UNIVERSITY OF CALIFORNIA AT LOS ANGELES
GIFT OF
David D. Thornton
TEXT-BOOK
OF
PEDIATRICS
EDITED BY
PROFESSOR E. FEER
DIRECTOR OF THE UNIVERSITY CHILDREN'S CLINIC, ZURICH
TRANSLATED AND EDITED BY
JULIUS PARKER SEDGWICK, B. S., M. D.
PROFESSOR OF PEDIATRICS, UNIVERSITY OF MINNESOTA, MEDICAL SCHOOL
AND
CARL AHRENDT SCHERER, M.D., F.A.C.P.
DULUTH, MINNESOTA
262 ILLUSTRATIONS
FIRST EDITION IN ENGLISH
PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY
COPYRIGHT, 1922, BY J. B. LIPPINCOTT COMPANY
PRINTED BY J. B. LJPPINCOTT COMPANY
AT THE WASHINGTON SQUARE PRliSS
PHILADELPHIA, TJ. S. A.
PREFACE
THE introduction of this work to the physician and student is made easy by the widespread and favorable acquaintance it has achieved among those who have studied on the Continent or have read it in the original. The preface to the first edition sets forth the value of a text produced by the collaboration of a number of authors, each a master of his branch of the specialty. The plan of collaboration has been carried on in the translation. Up to the present no similar one volume work has appeared upon the market.
A further distinct advantage is the concise treatment of the subject matter. The arrangement is such that no time is lost in referring to any one descriptive passage. The etiology, pathology, symptomatology and treat- ment are all complete, but as short as compatible with their purpose. The book covers the entire field of pediatrics as completely as more bulky vol- umes. The discussions of the individual disease conditions are absolutely dependable and the therapeutic measures advised are in line with the most recent accepted usage.
Due to the interest of the American collaborators much has been added to the original subject matter and, through the kindness of numerous friends, who know the book in the original, a large number of illustrations have also been added. The editors take this opportunity to thank their associates, by whose help we were enabled to bring this work to completion, for their keen interest and their painstaking study of the sections revised by them. We also wish to thank Dr. R. O. Beard, Secretary of the Medical School of the University of Minnesota, for his careful revision of the English. To J. B. Lippincott Company we feel especially indebted for their patience and their appreciation of the problems of the translation.
May the volume find as great a sphere of usefulness in this translation as it has had in the original.
J. P. S. C. A. S. November 1st, 1922.
PREFACE TO FIRST GERMAN EDITION
A LARGE number of medicaltext-books,the products of the collaboration of a number of authors, have recently appeared. The great favor with which these works are received is the best indication of their value. When, there- fore, I was approached in 1909 by Mr. Gustaf Fisher with the suggestion that I edit a work of this nature, as a companion piece to the text on Internal Medicine by Krehl-Mering, I had no hesitancy especially since pediatrics is no longer a subject in which one author can have complete knowledge of all branches. I was able to interest a number of the most prominent pediatrists who were competent to write on the special subjects assigned to them. I believe that the work of these associates and the new method of presenting the subject in this volume with its numerous apt illustrations justify its production in spite of the great number of text-books on pediatrics already on the market.
In order to give the student and general practitioner an introduction into the subject and an understanding of the child itself, it has been thought fit to make the general part very extensive. In the special part, those diseases not peculiar to childhood and fully described in text-books of gen- eral medicine were merely touched upon, in order to give space to the diseases that present definite peculiarities in childhood or occur only in children. A certain amount of duplication must of course occur, as for instance in those diseases classed as acute infections or " children's diseases." These are all considered in texts on general medicine, but belong specifically to this work. Special pains were taken to give full space to those diseases of childhood that are barely touched upon in general texts, but are of great importance to the podiatrist. Thus the subjects of varicella, pertussis and measles, given only one, two and one pages respectively in the Krehl-Mering text, have been accorded seven, ten and two and a half pages in this book.
More space than is customary is devoted to early infancy. The disturb- ances of nutrition are discussed by the most able authors in accordance with most recent research. Those physicians who are accustomed to the old classification of dyspepsia, catarrh and enteritis, may be somewhat confused at first. The discussion of the disturbance of nutrition is based upon the study of the nutritional processes in the light of functional tests. These have led to a new classification and a more rational treatment. The older classification, though simple, is actually of little value as far as treatment is concerned. Those, however, who have already acquired this more recent view as, no doubt, all undergraduates have, will gladly recognize its great advances and will take advantage, clinically, of the benefits afforded by it in the treatment of the disturbances of nutrition, a most difficult phase of the practice of pediatrics.
As far as the use of varied sizes of print is concerned, the small print is used for introductions and notes of a more or less general nature, not
vi PREFACE TO SEVENTH GERMAN EDITION
having direct bearing upon the subject under discussion, but essential for its understanding and to be especially brought to the reader's notice.
The excellent ensemble of the work is due to the interest and painstaking care of the publisher who has spared no means to produce the best at a reasonable price. His efforts have further made it possible to obtain new illustrations that are most applicable to the text.
May this new text-book be a reliable guide and advisor to both the undergraduate and practicing physician.
E. FEER.
PREFACE TO SEVENTH GERMAN EDITION
THE demand for a new edition, so soon after the appearance of the last, has necessitated but few changes. Nevertheless, all the authors have revised their sections and made additions and improvements. Special pains have been taken to enlarge upon the therapy. By more concise handling of several sections, it has been possible to reduce the size of the volume by twenty-four pages.
In place of our late colleague, Professor Tobler, Professor Noeggerath consented to take on a portion of the work and has completely revised the section on genito-urinary diseases, bringing out the advances made during the last few years in the study of the nephropathies.
Furthermore, we must again report the loss of a colleague, Professor Martin Thiemich, who died February 16, 1921, following a long illness, at the age of fifty-one. This was a great loss not only to our text-book but also to the science of pediatrics and the University of Leipzig. His last work was the correction and revision of his section of this text.
E. FEER.
TEXT-BOOK OF PEDIATRICS
EUROPEAN CONTRIBUTORS
PEER, E., PROFESSOR DR., Zurich. FINKELSTEIN, H.f PROFESSOR DR., Berlin. IBRAHIM, J., PROFESSOR DR., Jena. MEYER, L. P., PRiv.-Doz. DR., Berlin. MORO, E., PROFESSOR DR., Heidelberg. NOEGGERATH, C., PROFESSOR DR., Freiburg i Br. THIEMICH, M.; PROFESSOR DR., Leipzig. v. PFAUNDLER, M., PROFESSOR DR., Munich. v. PIRQUET, CL. FRH., PROFESSOR DR., Vienna.
AMERICAN COLLABORATORS
BRENNEMANN, JOSEPH, M.D., Chicago, 111.
Attending Pediatrist, Children's Hospital, Chicago. BYFIELD, ALBERT H., M.D., Iowa City, la.
Professor of Pediatrics, College of Medicine, State University of Iowa. CALHOUN, HENRIETTA M.A., M.D., Iowa City, la.
Assistant professor of Pathology, College of Medicine, State University of Iowa. DE BUYS, L. R., M.D., F.A.P.C., New Orleans, La.
Professor of Diseases of Children, School of Medicine, Tulane University of
Louisiana; Chief of Pediatrics, Turo Infirmary. DIETRICH, HENRY, M.D., Los Angeles, California.
' Attending Pediatrist, Children's Hospital, Los Angeles. FLEISCHNER, E. C., M.D., San Francisco, Calif.
Clinical Professor of Pediatrics, University of California. HESS, JULIUS H., M.D., Chicago, 111.
Professor and Head of the Department of Pediatrics, University of Illinois,
College of Medicine; Chief of Pediatric Staff, Cook County Hospital. HOFFMANN, WALTER H. O.f M.D., Chicago, 111.
Associate Attending Pediatrist, Children's Memorial Hospital, Chicago. HOOBLER, B. RAYMOND, M.D., Detroit, Mich.
Professor of Pediatrics, Detroit College of Medicine and Surgery. IRVINE, HARRY GARFIELD, M.D., Minneapolis, Minn.
Associate Professor of Dermatology and Syphilis, Medical School, University of
Minnesota; Director of the Division of Venereal Diseases, Minnesota State
Board of Health. JEANS, PHILIP C., St. Louis, Mo.
Associate Professor of Pediatrics, Washington University School of Medicine* MEYER, K. F., M.D., San Francisco, Calif.
Professor of Research Medicine, University of California. OTT, M. D., M.D., Minneapolis, Minn.
Associate in Pediatrics, University of Minnesota, Medical School. PIERCE, NABOTH OSBORNE, M.D., Minneapolis, Minn.
Assistant Professor of Pediatrics, University of Minnesota, Medical School, SCAMMON, RICHARD EVERINGHAM, M.D., Minneapolis, Minn.
Professor of Anatomy, University of Minnesota, Medical School.
CONTENTS
GENERAL CONSIDERATIONS
by PROFESSOR DR.' MARTIN THEIMICH,
Director of the University Children's Clinic, Leipzig.
PAGE
I. ANATOMIC AND PHYSIOLOGIC PECULIARITIES 1
Revised and Edited by DR. RICHARD EVERINGHAM SCAMMON, Minneapolis, Minn.,
Professor of Anatomy, University of Minnesota Medical School.
II. CARE AND FEEDING OF THE NORMAL INFANT 36
Revised and Edited by JULIUS H. HESS, M. D., Chicago, 111.,
Professor and Head of the Department of Pediatrics, University of Illinois, College of Medicine, Chief of Pediatrie Staff, Cook County Hospital.
III. GENERAL SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 70
Revised and Edited by L. R. DEBUYS, M. D., F. A. C. P., New Orleans, La.,
Professor of Diseases of Children, S?hool of Medicine, Tulane University of Louisiana; Chief of Pediatrics, Turo Infirmary.
IV. GENERAL PATHOGENESIS, MORTALITY AND MORBIDITY
Revised and Edited by B. RAYMOND HOOBLER M. D., Detroit, Mich.,
Professor of Pediatrics, Detroit College of Medicine and Surgery.
V. GENERAL PROPHYLAXIS AND THERAPY 98
Revised and Edited by ALBERT H. BYFIELD, M. D., IOWA CITY, IOWA.,
Professor of Pediatrics, College of Medicine, State University of Iowa.
SPECIAL PART
SECTION I. DISEASES OF THE NEW-BORN
by PROFESSOR DR. MED. AND PHIL. HEINRICH FINKELSTEIN,
Director of the Kinderkrankenhaus, Berlin, and
PRIVATDOZENT DR. LUDWIG MEYER,
Chief Pediatrist to the Orphanage and Children's Asylum of the City of Berlin.
Revised and edited by NABOTH OSBORNE PIERCE, M. D., Minneapolis, Minn.,
Assistant Professor of Pediatrics, University of Minnesota, Medical School.
DISEASES OF THE NEW-BORN 121
ASPHYXIA 125
BIRTH TRAUMATA 127
EXTERNAL CEPHALHEMATOMA : 127
INTERNAL CEPHALHEMATOMA 129
CEREBRAL HEMORRHAGE ... . 129
CONTENTS
PAGE
HEMATOMA OF THE STERNOCLEIDOMASTOID 130
PARALYSES ,00
DISEASES OF THE UMBILICUS
CONGENITAL ANOMALIES
INFECTIONS OF THE UMBILICUS
GANGRENE OF THE STUMP .. „„
BLENNORRHEA ^ -
UMBILICAL ULCER • • , oQ
UMBILICAL FUNGUS (GRANULOMA OF THE UMBILICUS) •••••• "»
OMPHALITIS (ACUTE INFLAMMATION OF THE UMBILICAL KING) i^y
GANGRENE OF THE UMBILICUS j^l
MIGRATORY INFECTION „
TETANUS NEONATORUM ™
UMBILICAL HEMORRHAGE JT:
SEPSIS 1 4£
MELENA NEONATORUM j|*
ERYSIPELAS |CQ
OPHTHALMIA NEONATORUM • ***?
SWELLING OF THE MAMMARY GLAND AND MASTITIS 101
ICTERUS NEONATORUM J^
EDEMA AND SCLEREDEMA OF THE NEW-BORN
ALBUMINURIA
URIC ACID INFARCTS . . . VAGINAL HEMORRHAGE.
154
SECTION II. PATHOLOGICAL CHANGES OF THE BLOOD AND BLOOD-FORMING ORGANS
CONSTITUTIONAL ANOMALIES AND DISEASES OF METABOLISM
by PROFESSOR DR. MEINHARD VON PFAUNDLER,
Director of the University Children's Clinic, Munich.
Revised and Edited by
M. D. OTT M. D., Minneapolis, Minn.,
Associate in Pediatrics, University of Minnesota, Medical School.
INTRODUCTION 156
PHYSIOLOGY AND PATHOLOGY OF THE BLOOD 156
A. GROUP OF ANEMIAS (GENERAL SYMPTOMATOLOGY) 159
ANEMIA DUE TO PRIMARY INTERFERENCE WITH ERYTHROPOIESIS 161
ANEMIAS DUE TO Loss OF BLOOD .' 164
HEMOCYTOLYTIC AND MYELOPATHIC ANEMIAS 165
THE TREATMENT OF ANEMIA 172
APPENDIX: PSEUDO-ANEMIAS 174
B. GROUP OF LEUCEMIAS AND PSEUDOLEUCEMLAS 175
LYMPHOCYTOMATOSES 176
LEUCEMIC LYMPHADENOSIS OR LYMPHATIC LEUCEMIA 176
LYMPHOSARCOMATOSES 178
THE MYELO-CYTOMATOSES 179
MYELOSARCOMATOSES 181
CHOROMATA 181
GRANULOMATOSES 182
PATHOGENESIS OF LEUCEMIA AND PSEUDOLEUCEMIA 183
THERAPY 183
HEMORRHAGIC DIATHESIS OR TENDENCY TO HEMORRHAGE 184
INFANTILE SCURVY (BARLOW'S DISEASE) 186
RICKETS 190
CLINICAL SYMPTOMS AND THEIR ORIGIN 196
SKELETAL MANIFESTATIONS 196
COURSE, COMPLICATIONS: TERMINATION 203
DIFFERENTIAL DIAGNOSIS 203
DIABETES MELLITUS 208
OBESITY 210
UNDER-NOURISHED OR FRAIL CHILDREN . . .211
CONTENTS xi
PAGE
TREATMENT 213
PECULIAR PREDISPOSITIONS TO DISEASE (DIATHESES) AND CONSTITU- TIONAL ANOMALIES 213
THE INFLAMMATORY OR EXUDATIVE DIATHESIS 214
ARTHRITISM IN CHILDHOOD 221
APPENDIX: PATHOLOGY OP THE GLANDS OF INTERNAL SECRETION 226
A. PATHOLOGY OF THE THYROID 226
HYPOTHYREOSIS; ATHYREOSIS 226
GENERAL SYMPTOMS AND THEIR CAUSES 227
SPECIAL CLINICAL CONSIDERATIONS OF HYPOTHYREOSES 231
INFANTILISM 233
TREATMENT 233
GOITRE 234
BASEDOW'S DISEASE ; 235
INFANTILE BASEDOWOID DISEASE 235
B. PATHOLOGY OF THE GERMINAL ORGANS 235
C. PATHOLOGY OF THE HYPOPHYSIS 236
D. DISTURBANCES OF GROWTH 236
GENERAL PHYSICAL ANOMALIES OCCURRING WITHOUT RECOGNIZED RE- LATION TO THE HEMIC GLANDS 236
OSTEOGENESIS IMPERFECTA (VROLIK) 237
OSTEOPSATHYROSIS 237
SECTION III. DISEASES OF THE DIGESTIVE SYSTEM
by PROFESSOR DR. MED. AND PHIL. HEINRICH FINKELSTEIN,
Director of the Kinderkrankenhaus, Berlin, and
PRIVATDOZENT DR. LUDWIG MEYER,
Chief Podiatrist to the Orphanage and Children's Asylum of the City of Berlin.
Revised and Edited by JOSEPH BRENNEMANN, M. D., Chicago, 111.,
Attending Podiatrist, Children's Memorial Hospital, Chicago.
DISEASES OF THE MOUTH 242
STOMATITIS 242
ANOMALIES OF THE TEETH AND TEETHING 247
DISEASES OF THE SALIVARY GLANDS 248
DISEASES OF THE TONSILS, THE PHARYNX AND THE ESOPHAGUS 248
ANGINA 248
CATARRHAL ANGINA AND EXUDATIVE ANGINA 249
HYPERPLASIA OF THE TONSIL 252
RETROPHARYNGEAL LYMPHADENITIS AND RETROPHARYNGEAL ABSCESS. . 252
CONGENITAL ANOMALIES OF THE ESOPHAGUS 254
ACQUIRED DISEASES OF THE ESOPHAGUS 254
NUTRITIONAL DISTURBANCES OF INFANTS 255
DISTURBANCES OF NUTRITION OF THE ARTIFICIALLY-FED INFANT 256
GENERAL ETIOLOGY AND PATHOGENESIS 256
GENERAL SYMPTOMATOLOGY 262
CLASSIFICATION 264
A. NUTRITIONAL DISTURBANCES WITHOUT Toxic MANIFESTATIONS
WITHOUT DIARRHOEA 265
DYSTROPHY 265
NUTRITIONAL DISTURBANCES WITHOUT Toxic MANIFESTATIONS WITH
DIARRHOEA 273
DECOMPOSITION (PEDATROPHY) 278
B. NUTRITIONAL DISTURBANCES WITH Toxic MANIFESTATIONS 289
ACUTE DYSPEPSIA 289
INTOXICATION (ALIMENTARY TOXICOSIS, ENTERO-CATARRH, CHOLERA
INFANTUM, ETC 291
INFECTION AND NUTRITION 299
THE DISTURBANCES OF NUTRITION OF BREAST-FED INFANTS 303
DISEASES DUE TO ENDOGENOUS (CONSTITUTIONAL) CAUSES 305
xii CONTENTS
PAGE
DISTURBANCES OF NUTRITION OP OLDER CHILDREN 307
ACUTE DYSPEPSIA AND DYSPEPTIC COMA 307
CHRONIC DYSPEPSIA 308
SEVERE CHRONIC DIGESTIVE INSUFFICIENCY IN OLDER CHILDREN 311
ACUTE INFECTIOUS DISEASES OF THE GASTRO-INTESTINAL TRACT 314
DYSENTERY 316
INTESTINAL TUBERCULOSIS 320
INTESTINAL POLYPOSIS 321
NERVOUS GASTRO-INTESTINAL DISEASES 322
CONGENITAL SPASTIC PYLORIC STENOSIS 322
HABITUAL AND UNCONTROLLABLE VOMITING OF INFANTS 325
SIMPLE PYLOROSPASM 325
THE PERIODIC VOMITING OF OLDER CHILDREN 326
NERVOUS VOMITING 327
NERVOUS ANOREXIA 328
OBSTRUCTION OF THE INTESTINAL CANAL 329
CONGENITAL INTESTINAL STENOSIS 329
DILATATION AND HYPERTROPHY OF THE COLON 330
HIRSCHSPRUNG'S DISEASE 330
CONSTIPATION 331
INTUSSUSCEPTION - 333
PROLAPSE OF THE RECTUM 335
HERNIAS 336
ENTOZOA 337
DISEASES OF THE LIVER 339
CATARRHAL JAUNDICE 339
OTHER FORMS OF ACUTE JAUNDICE 339
CIRRHOSIS OF THE LIVER 339
TUMORS OF THE LIVER 340
CONGENITAL OBSTRUCTION OF THE BILE DUCTS 340
DISEASES OF THE PERITONEUM 341
PURULENT PERITONITIS 341
PERITONITIS IN OLDER CHILDREN FOLLOWING APPENDICITIS 341
OTHER FORMS OF PURULENT PERITONITIS IN OLDER CHILDREN 342
TUBERCULOUS DISEASES OF THE PERITONEUM 34*3
TUBERCULOSIS OF THE MESENTERIC AND RETROPERITONEAL LYMPH
NODES 343
FETAL PERITONITIS 345
TUMORS 346
SECTION IV. DISEASES OF THE RESPIRATORY ORGANS
by PROFESSOR DR. CLEMENS FREIHERR VON PIRQUET,
Director of the University Children's Clinic, Vienna.
Revised and Edited by WALTER H. O. HOFFMANN, M. D., Chicago, III.,
Associate Attending Pediatrist, Children's Memorial Hospital, Chicago.
DISEASES OF THE NOSE 347
RHINITIS, CORYZA ] 347
THE CLINICAL SYMPTOMS OF ACUTE RHINITIS '. 350
CHRONIC CORYZA 352
ADENOID VEGETATIONS
FOREIGN BODIES IN THE NOSE • 354
EPISTAXIS 354
DISEASES OF THE EUSTACHIAN TUBES AND THE MIDDLE EAR . 355
OTITIS MEDIA CATARRHALIS NEONATORUM . 356
ACUTE OTITIS MEDIA 356
CHRONIC OTITIS MEDIA 359
FOREIGN BODIES IN THE EXTERNAL AUDITORY CANAL. . 360
CONGENITAL STRIDOR 360
ACUTE LARYNGITIS (PSEUDOCROUP) 361
FOREIGN BODIES IN THE BRONCHIAL TUBES 363
CONTENTS xiii
PAGE
PAPILLOMA OF THE LARYNX 364
THE ACUTE TRACHEOBRONCHITIS OF OLDER CHILDREN 364
BRONCHITIS 364
ASTHMATIC BRONCHITIS 368
CAPILLARY BRONCHITIS 370
BRONCHO-PNEUMONIA 373
LOBAR PNEUMONIA 376
CHRONIC PNEUMONIA 381
EMPHYSEMA 382
BRONCHIECTASIS 382
PLEURISY 383
EMPYEMA 384
SEROFIBRINOUS PLEURISY 386
TREATMENT OF SEROUS PLEURISY 388
SECTION V.— DISEASES OF THE HEART
by PROFESSOR DR. E. FEER,
Director of the University Children's Clinic, Zurich, Switzerland.
Revised and Edited by HENRIETTA CALHOUN, M. A., M. D., Iowa City, Iowa,
Assistant Professor of Pathology, College of Medicine, State University of Iowa.
DISEASES OF THE HEART 389
HEART MURMURS 391
NERVOUS DISTURBANCES 393
CONGENITAL HEART LESIONS 394
DEFECT OF THE INTERVENTRICULAR SEPTUM 396
ROGER'S DISEASE 396
PATENCY OF THE DUCTUS ARTERIOSUS (BOTALLI) 397
PULMONARY STENOSIS 398
AORTIC STENOSIS 399
TRANSPOSITION OF THE GREAT VESSELS 399
ACUTE ENDOCARDITIS 400
CHRONIC ENDOCARDITIS AND ACQUIRED VALVULAR LESIONS 403
ACUTE PERICARDITIS 407
PERICARDIAL ADHESIONS 411
MYOCARDITIS AND CARDIAC INSUFFICIENCY 413
APPENDIX: BLOOD-VESSELS AND JUVENILE HEART 417
SECTION VI.— DISEASES OF THE GENITO-URINARY TRACT
by PROFESSOR DR. C. NOEGGERATH,
Director of the University Children's Clinic, Freiburg in Breisgau.
INTRODUCTION 419
UREMIA 420
ORTHOTIC ALBUMINURIA 421
TUBULAR NEPHROPATHY OR NEPHROSIS 428
ACUTE DIFFUSE GLOMERULAR NEPHROPATHY, ACUTE GLOMERULAR
NEPHRITIS 431
GLOMERULO-TUBULAR NEPHROPATHY (MIXED FORM) 434
KIDNEY DISEASES IN INFANTS 436
CHRONIC KIDNEY DISEASE 436
CHRONIC NEPHRITIS OF CHILDHOOD (PEDONEPHRITIS) 437
NEPHRITIS WITH CONGENITAL SYPHILIS 438
PURULENT DISEASES OF THE URINARY TRACT AND THE KIDNEYS . . . 439
CYSTOPYELITIS; PYELONEPHRITIS AND RENAL ABCESSES 439
DIABETES INSIPIDUS 445
ENTJRESIS 446
VULVO-VAGINITIS 449
PHIMOSIS, PARAPHIMOSIS AND BALANITIS 452
X1V CONTENTS
PAGE
HYDROCELE (SEROUS PERIORCHITIS) 453
ANOMALIES IN POSITION OP THE TESTES 453
MASTURBATION 454
NEW GROWTHS 455
SECTION VII.— DISEASES OF THE NERVOUS SYSTEM
by PROFESSOR Da. JUSSUF IBRAHIM,
Director of the University Children's Clinic, Jena.
ORGANIC DISEASES OF THE NERVOUS SYSTEM 457
I. DISEASES OF THE MENINGES
TUBERCULOUS MENINGITIS 458
PURULENT MENINGITIS (MENINGITIS SIMPLEX) 465
MENINGOCOCCUS MENINGITIS OR EPIDEMIC CEREBRO-SPINAL MEN- INGITIS i 467
SEROUS MENINGITIS 474
MENINGISM, HYDROCEPHALOID 476
THE MENINGITIS OF CONGENITAL SYPHILIS 476
SINUS THROMBOSIS 476
II. CHRONIC HYDROCEPHALUS 477
EXTERNAL HYDROCEPHALUS 477
CHRONIC INTERNAL HYDROCEPHALUS 477
HYDRENCEPHALY 483
III. RETARDATION OF DEVELOPMENT 483
GROSS MALFORMATIONS OF THE BRAIN 483
MICROCEPHALY 484
SPINA BIFIDA (RACHISCHISIS) AND CEPHALOCELE 484
SPINA BIFIDA OCCULTA 486
HYPERTROPHY OF THE BRAIN 487
PYRGOCEPHALY, OXYCEPHALY 487
CONGENITAL FUNCTIONAL DEFECTS OF THE CRANIAL MOTOR NERVES. . . . 488 CONGENITAL APLASIA OF THE NUCLEUS; ABSCENCE OF THE NUCLEUS;
INFANTILE NUCLEAR ATROPHY 488
CONGENITAL MUSCULAR DEFECTS 488
CONGENITAL M YATONIA 489
IV. DISTURBANCE OF THE CEREBRAL CIRCULATION 489
CONCUSSION OF THE BRAIN (COMMOTIO CEREBRI) 490
V. ACUTE ENCEPHALITIS 491
APPENDIX : 493
VI. EPIDEMIC ENCEPHALITIS (LETHARGIC ENCEPHALITIS EPIDEMIC POLIOMY-
ELO-ENCEPHALITIS, SLEEPING SlCKNESS) 494
VII. BRAIN ABSCESS, PURULENT ENCEPHALITIS 496
VIII. CEREBRAL TUMOR 497
IX. CEREBRAL PARALYSIS OF CHILDREN; INFANTILE CEREBRAL PALSY 499
SPASTIC INFANTILE HEMIPLEGIA AND DIPLEGIA 499
SPASTIC INFANTILE HEMIPLEGIA; UNILATERAL CEREBRAL PARALYSIS
OF CHILDREN 501
SPASTIC INFANTILE DIPLEGIA; CEREBRAL DIPLEGIA OF CHILDREN 503
PECULIAR TYPES OF THE DISEASE 505
X. SCLEROSIS OF THE CENTRAL NERVOUS SYSTEM 510
XI. ACUTE POLIOMYELITIS; SPINAL PARALYSIS OF CHILDREN 510
HEINE-MEDIN'S DISEASE; ACUTE EPIDEMIC INFANTILE PARALYSIS... 510
XII. DISEASES OF THE SPINAL CORD 521
MYELITIS 521
TABES DORSALIS 521
TUMORS OF THE CORD 521
XIII. ENDOGENOUS OR HEREDITO-FAMILIAL DISEASES OF THE NERVOUS AND MUS- CULAR SYSTEMS 522
AMAUROTIC FAMILIAL IDIOCY (T AY-SACHS' IDIOCY) 523
JUVENILE AMAUROTIC FAMILIAL IDIOCY 523
FAMILIAL CEREBRAL DIPLEGIAS AND FORMS OF CEREBROSPINAL DISEASE 524
DISEASES OF THE MYOSTATIC SYSTEM 524
HEREDITARY ATAXIA (FRIEDREICH'S ATAXIA) 525
CONTENTS xv
PAGE
MUSCULAR ATROPHIES 526
UNCOMMON FORMS 528
XIV. DISEASES OF THE PERIPHERAL NERVOUS SYSTEM 528
PARALYSES 528
NEURALGIA 529
POLYNEURITIS 529
XV. DISEASES OP THE MUSCLES 529
FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM 530
I. CONVULSIVE DISEASES . '. 530
SPASMOPHILIA OR SPASMOPHILIC DIATHESIS 530
LARYNGOSPASM, TETANY AND ECLAMPSIA 530
ECLAMPSIA DUE TO NON-SPASMOPHILIC CAUSES 541
GENERAL MUSCULAR HYPERTONIA, WITHOUT SPASMOPHILIA 543
NUTANT AND ROTATORY SPASMS 543
PSEUDOTETANUS 544
EPILEPSY 545
II. CHOREA MINOR (ST. VITUS DANCE) 549
PARAMYOCLONUS MULTIPLEX; CHOREA ELECTRICA 553
III. NEUROPATHIC AND PSYCHOPATHIC CONSTITUTION 553
HEREDITARY NEUROPATHY 553
MIGRAINE: HEMICRANIA 556
MALADIE DBS TICS CONVULSIFS 556
EMOTIONAL RESPIRATORY CONVULSIONS: ABSENCES 557
PATHOLOGIC REFLEXES 558
PAVOR NOCTURNUS 558
NEURASTHENIA 559
PHOBIAS; UNCONTROLLABLE IDEAS AND ACTS 561
DISTURBANCES OF PSYCHICAL IMPULSES 562
HYSTERIA 562
IV. PSYCHOSES 567
CONGENITAL AND EARLY ACQUIRED DEFECT PSYCHOSES (FEEBLE MIND-
EDNESS, IDIOCY; IMBECILITY, MENTAL DEBILITY) • .... 567
ACQUIRED DEFECT PSYCHOSES 569
HEBEPHRENIA: CATATONIA OR DEMENTIA Pn^cox 570
PSYCHOSES WITHOUT DEFECTS OF INTELLIGENCE 570
SECTION VIII. THE ACUTE INFECTIOUS DISEASES
by PROFESSOR DR. E. FEER,
Director of the University Children's Clinic, Zurich.
Revised and Edited by E. C. FLEISCHNER, M. D., San Francisco, Calif.,
Clinical Professor of Pediatrics, University of California,
and K. F. MEYER, M. D., San Francisco, Calif.,
Professor of Research Medicine, University of California.
GENERAL CONSIDERATION 571
SCARLET FEVER 579
PECULIARITIES, SEQUELAE AND COMPLICATIONS OF SCARLET FEVER 588
MEASLES (MORBILLI) 598
RUBELLA (GERMAN MEASLES ROTELN) 616
INFECTIOUS ERYTHEMA 620
DUKE'S "FOURTH" DISEASE 622
VARICELLA (CHICKEN-POX) 623
PECULIARITIES OF THE EXANTKEM 626
VACCINATION (Cow-pox) 630
PECULIARITIES OF COURSE AND COMPLICATIONS 634
DIPHTHERIA 637
PATHOGENESIS AND PATHOLOGIC ANATOMY 641
THE GENERAL DISEASE-PICTURE 642
MILD FORMS 644
SEVERE FORMS . . 645
xvi CONTENTS
PAGE
SPECIAL LOCALIZATIONS OF DIPHTHERITIC MEMBRANES 646
NASAL DIPHTHERIA 647
AURAL DIPHTHERIA 648
DIPHTHERIA OF THE LARYNX, TRACHEA AND BRONCHI 648
RARE LOCALIZATIONS OF DIPHTHERIA 651
PECULIARITIES OF DIPHTHERITIC MEMBRANES 652
THE EFFECT OF DIPHTHERIA ON VARIOUS ORGANS 653
COMPLICATIONS AND SEQUELS 653
THE DIAGNOSIS OF DIPHTHERIA 656
DIFFERENTIAL DIAGNOSIS 656
DIFFERENTIAL DIAGNOSIS OF AFFECTIONS OF THE LARYNX 657
PERTUSSIS OR WHOOPING-COUGH 672
VARIATIONS IN COURSE 675
SPECIAL SYMPTOMS AND COMPLICATIONS 676
MUMPS (EPIDEMIC PAROTITIS) 684
TYPHOID FEVER 688
PECULIARITIES OF COURSE; COMPLICATIONS 692
PARATYPHOID 698
INFLUENZA AND GRIPPAL DISEASES 699
ACUTE ARTICULAR RHEUMATISM (POLYARTHRITIS ACUTA) 706
PECULIARITIES OF THE COURSE WITH IMPLICATIONS OF VARIOUS ORGANS . 708
CHRONIC RHEUMATISM 711
ERYSIPELAS 713
GENERAL SEPSIS 715
SECTION IX. TUBERCULOSIS
by
PROFESSOR DR. CLEMENS FREIHERR VON PIRQUET, ,
Director of the University Children's Clinic, Vienna.
Revised and Edited by HENRY DIETRICH, M. D., Los Angeles, Calif.
Attending Pediatrician, Children's Hospital, Los Angeles.
TUBERCULOSIS 720
CLINICAL MANIFESTATIONS 725
PRIMARY STAGE 725
TUBERCULOSIS OF THE BRONCHIAL LYMPH NODES 726
PRIMARY TUBERCULOSIS OF THE LUNGS 727
THE SECONDARY STAGES; OR THE GENERAL SPREAD OF TUBERCULOSIS. 728
SCROFULA 739
CHRONIC PULMONARY TUBERCULOSIS; THE TERTIARY STAGE 735
SECTION X. SYPHILIS
by PROFESSOR DR. ERNST MORO,
Director of the University Children's Clinic, Heidelberg.
Revised and Edited by PHILIP C. JEANS, M. D., St. Louis, Mo.,
Associate Professor of Pediatrics, Washington University School of Medicine.
ETIOLOGY AND NATURE 750
MODES OF INFECTION 752
CONGENITAL SYPHILIS . 754
FETAL SYPHILIS 755
INFANTILE SYPHILIS \ 757
RECURRENCES IN EARLY CHILDHOOD . 774
LATE CONGENITAL SYPHILIS: 775
THE DIAGNOSIS OF CONGENITAL SYPHILIS .... 777
PROGNOSIS [ 781
THE TREATMENT OF CONGENITAL SYPHILIS '. 782
ACQUIRED SYPHILIS IN CHILDREN 785
CONTENTS xvii
PAGE
SECTION XI. DISEASES OF THE SKIN
by PROFESSOR DR. ERNST MORO,
Director of the University Children's Clinic, Heidelberg.
Revised and Edited by HARRY GARFIELD IRVINE, M. D., Minneapolis, Minn.
INTRODUCTION. 787
ECZEMA 791
INTERTRIGINOUS ECZEMA 793
ERYTHRODERMIA 795
CONSTITUTIONAL ECZEMA OF INFANTS 796
URTICARIA 803
SIMPLE URTICARIA 804
ACUTE CIRCUMSCRIBED EDEMA OF THE SKIN (GIANT URTICARIA) 805
STROPHULUS 805
PRURIGO 807
MULTIPLE ERYTHEMA (ERYTHEMA MULTIFORME) 809
IMPETIGO 811
IMPETIGO CONTAGIOSA 811
PEMPHIGUS NEONATORUM 812
DERMATITIS EXFOLIATIVA 813
FURUNCULOSIS 814
PARASITIC SKIN DISEASES 815
PEDICULOSIS 815
SCABIES 816
TUBERCULOSIS 818
LUPUS 819
SCROFULODERMA 821
LICHEN, ACNE, ECZEMA 822
THE SMALL PAPULAR TUBERCULIDE OF INFANCY 824
THE PAPULO-NECROTIC TUBERCULIDE 824
SUPPLEMENT
EXUDATIVE DERMATOSIS 825
URTICARIA PIGMENTOSA (XANTHELASMOIDEA) 825
HERPES SIMPLEX (HERPES FEBRILIS, HERPES LABIALIS, COLD SORES,
FEVER BLISTERS) 826
HERPES ZOSTER (ZONA SHINGLES) 827
PEMPHIGUS 827
PEMPHIGUS ACUTUS 828
PEMPHIGUS FOLIACEUS 828
PEMPHIGUS VEGETANS 828
PEMPHIGUS VULGARIS 828
EPIDERMOLYSIS BULLOSA 829
HYDROA VACCINIFORME 829
INFLAMMATIONS OF THE SKIN 830
DERMATITIS VENENATA 830
DRY SCALY INFLAMMATORY DERMATOSES 831
PlTYRIASIS ROSEA (HERPES TONSURANS MACULOSUS, PlTYRIASIS
CIRCINATA) 831
PSORIASIS 832
INFECTIOUS DISEASES OF THE SKIN 834
GRANULOMA PYOGENICUM 834
FAVUS (TINEA FAVOSA) 834
TINEA TRICHOPHYTINA (RINGWORM, TRYCHOPHYTOSIS) 835
TINEA TRICHOPHYTINA CORPORIS (TINEA CIRCINATA: RINGWORM
OF THE BODY; TRICHOPHYTOSIS CORPORIS.) 835
TINEA TRICHOPHYTINA CRURIS (TINEA CRURIS; ECZEMA MARGI-
NATUM; DHOBIE ITCH) 836
ONYCHOMYCOSIS (RINGWORM OF THE NAILS) 837
TINEA TRICHOPHYTON CAPITIS (TINEA CAPITIS: TINEA TONSURANS: RINGWORM OP THE SCALP) 837
xviii CONTENTS
PAGE
DISEASES OP THE APPENDAGES OF THE SKIN 839
MILIARIA 839
MILIUM (STROPHULUS ALBIDUS, ACNE ALBIDA) 840
COMEDO 840
GROUPED COMEDONES IN CHILDREN 840
ACNE NEONATORUM - 840
ACNE VULGARIS 840
ALOPECIA AREATA 841
BENIGN EPITHELIAL GROWTHS 842
ADENOMA SEBACEUM 842
HYPERTROPHIES 843
VERRUCA VULGARIS 843
VERRUCA PLAN^E JUVENILIS 843
KERATODERMIA PALMARIS ET PLANTARTS (SYMMETRICAL KERATO- DERMIA OF THE EXTREMITIES, CONGENITAL KERATOMA OF THE
PALMS AND SOLES, ICHTHYOSIS, PALMARIS ET PLANTARIS) 844
ICHTHYOSIS (XERODERMA, FISHSKIN DISEASE) 844
ATROPHIES 847
XERODERMA PIGMENTOSUM 847
DEGENERATIVE NEOPLASMATA 848
MOLLUSCUM CONTAGIOSUM (MOLLUSCUM SEBACEUM, EPITHELIOMA
CONTAGIOSUM) 848
XANTHOMA (FIBROMA LIPOMATODES, XANTHELASMA) 849
NEVUS (BIRTH-MARK) : 849
NEVUS PlGMENTOSUS (PlGMENTED MOLE) 849
NEVUS VASCTTLOSUS (NEVUS SANGUINEUS, NEVUS FLAMMEUS, MOTHS
MARK, BIRTH-MARK, PORT-WINE-MARK) 851
TELANGIECTASIS . 852
GENERAL CONSIDERATIONS
BY MARTIN THIEMICH, LEIPZIG.
I. ANATOMIC AND PHYSIOLOGIC PECULIARITIES
REVISED BY Dr. RICHARD EVERINGHAM SCAMMON,
Professor of Anatomy, University of Minnesota Medical School, Minneapolis.
THE new-born infant is, by no means, to be considered a miniature of the adult. While obvious differences are shown externally in the relatively large head and small face, the short extremities, the notable arching of the thoracic walls, the undeveloped genitalia, etc; numerous other differences in anatomic and histologic structure and in the physiologic functions of the various organs and systems of organs are discoverable by careful study. Certain of these, of especial interest to the physician, will be described. Those which are merely of anatomic interest, or useful in the study of cases which come to autopsy will be specifically noted in Chapter III.
The body of the child contains more water than that of the adult; the largest percentage is found in the fetus; the proportion decreases rapidly toward puberty. The body of the new-born contains about 25 per cent, of solids and that of the adult about 33 per cent. Under normal conditions, an increased water content of the infant body causes a correspondingly increased turgor or sense of resistance of the skin and subcutaneous tissues.
Among the differences described in the chemical composition of the entire organism, special attention may be called to one item. In the last months of fetal life, a considerable deposit of iron salts is gathered in the liver, enabling the infant to exist for a varying length of tune upon a diet as poor in iron as mother's or cow's milk, without lack of this essential material for the purpose of blood metabolism.
The Anatomic and Hemodynamic Relations of the Heart. — These show great departures from adult life. The absolute weight of the heart in the new-born averages about 20-25 grams, about one-twelfth the adult weight of the organ. At birth the organ forms about 0.7 per cent, of the body-weight compared to about 0.4 to 0.6 per cent, of the body-weight in the nursling. The relative or percentage weight of the heart usually falls to about 0.5 per cent, during the first year. The weights of the musculature of the right and the left ventricle is usually about equal at birth, but the left ventricle is double the weight of the right by the close of the first six months. The wall of the left ventricle is only slightly thicker than that of the right; and the heart, with its large, wide ventricles, has a much lower resistance to work
1
2 TEXT-BOOK OF PEDIATRICS
against because of the relatively large lumen and the larger sectional area of the arteries. This is shown by the systolic pressure, which is 80-90 mm. of mercury in the infant and 110-120 mm. in the adult. The pulse is more frequent, ranging from 134 during the first year of life, and gradually de- creasing in rate to about 90 during the eighth or ninth years. It is more elastic and compressible. The complete circuit of the blood is more rapid than in the adult. When one considers that neither the heart muscle nor the arterial walls have been injured by the insidious poisoning of tobacco and alcohol, or by chronic and recurring infections, and that arterio- sclerosis is a condition almost unknown in childhood, it may be readily understood that the vascular system can withstand the severest demands upon it and can compensate serious obstructions to the circulation for a long time. However, for a time, during the development of puberty, the heart does not keep pace with the rapid growth of the body and changes in its anatomic relations may cause functional lesions or cardiac insufficiencies.
During the first few days of life, the period in which the physiologic loss of weight, due to the output of large quantities of fluid occurs, the blood has a relatively higher percentage of haemoglobin, an increased num- ber of cells and a higher specific gravity. This concentration disappears during the first month, and after that a very gradual decrease in the per- centage of haemoglobin, in the relative number of erythocytes and in the slight leucocytosis continues, until, by the end of the second year, the blood of the child is the same as that of the adult. It may be questioned whether the concentration of the blood through the loss of fluids from the body is the main cause of the natal leucocytosis since the number of cells drops rapidly in the second and third days after birth while the body is still losing in weight. A slight secondary rise in the white cell count is often noted in the second week coincident with the detachment of the umbilical cord. In general the total leucocyte count after this time is little higher in the infant than in the adult. The lymphocytes form from 30 to 40 per cent. of all leucocytes in the first year and the polymorphonuclear neutrophiles form 50 to 60 per cent. From this time on the neutrophiles increase and the lymphocytes decrease in relative numbers. Their percentages are about equal (at about 45 per cent.) at five to six years. The counts of eosino- philic and basophilic leucocytes and of transitional cells are about the same in infancy, childhood and maturity. The blood does not assume its normal adult picture until about the time of puberty. During the years of infancy, however, the leucocytes remain slightly increased and a peculiarity in the percentage of their various forms is maintained to the end of childhood; the lymphocytes representing 50 per cent., while, later, they decrease to about 25 per cent. During the first two weeks of life, the normal hoemoglobin content is about 36 per cent, greater than in the adult. From these high values, the percentage begins to diminish at once and, after two weeks, the fall is very rapid. By the fifth month the value reaches very nearly the minimum and is far below the value of adult life.
The respiratory apparatus and its mechanics present important differ-
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 3
ences. The thorax of the new-born, with its high arch and its lesser length, is always in the phase of almost extreme inspiration, the ribs forming nearly a right angle with the vertebral column. As a result, the breathing is almost entirely abdominal or diaphragmatic. To compensate for the shallowness of the respiration, its frequency is increased and every added demand upon the respiratory function of pathologic origin produces an increase in the number of respirations. As the child grows older and is not continuously recumbent, the upright position causes a gradual change in the form of the chest which makes thoracic breathing possible. The weight of the abdominal organs and of the thoracic walls in the vertical position tend to draw down the anterior wall of the thorax. The larger air passages, larynx, trachea and bronchi, are also affected by the downward stress. The ribs, which were initially transverse to the vertebral column, not only take an obliquely downward position but also change shape by the formation of a distinct angle, which increases the thoracic space and gives more room for the lungs, both anteroposteriorly and laterally. The ultimate results of these anatomic changes upon functional activity are seen in the gradual assumption of the mixed type of breathing (thoracic and diaphragmatic) in the increased volume of the respiration and in the reduced frequency of its rhythm.
These changes are completed at about the end of the first year, at which time the number of the respirations has been reduced from 40 or 45 per minute, at birth, to 25. The respiratory volume ranges from 27 to 42 c.c. during the first six months of life; while it increases to 78 c.c. during the second six months and to 135 c.c. by the end of the first year (Gregor).
Later, the number of respirations is reduced very gradually, so that the average, during rest and sleep, at two years of age, is about 24 per minute, at five years about 20 per minute, and at ten years about 18 per minute. The individual respirations grow deeper, the mechanism works more eco- nomically and is readily able to overcome temporary demands for increased activity by its. greater elasticity, indicated both in frequency and volume.
Attention should also be called to the fact that the respiratory rhythm, during the first months of life, and, at times, even up to the third year, is not always regular. In the young infant, pauses of varying length may occur (Czerny). The differences in respiration, dependent upon sex, the thoracic type of the female and the abdominal type of the male, do not make their appearance until after the tenth year. More or less permanent malformations of the thoracic wall may occur in infants as a result of pathologic conditions, such as forced respiration and an abnormal softness of the ribs. These may be due in part to an incurvation of the thoracic wall at the attachment of the diaphragm.
THE PHYSIOLOGY OF NUTRITION
The knowledge of the physiology of nutrition is of great importance in the understanding of the pathology of childhood. Because milk is the chief article of diet, during the first year we incline to classify the descrip-
4 TEXT-BOOK OF PEDIATRICS
tion of the digestive processes according to the kinds of milk in common use. Practically, it is necessary to consider, in addition to the human milk, only that of the cow and goat. Asses' milk, with its very low fat content, is hard to get and not indispensable.
In the following table1 the more important constituents and peculiar- ities of woman's, cow's and goat's milk are arranged for ready comparison and as a basis for discussion.
PERCENTAGE COMPOSITION AND PECULIARITIES OF MILK.
|
Woman's |
Cow's |
Goat's |
|
|
Water |
87 |
88 |
87 |
|
Solids |
13 |
12 |
13 |
|
Total nitrogen |
0.15-0.30 |
0.55 |
0.56 |
|
Nitrogen in protein |
0.12-0.17 |
0.5 |
0.43 |
|
Total protein |
1.0 -1.5 |
3.0-4.0 |
3.5 |
|
Caseinogen |
0.6 -1.0 |
3.0 |
3.8 |
|
Lactalbumin and globulin |
0.5 |
0.3 |
1.2 |
|
Lactose |
7.0 |
4.0-4.5 |
4.4 |
|
Fat |
4.0 |
3.0-4.0 |
4.0 |
|
Total ash |
(1.3-9.0) 0.14-0.28 |
0.7 |
0.7-1.0 |
|
Calcium oxide |
0.03 |
0.2 |
0.2 |
|
Phosphorus pentoxide |
0.05 |
0.24 |
0.28 |
|
Iron oxide . |
0.0005 |
0.001* |
0.003 |
|
Chlorine |
0.043 |
0.1 |
0.1 |
|
Heat value (calories per litre) |
650-750 |
650-750 |
|
|
Reaction to htm us |
alkalin |
amphoteric |
amphoteric |
|
Combining power (acidity), per litre with blue litmus in N/10 acid. |
85 |
320-550 |
* According to more recent estimations, only a part of this iron is actually a constit- uent of cow's milk. The greater part comes from the utensils of transportation, etc.
The total nitrogen consists largely of the nitrogen of the caseinogen, lactalbumins and lactoglobulins. A small fraction is found in ammonia and in extractives, which are probably excretion products of the lacteal gland; some may also be found in the questionable lactomucins. The caseinogen, or more properly the caseinogens, because we have to deal with different substances in the various kinds of milk, are acid protein bodies containing phosphorus. They are insoluble in water, but dissolve in acids, bases and salt solutions; and are held in solution or in an ultramicroscopically fine colloidal suspension in the milk by alkalis or, more properly, by alkalin earths. The lactalbumins and lactoglobulins are usually called soluble pro- teins, in contradistinction to the caseinogen which is called an insoluble protein. Clinically, great stress has been laid for a long while upon this difference, because the less digestible cow's milk actually and relatively contains more caseinogen than human milk. At first, it appeared that the greater digestibility of human milk was due to the presence of larger amounts
1 This, table, with a few minor changes, is taken from the chapter on milk by Raudnitz, in Pfaundler and Schlossmann's Treatise of Pediatrics. 2nd Edition, 1910, Vol. 1., pp. 133.
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 5
of the soluble protein, as well as to the demonstrated differences in the two caseins. When coagulated by acid or by the action of ferments, to the oper- ation of which the presence of calcium salts is necessary, the caseinogen of cow's milk forms a more solid and a coarser curd than that of human milk; and, upon digestion in vitro with pepsin and hydrochloric acid, leaves a residue of " pseudonuclein, " sparingly soluble and digested only after a long time and with great difficulty. This is not found in human milk. The facts, later to be discussed more fully, that the direct absorption of lactalbumin and lactoglobulin, formerly accepted as a fact, has been proved an error, and that the appearance in the intestine of this undigested "pseudonuclein" has no pathogenic significance, have limited the value of these findings.
Milk-sugar, of which human milk contains a larger percentage than either cow's or goat's milk, is chemically the same substance in the three varieties.
This is not true of the milk fats which represent complicated mixtures of various glycerin esters and free fatty acids. They are inconstant in their composition and are dependent, to a certain extent, upon the fats of the food digested by the milk-producer. Cow's milk contains, in round numbers, four times as much volatile fatty acid as does human milk.
The fat content (see table) shows greater minimal and maximal vari- ations than any other constituent. Apart from individual differences, found alike in human and in animal milk, we note that in both the first portion of the milk extracted from the organ contains a smaller percentage of fat than does the later output, and that the fat content increases pro- portionately and gradually as the gland is emptied; showing the most gradual increase in breasts which secrete large quantities. The average percentage of fat content is therefore smaller in milk obtained from a freely secreting organ than from one which secretes less.
The various mineral constituents shown in the ash receive much atten- tion at present. In part, these constituents are found in the organic com- ponents of the milk and especially in the protein bodies, in the molecules of which they are incorporated with greater or less stability; and, in part, they are found as certain preformed salts in diffusible and more or less ionized state in solution in the whey.
The quantity of mineral constituents is much greater in animal milk than in human milk, corresponding to the greater demand which the more rapid growth of the young animal makes. This is especially true of calcium and phosphorus, the two important inorganic constituents of bone. It is interesting to note that both human and animal milk are comparatively poor in chlorine. The mineral content of the ash of human milk has not the same relation to the body-ash of the new-born, as von Bunge has found to be true of the milk and body-ash of several very rapidly growing animals. It is adequate, however, with probably the single exception of its iron con- tent, to the normal nutritive demands of growth and repair and of functional development in all the infantile organs.
The reaction of fresh milk to litmus is amphoteric or alkalin. Upon
6 TEXT-BOOK OF PEDIATRICS
standing, the ensuing bacterial action ferments the milk-sugar and pro- duces acid. This is of great importance in milk intended for infant feeding and will, therefore, be discussed further in the chapter upon that subject.
The tendency of cow's milk to sour is twice as great as that of human milk. This is of major importance in the process of gastric digestion, for with cow's milk a much greater proportion of the hydrochloric acid secreted by the stomach is changed into combined form and the appearance of free hydrochloric acid may be greatly delayed or may entirely fail. While acid cells are found in the gastric glands both of the fetus and the new-born it is approximately two years before they reach their full develop- ment. The gastric mucosa of the infant is relatively thick and the mus- cular coat relatively thin, although all the layers of the latter are present. The elastic tissue of the stomach is limited to the walls of the arteries of the organ for some time after birth.
To the constant constituents of milk belong, in varying quantity, various ferments and certain immune bodies. The former have long been considered important to the process of digestion in the gastro-intestinal tract, while the latter have been supposed to be important factors in the development of the high grades of immunity which appear with the use of certain kinds of food. This view, on first consideration a very essential one, and chiefly because the usual practice of boiling milk for a short time, kills these ferments and immune bodies, but without affecting the food- value of the milk, does not seem tenable today.
Neither human milk nor cow's milk has the same composition at the beginning of lactation as it has when the function is fully established, save for relatively minor changes, it then becomes constant and remains so throughout the period.
The colostrum is the initial secretion of the functionating mammary gland; it is, at first, small in quantity, but gradually increases. It is a yellow fluid, viscid because of its high protein and globulin content, and coagulates upon heating. It contains about 3 to 5 per cent, of milk sugar; its fat content varies within wide limits. The fat is not chemically identical with the fat of the later milk of the same animal. In the woman, the transition from colostrum to milk is normally complete by the end of the first week.
The best evidence of the colostral condition of the milk is the discovery of colostral corpuscles (see Fig. 1) that is, of leucocytes loaded with coarse and fine fat droplets, which are, at first, very numerous in each microscopic field, but later are few and require careful search. Czerny has shown that they are leucocytes and, according to more recent investigation upon the human subject, are lymphocytes which take care of the unchanged, non- absorbable fat, present in the temporary hypersecretion of the mammary gland, by emulsifying it and removing it through the lymph channels, They are found whenever there is congestion of the gland and to this fact attaches their clinical interest.
Since the milk of animals is not used directly from the udder, but is usually pasteurized or sterilized and is variably diluted for infant use, it is
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 7
necessary to consider, from the viewpoint of clinical interest, the physical and chemical changes which follow.
Dilution produces a slower coagulation and a finer curd. Heating, and the effect is the same whether milk be heated to 70-80° C. (150°-180° F.), for a long time, or brought to the boiling point for a short time — causes a partial precipitation of the phosphates or alkalin earths and the formation of insoluble tri calcium citrate, which delays clotting, a process dependent upon the presence of soluble calcium salts, and thus forms a finer curd. Lactalbumin is partially coagulated at 55° C. (140° F.) but is not completely precipitated by boiling, a part being held in solution by the caseinogen and alkalin salts. A portion of the caseinogen is dissociated into casein and its
FIG. I. — Fat globules; above, in mother's milk; below, in colostrum.
base, which causes the formation of the skin or pellicle upon the surface of boiled milk. The milk-sugar is changed into caramel by continued boiling and the brown color of commercial preparations which have been excessively sterilized is due to a reaction between the milk-sugar and the caseinogen. Similarly, long continued heating causes a coalescence of the fat globules. The inorganic constituents are greatly changed upon boiling by the breaking up of their organic combinations, but nothing definite is known about the import of these changes in the physiology of nutrition. The ferments and the most of the immune bodies are destroyed at 60°-80° C. (140°-180° F.).
As the child develops, it is finally able to utilize the mixed diet of the adult, the discussion of which is not essential here.
During the first year of life, the child takes nourishment entirely by suckling and swallowing. It is only towards the end of the second year, when the premolars have developed, that the child learns to masticate his food.
8 TEXT-BOOK OF PEDIATRICS
In suckling from the mother's breast, even the new-born may develop considerable negative pressure. But this negative pressure of the oral cavity is by no means the only factor in the extraction of the milk. Besides this the closure of the jaws and the pressure upon the musculature of the areola cause a reflex relaxation of the sphincter muscles. Psychic influence also plays some part in the relaxation of the breast. From the very com- plexity of these reflex reactions, we may anticipate that there are wide individual differences in the ease with which the breast may be emptied, even though the suckling powers of the children be equal. This proves especially true when the milk is expressed or pumped out.
The liquid nourishment passes the comparatively small mouth of the infant rapidly. According to Tobler's observations on a four-year-old boy, 3-5 c.c. of saliva are added to 100 c.c. of milk. In children during the first four months, in whom the mouth is comparatively dry and the secretion of saliva scant, there is probably even less admixture. By the fourth to the sixth month, the secretion is much more abundant and until the child learns to swallow the saliva it may run from the mouth.
Attention may be called to certain anatomical peculiarities of the infant's mouth which fit it for the mechanics of suckling. The inner mar- gin of the lips is studded with numerous papilla? (the pars villosa) and the middle portion of the upper lip is prolonged in a median labial tubercle. These structures with a series of marked transverse ridges or rugce on the hard palate aid in holding the nipple. The collapse of the lateral parts of the cheeks in the suckling act is prevented by the presence of the sucking pads, specialized masses of fat which lie below the superficial fascia and are pressed against the gums when a negative pressure is produced in the oral cavity. Hasse has pointed out that in sucking, the milk passes the mouth by way of two functional passages — the median salivary cavity, between the tongue and soft palate, and the lateral salivary cavity between the cheeks and gums. In either case the .fluid is discharged into the pharynx through narrow posterior apertures lying between the soft palate and larynx medially and the posterior pillars of the fauces laterally. As the larynx lies at a relatively high level it is possible for fluids to pass through these openings into the lower part of the pharynx without entering the cavity of the larynx even when this structure is open.
Ptyalin is certainly found in the saliva of the new-born, although in small quantities, but there is nothing in the milk upon which it can act. When gruels or flour are added to the diet, its function is required.
The stomach of the young infant is but slightly developed as to the fun- dus; the lesser curvature, because of the fulness of the intestine, is more horizontal and its concavity is directed backward instead of to the right, as in the adult. This peculiarity changes as soon as the child begins to stand and to walk, when the vertical position of the organ develops. The capacity of the stomach is at first very small ; varying in individuals and according to diet; it increases rapidly in size as the child grows older. Exact figures can hardly be given because the capacity and the distensibility are not identical under varying conditions of feeding. Such conclusions as may be
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 9
drawn from the quantities of food that the healthy child spontaneously takes are noted in the second chapter. It is an established fact, however, that the healthy breast-fed babe occasionally takes much greater quantities of food at one time than would seem possible, according to the capacity of the stomach, and it has been shown that part of the milk passes unchanged from the stomach into the intestine while the child is nursing.2
The histologic structure of the stomach wall evidently shows no great differences from that of the adult. The hydrochloric acid and all the digestive ferments are present in the stomach of the new-born.
The casein formation in the stomach occurs rapidly with cow's milk, after it has become acid in reaction. With human milk the process is slower. In the former larger flakes of curd are formed than in the latter. The whey, which is separated after coagulation and which contains the greater part of the salts, the milk-sugar, the so-called soluble milk proteins, and other constituents about which little is known, is soon acted upon suffi- ciently by the pepsin and hydrochloric acid to permit its passage, in frac- tional quantities, into the intestine for its further digestion by trypsin and erepsin. The casein in the stomach content, which gradually becomes more solid, is digested more slowly but in an analogous manner, the fer- ments attacking the outer surface and digesting it. If more cow's milk be put into the stomach before this dense mass of cheese is completely dis- solved, the new milk spreads itself between the stomach wall and the outer surface of its older content and prevents its further digestion by taking up the hydrochloric acid and the ferments. It is possible that abnormal changes in the direction of decomposition may develop in this central mass.
The presence of free hydrochloric acid is dependent not only upon the total quantity secreted, but also and directly upon the power of the food to combine with it. For this reason it is present in the stomach of the breast- fed infant after one to one and a half hours, and in the child fed with cow's milk only after two and a half to three hours. This is important, because the free hydrochloric acid has an antiseptic action which the combined acid does not possess.
N
The total acidity, varying from 20-60 c.c. — acidity per 100 c.c. of con- tent is due to the organic acids and acid salts, and especially the acid phos- phates present, rather than to the hydrochloric acid. The organic acMs arise partly from the action of the ferment lipase upon the fats, which occurs in small measure in the stomach, and partly from bacterial action.
Flour or gruels, given with or without additions of milk, are not only
2 The stomach of the new-born infant is usually almost vertical in position with the greater curvature to the left. The transverse type of stomach characteristic of infancy is established with the distention of the viscus at birth either with injected fluid or with air and mucus. Until this distention has taken place the anterior surface of the organ lies entirely under the cover of the liver and is usually covered in part by the gastric surface of the spleen. The average anatomic capacity of the stomach is about 1 ounce (33 c.c.) at birth. This is doubled in the first ten days, tripled in the first month and increased over 6-fold by the end of the first six months. After the first four or five days the size of the average feeding is about a fifth to a quarter more than the anatomic capacity of the stomach at the same age.
10 TEXT-BOOK OF PEDIATRICS
changed digestively by the long continued action of the p.tyalin of the saliva, but are split further by bacteria mixed with them, inducing a fermenta- tion, the products of which are usually, in part, low fatty acids.
The duration of gastric digestion in the healthy child depends upon the kind and quantity of the food. After an abundant feeding of breast-milk, the stomach is empty at the end of two hours, and after the same quantity of cow's milk it is emptied in three hours. Smaller feedings leave the stom- ach in a correspondingly shorter time. These digestive periods obtain only in healthy children; even the slightest disturbance may influence the motility of the stomach so greatly that the food may remain for an hour or so longer.
The rapidity with which the stomach empties is regulated by the closure of the pylorus which is stimulated reflexly by the content both of the stomach and of the duodenum. According to Tobler's investigations, food rich in fat delays its emptying.
Small quantities of salt and sugar solutions and of albumoses are absorbed by the gastric mucosa. The larger part of the food mass passes into the intestine.
The acidity of the gastric contents is reduced in the duodenum by the addition of sodium carbonate, of which the pancreatic juice contains a large percentage. This causes a withdrawal of alkali from the body.
The digestive changes in the intestinal tract apparently occur in the same manner as in the adult. All the ferments of the intestine and the contiguous glands, even including the prosecretin and the hormone se- cretin, which are found in the adult, are present in the new-born, and, for the most part, have been identified in the fetus.
A more detailed description of the digestive function is hardly neces- sary here; but a few special points may be emphasized. As we have said, the absorption of the so-called soluble milk proteins unchanged was formerly accepted as a fact. This, however, has been disproved. They, as well as the casein, are split, in part even in the stomach, to the finer divisions of the protein molecule (amino-acids, and peptids) and, if they are not oxidized, are used in the intermediate metabolism of the synthesized body protein. This is true even of the proteins of the human milk.
Milk-sugar (lactose) if not given in quantities beyond the limits of digestion and absorption, is split by the ferment lactase into dextrose and galactose. If this enzymic action is not complete and if the remaining portion is not fermented by bacteria in the intestine, the milk-sugar may be absorbed unchanged and is then excreted in the urine, as it is if paren- terally formed. This incident plays a part in pathologic conditions.
For the clear understanding of many of the metabolic processes which are to be described later, attention must be called to the fact that not only are the products of the digested food absorbed during the whole course of gastro-intestinal digestion, but that there is, also, a secretion of a very con- siderable quantity of fluids containing proteins and salts into the tract. It should be noted, further, that the colon, in which no actual digestion occurs, is an organ of absorption, as well as of excretion, and especially for the
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 11
earthy and fixed alkalis and for iron and phosphorus. The tune necessary for the passage of food through the intestine varies, normally, from twelve to thirty-six hours.
The feces, consisting of particles of undigested food and remnants of the secretions of the intestinal tract and of the glands accessory to it, together with a considerable number of bacteria, naturally vary in consist- ency, color, odor and mass with the kind and quantity of food ingested, with the intensity of the various secretory influences, and with the rapidity of the peristalsis.
The first evacuations of the new-born consist partly of epithelial debris and of the secretions of the fetal intestinal tract and its adjacent glands and, in part, of the constituents of the ingested amnionic fluid and of sub- stances found in it, e. g., lanugo, epidermal cells, etc. Its dark green color and viscid quality, giving to it the name of meconium, disappear so soon as the results of milk digestion appear in the stool. This usually occurs between the second and fifth day.
Under normal conditions the stool of the breast-fed infant has a salve- like consistency, is egg-yellow in color, and has an aromatic and acid odor. The bowel movements should occur once or twice in twenty-four hours. More frequent bowel movements, generally regarded as signs of chronic dyspepsia, occur with surprising readiness in children who are developing normally. They are thin or watery, non-homogeneous and lumpy, or con- tain shreds, and are full of minute particles of greenish mucoid material in which traces of fecal matter are imbedded. The odor alone is like that of the normal breast-milk stool; it may be of stronger quality, but it never has the offensive character of putrefactive feces. According to the researches of Gregor, we are justified in the belief that the appearance of such stools, which are usually poor in substance, is due to a relative reduction of the amount of fat in the breast-milk, although an increased irritability of the secretory and motor functions of the intestine must be presumed as a causative factor.
Attention must be called to the fact that stools which are yellow when passed may change to a green color when left exposed to the air for a time. While the conditions necessary for the oxidation of bilirubin to biliverdin, in the intestine or after evacuation, are not fully understood, it must be stated emphatically that the condition is not in itself pathologic.
In artificial feeding with dilutions of cow's milk, or with mixtures of cow's milk and gruels or flour, the stool is usually better formed, is lighter in color than the breast-milk stool, and has a slightly unpleasant or even a putrefactive odor. Its reaction to litmus is alkalin. Every deviation from type in the artificially-fed must be taken much more seriously than variations in the stools of the breast-fed infant and must be regarded as a possible symptom of disturbance of nutrition.
As the change to a mixed diet, with only moderate quantities of milk, is made, the normal bowel movements take on the characteristic consistency of the evacuations of the adult.
The entire digestive tract, from mouth to anus, offers a suitable soil for
12 TEXT-BOOK OF PEDIATRICS
the growth of numerous varieties and strains of bacterial flora. It may be readily understood that, even during the first few hours after birth, the gastro-intestinal tract becomes infected, both by way of the mouth and the anus, with numerous micro-organisms from its immediate surroundings. All do not enter in the same manner, nor do all find an equally fertile soil. It is manifestly true that the bacteria found in the stool of the breast-fed child are of other varieties and of lesser number than those seen in the stool of the artificially-fed infant.
In the bowel of the breast-fed infant, the number of the anaerobic bacillus, bifidus communis (Tissier) greatly exceeds that of the aerobic bacilli, coli communis and the bacillus lactis aerogenes (Escherich). Besides these, streptococci, the bacillus acidophilus, the bacillus butyricus immobilis (the bacillus perfringens of the French authors), the "Koepfchen bacteria," (Escherich) the anaerobic bacillus, butyricus mobilis, and the bacillus putrificans coli (Bienstock) which causes putrefaction, and several others, are commonly found. In the artificially-fed infant, the colon bacillus and the intestinal cocci are most common, but many of those named above are also present and usually in larger number than in the stool of the breast-fed child.
From the clinical point of view, and for several reasons, the intestinal bacteria are interesting. From experimental researches upon new-born animals, which die when a sterile gastro-intestinal tract is maintained,3 it seems possible that an irreplaceable physiologic function is performed by them in the human infant. The fact that a continual germicidal activity is exhibited throughout the small intestine, especially in the intervals between the digestive acts, and that rapid bacterial growth occurs only in the colon, where the actual digestive process is completed, makes the problem a difficult one to solve. Nevertheless, the influence of the intesti- nal flora upon the reactions of the intestinal content has been established. These producers of fermentation and putrefaction exist in constant antag- onism to each other and determine an acid or alkalin reaction of the feces, according to the predominance of each type. Of course, the kind of food, apart from the general condition of the organism, has an influence in deter- mining this predominance.
Finally — another point not to be overlooked — is the possibility that under certain circumstances, with an increase of the usually harmless saprophitic bacteria, they may acquire a virulence which makes them pathogenic to the particular infant.
While the kidneys, relatively large in the new-born and during infancy, show normally some degree of fetal lobulation, they generally resemble those of the adult; so, also, does the urinary tract. The urine, during the first few days of life, is scanty and concentrated, tallying with the small quantity of fluid ingested and the large water output from the lungs. It contains a relatively large quantity of uric acid in an amorphous or crys- talline form. The explanation of the cause of albuminuria in the new-born,
3 Schottelius vs. Thierfelder, Nuttel, etc.
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 13
the subject of much discussion, an event common only during the first and second weeks of life and but rarely of longer duration, is no more definite than that of the occurrence of uric acid infarcts. Without going deeper into these questions, amply and critically discussed by Czerny and Keller, it may be asserted with confidence that this albuminuria and these infarcts, while probably non-physiologic, are, at most, conditions not particularly harmful to the individual.
The kidneys weigh about 25 grams in the new-born and increase in weight between 19- and 14-fold between birth and maturity. They double their weight in the first year and triple it by three years. They form about €.6 per cent, of the body-weight in the new-born as compared with 0.2 to 0.3 per cent, in the adult. They occupy a relatively larger proportion of the posterior abdominal wall in infancy than in later life, their lower poles generally lying below the iliac crests and their upper poles extending to the eleventh or even the tenth ribs. Their adult skeletal relations are estab- lished as the child habitually assumes the erect posture and the lumbar region elongates.
The bladder is almost entirely an abdominal structure at birth and in early infancy. In the contracted state its apex lies about midway between the umbilicus and pubis on the anterior abdominal wall and its base lies behind the middle third of the symphysis pubis. When filled the fundus may lie above the level of the umbilicus
So soon as the course of nutrition is normally established a close relation between the quantity of water taken and the quantity of urine excreted becomes clear; from 60 to 70 per cent, of the ingested water reappearing in the urine. Of course this is true only under perfectly normal conditions. The urine is voided about three times as frequently as food is taken and, if water be given between meals, micturition may occur twenty or twenty-five times in the twenty-four hours. We are not justified in speaking of phys- iologic incontinence in the infant; for there is no continuous flow of urine.
The infantile penis varies greatly in size in different individuals. Nor- mally there is more or less complete phimosis and usually but a pinhead opening, with complete adhesion between the glans and the inner surface of the prepuce. Neither this, nor the presence of epithelial concretions in the region of the coronary sulcus, should be, under any circumstances, an excuse for superfluous and disfiguring operations for phimosis. At the present time it is necessary to lay special stress upon this point.
The vulva of the female infant gapes because of the slight development of the labise. This physiologic prolapse is favorable to the entrance of fecal particles into the urethra and the resulting occurrence of cystitis. This etiology of cystitis is more fully discussed in the chapter on Genito-urinary Diseases.
The skin of the infant, because of the thinness of the epithelial layer and the greater vascularity of the papillary layer, is more tender, softer and more intensely colored than in later years. These differences are most marked in the new-born, whose skin is so vascular during the first few days that a physiologic erythema neonatorum is described. In all diseased con-
14 TEXT-BOOK OF PEDIATRICS
ditions and, especially in disturbances of nutrition, a distinct pallor rapidly takes the place of the blush of health, or, a more serious symptom, a slate- gray coloring may appear.
The subcutaneous fat is present and, in normal conditions, fairly well developed over the whole body and even over the extensor surfaces of the joints where it is absent later in life. When the watery and saline constit- uents of the organism are normal, the fat gives to the skin of the infant a tensity and elasticity — "turgor" — which, with its fresh color, is a distinct indication of health.
The anatomic development of the sweat glands is slight, while the opposite is true of the sebaceous glands which are well formed. The func- tional scantiness of the perspiration and the abundance of the secretion of sebum in the new-born tally with these facts.
Finally, the mammary glands, which are modified cutaneous organs, should be mentioned. In both sexes the body of the gland represents a flat disc, not more than one centimeter in thickness. It is usually sur- mounted by a pale, indistinct areola, in the centre of which is the mammilla about the size of a pinhead. An increase in the volume and an active functioning of the gland during the third or fourth day of life is quite a common rule. This is probably due to the action of the same hormone, circulating in the blood of the babe, which stimulates lactation in the mother. Since the secretion ("witch's milk") is not normally excreted and congestion results, the fluid has the consistency of colostrum. During the first few days of the first month, the secretion completely disappears. Histologic evidences of milk secretion, in the form of dilated ducts and alveoli containing remains of secretion, may be found six months or more after birth.
The body temperature4 of the infant depends upon the temperature of its surroundings to a greater extent than that of the adult. This is especially noticeable in premature infants and in those who are congeni- tally weak, so that we may speak of a poikilothermia in these cases. This condition may also appear, however, in normally strong children. Its cause is in part found in the thinner epithelial layers and the greater vascularity of the skin. On the other hand, the low water output from the skin of the new-born and the relative excess of the body surface to its actual volume.5 are material factors. Slight irregularities in heat distribution, which is largely a function of the body surface, may cause, therefore, slight variations of body temperature the more readily because the relatively small body mass is less able to equalize them by rapid changes in heat production.
It is not necessary to discuss, in this connection, the inadequacy of thermal regulation due to the non-development of thermotaxic and thermo- inhibitory centres, since analogies in other nerve functions, as in the motor field of the new-born, justify the assumption. However this may be, clinical
4 See technic of examination.
5 In the new-born we have, for each kilo of body- weight, approximately 810 square centimeters of surface; at six months, 620 square centimeters; at twelve months, 530 square centimeters; at four years, we still have 500 square centimeters; while the adult has only 300 square centimeters.
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 15
observation has proved that young infants may be cooled or overheated by external influences much more readily than older children. There is, at least, a reduced range of physiologic heat regulation. Within these limits, it is nevertheless very exact. The healthy infant, surrounded by non-con- ducting substances, maintains a temperature between 36.8° and 37.2° C. (98.2°-99° F.) almost continuously without the aid of external heat. These figures mark the slight morning and evening range of temperature by rectum. This practical monothermia, according to the careful studies of Jundell and Goffer je, who took temperatures every two to four hours by rectum, is found only during the first few weeks of life. By the second month, the temperatures similarly taken, revealed variations up to 1° C. (1.8° F.) a range in which, under regular conditions of sleep and growth, may be recognized a nightly fall and a daily plateau. Irregular variations and increases over 37.5° C. (100° F.) in children who have not been artificially warmed by hot-water bottles or similar agencies, must be considered pathologic.
THE PHYSIOLOGY OF METABOLISM
Attention has already been called to the great importance of the role which the nutrition and allied phenomena assume in the life of the infant — an importance which will be emphasized in other portions of the work. It seems necessary, therefore, to devote a special chapter, in addition to the subsequent detail of the process of digestion, to the physiology of metabolism.
a. NITROGEN
Nitrogen is present in milk almost entirely in the form of protein. The researches of Bahrdt and Langstein upon new-born animals have demon- strated that even the protein materials of the milk of the mother animal undergo very complete metabolism into amino acid and amino acid com- plexes (peptids). There is no reason why the results of these researches may not be transferred to the human new-born. If this were done, the hypotheses based upon the differing effects of feeding homologous and heterologous proteins, as represented in natural and artificial feeding would lose support, unless we also assume that their comparatively simple cleavage products (amino-acids, etc.), retain the identical characteristics of the protein from which they are derived. In support of this latter posi- tion, however, no definite proof has as yet been advanced. Recently various researches tend to show that foreign protein (egg) may be absorbed un- changed in certain nutritional disturbances. These proteins may be found in the blood and urine; the quantities depend upon the severity of the disturbance.
The nitrogen requirement of the infant is evidently small, as indicated by the low nitrogen content of human milk. This should be remembered in studying the requirements of the nutrition and the period of the greatest relative growth, for it shows how little an excessive protein diet can be justified by the indications of the demands of natural growth. Certain
16 TEXT-BOOK OF PEDIATRICS
authors claim that the protein need of the growing infant is fully supplied when 7 per cent, of its caloric need is supplied in protein. The first few days of life only, the period of the so-called physiologic loss of weight, present an exception to this, for if the child be nourished during this period with milk of an established lactation there is a distinct loss of body nitrogen, which is avoided if colostrum, which contains much more nitrogen than does the fuU milk (Birk) be fed.
In the healthy child the absorption and retention of nitrogen is very complete. The dried feces contain only 4-4^2 per cent, of nitrogen, and even this small amount consists only in part of the nitrogen of the food which has escaped absorption. At least an equal share comes from the nitrogen containing secretions of the intestine and its auxiliary glands and from the bacteria present. The retention is represented by the difference between the intake and the excretion in the feces and urine, but it may be said that a positive N. balance is not necessarily indicative of growth or, rather, of tissue building. Nitrogen retention may occur temporarily during periods of weight loss.
The end products of nitrogen metabolism in the urine are the same as in the adult, excepting that the amount of ammonia is normally somewhat greater. This will be more fully discussed in the chapter on Disturbances of Nutrition.
As in the adult, the addition of carbohydrate to the protein food leads to an increased N. retention, in spite of a poorer N. resorption, while fat reduces the N. absorption as well as the N. retention very slightly. This, however, is of no practical importance under normal conditions, since the nitrogen intake always exceeds the minimal requirements. It may become important in pathologic conditions.
6. FAT
The fat taken in milk feeding consists of neutral fats and contains only small amounts of free fatty acids.
As already stated, a slight fat-splitting by lipase occurs in the stomach of the infant. It is probably much less than takes place in the stomach of the adult, where the strong lipolytic secretions of the small intestine nor- mally flow back into the stomach and initiate a more complete breaking up of the fats. The purpose of this is probably to facilitate the emulsification of the coarser fat droplets by the alkalin carbonate of the pancreatic juice, which is dependent upon the presence of free fatty acids. In the infant whose fatty food is taken in the form of a fine emulsion this is unnecessary.
The amount of fat taken with the food varies greatly in the breast-fed child, not only from day to day, but also in the several feedings; doubling in quantity, in some instances, with the increase of the volume and the fat content of the different meals. This is readily understood when we recall the variations of the fat content of the human milk stated above. In the artificially-fed child these variations do not usually occur, since in children fed with milk mixtures, of closely similar quality at each feeding, the total
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 17
amount of fat ingested, e\en when cream is added, is far less than the breast-fed babe receives.
More than nine-tenths of the fat ingested is absorbed from the intestine of the healthy infant. Part of the fat recovered from the feces probably comes from the intestinal secretions and a small portion of the volatile fatty acids may originate from the breaking down of the carbohydrates. The fat of the feces consists of neutral fats, free fatty acids, and the earthy alkalin and fixed alkalin salts of the fatty acids (soaps). It is found in varying quantity. This is shown, without further examination, by the con- sistency, the reaction and the odor of the evacuations, in so far as the fatty acids are in excess in the acid stools; while in the dry alkalin feces the earthy alkalin soaps are in excess, only a minor part (about 10 per cent.) consisting of neutral fat which shows very slight variation.
The role of soap formation in the metabolism of the fixed and alkalin earths is evidently a very complicated one and, up to the present time, is not fully understood. As these are of special importance in pathologic con- ditions we dispense with their full discussion here.
The absorbed fat is required by the body partly for combustion and in part as a reserve of storage food.
c. CARBOHYDRATE
Only one carbohydrate, milk-sugar (lactose) is contained in human milk and in the milk of animals. It is a disaccharide and splits into one mole- cule of glucose (dextrose, grape sugar) and one molecule of galactose. These two monosaccharides are combined with a loss of one molecule of water.
Other disaccharides used in the artificial feeding of healthy infants are cane-sugar (saccharose = dextrose + levulose or fructose) ; and maltose ( = dextrose + dextrose) the latter being either an important constituent of the commercial malt extracts, or a product of enzymic action upon starch.
Preformed monosaftcharides are not contained in the nutriment of the infant. Only when the child is able to take honey and fruit does it receive levulose and glucose, as such.
Among the polysaccharides, starch and cellulose must be considered. The former is a constituent of the pure flours, partially dextrinized in toast (Zwieback) and found in several of the so-called infant foods; and the latter is a constituent of vegetables and fruits.
It is generally understood that only the monosaccharides are directly absorbed; other varieties of sugar being absorbed only after they have been split by the action of enzymes and, probably, by bacterial action as well. Only if greater quantities are ingested than can be broken up by the enzymes or fermented by bacteria, does the direct absorption of disaccharides occur; and then they are excreted unchanged in the urine, even as they are after parenteral absorption. It may be said, in this event, that the limit of assimilation has been exceeded. The polysaccharides undergo a compli- cated splitting before absorption.
It has been stated already that the various ferments necessary to carbo- hydrate digestion are found in the new-born, even though in very small 2
18 TEXT-BOOK OF PEDIATRICS
quantities. This is true both of the diastase of the saliva and the amylo- lytic secretion of the pancreas. In view of their scanty presence, it is prob- ably true that a relatively large part of the carbohydrate, the exact quantity not being determined, is split by bacterial action (fermentation) with the formation of the acid products of this decomposition.
The limit of assimilation for milk-sugar and maltose is higher in the infant than in the adult.
The carbohydrates of the food serve in the infant, even as in the adult, not only as material for combustion and as a source of energy, but they facilitate or even actualize the normal potential combustion of the fats. If they are absent, a disturbance of fat metabolism results, recognized by the appearance of acetone bodies in the urine. This is more readily developed in the infant than in the adult. It has been determined that a moderate amount of lactose in the diet increases the nitrogen retention, but that large amounts cause a negative N. balance. Also the complete withdrawal of carbohydrates causes a negative N. balance.
The amounts of blood sugar, as recently determined by Goetzky using the method of Bang, are 0.085 per cent, average for infants of twelve days; 0.095 per cent, for one month; and 0.102 per cent, at one year. In older children other authors have obtained an average of 0.072 to 0.113 per cent, which are approximately the same as the variations in the adult.
d. MINERAL CONSTITUENTS
Human milk contains all the minerals necessary for the life and growth of the infant. In the milk of the domestic animals they are present in much larger quantity, corresponding to the more rapid growth of their young. So plentiful are they, in fact, that in the feeding of the healthy infant with the usual milk dilutions their quantity is ample, with the probable excep- tion of iron which is very scanty in both human and animal milk.
The close relationship of inorganic to organic metabolism, and the rel- ative independence of individual kations and anions in their migration through the organism, make it plain that one mineral substance can act vicariously for another in only limited measure. In fact, the continued absence of even one certain ion is incompatible with growth and life. The danger of its lack may be overcome for a time by the ability of the tissues when subjected to "salt hunger" to retain their mineral substances with great tenacity; but this temporary protection is broken down after awhile. These inorganic ingredients have a great influence, also, upon the water content of the organism.
e. WATER
Water plays an important part in the life of the infant because the child takes more than double the quantity of water with his food per kilo of body- weight, than does the adult. His body, in fact, contains relatively more fluid. As with other tissue components, the organism regulates this water content, not according to the quantity obtainable, but according to its necessities, By the figures of Camerer it is shown that in the healthy
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 19
breast-fed child about two-thirds of the water ingested is excreted in the urine, and only 1 to 2 per cent, remains in the body; the remainder leaving the body by way of the lungs, the skin and the intestines.
The ingestion of larger quantities of water does not increase the storage but the excretion, especially by the kidneys; and since always it takes with it soluble substances (urea, salts, etc.) this probably leads to a partial leaching of the tissues. In order to increase the water content of the body, we must give salts or other substances, e. g., carbohydrates, favorable to water retention, in addition to sufficiently large quantities of water. On the contrary, a reduction of the water retention can be accomplished only by restricting the intake of salts or carbohydrates, or by a pathologic increase of the secretion of water and salts. The simple reduction of the water intake has the ordinary result of reducing its excretion. These con- ditions probably play some part in the etiology and pathogenesis of the various disturbances of nutrition. It seems, at times, that the possibility of regulating the water balance in the infant is less developed than in later life. Perhaps on the other hand the amount of water excreted from the body by the way of the intestine and the power of water retention play a most important role.
/. ACCESSORY FOOD SUBSTANCES
It has recently been recognized by experiments on animals and by observation on the human that there must be other food elements which by their presence in the diet promote normal growth in the young and prevent so-called " deficiency diseases" in the adult. To these Funk has applied the name of "vitamins," but Hofmeister's term of "accessory food substances" seems preferable because it is more noncommittal. Their chemical and biological study still offers a large field for research, but it is generally recog- nized that they occur in small quantities in certain food, and that they are not of animal origin, but are transmitted through milk and meat from vege- table food. Their importance as an etiologic factor of beriberi and the analogous polyneuritis of chickens, of scurvy, and of keratomalacia has been proved. In rickets, however, it is apparently only a factor. The anti- neuritic principle is contained in most vegetable foods and the form of polyneuritis known as beriberi is produced only by a continued one-sided diet with polished rice. The antiscorbutic principle is found in fresh green vegetables and certain fruits (lemons, oranges, raspberries and tomatoes), and in small amounts in milk and meat. It is quite resistant to heat, drying and preserving. The antirickitic element is found in green leaf vege- tables and in animal oils (butter, cod-liver oil, yolk of egg). Friese was able to cure the keratitis produced by the specific Hopkins diet by adding a small amount of fresh milk. The solution of the innumerable problems arising from the study of the accessory food substances is of great importance to the podiatrist.
g. THE TOTAL METABOLISM
The total metabolism of the child demands a greater intake of food than in the adult because of the added requirements of normal growth. If the
20 TEXT-BOOK OF PEDIATRICS
larger output, through the several channels does not counteract this intake, the margin of increase will be very slight, since even in the period of most rapid growth the greater part of the gain in weight consists of water.
Thus Camerer estimates that in a child ten weeks old, weighing five kilos, taking 800 gms. of breast-milk per day, and showing an average daily gain of 25 gms., the increase consists of 18 gms. of water, 0.7 gms. mineral substance, 3.0 gms. of protein and 3.3 gms. of fat.
Actually, a greater intake is counterbalanced by a notably increased physiologic output. In the resting infant, this output is the larger on account of its relatively greater heat radiation. Attention has been called to the fact that the body surface of the infant, as compared to his weight or mass, is two or three times greater than that of the adult. And since the heat radiation runs parallel, in definite degree, to the surface area, the out- put of the metabolism of the infant would be two to three times as great as in the adult and the intake, in order to maintain a positive balance, would have to be that much greater. As an actual fact Rubner has deter- mined experimentally, in his researches upon adult dogs of various sizes, that their carbon dioxide excretion is proportionate to their body surface, other things being equal ; and that it does not rise or fall in proportion to their body-weight. Since the carbon dioxide excretion may serve as a measure of the combustion of organic substances, in accordance with demonstrated physiologic principles, a close relationship is thus established between surface area and food requirement. This food requirement may now be measured by its caloric value, and the experimentally established values of the different food substances may be rated as follows: for 1 gm. of protein 4.1 calories; 6 for 1 gm. of fat 9.3 calories; and for one gm. of sugar 4.1 calories. The salts do not present a calculable caloric value.
Putting the clinical conception of food requirement aside, in favor of the energy requirement or rather the caloric index, which lends itself readily to physical and chemical investigation, the latter has gained recognition in scientific pediatrics by the epoch-making work and studies of the elder Camerer, of Rubner and Heubner; and is both lauded as an important advance and condemned as unscientific and contrary to clinical experi- ence. It may be acknowledged at once, that in considering food as an entity, basing its value upon its heat-producing power, we must accept as a premise that its component substances are capable of far-reaching physiologic interchange. This is based upon the idea of isodynamia, that is, that a calorie of one food component can be freely substituted for a calorie of another food component in the metabolism. At the same time, we must acknowledge that this premise is true only to a limited degree in the healthy infant, and is entirely untrue when applied to the child with disturbances of nutrition. Heubner, to whom the study of the problem of energy requirement in infant feeding owes its greatest advance, has replied to objections raised by Czerny and Keller, when they feared
6 Protein gives 5.6 calories in the calorimeter, but of this only 4.1 calories are physi- ologically available as useful calories in the organism, while 1.5 calories are lost in nitro- genous excretions (urea, etc.)-
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 21
that the physical viewpoint in the teaching of infant feeding would wholly supersede the physiologic-chemical view, by emphasizing that this is not the purpose of the proponents of the method, but that the aim is to give a better quantitative standard of the food requirement of the infant than was given by any former methods in determining the volume or weight of the food. He further asserts that with this common standard it is possible to obtain the most favorable quantitative variations in which the different food substances may and must be put together. The energy quotient fur- nishes us with a unifying principle and, whatever the choice or qualitative composition of the infant's food, informs us of the essential quantities, which, under all the variances in age and condition the infant demands.
Apart from the minor fact of the broad interchangeability of various food substances in infant feeding, the adoption by the clinic of the caloric method of treating the feeding problem meets with two other sources of error, which, while reflecting upon its absolute exactness, do not impair its approximate usefulness.
It should be noted, first, that a part of the raw calories taken in as food are lost to the metabolism, in that organic substances of definite caloric value are excreted unused in the urine and feces. The sum of the raw calories is, therefore, greater than that of the net calories which serve as the physiologic units of energy for growth and repair. A part of this error in reckoning the raw calories has been already noted (see footnote 6). The remainder because it is small and, in the healthy child at least, of slight variability is a negligible quantity.
In the second place, a further error is incident to the fact that the caloric requirement is estimated by body-weight rather than as the theory strictly demands — by body surface.7 This really important error is dis- counted in clinical practice by the fact that a gradual reduction of the caloric requirement is adopted corresponding to the decrease of surface as weight increases.
Attention is called to these limitations in order to protect the caloric method of determining food requirements, on the one hand, from the exces- sive enthusiasm of its advocates and from its indiscriminate application, and, on the other hand, from the unjust objections of its critics. Within these limitations, the method permits us to determine empirically a definite relation between body-weight and the total food requirement of the healthy child. Heubner has designated the number of calories which a normally growing child requires during the successive divisions of its first year of life, for every kilo of body-weight, as the energy quotient. The first figures given by Heubner were based upon a few observations only; but as experi- ence has added to the sum of knowledge these figures have been, again and again, corrected; and today we use, in round numbers, 100 calories, or a little more, in the first quarter year of life; 90 calories in the second; 80 in
7 The measurement of the body surface is an extremely difficult task; it takes a long time and is not applicable even in hospitals, to say nothing of private practice. The calculation of the surface area from body-weight, according to the formula of Meeh, demands a mathematical facility which is hardly to be expected of the physician and, therefore, it has not come into common use.
22 TEXT-BOOK OF PEDIATRICS
the third and 70 in the fourth, per kilogram of body-weight. For human milk, a caloric value of 700 (650-750) calories per litre has been adopted. The value for undiluted cow's milk is as great. The caloric value of various other milk mixtures will be given later in the chapter on Artificial Feeding.
The caloric requirement of the healthy, artificially-fed infant does not differ greatly from that of the breast-fed child. From various studies it appears that its demand is somewhat larger and these findings have been explained by the fact that the digestive labor is greater upon artificial food and that this necessitates an increased supply of food. Results recently reported by Engel and Samelson do not agree with this conclusion and it is a question whether other factors did not enter into the earlier observations; as, for instance, the greater loss of useful, but unused calories in the feces and urine; or, still more probably the less favorable nutritive balance induced by the greater restlessness of the artificially-fed child.
While the fact that the total metabolism of the child is more rapid than that of the adult has been incontrovertibly established, the rule of Rubner that metabolism and food requirement are, other things being equal, pro- portionate to surface area has not gone uncontradicted.
Several physiologists, Magnus-Levy, Sonden and Tigerstedt, and A. Loewy, have drawn the conclusion from their researches that a special increased energy is present in the infant because of his youth, which causes a peculiar excitability of the heat-producing agencies and, therefore, an excessive metabolism. Schlossmann and Murschhauser have gone over these results in very complete metabolic experiments in the calorimeter, but have found that they could not confirm them with the material used. They maintain that deviations from the rule laid down by Rubner are due to stiU another item, that of less economical muscular activity in the infant.
In the study of heat production in approximately normal infants from 19 days to 18 months of age, Benedict and Talbot found an average resting heat production of 65 calories per kilogram of body-weight. They state that "aside from a slight tendency for the total metabolism to be larger with increasing weight, no regular relationship exists with infants between the total heat production and the body weight, regardless of whether the body-weight was actually found, computed from statistics of average values for normal infants, or was the expected body- weight based on the birth weight." They conclude that the extent of metabolism is deter- mined neither by weight nor by surface area, but by the mass of active protoplasmic tissue. The varying amount of fat, comparatively inactive tissue, may influence the variations of caloric requirement.
The requirements of the child for specific materials are similar to those of the adult. Water, salts and protein serve for purposes of growth and repair; fats and carbohydrates are used for fat deposits and, especially, for combustion. It is not immaterial to the organism whether this necessary energy is supplied exclusively or predominantly by fat or by carbohydrate. In the total absence of carbohydrates, as already shown, disturbances of the internal metabolism arise, because an interaction between the digestive products of the carbohydrates and of the fats is necessary to complete the
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 23
combustion of the latter. If these products of carbohydrate digestion are wanting, the acetone bodies remain as incombustible end-products. If, however, fat is absent, the integrity of the chemical composition of the body is endangered, as is shown in the retention of abnormally large quantities of water in the tissues. The cause of this water-retention is not known. The fact that the glycogen deposited in the body holds two to three tunes its weight of water is not a sufficient explanation, since the amount of glycogen is so small. The harmful influence of a disproportionately fatty or carbohydrate diet is important clinically only when it has continued unchangingly for some time.
Corresponding to its more active metabolism, the infant uses more oxygen and excretes more carbon dioxide, although the difference is very small when the exchange is calculated not in ratio to body-weight, but to body surface. The figures, obtained by Schlossmann and his assistants, of 12.85 gms. of oxygen used and 15.75 gms. of carbon dioxide excreted, per hour, per square meter of surface area in the resting infant, agree with the average quantities determined by Rubner in the resting adult.
A very considerable part of the gaseous metabolism is represented in excretion through the lungs with the aqueous vapor. The so-called insen- sible perspiration, according to a table by Camerer, Jr., is about 1.3 to 1.7 grams per kilo per hour during the first half-year; about twice that in the adult. These averages, however, have been obtained from greatly varying individual determinations. Thus, for instance, an infant when at rest may lose only 2 to 3 grams per kilo per hour, but when extremely restless it may lose from 10 to 15 grams per hour.
GROWTH
In the preceding pages so much stress has been laid upon growth as a visible phenomenon in the life of the infant organism that it seems neces- sary to treat the principle of growth more fully. Aside from minor indices of growth, of interest only from a clinical standpoint, as, for instance, the increase of the circumference of the head and chest, to be discussed in a later chapter, growth may be determined by measurement in two ways: first, as weight and, second, as total body length.
The figures cited at the close of the preceding section concerning the volume of the insensible perspiration, as well as those which bear upon the capacity of the stomach, suggest that to be of value for comparison the child's weight must be taken always at the same hour. This is also true for the measurements of length, since it is well known that a slight decrease (1-3 cm.) occurs after the body has been in an upright position during the day. The disturbing factor of variance in the amount of the stomach- content is best avoided by weighing the child immediately before the first or second feeding of the day.
The average birth weight of healthy children is 3400 gms. (ll/2 pounds) for boys, and 3200 gms. (7^ pounds) for girls. Great variations from these averages are possible under entirely physiologic conditions. Usually the
24
TEXT-BOOK OF PEDIATRICS
first-born children are smaller than those of later birth.8 The size and weight of the mother do not always determine the size of the new-born child at full term and great variations, in both directions, often occur. This is also true in the degree of development of the subcutaneous fat.
The average weight of the American new-born (white) is about 3.45 kilos for boys and about 3.35 kilos for girls, being slightly above the European average usually quoted. Among the factors affecting the weight of the new-born are sex, activity of the mother in the last weeks of preg- nancy, age of the mother, parity and race. Most of these factors apparently influence the new-born weight through their effect on the duration of preg- nancy rather than through any direct influence on the rate of growth. There is no scientific evidence to show that changes in the nutrition of
Gervlcht
7Z 15 20 ^tf 28
Jff W
f.8 5Z.
9000
8000
7000
6000
5000
WOO
3000
FIG. 2. — Average weight of breast-infants weighing more than 2750 grams (6| pounds) at birth. (After Camerer, Sr.)
the human mother, within ordinary limits, has any constant effect on the weight of the offspring.
During the first two, three, or more days, all new-born infants show a physiologic loss of weight in varying amount,9 which is equalized again, in breast-fed infants, by the eighth to the tenth day. Then follows, under normal conditions, a continuous gain, which may be interrupted, as shown hi the daily weighings, by pauses or even by slight losses, but which, com- paring one week with another, indicate an almost regular rise.
This regularity is, of course, definite only in individuals of undisturbed development. As soon as an average of any large number of children, who are not always weighed at the same interval, is taken, it is lost. The fol-
8 To this is supposedly due, in part, the fact that the material of lying-in hospitals which consists largely of first-born children, shows a small average of weight.
9 This physiologic loss amounts to 200 gms. (7 ounces) or more, especially in chil- dren of heavy weight at birth.
ANATOMIC AND PHYSIOLOGIC PECULIARITIES
25
lowing tables were obtained by the elder Camerer from the study of 119 breast-fed and 84 artificially-fed infants, of more than 2750 gms. (6 pounds) birth weight, without consideration of sex. The table for breast-fed infants is presented in the form of a curve, so that it may be the more readily studied.
TABLE I.
Average weight during the first year of children weighing more than 2780 gms. (6.12 pounds) at birth.
Abbreviated from the table of Camerer, Sr. in the Jahrbuch fur Kinderheilkunde, Vol. LIII, pp. 409.
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End of Week |
Breast-fed Infants |
Artificially-fed Infants |
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Grams |
Pounds |
Grams |
Pounds |
|
|
Birth |
3433 3408 3567 3781 4008 4907 5600 5693 6294 6824 7289 7505 7774 8175 8655 8674 8855 9232 9589 10141 |
7.55 7.49 7.85 8.33 8.83 10.80 12.33 12.54 13.63 15.00 16.05 16.53 17.12 18.00 19.06 19.10 19.50 20.33 21.12 22.33 |
3467 3314 3384 3557 3683 4303 4911 5093 5532 6181 6836 7278 7207 7783 8161 8470 8306 8782 9192 9624 |
7.64 7.30 7.45 7.83 8.15 9.48 10.82 11.22 12.18 13.61 15.05 16.03 15.87 17.14 17.97 18.65 18.29 19.34 20.25 21.19 |
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1st |
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2nd |
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3rd |
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4th |
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8th |
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12th . . |
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13th . |
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16th |
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20th |
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24th |
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26th |
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28th |
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32nd |
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36th |
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39th |
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40th |
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44th |
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48th . |
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52nd |
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These figures of Camerer's may be considered rather high in their absolute values and indicative of a stronger tendency to growth than the average in these children. Every physician who has the opportunity to observe different types of children frequently meets with infants who, in spite of continuously undisturbed health and regular development, will not come up to these figures. Nor is the curve the same in all cases. In some, the greater increase occurs at the beginning, while a gradual flattening of the curve is evidenced by the sixth or seventh month; in others, an almost regular advance occurs during the entire first year. Between these extremes all possible transitional forms may exist. Further, attention must be called to cases in whom no actual increase occurs, during the first weeks, because of a slow increase in the quantities of breast-milk, but in whom the delay is fully equalized by the more rapid growth of following months. This is the best of evidence that a long continuance of even scant feeding at the breast has caused no lasting injury to the child.
From these figures it may be seen that the birth weight is about doubled by the beginning of the fifth month and is trebled by the close of
26
TEXT-BOOK OF PEDIATRICS
the first year. The differences in weight between boys and girls, which are not shown in the table, gradually become greater, being from 200 grams (7 ounces) to 500 grams (18 ounces) in favor of the boys by the end of the twelfth month.
After the second year, the weight increase is markedly slower. The fol- lowing table gives in round numbers the yearly averages and also the sex differences of weight.
A number of formulae have been developed for expressing the growth in height and weight during childhood, but most of these are too complex for immediate practical application. The following simple rules give
TABLE II. Increase in Weight.
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End of the Year |
Boys |
Girls |
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Body- Weight |
Annual Increase |
Body-Weight |
Annual Increase |
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Kilos |
Pounds |
Kilos |
Pounds |
Kilos |
Pounds |
Kilos |
Pounds |
|
|
Birth |
3.4 10.2 12.7 14.7 16.5 18.0 20.5 23.0 25.0 27.5 30.0 32.5 35.0 37.5 41.0 45.0 50.0 56.0 |
7.48 22.44 27.94 32.34 36.30 39.60 45.10 50.60 55.00 60.50 60.00 71.50 77.00 82.50 90.20 99.00 110.00 123.20 |
6.8 2.5 2.0 1.8 1.5 2.5 2.5 2.0 2.5 2.5 2.5 2.5 2.5 3.5 4.0 6.0 6.0 |
14.96 5.50 4.40 3.96 3.30 5.50 5.50 4.40 5.50 5.50 5.50 5.50 5.50 7.70 8.80 13.20 13.20 |
3.2 9.7 12.2 14.2 15.7 17.0 19.0 21.0 23.0 25.0 27.0 29.0 32.0 37.0 43.0 48.0 52.0 |
7.04 21.34 26.84 31.24 34.54 37.40 41.80 48.20 50.60 55.00 59.40 63.80 70.40 81.40 94.60 105.60 114.40 |
6.5 2.5 2.0 1.5 1.3 2.0 2.0 2.0 2.0 2.0 2.0 3.0 5.0 6.0 5.0 4.0 |
14.30 5.50 4.40 3.30 2.86 4.40 4.40 4.40 4.40 4.40 4.40 6.60 11.00 13.20 11.00 8.80 |
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4th |
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5th |
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6th |
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7th |
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8th |
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9th ... |
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10th |
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llth |
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12th |
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13th . . |
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14th . |
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15th |
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16th |
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17th .... |
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weights and heights which fall within the range of normal variation from the average for American children.
Height (in inches) equals twice the age (in years) plus 32 inches (good from 3 to about 14 years).
Weight (in pounds) equals seven times age in years minus 2 pounds for each year under seven (good from 3 to 7 years).
Weight (in pounds) equals seven times age in years plus 4 pounds for each year over seven (good from 7 to 12 years).
A more rapid increase of weight during the years of adolescence is very plainly indicated in this table and a corresponding rise is shown in the table of body lengths. Since puberty occurs earlier in girls, their increases during the thirteenth to the fifteenth years exceed those of the boys, not only relatively but absolutely. During the succeeding years the increase is always less.
27.
The growth in length corresponds to the weight increase, in so far as it is greatest during the first year of life and becomes more gradual with advancing age. The following table gives the yearly averages in round numbers:
|
TABLE III. Growth in Height. |
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End of the Year |
Boys |
Girls |
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|
Height |
Annual increase |
Height |
Annual Increase |
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|
Cm. |
Inches |
Cm. |
Inches |
Cm. |
Inches |
Cm. |
Inches |
|
|
Birth |
50 75 85 93 99 104 109 115 120 125 130 135 140 145 151 157 164 168 170 |
20.0 30.0 34.0 37.2 39.6 41.6 43.6 46.0 48.0 50.0 52.0 54.0 56.0 58.0 60.4 62.8 65.6 67.2 68.0 |
25 10 8 6 5 5 6 5 5 5 5 5 5 6 6 7 4 2 |
10.0 4.0 3.2 2.4 2.0 2.0 2.4 2.0 2.0 2.0 2.0 2.0 2.0 2.4 2.8 1.6 0.8 |
49 74 84 92 98 103 107 113 118 123 128 133 139 146 153 158 160 161 |
19.6 29.6 33.6 36.8 39.2 41.2 42.8 45.2 47.2 49.2 51.2 53.2 55.6 58.4 61.2 63.2 64.0 64.4 |
25 10 8 6 5 4 6 5 5 5 5 6 7 7 5 2 1 |
10.0 4.0 3.2 2.4 2.0 1.6 2.4 2.0 2.0 2.0 2.0 2.4 2.8 2.8 2.0 0.8 0.4 |
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1st : |
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2nd |
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4th |
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7th |
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8th |
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9th |
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10th |
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llth. . |
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12th |
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13th |
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14th |
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15th . |
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16th |
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17th |
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18th |
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Attention should be called to the fact that these measurements taken absolutely are, as already stated of the table of weights, rather high and that measurements which do not come up to them are still within the limits of normal individual variance.
A more rapid increase in girls, both relatively and absolutely, during the years immediately preceding early puberty is recognized. During the periods of sharply accelerated growth the child is commonly said to "shoot up." We distinguish such a period during the first year, which may be looked upon as a continuance of the rapid fetal growth; a second stage appears at about the same time in both sexes, in or near the seventh year; and a third acceleration, dependent upon the climax of puberty, sets in with boys from the fourteenth, to the sixteenth year, and in girls from the twelfth to the fourteenth.
Besides these variations in the rate of increase, alike in weight and length, dependent upon the factor of age in children after infancy, Mailing- Hanson first observed variations dependent upon seasonal change. These were confirmed later by the elder Camerer and by Schmid-Monnard. Three seasonal periods may be distinguished.
28 TEXT-BOOK OF PEDIATRICS
1. The period from the middle of August to the end of November or middle of December, the last third of the year, showing the greatest increase in weight and the least increase in length.
2. The period from November or December to the end of March, or the first part of April, the first third of the year, showing a moderate increase in weight and length.
3. The period from the end of March or the beginning of April to the middle of August, the second third of the year, exhibiting the greatest increase in length, with loss of weight.
It is probable that different modes of life and varying activities of children in the several seasons cause these altered relations in the factors of growth. Whether the sedentary habits and the long continued in- door life incident to attendance at school play an important part is not en- tirely clear.
The unfavorable influence of improper food and unhygienic surround- ings, as indicated by the greater morbidity and the greater frequency of the severer forms of rickets among the poorer classes, is suggested also by the fact, established in many tables of statistics, that, as a rule, the children of the well-to-do exceed those of the poor both in weight and in height. This general observation does not, of course, exclude far-reaching individ- ual differences.
The relations of age, weight and height which obtain in healthy children have been presented very clearly in von Pirquet in the form of the "meas- uring tape. "
To these considerations of general growth should be added some em- phasis upon the incidents of special growth.
The Brain. — The average weight of the brain at birth is 370 grams in male and 350 grams in female infants, while the adult brain weighs from 1260 to 1400 grams. One-third of this increase (300-350 grams) takes place in the first 9 or 10 months and the rest of the increase is attained by the middle of the third year. Roughly, the weight of the brain is doubled by the end of the first year and tripled at two and one-half years. The growth is completed by the 16th to 20th years. The sexual difference in weight of 10-15 grams at birth becomes greater, so that in adult life the brain of the male weighs 120 grams more than that of the female. Normal average weights for various ages are approximately as follows:
Grams
New-born 370
At 2 mos 460
At 4-6 mos 600
At 11-12" mos 850
At 2nd year 970
At 3rd year 1100
At 4th year 1190
At 5-8th year 1220
At 9-14th year 1300
At 15-20th year 1400
The variations in normal subjects are great and even during the first year may be 100-200 grams. There is no noticeable parallel between men- tal development and size of brain.
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 29
Skeletal Growth. — The centres of ossification may be studied in the liv- ing by the radiograph and are of clinical interest.
The ossification of the bones of the wrist is of particular interest ag indicating the physiologic age of the child. All of the bones of the wrist are commonly cartilaginous at birth although one and sometimes two small ossification centres may be seen in particularly well-developed new-born children. Two centres are usually present at 1 year, 3 at 2 years, 4 at 3 years, 5 at 4 or 5 years, and 6 at 5 or 6 years. The ossification of the wrist proceeds more rapidly in girls than in boys, the former being a full year in advance of the latter at 6 years.
The centres appear normally in regular order, subject to little vari- ation. The time of appearance is not so constant that the exact age of the child can be determined by their appearance. Any pronounced delay in the development of the ossification centres, however, must be considered pathologic and, under certain circumstances, as pathognomonic. It is not infrequently combined with a general delay of the growth in height.
Of the fontanelles, only the greater or anterior is normally open, that is closed only by a membrane, at birth. If the smaller or posterior fontanelle at the juncture of the sagittal with the lambdoid suture, or the parietal fontanelles between the temporal, parietal and occipital bones are still palpable as openings, these, as well as the open condition of the sutures, may be taken as evidence of retarded ossification. From birth to its com- plete closure, which occurs during the first half of the second year, the greater fontanelle decreases in size continuously. Any increase in area is to be considered pathologic and due either to rickets or to abnormal growth of the head. Complete bony occlusion before the end of the first year is found only in conditions where the growth of the entire head is abnormally retarded (microcephaly). There is great variation in the time of the com- plete closure of the anterior fontanelle, even in normal children. Collected statistics show that the structure undergoes but little change in size in the first 3 or 4 months after birth. It is closed in about 15 per cent, of all cases at one year and in about 50 per cent, at 15 months.
Dentition. — 'The physiology of dentition has always been of great interest to the physician. For hundreds of years,10 this interest was inspired entirely by the fact that the causation of all imaginable diseases of the first years was ascribed to dentition. If this theory which, in its extreme conclusions has led to much useless interference and senseless prescribing and in its actual disregard of disease present has resulted in the death of uncounted numbers of children, could be completely erased from the minds of all physicians of today, it would be as unnecessary to discuss the course of dentition as it is to discuss growth changes in the bones or in other parts of the body. Since this is not yet true, the following statement may be presented.
The cutting of the teeth has been erroneously considered a mechanical process and this one-sided consideration of the growth of the teeth has led
10 We must thank Ludwig Fleischmann, Clinic of Pediatrics, Vol. II, Vienna, 1877, and Kassowitz, Diseases During the Age of Dentition, Leipzig and Vienna, 1892, for interesting clinical and historical presentations of this subject.
30 TEXT-BOOK OF PEDIATRICS
to the complete oversight of the coincident growth of the jaw. Today, however, we know that most marked and rapid changes take place shortly after birth and that, running parallel with the development of the dental germ, there is an enlargement of the jaw and a gradual resorption of the tissues lying above and beside the growing tooth. This, curiously enough, is true not only during the later stages of development when the tooth has become hard, but, also, in the earlier phases when the tooth is but a soft sack which is capable of exerting only slight pressure.
The erupting tooth does not rupture the alveolus any more than the growing epiphysis ruptures the articular cartilage which covers it. It is rather a process of the spreading of the alveolus for the tooth, the opening out without force of a passage for it under the gum. The soft gum tissue then forms its only barrier, and this too is doubtless overcome, in an anal- ogous manner, by the gradual resorption of the soft parts without no- ticeable pain and, at least in the nervously normal child, without any disturbance either of a local or a general nature.
This does away with any physiologic basis for the teaching of difficult dentition. In its place, we are gaining an increasing knowledge of the pathology of infancy and a clearer comprehension of the nature of all those disturbances and diseases which were formerly ascribed to it.
A knowledge of the normal course of dentition is of importance for another reason; that is, in regard to the time of the successive appearance of the several groups of teeth. First, between the sixth and the ninth months, the lower central incisors appear; a few weeks later, the upper middle incisors; and, in rapid succession, the upper lateral incisors. The lower lateral incisors appear somewhat later; so that by the end of the first year, at least, all of the eight incisors have erupted. Usually several weeks or several months after, the premolars appear, first above, then below, and but very rarely in the reverse order; and, by the end of the second year of life, the cuspids come through. In the third year of life, the first molars finally appear and with these twenty teeth the temporary dentition is complete. The following method may be used in writing the tooth formula of a child, the horizontal line representing the buccal opening and the vertical the median line.
|
c' |
0 |
b |
a' |
a |
a |
a' |
1) |
B |
c' |
|
c' |
c |
b |
a' |
a |
B |
a' |
b |
C |
c' |
Any notable extension of the period of dentition marked by longer pauses between the eruption of the several teeth, or any great variation from the natural order in which the teeth appear must be considered as an evidence of rickets.
The second dentition begins with the eruption, in both the upper and the lower jaw, of the third pair of molars (six-year molar) ; then the milk teeth gradually drop out, in about the order of their appearance, and are replaced by the teeth of the permanent set. Just before the beginning of puberty the fourth molars erupt and finally the fifth pair, called the wisdom teeth, because they usually appear sometime after puberty.
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 31
The Nervous System. — The central nervous system of the new-born and the young infant has practically the same form as that of the adult. When we consider that the brain of the new-born is remarkably heavy, even in comparison to the total body- weight (about 1 : 8 at birth; in the adult about 1 : 40), we may readily understand that man brings into the world with him a brain which is laid out in external outlines and form upon a remarkably large scale, but the interior may be compared to an unfinished house. The interior is not hollow or empty, nor are its ventricles larger than in later life; but the greater part of its mass consists of unfinished tissue which apparently serves only for scaffolding and framework and which, in the course of later development, is gradually replaced by specific nerve tis- sue— ganglion cells and nerve fibres. This development involves not only a quantitative increase but also a qualitative change from the simpler forms resembling embryonic types to the higher differentiations which mark the adult. The most noticeable difference in the macroscopic comparison of the infantile and the adult brain and spinal cord is found in the development of the myelin sheaths.
In the cord of the infant born at term this is complete, excepting for a small remnant. Only the directed and crossed pyramidal tracts are almost wholly unmedullated. The cauda equina, the medulla and the cerebellum contain numerous medullated tracts even at birth; while only a few fibres or bundles of fibres, in the cerebellum and preponderantly in the projection system, are medullated. Because of this, the entire white portion of the brain appears gray upon section, being only slightly differentiated from the gray of the cortex. Further development continues progressively, with slight variations of rapidity and order in different individuals, one bundle of fibres after the other becoming medullated.
At about nine months, most of the long association tracts, with the exception of the projection fibres, are medullated, while the shorter fibres, connecting closely neighboring regions, and the radiation fibres are much slower of medullation and are probably not completely covered and definitely developed by the end of childhood or the period of com- pleted growth.
The brain has acquired nearly one-third of its adult weight at the time of birth and the spinal cord about one-seventh, whereas the body increases twenty-fold in weight between birth and maturity. Approximately two- thirds of the postnatal growth of the brain takes place in the first 18 months and over 90 per cent, is accomplished by 6 years. The different parts of the brain grow at somewhat different rates, the cerebellum and brain stem increasing more in postnatal life than the cerebrum. The primary and secondary fissures of the cerebrum are all present at the time of birth although some of the tertiary ones are formed during the first month after birth. It is probable that all of the nerve cells of the cerebrum and cerebellum are formed at birth.
The peripheral nerves of the new-born are very poor in covering and where neurilemma can be distinguished it is thin, unequally developed and frequently interrupted by non-medullated areas. The medullation proceeds
32 TEXT-BOOK OF PEDIATRICS
rapidly during the first few weeks; later more slowly, and is completed by the end of the first year. Other histological peculiarities of the peripheral nervous system of infants, which need not be specifically mentioned here, also disappear by the end of this period.
Of the cranial nerves, the optic nerve is only partly medullated at birth and in the region of the cribriform plate is entirely unmedullated. The medullation proceeds from the central to the peripheral end, that is in the reverse of the direction of the transmission of impulses through the fibres. The auditory nerve, on the contrary, is completely covered at birth.
The anatomical differences in the sense organs to which attention should be called, are first, the eye, which is hyperopic in the new-born, and second the middle ear, which is filled with mucous fluid, at least during the first few hours after birth and sometimes for a longer period. This probably comes from the amniotic fluid. The condition of the middle chamber might lead us to suspect a temporary deafness, especially when we consider, as already mentioned, that the auditory nerve is completely formed at birth.
To attempt a description of the psychic development of the child from birth to puberty, even though but the chief points were to be touched, would seem an impossible task. It is better that we refer to the works of Preyer, Compayre, Ament and others, where many references to the literature may be found. We can give only the following points:
At the age of three months, after the so-called stupid quarter of the year, the infant is so completely in control of all his senses that the move- ments of the eyes, incoordinate at first, have become completely balanced and objects which are not too small and lie in the line of direction of the vision will be fixed and followed. Frequently, images which the child has seen before, as for instance, the faces of his parents, are recognized and greeted with a smile. Similarly, there appears a tendency to turn toward the location of a noise, at first by turning the head and later by turning the eyes also.
Articles which the infant sees or which are laid in the palm of the hand are grasped. However, even up to the fourth month, the closing of the hand is accomplished by a palmar flexion of the hand as a whole. But shortly after, as evidence of purposeful central coordination, the closure of the hand occurs with a synchronous dorsal flexion. During the fourth or fifth month, active grasping motions are made.
The sense of smell, temperature and pain are soon much better devel- oped than they are at birth.
Among coordinated muscular movements, the lifting of the head is the first to appear when the child is laid upon its abdomen; and this position may be maintained for several minutes. At a slightly later period, when the child sits with some support, the head is held erect and is freely turned from side to side; while unsupported, sitting is not usually possible before the sixth month. This is more constant in its date of development than the power of standing, which shows great individual differences. With sup- port under the arms, strong children will stand for several minutes during the fourth or fifth month, and by the seventh or eighth month they will
ANATOMIC AND PHYSIOLOGIC PECULIARITIES 33
stand if they can hold fast to something with the hands. However, they sometimes let go suddenly and fall down. Shortly after this children, with well-developed static function begin to take their first steps, while they hold by or lean against the furniture. Children remain at this stage for a longer or shorter time, according to their temperament, before they dare to walk without support. This is usually accomplished between the tenth and the fifteenth month.
Delays may be caused by disease, especially by long-continued illnesses which disturb the entire development. More frequently, rickets may post- pone the date of any of these periods of progressively acquired function. Even the simple muscular stretching and the power of standing upon the feet which normal children attempt very early may be absent until late in the second year. These children, recognized for other reasons as back- ward rickitics, draw the legs up to the abdomen when they are lifted by the arms. Standing and walking, with them, may be delayed until the third or fourth year.
Marked delay in the development of coordinated motor function, even in the matter of holding up the head, is under certain circumstances to be considered an early symptom of imbecility. It doubtless depends, in the first place, upon the lack of attention and interest in the surroundings and is, therefore, to be considered an intra-psychic rather than a psychomotor defect. This is further shown in other respects, as in the reduction of the pain and taste senses phenomena of absence which can be demonstrated at one and the same time and can be explained in no other way.
The first motions of the new-born are in part automatic and in part reflex. This is true, not only of the complicated coordinated motions, such as suckling, but also of the mimic motions of expression.
It is a well-known fact that the new-born infant reacts to stimulation of the taste organs, by placing upon the tongue sweet, sour, salty or acid substances, by corresponding facial expressions. That these responses are brought about by reflex (subcortical) action, without psychical correlation is shown by the fact that hemi- and anencephalic infants in whom the cere- brum, the entire organ for psychic function, is absent, show the same re- sponsive power.
It is very interesting to note how the subcortical reflexes disappear in the course of the first year or are rather replaced by cortical action. This explains the fact that the facial mimicry is often absent in older idiots. Their subcortical reflex is lost, but the cortical action has not developed because of the central defect.
The same condition is seen in the sucking reflex. In the first weeks, it appears unconditionally every time the lips or the neighboring region re- ceive a sufficient stimulus, but later it occurs only when the child is hungry or is waiting for a feeding or the like, and then as a conditional reflex.
The light reflex and the corneal reflex are completely developed in the new-born, while the reaction of the pupil for accommodation appears in the second month. The blinking reflex, excited by the rapid approach of an object to the eye, first appears in the second or third month. 3
34 TEXT-BOOK OF PEDIATRICS
It must be noted that Babinski 's phenomenon (the dorsal flexion of the toes, and especially of the great toe, and the spreading of the toes when the sole of the foot is tickled) is physiologic even to the second year.
The skin reflexes, frequently absent in the new-born, are usually very active in older infants.
The lachrymal secretion is absent during the first few months. The tendon reflexes are active in the new-born, as well as in older infants, and are easily brought out when the limbs are relaxed as during the act of nursing. At other times they are masked more or less completely by the physiologic hypertonia of the muscles. It is not easy to explain the condition upon which this "hypertonia," a distinctly increased resistance to passive mo- tion, depends. It is a readily recognized stiffness and awkwardness of all active movements in the extremities of the new-born which exceeds the hypertonia of later infancy. That the muscle of the new-born animal does not respond to a nervous stimulus with lightning-like rapidity, but reacts with a more gradual and more or less tonic contraction — a fact discovered by Soltmann, has probably something to do with it, but the mechanism of the fact is far from clear.
Physiologic spasmophilia, in the sense of an increased excitability of the reflexes (Soltmann) exists neither in the new-born nor in older infants. Nor is the remarkably frequent occurrence of clonic and tonic convulsions at a definite period of infancy, chiefly during the second and third semesters of life, dependent so much upon any physiologic peculiarities of the infan- tile nervous system as upon special disturbances of metabolism incident to that age. (See chapter on Spasmophilia.)
The acquirement of speech, to which a certain degree of intellectual development is necessary, is timed rather closely. The child shows an understanding of words and simple sentences at about one year of age and soon after, say at about one year and three months, begins to speak. Even earlier, usually between the sixth and eighth months, the child exercises the mechanism of articulation with easy syllables, preparing for the func- tion of speech. Such periods, however, are subject to great variations, in part due to the inherent conditions of the child itself and in part to its environment. They may be markedly delayed without the presence of any mental defect. Such defect should be suspected only when the attain- ment of speech is delayed until the third or fourth year.
The further development of speech and the exercise of the mental faculties varies so greatly, even in children of similar or nearly similar intrinsic quality, under differing environment, that it is not as yet possible to establish any definite criterion which would be useful in judging the milder grades of mental deficiency. Long continued disease, conditions of exhaustion, and especially defect of sense organs, may delay the acquire- ment of speech and the exercise of mentality, but a definite prognosis of future development is entirely impossible. In the healthy child differences in temperament are often noticeable at an early period, even in the first or second year, but in these, even, the influence of intentional and unconscious training is very great.
ANATOMIC AND PHYSIOLOGIC PECULIARITIES
35
The sleep of the infant is normally sound and long continued. Healthy infants, during the first few months, sleep nearly all day, excepting when being fed or bathed or changed, and when asleep assume the position shown in Fig. 3, which is evidently a continuation of intra-uterine pos- ture. It is usually an indication that the child is ill when the arms sink to the sides. The length of time spent in sleep is gradually decreased, from about twenty hours, by occa- sional periods of wakefulness, but even during the third to the sixth year the child still sleeps twelve to fifteen hours and at school age from nine to eleven hours.
FIG. 3. — Position of healthy infant during sleep.
Puberty, the period of the de- velopment* of the genital functions and of the secondary sexual char- acteristics, gradually leads up to maturity and does not actually belong to childhood.
II. CARE AND FEEDING OF THE NORMAL INFANT
REVISED BY
JULIUS HESS, M.D.,
Professor and Head of the Department of Pediatrics, University of Illinois, College
of Medicine, Chicago.
THE science of the feeding of children and especially of infants, the differentiation of normal from pathological conditions, and a strict discrim- ination of what should be considered normal is more important in this than in any other division of pediatrics. The indefinite understanding of normality, the recognition or non-recognition, for instance, of constitutional anomalies even in the infant, the designation of nutritive results as satisfac- tory when we have only succeeded in causing a great increase in weight and large deposits of fat, have proved to be sources of serious error prejudicial to the science of pediatrics. In their Manual, Czerny and Keller define a new-born child as healthy, "when it is born of healthy parents in the inid- productive period, when it is carried to full term, is free from essential malformities, and is able, with the protection of non-conducting clothing, to maintain a normal body temperature." They further designate that method of feeding as suitable for a healthy child "by which the child devel- ops normally in body and, so far as this depends upon food, psychically, and remains free from disturbances of metabolism, as well as of those diseases the occurrence of which is influenced by disorders of nutrition." Only a strict adherence to these definitions has put an end to the former chaos in the teaching of infant-feeding.
In the future, whoever tries a favorite infant-food upon a number of children, without considering whether, in the strict sense, they are well or ill; and who attempts to draw conclusions of the values or non- value of a feeding method by such means, shows that the entire progress of modern pediatrics has passed him by without leaving any impression.
a. NATURAL FEEDING
The only natural food for the infant, during the first half year, at least, is the mother 's milk. To what extent this may be replaced by the milk of other women will be stated later. It is sufficient here to call attention to the fact that so-called artificial feeding should never be considered natural feeding for children of this age.
OBSTACLES TO NURSING
Before we describe breast feeding, the following question must be settled. Can all new-born children be nursed by the mother? This must be answered in the negative. There are doubtless obstacles to nursing upon the part of the mother and upon the part of the child, but they are much more rare than is generally believed, even by physicians. 36
CARE AND FEEDING OF THE NORMAL INFANT 37
All diseases of the mother, whether they are connected with the process of giving birth to the child, or whether they be of an infectious or constitu- tional nature, are only conditional obstacles. Since the feeding of the child, at least during the first period of life, requires only small quantities of mother's milk, the supply makes no special demand upon the physical strength of the mother. Further, lactation is in many respects necessary to her own health. The physician should not always look upon severe acute diseases, as eclampsia and nephritis or pneumonia, as reason to discontinue nursing. Especially is nursing not contraindicated under conditions, involving even large loss of blood in parturition, which give promise of the comparatively rapid recovery of the mother. On the other hand, marked puerperal sepsis, typhoid fever, severe erysipelas, and the like, make nursing impossible because they mean danger to the child. Similarly, malignant diabetes and epilepsy, with numerous crises, are contraindications.
For want of experience unimpeachably beyond the contradiction of critics, views are divided as to the propriety of a tuberculous mother nursing her child. While formerly nursing was absolutely forbidden in every definite case of tuberculosis, a view Czerny and Keller take, this is con- tradicted by Schlossmann, who bases his argument upon the favorable influence of lactation upon the health and weight increase of the mother, as well as upon the greater resistance of the breast-fed child to tuberculous infection. This claim seems to be supported by several clinical observations. Still later (Deutsch, Tuberculosis and Nursing, Munchner, Medizinische Wochenschrift 1910, page 1335) facts have been reported on the other side, under rather meagre observations, which indicate that the mother with distinct tuberculous pulmonary disease should be absolutely prohibited from nursing, for her own benefit as well as for that of the child ; while in mothers with suspicious changes it may be permitted only as an experiment under the observation of a physician. A positive von Pirquet reaction without physical lung findings, has never seemed to us sufficient reason to discontinue nursing or to interrupt it without mature consideration.
General weakness, anemia and emaciation, extreme youth, and in most cases, even a neuropathic constitution, are not adequate causes for the initial prohibition of nursing.
The majority of such women not only bear the added strain of nursing, but receive undeniable benefit to their own health which is not confined to the better and more complete involution of the puerperal organs — a well- known result, but manifests itself in the rarity with which carcinoma of the breast occurs in women who have nursed. No prediction can be made in the individual case as to whether the woman will lose or gain in weight while nursing. More usually the mother gains in weight, and hand in hand with this gain comes more blooming health, an increase of strength and an im- provement in her general well-being. Loss of weight is not in itself a cause for anxiety, for the mother may be placed under treatment and the child may be weaned at any time.
Bearing-down pains in the breast or back, sometimes present at the beginning of lactation, or appearing after getting up are usually dissipated
38 TEXT-BOOK OF PEDIATRICS
by suggestive treatment, as, is my experience, is the rare tenderness of the nipples in neuropathic women.
More serious difficulties are presented by fissures in the region of the nipples because of the severe pain which some women suffer and because of the danger of mastitis. Their appearance is not always preventable, even by the massage of the nipples with spiritous solutions which is frequently recommended during the last months of pregnancy.
Skill in placing the child to the breast, so that it sucks from the entire areola and not from the nipple alone and the avoidance of too long periods of feeding are probably the most successful preventatives.
The milder cases of fissured nipple are relieved by various methods of treatment. Glycerin, or glycero-tannin (5-10 per cent.) ; or the so-called "black salve" (silver nitrate 0.1, Balsam Peru 1.0, petrolatum 10.0), or napthalin ointment; or an antiseptic drying powder (bismuth subgallate, or the like), applied between feedings and removed before putting the child to the breast, give opportunity for the reformation of epithelium. Anesthesin ointment (5 per cent.), may be used to allay pain or, better still, a solution of silver nitrate (3-5 per cent.), may be used. The latter causes an anes- thesia of long duration after the short initial pain and repair occurs rapidly under the crust. In addition to these methods, it will be found necessary to bind, up the breasts and to empty them frequently by nursing or ex- pression. This may be done either completely, three or four times daily or by removing small quantities frequently. A nipple-shield of glass with rubber nipple may be used in exceptional cases, but the abuse of this device will be treated later. Only rarely do these methods fail to give relief, -so that in few cases, and especially in hypersensitive women, nursing has to be discontinued.
Cases of mastitis should be treated surgically with ice-bags, or with warm moist applications, or by carefully applied hyperemia. Later, radial incisions which do not enter the mammilla, may be made as soon as the pus is localized, followed by expression from the incisions.
With this treatment we must provide for the same satisfactory emptying of the breast as in fissures, both for its beneficial effect by reduction of pressure upon the circulation and to prevent the arrest of the secretion. This emptying may be accomplished by putting the child to the breast without hesitation, since, supported by numerous experiences, the admix- ture of even large amounts of infected pus with human milk is not dan- gerous to the healthy infant.
By this means it is possible, in most instances, if the inflammation is not of a phlegmonous type and inclusive of the entire breast, to combine the recovery from the inflammatory process with the preservation of function. The secretion of the unaffected breast does not suffer and in case of necessity may be increased to such a degree that its output will be sufficient for many months of lactation.
The form of the breast and nipple makes the first attempt at nursing difficult or easy. Distinctly retracted nipples, rather rare, but which may occasionally occur on both sides, may be an absolute obstacle to
CARE AND FEEDING OF THE NORMAL INFANT
39
nursing.1 Very flat, short nipples increase the difficulty of nursing, but do not make it impossible.
The only absolute and continuing obstacle to nursing upon the part of the child is a cleft palate. In children who are born weak or who have suf- fered considerably in the process of birth and have passed the first few days in a sort of comatose condition, nursing may be very difficult and, in certain cases and for the first few days, at least, may be impossible. In such cases, where suckling is temporarily precluded, the breast must be emptied arti- ficially and normal nursing delayed. The expressed or pumped mother's milk may be given the child by teaspoon or by means of a pipette through the mouth or nose.
In severe coryza, with marked swelling of the mucous membrane, the
FIG. 4. — First position. FIG. 5. — Second position.
Direct expression of milk.
application of epinephrin solution (1 : 3000) may relieve the difficulty. Con- genital syphilis, frequently the cause of such snuffles, is never a reason for prohibiting the nursing of the child by its own mother since infection from infant to mother is impossible.
THE ABILITY OF THE MOTHER TO NURSE
Up to this point, we have not raised the question whether there is always milk in the mother's breast. This question of the physical ability of the mother to nurse her infant is of general interest.
Comparing the reports of the large lying-in hospitals, according to which almost 100 per cent, of all women confined there are able to feed their children adequately, at least during the first nine to eleven days of the
1 In this case the milk secretion is to be maintained by regular expression which can be accomplished throughout the period of lactation.
40 TEXT-BOOK OF PEDIATRICS
puerperium, with the experiences of private practice, in which a certain per cent, of all women either do not attempt to nurse or give up the attempt after a short time, because of the alleged lack of milk, we might arrive at the conclusion that the ability to nurse differs widely in the various social strata. Whether this is actually so or not cannot be determined, because the ability or the lack of ability to nurse is not a definite and unchanging fact, but rather a relative condition dependent upon many other factors besides the anatomic and physiologic structure of the gland. This has been often shown by the experience of many institutions when, as a result of a change in medical direction, the ability to nurse has enormously increased, a fact which teaches us to recognize the influence of their surroundings upon young mothers. Anxiety for the health of the mother and doubt of her ability to nurse may, from the first, weaken her desire to overcome the difficulties which present themselves. To strive by personal influence over the mother and, as a teacher of midwives and nurses, for the increase of nursing-power among all classes of the women offers a grateful task to every physician.
Cases in which the breast of the puerperal woman altogether fails of secretion are so extremely rare that they are of no practical importance. The real question to be met is whether we may expect an adequate secretion. Frequently, this can be determined neither before nor shortly after delivery, for the rapidity with which lactation commences differs widely in individuals. As a rule, it is slower in primiparse than in women who have nursed before. Often it is impossible to express even a drop from the breast for the first two days and yet the milk secretion shortly becomes suf- ficient if the child is placed to the breast regularly and suckles strongly. We must admit that there are women whose breasts do not functionate nor- mally and whose power of lactation remains inadequate, especially if the child does not nurse energetically and does not empty the breast completely.
The physiologic increase of lactation power, which may drag along for weeks in women whose breasts do not secrete freely, should be remembered in attempting to judge the value or the non-value of the various galactagogues. Up to the present time all the preparations which have been praised, with more or less clamorous advertising, as "milk producers " (somatose, sanatogen, malt-tropon, lactagol, etc.), are no more specific for the mam- mary gland than are excessive amounts of liquid (soups, milk, etc.), or solid foods. The inefficiency of such agents is shown in the fact that while in some cases no physiologic increase of the lactation power occurs or becomes adequate under forced feeding for a considerable period of time, yet in these very cases a continued and complete emptying of the breast gradually accomplishes its desired result. The recommendations given in good faith by physicians concerning the results obtained by the use of various galactagogues given them for trial, are not testimonials to the scientific knowledge of such men. Galactagogues should be used only for the psychic support they may add to other means advised by the physician.
The fact, which may now be considered firmly established, that the relation between the mammary gland and the reproductive organs, in-
CARE AND FEEDING OF THE NORMAL INFANT 41
eluding the placenta, is not a nervous one, but rather one of chemically active substances of the hormone type, present in the blood, suggests that the time is approaching when specific galactagogues will be isolated and adapted to therapeutic use. Very suggestive experiments in this direction have been reported by Basch.
Spontaneous failure of lactation is certainly extremely rare and prob- ably always occurs in consequence of an incomplete emptying and an insufficient stimulation of the breast, as in cases where the child is weak and does not nurse properly. This is shown by the fact that this failure, fre- quently reported by the laity in private practice, is never, or hardly ever seen in institutions conducted by physicians. In spite of the reappearance of the menses, the normal duration of a well established lactation is almost unlimited and may, if a new conception does not occur, continue for several years in women of our race as well as in those of uncivilized peoples.
Eppstein 's interesting case, in which a wet-nurse after a continued lac- tation of over a year, undertook the nursing of the next child of the same family without interruption and with the best results is by no means unique. It shows that the milk of so "old" a nurse may be used for anew-born babe. This fact of the theoretically unlimited duration of lactation is but rarely made use of in practice, because we have to recommend complete weaning by the ninth month or, at least, by the end of the first year, for reasons which will be discussed later.
THE HYGIENE OF THE NURSING MOTHER
The nursing woman should change her mode of living as little as possible, avoiding only harmful excesses both of work and idleness. Special atten- tion should be directed to this with women of the well-to-do classes and with wet-nurses. So far as work is concerned, observations among the poor have shown that even a large amount of daily work in house or factory is borne without injury to the health, or to the secretion of milk of the constitu- tionally healthy nursing mother.
Psychic excitement, especially anger, pain, sorrow, etc., have no influ- ence upon the qualitative or quantitative condition of woman 's milk. The sudden stopping of the flow of milk, supposedly suffered under such con- ditions in especially sensitive women, is a psychic reflex and probably depends mainly upon the closure of the sphincter of the mammilla, which temporarily prevents the flow or makes the emptying of the breast more difficult. It may be gradually overcome, in every instance, by putting the hungry child to the breast at regular intervals. The idea of the so-called toxic effect of milk supposed to be sensitized by such circumstances should be relegated to the realm of the fable.
The nursing woman should take a sufficient amount of suitable nourish- ment, but should not limit herself to any particular diet. Nothing should be prohibited that agrees with her. She may eat, without fear for the con- sistency of her milk, not only spices and sour foods, but also lettuce, raw fruits, etc., with freedom, because in these foods the elements essential to the physiologic growth of the child are contained in larger quantities than
42 TEXT-BOOK OF PEDIATRICS
in many others. In women with small appetites as variable a diet as possible is to be recommended, while for those having a tendency to con- stipation it is well to give, instead of a largely milk and soup diet, foods yielding a large bulk of debris.
The quality of the milk, especially as to its fat content, varies in only slight and practically unimportant degree in any individual and cannot be influenced by the diet of the mother. Particular exceptions (Moll) are not proof against the argument for this view, when we consider that the child itself can regulate the quantity of food which it gets from the breast (Gregor).
Excessive eating and drinking, especially of such foods as milk and rich soups, do not lead to an increase in milk production, but merely cause the nursing woman to put on useless fat. Such excesses are not only useless but should be especially avoided in women who tend to corpulency and to insufficient physical exercise.
After lactation has been fully established, hunger is similarly without immediate effect upon the quality and quantity of the milk. Only after a long sustained and severe degree of starvation, when the bodily strength itself wanes and emaciation ensues, is a decrease in the quantity and proba- bly, also, unfavorable changes in the quality of the secretion to be noted.
The fluid requirement of the mother is naturally increased during nursing. This may be met by drinking large quantities of water, if the food contains sufficient nutriment. The use of large quantities of rich soup has no more effect upon the volume of the secretion than has alcohol in the form of beer or wine. Nothing can be said against the use of beer or wine in temperate quantity. Traces of alcohol are to be found in the milk only when it is taken in very large amount.
The general hygiene of the nursing woman should be the best that her environment will permit. The drawing pains in the back which so com- monly occur when the child is put to the breast may be relieved in many cases by supporting a pendulous abdomen or by taking a comfortable position while nursing the infant.
The breast, and especially the nipples, should be kept clean by fre- quent washing, for esthetic if not for hygienic reasons, even though the rough surface of the mammilla cannot be completely disinfected by ordi- nary measures.
Of the medicinal agents which it may be necessary to give internally to the nursing mother, only iodine, bromine and salicylic acid are excreted in the milk and these in absolutely harmless quantities. In animals, opium, morphine and atropine also pass through. Mercury, in event that the mother is treated by inunction, is excreted in the milk, but in such minute quantities that it is impossible to expect therapeutic results from it in the child. It may also be said that chloroform anesthesia in the mother is entirely without importance to the nursing babe.
After the confinement the menses do not appear at all, or only once some five to six weeks after, and then remain absent for months or until the end of lactation. Occasionally, they appear regularly during the entire
CARE AND FEEDING OF THE NORMAL INFANT 43
period of nursing. The occurrence of the menses has in itself no influence upon the quantity or quality of the milk, nor does it cause restlessness or digestive disturbances in the child. When the breast is functionating indifferently and the mother is much affected by the menstruation, an increased difficulty in emptying the breast may be experienced, together with an increased nervous irritability. This should never be considered cause for additional feeding.
To a certain extent pregnancy is more infrequent in nursing women than in others and doubtless the women who are amenorrhceic during the lactation period 2 do not conceive as readily as those who menstruate regularly. Neither the maintenance of lactation nor amenorrhcea give absolute assurance that conception may not occur during their course, but it is very probable that immunity from conception is present for several months of lactation and in nursing women a dangerously rapid sequence of conceptions is not seen as commonly as in those who do not nurse their children. The claim of some mothers that they have had to wean a nursing child because of a new pregnancy is often due to the error of regarding the absence of the menses as an indication of conception. Immediately upon weaning the infant, they conceive at the next ovulation. Other women, on the contrary, discover a pregnancy only after several months have passed, without either mother, nursing child or fetus suffering any harm from the continued lactation. This proves that pregnancy of several months' duration does not necessarily cause the secretion to dry up. The child, therefore, should never be weaned suddenly though pregnancy is suspected and even when it is definitely determined, the weaning should occur gradually.
All these facts tend to show that obstacles to nursing or legitimate causes for its interruption occur much less frequently than has been sup- posed both by the laity and the profession. The knowledge of this and the avoidance of those numerous rules and limitations with which the nursing mother has been unreasonably surrounded, have produced a gratifying increase in the number of mothers among the educated classes who are willing to nurse their children. It is knowledge, however, that must be brought home to all classes of people by the physician, and its spread will add greatly toward making mothers more ready and more able to nurse. Then, too, those social conditions which force the mother to seek employment will no longer necessarily rob the child of the food provided for it by nature. The value of this to the individual and to the nation is to be considered. (See Section IV.)
THE TECHNIC OF BREAST FEEDING.
The new-born should be put to the breast of the mother only after 24 hours. If the child seems hungry before this time has elapsed, it may be given, from a spoon, a little water sweetened with benzosulphinidum (saccharin). If the infant sleeps for a still longer time, the sleep should not
1 This physiologic amenorrhoea depends upon a more complete puerperal involution of the reproductive organs, in consequence of which ovulation is arrested.
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be interrupted. Quite a few children require no nourishment for 36 to 48 hours after birth.
Infants act differently in their first attempts at nursing. Some im- mediately suckle well and with much force ; others will not take the nipple or let go after a few attempts. Nothing is to be gained by force. The child is to be put back into its crib and the attempt repeated after an interval. With patience and continued application to the breast every normal child will learn to nurse. If the breast is very tense and difficult to empty it may
FIG. 6. — Method of holding baby during nursing.
be made more responsive to the effort of the child by expressing or pumping off small quantities of milk.
Emphasis should be put upon the fact, from the very first, that the child must take not the nipple only, but also almost the entire areola into its mouth; for the greater the portion of the breast included, the greater is the area affected by the stimulus of suckling and the greater is the reflex response. This practice is also less liable to tear the nipple and to pro- duce fissures.
The nipple shields or protectors, consisting of a glass to cover the mammilla and a rubber nipple for the child to suckle, which are in common
CARE AND FEEDING OF THE NORMAL INFANT
45
use and are intended to make the first application of the infant to the breast easier, or are used out of an excessive fear of mastitis, are dangerous. Their harmfulness lies in the fact that while they may make the work of suckling easier for the child, the unphysiologic stimulus makes the emptying of the breast much more difficult. The continued use of such an apparatus almost always leads to the drying up of the secretion and the under-nourishment of the child.
Conical breasts are more easily emptied by milking movements which make slight rhythmic pressure upon the areola; flat breasts are best emptied by pumping apparatus. Of pumping devices there are numerous types. The teterelle biaspiratrice, which was formerly in common use, consists of a glass bell placed over the nipple and supplied with two pieces of tubing, from the one of which the mother draws the air, while from the other the child takes the milk. In this form, the saliva of the mother easily flows into the apparatus, which does not seem to be very desirable. Of the various models in which a negative pressure is produced by a rubber bulb, the pattern designed by Ibrahim (Fig. 7) is easily handled and readily cleaned. With rhythmic compression and release of the heavy walled bulb, the action of the normal suckling apparatus may be imitated to some extent; but here also the rhythmic massage of the areola is lacking and the breast is never emptied as com- pletely as by the suckling of a strong child.
It is not only necessary to empty the breast completely in order to obtain suffi- cient milk for the child, but also because this is the only method which stimulates and increases the initial secretion and prevents congestion. If the breast is not completely emptied, the irre- parable result, an unavoidable one during the first few weeks and often within a few days, is the complete failure of the secretion.
The colostrum secreted during the first few days is very small in quantity and often measures only a few cubic centimeters. Usually, after the third or fourth day, but often not until the fifth or sixth, a rapid increase of the secretion ensues, which in many women is accompanied by the subjective feeling of the " shooting-in " of the milk. At the same time, the number of colostrum corpuscles rapidly sinks to a minimum.
The further increase of the quantity of the milk is dependent on the one hand, upon the amount of glandular tissue in the breast and, on the other hand, upon the demand made upon it. These two factors determine the total production of the secretion, as well as the time at which the function is fully established.
The question whether the child should be put to one or both breasts at each feeding can be answered only in a general way by saying that the
Fio. 7. — Breast pump (Ibrahim)
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object of the nursing should be to empty the breasts as completely as possible and that congestion must be avoided. Other things being equal, this occurs to a greater extent in small breasts than in large ones. It is per- missible at times, therefore, to apply the child to both breasts after an inter- val of at least three hours, taking care only that the child receives the second breast after it has emptied the first one sufficiently. By beginning alternately with the breast from which the child has nursed last, all these demands are fulfilled in the best manner. It is only with very well developed breasts that we may persist in giving only one breast from the beginning.
The ease with which the breast may be emptied, whether artificially or by the nursing infant, varies greatly in individuals in whom the quantity of secretion may be the same. It often happens that while the child is nursing from one breast, the milk drops or even spurts from the other.3 The number of feedings which the healthy infant will take spontaneously from a freely secreting breast varies between five and six in 24 hours; but it may occasionally fall to four or be increased to seven. It is recommended and is generally accepted, to-day, that three-hour intervals should be allowed be- tween the feedings during the day and that during the night two longer in- tervals are most satisfactory to the favorable development of the child.
A large experience with new-born and older infants has shown, and the method has been generally adopted by numerous pediatrists, that an interval of four hours is even more satisfactory. This is true both from the standpoint of the child and of the mother. The editors have used the four- hour feeding for a number of years. The schedule is placed in force 24 to 48 hours after birth. On the part of the child, less digestive disturbances are encountered and on the part of the mother, the great advantage lies in the fact that she is given more freedom for work or social duties. Even pre- matures are more successfully fed on this schedule. The hours for nursing most frequently recommended are 6 A. M.; 10 A. M.; 2 P. M.; 6 P. M.; 10 p. M. and one night feeding at 2 A. M., if necessary.
It is usually superfluous to prescribe the length of the individual period of nursing for the healthy infant, .because when satisfied it stops suckling, often falling asleep at the breast. Some children suckle for a moment and then stop, and when the attempt is made to remove them from the breast grasp it greedily, to suckle again for a moment. In such children the time of nursing should be limited to fifteen or twenty minutes at the most.
It may be shown, by weighing the child at equal intervals of about five minutes, that the quantities taken during successive periods of nursing decrease very rapidly and that only a few grams are taken after the first
3 After long intervals between nursings, and especially at night, is this apt to occur. In many women, some milk flows from the breast after long intervals in nursing and more especially after the night interval. This becomes annoying and disturbing only when it occurs immediately after putting the child to the breast and when because of an ab- normally low tone of the sphincter mammillae, a sort of incontinence or galactorrhea results. Obstinate eczema of the areola and of the skin over the breast may ensue. The treatment of this anomaly, which usually appears to be of neuropathic origin, is generally quite use- less and must confine itself to the application of dressings to absorb the milk and to the treatment of the eczema with ichthyol or with silver nitrate solution (2-3 per cent).
CARE AND FEEDING OF THE NORMAL INFANT 47
twenty minutes. The long-drawn-out nursing period not only wastes the mother's time and strength but is actually dangerous because of the maceration of the nipple and the consequent liability to fissures.
The quantity of milk taken at each nursing, determined by weighing the child before and after putting it to the breast, varies within wide limits. Usually the secretion is most abundant at the first morning feeding and is often two to three times as great as that of the smallest output which is usually had late in the afternoon. This is most definitely observed after an interval of the whole night especially in breasts of large capacity.
The total quantity of the twenty-hour hours' secretion is of greater import to the physician. It will be seen from the above statement that this total can never be obtained by multiplying the amount secured at one nursing by the number of feedings, but must be determined by weighing the child before and after each nursing. The quantity of milk which the infant receives within the 24 hours varies also from day to day; the variance running at times from 200-300 c.c., so that the knowledge of the quantity of any one day's feeding permits only indefinite conclusions upon the total amounts regularly taken. On this account, Czerny and Keller have adopted as a standard the average of the total output of five days. Except- ing from this estimate the first 8 or 10 days, when great irregularities occur, it has been determined that the amount of nourishment taken during the first few weeks equals about one-fifth of the body-weight. This quantity is gradually reduced to about one-sixth or one-seventh, between the first to the fourth month, and at the end of the first six months it equals about one- eighth of the body-weight. This gradual reduction of the relative quantities of food stands in close relation to the conditions described on page 22. When the quantities of food taken and the body-weight are represented by curves a marked divergence appears, in that the weight curve continually rises while the food curve, representing food quantities, becomes more and more flattened. It must be said, however, that cases have been observed in which the two curves ran parallel for months.
Under normal circumstances both breasts commonly secrete like quanti- ties, but it is not exceptional to find women in whom one breast secretes more freely than the other throughout lactation. Similarly, women are quite often found in whom one breast has been depreciated by a former mastitis, but are able, for many months, to produce sufficient milk with the remaining gland which has become structurally and functionally hyper- trophied. This is especially interesting when there are twins, in which case each child usually suckles one breast.
When the quantities of food fall markedly below the average given and still produce satisfactory increases in weight, we are justified in the suppo- sition that this depends upon a higher fat-content of the particular secretion. This has been proved in a case reported by Heubner. The occurrence of such individual differences, uninfluenced by the mode of life of the nursing mother, has been established by careful observations made under due pre- cautions. It would seem, generally speaking, that the fat-content of milk from breasts giving small total quantities is relatively much greater than in
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breasts which secrete greatly in excess of the quantities required by any one child. Wet-nurses, for instance, are found in institutions, who give two to three litres per day of such milk. When several children are put to the same breast in succession, the first child to nurse receives milk containing the lowest percentage of fat.
The weight increase is looked upon as the chief index to the results of feeding. This view is probably justified by the large consideration to be given to the congenital tendency to growth and the many-sided import of
FIG. 8.
weight increase, but it should not be permitted to overshadow such other signs of general well-being in the child as its color, turgor, disposition and sleep, the development of its static functions and its reaction to infections. The normal condition of the child in all these respects is more important than the rapid increase of weight.
In healthy children who develop well, the weekly increase varies in the second and third quarters of the first year between 150 and 250 grams and occasionally even 300 grams; and in such a regulated manner that especially large increases of one week will be equalized by smaller increases in the next, and vice versa.
If the increase in weight remains for a considerable period below what would naturally be expected, the cause should not be laid unconditionally
CARE AND FEEDING OF THE NORMAL INFANT 49
to underfeeding. We should rather seek to determine, by the methods already cited, whether the quantity of food is actually too small and if so whether the fault lies in a positive lack of milk, in a weakness of suckling, or in anorexia hi the child due, for instance, to parenteral infection. The last of these alternatives is much more common than is generally believed. To avoid serious errors, every other cause of disturbance upon the part of the child should be certainly excluded before means are taken to increase the food artificially.
As we have already said, the time of the "coming in" of the milk and the rapidity of its increase in quantity — stimulated by the suckling of the child and by the measure of its food requirement — varies greatly in dif- ferent individuals and is usually slower in primiparse than after repeated lactations. This possibility and the axiomatic fact that even scant nour- ishment at the breast for a certain period does not injure the child, justifies the physician in keeping the patient under careful observation and waiting, as long as possible, for the full establishment of lactation in these cases of delayed beginning, or slowly increasing output. As a guide, it may be stated that after the physiologic loss of weight has occurred (see page 24), a lesser loss of 5 to 10 grams a day may occur and that such loss may be permitted to continue for one or two weeks, giving the child only a little water sweetened with benzosulphinidum (saccharin). If no increase in milk secretion or in the body-weight of the child occurs by this time, it becomes necessary to supplement the insufficient breast-feeding and us- ually with some artificial mixture.
It may be possible, in rare cases, to give the child who does not receive sufficient milk from its mother, several adequate feedings a day at the breast of a wet-nurse. It may be stated emphatically, that in case of necessity, the child may receive each feeding from a different wet-nurse, as has been done in certain institutions, and it may still develop ex- ceptionally well.
The addition of artificial food to the breast feeding, a method to which the French term allaitement mixte, or mixed feeding, has been applied, serves much more favorably for the development of the child than arti- ficial feeding alone, and it should be recommended more frequently by physicians than it is. Since the once deep-rooted prejudice against this mixed feeding, or the alternation of natural and artificial food, has proven entirely without foundation, the lack of sufficient secretion by the mother 's breast should never be an occasion for weaning, but always an indication for the addition of other food. In such cases, it may be well to give the bottle once or twice daily, or later, at the most, three tunes during the 24 hours, in place of the breast; or instead of this to the scanty breast feeding, the artificial food may be immediately added once, or several times, a day in sufficient quantity to satisfy the infant.
Each of these two methods has been successfully used and has been recommended ; either is justified in suitable cases. It is of prime importance, whichever method is followed, to prevent the child from being weaned. Further, preference may be lent to the easier way of giving the added nour-
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ishment. The surest avoidance of weaning is found in the first form of mixed feeding, that is, by the alternate feeding at the breast and from the bottle. This type of mixed feeding is, too, the only possible one when the mother is hindered by outside demands from nursing the infant regularly. Either method, however, should be carried out under strict observation,
FIG. 9.
giving the child only such quantity of artificial food as is absolutely required, so that it will continue to empty the breast completely and so prevent congestion and the arrest of the secretion. Otherwise a result, frequently seen in practice, soon obtains in the infant 's refusal to nurse the scantily secreting breast, thus "weaning itself," because "it does not care for the breast any more." The choice of the food to be used in mixed feeding depends upon the accepted standards of artificial supply.
If the occasion for mixed feeding disappears, it may be possible to dis-
CARE AND FEEDING OF THE NORMAL INFANT 51
continue it in favor of exclusive breast feeding. Thus, with an initially scanty secretion, the continued strong suckling of the infant may stimulate the breast to the point of sufficiency; or, in event of hitherto enforced absence, it may become no longer necessary for the mother to be away from the child for hours at a time. Since the secretory capacity of the mammary gland is dependent within wide limits upon the demands made upon it, the quantity of the secretion usually becomes sufficient in amount within a few days after the abandonment of mixed feeding. It is even possible to bring a breast which has almost entirely dried up back to full function again. This so-called re-lactation, however, occurs only when the colostrum formation has not advanced too far.
WEANING
In spite of the fact that the period of lactation itself, as already said, is almost unlimited and that the secretion itself may be adequate to produce satisfactory and normal gains in weight even beyond the first year, it is neither customary nor advisable to continue breast feeding exclusively for so long a time. In the first place, the normally developed breast-fed child will indicate its desire for other food much earlier; often, at about the sixth or eighth month taking bread and the like in its mouth and eating it. In the second place, the additional food given at this time acts in a clearly favorable manner, maintaining the natural fresh color and sound turgor, promoting the development of the bones and the exercise of static functions.
Whether this beneficial action of the additional food is due to the added carbohydrate supply or to the increase of inorganic salts, particularly cal- cium and iron, both of which are present in relatively small amounts in human milk, is beside the question. It is certain that the natural transition to the mixed dietary of adult life is satisfactorily made in this manner.
The time as well as the methods of the transition show great variation in accord with the customs of the country and it is not always made in a proper manner The error of too early feeding, so early indeed as the third or fourth month with large quantities of sweet or starchy foods and breads or with animal milk, is much more common than the error of too long exclusive feeding with breast-milk
We recommend the method of Czerny, now very generally accepted by podiatrists, of beginning at the sixth or seventh month to substitute for the noon-meal of breast-milk some 5 to 7 ounces of farinaceous soup prepared with meat broth. The soup-stock should be prepared from a quarter of a pound of meat and should contain the same condiments (salt and vege- tables) as may be used for adults, but the fat should be completely skimmed off and it should not contain so large quantities of lime salts as may be found in broths made from calves' feet or young fowls, because these will produce diarrhoea in some children.
After several weeks, or even after several months, if perfectly safe milk cannot be obtained, as may be true during the summer months, a second breast feeding is replaced by an artificial feeding consisting of cow's milk and flour soup, or milk and toast. These feedings should be in accord in
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quantity with those recommended for a child of given age and weight. Gradually, with intervals of at least several days, the remaining breast feedings are replaced in a similar manner. During the process, however, the breast and the artificial feedings should alternate, in order to prevent marked congestion of the milk in the breast. When the weaning is com- plete, the child's menu may be varied by the addition of any one of the large variety of soups (rice, sago, potato, legumens, etc.), or of one or two tablespoonfuls of mashed vegetables (carrots, spinach, cauliflower, etc.), or by replacing the milk and flour soup, or the milk and toast by a more nourishing milk pap, made with cereals, rice, etc.
Stewed or raw, scraped vegetables should, for pedagogic reasons, be given only after the child has acquired the taste for several of the mashed vegetables, otherwise it may be difficult to teach the child to eat the latter. Even with the greatest variety of food, care should be taken to prevent the child from being " spoiled" and capriciously selecting its own food. When vegetables are given, it is well to warn the mother to expect the appearance of undigested shreds in the stool, for if this is not done she may become frightened and discontinue their use in the belief that they are indigestible.
Even large and strong children should not be given more than one quart of milk daily at the end of the first year. The milk other than contained in gruels, etc., should not be fed from the bottle. It is better, even if somewhat more troublesome, to teach the child to take the food from a cup or mug after it has learned to take soup from a spoon, because this is the natural mode of drinking.
The unpleasant custom, a widespread one in some countries, of allowing children, who are running about or even of school age, to take their milk from a bottle, because they will drink more by this means, is not only irra- tional and unesthetic but is a practice harmful, as all long-continued suck- ing is, to the process of dentition.
WET-NURSING
The only perfect substitute 4 for mother's milk is the milk of a wet-nurse. The only prerequisites are that the wet-nurse be healthy and that she have sufficient milk. The qualitative differences that may obtain in the milk of different women play no part in the nourishment of a healthy infant. As an actual fact, everything that has been reported concerning the unfitness of the milk of certain mothers is due to the improper inter- pretation of superficial observations.
Even though difficulties in the establishment and maintenance of wet-nursing are very frequently encountered in private practice, these difficulties almost always result from avoidable errors due to a lack of
4 This is not true in an ethical sense. The mother who does not nurse her child, but leaves its feeding and care to the wet-nurse, has later great difficulty in regaining the tender love of her babe which naturally turns from her to its nurse. She risks, further, the danger of having the child acquire the personal characteristics and habits of the nurse, which are often far from desirable. That individual peculiarities may be trans- ferred with the milk is not true, although it was formerly believed. Their acquirement is entirely due to the unconscious mimicry of the child.
CARE AND FEEDING OF THE NORMAL INFANT 53
knowledge of the basic principles of normal lactation or of the physiology and pathology of the breast-fed infant. The conditions for wet-nursing are the same as obtain for the feeding of the child at the mother's breast. The frequent change of wet-nurses is, therefore, in most cases, a poor testimonial to the knowledge of the physician in charge.
A very common error is made in demanding for a weak infant who can take but small quantities of food, a wet-nurse who has a large supply of milk, a condition always distinctly specified alike by physicians and parents. The natural results, in congestion of the breast and in decrease and final disappearance of the secretion, may be avoided, often, only by pumping the excess of milk or by permitting the wet-nurse 's own child,5 which she also nurses, to empty the breast completely. It is best, however, when selecting a wet-nurse to see that there is a reasonable relation between the quantity of milk secreted and the food requirement of the child.
The provision of wet-nurses was, up to a few years ago, a very serious matter and is still difficult from the medical as well as the sociologic and ethical viewpoint.
Wet-nurses recommended and introduced by employment agencies, by which they are tempted with promises of well-paid positions, are usually in the stage of well-developed congestion of the breasts and are often in danger of losing their milk when they accept a position. It is not surprising, under this method of hiring a wet-nurse, that her family history and the detail of her past life, previous illnesses, etc., most certainly necessary to establish her fitness as a wet-nurse, are usually intentionally falsified ; while the child which is shown to the physician is often not her own, a fact which develops most unexpectedly and unpleasantly later on.
Her physical examination should, of course, be very complete and should be directed especially to the discovery of tuberculosis, syphilis, gonorrhea, and parasitic and infectious skin diseases. In view of the frequency with which the von Pirquet reaction is positive, indicating latent tuberculous foci in the adult, it is not a sufficient reason for rejecting an otherwise satisfactory wet-nurse. The Wassermann reaction should be made as a matter of routine. The inspection of the wet-nurse 's child, which is not always possible, is much less certain than the blood examination in the exclusion of syphilis. With practice, it is possible to determine approx- imately by palpation of the breast, which is not intentionally congested, whether there is a sufficient output. There should be sufficient tense gland- ular tissue, which is harder than the surrounding fat. The skin over the breast is warmer than over the sternum and has numerous large veins passing through it. Exact knowledge of the quantity of milk may be obtained only by weighing the child before and after feeding.
The numerous dangers which arise in hiring a wet-nurse from an employment agency, briefly indicated above, may be avoided if the wet- nurse is taken from an institution, an infant and lying-in hospital, etc.,
8 This method, which is advisable because it is humane, is practicable in suffi- ciently well-to-do families and should be considered whenever possible.
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in which she and her child have been observed 6 by unprejudiced attendants, for weeks or months, as to their health and general characteristics and the adequacy of the breast yield. They have usually learned, in such an insti- tution, to handle and to properly care for an infant.
The old rule that the wet-nurse 's infant should be about the same age as the child that she is to nurse is now believed to be without foundation. It is rather desirable for the reasons cited to select a nurse for even a new-born infant, whose lactation has been established for several months. If we can be certain that the lactation is well established, a mother who is nursing for the first time will prove entirely satisfactory.
Even though she takes care of the child and helpswith the housework and is not fed with too great luxury, the wet-nurse tends to be a great expense because of her high wages and the necessity that a room be provided for her.
Mixed feeding (allaitement mixte) secured by the employment of a wet-nurse who comes to the home to nurse the infant once or twice a day, is much cheaper and is in most cases a satisfactory substitute for the exclu- sively used wet-nurse. Every healthy woman who has sufficient milk, if she wishes to nurse the child several times a day, may accomplish this either by going to the child or by having the child brought to her. If the child is given the breast three times a day, it will be necessary to give two artificial feedings in the intervals. When the nurse comes to the house for nursing periods only and keeps her own child, also partially fed at the breast, most of the unpleasant features of the situation arising when the wet- nurse must be taken into the house and treated as a companion disappear. The test weighings of the child, before and after nursing, to ascertain the quantity of milk obtained from the nurse, are to be recommended as a matter of reassurance to the parents and as a control measure when the child does not develop as well as might be expected. In this method of mixed milk feeding, a complete knowledge of the physiology and pathology of infancy is as necessary as it is in all other forms of feeding. It is especially important for the physician to meet the many superstitions of the mother, who will see a dietetic error of the nurse in every cry and in every irregu- larity of the stools of the infant.
6. ARTIFICIAL FEEDING
Artificial feeding, surrounded by a grim troop of dangers, stands in distinct contrast to the certainty with which normal growth and develop- ment occur at the mother's breast. This is proved most clearly by the high mortality rate of the artificially-fed. These dangers depend partly upon the decomposition of the component parts of the animal 's milk used in making the artificial food, and partly upon chemical differences between human and animal milk which cannot be entirely met. These dangers are greater the earlier the artificial feeding is begun.
6 In such institutions the wet-nurse 's child will find a home and be cared for, which, in part, reduces the expense. A law regulating wet-nurses, with special regard for the wet-nurse 's child, has been rightfully demanded from various sources.
CARE AND FEEDING OF THE NORMAL INFANT 55
MILK FOR INFANTS
The first of these difficulties of artificial feeding may be measurably reduced if the most scrupulous care is exercised in the dairying and handling of the milk. Milk so secured and treated is usually marketed under some distinctive name as "milk for infants," certified, sanitary, or inspected milk. Under insufficient legal regulation, no name in itself offers any assur- ance of the purity of the milk, unless it stands for actual inspection and certification. On the other hand, milk not sold under label, is not necessarily contaminated and unfit for infant feeding.
Aside from intentional contamination, punishable by law, such as partial skimming or the addition of water or preservatives, to hide already advanced souring, and aside from the accidental admixture of pathogenic organisms, the chief source of the impurities of milk lies in the implantation of greater or less numbers of saprophytes which, with varying rapidity, induce its complete decomposition.
The larger number of these organisms come from the impurities which fall into the milk during the process of milking, and consist of hairs, epidermal scales, manure, particles of food and stable dirt. These im- purities are carried into the milk by air currents, or from the hands of the milker, or from dirty vessels and implements, or by dirty water with which the latter are rinsed.
Therefore, the extreme cleanliness of the cow and especially of the cow's udder is important. Care should be taken not to stir up dust in the stable from bedding or foddering shortly before milking and the greatest possible cleanliness of the entire equipment, not only of the hands and clothes of the milkers but also of the vessels used in milking and in gathering and measuring the milk, of the straining cloths, etc., should be secured. In other words, asepsis, as complete as possible, should be practiced in obtaining the milk to be used for infant feeding. Further bacterial contamination occurring in the handling and transporting of milk, in pouring it into different containers and in measuring it for sale, is relatively small. The primary contamination which the milk receives in the dairy increases steadily and extensively, in proportion to the degree of its first infection, to the length of time during which it is kept at body temperature and to the period of tune consumed in carrying it from the dairy to the consumer.
Thus it will be seen that the proper care of milk demands the greatest precautions in milking, in immediate chilling, and in rapid delivery to the consumer. After it has reached the home, the responsibility of its keeping rests with the housekeeper.
It is self-evident that the milk of diseased animals should not be used for infants. The question whether the milk of cattle which give a positive reaction to tuberculin, but present no clinical evidence of tuberculosis and, especially, no sign of tuberculosis of the udder, is unsafe and one most diffi- cult to decide and is still under discussion. There is no doubt, however, that strict adherence to this rule will increase the price of milk very materially. In the better dairies, which furnish special milk for infants, it has been found sufficient to have the dry udder frequently and carefully examined, say at
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least once a month by a veterinarian, thus insuring the timely discovery of tubercles, as well as of the streptococcus infection or mastitis.
Green fodder and silage have to a great extent replaced dry fodder in the diets of dairy cattle. Such feedings must be regulated so as not to cause diarrhoea which increases the difficulty of obtaining sanitary milk on account of the soiling of the udder and the probable introduction of enor- mous numbers of acid-forming bacteria into the milk.
Where there are local dairies or institutions marketing milk for infant use which are well equipped and carefully managed, the milk should, of course, be procured from them. But the necessity of transporting milk a long distance by rail or wagon in the summer, may make the advantages of sanitary milking and immediate cooling somewhat illusive; so that it is usually better to purchase milk from a near-by source, which may not have been obtained under as sanitary circumstances, or even to secure it fresh from the cow several times a day and to use it immediately.
Where neither the one nor the other method of obtaining pure cow's milk is practical, all the difficulties may be surmounted by keeping a goat. Goat's milk is as satisfactory as cow's milk for infant feeding. Besides, tuberculosis is very rare among goats; the animal is more easily kept clean and the milk is more readily obtained in a sanitary state.
A far-reaching control of milk is possible under a system of municipal inspection. Such control concerns itself not only with examination of the milk as to its dilution, skimming, etc., but it also determines the presence of dirt, the number of leucocytes (Trommsdorf test) and of micro-organisms, and the degree of acidity, according to the method of Soxhlet-Henkel.7 Since the housekeeper has to depend upon the very indefinite tests of appearance, taste and smell, or finally, upon an experimental boiling, the knowledge of the source and freshness of milk is all the more important to her.
The Pasteurization of milk in bulk, which has been advised so frequently and is quite practical, cannot be recommended for milk intended for infant feeding. In the ordinary milk purchased in the open market, which is often consumed without being boiled, Pasteurization guarantees the destruction of pathogenic organisms; but in milk for infant use, which is always boiled before being used, it hides the important indications of age and insufficient cleanliness by destroying the relatively harmless acid-forming bacteria while the much more dangerous spore-forming peptonizing bacteria (Fliigge) remain active. Moreover, as the possibility of subsequent con- tamination makes the reheating of the milk in the home necessary, it is certainly not a particularly advantageous thing.
7 One degree of acidity is the amount of acidity in 50 c.c. of milk which will be
N neutralized by 1 c.C. -j sodium hydroxide. Phenolphthalein is used as an indicator.
Fresh milk has 2-4 degrees of acidity and remains at this stage (incubation) for from 3-8 hours at body temperature; or at 10° C. for 52-72 hours, depending upon the degree of cleanliness in milking. Milk curdles upon boiling when it has 5.5-6.5 degrees of acidity. Spontaneous curdling occurs in milk of 15-16 degrees of acidity. Thus we are able to determine age and composition approximately by titration. (Plaut; quoted from Finkelstein's Text-book.)
CARE AND FEEDING OF THE NORMAL INFANT 57
The question, actively discussed for years, whether the injuries con- nected with artificial feeding may not be more or less avoided by giving raw milk, may now be considered answered in so far that no recognizable advantage is seen in feeding the healthy infant raw milk rather than Pasteurized or sterilized milk. The theory that milk becomes unfit for infant feeding by brief boiling, seems most effectually contradicted by the observation that human milk, even after boiling ten minutes, is as effective in relieving seriously ill infants as is the mother's milk unboiled. On the other hand, the view is justified that boiling for a long time (^-1 hour) or very intense heating for even a short time, causes a definite dena- turization. Clinical experience, at least, has shown that the excessively sterilized milk of commerce causes anemia and under certain circumstances and if used for a long time produces scurvy.
In the home, only Pasteurization, that is heating to 60° or 65° C, (140 °-160° F.) for 30 minutes or boiling for a shorter tune, by the method to be discribed are to be considered. Pasteurization offers no advantage over the boiling of milk for infant feeding and is so awkward in process and so uncertain of results, even with the best apparatus, that it has never become popular and cannot be recommended. The method of choice, therefore, is boiling. It is of no importance whether the whole quantity intended for the 24 hours' feeding is boiled at once, in a glazed or enamel vessel, or whether the separate feedings are boiled in the bottles. The latter method is most readily accomplished by means of the well-known appa- ratus of Soxhlet. Instead of the patent rubber cover, which is drawn in by the negative pressure as the bottle cools and which seals the bottle hermeti- cally, a metal or glass cap may be placed over the mouth. The time for boiling may be gauged by allowing ten minutes from the first appearance of steam. By sterilizing the separate feedings, every possible contamination by later handling is most certainly avoided; but the likelihood of this is sufficiently reduced by boiling the entire mixture in a kettle, if everything else is cleanly. In this method of minute boiling the milk may be kept from running over by using a double boiler or one of the various milk cookers with perforated cover. In every case, where this method of sterilization, without immediate bottling, is employed, it is essential to cool the food as rapidly as possible by placing the container in running water and keeping it iced. In order to accomplish this, with the use of small quantities of cold water or ice, Fliigge has recommended a cooling-box constructed upon the lines of the fireless cooker.
It is self-evident that the physician must frequently prescribe, and often in detail, the methods of maintaining absolute cleanliness of all the utensils which come in contact with the infant 's food. Special points should be emphasized. All portions of the food which are left in the bottle, after the child has finished nursing, must be thrown away and the bottle must be washed immediately to prevent the drying of particles which would then be difficult of removal. The nursing-bottle and nipple with rubber fittings and glass tubing should be absolutely prohibited because it cannot be kept clean. The simple rubber cap nipple is best cleaned by washing it
5$ TEXT-BOOK OF PEDIATRICS
in running water after each use and boiling it once a day. In the intervals the nipple should be kept dry in a clean covered glass or cup, rather than in an antiseptic solution.
THE TECHNIC OF ARTIFICIAL FEEDING
In the practice of artificial feeding from birth, no food is given during the first day of life as with the breast-fed infant. In further imitation of the natural conditions, only three or four feedings are given during the second, third and fourth days, and five feedings only after the fourth or fifth days. Nor should this number of feedings be exceeded later on, the longer time required for the digestion of cow 's milk in the stomach making the greater intervals (preferably 4 hours) necessary. Artificial food, given in excess of the requirements of the new-born, is much more dangerous than is human milk.
Since the caloric values of cow's milk and of human milk are approxi- mately equal, it might seem rational to give the infant such quantities of undiluted cow's milk as are taken by the child on breast feeding and this is, indeed, still recommended by certain authors. The preponderant experience of almost all physicians has shown, however that good results may be more certainly obtained by the customary use of milk dilutions.
The researches of the past few years have taught that the advantage of such dilution cannot be laid to the indigestibility of the casein of cow's milk, for this has not been proved. On the contrary, it is equally question- able whether the avoidance of overfeeding with cow's milk of so reduced concentration is the only active factor of benefit. Probably other causes, which cannot be considered here, play an important role.
The reduction of the food value which results from dilution may not be equalized by an unlimited . increase of quantity, without causing injury through the excess of fluid. It is customary, therefore, to select food sub- stances which may be added to the diluent to equalize or diminish this deficit. Theoretically and empirically, sugar of milk seems to be the most acceptable item for this purpose. Cow's milk, diluted with two parts of water, to which has been added one level teaspoonful (3-4 grams) of sugar of milk for every 100 c.c., (3J/2 ounces) of fluid, is to be recommended for a two-day-old infant. Even if, at the end of the first week, the infant is taking five feedings of 100 c.c. (3J^ ounces), each, of such a preparation, its actual food value is so low that the danger of overfeeding is most certainly avoided. Indications for more or less rapid increase of the food, quantitatively or qualitatively, are gained by observation of the infant in regard to weight, stools and other clinical conditions.
In increasing the volume of the feeding,8 to meet the indications of need, we have a relatively definite standard in the volume of the daily food taken by the healthy breast-fed infant of normal weight and development.
8 If the amount of each feeding is to be measured by means of marks on the nurs- ing-bottle, it is well to be informed as to the accuracy of the markings represented by each line. Even with bottles of the same model it is impossible to depend upon their accuracy.
CARE AND FEEDING OF THE NORMAL INFANT 59
When we remember that the daily quantities of food taken represent one-fifth of the body-weight during the first week and that they should gradually sink to one-eighth of the body-weight by the end of the first half-year and when we see to it that this physiologic volume of the liquid food is not exceeded to any appreciable extent in artificial feeding, we soon find it necessary to increase the concentration, that is, the food value of the dilution, if the requirement of the child is to be met.
The concentration may be increased either in definite steps by passing from the proportion of one-third to one-half and later to two-thirds of milk, or it may be gradually secured by adding a few spoonfuls of milk without changing the amount of water. The latter method seems to resemble more closely the gradually increasing volume of food which the breast-fed child receives.
Since we do not wish to give undiluted cow's milk during the first month of life, and it has proved empirically undesirable, it will be necessary to increase the food value of the mixture by suitable additions and this is done by adding fats or carbohydrates. The latter need is met, in part, by the addition of sugar of milk as already suggested. The fat content may be increased most readily by the addition of fresh cream, as Biedert first proposed.
Because ordinary centrifuged cream, intended for the use of adults, does not fulfill the requirements of milk for infant feeding in the matter of freshness, low bacterial count and special selection of the cattle from which it is taken, it is better to prepare the cream from well-chosen milk at home. For this purpose the milk should be placed on ice in shallow vessels and be allowed to stand until the cream has separated. After the milk has stood for one or two hours an approximately 10 per cent, cream, or about 100 cc. per litre of milk, may be obtained by careful skimming.
This cream forms the basis for Biedert's "natural cream mixture. " For its graduation to the age of the child, he has evolved a scheme which need not be given here because it is not commonly used for feeding healthy infants. It seems more practical, without reference to any particular schedule, to add to the diluted milk and milk-sugar mixture, such quantities of fresh cream as are necessary to increase its food value to the desired degree, as may be borne by the infant without gastro-intestinal disturbance. Additions of cream exceeding a total 3 per cent, of fat in the whole mixture are hardly ever beneficial to the infant.
The ordinary proprietary preparations present absolutely no advantage, either theoretically or in their practical results in the feeding of the healthy infant, over the milk and milk-sugar dilution mixed with fresh cream. That they receive high recommendations and are frequently prescribed by mid- wives and physicians is due to the facts that they are sold with directions on the container and that no special knowledge of pediatrics is necessary in dispensing them. The thoughtful and conscientious physician robs himself in their use of the opportunity of changing the value of the food by varying its individual components. And this is a necessary opportunity, because the mere fact that the coarse chemical composition of such manufactured
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food is roughly similar to human milk does not make it at all the equal of breast-milk in value. It is useful only with those children who would do equally well upon a simple milk dilution sweetened with sugar. In many other children, the high fat and sugar content, which is borne without the least difficulty in the form of human milk, causes, with these preparations, diarrhoea and vomiting and permits only slight increases in weight which are not improved by increasing the quantity of the food.
Recently Czerny and Kleinschmidt have put forth a very valuable method of utilizing butter fat in infant feeding by their method of pre- paring the "Butter Flour" mixture. By this method it is possible to feed large amounts of fat to very young and poorly nourished infants and those which are difficult to feed by other methods. It may be continued for long periods and the gain of weight and general development is comparable to that of the breast-fed infant.
The food consists of a basic diluent prepared as follows: Seven grams butter are melted over a slow fire allowing it to fry until all the volatile oils and free fatty acid is evaporated. Then seven grams wheat flour is stirred in, allowing the mixture to brown a little. To this mixture is added 100 c.cs. boiling water in which five grams granulated sugar has been dissolved. This is brought to a boil, strained to remove any lumps and cooled.
A. Graeme Mitchell recommends the following practical formula: Butter 2 level tablespoonfuls, flour 2l/2 level tablespoonfuls, sugar 1^ tablespoonfuls and water 10 ounces. The proportion of this mixture is constant and equals 26.6 calories per ounce.
For children of less than 3000 grams body-weight, one-third milk isadded and for larger infants ^5 to }/£ milk. The milk should be certified grade or Pasteurized. The butter is sterilized by the heating. The authors advised 200 c.c. per kilo body- weight per day.
Various sorts of sugar and flour in the form of gruel, may be used to increase the food value of diluted cow's milk and, in particular, to enlarge its carbohydrate content. Of the former, sugar of milk has been repeatedly mentioned. Soxhlet, Heubner and Hofman have recommended its use in such quantities that the food value of the milk, lost by dilution will be restored. To do this, it is found necessary to use concentrated solutions of sugar which decidedly exceed the physiologic sugar content of human milk (6-7 per cent.)9 It is doubtless possible to feed many healthy infants successfully with mixtures containing so large percentages of sugar of milk, but it must be emphatically said that many infants will not tolerate it and that it will not produce satisfactory increase of weight. For this reason, it seems advisable to limit its addition so that the entire mixture shall not contain more than 6 per cent, inclusive of the 4 per cent, of milk-sugar con- tained in the cow 's milk itself and to make up any deficit, if necessary, by concentrating the milk or by adding flour.
Cane-sugar, because of its sweetening power, has played an important role in the artificial feeding of infants, even before the science of pediatrics
9 Milk-sugar is the only sugar that may be used in such quantities without making the solution nauseatingly sweet.
CARE AND FEEDING OF THE NORMAL INFANT 61
was established upon a scientific basis. In young infants it is better to avoid it and to substitute milk-sugar because of the readiness with which cane-sugar ferments; but in older children, if it fall short of such concen- tration as to make the food sickeningly sweet, it is often well tolerated.
Malt sugar (maltose) is used in the form of the various malt extracts which also contain dextrin, nitrogenous constituents, water, etc., but it is not commonly given to the healthy child. In the feeding therapy of sick infants, it plays an important part.
The gruels, representing the insoluble carbohydrates (polysaccharides) may be used even for very young infants. These gruels are prepared by long continued boiling (3/^-1 hour) of either oatmeal, rolled oats, rice, cracked or crushed barley, etc. The quantity of each of these cereals required for preparing a suitable gruel cannot be definitely stated because of the vari- ability of the manufactured products. A thin gruel should remain liquid when cooled, while a thick gruel should gelatinize. The various gruels do not in themselves present any essential differences in their use for infant feeding. They are distinguished from the flours in that the former do not consist so largely of starch, but contain, also, a variable but greater quantity of vegetable protein. The amount of solids contained is low, especially in thin gruels, and consequently their food value is small.
Of the flours, we must consider oatmeal, which is distinguished for its content of over 5 per cent, of fat, wheat flour and corn flour. Even though a large amount of undissolved residue always remains in the preparation of gruels, which should be separated by pouring off the supernatant fluid or by straining the gruel, the mixture after boiling for 10 to 20 minutes, contains exactly the same amount of food material in solution or rather in a col- loidal state, as was added in the beginning. The food value of these gruels is therefore, high. Corn flour considerably exceeds the other cereals in its solubility, so that a 2 per cent, gruel of corn flour equals a 5 per cent, gruel of wheat or oat flour in its consistency.
According to the experimental researches of Klotz, the various flours show important differences in their intestinal digestion as well as in their intermediate metabolism. It would appear that these differences do not permit the several flours to be used interchangeably in artificial feeding; but as yet no definite clinical observations are at hand. Nevertheless, a change from wheat to oat flour, or vice versa, if the child is not doing well may be justified. All flours have an extremely low content of mineral matter, so that the addition of a small amount of table salt (.3-. 5 per cent.) to all gruels is necessary.
In the practice of artificial feeding, it is well to avoid the addition of flour to the food of the new-born or of infants in the first two or three months. I feed cereal waters at the end of the first month and believe they are well digested and beneficial. The gruels are