COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64079244 R J45 K45 1 91 8 The practice oi pedi 9^ ^^ in tfje Citj) of i^ehj i^orfe \ «^ ^ ^ ; ^cl^ool of ©cntal anb 0xdi\ ^urgcrp -O^v^ V l^eference 2.itjrarp L^' '3^ THE PRACTICE OF PEDIATRICS BY CHARLES GILMORE KERLEY Professor of Diseases of Children in the New York Polyclinic Medical School and Hospital; Attending Physician to the New York Nursery and Child's Hos- pital; Consulting Physician to the Babies' Hospital; Consulting Physician to the Sevilla Home for Girls and to the New York Home for Des- titute and Crippled Children; Consulting Pediatrist to the Green- wich (Conn.) Hospital, to the Tarrytown (N. Y.) Hospital, to the Englewood (N. J.) Hospital, and to the Lawrence (Bronxville) Hospital; Ex-President American Pediatric Society; Ex-President New York County Medical Society SECOND EDITION. REVISED AND RESET PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1918 Copyright, 1914, by W. B. Saunders Company. Reprinted July, 1914, February, 1915, and October, 1915. Revised, entirely reset, reprinted, and recopyrighted January, 1918 Copyright, 1918, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA K TO MY PRACTITIONER STUDENTS PAST AND PRESENT iSfEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL, AT WHOSE SUGGESTION THIS WORK HAS BEEN PREPARED Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/practiceofpediat1920kerl PREFACE TO THE SECOND EDITION The progress made in Pediatrics since the previous edition in 1914 has necessitated many changes in this volume. Twenty-five new articles have been added, sixteen chapters largely re-written and lesser changes made in many others. A great deal of old material has been removed and in its place has been substituted that which it is hoped will be of more service to the practitioner and student. C. G. K. New York City, January, 1918. 11 CONTENTS Page The Newly Born 17 Nutrition and Growth, 17— Maternal Nursing, 21 — Human Milk, 31 — - Wet-nurse, 33 — The Breast, 34 — The Nursery, 36 — The Nursery-maid, 38 — Weight, 38 — Height, 41— The Care of the Stump of the Umbilical Cord, 41 — Mental and Physical Development in the Infant, 42 — Baskets for Early Exercises, 44 — Crying, 44 — Sleep, 45 — Stools, 46 — The Nursing- bottle and Nipple, 47 — Substitute Breast-feeding; Artificial Feeding, 48— Cow's Milk, 49— Modified Milk, 54— Cereal Gruels; Starch-feed- ing, 66 — Peptonized Milk, 68 — ^Milk for Traveling, 69 — Food Formulas, 70 — The Proprietary Foods, 71 — Cream, 73 — Sterilization and Pasteuri- zation of Milk, 74 — The Effect of Heating Milk upon its Assimilation, 77 — Scientific Infant-feeding, 78 — Habitual Loss of Appetite, 79 — Sub- stitutes for Stomach-feeding, 81 — Disorders of Nutrition, 86 — Marasmus (Arthrepsia; Infantile Atrophy), 86 — Malnutrition in Infants, 92 — The Ammoniacal Diaper, 100 — Tardy Malnutrition and Malnutrition in Older Children, 100— Feeding after the First Year, 102 — General Proper- ties of Foods, 102 — Diet from the First to the Sixth Year, 105 — Diet after the Sixth Year, 108 — Diet during Illness, 109 — Common Errors in Feeding, 110 — Scurvy (Scorbutus), 111 — Rachitis (Rickets), 115 — The Delicate Child, 122. Examination and Diagnosis — Care of Acute Illness 130 Diagnosis, 130 — First Examination, 132— Essentials in the Care of Acute Illness, 133 — The Sick-room, 137 — Necessity of Method in the Management of Children, 138 — Treatment of the Individual, 139. Diseases of the New-born 140 Premature and Congenitally Weak Infants, 140 — Cephalhematoma, 142 — Icterus, 143 — Sclerema, 145 — Sepsis, 146 — Asphyxia, 148 — Delayed Asphyxia, 152 — -Atelectasis, 152 — Amyotonia Congenita (Oppenheim's Disease), 153 — Congenital Absence of Bile-ducts, 153 — Umbilical Gran- uloma, 154— Umbilical Polyp, 154 — Mastitis, 155 — Tetanus, 156 — Hem- orrhagic Diseases, 157. Diseases of the Mouth and Esophagus 162 Sprue (Thrush; Mycotic Stomatitis), 162 — Stomatitis, 163 — Cancrum Oris (Noma), 166 — Fissure of Lips, 167 — Geographic Tongue, 167 — Ulcerations and Fissures at the Angle of the Mouth, 168 — Harelip and Cleft-palate, 168— The Teeth, 169— Malformation of the Esophagus, 171. Diseases of the Stomach, Intestines, and Peritoneum 172 The Stomach, 172 — Acute Gastritis and Acute Gastric Indigestion, 173 — Chronic Gastric Indigestion (Chronic Gastritis), 175 — Chronic Dilatation of the Stomach, 176 — Ptoses and Dilatation of Stomach in Older Children, 177 — Hemorrhage from the Stomach; Vomiting Blood, 182 — Ulceration of Stomach, 183 — Duodenal Ulcer, 184 — The Management of Vomiting Babies, 185 — Pyloric Stenosis, 185 — Acute Gastro-enteric Intoxication, 193 — Gastro-enteric Intoxication, 194 — Acute Enteric Intoxication, 201 — Acute Intestinal Indigestion, 204 — Persistent Intestinal Indigestion, 205 — Persistent Intestinal Indigestion in Older Children, 206 — j\Icchan- ical Agencies as Cause of Digestive Disturbances, 208 — Colic, 214 — Pre- A'-ention of the Acute Intestinal Diseases of Summer, 216 — Vomiting, 219— Rumination, 220— Acute Ileocolitis (Dysentery), 220 — Chronic Ileocolitis, 227 — Mucous Colitis, 229 — Hirschsprung's Disease (Idio- pathic Dilatation of the Colon), 230— Intestinal Infantilism of Herter, 231 — Incontinence of Feces, 232 — Intussusception, 233 — Constipation, 236 — Intestinal Obstruction, 244 — Intestinal Cysts or Diverticula (Con- genital), 246 — The Intestinal Parasites, 247 — Appendicitis, 252 — Chronic Appendicitis, 255 — Acute General Peritonitis, 256 — Peritonitis as a Complication, 256. 13 14 CONTENTS Page The Rectum and Anus 258 The Rectum in Children, 258 — Prolapse of the Anus and Rectum, 258^ Inflammation of the Anus, 260 — Fissure of the Anus, 260 — Proctitis, 261 — Ischiorectal Abscess, 262. The Spleen and the Liver 263 The Spleen, 263— Splenomegaly, 263— The Liver, 263— Icterus (Obstruc- tive Jaundice; Catarrhal Jaundice), 265. Diseases of the Respiratory Tract 267 The Nose and Throat, 267 — Acute Rhinitis (Coryza; Snuffles; Cold in the Head), 267 — Chronic Rhinitis (Nasal Catarrh),, 269— Nasal Hemorrhage, 271 — Throat Examination, 271 — Persistent Cough, 272 — Faucitis, 273 — Pharyngitis, 274 — Retropharyngeal Adenitis, 275— Acute Retrophaiyn- geal Abscess, 275 — Retropharyngeal Abscess — Tuberculous Caries of the Cervical Vertebraj, 278— Irrigation of the Throat, 278— The Tonsils, 279 — Tonsillitis — Acute Follicular Tonsillitis, 280 — Peritonsillar Abscess (Quinsy), 283 — Vincent's Angina, 285 — Septic Sore Throat (Milk Borne), 286 — Acute Catarrhal Laryngitis (Spasmodic Croup), 287 — Traumatic Laryngitis, 291 — ^Laryngeal Obstruction, 292 — Foreign Bodies in the Larvnx, 292 — Adenoids, 293 — Hypertrophied and Permanently Diseased Tonsils, 297— Pollinosis, Pollen Disease, Hay Fever, 301 — The Lungs, 302 — Examination of Lungs, 302 — ^Bronchitis, 310 — Recurrent Bronchitis, 314 — Acute Spasmodic Bronchitis (Bronchial Asthma), 316 — Pneu- monia, 320 — Lobar Pneumonia, 320 — Bronchopneumonia (Catarrhal Pneumonia), 332 — Interstitial Pneumonia, Including Bronchiectasis, 342 — Hypostatic Pneumonia, 345 — Pneumothorax, 345— Emphysema, 346 — Subcutaneous Emphysema (Emphysema of Mediastinum), 347 — Primary Pleurisy, 348 — Secondary Pleurisy, 348 — Empyema (Pleurisy with Puru- lent Effusion), 351 — Pulmonary Gangrene, 360 — Pulmonary Abscess, 360 — Pulmonary Tuberculosis, 361 — Heliotherapy, 366. Diseases of the Heart 368 Diagnosis in Diseases of the Heart, 368 — Heart Murmurs, 370 — Peri- carditis, 374 — Acute Endocarditis, 377 — Myocarditis, 383 — Congenital Heart Disease, 386 — Acute Endocarditis, 378 — Chronic Valvular Disease of the Heart, 389 — Adherent Pericardium, 393. The Blood and Blood Diseases 394 Blood in the Newly Born, 394 — Blood in Infancy or Childhood, 394 — ^The Blood in Different Diseases, 397 — Blood-pressure in Children, 401 — Coagulation Time, 402 — Anemia, 402 — Chlorosis, 405 — Pseudoleukemic Anemia of von Jaksch, 406 — ^Leukemia, 407 — Pernicious Anemia, 408 — Purpura, 409, Hemophilia (Bleeder's Disease), 411 — Hodgkin's Disease (Lymphadenoma), 413. The Glandular System 415 Diseases of the Lymphatic Glands, 415 — Acute Cervical Adenitis, 415 — Persistent Simple Adenitis, 418 — Glandular Fever, 419 — Tuberculous Adenitis, 420— Mastitis in Young Girls, 422— The Thymus Gland, 423— Status Lymphaticus, 424 — Dyspituitarism. Dystrophy Adiposogenitalis (Frohlich), 428. The Urogenital System 429 The Urine, 429 — Difficult and Painful Urination, 430 — Retention and Suppression of Urine, 430 — Incontinence of Urine (Enuresis), 432; — Hematuria (Blood in the Urine), 436— Hemoglobinuria, 436 — Pyuria, 436 — Glycosuria, 437 — The Kidneys, 438 — Tuberculosis of the Kidney, 438 — New Growths of the Kidney, 438 — Hydronephrosis and Pyonephro- sis, 439 — Cysts of the Kidney, 441 — Acute Parenchymatous Nephritis (Acute Diffuse Nephritis), 441 — Chronic Diffuse Nephritis, 449— Chronic Interstitial Nephritis, 452 — Orthostatic All^uminuria, 452 — Pyelocystitis CPyolitis), 453 — Precocious Menstruation and Precocious Maturity, 456 — the Bladder, 457 — Cystitis, 457— Vesical Calculus (Stone in the Bladder), 458— Exstrophy of the Bladder, 458— The Male Genitals, 459— Balanitis, 459 — Phimosis," 460 — Paraphimosis, 461 — Circumcision, 461 — Unde- scended Testicle, 462 — Orchitis, 462 — Hydrocele, 463 — Gonorrhea in the Male, 464 — Epispadias anrl Hypospadias, 464 — The Female Genitals, 465 — Vidvovaginitis (Simple), 465 — Gonorrheal Vulvovaginitis (Specific Vaginitis), 466 — Atresia of the Urethra and Vagina, 469. CONTENTS 15 Page Nervous Disorders. . . ; 470 Headache, 470 — Pavor Diurnus, 470 — Night-terrors (Pavor Nocturnus), 471 — Gyrospasm (Spasmus Nutans), 472 — Hysteria, 472 — Habits, 477 — Masturbation, 479 — Hiccup, 483 — Infantile Convulsions, 483 — Laryngis- mus Stridulus, 487 — Spasmophilia, 489 — Congenital Stridor, 491 — Tetany, 491 — Insanity, 497 — Malformations of the Brain and Cord, 499 — Type and Incidence of Brain Tumor, 502 — Mentally Deficient Children (Imbe- cility; Idiocy), 503 — Mongolian Idiocy, 503 — Amaurotic Family Idiocy, 507 — Hydrocephalus, 509 — Cerebral Palsies — The Prenatal and Birth Forms, 513 — The Acquired Form, 515 — Chorea (St. Vitus' Dance), 518 — Habit Spasm (Tic), 524 — Stammering, 525 — The Progressive Muscular Atrophies, 526 — Progressive Spinal Muscular Atrophy or Progressive Amyotrophy, 526 — The Progressive Amyotrophies (Primary Muscular Dystrophies), 530 — Epilepsy, 531 — Acute Poliomvelitis (Infantile Paraly- sis), 535— Multiple Neuritis, 542— Facial_ Palsy, 546— Erb's Palsy (Obstetric Paralysis), 547 — Friedreich's Ataxia (Hereditary Ataxia), 548 — Acute Infective Meningitis, 550 — Tuberculous Meningitis, 553 — Cerebro- spinal Meningitis, 557 — Meningismus (Serous Meningitis), 565 — Lumbar Puncture, 566. Diseases of the Skin 568 Miliaria (Prickly Heat), 569 — Urticaria (Hives; Nettle-rash), 570 — Rhus Poisoning (Ivy Poisoning), 571 — Scabies (Itch), 572- — Furunculosis (Boils), 573 — Pediculi (Head Lice), 514 — Tinea Circinata (Ring-worm), 575 — -Tinea Tonsurans (Ring-worm of the Scalp), 576 — Impetigo Contag- iosa, 579 — Pemphigus Neonatorum, 579 — Erythema Nodosum, 580 — Erythema Multiforme, 581 — Erysipelas, 581 — Eczema, 584 — Eczema ■ Intertrigo or Erythema Intertrigo, 590 — Eczema in Older Children, 591 — Seborrhea, 595 — Psoriasis, 597— Bed-sores (Decubitus), 597 — Nevus Birthmark), 598. Diseases of the Ear 600 Earache, 600 — Deafness, 600 — Acute Otitis, 601 — Chronic Suppui-ative Otitis, 605— Mastoiditis, 606— Sinus Thrombosis, 606. The Transmissible Diseases 608 Care to be Exercised by Physician in Visiting Infectious and Contagious Diseases, 609 — -Varicella (Chicken-pox), 609 — Mumps (Epidemic or Spe- cific Parotitis), 611 — Whooping-cough (Pertussis), 614 — Measles, 619 — German Measles (Rotheln; Rubella), 624 — Diphtheria, 625 — Scarlet Fever (Scarlatina), 643 — Typhoid Fever, 657 — Malaria, 666 — Influenza, 670 — Syphilis, 677 — Acute Hereditary or Congenital Syphilis, 678 — Ac- quired Syphilis, 685 — Tardy Hereditary Syphilis, 685 — Tuberculosis, 691 — ^ Abdominal Tuberculosis (Tuberculosis of the Mesenteric Gland; Tabes Mesenterica), 694 — Chronic Tuberculous Peritonitis, 695 — Dac- tylitis, 699— The Newer Diagnostic Methods, 701— Tuberculosis, 701 — Tuberculin Skin Reactions, 703 — Wassermann Test for Syphilis, 70-4 — Noguchi Butyric-acid Test for Syphilis, 705— Luetin Test, 706— The Widal Reaction for Typhoid Fever, 707 — Anaphylaxis, 708. Unclassified Diseases 709 Rheumatism, 709 — Acidosis, 713 — Cyclic Vomiting (Recurrent or Peri- odic Vomiting), 715 — Cyclic Diarrhea, 719 — Periodic Fever, 720 — Rheu- matic Fever (Acute Rheumatism), 721 — Rheumatoid Arthritis; Arthritis Deformans; Still's Disease, 724 — Chondrodystrophia (Achondroplasia), 725 — Cretinism (Infantile Myxedema; Cretinoid Idiocy), 727 — Dwarfs, 733 — ^Diabetes Insipidus, 734 — Diabetes Mellitus, 735 — Acetonuria in Children, 737— Pellagra, 738— Beriberi, 740. Miscellaneous Subjects 743 Heredity and Environment, 743 — Consanguinity, 744 — Temperature in Children, 744 — Obscure Elevations of Temperature, 747 — Anesthetics, 750 — Carcinoma, 751 — Obesity, 752 — Hematoma of the Sternocleidomas- toid, 752 — Hernia at the Umbilicus, 753 — Hernia of the Umbilical Cord, 753 — Congenital Umbilical Plernia, 754 — Inguinal Hernia, 755 — Ventral Hernia, 756 — Diagnosis in Bone and Joint Diseases, 757. Suggestions in Management 760 Vaccination, 760— Days to go Out-of- Doors ; Indoor Airing, 762 — Instruc- tions for the Summer, 763 — The Exercise Pen, 767 — Summer Resorts, 768- Foreign Bodies Swallowed, 768. 16 CONTENTS Page Therapeutic Measures \ , 771 Therapeutics in Children, 771 — The Therapeutic Value of Climate, 773 — Counterirritants, 775 — Cold Sponging in Fever, 776 — The Cool Pack, 777 — :Baths, 778 — Bathing the Sick, 781 — Unpalatable and Nauseating Drugs, 781-^ Alcohol, 783 — Heat as a Therapeutic Agent, 78^ — Cold as a Therapeutic Agent, 785 — Blood Transfusion and Intramuscular Injection, 786 — ^Lavage — Stomach-washing, 788 — Gavage, 790 — Colon Irrigation, 793 — Colon - Flushing, 795 — Hypodermoclysis, 796 — Vaccine Therapy, 797. Gymnastic Therapeutics 803 Rules, 803— Posture and Breathing, 806— Breathing, 812— Flat Chest, 815 — Kyphosis, 817 — Scoliosis, 820 — Empyema, 825 — Emphysema, 827— Congenital Ataxias, 829 — Anterior Poliomyelitis, 841 — ^Constipation, 843— Flat-foot, 844. Drugs and Drug Dosage 847 Drugs for Internal Use, 847 — Drugs for External Use, 859. Index 865 THE PRACTICE OF PEDIATRICS I. THE NEWLY BORN— NUTRITION— GROWTH Nutrition and Growth The fundamental principles in the life of the young of all animals are growth and development. This statement applies to the young of the lower animals as well as to man. Nature has fixed and definite laws in accordance with which this growth and development proceed. The type of animal produced depends in no small degree upon the way in which- we comply with nature's laws. Heredity. — Heredity is, of course, an important factor, but environ- ment counts for more. The young of the lower animals or of man may possess all that can be desired in the way of heredity, but if manage- ment during growth is faulty, the adult is almost certain to fall short of the normal. On the other hand, an individual without the benefits of good heredity, when given the advantages of faithful scientific care may develop into an adult decidedly superior in all respects to those more fortunate in birth. I have seen this demonstrated repeatedly, both in the lower animals and in man. Environment. — From my earliest recollection I have carefully watched the growth and development of animals. By observing care as to feeding, housing, ventilation, cleanliness, and exercise, I have seen animals which promised but little at birth develop into perfect mature specimens of their kind. During the past twenty-eight years I have been intimately associated with thousands of infants and growing children in private, in hospital, and in out-patient work. The possi- bilities of proper growth under good management when little was to be expected, judging from the original condition of the patient, have been impressed upon me repeatedly. The child is here through no choice of his own. He is to have a future. His health, vigor, powers of resistance, happiness, and useful- ness as a citizen are determined in no small degree by the nature of his care during the first fifteen years of life. He has a right to demand that such care be given him as will be conducive at least to a sound, well- developed body, and this should be our first thought and object regard- ing him. Consider for a moment the number of occupations, other than those of the army and the navy, which require physical fitness before a candidate is accepted. Competition is keen at the present time and will be keener in the future. Employers of men and women, whether in the office, the factory, or on the farm, cannot afford to employ the physically weak. 2 17 18 THE PRACTICE OF PEDIATRICS The most important factor in the making of men and women is nutrition. No great power of reasoning is required to appreciate the fact that the child who is fed on suitable food will become a more vigor- ous, better developed adult than one who, beginning with his birth and continuing throughout the entire period of his growth, is given only- food possessing indifferent qualities for tissue building. Next in im- portance to food, and following in close succession, are fresh air, clean- liness, cheerful surroundings, and healthful amusements, together with an absence of school work or service of an arduous nature. That the offspring of man suffers more from nutritional errors due to the lack of suitable care than do the young of the lower animals is lamentable, but nevertheless a fact. The absence of thought and care and of knowledge relating to children is due to the fact that the child as such has apparently no intrinsic value in dollars and cents, whereas the young of the lower animals represent no small part of their owner's material possessions. Feeding. — Success in the entire management of children demands daily attention to detail. Feeding the child properly one or two months out of the year is of little value. He should be fed properly every day in the year, for under normal conditions every day is a day of growth. Another factor having a deterrent influence upon the devel- opment of children is their unfavorable start during the first year. Unfortunately many mothers cannot supply to the infant the requisite nourishment. This brings us to the matter of substitute feeding, fraught with perplexities and uncertainties in the most competent hands, and with dangers and disasters in the hands of the incompetent and inefficient. In the chapter on Substitute Feeding in infants their nutrition is considered in detail. It is sufficient to remark here that nature has provided for the baby a food which contains the nutritional elements, fat, sugar, and proteid, in fairly definite proportions and in peculiar forms. Success in substitute feeding depends upon our ability to supply in suitable forms, and the child's ability to assimilate, a food containing the nutritive elements in approximately the quantities found in human milk. An exact reproduction of mother's milk by the use of cow's milk or other food is, of course, impossible. We can imitate human milk, however, with sufficient accuracy to make accept- able and sufficient food for most children who are deprived of the breast. After the nursing or the bottle age, the feeding must not be left to the family judgment, for at this period of rapid growth suitable nutrition is most important. Left to the family, the diet during the second year too frequently consists of milk, which in large cities is often of uncer- tain nutritive value, together with insufficiently cooked cereals, boxed breakfast foods, bread-stuffs, crackers, and cake — often procured at the grocer's or baker's. At the out-patient departments of the New York Babies' Hospital and the New York Polyclinic Medical School, only 20 per cent, of the children treated who are over one year of age are of normal development. In those under one year of age, only 35 per cent, are normal. While these children are not to be considered as NUTRITION AND GROWTH 19 representing the country as a whole, still they do represent a large part of the population of our larger cities. These children are the offspring of day-laborers, drivers, waiters, and small-wage earners generally. Such children were fed in the manner above described, not because of poverty, but because of an absence of the slightest knowledge on the part of the parents regarding suitability of foods. The children were not hungry; they were fed to satisfy the appetite; but when that was accomplished the parents considered their duty done. To feed with a definite purpose — with a view solely to the physical development of their children — had never entered the minds of the parents, yet most of them could read and write and possessed a fair degree of general intelli- gence. They were conversant with affairs and had attended the public schools, but were absolutely untaught as to how they should live. Selection and Preparation of Food. — The diet during this period of early childhood should be highly nutritious, and, in order to be properly digested, food should be given at definite intervals. It should be well cooked and properly seasoned. The habit of allowing children to eat between meals cannot be too strongly condemned. It not only spoils the appetite for suitable food at regular hours, causing children to crave delicacies, but prevents complete digestion and assimilation. The active "runabout" child and the school-child require a high proteid diet. This should consist of red meat, never oftener than once daily, poultry, fish, eggs, milk, butter, cream, whole-wheat bread and cereals, such as oatmeal, cracked wheat, cornmeal, and hominy. For the sake of variety other cereals may be used. Each cereal mentioned should be cooked three hours the day before using. It may be claimed that the prolonged cooking is impossible to secure. It is done, however, in dozens of families under my professional care. Green vegetables and stewed and raw fruits are important adjuncts to the dietary. Dried peas, beans, and lentils in the form of a puree are valuable articles of nutrition because of their large percentage of vegetable proteid, and they are particularly useful in children with a rheumatic tendency, for whom the use of red meat must be curtailed. Fresh Air — Doubtless the next most important factor after food and the means of giving it is good au'. It is a just criticism of the average American that he is afraid of fresh air, not only by night but by day. Ventilation is one of the most difficult features of a child's management with which I have had to deal. Mothers will feed the children in detail according to instruction. They will bathe them and follow out to my satisfaction every order and direction. The stumb- ling-block is the open window. If the mother opens it as du'ected, the grandmother or some other member of the family appears on the scene and closes it. The window-board (p. 138) and other means of ventilation on the market have their uses. The window-board in my hands has been most satisfactory. It is to be hoped that a knowledge of the means and results of treating tuberculosis by open-air methods, and the recent agitation concerning the treatment of pneumonia and other infectious diseases along similar lines, may so permeate the minds 20 THE PRACTICE OF PEDIATRICS of the masses as to quiet their fears regarding dangers of outdoor air. In my own experience I have been able to secure an ample supply of fresh air either by the window-board, already referred to, or the open fireplace. While the child is out of the living-room or nursery, the room should be ventilated by opening all the windows, when family conditions allow, the nursery always being aired in this way. The sleeping-room should always be aired for one hour before the child is put to bed. Indoor airing for which the child is dressed as for going out, placed in his carriage or cart, and wheeled up and down the room for an hour or two with the windows wide open regardless of the weather, is most satisfactory in treating very young and delicate chil- dren, and promoting convalescence from illness. On inclement days the well child accustomed to his daily outing will be greatly benefited by the indoor airing. It is fully appreciated that such a course of management is impossible in many households. The scheme is the ideal one, however, and should be followed out as closely as possible. Bathing. — The necessity for the daily bath is appreciated and acted upon by nearly all classes of society. From the time the cord falls and the cicatrix forins, the well infant or child should have one tub- bath daily. If he is too ill for the tub, he is not too ill to be sponged. Work and Stress. — The well child is naturally good-natured and happy. When such is not the condition, we have not a well child to deal with. Something is wrong. Oftentimes it is the home manage- ment. Adults often forget that exuberance of spirits and thoughtless- ness belong to childhood. Persistent child-nagging becomes a habit with many parents and teachers ; in fact, irritable mothers usually have irritable children. Work involving strain, whether physical or mental, should form no part of the life of the child. In our modern school system the forcing process, the competitions, the giving of rewards of merit, are all pernicious practices. As a result of the competitive system, progress, to be sure, is made along intellectual lines, but at the expense of the physical; and what does intellectual attainment count for in a weakly or diseased body? A child cannot do hard mental work, such as is required of many children from the tenth to the fifteenth year, and be expected at the same time to develop to the best advantage physically. The appetite and digestive powers, the capacity for taking and assimilating food, are diminished. I have seen the result in hun- dreds of cases. On the streets in New York two pictures always fill me with pity. One is that of the pale, slender school-girl struggling home with a load of books. Such a child who came to me recently had 11 text-book studies besides piano and dancing lessons! When the question is asked the child or the parents as to the necessity for all this work and worry and the close confinement which it entails, the reply almost invariably is that all the girls of her age do the same and she does not want to be behind. The other picture is that of the " little mother" — a pale, wan, tired child from seven to twelve years of age who "minds the baby" and the other younger members of the house- MATERNAL NURSING 21 hold while their mother is away from home or at work. Children so abused are happily growing fewer, owing to various factors which need not be discussed. It is needless to say that neither type of girl makes the ideal woman or mother in any station in life. The condition of boys who work in factories, sweat-shops, or elsewhere is no better. When too much energy is expended in work, it cannot go to the build- ing of a strong, normal body. The State is the loser and the child is robbed of his birthright. It is the duty of physicians having children under their care to explain in detail to parents their responsibility as regards the physical welfare of their children. Parents, as a rule, are ignorant concerning a child's management; but they are anxious and willing to do the best things possible, and will carry out suggestions if we take the trouble to enlighten them as to their errors. MATERNAL NURSING Writers on this subject are very prone to state that the ability of the mother, particularly among the well-to-do, to fulfil this most important function is surely decreasing. This may have been a true statement fifteen or twenty years ago; at the present time, however, I am sure it is erroneous. In my own medical life I have seen a change for the better, particularly during the past fifteen years. The young mother of today is better able to nurse her offspring than was her sister fifteen or twenty years ago. I attribute this to the fact that the youth of the present day are more vigorous, more nearly normal individuals than were those of an earlier date. The inability to perform the nursing function so that it will be successful has always been attributed to the mother ipse. This, I think, is an error. A child born with a generally enfeebled vitality, keenly feels any slight abnormality in the milk, or may not be able to digest perfectly normal milk; in either event, the milk disagrees and the nursing is discontinued. Not every breast-milk for two or three weeks after parturition is ideal, as I have found by the examinations of hundreds of specimens. Breast-milk during the first two or three weeks of the infant's life is produced under unfavorable conditions which do not indicate the possibilities of the breast as a secreting organ. Early nursing following, as it does, upon the stress of confinement, is not indicative of what may be possible later when the customary life and daily habits are resumed. Repeatedly I have found a very high fat or a high proteid, or both, entirely corrected after the first week or two, without interference. This condition at the time was considered sufficiently serious to warrant the discontinuance of nursing on the part of a weakly infant, while in a vigorous infant it would be entirely ignored. The change which enables more mothers successfully to nurse their infants is due to two causes — more vigorous fathers and mothers and more vigorous offspring. The more normal the mother, the better able is she to perform this normal function. That this is the case is 22 THE PRACTICE OF PEDIATRICS due, I believe, to the fact that growing girls and young women are leading more hygienic lives than formerly. The making of golf, bicycle and horseback riding, boating, and automobiling popular and fashionable — in short, the taking of girls out-of-doors and keeping them there a considerable portion of the day — has worked a marvelous change for the better, both physically and mentally. A neurotic mother makes the poorest possible milk-producer. Proportionate to the population, there are fewer neurasthenics among the young women today than there were twenty years ago, and there will be still fewer twenty years hence. At the present time the timid, retiring young woman of the neurasthenic type is not popular in her set. It is for- tunate for the future of the human race, at least for that portion which resides in the United States, that the young woman has transferred her allegiance from the crochet and embroidery needle to out-of-door sports. It may be said that our argument holds only with the wealthy or the well-to-do. Imitation is one of the strongest characteristics of the human race, and this tendency in America to outdoor hygienic living pervades all classes. Saturday half-holidays, and the excursions and outings afforded by reduced rates in transportation, are much more popular than they were twenty years ago. Food is better selected and better prepared, owing to increased knowledge on the part of the people as to what constitutes proper nutrition. These are facts, in spite of the sensational novelists and magazine- writers. A feature which marks an important advance in the right direction is the establishment of a department in dietetics and food economics in the New York Training School for Teachers. The Dean, Dr. James E. Russell, in establishing this course is producing benefits which per- haps are more far-reaching than he realizes. The students are taught food values, food preparation, and food economics, the science of pro- viding for a given amount of money the most nutritious food in its most attractive form. Of the hundreds of teachers sent out from this insti- tution every year to take their places of usefulness as instructors of the young in all portions of the country, each has learned something of food values, and, better still, each has been impressed with the impor- tance, to a growing child, of proper nutrition, without which the best possible type of adult cannot be produced. As a result of such in- struction these teachers will be of far greater service in their fields of labor; for not only can they teach what is laid down in the books, but, what is equally if not more important, they are competent to teach those under their care so to live as to attain proper growth, following out the maxim of Herbert Spencer that " the first requisite for success in life is to be a good animal ; and to be a nation of good animals is the first condition of national prosperity." It may be thought that we have wandered far from our subject, — maternal nursing, — but such is not the case; for conditions which relate even remotely to this im- portant function demand our respectful consideration. The food and care of the growing girl have the most intimate bearing upon her future life, and if she is to be called upon to perform the most impor- MATERNAL NURSING 23 tant function of womanhood, she surely has the right to demand that she receive during her girlhood proper preparation, which heretofore has too often been denied her. The family physician does not, in a great majority of instances, fulfil his function, or extend his field of usefulness to its full capacity, his conception of duty too often including only the care of the sick. Un- sought advice concerning the feeding and daily habits of a child's life, I find is usually welcomed and appreciated by the parents. In practi- cally every instance, according to my observation, errors in a child's management are due to ignorance. Parents, no matter what their station in life, are glad to do what is for the best interests of their children when the situation is made clear to them. It is our duty to take parents into our confidence and explain to them the reasons for the line of action advised. When they appreciate the reason for certain procedures, I find that they are far more apt to follow them. I am confident, from observations upon many cases, that if I could have the physical direction of ten average girls in any station in life, provided that they could have the benefit of fresh air and good food from infancy to adolescence, successful nursing mothers could be made out of eight of them. Certain rules of life having a direct bearing on nursing lead us nearer the ideal and may enable one who otherwise could not nurse her child to do so successfully. These requirements, it will be seen, are laid along common sense lines and cause no hardship or mental distress, one of the chief requirements of a nursing woman being that she shall be mentally normal. Few functions with which we are called to deal are so variable and uncertain as the production of breast-milk. Breast-milk is one of the most precious substances. It is invaluable — unless we can put a value on human life. The most successful nursing age is between the twen- tieth and thirty-fifth years. I have, however, seen successful nursing carried on in a girl of fourteen, in a woman of fifty-two, and in the much abused society girl, while I have seen it fail absolutely in peasant women fresh from the fields of Hungary and Bohemia. I have seen those whose nursing at first was most unsatisfactory develop into per- fect nurses. Some mothers will be able to carry on the nursing for only two months; others, three, five, seven, or nine months. In my experience in both out-patient and in private practice it is extremely rare for the breast milk to be sufficient for a child after the ninth month. A most unusual record in nursing is that of an Italian woman who nursed uninterruptedly and successfully three infants of her prolific employer. The first two children were each nursed for one year, the third child for ten months. Even then the supply had not diminished, but nursing was discontinued because of illness of wet nurse. The following may be laid down as nursing axioms : A diet similar to that which the mother was accustomed to before the advent of motherhood should be taken. There should be one bowel evacuation daily. 24 THE PRACTICE OF PEDIATRICS From three to four hours daily should be spent in the open air in exercise which does not fatigue. At least eight hours out of every twenty-four should be given to sleep. There should be absolute regularity in nursing. There, should be no worry and no excitement. The mother should be temperate in all things. The Diet. — Many times, when consulted by nursing mothers be- cause the nursing was unsuccessful or a partial failure, I have found that their diet had been restricted to an extreme degree. To put on a greatly restricted diet a robust young mother who has always eaten bountifully of a generous variety of foods is one of the best means of curtailing the quantity and lowering the quality of her milk-supply. When asked to prescribe a diet I tell such mothers to eat as they were accustomed to before the advent of pregnancy and motherhood. That this particular vegetable or that particular fruit should be forbidden on general principles is a fallacy. Food that the patient can digest with- out inconvenience is a safe food so far as the nursing is concerned, as may readily be determined in any given case. For certain individuals, however, a plain, more or less restricted diet is desirable. This must be remembered in the management of the wet-nurse (p. 33). Many a wet-nurse who has been carefully selected, and who to the best of our judgment should prove satisfactory, utterly fails in a few days to fulfil the duties of the office for which she was chosen. In not a few in- stances the failure is due to a very full diet of unusual articles of food, the existence of which, in many instances, she never dreamed. Indi- gestion and constipation follow, both the nurse and the baby are made ill, and the woman's usefulness ceases. A woman who has lived and kept well on the diet and food found in the home of the laboring man, whether in the city or country, will make a far better wet-nurse on this diet than if she indulges in food to which she is entirely unaccustomed. In general, the diet of a nursing mother, then, should be that to which she has been accustomed. Nursing is a perfectly normal function, and a woman should be per- mitted to carry it out along only natural lines. Inasmuch as there are two lives to be provided for instead of one, more food, particularly of a liquid character, may be taken than the mother may have been accustomed to. It is my custom to advise that milk be given freely. A glass of milk may be taken in the middle of the afternoon and eight ounces of milk with eight ounces of oatmeal or cornmeal gruel at bed- time, if it does not disagree with the patient. Our only evidence that a food is not disagreeing is the condition of the digestion. When any article of food disagrees with the mother, or if she is convinced that it disagrees, whether or not such is really the case, the food should be dis- continued. In a general way, milk in quantities not over one quart daily, eggs, meat, fish, poultry, cereals, green vegetables, and stewed fruit constitute a basis for selection. The method of preparation for the different meals is not arbitrary. MATERNAL NURSING 25 The Bowel Function.^ — A very important and often neglected matter in relation to nm'sing is the condition of the bowels. There must be one free evacuation daily. For the treatment of constipation in nurs- ing women I have used different methods in many cases. The dietetic treatment does not promise much. For here, again, manipulation of the diet may interfere with the milk production. Three methods are open to use — massage, local measures, and drugs. Massage is available in comparatively few cases. Local measures consist in the' use of enemas or suppositories. Every nursing woman under my care is in- structed to use an enema at bedtime if no evacuation of the bowels has taken place during the previous twenty-four hours. Many out- patients, in whom constipation is very prevalent, indulge in excessive tea-drinking, often taking from one to two gallons of tea daily. In treating such patients where an absolute discontinuance of the tea- drinking is often impossible and not absolutely necessary, I usually allow two cups a day. For a laxative in such cases and in many others, a capsule of the following composition has served well : I^ Extract! belladonnse gr. Extracti nucis vomicae gr. Extract! cascarae sagradae gr. v M. et. ft. capsula No. i. Sig. — To be taken at bedtime. The amount of the cascara sagrada may be varied as the case may require. In not a few instances I have found it necessary to give two capsules a day in order to produce the desired result. Neither the belladonna, the nux vomica, nor the cascara appears to have any ap- preciable effect on the child. Air and Exercise. — Outdoor life and exercise are not only as desir- able here as they are under all other conditions, but to the nursing woman, with her added responsibility, they are doubly valuable. In order to get the best results, exercise or work should so be adjusted as not to reach the point of fatigue. The mother whose nights are dis- turbed should be given the benefit of a midday rest of an hour or two. She should have at least eight hours' sleep out of every twenty-four. Certain annoyances, anxieties, and worries are inseparable from the life of every child-bearing woman. It should be our duty, however, to explain to the mother and to other members of the family that an important element in satisfactory nursing is a tranquil mind. During the lactation period she should be spared all unnecessary care and petty annoyances. Regularity in Nursing. — The breast which is emptied at definite intervals invariably functionates better than does one which is not, not only as regards the quantity, but also the quality, of the milk; so that system in breast-feeding is almost as essential to milk-production as to its digestion and assimilation. After it is demonstrated that the nursing is progressing satisfac- torily, as proved by the satisfied, thriving child, I begin with one bottle- feeding daily. The advisability of this is obvious: in case of illness of 26 THE PRACTICE OF PEDIATRICS the mother, if she is called away from home, or if, for any reason, the child cannot have the breast, the feeding is provided for. Another advantage of this provision is that it gives the mother needed freedom from restraint. She is thus enabled to have the benefit of a change of scene. Amusements and recreations which the invariable nursing period denies her can be indulged in. As a result of this greater free- dom she is able to supply better milk and to continue nursing longer than if tied continually to the baby, no matter how fond of the infant she may be. Frequency of Nursing. — From birth until the third month seven nursings in twenty-four hours are allowed as follows: 6 a. m., 9 a. m., 12 M., 3 p. M., 6 p. M., 10 p. M., 2 A. M. From the third to the completion of the six month, six nursings as follows: 6 a. m., 9 a. m., 12 m., 3 p. m., 6 p. M., 10 p. M. After the sixth month, and in large strong children after the fifth month, five nursings in twenty-four hours, as follows: 6 A. M., 10 A. M., 2 p. M., 6 p. M., 10 p. M. Giving of Water. — From one-half to one ounce of a 1 per cent, solution of milk-sugar shpuld be given the infant every three hours until the milk appears in the breast. Otherwise there will be unneces- sary loss in weight and perhaps a high degree of fever due to inanition. If the child is restless and uncomfortable, it is safe to conclude that he is thirsty; one ounce of the sugar water will usually satisfy him. With the commencement of nursing, the baby should be accustomed to getting his food at regular intervals. Signs of Successful Nursing. — The normal infant shows a gain of not less than four ounces weekly. This is the minimum weekly gain which may safely be allowed. When a nursing baby remains station- ary in weight or makes a gain of but two or three ounces a week, it means that something is wrong, and the defect will usually, but not invariably, be found in the milk-supply. When the baby is nursed at proper intervals and the supply of milk is ample and of good quality, he is satisfied at the completion of the nursing. Under three months of age he falls asleep after ten or twenty minutes at the breast. When the nursing period again approaches, he becomes restless and unhappy, crying lustily if the nursing is delayed. When the breast is offered, he takes it greedily. The stools are yellow and number from two to three daily. The weekly gain in weight under such conditions is usually from six to eight ounces. Signs of Unsuccessful Nursing. — Theoretically, every normal breast infant should be a thriving, well baby. That such is not the case, is an unfortunate fact. The standard established for a well baby is not upheld. When the supply of milk is scanty the child remains long at the breast and cries when he is removed. He shows signs of hunger before the nursing hour arrives. A cause of failure in breast- feeding, and probably the most frequent cause, is a scanty milk-supply. The chief nutritional elements in mother's milk are fat, 3 to 4 per cent. ; sugar, 7 per cent. ; proteid, 1.5 per cent. Failure may be due to a marked disproportion of these elements, which may cause sufficient indi- MATERNAL NURSING '■ ^7 gestion and resulting loss in weight to necessitate a discontinuance of nursing. Thus there may be a high fat — from 5 to 6 per cent. ; or very- low fat — from 1 to 1.5 per cent. In the high-fat cases there is usually diarrhea with green, watery stools. The child strains a great deal and there are green stains on many of the napkins. In high-fat cases there is also regurgitation or vomiting of sour material. The fat-globules may readily be made out if the vomited material is placed under a low- power microscope. Low fat means deficient nourishment and may cause constipation. Sugar is rarely a cause of trouble in nursing babies. It seldom varies, ranging from 5 to 7 per cent, in the great majority of breast- milks. Young children, further, have a marked toleration for sugar. Protein constitutes one of the most important constituents of mother's milk. Like the fat, the proteid may be so decreased that nutritional disorder may be induced in the patient, or it may be very much increased, the latter condition being usually the cause of colic or constipation in otherwise healthy nursing infants. The milk may contain the normal percentage of fat, sugar, and proteid, but be scanty in amount. Instead of the four or five ounces to which the child is entitled, he may get but one or two ounces. Whether or not the quantity is sufficient, may be determined by weighing the baby before and after each nursing for twenty-four hours. One ounce of breast-milk weighs practically one ounce avoirdupois. The quality or strength is determined by an examination of the milk itself (p. 32). The quantity is determined by noting the weight of the child, wearing the same clothing, before and after nursing. By nursing for fifteen minutes, a child under four v/eeks of age should gain from 2 to 3 ounces ; four to eight weeks of age, 3 to 4 ounces; eight to sixteen weeks of age, 4 to 5 ounces ; sixteen to twenty-four weeks of age, 5 to 6 ounces ; six to nine months of age, 6 to 8 ounces ; nine to twelve months of age, 8 to 9 ounces. Of course, arbitrary limits cannot be fixed as to the quantity. Stationary weight or loss in weight, with a dissatisfied child, usually means defects in quantity of milk, which are readily proved by the weighing. To be fed at the breast may also cause the child to suffer from an excess of good milk, in which event there will be vomiting or regurgitation, usually associated with colic. When this overfeeding continues, dilatation of the stomach develops, vomiting becomes habit- ual, the child loses in weight, the breast-milk is said not to agree, and often, unfortunately, the baby is weaned. This has been the outcome in scores of cases. When there is habitual vomiting and colic in a nursing baby, two things are to be done — the baby must be weighed before and after nursing, and the milk must be examined. I have repeatedly treated children for indigestion who were entirely relieved by shortening the nursing period. Weighing the baby at intervals of from three to five minutes and noting the gain has shown that the three or four ounces which may represent the child's stomach capacity were obtained in two, three, or five minutes, the excess which the child took over this amount being the cause of his trouble. From a free, full breast a vigorous nurser will take one ounce in one minute. 28 THE PRACTICE OF PEDIATRICS When the nursing "gait" is estabhshed, a child should be kept up to the schedule. There are few more pernicious teachings than that a baby should be allowed to nurse when he wants to and as long as he wants to. The idea that a nursing infant will take no more than is good for him is the fruit of inexperience. Recently a mother consulted me in regard to giving her one-month-old baby the bottle, as he had many green stools, cried a great part of his waking hours, and weighed but a few ounces more than at birth. Her milk was supposed to be "too strong" for the child. An examination of the breast and a talk with the mother satisfied me that the breast-milk was not at fault. An examination of the milk proved it to be good average milk, con- taining 3.5 per cent, fat, 6 per cent, sugar, 1.45 per cent, proteid. A one day's test by weighing was instituted. The infant was allowed to nurse one minute and rest one minute. During the resting period he was weighed. In this way, it was found that in three minutes he got from 3 to 33-^ ounces of milk. The nursing was then reduced to three minutes on one breast and five minutes on the other, which was the "slower" breast. Thereupon every sign of indigestion promptly disappeared, the stools became normal, and the infant made a satis- factory gain in weight of one ounce daily. The quantity may be suitable for the age, the child may not vomit or show a sign of indigestion, and yet may not thrive. In such a case an examination or repeated examinations of the milk at intervals of two or three days will usually show that it is poor, below the normal perhaps in both fat and proteid. Signs of Insufficient Nursing. — The baby remains long at the breast, perhaps one-half to three-quarters of an hour. When removed, he is restless and uncomfortable. After a short time, in an hour or less, he is very hungry and demands frequent nursings day and night. Management of Abnormal Milk Conditions.^ — When it is found that the breast-milk is too strong or too weak, or when the normal ratios of fat, sugar, and proteid are not maintained, it may be possible to increase or diminish the milk strength. When desirable, it may also be possible to increase either the fat or the proteid. The heavy milk will usually be found in mothers who are robust, who eat heartily, and who take but little exercise. In such a case, the prescribing of a plain diet, allowing red meat but once a day, discontinuing the malt liquors or wine, — which it will often be found that the mother is taking, — and directing that she walk a mile or two a day, will frequently bring the milk to digestible proportions. In some cases, however, this will not be successful, and the colic, constipation, and vomiting may continue, even though the quantity obtained at each nursing is within normal limits. In some instances it will be impossible to change the mode of the mother's life, except perhaps in the discontinuance of al- cohol. When such conditions prevail, the mother's milk may be modi- fied by giving from one-half to one ounce of boiled water or plain bar- ley-water before each nursing. This is a procedure to which I fre- quently resort. One teaspoonful of lime-water added to one ounce of MATERNAL NURSING 29 water before each nursing has made the breast-milk agree when other- wise breast-feeding would have been impossible. When the milk is deficient both in fat and proteid, a diet composed largely of red meat, poultry, fish, rye bread, or whole-wheat bread, oatmeal, cornmeal, with two or three pints of milk daily, will often be followed by an increase both in fat and proteid. The use of alcohol in moderate amounts, in the form of malt liquors or wine, will usually increase the fat. I have frequently seen it advance 2 per cent, in from two to three days. Disappointments in improving the quantity or quality of the breast-milk, however, are frequent. In addition to the one bottle which, for reasons above mentioned, is given early in the child's life, I find it necessary at the seventh month to add an extra bottle or two. Usually at this time the proteid in human milk begins to diminish in quantity, and as this is the most important nutritional element, an insufficient quantity at this rapidly growing period of life is of no little importance. At the twelfth month, with very few exceptions, my nursing babies are weaned from necessity. At this age exclusive breast-nursing, if one would consider the best interests of the child, is practically out of the question. Out of many thousands of cases I recall but one instance where a mother was able successfully to nurse her child after the twelfth month. This remarkable woman, a mother of six children, had nursed every one of them exclusively up to the fifteenth or the eighteenth month. Mixed Feeding. — With a diminution in the amount of milk secreted, the breast-milk must, of course, be supplemented by modified cow's milk. This method of feeding is usually successful. If the mother of a four-months '-old baby can satisfactorily nurse him three -times in twenty-four hours, he may be given, in addition, two or three bottle- feedings, supplementing the mother's milk. It is best, when using mixed feedings to alternate the breast and the bottle. The modified milk strength should be that which is suitable for the average child of the same age. (See Infant-Feeding, p. 58.) In beginning the use of cow's milk, however, it must be remembered that at first a weaker strength must be used than the child will require for growth, this weaker food being necessary in order gradually to accustom the infant to the change. If too strong a cow's-milk mixture is given at first, it will be very apt to disagree, causing colic and vomiting. Later, when the child has become accustomed to the new food, a stronger mixture may be given. When a mother cannot give her infant at least two satisfactory breast-feedings daily, it is advisable to wean the child. In infants under three months of age, it may be advisable to supple- ment the individual nursings. If the child requires four ounces at a feeding, and if we find by several weighings before and after nursings, that the breast capacity is but two ounces, an additional two ounces may be given by the bottle at the completion Of the nursings. Follow- ing out this scheme I have been able to establish entire breast feedings. Maternal Conditions Under Which Nursing is Forbidden. — When the mother has tuberculosis in any of its various forms or manifesta- 30 THE PRACTICE OF PEDIATRICS tions, whether it involves the glands, the joints, or the lungs, breast- feeding is to be forbidden. In epilepsy and syphilis nursing is likewise forbidden. In nephritis and malignant disease of any nature, and in chorea, nursing should be discontinued. Women who are rapidly losing weight should not be allowed to continue nursing their infants. In case of serious illness of any nature, such as typhoid fever, pneu- monia, or diphtheria, and upon the advent of pregnancy, nursing should be terminated. Care of the Breasts during Weaning. — When the breast-feeding is carried on the usual length of time, — from nine to twelve months, — the process of weaning ordinarily causes little or no discomfort. All that is usually required is to press out enough of the milk to relieve the patient as often as the breast becomes painful, which may not be more than two or three times a day. When the weaning is necessarily abrupt, no little discomfort may result. If there is a free flow of milk, which is apt to be the case when the weaning must take place in the early nursing period, tightly bandaging the breasts is required. When localized hardened areas occur in the glands, they should be massaged until softened, and the bandage reapplied and worn until the secretion ceases. When the weaning can be accomplished more gradually, the infant should have one less nursing every second or third day until only two are given daily. After this has been practised for one week, nursing can be discontinued. In cases where sudden weaning is re- quired, a saline laxative, such as citrate of magnesia or Rochelle salts, should be given every day for five days — sufficient to produce two or three watery evacuations daily. In the meantime the mother should abstain from fluids of all kinds up to the point of positive discomfort. Conditions Which may Temporarily Produce an Unfavorable Effect upon the Breast-milk, but not Necessitate the Discontinuance of Nursing. — The advent of the first menstruation period particularly, and in some cases the beginning of every menstruation period, is at- tended with an attack of colic or indigestion in the child. Such at- tacks, however, rarely necessitate the discontinuance of the nursing even for a single day. Factors influencing the mental condition of the mother, such as anger, fright, worry, shock, distress, sorrow, or the witnessing of an accident, may affect the milk secretion sufficiently to cause no little discomfort to the child, and oftentimes the lessening of the flow for a day or two. The influence of the mother's mental state upon the character of the milk was early brought to my attention while I was resident physician at the County Branch of the New York Infant Asylum. In this institution there were usually about two hun- dred nursing mothers, the majority of them from the lower walks of life, at least 95 per cent, of the infants being illegitimate. The neces- sity of placing a considerable number of these mothers in wards, in close social contact, gave rise to rather frequent disputes, and not infrequently to fistic encounters of a decidedly vigorous character. After a particularly active disturbance, several nursing infants in the HUMAN MILK 31 ward would become suddenly ill, usually with vomiting, diarrhea, and fever. We soon learned to know the cause when inquiry or hasty inspection showed that the mothers of those who were ill had been particularly active in the dispute. A small proportion of the mothers were from the better walks of life. Letters of forgiveness or reproach or visits of a like nature from fathers, mothers, or sisters, have brought many a sick baby to my attention and caused me many anxious moments. Conditions Which Call for Temporary Discontinuance of Nursing. — During an acute illness with fever, such as indigestion, tonsillitis, and minor illnesses of a like nature, nursing should be discontinued for a day or two. During this period it should be our effort to maintain the flow of the milk. This is best done by emptying the breast with a breast- pump at the usual nursing period until the time arrives when the nursing may be resumed. In such conditions the advantage of having the baby accustomed to one bottle a day will at once be appreciated. Care of the Nipples.^ — Six hours after delivery or confine- ment the nipples should be washed with a saturated solu- tion of boric acid and the child put to the breast and nursing attempted. After this, the at- tempts at nursing should be re- peated every four hours, although the milk does not appear in the breasts until from forty-eight to seventy-two hours after the birth of the child. Colostrum may be pres- ent. It is useful as a laxative and may satisfy the child. A further advantage of the nursing at this time is that it gradually accustoms both the infant and the nipple to what will be required later. Imme- diately after the nursing the nipple should be carefully washed with a saturated solution of boric acid and thoroughly but gentl}^ dried. A baby should never be allowed to nurse from a cracked or fissured nipple. For this very painful condition a nipple-shield (Fig. 1) should always be used. HUMAN MILK While human milk varies as to the proportion of its nutritional elements at different periods of lactation, and even at different times of the day, milks upon which infants thrive agree within certain limits, so that a standard of limitations may be laid down. Among a great many specimens which I have examined the solids have ranged between Fig. 1. — Nipple-shield. 32 THE PRACTICE OF PEDIATRICS 12 and 13 per cent. The range in fat has been from 2.75 to 4.65 per cent., proteid from 0.9 to 1.8 per cent., sugar from 5.50 to 7.3 per cent. These figures represent the analyses of the breast-milks given children who were thriving and who were of different ages. The variations are not as wide as have been reported by others, but it is to be remem- bered that all these babies were thriving. Whoever has examined breast-milk even a few times is aware of the existence of the widest possible variations. I have seen breast-milks which contained 8 per cent, of fat and others which contained only 0.5 per cent.; but chil- dren thus fed were not well. Fat exists in mother's milk as minute globules in emulsion, varying somewhat in composition, depending upon the kind of food eaten. The proteids of breast-milk offer a wide field for further study. There are several of these proteids, the most important being casein and lactalbumin. The proportions are subject to considerable varia- tion, depending upon the diet and habits of life of the producer. With a continuation of lactation there is a diminution of the proteid, so that at the ninth or tenth month it is considerably reduced, the total proteid often being not over 1 per cent. The sugar content varies less than does either the fat or proteid, its range of limitation, even in milk otherwise poor, being not over 1.5 or 2 per cent. Directions for nursing well children will be found on page 26. Whether or not the child is getting a sufficient quantity, of milk may be determined by weighing the baby before and after nursing. For this purpose the scales used for weighing children should weigh accurately in one-half ounces. The child, who need not be undressed, should be weighed when put to the breast and weighed at the completion of the nursing. I have repeatedly found that children who should get three ounces or more at a feeding, during the fifteen-minute nursings had in- creased in weight but one-half or one ounce, showing that only so much milk had been taken. Occasionally cases have been seen where there was no gain whatever after nursing and yet the child was sup- posed to have been fed. In the event of difficult breast-feeding it is well for the physician personally to supervise a nursing or two, for by this means much valuable information may be gained. Examination of Human Milk. — Milk of the mother is usually ex- amined to determine whether it contains a sufficient amount of fat, sugar, and proteid to nourish the infant; or to determine whether the quantity of one or more of the nutritional factors is excessive or deficient. Microscopic examination shows us little except the presence of colostrum, which usually disappears about the ninth day and is to be considered abnormal if present after the twelfth day. The presence of blood and pus may also be detected by the microscope. For an accurate analysis the milk should be sent to a laboratory properly equipped for such work. For absolute accuracy it is not safe to judge from the analysis of one specimen of milk; at least two, better three, specimens should be analyzed before coming to a conclusion. In collecting milk for exami- nation the middle of a nursing should be selected. THE WET-NURSE 33 THE WET-NURSE We are called upon to select a wet-nurse under various conditions. A few families, particularly those who have had disastrous feeding ex- periences, ask that no attempts at artificial feeding be made, but that a wet-nurse be engaged in advance of the confinement so as to be ready when the time for her service arrives. Usually, however, our minds and those of the parents turn to the wet-nurse when nutrition by other means is a failure. It is well to remember in this connection that it is not wise to postpone our resort to the wet-nurse until every chance for her being of assistance has passed. I may take a few days' observation or but a single glance at one of these difficult feeding cases to decide whether a wet-nurse must be secured. Cer- tain it is that in a few cases v/e cannot do without such aid. I see per- haps two or three cases a year, usually in consultation, in which I insist that further attempts at artificial feeding be discontinued because of the reduced condition of the patient. In the selection of a wet-nurse the age during which nursing is most successfully carried on is to be remembered. As a rule, a wet- nurse should not be under twenty-two or over thirty-five years of age. The peasant women of the continent of Europe make the best wet- nurses. A woman should not be selected as a wet-nurse without a thorough examination both of herself and of her infant, including the Wassermann test for syphilis. She must be free from skin diseases, tuberculosis, and syphilis. Whether she is stout or thin, tall or short, amounts to little. Neither can we place much reliance on the size of her breasts. Although full, firm breasts and prominent nipples are desirable, the best indication as to her nursing ability is the condition of her baby. For this reason it is best not to select a woman before her baby is four weeks old, for by that time his physical condition will indicate with considerable accuracy the kind of food he has been getting. The wet-nurse's milk need not correspond with the age of the patient for whom she is engaged, as breast-milk from the fourth week to the third month of lactation will answer for any infant. The results attending the first few days of wet-nursing are often most disappointing. The radical change which takes place in the nurse's habits of life, necessitating the leaving of her own child to the care of others, sometimes produces nervous conditions which may have a decidedly unfavorable influence upon her milk. Before arriving at the conclusion that she will not answer in a given case, she should there- fore have time to adjust herself to the changed conditions. Many a good wet-nurse, accustomed to a very plain diet and some work, which necessarily means exercise, has been ruined, so far as her usefulness as a milk-producer is concerned, by overindulgence at the table. Upon assuming her new office she is temporarily the most important member of the household, next to the baby, and articles of food are supplied to which she is entirely unaccustomed and of which she eats plentifull5^ The result is an attack of indigestion with fever, the baby is made ill, 3 34 THE PRACTICE OF PEDIATRICS and the usefulness of the wet-nurse in the family ceases. These women usually do best upon a plain diet of meat, poultry, fish, vegetables, cereals, and milk. If they are accustomed to taking beer, one bottle daily may be permitted. Coffee may be allowed to the extent of one cup daily, and of tea not more than two cups should be allowed. Women of this class are almost invariably neglectful of the bowel function, so that this must be attended to. One free evacuation should take place daily. As a rule, the wet-nurse has been accustomed to work and will be more contented and happy when her time is occupied. If she possess sufficient intelligence to take the baby for outings, she should be allowed to do so. Being out-of-doors from three to four hours a day is of decided advantage to every nursing woman. For the com- fort of the family it is wise not to let a wet-nurse know her full value. When she feels that she is indispensable, trouble is apt to follow. It is particularly necessary, therefore, that babies who are wet-nursed should be given one bottle-feeding daily as soon as they are able to take care of it. The wet-nurse will then realize that she can be dis- pensed with in case of misconduct, or if she leave with an hour's notice the child can be given the bottle until another nurse is secured. In the great majority of my cases it has not been necessary to continue the wet-nursing after the children are seven months of age, for by this time they can usually be fed on the bottle. Of course, unless her nursing proves unsatisfactory, a wet-nurse should not be dismissed at the commencement of or during the summer. THE BREAST Cracked and Fissured Nipples. — Fissures of the nipples often re- sult from lack of care and cleanliness. Nipples that are not washed and dried, but allowed to remain moist after nursing, particularly during the first few days, are also very apt to become macerated and cracked. In the cases in which there is a tendency for the breasts to "leak, " the milk decomposes on the nipples, and the nipple becomes actually ex- coriated by the acids formed by the decomposition in the milk. Leak- ing nipples should be kept covered with pads of sterile absorbent gauze. Cracks and fissures in the nipple may be sufficiently painful to pre- vent a continuance of the nursing. In getting the histories of not a few bottle babies, I have been told that nursing had been stopped be- cause of cracked nipples. The prevention and successful treatment of the condition, therefore, is a matter of no little importance. A strong child tugging on a fissured nipple may occasion excruciating pain to the mother, and when the fissures are not healed, it can readily be understood that such pain and the dread of nursing may produce sufficient mental distress to change the character or stop the flow of the milk, either of which conditions may require that the nursing be discontinued. Treatment. — The treatment which gives the best results, and which is used at the New York Nursery and Child's Hospital, is to bathe the parts with a saturated solution of boric acid after each nursing, THE BREAST 35 dry the nipple, and apply a pad of sterile gauze. Once or twice a day the cracks or fissures are painted with an 8 per cent, solution of silver nitrate. There is no pain attending this application. The pad of sterile gauze just referred to is placed over the nipple and held in posi- tion by a binder sufficiently tight to support the breasts. Before the nursing the nipple is bathed with sterile water and the infant takes the breast as usual. If there are deep fissures, it may be well for a day or two to use a nipple-shield (Fig. 1). Another important reason for a rapid healing is the danger of infecting the gland through the open nipple wound — the usual cause of mammary abscess. The use of an ointm_ent on the nipples is not advised, for the reason that it is of little or no service, and in most cases ointments do actual harm because they soften the epithelium and make the nipple tender. Diminishing the number of nursings to three daily has been of use in some severe cases which were slow to response of treatment. Removing the child from the breast entirely is to be advised only under conditions of much ur- gency. The milk may be entirely lost as a result of protracted ab- sence of this stimulation to the breast. Pig. 2. — English breast-pump. Depressed Nipples.^ — Not an infrequent source of difiiculty in the management of the nursing function in a primipara is depressed nipples. The child cannot get a sufficient hold to make suction possible. He thus fails to get the desired nutriment, and in consequence both the child and the mother become exhausted. When this is repeated a few times, the child is very apt to refuse to make any attempt at nursing. In such cases the use of the nipple-shield is often indispensable, until the nipple is sufficiently drawn out and developed for the child to get hold of. Preceding each nursing it is well to manipulate the nipple for a few minutes or to elongate it by the use of the breast-pump (Fig. 2), without using sufficient force to draw the milk. Caking of the Breasts. — So-called caking of the breasts is of very frequent occurrence during the first few days of nursing. The milk, when it appears in the breasts, is often secreted in large amount. A great deal more is supplied than the child, with his small stomach and usually indifferent nursing, is able to digest. The breasts should be watched very carefully during this time so as to guard against the 36 THE PRACTICE OF PEDIATRICS possibility of the milk remaining undrawn. After the completion of the regular nursing, if a considerable amount of milk remains in the breasts, it should be drawn by the breast-pump (Fig. 2) and the breast thus relieved. Caking is frequently the outcome of fissured nipples. Sucking on the part of the child, the use of the breast-pump, and hard pressure in milking are all- very painful procedures, with the result that the milk remains undrawn. Treatment. — When nodules form, they may readily be softened by gentle massage. Lanolin should be used on the fingers so as to avoid unnecessary irritation of the skin. The massage should be repeated as often as the nodules appear. The caking is more apt to occur in the dependent portion of the glands. The so-called pendulous breasts, which may show a tendency to cake, should be supported by a binder lightly applied. Acute and Suppurative Mastitis.' — When inflammation of the breast develops with fever, chills, and prostration, it is usually the re- sult of an infection through the nipple, generally one with visible cracks and fissures. For our purposes the different varieties of mastitis need not be considered. Nursing from the involved breast should be discontinued, for the sake of both the child and the mother; in fact, the pain is often so great that nursing is impossible. A supporting bandage should be applied and the milk drawn with the breast-pump at the usual nursing times. It must be our aim to induce resolution without the formation of pus. This is best accomplished by the use of an ice-bag which is applied to the inflamed, indurated area. If there is a tendency to constipation, saline laxatives should be used. In fact, the patient will often be beneflted not a little by two or three watery evacuations daily. With a subsidence of the temperature and an abatement of the inflam- mation, nursing may be resumed. As soon as the presence of pus is determined, it should be removed regardless of its location in the gland. I have seen cases of intestinal infection in the infant and of infectious processes in other parts of the body, that were undoubtedly due to nursing from suppurating breasts. THE NURSERY The nursery should be the largest and best ventilated room in the house. In a city home the room may well be located on the third or fourth floor, with a southern exposure. In apartments, quiet and the possibility of free ventilation and sunlight must be considered in selecting the room. For the sake of quiet, the nursery should not communicate with the sleeping-rooms of older children. In placing children in sleeping-rooms or in a nursery , or in estimating the capacity of hospital wards for children, it is to be remembered that at least one thousand cubic feet of air-space should be allowed to each child. The floor of the nursery should not be carpeted. A hard-wood THE NURSERY 37 floor is best. If this is not possible, covering the floor with oil-cloth or linoleum is always possible. This can be cleaned with a damp cloth every day. A broom should never be used in a nursery. Paint or hard finish on the walls is preferable to paper. There should be at least two windows and an open fireplace. If possible, the bath-room should be connected with the nursery, to be used not only for bathing the child but as a "changing room." The child's napkins should not be changed in its living-room if it can be avoided. It is needless to say that napkins should never be dried in the nursery. Steam heat as ordinarily used today is the least desirable means of heating, on account of its uncertainty. In many New York apart- ments of the better class, the fires are banked at 10 p. m. ; the tempera- ture when the child retires is perhaps 70°; by five or six o'clock in the morning a fall to 50° or 60°F. has taken place. Such a change in the temperature, with the tendency of children to kick off the bed-clothes, explains many cases of tonsillitis and bronchitis. The temperature of the nursery should be kept as even as possible. When for any reason this cannot be controlled, it is best to have two means of heating, so that when one fails the other may be used. The open grate fire or a small wood-stove is best. Gas should never be employed as a means of heating a child's sleeping-room, on account of the rapid exhaustion of the oxygen which results from its use. The furniture of the nursery should be of the plainest. Hard- wood chairs and tables with enamel or brass cribs or bedsteads should be used. There should be no arti cle of furniture or furnishings in a nursery, that cannot be washed. In the bath-room or in some room adjoining a pail should be kept containing some disinfectant solution, such as carbolic acid, 1 : 100, or carbonate of soda solution, 1 ounce to 2 gallons of water, in which the napkins are placed as soon as soiled. There should be two shades at each window, a light and a dark one, so that it will be possible to darken the room during the sleeping time, as well as to exclude the early morning light, which is the usual cause of too early waking. Babies should be taught to sleep until at least 6 o 'clock in the morning. This is far better for the child and also for the mother if she occupies the same room. The unnecessary habit of an early waking at 4 or 5 o'clock will in most instances readily be broken by keeping the room dark. The nursery should have suitable means for ventilation. For this purpose, aside from the fireplace, I have found the window-board of no little service. It can be made of any width. Ordinarily, I have it made about six inches wide. It is sawed so as to fit tightly under the lower sash. This leaves an open space corresponding to the width of the board between the upper and lower sash, and allows the en- trance of a current of air which is directed upward. There should be a thermometer in every child's living-room or nursery. It should reg- ister from 70° to 72°F. by day and from 60° to 65°F. by night. The nursery should be given an hour's airing twice a day. The child should sleep in a crib, alone, not with an adult or an older child. 38 THE PRACTICE OF PEDIATRICS The old-fashioned cradle in which generations have been rocked may be an interesting heirloom, but under no circumstances should it be re- moved from its place in the garret. It is realized that the above sug- gestions are not applicable in many homes. Nevertheless, if we aim at the ideal, existing conditions, no matter how unpromising, will in- variably be made better. THE NURSERY MAID In certain stations and conditions of society the young child is cared for by the mother with the assistance of the immediate members of the family. In thousands of homes, however, a helper is employed to take charge of the child or assist in its care. The selection of a nursery maid is a matter of much importance. Schools for training nursery maids exist in New York City, Boston, Albany, Newark (New Jersey), and doubtless in other cities. Although such trained help is greatly to be desired, the supply is very limited. Some of my best children's attendants have been women who, although they have not passed the meridian of life, still have reached the seasoned age when the attractive qualities of policemen and grocery boys have faded into a dim recollection. Any industrious, sensible young woman of quiet tastes who is fond of children can be trained in a few weeks into a most useful helper. The association of the nursery maid and child is a close one, and it is the physician's duty to know that the applicant is phys- ically fit for the position. During a single year the writer has known of three nursery maids who developed pulmonary tuberculosis while in service. Not only should the applicant's lungs be examined, but also the mouth, nose, and throat. Carious teeth and diseased conditions of the throat and nose should receive careful attention before the maid is allowed to assume the position. It is also important that something of the applicant's pre- vious life should be known. One of the most important things to know about an applicant in a large city, and one most difficult for the physician to discover, is the existence of leukorrhea, or vaginal discharge.* This, however, can usually be discovered by the tactful young mother. Not only should the ideal nursery maid be physically fit, she must be mentally fit as well. For proper mental and physical development, children must be enter- tained and pleasantly employed. An ill-natured, impatient nurse should be forced to seek other employment. It should not be a task for a child's attendant to play with him. A woman should not be con- demned, however, because she fails with any given child. With a child differently situated, with a different temperament, the results may be perfectly satisfactory. WEIGHT The average weight of the full-term, newly born infant varies from six to nine pounds. Some are born at term weighing less than six * A very severe gonorrhea was contracted by one of my patients from a nursery maid. WEIGHT 39 pounds and a few weighing over nine pounds, but in the great majorit}' the birth-weight will be found between these figures. Holt found from a study of the records of three large maternity institutions in New York City as follows: The average weight of 568 females was 7.16 pounds. The average weight of 590 males was 7.55 pounds. Every family which can afford it should have a scale (p. 41) for weighing the baby, for only by regular weighing during infancy and childhood can we gain an accurate knowledge of growth. During the first five days of life there is usually a loss in weight of four to six ounces. After this initial loss, which may be expected but which does not always occur, a weekly gain in weight is to be looked for, the child regaining the birth-weight on the eighth or tenth day. At first it is advisable to weigh twice a week, or even daily, if the child is not progressing satis- factorily. After the second month, when the infant is making satis- factory progress, a weekly weighing will answer, and this should be continued until the child is one year of age. Dwring the second year, bi-monthly weighings are sufficient. Girls of the same age, after the first year, will average from one-half to one pound lighter than boys. During the third year, monthly weighings will be sufficient to enable one to keep in touch with the child's condition. During the first six months of life a weekly gain of four to eight ounces has been made by the well children under my care. When a child does not make at least an average gain of four ounces weekly, I do not put him in the "doing well" class, but look into his care and nutrition to learn what is wrong. Children vary in growing capacity. Some will increase in weight rap- idly, gaining three ounces a day, while others will make a slower gain and yet be perfectly well. Through the care of many children, I have come to regard four ounces as the minimum weekly gain for a well child. In a well infant the birth-weight should be doubled by the fifth or the sixth month, and at one year the weight should be a little over two and one-half times that at birth. During the second year a gain of five and one-half to seven pounds will usually result under proper condi- tions. During the third year from five to six pounds will be added. At the fifth year the weight should be in the neighborhood of forty-one pounds. It is not to be inferred that these are arbitrary figures or that perfectly well children may not be under or above the figures given at the ages mentioned. These figures are, however, to be regarded as the average for the different ages. A weight chart with its colored "normal" line will not be found in this book, and physicians are advised against its use. Time and again I have seen well infants, though slow in growth, made ill by overfeeding, in the vain attempts of an ambitious mother or nurse to keep her in- fant up to the "normal" line. The weighing alone is not sufficient to inform us absolutely con- cerning the development of children. I have seen babies who showed a most satisfactory weight curve, yet who, on examination, were by no means up to the requirements for their age as regards their bone and 40 THE PRACTICE OF PEDIATRICS muscle development. A nursing or bottle baby should be examined once a month in order to determine if the progress is along the desired lines as shown by the condition of the teeth, the fontanels, the long bones, and the muscles. The following table from Holt's "Diseases of Infancy and Child- hood" gives the weight and height of children from birth to the six- teenth year. The weights under five years are taken without clothing. After the fifth year the weight of the clothing is to be deducted. The average weight of house-clothing, according to Holt, who quotes Bow- ditch, is at the fifth year 2.8 pounds for both sexes; at the seventh year, 3.5 pounds for both sexes; at the tenth year, 5.7 pounds for boys and 4.5 pounds for girls; at the thirteenth year, 7.4 pounds for boys and 5.6 pounds for girls; at the sixteenth year, 9.7 pounds for boys and 8.1 for girls. These weights must be deducted from the gross weights in order to obtain the net weights of the children. The season of the year, of course, would make some difference in the weight of the clothing, although this point is not mentioned by the observers. Age. Birth. Sex. Weight, Pounds. /Boys 7.55 6 months. 12 months. 18 months. \ Girls Boys Girls Boys Girls Boys Girls 7.16 16.0 15.5 21.0 20.5 24.0 23.5 "^ y^^^^ \ Girls 26.0 /Boys 32.0 1 Girls 31.0 /Boys 36.0 \ Girls 35.0 /Boys 41.2 1 Girls 39.8 /Boys 45.1 1 Girls ;. ...43.8 /Boys 49.5 1 Girls 48.0 / Boys 54 . 5 3 years. 4 years. 5 years. 6 years. 7 years. 8 years. 9 years. 10 years. 11 years. 12 years. 13 years. 14 years. 15 years. 16 years. \ Girls 52.9 Bovs 60.0 Girls 57.5 Boys 66.6 Girls 64.1 /Boys 72.4 \ Girls 70.3 Boys 79.8 Girls 81.4 Boys 88.3 Girls 91.2 /Boys 99.3 \ Girls ; 100.3 /Boys 110.8 /Girls 108.4 /Boys 123.7 \ Girls 113.0 Height, Inches. 20.6 20.5 25.4 25.0 29.0 28.7 30.0 29.7 32.5 32.5 35.0 35.0 38.0 38.0 41.7 41.4 44.1 43.6 46.2 45.9 48.2 48.0 50.1 49.6 52.2 51.8 54.0 53.8 55.8 57.1 58.2 58.7 61.0 60.3 63.0 61.4 65.6 61.7 The above table allows of considerable latitude and with the child THE CAKE OF THE STUMP OF THE UMBILICAL CORD 41 remaining within the normal. A boy patient who represented most rapid growth measured 69% inches when 12 years of age. Scales. —A scale for weighing the baby is a very necessary adjunct to the nursery furnishings. There are several varieties of scales on the market known as "baby scales." Their usual construction provides for a basket for holding the baby, the basket being supported by a steel rod which rests upon a spring. A needle indicates on a dial the weight of the child. This variety of scale is very unsatisfactory : it gets out of order easily, it is expensive, and with a vigorous, kicking child, the rapid oscillation of the needle makes an accurate reading of the weight dif- ficult if not impossible. Further, the weight capacity of these scales is but twenty pounds. When the child's weight reaches this figure, it necessitates the purchase of another scale. The scoop and platform scales used by grocers are best. They do not easily get out of order, they weigh correctly from one-half ounce to two hundred and eighty pounds, and being very simple in construction, they can readily be understood. The infant rests on his back in the scoop during the weighing process; older children stand on the platform. HEIGHT The length or height of children at the various ages is for conven- ience included in the weight table. From the standpoint of health or development, height is of no great significance. The length at birth usually varies from IQi-^ to 21 inches. Children suffering from tardy malnutrition, particularly if syphilitic, may be undersized. Not a few of the non-specific malnutrition and anemic children are tall and thin. It is often a matter of no little distress to parents that their children are undersized. Short mothers and fathers cannot expect very tall children. If the latter have right care, they will probably be larger than the parents, but cannot be expected to grow as much as play- mates whose fathers and mothers are tall. The height bears much less relation to the condition of the child than does the weight. THE CARE OF THE STUMP OF THE UMBILICAL CORD The space devoted to the care of the umbilical cord might seem out of place in a work of this nature. The excuse is the frequent appear- ance in private practice and in out-patient clinics of infants with umbilical polypi, granulomata, suppurating umbilical stumps, or eczema involving a considerable area about a moist, actively secreting umbilicus. The management of granuloma, polypus, and localized eczema about the umbilicus has been referred to elsewhere. In order to secure a rapid and complete cicatrization after the cord falls, it is essential that the parts be kept dry. I have used with gratifying success a powder composed as follows: I^ Pulveris acidi salicylic gr. x Pulveris acidi borici gr. xxv Pulveris aniyli Pulveris zinci oxidi aa5ss 42 THE PRACTICE OF PEDIATRICS Over this powder, which is used freely in the open wound, is placed a retaining pad of gauze. The dressing should be changed and fresh powder applied every time the child is fed. For the small unhealthy granulations often present, cauterizing with a 50 per cent, nitrate of sUver solution may be necessary once or twice, after which the powder should be used until the secretion has entirely ceased and cicatrization is complete. . MENTAL AND PHYSICAL DEVELOPMENT IN THE INFANT Dr. Frederick Peterson,* of New York, has made an exhaustive study of the mental development of the newly born. In all, 1060 newly born infants were examined, the observations extending over one year. His observations, which are to be looked upon as authentic, are as follows: "1. Sight. — Sensibility to light is present in most infants at birth, and this is the case even in those prematurely born. The optic nerve is, therefore, already prepared to receive impressions, sometimes even before the time of normal birth. ''2. Hearing.— Sensibility to sound is quite as apparent as sensi- bility to light at birth, for 276 normal white children reacted to sound on the first day of life, and 146 reacted to light. A similar condition existed among the premature infants, many reacting to sound on the first day as well as to light. The auditory nerve is already prepared to receive impressions of sound sometimes before the period of normal birth. This is wholly contrary to the opinions of other authorities. " 3. Taste. — The gustatory nerve not only reacts differently to salt, sweet, bitter, and sour at birth, but the same mimetic reactions are observed in premature infants. This nerve is, therefore, ready to re- ceive taste impressions some time before the normal period of birth. "4. Smell. — Two hundred and seven normal white children reacted to odors on the first day of birth, and similar reactions were observed in premature infants. The olfactory nerve is ready to receive smell impressions some time before the end of the normal period of gestation. "5. Cutaneous Sensibility. — Reactions to touch and temperature and affective manifestations of discomfort, obtained the first day in large numbers of normal infants, were similarly obtained in premature infants, showing that such sensibility is already present before the ex- piration of the period of normal gestation. There is every reason to believe that sensitiveness to painful stimuli is present, but the reactions are more vague and uncertain than in later life, which leads many to assume that the sense of pain is dull in the new-born. Muscular sense cannot be tested in infants, but there is every reason to believe that muscular sense, the sense of motion, and sense of position are developed early in utero. "6. Thirst-hunger and Organic Sensation. — The new-born child frequently reacts to thirst-hunger on the first day, though the actual * Bulletin, Lying-in Hospital, December, 1910. MENTAL AND PHYSICAL DEVELOPMENT IN THE INFANT 43 need of food is seldom apparent until after the first or second day. Discomfort is clearly marked when nourishment is not forthcoming. The cries of discomfort and pain are marked in the first day in full- term infants and noteworthy in the premature. "7. The Beginning of Memory, Feeling and Consciousness in the New-born Child. — There are good grounds for believing that the new-born child comes to the world already with a small store of experi- ences and associated feelings and shadowy consciousness. The fact that even in premature infants we find the senses already prepared for the reception of impressions on the five senses is some evidence of such impressions having been already received and stored up in the dim storehouse of a memory already begun. It may even be that some sort of vague light impressions have been received, for it is possible that in the interior of the body the alternation of day and night may in a mild degree be manifested. The transillumination of the hands before a candle, of the skull and face bones by examination of the frontal sinuses and antrum with electric lights, are evidence of a certain amount of translucency of the whole organism to sunlight, which is so much more powerful than any artificial light. There is greater possibility in the matter of the auditory sense, that it may be stimulated by sounds within the body of the mother (by bone conduction possibly) ^ — such sounds as the beats of the maternal and fetal hearts, the uterine and funic souffles, and the bruit of the maternal aorta. "Moderate stimulation of the gustatory nerve is thought to occur through the common swallowing of amniotic fluid by the fetus. " A marked development of receptivity in the senses of touch and of muscular sense during uterine life is undisputed. Movements begin considerably before the sixteenth week of pregnancy, and increase in character and extent from that time on. Often they are so violent as to be painful to the mother. The activity of the muscles and constant contact of various parts of the fetal body with the uterine walls for a period of months before birth must lay a foundation under the threshold of consciousness for a sense of equilibrium and vague spatial relations. The material basis of consciousness is prepared long before birth. ''There is already a feeling tone associated with the earliest re- actions, though we are altogether in the dark as regards its psychophys- iology. The process has been thus formulated: Stimulus — reaction — liking — reinforcement. Stimulus — reaction — dislike or pain- — in- hibition. This is the early simple associative memory in reactions to stimuli. "8. There are no perceptible differences in reactions of colored and white children or between pairs of twins. ''Ability to hold the head erect: This may be acquired at the third month. Few infants, however, are able fully to support the head be- fore the fifth month. Not a few perfectly normal infants will not be able to support the head before the ninth month. "Sitting erect: The ability to sit erect unsupported is acquired be- tween the sixth and eighth months. 44 THE PRACTICE OF PEDIATRICS "Standing: Many infants will stand with simply hand support at the tenth month. Exceptionally well-developed infants will stand with the hands resting on some object at the eighth month. A remark- able infant under my observation could stand at the fifth month, and walked alone at the eighth month. The average infant walks alone from the fourteenth to the sixteenth month. A few will be able to walk unsupported before this period, and other normal children will not walk alone before the eighteenth or, twentieth month. "Laughing: Many infants may be made to laugh from the third to the sixth week. "Memory: The infant's memory is very short. I have repeatedly known infants eighteen months of age who have entirely forgotten the mother in a week. " Speech: Intelligible words are formed at about the twelfth month. From the eighteenth month to the second year two or three words will be intelligently put together." BASKETS FOR EARLY EXERCISES It is a mistake made in many families to have the baby in the arms a greater part of his waking hours. This practice should be dis- couraged by physicians, for when the child is held, there is alwaj^s a tendency to make him sit upright on the arms or knee without proper support. During the early months of life the vertebrae and vertebral ligaments are not sufficiently developed to support the heavy head and trunk. If this thoughtlessness on the part of parents with its attend- ant dangers were explained, there would be fewer cases of displaced scapulae and spinal curvature to be treated later. Many cases of spinal curvature are the direct outcome of such early abuse of the spinal column. Still, it is not desirable that the child should constantly occupy the crib. A large clothes-basket in which a thick blanket and pillow have been placed affords a safe playground for a small baby. For the first few months he will lie on his back and amuse himself in his own peculiar way. After the sixth month, when he may be allowed to sit up for a short time each day, a pillow should be placed behind his back for support. The basket supplies plenty of room for toys and other means of entertainment. When the child begins to stand and attempts to walk, the basket period is at an end and the exercise pen (p. 767) should be brought into use. CRYING It is well for the young infant to cry a little every day. Muscular movements involving a greater part of the body accompany the act of crying and furnish exercise. Peristalsis is increased, as is often evi- denced by a movement of the bowels occurring during crying, particu- larly when there is diarrhea. In crying, deep breathing is necessary, the lungs are expanded, and the blood oxygenated. The well baby SLEEP 45 cries when frightened, or uncomfortable from hunger, soiled napkins, or inflamed buttocks. He cries from pain, from heat, from cold, from unsuitable clothing, and during difficult evacuation of the bowels. He also cries when displeased or angry. Authors are prone to refer to the diagnostic value of an infant's cry. It is my belief that characteristic cries are not to be depended upon sufficiently to give them a differential diagnostic dignity. Children slightly but painfully ill may cry inces- santly for an hour or two. Thus, with intestinal colic, the cry is loud and continuous until the child is relieved or falls asleep from exhaustion. Earache is not an infrequent cause. The habitual criers, the restless and vigorous, crying, whining infants, are uncom- fortable. With very few exceptions the trouble will be found in the intestinal tract. The well-trained, normal child, whose nourishment is suitable, is seldom troublesome. When well, all babies are natu- rally good-natured and happy in their own way. Badly managed, spoiled infants often cry vigorously when left alone. When attention is given them, when they are taken up and talked to, the crying ceases. This readily tells us that pain or discomfort was not an element in causing the cry. By these infants, discipline, not medication, is needed. The management of the habitual crier involves the relief of the condition which causes the discomfort, or the most rigid discipline, when it is demonstrated that we are dealing with a "spoiled infant." SLEEP The infant who sleeps well is almost always a normal, well-fed baby. Irritability and sleeplessness are associated with indigestion more frequently than with any other disorder. During the first few days of life the sleep, in normal conditions, is almost unbroken, except when the infant is fed. During the first month the infant sleeps about twenty- two hours out of every twenty-four; during the second and third months, from twenty to twenty-two hours. At the sixth month the child should sleep from 6 p. m. to 6 a. m. without interruption except for feeding or nursing, which need cause very little disturbance. At this age there should be a two-hour nap during the morning and a two- hour nap in the afternoon, although it is not well to have the baby sleep after three o'clock in the afternoon. The twelve-hour night rest should be continued until the child is six years of age. The day naps will gradually be shortened by the child. At one year of age, one hour in the morning and two hours in the afternoon suffice. From the eighteenth month to the second year the morning nap is given up. Afternoon rest for at least one and one-half hours should be continued until the sixth year of age, and longer if the child is inclined to be delicate. Regular sleep is largely a matter of habit, and if the infant started right with suitable feedings given at definite times, followed by the proper period of sleep, but little trouble will be experienced. When sleep is disturbed and broken, it means bad habits, unsuitable food, minor forms of indigestion, or positive illness of some kind. Sleep is 46 THE PRACTICE OF PEDIATRICS important for purposes of growth, not only in early infancy but throughout childhood. Not a few infants form habits of sleeping in the daytime and being wakeful at night. This is best remedied by keeping the baby awake during the day, by entertainment, and by keeping him in a well-lighted room. A proper amount of sleep is most essential to nutrition, and I am sure that the satisfactory results which I have had the good fortune to achieve in the treatment of secondary malnutrition and anemia have been due in part to my insistence that the child sleep in a quiet, darkened room for two hours after the noon- day meal. The energy expended in twelve hours by an active child is incalculable, and when a portion of this energy is reserved and the body fortified by rest and sleep during the middle of the day, there is a greatly diminished daily expenditure of strength units. For bathing newly born see p. 20. STOOLS Breast Fed Stools. — Infants on the breast average two to three large stools daily, although the number may range from one to five and still be consistent with perfect health. Their color is usually of a bright yellow or orange tint, and their character of a smooth and homogeneous consistency, with a slightly acid reaction. The odor is not as offensive as the cow's milk stool, as there is less putrefaction. of the protein while in the intestinal tract. The bulk or residue corresponds to the amount of ingested food. Cow's Milk Stools. — Infants on the bottle usually average only one stool a day, which oftentimes is smaller than that of the breast-fed baby. The color is lighter and the proportion of feces to the amount of food taken numerically less when artificially fed. Hard Constipated Stools. — A hard constipated stool, when not pro- duced by any mechanical cause, is usually due to a deficiency in the food of either carbohydrates or fats, generally the latter. Food too low in total solids, leaving an insufficient residue is also a cause. Irregular habits in the time of going to stool and a lack of systematic general training also play a part. Sterilization and, to a lesser degree, pasteurization, make milk somewhat constipating. Loose Watery Stools. — This type of stool is seen in indigestion, with fermentative changes in the carbohydrates of the food, and to a lesser extent of the fats. The stools vary in color from a yellow or yellowish brown to green. They are usually alkaline in reaction and have a foul, musty odor. Curds are seldom seen and there is very little mucus. Stool in Hard Balls. — This variety of stool is usually due to an excess of fat in the food. The feces vary in color from a light yellow to a light grey. They are sometimes large and hard and at other times dry, small and crumbly. Scrambled Egg Stools. — Stools of this order are seen when the carbohydrate digestion is at fault. Bacterial fermentations of the THE NURSING-BOTTLE AND NIPPLE 47 starch, or sugar which is not assimilated by the organism gives rise to loose, green, frothy movements. These are very acid, frequently causing excoriations of the buttocks and surrounding parts. Mucus in Stools. — Mucus in stools denotes a form of irrita.tion in the digestive tract which gives rise to an excessive secretion from the mucous glands of the intestine. It is almost invariably present in abnormal stools. Mucus and feces intimately mixed indicates the source of the trouble to be in the small intestines; or if on the outside of a constipated stool, from the rectum; if in combination with a clay- colored stool, from the duodenum. Blood in Stools. — In older children, blood in- timately mixed with the stools would suggest an ulceration of the stomach or small intestine. When on the outside of a constipated stool, it may indicate a rectal lesion, an anal fissure, diverticuli, or in- complete intussusception. A stool composed of blood and mucus without fecal material is very characteristic of intussusception. Melsena neona- torum or hemorrhage of the newly-born is char- acterized by a profuse discharge of blood from the rectum. Curds in Stools. — This is one of the most frequent of the abnormal constituents of infant's stools. Two kinds are found : one firm and tough and very hard to press out, insoluble in ether, varying in size from a small pea to a hickory nut, with a brown or greenish coating, but white on cross-section, which is known as a protein curd; the other is composed j'l|P I of fat, easily pressed out, does not sink in water varies in color from white or yellow to green, is somewhat soluble in ether, and is not hardened by formalins. THE NURSING-BOTTLE AND NIPPLE There are two requirements that a nursing- ^ V -- / bottle must fulfil : it must have a capacity sufficient |^^, ^ ^^ for one full feeding and it must be so constructed -p. „ ^ as to be readily cleansed. The oval bottle with ^fle and nim)l'e° ' rounded edges answers best. These may be ob- tained in sizes of from three to nine ounces. As many bottles are needed as there are feedings in twenty-four hours. The bottles should be boiled once a day, scrubbed with a stiff brush with hot borax water, and remain in the borax water until needed. Two teaspoonfuls of borax to a pint of water is the strength usually used. Before using, bottles should be rinsed in plain boiled water. The straight black nipple (Fig. 3) is also preferred, for the reason that it can be turned inside out and easily cleansed. A nipple which cannot be turned should never be used. After use, the nipple should be turned and 48 THE PRACTICE OF PEDIATRICS scrubbed with a stiff brush and borax water — a tablespoonful of borax to a pint of water. When not in use, the nipple should be kept in borax water. Before being placed on the bottle, it should be rinsed in boiled water. The nipple should be boiled once a day. The blind nipples — those without holes — are the best. Holes of the required size may be made with a red-hot cambric needle. Substitute Breast-feeding; Artificial Feeding A considerable number of the young of the human race are de- prived of the natural means of nutrition, the milk of the mother. For comparatively few is a wet-nurse available. While in proportion to the children born more mothers are nursing their infants now than formerly, nevertheless every year thousands of infants are brought into the world who have to be nourished by other means than human milk. The fact that an immense number of deaths occur every year among these infants because of defective nutrition speaks for itself. Nutritional Errors. — Mortality statistics give a very inadequate idea as to the part played by nutritional errors in the young, for the reason that in many instances such errors are not the direct or perhaps the immediate cause of death, and for this reason their influence does not appear in mortality statistics. As elsewhere pointed out, and dwelt upon at length in this work, in disease of any nature a child's resistance is a factor of paramount importance. With defective nutrition, resistance is invariably below the normal. Many of the infants who die from the intestinal diseases of summer, from grip, from tuberculosis, or from infectious diseases, suffer from defective, nutri- tion in different degrees of severity before the immediate cause of death exists. The Needs of the Patient Paramount. — As nutrition deals directly with questions of life and death, it is not surprising that volumes have been written on the subject, but it is surprising that the fundamental principles of infants' nutrition are so little understood. This is due in part to the fact that writers and teachers of infant-feeding, in their efforts to be scientific or ultra-scientific, have lost sight of the point that there is a patient as well as a pupil to be considered, and that not a few teachers with their algebraic or otherwise intricate formulas do little but obstruct the progress of rational feeding by making a readily comprehended subject impossible to many. Another common error is in not distinguishing between children — the rich and the poor, the sick and the well. A child with malnutrition, with marasmus, or with a temporarily disordered digestion is by no means a well baby, and when he is given food suitable only for the well, his condition very naturally is not improved. Environment. — In feeding an infant, several predominant factors must be considered. The influences of environment are most important. The infant in a children's institution has to be fed differently from one who comes to a dispensary for treatment, and both must be fed cow's MILK 49 differently in summer than in winter. The child of well-to-do, intelli- gent parents is fed still differently. There are no hard and fast lines in infant feeding other than that there must be an ample supply of such nourishment as the child can digest and thrive upon. Cow's milk is used as the basis of infant's food, for the reason that it is ordinarily readily adapted to the child's digestion and is the most available substitute for human milk. Successful Substitute Feeding. — Successful substitute feeding of infants consists, then, in giving something upon which the child can live and thrive, and when, in addition, this "something" supplies the nutrition which nature demands, it constitutes scientific infant-feeding, whatever the source of the nutriment. Cow's milk is just as fully an unnatural food for an infant as is barley or rice gruel or the milk of the goat or the ass; and cow's milk only is used, as already mentioned, because in a great majority of cases it answers the given purpose better than does any other food, in that it furnishes in an available form the nearest approach to the nutritional elements required. From an analysis of many human milks we know what should constitute a child's food. Cow's milk, however, differs from human milk in im- portant features. COWS MILK As cow's milk furnishes the most available basis of nutrition for the infant who is deprived of the mother's milk, it is essential in order to secure the best results from its use as an infant food, that it contain' total solids between 12 and 13 per cent, and that the solids be repre- sented in the nutritional elements in somewhat the following pro- portions : Fat 3.5 to 4 per cent. Sugar 4 to 4.5 " Total proteid 3.5 to 4 Ash 0.7 to 0.9 " Specific gravity 1.028 to 1.033 In order that the milk may be of a fairly constant strength, herd- milk is to be preferred to the product of one or two cows, as the quality of the latter may vary considerably from day to day. It has been demonstrated that the best cows for this purpose are what are known as "grade cows," that is, not pure bred. Such cows thrive better, are more easily kept healthy, and are more uniform in the nutritional equivalent of their milk-supply than are high-class registered herds of the Alderney or Jersey strain. There are several proteids of cow's milk, of which the most impor- tant and best known are casein, which forms the curd, and lactalbumin, the proportion being about three parts casein to one part of lactal- bumin. In mixed milk from several cows this proportion is by no means constant. The sugar of cow's milk is lactose, which is less sweet to the taste than cane-sugar or granulated sugar or maltose derived from starch. That cow's milk shall contain a certain quantity 4 50 THE PRACTICE OF PEDIATRICS of total solids, and that it shall be of a specific gravity within certain limits, is necessary in order that it may supply nourishment to the child. Another most important feature to be taken into consideration is cleanliness, which naturally brings us to a consideration of the bacteriology of milk — a large subject which can be but briefly referred to here. Milk fresh from the udder contains very few bacteria, parti- cularly if the first two or three jets from each teat are discarded. The time for bacterial contamination is during the milking and while the milk remains in the stable. Certain forms of bacteria are harmless, and it is impossible to have a milk absolutely free from bacteria. What we need to know is how dangerous bacteria get into the milk, and how they cause changes that may convert it into a poison of greater or less virulence. Harmless Bacteria. — The souring of milk is the result of the pres- ence of bacteria which produce changes in the sugar-of-milk, with the formation of lactic acid. The "turning" of milk during a thunder- shower is due to certain changes in the atmosphere that aid in the development of the bacteria which convert lactose into lactic acid. Harmful Bacteria. — Bacteria of decomposition, under conditions favorable to their growth, attack the proteid constituents of the milk, producing putrefactive changes with evolution of poisons which may be of the greatest virulence. The putrefactive bacteria are always pres- ent in stables where manure is allowed to collect and where cleanliness is not observed. When we remember what a culture-field milk affords to bacteria, and when we see the manure and the surroundings in which milk is often drawn, it is not surprising that the milk should contain many millions of bacteria to a cubic centimeter. They may enter the milk from the dust in the stable, — a very fruitful source, — or they may find entrance from the milker's hands or from droppings of fine particles of manure from the belly of the cow. Bacteria from these sources are among the most dangerous forms found in milk. When bacteria once gain entrance into the milk, their growth is most rapid. Market Milk. — The legal standards for pure milk in most instances relate only to the chemical composition of the milk. The laws of most of the States call for 12 per cent, of total solids, and at least 3 per cent, of fat. If the milk contains less than these percentages, it is considered impure, even if it is just as it was when it left the cow's udder. Some cows give milk considerably below this standard. The chemical analysis of milk does not show whether it is suitable for use as an infant food, this point being decided according to its freshness and the care with which it has been handled with reference to the exclusion of bacteria and the prevention of their growth. The produc- tion of clean, safe milk is expensive. It costs at least two cents a quart to produce milk, without allowing anything for the labor of caring for the cows. The milk must be carried to the consumer, which is also expensive. Certified Milk. — The best grade of milk, and the one which should cow's MILK 51 be used in feeding infants whenever possible is known as "certified milk," and is produced under the direction of what is known as a " milk commission." The establishing of "milk commissions" in different cities throughout the country has been the means of securing a much better milk-supply than was formerly possible, and has unquestionably been instrumental in saving thousands of lives. To Dr. H. L. Coit, of Newark, N. J., is due the credit of organizing the first milk commission. Certified milk must conform to certain standards as to its nutritional value and as to the number of bacteria per cubic centimeter. These standards are established by a committee of medical men who com- pose the milk commission, and who have complete control of the dairy and its entire output. The Milk Commission of the New York County Medical Society requires a standard of milk not containing over 10,000 bacteria in a cubic centimeter. When a dairyman has shown to the satisfaction of •the Commission that he can produce a milk up to the required stand- ard, he is allowed to attach to his bottles milk labels furnished by the Commission certifying to that fact. Milk thus "certified" is taken from the delivery wagon from time to time and subjected to examina- tion by their bacteriologist in order to determine whether it conforms to the requirements of the Commission. In order to show the care and supervision necessary for the production of certified milk, the requirements of the Milk Commission of the New York County Medical Society for the Production of "certified milk" are given in full.* "The most practicable standard for the estimation of cleanliness in the handling and care of milk is its relative freedom from bacteria. The Commission has tentatively fixed upon a maximum of 10,000 germs of all kinds per cubic centimeter of milk, which must not be exceeded in order to obtain the indorsement of the Commission. This standard must be attained solely by measures directed toward scrupu- lous cleanliness, proper cooling, and prompt delivery. The milk certified by the Commission must contain not less than 4 per cent, of butter-fat on the average, and must possess all the other characteristics of pure, wholesome milk. "In order that dealers who incur the expense and take the pre- cautions necessary to furnish a truly clean and wholesome milk may have some suitable means of bringing these facts before the public, the Commission offers them the right to use caps on their milk-jars stamped with the words: 'Certified by the New York County Medical Society Milk Commission.' "Rules for the Producer. — 1. The Barnyard. — The barnyard should be free from manure and well drained, so that it may not har- bor stagnant water. The manure which collects each day should not be piled close to the barn, but should be taken several hundred feet away. If these rules are observed not only will the barnyard be free from objectionable smell, which is always an injury to the milk, but *Chapm: "Infant Feeding." 52 THE PRACTICE OF PEDIATRICS the number of flies in summer will be considerably diminished. These flies, in themselves, are an element of danger, for they are fond of both filth and milk, and are liable to get into the milk after having soiled their bodies and legs in recently visited filth, thus carrying it into the milk. Flies also irritate cows, and by making them nervous reduce the amount of their milk. "2. The Stable. — In the stable the principles of cleanliness must be strictly observed. The room in which the cows are milked should have no storage loft above it; where this is not feasible, the floor of the loft should be tight, to prevent the sifting of dust into the stable beneath. The stable should be well ventilated, lighted, and drained, and should have tight floors, preferably of cement. They should be whitewashed inside at least twice a year, and the air should always be fresh and without bad odor. A sufficient number of lanterns should be provided to enable the necessary work to be done properly during dark hours. There should be an adequate water-supply and the. necessary wash-basins, soap, and towels. The manure should be removed from the stalls twice daily, except when the cows are outside in the fields the entire time between the morning and afternoon milk- ings. The manure gutter must be kept in a sanitary condition, and all sweeping and cleaning must be finished at least twenty-minutes before milking, so that at that time the air may be free from dust. "3. Water-supply. — The whole premises used for dairy purposes, as well as the barn, must have a supply of water, absolutely free from any danger of pollution with animal matter, sufficiently abundant for all purposes, and easy of access. "4. The Cows. — The cows should be examined at least twice a year by a skilled veterinarian. Any animal suspected of being in bad health must be promptly removed from the herd, and her milk rejected. Never add an animal to the herd until it has been tested for tuberculosis and it is certain that it is free from disease. Do not allow the cows to be excited by hard driving, abuse, loud talking, or any unnecessary dis- turbance. Do not allow any strongly flavored food, like garlic, which will affect the flavor of the milk, to be eaten by the cows. "Groom the entire body of the cow daily. Before each milking wipe the udder with a clean damp cloth, and, when necessary, wash it with soap and clean water and wipe it dry with a clean towel. Never leave the udder wet, and be sure that the water and towel used are clean. If the hair in the region of the udder is long and not easily kept clean, it should be clipped. The cows must not be allowed to lie down after being cleaned for milking, until the milking is finished. A chain or rope must be stretched under the neck to prevent this. "All milk from cows sixty days before and ten days after calving must be rejected. "5. The Milkers. — The milker should be personally clean. He should neither have nor come into contact with any contagious disease while employed in milking or handling milk. In .case of any such illness in the person or family of any employee in the dairy, such em- cow's MILK 53 ployee must absent himself from the dairy until a physician certifies that it is safe for him to return. "Before milking, the hands should be thoroughly washed in warm water with soap and a nail-brush and well dried with a clean towel. On no account should the hands be wet during the milking. " The milking should be done regularly at the same hour morning and evening, and in a quiet, thorough manner. Light-colored, wash- able outer garments should be worn during milking. They should be clean and dry, and when not in use for this purpose, should be kept in a clean place protected from dust. Milking-stools must be kept clean. Iron stools painted white are recommended. *' 6. Helpers, Other than Milkers. — All persons engaged in the stable and dairy should be reliable and intelligent. Children under twelve years should not be allowed in the stable during milking, since in their ignorance they may do harm, and from their liability to contagious diseases they are more apt than older persons to transmit them through the milk. "7. Small Animals. — Cats and dogs must be excluded from the stable during the time of milking. ''8. The Milk. — The first few streams from each teat should be dis- carded, in order to free the milk-ducts from milk that has remained in them for some time and in which bacteria are sure to have multiplied greatly. If, in any milking, a part of the milk is bloody or stringy or unnatural in appearance, the whole quantity of milk yielded by that animal must be rejected. If any accident occurs by which the milk in a pail becomes dirty, do not try to remove the dirt by straining, but reject all the milk and cleanse the pail. The milk-pails used should have an opening not exceeding eight inches in diameter. "Remove the milk of each cow from the stable, immediately after it is obtained, to a clean room, and strain it through a sterilized strainer. "The rapid cooling of milk is a matter of great importance. The milk should be cooled to 45°F. within one hour. Aeration of pure milk beyond that obtained in milking is unnecessary. "All dairy utensils, including bottles, must be thoroughly cleansed and sterilized. This can be done by first thoroughly rinsing in warm water, then washing with a brush and soap or other alkaline cleansing material and hot water, and thoroughly rinsing. After this cleansing, they should be sterilized with boiling water or steam, and then kept inverted in a place free from dust. "9. The Dairy. — The room or rooms where the bottles, milk-pails, strainers, and other utensils are cleaned and sterilized should be sepa- rated somewhat from the house, or when this is impossible, have at least a separate entrance, and be used only for dairy purposes, so as to lessen the danger of transmitting through the milk contagious diseases which may occur in the home. "Bottles, after filling, must be closed with sterilized discs and capped so as to keep all dirt and dust from the inner surface of the neck and mouth of the bottle. 54 THE PRACTICE OF PEDIATRICS " 10. Examination of the Milk and Dairy Inspection. — In order that the dealers and the Commission may be kept informed of the character of the milk, specimens taken at random from the day's supply must be sent weekly to the Research Laboratory of the Health Department, where examinations will be made by experts for the Commission, the Health Department having given the use of its laboratories for this purpose. "The Commission reserves to itself the right to make inspections of certified farms at any time and to take specimens of milk for examina- tion. It also reserves the right to change its standards in any reason- able manner upon due notice being given the dealers." Naturally, milk produced in this way is more expensive than when little or no care is used, more help is required, and help of a more ex- pensive type. Certified milk, or its equivalent, is sold in New York City at prices ranging from 15 to 20 cents a quart. Examination of Cow's Milk. — In the use of cow's milk, as in that of human milk, a chemical analysis is necessary, in order to know accurately the nutritional elements. The specific gravity varies from 1.029 to 1.035. Milk is acid in reaction to phenolphthalein, and may be neutral to litmus. The Babcock milk-test machine is what is generally employed in examining cow's milk in laboratories and insti- tutions. The test consists in mixing the milk with strong sulphuric acid, which dissolves the proteids and liberates the fat, the quantity of which is read off from the graduated neck of the bottle used in mix- ing the milk and acid. Only the fat is determined in this way. Know- ing the fat and the specific gravity, one may readily determine the solids other than fat by adding to one-fourth of the specific gravity, reading to the right of the decimal point, one-fourth of the percentage of fat. MODIFIED MILK At one time it was thought that, by changing the percentage com- position of cow's milk and altering the reaction, it could be made prac- tically identical with human milk, and the term ''modified milk" was applied to cow's milk so manipulated. A great variety of manipula- tions of cow's milk has been introduced, which often differ greatly in the principles involved. Yet to products of all these different manipu- lations the term "modified milk" is applied. It may mean any one of a dozen or more different products. Cow's milk diluted with water and given as a food to an infant is called "modified milk." When sugar, cereal gruel, lime-water, bicarbonate of sodium, or citrate of sodium is added, it is still "modified milk." When a prescription is sent to the laboratory calling for definite amounts of fat, sugar, and proteids, the product furnished is "modified milk." When a mother is told to use a definite amount of cream, milk, sugar, and water, "modified milk" is also the outcome. As a matter of fact, successful infant-feeding consists in what I have termed "milk adaptation," that is, modifying the milk to suit MODIFIED MILK 55 the case in hand. The routine prescriber is content to prescribe "modified milk," that which was originally supposed to be an imitation of human milk. The best-informed prescriber uses "an adapted modified milk" which he decides is indicated. The analysis of mixed dairy milk shows it to contain approximately : 4.0 per cent. fat. 4.0 per cent, sugar. 3.5 per cent, total proteid. Human milk contains approximately: 4.0 per cent. fat. 7.0 per cent, sugar. 1.5 per cent, total proteid. The Aim of Milk Modification. — The first aim in the modification is to make the chief nutritional elements in the food prepared from cow's milk correspond grossly to the nutritional elements in the human milk. The proteid must be reduced, the sugar increased, and the fat reduced even slightly below that usually found in mother's milk, as the child's digestive capacity for cow's-milk fat is less by from 15 to 25 per cent, than it is for human milk. The Proteid. — The proteid element in an infant's food is its chief nutritional content. This has to be reduced to approximately the pro- portions that exist in human milk, and the change can be accom- plished only by dilution. The diluent may be plain water or it may be a cereal gruel. The average cow's milk contains, as just mentioned: 4.0 per cent. fat. 4.0 per cent, sugar. 3.5 per cent, total proteid. If 8 ounces of milk is mixed with 8 ounces of water, we get a pint mix- ture with an approximate nutritional equivalent of: 2.0 per cent. fat. 2.0 per cent, sugar. 1.75 per cent, total proteid. If 4 ounces of milk is mixed with 12 ounces of water, we have a 16- ounce mixture with an approximate nutritional equivalent of: 1.0 per cent. fat. 1.0 per cent, sugar. 0.9 per cent, total proteid. If 6 ounces of milk is mixed with 10 ounces of water, a 16-ounce mix- ture is produced with an approximate nutritional equivalent of : 1.5 per cent. fat. 1.5 per cent, sugar. 1.3 per cent, total proteid. 56 THE PRACTICE OF PEDIATRICS By this simple dilution with water the desired proteid content of the food may be arrived at. The Sugar. — For nourishment for an infant, however, the mixture is weak in fat and very weak in sugar. The sugar content is increased by the addition of milk-sugar or cane-sugar. It will be remembered that in human milk there is a sugar content of 7 per cent. The com- bination of full cow's milk and water as above gives a sugar content of 2 per cent, or less, so that sufficient sugar must be added to make the increase approximately 7 per cent. What is necessary, then, is to in- crease the sugar content 5 per cent. A 1 per cent, sugar and water mixture would contain approximately 5 grains of sugar to the ounce. A 6 per cent, sugar mixture would contain 30 grains to the ounce, and as our dealings are with a 16-ounce mixture, we require an addition of 16 times 30 grains of sugar-of-milk, or 480 grains, so that if we direct that a pint mixture contain 6 ounces of a 4-4-3.50 milk, 10 ounces water, 1 ounce milk-sugar, there would be an approximate nutritional equivalent of: 1.5 per cent. fat. 7.5 per cent, sugar. 1.3 per cent, total proteid. Or if the mixture were 4 ounces milk, 12 ounces water, 1 ounce milk- sugar, there would be an approximate nutritional equivalent of: 1.0 per cent. fat. 7.0 per cent, sugar. 0.9 per cent, total proteid. The Fat. — While a child of from two to four months might thrive on the above formulas, the fat is obviously deficient and must be increased. This is accomplished by the use of cream. Cream of the same age as the milk should be used. When this method of feeding is carried out, in order to secure a suitable cream, a quart bottle of milk from a mixed herd of grade cows is allowed to stand at a temperature of 40° or 50°F. for five hours, when a cream which will be referred to as "gravity cream" (p. 73) will be produced of the approximate strength of: 16.0 per cent, butter-fat. 3.2 per cent, sugar. 3.2 per cent, total proteid. These were the percentages obtained in an analysis made for me from the Walker-Gordon Laboratory milk, which is produced by grade cows and has an average milk strength as regards the nutritional elements, and may therefore be taken as a guide in using gravity cream for infant- feeding. Cream from well-fed Jersey cows procured in this way will contain from 20 to 24 per cent, of fat. One ounce of gravity cream with 15 ounces of water gives a pint mixture with a nutritional equiva- lent of: MODIFIED MILK 57 1.0 per cent. fat. 0.2 per cent, sugar. 0.2 per cent, total proteid. Two ounces of gravity cream and 14 ounces of water give an approxi- mate nutritional equivalent of: 2.0 per cent. fat. 0.4 per cent, sugar. 0.4 per cent, total proteid. We now wish by using gravity cream (see p. 73) to raise the fat in the milk and sugar-water mixtures given above. In using the cream, all must be removed and mixed, as the upper layers in the bottle are much richer in fat than those nearer the milk. For this skimming process the Chapin dipper (Fig. 4) is em- ployed. Milk which is rapidly cooled immediately after being drawn and kept at a temperature of 50°F. or lower may be skimmed at the end of five hours, when all the cream that will rise will have done so. ILLUSTRATIVE FOOD FORMULAS Gravity cream 1 ounce Milk 4 ounces Milk-sugar 1 ounce Water 11 ounces Gravity cream 2 ounces Wilk 4 ounces Milk-sugar 1 ounce Mater 10 ounces Approximate Percentage Equivalent Fat 2.0 Sugar 7.2 Total proteid 1.1 Approximate Percentage Equivalent Fat 3.0 Sugar 7.4 Total proteid 1.3 Fig. 4.— Self- filling and empty- ing Chapin dipper. In the event of a weak proteid digestion in a young baby, gravity cream alone may be used temporarily; thus 3 ounces cream, 1 ounce milk-sugar, 12 ounces water, 1 ounce lime-water, which mixture gives an approximate nutritional equivalent of: 3.0 per cent. fat. 6.6 per cent, sugar. 0.6 per cent, total proteid. Of if a weaker food is desired for a younger infant, we may use 2 ounces gravity cream, 1 ounce milk-sugar, 133^^ ounces water, 3-^ ounce lime- water, which mixture gives an approximate equivalent of: 2.0 per cent. fat. 6.4 per cent, sugar. 0.4 per cent, total proteid. In the event of a good proteid digestion and poor fat digestion, full milk along with sugar and water should be used; thus 53^ ounces milk, 10 ounces water, 1 ounce milk-sugar, 1% ounces lime-water, which mixture gives an approximate equivalent of: 58 THE PRACTICE OF PEDIATRICS 1.33 per cent. fat. 7.33 per cent, sugar. 1.17 per cent, total proteid. Average skimmed milk with the gravity cream removed contains about 1 per cent, fat, 3.5 per cent, sugar, and 3 per cent, proteid. If for any reason a particularly weak fat food is required, skimmed milk may be used: 53-^ ounces skimmed milk, 9 ounces water, 1 ounce milk-sugar, 1% ounces lime-water, which mixture gives an approximate equivalent of : 0.33 per cent. fat. 7.17 per cent, sugar. 1.00 per cent, total proteid. If a stronger skimmed milk mixture is required, it may be prepared as follows: 8 ounces skimmed milk, 8 ounces water, 1 ounce milk-sugar, which mixture gives an approximate nutritional equivalent of: 0.50 per cent. fat. 7.75 per cent, sugar. 1.50 per cent, total proteid. It will thus be seen that with milk, cream, and sugar-of-milk, food of every possible strength may be made. If Hme-water is used, it simply takes the place of the milk diluent and replaces so much water. This method of milk preparation is more accurate than when top-milk mixtures are used, but it has the disadvantage of requiring two quarts of milk during the entire feeding period, one to supply the milk and the other the cream, all of which must be removed and mixed before any of it is used in the food. The following formulas for the different ages may be found useful for well babies : From the first to the third day: Milk-sugar J^^ ounce Boiled water 16 ounces }i to 1 ounce every two or three hours which mixture gives an approximate nutritional equivalent of 3 per cent, sugar. From the third to the tenth day: Gravity cream % ounce Approximate Percentage Equivalent Milk 43>^ ounces Fat 1 . 25 Milk-sugar 1 J^ ounces Sugar 6 . 85 Lime-water 1 ounce Total proteid . 75 Boiled water to make 24 ounces Seven feedings in twenty-four hours; 2 to 3 ounces at each feeding. One ounce = 12.8 calories. From the tenth to the twenty-first day: Gravity cream 1^^ ounces Approximate Percentage Equivalent Milk GJi ounces Fat 1.7 Milk-sugar 2 ounces Sugar 7.0 Lime-water 2 ounces Total proteid . 89 Water to make 30 ounces Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. One ounce = 14.4 calories. MODIFIED MILK 59 From the third to the sixth week: Gravity cream 2J^ ounces Approximate Percentage Equivalent Milk 8 ounces Fat 2 . 25 Milk-sugar 2 ounces Sugar 7.25 Lime-water 2 ounces Total proteid 1 . 13 Water to make 32 ounces Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. One ounce = 16.6 calories. From the sixth week to the third month: Gravity cream 3 ounces Approximate Percentage Equivalent Milk 9 ounces Fat 2.6 Milk-sugar 2 ounces Sugar 7.4 Lime-water 2^-^ ounces Total proteid 1.3 Water to make 32 ounces Seven feedings in twenty-four hours; 4 to 5 ounces at each feeding. One ounce = 18 calories. From the third to the fifth month: Gravity cream 4 ounces Approximate Percentage Equivalent Milk 15 ounces Fat 3.1 Milk-sugar 2 ounces Sugar 6.8 Lime-water 3 ounces Total proteid 1.6 Water to make 40 ounces Six feedings in twenty-four hours; 5 to 6 ounces at each feeding. One ounce = 18.9 calories. From the fifth to the seventh month: Gravity cream 6 ounces Approximate Percentage Equivalent Milk 18 ounces Fat 3.6 Milk-sugar 2 ounces Sugar 6.6 Lime-water 3 ounces Total proteid 1.9 Water to make 42 ounces Five to six feedings in twenty-four hours; 6 to 7 ounces at each feeding. One ounce = 20.5 calories. After the fifth month it is my custom to add from one to three tea- spoonfuls of a cereal jelly to each feeding. This may be added to the milk mixture when it is made in the morning. Thus, if one teaspoonful is to be given at each feeding, where a child is getting six feedings, six teaspoonfuls of the jelly may be added to the entire quantity. From the seventh to the ninth month: Gravity cream 6 ounces Approximate Percentage Equivalent Milk 23 ounces Fat 3.9 Milk-sugar 2 ounces Sugar 6.5 Lime-water 3 ounces Total proteid 2.1 Water to make 48 ounces Five feedings in twenty-four hours; 7 to 8 ounces at each feeding. One ounce = 21.4 calories. From the ninth to the twelfth month: Gravity cream 7 ounces Approximate Percentage Equivalent Milk 32 ounces Fat 4.28 Lime-water 4 ounces Sugar 7 . 25 Milk-sugar 2 J i ounces Total proteid 2.4 Water to make 56 ounces Five feedings in twenty-four hours; 8 to 9 ounces at each feeding. One ounce = 23.8 calories. Top-milk Feeding. — In using top-milk for infant-feeding the milk is allowed to stand in a quart bottle at a temperature of 45° to 50°F. 60 THE PRACTICE OF PEDIATRICS five hours. The quantity needed is then removed from the top of the bottle with a Chapin dipper (Fig. 4) and diluted as desired with water or gruel to which sugar-of-milk and lime-water are added. The milk selected should be the cleanest obtainable from grade cows; usually the most expensive is the best. From a quart bottle of milk on which the cream has risen, dip from the top with a Chapin dipper 16 ounces and mix. From average milk this should contain: 7.0 per cent. fat. 3.2 per cent, sugar. 3.2 per cent, total proteid. The following top-milk formulas are suggested for the various ages noted : From the third to the tenth day: Milk (top 16 OZ.) 6 ounces Approximate Percentage Equivalent Lime-water % ounce Fat 1 . 75 Milk-sugar 1 J^ ounces Sugar 6.6 Boiled water to make 24 ounces Total proteid 0.8 Seven feedings in twenty-four hours; 2 to 3 ounces at each feeding. One ounce = 12.5 calories. From the tenth to the twenty- first day: Milk (top 16 OZ.) 7/-^ ounces Approximate Percentage Equivalent Lime-water 2 ounces Fat 1 . 75 Milk-sugar 2 ounces Sugar. . 6.8 Water to make 30 ounces Total proteid 0.8 Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. One ounce = 14.2 calories. From the third to the sixth week: Milk (top 16 OZ.) 10 ounces Approximate Percentage Equivalent Lime-water 2 ounces Fat 2.2 Milk-sugar 2 ounces Sugar 7.0 Water to make 32 ounces Total proteid 1.0 Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. One ounce = 16 calories. From the sixth week to the third month: Milk (top 16 OZ.) 12 ounces Approximate Percentage Equivalent Milk-sugar 2 ounces Fat 2.6 Lime-water 2 ounces Sugar 7.2 Water to make 32 ounces Total proteid 1.2 Seven feedings in twenty-four hours; 4 to 5 ounces at each feeding. One ounce = 17.5 calories. From the third to the fifth month: After this age two bottles of milk are required, 16 ounces being taken from the top of each bottle and mixed. At this time a cereal jelly is usually added to the food. Milk (top 16 OZ.) 18 ounces Approximate Percentage Equivalent Milk-sugar 2 ounces Fat 3.15 Lime-water 3 ounces Sugar 6.4 Water to make 40 ounces Total proteid 1.4 Six feedings in -twenty-four hours; 5 to 6 ounces at each feeding. One ounce = 18.3 calories. MODIFIED MILK 61 , From the fifth to the seventh month: Milk|(top 16 OZ.) 21 ounces Approximate Percentage Equivalent Milk-sugar 2 ounces Fat • 3 . 50 Lime-water 3 ounces Sugar 6.4 Water to make 42 ounces Total proteid 1.6 Five to six feedings in twenty-four hours; 6 to 7 ounces at each feeding. One ounce = 19.6 calories. From the seventh to the ninth month: Milk (top 16 OZ.) 27 ounces Approximate Percentage Equivalent Milk-sugar 2K ounces Fat 3.9 Lime-water 3 ounces Sugar 7.0 Water to make 48 ounces Total proteid 1.8 Five feedings in twenty-four hours; 7 to 8 ounces at each feeding. One ounce = 21.7 calories. Frojn the ninth to the twelfth month: Milk (top 16 OZ.) 35 ounces Milk-sugar 2}4 ounces Fat 4.3 Lime-water 4 ounces Sugar 6.5 Water to make 56 ounces Total proteid 2.0 Five feedings in twenty-four hours; 8 to 9 ounces at each feeding. One ounce = 22.4 calories. After the twelfth month, plain cow's milk may be given with the cereal jelly in addition to the other articles of diet suggested for a child one year old. (See p. 105.) Considerable latitude is allowed as to the amount of food which may be given at each feeding, because of the difference in the capacity of individual children. It will be observed that the total quantity of food prepared may be a few ounces more than the amount which the child will ordinarily take in twenty-four hours. This extra amount often serves a most useful purpose when a bottle is broken or the food is otherwise lost. The average well child will require daily about 30 ounces of a suitably adapted food at the third month, about 36 ounces at the sixth month, and 40 to 45 ounces at the ninth to the twelfth month. Night Feedings. — After the third month the midnight feeding should be discontinued. Six feedings are sufficient, the first at 6 a. m. and the last at 10 p. m. Between 10 p. m. and 6 a. m. the child should sleep. Babies are easily weaned from the night bottle by substituting a bottle of boiled water or a milk mixture greatly diluted with water. The child soon discovers that this is not worth waking for. As a result of a fullnight's rest the digestive organs are better able to do their work, the appetite is increased, and. a larger amount of food may be given at each feeding. The Quality of Milk Variable. — It is not claimed that the nutri- tional value as indicated by the percentage equivalents in either of the above series is absolutely correct. Milks necessarily differ in com- position. Only mixed dairy milk is referred to, the product of several grade cows. The feeding of the cows and their care also influence the quality of the milk. The percentages given indicate approximately the nutritional value and are sufficiently accurate for purposes of 62 THE PRACTICE OF PEDIATRICS supplying satisfactory nutrition to well babies of the various ages, as, I have abundantly proved to my own satisfaction. The fat will not be found too low for proper nutrition in any of the formulas given. It may be too high for proper digestion and require adjustment. The proteids as given are sufficient for nutrition if they are assimilated. They also may require reduction to meet special conditions which are referred to under Milk Adaptation (p. 62). The adjustment of the food to the individual constitutes what I have termed ''milk adapta- tion," and suggestions for making the food fit the child's digestive capacity will be found under that caption. Adapted Milk. — In adapting milk for infant-feeding the milk must not only be "modified" (p. 54), by which process the nutritional ele- ments are changed in their proportions so as to make them conform as nearly as possible to mother's milk, but more is required — the food must be adapted to the child's digestive capacity. If the modification of milk, as we formerly understood, constituted all that was required in infant-feeding, the artificial feeding of infants would be a comparatively simple matter. Some infants will take read- ily any reasonable modification which by experience has been found suitable for children of their age. The majority, however, who are fed on cow's milk, must be fed according to their digestive capabilities. Every feeding case must be studied from the individual standpoint. How best to nourish the individual can be learned only by a study of the patient himself. No process of manipulation by the addition of chemicals or gruels can convert cow's milk into human milk. Various means, however, are available sufficient to overcome the existing dif- ferences, thereby making a suitable food even for those who at first show signs of marked intolerance of cow's milk. The strength of the food and the feeding intervals required for average well children of the different ages are given in the chapters on Modified Milk, p. 54. Symptomatic Adaptation. — If the child is getting a food of suitable strength at proper intervals and becomes ill, the food as a whole may be beyond his digestive capacity, or there may be an incapacity for one or more nutritional elements. If the food as a whole is too strong, there is very commonly vomiting, which may become habitual, or there may be colic or constipation or diarrhea. If the food as a whole is too weak, the fact will be evidenced by hunger, failure to gain in weight, and usually by constipation. If sugar is given in excess — a compara- tively rare cause of trouble, if not more than 7 per cent, of milk-sugar is given — it will be indicated by the regurgitation of sour, watery material. A sour odor to the patient's breath and clothing indicates sugar excess. There may not be pronounced vomiting in such a case, but the repeated regurgitation when the patient is awake is sufficient to deprive him of a goodly amount of his daily food. The digestion of both fat and proteid may be markedly interfered with, and the whole digestion deranged as a result of what was primarily a sugar incapacity or sugar excess. When sugar is at fault, the indigestion may readily be corrected by washing out the stomach for a few days (p. 788) and MODIFIED MILK 63 by reducing the sugar content of the food one-half. Later, after the condition is reheved, the sugar may gradually be increased to the nor- mal percentage of 7. A child may be getting but a 2 per cent, cow's- milk-fat mixture and yet suffer from fat-indigestion. Excessive fat or fat incapacity also gives rise to vomiting and regurgitation in which particles of fat may often be seen. Fat, moreover, may cause frequent green, undigested stools, the passage of which is associated with marked tenesmus. Fat-diarrhea is often the outcome of fat-indigestion. Cow's-milk fat was not intended for babies, and when it disagrees — since we cannot change its character — our only method of adaptation is to reduce the amount given, as with the sugar. Casein. — The casein in cow's milk is its important nutritional constituent, and in adapting cow's milk to a child's digestive capacity the casein is oftentimes a most difficult factor to deal with. Tempo- rarily it may be reduced with safety to a percentage below that of cow's milk — to 0.25 per cent., for instance — but it must be remembered that the patient cannot thrive or even long exist without this proteid ele- ment in the diet, so that a reduction will always be followed by malnu- trition. It is necessary, then, to give proteid, and successful infant- feeding means that we must adapt the proteid to the child's digestive capacity. This, fortunately, is oftentimes possible. The Use of Alkalis and Antacids. — The casein of human milk when it enters the infant's stomach separates into small, fiocculent masses. Cow's milk entering the infant's stomach, without an addition of an alkali or other modifying medium, is precipitated by the pepsin in the stomach and forms a heavy curd, consisting of paracasein, which fails of digestion or assimilation, and at which the child's stomach oftentimes rebels. The adaptation of the casein of cow^s milk to the child's diges- tive capacity, so as to maintain suitable nutrition, is a central point arouiid which the whole subject of infant-feeding revolves. It will be noted in the formulas for cow's-milk feeding for different ages that lime-water is used as a diluent. This is used not simply as a diluent of cow's milk nor to render the milk alkaline, as has frequently been stated; it is used to prevent the coagulation of the casein and the resulting forma- tion of tough curds of paracasein. Simple dilution with water may make a smaller curd, but does not produce the fiocculent character peculiar to human milk that follows the addition of alkalis and antacids to cow's milk. In the presence of an alkali the casein does not com- bine with the acid in the stomach; consequently the resulting acid coagulation does not take place. For this reason alkalis and antacids are added to cow's milk. Poynton, of London, advocates the use of citrate of soda with a view to preventing the solid coagulation of the casein. It is claimed that by using citrate of soda, 1 grain to the ounce, sodium paracasein is pro- duced, which is a fluid. Citric acid is liberated and unites with the calcium, forming the citrate of calcium, which is absorbed. Signs of indigestion of the casein in the milk are usually pain and discomfort. There are usually acute attacks of colic. There may be 64 THE PRACTICE OF PEDIATRICS constipation, or diarrhea alternating with constipation, associated with the passage of many hard curds in the stools, the patient losing steadily in weight. In such instances the best means of adaptation consists in reducing the amount of proteid to a total of 1 per cent, by dilution with water, and the addition of sufficient antacids, such as lime-water, bicarbonate of soda, or citrate of soda, to form a curd more readily attacked by the digestive juices. The writer feeds many hundreds of infants yearly, and is not in accord with the belief, which is now fashion- able, that the casein of cow 's milk is a factor of no im'portance in the adap- tation of cow 's milk. Whey-feeding. — Whey mixtures may be of temporary use in these cases. In whey the casein is largely removed — about 0.3 per cent, remaining. Analyses of whey show a nutritional equivalent of about: 0.5 per cent. fat. 0.9 per cent, lactalbumin. 0.3 per cent, casein. 4.5 per cent, sugar. As whey is ordinarily made, it is impossible to obtain a lower percentage of casein than 0.25. The amount of casein will oftentimes reach 0.5 per cent, unless it is heated and strained a second time. The deficiency in fat may be overcome by adding gra.vity cream (p. 73) of the same age as the milk from which the whey is obtained, in the proportion of one or two ounces to a pint of whey. This, of course, carries with it a very small amount of casein, which may make a total beyond the child's digestive capacity. Low proteid must be given only during acute illness or indigestion, and should be a diet for temporary purposes until the child is able to care for more suitable nourishment. Adaptation by the Use of Cereal Gruels. — Cereals may be added to milk with advantage from two standpoints : they increase the nutritive value of the food mixture and when cooked with milk add very mate- rially to the digestibility of the milk, particularly if an antacid like carbonate of soda or citrate of soda is added in small amounts — 5 grains to the day's allowance. That the cooking of milk with starch is of distinct value has been abundantly proven in the use of malt soup. Malt-soup Feeding. — The use of Loeffiund's nialt-soup extract (a preparation of malt and potassium carbonate), Keller's formula, offers a most satisfactory method of making cow's milk assimilable. It is not well borne in vomiting cases nor those in which there is a tendency to looseness of the bowels. When either of these conditions exists skimmed milk may be temporarily substituted. In following this method of feeding, the milk strength considered suitable for the condition and age of the child may be used. Lime- water is not employed because of the presence of carbonate of potash in the malt. The malt and the flour, a considerable portion of the latter having been dextrinized, take the place of milk sugar or cane- sugar in the food mixture. MODIFIED MILK 65 The chief use of this food is in malnutrition cases, in slow-growing infants, who though not actually ill, fail to show a satisfactory growth on any other food given. Time and again I have seen these children show surprising increase in weight without change in the milk strength when the malt-soup with its flour accompaniment was used. In treating bottle-fed infants who suffer from colic and marked con- stipation this food has a considerable field of usefulness. Malt-soup extract is not to be used in the strength indicated on the bottle, as the amount is entirely too high. I have found the following method the most satisfactory: For a 30-ounce mixture, dissolve 1 ounce of the malt extract in the amount of water used. Mix and blend from 1 to 2 ounces (by measure) of Robinson's Barley Flour or Imperial Granum with the milk, cream, or top-milk required. If there is abdominal distention and flatulence or other evidence of carbohydrate incapacity, the amount of flour should be reduced per- haps one-half. The milk and flour mixture is to be strained and added to the solution of malt and water. It should then be placed over a slow fire and "simmered" for thirty minutes, with constant stirring. Instead of using wheat flour as directed on the package of malt soup, I have for some time been using Robinson's Barley Flour (baked barley flour) or Imperial Granum (baked wheat flour) with better results in many difficult cases than when raw wheat flour was used. In the event of constipation continuing, the amount of malt used may be doubled. Excess of malt, however, may produce vomiting, so that any increase should be made with caution. Eiweiss Milch (Protein Milk). — The Eiweiss Milch of Finkelstein and Meyer is prepared as follows: To one quart of milk heated to 100°F. add one junket tablet dis- solved in water, and stir for a few seconds. Stand at room tempera- ture until firmly coagulated: strain through gauze and wash curd twice with cold boiled water. Rub dry curd through fine wire sieve, gradually adding one pint of lactic-acid milk. Enough boiled water is then added to make one quart. Lactic Acid Milk. — ^Lactic acid milk is prepared as follows: One Lactone Tablet (Parke, Davis & Co.) is added to one quart skimmed milk, and allowed to stand at 98°F. for twenty-four hours. Eiweiss Milch (Protein Milk) is a most satisfactory diet for infants acutely ill with diarrheal disturbances. (One grain of saccharine may be added to each pint to make it more palatable.) It may be given with advantage when plain cow's milk is dangerous. It may be used at all ages. It is well taken by most infants after a few trials; It is usually well retained. The stools improve rapidly under its use, be- coming yellow and smooth. It constitutes a means of nutrition, which may be brought into use much earlier than plain modified cow's milk, thus taking the place of the cereal decoctions. Our plan in a given case of acute intestinal intoxication is as follows : Two teaspoonfuls of castor oil are given. This is followed by plain barley-water, one ounce to the pint, for twenty-four hours. At the 5 66 THE PRACTICE OF PEDIATRICS end of this time, regardless of the character of the stools, the Eiweiss Milch is introduced. Aside from what action the protein milk may- possess as a remedial agent, it furnishes a food that may be given with safety in all cases during a very trying period. I usually begin with equal parts of Eiweiss Milch and barley-water and later increase the milk strength about 25 per cent. Children kept on the Eiweiss Milch for a considerable period rarely continue to do well, so that cow's milk is to be resumed as soon as it is thought safe, perhaps after a week or two. The Calorimetric Standard. — The calorimetric standard is based upon the amount of energy indicated in calories for each pound of body weight. A calorie is the amount of heat required to raise the tempera- ture of one liter of water 1°C. Heubner, of Berlin, several years ago began the employment of cal- orimetric principles in infant-feeding. His original observations, which were made on healthy breast-fed infants, weighed before and after each feeding, showed that under six months 100 calories were required daily for every kilogram of body weight. After the sixth month, the number of calories required gradually lessened, so that at the comple- tion of one year about 85 calories to each kilogram of body weight appeared to be necessary. Lamb has reduced Heubner 's figures to pounds. He gives the calorimetric requirements during the first three months of life as 45 calories daily per pound of body weight, during the next three months from 40 to 45 calories daily per pound, decreasing gradually during the next six months, so that at the twelfth month from 32 to 35 calories daily per pound of body weight are necessary. The following table represents the caloric values of foods ordi- narily employed in infant feeding. CALORIC VALUES 1 ounce 7 per cent, milk 27.5 1 ounce 4 per cent, milk 20 1 ounce Fat Free Milk 10 1 ounce Breast Milk 20 1 ounce Barley Flour 100 1 ounce Barley Water (1 tablespoon to 1 pint) 2.0 1 ounce Oat Flour 110 1 ounce Imperial Granum 100 1 ounce Milk Sugar . . . .• 116 1 ounce Dextro- Maltose 100 1 ounce Malt Soup 80 1 ounce Sweetened Condensed Milk 132 1 ounce Unsweetened Condensed Milk 42 CEREAL GRUELS; STARCH-FEEDING Much discussion has taken place concerning the use of cereals in infant-feeding. The cereals consist of plant embryos surrounded by a mass of highly nutritious proteids and carbohydrates in the form of starch, which nourish the embryonic plant until it becomes rooted in the ground. CEREAL gruels; STARCH-FEEDING 67 As the developing plant needs nourishment it converts the starch into dextrin and maltose. Cereals are analogous to eggs in that the germ is packed away in a supply of exceedingly nutritious food, which in the process of development it converts into tissue. Almost all of the pre- pared infant foods are made from cereal flours, with or without the addition of a little dried milk or sugar; or from cereals in which the starch has been transformed into dextrin and maltose. The proprie- tary meal foods, which consist of baked flours of different kinds, are useful aids in infant-feeding and most useful as milk substitutes when milk must temporarily be withheld. The conversion of starch into dextrin by the baking process is so slight that it may be ignored. Robinson's barley flour, Cereo Co.'s barley flour and the other gruel flours, and Imperial Granum (baked wheat flour) require boiling before use. They may be prepared according to the instructions given in the formulary (p. 71). It is my custom in bottle-feeding to begin with a cereal from the fifth to the seventh month, by using a cereal water as a diluent of the milk mixture. For this purpose barley or granum is usually employed. Very often in out-patient work I begin with a cereal diluent very early in life in order to make the food mixture more nutritious. This method of feeding is useful when accurate modifications are not possible and when the child for any reason cannot take a milk formula as strong as age and nutritional requirements demand. Such cases are frequently seen in the marasmic, the malnutrition, and the difficult feeding class. The addition of two or three tablespoonfuls of flour to the daily food will increase its nutritive value not a little. That boiled starch may be digested by the youngest and most marasmic infant has been proved under my own observation. The principal use of these flours, however, is in -the treatment of gastro-enteric diseases, where cereal may with safety replace the milk for considerable periods of time. By eliminating milk from the diet and giving carbohydrates, a putrefactive culture-fleld is removed and a less favorable soil is furnished for the development of the intestinal bacteria; further, there are no by-products formed to produce intestinal toxemia or kidney irritation. Two even tablespoonfuls of these flours to one pint of water give approximately a food strength of 0.07 per cent, fat, 0.3 per cent, proteid, 2 per cent, carbohydrate. In order to increase the nutritive value, cane-sugar may be added in sufficient quantity to bring the carbohydrate percentage up to 5. The addition of the sugar also makes the cereal more palatable, and therefore more acceptable to the patient. During an invasion of scarlet fever, pneumonia, or any of the ill- nesses of childhood which may be accompanied by great prostration, the usual foods, whatever their nature, should be withheld, and the cereal gruel alone or mixed with chicken or mutton broth used as a very satisfactory substitute. Likewise later in the disease it is never well to give full milk while fever and prostration are present. Cereal gruels are especially serviceable as diluents of the milk in conditions where 68 THE PKACTICE OF PEDIATRICS this combination must often furnish the nutrition for days. The use of the baked-flour gruels, with sugar or without, as a means of nutri- tion should be continued only during the active symptoms of the disease, whether it is scarlet fever or one of the intestinal diseases. In no sense are these gruels advocated as exclusive foods for infants or for growing children. . I have seen many cases in which this error has been made with most disastrous results. The Infant's Capacity for Starch Digestion Proved hy Experiment. — ■ It has been claimed with^nore or less tenacity by different writers that the young infant possesses no capacity for starch digestion. That the youngest infants may digest starch is now definitely established. The experiments of Moro, Zwiefel, Corwin, Hess* and the Author! have proven the earlier beliefs erroneous. PEPTONIZED MILK Milk is peptonized, or predigested, for the purpose of partially or completely digesting the proteid before it is given to the patient. As a means of assistance in making a milk food assimilable the usefulness of peptonization is limited. So-called complete peptonization pro- duces a product with a decidedly bitter taste, which few children will take. Peptonized milk, however, has other uses than as a means of daily feeding. Peptonized milk in which there is a complete conversion of the casein has been most useful in two types of cases : For Gavage. — During acute or chronic illness when a child cannot take food by the natural method, as in diphtheric paralysis, or when he will not swallow on account of an acute inflammatory disease of the throat, such as peritonsillitis, retropharyngeal abscess, or retropharyn- geal adenitis, or when he is in a comatose condition from any cause except intestinal infection, the feeding of completely peptonized milk by gavage (p. 790) is of inestimable value. For Nutrient Enema. — In conditions when stomach-feeding is im- possible either by gavage or the natural method — conditions met with in persistent vomiting due to acute cerebral diseases, in recurrent vomit- ing, in acute gastric indigestion — and as an accessory means of feeding when sufficient nourishment cannot be taken by the stomach, the colon- feeding of completely peptonized, skimmed milk has a decided field of usefulness, and in this way I often employ it. Feeding children by means of the bowel, however, is usually possible for a few days only, be- cause of the local irritation produced by the nutriment and by the pas- sage of the tube. Skimmed milk, peptonized, with the addition of the white of egg makes the best nutrient enema that I have used. It should be given at a temperature between 90° and 95°F, at from six- to eight-hour intervals. The tube should be introduced at least 9 inches. In cases of recurrent vomiting I have repeatedly seen both hunger and thirst relieved by feeding in this way. The following are the different methods for the peptonization of milk: * American Journal Diseases of Children. t Kerley, Mason and Cray. MILK FOR TRAVELING 69 Peptonization. — Immediate Process. — Fifteen minutes before feed- ing add from }'g to 3^^ of the contents of a Fairchild peptonizing tube to the milk mixture which is in the nursing-bottle ready for use. Place the bottle in water at a temperature of from 110° to 120°F., and let it remain for fifteen minutes. The amount of the powder used and the degree of heat of the water depend, of course, upon the amount of milk in the nursing-bottle. Cold Process. — Put 4 ounces of cold water into a clean quart bottle and dissolve in it, by shaking thoroughly, the powder contained in one of the Fairchild peptonizing tubes; add a pint of cold fresh milk, shake the bottle again, and immediately place it upon ice — directly in con- tact with it. The bottle should always be well shaken before and after pouring out a portion of its contents. Partially Peptonized Milk. — Put 4 ounces of cold water and the powder contained in one of the Fairchild peptonizing tubes into a clean saucepan, and stir well; add a pint of cold fresh milk and heat to the boiling-point, stirring constantly. The heat should be so applied that the milk will come to a boil in ten minutes. Let it cool until luke- warm, then strain into a clean bottle or glass jar, cork tightly and keep in a cold place. The bottle or jar should always be well shaken before and after pouring out a portion. Partially peptonized milk, if properly prepared, will not become bitter. Completely Peptonized Milk. — Put 4 ounces of cold water and the powder contained in one of the Fairchild peptonizing tubes into a clean quart bottle and shake thoroughly; add a pint of cold fresh milk and shake again ; then place the bottle in a pail or kettle of warm water at about 115°F., or not too hot to immerse the hand in it without dis- comfort. Keep the bottle in the water-bath for thirty minutes. Put it immediately upon ice — directly in contact with it. MILK FOR TRAVELING In making long journeys with infants by land or water, the feeding of the child is an important matter, and advice is often sought by moth- ers who wish to make the contemplated trip with the least possible risk. It is, of course, desirable that no change be made in the milk commonly used, and there are means of treating the milk and of keep- ing it which enable us to assure the patient of reasonable safety. It is my custom with city children to have the milk prepared at the Walker-Gordon Laboratory, where at a trifling expense small ice-boxes can be obtained which contain sufficient space for a few days' supply of milk and which can be conveniently carried on cars and boats. Larger boxes with a capacity of 12 quarts may be used for an ocean voyage. The smaller box will need refilling with ice, which is usually readily secured once or twice a day. The larger box for ocean voyages is packed in ice and placed in a cold-storage room of the vessel and will not need repacking during the trip. The milk prepared for a journey 70 THE PRACTICE OF PEDIATRICS should be cooled to 45°F. as soon as it is drawn, and kept at this tem- perature until it can be sterilized at a temperature of 212°F. for twenty minutes. It should then be cooled rapidly to at least 50°F. and kept at this point until used. These directions can be carried out by any intelligent family. When this is done, the milk will be safe for use for the time required — from seven to eight days. Of course, laboratory milk is available for comparatively few. But the suggestion as to the making of an ice-box can be followed in any town or village, so that a milk laboratory is not essential. All that is required is the ice-box, ice, the quart fruit-jars or quart milk-bottles, and clean milk. Those who for any reason cannot avail themselves, of the milk thus preserved will find in canned condensed milk a fairly good substitute. See Condensed Milk (p. 95). FOOD FORMULAS Beef-juice. — Take a round steak, cut into pieces the size of a horse- chestnut, place in a buttered pan in a hot oven, and bake for fifteen minutes; remove from the pan and press out the blood; add salt to the taste. Beef, Mutton, and Chicken Broth. — Take one pound of meat free from fat, cook for three hours in one quart of water, adding water from time to time, so that when the cooking is completed there will be one quart of broth. When the broth is cool, remove the fat, strain, and add salt to the taste. Scraped Beef.— Broil round steak slightly over a brisk fire. Split the steak and scrape out the pulp, using a dull knife. Egg-water. — The white of one egg, thoroughly beaten in one pint of cold boiled water; strain; add salt to the taste. Oatmeal Jelly. — Oatmeal, four ounces; water, one pint; boil for three hours in a double boiler, water being added, so that when the cooking is completed a thin paste will be formed. This while hot is forced through a colander to remove the coarser particles. When cold, a semi-solid mass will be formed. Wheat Jelly and Barley Jelly. — Wheat jelly and barley jelly are made in the same way as oatmeal jelly, using cracked wheat or barley grains. Barley-water No. i. — Robinson's barley flour or Cereo Co.'s barley flour, one rounded tablespoonf ul ; water, one pint. Boil thirty minutes; strain; add water to make one pint. In making barley-water No. 2 two tablespoonfuls of the flour are used, and for No. 3 three tablespoonfuls are used. Imperial Granum is used in strengths identical with barley. Rice-water No. i. — Rice, one tablespoonf ul ; water, one pint; boil three hours, adding water from time to time, so that there is one pint of rice-water at the end of the three hours. In making rice-water No. 2 two tablespoonfuls of rice are used. Percentage Gruel Flours. — There has recently been put on the market in tin boxes, the covers of which are used as measures, a series THE PROPRIETARY FOODS 71 of flours, especially made for preparing cereal gruels and jellies of known percentage composition. On the labels are given only the cooking directions for preparing plain or dextrinized gruels, and their com- position when different quantities of flour are used. They are as follows : APPROXIMATE COMPOSITION OF GRUELS MADE FROM GEREO GO.'S GRUEL FLOURS Barley Legume* Oat Wheat 4i Is PL, n 4i O u I.