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 Library 
 
 THE UNIVERSITY OF 
 NORTH CAROLINA 
 
 this book presented by 
 
 Dr. Lytt I. Gardner 
 
 
 
 
 
 
 
 
 
 
History Room 
 
 
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 ONLY, and is subject to a fine of FIVE 
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 DAY indicated below: 
 
 MAY 
 
LECTURES IN PEDIATRICS 
 
 TO THE 
 
 NORTH CAROLINA 
 POST-GRADUATE COURSE 
 
 1916 
 
 By 
 
 JESSE ROBERT GERSTLEY, M.D. 
 Assistant in Pediatrics. Northwestern University 
 Medical School, Chicago 
 
 Associate Attending Pediatrician. Michael Reese Hospital 
 
LECTURE I 
 
 3 
 
 MILK 
 
 Gentlemen, in coming down to Korth Carolina, this 
 summer, to discuss with you the subject of children’s 
 diseases, I have been confronted with a serious prob¬ 
 lem. To cover thoroughly the entire field of Pediatrics 
 in thirteen lectures is obviously impossible. To skim 
 over it superficially would leave you only with false 
 impressions, would be worse than useless, and would 
 do more harm than good. In attempting to plan the 
 course, I thought it might be wiser to devote most of 
 our time to those subjects in which ignorance or lack 
 of experience of the physician leads to the greatest in¬ 
 jury to the patient. Probably in no other field of medi¬ 
 cine are more terrible mistakes made than in the field 
 of infant feeding and infant nutrition. Most terrible 
 misfortunes are brought upon infants, due to mistakes 
 or to ignorance of some of the simplest rules of feeding 
 and hygiene. Indeed, one might almost say that if we 
 have mastered the subject of infant feeding in its larger 
 aspect, in addition to a little hygiene, there would be no 
 sick babies. Don’t take this statement too literally. But 
 I make it boldly, and repeat it, to show you how much 
 emphasis I wish to lay upon the subject. For this pur¬ 
 pose I intend devoting, by far the major part of the 
 course to the consideration of this fundamental branch 
 of Pediatrics. 
 
 If, when I leave, I feel that you have mastered these 
 problems thoroughly I shall be not only satisfied but 
 very happy indeed. 
 
 In the clinics following the lectures we probably shall 
 see and discuss some of the more familiar problems. If 
 at any time you have any suggestions to make or would 
 prefer other subjects to be considered, I shall be very 
 glad to hear from you. 
 
 In the lectures upon infant feeding and nutrition, 
 those of you who read German will find that I am 
 following rather closely the teachings and viewpoints 
 developed by the Finkelstein clinic and its converts. 
 I also am going to take the liberty of including in these 
 
4 
 
 discussions points advanced by other clinics; may at 
 times venture to criticise some of these views on the 
 basis of my own experience since returning to this coun¬ 
 try, and occasionally shall insert ideas of my own. We 
 of the Middle West are not un-American—by no means; 
 don’t misunderstand me; we have absolutely no objec¬ 
 tion to the percentage system of feeding. It undoubt¬ 
 edly gives good results in the hands of men used to it; 
 but we are also glad to recognize and incorporate 
 into our teachings any methods, be they American, 
 German, French, or English, that will aid us in treating 
 sick and suffering children; and we believe these 
 methods that I am about to teach you are simpler to use, 
 simpler to teach, and founded upon broader conceptions 
 than the older, more conservative teachings. 
 
 MILK 
 
 When a substitute is wished for breast milk, there 
 is one, and only one, substitute that we should offer, 
 and that food is a mixture of cow’s milk. No more 
 terrible injustice is done to a child than failure of a 
 physician to recognize or know this truth. No matter 
 what advertisements you read; no matter what claims 
 are made for proprietary foods, absolutely no substitute 
 can be found for cow’s milk. In view of the impor¬ 
 tance, then, of this food, let us devote ourselves this 
 morning to a rather careful study of it, studying it 
 from the viewpoint of its chemistry, bacteriology, and 
 its physical qualities. 
 
 After my emphasizing the importance of cow’s milk as 
 a food, all the more striking must be the statement of 
 Prof. M. J. Rosenau (the eminent professor of prevent¬ 
 ive medicine at Harvard), from whose writings on milk 
 I now rather extensively quote, that milk is responsible 
 for more sickness and more deaths than all other foods 
 combined. Gentlemen, just think of what this state¬ 
 ment means. The one food, next to breast milk in qual¬ 
 ity, is responsible for more deaths, not than any other 
 food, but than all other foods combined! And it is 
 this food that we must feed our babies. 
 
 According to Rosenau, the reasons for this statement 
 are four: 
 
 a. Milk is an ideal culture medium for bacteria. 
 They grow very well in it. 
 
5 
 
 b. It is the most difficult of all foods to handle and 
 to deliver. 
 
 c. It is the most decomposable of all foods. 
 
 d. It is the only standard article of diet obtained 
 from animal sources used raw. When one stops to 
 think how we cook meat, eggs, boil soups and cook all 
 animal foods, it is surprising that we still use milk in 
 raw form. 
 
 COMPOSITION OF MILK 
 
 Milk is composed of five elements of food—not three, 
 as we were wont to consider, but five. These five are: 
 protein, fat, carbohydrate, salts, and water. It is the 
 salts and water that are so frequently overlooked in the 
 feeding of children and in the treatment of nutritional 
 disturbances, and which are of such importance. We 
 shall hear more of these later. 
 
 Protein is the substance which, in connection with 
 salts, gives structure to the tissues. Protein is com¬ 
 posed in a general way of carbon, oxygen, hydrogen, 
 and nitrogen. When we speak of nitrogen-containing 
 foods, we mean protein in distinction to the fats and 
 carbohydrates, which contain only carbon, oxygen, and 
 hydrogen. Protein in the milk is not, as you may think, 
 a specific element, but consists of two kinds, viz., casein, 
 and albumins and globulins. 
 
 Casein is the substance that forms thick curds when 
 milk is coagulated. The curds in buttermilk are of 
 casein, and it is this casein that is the most important 
 form of protein from our standpoint of infant feeding. 
 
 Albumins and globulins are the substances that form 
 a scum on top of the milk when it is boiled. Up 
 to the present time we have always thought them unim¬ 
 portant as regards feeding. 
 
 Fat exists in the milk as an emulsion of fat droplets. 
 As a food, fat is of value in supplying some energy to 
 the body, and is also stored up in the warehouses of the 
 tissues. It is the most variable constituent of the milk. 
 The first milk of the nursing or of the milking is the 
 poorest in fat. The last milk of the nursing or of the 
 milking is the richest in fat. Fat varies in the milk 
 of different animals. Jerseys and Guernseys contain 
 more than Holsteins, and, not infrequently, a baby 
 who is vomiting can be cured by changing from a 
 Guernsey to the milk of a Holstein. 
 
6 
 
 Carbohydrate in milk, commonly known as sugar of 
 milk, is technically called lactose. Carbohydrate is of 
 value in supplying energy to the body. Like casein, 
 lactose is found only in the mammary glands and no¬ 
 where else in nature. When bacteria attack lactose it 
 is usually changed to lactic acid, this being the acid that 
 is formed in buttermilk; so buttermilk is simply milk 
 from which the fat has been removed and the sugar 
 changed to lactic acid. 
 
 Salts .—The salts are of value in furnishing structure 
 to the tissues in connection with casein, and are vitally 
 concerned in many of the nutritional disturbances. We 
 shall hear of them later. 
 
 Water is perhaps the most important element in the 
 body, being the universal solvent and constituting the 
 greatest proportion of the body tissues. 
 
 Besides these above substances, a great variety of 
 drugs are found in milk, and also some ferments. From 
 the standpoint of medicine, however, the great varieties 
 of drugs excreted in milk are unimportant, because they 
 are rarely of sufficient quantity to have any effect upon 
 the child. One exception may be made, however, to the 
 milk of cows that have eaten poisonous weeds and 
 grasses. 
 
 ADULTERATION OF MILK 
 
 If you, gentlemen, are interested in the study of 
 children’s diseases, you will frequently be asked the 
 ways in which milk is adulterated. The most common 
 methods employed are skimming, watering, adding 
 thickening agents and preservatives. You may be asked 
 what methods are employed in the determination of 
 these adulterations. In examining milk from this view¬ 
 point, we have three means at our disposal: 
 
 a. Simple inspection. 
 
 &. Bacteriological methods. 
 
 c. Chemical methods. 
 
 The method that I would recommend to you—which 
 is so simple that anybody could do it—is that of inspec¬ 
 tion. Simply take the milk and look at it. Here, of 
 course, you can detect any gross changes, and then filter 
 it through a piece of cotton placed in a little funnel. 
 Heating the milk makes it filter more easily. On this 
 cotton you will find a stain varying from light brown 
 
7 
 
 to black, depending upon tbe amount of dirt in tbe milk. 
 Looking at tbe cotton, one finds all sorts of things: 
 cow’s hairs, manure and feces, scales of her skin, sand, 
 straw, and food. It is well to remember that a wise milk 
 dealer sometimes filters the milk before selling it. 
 
 The only chemical test that I would recommend to 
 you is the Babcock. This requires a special apparatus, 
 but those of you who are interested in this subject may 
 at some time wish to have one, or to put one into your 
 hospital. It is a quantitative test for fat. This is the 
 technique: 
 
 Take 17% 0 cubic centimeters of milk. 
 
 17% 0 cubic centimeters of sulphuric acid. 
 
 2 cubic centimeters of amyl alcohol. 
 
 I give you these in the Metric System, for the tubes 
 are graduated that way. Remember that 30 cubic cen¬ 
 timeters equal 1 ounce; so that we are using approxi¬ 
 mately one-half ounce each of these mixtures. Cen¬ 
 trifuge for four minutes; then add boiling water to 
 bring the fat up into the graduated neck of the tube; 
 centrifuge for two minutes and read. 
 
 Other chemical methods and bacteriological methods 
 require special training. 
 
 DIFFERENCE BETWEEN COw’s MILK AND BREAST MILK 
 
 In considering the subject of cow’s milk, it is of im¬ 
 portance that you understand the difference in the com¬ 
 position of cow’s milk and breast milk. A proper under¬ 
 standing of this is absolutely essential to the feeding of 
 infants and is the basis of all our methods of treatment. 
 Let me give you this little table, which, though not abso¬ 
 lutely accurate, still is sufficient for all practical pur¬ 
 poses: 
 
 • 
 
 Breast Milk 
 
 Cow's Milk 
 
 Protein. 
 
 
 4% 
 
 Pat . 
 
 . 4% 
 
 4% 
 
 Carbohydrate . 
 
 . 6% 
 
 4% 
 
 Salts . 
 
 . 0.2% 
 
 0.7% 
 
 Water. 
 
 .88.0% 
 
 87.0% 
 
 This makes an easy way of carrying these numbers 
 in your head; breast milk being 2 4 6; cow’s milk 
 being 4 4 4. Looking at this table, one gets the im- 
 
8 
 
 pression that the only difference between the two milks 
 is in the amount of the different constituents. This, 
 however, is not the case. 
 
 Protein, as you remember, exists in the milk as two 
 different elements: casein, and albumin and globulin. 
 The proportion of these two elements in the milks is 
 entirely different. 
 
 Protein of cow’s milk contains: 
 
 Casein 85 -f- per cent. Albumins and globulins 14 -f- per cent. 
 
 The protein in the breast milk consists of: 
 
 Casein 61 -f- per cent. Albumins and globulins 38 -J- per cent. 
 
 To emphasize this all the more, let us look at their 
 weights. If we take 100 grams (that is, a little over 
 3 ounces) of milk, and weigh these different proteins, 
 we find: 
 
 Cow's Milk Breast Milk 
 
 Casein. 2.7 grams 0.8 grams 
 
 Albumins and globulins... 0.2 grams 0.6 grams 
 
 You see what a preponderance of casein there is in 
 cow’s milk; and, now, in addition to this difference is 
 also a difference in the caseins of the mixtures them¬ 
 selves. Cow’s milk casein precipitates in firm, thick 
 curds; breast milk casein forms only the finest curds— 
 sometimes none at all; and cow’s milk casein contains 
 much more phosphorus than breast milk casein. I em¬ 
 phasize these differences to show you how futile it is to 
 attempt to modify cow’s milk so as to make its protein 
 identical to that of breast milk. 
 
 As far as we know at present, the composition of 
 breast milk cannot be definitely influenced by diet, 
 other than that a poorly nourished woman who secretes 
 little milk may perhaps be made to produce larger quan¬ 
 tities by building up her nutrition. 
 
 7 y at. Like the proteins of the two mixtures, the fats 
 are of somewhat different chemical composition. The 
 fat of cow s milk contains more of the irritating lower 
 atty acids, ot which butyric acid is an example, and 
 there may also be some biological variations. 
 
 Carbohydrates, so far as we know, show few differ¬ 
 ences. 
 
9 
 
 Salts. —Like the protein and the fats, there is a great 
 difference in the salt content of the two mixtures, not 
 only in quantity but in quality. Those in cow’s milk 
 are chiefly calcium and magnesium. Those in breast 
 milk are chiefly sodium and potassium. And so you 
 see we cannot, in any simple way, modify cow’s milk 
 so as to make its salt content identical to that of breast 
 milk. I emphasize this because we shall hear much 
 more of these salts later. 
 
 BACTERIAL GROWTH IN MILK 
 
 In feeding an infant cow’s milk, we frequently over¬ 
 look the rapid growth of bacteria that may have taken 
 place in it, if this milk has not been properly cared for. 
 Even if it has been kept at a relatively low temperature, 
 within two days time bacteria will have multiplied by 
 millions, and at warmer temperatures the numbers of 
 bacteria found are absolutely incredible. The state¬ 
 ment impressed me very much, but is nevertheless true, 
 that the milk we drink or we offer to an infant may 
 contain more bacteria than are contained in ordinary 
 sewage. Just think of this, gentlemen: in feeding your 
 babies milk mixtures, you may be feeding them more 
 bacteria than are contained in ordinary sewage. These 
 bacteria are usually of the type attacking the sugar 
 and forming lactic acid, thus making sour milk, but 
 they may be of any sort; and as they grow, they may 
 produce two important types of change: 
 
 (1) If they attack carbohydrate they produce acid, 
 and this process is known as fermentation. In this 
 fermentation usually lactic acid is produced, but under 
 certain conditions many other acids result. 
 
 (2) If they attack the protein, on the other hand, 
 they produce alkaline products, this process being 
 known as putrefaction. 
 
 Gentlemen, I urge you to sharply distinguish between 
 these two processes and remember that we shall hear of 
 these, time and time again in our work, and you cannot 
 feed a normal baby or you cannot treat a baby sick with 
 nutritional disturbance unless you have a clear-cut un¬ 
 derstanding of these changes. 
 
 Let me repeat this once again: When bacteria attack 
 carbohydrates the process is known as fermentation, 
 
10 
 
 and acids result. When bacteria attack protein the 
 process is called putrefaction, and alkalies result. 
 
 From our standpoint of feeding, however, we must 
 remember that the numbers of bacteria that are present 
 in milk are by no means as important as the kind, and 
 this brings me to the discussion of the diseases which 
 we know definitely to be carried by milk. 
 
 MILK-BORNE DISEASES 
 
 Studies have shown us that tuberculosis, typhoid, 
 diphtheria, scarlet fever, dysentery, and many other 
 diseases have been traced definitely to the milk supply. 
 A study made in Boston some time ago shows what 
 an important factor milk is and can be in spreading 
 disease, particularly among children. 
 
 In 1907, in Boston, 72 cases of diphtheria and 717 
 cases of scarlet fever were transmitted by milk. In 
 1908, 400 cases of typhoid were due to this cause. In 
 1910, over 842 cases of scarlet fever were traced back 
 to the milk, and, in 1911, over 2,061 cases of septic sore 
 throat were again due to this same cause. Gentlemen, 
 you see what a tremendously important factor milk is 
 in the distribution of disease, and you see now to what 
 absolutely unnecessary and great danger we subject our 
 babies in offering them this food. But don’t forget that 
 in spite of all these dangers cow’s milk is by far infi¬ 
 nitely the best substitute for breast milk that we have. 
 Cow’s milk may become infected in several different 
 ways: it may be directly infected when obtained from 
 the cow, as in foot and mouth disease, malta fever, and 
 milk sickness. In tuberculosis, about 2 per cent of 
 tuberculous cattle have involvement of the udder, and 
 in these cases the milk may contain as many tubercle 
 bacilli as does the sputum of tuberculous patients. 
 Again, the cow with pulmonary tuberculosis coughs up 
 these organisms, swallows them, and they get distrib¬ 
 uted throughout the manure in the stable. During 
 the milking they frequently are whisked into the 
 buckets; these buckets of milk then being added to other 
 buckets of milk distribute tuberculosis throughout the 
 community. A study of market milk in Chicago in 
 1910 showed that 10.5 per cent of 144 specimens ex¬ 
 amined contained tubercule bacilli, as did 16 per cent 
 of all specimens of butter examined. You see, then, 
 
11 
 
 what a factor milk can be in the spread of tuberculosis. 
 In the same way many other diseases are distributed, 
 the most common epidemic attributed to milk being 
 typhoid. Widespread epidemics of this disease have 
 been reported in all parts of the world and have been 
 traced absolutely and definitely to the milk supply. 
 These organisms get into the milk as a rule, not so much 
 from a case of active typhoid as from a so-called typhoid 
 carrier who works around the farm, viz., a man in per¬ 
 fect health who harbors typhoid organisms in his secre¬ 
 tions. 
 
 It is interesting to note, by way of passing, that more 
 bacteria are found in top milk than in the lower layers, 
 the cream apparently carrying the bacteria with it. 
 
 How are we going to avoid these tremendous dangers 
 in feeding our babies? How are we going to feed 
 babies cow’s milk and, at the same time, not make our¬ 
 selves liable to the terrible accusation that we have in¬ 
 fected those babies with tuberculosis, typhoid, or dysen¬ 
 tery? There are at present three methods at our dis¬ 
 posal : 
 
 a. Pasteurization. 
 
 &. Demanding of certified milk. 
 
 c. Boiling. 
 
 I am going to speak very little of pasteurization, be¬ 
 cause, if you are in no position to get certified milk, I 
 doubt if a State pasteurization law would be a great 
 success. Indeed, pasteurization, in most ways, may 
 do more harm than good. Do you remember that we 
 spoke previously of the changes that bacteria cause in 
 milk, and we said that when bacteria attack the carbo¬ 
 hydrates, lactic acid is formed? How, in the greatest 
 percentage of cases,of spoiled milk, this milk has been 
 spoiled by fermentation and formation of lactic acid. 
 This lactic acid in itself is not harmful, but, by its 
 presence, it may prevent dangerous organisms, such as 
 typhoid or dysentery, from growing in that milk. If 
 we should pasteurize the milk back on the farm, thus 
 killing off all the germs that produce lactic acid, and 
 then, after having done this, we should permit a typhoid 
 bacillus or a dysentery bacillus or a tubercule bacillus 
 to get into that milk, this organism would have a per¬ 
 fectly clear field for growth. If, on the other hand, the 
 milk were unpasteurized and it became spoiled, in the 
 
12 
 
 great majority of cases the lactic acid produced might 
 have prevented the growth of these deadly organisms. 
 
 So if you are not in a position to keep that milk abso¬ 
 lutely free from contamination up till the time of its 
 delivery, I would not recommend to you pasteurization. 
 
 The term Certified milk” was introduced into our 
 literature by Dr. Henry Coit of Hewark, 1ST. J. Accord¬ 
 ing to our present conception, certified milk is simply 
 milk of the highest quality, uniform in composition, 
 obtained from healthy cows, under the supervision of a 
 milk commission. I should advise you, gentlemen, to 
 become interested in this subject. What is necessary 
 is for all of you, or some of you, to form a committee 
 and enter into a contract with a reliable milk dealer. 
 The milk dealer must allow frequent inspection of his 
 dairy and frequent analysis of his milk. The cows 
 must be pronounced free from tuberculosis by a reliable 
 veterinarian, and must show a negative tuberculin test. 
 They must be free from all communicable disease. They 
 must be housed in clean, properly ventilated stables; 
 the old wooden walls must give way to brick; the floors 
 must be sloping to allow for flushing out and to pre¬ 
 vent the accumulation of waste. Ho manure is allowed 
 to accumulate around the stalls. All persons coming 
 in contact with the milk must be free from the germs 
 of typhoid, tuberculosis, and diphtheria, and must ob¬ 
 serve scrupulous cleanliness. The milk must be drawn 
 under the cleanest of conditions; the cows are washed 
 before milking; the tail tied to the leg, and the udders 
 cleaned. The attendants are usually dressed in white 
 and must themselves observe great cleanliness during 
 the milking process. The milk is immediately cooled, 
 placed in sterilized bottles, and kept at a temperature 
 of not over 50 degrees until delivered. It must be de¬ 
 livered within twenty-four hours after milking, and 
 at that time may contain no more than 10,000 bacteria 
 per cubic centimeter. I should certainly advise you, 
 gentlemen, to take some interest in establishing a cer¬ 
 tified milk dairy in this neighborhood. 
 
 Until certified milk can be obtained, however, there 
 is one method that remains to you for making the milk 
 that you are feeding your babies perfectly safe, and 
 that method you can employ right now— this very ' 
 day and that method is to boil your milk. In the 
 
13 
 
 olden times—that is, a few years ago—when the science 
 of bacteriology was being developed, it was thought 
 necessary to boil, reboil, and again reboil the milk in 
 order to kill off any bacteria that it contained, and 
 in these processes changes took place which made the 
 milk a rather dangerous food. Children being fed 
 milk treated in this way frequently developed scurvy. 
 J^ow we know, however, that if milk is simply brought 
 to a boil, and boiled gently for a minute or two, no such 
 danger exists. We can speak with absolute assurance 
 as to the harmlessness of feeding milk so treated. Just 
 look for a moment to the European war fields. The 
 men of France, Austria, and Germany seem to he 
 pretty good fighting men, and every one of these sol¬ 
 diers who, when an infant, was not fed on breast milk, 
 was raised on boiled milk. In these countries raw 
 milk is absolutely unknown. So you see that very 
 good fighting men can be raised on boiled milk. If 
 you wish to make yourself entirely safe—to have your 
 conscience perfectly free—you may add a little orange 
 juice to the diet during the second or third months, and 
 with this routine I can assure you that no case of 
 scurvy will ever develop from this cause. 
 
 Tn the discussion of boiled milk another question is 
 raised which is of particular interest to me, being a 
 Chicagoan, for it was in Chicago that a very important 
 problem along these lines was solved. The old German 
 pediatrician, Biedert, described curds appearing in the 
 baby’s stools—curds which were hard, white, and very 
 much like a lima bean in appearance. He said these 
 curds were protein, and used them as evidence of the 
 indigestibility of this element of the milk. This view 
 was later corroborated by other observers. The new 
 German school, however, took a different view of the 
 matter. Using more scientific methods, they fed chil¬ 
 dren casein, and found hardly any increase of nitrogen 
 in the stools; and they argued that as feeding casein 
 causes no increase of nitrogen in the stool, these curds 
 could not be protein. American observers then became 
 interested, and, if I remember correctly, Talbot of Bos¬ 
 ton was one of those insisting upon the fact these curds 
 did consist of casein. The Germans rather scorned this 
 view, and claimed that the American methods were in¬ 
 accurate. The Americans replied with more delicate 
 
14 
 
 experiments, using serological methods, and again 
 claimed that these curds were casein. The Germans 
 replied that these methods were now too delicate, and 
 that the Americans had identified the small amounts 
 of protein that were present in the intestinal juices, 
 but that the main structure of the curd was fat. The 
 controversy waxed quite warm, and was finally settled 
 by Joseph Brenneman of Chicago, in one of the most 
 important pieces of work that has been done in the 
 field of pediatrics in America. 
 
 Brenneman studied the cases coming to the dispen¬ 
 sary of our medical college at home, The Northwestern 
 University Medical School. He found that the stools 
 of many infants contained these hard curds. Careful 
 study and observation showed him that these curds fre¬ 
 quently varied from day to day—some days being pres¬ 
 ent, some days being absent. Careful questioning of 
 the mothers showed that at times they boiled the milk, 
 at times they didn’t and continuation of the study re¬ 
 vealed the extremely interesting fact that on the days 
 that milk was boiled these curds did not appear in the 
 stools. When the milk was used raw the curds invari¬ 
 ably returned. Here, then, was the simple solution of 
 the great problem that had been vexing Europe and 
 America. On the continent, where raw milk is un¬ 
 known, the men had never even seen the casein curds 
 of which we have been speaking, and, sure enough, 
 what they had seen in the babies’ stools were curds of 
 fat. In this country, with the previously invariable 
 use of raw milk, we have seen the true casein curds. 
 In Europe, when Brenneman and I were together, 
 Brenneman demonstrated to some of the men the form¬ 
 ation of these casein curds by giving the children raw 
 milk, and the men to whom these experiments were 
 demonstrated were tremendously interested indeed. So 
 you see that the whole problem was caused by our 
 discussing and describing different things, and I can’t 
 help thinking that many of the great problems in 
 pediatrics are probably due to this same fundamental 
 error—describing and talking about different things. 
 The formation of these curds is purely a physical pro¬ 
 cess. It has nothing to do with digestion. These 
 curds will form in the bottle as well as in the stomach, 
 and are due not to digestive trouble, hut simply to shak- 
 
 
15 
 
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 ing of tlie milk after a ferment has been added. If we 
 add a ferment to milk in a bottle and shake it violently, 
 hard, tough curds will form. The same holds true in 
 the stomach. If, on the other hand, we introduce the 
 milk into the small intestine by means of a Hess tube, 
 thus saving it the mechanical shaking in the stomach, 
 no curds will form. The problem of this curd forma¬ 
 tion, then, is simply one of physics, and is not of tre¬ 
 mendous interest to us from the standpoint of physi¬ 
 ology. 
 
 Our time is about up. What are the important 
 points which we should and must remember to guide 
 us in feeding our babies and treating those with nutri¬ 
 tional disturbances? Remember, first, the fundamental 
 differences between cow’s milk and breast milk; re¬ 
 member that these are differences not only in quantity 
 of individual ingredients, but also in quality, and that 
 with no simple means at our disposal can we make 
 cow’s milk in any way identical to breast milk. Re¬ 
 member that w T hen cow’s milk is not properly handled, 
 bacteria will grow in it at a tremendous pace. In their 
 growth they may cause two important changes: If they 
 attack the carbohydrates they produce acids, this proc¬ 
 ess being known as fermentation; and if they attack 
 protein they produce alkaline products, this process 
 being known as putrefaction. I urge you, gentlemen, 
 not to forget these two processes: fermentation and 
 putrefaction. We shall hear them time and time again. 
 Remember, however, that the numbers of bacteria are 
 not as important as the kind, and that milk which may 
 be swarming with lactic acid germs is not nearly as 
 deadly as that which may contain smaller numbers of 
 typhoid or tubercule or dysentery. If you wish to have 
 a clear conscience in feeding your babies, if you wish 
 to feel sure that you have not been responsible for giv¬ 
 ing the baby tuberculosis or typhoid or dysentery, you 
 must see that their milk is pure. You have three 
 methods at your disposal. The one of these I urge upon 
 you most strenuously—the one which you may employ 
 today from the time you leave this lecture hall— at 
 once —is to boil the milk. In doing this you will posi¬ 
 tively work no injury to the child; you will change the 
 protein so that no hard curds will appear in the stool, 
 and you will protect the child from any one of these 
 
 deadly milk-borne diseases. 
 
LECTURE II 
 
 DIGESTION OE MILK 
 
 Gentlemen, in the last lecture we discussed the sub¬ 
 ject of milk. Today we are going to take up the sub¬ 
 ject of milk and the baby, considering the changes in 
 the milk due to the baby and changes in the baby due 
 to the milk. In taking up these problems this morn¬ 
 ing we shall dwell upon the points in practical phys¬ 
 iology that we absolutely must know in order to under¬ 
 stand what is to come. Even if some of these points 
 seem a little abstruse or a little impractical, neverthe¬ 
 less, I urge you to follow carefully what I am about 
 to say, for you will find that I am telling you nothing 
 that will not later be of importance. 
 
 PROTEIN 
 
 The old idea of the digestion of protein was that 
 in this process the protein simply became soluble. 
 ISTow, we note that protein digestion is a far more 
 complicated process, the protein being literally torn to 
 pieces by the ferments of the digestive tract. One 
 may compare protein to a great complicated structure, 
 such as a schoolhouse or a building, which in the 
 process of digestion is torn apart into the individual 
 blocks of stone (these being known as amino acids), 
 and in the process of assimilation these are put together 
 again and built into the structure of the baby’s tissue. 
 The protein digestion begins in the stomach and is 
 completed in full in the intestine. 
 
 In the intestine the protein performs an important 
 function, viz., large quantities of alkaline intestinal 
 juice are required for its digestion,, and, in this way, 
 protein digestion is associated with the formation of an 
 alkaline reaction in the intestine. Practically all of 
 the protein is absorbed from the gastro-intestinal tract, 
 particularly when the milk is boiled. In the use of raw 
 milk large casein curds escape digestion and increase 
 the nitrogen contents of the stool, but in boiled milk 
 very little nitrogen leaves the body by way of the stool. 
 
17 
 
 And this nitrogen does not necessarily have to come 
 from the protein of the food, but may also come from 
 the protein of the intestinal juices and protein of the 
 intestinal bacteria and of the intestinal epithelium. 
 Once past the digestive tract into the body, this food 
 has three important duties: 
 
 a. It will replace protein that has been lost from the 
 body. 
 
 b. It supplies structure to the tissues to satisfy 
 growth. 
 
 c. It can be used by the tissues for energy. 
 
 It is an interesting thing that the amount of protein 
 retained in the body does not depend markedly upon 
 the amount offered to the child, the child retaining 
 approximately about the same amount of nitrogen 
 whether fed on the low protein breast milk or the high 
 protein cow’s milk. When the protein leaves the body 
 it is excreted practically entirely through the urine. 
 About 60 to 80 per cent of it appears in the urine as 
 area and the remainder as ammonia and other waste 
 products. 
 
 FAT 
 
 As we said in the last lecture, the amount of fat in 
 ;he milk varies with the duration of nursing. Like the 
 >rotein, fat digestion begins in the stomach. Perhaps 
 15 per cent of the fat is partially split up in the 
 itomach, the rest being digested by the ferments of the 
 ntestine. Unlike the protein, however, some fat nor- 
 nally appears in the stool. Whether this fat has been 
 aken into the body and then excreted into the large 
 ntestine, or whether this fat simply passes through 
 he intestinal tract undigested, we do not know, but 
 he fact remains that approximately 1 to 10 per cent 
 f the fat taken by the baby in its bottle will appear 
 gain in the stool. It is important to remember that 
 be fat that appears in the stool is not necessarily in 
 be same form as it was when the baby drank it. It 
 ppears, as a rule, in three different ways, and these 
 free different ways, gentlemen, I urge you to note 
 ecause we shall hear of them later. Fat exists in the 
 ;ool as 
 
 (1) Ordinary neutral fat. This is the simple fat 
 lat was in the milk as the baby drank it. 
 
 2 
 
18 
 
 (2) It appears as soap. I won’t bother you with 
 the chemistry of the formation of soaps, but in a crude 
 general way remember that fat, when it joins alkalis, 
 such as calcium and magnesium, forms a soap. This is 
 not the absolutely correct chemical picture, but it will 
 suffice for our purpose. 
 
 (3) It may appear as a fatty acid. These in con¬ 
 trast to soaps are simply fat in combination with an 
 acid . Again, this is not strictly chemically correct, 
 but it will suffice. 
 
 So you see when the intestine is alkaline, soaps are 
 formed, and when the intestine is acid the soaps dis¬ 
 appear and the fat becomes changed to a fatty acid. 
 
 The great majority of fat that passes the digestive 
 tract is either burned in the body or else is stored in 
 the subcutaneous tissues and in the liver. Fat, in con¬ 
 trast to protein, is not an absolute essential to the diet. 
 Some babies are raised very nicely on buttermilk or on 
 skimmed milk in which there is practically no fat, 
 and never seem to suffer from the "want of it. However, 
 some clinical observation would suggest that these chil¬ 
 dren have a lessened degree of immunity to infection 
 than have the children on higher fat diets. 
 
 CARBOHYDRATES OR SUGARS 
 
 In taking up the subject of carbohydrates, we shall 
 consider almost the most important element of food 
 used in infant feeding. Carbohydrates exist in nature 
 in three different forms: 
 
 (1) They exist as the complex carbohydrates of 
 which starch is an example. 
 
 (2) They exist in less complex forms, known as di¬ 
 saccharides, of which lactose (or milk sugar), saccha¬ 
 rose (or cane sugar), and maltose (or malt sugar) are 
 examples. 
 
 (3) They exist in simple forms, of which glucose or 
 grape sugar is a good illustration. 
 
 Tt is indeed an interesting thing that the body can 
 use carbohydrate only in its simplest form, viz., that 
 form which glucose represents. If we should inject a 
 solution of lactose (milk sugar) under the skin, this very 
 same lactose would pass right through the body, would 
 be absolutely untouched by the body tissues, and would 
 
19 
 
 ifi 
 
 be excreted as lactose in the urine. This holds true for 
 practically all of the other more complicated sugars, 
 with the one exception of maltose. The cells of the body 
 seem in some mysterious way to have the faculty of 
 using maltose. So you see that the process of digestion of 
 carbohydrate is simply a means by which more compli¬ 
 cated carbohydrates are split down to form the simple 
 ones—a means to adapt all forms of carbohydrate to the 
 use of the body tissues. In this splitting down it is well 
 to remember the different stages through which a com¬ 
 plex carbohydrate like starch passes. The first product 
 is a substance called dextrin, which is very much like 
 thoroughly browned flour. The next step in the diges¬ 
 tion is the formation of maltose and the last step the 
 formation of the simple sugars, such as glucose. That 
 you may have a clearer picture of this process, let me 
 remind you that the simple sugar glucose is composed of 
 C 6 H 12 0 6 ; the disaccharides, meaning milk sugar, malt 
 sugar, and cane sugar, are composed of two of these 
 simple sugars fastened together; and the complicated 
 carbohydrates, such as starches, are composed of a great 
 many of them bound together in different fashions. 
 
 Just as with the other food substances, by far the 
 greater part of the digestion of carbohydrates goes on in 
 the intestine. Here they are split up to the simple 
 sugars and practically all absorbed. In the normal baby 
 one rarely finds any carbohydrate in the stool. One ex¬ 
 ception may be made, this being when a child is fed a 
 large amount of starch. If the starch is not thoroughly 
 iigested, it may then appear in the stools. 
 
 Having passed through the intestinal mucous mem¬ 
 brane, the carbohydrates enter the blood and are stored 
 jp in the liver and muscles as glycogen, and from these 
 *reat storehouses the amount of sugar in the blood is 
 sept at practically uniform composition, viz., 0.10 per 
 ;ent. The end products of the carbohydrates are those 
 firmed by burning, and are chiefly carbon dioxide and 
 vater. The carbohydrate is practically all burned and 
 lever normally appears in the urine as such, unless very, 
 r ery large quantities are given. 
 
 It is well to remember that a child has a very great 
 olerance for carbohydrate, apparently needing much 
 
 
20 
 
 more in proportion to his body weight than does an 
 adult. Just take this example, for instance: A baby 
 weighing 10 pounds will drink approximately 800 
 cubic centimetres of breast milk—almost a quart. In 
 this he gets 56 grams of lactose—almost 2 ounces. If 
 we wish to feed an adult, weighing 140 pounds, the 
 same amount of sugar in proportion to his weight, 
 we would have to feed him 800 grams a day—almost 
 27 ounces. So you see what tremendous need the child 
 has for sugar. Indeed, it is from the study of infant 
 nutrition and disease that we are just beginning to 
 learn the great value of carbohydrate to the body and 
 the variety of functions that this interesting food 
 performs. Let us study them for a moment. 
 
 a . First and foremost, sugars supply energy to the 
 tissues. The baby works and cries and performs all 
 his daily functions chiefly from the energy supplied 
 by the carbohydrate. 
 
 b. In an interesting way, not thoroughly explained, 
 carbohydrate seems to save the tissue protein. If we 
 feed a baby a rather high amount of sugar, the baby 
 seems to live on this and use up less of his body 
 protein. 
 
 c. The carbohydrate is related in a very interesting 
 way to the fat. If the baby’s body is not supplied 
 with enough sugar, the fat of the food becomes almost 
 poisonous and abnormal split products appear in the 
 urine. When the carbohydrate in the diet is increased, 
 these toxic products disappear. The old German clin¬ 
 ician, Haunyn, described these phenomena in the very 
 striking sentence: “The fat burns in the fire of the 
 carbohydrates.” Just remember that sentence gentle¬ 
 men, “The fat burns in the fire of the carbohydrates,” 
 and you will have a striking picture of fat and car¬ 
 bohydrate metabolism. 
 
 d. In contrast to the fat, sugar in the diet cannot be 
 absolutely replaced. Rosenstern, one of Finkelstein’s a&- 
 sistants, in very interesting experiments, showed that if 
 sugar is entirely removed from the baby’s diet the baby 
 will not thrive, and he proved conclusively that a baby 
 to live must have a definite minimum of sugar. So, in 
 
 contrast to the fat, sguar is absolutely essential to the 
 baby’s life. 
 
 
21 
 
 e. We are just beginning to learn of a very im¬ 
 portant relation that carbohydrates have to water in 
 the baby’s body. This point is not absolutely proven. 
 
 , Indeed I have had some very heated discussions with 
 scientists about this very subject. The scientists say 
 we have not as yet proven our point; but clinical evi- 
 : dence is very strong, and it is on the basis of this 
 | clinical evidence that I ask you to remember that car¬ 
 bohydrates help the baby to retain water. The follow- 
 1 ing curve illustrates to you the observations which led 
 
 $ 
 
 aI 
 
 st 
 
 
 A 
 
 From Langstein * - Meyer 
 
 
 if 
 
 t 
 
 Q' 
 
 >1 
 
 
 
 f, at point “A,” one should add a small amount, viz., 
 wo to three teaspoons of a simple carbohydrate to the 
 )ottle, not infrequently the weight jumps up many 
 •unces. How are we to explain this tremendous rise 
 n the curve ? A baby cannot gain several ounces 
 rom a few teaspoons of food. There is not enough 
 rotein, not enough fat, not enough carbohydrate in a 
 sw teaspoons to weigh several ounces. The logical con¬ 
 tusion is that this gain must be due to water. We know 
 aat the child is somewhat like a sponge, and absorbs 
 ater into his tissues and excretes it again very readily, 
 gain, the removal of a small amount of sugar from the 
 aby’s diet may lead to a sharp drop of 5 or 6 ounces. 
 
 /. Sugars' have an interesting relation to body tem- 
 erature: 
 
 (1) If the body is markedly cooled, the glycogen 
 >,ems to disappear from the muscles. 
 
 
22 
 
 (2) The following little temperature curve will il¬ 
 lustrate this point from a clinical standpoint: 
 
 This child, with only 2 per cent sugar in his diet, 
 may have had a subnormal temperature for several 
 days. If we increase the sugar or carbohydrate to 4 
 per cent, not infrequently the temperature rises to 
 normal. 
 
 MINERALS 
 
 Gentlemen, the mineral matter in the baby’s food 
 has been a subject long overlooked. Indeed, even 
 now, the door is barely open, but visions and dreams, 
 perhaps, begin to suggest to us the coming importance 
 of mineral metabolism. Indeed, one almost may say 
 that the physiologists are learning something of this 
 question from the pediatricians. The baby is the 
 simplest of all organisms to study. He is untouched 
 by disease, his food is the simplest of all foods, can 
 be analyzed and absolutely controlled, and to get cor¬ 
 rectly his total urine and daily stools in twenty-four 
 hours is not a very difficult task. Hence, the study 
 of the baby has increased our knowledge markedly in 
 some of the fields of physiology. 
 
 Of mineral matter, breast milk has 0.2 per cent; 
 cow’s milk, 0.76 per cent. 
 
 You see that cow’s milk has almost four times the 
 salt content of breast milk. Of practically only one 
 salt is there a smaller amount in cow’s milk than in 
 breast milk, and that salt is iron. 
 
 Strange that we have so long overlooked these great 
 differences in our study of infant feeding. The splen- 
 
23 
 
 did researches of Ludwig F. Meyer have been mainly 
 and only relatively recently responsible for bringing 
 them to our attention. Like other foods, salts are 
 absorbed chiefly from the intestines. In the body 
 they work great varieties of functions, and they leave 
 the body through the kidney and the bowel. Through 
 the kidney the great majority of salts are excreted; 
 through the intestines calcium, magnesium, and iron 
 leave. Of course, we cannot say whether the calcium, 
 magnesium, and iron that we find in the stool have been 
 absorbed into the body and thrown out again or whether 
 they have simply passed through the child’s digestive 
 tract unabsorbed; but we do know that we find these 
 salts in the stool. Let me just call attention to the cal¬ 
 cium salts in passing : 
 
 One quart of Breast Milk Cow’s Milk 
 
 Calcium 0.42 grams 1.72 grams 
 
 You see, gentlemen, the preponderance of calcium in 
 cow’s milk. I mention this just by way of interest in 
 passing, for, as you know, rickets rarely appears in the 
 breast-fed baby. Some men have attempted to explain 
 this by saying that the baby on the bottle, due to insuffi¬ 
 cient calcium, develops rickets. You see this theory is 
 in this simple form absolutely untenable, because the 
 baby is getting infinitely more calcium on the bottle 
 than on the breast. 
 
 In the normal baby the salts have a definite relation 
 to the protein, and for every definite amount of protein 
 that the baby absorbs into his tissues the correspond¬ 
 ing amount of salt is retained. This relation is far 
 more definite in the breast baby than in the bottle 
 baby. In the bottle baby the salts do not seem to be 
 in such definite relations to the protein, and in dis¬ 
 turbances often far more salts are lost than is protein. 
 This improper relation of the salt and the protein 
 in the artificially fed baby may in a way be a feature 
 in some of the disturbances. 
 
 Gentlemen, I don’t want to bother you too much 
 with chemistry, but let me give you one little glimpse 
 into the tremendous possibilities of salt metabolism. 
 Suppose we take a simple salt like calcium chloride; 
 suppose that salt is introduced into the intestine. In 
 the intestine it is split up into calcium and chlorine. 
 
24 
 
 We have just learned that chlorine is excreted chiefly 
 in the urine; that calcium is excreted chiefly in the 
 stool. We may picture to ourselves the following pro¬ 
 cess : 
 
 Chlorine cannot leave the body alone; must leave in 
 combination with some other salt, and usually takes 
 with it sodium. The calcium makes other combinations 
 in the intestines. Thus, by feeding a little simple 
 substance like calcium chloride we are forcing sodium 
 out of the body through the urine. This is just a simple 
 conception, hut see what tremendous possibilities open 
 to us! Just picture to yourselves all the different 
 salts of the baby’s diet pursuing their indi¬ 
 vidual courses through his body. Just see these possi¬ 
 bilities ! We are barely beginning to grasp them. 
 How utterly in the dark are we as to the real actual 
 effects upon the child’s organism of the complicated 
 mixtures that we are wont to prescribe! We are barely 
 at the beginning of understanding the true effects of 
 our simplest combinations, and you can see what enor¬ 
 mous differences absolutely unknown to us must there 
 be in the effects upon the child’s body of the markedly 
 different salt content of breast milk and of cow’s milk. 
 
 Like protein, water, and carbohydrates, minerals are 
 .absolutely essential to life, and removal of them results 
 in rapid death. The fascinating experiments of Jacque 
 Loeb show that not only are minerals absolutely essen¬ 
 tial to life, but, if they are not present in the body in 
 certain proportions, they may exert toxic influences. 
 To the eggs of certain sea animals solutions of salt 
 water are infinitely more poisonous than are solutions 
 of distilled water, and this poisonous quality can be 
 reduced by adding to the solution definite quantities 
 of potassium and calcium. The surgeons make use of 
 these principles in their so-called balanced salt solu- 
 
25 
 
 tions. Like carbohydrate, salts seem to have definite 
 relation to body weight and temperature: 
 
 The removal of the salts in this particular instance 
 at point “A” results in a drop of temperature and a 
 marked loss of weight. The most important of all 
 salts apparently in causing these effects is sodium. 
 Again, in chronic undernutrition, with deficiency of 
 salt in the diet, the temperature may be consistently 
 subnormal, and feeding a child in this stage about a 
 dram of sodium chloride may cause a marked rise in 
 the temperature, with fever. 
 
 WATER METABOLISM 
 
 The child’s tissues are somewhat richer in water and 
 the demands for it greater than in the adult. If the 
 child drinks a quart of breast milk a day—a quart be¬ 
 ing equal to 1,000 c.c.—he drinks 885 c.c. of water. 
 Just see the enormous percentage of water in the baby’s 
 diet—885 parts to every 1,000—or, to put it differently: 
 an adult uses approximately one-half ounce of water 
 for every pound that his body weighs, while the child 
 uses between 2 and 3 ounces of water for every pound 
 of body weight—almost four times the quantity of 
 the adult. Like the other foodstuffs, water is absorbed 
 chiefly from the small intestine. It is stored mainly 
 
26 
 
 in the muscles and normally it leaves the body about 
 60 per cent through the urine and about 40 per cent 
 through the lungs and skin. 
 
 We have spoken previously about the relation of car¬ 
 bohydrate and salts to water. Let me remind you of 
 this important fact once more, by the following curve: 
 
 If, at point “A,” we should add a teaspoon of salt 
 to the diet, the baby’s weight would rise sharply and 
 rapidly. The inexperienced physician and the happy 
 mother might exclaim: “At last we have found the 
 proper diet! The child is now finally gaining!” But, 
 unfortunately, after five days, a withdrawal of this same 
 
27 
 
 salt would cause just such precipitate a drop in the 
 baby’s weight as it previously caused a rise. The weight 
 would come down just exactly to where it had been be-r 
 fore the salt was added, and now would we rather rue¬ 
 fully learn that this great gain of the baby was not a 
 true gain of tissue substance, but was only a gain in 
 water content of the body. In all our dealings with 
 babies, let us not forget that in his great ability to ab¬ 
 sorb and squeeze out water the baby greatly resembles a 
 
 I sponge. 
 
 MILK IN THE GASTRO-INTESTINAL TRACT 
 
 Gentlemen, we have considered the individual ele¬ 
 ments of the milk. We have considered them in the 
 process of digestion in the gastro-intestinal tract; we 
 have followed them through the body; we have followed 
 them in their excretion. Let us pause for a moment 
 and look at the picture of the milk as a whole. 
 
 In the stomach two important changes take place: 
 the protein of the milk, due to the rennet ferment, 
 coagulates, and the milk separates into the curd and 
 the whey. You remember that the curd consists of the 
 casein and in its formation it ensnares in its meshes 
 some fat. Much of the calcium is dragged out of the 
 whey in this process and joined in chemical combina¬ 
 tion to the casein; so casein in connection with the 
 base calcium becomes a powerful agent for making the 
 intestine alkaline. The whey, you will remember, rep¬ 
 resents the water-soluble elements of the milk, i. e., 
 the water, salts, sugar, and the albumins and globulins. 
 This quickly leaves the stomach. The casein curd 
 with the entrapped fat to be thoroughly digested remains 
 often several hours. This interesting little point in 
 physiology explains to us the uselessness of following 
 the tables which the older scientists with great pride 
 and perseverance built for us, viz., feeding the child at 
 definite ages food in proportion to the capacity of his 
 stomach. As a matter of fact, because the whey leaves 
 the stomach so rapidly, we can often feed the baby 
 much more than we would imagine, and we may dis¬ 
 regard these older tables entirely. You see we have 
 at our hands a means for hastening or retarding: the 
 emptying: of a baby’s stomach. A mixture high in 
 whey will leave the stomach rapidly; a mixture high 
 
28 
 
 in casein and fat will leave slowly, and by altering our 
 mixtures we can greatly influence gastric motility. 
 
 In the intestine the milk meets the various digestive 
 ferments. The bile makes the fat soluble. This, in 
 addition to the ferments of the pancreas and the in¬ 
 testinal glands, seizes all the fat, carbohydrate, and 
 protein, and tears them down to their fundamental 
 elements. Then they leave the intestine to enter the 
 body. 
 
 This in a very superficial way describes the digestion 
 of the milk. Just what remains in the stool? In the 
 stool we have: 
 
 a. Great quantities of bacteria. I put these bacteria 
 first because I want to impress upon you how very im¬ 
 portant they are from our viewpoint. Up to the pres¬ 
 ent, in infant feeding, the bacteria of the stool have 
 been almost overlooked. They may at times be 16 to 
 18 per cent of the baby’s stool. You see w 7 hat tremen¬ 
 dous possibilities there are for bacterial action in the 
 intestine. Normally, these bacteria live only in the 
 large intestine, the upper intestine being sterile; but, 
 under conditions of which we shall hear later, these 
 bacteria leave their home in the large intestine, migrate 
 up to the small intestine, and flourish there. Why they 
 remain only in the large intestine, and do not thrive in 
 the upper intestine, is not absolutely known. Some men 
 claim that the upper bowel, either by its juices or by the 
 properties of its cells, is able to exert a strong bacteri¬ 
 cidal influence. Kendall has suggested to me that due to 
 the rapid absorption of the foodstuff bacteria may not 
 thrive in the upper intestine normally, as no food re¬ 
 mains there for them. Probably both factors are of im¬ 
 portance. 
 
 In the large intestine two radically different groups 
 of bacteria exist; those living chiefly on protein, at¬ 
 tacking this protein, and causing putrefaction and al¬ 
 kali formation; those living chiefly on carbohydrate, 
 attacking the sugars and causing fermentation and acid 
 formation. 
 
 Gentlemen, in our last lecture you heard of the 
 tremendous importance of these two processes: fermen¬ 
 tation and putrefaction. Just as readily as in the milk 
 that stands at the doorstep do these two processes pro- 
 

 29 
 
 ceed in the child’s intestinal tract; but here we have 
 them under our perfect control. Feeding high protein 
 will call forth the putrefactive organisms; feeding high 
 carbohydrate will call forth those producing fermenta¬ 
 tion. Remember here that putrefaction, with its re¬ 
 sulting alkaline change, slows down intestinal peristalsis 
 and leads to an alkaline foul-smelling stool. On the 
 other hand, fermentation, with its resulting acid forma¬ 
 tion, leads to increased peristalsis and to watery, green¬ 
 ish, sour-smelling diarrheal stools. I urge you, under no 
 circumstances, to forget protein putrefies; carbohydrate 
 ferments. 
 
 b. Besides the bacteria, the stool of course consists 
 of unabsorbed foodstuffs: 
 
 (1) Protein, we learned before, rarely appears in 
 the stool in any appreciable quantity normally unless 
 raw milk is given. 
 
 (2) Fat is somewhat concerned in the actual struc¬ 
 ture of the stool. Feeding skimmed milk often results 
 in rather thin bowel movements with mucus and small 
 amounts of solid material; increasing the fat in the 
 diet may give rise to a formed stool. It is the fat in 
 the form of soaps which has most influence on stool 
 structure. 
 
 (3) Like protein, little carbohydrate is found nor¬ 
 mally, except in those cases where a high amount of 
 starch is fed, this starch passing through the intestinal 
 tract undigested. 
 
 (4) The salts are of great importance. Calcium, for 
 instance, by its insolubility in water, gives bowel move¬ 
 ments of dry, alkaline nature. 
 
 c. Besides bacteria and the food substances in the 
 stool, we have the indirect products of the food sub¬ 
 stances. The protein, as you remember, calls forth an 
 alkaline intestinal juice, rich in albumin. Secondly, any 
 protein or albumin that is not absorbed into the system 
 through the intestine will be attacked by the putre¬ 
 factive bacteria, and alkaline products result. In the 
 same way any unabsorbed carbohydrate will ferment 
 into acid products. The amount of fermentation of this 
 carbohydrate we can influence markedly by the nature 
 of carbohydrate we feed. Bacteria do not attack read¬ 
 ily the complicated carbohydrates, such as starches and 
 
30 
 
 dextrins. When we feed starch or a dextrin to a baby 
 this carbohydrate is slowly changed by the digestive 
 processes to the simpler sugars, and these simpler sugars’ 
 as they are formed in small amounts, are absorbed 
 through the upper intestine before the bacteria can at¬ 
 tack them. Thus complex carbohydrates, such as starch 
 and dextrin, are normally rather constipating. The 
 lower carbohydrates, such as milk, sugar and glucose, are 
 readily attacked by bacteria. When a child receives a 
 large quantity of one of these sugars some of it easily 
 gets down to the region where intestinal bacteria are 
 flourishing, and fermentation, acid formation, and diar¬ 
 rhea results. It is an interesting thing that the fer¬ 
 mentation of these sugars is influenced by several dif¬ 
 ferent factors: 
 
 a. Feeding the baby whey seems to increase markedly 
 the degree of fermentability of the sugar. 
 
 b. An increased amount of protein in the diet, due 
 to its putrefying alkaline-forming properties, makes 
 the sugar less fermentable. 
 
 c. The condition of the intestine is of great im¬ 
 portance : 
 
 (1) A perfectly healthy intact mucous membrane 
 will probably be able to keep bacterial growth under 
 control and prevent a marked degree of fermentation. 
 
 (2) A diseased intestine will probably not be able 
 to combat a fermentation induced by a high degree of 
 sugar feeding. 
 
 You see, gentlemen, why I am dwelling upon these 
 subjects: The condition of the baby’s stools depends 
 absolutely upon you. You have in your hands the 
 means of making the baby’s stool alkaline, constipated, 
 and hard, or acid, diarrheal, and watery. There is no 
 mystery about this process; the explanation is simple, 
 and the means are at hand. Feeding a baby high pro¬ 
 tein, by inducing putrefactive changes, by calling forth 
 large amounts of alkaline intestinal juices, and by 
 bringing down large amounts of calcium in connection 
 with the casein, produces constipated, hard stools. 
 Feeding large amounts of sugars by inducing fermenta¬ 
 tion, with the resulting formation of various irritating 
 acids, will lead to diarrheal and acid stools. Dont for¬ 
 get these important factors. 
 
31 
 
 Just one word about the 
 
 ENERGY OF FOODS 
 
 In the science of physics the term “calory” is used. 
 This is purely a scientific term, and means the amount 
 of heat or energy that is required to raise 1 gram or 1 
 kilogram of water one degree; 30 grams are an ounce. 
 The old physicists investigated the energy content of 
 various foodstuffs, and in their investigations they 
 found: 
 
 1 ounce of protein represented about 120 calories. 
 
 1 ounce of carbohydrate represented approximately 120 calo¬ 
 ries. 
 
 1 ounce of fat represented approximately 270 calories. 
 
 This is pure physics. It was due to the investiga¬ 
 tions of the children’s specialist, Heubner, in connec¬ 
 tion with the physiologist, Rubner, that these physical 
 studies were applied to infant feeding. These men, in 
 their experiments, showed that a normal baby, to thrive 
 and gain, requires approximately 45 calories for every 
 pound of his body weight. For example, a baby weigh¬ 
 ing 6 pounds would require about 270 calories. This 
 system of feeding, advocated by Heubner, has been 
 adopted by many children’s specialists. We, of the 
 Middle West, do not follow very rigidly, but we recog¬ 
 nize that it is of value. We believe that its value is 
 chiefly that of a check upon us, and when a baby is 
 not gaining, one may run over the mixture, see approxi¬ 
 mately how many calories one is giving the baby, and 
 see if the wants are covered. But let me emphasize 
 that we do not advocate this as a method of feeding; 
 simply a check to be occasionally employed upon the 
 amount of food that we are offering. 
 
 Gentlemen, our hour is long since up. What points 
 of this lengthy discourse are going to be of value 
 in guiding you in your feeding and treatment of 
 nutritional disease? Remember, first and foremost, 
 the great differences in putrefaction and fermentation; 
 that any protein remaining unabsorbed in the intestinal 
 tract leads to putrefaction and alkaline formation, with 
 resulting hard, constipated stools. Remember that any 
 carbohydrate remaining unabsorbed in the intestinal 
 tract leads to fermentation, and acid formation with 
 
32 
 
 diarrhea and watery stools. Remember the fermenta¬ 
 tion of the carbohydrate is greatly increased by the 
 whey elements of the milk and by any diseased or 
 weakened condition of the child’s intestine. Remem¬ 
 ber, in a general way, what I told you of the stool con¬ 
 tent, and that the fat in the form of alkaline soaps is 
 an important factor in giving structure to the stool. 
 This is fat in combination chiefly with calcium and 
 magnesium. Remember that in the stools normally 
 no carbohydrate is present and that when milk is 
 boiled no undigested protein is present, thus disproving 
 in a rather general way the previously held idea of 
 indigestibility of cow’s milk casein. Remember the 
 functions of the different elements of the food. Pro¬ 
 tein and salts make up the tissues of the body. Re¬ 
 member what we have said about carbohydrate, and 
 remember that carbohydrate and salts seem to be im¬ 
 portant factors in pulling water into and out of the 
 child’s tissues. 
 
LECTURE III 
 
 MODERN CONCEPTION OF “DISTURBANCES 
 
 OF NUTRITION” 
 
 Gentlemen, in the last two lectures we concerned our¬ 
 selves with the subject of milk and with the subject of 
 milk and the baby. Today let us start the most fasci¬ 
 nating of all studies, the study of the baby. We wish 
 to consider that great bewildering group of ailing, non¬ 
 thriving, sick children, some with diarrhea, some with 
 constipation described by the various terms, atrophy, 
 marasmus, malnutrition, inanition, indigestion, gastro¬ 
 enteritis, ileo-colitis, cholera-inf an turn, and dysentery. 
 You gentlemen have probably been reading and study¬ 
 ing the methods and teachings of the Eastern schools. 
 I do not wish to discuss or criticise in any way what¬ 
 soever the methods of our Eastern friends. My pur¬ 
 pose solely is to give you also the viewpoint of the 
 Middle West. 
 
 As regards this great group of disturbances arising 
 chiefly in the artificially fed baby, the Middle West in 
 a general way follows the European ideas. Wishing 
 information from the very source, many of our younger 
 men have sought the European clinics, and it is infor¬ 
 mation thus obtained which I wish to convey to you. 
 After you have thoroughly mastered our methods, you 
 will be in a position to survey comprehensively the 
 entire field and to make an intelligent decision for 
 yourselves. 
 
 A little review of history will be of great aid to us 
 in understanding the modern developments. Let us 
 return for a moment to the autopsy room in Vienna 
 some twenty or thirty years ago. Vienna, as you know, 
 is almost the home of pathology. Post-mortem exami¬ 
 nation is conducted with the same risrid care and exact¬ 
 ness as is clinical investigation. Every patient who 
 dies in the Vienna hospital must come to the post¬ 
 mortem table. It is natural that with such tremendous 
 facilities the whole Vienna teaching should follow 
 pathological, anatomical lines. Even the clinicians 
 
 3 
 
34 
 
 made pathology the foundation of their diagnoses, and 
 it was only logical to attempt to divide this great group 
 of sick children into classes according to the pathologi¬ 
 cal findings. In Vienna in those days one could say 
 the conception was as follows: 
 
 The sick ~baby might be affected 
 
 The well baby was in a 
 group exclusively by 
 himself. 
 
 with 
 
 a. Dyspepsia, 
 
 b. Entero-catarrh, 
 
 c. Cholera infantum. 
 
 d. Follicular enteritis, etc. 
 
 This probably was the consensus of opinion of the 
 great Vienna pediatricians and pathologists. To them 
 a well baby was a child to be neglected, not to be con¬ 
 sidered at all by medical men. The well baby might 
 play in his nursery; be of no interest until he assumed 
 one of the types of disease. These types of disease 
 were described as local, pathological, anatomical 
 changes in the gastro-intestinal tract. In other words, 
 if the baby vomited he had gastritis. If he vomited 
 and had a slight diarrhea he had a gastro-enteritis. If 
 he had a diarrhea with bloody stools he had ileo-colitis 
 or possibly follicular enteritis. 
 
 You see, then, that such a viewpoint made a sharp 
 distinction between the well baby and the sick baby. 
 The well baby was uninteresting, but the sick baby by 
 showing local changes in his gastro-intestinal tract be¬ 
 came very attractive and an object of much study. 
 When it came to put this classification into clinical 
 practice, however, great difficulties arose, and when 
 these clinical, pathological diagnoses had been estab¬ 
 lished autopsy frequently failed to confirm them. 
 Often clinical pictures changed. What was one day 
 diagnosed entero-catarrh became the following day 
 cholera infantum. Hot even in sharp pictures, such as 
 follicular enteritis, could the ulcerated intestine always 
 be demonstrated. And in many cases showing the se¬ 
 verest clinical symptomatology, as, for instance, cholera 
 infantum, post-mortem examination not rarely showed 
 absolutely no change in the digestive tract, other than 
 perhaps a slight reddening of the mucous membrane. 
 
 Slowly the pathologists became discouraged. Gradu¬ 
 ally did they lose their interest in seeking a pathological 
 
35 
 
 foundation, and now if one goes to Vienna and stands 
 in the great autopsy room, the lack of interest shown in 
 the post-mortem examination of infants is impressive. 
 While great groups of men crowd around the tables 
 seeking knowledge from the carefully, accurately con¬ 
 ducted autopsies upon adults, dead infants are abso¬ 
 lutely neglected; not even examined. When one asks 
 the busy professor why such and such a child is not 
 autopsied, one receives for an answer a shrug of the 
 shoulders, and the reply, “What is the use? We never 
 find anything.” This mute evidence from the anatomy 
 room of Vienna speaks for the utter failure of path¬ 
 ology to provide a local anatomical basis as a classifi¬ 
 cation for these disturbances. 
 
 The next attempt was made by the great Vienna 
 pediatrician, Escherich. Noting the failure of pathol¬ 
 ogy, he and his assistants sought to find etiological fac¬ 
 tors in bacteria. They made numerous and valuable 
 researches with such ends in view. But again did the 
 search fail, for no specific micro-organisms could be 
 found to produce these specific clinical entities. When 
 I say he failed, gentlemen, I do not mean that lie failed. 
 His service was of course of tremendous importance, 
 because negative evidence is as valuable to us as posi¬ 
 tive evidence, and only could we proceed after having 
 learned the valuelessness of bacteriology as an aid to 
 our classifications. To this we must always be indebted 
 to Escherich and his assistants. 
 
 The next great step was taken by that almost ro¬ 
 mantic figure in pediatrics, Adelbert Czerny, the bril¬ 
 liant Austrian clinician, who was called to the chair of 
 children’s diseases at Breslau. The great dreams of 
 this wonderful man, aided by his keen clinical obser¬ 
 vation, have given the pediatricians of the world per¬ 
 haps one of the most novel and at the same time the 
 most useful conceptions that we have yet received. 
 We must forever be indebted to Czerny for the intro¬ 
 duction of the new term, “Disturbance of Nutrition.” 
 In employing the term, “Disturbance of Nutrition,” we 
 already have a premonition of great changes that are 
 going to result in our therapy. Disturbance of Nutri¬ 
 tion would imply that the child as a whole is affected, 
 rather than exclusively his gastro-intestinal tract. Even 
 though the trouble may have its origin in the stomach 
 
36 
 
 and intestine, even though the symptoms may be en¬ 
 tirely those from the stomach and intestine, still every 
 organ in the child’s body is influenced. What a tre¬ 
 mendous thought is this, gentlemen, to guide us in our 
 therapy! If the child as a whole is affected, we must 
 admit that changes may take place in his bones, in his 
 muscles, in his skin, in his entire organism; and already 
 our keen interest in the infant’s stool slightly must 
 wane. Whether this viewpoint is correct or not is not 
 for me to say, but it has been of great value in enhanc¬ 
 ing our studies and guiding us in new lines of treatment. 
 
 Czerny was one of the first to doubt the indigestibil¬ 
 ity of cow’s milk casein. With the doctrine, “Protein 
 can do no harm,” the very antithesis of former teach¬ 
 ing, his skeptical brain cast the pediatrics world into 
 furor. 
 
 Realizing the failures of pathology and bacteriology 
 as aids to us in classifying these conditions, he attacked 
 them from the viewpoint of etiology and gave to us the 
 famous Czerny classification, which is known all over 
 the pediatrics world, namely, the grouping of “Disturb- 
 ances of Nutrition” according to cause. Gentlemen, the 
 value of Czerny’s viewpoint has been very great, indeed. 
 
 1. Disturbances on the basis of infection. These may 
 be of two types: 
 
 (a) From direct bacterial infection of the child, or 
 
 ( b ) From taking milk or food spoiled by bacterial 
 action. 
 
 2. Disturbances on the basis of constitution. 
 
 3. Disturbances on the basis of food. Of this latter 
 Czerny described two clean-cut clinical entities: 
 
 (a) The condition, which is called “Milk Injury,” 
 namely, a rather pasty, flabby child, not very sick, but 
 not thriving, whose mother brings him to the physician, 
 chiefly for the relief of constipation. Czerny thought 
 that he found the etiological factor of this condition in 
 high fat feeding ; and so, though he gave to it the name 
 “Milk Injury,” he really meant to describe “Fat In¬ 
 jury.” 
 
 ( b ) The condition he called “Starch Injury”—a 
 little emaciated, weak, undernourished baby, who has 
 received an exclusively one-sided starch diet. 
 
 Czerny’s immeasurable contribution to us in this 
 classification was the introduction of food factors in the 
 
37 
 
 causation of a clinical picture. For the very first time 
 we now hear and think of a sharply defined, clearly 
 described disease being due to nothing else other than 
 the food that we are feeding the baby—perfectly good, 
 wholesome food, but mixed in improper proportions. 
 You see what a tremendous difference in our viewpoint 
 this makes as regards our conception of the well baby. 
 What Czerny has done is to impress upon us that the 
 well baby is not necessarily well, but by a little one¬ 
 sided feeding can he be brought right over into the 
 group which we formerly reserved entirely for the sick 
 baby. Like this— 
 
 In this wonderful study Czerny limited to two the 
 clinical types which improper feeding could produce, 
 namely, the pasty, constipated child resulted from fat,* 
 and the emaciated, undernourished one from exclusive 
 starch. The diarrheal diseases he believed due to either 
 definite intestinal infection or to milk spoiled by bac¬ 
 terial action. 
 
 Contemporaneous with Czerny, Finkelstein was mak¬ 
 ing his wonderful clinical studies in Berlin. Perfectly 
 independently these two men worked, Czerny seeking 
 the causes of diseases and Finkelstein describing clini¬ 
 cal pictures. Hot by theorizing, not by hypothesis, but 
 by careful observation at the bedside, sitting with his 
 little patients by the hour, studying them with the care 
 of a scientist in his laboratory, did Finkelstein arrive 
 at conclusions which threw the already perturbed pedia¬ 
 trics world into chaos. The opportunities for clinical 
 investigation in Berlin are enormous. Many great in¬ 
 stitutions are erected for the large number of illegiti¬ 
 mate children that exist in that city. In Finkelstein^ 
 institution over three hundred beds are reserved for 
 infants less than two years of age. The opportunities 
 for studying and investigating these infants are, of 
 course, much greater than in private practice, or even 
 in ordinary hospital work. Don’t think for a moment 
 that these children are harmed; they are simply studied 
 
38 
 
 very carefully. Many great men are in charge of such 
 institutions, many have had the same opportunity of 
 Finkelstein; hut few have had the great clinical insight 
 and judgment to accomplish what he has. 
 
 His work was of a purely clinical nature. He studied 
 the babies’ intestinal reactions. He saw that some of 
 these children had bad diarrheas; some had constipa¬ 
 tion. He saw that some of these children had fever, 
 some subnormal temperature. In some the pulse was 
 
 markedly accelerated; in others it was slow, feeble, and 
 irregular. In some the respiration was markedly in¬ 
 creased,- rapid and deep; in some it was slow and weak. 
 In some the urine was full of sugar, albumen, and casts; 
 in others it was perfectly normal. 
 
 Varying from the velvety pink of the normal baby, 
 to the inelastic, flabby, mud-colored tint of the child in 
 disease, the skin seemed subject to infinite variations 
 and change. So was it with the muscles, some being 
 normal, some rigid, some flabby. 
 
39 
 
 In one type of child with evidence of great cerebral 
 involvement, consciousness was markedly disturbed, and 
 in another the sensorium was perfectly free. 
 
 In these clinical studies Finkelstein brought out one 
 fact of tremendous importance, the importance of which 
 had been long overlooked, namely, the child’s iveight 
 
 curve. To make a weight curve one must weigh the 
 baby every few days, preferably every day, and plot out 
 a curve upon a tabulated sheet, or, just as simply, con¬ 
 ceive it in the mind, as one does for temperature, pulse, 
 and respiration. In calling to our attention weight 
 curves Finkelstein did us an inestimable service, for he 
 
40 
 
 showed that weight curves were diagnostic of definite 
 clinical entities. He called attention to the curve of the 
 healthy breast-fed baby, gaining steadily day by day, 
 the gain each day being like the one of the day pre¬ 
 vious. He reminded us of the zig-zag curve of the 
 bottle-fed baby, and suggested that this asymmetry 
 may be due to the irregular retention and excretion of 
 salts. You remember we told you that cow’s milk is 
 much richer in mineral matter than is breast milk, and 
 that being concerned in the retention of water in the 
 baby’s body, salts markedly influence the weight. He 
 showed us a curve characterized by cessation of gain. 
 He showed us a curve characterized by gradual loss. 
 He showed us a curve characterized by acute severe 
 loss. All these curves represent periods of days. And, 
 lastly, he showed us the curve of a chronically sick baby, 
 sick for weeks or months. 
 
 From these studies emerge four distinct groups. 
 What I am now going to give you is the famous Finkel- 
 stein classification, adopted almost all over Europe, 
 adopted by many of the men of the Middle West. It 
 is based purely upon clinical observation; based upon 
 no theory at all; has no foundation whatsoever other 
 than careful observation at the bedside. Why Finkel- 
 stein was not satisfied with etiology as a means of classi¬ 
 fication he explains in his modest way by saying: “We 
 are still in such a maze that it might perhaps be wiser 
 as a guide to us in further study for the present to con¬ 
 tent ourselves with clinical pictures. The truth is al¬ 
 ways to be found at the bedside.” The classification 
 is as follows: 
 
 1. Failure to Gain .—Infants who, though not very 
 sick, are not thriving and gaining as they should. They 
 usually have constipated, soapy stools, and are subject 
 to infections. 
 
 _ 2. Dyspepsia .—Here the picture is that of a mild 
 diarrhea. The child is not very sick, but is a little 
 peevish and irritable—the type which you gentlemen 
 would call a mild gastro-enteriti.s or a mild summer 
 complaint. 
 
 3. Intoxication .—This is a very sick child. Diarrhea 
 is marked; loss of weight rapid and severe. Conscious¬ 
 ness often is disturbed, and the temperature may be 
 high. It is much the same picture that you gentlemen, 
 
41 
 
 I presume, would call a very severe gastro-enteritis or 
 a cholera infantum. 
 
 4. Decomposition .—In this condition the child has 
 been chronically ill with feeding difficulties. Nothing 
 has agreed with him for weeks. He shows the great 
 emaciation and undernourishment of which the terms 
 atrophy, malnutrition, and marasmus are descriptive. 
 
 Not only are we indebted to Finkelstein for this beau¬ 
 tiful new clinical classification, but we everlastingly 
 owe him gratitude for the introduction of a new food 
 factor into the study of diseases. Czerny introduced 
 fat, and thought overfeeding in fat brought on milk in¬ 
 jury with its associated constipation. Finkelstein from 
 this same viewpoint of disturbance studied sugar, and 
 it was his idea that overfeeding in sugar produced 
 diarrhea. You see what a startlingly new conception 
 this was. When he described to the pediatrics world 
 the severe picture of intoxication, which as I previously 
 said you would call cholera infantum, and laid the 
 cause of this hitherto deadly, often mysterious disease 
 simply to excess of sugar in the feeding, the in¬ 
 terested profession was stunned, amazed, and unbeliev¬ 
 ing. In rapid succession from all parts of the world, 
 seeking to confirm or to disprove this view, volleys of 
 new investigation and experiments were started, and 
 although many of the original theories have been modi¬ 
 fied, still the infinite value of this fundamental observa¬ 
 tion is being day by day more and more impressed 
 upon us. 
 
 The third invaluable contribution of Finkelstein was 
 the grouping of these four types under the head of 
 “Disturbances of Nutrition.' 1 ’ Following the footsteps 
 of Czerny, when Finkelstein studied diarrheal diseases 
 and noted the changed pulse rate, the changed respira¬ 
 tion, the changed temperature, the disturbed conscious¬ 
 ness, and, above all things, the variable and impressive 
 weight reactions, we can readily imagine his reasoning 
 as follows: “Certainly, this disturbance must be one 
 involving more than the digestive canal. No matter 
 even though the origin be purely gastro-intestinal, if 
 every function of the body is involved and affected we 
 must think of the child as one in whom the entire nutri¬ 
 tion is changed, and certainly such change must have 
 great influence upon our treatment. Under no circum- 
 
42 
 
 stances must we think of the gastro-intestinal tract 
 alone.’ 7 This viewpoint has been of inestimable value 
 to us in directing our lines of therapy away from the 
 child’s stools to that of the child’s body. In this re¬ 
 spect you will find a great difference of opinion between 
 the Eastern schools and those of us who follow Finkel- 
 stein. According to our Eastern friends, stool exami¬ 
 nation is an absolute essential as a guide to proper 
 treatment. We believe that the stools are valuable 
 symptoms of disturbance of the gastro-intestinal tract; 
 but viewing our little patients from the conception of 
 “disturbance of nutrition,” after having noted the symp¬ 
 tom of the stool, we often neglect it entirely, consider¬ 
 ing it only in its relation to the entire clinical picture. 
 
 According to the viewpoint of Finkelstein, the group¬ 
 ing of these diarrheal diseases also as “disturbances of 
 nutrition” must make stool examination absolutely in¬ 
 cidental to the examination of the entire baby. The 
 symptom of the stool sinks into insignificance beside 
 the symptom of the baby as a whole. The one symp¬ 
 tom representing the baby is the weight. The stool is a 
 symptom to be considered, it is true, but not to guide 
 us. The weight becomes our index for treatment. 
 
 Finkelstein did not deny the influence of constitution, 
 as a factor, which Czerny had suggested, and did not 
 deny the importance of infection; but he believed first 
 and foremost that most of these disturbances were due 
 not so much to constitution, not so much to infection, as 
 they were due to food; and when we say food we mean, 
 of course, perfectly wholesome, good, fresh cow’s milk, 
 given to the child, however, in improper mixtures. 
 Whether one follows Czerny or whether one follows 
 Finkelstein is immaterial. Both men have done the 
 world a service for which generations to come must he 
 everlastingly grateful. From the point of view of the 
 clinician, however, the Finkelstein classification is per¬ 
 haps more practical. 
 
 By a crude illustration one might perhaps make the 
 methods of procedure of these two men more clear. 
 Suppose we lived two hundred years ago, when disease 
 was considered due to evil spirits, to witchcraft, and to 
 demons. Suppose at that time that some observer in 
 an inspired moment had conceived the idea of bacteria, 
 
43 
 
 and to the eager world exclaimed: “Some of these con¬ 
 ditions are ‘infectious diseases/ and they are three 
 types: 
 
 Those from Pneumococcus, 
 
 Those from Streptococcus, and 
 Those from Meningococcus.” 
 
 This is what Czerny did some ten years ago when 
 out of the bewildering maze of ailing infants he saw 
 “disturbances of nutrition/’ and said they could be 
 divided into three groups: 
 
 Those due to Constitution, 
 
 Those due to Infection, and 
 Those due to Food. 
 
 Finkelstein, on the other hand, had he lived two hun¬ 
 dred years ago when the above hypothetical individual 
 had discovered “infectious disease/’ would have jsaid: 
 “I certainly agree with you that there is a great group 
 of diseases due to infection. We know so little about 
 them, however, that I think we had better stick to the 
 clinical pictures and later we can worry about the 
 causes.” He then might have described, for example: 
 
 Pneumonia, 
 
 Meningitis, 
 
 Septicemia, 
 
 Rheumatism. 
 
 He would have agreed that these pictures might each 
 one be due to the pneumococcus, streptococcus, or men¬ 
 ingococcus, but would have left the field open for fur¬ 
 ther additions. In the same way, the Finkelstein 
 classification recognizes “disturbances of nutrition,” 
 and shows four clinical pictures: 
 
 1. Failure to gain. 
 
 2. Dyspepsia. 
 
 3. Intoxication. 
 
 4. ‘Decomposition. 
 
 He accepts the factors offered by Czerny as causes, 
 that is, constitution, infection, and food; but the ad¬ 
 vantage of this new point is that it leaves the field more 
 easily open for further study. 
 
 Either classification is correct. It makes no differ¬ 
 ence which you follow; but from the clinical aspect the 
 Finkelstein idea is perhaps more practical, for it com- 
 
44 
 
 pares with our clinical classification of infectious dis¬ 
 ease. As clinicians, what we seek first is a clinical 
 picture. When we go to the bedside we do not ask 
 ourselves, “Is this a disturbance due to pneumococcus 
 or streptococcus or meningococcus ?” But we do ask, 
 “Is this a pneumonia or a septicemia or a meningitis?” 
 And having established that, then we seek the etiological 
 factors. The beauty about a clinical classification is 
 that it i.s true. Theories may be altered, ideas changed, 
 new explanations advanced, but “in the clinic lies the 
 truth.” 
 
 Having clean-cut pictures, we are in a better position 
 to seek causative factors. Just as in septicemia we 
 have already learned that much the same picture may 
 be due to pneumococcus, streptococcus, or influenza, so 
 in the same way we can amplify these clinical types of 
 Finkelstein. This classification I do not myself believe 
 is the last word. I doubt if it will stay with us per¬ 
 manently; but it will be of invaluable help to us in 
 further study. 
 
 Having recognized these four clinical types, Finkel¬ 
 stein himself now began to seek causes; to fill in the 
 subheadings. Stimulated by Czerny’s description of 
 fat injury and by his own discovery of the diarrheal 
 effect of sugar, he attempted to place all four of these 
 clinical pictures upon a food basis. In a crude way 
 one might say his first idea was as follows: 
 
 Intoxication 
 
 Decomposition. 
 
 Failure to gain was due either to insufficient food or 
 to overfeeding with fat. The latter was the very same 
 condition that Czerny described as “Milk Injury.” 
 Finkelstein’s term, however, for reasons which we will 
 discuss later, being “Disturbed Balance.” Continuance 
 of the overfeeding with fat led to the decomposition 
 stage. Overfeeding with sugar led to the stage of dys¬ 
 pepsia. If the overfeeding with sugar were continued in 
 the stage of dyspepsia, intoxication resulted. If the 
 
45 
 
 mistake was overfeeding with fat in the stage of dys¬ 
 pepsia, decomposition resulted. 
 
 This viewpoint has been greatly modified. The hun¬ 
 dreds of studies all over the world, stimulated by this 
 novel idea, have brought great light. The all-import¬ 
 ant result of this first idea of Finkelstein was to bring 
 the well baby and the sick baby closer together. The 
 well baby can now no longer be secluded in his nursery, 
 independent of all interest, only to come to our notice 
 when he shows abnormal symptoms. The well baby 
 may at any moment, due to a little improper feeding, 
 enter the group of sick babies. Let me impress upon 
 you gentlemen that Finkelstein did not deny infections 
 as a factor, did not deny constitution as a factor; but 
 of all things he did impress upon us the very, very great 
 importance of food, and he attempted to show to us that 
 many of the clinical pictures of even the very worst 
 diarrheas were due, not to external influence, but due 
 - to the milk mixtures which we ourselves were feeding 
 the baby. This, of course, has been of absolutely un¬ 
 speakable importance to us in guiding our therapy and 
 stimulating us to deeper thought. 
 
 Finkelstein’s idea as to the importance of food dur¬ 
 ing recent years has undergone considerable revision. 
 Continued studies from all parts of the world have in¬ 
 troduced new and reemphasized old factors in the causa¬ 
 tion of these disturbances. ISTow we recognize many 
 influences. The most important of these are as follows: 
 
 A. Food. 
 
 I. Perfectly good, wholesome food. —Pure, fresh cow’s 
 
 milk. 
 
 a. Overfeeding .—This overfeeding may he of two 
 types: 
 
 1. Too great quantity. 
 
 2. A preponderance of one of the elements of the 
 milk, too much fat, 'or too much sugar. This is the 
 group which Czerny and Finkelstein have called so 
 strikingly to our attention. 
 
 b. Hunger .—This may be 
 
 1. Insufficient total quantity, or 
 
 2. Insufficiency of one or more elements of the milk — 
 as protein and salt deficiency in prolonged use of barley 
 water and gruel. 
 
46 
 
 II. Spoiled milk and food. —This was the factor to 
 which Czerny laid such great importance in diarrheal 
 disease, the factor which Finkelstein considered rather 
 insignificant as compared to the factor of sugar fermen¬ 
 tation. 
 
 B. Underlying, Weak Constitution. —This we re¬ 
 cognize as an influence of no small importance in 
 predisposing children to disturbances. 
 
 C. Only recently are we becoming impressed with the 
 great importance of the milder infections, such as 
 coughs and colds, bronchitis and cystitis, as predis¬ 
 posing agencies. 
 
 D. Horsing is becoming more and more important. 
 Improper nursing may be of two types: 
 
 (a) The failure of the individual nurse in taking 
 care of her charge, allowing him to suffer from im¬ 
 proper care of the skin, from lack of cleanliness, from 
 overclothing and overheating. 
 
 (b) A weakness inherent to our hospitals is that of 
 the infant ward. Here one nurse, no matter how effi¬ 
 cient, is in charge of many babies. She cannot give 
 each child individual care. She cannot take the proper 
 interest in the preparation and offering of the babies’ 
 bottles. The children suffering from lack of exercise 
 lie in their beds as plants rather than as animals, each 
 day approaching a little more closely the danger of a 
 disturbance of nutrition. 
 
 One last word a.s to diagnosis. How are we to diag¬ 
 nose a nutritional disturbance? We have two valua¬ 
 ble aids: 
 
 1. A careful history. Information of frequent di¬ 
 gestive disturbances, information of frequent infections, 
 improper care, a weak constitution, or backward devel¬ 
 opment, would lead us to think strongly of nutritional 
 disturbance as being a factor in the present complaint. 
 
 2. Above all things, gentlemen, never neglect, and 
 learn to know, the reactions to food and to hunger. 
 This is the immeasurable assistance which Finkelstein 
 has offered us. 
 
 ( a ) In one child with severe diarrhea the addition 
 of a full bottle of food is fatal, the child dying, with 
 
47 
 
 the severest symptoms of intoxication and with a rapid 
 loss of weight. In this same child the complete with¬ 
 drawal of food for twenty-four hours seems to effect a 
 rapid, striking improvement. It was, in a way, this 
 so-called paradoxical reaction that first led Finkelstein 
 to the careful study of food in these diarrheal condi¬ 
 tions. Addition of food kills, withdrawal of food saves. 
 What better clinical evidence can there be that food is 
 of vital importance in these processes ? 
 
 ( b ) In some children complete withdrawal of food 
 for twenty-four hours leads to a rapid loss of many 
 ounces of weight, and death, with all symptoms of 
 collapse. 
 
 Of these clinical pictures, of these weight curves, of 
 these food reactions, we shall hear more in the next 
 lectures. 
 
 To conclude, we have learned this morning, gentle¬ 
 men, that in the great group of nonthriving children, 
 the children with diarrhea, the children with constipa¬ 
 tion, pathological examination of the intestinal tract as 
 a means of classification is of little aid to us. We have 
 learned that the science of bacteriology helps us but 
 little. Czerny, with a wonderful conception of the 
 “disturbances of nutrition/’ takes our attention away 
 from the intestinal tract, makes us think of the baby 
 as a whole, and Czerny does us an infinite service by 
 doubting the danger of protein and first calling our 
 attention to the importance of food (of fat) in the pro¬ 
 duction of the clinical picture of nonthriving, consti¬ 
 pated children. Finkelstein, in a way following the 
 footsteps of Czerny, arriving at these conclusions 
 through careful clinical observation, impresses us with 
 the importance of all foods in causing these disturb¬ 
 ances, agreeing with Czerny in some respects as to the 
 effects of fat, doing us immeasurable good in calling 
 to our attention the effects of sugar in causing diar¬ 
 rheas. Laying small' value upon the factors of consti¬ 
 tution and of infection in the production of these dis¬ 
 eases, he believes disturbances of nutrition to be almost 
 exclusively due to food —perfectly good, wholesome 
 milk, given in improper amounts and diluted in im¬ 
 proper proportion. We can never be sufficiently grate¬ 
 ful to him for placing diarrheal diseases under the term 
 “Disturbances of Nutrition.” 
 
48 
 
 This magnificent conception is of inestimable value 
 to us in the treatment of our children. From this 
 viewpoint the stool becomes a symptom, the baby as a 
 whole becomes the important consideration. The stool 
 becomes absolutely subservient to the whole clinical 
 picture. Just think what this means. This means we 
 must never devote ourselves to the intestine alone, but 
 only the intestine in relation to the whole body. In 
 our deeper interests in the child’s body we may be 
 forced to do what seems to be worst for the intestinal 
 tract. This viewpoint impresses upon us finally, irre¬ 
 vocably, the tremendous importance of the weight curve. 
 The weight curve expresses the baby’s condition as a 
 whole. The stool is only the expression of the intes¬ 
 tinal tract. 
 
 With the conception of the great importance of food, 
 the well baby becomes a sick baby. The well baby can 
 be made to assume any clinical type due to variation in 
 his feeding. Gentlemen, if you only will remember 
 this, if you only will see your well babies more often, 
 if you only will think of them as sick babies, treat 
 them with the same care and consideration that you 
 would a patient with infectious disease, I can assure 
 you that you will have little trouble with the babies, 
 little trouble with the mothers, and the feeding cases 
 you get in your practice will become a pleasure rather 
 than a burden. 
 
LECTURE IV 
 
 FAILURE TO GAIN 
 
 Gentlemen, you remember that in our last lecture we 
 spoke of the various viewpoints given to us by the great 
 pediatricians. We told you of the failure of the Vienna 
 school to place these diseases upon a definite pathologi¬ 
 cal anatomical basis. We spoke of the failure of Es- 
 cherich to find .specific bacterial causes. Don’t misun¬ 
 derstand me, gentlemen; the ideas failed. The men 
 succeeded. Patient, conscientious perseverance of these 
 students cleared away the obstacles that would other¬ 
 wise have prevented the advent of the newer concep¬ 
 tions. You remember it was Adelbert Czerny, the 
 skeptic, the keen observer, the deep philosopher, who 
 gave to us the newer thoughts. You remember he no 
 longer spoke of diseases of the gastro-intestinal tract. 
 To him, these disturbances were “disturbances of nutri¬ 
 tion.” The baby was no longer diseased solely in his 
 stomach and intestines, but changes were effected in 
 every sinew and fiber of the body. It was Czerny who, 
 for the first time, cast doubt upon the old orthodox idea 
 of the indigestibility of cow’s milk casein. It was 
 Czerny who, for the first time, called to our attention 
 the factor of food in the production of definite clinical 
 pictures. Of the food elements he investigated, fat and 
 starch were the ones whose physiological action he 
 brought to our notice by two clean-cut clinical pictures: 
 Too much fat was the causative factor in nonthriving 
 constipated infants; too much starch produced another 
 clinical entity. It.was Czerny who gave to us an etio- 
 I logical classification. You remember the classification? 
 j Nutritional disturbances were those 
 
 a. On the basis of constitution. 
 
 b. On the basis of infection: these were the diar- 
 rheal diseases. Two factors might here be concerned: 
 
 (1) True infection of the gastro-intestinal tract with 
 germs of specific diseases, such as dysentery or cholera, 
 
 or > 
 
 (2) Poisoning, resulting from the drinking of spoiled 
 food—food which had not been properly cared for and 
 
 4 
 
 ' 
 
50 
 
 had become a great culture medium for the common 
 everyday organisms. 
 
 c. Disturbances due to food: 
 
 (1) Milk injury. 
 
 (2) Starch injury. 
 
 So, if we follow Czerny, we no longer speak of gas¬ 
 tritis, gastro-enteritis, and cholera infantum; but rather 
 of a disturbance due to constitution, due to infection, 
 or due to food. 
 
 In a and b he gave us etiological factors; in c he 
 gave us an etiological factor with two beautifully de¬ 
 scribed clinical pictures. 
 
 You remember that while this epoch-making work 
 was being evolved Finkelstein in Berlin was making 
 his great studies from a purely clinical viewpoint. 
 
 In today’s lecture I wish to discuss with you Czerny’s 
 “Milk Injury” and to show how this has been modified 
 by clinical observation. 
 
 Czerny’s description is about as follows: A mother 
 brings her infant to you, complaining that he is not 
 thriving and that he is very constipated; she does not 
 regard him as being sick—just wants a little advice. 
 You, doubtless, have seen many such cases in your 
 practice. Upon examination you will find a rather 
 pasty, not badly nourished, somewhat anemic-looking 
 child. He is a little flabby. You think of a beginning 
 rickets; you sit him up upon the table and he falls to¬ 
 gether, showing a somewhat flaccid musculature. His 
 weight is perhaps slightly below normal. Upon ques¬ 
 tioning the mother as regards the history, you learn 
 that he is not gaining as well as he used to; that he is 
 a little peevish and fretful; that he vomits occasionally; 
 that at times he is a little feverish; that he is subject 
 to mild infections; and above everything else, that the 
 mother dwells upon the constipated, dry, crumbly, soap- ' 
 like stools, which characteristically do not adhere to the 
 diaper, but can be easily brushed away. To the mother 
 the chief trouble is the constipation. 
 
 You think the child is perhaps undernourished; you 
 increase his diet; but he does not gain. If anything, he 
 becomes a little more peevish and irritable, and the 
 constipated stools more persistent. 
 
51 
 
 In seeking the cause of this condition, Czerny’s at¬ 
 tention became focused sharply upon these abnormal 
 bowel movements, and here he made a tremendous dis¬ 
 covery. You remember that in our second lecture we 
 spoke of the way in which fat normally leaves the in¬ 
 testine ; that a certain amount of it—a rather small per 
 
 I cent—normally combines with alkalies, such as calcium 
 
 , and magnesium, and leaves the intestine in the form of 
 soap. To Czerny’s great interest, the stools of the 
 babies we have described contained a much greater per¬ 
 centage of soap than do stools of normal babies. If 
 the soap in a normal baby was perhaps 20 per cent of 
 ihe fat of the stool, in these babies it might be 50 per 
 cent. Czerny’s reasoning was clear and simple. If a 
 
 I I soap consists normally of fats combined with calcium 
 or magnesium, if the stools in these children consist of 
 an abnormally increased amount of soap, then, from 
 these children, there must be an excessive excretion of 
 mineral matter—of calcium and magnesium—and the 
 general symptoms might be explained as a disturbance 
 of nutrition in which loss of mineral matter played a 
 prominent part. If the mineral matter combines with 
 fat to form soaps, then, by reducing the fat in the 
 
 i baby’s diet, we should decrease soap formation and thus 
 lessen mineral loss; by increasing fat in the diet, we 
 should enhance soap formation and increase mineral 
 
 : loss. True enough, Czerny’s assistants, by offering 
 these children increased quantities of fat, were able to 
 increase soap formation and cause greater mineral ex¬ 
 cretion. The solution to the question of treatment was 
 now relatively simple. All that was necessary was to 
 ! diminish the amount of fat in the baby’s bottle, substi¬ 
 tute for this some food of equal caloric value, and the 
 child should thrive. To accomplish this purpose, 
 Czerny used a mixture known as Keller’s Malt Soup. 
 This is made as follows: 
 
 a. Take one-third of-a quart of milk, adding to it 1 
 ounce of ordinary flour. 
 
 b. In another mixture, to two-thirds of a quart of 
 water add about 3% ounces of malt soup extract. In 
 this country this latter is put up by Borcherdt or the 
 “Maltine” concern. 
 
 c. Add the two mixtures together, boil, and you have 
 a food that is an absolute cure, a perfectly ideal treat- 
 
52 
 
 ment for this condition. The baby’s constipation sub¬ 
 sides, the stools become normal, be gains in weight, and 
 becomes brighter and happier in every way. 
 
 In taking up this subject of “Milk Injury” or “Fat 
 Injury,” I hesitated somewhat. I did not know whether 
 it would be wise to go into this detail, showing you the 
 reasoning of these observers, or to state simply that 
 “The symptoms are so and so the treatment so and so.” 
 Upon consideration, however, I thought I should like 
 to get you to see the fundamental “why” at the basis 
 of these observations, because if you master the under¬ 
 lying principles at stake, you will have the key, not 
 only to the treatment of this particular condition, but 
 also to many of the cases of constipation which you 
 meet in your daily children’s practice. 
 
 While these brilliant experiments in Breslau were 
 being conducted, Finkelstein, in his institution in Ber¬ 
 lin, was attacking the problem from the standpoint of 
 careful study at the bedside, of accurate clinical obser¬ 
 vation. Perfectly independently, he studied a great 
 group of children, many of whom were apparently not 
 very ill, all of whom showed a “failure to gain.” In 
 some, marked constipation was present; in others, bowel 
 movements were more nearly normal. In these studies 
 Finkelstein and the men influenced by his teaching 
 showed that there were many factors featuring in the 
 etiology: 
 
 (1) Some children showed the typical picture of 
 Czerny’s “Milk Injury,” who, however, were getting in¬ 
 sufficient food; increase of diet brought about a speedy 
 cure with correction of the intestinal symptoms. This, 
 you understand, strictly speaking, does not belong to 
 the group of cases we are discussing. I place it here, 
 however, as did Finkelstein, for, from a clinical stand¬ 
 point, you will meet with such cases frequently in your 
 practice. In true “Milk Injury,” as described by 
 Czerny, increase in total food volume does not result in 
 gain. 
 
 (2) Some children who were recovering from ordi¬ 
 nary infections showed this very same symptomatology. 
 These children had been thriving perfectly until taken 
 ill with a cough or a cold or a mild cystitis, and upon 
 recovery, with absolutely no change of diet, spontane¬ 
 ously developed this disturbance. Here, then, fat alone 
 
53 
 
 or even the food, could not be blamed, for the baby 
 bad previously been gaining on the very same mixture. 
 
 (3) In another group of cases, improper care of the 
 baby, whether in the home or in the hospital, in some 
 mysterious way seemed to predispose to this disturb¬ 
 ance. The explanation for this is not as yet clear. 
 You remember we are confining ourselves, for the pres¬ 
 ent, chiefly to clinical observation. 
 
 (4) A very important group of children, who seem 
 to suffer with a weak constitution, such as congenital 
 heart disease or other hereditary anomalies, easily pro¬ 
 gress to this condition. 
 
 (5) Lastly, there was the group in the clean-cut, defi¬ 
 nite form in which too much milk, or, as Czerny would 
 have it, too much fat, seemed to be the important factor. 
 
 Gentlemen, already you see what tremendous influence 
 clinical observation made upon our ideas of this dis¬ 
 ease. Czerny gave to us the wonderful conception of 
 disturbance of nutrition; then temporarily forgot it, in 
 his intense interest in the baby’s stool, and overlooked 
 other factors, perfectly independent of the food, which 
 might have been concerned. Finkelstein and his stu¬ 
 dents, in adhering to the broader conception, the origin 
 nal idea of Czerny, regarding the stool purely and 
 simply as a symptom and not a cause, were able to add 
 considerable to our knowledge. 
 
 Let us return for a moment to the type of case in 
 which both Czerny and Finkelstein noted a rather high 
 amount of fat in the diet. The tremendous number of 
 observations and experiments stimulated by Czerny’s 
 novel conception began to bear fruit, but, as time pro¬ 
 gressed, these observations and experiments began grad¬ 
 ually to speak against the primary influence of fat. 
 First, it was shown that in some cases, in spite of the 
 high fat diet, in spite of the soapy, fatty stool, there 
 was no total mineral loss to the body. True, the min¬ 
 eral matter in combination with the fat was increased, 
 but the mineral matter excreted in combinations as salts 
 was decreased, and so the sum total was not above 
 normal. 
 
 A second tremendous argument against the primary 
 importance of the fat were the brilliant metabolic 
 studies of young Hans Barth, whose tragic death in 
 the present war has been such a sad blow to modern 
 
54 
 
 pediatrics. He and his coworkers showed that in many 
 of these cases the amount of total mineral matter lost 
 in the form of calcium and magnesium was infinitely 
 greater than could be explained by the soap formation 
 in the stool. 
 
 And, lastly, comes the ever valuable, unexplainable 
 clinical observation that these children with well devel¬ 
 oped, perfectly typical milk or fat injury can be cured 
 in rapid, striking fashion by the use of breast milk. 
 Breast milk, as you remember, contains the very same 
 amount of fat as cow’s milk. This is an unanswerable 
 argument. If a baby, showing the picture of milk 
 injury on cow’s milk feeding, can he cured at once by 
 the use of breast milk, then fat exclusively, by itself, 
 can scarcely be the sole factor in the etiology. We, 
 blindly groping for explanation, must conclude that fat 
 alone cannot he responsible, but fat plus some invisible 
 mysterious element contained in cow’s milk and not in 
 breast milk. 
 
 During the furor accompanying Czerny’s discovery 
 and the battles waged by his supporters and his critics, 
 Freund was making brilliant, almost conclusive, experi¬ 
 ments in his own institution. He fed babies showing 
 the typical picture of milk injury various foods, such 
 as starch. This had little effect upon the stool. He 
 fed them sesam oil, sugar of milk, and malt extract. 
 Lo and behold! under the influence of these latter three 
 articles of diet the soaps disappeared; the fats were ex¬ 
 creted in other combinations, and the constipation was 
 cured. This observation seemed uncanny, full of mys¬ 
 tery. What could he the underlying principle? Freund 
 explains it for us in what seems very beautiful, simple 
 reasoning. 
 
 Gentlemen, you remember in our previous lectures 
 we dwelt upon the processes of putrefaction and fer¬ 
 mentation. We spoke of the alkali-forming protein, 
 of the rather nonfermenting higher carbohydrates, and 
 the acid-forming fermenting lower carbohydrates. The 
 substances which were apparently of great influence in 
 correcting the constipated stool were those aiding fer¬ 
 mentation, those tending to make the intestinal contents 
 acid; and now Freund reminds us of a little simple 
 chemical process which previously had been overlooked, 
 viz., that fat does not readily form into soaps in the 
 
55 
 
 presence of acids, but, in a way, combines with them 
 to form the so-called fatty acids. Soaps in the pres¬ 
 ence of acids are completely split up just as if they 
 were salts. Gentlemen, do you grasp the importance 
 of this contribution of Freund? Think of it carefully 
 for a moment. If this be true, soap formation is a 
 result and not a cause. Soap formation is simply a 
 symptom of the intestinal reaction and not a factor 
 in affecting it. Feeding substances like protein, which 
 alkalinize the intestine, favor soap formation and thus 
 constipation. Feeding substances like carbohydrate, 
 which make the intestine acid, break up the soap forma¬ 
 tion and cause the looser type of bowel movement. 
 Gentlemen, I urge upon you to give this matter care¬ 
 ful consideration, to hold the principle' before you at 
 all times, because in mastering it you have mastered 
 one of the great causes of constipation in infants. “Fat 
 in an alkaline intestine forms soap; in an acid intes¬ 
 tine, fatty acid.” 
 
 And now, if this great mass of careful observation 
 and scientific experiment proves to us that the con¬ 
 stipated soapy stool is an effect and not a cause, are 
 we any closer to a clearer understanding of the picture 
 of milk injury? With true American lack of respect 
 for dignity and title, one day I assailed Finkelstein 
 in a corner of his great institution, from which the 
 modest little man could not escape, and asked him to 
 make the matter clear to me. I never left him until, 
 filled with wonder and admiration, I had obtained his 
 own personal viewpoint. He reminded me that in feed¬ 
 ing a baby we must consider the food, the intestine, 
 and by all means that factor which so frequently and 
 at such tremendous cost is overlooked by men speaking 
 exclusively of “gastro-intestinal disease” rather than 
 “disturbance of nutrition”— the needs of the child’s 
 body. He reminded me that in feeding Keller’s Malt 
 Soup one reduces the fat, but, at the same time, mark¬ 
 edly increases the carbohydrate. Simple reasoning, 
 simple skepticism, forces the question, “How does one 
 know that this gain, that this recovery, was due to the 
 reduction of the fat?” Is it not just as reasonable to 
 assume that the increase of the carbohydrate was a 
 factor of equal or even greater importance? Is it not 
 likely that children with weak constitutions, children 
 
56 
 
 recovering from infections, children suffering from neg¬ 
 lect, need more carbohydrate, more energy, than does 
 the normal baby? Is not the primary consideration in 
 these cases the demands of the child's body rather than 
 the condition of his digestive tract? Have you forgot¬ 
 ten the striking statement of Naunyn, “The fat burns 
 in the fire of the carbohydrate ?” With such a remark¬ 
 able viewpoint, the condition of the digestive tract 
 fades into insignificance before the primary considera¬ 
 tion of the child’s body. The child’s vigor and strength 
 depend upon the amount of carbohydrate offered, and 
 are perfectly independent of the reaction of the intes¬ 
 tinal tract. Whether the fat in the stool is excreted 
 in the form of soap or whether it is excreted as fatty 
 acid depends upon the reaction of the intestinal con¬ 
 tents. If the contents are alkaline, soaps are formed; 
 if acid, fatty acids result. In Keller’s Malt Soup we 
 have an ideal mixture to create an acid condition in 
 the intestine. Low protein from the dilution of the 
 milk lessens the alkali formation; high carbohydrate 
 favors acid. Due to this acid, the fat soaps are split 
 up and constipation corrected; but the great benefit to 
 the child—the gain in weight, the improved tone of the 
 muscles, the returning elasticity to the skin—depends 
 not upon the correction of the stool, but upon the inr 
 creased supply of carbohydrate offered to the needy 
 tissues. 
 
 It was for this reason that Finkelstein introduced 
 the term “disturbed balance.” ITe meant to imply that 
 the primary fault was not one of fat injury, was not 
 one of chronic fat indigestion, as is the viewpoint of 
 so many men, but that the trouble lay in a disturbed 
 balance between carbohydrate and fat, perhaps carbo¬ 
 hydrate and protein, in the diet, the body not receiving 
 enough carbohydrates to satisfy its wants, probably 
 not receiving enough carbohydrates to successfully per¬ 
 form the metabolism of the fat. This viewpoint in a 
 striking way makes clear to us the brilliant success 
 from feeding of breast milk. Breast milk offers the 
 body high carbohydrate; breast milk, with its high car¬ 
 bohydrate and low protein, establishes processes of fer¬ 
 mentation in the intestinal tract and does away with 
 constipation. 
 
57 
 
 This viewpoint, perhaps, does not explain every case; 
 perhaps some cases are really due to a primary fat in¬ 
 digestion; but, at any rate, we learn much from this 
 conception, and a great group of cases become clear to 
 us. Probably in the majority of cases, as shown by 
 the results with breast milk, the fat is indeed only a 
 secondary factor. 
 
 Gentlemen, now you see why I have tried to go into 
 detail. If you have followed me carefully, if you have 
 understood the principles which I am trying to make 
 clear, you have in them the key to very many of the 
 cases of constipation with which you meet in your prac¬ 
 tice. You see also how chemistry, physiology, and clini¬ 
 cal medicine are no longer separate sciences, but must 
 be united and used by the modern medical man to build 
 up and fuse into a really complete structure. 
 
 The diagnosis of this condition is easy. In your 
 practice you will have to distinguish it only from chil¬ 
 dren not getting enough food; in these, an increase of 
 a half ounce to an ounce in each feeding will rapidly 
 result in cure. In the true case of disturbed balance 
 no improvement results. 
 
 TREATMENT 
 
 For the young baby breast milk, which is always the 
 ideal food, is, if it can be obtained, the best treatment. 
 In offering breast milk, let me warn you of a little com¬ 
 plication, simple in its physiology, ignorance of which, 
 however, may lead to unpleasant results. To illustrate: 
 
 At point “A” we have changed from the mixture of 
 cow’s milk, which the baby was getting, to one of breast 
 milk. A loss of several ounces occurs, lasting sev¬ 
 eral days. What is the explanation? Can any of you 
 
58 
 
 grasp why a loss of weight should result from the feed¬ 
 ing of breast milk? The answer is to be found in the 
 simplest physiology. In our first lecture we told you 
 that cow’s milk was much richer in mineral matter than 
 is breast milk. In our second lecture we told you that 
 minerals, particularly sodium, were important in bind¬ 
 ing water to the tissues. If our baby had been getting 
 a mixture of three-quarters of a quart of cow’s milk, 
 he would be getting 5.7 grams of salt—over a tea¬ 
 spoon. The- change to three-quarters of a quart of 
 breast milk reduces his salt intake to l 1 /*? grams. You 
 see what a great reduction there is in the mineral 
 matter of his diet. For this reason, until he gets prop¬ 
 erly adjusted, a water loss occurs from his body, thus 
 explaining the drop of several ounces in the weight 
 curve. This loss is not due to poor breast milk, is not 
 due to insufficient breast milk, but to perfectly normal 
 breast milk, and a knowledge of the very simple ex¬ 
 planation will save the mother, the wet nurse, and inci¬ 
 dentally you, much worry. 
 
 If artificial feeding is to be employed, what shall be 
 our procedure? Do we need Keller’s Malt Soup? FTo; 
 but we do need the principles upon which it is based. 
 We wish to offer more carbohydrate to the baby’s tis¬ 
 sues ; we wish and must do this without injuring the 
 intestinal tract. In our next lecture we shall learn that 
 mixtures of high carbohydrate in connection with high 
 fat, particularly in connection with concentrated whey 
 of cow’s milk, are dangerous from the intestinal view¬ 
 point. We, therefore, dilute our milk, not with the idea 
 of diluting the fat exclusively, but of simply making 
 up a mixture which will enable us to offer to the tissues 
 higher carbohydrate without causing intestinal compli¬ 
 cations. We dilute it to one-third, adding two-thirds 
 water, and then gradually increase carbohydrate until 
 we get the improvement of the general condition and 
 the more normal condition of the stool. Ordinary cane 
 sugar is the simplest and cheapest carbohydrate to use. 
 One word of warning, however, in employing it. It 
 may become necessary to add more than six or eight 
 teaspoons to a quart of the mixture in order to get the 
 physiological results. Under such circumstances the 
 mother and babe rebel at the sweet taste; therefore, if 
 it becomes necessary to increase over six to eight tea- 
 
59 
 
 spoons, it would be wise to add some easily fermentable 
 carbohydrate less sweet to the taste. This can be done 
 in the form of the above said malt soup extract. Don’t 
 make the mistake, however, of ordering pure malt ex¬ 
 tract. This does not mix so readily with the milk, and 
 you may get into difficulties with the mother; but show 
 your superior knowledge by impressing upon her the 
 necessity of getting Malt Soup Extract. Several con¬ 
 cerns put up the malt extract in this convenient form. 
 
 In children over two or three months of age, remem¬ 
 ber that one-third milk is not sufficient to provide for 
 continued growth. After a short time one must cau¬ 
 tiously increase the concentration of the milk. The 
 increased protein may temporarily cause an alkaline 
 action to the intestine with a renewal of the soap for¬ 
 mation and constipation. That can readily be com¬ 
 bated by additional increase of carbohydrate. 
 
 One point in the treatment, let me impress upon you, 
 what you should not do. How that you understand the 
 principles upon which this condition is based and upon 
 which we should direct our treatment, you see how 
 utterly unreasonable, how absolutely without scruple, 
 is the physician who drugs these patients, treating their 
 constipation with calomel, castor oil, and other cathar¬ 
 tics. At our hospital at home, Dr. Abt and his associ¬ 
 ate, Dr. Jampolis, some years ago made interesting 
 observations on perfectly normal babies. Feeding a 
 fine healthy baby a therapeutic dose of these drugs 
 caused the appearance of blood in the stool—not in 
 large quantities, but easily detected chemically. Just 
 think of that, gentlemen: feeding a perfectly healthy, 
 normal infant medicinal doses of calomel produces such 
 irritation of the iptestine as to make blood appear in 
 the stool. What a crime is it, then, to offer a little 
 child suffering from a condition of disturbed balance, 
 these strong intestinal irritants, to try to overcome con¬ 
 stipation, not by reason and principle, but by brute 
 force! What this baby needs is not medicine; he needs 
 sugar. 
 
 Gentlemen, we are now temporarily going to leave 
 Czerny. Kemember his great service to us, his service 
 in giving to us the conception of disturbances of nutri¬ 
 tion; his service to us in casting doubt upon the in¬ 
 digestibility of protein; his service to us in recognizing 
 
60 
 
 food as an important factor in nutritional disease. 
 W hat have we learned from this lengthy, perhaps com¬ 
 plicated discussion? We have learned to think. Only 
 the light shed by time, by distance, by laboratory ex¬ 
 periments stimulated by the keenest clinical observa¬ 
 tions, could make us change allegiance to Czerny’s first 
 idea. Every great pediatrician w T ho was able to read 
 these writings and to comprehend them was influenced. 
 The very foundation of pediatrics was moved. Now, 
 from across the space separating us bv years from 
 Czerny’s first work we ask ourselves, “Did we not all 
 err alike? Did we not all make the same fundamental 
 error?” We were stirred by the brilliant conception of 
 disturbance of nutrition; we temporarily lost sight of 
 this in our keen interest in one symptom—the stool. 
 In focusing our attention upon the stool we lost all 
 sense of proportions in the discovery of the soap. In 
 this maze of thought, we lost sight of the relation of 
 fat to the other elements in the milk; we lost sight of 
 the fact that fat in an acid intestine makes fatty acids; 
 in an alkaline intestine makes soaps. Not that our 
 observations were without value or interest; much good 
 has resulted; but they were in entire disproportion to 
 the great clinical picture. Only careful, frequently re¬ 
 peated, accurate, bedside study resulted in putting us 
 again upon the right path. Just as we had forgotten 
 to note the relation of the fat to the other elements of 
 the milk, so had we forgotten to note the relation of 
 the symptom —the constipated stool—to the main clini¬ 
 cal picture. Just as our exclusive attention to the fat 
 had led us astray, so did our exclusive attention to the 
 stool divert us from our original broad conception of 
 disturbance of nutrition. Gentlemen, what have we 
 learned? We have learned that if we wish to err only 
 slightly, if we wish to have an anchor that will hold us 
 secure, let us never forget that first, foremost, above 
 everything else, the fundamental truth is to be found 
 in careful, conscientious clinical observation and study. 
 
 What is the practical significance of this lengthy dis¬ 
 course? If a constipated baby is not gaining upon a 
 well regulated diet, carefully increase it. If he still 
 does not gain, make up a mixture with a higher per cent 
 of fermentable carbohydrate than was contained in the 
 original formula, and increase gradually this carbohy¬ 
 drate until improvement occurs. 
 
LECTURE V 
 
 THE STATES OF DYSPEPSIA AND 
 INTOXICATION 
 
 Gentlemen, if our last lecture was important from 
 a standpoint of therapy, today’s lecture is vital, for 
 it concerns life. You remember we spoke at our last 
 meeting of Czerny’s new viewpoint, “disturbance of nu¬ 
 trition.” We showed you bow he bad introduced food 
 as a factor in causing disease and bow he bad laid par¬ 
 ticular importance upon the fat. He doubted the in¬ 
 digestibility of protein; be gave us an etiological classi¬ 
 fication ; and due to this etiological classification, to bis 
 concentration, perhaps, on one causative factor, we 
 became side-tracked and focused too carefully upon 
 one symptom—the stool. Finkelstein, you remember, 
 accepted the new viewpoint of “disturbance of nutri¬ 
 tion,” agreed that infection and constitution were fac¬ 
 tors, but greatly enlarged upon the importance of 
 food. To him, most of these disturbances, including 
 even the diarrheas, were due not to infections, but 
 practically entirely to food alone. Clinical pictures to 
 be brought about by improper feeding were four: 
 
 The picture of milk injury be saw, just as did 
 Czerny, but for reasons*, which we stated in the last 
 lecture, he changed the name to Disturbed Balance. 
 The tremendous contribution of Finkelstein, in the 
 realm of these food disturbances, was the placing of 
 diarrheal cases within this group. To him the great 
 majority of diarrheas met do not belong to the infec¬ 
 tious group of Czerny; do not belong either to ( a ) the 
 group caused by specific bacterial infection of the intes¬ 
 tine, or to (b) those resulting from milk spoiled by bac¬ 
 terial growth, but do belong to the group of disturbances 
 arising from feeding of good, wholesome pure milk 
 made into improper mixtures. 
 
 The. history of the observation and development of 
 this food basis for diarrhea is fascinating. The very 
 first stimulus to the study came to Finkelstein and his 
 assistants with the appearance in their great institu¬ 
 tion of a number of cases of severe diarrbea-gastro-en- 
 
62 
 
 teritis as they might then have been called, or dis¬ 
 turbances of nutrition on the basis of infection, as 
 Czerny would have said. Perhaps it was in a way 
 Czerny’s conception of food disturbances^ that led 
 these men to investigate carefully conditions in their 
 diet kitchen. To their interest and amazement, they 
 discovered that by an error many of the mixtures were 
 being made with unusually high quantities of sugar. 
 Could the sugar be a causative factor ? 
 
 Pull of curiosity at this thought, they fed babies 
 large quantities of sugar, produced severe diarrheal 
 disease, and gave to the pediatrics world one of the 
 most wonderful contributions it has yet received. Not 
 only could high fat and low sugar produce a condition 
 of disturbed balance, hut high sugar, on the other hand, 
 could produce the severest diarrheal disease. For the 
 moment we see Finkelstein following the same error of 
 Czerny, focusing too carefully upon the stool, upon one 
 symptom, forgetting the big clinical picture and laying 
 the blame for almost every case of had diarrhea upon 
 too high carbohyrdate in the food. Not long, how¬ 
 ever, before he saw his error. 
 
 The same tremendous objection applied to this view 
 as did to the original idea of Czerny. Breast milk, the 
 ideal food, contains a large quantity of carbohydrate— 
 easily fermentable carbohydrate—hut children, when 
 fed breast milk, do not get these deadly diarrheal dis¬ 
 eases. There must he some other important factor in 
 cow’s milk—another mysterious influence. This is 
 simple reasoning, simple common sense. Careful clin¬ 
 ical study again guides us along the right path. 
 
 At this time Ludwig F. Meyer, Finkelstein’s first 
 assistant, made a very important clinical contribution. 
 While his experiments are open to all sorts of criti¬ 
 cism, while in the light of our present knowledge, they 
 can he attacked from all sides, nevertheless, in their 
 day they served their purpose. He took cow’s milk 
 and breast milk, separated them each into curd and 
 
 whey, as for example: 
 
 
 
 Breast Milk 
 
 Case in 
 
 -•Whey 
 
 Cow*6 Milk 
 
 Casein^ 
 
 ^Whey 
 
63 
 
 and after having divided these mixtures, he criss¬ 
 crossed, adding the whey of cow’s milk to the casein of 
 breast milk, and the whey of breast milk to the casein of 
 cow’s milk. Feeding these mixtures to children sick 
 with diarrheal diseases resulted in sharp differences. 
 Those children getting the mixture containing the whey 
 of breast milk made good recoveries; those children 
 getting the mixture containing the whey of cow’s milk 
 did not do so well. 
 
 Gentlemen, although this experiment is open to 
 much criticism, it nevertheless served its important 
 purpose. It called to our attention for the very first 
 time the whey of cow’s milk. ISTow, we hear of the 
 whey of cow’s milk as a factor in producing disturb¬ 
 ance. We have heard of protein, fat, carbohydrate, 
 and now we hear of whey; and, after all is it not 
 strange that for so many years we have neglected this 
 portion of the milk? Is it not likely that wbey, with 
 almost four times the salt content of breast milk, also 
 could exert harmful influences upon the intestine, per¬ 
 haps due to osmotic conditions or to who knows what? 
 To Ludwig F. Meyer, then, we are indebted for bring¬ 
 ing to our attention the whey. 
 
 While these observations were going on, clinical study 
 was again bringing Finkelstein toward the ultimate 
 truth. Increasing carbohydrate in some milk mixtures 
 resulted in diarrhea. Increasing carbohydrate in oth¬ 
 ers, to his mytisfication, had no such effect. What 
 could be the explanation? The solution was discovered 
 in the combining of the above two clinical experiments. 
 When carbohydrate is added to mixtures of cow’s milk 
 rich in the whey elements, diarrhea results; when car¬ 
 bohydrate is added to mixtures of cow’s milk poor in 
 the elements of the whey, no diarrhea results. The 
 more concentrated the whey the worse the diarrhea ! 
 Thus, you see, addi-ng carbohydrate to buttermilk or to 
 skimmed milk will make a laxative mixture—these mix¬ 
 tures containing all the whey elements of the milk. 
 Adding carbohydrate to pure whey would cause a very 
 intense diarrhea. I should certainly advise you not to 
 try this. What there is in the whey that causes these 
 symptoms I do not know. Perhaps it is the high salt; 
 maybe the soluble albumins; as I have said so fre- 
 
64 
 
 quently, “This is clinical observation.’ 7 Explanations 
 will come later. 
 
 It is human, however, to wish things clear, to have 
 a picture to hold before us, a guide for our thoughts. 
 I can offer you the picture that has been devised by 
 our great teachers. Do not take this as an absolute 
 truth, but simply as an illustration pointing out the 
 processes of modern reasoning. How can a mixture of 
 whey and carbohydrate produce these results? 
 
 formally, billions and billions of bacteria live in 
 the large intestine. The small intestine is relatively 
 sterile. Only at times wheen food is being digested 
 are bacteria found in any amount in the upper tract. 
 With the disappearance of food, with its absorption 
 through the intestinal wall, the bacteria rapidly go 
 back to their home—to their normal environs in the 
 large intestine. Those left in the upper tract are 
 killed probably by the intestinal cells and by the diges¬ 
 tive juices. 
 
 Post-mortem examination in many cases of severe 
 diarrhea, however, reveals the very interesting fact 
 that the upper intestine is swarming with micro-organ¬ 
 isms—not abnormal ones but simply those which live 
 normally only in the lower bowel. Gentlemen, what has 
 now happened? Normally the upper intestine is able 
 to keep its contents sterile, perhaps through the bac¬ 
 tericidal quality of the digestive juices, perhaps 
 through the properties of the living epithelial cells. 
 Something must have impaired this function. Is it 
 not possible that the digestive juices and the activities 
 of the epithelial cells have been handicapped by the 
 high salt content, perhaps by the changed salt rela¬ 
 tions of the cow’s milk whey? Moro’s experiments 
 in a way would tend to confirm this hypothesis. In 
 carefully conducted researches he and his assistants 
 showed that the intestinal cells are much more efficient 
 when active in a medium of breast milk whey than of 
 cow’s milk whey. 
 
 Once injured, these intestinal cells cannot suppress 
 bacterial growth in the upper intestine. The bacteria 
 will thrive and prosper, and now, when carbohydrate 
 is introduced, before the intestinal digestive enzymes 
 can alter it, prepare it for assimilation, and carry it 
 through the intestinal wall, the hungering bacteria have 
 
65 
 
 seized it, fermented it, and changed it to the irritating 
 lower fatty acids, such as acetic, butyric, and formic. 
 Gentlemen, do you remember that in the first lecture 
 and in the second, also), we tried to impress upon you 
 that when bacteria attack carbohydrate the process is 
 known as fermentation, and acid results? Now, you 
 understand why. This very same process proceeds 
 rapidly, unmolested by the injured intestinal epithelium, 
 and a tremendous quantity of irritating products result, 
 causing a severe acid, watery diarrhea. Such is what 
 we reasonably may believe. Clincial observation has 
 painted a picture in abnormal physiology. 
 
 To return to the bedside. Diarrheas are of two types: 
 (a) A rather mild attack, with symptoms described 
 usually as mild gastro-enteritis or mild summer com¬ 
 plaint. (b) A very intense attack, often deadly in na¬ 
 ture, described as very severe gastro-enteritis, very 
 severe ileocolitis, or, maybe, cholera infantum. 
 
 The first of these conditions Finkelstein called dys¬ 
 pepsia; the second, he called intoxication, not because 
 he had isolated any toxin, but because from a clinical 
 point of view the little patient appeared poisoned. This, 
 you remember, is a clinical classification, and a clinical 
 classification has many advantages. The picture is 
 constantly before us. Explanations will be varied, 
 causes amplified, new factors discovered; but the clin¬ 
 ical picture will be unchanged. 
 
 DYSPEPSIA 
 
 This is one of the most frequent ailments you meet. 
 The mother brings the babe mainly for relief of intes¬ 
 tinal symptoms. The child has a mild diarrhea—five, 
 six or eight watery, green, rather sour-smelling stools 
 with a little mucus; is occasionally vomiting, and has 
 some colic. 
 
 Careful history shows nothing of importance, other 
 than perhaps a slight cold. The baby’s sleep is dis¬ 
 turbed and for a few days he has not been gaining. 
 
 The examination shows a baby not very sick—often 
 slightly undernourished, pale and restless, perhaps a 
 little peevish and irritable. Consciousness is certainly 
 not disturbed; there may be shadows under the eyes 
 and the abdomen slightly distended. Temperature, 
 
 S 
 
 * 
 
66 
 
 pulse, and respiration, other than possibly a slight fever, 
 reveal no important change. 
 
 Gentlemen, we have spoken to you about the reactions 
 to food and to hunger. Addition of food or increase 
 of diet to this patient will have little effect. His 
 diarrhea may become slightly worse, his general symp¬ 
 toms a little increased; but he will show no radical 
 change. Withdrawal of food —absolute hunger — 
 causes a marked improvement. Diarrhea ceases and 
 the child becomes better, brighter, and happier. There 
 may be a moderate loss of a few ounces of weight for a 
 day or so, but then the curve rapidly swings to normal. 
 
 If we study such a child from a standpoint of 
 metabolism, if we analyze carefully the amount of food 
 taken in twenty-four hours, the amount of matter ex¬ 
 creted in the urine and the stool for twenty-four hours, 
 we find the following changes: 
 
 a . The protein excretion is slightly increased. 
 
 b. The fat is not changed greatly unless the child 
 has been receiving some quantity in its bottle. In such 
 cases a considerable quantity of fat is found in the 
 stools. 
 
 c. Starch may he found in the stool, particularly if 
 the baby has been receiving a starchy diet. 
 
 d. There may he at times a slight loss of mineral 
 matter, chiefly of sodium and potassium. 
 
 e. Above all things are found increased quantities 
 of the irritating volatile lower fatty acids, such as 
 acetic, butyric, and formic. 
 
 Where do these irritating acids come from? Czerny 
 would have said that they come from bacterial infection 
 of the milk outside of the body; Finkelstein, that these 
 acids are produced by the normal bacteria of the in¬ 
 testine, attacking the carbohydrates of the milk under 
 the accelerating influence of the whey. The splendid 
 studies of the younger men, such as Barth, Edelstein, 
 and others, stimulated by these controversies, have 
 shown that acid formation in the stool is infinitely 
 greater than the acid formation in spoiled milk. Thus 
 must they be created in the body. 
 
 Just as clinical study enlarged Czerny’s idea of fat 
 injury, so did clinical study enlarge Finkelstein’s idea 
 of whey-sugar injury. Hew points added as etiological 
 factors are: 
 
67 
 
 I. From the Standpoint of Food. 
 
 a. As regards good, wholesome, pure milk, the factor 
 upon whicJi Finkelstein has laid so great stress: 
 
 (1) Simple overfeeding is a frequent cause. 
 
 (2) Particularly is overfeeding with sugar-whey 
 mixtures a tremendous factor. This was Finkelstein’s 
 first great contribution. 
 
 (3) High sugar plus high fat, particularly in a me¬ 
 dium of cow’s milk whey, causes these diarrheas. Many 
 men lay primary emphasis upon the fat in these cases, 
 for the stools show great quantities of undigested fat. 
 We do not wish to be dogmatic. Undoubtedly, high 
 fat, particularly if not properly digested, can produce 
 irritating products and diarrhea. We believe, how¬ 
 ever, the more important process is the primary fer¬ 
 mentation of the carbohydrate, which whisks the fat 
 out in the resulting diarrhea, the fat appearing in the 
 stool as a neutral secondary element. We believe that 
 probably the fat suffers secondarily as the acids from 
 sugar fermentation interfere with the digestive 
 enzymes. The latter you know work best in an alka¬ 
 line meduim. 
 
 (b) As Regards Spoiled Food. From the view¬ 
 point of Czerny, spoiled milk undoubtedly at times pro¬ 
 vides irritants to the intestine sufficient to cause these 
 symptoms. Particularly in older children, during the 
 summer months, are spoiled foods of all sorts important 
 agents. 
 
 II. We have learned that constitution is a factor. 
 The weaker the baby the more is he predisposed. 
 
 III. Frequently repeated mild infections, as coughs 
 and colds, are of extreme importance. 
 
 IV. Heat and improper nursing must meet with our 
 consideration, and of course many other new influences 
 will he described. Probably all of these in some way or 
 another increase fermentation in the intestines. 
 
 From this viewpoint, you can see how relatively un¬ 
 important is examination of the stool; I mean, rela¬ 
 tively unimportant as a strict indication for therapy. 
 In any of these dyspeptic stools, had the baby been fed 
 starch, the starch granules would have been whisked 
 through by the increased peristalsis; had he received 
 high fat, the fat would have appeared in large quan- 
 
68 
 
 titles. Had we focused our attention exclusively upon 
 tlie stool, forgetting the more general considerations, we 
 would have said, “This is a disturbance due to starch; 
 this is a disturbance due to fat”; but now, as Ludwig 
 F. Meyer once said to me, in his pointed way, “When 
 you find high fat in the stool, seek the carbohydrate.” 
 
 TREATMENT 
 
 The treatment based upon these opinions must be 
 self-evident and simple—just plain reason. If the whey 
 is a factor injuring the intestine and permitting bac¬ 
 teria to flourish in the upper digestive tract, we must 
 dilute it. If carbohydrate ferments, we must give it 
 in a nonfermentable form. The more we dilute our 
 whey, the more we reduce this factor injuring the in¬ 
 testine, the safer is it to give carbohydrate. FTonfer- 
 mentable carbohydrates are, as we told you in the 
 second lecture, composed of mixtures of dextrin and 
 maltose and can be offered as Mead’s Dextri-Maltose, 
 Mellin’s Food, Horlick’s Malt Food (not Malted Milk), 
 etc. Remember, these substances are carbohydrates, 
 and under no circumstances baby foods. 
 
 Our treatment then for these milder conditions would 
 be: 
 
 Hunger for twelve to twenty-four hours, not forget¬ 
 ting, however, to keep up a sufficient supply of water 
 to the baby. During this hunger period the baby’s 
 vomiting and diarrhea empties his digestive tract of all 
 irritants. It is not necessary to give calomel and castor 
 oil, unless, perhaps', foreign stubistances have been 
 eaten; for the baby, as a rule, can well take care of him¬ 
 self. If you suspect that the trouble is due not to the 
 milk, but to corn or cucumbers or watermelon, a dose 
 of castor oil and a mild colonic flushing may do no 
 harm, if given once. 
 
 2. After this hunger period, we must start food. 
 To dilute our whey, we give one part milk, two parts 
 water. To this mixture we add 1 or 2 per cent of non¬ 
 fermentable carbohydrate. We boil these together and 
 in six feedings give a total of 6 to 10 ounces in twenty- 
 four hours, always keeping up the supply of water. 
 We can gradually increase about 3 ounces to the twenty- 
 four hours total every day or two until we have reach- 
 
69 
 
 ed our maximum quantity, depending upon the baby’s 
 age. Having reached our maximum total quantity, 
 gradually we increase the carbohydrate to 5 per cent. 
 In all this treatment our guide must not he so much 
 the stool as the baby’s weight curve : 
 
 At (a) we have withdrawn food; a gradual loss of 
 perhaps 7 to 8 ounces results during the next few days. 
 
 At (b), after twelve to twenty-four hours hunger, 
 we give the baby his 6 to 10 ounces. We hold 
 him there until at (c) the curve has straghtened out, 
 and then we gradually increase. Remember, the body’s 
 curve is the index of his general nutrition, and although 
 this dyspepsia is almost exclusively a local intestinal 
 affair, still the loss of weight resulting from improper 
 treatment proves that the baby’s general nutrition also 
 can and does suffer, and if we keep this broad picture 
 before our minds we shall be less likely to err badly. 
 
 In some cases physicians, instead of giving water 
 during the first day, give cereal waters—barley gruel, 
 etc. This, in many cases, is fully as efficient as is plain 
 t water. The dangers, however, are two: 
 
 a. The physician, in his carelessness, the mother not 
 knowing that barley water is a starvation diet, forgets 
 to add food, allows the baby to remain on barley water 
 for days; and, after a period of four, five, or six days, 
 the child rapidly goes down into the condition of 
 Czerny’s Starch Injury, or, as we shall call it, “De¬ 
 composition.” 
 
 h. Sometimes, after the baby has been on barley 
 water, for reasons which are not clear, upon the addi¬ 
 tion of milk to the diet, fermentation again becomes 
 active in the intestine, and diarrhea returns. 
 
 For dyspepsias in older children the same principles 
 hold good. We shall refer to them later. 
 
70 
 
 Gentlemen, suppose we are ignorant of the food factor 
 in this dyspepsia; suppose we have attributed the con¬ 
 dition to something else; suppose we have quieted the 
 child with opiate and allayed the mother’s tears; sup¬ 
 pose we have thoroughly cleaned out the child with 
 calomel and castor oil; and then suppose, in our folly, 
 thinking the baby must have food, we offer the child one 
 of those mixtures high in the whey elements of the milk 
 and rich in fermentable carbohydrate, such as butter¬ 
 milk with sugar or skimmed milk with sugar. Can 
 you grasp the result ? 
 
 Shortly we are called to see a desperately sick baby. 
 The child is feverish and lies in semi-stupor. The 
 sunken cheeks, the sharp nose, the ashen, mud-colored, 
 wrinkled skin, the cold extremities all show great loss of 
 weight and great prostration. Intense watery diarrhea 
 drains the body of its food pulls out the very building 
 blocks of the tissues. The pulse is rapid and weak. 
 Lying apathetically in his bed, our little patient no 
 longer interests himself in his surroundings. The barely 
 closed lids show the well-nigh glassy eves fixed unin- 
 telligently upon one corner of the room. Occasionally 
 he wakes for a moment, looks at us, cries fretfully, and 
 again wanders off into apathy. The breathing is charac¬ 
 teristic, deep, tireless, rapid, unceasing, like the air 
 hunger of diabetic coma. Occasionally one of the almost 
 limp extremities is moved slightly. Sometimes these 
 take on cataleptic attitudes. The arms, particularly, are 
 apt to assume the position typical to a prize fighter. 
 The urine may show sugar, albumin, and casts. 
 
 Examination reveals an enlarged liver. 
 
 What have we done, gentlemen? We have produced 
 a wonderful, a terrible clinical picture. We have pro¬ 
 duced the “Alimentary Intoxication” of Finkelstein. 
 For this description the pediatrics world forever must 
 be grateful. 
 
 . Gentlemen, we have spoken to you about the im¬ 
 portance of food reactions. Listen carefully: If in 
 this stage we offer our patient a full bottle of his diet, if 
 we offer him any large quantity of food, his weight 
 curve sinks precipitately, vertically, downward to 
 rapid death. We have killed our baby. Ho surer way 
 have we of doing this than by offering him food; no 
 surer way have we of saving him than by removing food. 
 
71 
 
 If at point “A” in the period of his dyspepsia, we 
 have mistreated our patient, so that steady progression 
 has thrown him into the stage of intoxication, at “B,” 
 addition of food brings the fatal drop; withdrawal of 
 food straightens out the curve and the child is saved. 
 What more beautful illustration has one of the effects 
 of food than this clinical observation, than this so- 
 called paradoxical reaction of Finkelstein” ? The 
 food which would cause a normal baby to gain, causes 
 destruction; the hunger which causes a normal baby to 
 lose is salvation. 
 
 Gentlemen, what processes are involved in this radi¬ 
 cal change in the progress of the mild dyspepsia to the 
 deadly intoxication ? Listen carefully: This progress 
 is one of transition from a mild, local, intestinal dis¬ 
 turbance to the severest “disturbance of nutrition.” In 
 the mild dyspepsia, constitutional symptoms do not 
 predominate. The acids formed irritate the mucous 
 membranes slightly and cause diarrhea, but nutrition is 
 not badly affected, as shown by the relatively slight loss 
 of weight. Now note the progress. Increasing acid form¬ 
 ation begins to injure the intestine wall. The acids are 
 now sufficient to interfere with the digestive enzymes. 
 Fat is no longer properly digested, and its split products 
 
 i 
 
72 
 
 aid in increasing the damage. In this acid medium new 
 types of bacteria flourish, bacteria which can attack the 
 fat, producing intense irritants. 
 
 Before these combined assaults the intestinal wall 
 begins to fail. The membrane is no longer imperme¬ 
 able to attack. Its weakened strength cannot be de¬ 
 tected by the microscope; it can be by physiological ex¬ 
 periment. Now for the first time do undigested food 
 substances pass through the membrane into the body. 
 We have not seen these undigested substances entering 
 the body, but our experiments have found them as they 
 leave. We feed children in this condition lactose, and 
 lactose appears in the urine. We feed these children 
 foreign protein, and foreign protein appears in the 
 urine. Gentlemen, the process of digestion is to pre¬ 
 pare foodstuffs for the use of the tissues. Remember, 
 undigested foodstuffs circulating in the body fluids are 
 poison. See the possibilities of this conception. The 
 mild dyspepsia has progressed so that now the entire 
 body has become severly and dangerously involved. 
 
 We can paint almost any picture. We see undigested 
 protein and poisonous products of the fat taken into 
 the circulation. We see the tissues bathed in strong so¬ 
 lutions of sugar; of strong salt. We see innumerable 
 products of bacterial activity rapidly entering the sys¬ 
 tem. We see chaos where we should see order. 
 
 Small wonder at the multitude of clinical symptoms. 
 Convulsions, strabismus, and cerebral cry may suggest 
 meningitis. Gastro-intestinal effects may be great 
 enough to resemble cholera. But in all cases, remember 
 that certain symptoms will be constant: the rapid loss 
 of weight, the toxic acidosis type of breathing, the dis¬ 
 turbed consciousness. 
 
 The examination of the food and the total excretion 
 of these children in contrast to the mild dyspepsia 
 shows a considerable loss of body substance. Pro¬ 
 tein, fat, and minerals are thrown out of the body by 
 the rapid intestinal movements, and the urine shows 
 the most profound changes of metabolism. 
 
 There is a tremendous loss of water,, due, perhaps, 
 not so much to the increased bowel movement, for this 
 is compensated by the decreased urine, but due to the 
 tireless, rapid deep respiration. In this condition, then, 
 are we dealing with an infinitely more important prob- 
 
73 
 
 lem than local intestinal diseases. As the mild tonsil- 
 itis results in endocarditis, as the insignificant wound 
 ends in deadly tetanus, so may the simple dyspepsia 
 lead to a profound “disturbance of nutrition”—the “Ali¬ 
 mentary intoxication.” 
 
 diagnosis 
 
 The history in a way makes the diagnosis. Improper 
 feeding, followed by a disturbance, such as we have de¬ 
 scribed, is in almost all cases “alimentary intoxication.” 
 In our history, however, before excluding this condition, 
 we must not focus too carefully upon the feeding alone, 
 but must recognize the new factors, which by their ef¬ 
 fect upon the baby’s general condition also predispose. 
 The same factors are those to which we referred in dys¬ 
 pepsia, viz., age, constitution, infections, poor nursing, 
 and heat. We have learned that this condition never 
 develops primarly in a well child. There must have 
 been a preceding state of dyspepsia or decomposition. 
 The latter we shall consider in the next lecture. 
 
 The diagnosis is definitely established upon with¬ 
 drawal of food: 
 
74 
 
 If, after twenty-four hours of hunger, the loss of 
 weight ceases, the temperature drops to normal, the 
 diarrhea improves—the latter, however, not being ab¬ 
 solutely essential—we make a positive diagnosis of ali¬ 
 mentary intoxication. 
 
 TREATMENT 
 
 1. Gentlemen, during the first twenty-four hours the 
 child must hunger. During this day the diarrhea and 
 the vomiting will empty the intestinal tract of irritants. 
 
 2. Under no circumstances shall we give calomel, cas¬ 
 tor oil, or any other irritating drug. See what one 
 does. Just think! The intestines are acting as rapidly 
 as possible to rid themselves of irritants. They are 
 moving just as quickly as they can; you can’t make 
 them move any more quickly; all that you are doing 
 with these drugs is to increase injury. What the intes¬ 
 tine needs is not stimulation; it needs a rest. For this 
 same reason we would not injure the stomach and in¬ 
 testines by getting a big pump and repeatedly washing 
 out the stomach and flushing out the bowels. Leave 
 them alone. They will take care of themselves if you 
 give them only half a chance. If your aim in using 
 these drugs is intestinal asepsis, your hope is in vain! 
 Ho drug is known which w T ill make the intestinal con¬ 
 tents sterile. Indeed, animals raised with sterile intesti¬ 
 nal tracts live only a short while. Barrels of medicine 
 haven’t nearly the effect of a slight change in diet. 
 
 In addition to the great principle of physiologic rest, 
 during these twenty-four hours we can aid our little 
 patient in other ways: 
 
 a. ITe is suffering greatly from loss of water; we 
 must supply fluids. Give him all the water he wants. 
 
 b. The use of a little salt will aid him greatly in 
 retaining water in his body. Simply take a little sur¬ 
 gical salt solution—physiological salt solution, made by 
 adding a teaspoon of salt to a pint of water; dilute 
 this to half strength, sweeten it with a little saccha¬ 
 rine, and offer the baby 3 to 4 ounces by mouth during 
 the first twenty-four hours. This aids him in retaining 
 water; but do not give over this amount or you will 
 produce edema and throw too great a strain upon the 
 heart. Edema readily results in these cases. 
 
75 
 
 c. Our little child may need to be stimulated. Under 
 these conditions^ brandy, in doses of 10 to 15 drops, 
 every few hours, caffein citrate in doses of *4 of a grain, 
 may be given by mouth. Infinitely more effective is 
 
 ' the hypodermic use of 10 to 15 minims of a 10 per 
 cent solution of camphor in oil, repeated, when neces¬ 
 sary, every few hours. Personally, I have come to 
 place more and more confidence in adrenalin. One reads 
 very little of this in medical discussions; but from 
 my own observations, I am absolutely convinced that 
 in the failing pulse, and sinking blood pressure of this 
 condition, just as in surgical shock, hypodermic in¬ 
 jections of 2 to 3 minims, repeated every two or three 
 hours, are of great value. In my own studies I have 
 found that the blood pressure is raised and held up for 
 periods of an hour following injection probably by the 
 gradual absorption, resulting from subcutaneous rather 
 than intravenous use. 
 
 d. During this first day treatment of the mother is 
 a most important consideration. She, in her maternal 
 anxiety, demands that we do something. The substitu¬ 
 tion of tea for water is a great help. From our stand¬ 
 point, children take it well, like it, and we supply fluid 
 to the tissues. We can explain to the mother, however, 
 that in tea we have caffein, which is a great stimulant, 
 tannic acid, which will tend to combat the diarrhea, and 
 we can make the matter more impressive by adding a 
 little saccharine tablet for sweetening. We can busy the 
 mother, during the first day, with the general care of 
 the baby, keeping him warm, offering with a medicine 
 dropper small doses of our salt solution and perhaps a 
 little medicine at regular intervals., but, under no cir¬ 
 cumstances, shall we be influenced to diverge radically 
 from our principles. 
 
 e. What medication shall we use for the intestine? 
 Gentlemen, if you have understood the principles of 
 this disturbance, you see that a little alkali can be rea¬ 
 sonable and logical. Chalk mixture with its calcium can 
 be given in doses of several teaspoons every few hours. 
 It is interesting to see how the older men empirically 
 arrived at this remedy; but, gentlemen, under no cir¬ 
 cumstances place your faith in medicine; medicines are 
 simply insignificant aids in our treatment compared to 
 the enormous influences exerted by food. 
 
76 
 
 /. While in the stage of simple dyspepsia ordinary di¬ 
 lution of the milk and reduction of the carbohydrate 
 suffices for a cure, in this condition we are reduced to 
 the use of two foods only. These are breast milk or, 
 if this is not obtainable, the famous “Eiweiss Milch,” 
 or Albumin Milk of Einkelstein and Meyer. 
 
 The principles upon which this food is based are 
 just ordinary common sense. If carbohydrate ferments, 
 it must be reduced. If whey so injures the intestines as 
 to enhance fermentation, the whey must be diluted. 
 If casein, by calling forth alkaline intestinal juice, by 
 aiding putrefaction, by combining with calcium, over¬ 
 comes fermentation and makes the intestine alkaline, 
 protein must be increased. With this object in view 
 Einkelstein and Meyer set about making the above mix¬ 
 ture. It was originally made as follows: 
 
 (a) To 1 quart of raw milk add enough ferment 
 to cause coagulation and formation of large casein 
 curds. Any milk-coagulating ferment will do. In Chi¬ 
 cago, we use Chymogen put up by Armour & Co., in 
 amounts of 1 dram to a quart of milk. 
 
 (b) In order to separate the curd from the whey, 
 we filter this mixture, letting it hang in a cloth bag for 
 an hour. During this process all the whey drips off 
 and the pure casein curd remains. 
 
 (c) This casein curd is put through a fine hair 
 sieve, the wire meshes of which must be finer than a 
 window screen. You understand if the casein is fed 
 in large pieces it will not exert its physiological effects, 
 for only a small amount of it will be exposed to the 
 intestinal juices and to the bacteria. The center of the 
 curd will be untouched. The success of the mixture, 
 then, depends upon a very fine division of the casein. 
 It must be put through the sieve two or three times. 
 
 ( d ) To the finely divided curd we add 1 pint of 
 buttermilk. Buttermilk supplies salts, and a baby must 
 have salts to live. You ask why a pint of whole milk 
 or skimmed milk will not suffice. Whole milk, you re¬ 
 member, contains fat, which we are glad to reduce in 
 these severe cases. Whole milk and skimmed milk 
 both contain lactose, which is very fermentable. But¬ 
 termilk not only has no fat, but also has very little 
 lactose, and possibly the lactic acid may be of some 
 aid. 
 
77 
 
 (e) Enough water is added to this mixture to make 
 1 quart. The mixture is now boiled, stirred with a 
 cutting motion to prevent the reformation of large 
 curds, and divided into bottles. Upon offering them to 
 the baby these bottles must not be heated above body 
 temperature, or large curds again will form. 
 
 You see now, gentlemen, what this mixture con¬ 
 tains : 
 
 ( a) We have the casein of 1 quart of milk plus that 
 of 1 pint of buttermilk. 
 
 ( b) We have the whey of 1 pint of buttermilk; thus 
 the whey has been reduced to one-half. 
 
 ( c ) We have almost no lactose. 
 
 Everything in this mixture speaks for alkali forma¬ 
 tion; speaks against acid formation. What a curious 
 world this is! In the olden times we used to throw 
 away the curd and use the whey; now we throw away 
 the whey and use the curd. This is an ideal mixture to 
 overcome the fermentative stool, to neutralize the in¬ 
 testinal reaction, and to stop the diarrhea. Shall we 
 feed this mixture to the baby? What an ideal mixture 
 is this to hill our little patient! You look somewhat 
 surprised. You have made just the same mistake that 
 Finkelsteiu and his assistants did. Reports came rap¬ 
 idly from all over the world protesting against the 
 use of his mixture. Rot long, however, before the error 
 was detected. Finkelstein and Meyer had made the same 
 mistake that we have seen repeated time and time again. 
 They focused too carefully upon the stool and forgot 
 the baby! True enough, the intestinal condition was 
 cured; the stools became alkaline and constipated, but 
 the baby died! Gentlemen, listen carefuly one moment: 
 The baby died from lack of carbohydrate. In our in¬ 
 tense desire to treat the diarrhea, we forgot the baby. 
 The child must have carbohydrate to live, and this baby 
 was getting an amount insufficient even for life. With¬ 
 out going too much into detail, it was learned that in 
 albumin milk it is perfectly safe to give at least 3 per 
 cent carbohydrate. If this is given in the form of non- 
 ferment'able carbohydrates, such as dextrin-maltose 
 preparations, no harm will result. So,, in making up 
 albumin milk, never commit the fatal error of omitting 
 3 per cent carbohydrate in every quart of mixture. In 
 offering the albumin milk, instruct the mother to use 
 
78 
 
 a large nipple, as some of the casein curds may stick 
 in a small one. You may also add a little saccharine 
 for sweetening, for when the child gets stronger he 
 may object to the taste of the buttermilk. 
 
 In offering the baby breast milk or albumin milk, 
 shall we give him a full bottle? Gentlemen, to do so 
 means death. Even if a wet nurse be obtainable, if we, 
 thinking that breast milk is an ideal food, recklessly 
 put the child to nurse, we probably shall lose him in a 
 very few hour^. With the intense degree of fermen¬ 
 tation that is existing in the intestine, the high amount 
 of sugar in breast milk, even though it be in the healing 
 breast milk whey, may ferment and increase the 
 damage. 
 
 In all cases our techinque must be extremely rigid 
 and exact. 
 
 1. Keeping up the same general treatment of the first 
 day: stimulation and fluids in the form of tea, we offer 
 ten feedings of about % ounce each of food. 
 
 2. The next day we increase these to ten feedings of 
 from two-thirds to one ounce, depending upon the 
 severity of the condition. 
 
 3. The following days we may increase gradually to 
 ten feedings of 1% ounces. 
 
 Here we must wait and note the reaction of our 
 weight curve: 
 
 We hold our food perfectly constant at 10 x 1% 
 independent of the stools until the weight curve has 
 
79 
 
 straightened out. If the weight curve .still sinks, if the 
 diarrhea continues, under no circumstances make any 
 change in the food. The danger of a change is much 
 greater than the danger of leaving it as it is. When, 
 however, the weight curve has become horizontal, we 
 safely may continue to increase gradually up to the 
 maximum quantity; that is, about 3 ounces of the mix¬ 
 ture for every pound of the baby’s weight. When we 
 reach our maximum quantity, slowly we increase our 
 carbohydrate to 5 per cent. After a few weeks we re¬ 
 turn to an ordinary milk mixture. 
 
 I have gone into such detail, gentlemen, not because 
 I want you to remember the technique exactly of making 
 albumin milk, but because I want you to remember the 
 principles upon which this technique is based. If you 
 have the principles, then, no matter where you are, 
 what means are at your disposal, simply make up a 
 combination of high protein, low whey, and nonfer- 
 mentable carbohydrate. Never commence with large 
 doses, but following a hunger period, being guided by 
 your weight curve, offer gradually increasing amounts. 
 
 These principles you can apply to your older chil¬ 
 dren—children of one to three years of age: 
 
 1. Hunger with tea and fluids for the first day. 
 
 2. Reduce the whey by removing milk or diluting it 
 to one-third or one-half. 
 
 3. Increase the protein by giving scraped meat, cot¬ 
 tage cheese, and curds of milk. 
 
 4. Give nonfermentable carbohydrates, Zwieback, and 
 mashed potatoes and cereals, such as corn starch, cream 
 of wheat, and arrowroot. 
 
 5. Supply salts best as vegetable purees. 
 
 Don’t forget the hunger period; don’t forget fluids, 
 and, above all thingsi, don’t forget the tiny doses of food 
 in the begining of the treatment. 
 
 Gentlemen, if you are thoroughly conversant with 
 these principles, no matter where you are, no matter 
 how primitive the home, you will be always completely 
 master of the situation. 
 
LECTURE VI 
 
 DECOMPOSITION 
 
 Gentlemen, in the previous lectures we discussed three 
 of the clinical types of nutritional disturbance which 
 Finkelstein called to our attention. You remember that 
 it was he who for the first time clearly and emphati¬ 
 cally laid great importance upon the factors of nutri¬ 
 tion and food in the production of what we previously 
 had called “The diarrheal diseases of infants.” That 
 many of his first explanations were incompletev, that 
 many of his views will again be amplified, there can be 
 no doubt. But the service he has done us is immeas¬ 
 urable. In the lectures on disturbed balance, dyspep¬ 
 sia, and intoxication we have given you these three 
 clinical pictures as he described them. Today we will 
 concern ourselves with the last of the four groups, the 
 subject of decomposition. Names, of course, make no 
 difference. It is perfectly immaterial what names we 
 use, provided we remember the clinical picture. Finkel¬ 
 stein in describing this condition did not describe a new 
 disease or even a new clinical syndrome. He did give 
 us, however, a new name and a new explanation, the 
 new name being decomposition , and that term being 
 used to explain and to emphasize that destruction was 
 occurring in the baby’s body. You gentlemen have 
 known this condition under the names of atrophy, mar¬ 
 asmus, and malnutrition. These conditions are fa¬ 
 miliar to you all. Finkelstein, however, does not think 
 that these terms describe accurately the complicated 
 processes that are being evolved in the child’s body, and 
 hence changes the term. It is hardly necessary for me 
 to describe to you the picture. Doubtless you have seen 
 it often in your practice. A tiny, undernourished in¬ 
 fant, weight far below normal, lies restless and crying 
 in its bed or in its mother’s arms. Simultaneously 
 one notices the pallid, blue, wrinkled, tissue-paper like, 
 fat-free skin, and the whole bony skeleton that seems 
 to protrude right through it. The face is that of a tired 
 old man. The large, deep-seated eyes move restlessly 
 
81 
 
 about; then fix upon you with an appealing, uncanny 
 stare. The large mouth, with its thin reddish lips, 
 opened wide in a never-ceasing fretful cry, is in strik¬ 
 ing disproportion to the small weazened face, and into 
 this mouth the child inserts one or both fists and sucks 
 and chews them in blind greed. His peevish tones 
 reveal perpetual misery. Through the emaciated skin 
 of the thorax the bony framework in all its detail pro¬ 
 trudes, and through the tissue-paper thinness of the 
 skin and muscles of the abdomen the abdominal viscera 
 may reveal their outlines and movements. On the ex¬ 
 tremities the skin hangs in large folds, apparently right 
 over the bones. 
 
 In sharp contrast to the condition of intoxication, 
 this child’s consciousness is undisturbed—if anything, 
 excited. You remember how the child with intoxication 
 lies drowsily upon the bed, eyes fixed apathetically on 
 one corner of the room, then arouses himself with a 
 short cry temporarily, and again lapses into semicon¬ 
 sciousness. This child, the child with the decomposi¬ 
 tion, is continuously on the alert, cries pitifully, never 
 ceasing, and, indeed, never seems to sleep. You re¬ 
 member the child with the intoxication had the rapid, 
 tireless, never-ceasing respiration. This child has the 
 slow, feeble, irregular type. In the intoxication the 
 pulse is rapid. In this child the pulse is slow and weak. 
 
 Normally, the pulse in an infant ranges around 120. 
 In this child it may be 80 or below. In the intoxication 
 stage the temperature is usually elevated. In the de¬ 
 composition the temperature is usually subnormal, the 
 more subnormal it is the worse being the state of the 
 disturbance. Rarely does the temperature even rise to 
 normal. In contrast to the albuminuria, glycosuria, and 
 the casts of the intoxication, the urine of this child is 
 normal. The intoxication suggests acute poisoning, the 
 decomposition chronic collanse. 
 
 Symptoms of the gastro-intestinal tract vary with the 
 food. Vomiting is not unusual. Stools, however, de¬ 
 pend to a large extent upon the diet. When the diet is 
 large, particularly when it is high in carbohydrate, we 
 usually have a fermentative process in the intestine and 
 a resulting diarrhea. Such a process is very easy to 
 understand when we consider that the intestinal tract 
 suffers in its general nutrition as much as does every 
 6 
 
 i 
 
82 
 
 organ of the body. It is perfectly rational, then, to 
 assume that the functionally injured intestinal cells of 
 the upper digestive tract do not suppress bacterial 
 growth as they do in the normal infant. Consequently, 
 any improper combination of food, especially mixtures 
 rich in whey and carbohydrate, will readily stir up 
 these bacteria to growth, and in the resulting fermenta¬ 
 tion are formed the irritating acid products which lead 
 to dyspepsia and intoxication. In such a condition, if 
 high fat is fed, the fat will be whisked through the in¬ 
 testine out in the stool. We do not mean to be too dog¬ 
 matic. It is perfectly reasonable and logical, and there 
 is also some good evidence to show, that the digestive 
 ferments are not very active in this condition, and we 
 can readily understand the appearance of fat in the 
 stools, due also to its improper digestion and assimila¬ 
 tion. We believe, however, that in the majority of 
 cases the fat appears passively in the stool, being second¬ 
 ary to the primary fermentation of the carbohydrates. 
 
 On the other hand, if a diet high in protein, low in 
 carbohydrate and whey, is given the stool will become 
 alkaline and hard. How less undigested fat will appear. 
 This observation supports our premise that the fat is 
 really the secondary factor. Again, the smaller the diet 
 the less likely is it that the stool will be diarrheal. Per¬ 
 haps no better illustration than this can be afforded of 
 the dangers of being guided in treatment by the condi¬ 
 tion of the stools. In many of these cases babies go 
 down and die in collapse with typical constipation. Ho 
 more terrible, no greater mistake can be made than that 
 of focusing all one’s attention upon the character of 
 the stool (treating the stool so as to change it from a 
 diarrheal type to a constipated type), and forgetting the 
 baby in the meantime; allowing the baby to go down and 
 to die in the collapse of hunger. This danger can be 
 avoided if one remembers the same thing that we have 
 repeated over and over again, that the stools are simply 
 indications of what has been put into the intestinal tract, 
 of the way that food has been handled, and are only a 
 very tiny guide to us—simply a symptom—of no more 
 importance as an absolute indication for therapy than 
 is the condition of the baby’s skin, no more so than is 
 the condition of the baby’s heart and pulse, no more so 
 than is the condition of the baby’s breathing. They 
 
83 
 
 constitute simply one of the many important symptoms 
 of the condition. As the weakened pulse points to the 
 failing circulation, so do the abnormal stools point to 
 an inefficient digestive tract. This latter is the object 
 of our therapy—not the stool. In all these conditions 
 we have spoken to you about the fundamental import¬ 
 ance of the weight curve and the food reactions. 
 
 If at point A —the child having reached the typical 
 stage of decomposition, after a history of trouble and 
 gradual loss of weight for several months—we feed him 
 with a diet such as a normal child should have, he 
 will lose steadily 3 to 5 ounces a day, go down and die, 
 not infrequently with diarrhea and symptoms of in¬ 
 toxication. On the other hand, if we withdraw food 
 for twenty-four hours we find a very sharp drop in 
 weight, the curve sinking precipitately; the child dying 
 with all the symptoms of acute collapse. 
 
 Gentlemen, no more terrible mistakes are made than 
 letting children in this condition hunger. These chil¬ 
 dren are so susceptible to all influences that a period of 
 hunger of twenty-four hours, which would scarcely bo 
 noticed by a normal baby, other than by its loud pro¬ 
 tests, results in rapid death. 
 
 In addition to these clinical symptoms, which we 
 notice at first examination, the child shows great 
 
84 
 
 -change in its various reactions to external influences. 
 These children are particularly susceptible to heat. 
 They are particularly susceptible to cold. They are 
 susceptible to all forms of violence. They are readily 
 injured by improper nursing and care, and are partic¬ 
 ularly likely to be attacked and carried away by the va¬ 
 rious infectious diseases. It is well to remember that 
 these children sicken from causes of nutrition and die 
 from causes of infection. Fatal infections are very fre¬ 
 quently overlooked, not only by the careless physician, 
 but by the most experienced, because the child is so 
 weakened in his reactions that even the most virulent in¬ 
 fections often give no clinical signs. The baby is too 
 weak to react with temperature, too weak often to show 
 acceleration of the pulse or of the breathing, and it is 
 only postmorten examination which reveals how fre¬ 
 quently our little patients have been carried away with 
 terminal pneumonias. 
 
 Hot infrequently we find masked types of this con¬ 
 dition. Upon hasty clinical examination we might 
 think our little patient was only in a stage of dyspep¬ 
 sia or disturbed balance. We would become a little sus- 
 
85 
 
 picious, however, with a history of previous very irreg¬ 
 ular weight curve and by noting in our examination 
 deficiency of fat in the subcutaneous tissues, and skin 
 of a rather muddy color. Our opinions will be con¬ 
 firmed when upon treating this child for a dyspepsia, 
 upon withdrawal of food, we find not the usual slight 
 reaction of the weight curve, but a sharp, severe drop 
 of many ounces, associated with subnormal tem - 
 perature. 
 
 Gentlemen, whenever you find a child reacting with 
 symptoms of collapse, and particularly subnormal tem¬ 
 perature upon withdrawal of food, no matter how 
 slight you thought the disturbance was, beware that you 
 are dealing with one of these masked types of decompo¬ 
 sition. Remember that that child of all children is sus¬ 
 ceptible to all external influences—to heat, to cold, to 
 infections, to poor nursing, particularly susceptible to 
 improper food—and look upon him as a critically sick 
 child. 
 
 METABOLISM 
 
 Having studied this clinical picture carefully, the 
 next thing to do is to investigate, if possible, the 
 causes. Don’t misunderstand me, gentlemen. It has 
 long been known that this clinical picture can be pro¬ 
 duced by tuberculosis, syphilis, wasting diseases, and 
 other conditions; but it remained for Finkelstein to 
 show that a great, great number of these cases, in 
 which the etiology had previously been mysterious or 
 unknown, was based upon and resulted from the same 
 fundamental errors of nutrition of which we have 
 spoken so frequently. For the first time now we see 
 this condition in careful clinical examination also 
 studied from the broad viewpoint of nutritional dis¬ 
 ease. If one places • such a child upon a metabolism 
 bed, analyzes carefully the food taken in, and the stools 
 and urine excreted, one finds that in sharp contrast to 
 dyspepsia and disturbed balance here there is an actual 
 loss of protein from the body. The body is losing 
 more protein than is being taken in. The same holds 
 true for the mineral matter. More salts are lost from 
 the body than are contained in the baby’s food. Indeed, 
 much of the clinical picture may be simulated by 
 mineral hunger. Such experiments are very difficult, 
 
86 
 
 are only few in number, but are of tremendous value. 
 It was due to this conception, to this idea that an actual 
 destruction was taking place in the body, that Finkel- 
 stein changed the term from atrophy to decomposition. 
 
 The fat metabolism depends upon the way fat is ad¬ 
 ministered. If it is given in a mixture rich in carbo¬ 
 hydrate and whey, the fat is lost in the resulting diar¬ 
 rhea. If, on the other hand, a reasonable quantity is 
 given in a mixture high in protein, low in carbohy¬ 
 drate and whey, the fat is well taken care of. 
 
 As regards the carbohydrates, the body itself seems to 
 need and use them well. The great difficulty, however, 
 is to get these carbohydrates into the body, for with 
 the weakened condition of the intestine permiting bac¬ 
 terial growth to flourish more readily than normal, car¬ 
 bohydrates, unless given very carefully, are apt to 
 ferment in the intestine and to cause diarrhea, with 
 pictures varying from the slightest dyspepsia to the 
 severist intoxication. 
 
 DIAGNOSIS 
 
 The diagnosis of this condition is easy. A freshman 
 medical student, a novice, a beginner, can recognize at 
 once such a clinical picture. It makes absolutely no 
 difference what name we give it, the clinical picture is 
 there; and it remains for us as medical men not to be 
 content with a mere diagnosis, but to insist upon a 
 diagnosis of the cause, of the etiology. We have spoken 
 before of tuberculosis, syphilis, and wasting disease. 
 These are well known; but of the new factors, the fac¬ 
 tors of tremendous importance, which Finkelstein has 
 taught us, we are beginning to learn more and more. 
 
 1. We have learned that this condition never comes 
 on in the midst of health. The child must have been 
 sick previously, usually with a history of ailing, or di¬ 
 gestive disturbance, and of not thriving for weeks or 
 months. 
 
 2. We have learned that age is of importance. The 
 younger the child, the more susceptible is he. 
 
 3. We have learned that diarrheas are of tremendous 
 importance—not only those diarrheas resulting from 
 improper feeding of which w r e have spoken, namely, the 
 dyspepsias, but also the diarrheas resulting from true 
 infection, with micro-organisms. In each of these 
 
87 
 
 diarrheal attacks the child probably loses a little bit 
 of mineral matter, and if this diarrhea is not properly 
 handled the loss may be eventually so great as to bring 
 on this state of decomposition. 
 
 4. We have learned that long continued undernour¬ 
 ishment is an important factor, the baby not getting 
 for a sufficiently long time a great enough total quantity 
 of food. 
 
 5. Hunger is a tremendous factor. Particularly hun¬ 
 ger applied too long to a sick child. You remember in 
 the state of intoxication when the weight curve was 
 dropping rapidly, if we removed food at A for twenty- 
 four hours usually the drop of weight ceased and the 
 curve straightened out. If at the end of twenty-four 
 hours, at B, we had not started to feed that baby per- 
 
 pearance of the stools, if instead of feeding that baby 
 we had prolonged the hunger period, guided only by the 
 condition of the stools, the weight curve would have 
 swung down, taken another sharp drop, and we would 
 
88 
 
 have added the severe calamity of a decomposition to 
 the great dangers already besetting our little patient. 
 
 6. Important as is absolute hunger, partial hunger is 
 perhaps even more important as regards frequency in 
 causing this condition. By partial hunger I mean one¬ 
 sided feeding, such as feeding with barley water or con¬ 
 densed milk. Due to the fault of the physician or the 
 carelessness of the mother, children frequently are kept 
 for days on a diet of barley water. This, as you know, 
 is largely carbohydrate, and after four, five, or six days 
 on this one-sided feeding, the child suffering in the 
 meantime from insufficiency of protein, salts, and fat, 
 the child rapidly reaches the state of decomposition. 
 This was the picture that Czerny described in his dis¬ 
 cussion of starch injury. 
 
 Condensed milk is perhaps the most frequent cause 
 of this trouble. Condensed milk is very high in sugar, 
 low in the other elements, as protein and salts. You re¬ 
 member in our second lecture we spoke to you about 
 the qualities that sugars have of pulling water into 
 the tissues and holding it there. Due to the high sugar 
 of condensed milk, a great deal of water is retained in 
 the tissues of these children. They gain for some 
 weeks in weight, and the doctor and mother are de¬ 
 lighted, because they think the baby is doing so well. 
 As a mater of fact, however, this baby is starving, his 
 tissues are being filled with water and his body cells are 
 dying from lack of protein and salt. Only the severe 
 reaction following a slight infection, following a little 
 exposure to heat or following a slight error in diet (such 
 as feeding this baby a little too much, or letting him 
 hunger too long), shows us that we are handling a 
 child who is really in the stage of decomposition. Too 
 long exclusive feeding with breast milk belongs to this 
 class. This sounds like heresy, gentlemen; but it is 
 nevertheless true. Too long exclusive feeding with 
 breast milk is a not infrequent factor in the production 
 of this disturbance. As you remember, breast milk is 
 very low in protein and very low in mineral matter. 
 After the child gets nine months or more in age, the de¬ 
 mands of his body are greater than those supplied by the 
 contents of breast milk. Kept too long upon this food 
 exclusively, without the addition of other substances to 
 
89 
 
 cover these wants, the body cells suffer from lack of pro¬ 
 tein and salts, and this child will also gradually merge 
 on into one of the types of decomposition. 
 
 7. The most frequent factor of all is probably the 
 fault of the physician, the one for which you largely 
 are to blame—I don’t mean you personally; I mean you, 
 me, all physicians—namely, the improper treatment of 
 the mild dyspepsias. The development is usually as 
 follows: The child gets a slight dyspepsia; the phy¬ 
 sician, not recognizing the food nature of this disturb¬ 
 ance, cleans him out with calomel and castor oil, gives 
 him, perhaps, a little paregoric to check the bowels, and 
 makes no change in the food. Repetition occurs in 
 perhaps two or three weeks. Again the child is cleaned 
 out with castor oil, again is he subjected to the irritating 
 effect of calomel, and again are the bowels drugged with 
 paregoric; but the food is unchanged. May be, now, 
 the factor of hunger is introduced. A recurrence of the 
 diarrhea leads to the same treatment. Perhaps now the 
 physician says: “We will certainly give these bowels 
 a rest. We are going to let this baby hunger a good 
 long time.” No factor, gentlemen is more important in 
 bringing these children to this condition than is this 
 frequent combination of improper therapy of the dys¬ 
 pepsia plus the improper use of hunger. Remember, 
 gentlemen, the longer the hunger, the greater the dan¬ 
 ger. Remember, the more frequently repeated the 
 hunger the greater the danger; and remember, the 
 closer together the hunger periods, the greater the dan¬ 
 ger. This combination of improper treatment of dys¬ 
 pepsia plus the improper use of hunger periods is the 
 most important of all the nutritional factors in bring¬ 
 ing about this disturbance. 
 
 Besides all these above errors in nutritional tech¬ 
 nique, we must never forget that the same other in¬ 
 fluences are also effective that were concerned in the 
 production of the dyspepsia and the intoxication, in¬ 
 fluences which are independent of our skill—for which 
 we are not to blame—namely, constitution, infection, 
 and improper care. A baby with a weak constitution, a 
 baby who has repeatedly had infections, a baby who is 
 improperly cared for, is jar more susceptible to any nu¬ 
 tritional error than is a healthy strong child. 
 
90 
 
 TREATMENT 
 
 Gentlemen, let me urge upon you that the most im¬ 
 portant treatment by far is prophylaxis. If we handle 
 our dyspepsias properly, if we realize the importance 
 of the state of disturbed balance, if we see to it that 
 the well baby is properly nursed and cared for, properly 
 dressed and properly fed, the number of cases of de¬ 
 composition arising from nutritional sources will be 
 very few indeed. 
 
 Once having developed, however, the condition is 
 difficult to treat, and requires a careful, definite rou¬ 
 tine. Only two foods can we rely upon. Just as in 
 the state of intoxication, so can we have confidence 
 only in breast milk or albumin milk. In either case 
 our technique must be about the same. 
 
 During the first day the child, if a bad diarrhea is 
 present, may be allowed to hunger from six to at the 
 very most twelve hours; never under any circumstances 
 over twelve hours. Preferably, he should miss only one 
 or two bottles, and if the stools are only a few in num¬ 
 ber, he need miss none. During this period the same 
 general treatment as in intoxication may be employed, 
 that is, the use of stimulants, the use of water and tea, 
 the use of a little salt. 
 
 Following this hunger period, or if no diarrhea be 
 present, absolutely at once we must start feeding. Dur¬ 
 ing the first day we shall offer ten feedings with a total 
 in twenty-four hours of 10 ounces. Gradually we in¬ 
 crease this total quantity, adding about 2 to 3 ounces to 
 the twenty-four hours total every other day, until we 
 have reached our maximum. Our maximum with albu¬ 
 min milk is 3 ounces for each pound of body weight, 
 that is, a baby weighing 7 pounds shall get a total of 21 
 ounces, a baby of 9 pounds shall get a total of 27 ounces. 
 During this gradual increase of our diet our guide is 
 solely and simply the weight curve. Gentlemen, let me 
 impress upon you that no graver mistakes can be made 
 than letting the condition of the stools influence your 
 treatment. We are interested in saving the baby. The 
 baby, to us, is infinitely more important than his gastro¬ 
 intestinal canal. If to save the baby apparent tempo¬ 
 rary neglect of all symptoms of impaired digestion is 
 necessary, we must neglect them. The gastro-intestinal 
 
91 
 
 tract, to us, is simply a means of getting food to this 
 baby. We absolutely must give him food. If we let this 
 one clinical symptom—the symptom of the stool—sway 
 us from our course, though we may correct the condition 
 of the stool, we frequently lose our patient. Our guide 
 of food increase shall be the weight curve. To illus¬ 
 trate : 
 
 The baby has been sick for weeks, the curve coming 
 constantly downward. At A he is in the state of decom¬ 
 position, where we allow him to hunger or feed him 
 small quantities of food, a total in twenty-four hours of 
 10 ounces. Due to the hunger or due to the small quan¬ 
 tities of food, he continues to lose weight slightly. We 
 must hold him at this stage until at B his weight curve 
 has straightened out. A continuation of the downward 
 curve to C shows us that the destructive processes still 
 going on. With the destructive process still continuing, 
 we are in no condition to increase our diet, nor are we in 
 a condition to change it or to withdraw it. If we wish 
 to save our baby we must hold our quantity constant 
 and steady until this weight curve has straightened out 
 and shown to us that destruction is ceasing and that the 
 baby is now in a position to assimilate some nourish¬ 
 ment.- This is the time to start a gradual cautious 
 increase of the diet according to the schedule we have 
 just given you. If the hahy is breast fed, under no 
 circumstances put the baby to the breast the first few 
 days. The mother must squeeze the breast milk from 
 her breasts into a clean glass and the baby fed these 
 quantities exactly from a bottle or medicine dropper. 
 
92 
 
 When the weight curve has finally straightened out— 
 a matter of a few days—we sigh with relief, for the 
 battle is won; and now, after the child has started 
 gaining slightly, it is perfectly safe to put the child 
 again gradually back upon the breast. 
 
 In our last lecture I gave you in detail the technique 
 of making albumin milk. I wanted you to know the 
 original process, so as to emphasize to you the principles 
 upon which the mixture was made. You remember the 
 principles were low whey and low carbohydrate to re¬ 
 duce the factors causing fermentation, high protein to 
 increase the factors causing alkalinity and overcoming 
 fermentation. Today I want to give you a simpler tech¬ 
 nique, one which you may use in the humble home in 
 which ignorance of the mother or lack of ability render 
 impossible the making of the more complicated mixture. 
 
 One takes 1 quart of buttermilk and 1 quart of water, 
 mixes them well, lets them boil a few minutes, and al¬ 
 lows them to stand for half an hour or more. During 
 this period the casein curd settles to the bottom and 
 the clear whey water mixture rises to the top. You see 
 now, by the addition of water we have diluted the whey 
 one-half. Without disturbing the casein curd lying be¬ 
 low, we pour off into another jar as much of this 
 whey as possible. In this way we have separated curd 
 from whey. Remember, in this mixture we have boiled 
 the milk. In the original technique we used the milk 
 raw. If we had boiled the milk in the original technique 
 the curds would have been so fine that we could not 
 have separated them from the whey, the curds being able 
 to pass during the filtration through the meshes of the 
 muslin hag. To the casein curd we add 4 ounces of 
 boiled cream. This is done because in the original mix¬ 
 ture during the precipitation of the casein considerable 
 fat was ensnared in its meshes, the fat content of the 
 albumin milk being 2 to 3 per cent. Accordingly, we 
 add cream to this mixture. We then add the usual 3 
 per cent per quart of dextrimaltose. Hot having dextri- 
 maltose, we can use foods of somewhat similar nature, 
 such as Mellin’s Food or Horlick’s Malt food, hut not 
 malted milk. Our mixture now contains high protein, 
 a certain amount of fat, a certain amount of carbohy¬ 
 drate in a non-fermentahle form, and to add salts 
 
93 
 
 we fill up to a total of one quart with the original water 
 whey mixture that we have in our second jar. You see 
 in this process we have reduced the whey to one-half 
 strength. In cases where the child does not take albu¬ 
 min milk very well, it can be sweetened with a little 
 saccharine. A large nipple should be used, as the curds 
 may stick in a smaller one. 
 
 And now, gentlemen, before concluding, let me call 
 your attention to a most fascinating study, one to which 
 this treatment with albumin milk has directed us. 
 
 At A the weight curve has straightened out, the de¬ 
 structive process has ceased, the battle has been won, the 
 child is getting the total prescribed amount of albumin 
 milk; but he is not gaining. We have pushed up the al¬ 
 bumin milk to the total quantity, namely, 3 ounces 
 for each pound of body weight, and the weight curve 
 is stationary. Here a very interesting study commences. 
 Our first idea that sugar alone was dangerous and harm¬ 
 ful makes us very careful about increasing the carbo¬ 
 hydrate. More with a feeling of conducting an ex¬ 
 periment than of aiding the baby, we increase the carbo¬ 
 hydrate to 5 per cent. In some cases the weight curve 
 makes a sharp ascent and the child starts to gain. In 
 some cases the weight curve remains stationary. After 
 a few. days, in the latter case, we cautiously feel our 
 way agin and increase to 7 per cent. Again the curve 
 may take a sharp rise and the improvement continue, 
 or it may remain absolutely horizontal. Again, but with 
 extreme care and caution, we increase to 9 per cent, and 
 almost invariably with 9 per cent each child will start to 
 gain. With 7 per cent or 9 per cent the stools may be¬ 
 come dyspeptic, but employing albumin milk we may 
 
94 
 
 overlook them. If we had previously, instead of in¬ 
 creasing to 7 or 9 per cent, added 1 to 2 per cent starch, 
 we might have produced this gain in weight a little more 
 quickly. 
 
 This most interesting clinical study gives an insight 
 into some of the processes that are taking place in the 
 child’s body. It shows us that this child needs more car¬ 
 bohydrate to make him thrive than does a normal child; 
 and when we stop to think, this does not seem so un¬ 
 reasonable, because this child is so handicapped that he 
 probably needs more energy to carry him along than 
 does the healthy baby. Now we see our problem. We 
 must convey food to this child’s tissues. In a few cases 
 the deficiency is one of protein and mineral matter. In 
 a majority of cases, however, high carbohydrate must 
 also be conveyed. We have before us the problem of 
 sending high carbohydrate into the baby’s body; of get¬ 
 ting it through the intestinal wall before the hungering 
 bacteria lying in wait for it in the intestine can fer¬ 
 ment it into the irritating acid products; without its 
 carrying the patient to death with a picture of intoxica¬ 
 tion before it can reach the body cells craving it. This 
 problem albumin milk has solved in a mysterious, unex¬ 
 plainable way. It was never put together for this pur¬ 
 pose, but it is just so effective, nevertheless. If we would 
 feed a child with decomposition a concentrated milk 
 mixture, containing high carbohydrates, the child would 
 rapidly develop the severest intoxication. With albu¬ 
 min milk we can feed this carbohydrate with relatively 
 slight danger of intestinal complication. 
 
 How albumin milk causes this is unknown. We have 
 much to learn, and perhaps some one will explain it to 
 us; hut it is a fact, nevertheless, that albumin milk 
 offers to us the vehicle for introducing carbohydrate 
 into the baby’s system. 
 
 The treatment with albumin milk should last four to 
 six weeks. After this the baby can he put at once upon 
 an ordinary milk mixture, and for a few days the stools 
 will he a little loose. These can be absolutely disre¬ 
 garded. If the baby has been fed breast milk, during 
 the latter part of the treatment the use of small quanti¬ 
 ties of buttermilk, up to one-third or one-half the total 
 amount, will he of value. Buttermilk contains high pro- 
 
95 
 
 tein and salts, the very elements in which breast milk is 
 somewhat deficient—deficient not for the normal baby, 
 but deficient for a badly nourished baby who has to 
 make up marked past losses. 
 
 Having mastered these processes, we are now in a 
 position to treat decomposition in an older child. 
 Always hold before you the picture of this technique 
 with albumin milk. In the older child the period of 
 hunger, if diarrhea is present, must also be short, and 
 then we must start to feed. How shall we make up 
 our food? First, we must reduce our whey as much as 
 possible, the whey being the element that seems to aid 
 fermentation and the formation of irritating acids in 
 the intestines. This means that we can either remove 
 the milk entirely from the diet or, preferably, dilute it 
 to one-third or one-half strength. To offer the child 
 foods which will tend to alkalinize the bowel and over¬ 
 come fermentative processes, we feed high protein, 
 namely, scraped meat, eggs, cottage cheese, or even the 
 ordinary curds of milk. Custards are taken well by 
 children and provide an easy method of feeding eggs. 
 To supply carbohydrate in a form not easily ferment¬ 
 able, we use cereals, such as corn starch, farina, cream 
 of wheat, arrowroot and well boiled rice. We would not 
 offer oatmeal, because in some cases this seems to fer¬ 
 ment easily. Other nonfermenting carbohydrates are 
 mashed Irish potatoes and the doubly baked bread, 
 known usually under the name “Zwieback.” Here, now, 
 we have a combination high in protein, low in whey, 
 containing nonfermenting carbohydrates, low only in 
 salts. These we supply by offering vegetables—ground 
 through a very fine sieve—in the form of purees; 
 broths and soups. We can supply a mixture high in 
 protein and in salts by offering a small quantity of but¬ 
 termilk; but remember that the butermilk has all the 
 whey elements of the milk in concentrated form, hence 
 tends to aid fermentation, and therefore should be used 
 in tiny quantities and handled very carefully. 
 
 Remember, gentlemen, that the technique we use, 
 however, must he identical to that employed with a 
 little baby. The hunger periods are short, the quantity 
 of food offered at first rather small, gradually increased, 
 and first, and above everything else, the guide to the 
 
96 
 
 quantity of food must be the weight curve rather than 
 the condition of the stools. 
 
 The general treatment must be that of intoxication, 
 laying particular emphasis upon the protection of the 
 child from all dangerous external influences. The child 
 must be well cared for, protected from infections, and, 
 above all things, guarded from extremes of heat and 
 cold. 
 
 Our hour is now up. I have tried to impress upon 
 you the great importance of looking upon these chil¬ 
 dren as children in whom entire nutrition is changed. 
 In treating such a baby under no circumstances let the 
 condition of the stools control you in your treatment. 
 The stools are only a symptom of the condition of the 
 gastro-intestinal tract. The gastro-intestinal tract is 
 simply a means for you to introduce proper elements 
 of food to the baby. If you decide that a child needs 
 carbohydrate, then you must give it. Even though the 
 digestive tract rebel, even though diarrheal stools point 
 to fermentation, don’t lose your courage, provided the 
 weight curve does not begin to sink. In the latter case, 
 under no circumstances totally withdraw the carbohy¬ 
 drate. Humor the digestive tract. Change your food 
 combination. Give your carbohydrate in the combina¬ 
 tions in which it will be relatively harmless—such as 
 breast milk or albumin milk—but don’t give up your 
 principles. With a little compromise, a little shifting 
 of technique, a wise general can make the digestive 
 tract his obedient servant. Never under any circum¬ 
 stances let it become your master. 
 
LECTURE VII 
 
 PARENTERAL AND ENTERAL INFECTIONS 
 AS FACTORS IN THE CAUSATION OF “DIS¬ 
 TURBANCES OF NUTRITION” 
 
 Gentlemen, we now have finished the original group 
 of disturbances of nutrition as Finkelstein classified 
 them. You remember that pathology, bacteriology, and 
 etiology have failed us, and in our present state clinical 
 classification is probably the safest. Do not for a 
 moment think that the last word has been said. We 
 are learning more every day. Hew factors are being 
 added, old ideas changed; but if we keep the clinical 
 picture constantly before us we shall probably not go 
 far astray. To show you how the clinical viewpoint is 
 constantly guiding us, let me remind you of the modifi¬ 
 cations that clinical studies made upon Czerny’s idea 
 of “Milk Injury.” You remember that bedside observa¬ 
 tion added the new factors of improper care, nursing, 
 post-infection, and insufficient sugar. In the same way, 
 this morning I wish to show you what careful clinical 
 observation has done toward increasing our knowledge 
 of dyspepsia. 
 
 The original viewpoint of Finkelstein was that all 
 cases of dyspepsia were due to sugar. Later this was 
 modified to sugar and whey. For a moment he was 
 side-tracked, concentrating too exclusively on the one 
 symptom—the acid watery stool; but clinical observa¬ 
 tion and thought saved the day. Let us illustrate: 
 
 1. In his institution ten babies lie in each ward. Fre¬ 
 quently it was noticed that after thriving for three or 
 four weeks every baby would develop a mild diarrhea. 
 Had we focused our attention too exclusively upon the 
 stools we probably should have observed a few curds of 
 fat, a little mucus, an acid reaction, and we would 
 have said, “Too much fat,” or “Too much sugar,” or 
 “Too much something else,” and changed the inoffen¬ 
 sive baby’s diet. As a matter of fact, by keeping the 
 broader picture before us, inquiring into every cause 
 that could be concerned, we learned that the day pre- 
 
 7 
 
98 
 
 ceding the disturbance there had been a change of 
 nurses in the ward. This observation was repeated 
 frequently. Almost invariably when a new nurse took 
 up her duties the children temporarily became ill. Why 
 a change of nurses should cause such a reaction I don’t 
 know. As I have said so often, “This is clinical obser¬ 
 vation.” Perhaps the secret lies in psychic or nervous 
 influences. At any rate, it was perfectly independent 
 of food. 
 
 2. Observations have shown that heat is an impor¬ 
 tant factor. This stimulated the very excellent re¬ 
 search of McClure and Sauer at the Children’s Me¬ 
 morial Hospital of our city. In very interesting experi¬ 
 ments they showed that retained heat is more important 
 than is the general temperature. A baby lightly clothed 
 on a very hot day is less likely to become dyspeptic 
 than is an overclothed baby during milder weather. 
 
 3. Keeping the broad clinical conception of “Dis¬ 
 turbance of Nutrition” before their eyes, Pinkelstein 
 and his assistants made the following observations of 
 unparalleled importance: A new baby would enter the 
 ward. In a day or two every child in the ward would 
 vomit and have watery, green, mucus stools. Clinical 
 pictures varied from dyspepsia to intoxication or to 
 decomposition. Had we studied the stools exclusively, 
 we should undoubtedly have said, “This child has re¬ 
 ceived too much fat; this one too much sugar; this 
 child too much protein”; but keeping a broader con¬ 
 ception before our eyes, trying to consider every factor 
 possible, we learned that the secret of the matter was 
 simply this: The food upon which the baby had previ¬ 
 ously been thriving had, of course, absolutely nothing 
 to do with it. The new baby had a little cough or cold, 
 a little nasopharyngitis and grippe, or if it were a 
 little girl, a cystitis. During the following days every 
 child in the ward started to cough and to sneeze, and, 
 following this infection, began to react with diarrheal 
 bowel movements. This observation was made so fre¬ 
 quently that the men in that institution and in many 
 others that I visited came to believe that these second¬ 
 ary diarrheas, secondary to little infections, were of as 
 great or even greater importance than the primary food 
 disturbances. To these infections they gave the name 
 “Parenteral Infections,” signifying by that, infectious 
 
99 
 
 in some part of the body other than the intestinal tract. 
 Gentlemen, under no circumstances forget Parenteral 
 infections. They constitute a large part of the diar¬ 
 rheal cases which you meet in your children’s practice. 
 
 Are you beginning to understand, gentlemen, how 
 the clinical classification of Finkelstein is helping us 
 in our study? I do not for a moment consider it a 
 finished affair, hut I do consider it a most valuable 
 outline, by which we may direct further observations. 
 
 Parenteral infections are of such tremendous impor¬ 
 tance, I want to talk about them for just a moment. 
 How a cough or a cold causes a diarrhea we do not 
 know. Such is purely bedside observation; but human 
 nature seeks explanations, and for that reason the fol¬ 
 lowing picture may partially satisfy you. Understand, 
 however, it is subject to great modification and change. 
 
 As in the primary food disturbance the whey of 
 cow’s milk seems to injure the intestine in some way 
 and to allow the bacteria which are normally present 
 in the large intestine to flourish in the upper tract, so 
 in these parenteral infections, as the stools are typically 
 of the “fermentative” type, must we also have an 
 agency stimulating bacterial growth in the small intes¬ 
 tine. How can a parenteral infection increase intes¬ 
 tinal fermentation? Two ways become apparent. 
 
 1. Finkelstein’s assistants have shown that during 
 the progress of these infections the qualities of the 
 digestive juices are changed. They are decreased both 
 in amount and in activity. As a result of such changes 
 two influences may be exerted: 
 
 (a) Undigested food and sugar will proceed lower 
 than usual down the intestinal tract. 
 
 (b) The bacteria of the large intestine may come up 
 abnormally high. 
 
 2. The products of the bacterial action in the nose 
 and throat may functionally injure the intestinal cells, 
 and impair their faculties of keeping the upper intes¬ 
 tine sterile. 
 
 In this way, gentlemen, you see conditions in the 
 small intestine are those predisposing to a disturbance 
 of nutrition. In this case, however, is the effect pro¬ 
 duced not by the concentrated whey of cow’s milk, but 
 by influences perfectly independent of the food, namely, 
 the products of the parenteral infection. In either 
 
100 
 
 case, the presence of hungering bacteria in the small 
 intestine must warn us that feeding fermentable sugar 
 will lead to the production of irritating acids and the 
 resulting diarrhea. The disturbance arising from the 
 latter, to distinguish from a primary disturbance in¬ 
 duced by the concentrated whey of cow’s milk, we may 
 call a secondary disturbance of nutrition. 
 
 Just as we have learned in all other conditions, the 
 clinical picture is greatly influenced by the factors of 
 age (the younger the child the severer the reaction), 
 constitution, nursing and care, heat, and, above all 
 things, food. The babies fed on mixtures very high 
 in carbohydrate and whey give the severest symptoms. 
 
 DIAGNOSIS 
 
 The diagnosis of such a disturbance is relatively 
 easy. 
 
 1. The history shows the child has had a little grippe 
 or febrile disturbance followed by the diarrhea. The 
 mother calls you for the intestinal condition, com¬ 
 pletely ignoring the fundamental factor. The history 
 showing that the diarrhea followed the cold practically 
 makes the diagnosis for you. 
 
 2. Food withdrawal for twenty-four hours causes a 
 great improvement in the intestinal condition and any 
 resulting disturbance of nutrition, but does not influ¬ 
 ence the temperature. The following day, if the tem¬ 
 perature is still elevated, you make a careful examina¬ 
 tion of the patient, and frequently you will find a 
 pneumonia or an otitis or a cystitis that had not been 
 evident upon the first examination. 
 
 TEEATMENT 
 
 The treatment divides itself into that of the primary 
 cause and that of the secondary nutritional disturbance. 
 
 The primary infection is, of course, to be treated 
 depending upon its nature. 
 
 The secondary disturbance of nutrition is to be 
 treated upon the lines we have already laid out, purely 
 and simply upon the nature of the weight curve. If 
 the curve rises continuously, as is usually the case in 
 the healthy breast-fed baby, a steady gain being noted 
 each day in spite of abnormal intestinal movements, 
 
101 
 
 leave that baby alone. Don’t, under any circumstances, 
 change the food. Just see the picture! Under the in¬ 
 fluence of the parenteral infection a little fermentation 
 has been induced in the intestine, but there has been 
 no nutritional reaction whatsoever. The effect is purely 
 and simply local and intestinal and needs no more food 
 treatment than does the irritated nose in a coryza. We 
 do not even have the picture of a dyspepsia. 
 
 The second type of reaction, the type which appears 
 most frequently in the somewhat undernourished breast 
 baby or in the fairly well nourished bottle baby, is 
 illustrated by the accompanying curve. At A the child 
 gets a parenteral infection. The accompanying fer¬ 
 mentation has become severe enough to produce a mild 
 
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 dyspepsia. The slight change in the weight curve 
 shows that the baby’s nutrition is beginning to suffer. 
 Shall we change the diet in this case? Leave the baby 
 
102 
 
 alone. Again see the picture! The fault was not pri¬ 
 marily with our food. The injury lay in the mild in¬ 
 fection of the nose and throat or of the bladder. A 
 mild secondary disturbance of nutrition has arisen, hut 
 if we simply wait for a few days the cough and cold 
 will disappear, and now that the injuring factor is 
 gone the intestine will correct itself; and at B the 
 weight curve will start to ascend and the diarrhea 
 disappears. 
 
 In these two instances treat the mother as you will, 
 hut unless he begins to lose weight don’t treat the baby. 
 Let him take as much food as he will. He usually 
 drinks less than his normal amount, and so spontane¬ 
 ously prevents the occurrence of the secondary disturb¬ 
 ance. 
 
 Fundamentally different is a third type of reaction. 
 This occurs in the babies fed on one-sided high carbo¬ 
 hydrate mixtures. The baby fed with condensed milk „ 
 or only barley gruel, the baby with the masked type of 
 decomposition of which we spoke last week, shows a 
 sharp and severe reaction. With the onset of the infec¬ 
 tion diarrhea commences. The stools, however, may 
 not vary markedly from those of the other children. 
 How we would be misled by focusing too exclusively 
 upon them! But the child reacts with a marked dis¬ 
 turbance of nutrition varying in type from a mild dys¬ 
 pepsia to the severest intoxication or decomposition. 
 
103 
 
 In these cases forget the primary factor. The mother 
 may think the baby is very sick from his cough and 
 cold, but you know that death is going to occur not 
 from the mild infection, but from the severe secondary 
 disturbance of nutrition. In these cases, first and fore¬ 
 most the latter must receive your immediate attention, 
 and you must handle it according to the principles laid 
 out in the previous lectures, depending upon the nature 
 of the nutritional disturbance. 
 
 Two symptoms arising in the course of a parenteral 
 infection may need treatment: 
 
 1. Vomiting. —If the vomiting be due to a primary 
 food disturbance, the child will recover upon removal 
 of the primary cause, namely, the food. If, however, 
 the condition arises from a parenteral infection, change 
 of food will have no effect, and unless we stop the vom¬ 
 iting we may meet with trouble. In these cases, gentle 
 stomach washing is of value, as are also mildly anes¬ 
 thetic drugs, such as novocain in doses of l-60th of a 
 grain before each meal. 
 
 2. Anorexia. —If the loss of appetite is due to food, 
 removal of the cause will cure the condition. If the 
 cause of anorexia, however, is the parenteral infection, 
 change of food will have no influence. It is in these 
 cases that physicians may make such fatal errors. One 
 often hears the expression, “If the baby won’t eat, we 
 will starve him to it.” No more serious mistake can be 
 made than this. The cause of the baby’s loss of appe¬ 
 tite is not the food, but is the product of the parenteral 
 infection, and you may starve him and starve him, but 
 his appetite will not return. What you will accomplish, 
 however, by introducing the factor of hunger is to 
 throw the baby into the state of decomposition. Many 
 of the deaths occurring during mild infections are due 
 not to this primary cause, but to the factor of decom¬ 
 position, developing from the associated anorexia. Gen¬ 
 tlemen, the baby must have food. If he takes it no 
 other way, you may use a stomach tube. I don’t mean, 
 now, that you must get a pump and pump gallons into 
 his stomach, but you must introduce small quantities, 
 enough to keep him alive, and of such proportions as 
 to avoid the dangers of a secondary dyspepsia or intoxi¬ 
 cation. 
 
104 
 
 The factors of heat, of food, of parenteral infection, 
 and of care are frequently all concerned in the produc¬ 
 tion of dyspepsias and intoxications. In recognition 
 of this, Finkelstein suggests classifying them into 
 groups, as follows: 
 
 I. Purely alimentary or food type. 
 
 II. Mixed type (in which all influences are con¬ 
 cerned). 
 
 Gentlemen, we have now finished the “Disturbances 
 of Nutrition.” I want to take you far away for a 
 moment to view an entirely different group of diseases. 
 While the success of this high protein, low whey, non- 
 fermentable carbohydrate treatment was being attested 
 by the consensus of opinion of the whole world, while 
 in the Finkelstein clinic a great international assem¬ 
 blage of men had collected—men from America, Eng¬ 
 land, Austria, Russia, Japan, Bulgaria, Roumania, 
 Switzerland, Portugal, and other countries—all testify¬ 
 ing to the great influence of these teachings, a com¬ 
 munication came from A. I. Kendall of the Boston 
 Floating Hospital saying that the treatment of severe 
 diarrhea was to be found in low protein and high car¬ 
 bohydrate. Could anything be more tantalizing, more 
 aggravating! Just at the moment when we thought 
 that the problem of diarrhea in children was forever 
 solved, when we thought that the infallible remedy for 
 
105 
 
 all diarrhea was high protein, low whey, nonferment- 
 able carbohydrate, we must read that the proper treat¬ 
 ment was low protein, high carbohydrate, and carbo¬ 
 hydrate in a fermentable form, such as lactose. The 
 first inclination was to do as we always do when some 
 one disagrees with us, to question the writer’s sanity. 
 Careful study of the publication, however, showed that 
 Kendall was speaking of a group of diseases entirely 
 different from those we were studying. His work had 
 to do with the true infectious diarrheas, those due to 
 specific micro-organisms; the type of case we were not 
 seeing. The communication was so interesting that I 
 resolved upon my return to this country to try to meet 
 Kendall and get his viewpoint. To my very great 
 pleasure, I learned that he had been called to take 
 charge of the department of Bacteriology at North¬ 
 western University Medical School, the institution with 
 which I was to be connected. Through the agency of 
 Dr. I. A. Abt, I had the pleasure of meeting Kendall 
 and of having many heated debates with him. He, 
 with the true interest of the bacteriologist, was con¬ 
 cerned mainly with the deadly infectious diarrheas. I 
 was interested chiefly in the question of nutrition. To 
 settle the point as regards the nature of the material in 
 Chicago, we made a little study during the summer of 
 1914. 
 
 Dr. Alexander Day, one of Kendall’s associates, who 
 had been with him during the work on the Boston 
 Floating Hospital, examined from the standpoint of 
 the bacteriologist all cases of severe diarrhea in our 
 hospital wards. He made careful cultures of all the 
 stools, while I studied the cases from the standpoint 
 of “nutritional disturbance,” looking at them from the 
 clinical aspect and noting their weight and food reac¬ 
 tions. Our results showed that during this summer in 
 our hospital wards in Chicago one or two cases of diar¬ 
 rhea showed the presence of the gas bacillus in the 
 stools, two cases showed the typical reactions to food as 
 are obtained in the primary food disturbances, and the 
 remainder of the cases were those associated with 
 coughs and colds, the so-called parenteral infections. 
 During a study made the following year, we found two 
 cases of severe dysentery sent to the hospital from out 
 of town, one to Dr. Abt, one to Dr. Julius Hess, cases 
 
106 
 
 entirely different in nature from our ordinary diarrheal 
 cases; babies showing the symptoms typical in every 
 respect to those of dysentery infection, which Kendall 
 had noted in Boston. Dr. Day discovered the true 
 organism of dysentery in these cases. 
 
 Why is it that in Boston infectious diarrheas prevail, 
 in Chicago the nutritional disturbances? The failure 
 to discover infectious diarrheas in Chicago could not 
 have been due to a different technique, as the investi¬ 
 gations were conducted by the same men. We must 
 regard these results as conclusive. Why this difference 
 prevails I do not know. Day and I offered the explana¬ 
 tion at that time that in the sense of Brenneman the 
 difference may be due to the fact that in the East raw 
 milk had been used, in Chicago boiled milk. Isn’t it 
 reasonable to assume that in the East, while raw milk 
 was used the deadly infectious diarrheas prevailed, that 
 in the Middle West, where these organisms with one 
 Stroke had been removed by boiling, the nutritional dis¬ 
 turbances only are seen? 
 
 Gentlemen, in this part of the country probably 
 many of your patients use raw milk. When you are 
 called to see a baby with diarrhea, you will be at once 
 confronted with the problem, “Is this an infectious 
 diarrhea or is it one of the nutritional type?” As you 
 will learn in a moment, to distinguish between these 
 two is of fundamental importance. We have several 
 means. 
 
 a. The history . The acute infectious diarrhea usu¬ 
 ally starts suddenly in a previously well baby, and pros¬ 
 trates him at once. The nutritional disturbance comes 
 about more gradually. We frequently can get a history 
 of improper feeding, of previous nutritional disturb¬ 
 ance, of parenteral infection. It is more gradually 
 progressive. 
 
 h. The stools. These are of considerable aid to us 
 in our diagnosis. In the infectious diarrhea, particu¬ 
 larly dysentery, the stools are small, consisting chiefly 
 of blood-stained mucus. They contain barely any solid 
 material, and by use of the microscope we may discover 
 pus. The reaction of the stool in dysentery is alkaline. 
 The stools in the nutritional disturbance are green, 
 usually acid and watery. They contain increased solid 
 material, some mucus, but rarely blood or pus unless 
 the case has long been neglected. 
 
107 
 
 c. The reaction to food is of some value. If, after 
 twenty-four hours of tea, the temperature continues 
 high, the weight curve sinks, the diarrhea continues 
 with small, bloody mucus stools, then some other factor 
 must be at hand, other than food. If careful physical 
 examination rules out parenteral infection, such as 
 pneumonia or sepsis, the diagnosis, by exclusion, will 
 probably be definite enteral infection. 
 
 Gentlemen, what I have to tell you about the treat¬ 
 ment of true infectious diarrheas will be disappointing. 
 All that I can do is to expose our ignorance and, per¬ 
 haps, by this exposure stimulate us to increased efforts 
 for progress. The treatment of infectious diarrhea 
 depends just as absolutely upon a definite bacteriologic 
 diagnosis as does the treatment of pneumococcus ton- 
 silitis depend upon throat culture to distinguish it 
 from diphtheria. How to treat cases of infectious diar¬ 
 rhea in this part of the country I do not know, for I 
 have absolutely no idea what types of infections you 
 meet. If it is a gas bacillus, one food must be given; 
 if it is a dysentery bacillus, radically the opposite treat¬ 
 ment must be instituted. Bacteriologic methods of 
 diagnosis are difficult. A trained bacteriologist is neces¬ 
 sary. An agglutination reaction in dysentery, such as 
 the Widal in typhoid, can he of service. All that I 
 can do, gentlemen, is to urge you, in connection with 
 your medical society, to cooperate with the State Board 
 of Health or with the State University in attempting 
 to discover the types of infections that exist here. 
 
 I won’t bother you even with the technique for dysen¬ 
 tery. The gas bacillus, however, can be detected by a 
 relatively simple test; hut this, too, requires some 
 training. 
 
 Get a sterile specimen of the baby’s stool. This can 
 he obtained by taking a sterile glass tubing with 
 rounded ends, about the thickness of a lead pencil, and 
 inserting it into the rectum as one would a thermom¬ 
 eter. Usually a little fecal material is obtained in the 
 tube. If the rectum is empty, repeat this in an hour. 
 Then inoculate a small quantity of the stool, about the 
 size of' a oea, into a test tube of milk. This test tube 
 is heated to 180 degrees for half an hour. During this 
 process all bacteria are killed except the spores forming 
 organisms. These resist heat and, when the milk is 
 incubated at body temperature for eighteen hours, grow 
 
108 
 
 rapidly. As the gas bacillus splits sugar into acetic 
 and butyric acids, a characteristic test would give the 
 odor of rancid butter. Secondly, the acid causes the 
 casein to coagulate. This is precipitated in large curds, 
 but, due to the growth of the gas bacillus, it has the 
 appearance of being completely “shot to pieces.” 
 Lastly, the microscope shows the large Gram positive 
 bacillus. 
 
 The treatment for gas bacillus infection, according 
 to Kendall, is based upon the observations that the gas 
 bacillus grows well in sugar and does not grow well 
 with high protein or lactic acid. In such an infection, 
 therefore, the treatment is buttermilk. The albumin 
 milk, of which we have spoken, due to its high protein, 
 low carbohydrate, and lactic acid, would also be an 
 ideal treatment. Kendall has made the interesting sug¬ 
 gestion that perhaps some of the cases that Finkelstein 
 treated so successfully with albumin milk were really 
 those of gas bacillus infection. This is a very interest¬ 
 ing criticism, but I don’t believe will bold true in many 
 instances. 
 
 The treatment for true infectious dysentery is based 
 upon entirely different principles. Here one has great 
 ragged ulcers in the intestine. In these the dysentery 
 organisms live and produce toxins, just as do the diph¬ 
 theria bacilli from their location in the throat. Death 
 occurs in dysentery largely from toxemia. You see, 
 then, gentlemen, how hopeless drug therapy is in dysen¬ 
 tery. We may give calomel. We may give medication 
 to flush out the intestine. In small quantities they 
 may do no harm. To me, however, the giving of cathar¬ 
 tics in such cases seems to he like the mechanical tear¬ 
 ing out of the membrane of diphtheria with a forceps. 
 What folly! If our sole therapy in diphtheria is physi¬ 
 cal injury, we kill the baby. Our treatment lies in 
 antitoxin; and so is it with dysentery. Our ultimate 
 success must lie in the administration of antitoxin, if 
 we can give it in time. 
 
 In speaking: of calomel, gentlemen, I understand that 
 this drug is used very considerably down here, and that 
 you place great faith in it. It may be very efficient. 
 I do not know, because I do not know the types of 
 infection with which you are dealing. Maybe you have 
 organisms to which calomel is deadly. That remains 
 
109 
 
 to be seen. The wisest, after all, is to try to establish 
 means for obtaining definite diagnoses. 
 
 The general treatment of dysentery must be that of 
 all infectious disease. Keep up the fluids, provide 
 proper nursing and care, stimulate if necessary. Opium 
 may be of great value. In the nutritional diarrheas 
 opium, by disguising the symptoms, might lull us into 
 an insecure, dangerous self-satisfaction. In dysentery, 
 however, where the bacillus and not the food is the 
 factor, we disguise no symptoms with opium, but quiet 
 our little patient and relieve the pain and tenesmus. 
 Give as much as you can with safety. As regards medi¬ 
 cation, quinine-tannate in doses of 3 to 5 grains three 
 times a day is highly recommended; but, as I have said 
 so frequently, do not put too much confidence in drugs. 
 
 The dietetic treatment is radically different from 
 that of nutritional disturbance and from gas bacillus 
 infection. Theobald Smith, the great American bac¬ 
 teriologist, years ago observed that if the diphtheria 
 bacillus be grown on carbohydrate media it will not 
 produce toxin, but if grown on protein it produces the 
 typical toxin of diphtheria. Kendall, working from 
 this viewpoint, experimented with the dysentery organ¬ 
 ism and found that if it be grown on carbohydrate no 
 poison is produced, while if grown on protein the deadly 
 dysentery toxin results. This explains, then, why he 
 advocated a high carbohydrate feeding and reported 
 good results in his cases of dysentery. He wished to 
 get carbohydrate to the dysentery organisms growing 
 in the intestine and thus prevent the formation of 
 toxin. From this standpoint two forms of dietetic 
 treatment can be employed: 
 
 1. Breast Milk .—Breast milk with its low protein 
 and high carbohydrate would make an ideal food such 
 as Kendall demands and at the same time would not 
 endanger the child by the causation of a disturbance 
 of nutrition. 
 
 2. The Frank Treatment .—This has been the most 
 successful in the realm of artificial feeding. I give it 
 to you as it is recommended. 
 
 (a) ' Tea for twenty-four hours, except in cases of 
 decomposition. 
 
 (b) Start on the second day with five feedings, each 
 of which is composed of 2 ounces of whey and 2 ounces 
 of gruel. 
 
110 
 
 (c) Gradually increase by the fourth or fifth day to 
 five feedings of 2% ounces each. 
 
 ( d ) On the fifth to the eighth day gradually replace 
 in teaspoonful doses the whey by milk. Gentlemen, see 
 how important the diagnosis is. Here, we have kept 
 our patient on a mixture of sugar, salts, and barely any 
 protein for five days. This would have been the worst 
 thing possible in cases of nutritional disturbance or gas 
 bacillus infection. 
 
 ( e ) On the twelfth to the fourteenth day perfectly 
 independent of the stools the little patient must be get¬ 
 ting 13 to 14 ounces of milk, 13 to 14 ounces of gruel, 
 and 6 to 7 ounces of broth. He may also receive a little 
 cereal, as rice, farina, cream of wheat, etc., and, if 
 over one year of age, a little meat. 
 
 This, then, is the most successful up-to-date treat¬ 
 ment for infection with true dysentery. How compli¬ 
 cated how long, often how unavailing! Why not with 
 one stroke save yourselves and your patients all this 
 wearisome treatment and danger, practice a little 
 prophylaxis, and boil the milk? 
 
 We have now finished the subject of nutritional dis¬ 
 ease. We have given you the viewpoints which have 
 been developed in the great European clinics and 
 adopted in the Middle West. You may frequently have 
 wondered at the hours given to nutritional conditions, 
 and may be disappointed in the few words given to in¬ 
 fection. Time prevents a thorough consideration of 
 everything. I laid most emphasis upon the former with 
 the idea of preparing you for the future. I believe that 
 if you boil your milk, disturbance of nutrition will be 
 the type preeminent, the picture which will become 
 more and more apparent in your practice. 
 
 We have spoken little of the American ideas. We 
 have done this because we feared that we might be 
 misinterpreted, that we were attempting to criticise. I 
 cannot conscientiously leave the subject without for a 
 moment giving you the opinions of our Eastern friends. 
 But don’t for a moment misunderstand me. So much 
 difference of opinion, so much unpleasantness, has 
 arisen by the discussion of different things, that I am 
 perfectly willing to admit that every man who makes 
 a classification is right, and that he classifies things 
 according to his own material. 
 
Ill 
 
 Holt, for instance, speaks of feeding and disturbances 
 of nutrition in one chapter. In disturbances of nutri¬ 
 tion be considers only inanition, malnutrition, and 
 marasmus. In discussing these, he does not give us 
 sharp clinical pictures, but describes conditions which 
 to us suggest different stages of the group that we call 
 decomposition. His diarrheal diseases he classifies 
 under those of the gastro-intestinal tract, and considers 
 that the great majority of them are of the type associ¬ 
 ated with definite pathological lesions in the intestine. 
 To him diarrheas do not belong to the group of dis¬ 
 turbances of nutrition. 
 
 Morse and Talbot devote most of their time to the 
 technique of feeding. The disturbances, they classify 
 as “Diseases of the gastro-intestinal canal,” and under 
 this group they place pylorospasm, pyloricstenosis, 
 nervous disturbance, constipation, digestive disturb¬ 
 ances, etc. This suggests the Vienna idea—the laying 
 of fundamental importance upon the gastro-intestinal 
 tract, but considering the disturbance in the modern 
 light of physiology rather than of pathology. Under 
 the digestive disturbances they speak of disturbances 
 from too much food. They speak of disturbances from 
 excess of one element of the food, such as from fat, 
 from carbohydrate, from protein, and from salts, and 
 they speak of indigestion with fermentation. 
 
 It is not for me to criticise any of these views. Each 
 one is undoubtedly correct, depending upon location 
 and material. From the viewpoint of Chicago, we pre¬ 
 fer the clinical classification because we believe the 
 broad conceptions in it will aid us in further study. 
 We like the term, “Disturbance of Nutrition,” rather 
 than that of gastro-intestinal disease, because we be¬ 
 lieve this conception prevents our focusing too closely 
 upon the stool—even though the primary causative fac¬ 
 tor lay in the intestinal canal—because we believe the 
 baby’s general condition is far more important than 
 that of his gastro-intestinal tract, because our whole 
 plan of feeding and therapy depends not upon the stool, 
 but upon the weight curve, and we believe that this 
 latter gives us the best index of the baby’s general con¬ 
 dition : of the combined influences exerted by “food,” 
 by “intestine ” and by “demands of the body.” 
 
 c 
 
112 
 
 Just one word more. A recent communication of 
 1916 from Dr. Louis W. Hill of Boston, who is con¬ 
 ducting so successfully the sections in the East, divides 
 diarrheas into three groups, namely: 
 
 1. The Infectious Type. 
 
 2. The Nervous Type. 
 
 3. The Fermentative Type. 
 
 Regarding the latter, he goes into some length show¬ 
 ing the antagonistic effects of protein and carbohydrate 
 and laying emphasis upon carbohydrate fermentation 
 in the production of the irritating lower fatty acids. 
 He recognizes carbohydrate as a primary factor even 
 in some cases where much fat is excreted. This is, of 
 course, typically Finkelstein. Hill still considers these 
 diarrheas as local intestinal affairs, but shows evidence 
 of the “nutritional” viewpoint in recognizing clothing 
 and heat as factors. 
 
 For the first time now the East is beginning to lay 
 great importance upon the fermentative factor in the 
 causation of diarrhea. Why it has not noticed this 
 before I do not know. 
 
 Powers of observation do not depend upon geographi¬ 
 cal location. There must be some deeper factor, some 
 truer explanation. One thought constantly repeats it¬ 
 self to my mind: Cannot the whole difference be ex¬ 
 plained upon this basis of boiled milk? Isn’t it pos¬ 
 sible that the East is in the stage of evolution, that 
 during the period of raw milk the pictures of the spec¬ 
 tacular, dramatic, deadly infectious diarrheas pre¬ 
 vailed? Small wonder that little attention was paid 
 to the milder, more easily controlled disturbances of 
 nutrition. But now, as I understand it, boiled milk 
 is coming to its own. Isn’t it possible that for the first 
 time the gradual waning of infectious diarrhea reveals 
 the slow rise of disturbance of nutrition? Hill’s classi¬ 
 fication, a radically different one from that advanced 
 by Morse and Talbot a few years ago, would suggest 
 this stage of evolution. We shall eagerly await new 
 developments. Will this conception reach sufficient 
 growth to alter the Eastern method of feeding, as it 
 has ours? 
 
LECTURE VIII 
 
 ARTIFICIAL FEEDING OF THE NORMAL 
 
 INFANT 
 
 Gentlemen, the system of artificial feeding developed 
 in the Middle West is based upon the studies that have 
 been pointed out to you. One does not start with a pre¬ 
 conceived idea as regards a definite and exact formula, 
 but by knowledge of the various disturbances that may 
 arise from improper combinations one attempts simply 
 to suggest mixtures which will not lead to future diffi¬ 
 culty. The fundamental requisite in infant feeding is a 
 little good common sense. 
 
 Before going into these methods it might be well to 
 rid ourselves of a few conceits. If one takes a young 
 animal and allows him to hunger, that animal, never¬ 
 theless, continues to grow. He will not gain in weight, 
 but he will grow in size. So is it with the baby. Don’t 
 for a moment think that you are responsible for the 
 baby’s growing. You are simply offering him bricks 
 and mortar ‘n the way of food, but certainly you are 
 not entirely responsible for his growth. Don’t take 
 yourselves too seriously! You are an outside factor, an 
 external influence—important, it is true, but by no 
 means the sole cause of the baby’s thriving. 
 
 Remember that the mother does not feed the baby 
 at the breast. The baby feeds itself. The mother does 
 not start with the preconceived idea of how much—of 
 how many ounces—she is going to give the baby. She 
 simply puts the baby to the breast, the child takes what 
 it wants, and when satisfied stops. 
 
 Gentlemen, get the Idea out of your head that you 
 are going to feed the baby. Leave a little of the re¬ 
 sponsibility to him! 
 
 Remember, by all means that the baby is human. 
 Think of yourselves, for instance. Your appetite varies 
 depending upon the weather, upon your mood, upon 
 the nature of the food. On a hot day you eat less than 
 on a cold day. You do not eat the same amount each 
 lay. Some of you are vegetarians; some of you are 
 
 8 
 
114 
 
 large meat eaters; some of you eat combinations of 
 both. So is it with the baby. Just remember that he 
 is human, that his appetite will vary, that no two babies 
 are alike, that it is only fair to meet him half-way and 
 to make a reasonable attempt to adjust our mixtures to 
 meet his individual demands, rather than to expect all 
 concessions from him. 
 
 Remember that when we eat our fundamental worry 
 is, “Will this food agree with me?” If we can take 
 our meal without causing digestive trouble, if we get 
 the food past the intestinal tract into the body, then 
 our troubles largely are over. The body uses what it 
 needs and throws out the excess. Why should the baby 
 be different? Any food which can pass the intestinal 
 tract into the body, any food which contains enough 
 bricks, and stones, and mortar, will provide for the 
 baby’s growth. The child retains in its body what it 
 needs and casts out what it does not need, whether the 
 food be breast milk or cow’s milk. 
 
 Thus you see any system of feeding which enables 
 the food to pass the intestinal tract into the body is 
 relatively successful. There is no right way nor no 
 wrong way of feeding; all methods are right. Our 
 main concern is simplicity. We must answer the body 
 requirements and therefore employ the intestine simply 
 as our agent in introducing foodstuffs for this purpose. 
 
 How often shall we feed a child? The great pedia¬ 
 trician, Czerny, helped us by suggesting the four-hour 
 feeding system—five feedings in twenty-four hours, 
 viz.: 6 :00 o’clock—10 :00—2 :00—6 :00—10 :00; and 
 
 none from 10 :00 p. m. to 6 :00 a. m. In Chicago, Gru- 
 lee is an ardent advocate of Czerny, and according to 
 Grulee every baby, whether it be a five-pound prema¬ 
 ture or a fine healthy ten-pound new-born, should re¬ 
 ceive feedings no oftener than once every four hours. 
 He has demonstrated the success of this method re¬ 
 peatedly. Personally, from my own experience, I be¬ 
 lieve some of the smaller children and some of the 
 children under four to six weeks of age do better with 
 the three-hour schedule. Four hours seem rather long 
 for them to wait. For this reason I recommend to 
 those under four to six weeks of age seven feedings, 
 viz.: 6 :00 o’clock—9 :00—12 :00—3 :00—6 :00—9 :00, 
 
 and once during the night. Undoubtedly, though, the 
 
115 
 
 majority of these would do equally well on the four 
 hours schedule. 
 
 The number of feedings offered varies somewhat with 
 locality. I believe in the East they feed more fre¬ 
 quently than we do. A simple little experiment which 
 we made in the Finkelstein Clinic might explain these 
 differences. Babies in some wards we fed according 
 to the percentage method; babies in others we fed ac¬ 
 cording to the methods I am about to teach you. All 
 were given five feedings in twenty-four hours. The 
 percentage babies vomited more than did the others. 
 As the percentage method frequently requires more fat 
 than does ours, we reasoned that this vomiting was due 
 probably to the fat, i. e., to the larger amount of the 
 lower fatty acids in cow’s milk fat. Just by empiricism 
 we found that we could stop these percentage babies 
 from vomiting by feeding smaller quantities more fre¬ 
 quently. So in a short time all the percentage babies 
 had several more feedings a day than did the others, 
 and thrived beautifully. I believe in a way this ex¬ 
 plains the differences in feeding schedule in the two 
 localities. The percentage system frequently requires 
 higher fat than does ours. 
 
 How much shall he offer our babies? As you see, 
 the amount offered in each bottle must depend upon 
 the number of feedings; the greater the frequency the 
 less the individual quantity. Again, don’t try to follow 
 any hard and fast rule. Some babies take more; some 
 babies take less. In a general way the first time we see 
 a child we can guide ourselves as follows: 
 
 a. From the second to the fourth or sixth week a 
 child will drink in twenty-four hours a total of about 
 20 ounces. 
 
 b. From the fourth to sixth week, to about the third 
 month, he drinks approximately a total of 25 ounces. 
 
 c. From about the* middle of the third month he will 
 drink a quart. 
 
 This is no rigid routine. Try the baby on this 
 amount and see how he reacts. Take the mother into 
 your confidence—many mothers have really more in¬ 
 telligence than we imagine; ask her if the baby seems 
 hungry, if he frets directly after finishing his bottle, if 
 he is peevish before the three hours are passed. If so, 
 increase the quantity. On the other hand, if the mother 
 
116 
 
 tells you “The baby is perfectly satisfied; does not even 
 finish the bottle,” or, perhaps, “vomits after taking the 
 bottle,” we simply suggest that instead of allowing the 
 baby twenty minutes for each feeding, she reduce the 
 time to fifteen. After a week or so you will find the 
 amount can again be increased. 
 
 What shall we offer the baby? Almost any system 
 of feeding has its ardent advocate. The possibilities 
 of the normal child’s intestinal tract are immense. The 
 normal baby takes almost anything and thrives. There¬ 
 fore, it’s easy to understand how many different sys¬ 
 tems of infant feeding have arisen, each with its enthu¬ 
 siastic adherents. The French, for instance, have at 
 times recommended full milk. Many children do well 
 on this; some don’t. The old German pediatrician, 
 Biedert (he was the one who first described the casein 
 curds in the baby’s stool), recommended the dilution 
 of milk to lower the protein. This weakened the milk, 
 of course, and so, to make up for the loss of strength, 
 he added cream and sugar. The resulting mixture was 
 somewhat like a percentage mixture. Some children 
 thrived beautifully on these combinations; some did 
 not. 
 
 A further advance was made by Heubner in bring¬ 
 ing calories to our notice. He it was who reminded us 
 that a baby should have 45 calories per pound body 
 weight. This system is not ideal, as you can readily 
 see. A child may have the proper number of calories 
 in his bottle, but these may be only fat or sugar, and 
 will not satisfy the demands of his body. Again, vari¬ 
 ous studies show that prematures require more calories 
 than do normal babies. Lastly, later studies show that 
 mysterious invisible substances, called vitamines, play 
 important roles in growth. These, of course, cannot be 
 measured by caloric value. 
 
 A very splendid igenious improvement in our 
 methods was that offered by the old percentage system. 
 We might say that the idea concerned in this was per¬ 
 fect, viz., the attempt to make cow’s milk resemble 
 breast milk. The unfortunate feature in this system 
 was—as we told you in our first lecture—that such a 
 modification is impossible. We cannot make cow’s milk 
 resemble breast milk. Again, these mixtures were made 
 upon the supposition that disturbances arise from un- 
 
117 
 
 digested casein. Such we believe, when milk is boiled, 
 to be very rare. Casein may, of course, produce dam¬ 
 age in the sense of the Vienna pediatrician, Ham¬ 
 burger, when it passes in undigested form through the 
 intestinal wall and circulates in the body as foreign, 
 protein; but this complication in a normal intestine 
 we believe to be uncommon. Another objection to the 
 old percentage system, according to our viewpoint, was 
 that it suggested in advance what a baby was to receive, 
 perfectly independent of the baby. Our method con¬ 
 siders the baby first, foremost, above everything else, 
 and then the mixture. Lastly, the old percentage sys¬ 
 tem offered mixtures of high carbohydrate and fat in 
 the medium of cow’s milk whey. In breast milk whey, 
 high carbohydrate and fat are harmless; in the mys¬ 
 terious whey of cow’s milk these combinations, as we 
 learned in our lecture on dyspepsia and intoxication, 
 seem to favor trouble. 
 
 Recently the percentage system has been modified. 
 We now read that primarily it is not intended to make 
 milk resemble breast milk, but only in a general way 
 should we follow the principles of breast milk, and that 
 it is no longer a definite system of feeding, but simply 
 a means of making up mixtures so that we know their 
 content exactly. This, we think, is a splendid and most 
 excellent step forward. Ludwig F; Meyer once said to 
 me, “What an ideal combination would result if one 
 would take your American percentage system and adapt 
 it to some of these principles which we have been de¬ 
 veloping!” Gentlemen, I think we are proceeding in 
 the right direction. 
 
 The Eastern methods are those attempting to avoid 
 the danger of protein and fat; our methods, of avoiding 
 whey and carbohydrate. Perhaps both of us are right; 
 perhaps the Eastern men see true disturbances arising 
 from fat because they use higher fat in their mixtures; 
 perhaps we see few disturbances from fat and almost 
 exclusively those from carbohydrate and whey because 
 our modifications are made chiefly with carbohydrate. 
 
 I understand that Dr. Hill, who is conducting the 
 sections in the eastern part of this State, has devised 
 aome simple rules for making accurate modification of 
 milk. Any means which will increase the exactness of 
 our knowledge, if it be simple enough to be practicable, 
 we welcome most heartily. 
 
118 
 
 OUR METHOD OF FEEDING 
 
 The system we have developed from these great Euro¬ 
 pean studies is prophylactic from the start. We have 
 learned that the fault does not lie exclusively with one 
 element of the milk; that the fault depends upon im¬ 
 proper relations of the different elements. Thus, if we 
 give sugar in concentrated whey, diarrhea results; if 
 we give sugar in highly diluted whey, the chances of 
 resulting disturbances are greatly decreased. If we 
 give fat in combination with high carbohydrate, in a 
 medium of cow’s milk, we frequently shall have trouble. 
 The fat may be involved either primarily or second¬ 
 arily. If, however, we give this very same fat in 
 combination with albumin milk, viz., with high pro¬ 
 tein, low whey, and nonfermentable carbohydrate, the 
 fat becomes harmless. Fat in an acid intestine en¬ 
 hances diarrhea, in an alkaline intestine enhances con¬ 
 stipation. Therefore, in our feeding we attempt to 
 dilute all elements of the milk and to have only one 
 element in large amount. In the baby’s intestine high 
 fat and high sugar in cow’s milk are not agreeable 
 companions. Prophylaxis, then, is our motto, and we 
 proceed as follows: 
 
 1. To exclude all possibility of infectious diarrhea, 
 to protect our baby from dysentery and other virulent 
 infections, and to prevent the formation of tough casein 
 curds, we boil the milk. 
 
 2. To prevent in any way the accusation that we are 
 predisposing to scurvy, we add at the end of the first 
 month orange juice in doses of a teaspoon each day. Dr. 
 Alfred Hess of Hew York has shown this to be ex¬ 
 tremely important. 
 
 3. We hear the following picture in our mind. Gen¬ 
 tlemen, I do not believe you will find this scheme given 
 in any text or definitely formulated just as I give it, 
 but in a general way it represents our point of view: 
 
 Well Baby 
 
 Disturbed Balanc 
 
 I 
 
 Dyspepsia 
 
 Intoxication 
 
 The above picture shows the well baby included in 
 the group of sick babies, and suggests that this very 
 same well baby can be made to assume any one of the 
 
119 
 
 four clinical types. The factors concerned in these 
 changes are the improper usage of carbohydrate and 
 whey and the improper understanding of the role of 
 fat as the secondary factor. The conditions on the 
 right develop from too high carbohydrate in whey; the 
 conditions on the left arise, as Czerny would have first 
 said, from too much fat; as Finkelstein would say, from 
 too little sugar. Of course, constitution, infection, etc., 
 are important accessory factors. 
 
 What is the purpose of this scheme? It suggests 
 that our attitude in feeding must be identical to that, 
 for example, in typhoid fever. In typhoid we don’t 
 treat the disease; we simply try to guide and to steer 
 our patient through the difficulties that lie in his path; 
 and so it is with infant feeding. We don’t feed the 
 baby; we simply guide him. We try to avoid the 
 dangers of excessive carbohydrate on the one hand and 
 of insufficient carbohydrate on the other. 
 
 4. The next step in our scheme of prophylaxis re¬ 
 quires a careful history and physical examination of 
 the patient. If he be a weak child, if he have dys¬ 
 pepsia, if he have a parenteral infection, if he be suf¬ 
 fering from poor care, we must be careful as to order¬ 
 ing large amounts of carbohydrate. If the examination 
 suggest a condition of disturbed balance or if the child 
 be recovering from an infection, he needs increased 
 carbohydrate. Our problem in the latter case is to offer 
 the increased carbohydrate to the body in such a way 
 as not to endanger the intestine. 
 
 How shall we make mixtures to avoid intestinal com¬ 
 plication? Gentlemen, this sounds complicated, but it 
 is extremely simple. There is absolutely nothing to it. 
 You may banish from your minds any worries that you 
 may have regarding the difficulties of infant feeding. 
 It is the simplest branch of pediatrics! Simplicity is 
 our motto, and, indeed, so simple is our method that 
 any novice may use it successfully: 
 
 (1) To avoid the occurrence of too many elements 
 in large amounts, we dilute the milk. 
 
 (2) Up to about the first four weeks we use one part 
 milk and two parts water. 
 
 (3) From then up to the third or fourth month we 
 use one-half milk and one-half water. 
 
 (4) From the third to the fourth month we use two- 
 thirds milk; one-third water. 
 
120 
 
 (5) Here I might mention the teaching of Dr. Julius 
 Hess of the University of Illinois. In discussing feed¬ 
 ing with his students, he frequently finds it very ad¬ 
 vantageous to follow the old Budin rule: l 1 /} ounces of 
 whole milk for every pound of the baby’s weight; but 
 I believe that even thi.s rule, though very convenienty 
 is scarcely necessary. 
 
 In these mixtures, as the strength of our milk is 
 weakened, we must offer additional food, and preferably 
 one element rather than two. This is best done by 
 adding a carbohydrate in a nonfermentable form, such 
 as the mixtures of dextrin and maltose. These are 
 Mead’s Dextri-Maltose, Mellin’s Food, etc. We add 
 these carbohydrates in amounts of approximately 3 
 per cent the first time we see the child, and, depending 
 upon the reaction, increase gradually to 5. 
 
 At six months we may start slowly with a soft diet 
 which I have so frequently given you, and then our 
 troubles are over. 
 
 During these first six months what shall be our 
 guide? How shall we know that the baby is doing 
 well ? Gentlemen, under all circumstances, let the 
 weight curve be your index. If the baby is gaining in 
 weight on an average of 5-7 ounces per week, and at 
 the same time seems clinically well, leave him alone. 
 Ho matter though his stools be a little dyspeptic, no 
 matter if he have a slight colic or slight diarrhea; if 
 he is gaining in weight, leave him alone. Your main 
 difficulty will he in treating the mother, particularly 
 the mother of the first baby. She sits at the baby’s 
 bedside; in one hand she clasps “Mother so and so’s 
 guide to infant feeding, based upon forty years experi¬ 
 ence.” She scans each stool with minute accuracy, 
 seizes with enthusiasm upon any slight abnormality 
 such as a tiny curd of fat or a little mucus, and tells 
 you with a sort of gloomy joy that the food is not agree¬ 
 ing with her baby. Under these circumstances treat 
 the mother as you will. Tell her that the condition is 
 normal; that mother so and so’s guide book is old- 
 fashioned. Do anything you wish; but leave the haby 
 alone. 
 
 Only in one condition may gain of weight be decep¬ 
 tive. This is when a baby has been fed condensed milk, 
 high starch, or high salt mixtures. In these cases the 
 
121 
 
 gain of weight may at times be due purely to a water¬ 
 logging of the body and not due to true increase in 
 tissue substance. History will at once reveal this error, 
 and, knowing the danger in advance, you will of course 
 not prescribe such feeding. 
 
 During the first few months you must see the baby 
 or hear from the mother every few weeks, and you will 
 be called to meet several indications: 
 
 a. After a week or so the baby may cease to gain and 
 the weight curve become straight. The stools are not 
 over two or three per day. Under these conditions, first 
 consult the mother and ask if the baby is hungry. If 
 the baby cries after his bottle, puts his fingers in his 
 mouth between feedings, frets before the next bottle, 
 seizes it with avidity, and drains it rapidly, increase 
 the total quantity of food; or, if the baby is getting a 
 sufficient quantity, increase the milk by a few ounces. 
 
 b. If the child is not gaining, does not seem extremely 
 hungry, and is suffering from marked constipation, 
 then it’s perfectly safe to increase the proportion of 
 carbohydrate in the diet. In this increase we have a 
 means of truly winning the mother’s affection. If our 
 increase is in nonfermentable carbohydrate, gain in 
 weight may result, but the constipation will persist. 
 If we increase with fermentable carbohydrate, such as 
 milk sugar or, more simply, cane sugar, not only will 
 the gain in weight result, but also the resulting fer¬ 
 mentation will correct constipation. So, by striking 
 the proper balance between dextrin-maltose on the one 
 hand and fermentable carbohydrate on the other, we 
 have a means by which we regulate absolutely the con¬ 
 dition of the intestine and by which we bring joy to 
 the anxious mother’s heart. 
 
 c. If the weight curve straightens out, but at the 
 same time the stools are fermentative, we are con¬ 
 fronted with the one problem that may arise in this 
 system of feeding. These dyspeptic stools we have 
 learned may be a symptom of underfeeding or may be 
 a symptom of a true beginning dyspepsia. Here we 
 are aided greatly by history and physical examination. 
 If the child shows definite symptoms of hunger, if 
 questioning shows the mother of her own accord has 
 not made some change in her milk mixture, and ex¬ 
 amination shows that tho child loohs well, then it is 
 
122 
 
 safe cautiously to increase slightly the amount of food, 
 noting the reaction. In such a case, however, one would 
 not increase the proportion of carbohydrate, but simply 
 would increase the total quantity, not changing the 
 relations of different elements. If, on the other hand, 
 the child shows a tendency to avoid food—these little 
 children are often so much wiser than we; if exami¬ 
 nation shows that he has perhaps a very slight fever, 
 that he does not look quite so well, that he has rings 
 under his eyes, and, above all things, if there is that 
 mysterious change of color of the skin, in a few hours 
 the rosy pink becoming an ashen gray, we know that 
 we are probably dealing with a case of beginning dys¬ 
 pepsia. In these cases, marked increase of food will 
 make the disturbance worse. It is best to give the baby 
 only the quantity he wishes and await results. 
 
 d. If, in connection with the fermentative stool and 
 the change of appearance of the child, the weight curve 
 starts to drop, then we are dealing with a case of dys¬ 
 pepsia or beginning intoxication of decomposition, and 
 treatment must be instituted accordingly. 
 
 In all cases, however, by watching our weight curve, 
 and by studying our little patient carefully, we can 
 check these disturbances before they originate, and the 
 amount of severe conditions arising will be very few 
 indeed. 
 
 What is the advantage of our method over the others ? 
 Perhaps its extreme simplicity. Any method used by 
 the man trained in its application will be successful. 
 Our method, however, we believe to be easiest for the 
 untrained man—the man who has not had time to work 
 up his own technique. 
 
 As an example of this, let me quote my experiences 
 in the Chicago Infant Welfare Society. This organiza¬ 
 tion was founded by private subscription some six or 
 
123 
 
 seven years ago. Its object was not charity, but was 
 education. The idea was to reduce infant mortality, 
 not by medical treatment but by prophylaxis; not by 
 curing the sick baby but by keeping the well baby well. 
 With this end in view, one station was organized in our 
 poorer districts. A physician attended twice a week. 
 A salaried nurse was in charge. Mothers were urged 
 to bring their well babies for advice as to feeding, and 
 during the intervals between conferences the nurse went 
 into the home and gave the mothers simple instruction 
 as to the technique to be employed in the making up of 
 mixtures. Ho medicine was given; no milk supplied. 
 The mothers could buy their milk where and from 
 whom they chose. At the station they got nothing— 
 but advice. 
 
 Gentlemen, the success of this new experiment was 
 astounding. The swarms of mothers flocking to thi3 
 first station, the immediate lowering of infant mortal¬ 
 ity, were all the evidence necessary to show that this 
 new departure was a brilliant success. The organiza¬ 
 tion has now grown in the last few years from the 
 original one station to twenty-one. The numbers of 
 infants seen at each conference average about thirty, 
 but often run up to fifty of an afternoon. Whenever 
 one of these stations is opened, in that district does 
 infant mortality drop. This experience was in a way 
 very humiliating to me. I served the society for 
 several years in the capacity of assistant medical direc¬ 
 tor. During that time I had ten or eleven stations 
 under my charge and visited them each once a month. 
 I saw many men for the first time come to take charge 
 of these stations; saw these men instructed in the 
 simple methods of feeding which I have laid out for 
 you, and saw these men in a very few weeks time get 
 just as successful results as did I with a much wider 
 experience. These men had never read nor probably 
 had ever even heard of Finkelstein or Czerny or Heub¬ 
 ner ; but the results they accomplished were all that was 
 necessary. Nothing speaks more for the simplicity in 
 our method of feeding than does the success of our 
 infant welfare society. True disturbances of nutrition 
 rarely arise. The children become simply “feeders.” 
 
 From this experience, gentlemen, one impression is 
 growing more and more upon me. This is the funda- 
 
124 
 
 mental, the previously unrecognized but the indispen¬ 
 sable service of our nurses. We, in the stations or in the 
 dispensaries, see the baby for a moment and write out 
 a formula for a milk mixture; the nurse, however, gets 
 into the home and meets the true condition. She sees 
 all the great influences which are at work—the acces¬ 
 sory aiding influences, the influences which are con¬ 
 stantly at work undermining the baby’s constitution 
 and upsetting our plans. She instructs the mother as 
 to the proper clothing of the baby; she tells the mother 
 that on a warm summer’s day it is unwise to wrap the 
 baby up in thick layers of clothing, surround him with 
 a pillow, place him near the kitchen stove. She informs 
 the mother, on the other hand, that under these same 
 conditions it is unwise to put the baby in the ice box. 
 She informs the mother about the dangers of flies, and 
 attempts to guide the mother in a simple way to protect 
 the child from these pests. She shows the mother how 
 to bathe the baby. She dwells upon the importance of 
 regularity of feeding; she demonstrates the proper care 
 of the bottle and the cleansing of the rubber nipple; she 
 shows the mother how to keep the milk cool by placing 
 the bottle in a tub of cool water, if no ice box is avail¬ 
 able. In short, she fulfills the indications which 
 Schlossman so pointedly expressed when he said, “A 
 good nurse can always overcome the mistakes of any 
 poor physician.” 
 
 Gentlemen, those of you who are interested in infant 
 feeding, those of you who wish wider experience in 
 dealing with nurslings, those of you who wish to do an 
 inestimable amount of good in the poorer districts, 
 should attempt to establish such an organization as an 
 Tnfant Welfare Society; and, in your own practice, put 
 into execution the lessons that we have learned from 
 our experience. Where you have not one of these 
 splendid nurses available, be yourselves a little more 
 the nurse, a little less the physician. Make the mother 
 clearly understand that she is not doing her duty by 
 simply mixing up the milk in the proportions which 
 you have suggested, but that she must fulfill all the 
 other requirements which are so essential to the baby’s 
 general health, and without which any system of feed¬ 
 ing will fail. If you only will lay sufficient emphasis 
 upon the nursing care of your infants, the feeding will 
 almost take care of itself. 
 
125 
 
 Have we solved the last word in infant feeding? Is 
 our method going to last? I do not think so. Hew 
 advances will constantly be made—advances which we 
 always shall be ready to adopt, no matter what be their 
 source. I believe firmly that we have mastered the art 
 of guiding food past the intestinal tract into the body, 
 but rather than rest upon our laurels we must arise to 
 attack newer and more intricate nroblems—problems 
 which loom ominously before us. Are our combinations 
 those best adapted to meet the demands of the body? 
 In years to come we may learn that boiled milk has 
 produced some hidden, undiscovered damage. We have 
 learned that high carbohydrate fed exclusively or in 
 combination with high salts fills the tissues with water 
 but does not satisfy their hunger. Some evidence 
 shows that children fed with no fat in the diet may at 
 times possess a decreased immunity to infection. We 
 may learn in time that our slight reduction of fat, that 
 our slight relative increase of carbohydrate, though 
 passing the intestine easily and safely, may not have 
 been a combination best adapted for the use of the body 
 tissues. Only years of study and observation will 
 answer these questions. The physiologist, Friedenthal, 
 has recently devised a mixture in which the salt pro¬ 
 portions are identical to those of breast milk. Normal 
 amounts of fat and carbohydrate may be given in this 
 mixture with little evidence of intestinal disturbance. 
 This is a splendid step forward—a means of introduc¬ 
 ing fat and carbohydrate into the tissues in the same 
 proportions as they exist in breast milk, and with no 
 danger to the intestinal tract—but is as yet somewhat 
 impracticable. 
 
 Until these indications can be met practically and 
 simply, until we can introduce to the tissues foodstuffs 
 in the same proportions as they exist in breast milk 
 without in any way impairing digestive and assimila¬ 
 tive functions, we believe that our method of feeding 
 is the most feasible. It is easily employed, seems to 
 satisfy the mothers, seems to provide for the growth 
 of healthy, thriving, happy babies, who look ivell and 
 strong and appear smiling and contented, and, first and 
 foremost, it answers the requirements of simplicity . 
 
LECTURE IX 
 
 BREAST FEEDING 
 
 Gentlemen, we shall concern ourselves today with the 
 breast-fed infant. I have neglected the subject of 
 breast feeding until now because in many cases must 
 one supplement the breast with the bottle. If one has 
 mastered the art of prescribing artificial mixtures, then 
 difficulties of supplementary feeding will be very slight 
 indeed. 
 
 It is not necessary to emphasize to you the import¬ 
 ance of breast feeding. All of you know that breast 
 milk is the natural food. All of you know that the 
 breast-fed infant is much more immune to infectious 
 disease than is the artificially fed. All of you know 
 that mortality is much less among the breast-fed than 
 among the bottle-fed babies. Whenever there is any 
 possibility of offering the baby breast milk, by all means 
 do so. 
 
 Contraindications to breast feeding are becoming 
 fewer and fewer. Among the more general: 
 
 1. Tuberculosis of the mother almost unanimously 
 is agreed a distinct contraindication to nursing. 
 
 However, against this practically universally ac¬ 
 cepted idea some voices are lifted. Tubercle bacilli 
 have never definitely been demonstrated in the human 
 breast milk. Some men claim if the mother during 
 nursing will protect the baby from her coughing, that 
 tuberculosis is a contraindication only from her own 
 standpoint and not from that of the child. This is, 
 however, the opinion of a few, but I give it to you to 
 show how even against this most orthodox of all our 
 contra-indications objections slowly are being raised. I 
 believe, though, that the great consensus of opinion 
 makes tuberculosis of the mother a contraindication to 
 nursing, not only from her own standpoint, but also 
 from that of the child. 
 
 2. Severe constitutional disease, such as diabetes, epi¬ 
 lepsy, and malignancy, of course are contraindications. 
 
 3. As regards acute infectious diseases, such as ty- 
 
127 
 
 phoid, scarlet fever, diphtheria, etc., opinion, particu¬ 
 larly in the European clinics, is becoming more and 
 more tolerant. The new-born has considerable immun¬ 
 ity to infectious disease. Again, pathogenic bacteria 
 have never been demonstrated as transmitted by breast 
 milk, and the theoretical objection that toxins are ex¬ 
 creted may be met with the theoretical answer that anti¬ 
 toxins also will pass to the child. Even in diphtheria, 
 if a child be properly immunized, breast feeding is per¬ 
 mitted. 
 
 These are the opinions of many of the leading Euro¬ 
 pean men. They may seem rather radical to you, gen¬ 
 tlemen. I give them to you, however, to emphasize the 
 importance in which breast feeding is held, and to show 
 that most contraindications are those raised in consid¬ 
 eration of the mother rather than the infant. Even 
 in erysipelas, where a superficial infection of the breast 
 makes it possible that organisms may be found in the 
 milk, the latter may be drawn off, boiled, and then 
 offered to the baby. 
 
 4. Syphilis is an indication for nursing rather than a 
 contraindication. Whether the syphilitic woman be 
 mother of an apparently well baby or whether an en¬ 
 tirely well woman be mother of a synhilitic baby, in all 
 cases should we insist upon breast feeding, for in both 
 these conditions we believe that mother and child are 
 alike infected. 
 
 As regards local contraindications from the stand¬ 
 point of the mother, there are perhaps two to be con¬ 
 sidered : 
 
 1. Retracted nipples cause a great deal of difficulty, 
 cause much anxiety to the mother, and add great diffi¬ 
 culties to the child. In many cases, however, if you 
 practice a little patience these difficulties will be over¬ 
 come. Instead of surrendering in despair to the mother, 
 simply tell her, “Yes, it’s going to be hard for the baby 
 to nurse; but if you practice patience and perseverance, 
 frequently after a week or two the child will learn to 
 take the breast.” Patience and perseverance are the 
 requisites necessary, and after a week or two of con¬ 
 scientious work the mother may be able to educate her 
 child to nurse from nipples that previously seemed 
 hopeless. An aid in this treatment is drawing out the 
 nipples between nursing periods by the use of a breast 
 pump. 
 
128 
 
 2. Erosions and fissures of the nipples are extremely 
 disagreeable complications—ones which will cause you 
 a great deal of anxiety and ones which by the pain in¬ 
 flicted upon the mother make nursing a very great 
 burden indeed. The variety of treatments offered for 
 fissured nipples is of itself sufficient evidence of the in¬ 
 efficiency of any particular method. Medicaments sug¬ 
 gested are: 
 
 (a) The use of a little cotton swab saturated in a 
 one to two per cent silver nitrate solution laid upon the 
 fissure for one minute once during the day. 
 
 ( b ) The following prescription is one quite highly 
 recommended. Personally, I have had no experience 
 with it whatsoever, but I give it to you upon the recom¬ 
 mendation of foreign writers: 
 
 Silver Nitrate Gr. XV 
 
 Balsam of Peru M LXXV 
 
 Lanolin 
 
 Vaselin AA Oz. Ill 
 
 This may he applied frequently. 
 
 A very valuable point in treating this distressing 
 complication is the use of a mild local anesthetic oint¬ 
 ment. A 5 per cent salve of anesthesin applied to the 
 fissure just before nursing is to the mother a very great 
 relief. Anesthesin is not poisonous to the child, and 
 is very grateful to the mother on account of the relief 
 of the severe pain. 
 
 (c) In treating this complication, to give the painful 
 nipple as much rest as possible, longer feeding intervals 
 should be employed. Indeed, one might substitute a 
 bottle for one nursing. Hiople shields, too, are of value. 
 The very best of these is a large one made of pure rub¬ 
 ber almost covering the breast, and called the “Infanti- 
 bus.” It is an imported shield; so I doubt whether you 
 can get it now; but when the war is over probably you 
 may again obtain it, and it is, I believe, the best on the 
 market. 
 
 Contraindications from the standpoint of the child 
 are not many. Cleft palate may at times interfere with 
 a child’s nursing. This, like the difficulty of retracted 
 nipple, often can be overcome by patient, conscientious 
 work of the mother. Many cases which seem hopeless 
 at first, after a week or two of devoted care by the un- 
 
129 
 
 tiring mother, may learn in some way or another to 
 obtain milk from the breast. 
 
 The difficulty not infrequently met with, most ex¬ 
 asperating both to the mother and to the physician, 
 ignorance of which leads to the greatest dangers to the 
 child, is with the so-called neuropathic child. The 
 mother’s breast may be abundantly supplied with milk. 
 The slightest pressure applied may cause the milk to 
 gush forth. The child, however, when put to the breast, 
 takes one or two swallows, then seems to show an abso¬ 
 lute lack of interest in anything connected with his 
 feeding and lies gazing off into distance, playing with 
 the nipple 
 
 Analysis of this type of case shows not infrequently 
 that two factors are concerned: The one is simple 
 weakness. The baby has been born with little strength, 
 and when placed to the breast tires rapidly and wants 
 a rest between drinks. The more important factor, 
 however, is a neuropathic constitution. In the latter 
 case the infant usually is a child of nervous parents; 
 often the only child at that. He has come into the 
 world with an incompletely developed nervous system. 
 The swallowing reflexes are not as they should be, the 
 child making clumsy, awkward attempts. The breast 
 milk is all right in every way; there is absolutely noth¬ 
 ing wrong with it; the difficulty is solely with the child, 
 and that difficulty not a serious one. This objection, 
 like many others, can by perseverance and education 
 frequently be overcome. Usually after the second week 
 the child has learned to swallow properly. If after the 
 third week he still shows a marked aversion to the 
 breast, a very good tentative diagnosis of idiocy may 
 be made. Children who show after three weeks of time 
 a marked aversion to the breast are almost invariably 
 backward, feeble-minded babies. But you see, gentle¬ 
 men, what grave errors might arise from not under¬ 
 standing this condition. The mother in great trouble 
 says to you, “My child absolutely will not nurse. I 
 have tried everything possible, and he will not. He 
 doesn’t like my milk, and I think we ought to wean 
 him and give him the bottle.” When the physician 
 weakly hearkens to this plea of the mother the new 
 born child is placed upon artificial feeding and sub¬ 
 jected to its resulting dangers and disasters. In these 
 
 9 
 
130 
 
 cases humor the mother, if you will; treat her any way 
 that will bring you results. If she be of the type that 
 wishes the quality of her breast milk changed, get a 
 specimen of breast milk, tell her that the fat or protein 
 or something else is not quite up to normal, give her 
 some medicine, and, after a few days or weeks, tell her 
 that her milk is responding nicely; but under no cir¬ 
 cumstances remove the child from the breast. 
 
 The entrance of milk into the breast occurs between 
 the first and eighth day, usually about the fourth. In 
 many cases, however, it is delayed, and you are asked 
 by all concerned, “Can we hasten this process?” Gen¬ 
 tlemen, there is one and only one lactagogue which you 
 may use with any degree of assurance, and that lacta¬ 
 gogue is the nursing infant. The one stimulus to a 
 breast is the stimulus arising from this source. In the 
 European clinics, where many wet nurses are used, 
 where one woman sometimes nurses four or five babies, 
 these wet nurses often secrete 2 to 3 quarts of milk 
 daily. The greater the stimulus to the breast the 
 greater the response. And so, gentlemen, to hasten the 
 entrance of milk into the lagging breast, urge the fre¬ 
 quent application of the infant. Between times one 
 may use the breast pump, but this latter, in connection 
 with massage, electricity, and the use of all other arti¬ 
 ficial aids, is infinitely less efficient than the normal, 
 natural method. 
 
 If in spite of frequent regularly repeated applica¬ 
 tions of the babe to the breast the milk still delays, 
 how long shall we wait? Safely a few days; and 
 during this time must we he very careful not to en¬ 
 tirely appease his appetite with artificial food. We 
 want to keep this babe hungry; we want him to tug 
 good and hard at the breast when nursing; and, there¬ 
 fore, during these days we offer him only a little water 
 and tea. By this method can we frequently accelerate 
 the appearance of the milk. 
 
 However, gentlemen, don’t focus your attention so 
 carefully upon the mother that you forget the child; 
 don’t allow your zeal for hunger lead you into the great 
 error of letting the child suffer too much from hunger. 
 In all these cases, as I have repeated over and over 
 again, our index is the baby’s weight curve. As you 
 know, the physiologic loss of weight during the first 
 
 
131 
 
 few days amounts to from one-half to one pound, and 
 this loss should he recovered within the second week. 
 If by this time the baby still is losing or shows no 
 tendency whatsoever toward gain, we consider this 
 the danger signal, and direct our attention more to the 
 babe and less to the mother. We must put the child to 
 the breast more frequently, or, in case this is impossi¬ 
 ble, add a little bottle to the diet. We must never for 
 a moment let the baby’s hunger get to such a point that 
 he develops weakness, because if he becomes too weak 
 to nurse properly we defeat our own purpose. This 
 treatment should be applied, also, to those weak and 
 those neuropathic children who, in spite of a rich of¬ 
 fering of milk, do not drink enough. Let the weight 
 curve be your guide, and if this does not ascend, in¬ 
 crease the number of nursings or add a milk mixture 
 after each application to the breast. 
 
 What shall be the diet of the nursing mother? As far 
 as we know now, the nursing mother may eat absolutely 
 anything which agrees with her and makes her happy 
 and contented. We may disregard totally the man¬ 
 dates of our grandmothers in this respect. If the nurs¬ 
 ing mother likes vinegar, and it agrees with her, let 
 her have it. Whatever she craves, whatever she can 
 digest, whatever pleases her and makes her happy and 
 contented, she shall have. Our sole desire in regula¬ 
 ting her diet shall be to fulfill three requirements: 
 
 a. She must have enough food. Many a poor woman 
 does not secrete a good supply of milk because she, her¬ 
 self, is starving. 
 
 b. The food must be digestible. The nature of the 
 food depends upon the mother’s social condition and 
 her taste; but anything that she can digest, she may 
 eat. 
 
 c. Lastly, we must gratify her thirst. The mother 
 secretes about a quart of breast milk a day. This 
 means almost a quart of water in addition to the other 
 normal excretions. You see, then, gentlemen, that this 
 woman has every reason to be thirsty. Here is where 
 many mistakes, even by well educated physicians, are 
 made. The physician takes advantage of this thirst 
 to force extra food. The woman does not need extra 
 food at this time—her normal appetite is taking care 
 of that—but she needs fluid. This should be given as 
 
132 
 
 water, tea, broth, and thin soup. How wrong is it, 
 then, to take advantage of this need of fluid to throw 
 into her body a great excess of starches, such as are 
 contained in thick .soups and gruels! The woman does 
 not need this excess of food, provided she is getting her 
 meals normally. She needs simply more water. 
 
 “Can the supply of breast milk be influenced as re- 
 gards quantity and quality?” It is the idea of the 
 laity, particularly of the grandmother who has raised 
 seven children and the aunt who has raised ten, that 
 the quality of breast milk is affected by many, many 
 influences, by psychic and nervous changes in the 
 mother, by pregnancy, and by menstruation. As a 
 matter of fact, scientific experiments showing changes 
 in quality of breast milk are very few indeed. 
 
 You must remember that the amount of breast milk 
 secreted at each nursing varies. You must remember 
 that the amount of the individual ingredients secreted 
 during the individual nursing varies—fat being small 
 in amount at the beginning of the nursing and increas¬ 
 ing in amount toward the end of the period. To get 
 definite, clean-cut exneriments not subject to criticism, 
 one must obtain twenty-four-hour specimens of breast 
 milk, analyze them very carefully; and repeat this upon 
 successive days. The number of such experiments 
 which will withstand searching criticism is few, but 
 those experiments which have been made, suggest that 
 nervous and psychic factors, pregnancy, and menstrua¬ 
 tion positively have no effect upon quality of breast 
 milk. Undoubtedly, children show disturbance at 
 times, particularly during the menstrual period; but 
 our present observations tend to show that these dis¬ 
 turbances are due to change in quantity rather than in 
 quality of the breast milk; less milk is secreted, the 
 child is hungry, becomes peevish, irritable, and fretful, 
 and the natural conclusion is that the quality of the 
 milk is changed; that the milk is not agreeing with the 
 child. As far as we know now, however, the only defi¬ 
 nite change is one of quantity, and this usually a dimi¬ 
 nution of total secretion. 
 
 As regards the influence of diet upon the breast milk, 
 we despair more and more. Yo one in experiments de¬ 
 void of criticism has definitely shown that he can con¬ 
 trol at will the quality or quantity of breast milk by 
 
133 
 
 any change of diet. Many of the statements you read 
 as to the efficiency of diet are based upon only the most 
 superficial of investigations. There is one exception, 
 perhaps, and this is with fat. In underfed, badly 
 nourished women, high fat feeding at times seems to 
 increase the fat in the milk secreted. There is some 
 doubt, however, as to whether this influence is exerted 
 in a well-nourished woman or not. It will hold only 
 absolutely true for the undernourished woman. 
 
 As regards medicines, every drug in the pharmacopeia 
 has been tried at some time or another as a lactagogue. 
 Each one has in turn been given up. The latest to 
 be tried is Pituitrin. This, in definite physiological 
 experiment, will increase the amount of milk in a given 
 time; but again are we doomed to disappointment. The 
 most recent observations show that this drug acts upon 
 smooth muscle fibers; that it causes them to contract, 
 thus forcing the milk more rapidly from the breast; 
 but that in absolutely no way does it affect the total 
 secretion. 
 
 There is one, and only one agency you may employ 
 successfully as regards improving the quality of breast 
 milk, and that is recommendation to the mother of 
 good hygiene, good food, fresh air, and plenty of exer¬ 
 cise. Many nursing mothers are very lax in this matter. 
 So, to summarize, then, we may say that as regards 
 influencing the quality of breast milk, we are practi¬ 
 cally helpless. 
 
 Just as inefficient as are our methods of influencing 
 quality are those influencing quantity. Only one scheme 
 is known definitely to increase the amount of milk 
 secreted, and this scheme, gentlemen, will bring woe to 
 you if you attempt it in private practice. In an insti¬ 
 tution where wet nu.rses are employed one may stimu¬ 
 late a lagging breast by placing to it a healthy, strong 
 child. This proves very satisfactory; but woe to you 
 if you suggest to your private patient, with her nine 
 generations of unadulterated American blood, to place 
 to her aristocratic breast the lustily howling infant of 
 the common folk—for instance, the washwoman. The 
 wrath of mother, grandmother, grandfather, uncles, 
 aunts, cousins, and neighbors falls heavily upon your 
 head. So, gentlemen, if you are not absolutely sure of 
 your practice, in such cases it is better to get a wet 
 
134 
 
 nurse from the start or to add a supplementary bottle 
 after each feeding. 
 
 As a general rule, I have found the following scheme 
 to be efficient in perhaps 999 out of 1,000 cases: Make 
 up your mind from the start that breast milk is always 
 all right in quality. Make up your mind that the only 
 difficulties that arise from breast feeding are those due 
 to quantity. Treat the mother as you will to put her 
 mind at rest, but from your own standpoint conduct 
 your treatment along the lines of correction of the 
 amount; and if you keep your child on four-hour feed¬ 
 ing, this correction will usually be one for underfeeding 
 rather than for overfeeding. 
 
 As regards the general technique of nursing, during 
 the first twenty-four hours some men do not place the 
 child to the breast; others do once every six hours. As 
 long as one keeps up the supply of fluids, these differ¬ 
 ences in technique are of little importance. Personally, 
 I believe application to the breast is better for its stim¬ 
 ulating effect upon the breast and possibly upon uterine 
 contraction. 
 
 As regards rigid disinfection of the breast, we are 
 changing ideas more and more. Where * the mother 
 practices ordinary cleanliness, the application of strong 
 chemicals to the nipples is absolutely uncalled for. 
 Of course, in the very poor districts, where the breasts 
 are caked with dirt, they must be washed thoroughly; 
 but in ordinary private practice among the better class 
 families the use of a little piece of cotton with luke¬ 
 warm water is all that is necessary. If the mother be 
 one of the modern scientific type, and wishes something 
 fashionable and antiseptic, use a little boric solution. 
 Personally, however, I believe that the use of a strong 
 antiseptic is a frequent cause of the painful fissured 
 nipple. 
 
 How often shall we put the baby to the breast? 
 Four-hour feeding was reintroduced by Czerny in 1905. 
 Undoubtely, the majority of children do well upon this 
 schedule from the very beginning—five feedings in 
 twenty-four hours. Personally, I believe a small per 
 cent have difficulty in waiting so long, and so as to in¬ 
 clude this group I order as a routine, during the first 
 four to six weeks, seven feedings—one every three 
 hours. Undoubtedly, the majority of children will do 
 just as well upon the four-hour schedule. 
 
135 
 
 How long shall we allow the baby to nurse? He 
 shall nurse until he is satisfied. This requires usually 
 from fifteen to twenty minutes. The first five of these 
 are the most important, for in the first five the baby 
 gets the greatest amount of milk. You easily can tell, 
 gentlemen, when he is satisfied, by the cessation of the 
 swallowing sound. When the child is hungry he nurses 
 vigorously and swallows continuously. When he ceases 
 to swallow and lies playing idly with the nipple, he has 
 had enough. If the child empties the breast thoroughly 
 and still is not satisfied, you either may increase the 
 number of feedings or put him to the other breast; but 
 in case you do the latter, be perfectly sure that the first 
 breast has been thoroughly emptied. A child is easily 
 spoiled, and if the second breast is waiting for him, 
 often he will not empty thoroughly the first. The re¬ 
 duction of this stimulus, then, will cause a correspond¬ 
 ing reduction of the amount of milk secreted. 
 
 One little point of technique frequently is overlooked, 
 and is of infinite value to the physician—one our grand¬ 
 mothers used to employ. You remember our old grand¬ 
 mothers used to interrupt the nursing at intervals, plac¬ 
 ing the baby upright on the left shoulder, the abdo¬ 
 men being against the mother’s body. They then would 
 pat the child upon the back until he belched up some 
 air. In the younger days of science any practice inter¬ 
 fering with the quiet of the nursing was deprecated. Re¬ 
 cently, however, we are learning that there is much 
 truth in our old grandmothers’ advice. If you will hold 
 a child in front of a fluoroscope, you will see that when 
 nursing he frequently swallows air. This collects in a 
 large bubble in the upper part of the stomach. It in¬ 
 terferes with the proper filling of the stomach. It 
 prevents his taking sufficient food, often makes him 
 vomit, and may cause colic. If you break the nursing 
 interval every few minutes and pat the child upon the 
 back as did grandmother, this air will be belched up, the 
 tension ip the stomach relieved, and the child nurses 
 with renewed vigor. Many almost unsurpassable diffi¬ 
 culties with breast feeding are overcome by this simple 
 little bit of technique. 
 
 In instructing the mother as to nursing, tell her the 
 baby usually does better if he has not only the nipple, 
 but also a little of the areola in his mouth. 
 
136 
 
 How shall we know when the baby is doing well? 
 The best index, gentlemen, is bis weight curve, and if 
 be gains on an average of about 6 ounces a week, no 
 fault should be found with his nutrition. 
 
 Just a word about the feeding of prematures. First, 
 remember that in every case of premature birth you 
 should suspect Lues; not that this disease will always 
 be met, but it is worth considering. Next, remember, 
 if you are working with calories, that prematures re¬ 
 quire more calories than do normal babies. Hr. Julius 
 Hess of our city made a nice study showing this higher 
 caloric requirement. This is almost self-evident, of 
 course, for the premature must not only gain as does 
 a normal baby, but has to make up back losses. 
 
 A very interesting point in the treatment of prema¬ 
 tures I learned from an address of Langstein. Up to 
 the time of his studies the mortality of these babies in 
 bis institution was very high. He found that this was 
 due to their great weakness. In many cases these chil¬ 
 dren when put to the breast were too weak to take the 
 required nourishment. They tired before they got suf¬ 
 ficient food, and rapidly, from the resulting hunger, 
 developed the condition of decomposition and death. 
 Langstein found that by forcing feedings either with a 
 medicine dropper or a stomach tube, by getting more 
 food into these babies, mortality was very greatly re¬ 
 duced. So, gentlemen, if your premature is not gain¬ 
 ing, don’t waste time. Put him to the breast more fre¬ 
 quently. If be still does not gain, force more food into 
 him, first with a medicine dropper, and, if this fails, 
 then with a stomach tube. 
 
 In conclusion, I wish to call your attention to a most 
 fascinating point in physiology. Clinical observation 
 has long taught us that most prematures and also many 
 twins develop during the third or fourth months severe 
 anemias and bad rickets. This is an almost invariable 
 rule. It was the great Czerny who offered an expla¬ 
 nation. Just see the composition of breast milk. In 
 1 quart of breast milk there is of a grain of iron 
 and a little over % grain of calcium. There is abso¬ 
 lutely insufficient iron, barely enough calcium, to cover 
 the needs of a child’s body for these minerals. It was 
 Czerny who suggested that during the last three months 
 of intra-uterine life storage warehouses of iron are de- 
 
137 
 
 veloped in the body. The main one of these seems to be 
 in the liver, and during the first months of life, until 
 the baby gets a mixed diet, he does not live upon the 
 iron of the breast milk, but does live upon the iron kept 
 in the depot of the body. In a like manner Czerny 
 has suggested a calcium depot, although the latter is 
 not quite so well established as the former. How, you 
 see, gentlemen, why prematures develop anemia and 
 rickets. They have come into the world before these 
 depots have been developed, and the supply of iron and 
 calcium in the breast milk is insufficient for their needs. 
 
 If you wish, then, to prevent all these unpleasant re¬ 
 sults and dangers in the treatment of your prematures, 
 practice a little prophylaxis. At the third month you 
 may add a little iron. This can be given in the form 
 of Ferri Carbonas Saccharatus three times daily in 
 quantities equal to the amount that can be placed 
 upon the point of a knife. It mixes well with water in 
 a teaspoon. Calcium may be given in any agreeable 
 mixture in doses of 5 to 10 grains three times daily. 
 Cod liver oil is best given as the phosphorated cod 
 liver oil, as follows: 
 
 Prescription: 01. Morrhuae Oz. VIII 
 01. Phosph. Drachm I 
 
 The dose is 1 teaspoon three times daily, each tea¬ 
 spoon containing 1 drop of 01. Phosph. and thus 1/100 
 of a gr. of phosph. 
 
 If you practice these methods of prophylaxis you will 
 be really gratified with your twins and prematures; you 
 will be glad to see that severe anemias do not develop, 
 and you will note that the dreaded rickets will appear 
 only in a mild form. 
 
 Gentlemen, from these studies of physiology you un¬ 
 derstand now why I have insisted upon a mixed diet 
 for every child of six months of age. The purpose is 
 to provide for some of these known deficiencies and 
 also for those whose existence, though now unknown, 
 may be revealed in future observation and experiment. 
 
LECTURE X 
 
 THE DISTURBANCES ARISING IN THE 
 
 BREAST-FED 
 
 Gentlemen, in speaking of the disturbances of the 
 breast-fed, we prefer to consider them also as “Disturb¬ 
 ances of Nutrition.” Just as in the artificially fed 
 child, so in the breast-fed are the symptoms arising 
 many more than those from local gastro-intestinal irri¬ 
 tation. In addition to symptoms from stomach and 
 intestines, the skin, the weight curve, the nervous sys¬ 
 tem, the decreased immunity to infections show also 
 that involvement is general. 
 
 Disturbances of nutrition arising in breast-fed babies 
 are due to two causes: 
 
 I. Exogenous causes, i. e., outside factors. 
 
 These may be: 
 
 a. Errors in the technique of nursing, which we con¬ 
 sidered last week, and, of course, improper food given 
 in addition to the nursing. 
 
 b. Parenteral infections. These are becoming more 
 and more important. 
 
 c. Improper nursing, improper care, overclothing, 
 and overheating. 
 
 d. Let me emphasize again: diagnose only rarely 
 changes in quality , but much more frequently changes 
 in quantity of breast milk. 
 
 II. Endogenous causes, i. e., those due to the baby 
 himself— i. e., to his constitution. We are learning to 
 recognize more and more the importance of the baby’s 
 constitution as a factor in causing trouble. Our studies 
 show that there are two distinct types of constitution: 
 
 a. The Exudative type, in which the child’s cheeks 
 are covered with infiltrated encrusted weeping eczema, 
 and, 
 
 b. The Neuropathic type, in which the thin, pale, 
 often rigid baby shows distinctly neurotic tendencies. 
 
 More and more are we learning the great and ever 
 growing importance of these endogenous factors. Until 
 very recent years all disturbances arising in breast-fed 
 
139 
 
 children were considered due chiefly to poor milk, and a 
 diet for the mother or wet nurse was prescribed. Now 
 we realize that this idea was wrong; that the fault very 
 frequently was that of the baby. 
 
 Before discussing disturbances of nutrition, let me 
 call your attention to two isolated symptoms—symp¬ 
 toms which are not important from the standpoint of 
 the baby, but are of vital importance from the stand¬ 
 point of your practice. 
 
 I. The first of these is vomiting. This exists in two 
 distinct types: 
 
 a. The Atonic type, in which the food simply rolls 
 out of the side of the mouth, and 
 
 b. The Spastic type, in which the food is regurgi¬ 
 tated with considerable force. 
 
 Notwithstanding this symptom, if the baby is gain¬ 
 ing, if he is well and happy and contented, by all means 
 leave him alone. Keep your eyes open for errors in 
 the technique of nursing, such as overfeeding, irregu¬ 
 larity of feeding, neglect of the little technique of pat¬ 
 ting the baby on the back, and too rapid feeding; but 
 frequently will this vomiting persist in spite of perfect 
 and unimpeacable routine. In the latter case, the dis¬ 
 turbance is due probably to the baby’s constitution, the 
 fault lying with a hyperesthetic mucous membrane or 
 to faulty reflexes. No matter what be the underlying 
 cause, if the baby is thriving, if he is happy, and con¬ 
 tented, and satisfied, take the mother into your confi¬ 
 dence; tell her this condition exists frequently in chil¬ 
 dren, that it is to be considered almost normal, and 
 explain to her that from the third to the sixth month 
 vomiting spontaneously will cease. Remember, gen¬ 
 tlemen, that this type of which I am speaking occurs 
 perfectly independent of nutritional disturbance. Py¬ 
 loric Stenosis and Pyloro Spasm give persistent vomit¬ 
 ing, but, in addition, grave symptoms of disturbed nu¬ 
 trition. 
 
 II. Abnormal bowel movements. 
 
 a. In reading the text-books you will find described 
 that the stool of the normal breast-fed child is soft, 
 homogeneous, pasty, yellow, and smooth. This un¬ 
 doubtedly is a normal stool—indeed, one almost might 
 say it is ultra-normal. But, gentlemen, if you examine 
 a great number of breast-fed babies, you will find that 
 
140 
 
 the stools are green, slightly watery, somewhat acid, 
 and contain mucus and curds. These you will find 
 more frequently or at any rate fully as frequently as 
 the ones described by the text-book. In spite of this 
 apparent abnormality, the baby thrives, gains consist¬ 
 ently, is happy, contented, and satisfied. Under such 
 circumstances why these stools are not to be considered 
 normal I do not know. The text-book ideal stool is 
 almost more than normal. 
 
 The cause of these increased stools is not certain. 
 It may lie in intestinal fermentation; it may lie in a 
 neuropathic constitution; it probably is to be found in 
 both. But as long as the baby is happy and contented 
 and gaining, leave him alone and instruct the mother 
 that in this type of child this stool is absolutely normal. 
 
 Tell her that usually it will correct itself by the 
 third to sixth month. If it does not, we can be of 
 service in a way to be mentioned later. 
 
 b. Constipation. In discussing the constipation that 
 occurs independent of nutritional disturbance, let me 
 present an idea of my own. I present this to you 
 purely as an idea, not as a fact—one which you may 
 in your leisure moments consider, but not necessarily 
 believe. For my own purposes, I divide constipation 
 into two types. These two you will not find described 
 in text-books, but this classification has been of great 
 value to me. 
 
 (1) The type which I call pseudo constipation. In 
 this the baby is perfectly happy, contented, and thriv¬ 
 ing. His bowel movements occur perhaps once in two 
 days. They are normal, soft, and homogeneous. The 
 mother complains to you bitterly. She has read in her 
 guide book or has been instructed by the family phy¬ 
 sician that unless the bowels move once a day the baby 
 will not sleep well, will be very restless, will have colic. 
 As a matter of fact, gentlemen, these symptoms exist 
 only in the mother’s mind. They are in the guide 
 book, or in advice obtained from outside sources; but in 
 the baby they do not exist. He goes sailing along per¬ 
 fectly independent of the anxiety which he is causing. 
 Gentlemen, has it ever occurred to you to question the 
 authority which states that a baby must have one 
 bowel movement a day? Frequently have I asked my¬ 
 self, “What right ha£ this author to state definitely 
 
141 
 
 that a child must have one bowel movement daily? We 
 do not lay down definite rules as to the frequency of 
 urination.” We know that this depends upon many 
 different factors. 
 
 The text-books make the definite statement, but 
 where is their authority? It comes from books written 
 in previous times. These books when written were 
 founded upon more previous observations, and ulti¬ 
 mately, I presume, we would find the statement to have 
 originated in the ages gone by, in those medieval, mys¬ 
 terious ages when knowledge was dogma, when wisdom 
 was superstition. In this type of case, usually, I tell 
 the mother, “In this baby this condition is normal. 
 Don’t worry. The baby’s intestine is so strong that he 
 is absorbing most of his food; very little remains in the 
 intestine, and two days are required for sufficient resi¬ 
 due to accumulate to cause a normal bowel movement.” 
 As I say, gentlemen, this idea may be wrong, but it 
 gives good practical results. 
 
 (2) The type which I call true constipation requires 
 more definite treatment. In this child the stools are 
 definitely hard and soapy, i. e., truly constipated. They 
 do not adhere to the diaper, and the baby may strain 
 and have pain. Ho matter how well the child may be 
 thriving, if he strains, woe be to you if you tell the 
 mother to leave him alone. If you wish to retain your 
 practice, you must suggest definite therapy. How shall 
 we proceed? First, we must make a careful examina¬ 
 tion to rule out any organic cause, such as tumor or a 
 congenitally dilated colon. Shall we give physics? 
 This, of course, is not a reasonable procedure. Physics 
 simply flush out the bowel, but do not improve the 
 fundamental cause. Enemas often do more harm than 
 good. When these are repeated daily the child’s rectum 
 becomes sore and he voluntarily restrains himself so 
 as to avoid the pain. Thus we defeat our own purpose. 
 If the mother demands active treatment, an enema of 
 1 ounce or more of olive oil may be introduced into the 
 rectum- once or twice a week. Advise this just before 
 the baby goes to sleep, instruct the mother to hold the 
 buttocks together so that the oil remains in the intes¬ 
 tine all night, and in the morning, either spontaneously 
 or from a mild suppository the child will have a soft 
 bowel movement. 
 
142 
 
 As regards correcting the underlying cause, we must 
 attempt as closely as possible to simulate the normal. 
 In the perfectly normal breast-fed child a state of mild 
 fermentation exists in the intestine. As you gentle¬ 
 men remember from the lecture on artificial feeding, 
 such a condition may easily be produced by the use of 
 carbohydrate. Offer your patient after each nursing 
 an ounce or more of cereal water with 5 per cent to 
 10 per cent lactose, or else add from V 2 ounce to an 
 ounce after each nursing of a 10 per cent watery solu¬ 
 tion of malt soup extract. In addition, use fruit 
 juices and, after the third or the fourth month, a little 
 apple sauce. With such simple procedure these cases 
 respond readily. 
 
 TRUE DISTURBANCES OF NUTRITION 
 
 The first of these is Inanition, the condition arising 
 from insufficient milk. As regards symptoms in the 
 gastro-intestinal tract, the stools usually are those of 
 the truly constipated type, being infrequent, dark, and 
 tenacious; but, gentlemen, let me urge upon you strongly 
 that in some cases stools are green, watery, and contain 
 mucus and curds. Ho worse mistakes can be made in 
 diagnosing such cases—as is so frequently done —as 
 gastro-enteritis from overfeeding. 
 
 The general symptoms showing that the state of nu¬ 
 trition also is affected are cessation of the normal gain 
 in weight, pallid, inelastic skin, lost agility, and sunken 
 abdomen. The nervous system is involved. Often the 
 child cries continuously, showing neurotic tendencies 
 by scratching the skin of the face and body and even by 
 rubbing it off of the foot-soles. Crying, however, may 
 be entirely absent. 
 
 In the etiology of the condition two factors are to be 
 considered: 
 
 1. From the standpoint of the mother retracted nip¬ 
 ples, fissured nipples, or insufficient milk may be funda¬ 
 mental. 
 
 2. From the other standpoint, however—and what so 
 frequently is overlooked or underestimated by the phy¬ 
 sician—is the fundamental importance of the child. In 
 twins or prematures weakness may be solely to blame. 
 A neuropathic constitution is frequently the basis of 
 the whole trouble, and creates a distracted physician 
 
143 
 
 and a most perturbed household. In the new-born 
 neuropathy will show itself by undeveloped swallowing 
 reflexes. These we considered last week. During the 
 third or fourth month, however, this constitution shows 
 itself in more persistent form, viz., 'prolonged loss of 
 appetite, Ho matter how much milk is in the breast, 
 do what you will, the little fellow takes no interest in 
 his food, takes one or two swallows, and then plays idly 
 with the nipple. He looks around the room, smiles, is 
 happy, but will not nurse. These are the cases in which 
 the distracted mother insists, “My milk is no good; the 
 baby absolutely refuses it.” These are the cases in 
 which the unfortunate, innocent physician gets a wet 
 nurse. Added to his worries now are not only com¬ 
 plaints of the mother, but also the domestic infelicity 
 which arises from the mother’s superintending the 
 nursing technique of the new acquisition to the family. 
 The baby refuses the breast of the first wet nurse, and 
 a new one is employed. Sometimes four or five are 
 obtained before the unhappy, by this time well-nigh 
 insane, physician realizes that fundamentally the fault 
 did not lie with the breast milk, but did lie with the 
 baby. 
 
 DIAGNOSIS 
 
 First, is this a case of inanition, or, if the stools be. 
 dyspeptic, is it a case of overfeeding? Gentlemen, in¬ 
 stead of wasting time speculating, simply weigh the 
 baby for a day or two before and after each nursing. 
 If he got only a few ounces, no matter what be the 
 nature of the stool, he did not get enough. If he gets 8 
 or 9 ounces at a feeding he is getting too much. This 
 simple procedure makes a difinite diagnosis. 
 
 More important is it to diagnose the cause. Re¬ 
 tracted or fissured nipples speak for themselves. If the 
 fault be insufficiency of milk, the baby comes to the 
 breast and after five or ten minutes ceases nursing and 
 cries irritably. Examination of the breast at this time 
 shows it to be empty, or, if the nursing be interrupted, 
 one finds that the milk oozes from the nipple simply 
 drop by drop. 
 
 If the fault lie with the child, observation of the 
 nursing process makes! the diagnosis. The clumisy 
 swallowing of the new-born points to undeveloped re- 
 
144 
 
 flexes; the lack of interest in the older child shows 
 the neuropathic loss of appetite. 
 
 Prognosis .—In the breast-fed baby this is relatively 
 good. Rarely does the breast-fed child ever progress 
 to the true stage of decomposition so easily reached by 
 the bottle-fed baby. Decomposition results only in 
 extreme cases. 
 
 Treatment .—This depends upon the cause. 
 
 1. If the fault lies with insufficient milk, the child 
 may be put to the breast more frequently or else both 
 breasts may be used. If the weight curve does not show 
 a rise after a few days of this treatment, a bottle may 
 be added after each nursing, the amount depending 
 upon the amount of milk obtained from the breast. As 
 children wean themselves rapidly, never give the child 
 the bottle until the breast has been thoroughly emptied. 
 
 2. When the fault lies with the child: 
 
 ( a ) If it be due to the undeveloped reflexes of the 
 new-born, patience must be exerted by the mother, and 
 the condition corrects itself in a few weeks. But dur¬ 
 ing this time see that the baby’s nutrition does not 
 suffer, and see that the breast is emptied after each 
 nursing, so that the supply does not fail. 
 
 ( b ) If the fault lie with the loss of appetite, correc¬ 
 tion is more difficult. Sometimes a few drops of pepsin 
 with dilute hydrochloric acid, given a few minutes be¬ 
 fore each meal, seem to stimulate the appetite. A daily 
 stomach washing may be of value. A lukewarm bath fol¬ 
 lowed by a cool spray occasionally gives striking re¬ 
 sults. Gentlemen, in the latter be very careful not to 
 shock the child. Babies are very susceptible to cold. 
 Make the spray just cool enough to be mildly stimula¬ 
 ting and to make the child breathe deeply—to make 
 him cry, perhaps, but under no circumstances to shock 
 him severely. If this is done once or twice a day a few 
 minutes before meal times, often the child nurses with 
 considerably more vigor. 
 
 During this period of treatment the child’s nutrition 
 must by no means be neglected. Here great errors are 
 made. The physician too frequently says, “If this 
 child won’t nurse, we will let him get so hungry that 
 he will have to.” Such treatment accomplishes noth¬ 
 ing. The child’s loss of appetite is not due to his hav¬ 
 ing obtained sufficient food. It is due to the condition 
 
145 
 
 of his nervous system. Whether you give food more 
 frequently or less frequently, his appetite will not 
 change unless the underlying fault can be corrected. 
 Under these circumstances, as the baby takes only the 
 slightest amount of food at each nursing, put him to 
 the breast oftener , and then, if his weight curve doesn’t 
 ascend, use forced feeding, even the stomach tube, be¬ 
 cause there is no reason for his nutrition suffering dur¬ 
 ing the period that you are trying to overcome his 
 nervous tendencies. Lastly, as this neuropathy is in¬ 
 herited from nervous parents, as the baby makes the 
 mother nervous and the mother in turn makes the baby 
 more nervous, at times the only thing we can do is to 
 order a change of environment. If you can get a good 
 wet nurse, a sane woman who takes a perfectly disin¬ 
 terested sort of interest in the child, results frequently 
 are very gratifying. 
 
 3. In all cases, no matter what be the cause of the 
 inanition, don’t neglect the child’s water supply. Chil¬ 
 dren suffer grievously from lack of water. In getting 
 small quantities of breast milk, naturally they reduce 
 markedly their water intake. In your treatment don’t 
 neglect to make up this deficiency. 
 
 The other marked disturbance of nutrition on the 
 breast is dyspepsia. This is very much like the dyspep¬ 
 sia arising on the bottle. 
 
 The gastro-intestinal symptoms are those of vomit¬ 
 ing, regurgitation, diarrhea, anorexia, flatulence, tym¬ 
 panites, and colic. 
 
 General symptoms other than those of the intestinal 
 tract are change of weight curve, change in the quality 
 of the skin, slight temperature, nervous reactions, as 
 sleeplessness and unrest, and decreased immunity to in¬ 
 fection. 
 
 Etiology. —Several, factors may be concerned: 
 
 1. Alimentary influences up to the present have been 
 considered most important, and of these: 
 
 (a) Overfeeding is given by all text-books the first 
 place. Gentlemen, I don’t want to be too radical, but 
 I believe that more and more are we beginning to doubt 
 the importance of overfeeding as a cause. As the im¬ 
 portance of constitution grows in our mind, as we begin 
 to recognize the exudative and the neuropathic type of 
 
 10 
 
146 
 
 child, as we learn to recognize fundamental differences 
 in the baby himself, just so much are we decreasing 
 our emphasis on the outside factors. Irregularity of 
 feeding, in our mind, is perhaps of much more import¬ 
 ance than is overfeeding, and, let me remind you that 
 irregularity of feeding is due frequently to underfeeding 
 rather than to overfeeding. Indeed, we even are begin¬ 
 ning to doubt whether many cases of dyspepsia on the 
 breast result from overfeeding. So great is the adapta¬ 
 bility of the mother’s breast to the baby’s demands— 
 when a baby wants more, more is secreted; when the 
 baby wants less, less is secreted—so great is this adapta¬ 
 bility that if the baby be nursed regularly every four 
 hours it is a question whether many mothers can over¬ 
 feed their babies. Perhaps overfeeding is a factor in 
 those cases in which an undernourished baby is put to 
 the breast of a fine healthy wet nurse. Before the baby 
 has adapted itself to the breast, and vice versa, often 
 too much milk is taken. Such statements are of course 
 heresy, gentlemen; but weigh the baby before and after 
 nursing and see for yourselves. 
 
 ( b ) Of alimentary factors, we believe irregularity of 
 nursing to be most important; and never forget inani¬ 
 tion may produce a picture identical to dyspepsia. 
 
 ( c ) Foreign substances secreted in breast milk and 
 causing this dyspepsia we believe very rare indeed. 
 
 ( d ) Shifting proportions of the different elements, 
 as, for example, too much fat, are frequently described. 
 Undoubtedly, some breast milk contains more fat than 
 the average. As the stools of many of these children 
 are typically fermentative, frequently do I wonder 
 whether perhaps too much sugar is not being secreted. 
 In all cases, however, very little clear-cut, definite, ex¬ 
 act, scientific evidence proves that disturbances arise 
 from this cause.. We may learn more of this later. As 
 I mentioned in our last lecture, one will make fewest 
 grave errors for the present if he considers that invari¬ 
 ably breast milk is absolutely perfect in quality, and 
 disturbances are due only to changes in quantity. 
 
 2. Infections .—The more dyspepsias on the breast, 
 the more do we realize the fundamental influence of 
 infection. A baby has been thriving, becomes infected 
 with a naso-pharyngitis, a bronchitis, an otitis, or a 
 cystitis, and a dyspepsia results. When the infection 
 
147 
 
 has run its course the intestinal tract corrects itself, 
 fermentation ceases, and the stools again become nor¬ 
 mal. It is this type of case in which such frequent 
 errors are made. The mother says the milk is not 
 agreeing with the baby. The physician may prescribe 
 a wet nurse; may take the baby from the breast; may 
 order medicine for the child; may diet the mother, and, 
 in spite of all treatment, improvement occurs. Why? 
 Gentlemen, improvement does not occur from the ther¬ 
 apy; it occurred at this time because the child had 
 recovered from the infection. In all cases of dyspepsia 
 on the breast, don’t neglect searching for parenteral 
 infections. 
 
 3. Our old friends, overclothing, overheating, im¬ 
 proper care, overcooling, are of course never to be for¬ 
 gotten. 
 
 The symptoms depend to some extent upon the cause. 
 Those due to alimentary factors develop gradually. 
 Nervous changes evidence themselves first with dis¬ 
 turbed sleep and restlessness. Later symptoms of the 
 gastro-intestinal tract develop. General symptoms and 
 fever are, as a rule, not very severe. The type due to 
 infection appears rather suddenly in the previously 
 thriving child. General symptoms and fever are more 
 in evidence than in the previous types. 
 
 The severity of the reaction and the course depend 
 upon the child’s constitution ; the better the constitu¬ 
 tion the less the reaction. The alimentary type is usu¬ 
 ally somewhat progressive and often ends in anorexia. 
 The infectious type is short and ends in a cure with 
 recovery from infection. 
 
 The pathogenesis is not absolutely known, hut proba¬ 
 bly has to do with carbohydrate fermentation in the 
 intestinal tract. 
 
 The diagnosis is made from the history. 
 
 The treatment is' relatively easy where alimentary 
 factors can be corrected. Where infection is the basis 
 of the disturbance, wait. In both types, and also in the 
 type which was mentioned at the beginning of the lec¬ 
 ture, powdered casein is of great value. Formerly, 
 this could be obtained as powder. Since the war, I 
 doubt if it is obtainable; but we may make it ourselves 
 by getting the curds of mi^k and putting them through 
 a sieve. You remember that casein is the great agent 
 
148 
 
 for making the intestine alkaline, and as most of these 
 diarrheas are of a fermentative acid nature, casein is 
 the ideal substance to meet our requirements. Give it 
 in doses of one or two teaspoons after each nursing and 
 increase until you obtain the desired results. 
 
 One must never neglect the general care of the child 
 and inquire earnestly into the conditions in the house¬ 
 hold, his clothing and general hygiene. 
 
 One danger in the treatment leads frequently to 
 serious complications. The mother or the physician, 
 not recognizing that an infection is the cause, lays 
 great emphasis upon the importance of the breast milk. 
 Something must have changed the quality of the breast 
 milk. Therefore, we shall take the baby from the 
 breast and not put him back until the milk has cor¬ 
 rected itself, and put nothing into the stomach until 
 the stools are normal. In this treatment, gentlemen, 
 all that we have accomplished is to add to our patient’s 
 troubles the damaging influence of hunger. Frequently 
 he gets better with this treatment; but this change is 
 due to cessation of the infection. Under these circum¬ 
 stances, gentlemen, don’t make unnecessary use of hun¬ 
 ger in your treatment. Children have so much intelli¬ 
 gence—often so much more than we—if you weigh this 
 baby before and after nursing you will find that in¬ 
 stinctively he cuts down his diet. You will find that 
 he drinks far less during these few days than he does 
 ordinarily. It is my custom simply to put the children 
 to the breast, allow them a shorter interval than that 
 to which they are accustomed—five minutes, for ex¬ 
 ample—and to repeat this at the regular feeding time, 
 but never to let them hunger markedly. By ,this pro¬ 
 cedure will you find that the baby’s general nutrition is 
 maintained during these few trying days. 
 
 From the above considerations, gentlemen, you see 
 how unnecessary, in many cases, is a wet nurse. The 
 fault lies so frequently with the baby rather than with 
 the milk, so frequently with outside factors, such as 
 infections, rather than with the mother serself. 
 
 Just one word about very severe diarrheas occurring 
 in the breast-fed. Breast-fed children rarely, it is true, 
 but still definitely develop symptoms almost identical 
 to the alimentary intoxication of the bottle baby. Our 
 previous ideas were that a toxin was being secreted by 
 
149 
 
 the breast milk. I believe this has been definitely dis- 
 proven. I doubt if people ever find human breast milk 
 definitely poisonous to the child. However, in these 
 cases we are learning to recognize other factors. We 
 are learning that parenteral infections may be at fault; 
 that true intestinal infections, such as dysentery, that 
 overheating, may all be the basis of the trouble; and, 
 lastly, we are learning to recognize that children in 
 states of severe decomposition or intoxication, when 
 fed large quantities of any breast milk whatsoever, go 
 down and die with the severest alimentary symptoms. 
 
 The treatment in these conditions is identical to that 
 of the alimentary intoxication of the artificially fed. 
 
 This finishes, gentlemen, the subject of infant feed¬ 
 ing. There are many, many phases of this interesting 
 subject which I should like to discuss with you. Time, 
 however, forbids. If you have followed me carefully, 
 you will perhaps have obtained some idea of the meth¬ 
 ods of our Middle West as I understand them. I do 
 not urge these exclusively upon you. I trust that you 
 have become interested and will investigate the teach¬ 
 ings of the great men all over this country of ours. 
 After you have a comprehensive view of the whole field, 
 select the method which pleases you most, or, better yet, 
 with your perfectly neutral viewpoint, you may be in a 
 position to select from the different teachings many 
 points of value, and I trust that you will be able to use 
 them all, no matter what be their source, to aid sick 
 and suffering children. 
 
LECTURE XI 
 
 ACUTE ANTERIOR POLIOMYELITIS 
 
 Gentlemen, you have requested a discussion of acute 
 Anterior Poliomyelitis. This disease is of particular 
 interest, not only due to the present epidemic, but also 
 because its history is of comparatively recent origin 
 and because this history shows our ever steady, suc¬ 
 cessful progress. From great groups of paralyzed 
 crippled children Heine, a German physician, in 
 the year 1840 thought he recognized a distinct disease, 
 described it as children’s paralysis, and reasoned that it 
 must have its origin in the spinal cord. In 1860 he re¬ 
 described this condition with more emphasis, insisted 
 upon it as a clinical entity, and again insisted that it 
 must be related to the spinal cord. Cornil, a French¬ 
 man, in 1863 by pathological studies showed that in 
 these cases, changes were to be found in the anterior 
 horn cells of the gray matter of the spinal cord. Re¬ 
 peatedly has this observation been confirmed. Of ex¬ 
 treme value were contributions of the French school in 
 the year 1883. Having obtained for the first time per¬ 
 fectly fresh specimens, they showed that the inflamma¬ 
 tion was not limited to the anterior cells exclusively, 
 but extended throughout the entire gray matter, and 
 even at times involved some of the white. Thus by the 
 year 1883 our knowledge had so far progressed that we 
 knew the condition to be not exclusively an anterior 
 poliomyelitis, but a diffuse inflammation of the cord, 
 a true myelitis. Strange that this observation has at¬ 
 tracted so little notice. Repeated confirmation, how¬ 
 ever, from all parts of the world proves its truth. 
 
 At present our knowledge of the pathology may be 
 summed up as follows: 
 
 A. Of the cord. 
 
 1. Gross examination of a freshly cut section shows 
 the cord to be swollen, edematous, dark red with slight 
 protrusion of the gray matter. These areas of involve¬ 
 ment exist as cylinders scattered throughout the cen¬ 
 tral nervous system about half an inch in length and 
 follow the course of the blood vessels. 
 
151 
 
 2. Microscopic examination. 
 
 ( a ) The fresh specimen would show a profuse in¬ 
 flammation throughout the whole gray matter, being 
 most marked, however, around the anterior cells. The 
 inflammation is most marked along the course of the 
 vessels, which are dilated, distended, and often throm¬ 
 bosed. The ganglion cells show all stages of degenera¬ 
 tion. A slight meningitis is noticeable. 
 
 ( b ) Examination of an old case shows no evidence 
 of acute inflammation. The gray matter has practi¬ 
 cally recovered, with the exception of destruction of the 
 anterior horn cells; and in their place is scar-tissue 
 formation. These changes are most marked in the 
 lumbar segments. 
 
 B. As regards the other organs. 
 
 1. A fresh case shows inflammation and irritation of 
 the mucous membrane of the intestine. 
 
 2. In an old case the affected muscles have atrophied 
 almost to disappearance or have been replaced by fat 
 infiltration. The bones of the affected extremity are 
 .shortened and decreased in thickness. 
 
 Just as our progress in diseases of nutrition required 
 first the exhaustion of pathology and required the newer 
 aids, such as repeated clinical studies and studies of an 
 etiological nature, just so have we required these aids 
 in our study of acute anterior poliomyelitis. 
 
 Clinical Studies .—Among the first of the clinicians 
 to lay emphasis upon the infectious nature of the dis¬ 
 ease was Strumpell of Leipzig. He argued that from 
 the mode of onset, the sudden rise of fever, the gastro¬ 
 intestinal symptoms, the perspiration, and the general 
 malaise, the disease must be an infection; but he gave 
 no proof. Epoch-making in this respect was the'Study 
 of Medin in 1899 and of Ivan Wickman in 1905, both 
 of Sweden, who carefully studied and described epi¬ 
 demics of this disease. From these extremely import¬ 
 ant studies we learn that the disease is not only infec¬ 
 tious, but also is contagious in nature; that not only is 
 it transmitted from patient to patient, but also that it 
 may be.carried by a second person. Studies of epi¬ 
 demics from all over the world repeatedly have con¬ 
 firmed these first brilliant observations. A large epi¬ 
 demic was described in Hew York in 1907 and 1908. 
 Few of the observers lay such definite emphasis upon 
 
152 
 
 the contagiousness of the disease as did Wickman, with 
 the exception of Mueller in Marburg and Treves in 
 England. The latter epidemic, consisting of only eight 
 cases, is of special interest, because Treves is able to 
 show that there was a clear-cut definite incubation 
 period of six days as the disease traveled from patient 
 to patient. 
 
 From the standpoint of clinical observation these 
 studies are of incalculable value. They have shown: 
 
 1. The incubation varies from one to eight days. 
 
 2. The disease, though infinitely more common in 
 children, not rarely attacks adults. 
 
 3. The disease is essentially a summer sickness, rag¬ 
 ing particularly during the months of July to October. 
 
 4. As regards means of distribution, the infection 
 seems to follow the railroads, country roads, and per¬ 
 sonal contact among neighbors. Transmission seems 
 to be essentially of human source. 
 
 5. Of particular value were these studies in eluci¬ 
 dating atypical types. Before the days of Wickman, 
 severe nervous diseases, such as encephalitis, acute 
 ataxia, and Landry’s paralysis, had been ascribed to 
 undiscovered, unknown, mysterious cases. Sudden in¬ 
 crease of these clinical entities during periods of polio¬ 
 myelitis epidemic show that these, too, must be classed 
 as belonging to that disease. 
 
 6. Lastly, Wickman ha.s brought to our attention the 
 abortive types of this infection. A little child is taken 
 sick, shows the slightest transient paralysis, and recov¬ 
 ers speedily. Only the occurrence of an attack of acute 
 anterior poliomyelitis in his brother or sister just pre¬ 
 vious to or just following this attack shows that this 
 child has suffered from an abortive attack of this 
 disease. 
 
 THE SYMPTOMS 
 
 Prodromes are rare. Occasionally does the mother 
 tell you that the child has suffered from loss of appe¬ 
 tite. As a rule, however, the child is stricken sud¬ 
 denly. 
 
 The onset may show five different variations: 
 
 1. The abortive type, in which the paralysis is very 
 slight and transient. Usually this is overlooked, unless 
 it occurs during an epidemic. 
 
153 
 
 2. The meningeal type, in which the onset is typical 
 to that of acute menigitis, conclusions, rigid neck, 
 Kernig, and coma necessitate an immediate lumbar 
 puncture. 
 
 3. The encephalic type. Convulsions are usually 
 one-sided or involve one extremity; but the coma, the 
 severe vomiting, the strabismus, and the changed respi¬ 
 ration all point to serious intracranial injury. 
 
 4. The type in which the lesion is in the medulla or 
 in the pons leads to rapid death from circulatory or 
 respiratory failure. This frequently is not diagnosed 
 without the presence of an epidemic. 
 
 5. The spinal type is the one which you gentlemen 
 will be most likely to meet, and therefore just a few 
 words about the symptoms. 
 
 I. The initial stage is characterized by a sudden on¬ 
 set, with fever reaching sometimes 105 degrees. A chill 
 is rare. In this stage a sore throat, coryza, or bronchi¬ 
 tis may be evident. Perspiration is profuse. The baby 
 vomits, and may show intestinal disturbance severe 
 enough to be associated with bloody stools. The main 
 symptoms are those of the nervous system. Drowsi¬ 
 ness and apathy may give way to coma. Convulsions, 
 especially in the encephalic type, may monopolize your 
 attention. Pain of a meningeal nature is almost invari¬ 
 ably present, and leads frequently to a false diagnosis. 
 Pain is most marked in the back and in the legs. As 
 the child not infrequently has just met with an injury, 
 the mother may complain to you of the knee joint. 
 Careful examination, however, will show that the pain 
 is not limited exclusively to the knee, but that the child 
 cries whenever the extremity is touched. The child 
 does not wish to be disturbed or moved. Suboccipital 
 headache may be most severe. Rarely are there sphinc¬ 
 ter disturbances, no-r are there disturbances of sen¬ 
 sation. 
 
 As you see, gentlemen, during this stage the symp¬ 
 toms are those of acute infection. Nothing definite 
 can as yet be said. We exhaust our means of diagnosis. 
 We make a blood count. Up to recently leucopenia was 
 considered characteristic. In this recent epidemic, how¬ 
 ever, we see that blood counts have varied up to 12,000. 
 So from leucocyte counts we obtain little of value. 
 
154 
 
 A lumbar puncture in many cases absolutely is indi¬ 
 cated. In beginning cases the fluid escapes under slight 
 increase of tension. It is clear, however; shows no 
 marked change in the cell count, but does show evi¬ 
 dences of spinal cord irritation, such as positive globu¬ 
 lin test. 
 
 The technique for these is as follows. The Hoguchi 
 test is the most valuable. 
 
 (a) Noguchi: 
 
 .2 cc. centrifuged fluid in test tube. 
 
 Add .5 cc. 10% butyric acid. Boil and quickly add 
 
 .1 cc. 4% NaOH and boil again. 
 
 (A fine or coarse granular precipitate is positive— 
 usually found within 20 minutes. If not found at the 
 end of 2 hours, absolutely negative.) 
 
 (b) Ross- Jones: 
 
 1 part sat. sol. aqueous Ammon. Sulph. superimpose 
 equal vol. of C. S. fluid by allowing to flow down side 
 of slanted test tube. 
 
 A contact ring white and granular in 3 minutes is 
 positive. 
 
 \ 
 
 II. This stage of maximum intensity lasts up to 
 £even days, the fever falling usually on the third or 
 fourth. The diagnosis is made by the rapid onset of 
 an acute severe paralysis, occurring during the 
 first tw T enty-four to forty-eight hours. This paralysis 
 may involve any group of muscles or all, and is charac¬ 
 terized by the fact that it comes .suddenly from a clear 
 sky, that it is a total paralysis, and that it is nonpro¬ 
 gressive. It comes with one severe stroke, and does not 
 travel from muscle group to muscle group. The reflexes 
 of the affected muscles are diminished if the lesion be in 
 the cord, or increased if it be in the brain. During 
 this stage not infrequently does death occur from the 
 acute toxemia of the infection or from paralysis of the 
 respiratory muscles. This stage lasts not over a week, 
 and, if the child be spared, rapidly proceeds to 
 
 III. The period of retrogression. For the first six 
 weeks after the onset of the paralysis recovery of the 
 infected muscles is rapid. After these six weeks recov¬ 
 ery proceeds more slowly, but it is said does continue - 
 for months or even years. The recovery is practically 
 never complete, however. Those muscles whose ener¬ 
 vating cells in the spinal cord have been absolutely 
 destroyed will never regain their function. Which mus¬ 
 cle groups are to be thus affected one may surmise by 
 
155 
 
 the end of the first week. At this time atrophy is 
 already marked and the reaction of degeneration pres¬ 
 ent. Gentlemen, in those cases where the reaction of 
 degeneration is early present the prognosis for recovery 
 is bad. These muscles atrophy almost to disappear¬ 
 ance, the bones in the affected extremities become 
 shorter and smaller, the surrounding skin cold, cyam 
 otic, and shows vaso-motor changes. Contractures de¬ 
 velop from 
 
 (a) Paralysis, leaving a muscle group without its 
 antagonist; 
 
 (b) Static causes, such as gravity and the weight of 
 bed clothing; 
 
 (c) Definite contractures in the affected muscles 
 from changes in their nutrition. 
 
 Diagnosis .—The diagnosis is relatively easy. His¬ 
 tory of the onset followed by acute paralysis rules out 
 almost every other condition. A few rare nervous 
 lesions may cause confusion. These might be hemor¬ 
 rhage into the cord, Spina Bifida with its resulting 
 paralyses, birth paralysis and congenital muscular de¬ 
 fects. The pain of scurvy, involving as it does particu¬ 
 larly the knee joint, may at times cause confusion with 
 a pain associated with Poliomyelitis. Perhaps the most 
 confusing condition for differentiation is a multiple 
 neuritis. Careful history and examination, however, 
 will prevent difficulties. 
 
 The history of multiple neuritis shows a previous 
 typhoid, scarlet, diphtheria, pertussis, or mumps; or, 
 in an older child, may show lead, arsenic, or alcohol. 
 Poliomyelitis on the other hand, comes from a clear 
 sky, with one stroke, having no predisposing cause. 
 
 The fever in multiple neuritis is intermittent and 
 continuous, often lasting for weeks. In poliomyelitis 
 the fever lasts a few days. 
 
 The paralysis in multiple neuritis is symmetrical and 
 often progressive, one muscle group after the other 
 being involved, and the course is prolonged. In poli¬ 
 omyelitis paralysis is usually asymmetrical, is typi¬ 
 cally nonprogressive, and recovery in all but a few 
 muscle groups very rapid. If the upper extremity is 
 affected, multiple neuritis by preference selects the 
 muscles enervated by the radial nerve, poliomyelitis the 
 muscles of the shoulder girdle. 
 
156 
 
 Prognosis .—Since we have come to recognize tlie 
 severe forms, such as Landry’s paralysis, we are learn¬ 
 ing that the prognosis as to life is not as good as was 
 previously held. Still in the majority of cases children 
 make recovery. 
 
 Treatment .—The treatment self-evidently must be of 
 the cause. Sane, rational treatment must be directed 
 to overcoming the virulent poison and neutralizing the 
 effects of the agent which is so disastrous to the cells 
 of the central nervous system. This brings us to the 
 fascinating studies concerning the etiology of this 
 disease. 
 
 The year 1909 was epoch-making as regards history. 
 Studies from various countries, Flexner and Lewis in 
 New York, Leiner and Wiesner, also Landsteiner and 
 Popper in Vienna, and Roemer and Mueller in Mar¬ 
 burg, showed that by injecting the medullary substance 
 of patients dying with this disease into monkeys the 
 disease could be transmitted to these animals. And, 
 what was still more vital, the contagion could be car¬ 
 ried from one infected monkey to another. So the year 
 1909 shows us that the virus causing acute anterior 
 poliomyelitis is a living virus. Prom this time the 
 studies have been carried on mainly by the brilliant 
 group of scientists of the Rockefeller Institute in New 
 York. 
 
 Me now have learned that the disease is caused by a 
 definite micro-organism. It is very small, barely visible 
 under the microscope, but can be obtained from the 
 diseased tissues, and grows with difficulty in artificial 
 medium. It is located in the central nervous system, 
 the mucous membrane of the nose, throat, and intestine, 
 but not as yet found in the blood of patients sick with 
 this disease. No matter what be the clinical type of on¬ 
 set, the location is the same. It enters the body through 
 the nose and throat, whence it proceeds by lymphatics 
 to the brain and cord. No matter how introduced into 
 the body, whether by the nose, throat, or intestine, or 
 whether injected into the abdomen, blood, or brain, in 
 all cases does the virus leave the body by means of the 
 secretions of the nose and throat and from the intestine. 
 Healthy persons in contact with a sick child may har¬ 
 bor this virus in their nasal secretions for weeks. One 
 case is reported definitely in which a healthy person 
 was a carrier for a period of five months. 
 
157 
 
 The virus leaves the central nervous system rather 
 rapidly, not being found therein for longer than two 
 weeks. In the secretion of the nose and throat it re¬ 
 mains longer, generally disappearing, however, after 
 the fourth or fifth week. 
 
 It is a resistant virus, withstanding drying and weak 
 carbolic solutions very well, and so is readily adapted 
 to being carried by fingers, by infectious droplets, 
 coughing, sneezing, kissing, and dust. Attempts have 
 been made to lay the blame for transmission of this 
 virus to insects, such as the stable fly, mosquito, bed¬ 
 bugs, and lice. This has not as yet been proven; but 
 one thing have we definitely learned: The common 
 house-fly, after being allowed to feed upon nasal secre¬ 
 tions of a sick child, may harbor the virus in his intes¬ 
 tinal tract for forty-eight hours. 
 
 During periods of epidemic domestic animals such 
 as pigs, dogs, cats, and poultry, frequently are affected 
 with acute paralyses. Attempts have been made to fix 
 the blame upon these creatures, but newer studies have 
 shown that these paralyses are due to an entirely differ¬ 
 ent disease and should in no way be confused with 
 poliomyelitis. 
 
 The disease leaves a definite immunity, the blood 
 destroying or neutralizing the virus for over twenty 
 years after infection. It is this immunity which offers 
 us the greatest hope for a successful treatment. Already 
 have vaccines been employed. In the experimental 
 work their use has been attended with the greatest of 
 success. Animals thus injected become immune to 
 lethal doses of the virus, but the occurrence of an occa¬ 
 sional paralysis during this treatment makes it as yet 
 inapplicable to clinical use. Without a doubt the bril¬ 
 liant scientists now at work will shortly discover the 
 cause of this danger, and by weeding it out will offer 
 us the one great hope of prevention that we have. 
 
 Hot only has the vaccine treatment proven successful 
 in prophylaxis, but also has the serum of recovered 
 children and monkeys proven of value in active treat¬ 
 ment. 
 
 TREATMENT 
 
 Prophylactic treatment requires considerable care. If 
 possible, the patient should be placed in a hospital 
 ward. Studies have shown that the virus is easily con- 
 
158 
 
 trollable. In environments of good hygiene, where the 
 urine and howel movements are disinfected, where the 
 nasal and throat secretions are caught in gauze and 
 burned, where promiscuous handling of the patient is 
 not allowed, never does the disease spread by direct 
 contact. It is as readily controllable as typhoid in a 
 hospital ward. If the hospital is not available, the 
 patient should be isolated in his home. The nurse in 
 charge of the case must understand thoroughly that 
 she is handling an acute infectious disease. She must 
 understand the necessity of rigid disinfection of all the 
 excreta; she must know the necessity of catching the 
 throat and nasal secretions and burning the cloths; she 
 must know the absolute urgency of keeping adults, par¬ 
 ticularly anxious parents, from fondling the sick baby. 
 All our observations up to the present show that the 
 disease is carried more by human source than by any 
 other agency. We must attempt with every means in 
 our power to protect other well babies from the danger 
 of adult carriers of this disease. 
 
 Self-evident, of course, is proper screening and pro¬ 
 tection of the infected child from flies. 
 
 ACTIVE TREATMENT 
 
 In all cases where serum of recovered patients may 
 be obtained the intraspinous use of this is our ideal 
 procedure. It is the only method of treatment from 
 which we may hope for cure. Lumbar puncture, how¬ 
 ever, must be made with care, for with the hyperemic 
 condition of the cord sudden relief of pressure may 
 result in hemorrhage. Release the fluid slowly and 
 gradually and inject approximately as much serum as 
 you have withdrawn fluid. This must be repeated sev¬ 
 eral times. 
 
 Failing serum, one may in desperation try the recom¬ 
 mendation of Meltzer, viz., the intraspinous injection 
 at repeated intervals of .5 to 1 cubic c. of adrenalin 
 chloride in salt solution. In some cases, for reasons 
 which I do not know, clinical improvement seems to 
 have followed this treatment. 
 
 Lastly, urotropin may with some degree of ration¬ 
 ality be given. This drug is an antiseptic and is known 
 definitely to be excreted into the spinal canal. Monkeys 
 
159 
 
 fed with urotropin in a certain proportion of cases show 
 more resistance to infection than did untreated 
 monkeys. 
 
 The general treatment is purely symptomatic. Pain 
 may be relieved by narcotics or salicylates. Severe 
 convulsions at the onset not infrequently are relieved 
 by the diagnostic lumbar puncture. Still continuing, 
 however, they may be controlled by bromides, chloral, 
 and narcotics. 
 
 Consensus of opinion seems to be that a prolonged 
 period in bed is most to be advised. During this period 
 massage, electricity, and gymnastics are advised and 
 employed. I know little of osteopathy, but it seems to 
 me that this condition should be an ideal indication 
 for an osteopath. The resulting deformities with loss 
 of functions are best to be treated along surgical lines, 
 and by muscle transplantation. 
 
 Recent and almost experimental in nature is the sur¬ 
 gical procedure of nerve transplantation. The surgeons 
 take a nerve from an unimportant group of muscles and 
 transfer it to the degenerating affected nerve of a more 
 important group. In this way restoration of function 
 sometimes results, and this surgical procedure offers us 
 considerable hope. 
 
LECTURE XII 
 
 OBSCURE CAUSES OF FEVER 
 
 Gentlemen, today I thought we might consider some 
 of the obscure causes of fever, cases which you are 
 called to see, where fever is present, hut where physical 
 diagnosis is absolutely negative. It is in this group of 
 cases that the children’s specialist has considerable ad¬ 
 vantage over the general practitioner. To go into 
 detail would require too much time, and so I am just 
 going to give you a little scheme by way of illustration. 
 
 First. You are called to see an infant two days old. 
 The temperature is between 102 and 104 degrees. 
 Physical examination is absolutely negative. In a few 
 days the temperature may go down or, in rare instances, 
 after a short while the child may die. A diagnosis has 
 never been made. 
 
 This condition has most forcibly been brought to our 
 attention by Holt, who describes it as Inanition Fever. 
 It is due to failure of the breast to secrete milk, the 
 child meanwhile suffering from insufficient food and 
 from what now is believed to be even more important, 
 insufficient water. With the appearance of milk in the 
 breast and the satisfying of the child’s demands for 
 fluid the condition disappears. In rare cases where 
 one has concentrated exclusively upon the child, failing 
 to note the insufficiency of breast milk, death may occur 
 from lack of food. In such cases if the breast does not 
 start secreting after a reasonable period, get a wet 
 nurse or order a bottle, and your troubles will be over. 
 
 Second. You are called to see a premature or the 
 smaller one of twins. The child has a temperature of 
 105, hut physical examination reveals nothing. Half 
 an hour after your examination the temperature is 
 normal. Don’t forget, gentlemen, that these little chil¬ 
 dren are very susceptible to external temperature. In 
 this latter case the child has been in an overheated in¬ 
 cubator or has been surrounded by too many hot-water 
 bottles and too heavy blankets, taking on the tempera¬ 
 ture of the surrounding atmosphere. During your ex¬ 
 amination the little one becomes cooled again. ♦ Never 
 
161 
 
 forget, when you examine a weak child with fever— 
 before you get ready your doses of medicine, the enema 
 can, and your hypodermics—to examine the environs 
 in which the little one has been placed. 
 
 A mother brings a little child of four to six years of 
 age fearful of tuberculosis. There is a history of tuber¬ 
 culosis in the family. The child coughs and expecto¬ 
 rates. The temperature is down in the morning and 
 up every evening. Examination is without result. The 
 Pirquet Test is negative. Sputum examination reveals 
 no tubercle bacilli. You apply more delicate tests, in¬ 
 jecting tuberculin into the skin—the intracutaneous 
 method. This is of no avail. In desperation, never¬ 
 theless, you insist, “This must be tuberculosis any¬ 
 way/’ It is not, however. It is a chronic inflamma¬ 
 tion of the naso-pharynx. Careful examination of 
 throat will show mucus falling from the back of the 
 nose into the pharynx. Sometimes infected adenoids 
 may be the cause, but not infrequently this condition 
 exists without them. Chronic posterior naso-pharyn- 
 gitis has given rise to many false diagnoses of tuber¬ 
 culosis. 
 
 The next condition in connection with the subject 
 of infant feeding belongs almost exclusively to the do¬ 
 main of the pediatrician, so common is it to be found in 
 children. After an attack of pharyngitis you are called 
 to see a child whose temperature may be 104 or 105 
 degrees. You search carefully for the cause of this 
 fever and find absolutely nothing other than perhaps 
 a very slight rigidity of the head or neck, tending to 
 a mild torticollis. You make little of the condition, 
 order medication, and leave. A few days later, amid 
 great excitement and urgent appeals, you hasten to the 
 child’s bedside. He is cynanotic, gasping for breath, 
 and he holds his head drawn backward, attempting in 
 every way possible to- relieve pressure upon the larynx. 
 Respiration is accompanied by a loud gurgling noise. 
 You ask yourself, “Can I possibly have overlooked a 
 laryngeal diphtheria?” You get your incubation outfit 
 ready. You call the surgeon, who sharpens his knives, 
 preparatory to performing: tracheotomy. Suddenly the 
 symptoms are relieved by the rupture of a retro-pharyn¬ 
 geal abscess. Gentlemen, no condition more frequently 
 is overlooked than is retro-pharyngeal abscess in chil¬ 
 dren. Upon inspection of the throat it is not visible. 
 
 11 
 
162 
 
 It can never be seen unless it bas assumed large pro¬ 
 portions. Tbe only way to diagnose it when suspected 
 is to palpate very gently the back of the throat with 
 the finger. The abscess is apparent as an area of soft 
 fluctuation about the level of the base of the tongue 
 and just to one side of the median line of the pharynx. 
 
 The treatment consists of incision with a guarded 
 scalpel, or, better yet, guiding yourself with a finger of 
 the left hand to the area of greatest fluctuation, with 
 the right hand insert an artery forceps about a quarter 
 of an inch and spread open. Hold the child’s head for¬ 
 ward so that the pus gushing forth will not fall into the 
 trachea and cause pneumonia. 
 
 It is not necessary, of course, to remind you that 
 syphilis and tuberculosis cause chronic temperatures 
 with at many times few physical findings. In all cases 
 of persistent temperature never forget to consider these 
 two diseases. 
 
 Again, gentlemen, the telephone rings in the dead 
 of night. The mother calls you, complaining in dis¬ 
 tressed tones: “Reginald has a terrible attack of the 
 colic. The poor dear is suffering terribly. He has 
 vomited up some sour-smelling undigested fluid, and I 
 am absolutely sure that he has eaten something that 
 is producing awful indigestion.” The vibrating win¬ 
 dow-panes responding to Reginald’s lusty cries show 
 you that the mother’s anxiety may to some extent be 
 justified. You rush to the bedside, give peppermint 
 water, give enemas and colonic flushings, order hot 
 water bags to the abdomen, and busy grandmother in 
 making a turpentine stupe. As a matter of fact, the 
 child is suffering from otitis media. I am not sure as 
 regards this climate, but at home whenever a child gets 
 any sort of infection of the respiratory passages he gets 
 almost invariably an otitis media. Hot necessarily 
 does this infection proceed to the point of suppuration, 
 but it does proceed to a point sufficient to cause pain. 
 I do not wish to tread upon the ground of the ear 
 specialist, but from the standpoint of the pediatrician 
 otitis media with very simple technique can frequently 
 be diagnosed. In a normal child, if you exert mild 
 pressure upon the tragus he pays little attention. 
 I don’t mean, of course, that you must exert sufficient 
 pressure to attempt to penetrate into his cranial cavity. 
 Be very gentle and mild. If the child is crying, he 
 
163 
 
 continues to cry. In a child with an otitis media this 
 same mild pressure causes him definitely to wince, to 
 jerk his head away sharply, to screw up his face, and, 
 if he is not crying, to cry loudly. I dare say in 90 per 
 cent of cases with this simple procedure you may diag¬ 
 nose some involvement of the ear, either external or 
 middle. So, when Reginald has the colic, especially 
 if he has a little cold and cough at the same time, don’t 
 forget this colic may be otitis media. 
 
 Lastly, you are called to see a rather sick-looking 
 infant, usually a little girl. The skin is pallid. Dark 
 rings encircle the eyes. The appearance is so character¬ 
 istic that frequently one is justified in suspecting the 
 diagnosis from first glance at the baby. The temper¬ 
 ature is low in the morning, perhaps subnormal, and 
 may rise to 104 or 105 in the afternoon. Repeated 
 physical examination is of absolutely no service. The 
 mother tells you that at times the child suffers from 
 colic. You diagnose all sorts of terrible conditions. 
 You think of malignant endocarditis or of pyemia. The 
 temperature curve suggests malaria and leads to large 
 doses of quinine. As a matter of fact, gentlemen, the 
 child is suffering with a pyelo-cystitis. In all cases 
 where the temperature is persistent for a day or two, 
 particularly in a girl, where physical examination is 
 negative, insist upon a urinalysis. Many, many times 
 will you be rewarded. The centrifuged specimen will 
 be loaded with pus cells. In order to make these cells 
 more apparent a drop of dilute acetic acid added to the 
 centrifuged specimen will bring out the nuclei of these 
 cells and make the diagnosis easier. 
 
 In treating the condition, remember that it runs a 
 rather chronic course. The urine, contrary to adult 
 cystitis, is acid. , For this reason hexamethylamine, 
 which acts only in acid medium, may be given in doses 
 of 1 grain three times daily. Remember, however, that 
 this drug is irritating to the kidneys and should be used 
 with care. Perhaps the best treatment, after all, is the 
 use of the alkaline diuretics, potassium citrate or ace¬ 
 tate in doses of 15 or 20 grains daily, and increased 
 until the urine becomes alkaline. After the latter is 
 accomplished hexamethylamine is ineffective; but the 
 simple change to alkalinity frequently is the only 
 therapy necessary, and the case with mild remissions 
 proceeds rather rapidly to cure. 
 
LECTURE XIII 
 
 CONVULSIONS 
 
 Gentlemen, when called to a case of convulsions in a 
 child, particularly if it be your first case, you will be 
 bewildered. The white-faced mother, the anxious 
 father, the severe, critical grandmother, the excited 
 neighbors, and the austere nurse all look at you more 
 as an enemy than a friend. Mother urges you to do 
 something quickly. Grandmother says to the neigh¬ 
 bors, “He looks so young!” The nurse looks at you 
 with the expression of “Wonder if this treatment is 
 going to be like that of Dr. X” who, you know, looks 
 wise behind his ambush of whiskers. Under these 
 trying circumstances, if you wish to be completely 
 master of the situation you must at once provide work 
 for everybody. Get grandma and all the neighbors out 
 of the way by ordering them to prepare a hot bath. 
 One word of caution, however. Grandma in her enthu¬ 
 siasm to help frequently heats the water hot enough 
 to boil the baby. Many a child has been badly injured 
 in this way. So before making use of the bath, always 
 test the temperature first with your finger. Mother 
 we can occupy by ordering material for a soap-suds 
 enema. Father we send to the drug store for .some 
 medicine, and the nurse shall undress the baby. 
 
 In treating a case of convulsions don’t make the mis¬ 
 take which so frequently is made, namely, considering 
 that you have done your duty simply by relieving the 
 child for the moment. Don’t forget that a convulsion 
 is not a disease, but is a symptom, a symptom of some 
 great disturbance of the nervous system. It is your 
 duty not only to relieve the convulsion, but also to 
 study the child carefully and to attempt to determine 
 the cause. The treatment of the immediate convulsion 
 is easy. Depending upon which is prepared first, the 
 hath or the soap-suds, use either the tub or the enema. 
 If this does not control the situation, without wasting 
 any more time you may resort to the use of morphine. 
 Give a hypodermic of gr. 1-100 to a new-born baby, of 
 1-50 gr. to a babe of six months, 1-25 gr. to a child of 
 
165 
 
 one year, and 1-16 gr. to a two-year-old. In the ma¬ 
 jority of cases morphine is sufficient. If not, chloral 
 hydrate is a valuable adjunct. Send for Gr. XV and 
 dissolve these in a little starch water. Use half this 
 solution for a rectal instillation, thus giving about Gr. 
 YII of chloral. The child quiets in ten to fifteen min¬ 
 utes and falls into a peaceful sleep lasting about two 
 hours. If the first injection of chloral is expelled, the 
 second dose may be given. As this drug is very irri¬ 
 tating to the stomach, it should not be given through 
 the mouth. In extreme cases a few whiffs of chloro¬ 
 form may be offered. 
 
 Having quieted the spasm, your duty has barely com¬ 
 menced. It is not sufficient to leave and to tell the 
 mother, “The baby is over its trouble. If he seems 
 sick again, call me.” This is inexcusable carelessness. 
 In such a case, gentlemen, it is our duty to discover the 
 underlying cause of the disturbance. For this reason 
 I have prepared a little table showing the different 
 causes of convulsions, a table which may be of service 
 to you. 
 
 I. Convulsions due to direct irritation of the brain. 
 
 a. Brain hemorrhage is a frequent source of trouble. 
 When following a difficult labor or following instru¬ 
 mental delivery the baby shows spasms, be suspicious 
 of meningeal hemorrhage. 
 
 b. Malformations of the brain in children of alco¬ 
 holic or degenerate parents frequently causes this 
 symptom. 
 
 c. Hydrocephalus. 
 
 d. Brain Tumor. 
 
 e. Brain Abscess. 
 
 Convulsions due to the above are characteristically 
 without fever and often one-sided. 
 
 II. The group due to reflex causes is emphasized 
 particularly by American authors. Such factors would 
 be 
 
 a. Severe injury or accident. 
 
 b. Renal colic. 
 
 c. Phimosis. 
 
 d. Uentition. 
 
 e. Worms. 
 
 The latter three we shall refer to later. 
 
 III. Another group particularly emphasized by all 
 writers is the toxic group. 
 
166 
 
 a. Don’t forget, gentlemen, that the onset of any in¬ 
 fectious disease may be ushered by a convulsion. In¬ 
 deed, so frequent is this phenomenon that it may be 
 compared to the chill of an adult. When called to such 
 a child, when the convulsion subsides under the influ¬ 
 ence of a hot bath or a colonic flushing, don’t say 
 simply, “Baby ate something that did not agree with 
 him.” Tell the mother that the above might have been 
 the case, but, also, “Mother, possibly the baby is get¬ 
 ting scarlet fever, measles, whooping-cough, or pneu¬ 
 monia,” and in your own mind keep reserved menin¬ 
 gitis, and in times like the present, poliomyelitis. 
 Convulsions at the onset of an infectious disease are 
 of little signifiance, but a convulsion occurring during 
 the course of an infectious disease is grave. Such an 
 occurrence means that an area of inflammation has 
 been established in the brain and that if death does not 
 occur permanent paralysis will result. Beware of these 
 convulsions occurring during the course of infectious 
 disease. 
 
 b. Acute nephritis may have its onset with a con¬ 
 vulsion. Don’t forget urinalysis. 
 
 c. Food is an important factor, either good food 
 given to the young infant in improper proportions or 
 spoiled food to an older child. 
 
 The above three types are characterized by high 
 fever. When called to such a case, instead of ordering 
 a hot bath, one may sponge the baby with lukewarm 
 water, apply cool cloths to the head, give a bath at a 
 temperature slightly below that of the body, or a col¬ 
 onic flushing of water a few degrees below that of the 
 body. 
 
 d. One of the toxic causes upon which not sufficient 
 emphasis is placed, either by Americans or by Euro¬ 
 peans, is the group included under the term “Atelec¬ 
 tasis.” This means collapse of the lungs. You would 
 suspect atelectasis with a following history: The baby 
 is a premature, is the smaller one of twins, or is simply 
 a weak child. He usually is under one month of age. 
 The mother or nurse tells you, “This is the best baby I 
 ever have seen.” He sleeps all the time; he never cries; 
 he doesn’t fuss about his bottle.” When you get this 
 history, beware! The baby is not quiet because he is 
 unusually good; he is quiet because of his extreme 
 
167 
 
 weakness. He is too weak to cry. He is too weak to 
 call for his food. Mother or nurse, thinking he is so 
 good, doesn’t wake him up for his feedings. Hot get¬ 
 ting sufficient food, his strength becomes less and less. 
 The muscles of respiration are affected, and one fine 
 day they are not strong enough to move his chest. He 
 is too weak to breathe, and now the little alveoli of the 
 lungs collapse. He becomes very cyanotic, and when 
 the carbon dioxide tension in the blood becomes suffi¬ 
 ciently high a convulsion results. 
 
 Vou see, gentlemen, what a terrible mistake one 
 would make by treating this child as one treats the 
 others. What this child needs is not depressants, is 
 not chloroform, not chloral, not bromides, certainly not 
 morphine; but what he needs is stimulation. He needs 
 a hypodermic of camphor in oil, a hypodermic of 
 adrenalin, oxygen, if obtainable, and artificial respira¬ 
 tion. He may be placed in a warm mustard bath and 
 sprayed very gently with water just a bit cooler than 
 that of the bath. But remember that he is almost dead, 
 and under no circumstances do anything to cause any 
 sort of a shock. Having combatted the acute attack, 
 shall we leave, thinking we have done our duty? Under 
 no circumstances. This child may have fifteen such 
 attacks a day. We must instruct nurse or mother con¬ 
 stantly to be on the lookout for a recurrence. We 
 rapidly must build up this baby’s strength. We must 
 wake him up regularly for feeding, and if he be too 
 weak to nurse, we must force feeding with a medicine 
 dropper or a stomach tube. Several times a day we 
 use a warm bath followed by the gentlest sort of mild 
 spray, just enough to make him take a few deep breaths, 
 expand his chest muscles, and cry, but never to shock 
 him. We may pinch him a little to make him cry, and 
 under no circumstances let him sleep so long that he 
 misses the feeding which should come every two hours. 
 This condition of atelectasis is a source of frequent 
 death in tiny infants, and certainly deserves your 
 study and your consideration. 
 
 IV. The group due to constitutional factors has par¬ 
 ticularly been emphasized by the European schools. 
 First and foremost is 
 
 a. The condition known as Spasmophilia, which 
 means simply tendency toward spasms. This group is 
 
168 
 
 of ever growing importance in our daily practice. One 
 would suspect Spasmophilia with a history of artificial 
 feeding or of prolonged breast feeding without the addi¬ 
 tion of other food. Either one of these two factors pre¬ 
 disposes to rickets, with which Spasmophilia is closely 
 associated. With such a history and when examination 
 shows the beading of the ribs known as the Rosary, or 
 shows softness of the bones of the skull-craniotabes, we 
 would be justified in suspecting this condition. Mani¬ 
 festations as described by the mother are three: First, 
 the baby crows. Hot every case of crowing of a child 
 is due to Spasmophilia, but its occurrence should make 
 us suspicious. This crowing is due to spasm of the 
 muscles of the larynx, technically called Laryngo 
 Spasm. The second manifestation is an out-and-out 
 convulsion. Laryngo spasm and convulsion are char¬ 
 acteristic in the fat, pasty, overfed child. The under¬ 
 nourished baby fed on condensed milk or barley gruel 
 is more likely to show a generalized rigidity, not of 
 sudden appearance, but of chronic duration. 
 
 The diagnosis of this condition is made from the 
 above history and physical examination. Examination 
 demonstrates the nature of the underlying condition, 
 namely, an increased irritability of the nervous system, 
 both to mechanical and electrical stimulation. Three 
 symptoms are induced by mechanical means: 
 
 1. The Chvostek or Facial Phenomenon. This con¬ 
 sists of tapping lightly with your finger or with your 
 percussion hammer over the facial nerve. If one taps 
 over the branch going to the eye muscles, these will 
 contract. If one taps over the lower branch enervating 
 the muscles of the mouth, these respond. 
 
 2. The Trousseau sign—putting a rubber band or 
 simply employing your fingers to tightly encircle the 
 upper arm—makes a classical picture. The constric¬ 
 tion must last about two minutes and must be sufficient 
 to cause a definite anemia of the lower arm. When 
 positive, the test shows the hand tightly clenched in the 
 .so-called obstetrical position, namely, flexion of the 
 fourth and fifth fingers, extension of the first, second, 
 and third; the so-called Obstetrician’s hand.” 
 
 3. The peroneal is the most delicate of the three 
 mechanical tests. Tap lightly upon the nerve as it 
 emerges around the head of the fibula. In cases of 
 
169 
 
 Spasmophilia the muscles enervated by the peroneal 
 will contract and the foot jerks laterally and dorsally. 
 
 4. Many children, however, are in a state of Spas¬ 
 mophilia, hut still do not show these three tests. Here 
 the diagnosis can be made only by the use of an elec¬ 
 trical apparatus. Don’t get excited, gentlemen. This 
 sounds complicated, but is really very simple. Those 
 of you who are doing much children’s work should cer¬ 
 tainly get an electrical machine. Taking these reac¬ 
 tions requires about two minutes time. Simply place 
 the cathode over the median nerve, open and close the 
 current, and if the muscles of the hand contract with 
 less than five milliamperes a diagnosis of Spasmophilia 
 can be made. It is unnecessary to go much over five 
 milliamperes, for the child may suffer pain. If con¬ 
 tractions do not result from this strength of current, 
 the child is not in a condition of Spasmophilia. 
 
 The treatment of this condition is that of the under¬ 
 lying rickets. Diet must be carefully corrected. Phos¬ 
 phorated Cod Liver Oil may be given in doses of one 
 teaspoon three times daily. During the days or weeks 
 required to relieve the child until the nervous system 
 again becomes normal, convulsions are apt to recur. 
 The treatment of the immediate convulsion is along the 
 lines which we laid out at the beginning of the lecture. 
 A valuable aid, however, in our therapy is the use of 
 calcium bromide in doses of Gr. XY daily. Ludwig 
 F. Meyer recommended this drug for two purposes, the 
 calcium overcoming the rachitic tendencies and the 
 bromide acting as a depressant to the nervous system. 
 
 How, gentlemen, to return to the reflex causes of 
 convulsions: phimosis, dentition, and worms. The pres¬ 
 ent tendency among the men who have had greatest 
 experience with Spasmophilia is to regard those cases 
 of convulsions occuring from reflex causes as cases in 
 which the underlying factor has been this constitutional 
 change of Spasmophilia. Reflex irritation certainly 
 does not cause spasm in every baby, but will be suffi¬ 
 cient to produce this symptom in a child with a con¬ 
 stitutional predisposition. In the same way perhaps 
 those children who suffer a convulsion at the onset of 
 an infectious disease are also predisposed. You see, 
 gentlemen, with this conception what gross neglect 
 we are guilty of when we say in an offhand way, “The 
 
170 
 
 baby is teething and needs bis gums lanced.” You will 
 be surprised in bow many cases your mecbanical and 
 electrical tests will show that the fundamental fault 
 lies in the baby’s constitution. 
 
 b. Epilepsy is recognized more and more frequently 
 in children. Without the use of the electrical machine 
 one would hesitate making the diagnosis in a small 
 infant, for many of these spasms will be due to Spas¬ 
 mophilia. On the other hand, the electrical tests, if 
 made, readily will differentiate the two, epilepsy not 
 showing the heightened electrical irritability. The his¬ 
 tory of the epileptic attack also is characteristic. Thq 
 child is either from alcholic parents or from parents 
 with grave nervous disorder. The convulsion itself is 
 typical. An aura warns the child of the impending 
 attack. The onset is sudden, with a tonic spasm. Fol¬ 
 lowing this come the clonic jerking movements. During 
 this stage the child froths at the mouth, bites the 
 tongue, often urinates, and has a bowel movement. Then 
 follows a deep sleep. 
 
 These, gentlemen, are the main causes of convul¬ 
 sions in children. I am going to give you a little 
 scheme which may help you toward a quicker diagnosis. 
 When you are called in, when the family is in furor, 
 when mother, grandmother, aunts and uncles are urg¬ 
 ing you to “Do something,” if you sit down and say, 
 “I would like half an hour to study this out,” you will 
 not last long in the family. You must at any rate give 
 grandmother some definite information, and for this 
 purpose this little outline may be of value: 
 
 1. During the first month of life the most likely 
 causes are: 
 
 a. Meningeal hemorrhage, 
 
 b. Cerebral malformations, 
 
 c. Acute meningitis, 
 
 d. Atelectasis. 
 
 As you see, gentlemen, these are all grave factors. 
 Hemorrhage, if it does not result in immediate death, 
 gives rise to brain injury which manifests itself later 
 by feeble-mindedness and the general picture known as 
 Little’s disease. Malformations mean idiocy. Menin¬ 
 gitis in the new-born is most severe, and atelectasis 
 occurs only in conditions of marked weakness and 
 debility. 
 
171 
 
 After tlie first month up through the second year the 
 most likely causes are: 
 
 a. If the baby be rachitic, spasmophilia, 
 h. Always keep in mind the onset of acute infectious 
 disease, and where convulsions are very severe, not re¬ 
 sponding readily to treatment, beware of a meningitis. 
 
 c. Spoiled food is always to be considered. This may 
 be the most important in this section of the country, 
 although Dr. Summerell informs me that the febrile 
 stage of malaria almost invariably is accomplished by 
 severe convulsions in his practice. 
 
 Over two years of age the above factors must he con¬ 
 sidered, and, in addition, epilepsy becomes more and 
 more prominent. Convulsions starting in after the 
 second year of life are far more likely to be epilepsy 
 than spasmophilia. At this age the rarer causes of 
 convulsions must meet with our consideration. Occa¬ 
 sionally will a brain tumor or brain abscess be the 
 etiological factor. 
 
 Gentlemen, this ends the subject of convulsions. As 
 you see, it is no small problem, covering almost the 
 whole field of medicine. This lecture is barely an out¬ 
 line to guide you in further study. If I have impressed 
 upon you that a convulsion is a symptom and not a 
 disease; if I have shown you that when you have treated 
 a convulsion your work is not finished, but is just com¬ 
 mencing, I shall be most happy indeed.