58 PRACTICAL INFANT FEEDING borne in mind in considering the figures for absorption, whether for total ash or for individual salts, and by "absorption" is ordinarily meant the difference between the intake and what appears (either re-excreted or unabsorbed) in the stools. Physiologic Importance of the Salts. — ^Hoobler^ has summa- rized very clearly the physiologic importance of the salts: "(1) They maintain the osmotic pressure in tissue cells, blood, and body fluids; controlling the flow of water to and from the tissues; any deviation from normal causing a shrinking or swelling of tissue cells. "(2) They regulate the reaction of the blood and tissue fluids. A deviation from this reaction inhibits the action of the various ferments, delays chemical processes, and, if such reaction suffers much variation, death results (acidosis). "(3) Their presence in tissues and fluids gives rise to irri- tability of muscle and excitability of nerve through the action of their respective ions. Through this function the rhythmic contractions of the heart are maintained. "(4) They act as catalysts for a large series of chemical reactions which take place during the processes of absorption, retention, utilization, and form combinations with waste prod- ucts of metabohsm in order to effect their elimination; for example, they act as carriers of excess acid materials in oxidation processes. "(5) They share in the upbuilding and growth of the body, since they are a constituent of every cell; particularly do they take part in the changes which go on in the albumin bodies as they become intimately bound with the body proteins. "(6) Their fuDction in the intermediary metabolism of the ductless glands is very apparent from the large quantities of mineral salts found in these organs. ''(7) Through a most excellent self-regulation they protect against the acid poisons which the body is constantly producing. "(8) Through the work of the various ions, electrically charged, some positively, some negatively, many important lAmer. Jour. Dis. Chil., vol. 2, 1911. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 59 functions are being assigned to them, such as contr6lling body weight, temperature, regulating the pulse, increasing leukocytes, etc. These and msiny more functions, not clearly defined, depend upon the presence of the mineral salts in the body, and not on their presence alone, but their presence in definite rela- tionships to one another." (9) They form an important part of all the digestive juices. (L. W. H.) Total Ash. — 1000 c.c. of cow's milk contains 7.8 gm. of total ash; 1000 c.c. of human milk contains 2 gm. of total ash. The absorption of ash is not so good as that of the inorganic food elements. According to different observers, the percentage absorption varies from 65 to 75 per cent, in the bottle-fed babies, and is somewhat higher for the breast fed. The actual absorption is higher in the bottle fed. In any diarrhea the absorption may be very poor, so that there is an actual negative salt balance, with a loss of mineral substance from the body. This is important clinically and un- doubtedly has a great deal to do with the clinical picture seen in severe cases of diarrhea. Calcium and Magnesium. — 1000 c.c. of human milk contains 0.42 gm. of CaO and 0.082 gm. of MgO; 1000 c.c. of cow's milk contains 1.72 gm. of CaO and 0.20 gm. of MgO. Calcium is present in cow's milk in three different forms (Bosworth^) : 1. As insoluble phosphate, which is practically inert, is not absorbed, and is recovered in the stools as such. 2. Combined with protein as calciiun caseinate. 3. As soluble salts in the whey. It is not possible to tell accurately how much calcium is actually absorbed, as the excretion of calciiun in the bottle fed takes place almost entirely through the intestine, and only a small amount is excreted through the urine. According to Bos- worth the calcium metabolism of the bottle-fed baby is seldom greater than that of the breast-fed baby, and may actually be 1 Amer. Jour. Dis. Chil., vol. 15, 1918. 6o PRACTICAL INFANT FEEDING less, even if there is more calcium in the food, as most of the calcium is eliminated in the feces as insoluble calcium phosphate and calcium soaps. Breast baby Bottle baby (gm. per 240). (gm. per 240). CaO in urine 0. 069 gm. 0. 025 gm. CaO in feces 0.038 " 1.672 « The figures given for the absorption of calcium vary so much that it is impossible to draw any very exact conclusions from them. The methods used for analysis, the age and nutri- tional condition of the baby, the amoimt of calcium in the food, and its relation to the other food elements probably account for these differences. From a study of the figures available it would seem that the percentage absorption in babies fed on cow's milk is low, and that the percentage absorption, although not the actual absorption, is certainly a third greater, and perhaps nearly twice as great in the breast fed as in the bottle fed. The latest and probably the most reliable work is by Holt, Courtney, and Fales,^ who found that bottle-fed babies absorbed from 35 to 55 per cent, of the intake, while breast-fed babies absorbed 66.7 per cent. "The average absorption of CaO for 5 healthy breast-fed babies was foimd to be 0.054 gm. per kilogram. Since infants taking cow's milk absorb only about 45 per cent, of the calcium intake, it is necessary to provide for them a minimum intake of 0.130 gm. CaO per kilogram of body weight in order to have them absorb as much as a breast baby." Since cow's milk contains on an average of 1.72 gm. CaO per liter, I liter of milk would amply cover the calcium needs of a baby of 6.5 kgm. or about 14| pounds. A baby of about 20 pounds would require, according to these figures, 1.17 gm. CaO per day, and would be getting considerably more than this in a liter of milk. If these figures are correct there is, therefore, little danger of not covering the calcium needs of infants with the ordinary methods of feeding, especially as usually after the eighth 1 Loc. cit. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 6 1 or ninth month cereal is added to the diet, which contains a not inconsiderable amount of calcium. The three pathologic conditions which are of most impor- tance in connection with abnormal calcium metabolism are chronic fat indigestion (Bilanzstorung), rickets, and spasmo- philia. Rickets and spasmophilia will be discussed later. The relation of calcium excretion to the fat in the diet has long excited interest, and many metabolism experiments have been carried out to determine what effect increasing amounts of fat in the diet had upon calcium absorption. The consensus of opinion seems to be that increased fat in the diets of normal babies does not decrease calcium absorption (Holt, Courtney and Fales,^ Meyer ,^ Aschenheim^). As regards babies who have a chronic incapacity for fat, particularly those who pass the colorless, dry, constipated stools which contain a large excess of soap, the conditions are quite different, and there may be a large loss of calcium in such stools, enough in many cases to cause a negative calcium balance. According to Meyer,* in Bilanzstorung (chronic fat indigestion) as much as 60 per cent, of the calcium intake may be lost in these stools, but soap stools in themselves do not always mean that there is an increased calcium output or a negative calcium balance. One can only say that very frequently when typical soap stools are passed there is a negative calcium balance. Bos- worth, Bowditch, and Giblin^ believe that the large excess of calcium in cow's milk is the prime reason why certain infants suffer nutritional disturbance when considerable amounts of fat are taken, and they have shown in these cases that it is possi- ble by feeding a decalcified milk to greatly increase the tolerance toward fat. In one of their cases the total fat in the stools dropped from 4 gm. per day to 0.66 gm. per day as soon as the feeding with decalcified milk was started, and they have found 1 Amer. Jour. Dis. Chil., vol. 19, 1920. 2 Jahrb. f. Kinderh., 71, 1, 1910. 3 Ibid., 77, 1913. ^ Loc. cit. 5 Amer. Jour. Dis. Chil, vol. 15, 1918. 62 PRACTICAL INFANT FEEDING that many infants who on ordinary milk mixtures are able to handle practically no fat at all, thrive on as much as 3 per cent, when the decalcified milk preparation is used. In spite of much research on the subject the interaction of fat and of calcium and their relative importance in chronic fat indigestion are still obscure. We know that in many cases where there is poor util- ization of fat there is also pure utilization of calcium; we know that the simple loss of calories from the poor fat absorption is not enough to account for the disturbance of nutrition; we know that the loss of calciiun is not entirely accounted for by a simple binding with fatty acid to form insoluble calcium soaps; still, the characteristic nutritional change does not occur unless fat and calcium are both present in relatively large amounts, and it never occurs in infants fed on breast milk, where the fat is high and the calcium is low. About all that can be said in the present state of our knowledge is that in some babies high fat plus high calcium is not well tolerated. Magnesium. — There is only a small amount of magnesium in either cow's or human milk. It is not so important as calciimi in the pathogenesis of nutritional disturbances, but being closely allied to it chemically, in general acts in the same way, and forms insoluble soaps with fatty acids. The percentage absorp- tion of magnesium is about the same as that of calcium. Sodium and Potassium. — 1000 c.c. of cow's milk contains 0.46 gm. of Na20 and 1.72 gm. of K2O; 1000 c.c. of human milk contains 0.16 gm. of Na20 and 0.88 gm. of K2O. The absorption of both sodium and potassium is relatively better than that of the other salts, from 75 to 90 per cent, of the intake being absorbed. They are excreted partly through the urine as phosphates and chlorids, and partly through the intestine (digestive juices) . In diarrhea the sodium and potassium absorp- tion especially suffers, and there may be a negative balance^ while the calcium and magnesium balance is positive. With constipation, especially of the soap stool type, there is likely to be a good and perhaps in certain cases an excessive retention of sodium and potassiimi. There is normally a certain fairly defi- PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 63 nite balance between the amount of sodium and potassium in the body, on the one hand, and the calcium and magnesiiun on the other hand, which is necessary to preserve the proper degree of nerve irritability. If too little calciimi and magnesium and too much sodium and potassium are retained, a condition of increased nerve irritability is likely to result (see Spasmophilia). Sodium and potassium are also important in furnishing alkali for the pancreatic and intestinal digestive juices, and for the bile. Phosphorus. — 1000 c.c. of cow's milk contains 2.25 gm. of P2O5; 1000 c.c. of human milk contains 0.40 gm. of P2O5. Phosphorus is needed especially by the body for the forma- tion of bone, glandular tissues, and the central nervous system. Part of the phosphorus present in milk is in organic form con- tained in the milk casein, partly in inorganic form. In cow's milk a large part of the phosphorus exists as insoluble calcium phosphate, which is inert as far as metabolism is concerned, and goes through the intestinal tract quite without absorption (Bosworth). In cow's milk a much greater amount of phos- phorus is present than can possibly be used by the baby, and the percentage absorption is not nearly so high as that of the phos- phorus contaiaed in breast milk, although the actual absorption may be more. The figures given by various authors for phos- phorus absorption vary between 53 and 83 per cent, for cow's milk and 65 and 89 per cent, for human milk. The breast-fed baby excretes only traces of phosphorus in the urine, and the bottle-fed baby may excrete a fifth or a sixth as much in the urine (0.34 gm.) as he does in the stools (1.67 gm.) (Bosworth). According to Hoobler the elimination through the urine and intestine is about equal. Iron. — 1000 c.c. of cow's milk contains 0.0006 gm. of Fe203; 1000 c.c. of human milk contains 0.0017 gm. of FeoOs. On account of faulty methods of analysis there seems no question that the older figures given for iron were altogether too high, and that both human and cow's milk contain only very small amounts. It is the only mineral element which is 64 PRACTICAL INFANT FEEDING present in smaller quantities (one-third as much) in cow's milk than in human milk, and when cow's milk is diluted, as it is in infant feeding, the amount of iron present is almost negligible. Despite this, babies seem to thrive during the first eight or nine months, at any rate, on dilutions of cow's milk which contain practically no iron. It is a clinical fact that babies after this time are likely to become anemic, whether bottle or breast fed, if additional iron-containing food is not given. This is especially true of premature infants and twins. It is well known that the newborn infant contains a considerable store of iron in the liver, which probably acts as a reserve depot, and it is supposed that this accounts for the fact that the bottle-fed baby gets along on a food containing only traces of this element. The iron needs of babies are not definitely known, and the only data available is the iron intake of the naturally fed infant, who is supplied about 1.5 mgm. Fe203 per day in his ration of breast milk. Soxhlet^ calculated that if a baby gained 25 gm. in weight a day there would be a daily gain of 1.92 gm. of blood, which would require 1.34 mgm. of iron oxid. This amount is well covered by the breast milk. It is likely that in the early months of life more iron is excreted than is taken in (Blauberg, Camerer), and as long as the fetal iron deposit in the liver is taking part in the iron metabolism it is not possible to determine the amount or iron absorbed or retained. From a practical point of view it seems certain that the iron in the liver plus the very small amount contained in cow's milk modifications is enough to cover the iron needs of artificially fed babies for the first eight or nine months at any rate. These needs must, therefore, be very small, and if after the eighth month food is added which contains only a very small amount of additional iron, there is no danger of anemia developing. Sulphur, — 1000 c.c. of cow's milk contains 0.33 gm. of SO3 (Hoobler); 1000 c.c. of human milk contains 0.14 gm. of SO3 (Blauberg). According to Hoobler the percentage of sulphur absorbed 1 Munch, med. Woch., vol. 59, 1912. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 65 varies from 88 to 95 per cent. Most of the sulphur in milk is a constituent of the casein. Chlorids. — 1000 c.c. of cow's milk contains 0.82 gm. of CI; 1000 c.c. of human milk contains 0.34-0.59 gm. of CI. The absorption is from 90 to 95 per cent, of the intake. The excretion is largely through the urine, as sodium chlorid, except in diarrhea, when considerable amounts may be lost in the stool. 5. The Vitamins.^ — It is now recognized that, in addition to fat, carbohydrate, salts, and water, food-stuffs contain other substances which are necessary for proper growth and main- tenance. These substances have been variously called "vita- mins," "accessory" food factors, and "fat-soluble A," water- soluble "B" and "C." In 1897 Eijkman, who was studying the Eastern disease beriberi, found that pigeons who were fed solely upon polished rice developed in three or four weeks a condition of paralysis, which was a polyneuritis, and was analogous to beriberi in man. When instead of being given polished rice they were fed upon whole rice kernels they did not develop beri- beri, and, furthermore, it was found that the administration of rice poUshings would cure the disease after it had developed. The natural inference was that it was caused by a lack of some unidentified substance or substances contained in the rice polishings. In 1912 Hopkins foimd that maintenance of body weight and growth in rats could not proceed with a diet of purified food substances, but that if milk was added growth proceeded. He suggested the existence of imidentified food substances which were supplied by the milk, and gave them the name of "accessory" food factors. In 1914 Funk called these substances "vitamins" and believed that beriberi, scurvy, and rickets were caused by a lack of them in the diet. McCollimi and Kennedy, who had been for some time working along 1 Only a very brief outline of this fascinating subject is possible here. If the reader desires to go further with it he is referred to that most inter- esting book of E. V. McCoUum's, "The Newer Knowledge of Nutrition" (Macmillan Co., 1918), of which I have made free use in this section, and to the Journal of Biological Chemistry, 1915-1921, in which most of the original articles concerning the vitamins have appeared. S 66 PRACTICAL INFANT FEEDING the same lines, believed that there were two substances, and suggested for them the names fat-soluble "A" and water- soluble "B." Still later a third substance was beKeved to be present, and was called water-soluble "C." While it is true that the word "vitamin" has certain objections as a term of nomen- clature for these substances, it is the one most commonly used to designate them collectively. The individual vitamins are best spoken of as fat-soluble "A,'' etc. Nature and Occurrence of the Vitamins. — ^The chemical con- stitution of the vitamins is unknown, and they have never been isolated in pure form. Funk believed that they were nitrogenous bodies chemically allied to the amins, hence the term "vitamins." It is probable, however, that this view is erroneous, at least for the fat-soluble "A," as it occurs in fats, which contain no nitrogen. They cannot, apparently, be produced in the animal body unless food containing them is ingested, and the amount of vitamin in milk, for example, has been found to be directly proportional to the vitamin content of the food eaten by the cow. Fat-soluble "A" and water-soluble "B" are comparatively stable substances, not easily destroyed by heat or other agencies, while the water-soluble "C" is more easily destroyed by heat, oxidation, alkalies, or aging of the food in which it exists. Fat- soluble "A" occurs especially in butter fat, cod-liver oil, the fat of egg yolk, and the leaves of plants (spinach). It occurs to a slight degree in the roots of vegetables, such as carrots. It does not occur in vegetable oils, and only slightly in most animal fats, such as lard or beef fat. Water-soluble "B" is found especially in milk, the outer covering of the seeds of plants (rice, oats, wheat), and in brewer's yeast. Water-soluble "C" occurs especially in fruit juices and vegetables, and to a lesser extent in milk, germinated cereal grains, and meat. It does not occur in cereal grains that are not germinated. Action of the Vitamins. — Fat-soluble "A." — ^A lack of this in the diet causes lack of growth and a peculiar disease of the eyes called xerophthalmia, manifested especially by an inflam- mation of the cornea and possible blindness. Much experi- PHYSIOLOGY AND PATHOLOGY OP DIGESTION AND NUTEITION 67 mental work has been done on animals (rats) by several investi- gators, with diets lacking the fat-soluble "A" factor, and failure of growth and xerophthalmia have been regularly produced. As soon as food-stuffs containing this factor are added to the diet, such as butter fat, cod-liver oil, or spinach, growth pro- ceeds, and the eye condition is cured in a very few days. It has been held by some that a lack of fat-soluble "A" is the cause of rickets, but this is by no means assured (see chapter on Rickets). Water-soluble "B." — ^A lack of this causes beriberi and possibly retarded growth. As far as is known it has no other specific action. Water-soluble "C." — ^A lack of this in the diet causes scurvy, which can be readily cured by the ingestion of food- stuffs (fresh milk, fruit juices, vegetables) which are rich in it (see chapter on Scurvy). Practical Importance of the Vitamins in Infant Feeding. — The subject is a new one, and, like all new discoveries in medi- cine, has been somewhat overdone. There is no question that there are such substances, the lack of which does produce cer- tain abnormal conditions, but there has been a great tempta- tion, especially in commercial quarters, to give the vitamin hypothesis undue prominence, and to assume that many condi- tions of ill being are dependent upon lack of vitamin in the diet. As regards infant feeding, we have in this part of the world, for practical purposes, only the fat-soluble "A" and water- soluble "C to consider, as beriberi (caused by a lack of water- soluble "B") occurs only in Eastern coimtries. It is quite conceivable that an infant or a child could receive in its diet too small an amount of fat-soluble "A." If the diet were fat free and vegetable free he would receive little of it, as it is contained in only very small quantities in fat-free milk. Or if the cows from which the milk came were fed on vitamin-poor diets, as they often are in the winter, their milk would in aU likelihood contain but small quantities of the vitamin. With breast feeding, Hkewise, the breast milk would be poor in this factor if the mother did not take sufficient quantities of butter ( 68 PRACTICAL INEANT FEEDING fat or of green vegetables. It is known, however, from clinical experience that it is possible to feed a baby on a practically fat-free diet over a long period of time without any apparent ill results, and it is probable that in the vast majority of in- stances breast milk or cow's milk even after it has been skimmed contains enough of the fat-soluble factor to prevent any unto- ward results. In times of famine, however, epidemics of xeroph- thalmia have been noted among children, and in the post-war German medical literature there are a number of papers describ- ing the ill effects of lack of fat in the diets of Austrian children. The relation of the fat-soluble vitamin to rickets has not yet been settled, but there is evidence to show that it may have some- thing to do with it, although not the essential cause. Most of the experimental work on the fat-soluble vitamin has been done with animals, and we have not at present suffi- cient knowledge as to how often it is lacking in the dietaries of infants and children, or what the exact effect of such lack may be. As a summary it may be said, however, that the experimental work on animals points the way, and that it can do no harm, and in all likelihood some good, for us to see to it that infants and children under our care receive an adequate amount of this accessory food factor. Water-soluble "C" (TIte Antiscorbutic Vitamin).— From a practical point of vievvr this is the most important vitamin con- cerned in infant feeding, as it is well established that a lack of it in the diet causes scurvy, which is not at all an uncommon con- dition. This will be discussed more completely in the chapter on Scurvy. It is probable that the diseases xerophthalmia, beriberi, and scurvy, caused respectively by a lack of fat-soluble "A," water- soluble "B'' and "C,'' represent the final pathologic condition brought about by a prolonged dietary deficiency, and that the earlier effect is manifested simply by general poor growth and nutritional state. Therefore, although xerophthalmia, beriberi, or scurvy may not be actually present, it may be possible that an undernourished child whose eating habits are peculiar may be PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 69 suffering from vitamin deficiency, and it is thus advisable that all children as soon as they are old enough to take a mixed diet should have an adequate supply of milk, fresh vegetables, and fruit or fruit juices, which will supply in abundance the three vitamins. ENERGY REQUIREMENTS The caloric requirements of infants has been the subject of extensive study, with somewhat varying results. Food is looked upon as fuel, and is measured in terms of calories or heat units; the caloric requirements represent simply the num- ber of heat units per unit of body weight which it is necessary for the individual to ingest in order to thrive. The calorie used in infant feeding is the large calorie, and represents the amount of heat necessary to raise 1000 c.c. of water l"" C. One gram of fat furnishes 9 . 3 calories. One gram of protein furnishes 4. 1 calories. One gram of carbohydrate furnishes 4 . 1 calories. In calculating, the caloric requirements of infants and children must be taken into account:^ 1. The basal requirement. 2. Growth needs. 3. Needs for muscular activity. 4. Food value lost in excreta. The basal energy requirement represents that number of calories which is just sufficient to maintain life with the baby in complete repose, and is fairly constant in babies of the same weight. According to Morse and Talbot^ normal babies have a basal metabolism of between 52 to 63 calories per kilogram of body weight. Very fat babies have between 40 to 50, and most infants who are underweight have more than 65 per kilogram. The growth needs, the needs for muscular activity, and the food values lost in the excreta vary a great deal according to the baby. The growth needs of the infant during the first six months ^ Holt and Fales, Amer. Jour. Dis. Chil., 1921, vol. 21. 2 Diseases of Nutrition and Infant Feeding, New York, 1915. 70 PRACTICAL INFANT FEEDING are greater than at any other corresponding period, as this is the time of most rapid growth. The needs for muscular activity are of great importance, and vary in different babies, according to whether they are active or sluggish. The newborn baby uses up relatively little energy in this way on account of his com- parative inactivity. An unusually nervous, active baby needs more calories than a phlegmatic, inactive one, and Howland has shown that simply hard crying increased the heat elimination 18 per cent, in one infant and 39 per cent, in another.^ The food value lost in the excreta of course varies somewhat with different babies, but in general is fairly constant, and is not so important a variable as is the muscular activity and the rate of growth. Heubner^ was the first to use the term "energy quotient,'^ and by it meant the number of calories per kilogram of body weight required per day. He estimated that the breast-fed baby needed in the first six months 100 calories per kilogram; that the artificially fed needed up to the third month 120, and that at the end of the first year from 70 to 80 was sufficient. Beck^ estimated that the energy quotient in breast-fed babies was as follows: First three months, 107. Second three months, 91. Third three months, 83. Fourth three months, 69. The results for breast-fed babies according to various observers have been somewhat conflicting, and are probably not very accurate, because the amount of breast milk taken has been determined by weight, and a constant composition assumed for it, which is probably not justifiable. Hoffman^ found an energy quotient in breast-fed babies 1 Rowland, Amer. Jour. Dis. Chil., vol. 5, 1913, No. 5, 2 Monatsch. f. Kinderh., 1904^5, iii, 206. 8 Jahrb. f. Kinderh., 1910, Ixxii, 121. 4 Arch. f. Gynakol., 106, 159, 1916. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 7 1 (reckoning breast milk as 700 calories to the liter) of 113.8 for the first and second months, 96.5 for the third month, and 91.4 for the fourth month. In the first four months the average energy quotient was 107.4, in the second four months 87.4. Von Jaschke,^ by careful daily determination of the amount of milk taken from the day of birth onward, assuming the liter of breast milk to contain 720 calories, found the following energy quotients: Day. Energy quotient. 1 9.8 2 17.9 3 24 4 41 5 60 6 72 7 88 8 108 9 114 10 119 12 103 21 122 56 110 75 102 90 104 98 105 As regards the energy quotient in artificially fed babies, the results of most observers are so conflicting, and their con- clusions are so often founded upon inadequate data, that a summary of them would not be of value. The most extensive and most accurate work on the caloric requirements of infants and children has been done by Benedict and Talbot, and reported in many publications. Holt and Fales,^ with this work as a basis, to which they have added numerous observations of their own, have compiled what is probably the most accurate and useful tables of the caloric requirements of normal babies and children that have yet been published. These tables are reproduced on pages 72 and 73. 1 Ztschr. f. Kinderh., vol. 16, June, 1917. 8 Amer. Jour. Dis. Chil., vol. 21, 1921. 72 PEACTICAL INFANT FEEDING TABLE IV Calories Per Kilo^ for Boys Weight, Basal. Growth. Calories per kUo. Total calories daily. kilos. Activity. Excreta. Total. 3 46 56 8 10 120 360 4 50 52 8 10 120 480 5 54 46 8 10 118 590 6 56 38 10 10 114 685 7 57 32 11 10 110 770 8 56 28 12 10 106 850 9 56 25 12 10 102 920 10 54 22 13 10 99 990 11 53 19 14 10 96 1060 12 52 16 16 9 93 1120 13 51 14 17 9 91 1180 14 50 13 17 9 89 1240 15 49 12 17 9 87 1300 16 48 10 18 9 85 1360 17 47 9 19 8 83 1410 18 46 8 20 8 . 82 1470 19 45 7 21 8 81 1540 20 44 7 21 8 80 1600 22 42 7 23 8 80 1760 24 41 8 23 8 80 1920 26 39 8 25 8 80 2080 28 38 7 27 8 80 2240 30 Z6 7 29 8 80 2400 33 35 7 30 8 80 2640 36 33 8 31 8 80 2880 39 32 9 31 8 80 3120 42 31 10 31 8 80 3360 45 30 11 31 8 80 3600 48 30 11 31 8 80 3840 51 29 11 31 8 79 4030 54 29 8 31 8 76 4100 57 28 5 30 7 70 3990 60 27 2 27 7 62 3720 68 25 18 5 48 3265 (Adult) iKilo = 2.2 pounds. PHYSIOLOGY AND PATHOLOGY OF DIGESTION AND NUTRITION 73 TABLE V Calories Per Kilo^ for Girls Weight, Basal. Growth. Calories per kilo. Total calories daily. kilos. Activity. Excreta. Total. 3 51 51 8 10 120 360 4 53 49 8 10 120 480 5 55 45 8 10 118 590 6 56 3S 10 10 114 685 7 56 33 11 10 110 770 8 57 27 12 10 106 850 9 56 24 12 10 102 920 10 55 21 13 10 99 990 11 53 19 14 10 96 1060 12 51 17 16 9 93 1120 13 49 16 16 9 90 1170 14 47 14 17 9 87 1220 15 45 12 19 8 84 1260 16 44 11 19 8 82 1310 17 43 10 19 8 80 1360 18 42 9 19 8 78 1400 19 41 8 20 8 77 1460 20 40 7 21 8 76 1520 22 38 8 22 8 76 1670 24 37 8 23 8 76 1820 26 36 8 24 8 76 1980 28 36 8 25 8 77 2155 30 36 9 26 8 79 2370 33 35 10 27 8 80 2640 36 35 10 27 8 80 2880 39 35 10 27 8 80 3120 42 34 9 27 8 78 3275 45 34 7 26 7 74 3330 48 33 5 22 7 67 3215 51 32 3 21 6 62 3160 54 31 18 5 54 2915 60 25 15 4 44 2640 (Adult) 1 Kilo = 2.2 pounds. As regards abnormal babies, very fat babies need fewer calories than very thin ones; in general, the thinner the baby, the more 74 PRACTICAL INFANT FEEDING calories he needs. A very thin baby may need an energy quotient as high as 160 before he can begin to gain weight, and underweight babies in general, of whatever class, always need more than those of normal weight. According to Dennett^ the average needs of bottle-fed babies are as follows: Fat infants over four months of age 40 to 45 calories per pound per day. Average infants under four months of age, and moderately thin babies of any age 50 to 55 calories per pound per day. Emaciated infants 60 to 65 calories per pound per day. Ladd^ found in a large series of poorly nourished infants that most of them did not make satisfactory gains in weight until the energy quotient was raised to 140 to 160, and some- times as high as 175 or 190. The practical conclusion to be drawn from all these figures is that theoretic caloric requirements are only a rough guide in the practical feeding of undernourished babies, and that the food must be pushed to the very limit of tolerance, irrespective of calories, until the baby begins to gain weight. 1 Infant Feeding, 1920, p. 70. ^2 Arch. Ped., vol. xxix, No. 5, 1912. CHAPTER n THE STOOLS IN INFANCY A KNOWLEDGE of how to interpret the stools is of the utmost importance in practical infant feeding, and the intelligent pediatrician should be able to reason backward from data ob- tained by stool examination, so that he can tell fairly accurately what processes are going on in the baby's intestine. The macro- scopic examination is the most important, but in many cases microscopic examination also adds valuable data. While stool examination is important, the characteristics of the stools must not be taken by themselves in determining what to feed any given case, but must be considered in relation to the gain in weight, general condition of the baby, history, etc. Let us take up the discussion of stools in the following order: 1. General characteristics. 2. Fat in the stools — its amount, form, and significance. 3. Sugar and starch. 4. Protein. 5. Miscellaneous. General Characteristics. — Number per Day. — ^The number of stools passed in twenty-four hours varies considerably with the individual baby and the sort of food that he is taking. The average breast-fed baby has, as a rule, more stools than the normal bottle-fed baby. The breast baby has ordinarily from one to three stools a day, but in certain cases may have as many as six or seven and still do perfectly well. This would be im- possible in a bottle baby. The number of stools a normal bottle- fed baby has depends a good deal upon what sort of food he is taking. If he is taking a formula containing a good deal of mal- tose he will have usually three or four stools a day, or the same number may result if he is taking a food high in sugar and fat 75 76 PRACTICAL INFANT FEEDING and low in protein. This is due to the stimulating action of the fatty acids formed from sugar and fat decomposition on intes- tinal peristalsis. If a food low in sugar and high in protein is fed the number of stools will be considerably diminished, and he will have only one or two a day, or one every other day. Bottle- fed babies ordinarily have fewer stools than those fed on the breast because breast milk contains so much more sugar and fat than most cow's milk modifications do, and, moreover, the casein and calcium of cow's milk tend to be constipating. If there is anything irritating in the intestine, increased peristalsis and an increased number of stools result. This may be brought about by nervous influences, but almost always is due to un- digested or fermented food products or to actual infection of the intestinal wall by bacteria. In general, it may be said that any number of stools over four per day is abnormal for a bottle-fed baby. Form and Consistency. — ^The stools of a breast baby are rarely formed, and resemble thick porridge in consistency. They are rarely smooth, and may normally contain small white fat curds and small amounts of mucus. The normal stools of a bottle-fed baby are usually formed and are smooth and homogeneous; they should contain no curds, and none but the very smallest quantity of mucus. They may vary a great deal in consistency; in, general, those babies who are fed on high casein and low sugar will have rather hard, dry stools, while those on high sugar and fat feeding are likely to have softer stools, which are not so well formed as those of the former type. If the baby's absorptive power is very good and if he is thus absorbing most of the food he takes in, the stools may have to stay in the colon and rectum for a considerable period of time before enough is collected to be evacuated; therefore the stool becomes hard and scybalous from loss of water. Skimmed milk and buttermilk stools are usually very smooth and shiny when spread out with a throat stick; if fat is added, they remain smooth, but lose their shiny character. Odor. — ^The stools of babies fed on a milk diet rarely are very offensive. Those of the breast-fed baby have an aromatic acid THE STOOLS IN INFANCY 77 odor, while those of the bottle baby usually have a cheesy, slightly foul odor. If a high sugar and fat is fed, however, the odor is likely to be slightly acid, even in the normal bottle baby. With sugar and fat fermentation the odor is always acid (acetic and butyric acids), with a diarrhea caused by protein putrefac- tion the odor is foul. If the baby is being fed a large amount of starch which he is not digesting well, and which is fermenting in his intestine, the odor may be very offensive, like that of a pig- pen. The odor of ammonia is often noticed in connection with high protein stools, but may in a good many cases be due actually to ammonia on the diaper from an alkaline, concentrated urine, rather than to the stool. Color.— The color of the breast baby's stool is golden yellow, or may sometimes normally be greenish. The color of a bottle baby's stool depends upon what sort of food he is being fed, and whether or not he has indigestion. The color is usually a rather light yellow or yellowish brown. If a considerable amount of fat is fed it will be lighter, and if high fats plus high sugars are fed it is likely to be a brighter yel- low. With high fat and casein and low sugar it is grayish, some- times almost white. Skimmed milk mixtures high in protein give a stool of light gray or grayish-brown color, of smooth shiny consistency when smoothed out with a throat stick. The stools of diarrhea due to protein putrefaction are brown. Adding a malt soup preparation to the diet gives a brown color similar to that of the original malt soup; starch in the diet also tends to cause a brownish color. Beef juice if added to the diet in sufficient quantities gives a dark brown color. Bismuth and iron give a grayish-black color. Argyrol when put in a baby's nose usually comes out in the stools unchanged in color and may cause a good deal of worry to the mother. Blood coming from the stomach gives a rich dark black color (tarry stool), while blood from the intestine gives a dark brick-red color if digested, or if not digested may appear in small bright red streaks. Blood on the outside of a constipated stool usually simply means that the rectum has been irritated somewhat by the progress of the 78 PRACTICAL INFANT FEEDING hard stool. Green is the most common abnormal color, and is seen in cases where there is fat, or more particularly sugar fer- mentation going on. A stool which is yellow when passed, but which turns green on standing in the air, is not abnormal. The green color is caused by the oxidization in the air of the bile- pigments. Stools which are green when passed are always ab- normal. The explanation of the green color so commonly seen is as follows (Hecht) ; Normally in stools there is hydrobilirubin (from the bile- pigments). This arises from bilirubin by reduction under the influence of intestinal decomposition, from the ileocecal valve onward. If the reduction processes are particularly active then the reduction of hydrobilirubin follows still a step further, to the colorless leukohydrobilirubin. If peristalsis is increased, so that there is no time for reduction, then the oxidation product of bili- rubin (green biliverdin) is found in the stool. Reaction. — The reaction of the stools is of great practical importance in infant feeding. As we have said before several times, there are always two opposing processes going on in the infant's intestine — fermentation of carbohydrate and putrefac- tion of protein. The breaking down of carbohydrate gives rise to acid end-products, with acid intestinal contents; the breaking down of protein gives alkaline end-products. There should be in the normal baby's intestine a certain balance between the two — that is, there should not be excessive fermentation or ex- cessive putrefaction. Any baby fed on a milk containing a large amount of protein and but little carbohydrate will have alkaline stools, any baby fed on a high fat and sugar with little protein will have acid stools. Both of these conditions are normal, pro- vided, however, that the alkalinity or acidity does not reach an excessive degree. If too much fermentation of carbohydrate or fat or too much putrefaction of protein takes place, the reaction becomes too acid or alkaline and trouble in the form of diarrhea results, due to too great a concentration of irritating alkaline or acid end-products. Excessively acid stools of abnormal con- sistency and appearance mean, then, that sugar or possibly fat THE STOOLS IN INFANCY 79 is not being taken care of; excessively alkaline stools mean that protein is being putrefied. In a few cases of sugar fermentation where there is a great deal of mucus present it may be possible to have neutral or alkaline stools, owing to the fact that the decomposition products of mucus are alkaline in character and may neutralize the original acidity. The breast baby has, it is true, very acid stools, of a degree of acidity which would be quite abnormal for the bottle baby. The probable reason why this excess acidity does not harm the breast baby is that it is mostly in the large intestine, whereas in the bottle-fed baby the excess acidity is usually in the small intestine where the deli- cately adjusted digestive processes are taking place. What bearing has all this on practical infant feeding? A good deal. If a strongly acid, normal appearing stool is seen, it means that it is not safe to add any more sugar to the diet, and if anything is added it should be protein or possibly starch, as the acidity shows that the baby is approaching the limit of his sugar toler- ance. If an abnormal appearing, strongly acid stool is seen, it means that the limit of sugar tolerance has been exceeded, and that the sugar in the diet must be reduced or a change must be made to a sugar which does not ferment so easily. The normal appearing, alkaline stool is the type that we like to see. This tells us that there is a mild putrefaction going on in the intestine (the normal condition when cow's milk is fed) and that if for any reason we desire to add sugar to the diet it is perfectly safe to do so, as the stool is alkaHne, and there is a wide margin of safety. An abnormal appearing alkaline stool means that too much protein is being decomposed, and a decrease in the amount of protein and increase in the sugar is indicated. These conceptions help me a great deal every day in my practical feeding work. The foregoing can perhaps be more clearly expressed in the form of a diagram. Alkaline Neutral Acid. / z 3 X 1 1 1 Y Fig. 1. 8o PRACTICAL INFANT FEEDING The reaction of the normal stool is at 1, 2, or 3, and if the amount of acid or alkaline decomposition products in the in- testine does not get too far away from the neutral point, over to the extreme limits of X and Y, the baby gets along well; if the reaction becomes excessively acid or alkaline, he gets into trouble. The reaction is easily determined by little pieces of red or of blue litmus-paper, or, after a certain amount of practice, by the smell of the stool. Fat in the Stools (See Section on Metabolism of Fat). — ^A considerable amount of fat occurs in the stools normally, and in cases of fat indigestion this may be markedly increased. (a) Macroscopic Examination. — The macroscopic appear- ance of the stools is often suggestive of an excessive fat con- tent. Stools of four different sorts containing an excess of fat may be seen. The Soapy Stool. — ^This is a large, dry, crumbly, light colored stool, which contains a large excess of insoluble calcium soaps. Its reaction is usually alkaline, and it is seen in babies who are being fed on a fairly high fat, low sugar, and high pro- tein. It is evidence of fat fed in improper relationship to the other food elements, rather than of a disturbance caused by fat per se. The "Scrambled Egg" Stool. — ^This stool is loose, of the consistency of thin scrambled eggs, and is strongly acid in reac- tion. It contains many small white, fat curds, and usually ex- coriates the buttocks, due to excessive acidity. It contains a large amount of fat partly in the form of soaps, but especially as fatty acids. It is usually seen in babies who are being fed on a high sugar and fat diet. The Oily Stool. — This stool is usually bright yellow or sometimes yellowish-gray in color. It looks greasy, and if placed on a piece of paper leaves a transparent oil stain. It is usually of the consistency of thick commeal mush, and contains a large excess of neutral fat and fatty acid. The occurrence of this type of stool means almost always that the baby is being THE STOOLS IN INFANCY 8 1 grossly overfed with fat, and more neutral fat (entirely undi- gested) is seen in it than in any other type of stool except those of severe diarrhea. There may be only two to four of these stools a day, or they may be more frequent (six to seven) and very loose (fat diarrhea). The Normal Appearing Stool. — ^An excess of fat may be present in a stool which appears normal macroscopically, and is revealed only by the microscope. Microscopic Examination. — ^The microscopic examination of the stools for fat is of value if interpreted correctly, but may lead to entirely erroneous conclusions if it is not. The usual mistake that beginners make is to disregard the clinical appear- ance of the baby, his weight and his well being, and to rush to the laboratory with a stool. If they see a little fat under the microscope, they immediately make a diagnosis of ''fat indiges- tion," cut down or omit entirely the fat in the diet, and thus deprive the baby often unnecessarily of many valuable calories. This has led many men astray, and under such circumstances microscopic examination of the stools for fat does more harm than good. It must he remembered that there is always in the normal stools of all babies faking any fat in their milk a consider- able amount of fat. According to Holt, Courtney, and Fales the dried stools of normal breast-fed babies contain on the average about 35 per cent, of fat, in bottle-fed babies 36 per cent.^ The fat in the stools is in the form of neutral fat, fatty acids, and soaps; mostly soaps. Fatty acids and soaps represent fat which has been digested, but not absorbed, neutral fat represents fat which has not even been digested. There are methods of microscopic stool examination which attempt to distinguish between all these three constituents and to determine approximately how much of each one of these is present. It is this which has created so much confusion in the minds of students, but from a clinical point of view is entirely unimportant and cannot be done accurately anyhow. What is important to determine is whether or not there is an excess of 1 Amer. Jour. Dis. Chil., vol. 17, April and June, 1919. 82 PRACTICAL INFANT FEEDING neutral fat and of total fat (neutral fat, fatty acids, and soaps together). This is done as follows: First Procedure.— A small portion of the stool is rubbed up with a little water on a glass slide until a thin, smooth paste is formed. A drop or two of an alcoholic solution of "soudan III" stain is then mixed with this, and the film spread thin so that the Hght will shine through it. The preparation is then examined under the microscope with the low power. Neutral fat stains in bright orange-red globules. It is abnormal for more^ than a very few stained globules to appear with this first pro-' cedure, and shows that an abnormal amount of fat is coming through entirely unsplit. It is not at all common to see any neutral fat in a stool unless it is a diarrheal one, as usually most of the excess fat is in the form of fatty acids and soaps. Neutral fat is seen especially in the stools of babies who are being grossly overfed with fat, or in diarrheal stools, where the intestinal con- tents has been hurried through so quickly that the fat has not had a chance to be split. Second Procedure. — ^A drop or two of glacial acetic acid is added to the first preparation and mixed thoroughly with it. Then the slide is heated for a moment over the Bunsen burner. In this procedure the heat and acetic acid break down the soap and neutral fat which are present into fatty acid; this fatty acid when melted is in the form of globules, and takes the stain in the same way that the neutral fat did originally. Any fatty acid which may have been originally present is also melted, and takes the stain. By microscopic examination of the preparation after this second procedure a rough idea of the total fat content may thus be obtained. There are so many factors that enter into the composition of a stool that it is impossible to have any absolute standard for what is an excess and what is not. In the first place, a dry, concentrated stool is likely to contain more fat than one of thinner consistency, which contains more water. Also, practically always when there is a diarrhea of any sort there is likely to be a large amount of fat in the stool, owing to the fact that the increased intestinal peristalsis sweeps out THE STOOLS IN INFANCY 83 neutral fat, fatty acids, and soaps before they have had a chance to be digested or absorbed. So excess fat in a stool does not necessarily mean a primary fat indigestion. Again, if a baby were having only one stool a day of moderate size, his fat absorp- tion might be quite normal even if the stool when examined microscopically showed a large amount of fat, whereas if there were three or four large stools a day containing the same pro- portion of fat, the fat absorption would be considerably de- creased, and a fat indigestion would be indicated. Furthermore, as Grover^ has pointed out, if a large amount of protein is being fed, and there is consequently in the stool a considerable protein residue, there will not appear to be as much fat in the stool as in one where less protein residue is present. From a practical point of view the fat content of stools as determined by this method may be divided into three groups: 1. In almost any normal stool, after Procedure II, there will be seen a good many fat globules scattered through the micro- scopic field. These do not run together much, and it is obvious that most of the stool consists of something else than fat. This is normal, and does not indicate that any reduction of fat in the diet is necessary. 2. There is a larger amount of fat in the stool than there is in the stools of Group I, and the stained globules are scattered very thickly through the microscopic field. If the baby is doing well and gaining weight, without symptoms of indigestion, such a stool picture does not call for any interference. If the baby is not doing well, it is best to reduce the amount of fat in his diet. 3. In the third group after Procedure II almost the whole stool seems to turn to melted fat globules, and under the micro- scope they are crowded together so thickly that they take up the entire field. Such an excess as this is usually seen in hard, dry, crumbly, light colored, "soapy" stools, or in oily, greasy stools, and practically always means that a reduction of the fat intake is indicated. The only possible way that anyone can learn to interpret the 1 Jour. Amer. Med. Assoc, vol. 6, No. 6, February 5, 1921. 84 PRACTICAL INFANT FEEDING fat content of stools is by examining a great many of them, and by comparing their content in fat carefully with the condition of the baby, the composition of his food, and the macroscopic character of the stool. The procedure is an art rather than an exact science, and each individual after practice establishes his own standards. Properly used, it gives information of con- siderable value in handling the case. Older Children. — ^With older children on a mixed diet there is not so much fat in the stools as there is with smaller babies; therefore what might be quite normal for a baby would be ab- normal for a child of two or three years. A considerable amount of fat in the stools is, therefore, of more importance in the case of an older child than it is in a baby. Babies under two months old almost always have a large amount of fat in the stools, even if they are doing well. Sugar and Starch. — Sugar. — The stools of a baby who is utilizing sugar normally contain no sugar, as the absorption is nearly 100 per cent. If for any reason the absorption is poor, the unabsorbed sugar undergoes fermentation, and the acids which have been formed appear in the stools, giving the char- acteristic sour smell and acid reaction. In a very few cases unaltered sugar may be demonstrated in the stools, but this is by no means usually the case, and most investigators have re- ported negative findings. We do not, therefore, test directly for sugar in the stools, but depend upon the recognition of its de- composition products to determine whether or not it is being well utilized. It is probably not possible to have sugar indiges- tion without some sugar fermentation, and the type of stool depends largely upon the amount of undigested sugar that is being fermented. The stools of mild sugar indigestion are loose in consistency, usually yellowish-green in color, in number three or four per day, smelling strongly of acetic acid, and containing a good many small fat curds. They react strongly acid to litmus. In more severe sugar indigestion they are more fre- quent, watery, of a light or dark green color, strongly acid in reaction, and usually contain a good deal of mucus. They also THE STOOLS IN INFANCY 85 may contain fat curds or even casein curds, which have been hurried through the intestine too fast to be absorbed. Micro- scopic examination for fat in stools such as this is of no value, as they always contain large quantities of fat if the baby is tak- ing an appreciable amount in his food. The macroscopic appear- ance, the smell, and the reaction are the important things to consider in the stools of sugar indigestion. Starch. — ^Normally, there is only a very small amount of starch in the stool. Starchy stools may be of two types: The Fermented Starch Stool. — This is the most common type of stool seen in starch indigestion. It is large in size, of mushy consistency, of very offensive odor, either foul or resem- bling the sour smell of a pigpen. The end-products of starch fermentation are acid in reaction, but the reaction of these stools may be either acid or alkaline, depending upon the degree of fermentation, the amoimt of mucus present, and the amount of protein food which is being taken. These last two factors tend to give an alkaline reaction. These stools are usually olive green or brownish in color, are not homogeneous, and usually contain many small macroscopic masses of undigested starch and cel- lulose, which may be of a mucilaginous consistency. Microscopically they show a large amount of undigested starch, either in the form of broken up granules or whole starch globules. Also many large iodophilic bacteria and yeasts are likely to be seen in any starchy stool. The Unfermented Starch Stool. — ^In the fermented starch stool there has been a poor digestion of starch, and the undi- gested residue has undergone fermentation, with the production of irritating and offensively smelling substances. In the unfer- mented starchy stool there has been, it is true, an inadequate digestion and absorption of starch, but the unabsorbed residue has not fermented. These stools are large in size, usually brown in color, alkaline, rather smooth in consistency, of moderately foul odor, and have much the appearance of normal stools. Microscopically, however, they show a large amount of undigested 86 PRACTICAL INFANT FEEDING starch, which would never have been expected were it not for the microscopic examination. The children with this type of stool may seem well, and may show no symptoms of indigestion. It is probable that if fermentation does not take place the presence of undigested starch does little actual harm, but it is an indication that the amount of starch taken is more than the child can digest, and there is no telling when it may start to ferment and do him considerable harm. Technic of Microscopic Examination for Starch. — To a small portion of stool rubbed up with a little water on a glass slide a drop or two of Lugol's solution is added (iodin 2, KI. 14, water 100). If there is much starch present this turns a dark blue or black color, and when examined under the microscope many black masses of undigested starch are seen. If the starchy part of the food intake has been thoroughly cooked the starch in the stool will appear as small masses of irregular shape and size; if the food has not been thoroughly cooked so that the starch granules have not been broken down, characteristic round or oval unbroken starch granules are seen. Different sorts of starches have different granules, and by careful examination one may often determine exactly what kind of starch is not being digested (oatmeal, barley, vegetable starch, etc.). Granules or masses which stain a purplish-red color represent starch which has been partly dextrinized by the processes of digestion. Un- digested cellulose does not take the blue color with Lugol's solu- tion, but is stained a light brown. If it has been partly broken down by the intestinal bacteria, which is often the case, it stains a light blue or a violet. Protein. — ^As we have said before, the feeding of a high pro- tein percentage in connection with a low fat and sugar produces, if the protein is well digested, a smooth, yellowish-brown or grayish-brown, alkaline stool, of rather cheesy odor. This ap- pears shiny and glistening when smoothed out with a throat stick. Lactic acid, buttermilk, and skimmed milk stools are of this type, and are called normal "high protein" stools. Abnor- mal protein stools may be divided into two groups: THE STOOLS IN INFANCY 87 Those with casein curds. Those in which there is excessive putrefaction of protein. Casein curds are small, smooth, bean-shaped, yellowish-white masses. They range from the size of an ordinary baked bean to that of a large lima bean. They are tough and leathery in con- sistency, sink in water, and do not dissolve in ether. They can be confused with nothing else after one has once become familiar with their appearance. They do not look anything like fat curds, and if one has once seen a fat and a casein curd side by side he will never have any difficulty in distinguishing them thereafter. Casein curds do not ordinarily occur in the stools if anything has been done to the milk to modify the coagulation of casein, such as the addition of an alkali, boiling, peptonization, or treating with the lactic acid bacillus. Undigested casein may also sometimes appear as small indeterminate brownish-yellow masses of thick, gluey consistency. The exact significance of casein curds is in some dispute. A stool which contains them certainly cannot be considered normal, but it is a question whether they do much harm or represent a severe digestive dis- turbance. They act more as foreign bodies than in any other way, and represent a non-digestion of a certain portion of casein, without the addition of any bacterial decomposition. They may occur in stools of almost any color or consistency. Putrefaction of Protein. — If there is an excessive putrefaction of protein in the intestine the stools become increased in num- ber, loose in consistency, brownish in color, foul in odor, and alkaHne in reaction. This type of stool is quite different usually from the casein curd stool ; in the former we have a non-digestion of casein, without any extensive bacterial putrefaction; in the latter we have a non-digestion of protein with added bacterial putrefaction. Such stools as this usually indicate a more severe disturbance of digestion than do those of the first type. Miscellaneous. — The Starvation Stool. — ^This type of stool occurs when the baby is being actually starved or is taking a weak cereal water preparation. It naturally contains very little food residue, and is made up of intestinal secretions, bac- 88 PRACTICAL INFANT FEEDING teria, mucus, and bile. It is usually alkaline in reaction, rather dark brown or greenish-brown in color, foul in smell, and sticky and loose in consistency. A common mistake is to confuse it with the stools of indigestion, and to continue the starvation, when, in reality, more food is needed. Test For the Gas Bacillus. — Most of the procedures involved in bacteriologic examination of the stools are too complicated for clinical use. There is one organism, however, which may be of considerable importance in diarrheal diseases and in chronic indigestions. This is the gas bacillus, the significance of which has caused a good deal of controversy. It is true that it may occur in the stools of normal babies; it is also true that it some- times occurs in the stools of babies with diarrhea, and seems to be the cause of the disturbance, as the diarrhea improves as soon as the gas bacillus infection has been overcome, usually by the employment of a milk containing large numbers of lactic acid bacilli, which are directly antagonistic to the gas bacillus. The technic of the gas bacillus test used at the Children's Hospital is as follows: 1. Fill a U-shaped fermentation tube and a test-tube with concentrated nitric acid, let stand three minutes, and empty out the nitric acid. 2. Rinse both tubes with hot tap-water until neutral to litmus-paper. 3. Place a small bit of stool, about a gram of dextrimal- tose, and about 15 c.c. of hot tap-water in the test-tube, and boil vigorously for half a minute. 4. Put the contents of the test-tube iQto the fermentation tube, taking care that it is filled up to the top, and that no air- bubbles remain in it. 5. Plug the tube with flamed cotton and incubate for twenty- four hours. Gas in the top of the tube indicates that the gas bacillus is present in greater or lesser munbers, depending upon the amount of gas present. Less than one inch of gas in the tube is prob- ably of no significance. THE STOOLS IN INTANCY 89 Bile. — It is occasionally of importance to test for bile in the stool. Rub up a small portion of stool in a mortar or evaporating dish, with a concentrated solution of corrosive sublimate, and let it stand for three hours. A brick-red color indicates that bile is present. CHAPTER III HUMAN MILK Colostrum. — The breast does not begin to secrete milk im- mediately after parturition. For the first few days there is a scanty secretion of a slimy, yellowish fluid — the colostrum. The amount of colostrum is not large, the following figures being given by Von Jaschke:^ First day, 2 c.c. Second day, 6 c.c. Third day, 10 c.c. The composition of colostrum seems to vary considerably according to the figures given by various observers: Fat. ' Sugar. Protein. Salts. Holt, Courtney, and Fales^ 2.83 7.59 2.25 0.30 Pfeiffer^ 2.17 3.5 6.45 0.34 Adriance^. . . 3.77 5.39 3.31 0.27 It is certain, despite the rather wide variations in the above table, that it is relatively low in fat and sugar, and high in protein and salts. A considerable amount of the protein is in the form of globulin, which causes colostrum to coagulate when heated. According to Courtney the composition of the ash as con- trasted with the ash of mature milk is as follows: Total ash, CaO. MgO. P2O6. N02O. H2O. CI. per cent. Colostrum 0.30 0.044 0.010 0.041 0.045 0.093 0.056 Mature milk 0.20 0.045 0.007 0.034 0.034 0.060 0.035 iZtschr. f. Kinderh., vol. 16, June, 1911. 2 Amer. Jour. Dis. Chil., vol. 10, No. 4, 1915. ^ Czerny and Keller, Des Kindes Ernahrung, Leipzig, 1906. 90 HUMAN MILK 9 1 Colostrum is especially characterized by containing numer- ous large leukocyte-like bodies, the ' 'colostrum corpuscles," which contain many fat-droplets within the protoplasm, and which give to the colostrum its characteristic yellow color. The smaller corpuscles are probably leukocytes, according to Czerny, the larger ones large mononuclear cells. They may appear in mature milk if for any reason nursing has been interrupted, milk is allowed to collect in the breast, and there is consequently a diminished milk secretion. They disappear again as soon as nursing is resumed. "Coming In" of the Milk. — The true breast milk "comes in" usually anywhere from forty-eight to ninety-six hours post- partum, but in some cases may be delayed considerably longer. It may come in gradually, so that the mother does not notice it, or it may, on the other hand, come in more suddenly, so that she can feel her breasts filling hour by hour. Dluski,^ in 326 primipar^, found that the time of coming in of the milk was as follows : 9 times, 24 to 48 hours. 115 times, 48 to 72 hours. 159 times, 72 to 96 hours. 42 times, 96 to 120 hours. 1 time, 120 to 144 hours. Physical Properties of Human Milk. — The specific gravity is from 1030 to 1032. The color is similar to that of cow's milk; the taste is a little sweeter, owing to the larger amount of milk- sugar that it contains. In certain cases the colostrum may be much more yellow than usual, and this yellow color may per- sist for a considerable period after the colostrum stage has passed. Very yellow milks of this nature do not ordinarily agree with babies, and in the few cases of mothers with bright yellow milk that I have seen the baby has usually been troubled a good deal with vomiting. The pigment is contained in the fat, accord- ^ These de Paris, 1894 (quoted by Morse and Talbot, Diseases of Nutri- tion, etc.). 92 PRACTICAL INFANT FEEDING ing to Palmer and Eckles/ and is tlie same pigment that there is in normal colostrum except that it is present in a more concen- trated form. It consists of a mixture of carotin and xantho- phyll, and is closely allied to vegetable carotin. It is derived especially from the chlorophyll in green vegetables, but may also be present in such vegetables as carrots, beets, and yellow corn. It is well, therefore, in any case where the milk is much more yellow than normal, and seems to upset the baby, to omit all green fruits and vegetables from the diet for a few days. It is in the first few weeks of lactation that this excessive yellow pigmentation is most likely to be observed. Amount. — ^Nature has apparently not intended that the infant should receive much food in the first few days, therefore the amount of milk produced during the first week is not large. It increases gradually up to a certain point, as the baby's diges- tive powers develop, and then the amount remains more or less stationary during the rest of lactation. The following table, by von Jaschke,^. shows the amount of breast milk that a normal breast-fed baby received on various days during the period of lactation: Colostrum period Day. Amount. First 2.5 c.c. Second 6.0 c.c. Third 10. 5 c.c. Fourth 19. 5 c.c. Fifth 300 c.c. Sixth 360 c.c. Seventh 440 c.c. Fifteenth 570 c.c. Twentieth 720 c.c. Thirty-seventh 805 c.c. Seventy-second 825 c.c. Eighty-seventh 925 c.c. Ninety-second 950 c.c. By putting several babies to the breast, and thus furnishing a considerable extra stimulus, it is possible sometimes to greatly 1 Jour. Biol. Chem., vol. xvii, 1914. 2 Loc. cit. HXJMAN MILK 93 increase the amount of milk. Sommerfeld^ cites a wet-nurse of Finkelstein's whose daily average in the twenty-fifth month of lactation was 1700 ex., and cases are on record where as much as 3 liters a day have been produced over a considerable period of time. The amount of milk produced is ordinarily between one-sixth and one-quarter the weight of the baby after lactation has become well established. The amount taken at each feeding varies a good deal, but the twenty-four-hour quantity remains fairly constant. According to EngeP the largest amount is always given at the first feeding in the morning, and tends to decrease as the day progresses. It is a commonly observed fact that in many cases when the supply of milk is not enough for the baby, this scantiness shows itself first by signs of hunger on the part of the baby after the 6 or 9 p. m. feeding. Galactogogues. — "An artificial enrichment of milk secretion is not possible, and can be brought about by no drug or prepara- tion, no matter what name it may bear, no matter what recom- mendation it may hold" (Engel). If there is one thing that pediatricians are agreed upon it is that there is no practical, satisfactory galactogogue, and that the best way of increasing milk production is by stimulation of the breast by vigorous and frequent nursing. Especially is it necessary, in order to have abundant milk production, that the breast be completely emptied at each feeding. It has been said that pituitrin increases the flow of milk; this increase is only temporary, however, and is followed later by a diminution. Cornell^ in 1918 carried on an interesting series of observations with placental extract. To 100 mothers, just delivered, he fed 5 grains of a preparation of placental extract four times a day for three days. He observed also 70 control cases to whom no pla- cental extract was given. He found that 87 per cent, of the babies whose mothers received placental extract began to gain on the fourth and fifth days, as against 69 per cent, whose mothers did not receive it. Also, 44 per cent, of the babies 1 Handbuch der Milchkunde, Wiesbaden, 1909. 2 Ibid. ^ Surg., Gyn., and Obstet., vol. xxvii, 1918. 94 PRACTICAL INFANT FEEDING whose mothers received it regained their birth weights before leaving the hospital, as against 24 per cent, of those whose moth- ers did not receive it. Such a piece of work is suggestive, but at the present time it is fair to say that we have no proved galac- togogue. The repute that malt liquor enjoys as a galactogogue is prob- ably due more to the increased amount of fluid ingested than to any specific property. Chemical Composition. — The reaction of human milk is amphoteric; acid to phenolphthalein, alkaline to litmus. The reason for this amphoteric reaction is that it contains both mono- and diphosphates. The first react as weak acids (acid to phenolphthalein), the latter as bases (alkaline to litmus). The milk of all mammals contains the following substances in an aqueous medium: Fat — In emulsion. Casein and lactoglobulin — in suspension. Lactalbumin Sugar Salts Extractives , in solution. Salts The composition of human milk is usually given as Fat. . , 4. GO per cent. Sugar 7 . 00 per cent. Protein 1. 25 per cent. Salts 0. 20 per cent. The variations may be considerable, however, in the milks- of different women, and a baby may thrive on a milk which is far different from the average composition. According to Schlossmann,^ the variations may be within the following wide limits : Fat 1. 65— 9.46 per cent. Sugar 5.2 —10. 9 per cent. Protein 0. 56 — 3 , 4 per cent. 1 Ztschr. f. Physiol. Chemie, Bd. xxii, p. 5197. HUMAN MILK 95 Fat. — The fat is the one most likely to vary of all the food elements, and very high or very low percentages are not un- common. Low fat precentages are often found in combination with high protein percentages. There does not seem to be any relation between the stage of lactation and the amount of fat present. There is much less fat in the milk at the beginning of a nursing (fore-milk) than at the end (strippings) . The extreme variations in this respect observed by Denis and Talbot^ were 0.66 per cent, fat in the first part of the nursing and 10 per cent, in the last part. There is usually, however, less than 4 per cent, difference, as can be seen from the figures below, taken from their table: Fore-milk. Strippings. Case 1 — 4.0 per cent. fat. 8.0 per cent, fat Case 2 — 6.4 per cent, fat 16.0 per cent, fat Case 3 — 2 . 4 per cent, fat 8.0 per cent, fat Case 4 — 2.4 per cent, fat 3 . 8 per cent, fat Case 5 — 2.5 per cent, fat 4.4 per cent, fat Case 6 — 3.2 per cent, fat 6.6 per cent, fat Case 7 — 1.5 per cent, fat 2.9 per cent, fat Case 8 — 0.66 per cent, fat 10.0 per cent, fat Sugar. — The average amount of lactose in 60 samples of milk examined by Talbot and Denis was 7.19 per cent. There is less variation of the lactose content than is the case with either the fat or protein. There is a general tendency for the concentration of lactose to increase throughout the period of lactation. During the first ten weeks of lactation two-thirds of the samples examined by Talbot and Denis contained less than 7 per cent. After the tenth week there were many samples containing as high as 8 per cent. The smallest percentage of lactose found after the colostrum period was 5.49 per cent.; the highest, 8.35 per cent. Chemically the lactose in human milk is identical with that in cow's milk. Protein. — ^According to Engel the protein in human milk averages 1.04 per cent., according to Courtney, 1.15 per cent., 1 Amer. Jour. Dis. Chil., vol. 18, No. 2, 1919. 96 PRACTICAL INFANT FEEDING according to Denis and Talbot it is usually over 1.5 per cent, up to the fourth week, and after the twelfth week averages below 1.2 per cent. There is a tendency for it to become low late in lactation, and it may be 1 per cent, or lower from the tenth month onward. The amount of protein in the fore-milk and strippings varies but little. The proteins of human milk fall into two groups: 1. Casein. 2. Lactalbumin and lactoglobulin. Casein is a water-insoluble, phosphorus-containing protein. It is held in suspension in milk on account of its combination with calciimi and on account of the reaction of the milk. If human milk is acidified or treated with rennin the casein is precipitated in fine delicate flakes. Lactalbumin and lactoglobulin are water-soluble proteins which coagulate on heating. There has been a good deal of dis- cussion as to the relative amounts of casein and lactalbumin (plus globulin) in human milk. According to most authorities the casein makes up about 40 to 45 per cent, of the total nitrogen in human milk, the albumin plus globulin from 35 to 40 per cent., and the various non-protein nitrogenous constituents the re- maining 20 per cent. The amounts of the non-protein ni- trogenous constituents is not inconsiderable, and according to Denis, Talbot, and Minot^ approximate closely the amounts contained in blood. Non-protein Nitrogenous Constituents of Human Milk (Dennis, Talbot, and Minot) Total non-protein N 20 -37 mgm. per 100 c.c. milk Urea N 8. 3-16. mgm. per 100 c.c. milk Amino N 3.0- 8.9 mgm. per 100 c.c. milk Preformed creatinin N 1.0-1.6 mgm. per 100 c.c. milk Creatin N 1.9-3.9 mgm. per 100 c.c. milk Uric acid N 1.7-4.4 mgm. per 100 c.c. milk Caloric Value. — ^The caloric value of human milk is from 700 to 800 calories per liter. ^ Jour. Biol. Chem., vol. xxxix, 1919. HUMAN MILK 97 Salts. — The following mineral elements are found in human milk: Phosphorus 0. 029-0. 041 gm. P2O6 per 100 gm. milk Calcium 0. 042 CaO per 100 gm. milk Magnesium 0. 0068 MgO per 100 gm. milk Sodium 0.016 NaaO per 100 gm. milk Potassium 0. 069 K2O per 100 gm. milk Iron 0. 0001-0. 0004 Fe203 per 100 gm. milk Sulphur 0. 014 per 100 gm. milk The phosphorus is present partly in inorganic, partly in organic form. The inorganic phosphorus is combined with calcium as calcium phosphate, the organic is mostly contained in the casein (about 40 per cent.). The calcium content may show great variations, according to Bahrdt and Edelstein^ from 0.03 to 0.08 per cent. There is a considerable diminution of calcium toward the end of the first year of lactation, which perhaps partly explains why some babies who have been fed exclusively on the breast too long become rachitic. Bahrdt and Edelstein found that in anemia of the mother and child the calcium of the milk was not dimin- ished. They could not increase the calcium content of the milk by feeding a diet rich in calcium. The older figures for iron (4 to 5 mgm. per liter) were probably too high, and with improved methods of analysis it has been shown that the iron content of human milk is very meager, probably rarely over 1.6 mgm. per 100 c.c. of milk (0.0016 per cent.). Bahrdt and Edelstein were able to increase the iron in the milk of an anemic woman by giving iron as a therapeutic measure. Coincidently with this the hemoglobin percentage of her baby^s blood, who was also anemic, was increased. Citric Acid and Chlorids. — The citric acid content of human milk is 0.05 per cent., the chlorid content, 0.035 (CI). Biologic Substances. — Besides the constituents already men- tioned human milk contains biologic substances which may be divided into two groups (Engel): 1 Jahrb. f. Kinderh., Ixxii, 1910. 7 gS PRACTICAL INFANT FEEDING 1. The immune bodies, antitoxins, etc. 2. The ferments. It is known that immunity can be conferred by the milk of the mother to the nursing infant, also that agglutinins may occur, and that the milk of a woman with typhoid fever may give the Widal reaction as well as the blood. It has been shown by Salge^ that diphtheria antitoxin may pass into the milk of a woman who has received it. A number of different ferments, such as lipase, amylase, etc., are present in milk, and even to a greater extent in colostrum. They are of considerable theo- retic interest, but of little practical significance as far as human milk is concerned. Variation in Milk Elements Through Changes in Food. — It is possible to change the chemical nature of the fat in human milk by changes in the kinds of fat fed in the food, and it has been shown that when certain kinds of fat are fed they pass unchanged into the milk. The chemical characteristics of the other food elements cannot be changed by diet. To a certain extent it is possible to change the amounts of fat or of protein by increasing or diminishing the amount of the food intake or by exercise. The sugar varies but little. (See next chapter.) Drugs in Milk. — ^According to Engel, the only drugs that have been shown with certainty to pass from the mother into the milk are potassium iodid, soda salicylate, aspirin, anti- pyrin, mercury, calomel, arsenic, and bromid. All of these, however, are present probably in only very small quantities, and it is doubtful if breast milk ever contains enough of any one of these drugs to do the baby any harm. Bacteriology. — Staphylococcus albus and aureus may be found in the milk of healthy women and are of no pathologic significance. The probable explanation of their presence is that they have penetrated from the outside a short distance into the milk-ducts, and are washed out again in the stream of milk. In such conditions as mastitis, where there is infection of the breast itself, streptococci may appear in the milk, but 1 Jahrb. f. Kinderh., Bd. 68, 1904. HUMAN MILK 99 most authors are agreed that ordinarily bacteria do not pass from the blood-stream to the milk. Lav/rence/ however, found typhoid bacilli in the milk of a nursing mother who had t3^hoid fever. In a few cases it has been proved that tubercle bacilli may occur in the milk of tuberculous women even if the breast is not diseased, but this is the exception rather than the rule. In the vast majority of cases tubercle bacilli cannot be demon- strated in the milk of a tubercular woman. 1 Boston Med. and Surg. Jour., clxi, 1909. CHAPTER IV BREAST FEEDING Importance. — The importance of breast feeding cannot be overestimated. Despite the great improvements that have been made in artificial feeding in recent years, it is not easy to produce a baby by artificial feeding that can equal in any way a baby the product of successful breast feeding. The following bare statistical facts collected by Davis^ illustrate better than pages of argument or more numerous quotations the value of breast milk to the baby. 1. In Boston in 1911 there were 621 deaths from diarrheal diseases in babies under one year of age. Of these, 534 were bottle fed. 2. Of infants reaching the age of two weeks in Boston, 1 in 5 dies before it is one year old if bottle fed, while if breast fed, only 1 in 30 dies. 3. If all babies could be breast fed the deaths would be 60 per cent. less. 4. The actual number of infant deaths in Boston in 1911 was 2248. Breast feeding would have saved nearly a thousand of these, and the death-rate instead of being 127 per 1000 births would have been 71. These figures are taken from but one city it is true, but similar figures hold for all cities of all nations. Many mothers, and, unfortunately, many doctors likewise, do not realize the importance of breast feeding, and the general tendency is to deprive the baby of the advantages of this on entirely insufficient grounds. It is, of course, true that some women cannot nurse their babies at all, but the number of these is not large, and the vast majority of all women can give their babies a start on the breast at any rate. It is in the first few weeks of life 1 Amer. Jour. Dis. Chil., vol. 6, 1913, 1234. BREAST FEEDING lOI that artificial feeding is most difficult and more likely to be un- successful than at any other time. There are very few women at the present time who are unwilling to nurse their babies when they can. Rarely will such a woman be met with, even among the much maligned upper classes. If, after careful explanation of the advantages of breast feeding, the mother declines, without good reason, to nurse the baby, it is best to withdraw from the case entirely. In Manning's^ series of 1000 cases from private practice there was only one mother who refused to nurse. The following figures from this series show very well the average duration of nursing, and represent fairly closely, I believe, the situation among the better classes in the average community: Duration of nursing. Per cent. 13 months 1.7 14 months 1.0 15 months 0.8 16 months 0.4 17 months 0.2 18 months 0.9 19 months 0.1 20 months 0. 1 21 months 0.1 22 months 0.1 22 months 0.1 30 months 0.1 36 months 0.1 These figures make an interesting comparison with those of Mitchell,^ whose statistics are drawn from the hospital class, and represent 2819 cases: One Three Six Nine One Eighteen Two Nursed week months months months year months years not at all. or more, or more, or more, or more, or more. or more, or more. Duration of nursing. 1 week Per cent. 8.1 2 weeks 1.8 3 weeks 4 1 month 4.9 3 months 7.9 4 months 9.2 5 months 6.8 6 months 5.5 7 months 4.7 8 months 4.2 9 months. . . 7 5 10 months 4.5 11 months 3.0 12 months. . . . . . 6.1 Mitchell.. .20.0% 80.0% 55% 42% 34% 27.0% 9.0% 2.0% Manning. . . 8.1% 91.9% 64% :4i% 26% 11.8% 1.6% 0.3% 1 Arch. Ped., vol. xxxvii, No. 4, 1920. * Amer. Jour. Obstet., 1912, Ixvi. I02 PRACTICAL INFANT FEEDING Sedgwick^ sent questionnaires in 1912 to a large number of doctors requesting information as to the ability of their wives to nurse. The results showed that about 80 per cent, of the wives of American physicians succeeded in nursing one or more children three months or longer. The Nursing Mother. — Nursing a baby is a natural, physio- logic process, and should not necessitate any great change or modification in a woman's habits provided she is leading a reasonable life already. A woman of even, quiet temperament usually makes the best nurser, and the unstable, nervous type of woman is likely to be unsuccessful. Women between the ages of twenty and thirty-five usually are able to feed their babies most successfully, but I have seen satisfactory nursing in women over forty. There seems to be no especial criterion by which to judge whether a woman will have an abundant supply of milk or not; other things being equal, a robust, strong woman is more likely to have good milk and plenty of it than a small, delicate woman; but many women in the pink of con- dition who lead the most healthy, athletic sort of Hves have practically no milk, and others, who seem frail and ill fitted for motherhood, will have an abundant supply. The best nursing mother that I have ever seen in private practice weighed under 100 pounds, and nursed her baby without supplementary feeding, and without apparent detriment to herself, up to ten months, at which time the baby weighed 20 pounds. A considerable amount of physical exercise, though not to the point of fatigue, is always advisable; and many nursing mothers during the first few months, especially if they take care of the baby themselves, do not get outdoors enough, and are likely to get into rather an unhealthy condition. Many women while in bed during the first few weeks have little milk, and this is often greatly increased after they get up and around. As an old Boston obstetrician used to say, a woman should be trained for the ordeal of labor just as an athlete is trained for a race. The same holds true of the nursing period, and the 1 Jour. Amer. Med. Assoc, 1916, Ixvi, p. 1690. BREAST FEEDING IO3 daily life and routine of a nursing woman should be as sane and as wholesome as possible. No woman, unless it is abso- lutely necessary for financial reasons, should attempt to do the housework and look after the baby into the bargain, whether the baby is breast or artificially fed. There is nothing that is more tiring than looking after a little baby day in and day out, and motherhood plus too heavy household cares is the cause of most of the wornout, young-old women that we all see so frequently. It is far better for a family to economize in some other way, and have a cook or a nurse girl. In these days this is often a real problem. The nursing mother should eat a reasonable, well-balanced diet, the same as any normal woman would eat. She must naturally eat a little more of it when she is nursing a baby, as she is feeding two individuals instead of one. Particularly is it advisable for her to have a considerable amount of protein in her diet, but only a sufficient amount to cover her own pro- tein needs, and that extra amount demanded by the milk. Hoobler^ has shown that animal protein is more efficient than vegetable protein in supplying nitrogen for milk and for the maintenance of nitrogen balance. Cereals and other starchy foods, fruits, and vegetables are valuable foods in any well- balanced diet, but the diet should not be one-sided in this respect, as these articles do not furnish enough protein. The practice that some nursing women have of stuffing with all sorts of rich food in the belief that they will produce more milk in so doing rarely does any good. There is no need of abstaining from green vegetables and acid fruits in the vast majority of cases, although many women have the idea that these are injurious to the baby. The best plan to follow is to let the mother eat anything she desires within reason, and then if any particular article is found to upset the baby, to omit this from the diet. A considerable fluid intake is necessary for every nursing mother, although here, again, no extremes are necessary. Three 1 Amer. Jour. Dis. Chil., vol. 14, 1917, No. 2. I04 PRACTICAL INEANT FEEDING pints of fluid daily is probably a sufi&cient quantity for most women. In most eases it is not possible to produce more milk by drinking more fluid. There are a few women, however, who seem to need large amounts of fluid in order to have a sufficient quantity of milk, and in a munber of cases I have seen the milk supply become insufficient if they did not keep up this practice. The kind of fluid makes very little difference; plain water is just as good as cocoa, malted milk, or gruels, although the psychologic effect is probably rather important; a woman feels that she is accomplishing considerably more for her baby if she drinks 3 glasses of milk or of malted milk than would be the case with an equal amount of water. Care of the Nipples. — It goes without saying that the nipples should be kept scrupulously clean. SmaU amounts of milk are likely to remain after the nursing or to run out between the nursings. This decomposes, and an uncared for nipple may be a very dirty article indeed. Dirty nipples are the most frequent cause of breast abscess. It is the common practice to wash the nipples with a saturated solution of boric acid before and after nursing. The boric acid certainly does no harm, but it is doubtful whether it does any good, as an anti- septic strong enough to kill the bacteria present would erode the nipple. Plain boiled water is probably as efficient a nipple wash as anything else, although I suppose if a physician ordered it instead of boric acid solution, and a breast abscess developed, he would probably be considered very careless. It is important to wipe the nipple dry after it has been washed, as it is likely to keep in a much more healthy condition when dry than if it is allowed to stay wet. Little pads of gauze should be kept in place over the nipples between nursings, and a firm breast binder is acceptable to many women, especially during the first few weeks. If the nipples are rough, they should be smeared with lanolin after each nursing. Feeding in the First Few Days. — If the labor has been an ordinary one the baby can be put to the breast about twelve hours after delivery. The baby should be given as much water BREAST FEEDING IO5 as he will take before this, however. The common practice is to give sugar and water, or, as many of the books say, water sweetened with saccharin. Neither one of these practices has an5^thing to recommend it; plain boiled water is just as good. Furthermore, a newborn baby does not need to have any food in the first few hours, and nature never intended that he should. By introducing sugar into the intestine at such an early time there is a possibility of interfering with the development of the natural bacterial flora, which was meant to develop upon colos- trum and not upon sugar. I believe it best to use three-hour intervals from the start, as the more the breast is stimulated, the more quickly is the milk likely to come in. If six- or four-hour intervals are used, the breast is naturally stimulated much less than with the three-hour intervals. Also, there is often some little difficulty in teaching a newborn baby how to suck, and the more often he practices, the quicker will he learn. The nursings should at first not be longer than five minutes, however, as the nipples are at first very tender. In the first three days the baby gets very little nourishment, and loses weight, partly as a conse- quence of this and partly from other causes (see Chapter I). The breast milk should be in normally by the third or fourth day, and if it is delayed longer than this it is best to start a weak artificial feeding given in small amounts after each breast feeding. The milk is often considerably delayed in coming into the breast, and breast feeding should never be discontinued on account of this. If the baby is rather small and weak, and does not nurse well, stimulation of the breasts as advocated by Sedgwick often seems to help a good deal in producing secre- tion, and it is certain that failure of breast feeding is often caused by insufficient stimulation of the breasts during the early days. Directions for Milking (Sedgwick^). — "The breast is grasped about 1 or 2 cm. back of the colored areola, and a milking motion is carried out toward the nipples. No massage of the breast 1 Jour. Amer. Med. Assoc, 64, p. 417, 1917. Io6 PRACTICAL INFANT FEEDING proper is allowed, as it is of little if any value, and sometimes causes traumatic inflammatory reaction. If we consider the anatomy of the breast, we learn that the ducts which contain the milk extend but a short distance back of the areola. Any one who has ever seen a cow knows that the teats are milked and not the cow's bag, and yet we often find head nurses, physi- cians, and even pediatricians giving instructions to milk or 'massage' the breast itself. If our method is intelligently followed it is possible to keep the mother of a premature infant from losing her milk. I have seen some such mothers supply not only milk for their own baby but also enough for another infant." The baby should usually stop losing weight at about the fourth day, and if he does not start to gain by this time it is best to keep on with the complemental feeding, as in this way much valuable time can be saved, and an excessive loss of weight can be prevented. This is rather important, as a too large loss of weight in the early days may be a severe handicap to a small baby. The chart (Fig. 2), taken from my case records, shows about what the weight of a normal newborn breast-fed baby can be expected to do in the first two weeks. By the time the baby is two or three weeks old he should have regained his birth weight and should be gaining regularly. A newborn baby usually passes meconium soon after birth, and continues to pass it until the milk comes in, after which the stools begin to take on the characteristic golden yellow color. If no meconium has been passed in the first twenty-four hours it is well to give | teaspoonful of castor oil, as it is not uncommon for decomposing retained meconium to cause fever, and more rarely convulsions. In general, however, it is best to avoid the indiscriminate use of castor oil in newborns, and to give instruc- tions to the nurse that it shall not be given, as many of them have a bad habit of giving castor oil every day, for just what reason I have never been able to find out. Gain in Weight. — The best index of the well being of a baby, whether breast or bottle fed, is a steady and satisfactory gain in weight. A breast-fed baby should gain from 6 to 8 ounces BREAST FEEDING 107 ■^ ' r r 1 z 3 4 5 6 7 8 9 i.0 11 ■ 12 13 14 15 16 17 6 rtt8» 7 oz. H n 6 •* # » 9 5 '• » A oh 4 «♦ «( « " 3 " 1 H M 2 " / « « 1 " d / 5 « 15 " ^ ^ • - 14 " •» •• 13 •» \ " " 12 " •» - 11 •» \ " " 10 ♦» h •' # « » 9 n \ r \ > r ft » g n \ / ) ^ 4^ » - 7 « ^ i- / • - 6 »♦ W i __j — Fig. 2. — Baby W. Birth weight, 6 lbs. 1 oz. Loss, 11 oz. Lowest weight on fourth day. Birth weight regained on the thirteenth day. BABY'S WEIGHT RECORD WEIGHT OF BABY LBS... ■ DATe t«« LBS. OZS OATl wVeks LBS. OZS, DATE ASE I^ LBS. Oz| DATS AOt IN WCCKS LBS. PZi 1 14 27 40 2 15 28 41 3 16 29 42 4 17 30 43 5 18 31 44 6 19 32 45 7 20 33 46 8 21 34 47 9 22 35 48 10 23 36 49 1 1 24 37 50 ■■"* 12 25 38 51 13 26 39 z 52 Fig. 3. Io8 PRACTICAL INFANT FEEDING a week during the first six months, and 4 to 5 ounces a week the next three months. Anything less than this is not satis- factory. Accurate weekly weighing is of the utmost importance, and it is often surprising to see how many otherwise intelligent doctors and mothers neglect this. It is very convenient to have little printed cards,^ such as is shown in Fig. 3, to give to every new mother, so that she can have an accurate record which the doctor can scan at a glance to see how the baby is doing. Plotting the baby's weight against a theoretic curve is a pernicious practice, as babies vary so much in their initial weights that often the mother is imnecessarily worried by the failure of the baby to follow the curve. Another pernicious practice after the first three weeks is to weigh the baby every day or so. No baby gains regularly every day, and may often lose several ounces, which he will gain back the next day. Daily weighing is one of the most potent sources of worry to a nervous mother. Intervals of Nursing. — There is always much discussion concerning the correct nursing interval. With breast-fed babies the three-hour interval has seemed to me the most satis- factory in the vast majority of cases. Only in the case of very weak or premature babies, who take little at a feeding and do not nurse vigorously, is a more frequent nursing necessary. Many breast babies do very well on four-hour feedings, par- ticularly if the baby is robust and the supply of milk abundant. Absolute regularity should be adhered to in the nursing hours; one cannot start to train a baby too soon, and it is the babies trained in regular habits of eating and sleeping who, as a rule, do best. Undoubtedly many breast-fed babies do well who are fed every time they cry, but these are the exception rather than the rule. One of the hardest things to teach dispensary patients is that regular nursing hours are better than irregular. A good start means a great deal to the baby, and to the peace of mind of his mother, and a really good obstetric nurse will 1 These are kindly supplied me by E. F. Mahady Co., Boston. BREAST FEEDING 109 do wonders in getting the daily routine running smoothly. Some writers believe that a baby should never be waked from sleep to nurse. The best answer to this is that as a great many small babies sleep most of the time, they would get very little to eat if this rule were adhered to. In my opinion a baby should always be waked to nurse. He will usually go to sleep again immediately afterward. Amoimt at Each Feeding. — ^A baby rarely gets the same amount at each feeding during the course of the day, but the twenty-four-hour amount is likely to remain fairly constant. The supply of breast milk is usually most abimdant in the morning and scantiest at the late afternoon and evening feed- ings. Most of the milk is obtained in the first five minutes of nursing, although the richest part of the contents of the breast, the "strippings," containing a high fat percentage, is not with- drawn until toward the end of the nursing. Most babies nurse about fifteen minutes as a rule. A few unusually strong, greedy babies will empty the breast in much less time than this, how- ever, and a weak baby may remain at the breast for half an hour or more. In general, if the baby nurses over twenty minutes it indicates that the breast milk is scanty in amount, and that by keeping on nursing the baby is hoping against hope to squeeze out a few drops more. Substitution of One Bottle Feeding. — It does no harm, and is indeed a good idea in many cases after the first month to substitute one bottle feeding for a breast feeding. This gives the mother a chance to get out and see her friends, and to get away from the baby for a while, which may be just what she needs. The usual feeding substituted is the 3 p. M. feeding. This leaves the mother free from 12 m. to 6 p. m. Night Feedings. — There is no reason why a normal baby over a month old should be fed in the middle of the night, and it is always a good plan to have the baby broken of the 2 a. m. feeding as soon as possible. I have known this to be done in a good many cases before the mother and baby left the hospital, and I always try to have it accomplished by the obstetric nurse no PRACTICAL INFANT FEEDING before she leaves, so that the mother will not be bothered with it. The best plan to follow is to use a somewhat longer interval after the 6 p. m. feeding, making the last feeding at 10 or 10.30, being sure that the baby gets plenty, with the addition of a small complemental feeding if necessary. This may carry him through the night; if it does not, it is best to give a little water for a few nights, or to let him "cry it out." In these days the old idea of waking up every few minutes during the night to feed the baby is, or should be, obsolete. Stools. — The stools of a breast-fed baby are usually two or four daily, golden yellow in color, mushy in consistency, and have an aromatic, sour smell. Variations may occur quite normally, however. A not inconsiderable number of perfectly normal breast-fed babies will have as many as six or seven green, curded stools daily, without any harm whatsoever. Other normal babies will have a stool only every other day. Mothers have it clearly fixed in their minds that a baby must move its bowels every day in order to be well. This is not so, and many well babies very frequently skip a day. If loose green stools or constipated stools are accompanied by symp- toms of gas, vomiting, excoriated buttocks, etc., the condition is, of course, abnormal, and calls for treatment, but it is sur- prising to see how many breast-fed babies will have all during the nursing period five or six green, loose, curded stools a day and still gain regularly and do well. Weaning. — In most cases a baby should not be allowed to nurse at the breast after the ninth month, and it is well to have him accustomed to the bottle before this time so that there will be no trouble with the weaning. The best way to wean is to gradually replace the breast feedings by the bottle, substituting a bottle feeding for a breast feeding every two or three days, until the baby is getting the breast only twice a day. When this stage has been reached he may be weaned entirely. In most cases there will be little difficulty with weaning, espe- cially if he has been previously accustomed to the bottle or the spoon. In a few cases considerable difficulty is experienced, BREAST FEEDING III owing to the fact that the baby will not take the bottle if he has any chance of getting the breast. If this difficulty arises the weaning must be abrupt and the breast milk dried up at once. After the baby has gone for a few feedings without any- thing to eat, and once he clearly understands that there is to be no more breast milk for him, it is usually plain sailing. It is best to have the mother out of sight when the bottle is given, until the baby becomes well accustomed to it. As soon as he is taking bottle milk well, cereal and soup or zwieback may be started, according to the principles of artificial feeding laid down in another chapter. In hot climates during the summer, where the purity of the milk supply is uncertain, it is usually best not to wean during the hot weather. In places where the milk supply is good, and the weather is not excessively hot, weaning can be done at any time of the year. The mother usually experiences little difficulty in drying up her breasts. Enough Epsom salts should be given each day to produce two or three watery movements, and she should take as little fluid as possible. Diffictilties Arising During Lactation. — Depressed or In- verted Nipples. — Not a few women have poor nipples. They may be either merely rather flat, and therefore difficult for the baby to take, or they may be actually inverted, and therefore prevent nursing entirely. The time to treat flat nipples is several months before the birth of the baby. The mother should be instructed to pull them out several times daily, and if she does this faithfully, they may become considerably elon- gated. With actually inverted nipples little can be done, and the use of a nipple shield is necessary. Some babies take nipple shields very weU; others refuse them absolutely. In general, it has seemed to me that nipple shields are most unsatisfactory. Cracked Nipples. — If care is taken, cracked nipples should not develop. The baby should take not only the nipple in his mouth but also a considerable area of the areola behind the 112 PRACTICAL INFANT FEEDING nipple. If this is done the nipple suffers less trauma. It is especially important to keep the nipples dry and to leave no decomposing milk on them. If they show a tendency to dryness and hardness, they can be smeared with a little lanolin after each nursing. If fissures develop, the nursing may be extremely painful to the mother, often so much so that it becomes practically impossible. If cracked nipples could be left alone for a few days they would heal readily, but it is the continual irritation and pulling of the baby upon them that keeps the cracks open and prevents healing. The best plan to follow is, first of all, to try a nipple shield, and if this does not work, to remove the baby from the breast in question for several days, and feed him artificially, taking care, however, to empty the breast with a pump at regular intervals, in order to keep up the milk secretion. During the few days that the baby is not taking the breast applications of a 5 per cent, silver nitrate solution to the fissures has seemed to me to be the most ejQBicient method of treatment. There is little use in trying to heal cracked nipples with the baby sucking at them every three or four hours; if he is fed otherwise, and the crack given a chance to heal, the condition usually clears up readily. Caking of the Breast. — If there is a large amount of milk in the breast, particularly during the first few weeks of lacta- tion, and the baby on account of feebleness or otherwise, does not empty it completely, caking is likely to occur. This is shown l)y the presence of hard, sometimes slightly tender lumps in the breast, particularly in the dependent portions. This should not be confused with mastitis. The treatment is to see that the breast is completely emptied after each nursing, with a breast- pump if necessary. Mastitis and Abscess, — ^Mastitis means an actual inflamma- tory condition of the glandular tissue of the breast. The infec- tion practically always gets in through the nipple, and is usually due to the staphylococcus. Cracked nipples and undue caking of the breast may be important causes. Any septic condition BREAST FEEDING II3 of the baby may be also a cause. According to Norris, mastitis occurs in from 0.5 to 4 per cent, of all nursing mothers, par- ticularly in the early weeks of lactation. It is very likely to start with a chill, and an abrupt rise of temperature to 101° or 102° F. The infected part of the breast is hot, red, and tender. The baby should at once be prohibited from nursing on the infected breast, although he may continue to nurse on the normal one in most cases, unless the mother is too sick. The object of treatment in mastitis is to prevent the condition from going over into actual abscess formation, and for this purpose the continued application of cold in the form of an ice- bag is the most efficient means. If a high temperature lasts for more than forty-eight hours it is probable that pus is present, and that surgical intervention will have to be resorted to. If in conjunction with the continued high temperature the mass in the breast increases in size, redness, and tenderness, and becomes fluctuant, it is certain that a breast abscess is present, the treatment of which is incision and drainage. After most cases of single mastitis the supply of milk on that side will be considerably diminished, but with a complementary feeding nursing at that breast may be continued. After abscess there will probably be no milk in the breast, and half-substitute feeding will have to be employed. Acute Disease in the Mother. — ^When a nursing mother develops an acute infectious disease it is often a question of nice judgment whether the baby should continue nursing or not. Although it is undoubtedly possible in some cases for the baby to continue nursing during certain long-drawn-out febrile conditions in the mother, and although in the last few years a number of pediatricians have advocated the continuance of nursing during such diseases as tj^hoid fever and pneumonia, my personal feeling is that it is best to wean the baby if the mother is going to be sick more than a few days. Artificial feeding is so successful now compared to what it used to be that there is a good deal more danger of the baby's going wrong if nursing is continued than if he is weaned. Furthermore, 114 PRACTICAL INFANT FEEDING a really sick woman, with any febrile disease which is going to last for more than a few days, has need of all her energy, and has none to spare in feeding a baby. In such conditions as tonsillitis or uncomplicated influenza there is no need of weaning. In the longer infections, as I have said, it is generally best to discontinue nursing, although, of course, no hard-and-fast rules can be laid down, and each individual case has to be decided according to circumstances. Pregnancy. — If a nursing mother becomes pregnant again the baby should in most cases be weaned. Here again, how- ever, one must not be too dogmatic, for special circumstances may have to be considered. If the baby is a small one and needs breast milk, if it is during the very hot weather, if the baby is acutely sick or is recovering from some infectious disease, it is better to let nursing continue for a month or two. It is undoubtedly possible for some women to carry one baby in utero and nurse another; but, unless there are some special reasons to the contrary, the nursing baby should be weaned as soon as pregnancy has been recognized. In the South during the summer the question of weaning a baby on account of acute infection or pregnancy in the mother has to be regarded in a somewhat different light from what it is in the North. So many artificially fed babies die every summer in the South from the diarrheal diseases that breast feeding must never be discontinued at this season if it is humanly possible to con- tinue it. Menstruation. — Some women menstruate while nursing, some do not. It is a clinical fact that many babies are upset during the first day or two of menstruation. This is shown by fussiness, colic, green, loose stools, and sometimes vomiting. The cause of this is not clear. It is not unreasonable to sup- pose that there should be changes in the breast milk during menstruation, as the breasts and the uterus are intimately con- nected organs. There is much difference of opinion as to this, however. Czerny and Keller say that there is no chemical change in the breast milk during menstruation. Langstein and Meyer BREAST FEEDING II5 believe that while there is no change in composition, there is a diminution of milk, which makes the baby fretful. This question has been investigated by Rantenga and Filippo.^ They examined the breast milk of menstruating women, some of whose babies were upset by the menstruation, some not. They studied particularly the lactose and chlorid content, and found that the lactose and chlorids were normal in all cases where the baby was doing well (7.3-7.8 per cent, lactose — 24-43 mgm. chlorids per 100 c.c. of milk). In another series of cases where the babies were restless and irritable, and were having^ loose green stools, they found a low lactose and a high chlorid content. The lactose ran as low as 4 per cent, and the chlorids as high as 168 mgm. per 100 c.c. of milk. This condition of the milk they found most likely to be present twenty-four hours before the onset of the menses. They also found that in all cases where the baby was upset the quantity of milk was de- cidedly less than normal. This is the first real light that has been shed on the subject. It is practically never necessary to wean a baby on account of menstruation of the mother. The upset lasts only a day or two in most cases, and if it should last longer than this, bottle feedings can be given and the breasts pumped until menstruation ceases. Contraindications to Nursing. — Any chronic, wasting disease in the mother is a contraindication to nursing. Under this head come cancer, tuberculosis, chronic nephritis, secondary anemia or any other blood disease, hyperthyroidism and decom- pensated heart disease, and diseases of the nervous system. There is no particular reason why an epileptic should not nurse her baby if the attacks are infrequent and if the nursing seems to do her no harm. No woman with tuberculosis in any form ought to nurse her baby, as small babies are extremely suscep- tible to tuberculosis, and the baby will certainly get it if he is in close association with the mother. Syphilis, unless it takes such a form that the mother is feeble, on the other hand, is art indication for breast feeding rather than a contraindication,, 1 Ztschr. f. Kinderh., vol. 14, No. 182, 1916. Il6 PRACTICAL INFANT FEEDING as if the mother is syphilitic, the baby probably is, and needs the very best food possible. Most women with neurasthenia are too nervous to nurse their babies. Women who have had eclampsia and who have been delivered prematurely on this account should not nurse their babies, as their milk is usually poor, and they are not in good condition. In cases where the mother has had a little albumin in the urine, and a somewhat increased blood-pressure during the latter months of pregnancy, nursing does not necessarily need to be prohibited, but the baby needs to be watched carefully, as it is very likely that the breast milk will not be abundant in amount or of particularly good quality. The Abnonnal Breast-fed Baby. — Vomiting in the Early Days. — Not a few newborn babies vomit or regurgitate con- siderably during the first week, and often are unnecessarily weaned on this account. This is a great mistake, as this type of vomiting almost always ceases as soon as the mother is out of bed and lactation has been well established. Many times I have seen babies who were vomiting nearly every feeding in the hospital stop as soon as the baby and mother went home, and the mother began to be up and around. Particularly if the colostrum corpuscles persist in the milk for a longer period than is usual, the baby is likely to vomit. Colostrum is normally yellow in color, and in some cases this yellow color is greatly intensified, and may persist for a week or ten days. In several cases with this deep yellow breast milk that I have seen the baby has vomited excessively. The yellow color is not always due to colostrum corpuscles, as in one case the milk was a deep lemon color, and no colostnun corpuscles could be seen under the microscope. In this type of milk the fat is usually, but not always, high. The pigment is probably a combination of carotin and xanthophyll (see Chap. Ill), and is contained in the fat globules. These pigments come from the chlorophyl in green vegetables and fruits, and in any case with yellow breast milk where the baby is upset these should be omitted temporarily from the diet. BREAST FEEDING II7 The most common cause of vomiting in the early days is improper technic in taking care of the baby. This occurs espe- cially in hospitals, where one baby may have five or six different nurses take care of him during the course of the day, each with different methods of handling. He may be kept quiet after nursing or he may not be — one nurse may handle him with quick, jerky motions, another slowly and deliberately — ^his diapers may be changed when they are wet or dirty, or they may stay on him for hours. All these things upset a baby, and there is no question that in many of these vomiting babies the trouble is caused by "too many cooks." Newborn babies, as a rule, do far better at home than they do even in the best lying-in hospital, although in the days when so many people live in small apartment houses the lying-in hospital is a necessity. There should be special nurses for the nursery, however, whose sole duties should be to look after the babies. Another cause of vomiting in the early days of life is an overabundant supply of breast milk. A baby a week old natur- ally has a good deal smaller stomach than an older baby, and if the breast is a fast one and there is a large amount of milk in it, he may get so much at each feeding that he vomits the overflow and sometimes the rest besides. The treatment of this type of vomiting is simple and satisfactory, and consists in increasing the interval between nursings, reducing the time of each individual one, and in stopping for a minute or two several times during the nursing. Occasionally a baby will be seen who vomits more persistently without apparent reason, and all attempts at treatment are unavailing. No baby should be weaned during the first two weeks on account of vomiting, no matter how bad it is. If the vomiting is persistent and resists all measures of treatment, pyloric stenosis should be considered, and appropriate treat- ment instituted. In a few cases, although pyloric stenosis is evidently not present, and all methods of treatment are tried, the vomiting persists, and the baby does not gain weight. These babies must be weaned. Il8 PRACTICAL INFANT FEEDING Underfeeding. — The underfed breast-fed baby is common. Underfeeding is manifested especially by failure to gain properly — 1, 2, or 3 ounces a week instead of the usual 6 or 8. There are usually, but not always, symptoms of hunger, sleeplessness, irri- tability, etc. The stools may be small and constipated, or typical "starvation" stools may be passed, which are rather small in size, brown in color, contain considerable mucus, a few curds, and seem sticky in consistency. Such stools as this mean usually not indigestion, but underfeeding. The underfeeding may be qualitative or quantitative, that is, the breast milk may con- tain an insufficient amount of one of the individual food ele- ments, particularly the fat, or it may be deficient in both quantity and quality. The most common deficiency is a lack of fat, and the fat percentage may be as low as 0.50 per cent. Com- bined with the low fat percentage is usually a high protein per- centage, which may or may not give rise to symptoms of indiges- tion. For practical purposes cases of underfeeding may be divided into two groups: 1. Those which are simply not getting enough to eat, but have no symptoms of indigestion. 2. Those which do not get enough to eat, and have indiges- tion also, usually from a too high protein percentage in combi- nation with a low fat. The treatment of the first group is most satisfactory, and consists simply in giving the baby extra food in the shape of cow's milk modification. If there is not much deficiency in the breast milk the artificial feeding can be given immediately after each breast feeding in amounts suitable to the exigencies of the case and the age of the child. The amount to give can be determined approximately by weighing the baby before and after each breast feeding, and by finding out in this way how much he gets from the breast. A series of such observations conducted over a period of several days give considerable information, and enables one to regulate accurately the amount of extra bottle milk which should be given. The following tables show the amount of BREAST FEEDING 119 breast milk that an underfed baby of six weeks was getting, and also how the amount diminished in the course of two weeks: January 19th: 3.30 A. M. 7.00 « 10.00 « 1.00 p. M. 4.00 « 7.00 « 10.00 « Total. . ..2 ..4 ..2 ..3.5 ..1 ..5 ..1 oz. . 18.5 oz. January 20th : 7.00 a. m. . . . 3.5 oz. 10.00 1.00 4.00 7.00 10.00 p. M. .2.5 .3 .1 .1.5 .3 Total. . . 14.5 oz. January 21st: 4.00 A. M 2 7.00 « 2 1.00 p. M 3 4.00 « 3.5 7.00 « 3 10.00 « 3 Total 16.5 oz. The next three-day period, taken about two weeks later, shows how the supply of breast milk had diminished: 6th: 7.00 a. M 3 oz. February 7th: 7.00 a. m.. . . . 3 oz. 10.00 " ... 1 « 10.00 " .. .. 2 " 1.00 p. M. . . . 2 « 1.00 p.m... .. 2 " 4.00 « ... 1 « 4.00 " .. .. 1 " 7.00 « ... 3 « 7.00 « .. .. 2 « 10.00 « ... 1 « 10.00 « ,. Total. . . .. 1 " Total 11 oz. . . 11 oz. February 8th: 4.00 a.m... . loz. 7.00 " . . . 3 « 10.00 " . . . 1 « 1.00 P.M... . 2 « 4.00 " .. . 2 « 7.00 « . . . 2 " 10.00 " . . Total. . . . 2 « .13oz. The giving of bottle milk immediately before or after the breast feeding is known as complemental feeding, and is usually I20 PRACTICAL INFANT FEEDING the best way to give extra artificial feeding, as the breast is stimulated with each nursing act in this way, whereas if several bottle feedings were substituted for several breast feedings, the breast would get no stimulus at these times, and the already deficient store of milk might be further reduced. There is no contraindication to giving cow's milk and breast milk together; indeed, it seems as though cow's milk were easier to digest when in the stomach at the same time with breast milk, and it is rare to have any sjanptoms of indigestion during mixed feeding of this sort. If the mother's supply of milk is very scanty indeed, and she has only enough to feed the baby perhaps twice during the day, it is best to let her do this, and to substitute a bottle for the other breast feedings. This is known as supple- mental feeding. Unless the mother can give the baby two full breast feedings a day it is best to discontinue nursing alto- gether. A baby should never be weaned simply because he does not get quite enough to eat on the breast; every few ounces of breast milk that he can get will help him, and the deficiency can be very easily made up with the bottle. Mothers and doctors, as a rule, do not appreciate this, and have a most unfortunate tendency to discontinue nursing entirely if the baby does not gain weight satisfactorily or if he seems hungry. If the mother is leading a reasonable life, is well physically, has no worries, and is eating and drinking plenty it is not pos- sible to do much toward improving either the quantity or quality of her milk. If she is overtired or overnervous the removal of the causes that have produced these conditions may bring about a betterment of her milk; if she does not eat the right sort of food or drink enough, a better balanced diet will help her. The treatment of the babies who are underfed and who have symptoms of indigestion is more difiicult. Here the baby does not gain weight, is fussy and irritable, is likely to vomit considerably, to have a good deal of gas and colic, with loose, green, curded stools. The difficulty here is also likely to be BREAST FEEDING 121 caused by a too low fat and a too high protein percentage. The fat may be down to 0.50 per cent, and the protein up to 3 or 3.50 per cent. This type of milk is most likely to be seen in overworked, underfed women of the lower classes, or in highly strung nervous women of the upper classes. A good deal may be done for the milk of the underfed, overworked woman by mental and physical rest and a suitable diet, especially high in fats. Complemental feeding should, of course, be used at the same time. The highly strung, nervous woman, who has a poor milk more on account of the composition of her nervous system than on account of any errors in diet or hygiene, is a more difficult problem, and it may be necessary to wean the baby in such cases.. Overfeeding. — If a baby has indigestion with artificial feed- ing it is comparatively easy to tell from the symptoms and the character of the stools which food element is causing the trouble. This is not so easy with a baby fed on the breast. The stools of any breast baby with indigestion are likely to look very much the same, whether the trouble is due to fat, sugar, or protein. Occasionally, when the breast milk contains a very large amount of fat the stools may appear oily. Micro- scopic examination of the stools is by no means always reliable if the baby is breast fed, for there is so much fat in any good breast milk that there is likely to be a large amount of it in the stools of any normal breast-fed baby. The general symptoms of overfeeding or of indigestion due to any one of the food ele- ments are vomiting, colic, gas, frequent green curded stools, poor sleeping, and failure to gain properly. Much trouble is caused by too frequent and irregular feed- ings. The baby's stomach does not get a chance to empty itself before new food is introduced; part of this will probably be vomited, the rest enters the small intestine, where, on account of its large amount, it cannot be wholly absorbed. What is not absorbed undergoes fermentation, with the production of loose green stools, gas, and colic. The first thing to do is to increase the interval between the 122 PRACTICAL INFANT FEEDING feedings if it is too short, and to see also that the baby is fed with absolute regularity. Also a couple of tablespoonfuls of lime-water, or of plain boiled water, can be given before each nursing, in order to dilute the milk, and the time of nursing can be shortened from fifteen or twenty minutes to eight or twelve minutes. Most babies who are getting simply too much milk of normal composition at too frequent intervals will respond readily to this treatment. If these changes do no good, the composition of the breast milk should be determined by analysis. The sugar varies the least of any of the food elements; the fat and the protein may vary considerably. The German school believes that all breast milk is good milk, that excessive amounts of the individual elements do no harm, and that disturbances of digestion or of nutrition are always due to underfeeding, overfeeding in toto, sickness of any sort in the baby, or faulty methods of caring for him. While it is imdoubtedly true that many breast-fed babies thrive on milks of markedly abnormal composition, it is also true, in our opinion, that abnormality in the composi- tion of the breast milk accounts for indigestion in a great many cases. Breast milk analyses are entirely unreliable unless the milk is obtained in a certain way, and unless the analysis is done by exact quantitative methods by a competent chemist. Either the whole contents of the breast should be sent for analysis or the middle portion of the nursing. In practice it is usually simpler to obtain the middle portion of the nursing. The baby is permitted to nurse about a quarter of his usual time, then an ounce or two of breast milk for analysis is expressed either manually or with a pump. The fore-milk or first por- tion of the nursing is very low in fat, the strippings, or last portion, is rich in fat. The middle milk gives a fairly accurate representation of the average composition. If the percentage of fat is found to be too high, the best way to reduce it is to have the mother eat less food in general, and exercise more. If the percentage of protein is too high, exercise and freedom from nervousness and household cares may diminish it. Dimin- BREAST FEEDING 1 23 ishing the protein in the food probably has little effect in diminishing the protein in the milk. Although the sugar may not be excessive in amount, it may none the less be the cause of indigestion. There is no satisfactory way of influencing the amount of sugar. In general it is rather difficult to treat a breast-fed infant with indigestion. With bottle feeding we can change the amounts of the various food elements in the diet at will, and we can usually tell very easily by the stools which element is causing the trouble. With breast feeding, on the other hand, we are working at a considerable disadvantage. The picture is not nearly so clear, and it is much more difficult to change the character of the milk. Furthermore, indigestion may occur even when the breast milk is apparently perfectly normal in composition. In this group of cases particularly, but also in any case with an excessive number of stools, and evidences of intestinal fermentation, an ounce or two of fat-free lactic acid milk or buttermilk given immediately after the shortened nursing period may help a great deal, and is one of the most satisfactory methods of treatment. A half teaspoonful of pow- dered casein (Larosan, Casec) dissolved in a tablespoonful of water, and given after each feeding, is also efficient in cases which are due to sugar or fat fermentation. It is our duty to go through all methods of treatment before weaning the baby, and in most cases weaning is not necessary. Occasionally, however, the baby fails to do well, no matter what we do, and breast feeding has to be discontinued. CHAPTER V THE DEVELOPMENT OF MODERN ARTIFICIAL FEEDING! The artificial feeding of infants has been, is, and probably will continue to be a much discussed subject. Our opinions regarding it are constantly changing and developing; its litera- ture is assuming enormous proportions, and each year we are learning more and more concerning the fundamental nutritional processes of the infant, upon which all nutritional therapy depends. It is in a constant state of flux; certain ideas are in the foreground for a few years and then gradually recede, leav- ing, however, their faint or pronounced marks upon the fabric of the whole. The healthy infant has the power, in a large measure, of adapting itself to widely varying artificial diets; this accounts to a great extent for the success that pediatricians in different parts of the world have had, using their own par- ticular methods, which may differ considerably. There is no one way to feed an infant; it is true that he must be fed a food that furnishes enough fuel value; also that he must have a food which he can digest and which contains the proper materials for the growth of his body; but it is possible to meet these demands in a variety of ways. We know, even at the present time, comparatively little about the factors which are con- cerned in the disturbances of digestion and of nutrition; further- more, babies fed according to one method are likely to have somewhat different types of disturbance than those fed accord- ing to another method; therefore there is plenty of chance for different ways of looking at these disturbances, and for difference in their classification. * This chapter appeared in the Boston Medical and Surgical Journal, vol. dxxii, No. 13, 1920 and I am indebted to the editors for permission to re- print it. 124 DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 25 Liberality, broadness of vision, and respect for the opinions of others are essential in medicine; in no branch of medicine are these qualities more essential than in infant feeding. There are many ways of approaching the subject, many viewpoints of value besides the ones which we may ourselves happen to hold, and it is vital in order to have a clear vision of the subject to give heed to the thoughts of eoery competent observer, to adopt what seems good in his teach- ings, and to amalgamate it with our own ideas. Therefore, it should be of value to consider the development of modem infant feeding, the opinions that have been held by the great teachers of the subject, their influence upon those who have followed them, and their relationship to the teachings of the present day. Biedert, Meigs, and Rotch (the Protein Period). — Modem infant feeding may be said to have started with Philip Biedert's inaugural dissertation in 1869. Previous to this time but little scientific investigation had been produced in connection with it; the little that was known was almost entirely empirical and the results of artificial feeding were uniformly bad. Biedert's monograph of 64 pages is entitled ^'Investigations Concerning the Differences Between Human Milk and Cow's Milk." Previous to his time there were on record many analyses of cow's milk, but few of human, and the figures varied so widely that it was quite certain that but few of them could be correct. Cow's milk was supposed to contain about 5 per cent, of casein, hxmian milk, 4 per cent. Biedert started with the central idea that in order to have a rational basis for the artificial feed- ing of infants it was necessary to know the exact composition of human milk, the baby's natural food, and then to imitate this as closely as possible in the artificial mixture. He showed by many analyses that the amount of casein in htunan milk was very much less than that in cow's milk, about 2 per cent., he believed. He also laid especial stress on the fact that cow's milk when treated with acid formed large tough curds, and that human milk formed very small soft curds. ■• This was due, he said, not only to the fact that there was much less casein in 126 PRACTICAL INFANT FEEDING human milk than in cow's, but also that the casein was different qualitatively; cow casein was an entirely different substance from human casein. He called all the protein of milk casein, and did not know that lactalbumin was also present; with him "casein'^ and "protein" are synonymous terms. His two basic conceptions: that the protein of human milk is less than half that of cow's milk and that the proteins are of different quality were fundamentally correct, and were of epoch making impor- tance. We shall find that for many years thought in infant feeding was greatly influenced by them. He believed that the ratio of fat to casein in human milk was as 3.5 to 2 — that in cow's milk it was as 4 to 5. The more fat there was in relation to the amount of casein present, the more likely was there to be a soft curd; this was the reason that the curd of human milk was soft and small, and the curd of cow's milk was hard and large. Also, he thought that a certain amount of protein was necessary to hold the fat in emulsion and facilitate digestion; thus we see the beginnings of the idea of the importance of the ratio between the food elements. Biedert wrote many articles after his first one, and in 1880 the first edition of his text-book appeared, going through four editions, the last in 1900. His central idea was the indigesti- bility of the cow casein, and his methods of feeding were all based on this. He believed that a mixture should be made in which the amount of casein should be reduced considerably below that in human milk (to 1 or 1.50 per cent.) and that the ordinary milk and water dilutions then in use did not accomplish this. In order to raise the nutritional value of the food and also to aid in the digestion of the curd, he used dilutions of cream or mixtures of whey and cream. In his cream dilutions there was a ratio of fat to casein as of 2.5 to 1, which he thought was the most favorable one for the proper digestion of the casein. The cream mixture usually had sugar added up to about 5 per cent. Besides his regular cream dilutions he developed his famous "cream conserve," a thick paste which would keep for a con- DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 27 siderable period, and which needed simple dilution with water before using. This was made from casein, butter, milk, and cane-sugar, and the salts of milk. When diluted, according to his directions, it contained about 2.50 per cent, fat, 4 per cent, sugar, 1 per cent, protein, and 0.20 per cent, salts. He recommended this for use only when fresh milk could not be obtained, and was always a vigorous advocate of mixtures made from fresh, clean milk. He attacked especially the various condensed milk mixtures and proprietary foods which had begun to spring up, and insisted that nothing could ever take the place of fresh cow's milk. Most of his writings are concerned with the chemical differences between human milk and cow's milk and the proper mixtures to feed to normal babies. In the first edition of his text-book there are 377 pages, 321 of which are devoted to these subjects, and only 56 to patho- logic conditions, nor did he attempt any special classification of digestive disturbances. He believed that most digestive troubles were due to the casein curd, he denied the good of the gruel and nulk dilutions in general use, and advised strongly against feeding starch to small babies. The sugar, he thought, was practically harmless and did not recognize any particular type of indigestion caused by it. He found, however, that if too much fat was fed diarrhea resulted in certain babies, and that in these cases the fat might be as much as 50 per cent, of the dried stool. He looked at these stools microscopically and mentions the presence of an excess of fat droplets. The condition was, he said, probably due to a duodenal catarrh, which hindered fat absorption. He also described very dry white stools containing an excessive amount of fat, and thought they were due to a lack of bile secretions ("soap stools"). He believed that failure of fat absorption might have considerable importance in causing infantile atrophy, but that in acute disturbances the casein was more important. Biedert was a scholar, a shrewd observer, a clear writer, and his ideas influenced the trend of thought in infant feeding for twenty years or more. 128 PRACTICAL INFANT FEEDING Developments in America. Influence of Biedert. — In 1880 Dr. John Forsyth Meigs of Philadelphia was the most successful and most widely known feeder of infants in America. His methods were largely empirical, but he got better results than had ever before been obtained. About this time he asked his son, Dr. Arthur V. Meigs, to make for him some analysis of condensed milk. This led the younger Meigs to investigate the composition of breast milk, to which he devoted a great deal of time, being interested in it up to the time of his death in 1911. Meigs states his fundamental ideas as follows: "There are but two possible methods in endeavoring to reach a conclusion about what is right to feed babies, the one purely empiric; to experiment with various foods until the best is found; and the other by analysis to learn as nearly as possible what human milk is, which we all know to be the most perfect food for infants, and then to make an imitation of it." . In 1882 he made the statement, following much experimental work, that human milk never contained more than 1 per cent, of casein, and this statement may be said to be at the bottom of most of his ideas on feeding. This was about half Biedert's figure for the amount of casein present in human milk. Inas- much as this is the figure for human milk, said Meigs, in artificial feeding more than 1 per cent, of casein should never be in the cow's milk mixture offered to the baby. In making a food for babies two matters should be considered: the constituents must be in the same relative proportions as they are in himaan milk, and they must be in a medium which shall be as human milk is, alkaline. Furthermore, it is a great mistake to keep changing a baby's food in the early months; the baby should be started on a food which shall imitate breast milk and this should be fed to him without change in strength until he is eight or nine months old. He can take as much of it in amount as he desires, however. Meigs gives the following directions for preparing this food: "One quart of whole milk is put into a pot or a high pitcher and allowed to stand three hours; then DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 29 one pint is poured from this. When the child is to be fed there are taken of this weak cream 3 tablespoonfuls; of lime-water, 2 tablespoonfuls; of sugar- water, 3 tablespoonfuls. This makes 4 oimces of food. Sugar-water is made by dissolving 18 drams of lactose in 1 pint of water. This mixture contains about 4 per cent, fat, 7 per cent, sugar, and 1 per cent, protein — ^according to Meigs an exact imitation of mother's milk. He fed this to babies of all sizes and ages, in all stages of malnutrition. His results in hospital practice were rather disappointing, he says, and a good many of his babies died, but in private practice the results were most gratifying. In 1885 appeared his little book, ^'Milk Analysis and Infant Feeding," most of which he devoted to a technical discussion of his methods of milk analysis, and very little to practical feeding. Meigs summarizes his principles as follows: "The end to be striven for in order that a more general success may be attained in the artificial feeding of infants is to diffuse more widely and to make common property of the knowledge of the small amount of casein in human as compared with cow's milk, and that, in addition to the dilution which is necessary to reduce the amount of this constituent, we must use in proper proportions cream, sugar, and lime-water." Meigs' influence was felt all over the country and his ideas were widely followed. He had worked along the same lines as his predecessor, Biedert, but had added to his work in that he came nearer to the actual amount of casein in human milk, and devised a more exact formula to be used in the imitation of the baby's natural food. Rotch. — ^About 1887 Dr. Thomas Rotch of Boston began to be interested in infant feeding. He was well acquainted with the literature of the day, and was influenced very largely by the teach- ings of Biedert. About the time that Meigs was doing his work in Philadelphia, Rotch began to study various infant foods. On his service at the Infants' Hospital the best results were being obtained with condensed milk. This led him to make an analysis 130 PRACTICAL INFANT FEEDING of the condensed milk mixtures that were being fed, and he found that most of them contained very close to 1 per cent, of casein. From this he argued that 1 per cent, of casein was probably the best amount to use, so he turned to Meigs' mixture, and gave it a thorough trial. He soon began to see, however, that it had its limitations. He said, "We began to appreciate that the infants' idio- syncrasy was not for any one of the especial combinations usually found in human milk, such as high or low total solids, or in other words, a strong or a weak mixture, but that any one of the various constituents, according as it was in high or low percentage, might be the cause of what was represented by the especial idiosyncrasy, and thus we arrived at the con- clusion that in a multitude of variations and degrees the human infant may have an especial idiosyncrasy for a high or low per- centage of any one of the food-stuffs or for any combination of them. Resulting from this we deduced that to obtain a suc- cessful feeding and nutrition for infants we must be able to prepare an almost innumerable number of foods, varying in the percentage of any one of their ingredients, and in the combi- nations of these percentages. Percentage feeding is the varia- tion of the individual food elements so that we can give various babies the percentages of these elements which are adapted to their special digestions." These were revolutionary ideas and epoch making. Rotch cast down at a blow the teachings of the day, that human milk must be imitated, and the same mixture fed to all babies. To him we owe the birth of the idea of individualization and varia- tion. He looked upon digestive and nutritional disturbances as being caused by elements in the diet rather than by the diet as a whole, and emphasized strongly the necessity of thinking of the food in terms of its elements. He followed Biedert in the belief that the casein was the cause of more digestive troubles than any other food element, and recommended feeding it in very small amounts to young babies especially — smaller even than Biedert had used. The DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 131 fat he regarded as secondary to the casein in importance; the sugar he thought least important of all. He devised the gravity cream and skimmed milk method of modification, which allows of great elasticity in the preparation of milk formulae, and almost any ratio between the various food elements that is desired. He started milk laboratories in 1891 where the food was prepared exactly according to the doctor's prescription and delivered to the home ready for use. He insisted upon the necessity of thinking in percentages, and the physician's knowing as accurately as possible what is in the mixture that is being fed to a baby. He believed that very small variations in the percentage of the elements in the food were of very great significance. He wrote many papers of importance, and for long was regarded as the greatest American authority on infant feeding. Retrospect of Biedert, Meigs, and Rotch. — To Biedert we owe the first really important scientific investigations in infant feeding, and the proving that human milk and cow's milk are very dissimilar in composition, especially as regards their casein content. To Meigs we owe a more accurate analysis of human milk, and the wide-spread diffusion of his own and of Biedert's ideas in America. To Rotch we owe the great prin- ciple of individualization, the new conception that it is not the food as a whole, but its elements that must be considered. Much of the teachings of these men, in the light of our present knowledge, does not seem to be, and is probably not, correct, but they may be regarded, however, as three of the great pi- oneers in infant feeding. Biedert, Meigs, and Rotch devoted most of their time to the study of what to feed to the baby; their classifications of digestive disturbances were quite secondary and relatively unimportant. They did very little regarding the physiologic, bacterial, and chemical processes within the baby's body; they studied his food rather than himself. The next four men that we have to discuss— Widerhofer, Escherich, Czemy, and Finkelstein— studied the baby primarily and his food secondarily. 132 PRACTICAL INFANT FEEDING Widerhofer, of Vienna, was essentially a pathologist. Vien- nese medical thought in his day was largely influenced by the studies of Rokitansky, the greatest student of gross pathology. It was the age of anatomic pathology: Rokitansky in Vienna and Virchow in Berlin were the two greatest pathologists in the world, and their influence was felt everywhere. In every branch of medicine changes in anatomic structure, both gross and microscopic, were made the basis of classification. It was natural for students of infant feeding to apply these principles to their work. They attempted to find for every clinical pic- ture anatomic changes in the organism, and Widerhofer's classi- fication is almost entirely an anatomic one. In Gerhardt's Handbook of Diseases of Children, published in 1880, he writes a very complete chapter on gastro-intestinal disease in babies, from the standpoint of a pathologist. He recognizes innumer- able pathologic conditions, each of which he believes has a cor- responding clinical picture. Some of his main divisions are as follows: 1. Acute gastritis. 2. Chronic gastritis. 3. Dilatation of the stomach. 4. Toxic gastritis. 5. Helena. 6. Dyspepsia. 7. Enteralgia. 8. Acute and chronic enterocatarrh. 9. Follicular enteritis. 10. Membranous enteritis. 11. Croupous and diphtheric processes. 12. Syphilitic enteritis. 13. Amyloid degeneration. 14. Cholera infantum. Such a classification as this is very unsatisfactory, as it does not sufficiently take into account the processes which have produced the pathologic picture. Furthermore, in many of the severest types of gastro-intestinal disturbance in babies DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 33 there are no pathologic lesions that can be demonstrated, either in gross or by the microscope. The changes are largely of func- tion rather than of structure. Widerhofer^s classification lasted some time, however, and traces of it are still to be seen in several modem text-books. Most authorities are agreed, however, that the viewpoint of anatomic pathology is not the best one to adopt in considering these disturbances. Escherich. — No consideration of the development of infant feeding would be complete without reviewing the work of Theodore Escherich, although he proposed no new system of feeding or of classification. In his day (1886) the science of bacteriology was in its infancy, and he was the first to study carefully the bacteria in the infant's intestine, and to show the significance that they had in the normal and abnormal intestinal processes and their relation to food in the intestines. He in- vestigated the normal intestinal flora, and showed that it was of two sorts, the fermentative and putrefactive. He showed how the bacteria are necessary for the normal functions of digestion, and how they may cause trouble. He was the first to see clearly that there are two processes going on in the intes- tine: putrefaction of protein and fermentation of carbohydrate, and he laid down the great principle that the tj^es of bacteria that exist in the intestine are dependent upon the kinds of food fed. That high carbohydrate feeding favors the growth of one group of bacteria, that high protein feeding favors the growth of another group, and that if one type predominates and if the excessive breaking down of either carbohydrate or protein results, the baby gets into trouble. He recognized the fact that when carbohydrate fermentation exists carbohydrate should be withdrawn from the diet, and protein substituted, to change the type of intestinal flora, and vice versa. This is a fundamental principle which cannot be neglected in infant feeding. Indeed, I do not believe it is exaggerating to say that in dealing with abnormal intestinal processes it is the most important principle of all, and nobody can feed babies suc- cessfully without taking it into consideration. Bacterial proc- 134 PRACTICAL INFANT FEEDING esses in the intestine, and their relationship to the food supply can never be separated from questions of practical infant feed- ing, either normal or abnormal. In Escherich's own words, "The fact that through designed changes in the food supply the character of the bacterial vegetation, and all the processes that go with it, can be altered, opens to us a broad and remunera- tive perspective, and in order to apply our knowledge of intestinal bacteriology practically the first and most important thing is a thorough study of bacterial processes in the normal intestine. May the views put forth here not be without practical value in the treatment of that murderous pestilence of the first year of life — diarrhea." Czerny and Keller (the Fat Period; About 1900). — Previous to Czerny, as we have seen, much had been accomplished in the study of the baby's food, of intestinal bacteria, and of the pathology of the intestine; attention had been focused either on the food before it was given to the baby, or on the digestive processes in the bowel; not enough had been given to a con- sideration of the baby as a whole, and the effect of the different food elements in normal and abnormal conditions upon the general metabolism. It remained for Czerny to take a broader view, to suggest the term "disturbances of nutrition" instead of "gastro-intestinal diseases," and to follow carefully the etiologic influence of the various food elements in causing these disturbances. "A study of the general metabolism allows us to follow the fate of the food-stuffs after they have passed through the digestive tract and the influence of unsuitable nourishment upon the whole organism of the infant. Metabolic studies do away with empirical methods of feeding." Czerny and Keller's monumental text-book on infant nu- trition appeared in several parts, the first part coming out in 1906. It is really a marvelous book, showing a broad knowledge and a great power of putting together facts and theories to make a harmonious whole. Czerny and Keller's classification of nutritional disturbances is an etiologic one, and was undoubtedly the best that had DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 135 appeared up to that time. They divided nutritional disturbances into three broad groups: (1) from food, (2) from infection, (3) from constitution. In the first group comes: (1) fat injury, (2) starch injury, (3) gelatin injury, (4) scurvy. They describe with great clearness the picture of fat injury (Fettnahrschaden) and consider it one of the most important of all food injuries. It arises from overfeeding with fat, is evi- denced by constipation, pallor, loss of turgor, and failure to gain. They consider fat the most important of all the food elements in causing nutritional disturbance. Starch injury (Mehlnahrschaden) comes from a one-sided starch diet in the first few weeks of life especially. The baby is much emaciated from lack of nourishment. He has had just enough starch barely to keep him alive, but no more, and his body cells are dying from lack of salts and protein. Thus we see the results of the food injury extending beyond the intestine and affecting every cell in the body; a true metabolic disease is present, and not a mere "indigestion." Czerny also attacked the old supposition that protein was the most important cause of digestive troubles. He believed it did practically no harm, and did not recognize any such thing as protein injury in his group of food injuries. This was revolu- tionary, as previous to him attention had been focused on the protein, and all the attempts in milk modification had one particular end in view, to make it of easy digestion. He says, "There is no single symptom which can show us injury to the infant through protein, and from the standpoint of the clinician it is impossible to speak of a protein injury. It is possible that with abnormal flora in the intestine, putrefaction of the casein might occur. It is, however, as yet unknown whether or not this actually does happen; and, furthermore, if it should occur, whether or not it has anything to do with nutritional disturb- ances. In overfeeding with milk, in our experiences, a fat injury, and not a protein injury, occurs. Overfeeding with protein is hardly possible; it is much more likely that in an artificially 136 PRACTICAL INFANT FEEDING fed baby there should be protein underfeeding. We cannot take into consideration a disturbance of nutrition from protein/' Disturbances of nutrition from infection include all condi- tions which might be caused by bacteria or their products: (1) Infection of the food before it enters the body in such a way that toxic products are formed in it. (2) Infection of the food in the intestine. (3) Infection of the intestinal mucosa itself. Alimentary intoxication is a condition in which the symptoms are caused by the toxic products of destroyed food; in enteral and parenteral infections the trouble is caused by the bacteria themselves attacking the body; in the former group by infecting the intestinal wall; in the latter group by infecting other parts of the body and causing gastro-intestinal and nutritional disturbances secondarily. There are two t5^es of alimentary intoxication: one in which chiefly sugar is being decomposed; one in which the fat is. Fever in these conditions means an injured intestinal wall which makes it permeable for bacteria or their toxins, and very small injuries to the intesti- nal wall may allow this. The acids from fat or from carbo- hydrate decomposition are the starters of the trouble in alimen- tary intoxication. These may be introduced in spoiled milk or may arise in the gastro-enteric tract from bacterial decom- position of food. The symptoms of intoxication have many causes, of which only a part are as yet known. It can be assumed as true that a part of the symptoms are caused through water and salt loss, another through the absorption into the body of toxic material from the intestine which could not normally pass the intestinal wall, and finally, acidosis must be taken into consideration. Special toxins have as yet not been discovered. Special toxins are not necessary, however, to explain the clinical picture, as nearly all the symptoms are dependent upon dis- turbances of the intermediary metabolism which are brought about by the pathologic processes in the digestive tract. As to milk modification, Czerny recommends simple milk dilutions with addition of carbohydrate — one-third milk, two- thirds water for a baby in the first few weeks; then one-half DEVELOPMENT OF MODERN ARTIFICIAL FEEDING I37 milk, one-half water; later, two-thirds milk, one-third water, and finally, about the eleventh month, whole milk. He does not believe in the use of cream in any way, as it is likely to cause fat injury. We owe to Czerny the first really adequate study of the nutritional disturbances, and the most comprehensive classi- fication of them that had yet appeared. Finkelstein. — The teachings of Finkelstein and his co- workers, Langstein and Meyer, began to come into prominence about 1907, and from then up to the present time have received a great deal of attention. Finkelstein's chief contributions may be summed up in four phrases: sugar, salts, clinical classi- fication, and protein milk. Sugar had been, before his day, comparatively neglected as a source of digestive and nutritional disturbances; he makes it the cause of most of them. He studied carefully sugar fermentation in its different degrees, and the results of sugar fermentation, both immediate and remote. Sugar fermentation can be brought about in many different ways, but it is most likely to ferment in a medium which is rich in whey salts, particularly sodium salts. It is the whey salts of cow's milk which are injurious, and not the protein. The whey salts depress the antibacterial function of the cells of the small intestine and thus allow too profuse bacterial growth and consequent fermentation of the sugar. The intestinal mucosa is impaired functionally by the acids which are formed from sugar fermentation, and this functional injury allows the salts and unaltered lactose to pass through it into the general circulation. Finkelstein at first thought that the lactose was the cause of the fever and symptoms of intoxication which occur in some of the more severe cases of sugar fermentation, but later changed this view, and came to regard the salts as the cause of fever. Bacteria and bacterial toxins he does not con- sider important, except as they are concerned in the original fermentation. His new and startling ideas concerning the salts have caused a good deal of discussion, and have stimulated much research, some of which is in accord with his views, some 138 PRACTICAL INFANT FEEDING of which is not. Protein never does any harnij and fat is harm- ful only when there is a primary sugar injury; sugar is the one particular thing that causes trouble for babies. Thus we see that every food element in its turn has been considered the chief offender — with Biedert, Rotch, and Meigs the protein, with Czerny the fat, and lastly, with Finkelstein, the sugar and the salts. Finkelstein's classification of nutritional disturbances is like- wise different from anything that preceded it. He sees these conditions with entirely new eyes, and builds up a most in- genious edifice in his classification and treatment. His classi- fication is purely cHnical; he recognized and studied carefully certain conditions that babies get into through errors in digestion or nutrition; the etiology of those conditions is a secondary consideration. He says, "An etiologic diagnosis I hold to be practically impossible, and if it were possible — ^not desirable. How little, for example, does the diagnosis 'nutritional disturb- ance from infection' mean, when it remains in the dark where the origin of the condition Hes, whether from secondary dys- peptic fermentation or other causes. It is best to discard all etiologic nomenclature and to adopt the clinical; it is desir- able for the physician to be able to say what sort of child he has before him and how this child will react to definite dietetic influences." He admits himself that his classification is by no means perfect, and doubts whether there ever can be an abso- lutely satisfactory classification, as many of the various disturb- ances shade into one another so closely that it is impossible to separate them thoroughly. To each food of a certain com- position there belongs a certain type of disturbance, and there must be as many types of disturbances as there are combinations of food elements. His four main clinical groups are as follows: (1) Disturbed balance; (2) dyspepsia; (3) intoxication; (4) decomposition. By disturbed balance he means especially the fat injury of Czerny. A baby has previously done well despite adequate or overadequate caloric intake, does not gain, or may actually DEVELOPMENT OF MODERN ARTIFICIAL FEEDING I39 lose. Instead of a gain of weight resulting from an increase of food, a loss is likely to result (the "paradoxic" reaction). The food which brings about this disturbance is usually a food rich in fat and protein and relatively poor in carbohydrate; accord- ing to Czerny, overfeeding with milk; according to Finkelstein, underfeeding with carbohydrate. His principles of treatment are essentially the same as those of Czerny; reducing the amount of milk and adding carbohydrate in the form of maltose and starch. 2. Dyspepsia is the milder form of sugar fermentation. In this condition the process is locahzed in the intestinal tract, the loss of weight is not large and there are no symptoms of intoxication; the baby, as a whole, does not suffer, nor are there serious symptoms unless the condition is untreated or treated wrongly. Dyspepsia is Hkely to arise from food rich in sugar and whey salts ; is favorably influenced by a food low in sugar and high in protein. 3. Intoxication represents a severe metabolic disturbance. It may have started as a dyspepsia, or may be engrafted on to a decomposition. The process here is not localized in the intes- tine, the whole organism suffers ; the child's body is in a state of "metabolic bankruptcy," there is chaos where there should be order. The temperature is high and the baby's general condi- tion bad. The baby is losing nitrogen, water, and salts, and there is likely to be considerable acidosis present. The fever and most of the untoward symptoms are caused by the whey salts, which have gone through the unhealthy intestinal mucosa into the general circulation. The prognosis is grave. This is the condition which Czerny also describes under the head of alimentary intoxication, although he does not believe it is due to as specific causes as does Finkelstein. He believes it is a resultant of several conditions, many of which we know little about. 4. Decomposition represents what was known to the older WTiters as "marasmus," "athrepsia," or "infantile atrophy." The condition may arise in a number of ways, either as a result I40 PRACTICAL INFANT FEEDING of a prolonged ''balance disturbance" or a chronic dyspepsia, from an improperly treated intoxication or from prolonged underfeeding or improper feeding. The chief thing about decomposition is the very low tolerance for food; increasing it beyond the limit of tolerance may result either in dyspepsia or intoxication. The baby's body is actually decomposing, every cell in the body is affected, and the organism is not able to assimilate food, even if the digestive processes in the intestine were not impaired. In order to treat sugar fermentation Finkelstein desired a milk preparation very low in sugar and high in protein. The purpose is to inhibit sugar fermentation by withdrawing the fermenting substance, and to change the bacterial flora of the intestine from carbohydrate splitters to protein splitters by offering a low carbohydrate and high protein food; to promote an alkaline instead of an acid intestinal contents. For this purpose he devised the famous "eiweiss" or protein milk, a prepa- ration containing fat 2.5 per cent., sugar 1.5 per cent., protein 3.5 per cent. This was made from equal parts of buttermilk and water to which a certain amount of finely sifted milk curd has been added. The principle of protein milk feeding is un- doubtedly one of the most important advances ever made in infant feeding, and pediatricians all over the world have become convinced of the worth of Finkelstein's milk or modifications of it. Used in the right type of case, it is without question remarkably efficacious, but like all good things it has been used too much, and in cases in which there is no possible indication or need for it. It is not a universal food for all feeding troubles, but is merely one more very excellent weapon added to our armamentarium. As does Czerny, Finkelstein recommends simple dilutions of whole milk for feeding most babies, and following him, this method of feeding is used by most of those who have studied in Germany, It has the advantage of simplicity, but does not offer the wide variety of choice in the various combinations of the food elements that the older methods of cream dilutions DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 141 and cream and skimmed milk modifications do. In the last ten years the influence of Finkelstein has been profound, and it is probable that his teachings are followed more than those of any other authority at the present time. What conclusions may be drawn from this brief resume of these various stages in the development of infant feeding? Can we believe that we in the present epoch are entirely right, and that our predecessors have been wrong? This is hardly reasonable, and yet each epoch has been insistent that its ideas are the best, which is only natural. Any period in the develop- ment of any human activity is at best only an imperfect frag- ment, and as research advances many of the old ideas are dis- carded, some retained, and some modified. Any period in the development of any science always owes most of its ideas to the thought of those periods which have preceded it. This is particularly true of infant feeding. There has been in infant feeding no one startling discovery, such as has occurred in most other branches of medicine; its progress has been rather in the nature of a gradual development, and it is still in the develop- mental stage. When we reaKze that most of what we have come to believe as true regarding infant feeding has been developed in the last fifty years, it is not difficult to grasp what enormous changes may take place in the next fifty. We are at present in a period — the period of sugar — ^we have gone through the period of protein and of fat. As we learn more our present ideas will undoubtedly change and the infant feeding of 1950 will prob- ably be little like that of 1920. Whatever classification we use, whosesoever teachings we adopt, we must realize that there is more than one way of looking at the subject. If we adopt Rotch's teachings, Finkelstein's need not necessarily be wrong; or, if we accept Finkelstein's, Czerny's need not be considered erroneous. Rotch's postulate of knowing approximately the percentage composition of the food we offer, and expressing our milk modifications in terms of percentages of the food ele- ments, can perfectly well be combined with the teachings of Czerny and of Finkelstein, and should be. 142 PRACTICAL INFANT FEEDING Something has been gained, something has been added to the whole, by each of the various periods, and the teachings of all these different men are not incompatible. Czerny's classifi- cation is excellent, so is Finkelstein's; babies undoubtedly do suffer from fat, likewise from sugar. Some things are not sound in the teachings of either; these will soon be discarded and the good points will remain. Much of Rotch's teachings we do not agree with today — but his main principle, that we must have some method of feeding which will allow us variation in dealing with the individual, some method by which we can express accurately and concisely to others what combination of the food elements we are feeding to any given baby, will always remain. This principle is absolutely sound, and cannot be passed over. It is a pity that European students have not paid more attention to American methods, and it is rare indeed to see a reference to the name of any American author in a German text-book. We in America are far ahead of any method that Europe has yet produced in the modification of milk. European students are far ahead of us in the study of the normal and abnormal chemistry of the baby. As I said before, studies in this country have dealt chiefly with the baby's food and how to prepare it; German studies chiefly concern the baby him- self. German methods of milk modification have little elasticity; their whole milk mixtures are, in many cases, quite inadequate. We can learn much from them, however, concerning abnormal processes in the baby, concerning the pathogenesis of the digest- ive and nutritional disorders, and we should combine our own ideas of milk modification with their ideas of the baby. There are too many practitioners in this country who feed blindly; they have not the remotest idea of the underlying reasons for their procedures, and we can arrive nowhere, no matter how carefully our milk modifications are prepared, or our percentages calculated, unless we understand the fundamentals of the science of nutrition, the digestion and absorption of the food-stuffs, their influence upon each other and the influence of the intestinal bacteria upon them all. . DEVELOPMENT OF MODERN ARTIFICIAL FEEDING 1 43 Different sections of the country use different methods and look at feeding problems somewhat differently, despite all that has been written, ''that we all feed the same.'' We do not all feed the same, and probably never will. In the last few years many American pediatricians, particularly from the Middle West, have studied in German cHnics, have brought home the German ideas and have taught them in the medical schools. Followers of these methods have been rather incHned to look down on the older methods of "percentage feeding," and those who have been brought up in the old methods have given in many cases Httle heed to the new. The younger disciples of the German school have not investigated carefully enough the teachings of the older American authorities, nor have many of these older American authorities paid much attention to the newer German ideas. The two should be combined: German chemistry, American milk modification. More good research work in problems of infant nutrition is being done in this coun- try than ever before, however, and it will undoubtedly be pro- ductive of much good. We owe to German investigators most of what we know regarding the baby's normal and pathologic chemistry; we owe to American investigators most of our knowl- edge regarding modifying cow's milk to make a suitable food for him. Infant feeding need not necessarily be made abstruse and compHcated, but it must not, on the other hand, be made too superficial. The practitioner must know his food elements and he able to trace them in their progress through the digestive tract; he must also have several methods of milk modification at his command, so that he can combine these elements in any way he desires to meet special indications; the various milk preparations and methods of milk modification are the "tools of the frade,^' as Dr. Rachford of Cincinnati has said. Whatever we believe about the various food elements, we must realize that most of the time it is not exclusively one food element that causes trouble; it is rather improper combinations of the elements. We may be able to feed a baby successfully on a high fat and low protein, but as soon as we employ a high protein and high fat we may 144 PRACTICAL INFANT FEEDING begin to get trouble with the fat digestion. Large amounts of one element may be handled well by the baby, large amounts of two or more elements usually get him into trouble. I can conceive of only two reasonable methods of classifica- tion, the etiologic and the clinical. Whichever we follow we must realize that the other is not necessarily wrong; it is merely another way of looking at the same phenomena; a difference in nomenclature rather than in actuahty. My personal feeling is that the etiologic nomenclature is the more satisfactory, despite certain disadvantages; there are many, however, who would not agree with this. This nomenclature is advantageous in that it makes us think especially of the various elements and what they can do to the baby; it is dangerous in that it has a tendency to focus itself upon one element to the exclusion of the others, and it unquestionably does not describe the various conditions in which the baby may be, as well as does the clinical nomenclature of Finkelstein. There is no question but that at the present time Finkelstein's teachings are influenc- ing infant feeding more than those of any other man or group of men. Many of his ideas will last, but a good many will un- doubtedly be discarded as further progress is made. There is no telling what the next generation will bring forth, but judging from past history, our ideas concerning infant feeding then will bear little resemblance to our ideas now; in such a young science there is possibility of infinite change in the next few years. The salts and their relationship to the other food elements, their influence upon digestion and upon cell metabo- lism seem to offer the most fertile field for research and progress. Realizing that we have by no means as yet reached the solution of the problem, we must be broad minded, must keep away from fads, must not focus on one point to the undue exclusion of others, must accept the fact that there is more than one way of looking at this most interesting subject, be not too assertive and dogmatic in our statements, and remember that what is apparently true today may be proved false tomorrow. CHAPTER YV COW»S MILK Average Composition. — The following table, from Heine- man, shows the average composition of cow's milk, as given by different authors : Van Slyke. Bobesch. Richmond. Oliver. Fleishmann. Per cent. Per cent. Per cent. Per cent. Per cent. Water 87.1 87.3 87.1 87.6 87.75 Fat 3.9 3.6 3.9 3.25 3.40 Casein 2.5 3.0 3.0 3.40 2.80 Lactalbumin 0.70 0.60 0.40 0.45 0.70 Total protein 3.2 3.8 3.4 3.85 3.50 Lactose 5.1 4.50 4.75 4.55 4.60 Ash 0.70 0.70 0.75 0.75 0.75 Total solids 12.9 12.7 12.7 12.4 12.25 The most common figures used are: Fat 3.5 to 4 per cent. Lactose 4.50 per cent. Protein 3.50 " Salts 0.70 There may be considerable variation in the composition of milk from different cows; therefore, it is best in infant feeding to use the milk from a mixed herd, the fat standard of which is kept close to 4 per cent. Toward the end of the period of lac- tation (eighth or ninth month) the total solids, especially the fat and protein, may be increased considerably. Dry fodder does not further milk flow as well as green fodder, and often a ^ In the preparation of this chapter I have made extensive use of Heine- man's book, "Milk" (W. B. Saunders Co., 1919), especially as regards the section on bacteriology, also of Sommerfeld's "Handbuch der Milchkunde," Wiesbaden, 1909. lo I4S 146 PRACTICAL INFANT FEEDING change from the stable to the pasture in the spring increases the total amount of milk, and its content of solids as well. Increased exercise and more sunshine also probably partly account for this change. Reaction. — The reaction of fresh cow's milk is amphoteric, that is, it turns red litmus blue and blue Htmus red. On stand- ing, the reaction soon becomes acid, owing to the lactic acid that is produced from bacterial decomposition of the milk- sugar. Cow's milk, as ordinarily used, is, therefore, more acid than human milk. Physical Properties. — ^The freezing-point of cow's milk is from —.54 to —57° C, the boiling-point about 101° C. Its specific gravity is from 1.027 to 1.034. It is more opaque than human milk, owing to the larger amount of calcium casein that it contains. It is likely to be more yellow in color when the cows are taking considerable green fodder. This pigment is contained in the fat, and is derived from the carotin and xanthophyll present in most chlorophyl containing vegetable matter. The milk of different animals and, indeed, of different cows has different creaming properties. This is probably due largely to the size of the fat globules; the cream of a milk with large fat globules, such as Jersey milk, rises much more rapidly than the cream of a milk with small fat globules, probably due to the fact that the emulsion with large globules is not so per- fect, and therefore allows them to become separated from the rest of the milk more easily. Goat's milk, which has very small fat globules (3 to 4.5 microns), does not cream at all, and human milk, in which the majority of fat globules are probably smaller than those in cow's milk, does not cream as readily as cow's milk. Milk which has been boiled is also very slow in creaming, and milk which has been ^ 'homogenized" by mechanically breaking up the large fat globules into smaller ones does not cream at all. The fat globules rise more rapidly in fresh than in old milk, and more slowly in cold than in warm milk. Fat. — The fat exists in milk in the form of an emul- sion of fat globules. They usually measure from 0.0016 to cow's MILK 147 0.01 mm. in diameter, but may vary a good deal in size accord- ing to the breed of the cow. Those of Jersey milk are larger than those in the milk of any other breed. There is no relation- ship, however, between the size of the fat globules and the richness of milk. According to Eckles and Shaw there is no appreciable difference in the nature of the fat of different breeds, except as regards the size of the globules. The amount of fat, however, may vary considerably with the breed, as shown in the following table by Van Slyke and Publow (cited by Heine- man) : Breed. Fat percentages. Holstein-Friesian 3 . 26 Ayreshire 3 . 76 American Holderness 4. 01 Shorthorn 4. 28 Devon 4. 89 Guernsey 5 . 38 Jersey 5 . 78 Butter fat is more compKcated in composition than most other animal or vegetable fats. It consists chemically of glycerin in combination with a number of fatty acids, forming a so- called "triglycerid'' or "ester." The acids which are found in the fat of cow's milk in combination with glycerin are many^ in the following proportions: Acids. Percentage. Butyric, caproic, caprylic, and capric acids 6.$ Myristic, palmitic, and stearic acids 49.46 Oleic acid 36. 10 Glycerol 12. 54 Some of these acids are solids at ordinary temperature, and are non-irritating to the digestive tract; some, such as butyric, are Kquids, very volatile, and more irritating. The acids in butter fat may then be divided into the volatile (irritating) and non- volatile (non-irritating) groups. Of the total fatty acid content of cow's milk fat about 15 per cent, are of the volatile, irritating group (5 to 27 per cent., according to different 148 PRACTICAL INFANT FEEDING observers). Of these volatile acids, butyric is probably the most important. This high content in volatile acid may be of considerable practical importance in infant feeding, as will be seen later. Lactose is the sugar found in the milk of all mammals. It is a disaccharid, that is, a sugar consisting of two molecules of a simpler sugar, or monosaccharid. The amount of lactose varies but little in the milk of different cows. The lactose in cow^s milk is identical with that in human milk. Protein. — ^The proteins in cow's milk are casein, lactalbumin, lactoglobulin, and opalisin. The only two that exist in amounts sufficient to be of any importance are casein and lactalbumin. Casein is a phosphorus-containing protein of complex chemical composition. It is insoluble in water and exists in milk in the form of a suspension. It does not coagulate on boihng, but is easily precipitated by weak acids and by rennin. It is coagu- lated in the stomach by the action of the gastric juices into a tough leathery curd. Lactalbumin belongs to a different group of proteins than casein, and is somewhat similar to egg-albumen. It is soluble in water, is not coagulated by acids or by rennin, but is coagulable by heat at about 72° to 80° C. Cow's milk contains about 3 per cent, of casein and 0.50 per cent, of lactalbimiin. Salts. — ^The most striking thing about the ash of cow's milk is its high calcium content in the form of insoluble dicalcium phosphate. According to Langstein and Meyer^ 1000 gm. of cow's milk contain the following: K2O 1.77 gm. Na20 0.46 gm. CaO 1.72 gm. MgO 0.20gm. Fe203 0. 0004-0. 0007 gm. CI 0.82 gm. P2O6 2.06-2.43 gm. 7.55 gm. * Sauglingsernahrung und Sauglingsstoffwechsel, Wiesbaden, 1914. cow's MILK 149 According to Bosworth and Van Slyke^ these salts are arranged as follows : Percentage. Sodium chlorid 10. 6 Potassium chlorid 9.1 Monopotassium phosphate 12. 7 Dipotassium phosphate 9.2 Potassium citrate 5.4 Dimagnesium phosphate 3.7 Magnesium citrate 4.0 Dicalcium phosphate 7.4 Tricalcium phosphate 8.9 Calcium citrate 23 . 5 Calcium oxid (caseinate) 5.1 In solution are the salts of potassium, sodium, chlorin, citric acid, and some of the phosphates, calcium, and magnesium salts. The di- and triphosphates are in suspension and do not pass through a porcelain filter. Ferments. — Cow's milk contains a number of enzymes or ferments, proteolytic, carbohydrate splitting, oxidizing, and reducing. Little is known about the action of these enzymes, or whether they are of any particular value in the nutrition of the infant. Their activity is seriously affected by heat at 70° C. and they are destroyed at 80° C. Vitamins. — (See chapter on Scurvy.) Cells. — Cow's milk contains moderate numbers of epithelial cells and sometimes leukocytes or red blood-corpuscles derived from the circulation. If leukocytes are in excess, disease of the udder should be suspected. The Bacteriology of Milk. — ^The most important sources of the bacteria in cow's milk are: 1. Manure and dirt about the cows. 2. Dust and dirt in the bam. 3. Dirty utensils. 4. Hands of the milker. Milk is one of the best of culture-media for bacteria, and consequently dirty milking methods favor the growth of an 1 Jour. Biol. Chem., vol. xxiv, No. 31,916. 150 PRACTICAL INFANT FEEDING eaormous and varied flora. Even with clean milking methods it is extremely difficult to keep down bacterial growth within reasonable limits. A clean milk suitable for infant feeding should contain a maximum of not over 10,000 bacteria per cubic centimeter. Ordinary market milk should be kept below 100,000 per cubic centimeter. Most of the bacteria found in milk are saprophytes, and are harmless for adults. This does not hold true for babies, however, and milk infected with large numbers of saprophytic organisms is probably one of the greatest causes of infant mortality that there is. As regards infant feed- ing it is not the typhoid bacillus, etc., which may occasionally occur in milk that we are especially interested in, but these ordinary saprophytic bacteria. They do not attack the baby in the sense of invading his tissues, but attack the food in his intestines, and either ferment or putrefy it, forming irritating end-products which may bring about severe nutritional dis- turbance. The saprophytic organisms in milk may be classified as follows (Heineman) : 1. Lactic acid bacteria. 2. Spore-bearing bacteria. 3. Bacteria causing abnormal conditions in milk (pigmen- tation, etc.). 4. Molds and yeasts. 1. The lactic acid organisms include three groups — the Bacil- lus aerogenes, the Streptococcus lacticus, and the lactobacilli. The first two types are practically always present in market milk, and are the ones which cause ordinary souring. The Streptococcus lacticus is the most important and most frequent in occurrence of all the lactic acid products. In nature this organism is widely distributed in plants and cultivated lands, in dust, manure, or hay. Its occurrence in cow manure explains its constant presence in milk. The lactobaciUi are the ones chiefly used in the production of sour fermented milk (lactic acid milk, Bulgarian mifl^, etc.). There are many varieties, but they are all closely related. They are large Gram-positive cow S MILK 151 badlli, and produce large amounts of lactic acid in milk, some- times up to 3 per cent. The most important members of the group are the Bacillus bulgaricus, B. acidophilus, B. bifidus, and Boas-Oppler bacillus. 2. Spore-bearing Bacteria. — ^Milk practically always contains moderate numbers of spore-bearing bacteria. These consist of the Bacillus pro tens, members of the hay bacillus group, the bacillus of Fliigge, the gas bacillus (Bacillus aerogenes capsulatus), and others. Some of these are organisms which attack protein and cause putrefaction of the milk. Others have the power of producing butyric or propionic acid from milk-sugar. The protein-splitting bacteria ("peptonizers") are not present in such large numbers as the lactic acid bacilli, and their growth, as a rule, is not particularly easy, as they are crowded out by the numerous lactic acid bacilli present, and also inhibited to a certain extent by the lactic acid which is formed. 3. Bacteria Causing Special Abnormal Conditions in Milk, — Certain bacteria may produce pigments which cause color changes in milk. Most of the pigments are of no pathologic significance. Other bacteria may produce slimy, stringy, or ropy milk. Still others may cause a very noticeable bitter taste to appear. Blue Milk. — ^Blue is the most common abnormal color. Bacillus cyanogenes is the most common cause of it, and, accord- ing to Weigmann, may be produced by feeding turnips or clover mixed with horsetail which contains the characteristic bacillus. Red Milk. — ^A red color may occasionally appear in stale milk, and is usually due to the Bacillus prodigiosus. Slimy and Stringy Milk. — In stringy milk the consistency of the milk is changed so that it can be drawn out into threads, sometimes to a length of several feet (Heineman). SHmy or stringy milk may be caused by certain slime-forming bacteria, or by disease of the udder in some cases. Occasionally certain strains of the Streptococcus lacticus may produce sHmy milk, but the chief cause of it is the Bacillus lactis viscosi. This 152 PRACTICAL INFANT FEEDING organism is found in nature or the surfaces of stagnant pools, and cows carry it on their legs after they have been in wading. It grows preferably at low temperature, even as low as that of an ice-chest, and when it is once introduced into a dairy it is very hard to get rid of. Bitter milk is caused by the formation of peptones from the milk protein by certain peptonizing bacteria (usually cocci) which have the power to attack it, or by feeding certain foods to the cow, such as lupine, turnips, or cabbages. 4. Molds and yeasts are present in all milks, and are espe- cially noticeable in very old milks. Some of them have the power of attacking protein, some carbohydrate. The Souring of Milk. — The kind of decomposition that occurs in milk depends largely upon the predominating kinds of organisms, and the temperature at which it is kept. The bacterial flora of milk practically always includes lactic acid organisms, and these usually multiply at such a rate as to out- strip all others. They attack the milk-sugar and produce lactic acid from it. When the degree of acidity becomes sufficient the protein is precipitated ("curdling"). The acidity of milk does not usually increase until several hours after milking, and then the increase is rapid. As the acid increases the growth of the proteolytic bacteria is inhibited, and the lactic acid organisms multiply at an extraordinary rate, so that soon enough acid is produced to restrain the growth of the proteolytic bacteria entirely. When the acid content becomes high, molds and yeasts, which prefer an acid medium, begin to multiply, the molds attack chiefly the protein, and by protein decompo- sition the acid is gradually neutralized. By degrees the acid disappears entirely, and the proteolytic bacteria, having sur- vived as spores, begin to multiply, producing protein cleavage products, and a putrid milk results. In some milks the number of lactic acid bacteria is very low, and the protein-splitting types may obtain an early foothold. In such cases the milk putrefies before enough acid is formed to check the putref)dng bacteria. 153 According to Bos worth and Van Slyke^ the following chem- ical changes take place in sour milk : 1. About 22 per cent, of the milk-sugar is changed by the lactic acid bacteria, 88.5 per cent, of this being converted into lactic acid. 2. Citric acid completely disappears from the milk, being decomposed into acetic acid and carbon dioxid. 3. The insoluble inorganic constituents (dicalcium phos- phate) of the fresh milk are made soluble by the lactic acid. 4. The calcium casein present in the fresh milk is changed into free protein and precipitated, the calcium forming lactate. It has been said that pasteurized milk putrefies instead of souring, because the lactic acid bacilli are killed by pasteuriza- tion, whereas the spore-bearing peptonizing bacteria are not. This has been disproved by Ayers and Johnson,^ who arrived at the following conclusions : 1. Pasteurized milk always sours because of the develop- ment of lactic acid bacteria, which on account of their high thermal death-point survive pasteurization. The acid develop- ment in an efficiently pasteurized milk is about the same as that in a clean raw milk. 2. The relative proportion of the groups of peptonizing and lactic acid bacteria is about the same in efficiently pasteurized milk as it is in clean raw milk. 3. The number of peptonizers in a good grade of pasteurized milk on the initial count and on succeeding days is approxi- mately the same as in clean raw milk under similar temperature conditions. Milk also may contain a number of true pathogenic organ- isms which produce specific diseases. These, as a rule, get into the milk either from a diseased cow, from an infected milker, or from water used in washing milk-pails or bottles (typhoid). Streptococci. — The most common causes of pathogenic 1 Jour. Biochem., 24, 191, March, 1916. 2 Bureau of Animal Industry, Bull. 126, 1910. 154 PBACTICAL INFANT FEEDING strq)loc6cd in milk are masMMs ("garget") in the cow, or strep- tococcic infection of the throat of the milker. Mastitis or "garget" is a very common condition. It is an inflammation of the udder, either acute or chronic, due in most instances to a streptococcus. In certain cases, particularly in the early stages, the most careful physical examination of the cow may fail to reveal it. Later the inflammatory condi- tion becomes evident. It is, therefore, a most insidious condi- tion, as despite the most careful precautions a cow in even a certified milk herd may have mastitis and pathogenic strepto- cocci may have been occurring in the milk for several days before anything wrong with the cow is noticed. Milk from a cow suffering with mastitis if it contains pus may appear thick and yellowish, and after standing a yellowish sediment may separate out. The heat-coagulable albumin is likely to increase considerably, while the casein diminishes. The reaction is likely to be alkahne. The number of leukocytes in the sediment of the milk is greatly increased, and a large number of leukocytes plus chains of streptococci are important points in diagnosing a mastitis milk. The difficulty is that practically all market milk contains the Streptococcus lacticus, which is an organism non-pathogenic for man or for cows, and it may be very difficult indeed even for a competent bacteriologist to distinguish between the various types of streptococci and to tell which are harmful and which are not. Probably many reports of finding the Streptococcus pyogenes in milk from apparently healthy udders really mean the presence of Strepto- coccus lacticus. Not a few epidemics of so-called septic sore throat have been traced to a milk supply infected with virulent streptococci from a milker with tonsillitis. In some cases an epidemic has assumed serious proportions, and fatal generalized strepto- coccus sepsis has followed the initial throat infection. In the 1915 Boston epidemic over 2000 persons were affected. Tuberculosis. — Many cows are infected with tuberculosis, and the bovine tubercle bacillus is definitely pathogenic for 155 man, particularly for young babies and children. The bovine bacillus when taken through infected milk is more likely to cause glandular and abdominal tuberculosis than any other type. According to Pottenger^ about 10 per cent, of all tuber- culosis in human beings is due to the bovine bacillus. Heineman estimates that probably 10 per cent, of all dairy cows are tuber- cular, and Carpenter found in 1910 that of 421 herds in New York State tested by him, 302 contained cows reacting to the tuberculin test. The total number of cows tested was 9633, and of these, 3432 reacted. According to Heineman a con- servative estimate might place the market milk infected with the tubercle bacillus at from 6 to 8 per cent. This is, in truth, a high percentage, but it is probable that many specimens of milk contain so few bacilli that they are destroyed in the stomach or pass through the digestive tract without doing any harm. None the less the danger to babies and young children from milk of tubercular cows is a real one, and it is undoubtedly true that a considerable number become infected with tuber- culosis in this way. If the trouble with the infected cow is tuberculosis of the udder, the bacilli get into the milk directly from that source in large numbers. If the trouble is pulmonary tuberculosis, the feces of the cow is probably the chief source of infection, as much tubercular material is swallowed, and there is always a not inconsiderable amount of cow manure in milk, unless the milking is done with the utmost care (see Standards for Certified Milk). The Tuberculin Test. — This test is of very great value in detecting tuberculosis in cows, as it is almost impossible to detect it in the early stages by physical examination alone. In the later stages the cow develops symptoms such as diarrhea, loss of weight, cough, etc. This test is usually considered a very accurate one, and according to various observers it is stated that it is correct in from 95 to 98 per cent, of all cases. The chief trouble with it 1 Southern Med. Jour., 1915, vii, 935. 156 PRACTICAL INFANT FEEDING is that it does not distinguish between mild and severe forms of tuberculosis. A cow with a small tuberculous gland which could not by any possibility infect the milk supply is likely to give as marked a tuberculin reaction as one which is in an advanced stage of pulmonary tuberculosis. After a tubercuhn test has been performed a cow, even if tubercular, will not react again for a period of about six weeks. This phenomenon has been often taken advantage of by unscrupulous dealers, who perform tuberculin tests on their cows just before they are offered for sale. The tuberculin test is usually carried out as follows (Heine- man): The temperature of the cow is taken during the day every two or three hours, and the tuberculin is injected the even- ing of the same day. Beginning early the next morning the temperature is taken again at regular intervals. The temper- atures of the day previous to and that following injections are plotted on a chart and the curves compared. If the maximum temperature after injection is 2 degrees or more above the normal, tuberculosis is indicated. Other Diseases Transmitted by Milk. — ^Epidemics of dysen- tery, scarlet fever, typhoid fever, and diphtheria have many times been traced to infected milk supplies. Preservatives in Milk (Formalin). — ^Although many chemical preservatives have been used by unscrupulous dealers in order to preserve old milk, formalin is by far the most common. If present in a dilution of 1 : 10,000 there is a marked restraining influence on bacterial growth, and in a dilution of 1 : 40,000 it also probably prevents it to a certain extent. In this dilution there is a question whether it is harmful or not, but while the occasional ingestion of small amounts of formalin might do no harm, it is conceivable that in long-continued doses it might. Detection of Formaldehyd (Hehner's Test). — ^Place 5 c.c. of the milk in a test-tube and pour about 3 c.c. of commercial concentrated sulphuric acid slowly down the side of the tube so that the hquids do not mix. At the junction of the Hquids 157 a violet zone appears in the presence of formaldehyd. If pure sulphuric acid is used, a few crystals of ferrous sulphate should be added to the acid, as iron is a necessary ingredient for this test. Frozen Milk. — In severe winters milk is often delivered in a frozen condition, and mothers are in doubt as to whether it should be used. My own opinion is that it should not be used if any other can be obtained, as I have seen it apparently cause severe vomiting in a few babies. In others it appears to do no harm. Mixsell,^ in an excellent article on frozen milk, quoted below, says he has personally seen no ill effects from its use, but advises against it, as there are so many differences of opinion regarding it. The freezing-point of milk is about 55° C. The water freezes at first in proximity to the wall of the jar; the solids are forced toward the center, where a more concentrated solution is formed, which freezes only at lower temperatures. The chemical action of freezing on the fat and on the lactose is slight; the protein is split into peptones and eventually into amino-acids, but this occurs only after a period of two weeks or more. Freezing does not destroy the pathogenic bacteria, and milk kept very cold does not sour, but turns putrid, because the lactic acid bacteria do not grow at low temperature, while the putrefying organisms do. Thawed milk is never exactly the same as milk which has not been frozen. The natural emulsion of fat is never restored after freezing, and the casein is likely to appear in flakes rather than in its original colloidal condition. If frozen cream is added to coffee the fat of the cream does not mix homogeneously, but rises on the surface in large oily, yellow globules. The probable reason why milk which has been frozen upsets some babies is that the fat is rendered more difficult of digestion owing to the breaking up of its emulsion. CERTIFIED MILK The term "certified milk" was first introduced by the late Dr. Coit, of Newark, New Jersey, and simply means a clean ^ lArch. Ped., vol. xxxvii, No. 5, 1920. 158 PRACTICAL INFANT FEEDING raw milk produced under the most careful conditions, which is certified by a medical milk commission to measure up to the standards set by the Association of Medical Milk Commissions. The production of clean milk is the first and fundamental step in infant feeding, and it is so important for the physician to understand the conditions under which such milk is produced that I have included (copied from Heineman) the more impor- tant portions of the rules adopted by the American Association of Medical Milk Commissions for the production of certified milk. Standards for Certified Milk Hygiene of the Dairy. — 1. Pastures ox paddocks to which the cows have access shall be free from marshes or stagnant pools, crossed by no stream which might become dangerously contami- nated, at sufficient distances from offensive conditions to suffer no bad effects from them, and shall be free from plants which affect the milk deleteriously. 2. Surroundings of Buildings. — ^The surroundings of all buildings shall be kept clean and free from accumulations of dirt, rubbish, decayed vegetable or animal matter or animal waste, and the stable yard shall be well drained. 3. Location of Buildings. — Buildings in which certified milk is produced and handled shaH be so located as to insure proper shelter and good drainage and at sufficient distance from other buildings, dusty roads, cultivated and dusty fields, and all other possible sources of contamination; provided, in the case of unavoidable proximity to dusty roads or fields, the exposed side shall be screened with cheese-cloth. 4. Construction of Stables. — ^The stables shall be constructed so as to facilitate the prompt and easy removal of waste products. The floors and platforms shall be made of cement or other non-absorbent material and the gutters of cement only. The floors shall be properly graded and drained, and the manure gutters shall be from 6 to 8 inches deep and so placed in relation to the platform that all manure will drop into them. 5. The inside surface of the walls and all interior construe- 159 tion shall be smooth, with tight joints, and shall be capable of shedding water. The ceiling shall be of smooth material and dust-tight. All horizontal and slanting surfaces which might harbor dust shall be avoided. 6. Drinking and Feed Troughs. — Drinking troughs or basins shall be drained and cleaned each day, and feed troughs and mixing floors shall be kept in a clean and sanitary condition. 7. Stanchions, when used, shall be constructed of iron pipes or hard wood, and throat latches shall be provided to prevent the cows from lying down between the time of cleaning and the time of milking. 8. Ventilation. — ^The cow stables shall be provided with adequate ventilation either by means of some approved artificial device, or by the substitution of cheese-cloth for glass in the windows, each cow to be provided with a minimum of 600 cubic feet of air space. 9. Windows. — ^A sufficient number of windows shall be in- stalled and so distributed as to provide satisfactory light and a maximum of sunshine, 2 feet square of window area to each 600 cubic feet of air space to represent the minimum. The coverings of such windows shall be kept free from dust and dirt. 10. Exclusion of Flies, etc. — All necessary measures should be taken to prevent the entrance of flies and other insects and rats and other vermin into all the buildings. 11. Exclusion of Animals from the Herd. — No horses, hogs, dogs, or other animals or fowls shall be allowed to come in con- tact with the certified herd, either in the stables or elsewhere, 12. Bedding. — No dusty or moldy hay or straw, bedding from horse stalls, or other unclean materials shall be used for bedding the cows. Only bedding which is clean, dry, and ab- sorbent may be used, preferably shavings or straw. 13. Cleaning Stable and Disposal of Manure. — Soiled bed- ding and manure shall be removed at least twice daily, and the floors shall be swept and kept free from refuse. Such cleaning shall be done at least one hour before the milking time. Manure, l6o PRACTICAL INFANT FEEDING when removed, shall be drawn to the field or temporarily stored in containers so screened as to exclude flies. Manure shall not be even temporarily stored within 300 feet of the barn or dairy- building. 14. Cleaning of Cows. — ^Each cow in the herd shall be groomed daily, and no manure, mud, or filth shall be allowed to remain upon her during milking; for cleaning, a vacuum apparatus is recommended. 15. Clipping.— "Long hairs shall be clipped from the udder and flanks of the cow and from the tail above the brush. The hair on the tail shall be cut so that the brush may be well above the ground. 16. Cleaning of Udders. — ^The udders and teats of the cow shall be cleaned before milking; they shall be washed with a cloth and water, and dry wiped with another clean sterilized cloth — a separate cloth for drying each cow. 17. Feeding. — ^All food-stuffs shall be kept in an apartment separate from and not directly communicating with the cow barn. They shall be brought into the barn only immediately before the feeding hour, which shall follow the milking. 18. Only those foods shall be used which consist of fresh, palatable, or nutritious materials, such as wiU not injure the health of the cows or unfavorably affect the taste or character of the milk. Any dirty or moldy food or food in a state .of decomposition or putrefaction shall not be given. 19. A well-balanced ration shall be used, and all changes of food shall be made slowly. The first feedings of grass, alfalfa, ensilage, green corn, or other green feeds shall be given in small rations and increased gradually to fuU rations. 20. Exercise. — ^All dairy cows shall be turned out to exercise at least two hours in each twenty-four in suitable weather. Exercise yards shall be kept free from manure and other filth. 21. Washing of Hands. — Conveniently located facilities shall be provided for the milkers to wash in before and during milking. 22. The hands of the milkers shall be thoroughly washed with soap, water and brush, and carefully dried on a clean towel cow's MILK l6l immediately before milking. The hands of the milkers shall be rinsed with clean water and carefully dried before milking each cow. The practice of moistening the hands with milk is forbidden. 23. Milking Clothes. — Clean overalls, jumper, and cap shall be worn during milking. They shall be washed or sterihzed each day and used for no other purpose, and when not in use they shall be kept in a clean place, protected from dust and dirt. 24. Things to be Avoided by Milkers.— While engaged about the dairy or in handling the milk employees shall not use tobacco or intoxicating Kquors. They shall keep their fingers away from their noses and mouths, and no milker shall permit his hands, fingers, lips, or tongue to come in contact with milk intended for sale. 25. During milking the milkers shall be careful not to touch anything but the clean top of the milking stool, the milk pail, and the cow's teats. 26. Milkers are forbidden to spit upon the wails or floors of stables, or upon the walls or floors of milk houses, or into the water used for cooHng the milk or washing the utensils. 27. Fore-milk. — The first streams from each teat shall be rejected, as this fore-milk contains large numbers of bacteria. Such milk shall be collected into a separate vessel and not milked on to the floors or into the gutters. The milking shall be done rapidly and quietly, and the cows shall be treated kindly. 28. Milk and Calving Period. — Milk from all cows shall be excluded for a period of forty-five days before and seven days after parturition. 29. Bloody and Stringy Milk. — If milk from any cow is bloody and stringy or of unnatural appearance, the milk from that cow shall be rejected and the cow isolated from the herd until the cause of such abnormal appearance has been deter- mined and removed, special attention being given in the mean- time to the feeding or to possible injuries. If dirt gets into the pail, the milk shall be discarded and the pail washed before it is used. l62 PRACTICAL INFANT FEEDING 30. Make-Up of Herd. — No cows except those receiving the same supervision and care as the certified herd shall be kept in the same barn or brought in contact with them. 31. Employees Other than Milkers. — The requirements for milkers, relative to garments and cleaning of hands, shall apply to all other persons handling the milk, and children unattended by adults shall not be allowed in the dairy nor in the stable during milking. 32. Straining and Strainers. — ^Promptly after the milk is drawn it shall be removed from the stable to a clean room and then emptied from the milk pail to the can, being strained through strainers made of a double layer of finely meshed cheese- cloth or absorbent cotton thoroughly sterilized. Several strainers shall be provided for each milking in order that they may be frequently changed. ?>2>. Dairy Building. — ^A dairy building shaU be provided which shall be located at a distance from the stable and dwelling prescribed by the local commission, and there shall be no hog- pen, privy, or manure pile at a higher level or within 300 feet of it. 34. The dairy building shall be kept clean and shall not be used for purposes other than the handhng and storing of milk and milk utensils. It shall be provided with light and ventila- tion, and the floors shall be graded and water-tight. 35. The dairy building shall be well lighted and screened and drained through well-trapped pipes. No animals shall be allowed therein. No part of the dairy building shall be used for dwelling or lodging purposes, and the bottling room shall be used for no other purpose than to provide a place for clean milk utensils and for handling the milk. During bottHng this room shall be entered only by persons employed therein. The bottle room shall be kept scrupulously clean and free from odors. 36. Temperature of Milk. — ^Proper cooling to reduce the temperature to 45° F. shall be used, and aerators shall be so situated that they can be protected from flies, dust, and odors. cow's MILK 163 The milk shall be cooled immediately after being milked, and maintained at a temperature between 35° and 45° F. until delivered to the consumer. 37. Sealing of Bottles. — Milk after being cooled and bottled shall be immediately sealed in a manner satisfactory to the commission, but such seal shall include a sterile hood which completely covers the lip of the bottle. Zd), Cleaning and Sterilizing of Bottles, — ^The dairy building shall be provided with approved apparatus for the cleansing and steriHzing of all bottles and utensils used in milk produc- tion. All bottles and utensils shall be thoroughly cleaned by hot water and sal soda, or equally pure agent, rinsed until the cleaning water is thoroughly removed, then exposed to live steam or boiling water at least twenty minutes, and then kept inverted until used, in a place free from dust and other con- taminating materials. 39. Utensils, — ^All utensils shall be so constructed as to be easily cleaned. The milk pail should preferably have an elliptic opening 5 by 7 inches in diameter. The cover of this pail should be so convex as to make the entire interior of the pail visible and accessible for cleaning. The pail shall be made of heavy seamless tin, and with seams which are flushed and made smooth by solder. Wooden pails, galvanized-iron pails, or pails made of rough, porous materials are forbidden. AH utensils used in milking shall be kept in good repair. 40. Water-supply. — ^The entire water-supply shall be abso- lutely free from contamination, and shall be sufficient for all dairy purposes. It shaU be protected against flood or surface drainage and shall be conveniently situated in relation to the milk house. 41. Privies, etc., in Relation to Water-supply. — ^Privies, pigpens, manure piles, and all other possible sources of con- tamination shall be so situated on the farm as to render impos- sible the contamination of the water-supply, and shaU be so protected by use of screens and other measures as to prevent their becoming breeding ground for flies. 164 PRACTICAL INFANT FEEDING 42. Toilet Rooms, — ^Toilet facilities for the milkers shall be provided and located outside of the stable or milk house. These toilets shall be properly screened, shall be kept clean, and shall be accessible to wash basins, water, nail-brush, soap and towels, and the milkers shaU be required to wash and dry their hands immediately after leaving the toilet room. 43. Transportation. — In transit the milk packages shall be kept free from dust and dirt. The wagon, trays, and crates shall be kept scrupulously clean. No bottles shall be collected from houses in which communicable diseases prevail, unless a separate wagon is used and under conditions prescribed by the department of health, and the medical milk commission. 44. All certified milk shall reach the consumer within thirty hours after milking. Veterinary Supervision of the Herd. — ^45. Tuberculin Test. — ^The herd shall be free from tuberculosis, as shown by the proper application of the tuberculin test. The test shall be applied in accordance with the rules and regulations of the United States Government, and all reactors shall be removed immediately from the farm. 46. No new animals shall be admitted to the herd without first having passed a satisfactory tuberculin test, made in accord- ance with the rules and regulations mentioned; the tuberculin to be obtained and applied only by the official veterinarian of the commission. 47. Immediately following the application of the tuberculin test to a herd for the purpose of eHminating tuberculous cattle, the cow stable and exercising yards shall be disinfected by the veterinary inspector in accordance with the rules and regula- tions of the United States Government. 48. A second tubercuHn test shall follow each primary test after an interval of six months, and shall be applied in accordance with the rules and regulations mentioned. Thereafter, tuberculin tests shall be reapplied annually, but it is recommended that the retests be applied semi-annually. 49. Identification of Cows. — ^Each dairy cow in each of the i65 certified herds shall be labeled or tagged with a number or mark which shall permanently identify her. 50. Herd-hook Record. — Each cow in the herd shall be registered in a herd book, which register shall be accurately kept so that her entrance and departure from the herd and her tuberculin testing can be identified. 51. A copy of this herd-book record shall be kept in the hands of the veterinarian of the medical milk commission under which the dairy farm is operating, and the veterinarian shall be made responsible for the accuracy of this record. 52. Dates of Tuberculin Tests. — ^The dates of the annual tuberculin tests shall be definitely arranged by the medical milk commission, and all of the results of such tests shall be recorded by the veterinarian and regularly reported to the secretary of the medical milk commission issuing the certificate. 53. The results of all tuberculin tests shall be kept on iAe by each medical milk commission, and a copy of all such tests shall be made available to the American Association of Medical Milk Commission for statistical purposes. 54. The proper designated officers of the American Associa- tion of Medical Milk Commission should receive copies of reports of aU of the annual, semi-annual, and other official tuberculin tests which are made and keep copies of the same on file and compile them annually for the use of the association. 55. Disposition of Cows Sick with Diseases Other than Tuber- culosis. — Cows having rheumatism, leukorrhea, inflammation of the uterus, severe diarrhaea, or disease of the udder, or cows that from any other cause may be a menace to the herd shall be removed from the herd and placed in a building separate from that which may be used for the isolation of cows with tuberculosis, unless such building has been properly disinfected since it was last used for this purpose. The milk from such cows shall not be used nor shall the cows be restored to the herd until permission has been given by the veterinary inspector after a careful physical examination. 56. Notification of Veterinary Inspector. — In the event of l66 PRACTICAL INFANT FEEDING the occurrence of any of the diseases just described between the visits of the veterinary inspector, or if at any time a number of cows become sick at one time in such a way as to suggest the outbreak of a contagious disease or poisom'ng, it shall be the duty of the dairyman to withdraw such sickened cattle from the herd, to destroy their milk, and to notify the veterinary inspector by telegraph or telephone immediately. 57. Emaciated Cows. — Cows that are emaciated from chronic disease or from any cause that in the opinion of the veterinary inspector may endanger the quality of the milk, shall be removed from the herd. Bacteriologic Standards. — 58. Bacterial Counts. — Certified milk shall contain less than 10,000 bacteria per cubic centi- meter when delivered. In case a count exceeding 10,000 bacteria per cubic centimeter is found, daily counts shall be made, and if normal counts are not restored within ten days the certificate shall be suspended. 59. Bacterial counts shall be made at least once a week. 60. Collection of Samples. — ^The samples to be examined shall be obtained from milk as offered for sale and shall be taken by a representative of the milk commission. The samples shall be received in the original packages, in properly iced con- tainers and they shall be so kept until examined, so as to limit as far as possible changes in their bacterial content. 61. The fat standard for certified mUk shall be 4 per cent., with a permissible range of variation of from 3.5 to 4.5 per cent. Methods and Regulations for the Medical Examination of Employees, Their Health and Personal Hygiene 62. A medical officer, known as the attending dairy physi- cian, shall be selected by the commission, who should reside near the dairy producing certified milk. He shall be a physi- cian in good standing and authorized by law to practice medicine; he shall be responsible to the commission and subject to its direction. In case more than one dairy is under the control of the commission and they are in different localities, a separate cow's MILK 167 physician should be designated for employment for the super- vision of each dairy. 63. Before any person shall come on the premises to live and remain as an employee, such person, before being engaged in milking or the handling of milk, shall be subjected to a com- plete physical examination by the attending physician. No person shall be employed who has not been vaccinated recently or who upon examination is found to have a sore throat, or to be su'ffering from any form of tuberculosis, venereal disease, conjimctivitis, diarrhaea, dysentery, or who has recently had typhoid fever or is proved to be a typhoid carrier, or who has any inflammatory disease of the respiratory tract or any suppu- rative process or infectious skin eruption, or any disease of an infectious or contagious nature, or who has recently been asso- ciated with children sick with contagious disease. 64. In addition to ordinary habits of personal cleanliness all milkers shall have well-trimmed hair, wear close-fitting caps, and have clean shaven faces. 65. When the milkers live upon the premises their dormi- tories shall be constructed and operated according to plans approved by the commission. A separate bed shall be provided for each milker and each bed shall be kept supplied with clean bedclothes. Proper bathing facihties shall be provided for all employees on the dairy premises, preferably a shower-bath, and frequent bathing shall be enjoined. 66. In case the employees Hve on the dairy premises a suitable building shall be provided to be used for the isolation and quarantine of persons under suspicion of having a contagious disease. The following plan of construction is recommended: The quarantine building and hospital should be one story high and contain at least two rooms, each with a capacity of about 6000 cubic feet and containing not more than three beds each, the rooms to be separated by a closed partition. The doors opening into the rooms should be on opposite sides of the building and provided with locks. The windows should be l68 PRACTICAL INFANT FEEDING barred and the sash should be at least 5 feet from the ground and constructed for proper ventilation. The walls should be of a material which will allow proper disinfection. The floor should be of painted or washable wood, preferably of concrete, and so constructed that the floor may be flushed and properly disinfected. Proper heating, lighting, and ventilating facilities should be provided. 67. In the event of any illness of a suspicious nature the attending physician shall inunediately quarantine the suspect, notify the health authorities and the secretary of the commis- sion, and examine each member of the dairy force, and in every inflammatory affection of the nose or throat occurring among the employees of the dairy, in addition to carrying out the above-mentioned program, the attending physician shall take a culture and have it examined at once by a competent bac- teriologist approved by the commission. Pending such examina- tion, the affected employee or employees shall be quarantined. 68. It shall be the duty of the secretary, on receiving notice of any suspicious or contagious disease at the dairy, at once to notify the committee having in charge the medical super- vision of employees of the dairy farm upon which such disease has developed. On receipt of notice this committee shall assume charge of the matter, and shall have power to act for the com- mission as its judgment dictates. As soon as possible, there- after, the committee shall notify the commission, through its secretary, that a special meeting may be called for ultimate consideration and action. 69. When a case of contagious disease is found among the employees of a dairy producing certified milk under the control of a medical milk commission, such employee shall be at once quarantined and as soon as possible removed from the plant, and the premises fumigated. 70. When a case of contagion is found on a certified dairy it is advised that a printed notice of the facts shall be sent to every householder using the milk, giving in detail the precau- tions taken by the dairyman under the direction of the com- 169 mission, and it is further advised that all milk produced at such dairy shall be heated at 145° F. for forty minutes, or 155° F. for thirty minutes, or 167° F. for twenty minutes, and imme- diately cooled to 50° F. These facts should also be part of the notice, and such heating of the milk should be continued during the accepted period of incubation for such contagious disease. The following method of fumigation is recommended: After all windows and doors are closed and the cracks sealed by strips of paper applied with flour paste, and the various articles in the room so hung or placed as to be exposed on all sides, preparations should be made to generate formaldehyd gas by the use of 20 ounces of formaldehyd and 10 ounces of permanganate of potash for every 1000 cubic feet of space to be disinfected. For mixing the formaldehyd and potassium permanganate a large galvanized-iron pail or cylinder holding at least 20 quarts and having a flared top should be used for mixing therein 20 ounces of formaldehyd and 10 ounces of permanganate. A cylinder at least 5 feet high is suggested. The containers should be placed about in the rooms and the necessary quantity of permanganate weighed and placed in them. The formaldehyd solution for each pail should then be measured into a wide- mouthed cup and placed by the pail in which it is to be used. Although the reaction takes place quickly, by making prepara- tions as advised all the pails can be ''set off" promptly by one person, since there is nothing to do but to pour the formaldehyd solution over the permanganate. The rooms should be kept closed for four hours. As there is a slight danger of fire, the reaction should be watched through a window or the pails placed on a non-inflanmiable surface. 71. Following a weekly medical inspection of the employees, a monthly report shall be submitted to the secretary of the medical milk commission on the same recurring date by the examining visiting physician. 170 PRACTICAL INFANT FEEDING THE COOKING OF MILK In order to reduce the normal bacterial growth in milk and to kill pathologic organisms it is heated by one of two methods: 1. Pasteurization. 2. Boiling. Let us see what is accomplished by each of these methods, and what their advantages and disadvantages are as regards infant feeding. Pasteurization. — In pasteurization the milk is heated to a temperature considerably below the boiling-point and is kept at that temperature for a period of time. A number of different methods are used commercially, but the most common and most satisfactory one is known as the "holding" method, where the milk is heated to 140° F. (60° C.) and is kept at that tempera- ture for twenty minutes. In the home milk can be efi&dently pasteurized in an ordinary tin pail. The individual milk bottles are put into the pail and water is added so that the bottles will be well covered up to the necks. Then the water is heated up to 160° F. When this temperature is reached the pail is removed from the stove and a heavy blanket is put over it to keep the heat in. It is allowed to stand one- half hour; then it is rapidly cooled and is put on the ice. Rapid cooling is important after pasteurization or boiling, as slow cooling, with the temperature of the milk at blood heat for a considerable period of time, favors the development of bacteria from the spores which have not been killed by the heat. There are a number of very con- venient small home pasteurizers on the market, one of the best of which is that devised by Freeman. What Pasteurization Accomplishes. — By pasteurization the vast majority of all organisms except spore bearers are destroyed. Especially is it to be noted that pasteurization kills the tubercle bacillus, and all the other ordinary pathogenic bacteria found in milk. It has been commonly believed that the vitamins are not destroyed by pasteurization, but there is some evidence, according to Hess, to show that their efficiency may be con- siderably impaired, especially if the milk is rather old when cow S MILK 171 it is pasteurized, and if the pasteurization is continued more than the ordinary time. (See chapter on Scurvy.) Pasteurized milk sours normally, as does imcooked milk, owing to the fact that some lactic acid bacteria of high thermal death-point practically always survive. Pasteurized milk natur- ally keeps longer than unpasteurized milk of the same grade. The commercial pasteurization of milk has undoubtedly accom- plished much and is a practical necessity for the general milk supply of large cities. Boiling. — Boiling is usually done in the home in either one of two ways: Open Boiling in a Saucepan. — By this method the temperature of the milk reaches about 101° C. If the chief purpose of boiling is to render the casein curd more digestible, this is the best method to use, and the milk should be boiled vigorously for from three to ^wt minutes. It is very likely to ^'boil over" and has to be watched and stirred constantly, so that ordinarily it is simpler to employ the second method, which requires less attention. Boiling in a Double Boiler. — By this method the milk reaches a temperature of about 99° C. and does not actually "boil." For all practical purposes, however, it is "boiled milk." The bacterial content is reduced as efficiently as it is by the open method, but boiling in a double boiler is not so efficient in making a soft curd. The water is put into the double boiler cold, and the milk allowed to cook for ten or fifteen minutes after the water in the outer vessel has come to a boil. It is then taken from the stove, and the outer vessel filled with several dianges of cold water so that the milk may cool as rapidly as possible. Changes Produced by Boiling. — By boiling aU bacteria are destroyed except the most hardy spores. When milk is boiled a thin scum forms on the surface of the milk. This is partly due to coagulated proteias (lactalbumin, lactoglobulin) and partly to drying of the milk constituents on the surface. This scum consists chemically of 172 PRACTICAL INFANT FEEDING Fatty matter 45.42 per cent. Casein and albuminoid material 50.86 " Ash 3.72 « (Rosenau) Fat.— The emulsion of fat is partly broken up, and there is coalescence of some of the fat globules. Cream does not rise as well on boiled milk as it does on raw or on pasteurized milk. Sugar. — ^There is a caramelization or charring of a certain amount of the lactose. This does not usually take place to any extent below 120° C, which is never reached in ordinary boiling. Protein. — The lactalbumin and lactoglobulin are coagulated. This begins at about 75° C. The casein is rendered less easy of coagulation by rennin, and a soft and flocculent curd is formed in the stomach instead of a hard, tough curd. Salts. — There is a precipitation in insoluble form of a por- tion of the calcium and magnesium salts, and a considerable part of the phosphates. According to Soldner^ (quoted by Lane- Clayton) about a sixth of the total calcium content is precipi- tated in this way, which is not enough to greatly reduce the available calcium to any great extent, although, according to Bosworth,2 it is precipitated in a form (insoluble calcium phos- phate) which cannot be absorbed by the baby. Taste. — ^A characteristic "cooked" taste and smell devel- ops, which is probably due to the liberation of minute quantities of hydrogen sulphid. Vitamins and Ferments. — Ferments are destroyed by boiling, as are true bacterial toxins. There may be, however, other toxic decomposition products present in stale milk, which are not destroyed by boiling. The antiscorbutic vitamin is rendered less efficient, and probably destroyed by prolonged boiling. The other two vitamins are apparently not affected. Souring. — Boiled milk ordinarily does not sour. It putre- fies, owing to the fact that all of the lactic acid forming bacteria have been destroyed. 1 Landw. Versuchs, 1888, p. 35. 2 Personal communication. cow's MILK 173 The advantages of boiled milk are obvious: 1. By a very simple procedure the milk is rendered practically sterile, and the dangers which go with a bacterially contaminated milk are at once done away with. This is of tremendous impor- tance, and if physicians living in places where the milk supply is doubtful would only realize this they would not need to turn to condensed milk and proprietary foods in the summertime as so many do. 2. The casein curd is rendered soft and flocculent, so that the chances of disturbing the baby's digestion from difficulty of casein digestion is greatly diminished, and a greater concen- tration of milk can be taken than would be the case with raw milk. The main disadvantages that have been attributed to boiled milk are these: 1. The antiscorbutic vitamin is impaired in efficiency, thus predisposing to scurvy. 2. It is possible that the calcium salts are rendered less available in boiled milk than in raw. 3. Boiled milk is somewhat more constipating than raw milk. 4. It has been said that boiled milk is less nutritious than raw milk. 5. It has been said that babies fed on boiled milk are more likely to develop rickets than those fed on raw milk. 6. The ferments are destroyed by boiling. Let us consider critically how real these "disadvantages" are. It is probably true that babies fed on boiled milk are more likely to develop scurvy than those fed on raw milk. In most of the investigations of scurvy that have been undertaken it has been found that more babies developing it have been fed on boiled milk than on any other one sort of diet. On the other hand, in Germany and France, where boiled milk is used almost exclusively, there is apparently no more scurvy than there is here, where more raw milk is used. Boiled milk is certainly not 174 PEACTICAL INFANT FEEDING the entire cause of scurvy, as babies may sometimes develop it when fed on raw cow's milk or even on the breast. Orange juice in sufficient quantities (1 ounce a day) is a practically sure prophylactic, and the dangers of scurvy in a baby who is being fed intelligently on a sufficient quantity of fresh boiled milk, with the addition of orange juice, are practically nil. The fact that some babies develop scurvy when fed on boiled milk without the addition of orange juice in sufficient quantity cannot be taken as an argument against boiled milk. I say "sufficient quantity" because I have seen a number of babies with scurvy who had been taking an insufficient quantity of orange juice — 1 teaspoonful a day or less. It is true that a cer- tain amount of the calcium salts present are precipitated in insoluble forms by boiling milk, and are thus probably made unavailable for the baby. But there is such a large excess of calcium salts present in cow's milk that it is probable there is enough left in available forms to supply the baby's needs. There are few exact investigations on record concerning this point, and it must remain more or less a matter of conjecture until more light is shed upon it. As regards rickets, it has been said that lack of available calcium and destruction of vitamins in boiled milk cause babies fed on it to develop rickets more often than those fed on raw milk. There is no positive evidence to support this. We do not know that the calcium balance in babies fed on boiled milk is affected unfavorably, nor has it ever been positively shown that lack of vitamins is the cause of rickets. Inasmuch as there is no exact experi- mental evidence to support this idea, we must rely on general clinical observation, and from my own experience and from that of my colleagues at the Children's Hospital I should say that babies fed on boiled milk were no more likely to develop rickets than those fed on raw milk. It is true that in some cases boiled milk is somewhat con- stipating, but this constitutes no real disadvantage, as a slight amount of constipation does no harm and can be easily con- trolled. Boiled milk is just as nutritious as raw milk, as it has 175 been shown a number of times that the absorption of the food elements is not deleteriously affected by boiling. It is true that the ferments of milk are destroyed by boihng, but inas- much as it is not known what place the ferments hold in nutri- tion or whether they are of any value, their destruction cannot count as an important argmnent against boiled milk. We see, then, that there are very few tangible arguments against boiled milk; we really know practically nothing about the relationship of boiled milk to rickets, and can protect our babies easily against scurvy. These possible disadvantages of boiled milk certainly cannot outweigh that most important of all advantages — a milk free from harmful bacteria. Raw Milk versus Boiled or Pasteurized Milk. — There are many differences of opinion as to whether milk for infant feed- ing should be used raw, boiled, or pasteurized. My own per- sonal opinion is as follows: No milk should he fed raw to infants or children under three years of age unless it is certified milk or of equal grade. During hot, muggy weather even certified milk should not he used raw, and in the South all milk for hahies should he either hoiled or pasteurized at all times, whether it is certified or not. Inas- much as the amount of certified milk availahle comprises only ahout 1 per cent, of the total milk supply, most hahies will have their milk cooked. Boiled versus Pasteurized Milk. — ^As far as the general milk supply is concerned, pasteurization is satisfactory. As regards infant feeding and the heating of milk in the home, boihng is so much more simple than pasteurization that most pediatrists have discarded the latter method, and although certain disadvantages have been supposed to go with boiled milk, these do not equal its advantages. In using market milk which has already been pasteurized in the winter there is no need to recook it in the home unless to make a softer casein curd; in the smnmer it should be reboiled. Milk at Summer Resorts. — Most mothers who take their children away for the summer to the seashore or country worry a great deal about the milk supply, and often have their pet 176 PRACTICAL INFANT FEEDING milk sent each day from the city in special ice-boxes at con- siderable expense and trouble. There is no need of this. At almost any summer resort a farmer can be found who has reason- ably good milk; this can be boiled as soon as it is delivered, and is Kkely to be a good deal better than any milk from the city, as it is very much fresher. THE ESSENTIAL DIFFERENCES BETWEEN COW'S MILK AND HUMAN MILK It is necessary, in order to understand the nutritional proc- esses of babies fed on cow's milk, to have a clear idea of the essential points in which it differs chemically from human milk. Fat. — ^The fats of the two milks differ considerably in their chemical nature. The fat of human milk contains only about 2 per cent, of the lower irritating volatile fatty acids, that of cow's milk contains anywhere from 6 to 27 per cent., accord- ing to different observers. It is possible that this high content in irritating acids, especially butyric and caproic, may have a good deal to do with the difficulty that some infants have in digesting cow's fat. Of the more volatile acids, oleic makes up at least 50 per cent, of the total fatty acid content of human milk fat, whereas it makes up only 35 per cent, of the total content of cow's fat. Cow's milk fat contains a good deal more palmitin than does that of human milk. The calcium soaps of oleic acid are much more easily absorbed than those of palmitic acid. This may be another reason why the fat of human milk is tolerated better than that of cow's milk. The fat globules of human milk are probably in a much finer emulsion than in cow's milk. "When the number of droplets are counted in a counting chamber there are always more in human than in cow's milk. The fat globules in human milk measure between 0.001 and 0.02 mm., while those in cow's milk measure 0.0016 to 0.01 mm. Since the measurements given above show that the fat droplets in himian milk may be of greater diameter than those in cow's milk, it seems inconsistent that there should be a larger number cow's MILK 177 in the former than in the latter. The explanation must be that the majority of fat droplets in human milk are small and measure about 0.001 mm., while the majority of those in cow's milk must be closer to the upper limit and measure nearly 0.01 mm."^ The larger the number of fat globules, the greater the surface area for the fat-splitting ferments to work on, and, therefore, more complete digestion of the fat. This may be another reason why the fat of human milk is better as an infant food than that of cow's milk. Protein and Salts. — Cow's milk contains over twice as much protein and over three times as much ash as does human milk. This is on account of the more rapid growth of the calf, which needs a large amount of protein and of salts in order to supply material for the rapid growth of bone and muscle tissue. It is interesting to note that in most mammalia the ash and protein content of the milk of each species is in inverse proportion to the length of time needed for the young to double its birth weight.^ Period in which Species. weight of newborn 100 grams of milk contain is doubled (days). Protein, gm. Salt, gm. Man.... 180 1.25 0.20 Horse 60 2.0 0.40 Cow 47 3.5 0.70 Goat 22 3.7 0.80 Sheep 15 4.9 0.80 Pig 14 5.2 0.80 Cat 9.5 7.0 1.0 Dog 9 7.4 1.3 Rabbit 6 10.4 2.50 Most of the protein in cow's milk is casein, in the proportion of about 6 parts of casein to 1 of lactalbumin. In human milk, according to most authors, the casein and lactalbumin are about equally divided. Cow casein is probably not the same substance chemically that human casein is. Cow casein contains 0.87 per cent, of ^ Morse and Talbot, "Infant Feeding and Diseases of Nutrition," 1915. 2 Table by Proscher and Abderhalden (quoted by Hawk, Physiological Chemistry). 178 PRACTICAL INFANT FEEDING phosphorus, human casein only 0.25 per cent. Cow casein coagulates in the stomach in tough, leathery masses, human casein in fine flakes. The salt content of cow's milk is greatly in excess of that of human milk, and although we know as yet relatively little re- garding the metabolism of the salts and their effect in produc- ing disturbances of digestion or of nutrition, it is undoubtedly true that the large amount of inorganic material, particularly salts of calciimi, of sodium, and of phosphorus, and the forms in which they are found, have a great deal to do with some of the disturbances in babies fed on cow's milk. Cow's milk is, however, much poorer in iron than human milk, and this, too, has an important bearing on practical infant feeding, because babies fed too long on milk, without other iron-containing food are likely to become anemic and flabby. Salt Content of Human and Cow's Milk (Langstein and Meyer) 1000 grams of ash contains: Human. Cow. K2O, 0.69 gm 1.885 gm. NaaO, 0.16 " 0.465 " CaO, 0.42 " 1.72 " MgO, 0.068 " 0.205 " FeaOs, 0. 001-0. 004 gm . 0004-0 . 0007 gm. CI, 0. 294 gm 0. 820 gm. SO3, 0.143 " " P2O5, 0. 249-. 0418 gm. 2.065-2.437 gm. 1.988 gm 7.553 gm. The high salt content is important in relation to the fat digestion also, as it probably favors the formation of insoluble calcium soaps, which are difficult of absorption. To sum up: 1. There are important physical and chemical differences between the fats in the two milks, which indicate that the fat of cow's milk would be digested and absorbed with more diffi- culty than that of human milk. 2. The total protein is considerably higher in cow's milk. This is due to the large amount of casein in cow's milk. It is cow's MILK 179 a different substance chemically from that in human milk, and is probably digested with more difficulty. 3. The salt content of cow's milk is very high in comparison with that of human milk. This would seem to be of especial importance as regards the calcium salts, the large excess of which probably has a good deal to do with disturbances of fat metaboHsm. With these differences in mind it is not hard to see why the metabolic processes of breast-fed and artificially fed babies are very different, and why there is so much possibility for a totally different category of digestive and nutritional disturb- ances to develop in the artificially fed than in the breast-fed infant. CHAPTER VII THE MODIFICATION OF MILK^ By the "modification" of milk is meant changing the compo- sition of the original cow's milk in order to make it suitable for the digestion of the particular infant that is being fed. It is possible to successfully feed some babies on undiluted cow's milk, but these babies represent a very small minority, and for practical purposes it may be said that it is always neces- sary to modify cow's milk before it is fed to young babies. In the past fifty years there have been proposed numerous methods of modif5dng milk; some authorities have recommended simple dilutions of whole milk, while some have felt that babies generally do better if more fat is given, and have, therefore, added cream to the modification or have used dilutions of cream in order to obtain the higher fat content. It is often possible to feed the normal baby on a wide variety of foods, as he has considerable power of adapting himself within certain limits to changes in the composition of his diet. Thus it may be said that no one method of milk modification is the only one that should be used, and others need not be necessarily erroneous. Any method of milk modification is correct for any particular baby if the mixture contains the proper amounts and proportions of the various food elements for him to grow and develop normally. It is desirable, however, to proceed in a rational manner, to change the original cow's milk by design and not haphazard, and to have at one's command methods of milk modification which will allow of varying at will the individual constituents of the milk — fat, sugar, protein, and salts — to meet the needs of various babies with different digestive powers. It is also desirable in any system of milk modification to have a way of * Part of this chapter was published in the Journal of the American Medical Association, March 5, 1921. i8o THE MODIFICATION OF MILK l8l expressing what has been done in the exact language of figures in order to make it clear to ourselves, in order to make it intel- ligible to others, and in order to make our procedures avail- able for purposes of record. There is, therefore, involved in any method of milk modification a certain amount of calcula- tion. Much of the confusion in the minds of practitioners and students that there is in regard to infant feeding has arisen on account of the numerous ways of calculation and methods of modification that have been recommended by different authori- ties. The important thing to remember is that the particular method of modification which has been used is not the significant fact, but that the content of the resulting mixture as regards the various food elements is the point that must be continually borne in mind, and that many times the identical result may be obtained by two quite different methods of modification. An intelligent practitioner should know his food elements, should have clearly fixed in his mind approximately how much of each one of these elements he desires to feed to the baby, then he may proceed to concoct this combination by means of any method of modification with which he may be familiar. Some men get into the habit of using one particular method, others may use methods which are radically different, but may secure equally good results. Any one who is feeding babies should have at his command several methods, and should use the one which is most adaptable to the particular case with which he happens to be dealing. No matter what methods he uses, he must continually keep the food elements in mind, and must have some method of expressing to himself and to others the amounts of these that he is using. There are at present three methods of milk modification in general use: 1. The method of whole milk dilution. 2. The method of top milk (cream) dilution. 3. The method of gravity cream and skimmed milk mixtures. Whole Milk Dilutions. — This is the simplest method of milk modification. It was the first one used in the early days l82 PRACTICAL INFANT FEEDING before the development of modern infant feeding, and in the last ten years has had a revival of popularity. Its chief advantage is its simplicity; any mother, no matter how ignorant she may be, can be easily taught to mix together milk, water, and sugar. It is also easy for the doctor; and most men who are in the habit of using whole milk dilutions pay but Uttle attention to the percentages of the food elements in the mixture; they think rather in terms of ounces of milk and of sugar. It is possible in many cases to feed babies successfully by this method, but it has its limitations, in that it is not at all elastic, and often the ratios which one would like to have between the fat and protein in the mixtures cannot be obtained, owing to the fact that if the milk is diluted one-third or one-half, as the case may be, the fat and the protein will each be diluted in the same proportion. It is very successful with many well babies, but as soon as the baby fails to gain, or begins to do poorly in any way, its disadvantages become apparent, as all that can be done is to either increase or diminish the total concentration of milk or of sugar in the mixture. In whole milk dilutions, therefore, the ratio between the fat and the protein will always be the same, and it is impossible to feed high fats by the use of this method, as the fat content of the milk is so much reduced by dilution. It does not apply so well to very young babies as do the other methods of milk modification, as the usual dilution is so great that the fat percentage of the resulting mixture is much lower than the baby might be able to take with advantage. In normal babies after the eighth or ninth month it is, however, the method of choice, as the dilution for these older babies is so sUght that the fat percentage is not much reduced. My own feeling is that young babies as a rule do better on higher fat and lower protein percentages than can be obtained by this method of feeding. There is no question, however, that many babies may be successfully fed in this way. The chief objection to it is that it is not comprehensive nor elastic enough to furnish us with certain combinations of the food elements that we may need, and every practitioner should have in his armamentarium other THE MODIFICATION OF MILK 183 methods in addition to this one. Even if whole milk dilutions are used, and no matter how much infant feeding is simpHfied by their use, it is always well to keep track of the approximate percentage of each food element in the mixture. It is not pos- sible nor desirable to get away from a certain amount of calcu- lation, and a knowledge of the percentage composition of the food acts as a check upon what is being done. No matter what method of milk modification one adopts, in order to have any idea whatsoever about the possibiHties of his mixture he must have at least approximate knowledge of its elementary compo- nents (fat, sugar, protein) . The easiest way to have this knowl- edge is to think and speak in terms of percentages. Whole milk dilutions may be used in either one of two ways; the usual procedure being the first: 1. The desired number of ounces of milk and water plus the desired number of tablespoonfuls of sugar are prescribed; then the percentage composition of the mixture is calculated. In using whole milk dilutions one does not usually pick out in advance the percentage composition of the formula, as in many cases he will have picked out a formula which cannot be obtained by these methods. After a certain amount of experience in using this method, one knows without calculation about what the percentage composition of any given dilution of whole milk is, and he expresses his formula in terms of ounces of milk and water and tablespoonfuls of sugar rather than in terms of percentages. In order to proceed rationally, in order to have a clear conception of what he is doing, and especially in order to keep his food elements in mind, he must, however, have an idea of the percentage strength of his mixture. Every competent jeeder of infants has this knowledge, whether he expresses it on paper or not. Let us suppose that the baby is being fed on whole milk, 36 ounces; water, 12 ounces, and lactose (milk-sugar), 4 level tablespoonfuls. Then, as whole milk contains fat, 4 per cent.; sugar, 4.5 per cent., and protein, 3.2 per cent., we are giving if or f whole milk, which equals f of 4=3 per cent, of fat l84 PRACTICAL INFANT FEEDING in the mixture; | of 4.5=3.3 per cent, of sugar in the mixture, and f of 3.2 = 2.4 per cent, of protein in the mixture. A level tablespoonful of lactose added to a 48-ounce mixture raises the sugar percentage 0.8 per cent. (Table I). Therefore, using 4 level tablespoonfuls of dry lactose, we have added 3.2 per cent, of sugar to the mixture, which, plus the sugar that has already been put in with the milk (3.3 per cent.), gives 5.5 per cent, total sugar, and the baby is getting: fat, 3 per cent.; sugar, 5.5 per cent., and protein, 2.4 per cent. The same method is used in figuring any whole milk dilution.^ Level tablespoonfuls of sugar are best calculated by the use of the sugar table, and ordinarily I believe it is best to use level tablespoonfuls instead of rounded, as more accuracy is obtained in this way. If rounded tablespoonfuls were used the calculation would be a little different. Suppose we had used in the foregoing formula 3 rounded tablespoonfuls of lactose. A rounded tablespoonful of lactose weighs | ounce; therefore we have added IJ ounces of lactose. To transfer this to per- centages, ^^ X 100 = 3.1 per cent, sugar added. Table I will be found convenient to remember; it is, I think, the easiest way to calculate sugar. Sucrose (cane-sugar) is somewhat heavier than lactose. Dextrimaltose is somewhat lighter (Table II). It is not necessary, however, to make special calculations for sucrose or for dextrimaltose; it is usually accurate enough to calculate as if for lactose, and then, if using sucrose, to use a little less than the calculation calls for; if using dextrimaltose, a little more. 2. The second way of using whole milk dilutions is with the aid of a table, and is not quite so practical as the first method. In any whole milk and water dilution, if five-sixteenths of the mixture is milk, that is, 5 ounces of milk in a 16-ounce mixture, * In using this method there is no necessity of being too accurate ; for example, supposing we were using 10 ounces of milk and 22 ounces of water in a mixture, it would be perfectly correct to call this one-third milk, or fat, 1.3; sugar, 1.5; protein, 1.1. THE MODIFICATION OF MILK 185 and the rest water, the percentages are: fat, 1.25; sugar, 1.40; protein, 1. Similarly, if more milk is added, the percentages are as given in Table III. TABLE I Calculation of Sugar One level tablespoonful of lactose raises the sugar percent- age^- 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 0. 80 in a 48-ounce mixture TABLE II Comparative Weights of Sucrose, Lactose, and Dextrimaltose Sucrose, Lactose, Dextrimaltose, gm. gm. gm. 1 level tablespoonful ... 15 10 9 1 rounded tablespoonful. ... 25 16 14 Measures 3 level teaspoonfuls = 1 level tablespoonful 2 level tablespoonfuls = 1 large kitchen spoonful TABLE III Percentages of Fat, Sugar, and Protein, According to Proportion OF Milk in Mixture Milk. Fat. Sugar. Protein. A-... 1.50 1.70 1.20 ■^ 1.75 2.00 1.40 •^ 2.00 2.25 1.60 A 2.21 2.50 1.80 if 2.50 2.80 2.00 ^ 2.75 3.00 2.20 T6 16 ^ 3.00 3.30 2.40 The amount of sugar necessary to add can be determined by referring to the sugar table (Table I). The table of whole milk dilutions is calculated on the basis of sixteenths. Of * These figures are not absolutely accurate, but are near enough for prac- tical purposes, and are adopted for the sake of convenience. l86 PRACTICAL INFANT FEEDING course, if one is dealing with a 32-ounce or a 48-ounce mixture, the fraction A or A, etc., is multiplied through by 2 or 3, as the case may be; that is, A is the same as M or if. Propor- tionate calculations can be made for 24-ounce or 40-ounce formulas; that is, in a 24-ounce mixture the amount of milk required to give the same percentages would be IJ times what it would be for a 16-ounce mixture, or in a 40-ounce mixture it would be IJ times what it would be for a 32-oimce mixture. Thus we can accurately figure from this table 16-, 24-, 32-, 40-, and 48-ounce mixtures, which are the most common ones used. Top Milk (Cream) Dilutions. — The top portions of a quart of milk, after it has been allowed to stand about six hours, con- tain varjdng amounts of fat, as in Table IV. TABLE IV Amount of Fat in Top Milk^ Per cent. fat. Top 2 ounces mixed contain 24. Top 3 ounces mixed contain 22.5 Top 4 ounces mixed contain 21.4 Top 5 ounces mixed contain 19. 2 Top 6 ounces mixed contain 16. 8 Top 7 ounces mixed contain 15. Top 8 ounces mixed contain 13 . 3 Top 9 ounces mixed contain 11.5 Top 10 ounces mixed contain 10. 5 Top 12 ounces mixed contain 9.0 Top 14 ounces mixed contain 7.8 Top 16 ounces mixed contain 7.0 Top 18 ounces mixed contain 6.3 Top 20 ounces mixed contain 5.8 Top 22 ounces mixed contain 5.4 Top 24 ounces mixed contain 5.0 Top 26 ounces mixed contain 4.7 Top 28 ounces mixed contain 4.5 Top 30 ounces mixed contain 4.3 It is possible by different dilutions of these creams of vary- ing fat percentage to secure mixtures containing more fat than is possible with the use of whole milk dilutions. High fats and * From Morse and Talbot's Infant Feeding. THE MODIFICATION OF MILK 187 rather low proteins are obtained by the use of this method of modification, whereas by the use of whole milk dilutions low fats and relatively high proteins are obtained, as we have seen. As may be seen from the table, there are a good many different strengths of cream which may be used; practically it will be found best to confine oneself to the use of the top 10 ounces, top 16 ounces, and top 24 ounces, containing 10, 7, and 5 per cent, of fat respectively. The amounts of sugar and of protein contained in these three different creams vary a Kttle, as shown by Table V; but the variations are so shght that they may be disregarded, and for practical purposes the sugar and protein content of the various creams may be considered to be 4.50 and 3.20 per cent, respectively. In using these three creams the possible combinations which would be of practical value in infant feeding are as given in Table VI. Sugar may, of course, be added up to any desired percentage, using the same sugar table as for whole milk dilu- tions. TABLE V Composition of 10, 7, and 5 Per Cent. Creams^ . Percentages . Fat. Sugar. Protein. 10 per cent, cream 10.00 4.40 3.25 7 per cent, cream 7.00 4.45 3.40 5 per cent, cream 5.00 4.50 3.50 TABLE VI Formulae From 10, 7, and 5 Per Cent. Creams of Practical Value Combination. , Percentages . 10 per cent. : Fat. Sugar. Protein. Cream, 1 part ; water, 2 parts 3.3 1.5 1.1 Cream, 1 part; water, 3 parts 2.5 1.1 0.80 7 per cent. : Cream, 1 part; water, 1 part 3 . 50 2 . 25 1 . 60 Cream, 1 part; water, 2 parts 2 . 50 1 . 50 1 . 10 Cream, 1 part; water, 3 parts 1 . 80 1 . 10 0. 80 5 per cent.: Cream, 2 parts; water, 1 part 3.2 3. 00 2.2 Cream, 1 part; water, 1 part 2 . 50 2 . 25 1 . 60 Cream, 1 part; water, 2 parts 1 . 70 1 . 50 1 . 10 1 From Morse and Talbot's Infant Feeding. l88 PRACTICAL INFANT FEEDING This method of milk modification is employed considerably, and when used with intelligence carries with it no objections. It is not at all imcommon, however, to see mixtures containing 5 or 6 per cent, of fat obtained by this method, which is, of course, quite unsuitable for any baby. If cream dilutions are used, the fat content of the original cream and of the resulting mixture must be borne carefully in mind. Many men forget this. It is possible, of course, in using this method to get in- numerable formulas by various dilutions of 6, 8, and 12 per cent, creams, or by dilutions of the bottom milk after certain amounts of the cream have been removed; but the introduction of so many different strengths of cream and of milk makes such a complicated array of figures which are so difficult to remember that it is best for practical purposes, if using this method, to confine oneself to dilutions of 10, 7, and 5 per cent, creams, as given above. The use of even these three strengths of cream introduces an unnecessary complication, as any mixture that can be obtained by these methods can likewise be obtained by the gravity cream and skimmed milk method by using only one standard strength of cream in combination with skimmed milk. Gravity Cream and Skimmed Milk Mixtures. — The method of gravity cream and skimmed milk mixtures is the method of milk modification that is the most adaptable to the needs of various babies. In one respect it is more complicated than the other methods, as instead of using simply dilutions of milk or of cream, when we have but one diluted factor to consider, we have here two diluted factors. The purpose of this method is to furnish a means of obtaining practically any combination of the food elements that we desire. Most of the protein is furnished by the skimmed milk; then enough cream of a known fat content (16 per cent.) is added to supply the required fat percentage. It is inevitable in any such method as this that there should be a certain amount of calculation; we could not speak simply in terms of so much cream, skimmed milk, water, and sugar, and have any idea whatever of what we were giving to the baby. We must speak in terms of percentages always in using this method. THE MODIFICATION OF MILK 189 My own feeling is that this is the best method of milk modi- fication for general use. It does not apply to very ignorant patients who have not the inteUigence or the desire to go through the procedure involved; for these whole milk dilutions must be used. Most mothers or nurses will be able to handle gravity cream and skimmed milk dilutions without trouble, however, and the amoimt of calculation involved for the practitioner is not at all difficult or complicated when it has been once mastered. It is a most practical and intelligent way of feeding, and enables the practitioner to change the amounts of protein and of fat in his mixtures much more easily than by any other method. It tends to do away with empiricism, and tends to make those using it think more accurately in terms of the food elements than they would otherwise. Its disadvantage is that there is more calculation involved in it than in the other two methods of milk modification. If it is worth while, if it offers advantages, and I believe it does, the small amount of extra trouble involved should not count against it. Let us consider for a moment what we mean by gravity cream and skimmed milk. After a quart of milk in the ordinary milk jar has stood about six hours the cream comes to the top, and is separated from the milk by a fairly definite line known as the cream line. All this cream is known as gravity cream. This will usually amoimt to about 6 ounces. All the cream down to the cream line is then gravity cream, and contains: fat, 16; sugar, 4.5, and protein, 3.2 per cent. What is left behind is the "skimmed milk," which contains: fat, 0; sugar, 4.5, and protein, 3.2 per cent. These figures are not strictly accurate, but the errors in one counterbalance those in the other. "Skimmed milk" actually contains a little fat, but for practical purposes this may be disregarded. The advantages of using "gravity" cream instead of creams obtained in other ways is that it does away with confusion, and we have simply to remember that the cream we are dealing with always contains 16 per cent, of fat instead of trying to remember the fat content of several different layers of cream, as is done by the "top milk" method. The igo PRACTICAL INFANT FEEDING best method of separating the gravity cream from the skimmed milk is to dip it off with a Httle dipper devised by Dr. Henry Chapin, of New York, and called, after him, the ''Chapin dip- per.'' This can be obtained at any large drug store. Pouring can be used if no dipper is obtainable, but it is not quite so accurate. An important practical point to remember is to tell the mother to remove all the cream on the quart, and to explain to her carefully what gravity cream is. Otherwise she is very likely, supposing the formula calls for 3 or 4 ounces of cream, to take off simply the top 3 or 4 ounces, and use this, in which case she would be using a 20 or 22 per cent, cream, and would be putting more fat in the mixture than was prescribed. All the cream down to the cream Hne should be removed, put into a bowl, and mixed; then the required number of ounces is taken from this. Calculation of Formulce. — There are two ways of calculat- ing gravity cream and skimmed milk mixtures, which may be called the "long" method and the "short" method. The long method employs no short cuts, calculates each ingredient step by step, and is a rather laborious procedure. It is not necessary to use it in actual practice, but it is desirable to know, as he who understands this method of calculation will understand the principles of calculating the percentages of any formula, no matter what its ingredients are, without the use of any tables or equations. Inasmuch as the "short method" is the best to use in actual practice, however, and in order to avoid con- fusion, I have put the long method in an Appendix at the end of the chapter. Short Method. — The easiest way of calculating gravity cream and skimmed milk mixtures is by the use of a table of factors, which can be carried in the pocket or notebook on a little card, and which is easily memorized after it has been used a few times. By its use all the necessary calculation can be done in the head. The question of calculation is what has deterred many men from using the gravity cream and skimmed milk method, and it is true that the i Fig. 19. — Figures 19 to 22 inclusive are all from cases of rickets in the florid stage. Note especially the frayed-out appearance of the ends of the diaphyses and the indistinctness of the epiphyses. Rowland^ have recently pointed out. There may be a pro- gressive reduction in the size of the thorax, and loss of power to expand, followed by atelectasis of portions of the lungs, con- sequent impediment to the pulmonary circulation, and hyper- trophy of the right side of the heart. With very severe de- formity the power of the respiratory apparatus may be barely 1 Bull. Johns Hopkins Hosp., 32, 101, April, 1921. 39° PRACTICAL INFANT FEEDING sufficient for the needs of the body, and if any pulmonary infec- tion is added it fails and death results. A low-grade, patchy type of bronchopneumonia is responsible for many deaths in rachitic infants, and this is indeed the chief danger to life that rickets offers. Fig. 20. — Knee: Florid stage. Most rachitic children are anemic, occasionally to a severe degree, the anemia being of the ordinary ^'secondary" type with low hemoglobin and moderate diminution in the numbers of the red cells. This anemia is often associated with enlargement of the spleen, and probably a good many cases of "Banti's disease'^ RICKETS 391 and "pseudoleukemia" that have been reported in infants have had rickets as their basis. The spleen is frequently slightly enlarged in moderately severe cases without much anemia^ and should always be carefully felt for if rickets is suspected, as it is a diagnostic point of some importance. It is often difficult to Fig. 21. — Knee: Florid stage. feel a slightly enlarged spleen in a baby. The mistake that many people make is to press in too deeply, and to feel with too large an area of the fingers instead of with the tips alone. There is likely to be a slight enlargement of the lymph-nodes. 392 PRACTICAL INFANT FEEDING This is, however, not especially characteristic of rickets, and may occur in any poorly nourished infant. The liver is enlarged in some cases, particularly if the diet has been very high in carbohydrate. The nervous system in rickets shows an increased irritability. It may take the form of spasmophilia, which is so often asso- ciated with rickets, or it may manifest itself simply by restless- ness on the part of the child, especially at night, and by a Fig. 22. — Ankle: Florid stage. tendency to jump at noises or any unexpected sudden motion on the part of the nurse or the mother. The disposition is likely to be peevish and fretful, and in a hospital ward a child with severe rickets is usually the ''bad boy" of the ward. The tone of the muscles is poor, and in some cases the leg muscles may be so weak as to suggest paralysis. The abdominal muscles are also thin and weak, giving rise to the ''pot belly" RICKETS 393 and soft relaxed abdominal walls which are so characteristic of this disease. The hair is sparse, and owing to the nervousness of the child and his tendency to roll his head about, it may wear off in spots, giving rise to a patchy, moth-eaten appearance. Fig. 2d>. — Stage of healing. Note especially the clearer outline of the epiphyses, also the broadening of the ends of the diaphyses. The white line is also visible, but not so marked as it is in some cases. Diagnosis. — ^A well-marked case of rickets can scarcely be confused with anything else. It is sometimes difficult to decide, however, in the early stages how much evidence is necessary before it is allowable to make the diagnosis. Head sweating, restlessness at night, enlarged fontanel, slow dentition, poor tissue turgor, and slight 394 PEACTICAL INFANT FEEDING rosary constitute enough evidence upon which to base a diag- nosis of early rickets. Later on the enlarged epiphyses, shape of the head and chest, bowing of the legs, etc., make an unmis- takable picture. Fig. 24, — Stage of healing. Note especially the thickness of the tibia and the white line at the lower diaphyseal end. Chondrodystrophy Jcetalis is a condition which has sometimes been mistaken for rickets. This begins in fetal life and con- sists of a disturbance of ossification resulting in a premature ossification of the cartilage, with a consequent short bone. The arms and legs are very short in relation to the trunk, there RICKETS 395 is no rosary, and the epiphyses are not enlarged. The x-ray shows a normal appearing epiphysis, ''which maintains its clear- ness and regularity of outline throughout the affection" (Lovett). The diaphyseal ends of the long bones also are sharp and clean cut in outline, and never show the frayed appearance so char- acteristic of rickets. In Jragilitas ossium there are multiple fractures, but this is its only real resemblance to rickets. The long bones are very slender, and show an extreme fragility, so that they fracture on the very slightest provocation. The epiphyses show none of the characteristic changes seen in rickets. Osteogenesis imperfecta is usually seen in stillborn babies. The bones are very thin and extremely soft, more so than in rickets, and bend easily in all directions. The bones of the skull are especially very soft and thin, so that the cranium may be almost entirely membranous. The condition is incompatible with life, and infants with it usually die soon after birth. Scurvy probably bears no etiologic relationship to rickets, but the two often coexist. In rickets there may be some pain in the legs, especially about the knee, but it is never as severe as the pain in scur\y, and most of the cases which have been called "acute rickets" are, in reality, probably scur\y. In scurvy the trouble is along the shaft of the bone, in rickets mostly in the epiphysis. In scurvy the x-ray shows the clear outline of the epiphysis, in rickets it does not. The ''white line" is present in both. "On the appearance of the epiphysis alone it is possible to differentiate the two diseases" (Lovett). Prophylaxis. — The prophylaxis of rickets is important, and it is theoretically possible by proper prophylaxis to do away with the disease. Sunshine, fresh air, and proper feeding are the cornerstones of prophylaxis, and it is probably true that few babies will develop rickets if they are properly fed and get a sufficient amount of outdoor air. Under proper feeding comes weaning at the right time, which should be done in most cases not later than the eighth or ninth month; babies fed at the breast longer than this will certainly in many instances develop 396 PRACTICAL INFANT FEEDING rickets. Whether or not green vegetables are of any value as a prophylactic is an undecided question. The fact remains, how- ever, that babies fed upon suitable milk modifications — cereals, soups, and beef juice — up to the fourteenth or fifteenth month, and cared for adequately as to their general hygiene, do not develop it, so it would seem that green vegetables are not neces- sary as a prophylactic, provided the diet is suitable in other respects. Cod-liver oil is of unquestioned prophylactic value, and it has its particular field of usefulness in premature babies, who are so likely to develop rickets. It is a good idea with all prematures, at the third or fourth month, to begin feeding cod-liver oil in doses of 10 to 20 drops three times a day, which may be increased at the eighth month to J teaspoonful or even a whole teaspoonful at a dose. Rickets is such a wide-spread disease that it must be borne in mind that any feeding case or apparently normal baby in one's practice may develop it. Prophylaxis and a careful exami- nation for early rickets each time the baby is seen are, therefore, important. Treatment. — The treatment of rickets is satisfactory and good results may be obtained. Feeding. — If there is any special type of indigestion present, this must be corrected. The most common type likely to be found is a chronic fat indigestion with constipated stools con- taining a large amount of soap; the stools should, therefore, be examined. If the baby has been on a diet high in carbohydrate and low in protein and fat, the carbohydrate should be reduced and the fat and especially the protein raised to the limit of toler- ance. A mixed diet should be begun as early as possible; rachitic babies almost always do better on this sort of diet than on milk alone. Orange juice may be used any time, small amounts of strained oatmeal and meat soups may be begun at the seventh month, while spinach or carrot puree and beef juice may be started at the eighth or ninth month. Egg yolk is also of value, and may be given at the end of the first year. It is best given by hard boiling the egg, separating the yolk from the white, RICKETS 397 grating it, and mixing it with the vegetables or cereal. The rachitic child will, therefore, be taking a much more varied diet than would a normal child of the same age. It is hard to explain scientifically, in view of what we know concerning the etiology of rickets, why green vegetables should be of value in the treat- ment, inasmuch as it is not generally believed that lack of the fat-soluble vitamin, which is contained in considerable amounts in green vegetables (especially spinach) is the cause of the disease. Also, inasmuch as it is not caused by lack of calcium in the diet, the moderate amounts of calcium contained in vegetables would not be especially indicated. The fact remains, however, that green vegetables in the diet do seem to do good in the treatment, whatever the exact explanation may be. Drugs. — Cod-liver oil and phosphorus have for long been used in the treatment of rickets. This combination was first extensively used by Kassowitz about 1880, and had consider- able popularity for a while, after which it rather fell into mild disfavor for a period, but in the last few years has had a great revival of popularity. At present practically all students of rickets are agreed that cod-hver oil alone, or combined with phosphorus, is of great value, and it has been shown by several investigators that cod-liver oil when ingested increases the retention of calcium and of phosphorus by the growing bone. It is probably even more efficient when combined with phos- phorus than when used alone. Prolonged administration is necessary if the best results are to be obtained, but Howland and Park^ were able to show by means of the x-vd^y that there was definite calcium deposition in the ''osteoid" tissue as soon as three weeks after beginning treatment with cod-liver oil. The reason why administration of cod-liver oil should increase the deposition of calcium in the growing bone is not known. It is rich in the fat-soluble vitamin, and contains a not incon- siderable quantity of iodin; aside from this there is probably nothing different about it chemically from any other fat. The usual dose of cod-liver oil to begin with for a baby of six months 1 Arch. Ped.. 37. 1920. 398 PRACTICAL INFANT FEEDING or under is about 20 drops three times a day. After the ninth or tenth month a teaspoonful at a dose may be taken. Babies usually take it readily, and it is less likely to upset the stomach or to cause loss of appetite if it is given immediately after the feeding than at any other time. If the stools begin to smell like cod-liver oil this is a sign that it is not being well assimilated, and is an indication for a reduction in the dose. If it is desired to use phosphorus in conjunction with the cod-liver oil, the best prescription is the following: R. Phosphorated oil 3ss; Cod-liver oil giv. — M. Shake well before using. S. — One teaspoonful three times a day. Each minim of the official phosphorated oil of the Phar- macopeia contains about rio grain of phosphorus, therefore each teaspoonful dose of the above prescription would contain about that amount. Phosphorated oil is heavier than cod-liver oil and has a tendency to settle to the bottom of the bottle, therefore it must be shaken vigorously before using, as, if it is not, the last dose in the bottom of the bottle might contain enough phosphorus to poison the child. Calcium. — There is probably no advantage in giving calcium salts to a baby with rickets, inasmuch as the food contains a great sufficiency, and it is probable that increasing the amount of calcium in the diet has no effect on the retention of cal- cium. Tincture of Nux Vomica. — Small doses of tincture of nux vomica may be of value for rachitic children over a year old, particularly if they are constipated. A child of this age would take from 1 to IJ minims three times a day. It is best given in orange juice. Iron. — Inasmuch as almost all rachitic children are some- what anemic, some markedly so, iron is usually indicated, and seems to do good. The best iron preparation for babies is the saccharated oxid, and is prescribed in powder form, a pinch or RICKETS. 399 two to be given three times a day in orange juice, or mixed with the food. I^. Saccharated oxid of iron (powdered), gij. S. — One pinch three times a day. General Treatment. — Sunshine and fresh air are of the utmost importance. The rachitic baby should be out of doors as much as possible on the sunny side of the house. In summer there is no place like a beach for a rachitic child, and a month or two at the seashore sometimes works wonders. If the child is old enough he may be put on the beach in his pen, and may spend most of the day there. Several competent observers have thought that lack of light had a good deal to do with the development of rickets, and it certainly seems as though this might be true in some cases. On a broad beach of light colored sand the Hght is intense on sunny days, and it is, therefore, an ideal place to secure any possible therapeutic effect that light may have.^ Salt-water baths are also of value, and if a rachitic baby is at the seashore they should certainly be used. The rachitic baby should not be urged to sit up or to walk, but should be left to his own devices in this respect. He should be rather held back than pushed ahead, as if he walks much while the rachitic process is still active, particularly if he is a heavy baby, any bowing of the legs will become much intensified. Prevention of Deformity. — The treatment of the deformities resulting from rickets is an orthopedic problem, and there should be a close co-operation between the pediatrician and the orthopedist in this respect. It is well not to wait too long before calling in the orthopedist, as by the use of suitable apparatus he can usually prevent severe deformity from taking place. The three deformities that are most amenable to treatment in the florid stage of rickets and which come under the observa- tion of the medical man are bow-legs, pronated feet, and kyphosis. If the bowing of the legs is at all extensive it is well ^ Since this was written several papers have appeared, showing definitely that exposure to sunlight increases markedly calcium deposition in rachitic bone. 400 PRACTICAL INFANT FEEDING to have proper braces applied, and in conjunction with diet, cod-liver oil, and hygiene, it is often remarkable to see what good results may be obtained in a few months. Bowing of the legs may occur even before the baby starts to walk, and in these cases the bowing is, of course, greatly intensified as soon as walking begins. It is therefore wise to have the braces applied early, even if the baby is not walking. Braces are also often necessary for weak legs without any bowing. Extreme pronation of the feet is very common and is due to the laxity of the ankle ligaments. This alone may prevent walking, but responds very readily to treatment, and it is remarkable to see sometimes how well a rachitic child of eighteen or twenty months will walk if he has proper shoes and proper ankle braces, when he could perhaps barely stand before their appHcation. The type of shoe for rachitic children just begin- ning to walk is of importance. It should be a high laced shoe of fairly heavy leather, with a stiff sole, and often needs a steel ankle shank and a modified Thomas heel in order to throw the balance of the foot outward. A word of warning as to mocca- sins, which are so popular for young babies of a year or two old. They give practically no support to the foot, and should not be used for either normal or rachitic babies. Mild degrees of kyphosis may be treated by having the baby He on a hard flat surface and by not allowing him to sit up. More severe cases may need to be kept strapped continually to a Bradford frame. Course and Prognosis. — Rickets tends to heal spontaneously, and after a few months of diminished calcium deposition in- creased amounts are retained and the bone becomes hard again. It is not common to see active rickets after the age of two years. The course of the disease without treatment may last anywhere from four to fifteen months. With proper treatment it may be considerably shortened. The end-results with good treatment are usually satisfactory, but depend to a very large degree upon how soon the case is seen. It should be possible in any early case to prevent deformity from occurring. It is remarkable to see how few signs of rickets are left in most cases as the child RICKETS 401 grows up if excessive deformities were not present. The legs slowly straighten, the epiphyses come back to normal size, the rosary disappears, and the head assumes a normal shape, so that in a great many cases by the time the child is ^ve or six years old one would not know that he had had rickets. The second dentition, however, is likely to be poor, and there is no doubt that a good many of the carious teeth occurring in child- hood have an earlier rickets as their basis. In some cases the deformity of the legs is so great, either extreme bow-legs or knock-knee, that operation has to be resorted to. The disease is not ordinarily dangerous to life except indi- rectly. Rachitic children are prone to infection and bear it poorly. Pulmonary infection of any sort is an especially com- mon cause of death. 26 CHAPTER XVIII SPASMOPHILIA Spasmophilia is a not uncommon chronic disorder of metab- oKsm seen usually in infants, and manifested by an increased irritability of the central nervous system, which shows itself by spasm of the larynx (laryngismus stridulus), carpopedal spasm (tetany), or by general convulsions. It is often latent, in which case it is manifested merely by increased electric and mechanical irritabihty. It is probably dependent upon faulty calcium metabolism. Occurrence. — ^The youngest case reported is by Wolff, in an infant of seven weeks.^ It is, however, rare before the age of three or four months, and occurs most commonly between the fifth and eighteenth months. It may be seen in older children or even in adults after parathyroid extirpation or in certain gastric conditions. It is not at all uncommon, and according to various observers occurs in from 1 to 2 per cent, of all infants under two years of age. It is not unlikely, however, that it is much more common than this, as many cases are latent, without active manifesta- tions, and pass unrecognized. It is undoubtedly true that a large proportion of the convulsions seen in infancy, and formerly thought to be due to many varied etiologic factors, actually rest upon a spasmophilic basis. Almost all cases are seen in bottle-fed babies, but it can occur in the breast fed. It is almost always associated with rickets, and has been regarded by some observers not as a separate disease, but as a complication or manifestation of this disorder. This, however, is probably not true, as it is sometimes seen in infants who show no 1 Arch. f. Kinderheilk., August 31, 1920, 68, 1 and 2. 402 SPASMOPHILIA 403 signs of rickets. It occurs most commonly in poorly nourished infants who have had trouble with their feeding, and is especially likely to be seen in those who have been fed on proprietary foods, or on any mixture excessively high in carbohydrate and poor in the other food elements (cf. Rickets). The seasonal incidence is very striking. It is most com- mon in the winter and spring, and only rarely occurs during the summer months. In a series of 246 cases collected by Wilcox,* 74 per cent, occurred during the months of January, February, March, and April. The highest incidence (24 per cent.) was in March. Of 47 cases reported by McLean^ from the Out-patient Department of the Babies' Hospital, New York, none occurred during July, August, or September. There is some evidence to show that there may be a famihal tendency to spasmophiKa, but it is not a truly hereditary disease. Etiology. — Numerous theories of etiology have been pro- posed in the last fifteen years which would be tedious to review, and it is best to confine ourselves to the views held at the present time by the majority of authorities. The Parathyroids. — The parathyroid glands are small bodies which lie in the fatty and connective tissue about the thyroid, and are usually four to six in number. It is possible to produce a condition very similar to or identical with spasmophiKa in infants in experimental animals (dogs) by extirpation of these glands, or in human beings (adults) when the parathyroids have been inadvertently removed during the course of a thy- roidectomy. In experimental animals electric irritability of the central nervous system is increased, the blood calcium is lowered, and there may be carpopedal spasm in the same way that there is in naturally occurring spasmophiKa. Furthermore, the same methods of treatment apply to the one as to the other. Also, in a good many infants dying during a period of active spasmo- 1 Amer. Jour. Dis. Chil., vol. 1, 1911. 2 Arch. Ped., vol. 37, 1920. 404 PRACTICAL INFANT FEEDING philia, old or fresh hemorrhages in the parathyroid glands are found, and this has led some investigators to the belief that abnormality of these bodies is the cause of the disease. How- ever, many autopsies show lesions of the parathyroids, yet the babies during Hfe have had no sjnnptoms of spasmophiKa. Furthermore, inasmuch as many spasmophiHc infants show no signs whatever of damage to the parathyroids,^ and as the condition may be produced in other ways quite independently of these bodies, it is the consensus of opinion that parathyroid insufficiency has little to do with spasmophilia as it is ordinarily seen. Calcium. — ^AU experimental and clinical evidence points to the fact that faulty calcium metabolism is the most important factor in the etiology of spasmophilia. One of the first observa- tions was the oft-quoted one of Quest,^ who found that the brains of spasmophilic infants contained less calcium than those of normal infants. A most significant fact is that the blood calcium is con- sistently low both in natural and artificially produced spasmo- philia. Howland and Marriott^ found that in normal infants and adults the blood calcium was constantly between 10 and 11 milligrams per 100 c.c. sermn. In 18 cases of active tetany the average was 5.6 mgm. per 100 c.c. serum, a reduction of from 40 to 50 per cent, in nearly all cases. In convulsions not due to spasmophiKa the calcium content of the serum was foimd to be normal. These results have been confirmed by other observers. It has also been found that during the active period of tetany there is a considerably diminished retention of calcium, and that as the tetany disappears the calcium retention im- proves. ^>^ It is possible either in artificially produced or naturally occurring spasmophilia to relieve the active symptoms, and to 1 According to Howland and Marriott (Quart. Jour. Med., 11, 289, 1918) parathyroid lesions are the exception rather than the rule. 2 Jahrb. f. Kinderheilk., Ixi, 114, 1905. ^ Loc. cit. ^ Schwartz and Bass, Amer. Jour. Dis. Chil,, vol. 3, 1912. ^ Brown and Fletcher, Amer. Jour. Dis. Chil,, vol. 10, 1915. SPASMOPHILIA 405 bring about a more normal nerve irritability by the adminis- tration of calciiun salts. The Relation of Sodium to Spasmophilia. — ^The sodium ion acts as a nerve irritant, and excess of this ion in the blood can bring about such an increased irritability as to cause spasmo- philia. Rowland and Marriott^ report 3 typical cases of tetany caused by intravenous injections of sodium bicarbonate for acidosis. Morse/ likewise, reports the case of a girl who was given large doses of sodium bicarbonate at one time, and a considerable amount of sodium phosphate another time for the treatment of a long-standing pyelitis. Both times she developed typical and severe tetany. Her renal function was found to be very poor, with an extreme fixation of specific gravity and a very low phthalein test. At autopsy her kidneys were much atrophied and showed typical chronic ' 'interstitial nephritis.'' The func- tion of the kidney was so poor that the sodium salts given could not be excreted, but were retained in the blood, and increased nerve irritability to such an extent as to cause tetany. A similar case has been reported by Grulee,^ and he likewise points out the fact that whey, which is rich in sodium salts, when fed to spasmophiHc infants may precipitate an attack of tetany or general convulsions, or may make an already existing tetany worse. The Interrelationship of Sodium and Calcium. — It is probable that faulty calcium metabolism alone is not the cause of spasmo- philia, and that the significant fact is the ratio in the blood- serum between the calcium, on the one hand, and the sodium on the other. Calcium is a nerve sedative, sodimn a nerve irritant, and in order to maintain the correct degree of nerve irritability there must be a definite ratio between the amount of calcium and of sodium in the blood. Increased sodium or 1 Loc. cit. 2 N. Y. Med. Jour., No. 25, December 18, 1920. •Amer. Jour. Dis. Chil., vol. 13, 44, 1917. 406 PRACTICAL INFANT FEEDING diminished calcium cause an increased nerve irritability, i. e., spasmophilia. This disturbance of equiHbrium is brought about by faulty metaboHsm in bottle-fed babies suffering from certain digestive disturbances. The exact mechanism of its production is obscure. This theory has been advocated especially by Brown and Fletcher.^ It is probably not far from the truth, and has considerable experimental and clinical evidence to support it. The fact that the blood calcium is low, that feeding calcium salts either to dogs with experimental tetany or to infants with spasmophiHa reduces the nerve irritabihty, and that sodium salts either by mouth or intravenously greatly increase it, which has been shown by numerous investigators, are all strong argu- ments. Brown and Fletcher have also shown that in the active stage of spasmophilia there is a great storing up of sodium and potassium in the body, and a loss of calcium and magnesium,^ and that when the S3rmptoms begin to improve these conditions are reversed. They believe that free diuresis and free action of the bowels are very important in getting rid of sodium and potassium, and record several cases in which there was great improvement coincident with a diarrhea, during which there was probably a sweeping out of these elements from the body. Symptoms. — Spasmophilia may be latent, with no symp- toms except an increased mechanical and electric nerve irrita- bility, or it may be active, when it is manifested by laryngismus stridulus, tetany, or general convulsions. SHght causes of irri- tation, such as indigestion, teething, or acute respiratory infec- tions, which would probably cause no nervous disturbance in a normal infant, may be enough in a spasmophilic baby to convert the latent condition into the active. Signs of Increased Nerve Irritability. — ^The so-called "Chvos- tek" sign or ^ ^facial phenomenon" occurs in most cases, whether latent or active, and is one of the most practical and rehable * Loc. cit. 2 Rowland and Marriott have found that the magnesium content of the blood in spasmophilia is normal, and believe that this element has little to do with it. SPASMOPHILIA 407 diagnostic signs that we have in spasmophilia. It consists of a quick contraction of the small muscles about the mouth, nose, or temporal region, when the facial nerve is lightly tapped, either with the finger or with a small percussion hammer, in the middle of the cheek just under the malar bone. Escherich^ records this sign in three degrees as follows: 1. A slight twitching at the angle of the mouth or of a small muscle bundle in the nose or forehead. 2. A strong twitch at the corner of the mouth, alas nasi, or labialis or frontalis muscles. 3. A definite twitch in all the muscles suppKed by the facial nerve. The Peroneal Sign. — This sign is elicited by tapping lightly over the peroneal nerve at the head of the fibula on the outside of the leg. A quick outward jerk of the foot follows. Trousseau's Sign. — If the upper arm or leg is constricted by compressing the limb with a tourniquet, typical carpopedal spasm may result. In our opinion this is not a very valuable sign, as it is absent in many cases of spasmophilia, and it is not of enough value to subject the baby to the discomfort and possi- ble danger of carpopedal spasm. If it occurs it is, however, pathognomonic. It is not a necessary sign for the diagnosis of spasmophilia, and I have given up even trying for it on accoimt of the reasons given above. Electric Irritability. — Increased irritability of the nervous system as measured by the response (usually of the peroneal nerve) to stimulation by the galvanic current is the most char- acteristic, constant, and reliable finding in spasmophilia. This is known as Erb's phenomenon. The determination of the electric reactions is undoubtedly the most accurate method of diagnosing the condition and of following the results of treat- ment. It is not an especially complicated test to perform by those who are familiar with it, but requires a certain amount of electric apparatus and considerable practice before reliable results can be obtained. It is for use in hospitals and by pedi- * Quoted by Holmes, Amer. Jour. Dis. Chil., vol. 12, i, July, 1916. 408 PRACTICAL INFANT FEEDING atrists who are seeing many cases of spasmophilia, or who are especially interested in the subject. It is not practical for others to use, and it is quite possible to diagnose and to treat active spasmophilia successfully with- out it. Therefore, as I do not wish to bore the average reader by filling up space in the middle of a chapter with something that is of no practical value to him, I have discussed the electric reactions in an appendix at the end of the chapter. Active Symptoms of Spasmophilia. — The most common active symptoms are: 1. Laryngismus stridulus. 2. Tetany. 3. General convulsions. Spasm of the bronchial musculature ("bronchotetany") has also been observed. Laryngismus Stridulus. — This is a frequent and character- istic manifestation of spasmophilia. It consists of a spasmodic contraction of the laryngeal muscles, and in the mildest cases is manifested merely by a crowing sound during inspiration, when the child is laughing or crying. In somewhat more severe cases there is a momentary cessation of respiration, accompanied by a slight degree of cyanosis, and followed by the characteristic "crow." In the most severe cases the symptoms may be ex- tremely alarming. The attack of apnea comes suddenly, pre- ceded by a short intake of the breath. Cyanosis is marked, the baby struggles for the breath it cannot get, and loses conscious- ness if the period of apnea lasts more than a few seconds. There may be also associated general convulsions. After a few seconds, in most cases, the spasm relaxes, the breath is drawn in with a crowing sound, and consciousness returns. In rare cases the spasm may be so severe that intubation or tracheotomy is necessary, and death has been reported. Attacks of laryngismus stridulus may be very frequent, often as many as thirty or forty in the twenty-four hours. Tetany or carpopedal spasm consists of a tonic contraction of the hands and feet. It may or may not be accompanied by SPASMOPHILIA 409 general convulsions. The position of the extremities is quite characteristic, the hands being flexed at the wrists, turned to the ulnar side, with the thumb drawn across the hand toward the little finger. The feet are extended on the legs, and the toes are tightly flexed. There is usually evidence of considerable pain during the spasm, especially if one tries to unclinch the hands, and some- times the backs of the hands and feet may be considerably swollen. There is usually no loss of consciousness during carpo- pedal spasm unless general convulsions occur along with it. The spasm ordinarily lasts from a few minutes to a few hours, but may continue for several days or even weeks. It occurs in by no means a large proportion of spasmophilic cases, but when it does occur is pathognomonic. General Convulsions. — General convulsions represent one of the most common manifestations of spasmophilia, and may occur with laryngismus or tetany or, more commonly, alone. It is probably true that the majority of repeated convulsions occurring in infants under two years of age are manifestations of spasmophilia. Some exciting cause is usually necessary, such as the onset of an acute infectious disease, teething, indi- gestion, etc. There is nothing especially characteristic about spasmophilic convulsions, except that a great many may occur in the course of twenty-four hours, and that there is sometimes an associated tetany. Bronchial Tetany. — This condition is probably more common than is generally realized. It was first described by Lederer^ in 1913, who gave it the name "bronchial tetany." Curschmann soon after described certain other cases of a somewhat different type from those of Lederer.2 Short papers by Rietschel and by Wieland appeared in 1913 and 1914, but aside from this very little has been written regarding it. Lederer saw 58 cases of spasmophilia among 5903 ambulatory and 767 ward patients; 6 of these showed "bronchial 1 Ztschr. f. Kinderheilk., 1913, Bd. 7, 51. 2 Munch. Med. Woch., 1914, Ixi, No. 6. 4IO PRACTICAL INFANT FEEDING tetany/^ His patients were all under six months of age and all of them died. In most of his cases there was continued spasm of the bronchioles, probably lasting until death, and giving rise to pulmonary atelectasis, cough, cyanosis, and rapid respiration. According to Lederer the condition most likely to be confused with bronchial tetany in infancy is pneumonia. it:-Ray of the chest is of the greatest value in diagnosis, and serves to differ- entiate the two conditions. The atelectasis is caused by tonic spasm of the bronchial smooth muscle, which shuts off the air- supply to the alveoli supplied by that particular bronchial tube. Since the condition of spasm may last for days, weeks, or months, the air in the shut-off alveoli is absorbed, the walls collapse, and that portion of the lung becomes atelectatic. In Lederer's cases there was dulness over certain portions of the chest, which seemed sharply demarcated, while over the rest of the chest there was likely to be emphysema. The bronchial spasm may be continuous or intermittent, and in one case seen by us^ the intermittent attacks of spasm somewhat resembled whooping-cough. General Condition of Spasmophilic Infants. — ^The nutri- tional condition is never normal, although sometimes these children may appear fat, and may be of normal weight, or even above it. The flesh is not firm, however, nor is the color good. In most cases the baby is obviously undernourished and suffering from indigestion. The most common type of indigestion seen is probably chronic fat indigestion. Diagnosis. — ^The diagnosis should not be difficult in most cases. The Chvostek sign is present in about three-quarters of all cases, and if present in children under two years of age is pathognomonic. According to Holmes^ it is highly suggestive under four or five years, but may occur in mild degree in normal children of over three years. The appearance of tetany is quite characteristic, and can hardly be confused with anything else. 1 Med. Clin. North America, September, 1920. 2 Loc. cit. SPASMOPHILIA 411 Laryngismus stridulus, likewise, is such a striking condition that it should not ordinarily be mistaken. The two conditions with which it might be confused are congenital laryngeal stridor and breath holding due to temper. Congenital laryngeal stridor sounds a good deal like laryngis- mus stridulus to the inexperienced observer. It is probably caused by a congenital narrowing of the epiglottis,^ and gives rise to a noisy inspiration sometimes, but by no means always, accompanied by crowing. The noisy inspiration is continuous, however, and not spasmodic, as it is in laryngismus stridulus, nor is it accompanied by cyanosis, loss of consciousness, or convulsions. Breath holding h common in certain highly strung children. It is usually brought on by attacks of temper, when the child has been crossed in some way. He starts to cry vigorously, begins to get red in the face, then blue, and finally becomes limp and stops breathing for a moment, sometimes with a loss of consciousness, sometimes without. The period of apnea is only of short duration, and he soon "catches his breath." There is no crowing inspiration, no convulsion, and the attacks come on almost invariably following a display of "temper." These characteristics should easily serve to differentiate the two con- ditions. It should practically always be possible to diagnose active spasmophilia without the use of the electric reactions. In latent cases and in certain active cases manifested by convul- sions, but not by tetany or by laryngismus stridulus, when the Chvostek sign is negative, the determination of the electric reactions is necessary in order to make a certain diagnosis. These are, without doubt, the most reliable diagnostic criteria of spasmophilia, but, as we have said before, are not practical for average use (see Appendix). Prognosis. — Spasmophilia is not without danger to life, as occasionally a child with largygismus stridulus or general con- vulsions may die. The prognosis as to cure should be good in ^ Morse, Case Histories in Pediatrics, Boston, 1920. 412 PRACTICAL INFANT FEEDING the vast majority of cases, as there are fairly satisfactory methods of treatment. It is possible, however, that considerable permanent damage may be done to the central nervous system, and some clinicians believe that spasmophilic children who have suffered from re- peated convulsions are never quite normal mentally. Treatment. — Of the Active Manifestations. — ^A spasmophilic convulsion is treated in much the same way as any other con- vulsion would be. A good sized dose of castor oil should be given, and the lower intestine emptied by an enema. It is likely that these things will have been done before the doctor arrives. The next thing to do is to relieve the convulsion. This may be done in any one of three ways: Chloral. — ^The rectal administration of chloral is probably the most generally satisfactory way of controlling convulsions. Even small infants bear it well, and it works quickly, usually in about twenty minutes. I always carry in my bag a solution of chloral hydrate containing 5 grains to the teaspoonful, and give it mixed with a little warm milk high into the rectum with a glass syringe and a small rectal tube. It is usually well retained if the buttocks are held together for fifteen minutes or so after administration. The dose is relatively large, partly on account of the method of administration, partly because large doses are needed to overcome the extreme nervous irritability which is present. An initial dose of 5 grains is usually not too much for a well-grown baby of seven months, and another dose half the size of the first should be repeated in half an hour if the first has not taken effect. Despite the fact that it is well borne by even young infants, chloral is not a drug that can be used care- lessly, as it is sometimes very depressing to the circulation. I have seen the heart rate drop to 12 to the minute following a moderate sized dose of chloral to a baby of six months. The heart rate should, therefore, always be carefully watched, and camphor or brandy given if it is much lowered or shows signs of irregularity. Ether or Chloroform. — The inhalation of a small amount of SPASMOPHILIA 413 ether or chloroform is a vei}' efficient method of controlling convulsions, and works more quickly than does chloral. On account of the danger to the heart in infants from chloroform, and the possibility of starting up a respiratory irritation (par- ticularly in rachitic children) with ether, my personal preference is for chloral. Morphin. — Subcutaneous injections of morphin are likewise efficient, but I never like to use this drug in children under two years of age, as they are very susceptible to it, and doses which would not be considered at all large may cause poisoning. Inasmuch as almost all children who have spasmophilia are under two years, it has not, in my opinion, a very wide applica- tion in this disease. It is, however, recommended by several good authorities. Carpopedal spasm may often be relieved by a hot soak in the tub at about 110° F. If this does no good, chloral may be used in the same way that it is in general convulsions. The subcutaneous injection of magnesium sulphate is said to be very efficient in controlling carpopedal spasm, although I cannot vouch for it from personal experience, ha\dng never had occasion to try it. It was first used by Berend,^ who injected 20 c.c. of an 8 per cent, solution into the subcutaneous tissue of the buttocks. It has since been used by a number of other students of spas- mophilia -^dth apparently good results, and no bad ones, save a moderate amount of discomfort at the site of the injection. One injection is usually enough to control the spasm, but it may be necessary to repeat it again the next day. Its efi'ect is not of long duration, and its use applied only to the control of the active manifestations, and not to the correction of the amderlying disorder of metabolism. It is certainl}^ worth a trial either in obstinate tetany or in general con\ailsions which do not respond to other methods of therapy. Laryngismus Stridulus. — Slapping the baby on the back or i Monatschr. K. finderheilk., Orig. 12, 1913-14. 414 PRACTICAL INFANT FEEDING throwing cold water in his face often relieves laryngismus stridu- lus. In severe cases it may be necessary to undress the baby and dip him alternately in warm and cold water, or in rare cases artificial respiration, tracheotomy, or intubation may need to be resorted to. General Treatment of the Underlying Condition. — The whey of cow^s milk aggravates spasmophilia; breast milk cures it. For twenty-four to forty-eight hours after severe convul- sions, tetany, or bad attacks of laryngismus no milk should be given, but the baby should be fed on a cereal gruel with sugar added if desired, but no salt. It is of the utmost importance to keep the bowels moving freely either by the use of castor oil or milk of magnesia, and it is also probably of some importance to promote a free diuresis. The fluid intake shoiild, therefore, be pushed. In the treatment of spasmophilia there is nothing to be compared to breast mQk, and for the permanent feeding a wet- nurse should be secured if possible. The manifestations of spas- mophilia are so terrifying to the parents that they are usually glad to do anything that promises rehef, and a diet of breast milk almost always relieves the active manifestations. Some- times it acts almost like a miracle, and I well remember one infant of seven months who had been having repeated convul- sions for several weeks. He never had another after breast feeding was begun. It may be said that breast milk is almost a specific, and that there are but few cases in which a preven- tion of the occurrence of active symptoms cannot be expected. If it is not possible to secure a wet-nurse, artificial feeding is carried on according to the general principles of infant feeding. It is important to correct any existing disturbance of digestion, and after this has been done the spasmophilic condition may change from the active to the latent t3^e. It is very important not to feed a mixture rich in whey, as the sodium and possibly potassium salts of the whey tend to increase nerve irritability, and thus to aggravate the spasmophilia. A cream and precipi- tated casein mixture contains only small amounts of whey SPASMOPHILIA 415 salts, and may be of service for a while, although it might not be suitable for continued administration. The addition of cereal and of vegetables to the diet should be begun as early as possible; cereal at the sixth or seventh month, and vegetable purees at the eighth or ninth. The sodium content of the diet must be kept low, therefore meat soups, which contain consider- able amounts of sodium salts, should not be used, and no salt should be added to any cereal or vegetable puree that is given. The baby must not be allowed to be constipated, and it is well, for a while, to put a teaspoonful of milk of magnesia in the day's feeding as a routine. Drugs. — Calcium therapy is of very definite value in most cases, as might be expected from the nature of the disease. Most students of spasmophilia who have had experience with this praise it highly, and it is probable that those who have not secured good results have used too small doses. Marriott and Howland,^ who are perhaps somewhat more enthusiastic on the subject than the majority of clinicians, say, ^'Calcium has a very prompt effect in preventing aU the S3rmptoms of active tetany, and if present they almost always disappear in thirty-six to forty-eight hours. The electric reac- tions also change, so that a cathodal opening contraction with a current of less than 5 miUiamperes is no longer obtained. The calciima content of the senmi also rises, but in most cases does not come quite back to normal. We know of hardly another drug which acts with the promptness and the regularity that calcium does in tetany." Method of Administration. — ^Large and frequent doses are necessary in order to flood the system with calcium, and to keep it so flooded. Either calcium chlorid or calcium lactate may be used, the former usually being preferred on account of its greater calcimn content. Calcium chlorid exists in two forms, the crystalline, which contains only about 18 per cent, of calcium, and the fused, or anhydrous, which contains 36 per cent. Cal- ciimi lactate contains about 13 per cent. As it is the calcium ^Loc. cit. 41 6 PRACTICAL INFANT FEEDING content of the drug in which we are chiefly interested, the an- hydrous salt is what should be written for, and if the crystalline form of calcium chlorid or calciimi lactate is used it is neces- sary to give twice as much in order to secure the same amount of calcium contained in half the amount of the anhydrous chlorid. Good results cannot be secured without large doses, and there- fore from 10 to 15 grains of the anhydrous chlorid should be given four or five times a day to begin with, and may be reduced as the active symptoms of spasmophilia subside. It can be given in the milk, or its somewhat unpleasant taste is perhaps better disguised if it is given in orange juice. i^. Calcium chlorid (anhydrous) .. . Six; Water ad. Bvj.— M. S. — One teaspoonful five times a day in milk or orange juice. Calcium treatment should be continued for a considerable period until the tendency to spasmophilia has entirely dis- appeared. It is well usually to continue it until May or June (Rowland and Marriott), but the dosage need not be always so large as at the beginning of treatment. If the chlorid upsets the stomach, the lactate may be used instead, but must be given in very large doses in order to secure results. Its taste is not unpleasant, it is readily soluble, and is best given in powdered form mixed with the baby's milk. About 120 grains a day should be given. According to Bachenheimer,^ a heaping teaspoonful of powdered calcium lactate weighs about 75 grains; thus about IJ teaspoonfuls divided between the different feedings would be the correct daily dose. Cod-liver Oil and Phosphorus. — Inasmuch as rickets is so constantly associated with spasmophilia, cod-liver oil and phosphorus should be given, and it is possible that this may help not only the rickets but also the spasmophilia by causing an increased calcium retention. The Electric Reactions. — ^The apparatus necessary consists of a battery, a milliamperemeter, a switch for reversing the 1 Monatschr. f. Kinderheilk., Bd. 14, 1916. SPASMOPHILIA 417 polarity of the current, a rheostat for controlling its strength, and two terminal electrodes covered with absorbent cotton moistened in salt solution. The inactive electrode is applied over the abdomen, the active over the peroneal nerve as it winds about the head of the fibula, on the outside of the leg. The current is then made or broken, first with the cathode and then the anode as the active electrode. According to Wilcox the test for cathodal closure should be made first, as response to this occurs most readily. Then the anodal closure, anodal opening, and cathodal opening should follow in order. It is best to begin the tests with a strength of current sufficient to produce a muscular response, and then to reduce it gradually to the point at which the response fails. According to Wilcox one hand should be kept over the foot, as it is often possible in this way to feel a slight twitch when it cannot be detected with the eye. Response to the electric reactions varies considerably, according to the age of the child, and even from day to day in the same child, so it is not always possible to tell definitely what is normal and what is abnormal by any absolute standard. According to Holmes, who has most thoroughly studied the electric reactions in normal and spasmophilic infants and chil- dren of various ages, the following is the correct interpretation: Cathodal Opening. — A cathodal opening contraction with less than 5 ma. of current is pathognomonic of spasmophilia in children under five years of age. Anodal Opening. — An anodal opening contraction appearing with a current less than that causing an anodal closing contrac- tion, and less than 5 ma., is pathognomonic in almost all cases during the first six months of Hfe. Its appearance with a current of less than 2 ma. is probably pathognomonic up to the fourth or fifth year. Cathodal Closing. — The cathodal closing contraction is almost always obtained with a current of less than 5 ma. in normal children under six months, and after this time it is regularly 27 41 8 PRACTICAL INFANT FEEDING present with a current of less than 5 ma. It is, therefore, of no value in the diagnosis of spasmophilia. Anodal closing contraction usually requires more than 5 ma. in infants less than six months old. From then up to two years the A. C. C. is frequently, and after two years regularly, obtained with a current of less than 5 ma. An anodal closing contraction with a current of less than 5 ma. is, therefore, suggestive in the first six months only. The only two really important reactions are the cathodal opening and the anodal opening, and of these two, the former is the more important. As a summary it may be said that if the cathodal opening contraction occurs with less than 5 ma., or if the anodal opening is less than the anodal closing, and less than 5 ma., spas- mophilia is present. For a more complete discussion of the electric reactions, see the following references : Holmes, Amer. Jour. Dis. Chil., vol. 12, 1, July, 1916. Rowland and Marriott, Quart. Jour. Med., 11, 289, 1918. Wilcox, Amer. Jour. Dis. Chil., vol. 1, June, 1911. Reye, Arch. Ped., 31, 1914. von Meysenburg, Amer. Jour. Dis. Chil., vol. 21, 1921. CHAPTER XIX SCURVYi Infantile scurvy is a disease of nutrition probably de- pendent upon the prolonged lack of some essential element in the diet. It is characterized especially by a weakened or inef- ficient condition of the endothelial lining of the blood-vessels, which predisposes to hemorrhage, especially under the peri- osteum of the long bones, into the skin and mucous membranes, and from the kidney. Barlow^ in 1883 was the first to emphasize the fact that infantile scurvy is a distinct disease. Its occurrence had been noted long previously, but it was usually considered an acute manifestation of rickets. It occurs frequently in con- junction with this disease, but probably bears no relationship to it. It is the same disease as adult scurvy. Occurrence. — Scurvy is not at all an uncommon disease, and is apparently on the increase. Its incidence in the Out-patient Department of the Children's Hospital, Boston, from 1904 to 1913 was found by Morse^ to be as follows: Year. Percentage of scurvy cases. 1904 0.11 1905 0.43 1906 0.17 1907 0.33 1908 0.24 1909 0.24 1910 0.47 1911 0.61 1912 0.67 1913 0.87 ^ For the most exhaustive account of scurvy yet pubhshed in any language see Dr. Alfred F. Hess's fascinating monograph, "Scurv^^, Past and Present," to which I shall often refer in this chapter. ^Abstr. Proc. Roy. Med. and Surg. Soc, London, n. s. 1, 102, 1883. 3 Boston Med. and Surg. Jour., 1914, clxx, p. 504. 419 420 PRACTICAL INFANT FEEDING Glendenning/ in a study of the out-patient records for 1916-20 from the same hospital, found that the incidence for these five years averaged about 1 per cent., a considerable increase over Morse's figures. This increase is probably due to the fact that more babies are being fed on heated milk than was formerly the case, and undoubtedly the disease is much more prevalent than even these figures show, as many latent or subacute cases pass unrec- ognized. It is not a disease of poverty or poor hygiene, and is as common in the well-to-do as in the poor — according to some authors, more so. It is a disease which can be prevented, and which should not occur at all if the baby is being fed intelli- gently. Season apparently has very little influence on its occur- rence, nor has the previous nutritional state of the child. It is confined almost entirely to bottle-fed babies, but may occur exceptionally in the breast fed. It is most common in the second half of the first year, but occurs not infrequently in the first half of the second year, and rarely in older children. The youngest case in the American Pediatric Society's oft-quoted report (1898) was at three weeks; the youngest case seen by Hess was at 4J months. ^ In none of Still's 54 cases was the age under five months.^ Etiology. — ^All experimental and clinical data indicate that scurvy is caused by the lack of some essential element in the diet rather than to the presence of some harmful element, to a faulty proportion of fat, carbohydrate or protein in the diet, or to other factors. At the present time the general opinion is that it is due to the lack of a specific vitamin, which has been called "water-soluble C" or the antiscorbutic vitamin. This view is supported by much evidence, both experimental and clinical. Our modern knowledge of this disease dates from 1912, when Hoist and Frohlich^ produced it in guinea-pigs by limiting 1 To be published. 2 Scurvy, Past and Present (Hess). 3 Brit. Med. Jour., July 28, 1906. * Ztschr. f. Hygiene u. Infectionskrankheiten, 1912, vol. Ixxii. SCURVY 421 the diet to grain, and cured it quickly by the addition of fresh vegetables. Since then we have learned a great deal more about it, largely through the efforts of Hess and McCoUum and their collaborators in this country. Scurvy in infants occurs espe- cially with three sorts of food: proprietary foods, condensed milk, and heated milk, either boiled or pasteurized, all foods which are not ''fresh," and in which the antiscorbutic vitamin is lacking. It is easily cured in many cases by simply substi- tuting a diet of fresh raw milk for the pre\dous food, or still more quickly and with more certainty if orange juice or a vege- table is added. It is probable that it is necessary for a baby to take a vitamin-poor diet over a considerable period of time before manifest scurvy develops, according to Hess about six months. Active scurvy represents, however, the end-result of a long-continued lack of the antiscorbutic \dtamin in the diet, and probably long before this condition appears there is a state of poor nutrition present (of "latent" scurvy). The antiscorbutic vitamin occurs in fruit juices, in vege- tables, in germinated pulses and cereal grains, in meat (espe- cially glandular organs), and in milk. It is the most sensitive and unstable of the three vitamins, and in milk especially is easily destroyed by heat, alkalinization, aging, drying, or oxida- tion. Its exact chemical composition is unknown, and it has not been isolated in a pure state. Milk is rather poor in antiscorbutic vitamin, and consider- able quantities must be taken in order to protect from scurvy, according to Hess, at least a pint daily. It is therefore possible for scurvy to develop on a diet of raw milk if not much is taken; 100 c.c. of fresh raw cow's milk is equal in antiscorbutic power to only about 3 c.c. of orange juice,^ and as Hart, Steenbock, and Ellis^ have shown, the vitamin content of the milk is directly proportional to the vitamin content of the cow's fodder. They found that summer pasture milk was much more potent as an antiscorbutic than dry feed milk or winter-produced milk, 1 McCollum in Nelson's Loose Leaf Medicine. 2 Jour. Biol. Chem., 1920, xlii, 383. 422 PRACTICAL INFANT FEEDING involving the ration of corn, ensilage, or sugar mangels. This, then, may be a factor in the production of scurvy. Although cow's milk is not rich in the antiscorbutic factor, it is not at all common to see scurvy in babies who have been taking raw milk. It is common, however, on a diet of boiled or pasteurized milk. It is possible, however, for babies to be fed on boiled milk for a long period of time without developing scurvy, and without the addition of an antiscorbutic, provided the milk is fresh to begin with and is used soon after being boiled. If boiled milk were the most important cause of scurvy, one would expect it to be very common in France and Germany, where all milk fed to infants is boiled as a routine. Such, is, however, not the case, and Hess^ quotes Variot, who during twelve years distributed in his out-patient department 400,000 quarts of sterilized milk, heated in J-liter bottles and sealed at the farm, without ever having had a case of scurvy develop. According to Hess, other factors may be just as important as boiling, and prolonged heating at a lower temperature, as in pasteurization, may be more deleterious to the antiscorbutic vitamin than the higher temperature reached when milk is boiled for a few minutes. The freshness of the milk has a great deal to do with it, and Hess is of the opinion that the aging incident to pasteurization is fully as important as the heat in the destruction of the anti- scorbutic power of the milk. Oxidation is another factor which he considers important, and in most of the methods of com- mercial pasteurization there is ample chance for this to take place. Thus it may be said that stale^ heated milk, whether boiled or pasteurized, predisposes to scurvy. It has also been shown that the antiscorbutic vitamin is especially sensitive to alkalin- ization. This may be of considerable practical importance if the baby is being fed on a food to which an alkali has been added, such as sodium citrate or potassium carbonate (malt * Amer. Jour. Dis. Chil., November, 1917, vol. 14. 2 This means merely milk which is not fresh; it does not mean sour or putrid milk. SCURVY 423 soup). Faber^ showed that potassium citrate even in a con- centration of 0.25 per cent, was able to diminish or destroy the antiscorbutic power of cow's milk. Hess and linger- have also found that milk to which alkali (potassium carbonate) has been added will not protect against scurvy as efhciently as does milk without the addition of an alkali, and that the antiscorbutic principle in orange juice is made inefficient by being rendered twentieth normal alkaline to phenolphthalein. Individual predisposition probably has something to do with the development of scurvy, and cases are on record where one of twins developed it, while the other, who was fed on exactly the same diet, did not. There is no good evidence to show that infection, indigestion, or constipation play any role in the etiology. It may he said as a summary that infantile scurvy is caused by a lack of the antiscorbutic vitamin in the diet. This lack may be brought about by feeding proprietary foods or condensed milk, which are notably lacking in the vitamin, or by using too little raw milk in a weak milk modification, or by using milk in which the vitamin content has been lowered by boiling, pasteurization, aging, or alkalinization. Although fully developed scurvy is a hemorrhagic disease, the clotting power of the blood is only slightly diminished, and even this is not constant.^ The number of platelets is within normal limits. There is, however, always an anemia of the ordi- nary secondary type, which may occasionally be severe. The metabolism shows nothing of especial interest or importance. Signs and Symptoms. — Scurvy should be regarded not as an essentially acute disease, but as a long-continued nutritional disturbance, which may exist for months before characteristic hemorrhagic symptoms develop. Hess especially has insisted strongly upon this, and has called attention to what he calls ''latent" and ''subacute" scurvy. 1 Proc. Soc. Exper. Biol, and Med., N. Y., 1919-20, xvii, p. 40. 2 Jour. Amer. Med. Assoc, November 1, 1919, vol. 73. 3 Hess and Fish, Amer. Jour. Dis. Chil., 1914, vol. 8, pp. 386-405. 424 PRACTICAL INFANT FEEDING The latent condition represents the earhest stage, and is difficult to recognize. ''When about six months of age the baby has ceased to thrive, to gain satisfactorily, to look strong, or to eat as we should desire. The most careful physical examination has failed to solve the difficulty. On the other hand, the history of a diet of heated milk and lack of antiscorbutic food, considered in conjunction with the pallor and lack of appetite, the increased knee-jerks, and perhaps the cardiorespiratory syndrome (increased pulse and respiration rate, see below) has awakened suspicion, and has led us to prescribe orange juice with a view to diagnosis as well as treatment. The result frequently has been magical.''^ ''Subacute" scurvy is somewhat more definite. The baby does not thrive, and fails to gain, or gains only a little, despite a diet which fulfils his caloric needs. He is irritable, has a poor appetite, and perhaps has slight edema of the eyelids. The papillae at the tip of the tongue are congested and prominent, and there may be seen an occasional petechial spot over the body. There may be slight tenderness of the legs, especially to pressure, and the knee-jerks are markedly exaggerated. There is likely to be enlargement of the heart, especially to the right, which shows well by the x-ray, but which may be difficult to detect by percussion. The pulse and respiration are especially important, according to Hess. Both are considerably increased in rapidity, the respiration relatively more than the pulse, and there may be a rapid drop in both soon after orange juice is given. The urine may contain a few red blood-cells or albumin. The bones may show by the x-ray slight periosteal hemorrhages, or the "white line" of Frankel (see below). Such a picture may go on for some time before active scurvy develops, and is usually not recognized. Active Scurvy. — When the scorbutic process is well developed well-marked signs and symptoms occur. The usual story is that babies who have been fed on proprietary foods or heated milk, without the addition of orange juice, develop a marked tender- * Jour. Amer. Med. Assoc, vol. Ixviii, January 27, 1917 (quotation, Hess). SCURVY 425 ness of the legs, and cry with pain every time they are moved. This is the most common symptom — often the only one — and is usually sufficient upon which to make a diagnosis of scurvy. An interesting analysis of the first symptom noted by the mother was made from the records of 93 cases by Morse^ in 1914 as follows : First Symptom Noted Crying on handling 69 Paresis 11 Swelling of legs 5 Abnormality of gums 2 Ecchymosis 1 Bloody urine 2 Failing 1 Condition discovered at hospital 2 Some of the most important signs and S3miptoms are the following, which, however, are not likely to occur all together in the same case: General Symptoms. — The state of nutrition may be poor or good, according to what the child has been previously fed on. The average case does not, however, show evidences of severe malnutrition, but the flesh is always flabby and the color poor. The child is extremely fretful and irritable, and shrieks with pain every time he is moved. There is usually no associated gastro-intestinal disturbance, but there may be sometimes looseness of the bowels. The appetite is poor, a condition which does not usually come on suddenly with the other acute symp- toms, but has been present for some time while the scurvy was developing. The temperature is more likely to be normal than elevated, but not uncommonly reaches 101° or 102° F. If it continues for any length of time after orange juice therapy has been started, there is probably some compHcating infection present. Scorbutic babies are very susceptible to infection, and for this reason care should be taken, especially in a hospital ward, that they are not exposed to respiratory infection. Pye- litis is not an uncommon complication. ^ Loc. cit. 426 PRACTICAL INFANT FEEDING There may be a "rosary" which is very similar to a rachitic rosary except that the beading is more angular. That this is a true manifestation of scurvy, and not caused by a complicat- ing rickets, is shown by the fact that it rapidly disappears when orange juice is added to the diet (Hess). The legs are practically always tender, usually exquisitely so, so that the slightest movement or pressure causes the most severe pain. The tenderness is caused by subperiosteal hemor- rhage, which occurs most commonly in the lower portion of the femora (Fig. 25). There may be no swelling apparent if the hemorrhage is not extensive, but if it is extensive there may be a great deal of swelling, noted especially on the front of the thighs or Fig. 26. — Characteristic position of the legs in scurvy. Note also exoph- thalmos. lower legs. This may feel very hard if the hemorrhage is of long standing and has begun to organize, and there are cases on record where an operation has been performed, mistaking the swelling for a bony tumor. If the tenderness is well marked, motion is so painful that there is likely to be a pseudoparalysis, and the baby lies in a characteristic position, with the legs everted (Fig. 26). It is very rare for hemorrhage to occur within the capsule of a joint, but there may be hemorrhage into the loose tissue about the joint. The tenderness is, however, almost always of the shaft of the bone and not of the joint. Fractures at the lower third of the femur or tibia are not un- common, and there may be separation of an epiphysis. Sub- \ ■ Fig. 25. — Infantile scurvy. Section of femur showing subperiosteal hemorrhages with periosteal bone formation. There are hemorrhages in the bone-marrow and distortion of the line of ossification at the lower end. (MacCallum.) SCURVY 427 periosteal hemorrhage may also occur in the bones of the arm, but is not at all common. Hemorrhage in Other Localities. — The Skin. — Petechial hemor- rhages into the skin and mucous membranes are common, and should always be carefully looked for, as they are often of great value in diagnosis. They are most common on the hard palate, on the upper part of the back and neck, on the chest, and more often on the upper than on the lower extremities (Hess and Fish). I recall one case a few years ago in which the tenderness of the legs was only very slight, and the suggested diagnosis was con- firmed by a few small petechial spots hidden behind the ear, the only other physical sign present. In some cases the hemor- rhages in the skin may be more extensive, and resemble the large "black-and-blue" spots so often seen in purpura. The Gums. — ^A spongy, hemorrhagic condition of the gums is common, and is a valuable diagnostic sign. This is seen usually only when teeth are present, and is most likely to occur about the central upper incisors. There is a turgid, purplish swelling of the mucous membrane of the gum about the teeth, which is rather soft and tender, and which bleeds easily. It is almost always present in well-developed scurvy if the teeth have come through, but in a few cases it may be lacking when weU-marked signs of scurvy are present in other localities. In some cases the hemorrhagic condition of the gums may be evi- denced only by a thin red line or a smaU patch behind the tooth, and may be easily overlooked (Still^). In severe, long-standing cases the gum condition may be serious, and extensive ulcera- tion and slough may be present. While it is not common to observe disturbance of the gum if no teeth are present, it may be seen in some cases if the teeth have come down so far that they are near the surface of the gum. The Urine. — Blood in the urine is not at all uncommon, and in a few cases may be the first symptom noted. Any baby during the second half-year showing this symptom should always be suspected of having scurvy, until it is proved to be due to 1 Brit. Med. Jour., July 28, 1906. 428 PRACTICAL INFANT FEEDING other causes. Occasionally the blood is visible macroscopically, so that the urine is colored bright red, but far more often it is normal in appearance macroscopically, and a few red cells are seen under the microscope. The urine is also likely to be considerably diminished in quantity during the acute stage, Fig. 27. — Exophthalmos with edema and extravasation of blood into the eyelids. and a marked diuresis may be seen after the administration of orange juice as the child improves. Exophthalmos. — Hemorrhage under the periosteum of the orbital plate of the frontal bone occurs occasionally, giving rise to exophthalmos. This usually comes on suddenly, and is one of the most striking rare manifestations of scurvy. It may be unilateral or bilateral, most commonly the former, and may SCURVY 429 be of such a degree that the eye Hterally bulges from the head. The eyelids are usually more separated than normal on account of the eyeball which bulges between them, but if there is a good deal of extravasation of blood and edema of the lids the eye may be closed, as is shown in Fig. 27. There may be sometimes merely a swollen discolored condition of the lids without exophthalmos. The exophthalmos of scurvy comes on much more suddenly than any other form of exophthalmos, which should serve to differentiate it from other conditions; also it is in most cases easily cured by the addition of orange juice to the diet, and in a few days the eye resumes its normal position. The Digestive Tract. — Hemorrhage from the digestive tract is not common, but small amounts of blood may occur in the stools. The Circulatory System.— As Hess has pointed out, the heart is almost always enlarged, especially to the right. This may sometimes be detected by percussion, but is more accurately determined by x-ray examination. The blood practically always shows a secondary anemia, which may be of severe degree. This is probably very slow in its development, and one of the characteristic things about ' 'latent" scurvy is the pallor. The blood-vessels are weakened, allowing extravasations of blood, which accounts for the hemorrhage. In order to demonstrate this Hess and Fish^ devised the ^'capillary resistance test." An ordinary blood-pressure arm band is attached to the arm. The pressure is raised to 90 and is held there three minutes. The band is then removed, and when the cyanosis has faded, examination is made for petechial spots below the constriction. They found that most scurvy cases showed many petechias, and normal subjects did not. Normals may, however, show a few petechias just below the pressure band which are of no signifi- cance. The pulse and respiration are increased sometimes to a considerable degree, and the increased pulse particularly may persist for a considerable period after the baby has been appar- 1 Loc. cit. 430 PRACTICAL INFANT FEEDING ently cured of scurvy. The respiration is increased relatively more than the pulse, and instead of the normal 1 : 4 ratio, the ratio may be 1 : 3 or 1 : 2 (Hess) . Diagnosis. — The diagnosis of well-developed scurvy is not at all difhcult if one is familiar with the disease. The chances are that any baby from the age of six to eighteen months has scurvy who begins suddenly to have pain in the legs and to cry when handled. If, added to this, some of the other signs of scurvy are present, such as spongy gums, petechial hemorrhages into the skin, or blood in the urine, the diagnosis is unmistakable. Despite its characteristic symptomatology, scurvy is a disease which is often overlooked or wrongly diagnosed simply because the practitioner is not familiar with it. In 37 cases seen by Morse^ in consultation, from 1909 to 1914, the disease was recognized by the attending physician but four times. The most frequent diagnoses made were rheumatism, acute nephritis, and poliomyelitis. Syphilitic epiphysitis and osteomyelitis are two other diseases not infrequently mistaken for scurvy. The differential diagnosis between scurvy and these five conditions is not difficult in most cases. Rheumatism. — Babies very seldom have rheumatism. It occurs most commonly between the age of four and twelve years. The youngest case I have myself seen was at two years. Fur- thermore, in rheumatism the tenderness is about the joint and not in the shaft of the bone, as it is in scurvy. The temperature would be more likely to be elevated in rheumatism, and the other signs of scurvy would not be present. Despite the fact that rheumatism practically never occurs in small babies, this is the mistake most commonly made in the diagnosis of scurvy. Syphilitic Epiphysitis .—This condition almost always occurs before the age of five months, scurvy rarely does. Furthermore, the trouble is about the epiphysis and not in the shaft of the bone, as it is in scurvy, and practically always other signs of syphilis are present. If the diagnosis is in doubt, the Wasser- ^ Loc. cit. SCURVY 431 maiin test, x-ray, and therapeutic test should easily serve to differentiate the two conditions. Osteomyelitis is not common in babies of the age who would have scurvy. The septic appearance of the baby, high tempera- ture, leukocytosis, absence of other signs of scur\y, and the x-ray should make confusion unlikely. Poliomyelitis. — ^This disease is not infrequently confused with scur\y. In poliomyelitis there is not, however, the extreme tenderness seen in the former disease, the knee-jerks are absent, and in the acute stage there is usually a high fever. If in scur\y there were sufficient periosteal hemorrhage to cause pseudo- paralysis, enough to confuse the condition mth pohomyelitis, there would ahnost certainly be some swelhng of the leg and other signs of scur\y present elsewhere. If there is still doubt, limibar puncture or x-ray should clear it up. Acute Nephritis. — If a baby has blood in the urine, with other symptoms of scur\y also, there is no danger of confusing scurvy wdth acute nephritis. If, however, the only definite sign consists of a Kttle albumin and a few red blood-ceUs in the urine microscopically, the dift'erential diagnosis may not be easy. There are certain points of differentiation, however. In the first place, if a small baby has acute nephritis, he usually is fairly sick with it, and has considerable albumin in the urine, with many casts and red cells in the sediment. Edema would probably also be present, and there would probably be also a history of some previous infection to account for the nephritis. The history of the previous diet of the baby is of considerable importance: if he has been recei\dng an adequate amount of fresh raw milk, with as much as a tablespoonful of orange juice a day, he certainly is not suffering from scur\'y. If he has been on a scurvy -producing diet, and has gradually been faiHng, is pale, and has a poor appetite, the chances are that he has scurvy. If after these considerations it is impossible to decide, the therapeutic test (2 tablespoonfuls of orange juice a day) will make the diagnosis in a few days. The x-Ray Diagnosis. — The x-ray is often valuable in giving 432 PRACTICAL INFANT FEEDING confirmatory evidence for the diagnosis of scurvy. The outline of the epiphysis is quite distinct in contradistinction to its appearance in rickets, and this alone should serve to distinguish the two conditions (Lovett). There may be considerable bone atrophy, which is uniform along the whole shaft of the bone. There is likely to be at the end of the diaphysis the so-called ''white line" of Frankel, which was formerly thought to be diagnostic of scurvy. It may also occur in rickets, however. It is due to an increased density of bone at the end of the di- Fig. 28. — Well-marked "white line." Arrow indicates slight elevation of the periosteum. aphysis. The ''white line" may be seen early in the disease, some- times before any evidence of periosteal hemorrhage is visible, and is likely also to persist for a considerable period after the clinical symptoms have subsided. It is, therefore, of some diag- nostic value in early cases, provided rickets can be ruled out. The most characteristic feature seen in the rr-ray appearance of the bones in scurvy is the hemorrhage. In mild cases this may be manifested simply by a Httle thickening or bulging of the periosteum, or in more severe cases by most extensive irregular SCURVY 433 shadows indicating blood-clot which has involved the soft tissues (Figs. 29,30). J Fig. 29. — Separation of epiphysis of femur, also large blood-clot. Prophylaxis. — The prophylaxis of scurvy is of the utmost importance, and, what is more, is successful. If a baby is properly fed, scurvy should not occur. In spite of the fact that boiled and pasteurized milk pre- 28 434 PRACTICAL INFANT FEEDING dispose to scurvy, this does not outweigh the great advantage obtained from their relative freedom from bacteria, and it is easy enough to give an antiscorbutic. Every baby taking pasteurized or boiled milk should be started on orange juice Fig. 30. — Large blood-clots of both femur and tibia as soon as he is three months old, and it is probably not pos- sible for any baby who is taking daily an adequate amount of this most potent antiscorbutic to develop the disease. What constitutes an adequate amount is not certain, but probably SCURVY 435 2 tablespoonfuls a day is enough, and this is the quantity that it is best to use. I have recently seen a number of cases of scurvy where the mother said that she had been giving the baby orange juice, but on closer questioning it was found that the baby did not like it very well, so perhaps only as much as a teaspoonful three or four times a week had been taken. I have never seen a case where as much as a tablespoonful has been given every day. Babies usually take orange juice readily. It is best given about one hour before the feeding, twice daily, in doses of 1 tablespoonful at a time. It may be diluted or sweetened with cane-sugar, if the baby takes it more readily in this way, and if it causes "sour stomach" with regurgitation, which it may do occasionally, it may be diluted with a little lime-water just before administration. In a very few babies orange juice causes looseness of the bowels, but these are very few and far between, and, as a matter of fact, orange juice does not deserve at all the reputation it has as a laxative; in most cases it is entirely without action on the bowels. In the rare cases where orange juice is not well borne, canned tomato juice or potato soup can be used (see below). Green vegetables, such as spinach or carrots, have but little place in the pro- phylaxis of scurvy in infants, as their antiscorbutic power is low, and it would be necessary to take relatively large amounts in order to secure any effect. Is it necessary to give orange juice to babies who are tak- ing raw milk? It probably is not necessary in the vast majority of cases, provided an adequate amount of milk is taken, but in view of the fact that even raw milk may vary a great deal in its antiscorbutic power, it is well to give orange juice to every baby as a routine. It is common, when a barley- or oat-water diluent is being used in the milk formula, for the mother to add boiling hot diluent to the milk; then it stands for a considerable period of time, slowly cooling, and although I have no idea what the temperature of such a mixture would be, I have seen several cases of scurvy when the milk was not boiled or pasteur- ized, where this seemed to be important as a causative factor. 436 PRACTICAL INFANT FEEDING Treatment and Prognosis. — There is no therapeutic procedure in medicine where more striking and rapid results are obtained. If a boiled or pasteurized formula has been used, this should be discontinued and a raw formula of the same strength substituted, or if a proprietary food has been the previous diet, the baby should be put at once on a suitable raw milk modification. In many cases this would suffice to cure the condition, but results are so much more brilliant and rapid if orange juice is added that one would not try to treat scurvy without it. An ounce a day is sufficient, given half in the morning, half in the afternoon, an hour before the feeding. In practically all cases the acute symptoms will be much improved in forty-eight hours, and at the end of about four days should have practically sub- sided. Results are so certain that, if improvement does not take place, there should be considerable doubt that the baby has scurvy. Although the acute symptoms subside rapidly, the bone changes, the anemia, and the rapid heart action may per- sist for some weeks, and it may be some time before the baby is in first-class condition. In addition to the orange juice it is well to give 3 grains of the saccharated oxid of iron three times a day in order to aid in the correction of the anemia. It is need- less to say that the baby should be handled as little as possible while his legs are tender, and that small doses of paregoric should be given to make him comfortable, if necessary. The prognosis is almost always good, provided the condition has not progressed too far. If no treatment is given, the baby slowly wastes away and dies from weakness and malnutrition. In long-standing, exceptionally severe cases, even orange juice may be unavailing, and Holt records 4 deaths out of 100 cases. In the extreme type of case, where the stomach may be so irri- table that orange juice cannot be retained, it may be given intra- venously, apparently with good results. The orange juice is boiled five minutes, is made neutral or slightly alkaline by means of N/1 NaOH just before administration, and 10 c.c. is given intravenously each day for several days (Hess). Antiscorbutic Foods. — The antiscorbutic vitamin exists in all SCURVY 437 fruit and vegetable juices, germinated cereal grains and pulses, in glandular animal tissues, such as liver, kidney and pancreas, and in milk. Non-germinated cereal grains contain no antiscorbutic factor, and muscle tissue contains so little as to be negligible. Orange, Lemon, and Lime Juice. — Orange and lemon juice are the most powerful antiscorbutics known. Lime juice is not nearly so powerful. Orange juice can be dried, preserved in the form of a powder, and it retains its antiscorbutic power. It can also be boiled and still remain potent, but if stored in the cold for three to six months it becomes inactive. Alkalinization for twenty-four hours likewise renders it non-potent; 3 c.c. of orange juice equal in antiscorbutic power about 100 c.c. of milk. The juice of orange peel is also markedly antiscorbutic. Tomato Juice. — Next to orange juice, tomato juice is an efficient practical antiscorbutic. Hess has used it extensively in an infant asylum, and has found it very satisfactory. He gives 2 tablespoonfuls of the juice from canned tomatoes daily to babies of oVer two months, and has noticed no ill effects from much larger doses. If oranges cannot be obtained, this is probably the best antiscorbutic to use. Potato. — ^Although adults depend largely upon potatoes as an antiscorbutic, they are not at all rich in the antiscorbutic principle, and it is necessary to take so much in order to secure an effect that potato is not at all important as a therapeutic agent for infantile scurvy provided orange, lemon, or tomato juice can be obtained. If these are unobtainable, potato-water should be used. One tablespoonful of mashed potato (the outer mealy layer from a boiled potato) is shaken in a pint of water in which the potatoes have been boiled, and the resulting gruel is used as a diluent for the milk modification.^ Carrots, grapes, apples, and bananas have only slight anti- scorbutic power. As a general thing the leafy vegetables have more potency than the roots and the tubers, and young vege- tables more than old. Cabbage is the most potent of all the vegetables. * McCoUum and Ruhrah, loc. cit. CHAPTER XX THE TREATMENT OF ECZEMA IN INFANCY Eczema is a very common condition during the first year of life, and often has a good deal to do with the feeding; hence its inclusion here. It may be divided into two broad types, the wet, or exudative, occurring usually in otherwise healthy, overfed babies, most commonly breast fed, or the dry type, which is more likely to occur in undernourished babies. It is not likely to start before the first month, and often shows a tendency to disappear spontaneously after the first year, although it may persist for years in many cases. The exact processes which go on in the body to produce eczema are not known, but it is certain that three factors are often operative: 1. Local irritation. 2. Overfeeding with fat or sugar, or in some cases with starch. 3. Anaphylactic idiosyncrasy to foreign protein (most com- monly lactalbumin, casein, egg-white, or beef). The therapy in the present state of our knowledge is based upon these three etiologic factors. No good results can be obtained if the greatest attention to detail is not observed, and if the patient is not seen often. In severe cases the child should be seen every day. With pains- taking, intelligent treatment there is no case of eczema in infancy that cannot he greatly helped, and most cases can he cured entirely. In my opinion local treatment is of paramount importance, and the reason for most failures is that it is not carried out cor- rectly. It should be used, however, in conjunction with the other two measures. Local Treatment. — The essential thing to remember is that in any given case of eczema the condition may differ widely on various parts of the body, and that, therefore, it may be neces- 438 THE TREATMENT OF ECZEMA IN INFANCY 439 sary to use several diflerent preparations at the same time for local application. For instance, what is suitable for a sebor- rheic scalp, is not at all suitable for an oozing eczema of the cheek or for a cracked eczema of the popliteal space. In most cases that one sees there usually are different types or stages of eczema on different parts of the body, and it is necessary, therefore, to know what sorts of application are suitable for each type. At the first \dsit I very frequently give the mother as many as three or four dift'erent preparations and teach her the name and special purpose of each, so that she will know, as she goes along from day to day, which one to use, according to the particular stage that the eczema happens to be in. This is of considerable importance, and it is of great value to teach the mother to recognize a seborrhea, a dry scaHng, or a weeping eczema, and to know which preparation to use for each type. In a general way the following are the types or stages of eczema that are seen, sometimes all in the same patient: 1. Wet. 2. Dry, very red, and acutely inflamed. 3. Dry and rough, not acutely inflamed. 4. Seborrheic. 5. Intertriginous. 6. Difluse papular or vesicular. 7. Infected. Wet, oozing eczema is most likely to be seen in fat, overfed babies. It occurs especially on the cheeks, behind the ears, and in the pophteal and antecubital spaces. It begins usually as small, red, acutely inflamed papules, which soon coalesce, and finally begin to exude serum. Crusts may form, and under- neath the crusts the skin is raw and oozing. If in a locality where there are folds of skin, as in the pophteal space, large bleeding cracks may develop. Crude coal-tar is so successful in curing this type of eczema that it works in practically every case. There is nothing else that can approach it in efficiency, and since its introduction a few years ago the treatment of infantile eczema has been revo- 440 PRACTICAL INFANT FEEDING lutionized, and where it used to take weeks of constant struggle to effect any improvement in a weeping eczema, it may now be controlled in most cases in a few days. Crude coal-tar is not the same thing as the ordinary wood tar of the Pharmacopeia, which has been so long used in the treatment of skin affections, and has nothing whatever to do with it. It is a by-product in the manufacture of coal-gas, and cannot be obtained from most retail druggists, but may be secured from many of the large drug houses, who get it from the coal distilleries. Different ''lots" of crude coal-tar vary considerably, as there is no stand- ardization of the product, and not infrequently one may get a shipment of tar which is not good. A good crude coal-tar should be of an inky black color and of a very thick consistency, so that it will barely run out of a bottle. It should be perfectly smooth and should contain no granules whatever. This is the preparation to use in every moist case of eczema, except where there is infection or on the scalp. It is not used where there is infection, as it may make it worse, and it is not suitable for use on the scalp, because it makes a sticky mess with the hair. Method of Use. — The crude tar is painted over the raw sur- face twice a day by means of a cotton swab on the end of a throat stick. After it dries, which usually takes only a few minutes, a dusting-powder may be applied, but is not necessary. The skin is painted in this way morning and night until the oozing has been stopped, which rarely takes over two or three days. It should not be removed with olive oil, vaselin, or anything else, but should be allowed to wear off gradually, which does not take long. When it has worn off, a rather smooth, red, and tender new skin is seen underneath, which is very easily irri- tated if rubbed or scratched. At this stage a bland protecting ointment is used, such as either one of the following: I^. Bismuth subcarbonate 5ij; Lime-water q. s. Anhydrous lanolin ad. Sij. — M. ^- f^^'^^J aa 5ii; Zmc oxid j Vaselin ad. §ij. — M. THE TREATMENT OF ECZEMA IN INFANCY 44I Tar contains a certain amount of phenol, and there is a possible danger of toxic absorption if it is used on a large area of broken skin. In the ordinary case of eczema this does not, however, have to be considered, and I have never seen any ill results from its use. Dry, Red, Acutely Inflamed Eczema. — This type of eczema is perhaps the most common, and is likely to be seen on almost any part of the body. It may occur in small red papules of varying sizes, or in large patches, with sharply defined edges, or in diffuse irregular areas. Tar is also very efficient here, but is best used in the form of a paste. It should be applied twice a day, or if on an exposed place such as the face, where it is easily rubbed off by the baby, frequently enough so that there will always be present a fairly thick coating of the paste: I^. Crude coal-tar 3 J ; Zinc oxid 1 .. „.. starch )■■■ ^^ 5'^-' Vaselin ad. gij. — M. This paste is rather thick and of a blackish- brown color. It is very dirty, of course, and therefore old clothes should be used, or if the eczema is in a locality where bandages can be applied, these should be used. The best cloth as a bandage for eczema is old linen or cotton, which has been scorched in the oven. Scorched cloth is much less irritating to the skin than unscorched, and sometimes such a small detail as this may make a good deal of difference. If there is considerable induration or scaling of the skin, and the eczema is of long standing, the addition of 10 grains of salicylic acid to the ounce of ointment is of value. Dry, Rough, Not Acutely Inflamed Eczema. — For this type of eczema tar is not usually necessary, and it is possible to employ something that is less dirty. For very mild cases, where the skin is simply a little rough and dry, either plain lanolin or bismuth ointment are the best preparations. 442 PRACTICAL INFANT FEEDING I^. Bismuth siibcarbonate 5ij ; Lime-water q. s. ; Anhydrous lanoHn ad. gij. — M. It is important to remember when using any ointment not to simply give directions to apply it two or three times a day, hut to apply it often enough so that the irritated surface will be continually covered by the salve, no matter how often it has to be If there is a good deal of roughening and thickening of the skin, the following is better: I^. Salicylic acid gr. xx; Zinc oxid 1 -- rr-- Starch / ""3.]; Vaselin ad. Sij. — M. Seborrheic Eczema. — This type of eczema, usually occurring on the scalp, is very common in small babies, and may be present when there is none on any other part of the body. It is usually called "cradle cap." It consists of many greasy scales and crusts. The best preparation to use on the scalp in most cases is ordinary boric ointment. This is applied very thickly, with a good deal of rubbing, twice a day, and then a turban made from an old handkerchief or towel is fitted to the head and kept there. Or with small babies it is usually simpler to have the mother get a few cheap cotton bonnets, and use these instead, as they fit better. It is very important to use a large amount of salve, to rub it in well, and to prevent it from being rubbed off by the use of a cap or turban. The boric ointment is applied every day, and no attempt made to remove it until the fourth day, when a gentle shampoo with castile soap is given, during which it will usually be possible to remove most of the seborrheic material. After this the boric ointment applications are con- tinued as before, with a shampoo twice a week. When the seborrhea is considerably better, and most of the scales have been removed, it is often well to shift to a salve containing THE TREATMENT OF ECZEMA IN INFANCY 443 resorcin, which is often very efficient in finishing the cure, and in preventing the seborrhea from recurring : i^. Resorcin gr. xx; Vaselin ad. §ij.— M. For scalps with only a mild seborrhea or a dry scaling condi- tion a daily gentle rubbing with olive oil and shampoo three times a week usually is efficient, and keeps the skin in good condition. Intertriginous Eczema. — This type of eczema is usually seen on the inner side of the thighs, about the genitalia, symphysis pubis, and often extends up the abdomen as far as the umbilicus. It consists of an intense fiery redness, occasionally with con- siderable thickening, but with little scaling. It is not ordinarily moist, except as it occurs in very fat babies where two opposing skin surfaces come together, at the neck, under the armpits, etc. The fiery red, intensely irritated condition occurring on the inner side of the thighs and on the lower part of the abdomen is often rather difficult to treat, as it is impossible to keep it dry and to prevent irritation by urine and feces. It is probably caused in the beginning by irritation from urine, especially if it be strongly acid. The first essential in treatment is to prevent irritation in so far as possible. In order to accomplish this no diapers are to be used on the baby, and the lower part of his body is to be kept exposed to the air most of the time in a rea- sonably warm room. A thick pad of absorbent cotton is put between the legs to absorb urine when passed, and a diaper underneath to receive the stool. The cotton and diaper should, of course, be immediately changed as soon as they are dirtied. If the urine is strongly acid, enough potassium citrate is given in each feeding to make it slightly alkaHne; 10 grains usually suffices. Local applications are not so efficient as in some of the other forms of eczema. The best one to begin with is "white- wash": I^. Zinc oxid §j; Lime-water ad. § vj. — M. 444 PRA.CTICAL INFANT FEEDING This is shaken vigorously, and applied every hour in liberal amounts, on soft scorched old cotton or linen cloths. If 'Whitewash" is unavailing, bismuth ointment or tar paste is used. In using a salve with this type of eczema it is better to spread it thick on pieces of soft scorched linen or cotton cloth, and then to apply these to the parts. If the irritated area can be kept reasonably free from urine and feces cure should be fairly rapid; if not, it may take a long time. Between skin surfaces, such as the axilla, folds of the neck and groin, this type of eczema, or intertrigo, is likely to be moist, and the treatment is somewhat different. The irritated areas should be cleansed once daily with warm lime-water, or a weak sodium bicarbonate solution, dried carefully, and liberally sprinkled with a dusting-powder, such as zinc stearate. It is of the great- est importance to prevent the two skin surfaces from coming together, and for this purpose small pledgets of absorbent cotton sprinkled with the dusting-powder are used. Diffuse Papular or Vesicular Eczema. — This occurs more frequently in children over eighteen months of age than in small babies. It comes on acutely, and is characterized by innumerable small vesicles or papules which are distributed evenly over the whole surface of the body, particularly the trunk. It is best treated by starch baths and tar paste. A rather thin solution of starch is made in the same way that one would prepare it for laundry purposes. In the morning the child is stripped and bathed all over with the starch solution, sopping it on gently. It is allowed to dry on. In the evening tar paste is applied and rubbed well into the skin with the flat of the hand, not using it quite so thickly as would be the case with a facial eczema. Infected Eczema. — If secondary pyogenic infection is present, as is not infrequently the case, this must be cleared up before improvement can take place. If the infection is diffuse, with a good deal of septic oozing and crusting, there is nothing so efficient as a 10 per cent, oint- ment of ammoniated mercury in vaselin. This should be used THE TREATMENT OF ECZEMA IN INFANCY 445 frequently enough so that a thick coating of it will be over the infected areas all the time. If the infection is in the form of a few boils, which are especially likely to occur on the scalp, their contents are expressed and a 20 per cent, solution of silver nitrate applied to the cavity of the boil and to the skin in the immediate vicinity. Tar, or any thick paste, should never be used until all infection has subsided. If the reader will remember the following ten preparations, which have all been mentioned above, but are repeated in table form for the sake of clearness, and will learn how and when to use them, he will need no other local applications in the treat- ment of infantile eczema : 1. Crude coal-tar. 2. Tar paste: Crude coal-tar, 5ij; Starch J Vaselin, ad. gij. 3. Lanolin. 4. Boric ointment. 5. 20 per cent, silver nitrate solution. 6. 10 per cent, ammoniated mercury in vaselin. 7. Starch paste: Zinc oxid 1 __ ^j. Starch J Vaselin, ad. Sij. Or the same, with gr. xx of salicylic acid added. 8. Bismuth ointment: Bismuth subcarbonate, 5ij; Lime-water, q. s.; Anhydrous lanolin, ad. §ij. 9. Resorcin ointment: Resorcin, gr. xx; Vaselin, ad. 5ij- 10. "Whitewash": Zinc oxid, §ij; Lime-water, ad. 5vj. Prevention of Scratching. — If the child is continually scratch- ing there is no chance for the eczema to heal, and one night of scratching may undo the good results of a week of treatment. There are two good methods of preventing this. By the use of 446 PRACTICAL INFANT FEEDING cuffs about 8 inches long of stiff cardboard, covered with cloth, which fit tightly over the elbows, and by preventing any flexion at the elbow, prevent scratching of the face. Cuffs do not, however, prevent scratching of other parts of the body, and it is always advisable in a bad case to use aluminum mittens as well. These are hollow cylinders of thin aluminum, which fit over the hands and fasten to the sleeve of the night dress. For all bad cases of facial eczema a mask with small holes for the eyes, mouth, and nose should be used. This is cut from old cotton or linen cloth, and should be kept on continuously while the eczema is acute. Mothers, as a rule, are very inefficient in handling eczema until they have had a considerable amount of instruction, and it is therefore essential to go over all details with them with a good deal of care at the first visit, and to see the child frequently in order to be sure that they are carried out. It is always a good plan to have a well-trained children's nurse for a while at the start of a bad case, and I cannot impress too strongly upon the reader that eczema in infants is a condi- tion where it is vital to pay careful attention to the smallest details in order to secure good results. Water is ordinarily irritating to the skin in most cases of eczema, and baths should not, therefore, be employed. The genitalia and buttocks may be cleansed with absorbent cotton and water; during the acute stages it is best to let the rest of the body alone. If caking of any paste used has taken place, or if crusting is excessive, it may be softened and removed with a little lanolin or vaselin. In general, it is best, however, to let any applications that have been made gradually wear off, rather than to remove them. When the eczematous condition is much improved baths may be given, and it is well with all infants who have a tendency to eczema to make the water less irritating by using bran or oatmeal. A cup of bran or oatmeal is put into a small cheese- cloth bag and stirred about in the bath water for a few minutes, so that it becomes milky. A superfatted lanolin soap should be used, which is much less irritating to the skin than ordinary THE TREATMENT OF ECZEMA IN INFANCY 447 soaps, and it is well with all babies who have a tendency to eczema to give a lanoHn rub every day after the bath. If the face has a tendency to dryness or chapping after the acute stages of the eczema have been controlled, bismuth paste should be applied each time the baby goes out of doors, and especial care should be taken that the face is not exposed to cold, blustering winds. The Feeding. — Most babies with eczema are well nourished, indeed, it is the very fat, overfed breast baby who is most likely to have it, and improvement cannot usually be expected until the food is reduced in quantity or quality. It is always weU to secure a specimen of the breast milk for analysis if the baby is breast fed, and in a large proportion of cases the fat will be found too high, often from 4 to 6 per cent. The sugar may be also at fault, but its percentage in breast milk ordinarily varies but Httle. It is probable, when sugar is at fault, that the trouble is caused rather by too much food than too high a sugar percentage. The stools are likely to be rather oily, and usually show a large excess of fat under the microscope. In order to reduce the amount of food the feeding intervals are lengthened from three to four hours, nursing is permitted for only about eight minutes, and about 2 ounces of water or barley-water is given either before or after the breast feeding. The mother should be made to exercise, and should omit fats, potatoes, bread, desserts, and candy from her diet for a while. In this way it is often possible to considerably reduce the fat content of her milk. If all this is unavailing, there is some temptacion to wean the baby, but in most cases this is not advisable, as it is by no means certain that the eczema will improve on a diet of cow's milk. In cer- tain cases, however, weaning does cure the eczema, as I had brought out a few weeks ago. A large, overfed breast baby of three months began to lose his appetite and to have eczema on the face, arms, and scalp. There was a large amount of breast milk which showed 5.5 per cent, of fat. The mother was made to exercise, her diet was reduced, and the baby was given water before feedings — all to no avail. The eczema could be kept 44^ PRACTICAL INFANT FEEDING under control by the use of local applications, but it was never possible to get rid of it entirely. The baby was finally weaned at the urgent request of the mother and was fed on a simple milk modification low in fat. In a very few days his eczema disappeared entirely without the use of local applications, and has never returned. If any food element is at fault when a baby fed on cow's milk has eczema it is most likely to be the fat, or more rarely the sugar. If fat is at fault, there may or may not be evidences of fat indigestion; if sugar is to blame, loose acid stools are usually present. If the baby is a fat, strong baby, in a good state of nutrition, feeding for a time on a fat-free or low fat food is desirable. He will probably lose some weight, but it will do him no harm, and his eczema is very likely to improve considerably. If the baby is not well nourished it is not advisable to reduce the fat in the food unless he is grossly overfed with fat, unless there are evidences of considerable fat indigestion, or the eczema is an unusually severe one. In most cases, however, the undernourished baby does not have a severe eczema, of the raw weeping type, and it is important for him to gain weight and to secure a better nutritional condition. There- fore the food should not be reduced, and it is possible to keep the eczema within reasonable limits by local treatment. As a matter of fact, in a good many of these undernourished babies with a dry, reddened, but not exudative eczema the condition shows a tendency to disappear as soon as the nutrition becomes better. In children over a year old, who are on a mixed diet, overfeeding with starch is not an uncommon cause of eczema, and the stools should be examined carefully to see if any evi- dences of starch fermentation are present. In this type of case there will usually be three or four mushy, foul stools a day, containing a large amount of undigested starch and cellulose. There is occasionally a chronic infection of the intestinal con- tents with the gas bacillus in these cases, which plays a part in the indigestion, and hence in the eczema. Such a child should be fed on a low fat and low starch diet, with lactic acid milk as its basis. THE TREATMENT OF ECZEMA IN INFANCY 449 For some years Dr. C. J. White, Professor of Dermatology in the Harvard Medical School, has been sending me the stools of his eczema patients for examination, and, without quoting any exact figures, I should say that over half certainly showed some abnormahty of digestion, either fat, starch, or abnormal fermentation. It is always worth while to carefully investigate the condition of the digestive tract in any case of eczema. Sometimes indigestion seems not to be a factor, and changing the diet has no beneficial effects on the eczema; in other cases the results are brilliant. Idiosyncrasy to Food Proteins. — In some cases of eczema there is an anaphylactic idiosyncrasy to food proteins, the most common ones being the lactalbumin or casein of human or cow's milk, egg-white, or occasionally egg yolk, and the protein of beef. This idiosyncrasy seems to be the cause of the eczema, for when the offending protein is removed from the diet the eczema is improved or cured in most cases. It is, therefore, well worth while to endeavor to determine, in any case of eczema, especially with children on a mixed diet, whether any such idiosyncrasy exists, and while I do not agree with those who believe that most cases of eczema are due to anaphylactic idiosyncrasy, I still have seen enough cases where this was undoubtedly a factor to consider that the anaphylactic food tests constitute one weapon, at any rate, by which we may attack the disease. These tests are performed as follows: Small linear scratches about J inch long are made with a needle on the skin of the back, deeply enough to penetrate well into the skin, but not enough to draw blood. Then a small amount of the dried protein^ of the various foods to be tested is put on the scratch, a drop of 1/10 normal (0.4 per cent.) sodium hydrate added, and rubbed into the scratch with the protein powder. One scratch is left as a control, and has sodium hydrate added to it, but no protein. If any protein gives a positive test, in about fifteen minutes (less in many cases), an urticarial wheal at the site of the inoculation develops, which ^ Proteins are furnished by the Arlington Chemical Co., Yonkers, N. Y. 29 4 so PRACTICAL INFANT FEEDING is surrounded by an area of erythema. Usually a positive reaction will give a wheal at least 0.50 cm. in diameter, but it is better to read the tests rather by their relation to the other scratches and to the control than by any standard size. If one wheal is considerably bigger than the reaction caused about any of the other scratches it should be called positive, even if it is not quite 0.50 cm. in diameter. Or if one scratch shows a large area of erythema without any wheal, and the other scratches show none, the test showing the erythema may be called positive. On very sensitive skins sometimes all the scratches will develop wheals of fair size, so it is rather in relation to the other scratches that we must interpret results than by any set standard. Dr. Joseph Grover and I have done some thousands of skin tests in the last two years on children with eczema and asthma, and we cannot help but feel that a great deal of caution is needed in interpreting these tests, and that, in general, those who have used them have been too eager to report positive reactions. If in a young breast-fed baby the test should be positive to one of the proteins of human milk, the baby should not be weaned, but the eczema should be treated locally, and the amount of milk taken by the baby somewhat reduced, in accordance with the directions given in the last section. If in a bottle-fed baby casein or lactalbumin gives a positive test, the amount of protein in the formula should be reduced to as low a point as is consistent with the baby's nutritional needs, and supplementary feeding of solid food begun as early as possible. If the idiosyncrasy is very marked it may be advisable to use goat's milk. If the eczema is in a very bad condition, temporary improvement may sometimes be secured by feeding the baby on a cereal and sugar diet for a few days, without any milk protein. This cannot, of course, be kept up for any length of time. We have seen comparatively few reactions to the proteins of milk, and in our experience beef and egg protein are the most common offenders. These last two are, of course, easily removed from the diet. In doing skin tests on breast-fed babies it is not infrequent to find that a positive test may be THE TREATMENT OF ECZEMA IN INFANCY 45 1 obtained to some food (egg, cow's milk, beef) which the baby has never eaten. In these cases, according to O'Keefe,^ the sensitization has occurred through the breast milk, and if the foods which have given positive tests are omitted from the diet of the mother great improvement of the baby's eczema may take place. This is certainly worth taking into consideration in the treatment of eczema in the breast fed. 1 Boston Med. and Surg. Jour., vol. 185, August 18, 1921. CHAPTER XXI PYLORIC STENOSIS AND SPASM Pyloric stenosis, or to give it its full name, "congenital hypertrophic stenosis of the pylorus," consists of an hypertrophy of the circular muscle-fibers of the pylorus, giving rise to obstruc- tion, with consequent projectile vomiting, rapid loss of weight, and final death from starvation if not relieved. Occurrence. — It is not an uncommon condition, but not much attention was paid to it until a comparatively few years ago. Martin, in Osier's "System of Medicine" (1908), says that "there are now more than 150 cases recorded in the literature." From 1914 to 1920 Downes, of New York, himself operated on 217 cases. ^ These figures show how much more commonly it is now recognized than was formerly the case. For some unknown reason it occurs more frequently in males than in females, the ratio being about 4:1. It is seen more frequently in breast-fed than in artificially fed babies, the probable reason for this being that the majority of babies are fed on the breast during the first few weeks of life, after which period the symptoms of pyloric stenosis rarely make their appearance. Etiology. — The pyloric hypertrophy is undoubtedly congen- ital in origin, and a pyloric tumor has been observed in a seven months fetus (Dent) and in a number of infants a day or two old upon whom autopsies were performed. Its causation is obscure. According to Strauss^ it is caused by rhythmic con- tractions of the pylorus during fetal life, which start at that time due to some abnormal stimulation of the nerves of the stomach. The condition of hypertrophy, he believes, progresses during 1 Jour. Amer. Med. Assoc, vol. 15, No. 4, July 24, 1920. 2 Ibid., vol. 71, No. 10, September 7, 1918. 452 PYLORIC STENOSIS AND SPASM 453 fetal life, but becomes greatly increased after birth, owing to the additional irritation produced by food. Wall,^ on the other hand, as do most other observers, believes that it is a simple developmental anomaly, and that any spasm which is present is secondary to the hypertrophy. He does not believe that "any muscular contraction would be able to produce such a large, hard mass of tissue" as the hyper trophied mass of muscle seen in these cases. Pathology. — The circular, smooth muscle-fibers of the py- lorus are hypertrophied, giving rise to an oval, hard, cartilaginous- Hke tumor, usually about the size of a small ripe olive. On section, the tissue of this tumor is whitish, porky, and non- vascular. The hypertrophy of the muscle-fibers causes narrow- ing of the pyloric orifice, and hence obstruction. This narrowing produces an infolding of the mucous membrane into rugae, and the opening at the pylorus in severe cases may be so small that it will admit only a fine probe. The walls of the stomach proximal to the pylorus are con- siderably thickened, and the stomach itself is usually dilated. The intestine in cases of average duration is small and col- lapsed, owing to the fact that it has received little food. Symptoms. — The important signs and symptoms are: 1. Persistent projectile vomiting. 2. Progressive loss of weight. 3. Constipation. 4. Visible gastric peristalsis. 5. Palpable tumor. The obstruction may be complete or partial, the severity of the symptoms depending upon the extent of the obstruction. The baby is born apparently in good health, and does well for the first week or two, when he suddenly begins to vomit without apparent cause. The vomiting rarely begins before the end of the first week or after the sixth. At first there may be nothing especially characteristic about it, but it soon becomes explosive, and food may be forcibly ejected for a distance of a foot or two. i Arch. Ped., vol. 36. 1919. 454 PRACTICAL INFANT FEEDING The vomitus shows no particular evidences of indigestion. The vomiting may occur immediately after feeding or in between feedings, and is usually constant, but not infrequently several feedings a day may be retained, in which case the next time the baby vomits the vomitus is larger than the amount of the pre- vious feeding. This is quite characteristic. The appetite is usually voracious, and these babies are almost always con- tinually hungry, and will take large amounts of whatever is offered them. In cases with almost complete obstruction severe constipa- tion is the rule; the stools are infrequent, very small, and may contain but little fecal material. They not infrequently some- what resemble meconium. Loss of weight is very rapid and large, and not infrequently as much as one- third of the body weight will be lost. With changes in food temporary improvement for a few days is likely to occur, but is not permanent. If untreated, the baby dies in a few weeks from starvation. Visible gastric peristalsis is an important sign and is present in practically all cases. It is best elicited by giving the baby an ounce or so of water, waiting a few minutes, and then gently scratching the skin over the stomach with a throat stick, when waves of peristalsis may be easily seen following each other from left to right across the abdomen. These waves in some cases may be as large as a small egg. The stomach is in most cases considerably dilated, and the dilatation is easily visible, giving rise to an undue prominence of the upper portion of the abdomen. Palpable Tumor. — Usually under the right conditions the pyloric tumor may be felt through the abdominal wall, most commonly sKghtly to the right and a little above the umbilicus, but occasionally high up under the edge of the liver. It takes a good deal of practice to feel a pyloric tumor on account of its relatively small size and on account of the fact that it is some- times difficult to secure sufficient relaxation of the abdominal wall. When it is felt it is a diagnostic sign of the greatest im- PYLORIC STENOSIS AND SPASM 455 portance. The absence of a palpable tumor does not, however, rule out pyloric stenosis. The tumor is best felt when the stomach is empty and when there is no gaseous dilatation of the Fig. 31. — Visible gastric peristalsis. stomach or intestines, and cannot be felt when the baby is crying, with consequent spasm of the abdominal muscles. In Fig. 32. — Visible gastric peristalsis. order to get rid of gas a small catheter may be passed into the stomach, and in order to secure relaxation of the abdominal wall a little water is given to the baby in a bottle while feeling 456 PRACTICAL INFANT FEEDING for the tumor. If these conditions are present it may be felt, by experienced observers, in most cases. (The diagnosis, prognosis, and treatment of pyloric stenosis and pyloric spasm will be considered together.) Pyloric spasm consists of a spasm of the pyloric muscle, giving rise to much the same s3anptoms seen in pyloric stenosis, but to a lesser degree. The line between the clinical appearance of the two conditions is often not sharply defined, as in pyloric stenosis there is almost always some complicating spasm, and in pyloric spasm there may be enough hypertrophy of the cir- cular muscle-fibers or the redundant mucous membrane to give rise to a palpable tumor. Some authorities believe that there are not two separate conditions, but that all cases should be grouped under the head of pyloric stenosis, and considered under two groups, those with complete and those with partial obstruction. The weight of opinion, however, is that there are two separate conditions. This is borne out by the fact that in one group of cases the tumor at the pylorus is hard, non- vascular, and cartilaginous in character, while in the other group there may be no tumor at all, or if one is present it is soft and vascular, quite different from the tumor of true pyloric stenosis. The etiology of pyloric spasm is obscure; it may occur either in breast- or bottle-fed babies, but is more common in the latter. It is commonly seen in children of neurotic families, and besides the spasm of the pylorus there may be a hypertonicity of the voluntary muscles of the body as well, so that the baby holds his arms and legs very stiffiy. This has been especially emphasized by Haas,^ and since reading his paper I have noticed it in a number of cases. It is probably not far from correct to regard pyloric spasm as a result of gastric indigestion in a nervous baby. Symptoms of Pyloric Spasm. — ^We are dealing here with a functional, partial occlusion. The symptoms resemble those of true pyloric stenosis, but are not so marked. The baby is likely to be of a fussy, irritable type, easily frightened by noises and 1 Arch. Ped., vol. 36, 1919. PYLORIC STENOSIS AND SPASM 457 disturbed by handling. On the other hand, I have seen pyloric spasm in a baby who never cried and who always slept all night and a good part of the day. The vomiting is more inter- mittent, not so explosive, and the stomach is usually little if any dilated. It is not common for more food to be vomited than has been taken at the preceding feeding. Temporary improvement for a day or two is very likely to occur after a change in the food, the same as it does in pyloric stenosis. There may be a moderate degree of constipation, but never to the extent that is seen in pyloric stenosis, and the stools are always fecal. They are often green and undigested and may contain mucus. Visible peristalsis is more frequently seen than not, but may be absent. In a few cases a tumor may be felt, but this is the exception rather than the rule. Loss of weight is not so marked as in true pyloric stenosis, as a not inconsiderable amount of food reaches the intestines. Stationary weight or slight gains may be the rule, but if the condition persists, considerable loss may occur, and the baby may ultimately reach a severe degree of malnutrition. Diagnosis. — Pyloric stenosis and spasm are differentiated from simple indigestion with vomiting in that in the latter con- dition the vomiting stops when the food is regulated, and the evidences of obstruction, such as explosive vomiting, palpable tumor, etc., are not present. Visible peristalsis may be seen in rare cases. The Roentgen ray shows but little interference with the emptying time of the stomach. The diagnosis of pyloric stenosis when the obstruction is nearly complete is not difficult. The characteristic history, with explosive vomiting, small infrequent bowel movements, and marked loss of weight; the physical examination, with visible peristalsis and palpable tumor, form a picture which is definite and clear cut. A palpable tumor, is, however, not pathognomonic of stenosis, as it may be present in spasm when there is comparatively little obstruction. The chief difficulty is in determining the extent of the obstruction, which is essen- tial in order to decide upon the method of treatment to be 458 PRACTICAL INFANT FEEDING Fig. 33. — Immediately after eating. Fig. 34. — One-half hour after. \ 4 Fig. 35. — One hour after. Fig. 36. — Three hours after. Figs. 33 to 36. — Pyloric spasm, showing somewhat delayed emptying time, but by no means complete obstruction. PYLORIC STENOSIS AND SPASM 459 Fig. 37. — Immediately after eating. Fig, 38. — One-half hour after. Fig. 39. — One hour after. Fig. 40. — 2l hours after.* Figs. 37 to 40. — Pyloric stenosis, showing almost complete obstruction. ' Not from the same case as Figs. 37—39. 460 PRACTICAL INFANT FEEDING employed. The Roentgen ray, taken in conjunction with the clinical findings, is here of great value, and although it has been said by some that this method of diagnosis is of com- paratively little value, in my opinion it is invaluable, and gives us more accurate and valuable data as to the extent of the obstruction and the advisability of operation than do any of the other procedures which have been used for the same purpose, such as the passage of duodenal catheters or aspiration of the stomach contents. A feeding of about 2 ounces of a weak milk modification containing about a teaspoonful of bismuth sub- carbonate is given by gavage, and plates are taken immediately afterward, in one-half hour, one hour, two hours, and four hours. In many cases it is not necessary to take the last plate, as the first ones may give enough data on which to base conclusions. There is no need of taking plates later than four hours after the bismuth meal, although this is sometimes done as a matter of interest. The first plate, in a normal series, would show that a small amount of bismuth has come through, the second and third should show that a considerable amount has passed the pyloric orifice, the fourth, that most of the bismuth has gone through, while the last plate should show the stomach nearly empty. In pyloric stenosis with marked obstruction the first two plates usually show that no bismuth at all has left the stomach, the third and fourth, that most of it is still retained. With partial obstruction, the picture is different according to the amount of obstruction present. In most cases of partial obstruction, whether due to true stenosis of mild degree or to spasm, half or more than half of the bismuth is likely to have left the stomach at the end of four hours. In cases of simple indigestion the emptying time may be somewhat delayed, but most of the bismuth will have left the stomach at the end of four hours. In pyloric spasm the baby is more likely to be bottle fed than breast fed. The evidences of obstruction are not nearly so marked as in stenosis — the stools always contain considerable PYLORIC STENOSIS AND SPASM 46 1 fecal material — a tumor is not likely to be felt, and if it is felt it is smaller, especially longer and thinner (Morse) than the tumor in pyloric stenosis, and may sometimes be felt to con- tract beneath the finger. The loss of weight is usually not ex- cessive, and there may be even a slight but unsteady gain. Visible peristalsis may or may not be present; it is practically always present in stenosis. The Roentgen ray shows some interference with the emptying time of the stomach, but it is never so marked as in true pyloric stenosis with nearly complete obstruction. Treatment of cases with extensive obstruction, where there is marked loss of weight, visible peristalsis, palpable tumor, and a large amount of the bismuth meal remains in the stomach at the end of four hours (true pyloric stenosis) . Although not a few competent observers have reported good results in this type of case with medical treatment, the consensus of opinion is in favor of operation. In my opinion true pyloric stenosis is a surgical disease, and operation should be done as soon as the diagnosis is made. It is of very great importance to operate when the baby is in good condition, and although there is a possibility that he may improve under medical treatment, the chances are against it, and much valuable time may be lost. Surgical intervention, as performed now, carries with it a comparatively low mortality, and is far ahead of medical treatment of any sort. It is probable that many of the cases of so-called pyloric stenosis that have recovered under medical treatment have, in reality, been cases of spasm. The operation usually performed up to about six years ago was a posterior gastro-enterostomy. This was a rather long, serious operation, and the mortality was high. The operation used now almost exclusively is the so-called Fredet-Rammstedt operation, or modifications of it, which con- sists simply in splitting the hypertrophied circular muscle- fibers of the pylorus down to the mucous membrane. This allows the mucous membrane to bulge out into the wound and overcomes the stenosis. The cure is permanent, and 462 PRACTICAL INFANT FEEDING although the tumor may persist for a considerable time after the operation, the stenosis does not. The operation carries with it comparatively little shock, and a skilled operator can do it in twelve or fifteen minutes. The postoperative management is of great importance, and may mean all the difference between the life and death of the baby. It is especially important before operation to remove from the stomach any gas, mucus, and especially bismuth which may be still retained after the bismuth meal. I have only re- cently seen a case where the baby nearly died because he had a stomach full of bismuth which was not removed by gavage before operation. After operation it is well in much emaciated cases to give a subcutaneous infusion of normal saline (about 150 C.C.). Stimulation with adrenalin, caffein, or brandy may also be necessary. Feeding is begun an hour or two after the baby comes out of ether, and it is of very great importance to secure breast milk if possible. About a dram of this may be given at first, diluted with an equal amount of water. For a few feedings it is given every hour. In the next few days the amount at each feeding, the strength, and the interval between feedings are increased, so that at the end of about two days an ounce at a feeding of nearly undiluted breast milk would be taken. It must be remembered that the intestine is in a collapsed condition and is not ready to receive much food ; therefore the feeding in the first few days must be very cautious. At the end of about a week the baby can be put to the breast. If artificial feeding has to be used, whey is the best thing to begin with. In the course of a day or two fat is added to this in the form of 16 per cent. cream, so that the baby would at first get 0.50 per cent, fat, then 1 per cent., and finally, after about ten days, 2.50 or 3 per cent. As improvement continues and the baby becomes stronger the split protein feedings are discontinued, and a return to ordinary milk modifications is gradually made. Prognosis. — The prognosis depends very largely upon the general condition of the baby and upon how long the symptoms PYLORIC STENOSIS AND SPASM 463 have been present. It is always doubtful in cases of long stand- ing; it should be uniformly good if operation is done within a week or two after vomiting has started. The case from which the Roentgen-ray plates were taken was operated on only three days after the beginning of vomiting. In 100 consecutive cases at the Babies' Hospital, New York, in which the vomiting had lasted less than four weeks, the mortality was only 8.7 per cent.-^ In those cases which had vomited more than four weeks it was 50 per cent. Kerley^ states that the mortality in infants who have not vomited for more than two weeks should not be over 5 per cent. In 78 consecutive pyloroplasties at the Children's Hospital, Boston, done by various members of the surgical staff, the mortality was 7.6 per cent.^ Porter^ reports 26 cases, all except 2 of which recovered. In Downes' large series of 217 cases'' there were 30 deaths, giving a mortality of 17.1 per cent. Almost all the babies who died had been vomiting for a long time and were in poor con- dition at the time of operation. Treatment of Pylorospasm or of Pyloric Stenosis with Compar- atively Slight Obstruction. — Treatment depends rather upon the extent of the obstruction than whether the condition is one of spasm or stenosis. Few cases of pylorospasm come to operation. It is always a question of nice judgment to determine whether or not cases with incomplete obstruction need operation. If loss of weight is not great, or if the baby has been holding his weight, if the stools are fecal, and fairly large and frequent, and particularly if the Roentgen-ray plates show that obstruction is relatively slight (about three-quarters of the bismuth meal having left the stomach at the end of four hours), it is advisable to try medical treatment. If after ten days or two weeks the vomiting is no better and the baby is losing weight, operation 1 Holt (Discussion), Trans. Amer. Ped. Soc, vol. xxx, 1918. 2 Ibid. 3 Ladd: Surg. Clin. North America, vol. No. 3, June, 1921. 4 Arch. Ped., vol. xxxvi. No. 7, 1919. 5 Jour. Amer. Med. Assoc, July 24, 1920. 464 PRACTICAL INFANT FEEDING should be resorted to. Rapid loss of weight is the most important point in favor of operation, and if progress down hill is steady and rapid, operation must not be delayed, as it is of the utmost importance to do it before the baby is in very bad nutritional condition. Medical treatment may be discussed under three headings: feeding, stomach washing, and drugs, of which the first is the most important. Feeding. — In either type of case, whether spasm or stenosis, it is worth while to try feeding with breast milk, provided the baby is not already on the breast. If he is already on the breast and vomits, or if breast milk is unobtainable, the thick cereal feeding, first advocated by Sauer,^ is the most successful method. His original formula was as follows: Skimmed milk 9 ounces; Water 12 ounces; Farina 6 tablespoonfuls; Dextrimaltose. 3 tablespoonfuls This is boiled one hour in a covered double boiler, and con- tains about 15 per cent, of cereal. It must be of a thick con- sistency, so that it will barely run off a spoon. From 2 to 8 tablespoonfuls, according to the size of the baby, are given every three hours. Since Sauer's original paper it has been found that some- what thinner mixtures work better, and the amount of farina now ordinarily employed is 1 tablespoonful to 5 ounces of liquid. Porter^ recommends using rice flour in the proportion of 1 tablespoonful to 7 ounces of liquid, and believes that this works better than farina, especially if farina causes a tendency to diarrhea, which it may do occasionally. The mixture is so thick that it cannot ordinarily be taken from a bottle. It is usually given on the end of a throat stick, then the cereal is pushed into the back of the mouth wdth another throat stick. Or, as Dr. Griffith, of Philadelphia, suggests,^ it 1 Arch. Ped., July, 1918. 2 Trans. Amer. Ped. Soc., 1921. 3 Ibid. PYLORIC STENOSIS AND SPASM 465 may be given through a large-holed Hygiea nipple by pushing it through with a spoon, while the nipple is in the baby's mouth. It is not necessary to adhere strictly to any set formula in using the thick cereal principle; it is merely necessary to use small amounts of a concentrated, rather thick mixture, con- taining large amounts of starch, which is so thick and adhesive that it is vomited with difficulty. Whole or skimmed milk may be used in various proportions, according to the exigencies of the case, and sugar may or may not be added. It must be remembered that these mixtures contain a large amount of starch, and that although the vomiting may stop, an intestinal indigestion due to excess of starch may arise. It is well, therefore, to examine the stools for starch under the microscope occasionally, and to cut down the amount fed if much undigested starch is coming through. It is always neces- sary to give water between feedings in order to cover the baby's fluid needs. This is probably the most successful method of feeding this group of cases, and good results have been reported by almost all those who have used it. Personally, I have had compara- tively little experience with it, but have secured good results in the few cases where it has been used. Another way of feeding, especially in pylorospasm, is with dried milk containing a low fat (Dryco). This often works sur- prisingly well. It is usually best to begin with one-half strength, 4 level tablespoonfuls of dried milk to 8 ounces of water, and to gradually increase until full or nearly full strength is reached. Occasionally it is advantageous to combine a barley or farina gruel (about 3 per cent.) with the dried milk mixture. Whey is often of value as a temporary food, and mixtures of gravity cream and whey have long been used. These are, as a rule, not very satisfactory, as in order to supply sufficient caloric value for weight increase it is necessary to use a fairly high fat percentage which is directly contraindicated in feeding any baby with an irritable stomach. Stomach washing may sometimes be of value. A 1 per cent. 30 466 PRACTICAL INFANT FEEDING solution of sodium bicarbonate at blood heat is used. The wash- ing is best done about one-half hour before feeding once or twice a day. Stomach washing has the great disadvatage that it disturbs the baby a good deal. It is worth a trial, however. Atropin. — Inasmuch as the pathologic condition in pyloro- spasm consists of a spasm of smooth muscle, and as most cases of pyloric stenosis are complicated by spasm, the administration of atropin would seem to be theoretically indicated. This has been used for a long time, with not very enthusiastic reports, until that of Haas^ in 1919, who believes that excellent results can be secured with larger doses without danger to the baby. He reconunends a 1 : 1000 solution of atropin sulphate, con- taining about T^^ grain to the drop. A drop of this is put into each feeding, or is given in water if the baby is breast fed. If this is well borne, 2 drops are used at the next feeding, and so on, until at the end of twenty-four hours the dose may be 3 or 4 drops with each feeding. If the dosage used does not produce beneficial results, and if there are no symptoms of atropin- poisoning, the dose is increased to 5 or 6 drops with each feeding. It may be necessary to keep up the treatment for several weeks or even months. Atropin treatment should always be tried. I have myself, however, never seen any very striking results from it. Prognosis.— Most cases of pylorospasm recover with careful medical treatment. It is, however, a most annoying condition, and progress is likely to be slow. The institution of thick cereal feeding has done more to help us than anything else. ^ Not a few cases of mild pyloric stenosis likewise recover under medical treatment. There is always the suspicion that these may be cases of spasm and not of true pyloric stenosis. If after ten days or so of medical treatment loss of weight con- tinues, and the vomiting is no better, operation should be resorted to at once. 1 Arch. Ped., vol. Z6, 1919. INDEX Abnormal breast-fed baby, 116 Abscess of breast, 112 Absorption of ash, 59 of calcium, 59, 60 effect of increasing amounts of fat on, 61 of chlorids, 65 of fat, 39 of iron, 64 of phosphorus, 63 of potassium, 62 of protein, 37 of sodium, 62 of starch, 56 of sugar, 48 of sulphur, 64 Accessory food factors, 65^ Acid, hydrochloric, free, in stomach, 24 in fat of cow's milk, 147 lactic, organisms in cow's milk, 150 stools, 78 Albumin milk, 215 Alimentary intoxication, 139, 299 Alkalies for normal artificially fed infant, 239 used in special preparations, 212 Alkaline secretion of duodenum, 25 stools, 79 American Association of Medical Milk Commissions, 158 Amylopsin, 27 Anaphylactic food tests in eczema, 449 Antiscorbutic foods in scurvy, 436 vitamin, water-soluble C, 68 Appetite, habitual loss of, 360 causes, 360 loss_ of, in children from one to eight years old due to poor daily routine, 363 poor, in children from four to eight years of age, 365 tonic for, 366 Aprotein, 219 Artificial feeding, modern, develop- ment of, 124 Biedert, Meigs, and Rotch in, 125 Czerny and Keller's work in, 134 ^ Escherich's work in, 133 fat period in, 134 Finkelstein's work in, 137 in America, 128 influence of Biedert, 128 Meigs' work in, 128 protein period in, 125 retrospect of Biedert, Meigs, and Rotch, 131 Rotch's work in, 129 Widerhofer's work in, 132 of normal infant, 228 alkalies for, 239 amount at each feeding, 237 of fat for, 238 of protein for, 239 of starch for, 239 of sugar for, 238 amounts of food elements to use, 238 caloric method, 229 general plan, 230 green vegetables, 234 interval for, 238 newborn period, 231 nine months to one year, 233 orange juice in, 243 second period, 232 solid food, 234 third period, 233 three weeks to nine months, 232 water for, 243 whole milk mixtures from start, 233 Artificially fed infant, acute fat in- digestion in, 258 treatment, 258_ protein indigestion in, 263 467 468 INDEX Artificially fed infant, acute protein in- digestion in, treatment, 264 starch indigestion in, 264 sugar indigestion in, 259 ^ treatment, 261, 262 chronic fat indigestion in, 265 with constipated stools, 268 with loose stools, 272 sugar indigestion in, 274 treatment, 274 digestive and nutritional dis- turbances in, 252 energy quotient in, 74 intestinal flora in, 31 underfeeding in, 256 normal infant, gain in weight in, 240 general condition, 244 stools of, 242 urine of, 243 Ash, absorption of, 59 content of colostrum, 18, 90 of human milk, 90 in cow's milk, 59 in human milk, 59 Assimilation limits of different sugars, 49 Athrepsia, 139, 275 Atrophy, infantile, 139, 275 ^ Atropin in pyloric stenosis with slight obstruction, 466 Babies fed on condensed milk, types of, 233 Bacillus, gas, test for, in stools, 88 lactic acid, inoculating milk with, 213 Bacteria in cow's milk causing ab- normal conditions in milk, 151 intestinal, 28 kinds, 31 protein-splitting, 151 relation of, to food, 28 spore-bearing, in cow's milk, 151 types of, dependence of, on food supply, 32 which produce fermentation, types of, 34 putrefaction, types of, 34 Bacteriology of cow's milk, 149 of digestive tract, 28 of human milk, 98 of large intestine, 31 of small intestine, 30 of stomach, 29 Barley jelly, 211 malt, 205 Barley-water, 210 Basal energy requirement, 69 Bathing in eczema, 446 Beef juice, 222, 248 Biedert, influence of, in development of modern artificial feeding, 128 Meigs, and Rotch in development of modern artificial feeding, 125 Biedert 's cream conserve, 126 Bilanzstorung, 40, 268 Bile, 27 color of, 27 function of, 27 in stools, test for, 89 Bismuth in fermentative diarrhea, 308 in infectious diarrhea, 317 ointment for dry, rough, not acutely inflamed, eczema, 441 Bitter milk, 152 Blood in urine in scurvv, 427 Blue milk, 151 Body temperature of newborn, 19 Boiled milk, advantages of, 173 disadvantages of, 173 versus pasteurized milk, 175 Boiling of milk, 171 changes produced by, 171 Bones in rickets, Roentgen-ray appear- ance of, 387 long, in rickets, 383 Borcherdt's drimalt soup extract, composition of, 207 dry malt soup extract with wheat flour, composition of, 208 malt soup extract, composition of, 207 sugar, 206 composition of, 207 Boric ointment in seborrheic eczema, 442 Bottle fed. See Artificially fed infant. Bow-legs in rickets, 386 Brandy, 308 Breast, abscess of, 112 caking of, 112 fed, fecal flora of, 31 feeding, 100 amount at each feeding, 109 at night, 109 contraindications to, 115 during menstruation, 114 importance of, 100 in first few days, 104 in pregnancy, 114 intervals of nursing, 105, 108 overfeeding in, 121 substituting one bottle feeding, 109 three-hour interval in, 105, 108 INDEX 469 Breast feeding, underfeeding in, 118 vomiting in, 116 milk, average amounts taken in first ten days, 23 in spasmophilia, 414 Breast-fed infant, energy quotient in, 70 fecal flora of, 31 intestinal flora in, 31 normal, average weights at differ- ent ages, 240 overfeeding of, 121 stools of, 110 underfeeding of, 118 weaning of, 110 Breath holding, 411 Breck feeder for premature infants, 352 ^ Bronchial tetany in spasmophilia, 409 Butter fat, use of other fats in place of, 201 Buttermilk and water with dried casein, 218 composition of, 214 Buttocks, excoriated, applications for, 308 Caffein, 308 Caking of breast, 112 Calcium, absorption of, 59, 60 effect of increasing amounts of fat on, 61 and sodium interrelationship in spasmophilia, 405 in cow's milk, 59 in human milk, 59, 97 in rickets, 398 in spasmophilia, 415^ lack of, as cause of rickets, 374 metabolism in etiology of spas- mophilia, 404 Caloric method of artificial feeding, 229 requirements of infants, 69 of normal babies and children, tables of, 72, 73 children of different ages, table showing, 329 value of human milk, 96 Calorie, 69 Calories in modified milk feeding, 194 Cane-sugar, 204 Carbohydrate, metabolism of, 45 Care of nipples, 104 Carpopedal spasm in spasmophilia, 408 treatment, 413 Casafru in constipation, 358 Casec, 219 milk, 259 Casein, coagulation of, mechanism of, 37 curds, 263 in protein stools, 87 dried, plus whole milk or butter- milk and water, 218 in cow's milk, 148 in emptying time of stomach, 25 in human milk, 96 Castor oil in constipation, 358 Celiac disease, 321 Cells in cow's milk, 149 Cereal diluents, 210 Certified milk, 157 standards for, 158 Chalk, precipitated, in fermentative diarrhea, 307 Children, normal, of different ages, caloric requirements of, table showing, 329 older, chronic intestinal indigestion in, 321 weights of, 241 Chloral in spasmophilia, 412 Chlorids, absorption of, 65 in cow's milk, 65 in human milk, 65, 97 Chloroform in spasmophilia, 412 Chondrodystrophy fcetalis, 394 Chvostek's sign in spasmophilia, 406 Circulatory system in scurvy, 429 Citric acid content of human milk, 97 Classification and nomenclature in infant feeding, 254 etiologic, of disorders of infant feeding, 255 Coagulation of casein, mechanism of, 37 Coal-tar, crude. In wet, oozing eczema, 439, 440 Cod-liver oil, 246 in rickets, 397 in spasmophilia, 416 Collapse in infectious diarrhea, treat- ment, 318 Colonic irrigations in fermentative diarrhea, 304 in infectious dysentery, 316 Color of bile, 27 of normal infant, 245 of stools in infancy, 27, 77 Colostrum, 18, 90 amount of, 18, 90 ash content of, 90 composition of, 90 contents of, 18 470 INDEX Colostrum corpuscles, 91 period, 18 Complemental feeding, 119 Condensed milk, 222 composition of, 223 types of babies fed on, 223 Congenital hypertrophic stenosis of pylorus, 452 Conserve, cream, Biedert's, 126 Constipation in infancy, 356 drugs in, 358 enemata in, 358 food in, 357 milk of magnesia for, 242 suppositories in, 358 treatment, 357 Contraindications to nursing, 115 Convulsions, general, in spasmophilia, 409 Cooking of milk, 170 Corn syrup and lactic acid milk mix- tures, 209 composition of, 209 Corpuscles, colostrum, 91 Cow, garget in, 154 mastitis in, 154 tuberculosis in, 154 tuberculin test for, 155 Cow's milk and human milk, essential differences between, 176 ash in, 59 bacteria in, _ causing abnormal conditions in, 151 bacteriology of, 149 calcium in, 59 casein in, 148 cells in, 149 chlorids in, 65 fat in, 146 acids in, 147 ferments in, 149 idiosyncrasy to, 289 desensitization, 292 diagnosis, 290 treatment, 291 iron in, 63 lactalbumin in, 148 lactic acid organisms in, 150 lactose in, 148 magnesium in, 59 phosphorus in, 63 potassium in, 62 protein in, 148 salt content of, 55, 148 saprophytic organisms in, 150 sodium in, 62 spore-bearing bacteria in, 151 streptococci in, 153 sulphur in, 64 Cracked nipples, 111 Cradle cap, 442 Cream conserve, Biedert's, 126 dilutions, 186 gravity and skimmed milk mixtures, 188 long method of calculation, 197 principles of calculation, 191 short method of calcula- tion, 190 Crying, 244 Curdling of milk by rennin, 211 Curds, casein, 263 Czerny and Keller's classification of nutritional disturbances, 134 work in development of modem artificial feeding, 134 Czerny's milk modification, 136 Dairy, hygiene of, 158 Decomposition, 139, 275 Deformity, prevention of, in rickets, 399 Dehydration, prevention of, in fer- mentative diarrhea, 304 Depressed nipples, 111 Development of modern artificial feeding, 124 Dextrimaltose, Meade's, 206 composition of, 207 Dextrose, 209 Diarrhea, 27, 293 fat, 81 absorption in, 40 fermentative, 260, 294, 296 bismuth in, 308 colonic irrigations in, 304 constitutional weakness in, 297 dehydration in, 304 drugs in, 307 electric fan in, 308 excoriated buttocks In, 308 gas bacillus test in, 313 infected milk in, 297 intraperitoneal saline injection in, 306 intravenous injections In, 307 medicinal treatment, 304 opium in, 307 overfeeding with sugar In, 296 overheating of body in, 297 parenteral infections in, 297 precipitated chalk in, 307 protein form of, 309 stimulants in, 308 subcutaneous saline injections in, 305 INDEX 471 Diarrhea, fermentative, sugar fermen- tation in, 298 treatment, medicinal, 304 of mild cases, 300 of severe cases, 300 water in, 304 from sugar, 43 infectious, 309 bismuth in, 317 collapse in, treatment, 318 diagnosis, 312 drugs in, 317 feeding in, 315 hyperpyrexia in treatment, 318 intussusception and, differentia- tion, 312 nervous symptoms in, treatment, 318 ^ opium in, 317 prognosis, 318 symptoms, 310 tannalbin in, 317 treatment, 313 of special symptoms, 318 vomiting in, treatment, 318 mechanical, 294, 295 stools of, 77 summer, 293 Diarrheal diseases, 293 groups of, 294 prophylaxis of, 319 Diastoid, Horlick's, composition of, 207 Diet at fourteen months, 249 during second year, 246 from sixteen months to two years, 250 from two to three years, 250 in moderately severe starch Indi- gestion for baby of 2| years weighing 20 pounds, 335 in severe combined starch and fat indigestion, 335 fat indigestion for baby of 2| years weighing 18 pounds, 333 of nursing mother, 103 Diffuse papular eczema, 444 . Digestion in intestines, 26 in mouth, 22 in stomach, 24 of protein, 37 of sugar, 48 pancreatic, 27 pathology of, 17 physiology of, 17 Digestive and nutritional disturb- ances in bottle fed, 252 tract, bacteriology of, 28 in scurvy, 429 Digestive tract, physiology of, 22j Diluent, cereal, 210 Disaccharids in infant feeding, 204 Disease, acute, in nursing mother, 113 Diseases transmitted by milk, 156 Disturbed balance, 138 Dried casein plus whole milk or butter- milk with water, 218 Drimalt soup extract, Borcherdt's, composition of, 207 Drugs in constipation in infancy, 358 in fermentative diarrhea, 307 in human milk, 98 in infectious diarrhea, 317 in rickets, 397 in spasmophilia, 415 " Dry milk powders, 219 Dryco, 219 brand of dried milk, composition of, 219 Duodenum, secretion of, 25 Dysentery, feeding in, 314, 315 infectious, colonic irrigations in, 316 ^ purgation in, 314 starvation in, 315 treatment in, 314 Dyspepsia, 139, 260 Eczema in infancy, anaphylactic food tests in, 449 bathing in, 446 diffuse papular or vesicular, 444 dry red, acutely inflamed, 441 rough, not acutely inflamed, 441 etiology, 438 feeding in, 447 idiosyncrasy to food proteins in, 449 infected, 444 intertriginous, 443 whitewash for, 443^ prevention of scratching, 445 seborrheic, 442 treatment, 438 local, 438 ten preparations for, 445 types, 438 wet, oozing, 439 crude coal-tar for, 439, 440 Egg and potato, 249 Eiweiss milk, 54, 140, 215 Eiweissmilch, 54, 140, 215 purpose of, 54 Electric fan in diarrheal diseases, 308 irritability in spasmophilia, 407 reactions in spasmophilia, 416 472 INDEX Emptying time of stomach, 24 Enema, soapsuds, for constipation, 242 for gas, 244 Enemata, 358 Energy quotient, 70 in breast-fed babies, 70 requirement, basal, 69 of infants, 69 Enterokinase, 26 Epinephrin, 308 Epiphyses at knee and ankles in rickets, 387 Epiphysitis, syphilitic, scurvy and, differentiation, 430 Erb's phenomenon in spasmophilia, 407 Erepsin, 26 Escherich's work in development of modern artificial feeding, 133 Ester, 147 Ether in spasmophilia, 412 Etiologic classification of disorders of infant feeding, 255 Evaporated milk, 224 Excoriated buttocks, applications for, 308 Exophthalmos in scurvy, 428 Exsiccation fever, 21 Extremities in rickets, 385 Facial phenomenon In spasmophilia, 406 Fat, absorption of, 39 and starch indigestion, severe, com- bined, diet for, 335 butter, 147 use of other fats in place of, 201 content of colostrum, 18 of stools, groups of, 83 diarrhea, 81 in cow's milk, 146 acids in, 147 in stools, 80 in older children, 84 macroscopic examination, 80 of normal and abnormal bottle- fed babies, 44 breast- and bottle-fed babies, 44 increasing amounts of, effect on calcium absorption, 61 indigestion, acute, in bottle fed, 258 treatment, 258 chronic, 40, 61 in bottle-fed, 265 with constipated stools, 268 with loose stools, 272 severe, diet for baby 2| years old weighing 18 pounds, 333 Fat Injury, 135 intake, percentage absorbed, 39 metabolism of, 38 mixtures, synthetic, prepared to resemble fat of human milk, 203 of human milk, 95 and of cow's milk, differences between, 176 synthetic fat mixtures pre- pared to resemble, 203 of milk, effect of boiling on, 172 partition in stools, 42 period in development of modern artificial feeding, 134 Fat-soluble A, 65, 66 action of, 66 as cause of rickets, 375-377 Fats used in place of butter fat, 201 Fecal flora of breast fed, 31 Feeding, artificial, 124. See also A rtificial feeding. at fourteen months, 249 breast, 100. See also Breast feeding. complemental, 119 difficult, general suggestions for cases of, 286 during second year, 246 from sixteen months to two years, 250 from two to three years, 250 supplemental, 120 Fermentation, 32 of sugar, 50 chemistry of, 50 conditions which bring about, 52 degrees of, 298 feeding in, 301 FInkelstein's treatment of, 140 lactic acid milk in, 303 protein milk in, 301 purgation in, 300 simple skimmed milk dilutions In, 304 skimmed milk with powdered casein In, 302 treatment in mild cases, 300 In severe cases, 300 types of bacteria which produce, 34 Fermentative diarrhea, 260, 296. See also Diarrhea, fermentative. Fermented starch stools, 85 Ferments In cow's milk, 149 In milk, effect of boiling on, 172 Fetal rickets, 367 Fettnahrschaden, 135 Fever, exsiccation, 21 inanition, 20 transitory, of newborn, 20 INDEX 473 Fever, transitory, of newborn, diag- nosis, 21 etiology, 21 treatment, 22 Finkelstein's classification of nutri- tional disturbances, 138 milk, 140 treatment of sugar fermentation, 140 work in development of modern artificial feeding, 137 Fissures of nipples, 112 Food, changes in, variation in milk elements from, 98 elements, metabolism of, 34 Horlick's, composition of, 207 Mellin's, composition of, 207 proprietary, 225 proteins, idiosyncrasy to, in ec- zema, 449 relation of bacteria to, 28 supply, dependence of type of bacteria on, 32 tests, anaphylactic, in eczema, 449 values, table of, 328 Formaldehyd in milk, Hehner's test for, 156 Formalin as preservative of milk, 156 Fragilitas ossium, 395 Fredet-Rammstedt operation in py- loric stenosis and spasm, 461 Frozen milk, 157 Gain in weight in normal artificially fed infant, 240 Galactogogues, 93 Garget in cow, 154 Gas bacillus, test for, in stools, 88 technic of, 313 soapsuds enema for, 244 Gastro-intestinal tract, bacteriology of, 28 General suggestions for difficult feed- ing cases, 286 Goat's milk, 220 composition of, 221 evaporated, 221 Grape sugar, 204 Gravity cream and skimmed milk mixtures, 188 long method of calculation, 197 principles of calculation, 191 short method of calcula- tion, 190 Green vegetables, 248 in artificial feeding of normal Infants, 243 Gums in scurvy, 427 Habitual loss of appetite, 360 Harrison's groove in rickets, 383 Hehner's test for formaldehyd in milk, 156 ^ Hemorrhage into skin in scurvy, 427 High protein stools, 86 Holt and Fales' tables of caloric requirements for normal babies and children, 72, 73 Homogenization of milk, 201 Homogenized olive oil in place of butter fat, 202 Horlick's diastoid, composition of, 207 food, composition of, 207 Human milk, 90 amount of, 92 ash content of, 59, 90 bacteriology of, 98 biologic substances of, 97 calcium in, 59 content of, 97 caloric value of, 96 casein of, 96 chemical composition of, 94 chlorids in, 65, 97 citric acid content of, 97 color, 91 coming in of, 91 drugs in, 98 fat of, 95 synthetic fat mixtures pre- pared to resemble, 203 galactogogues for, 93 iron in, 63, 97 lactalbumin of, 96 lactoglobulin of, 96 magnesium in, 59 non-protein nitrogenous consti- tuents of, 96 phosphorus in, 63 physical properties of, 91 potassium in, 62 protein of, 95 salt content of, 55 salts of, 97 sodium in, 62 specific gravity, 91 sugar in, 95 sulphur in, 64 taste, 91 ^ variations in, through changes in food, 98 ^ Hydrobilirubin in stools in infancy, 78 Hydrochloric acid, free, in stomach, antiseptic power of, 24 Hygiene of dairy, 158 Hyperpyrexia in infectious diarrhea, treatment, 318 474 INDEX Idiosyncrasy to cow's milk, 289 desensitization, 292 diagnosis, 290 treatment, 291 to food proteins in eczema, 449 Inanition fever, 20 Indigestion, fat, acute, in bottle fed, 258 treatment, 258 chronic, 40, 61 in bottle fed, 265 with constipated stools, 268 with loose stools, 272 severe, diet for baby 2| years old weighing 18 pounds, 333 intestinal, chronic, 276 in older children, 321 protein, acute, in bottle fed, 263 treatment, 264 starch, acute, in bottle fed, 264 moderately severe, diet for baby of 2| years weighing 20 pounds, 335 omitting all starch in, 334 sugar, 260 chronic, in bottle fed, 274 treatment, 274 in bottle fed, 259 treatment, 261 Infancy, constipation in, 356, See also Constipation in infancy. eczema in, 438. See also Eczema in infancy. stools in, 75. See also Stools in infancy. Infant, energy requirements of, 69 feeding, classification and nomen- clature in, 254 special preparations used in, 201 newborn, average weight of, 17 birth weight of, regaining, 19 body temperature of, 19 gain in weight of, 106 loss of weight of, 17, 106 amount, 18, 19 duration, 18 prevention of, 19 sepsis in, 21 transitory fever of, 20 vomiting in, 116 cause, 117 normal, artificial feeding of, 228. See also Artificial feeding. premature, 340. See also Premature infants. Infantile atrophy, 139, 275. scurvy, 419. See Scurvy. Infantilism, intestinal, 276, 321 Infected eczema, 444 Infected milk in fermentative diar- rhea, 297 Infection, nutritional disturbances from, 136 parenteral, in fermentative diarrhea, 297 Infectious diarrhea, 309. See also Diarrhea, infectious. Injections, intraperitoneal saline, in fermentative diarrhea, 306 intravenous, in fermentative di- arrhea, 307 subcutaneous saline, in fermentative diarrhea, 305 Intertriginous eczema in infancy, 443 whitewash for, 443 Intestinal bacteria, 28 indigestion, chronic, 276 in older children, 321 articles of food used in, 329 cottage cheese in, 331 course, 337 definition, 321 diagnosis, 325 eggs in, 331 etiology, 321 fat in, 330 fruit in, ZZZ protein in, 330 prognosis in, 337 milder cases, 338 milk, in 329 starch in, 330 sugar in, 2>dt 1 symptoms, 323 treatment, 325, 336^ tubercular peritonitis and, differentiation, 326 vegetables in, 332 infantilism, 276, 321 Intestines, 26 action of protein in, 37 digestion in, 26 large, bacteriology of, 31 small, bacteriology of, 30 secretion of, 26 sugar in normal action of, 49 Intoxication, 139 alimentary, 139, 299 Intraperitoneal saline injection in fermentative diarrhea, 306 Intravenous injections in fermentative diarrhea, 307 Intussusception, infectious diarrhea and, differentiation, 312 Invertase, 26 Inverted nipples, 111 Invertin, 26 Iron, 57 INDEX 475 Iron, absorption of, 64 in cow's milk, 63 in human milk, 63, 97 in rickets, 398 Jaws and teeth in rickets, 382 Jelly, barley, 211 oat, 211 Juice, beef, 222, 248 lemon, 437 lime, 437 orange, 235, 243, 437 tomato, 437 Keller and Czerny's work in develop- ment of modern artificial feeding, 134 Keller's malt soup, 207 Klim dried milk, composition of, 219 Knock-knee in rickets, 386 Kyphosis in rickets, 387 Lactalbumin in cow's milk, 148 of human milk, 96 Lactation, difficulties arising during, 111 Lactic acid bacilli, inoculating milk with, 213 milk, 213 and corn syrup mixtures, 209 in sugar fermentation, 303 organisms in cow's milk, 150 Lactoglobulin of human milk, 96 Lactose, 50 content of colostrum, 18 in cow's milk, 148 in infant feeding, 204 Large intestine, bacteriology of, 31 Larosan, 218, 259 Laryngeal stridor, congenital, laryn- gismus stridulus and, differentia- tion, 411 Laryngismus stridulus, congenital lar- yngeal stridor and, diflferentia- ation, 411 in spasmophilia, 408 ^ treatment, 413 Legs in scurvy, 426 Lemon juice, 437 Lime juice, 437 Lime-water, 212 Liver, 27 function of, 27 Long bones in rickets, 383 Loss of water from body, 18 Macroscopic examination of stools, 80 _ Magnesia, milk of, in constipation, 358 Magnesium in cow's milk, 59, 62 in human milk, 59, 62 Malnutrition, Marriott's method of feeding in, 209 Malt soup extract, Borcherdt's, com- position of, 207 dry, Borcherdt's, with wheat flour, composition of the, 208 Meade's, with wheat flour, composition of, 208 Maltine, composition of, 207 Keller's, 207 sugar, 204 Borcherdt's, 206 composition of, 207^ preparations, composition of, 207 Maltase, 26 Maltine malt soup, 206 extract, composition of, 207 Maltose in infant feeding, 204 Maltose-dextrin preparations, 204 contraindications for, 206 indications for, 206 Marasmus, 139, 256, 275 artificial feeding in, 280 clinical appearance, 278 history, 277 course, 284 definition, 275 drugs in, 284 etiology and pathogenesis, 276 injections in, 284 occurrence, 276 prognosis, 286 treatment, 279 warmth in, 283 Marriott's method in malnutrition, 209 Mastitis, 112 in cow, 154 milk, 154 Meade's dextrimaltose, 206 composition of, 207 dry malt-soup extract with wheat flour, composition of, 208 Mechanical diarrhea, 294. See also Diarrhea, mechanical. loss of weight in newborn, 17 Meconium, 106 Medical Milk Commission, 158 Mehlnahrschaden, 135 Meigs, Biedert, and Rotch in develop- ment of modern artificial feeding, 125 476 INDEX Meigs' work in development of modern artificial feeding, 128 Mellin's food, 206 composition of, 207 Menstruation, breast feeding during, 114 Metabolism of carbohydrate, 45 of fat, 38 of food elements, 34 of mineral salts, 56 of protein, 34 Microscopic examination of stools, 81 first procedure, 82 for starch, technic, 86 second procedure, 82 Milchnahrschaden, 48 Milk, albumin, 215 at summer resorts, 175 bitter, 152 boiled, advantages of, 173 disadvantages of, 173 boiling of, 171 changes produced by, 171 breast, in spasmophilia, 414 blue, 151 casec, 259 certified, 158 standards for, 158 condensed, 222 composition of, 223 types of babies fed on, 223 cooking of, 170 cow's, ash in, 59 average composition, 145 bacteria in, causing abnormal conditions in, 151 bacteriology of, 149 calcium in, 59 casein in, 148 cells in, 149 chlorids in, 65 fat in, 146 acids in, 147 ferments in, 149 idiosyncrasy to, 289 desensitization, 292 diagnosis, 290 treatment, 291 iron in, 63 lactalbumin in, 148 lactic acid organisms in, 150 lactose in, 148 magnesium in, 59 phosphorus in, 63 potassium in, 62 protein in, 148 salt content of, 55, 148 saprophytic organisms in, 150 sodium in, 62 Milk, cow*s, spore-bearing bacteria in, 151 streptococci in, 153 sulphur in, 64 curdling of, by rennin, 211 diseases transmitted by, 156 dried, 219 eiweiss, 140 evaporated, 224 Finkelstein's, 140 formaldehyd in, Hehner's test for, 156 frozen, 157 goat's, 220 composition of, 221 evaporated, 221 homogenization of, 201 human, 90 amount of, 92 and cow's milk, differences be- tween, 176 ash content of, 59, 90 bacteriology of, 98 biologic substances of, 97 calcium content of, 59, 97 caloric value of, 96 casein of, 96 chemical composition of, 94 chlorids in, 65, 97 citric acid content of, 97 color, 91 coming in of, 91 drugs in, 98 fat of, 95 synthetic fat mixtures pre- pared to resemble, 203 galactogogues for, 93 iron in, 63, 97 lactalbumin of, 96 lactoglobulin of, 96 magnesium in, 59 non-protein nitrogenous constit- uents of, 96 phosphorus in, 63 physical properties of, 91 potassium in, 62 protein of, 95 salt content of, 55, 97 sodium in, 62 specific gravity, 91 sugar of,^ 95 sulphur in, 64 taste, 91 variations in, through changes in food, 98 infected, in fermentative diarrhea, 297 inoculating with lactic acid bacilli, 213 INDEX 477 Milk, lactic acid, 213 and corn syrup mixtures, 209 in sugar fermentation, 303 magnesium in, 62 mastitis, 154 modification of, 180 Czerny's formula, 136 gravity cream and skimmed milk mixtures, 188 methods of, 181 top milk (cream) dilutions, 186 whole milk dilutions, 181 modified, calories in formula, 194 molds in, 152 of magnesia for constipation, 242, 358 pasteurization of, 170 what it accomplishes, 170 peptonization of, 212 preservatives in, 156 protein, 55, 140, 215 dried, 218 preparation of, 216 in sugar fermentation, 301 salt content of, 55 red, 151 skimmed, and gravity cream mix- tures, 188 long method of calculation, 197 principles of calculation, 191 short method of calculat- ing, 190 dilutions in sugar fermentation, 304 with dried casein, 218^ with powdered casein in sugar fermentation, 302 slimy and stringy, 151 sour, chemical changes in, 153 souring of, 152 taste of, effect of boiling on, 172 top (cream), dilutions, 186 whole, dilutions, 181 with dried casein, 218 yeasts in, 152 Milk-sugar, 204 Milking, directions for, 105 Mineral salts, metabolism of, 56 Modification of milk, 180. See also Milk, modification of. Molds in milk, 152 Monosaccharids in infant feeding, 204 Morphin in spasmophilia, 413 Mother, nursing, 102 acute disease in, 113 diet of, 103 Motility of stomach, 24 Mouth, digestion in, 22 Nephritis, acute, scurvy and, differ- entiation, 431 Nervous symptoms in infectious diar- rhea, treatment, 318 Newborn, average weight of, 17 birth weight of, regaining, 19 body temperature of, 19 gain in weight of, 106 loss of weight of, 17, 106 amount, 18, 19 duration, 18 prevention of, 19 sepsis in, 21 transitory fever of, 20 diagnosis, 21 etiology, 21 treatment, 22 vomiting in, 116 cause, 117 Nipples, care of, 104 cracked. 111 depressed. 111 fissures of, 112 inverted. 111 Nitrogen and salts retention, relation of sugar to, 46 Nomenclature and classification in infant feeding, 254 Non-protein nitrogenous constituents of human milk, 96 Non- volatile acids, 51 in butter fat, 147 Normal appearing stool, 81 infant, artificial feeding of, 228. See also Artificial feeding. average weight of, 17 Nursing mother, 102 acute disease in, 113 diet of, 103 Nutrition, pathology of, 17 physiology of, 17 Nutritional and digestive disturbances in bottle fed, 252 disturbances, Czerny and Keller's classification of, 134 Finkelstein's classification, 138 from infection, 136 Nux vomica, tincture of, in rickets, 398 Oat jelly, 211 Oat-water, 210 Oatmeal-water, 210 Oil, cod-liver, 246 ^ olive, homogenized, in place of butter fat, 202 in place of butter fat, 202 Oily stool, 80 478 INDEX Ointment, bismuth, for dry, rough, not acutely inflamed eczema, 441 boric, in seborrheic eczema, 442 Olive oil, homogenized, in place of butter fat, 202 in place of butter fat, 202 Opium in fermentative diarrhea, 307 in infectious diarrhea, 317 Orange juice, 235, 437 for artificially fed normal infant, 243 Ossification, zone of, 369 Osteogenesis imperfecta, 395 Osteomyelitis, scurvy and, differentia- tion, 43 1_ Osteoporosis, 374 Overfeeding in breast feeding, 121 Overheating of body in fermentative diarrhea, 297 Pancreas, secretions of, 27 Pancreatic digestion, 27 Papular eczema, diffuse, 444 Parathyroid glands in etiology of spasmophilia, 403 Paregoric, 308 Parenteral infections in fermentative diarrhea, 297 Pasteurization of milk, 170 what it accomplishes, 170 Pateurized or boiled milk versus raw milk, 175 versus boiled milk, 175 Peptonization of milk, 212 Percentage composition of feeding mixtures for infants three months old, 227 Peristalsis of stomach, 24 Peritonitis, tubercular, chronic in- testinal indigestion and, differentia- tion, 326 Peroneal sign in spasmophilia, 407 Phosphorus, absorption of, 63 in cow's milk, 63 in human milk, 63 in rickets, 397 in spasmophilia, 416 lack of, as cause of rickets, 377, 378 Physiologic importance of salts, 58 loss of weight in newborn, 17 Physiology of digestive tract, 22 Poliomyelitis, scurvy and, differentia- tion, 431 Potassium, absorption of, 62 in cow's milk, 62 in human milk, 62 Potato and egg, 249 as antiscorbutic food, 437 Precipitated chalk in fermentative diarrhea, 307 Pregnancy, breast feeding during, 114 Premature infants, 340 artificial food for, 353 bath thermometer for, 350 bed for, 348 breast milk for, 351, 353 Breck feeder for, 352 feeding of, 351 fluids for, 351 general care, 346 gown for, 349 heat for, 347 regulation, 349 interval for feeding, 352 oiling, 349 physiology of, 342 prognosis, 354 room for, 348 treatment, 346 weight of, 345 Prematurity, causes, 341 definition of, 340 incidence, 341 Preservatives in milk, 156 Prophylaxis of diarrheal diseases, 319 Proprietary foods, 225 Protein, 211 absorption of, 37 action of, in intestine, 37 content of colostrum, 18 digestion of, 37 excessive putrefaction of, in protein stools, 87 form of fermentative diarrhea, 309 function of, 34 in cow's milk, 148 indigestion, acute, in bottle fed, 263 treatment, 264 metabolism of, 34 milk, 55, 140, 215 dried, 218 preparation of, 216 in sugar fermentation, 301 salt content of, 55 needs, minimum, 35 of cow's milk and of human milk, differences between, 177 of human milk, 95 groups of, 96 of milk, effect of boiling on, 172 period in development of modern artificial feeding, 125 stools, 86 with casein curds, 87 with excessive putrefaction in, 87 Protein-splitting bacteria, 151 INDEX 479 Proteins, food, idiosyncrasy to, in eczema, 449 Purgation in dysentery, 314 in fermentative diarrhea, 300 Putrefaction, 32 of protein, excessive, in protein stools, 87 types of bacteria which produce, 34 Pyloric spasm, 456 diagnosis, 457 Fredet-Rammstedt operation in, 461 postoperative management in, 462 prognosis, 462 Roentgen ray in, 460 symptoms, 456 treatment, 461 stenosis, 117, 452 diagnosis, 457 etiology, 452 Fredet-Rammstedt operation in, 461 occurrence, 452 pathology, 453 postoperative management in, 462 prognosis, 462^ Roentgen ray in diagnosis, 460 symptoms, 453 palpable tumor in, 454 visible gastric peristalsis in, 454 treatment, 461 with slight obstruction, atropin in, 466 feeding in, 464 prognosis, 466 stomach washing in, 465 treatment, 463 Red milk, 151 Rennin, curdling of milk by, 211 Rheumatism, scurvy and, differentia- tion, 430 Ribs in rickets, 383 Rickets, 41, 367 bow-legs in, 386 calcium in, 398 cod-liver oil in, 397 course, 400 diagnosis, 393 drugs in, 397 epiphyses in, 387 etiology, 372 chemical and experimental find- ings in, 374 clinical observations in, 373 extremities in, 385 feeding in, 396 Rickets, fetal, 367 general treatment, 399 Harrison's groove in, 383 iron in, 398 knock-knee in, 386 kyphosis in, 387, 399 long bones in, 383 occurrence, 367 pathology, 369 phosphorus in, 397 prevention of deformity in, 399 prognosis, 400 prophylaxis in, 395 ribs in, 383 Roentgen-ray appearance of bones in, 387 rosary in, 384 scurvy associated with, 395 shoes and braces in, 400 spine in, 387 stages of progress, 387 sunlight, therapeutic effect in, 399 symptoms, 379 systemic changes in, 389 teeth and jaws in, 382 tincture of nux vomica in, 398 treatment, 396 Roentgen ray in diagnosis of pyloric spasm, 460 of scurvy, 431 Roentgen-ray appearance of bones in rickets, 387 Rosary in rickets, 384 Rotch, Biedert, and Meigs in develop- ment of modern artificial feeding, 125 Rotch's work in development of modern artificial feeding, 129 Saline injection, intraperitoneal, in fermentative diarrhea, 306 subcutaneous, in fermentative diarrhea, 305^ Saliva, quantity of, in newborn, 22 Salt content of cow's milk, 55, 148 of human milk, 55, 97 of protein milk, 55 Salts and nitrogen retention, relation of sugar to, 46 in cow's whey, 54 mineral, metabolism of, 56 of milk, effect of boiling on, 172 physiologic importance of, 58 Saprophytes, 28 Saprophytic organisms in milk, classi- fication, 150 Scrambled egg stool, 80 Scratching, prevention of, in eczema, 445 48o INDEX Scurvy, 419 active, 424 acute nephritis and, differentiation, 431 antiscorbutic foods in, 436 associated with rickets, 395 capillary resistance test in, 429 circulatory system in, 429 diagnosis, 430 digestive tract in, 429 etiology, 420 exophthalmos in, 428 general symptoms, 425 gums in, 427 hemorrhage into skin in, 427 latent, 423 legs in, 426 occurrence, 419 osteomyelitis and, differentiation, 431 poliomyelitis and, differentiation, 431 prognosis, 436 prophylaxis in, 433 rheumatism and, differentiation, 430 signs, 423 subacute, 423, 424 symptoms, 423 syphilitic epiphysitis and, differ- entiation, 430 treatment, 436 urine in, 427 3c-ray in diagnosis, 431 Scybala, 357 Seborrheic eczema in infancy, 442 Secretion of duodenum, 25 of pancreas, 27 of small intestine, 26 of stomach, 24 Sepsis in newborn, 21 Shoe for rachitic children, 400 Short method of calculating gravity cream and skimmed milk mixtures, 190 Skimmed milk and gravity cream mix- tures, 188 long method of calculation, 197 principles of calculation, 191 short method of calcula- tion, 190 dilutions in sugar fermentation, 304 with dried casein, 218^ with powdered casein in sugar fermentation, 302 Skin, hemorrhage into, in scurvy, 427 Skin of normal infant, 244 test in idiosyncrasy to cow's milk, 290 ^ Slimy and stringy milk, 151 Small intestine, bacteriology of, 30 secretion of, 26 Soap stools, 40, 80, 127 conditions in which formed, 41 Soapsuds enema for constipation, 242 for gas, 244 Sodium, absorption of, 62 and calcium, interrelationship of, in spasmophilia, 405 bicarbonate, 212 citrate, 212 in cow's milk, 62 in human milk, 62 relation of, to spasmophilia, 405 Soup, drimalt, extract, Borcherdt's, composition of, 207 malt, extract, Borcherdt's, com- position of, 207 dry, with wheat flour, com- position of, 208 Keller's, 207 Maltine malt, 206 Sour milk, chemical changes in, 153 Souring of boiled milk, 172 of milk, 152 Spasm, carpopedal, in spasmophilia, 408 treatment, 413 pyloric, 456. See also Pyloric spasm. Spasmophilia, 41, 269, 402 active symptoms, 408 breast milk in, 414 bronchial tetany in, 409 calcium in, 415 metabolism in etiology of, 404 carpopedal spasm in, 408 treatment, 413 chloral in, 412 Chvostek's sign in, 406 cod-liver oil in, 416 diagnosis of, 410 drugs in, 415 electric irritability in, 407 reactions in, 416 Erb's sign in, 407 ether or chloroform in, 412 etiology, 403 facial phenomenon in, 406 general condition of infant in, 410 convulsions in, 409 ^ laryngismus stridulus in, 408 treatment, 413 morphin in, 413 occurrence, 402 INDEX 481 Spasmophilia, parathyroids in etiology of, 403 phosphorus in, 416 peroneal sign in, 407 prognosis, 411^ relation of sodium to, 405 signs of increased nerve irritability in, 406 sodium and calcium interrelation- ship in, 405 symptoms, 406 tetany in, 408 treatment of active manifestations in, 412 of underlying condition, 414 Trousseau's sign in, 407 Spine in rickets, 387 Spitting up, 243 Spore-bearing bacteria in cow's milk, 151 Starch, 210 absorption of, 56 and fat indigestion, severe, com- bined, diet in, 335 calculation of, 196 in stools, 85 fermented type, 85 microscopic examination for, technic, 86 unfermented type, 85 indigestion, acute, in bottle fed, 264 moderately severe, diet for baby of 2| years weighing 20 pounds, 335 omitting all starch in, 334 injury, 135 Starvation in dysentery, 315 stool, 87 Steapsin, 27 Stenosis, pyloric, 117, 452. See also Pyloric stenosis. Stomach, 23 anatomic capacity of, 23 bacteriology of, 29 digestion in, 24 emptying time of, 24 free hydrochloric acid in, 24 motility of, 24 peristalsis of, 24 position of, 23 secretions of, 24 size of, 23 Stools, color of, 27, 77 fat in, of normal and abnormal bottle-fed babies, 44 breast- and bottle-fed babies, 44 partition in, 42 in infancy, 75 31 Stools in infancy, acid, 79 alkaline, 79 bile in, test for, 89 color, 27, 77 fat in, 42, 44, 80 form and consistency of, 76 general characteristics, 75 hydrobilirubin in, 78 macroscopic examination, 80 microscopic examination, 81 normal appearing, 81 number per day, 75 odor, 76 oily, 80 protein, S6 with casein curds, 87 with excessive putrefaction in, 87 reaction of, 78 scrambled egg, 80 soapy, 80 starch in, 85 fermented type, 85 microscopic examination for, 86 unfermented type, 85 starvation, 87 sugar in, 84 test for gas bacillus in, 88 of breat-fed baby, 110 of diarrhea, 77 of normal artificially fed infant, 242 soap, 40,12 7 _ conditions in which formed, 41 Streptococci in cow's milk, 153 Subcutaneous saline injections in fer- mentative diarrhea, 305 Succus entericus, 26 Sucrose in infant feeding, 204 Sugar, absorption of, 48 assimilation limits of, 49 diarrhea from, 43 digestion of, 48 fermentation, 50 chemistry of, 50 conditions which bring about, 52 degrees of, 298 feeding in, 301 Finkelstein's treatment of, 140 lactic acid milk in, 303 protein milk in, 301 purgation in, 300 simple skimmed milk dilutions in, 304 skimmed milk with powdered casein in, 302 treatment in mild cases, 300 in severe cases, 300 in intestine, normal action of, 49 in stools, 84 482 INDEX Sugar indigestion, 260 acute, in bottle fed, 259 treatment, 261 chronic, in bottle fed, 274 treatment, 274 malt, Borcherdt's, composition of, 207 of human milk, 95 of milk, effect of boiling on, 172 overfeeding with, in fermentative diarrhea, 296 relation of, to gain in weight, 46 to retention of nitrogen and salts, 46 substitutes for, in infant feeding, 204 Sulphur, absorption of, 64 in cow's milk, 64 in human milk, 64 Summer diarrhea, 293 Sunlight, therapeutic effect of, in rickets, 399 Supplemental feeding, 120 Suppositories, 358 Synthetic fat mixtures prepared to resemble fat of human milk, 203 Syphilitic epiphysitis, scurvy and, differentiation, 430 ^ Syrup, corn, composition of, 209 Tannalbin in infectious diarrhea, 317 Taste of milk, effect of boiling on, 172 Teeth and jaws in rickets, 382 time of cutting, 245 Temperature, body, of newborn, 19 Tests, anaphylactic food, in eczema, 449 gas bacillus, technic of, 313 Tetany, bronchial, in spasmophilia, 409 in spasmophilia, 408 Tomato juice, 437 Tonic for poor appetite, 366 Tonsillitis, milker with, epidemics from, 154 Top milk (cream) dilutions, 186 Transitory fever of newborn, 20 diagnosis, 21 etiology, 21 treatment, 22 Triglycerid, 147 Trousseau's sign In spasmophilia, 407 Trypsin, 27 Tubercular periotonitis, chronic in- testinal indigestion and, differentia- tion, 326 Tuberculin test, 155 Tuberculosis in cows, 154 tuberculin test for, 155 Tumor, palpable, as diagnostic sign in pyloric stenosis, 454 Underfeeding in bottle fed, 256 treatment, 257 in breast-fed baby, 118 Unfermented starch stool, 85 Urine in scurvy, 427 of artificially fed normal infant, 243 Vegetables, green, 248 in artificial feeding of normal infant, 243 Vesicular eczema, 444 Vitamins, 65 action of, 66 antiscorbutic, water-soluble C, 68 importance of, in infant feeding, 67 in milk, effect of boiling on, 172 nature of, 66 occurrence of, 66 Volatile acids in butter fat, 147 fatty acids, 51 harmful changes from increased amounts of, 52 Vomiting in infectious diarrhea, treat- ment, 318 in newborn, 116 cause, 117 Warmth for marasmic baby, 283 for premature infant, 347, 349 Water, barley-, 210 for artificially fed normal infant, 243 in fermentative diarrhea, 304 lime-, 212 loss of, from body, 18 oat-, 210 Water-soluble B, 65, 66 action of, 66 C, 65, 66 action of, 66 antiscorbutic vitamin, 68 Weaning, 110 Weight, birth, regaining of, 19 gain in, in newborn, 106 in normal artificially fed infant, 240 relation of sugar to, 46 loss of, in newborn, 17, 106 amount, 18, 19 duration, 18 prevention of, 19 of newborn, 17 of older children, 241 of premature infant, 345 INDEX 483 Wet, oozing eczema, 439 crude coal-tar for, 439, 440 Wheat flour with dry malt soup extract, composition of, 208 Whey, composition of, 213 cow's, salts in, 54 mixtures, 213 calculation of, 195 preparation of, 2 13 Whitewash for intertriginous eczema, 443 Whole milk dilutions, 181 Whole milk dilutions, way of using, 183, 184 with dried casein, 218 Widerhofer in development of modern artificial feeding, 132 Widerhofer's work in development of modern artificial feeding, 132 Yeasts in milk, 152 Zone of ossification, 369