COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64078736 R J45 D92 1917 Pediatrics : the \ intt)e€itp0f3^rmg0rk */. / College of ^fipgictang ant burgeons Hibvavv Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/pediatricshygien01dunn THOMAS MORGAN ROTCH, M. D. PEDIATRICS The Hygienic and Medical Treatment OF CHILDREN BY CHARLES HUNTER DUNN, M. D. INSTRUCTOR IN PEDIATRICS, HARVARD UNIVERSITY PHYSICIAN IN CHIEF AT THE INFANTS' HOSPITAL FOUNDED UPON THE TEACHINGS OF THOMAS MORGAN ROTCH, M. D. VOLUME I Second Edition THE SOUTHWORTH COMPANY, PUBLISHERS TROY, NEW YORK 1917 Copyright 19 17 By The Southworth Company To Clarence John Blake, M.D., O.M. (Vienna), F.A.C.S. Professor of Otology (Emeritus), Harvard University This Volume is Inscribed As a tribute to his high professional attainments and to his unfailing interest in the welfare of children, and in grateful remembrance of many acts of kindness By the Author PREFACE The "Pediatrics" of Dr. Thomas Morgan Rotch was for many years the official text-book used in the Harvard Medical School. Professor Rotch originated many new ideas, and his book contained many contributions of permanent value in the teaching of pediatrics. The last edition was published in 1906, and is now entirely out of date. At the time of Dr. Rotch's death, he was contemplating the bringing out of a new edition. It seemed a pity that the permanent and distinctive features of Dr. Rotch's teaching, which constitute the foundation of the teaching of pediatrics at Harvard, should not be preserved in written form. As much therefore of this teaching as has seemed to the author of permanent value, has been incorporated in the present work, with such revision as modern progress demands. The work is not, however, designed to be merely a revision of Dr. Rotch's book. It is designed to be an entirely new modern text-book of the diseases of infancy and childhood. Recent progress in the diagnosis and treatment of disease is be- coming more and more centered upon the problems of etiology. For this reason, especial attention has been devoted to the discussion. of the causes of the various diseased conditions of early life. Modern diagnosis concerns itself less with names than in former times, and consists in a recognition of the nature of the lesions and functional disturbances which constitute disease, and of their causes. Modern treatment concerns itself mainly with the prevention or removal of etiological factors. Progress in knowledge is so rapid, that before a book on any sub- ject in medicine is published, it is likely to be already out of date. One reason for this is that the writers of text-books hesitate to in- corporate many new advances in research for fear that they will not stand the test of final proof. This leads to the exclusion of much material which does prove of final value, and justifies the criticism that the latest advances, the things which are being most widely discussed, are not to be found in the most recent text-books. The author has in this book attempted to obviate this difficulty, by means of a special subdivision under each disease, which, under the heading of Problems and Research, deals with the most recent advances in scientific medicine, and summarizes the problems awaiting future solution. The reader can thus easily distinguish the proven facts from the interesting and suggestive theories. VI Preface The author acknowledges his indebtedness to Dr. WilHam W. Howell, and Miss Margaret Farquhar, Head Social Worker at the Infants' Hospital, for many valuable suggestions, to Dr. Joseph I. Grover for revision of manuscript, to Dr. John W. Hammond for assistance in collecting material for the division on gastro-intestinal diseases, to Dr. William Weston for supplying material for the article on pellagra, and to Dr. Percy Brown for selecting and collecting the roentgenograms. CONTENTS DIVISION I THE NORMAL CHILD PAGE I. — Introduction i II. — ^The Infant at Term 3 Physical Examination 3 Internal Structure 5 III. — Normal Development 8 Physical Examination 8 Internal Structure 27 IV. — Hygiene and Care of Normal Infants 34 Care of the Newborn 34 Weighing '. 35 Bathing 35 Care of the Mouth and Teeth 36 Care of the Skin 37 Care of the Genitals 37 Care of the Hair 37 Clothing 37 Sleep 42 F esh Air and Going Outdoors 42 Exercise 45 Hygiene of the Nervous System 46 Training and Discipline — Habits 48 The Nursery 51 Nursery Maids 52 Prevention of Exposure to Contagion 53 Summer Resorts 53 The Daily Routine of the Normal Child 53 DIVISION II disease in early life I. — Etiology and Classification 55 The Causes of Disease 56 How the Various Causes Act in Producing Disease 57 The Classification of Disease 59 II. — Pathological Anatomy 60 III. — Symptomatology and Diagnosis 63 The History 63 a. Significance of Symptoms in Early Life 64 b. The Family History 64 c. The Previous History 65 d. The Present Illness 66 e. General Questions as to Symptoms 67 The Physical Examination 67 a. Method of Examining a Sick Child 67 viii Contents III. — Symptomatology and Diagnosis — Continued. The Physical Examination — Continued. page b. General Examination of the Body 72 (i) Nutrition, size, weight 73 (2) Skin 73 (3) Position of the body 73 (4) Mental condition 73 (s) Lymphnodes 74 (6) Bones and joints 74 (7) Muscles 74 (8) Temperature 75 (9) Pulse 75 (10) Respiration 76 c. The Head 77 (i) The cranium 77 (2) The facies 78 (3) The eyes 79 (4) The nose 79 (5) The mouth 80 (6) The throat 81 (7) The nasopharynx 82 (8) The larynx 83 (9) The ear 83 (10) The neck 83 d. The Chest 84 (i) Inspection 84 (2) Palpation 85 (3) The thymus ' 85 e. The Heart 85 (i) Inspection 85 (2) Palpation 85 (3) Percussion 86 (4) Auscultation 86 f . The Lungs 87 (i) Inspection 87 (2) Palpation 87 (3) Percussion 87 (4) Auscultation 90 g. The Abdomen 93 (i) Inspection 93 (2) Palpation 94 (3) The stomach 95 (4) The liver 95 (5) The spleen 95 (6) The kidneys 96 (7) The bladder 96 (8) The external genitals 97 (9) The anus 97 (10) The rectum 97 h. The Extremities 97 (i) The limbs 97 (2) The spine 99 Contents ix III. — Symptomatology and Diagnosis — Continued. The Physical Examination — Continued. page i. The Nervous System 99 (i) Testing the mental condition 99 (2) Paralysis and spasm 99 (3) The reflexes 100 (4) Special signs loi (s) Sensation 104 (6) The special senses 104 Special Methods of Examination 105 a. Lumbar Puncture 105 b. Thoracentesis 108 c. Exploratory Puncture of the Peritoneal Cavity 108 d. Exploratory Puncture of the Pericardial Cavity 109 e. Examination of Gastric Capacity 109 1. Examination by Duodenal Catheter 109 g. The Electrical Reactions 109 h. Laryngoscopy no i. Ophthalmoscopy no j Rectal Examination no k. Roentgen Ray Examination no Laboratory Methods of Diagnosis no a. The Urine 112 b. The Blood n8 c. The Stools 125 d. The Cerebrospinal Fluid 13° e. Exudates and Transudates 134 f . The Vaginal Discharge 136 g. The Sputum 136 h. The Gastric Contents 138 i. The Widal Reaction for Typhoid 138 j. The von Pirquet Test for Tuberculosis 139 k. The Wassermann Reaction for Syphilis 140 1. The Schick Test for Immunity in Diphtheria ■ 141 m. Throat Cultures 142 n. Blood Cultures 142 o. The Phenolsulphonephthalein Test of Renal Function 143 Differential Diagnosis i43 IV. — Prognosis in Early Life i45 V. — Treatment i47 General Principles i47 Special Indications in Early Life 148 Specific Treatment 148 a. Serum Therapy i49 b. Vaccine Therapy 151 c. Drugs • 153 Hygienic Treatment T-S3 Dietetic Treatment i54 Symptomatic Treatment i54 Therapeutic Measures Other than Drugs i55 a. Heat and Cold i5S (i) The ice bag i5S (2) The hot pack i55 (3) The hot air bath i5S X Contents V. — Treatment — Continued. page b. Hydrotherapy ' 155 (i) The hot bath 155 (2) The tepid bath 156 (3) The cold sponge 156 c. Counterirritation 157 (i) Mustard paste 157 (2) The mustard pack 157 (3) The turpentine stupe 157 (4) Dry cupping 157 (5) Bleeding 157 d. Irrigations and Sprays 157 (i) Irrigation of the colon 157 (2) Gastric lavage 159 (3) Irrigation of the nose 161 (4) Spraying the nose and throat i6r (5) Gargles 161 (6) Syringing the mouth and pharynx 161 (7) Irrigation of the ears 160 e. Inhalations 162 f . Enemata 162 (i) Cleansing enemata 162 (2) Nutrient enemata 162 (3) Stimulant enemata 163 g. Gavage and Nasal Feeding , 163 h. Massage 163 i. Hypodermoclysis 164 j. Intravenous Injections 165 Useful Drugs in Infancy and Childhood 167 a. List and Description 167 b. Table of Dosage 167 c. Methods of Administration 167 The Routine Treatment of an Acute Self-limited Disease 180 The Routine Treatment of Chronic Diseases 183 DIVISION III DISEASES OF THE NEWBORN I. — Malformations 184 II. — Traumatic Conditions 184 Caput Succedaneum 184 Cephalhematoma 185 Hematoma of the Sterno-Cleido-Mastoid Muscle 186 Intracranial Hemorrhage 186 Obstetrical Paralysis '. 189 III. — Non-Traumatic Mechanical Disturbances 194 Umbilical Hernia i94 Prolapse of Meckel's Diverticulum 196 IV. — New Growths 107 Umbilical Granuloma i97 Naevus i97 V. — Functional Disturbances i99 Congenital Pulmonary Atelectasis i99 Hemorrhagic Disease of the Newborn 202 Contents xi V — Functional Disturbances — Continued page Icterus Neonatorum 212 Congenital Cirrhosis of the Liver; Congenital Obliteration of the Bile Ducts 214 Sclerema 218 Edema 219 VI. — Infections 221 Infectious Disease of the Newborn 221 Ophthalmia Neonatorum 225 Tetanus Neonatorum 227 Dermatitis Exfoliativa 228 Infectious Haemoglobinuria (Winckel's Disease) 229 VII. — Premature Infants 231 DIVISION IV FEEDING I. — General Principles 239 The Mammary Gland 240 II. — Maternal Feeding 243 Human Milk 243 a. Physical Characteristics 243 b. Chemical Composition 244 c. Variations in Milk 245 d. Colostrum 246 e. Daily Quantity of Milk 248 f . Bacteriology 249 g. Conditions Affecting Lactation 249 Maternal Nursing 250 a. Normal Maternal Conditions 250 b. Contraindications for Breast Feeding 250 c. Sucking 250 d. Care of the Breasts 251 e. Nursing the Newborn ^ 252 f. Management of Normal Nursing 253 g. Hygiene of the Nursing Mother 255 Disturbances of Breast Feeding 257 a. Causes 257 b. Symptoms and Diagnosis • 258 c. Management of Disturbed Breast Feeding 259 Wet-Nursing 262 Weaning 264 III. — Artificial Feeding 266 Preliminary Considerations 266 Source of Food 267 a. Requirements • 267 b. Cow's Milk 267 (i) The cow 267 (2) Composition of cow's milk 267 (3) Bacteriology 269 (4) Certified milk 270 c. Sterilization and Pasteurization 271 (i) Effect of heat on bacteriology 271 (2) Effect of heat on composition 272 xii Contents III — Artificial Feeding — Continued Sterilization and Pasteurization — Continued page (3) Effect of lieat on digestibility 272 (4) Sterilization or pasteurization 273 (5) Indications for pasteurization 274 (6) Technique of pasteurization 274 d. The Examination of Milk 275 (i) The fat 275 (2) The protein 276 (3) The carbohydrate and salts 277 (4) Microscopic examination 277 The Modification of Cow's Milk 277 a. Sources of Difficulty in Artificial Feeding 277 b. Caloric Requirements and Digestive Requirements '. 279 (i) Minimum caloric requirements 280 (2) Protein requirements 280 (3) Caloric requirements as a basis for feeding 280 (4) Digestive requirements . 281 (5) Value of caloric estimation 281 c. Percentage Feeding 282 d. The Modification of Cow's Milk — Theory 283 (i) Milk and cream dilution 284 (2) Starch; cereal diluents 286 (3) The alkaUes; lime water, sodium bicarbonate, and sodium citrate 286 (4) Peptonization 288 (5) Whey mixtures; the split protein 289 (6) Maltose, dextri-maltose, and cane sugar 291 (7) Lactic acid milk 292 (8) Precipitated casein .' 293 (9) Cooking ; 294 (10) Homogenized fat 295 (11) Albumin milk 295 (12) Malt soup 297 How the Resources of Cow's Milk Modifications are Realized in Practice 298 a. Prerequisites 298 b. The Patent Foods 299 c. Milk Laboratories 299 d. Home Modification 3°''- (i) Technique 302 (2) Calculation 3°3 e. Laboratory Feeding and Home Modification — Relative Advan- tages and Disadvantages 3^^^ f. Calculation of the Calories 3^7 g. Calculation of Percentage Composition in a Food of Known Ingredients 3^^ The Practical Management of Artificial Feeding 321 a. General Principles 321 (i) Ends to be attained 321 (2) Conditions of the problem 322 (3) General conduct of artificial feeding 322 b. The Feeding of Normal Infants 323 (i) Quantity of food • 324 (2) Intervals between feedings 32S Contents xiii III — Artificial Feeding — Continued The Feeding of Normal Infants — Continued page (3) Percentage formulae for starting average well babies. 326 (4) Percentage formulae for feeding average well babies. . 328 (5) Increasing the strength of the food 328 c. The Feeding of Infants Having Difficulties of Digestion 329 (i) Causes of digestive disturbance 329 (2) Symptoms of digestive disturbance 329 (3) Clinical types of disturbance seen in artificial feeding. 330 (4) Vomiting cases 330 (5) Undigested movements 331 (6) Green or discolored movements 332 (7) No symptoms 332 d. The Feeding of Difficult Cases 333 e. Clinical Indications for the Various Methods of Modif^-ing Cow's Milk 334 f. Inability or Refusal to Take Food From the Bottle 337 IV. — Feeding in the Second Ye.ar 339 Feeding of Healthy Infants 339 a. Weaning From the Bottle 341 b. Preparation of Foods 341 c. Diet From the Twelfth to the Fifteenth Month 342 d. Diet From the Fifteenth to the Eighteenth Month 343 e. Diet From the Eighteenth to the Twenty-fourth Month 344 Feeding in Difficult Cases 345 V. — Feeding After the Secont) Year 347 DIVISION V diseases of the g.astro-enteric tract Class fication 349 I. — ^Malformations 351 II. — Traumatic Mechanical Injuries 353 Foreign Bodies 353 "Hair Ball" in the Stomach 354 Corrosive Gastritis 354 III. — Mechanical Conditions of Internal Origin 356 Hypertrophic Stenosis of the Pylorus 356 Spasm o the Pylorus 367 D latat'on of the Stomach 370 Contraction of the Stomach 373 Dilatation and Hypertrophy of the Colon 374 Intussusception 377 Volvulus f 380 Hernia 380 Fissure of the .\nus 381 Hemorrhoids 381 Prolapse of the Rectum 381 IV. — New Growths 383 V. — Nervous Disturbances 384 Nervous Diarrhea 384 Nervous Vomiting 386 xiv Contents PAGE VI. — DiSTUKBANCES OF DIGESTION 388 General Considerations 388 a. Etiology 388 b. Pathology 392 c. Classification 394 d. Symptomatolog}'' 398 e. Diagnostic Methods 399 f . General Treatment 399 Indigestion from an Excess of Food 402 Indigestion from an Excess of Fat 407 Indigestion from an Excess of Carbohydrate 422 Indigestion from an Excess of Protein 433 Indigestion from an Excess of Mineral Salts 440 Indigestion with Fermentation 442 VII. — Infections 457 Infectious Diarrhea 457 Summary of the Diarrheas and Disturbances of Digestion 481 Problems and Research in Diseases of the Digestive Tract 484 Cholera Infantum 485 Gastritis 488 Proctitis 490 Appendicitis 49 VITI. — Unclassified Diseases 496 Constipation 496 Incontinence of Feces 505 Intestinal Worms 505 LIST OF ILLUSTRATIONS PLATE COLORED PLATES page XV. — The blood in infancy and childhood 120 II. — Icterus neonatorum 213 FIG. FULL PAGE ILLUSTRATIONS page 19. — Position for examination of the ears 83 21.— Normal areas of dulness to percussion of the front of the chest 86 23. — Boundaries of the lobes of the lungs from in front 89 27. — Proper method of palpating the spleen 96 28. — Examination of the flexibility of the spine 99 SS- — Lumbar puncture 107 35. — Obtaining urine from the male infant 113 40- — Scarifying for the von Pirquet tuberculin test 139 44- — Gastric lavage, first step .^ . 159 45. — Gastric lavage, second step 161 46. — Gastric lavage, third step '. 163 49- — Tube feeding, first step 167 SO. — Tube feeding, second step 169 68. — Incubator bed for premature infant 232 69. — Articles for premature infant 234 70. — Premature infant in incubator bed 236 81. — Congenital atresia of the intestine 351 82. — Pyloric stenosis with complete occlusion, roentgenogram , 359 83. — Pyloric stenosis with partial occlusion, roentgenogram 360 Contents xv FIG. PAGE 84. — Pyloric stenosis with partial occlusion, roentgenogram 361 85. — Pyloric stenosis with partial occlusion, roentgenogram 362 86. — Pyloric stenosis with partial occlusion, roentgenogram 363 94. — Hirschprung's disease, roentgenogram 376 95. — Hirschprung's disease, roentgenogram 377 99. — Follicular inflammation of the intestine 461 100. — Follicular ulceration of the colon 462 loi.— Colitis 463 102. — Follicular ulceration of the colon 464 103. — Follicular colitis 465 104. — Pseudomembranous colitis 466 105. — Ulcerative colitis 467 106. — Ulcerative ileo-colitis 468 FIG. ILLUSTRATIONS IN THE TEXT page I. — Stomach, natural size 7 2. — Five periods of development in the first dentition 10 3. — Eight periods of development in the second dentition 12 4. — Normal infant seven months old 14 5. — Normal development at six years 15 6. — Normal development at twelve years 16 7. — Respiration at birth 21 8. — Section of fetal lung at five months, — section of infant's lung at ten months . 30 9. — Clothing for an infant 39 10. — Clothing for an infant 39 1 1 . — Clothing for an infant 4° 12. — Clothing for an infant 4° 13. — Infant's bed. Infants' Hospital 51 14. — Proper position for the child when examined in a sitting position 69 15. — Method of holding an infant for examination of the back of the chest 70 16. — ^^Position for examination of the throat 71 17. — Method of holding an infant for examination of the mouth and throat 72 18. — Obtaining pulse rate in infants 75 20. — Examination for rigidity of the neck 88 22. — Percussion of the front of the chest 84 24. — Boundaries of the lobes of the lungs from behind : 89 25. — Percussion of the back of the chest 90 26. — Percussion of the apex of the lungs • 91 29. — Testing the knee-Jerks loi 30. — Examination for Kernig's sign 102 31. — Examination for Brudzinski's neck sign 103 32.- — Position for lumbar puncture 106 34. — Normal roentgenogram, infant six months old m 36. — Apparatus for obtaining urine from a female infant ii'3 37. — Method of collecting urine from a female infant 113 38. — Catheterization of a female infant 114 41. — Obtaining blood for the Wassermann reaction from the longitudinal sinus of an infant 140 42. — Injecting diphtheria toxin for the Schick reaction 141 43. — Irrigation of the colon 158 47. — Irrigation of the ear 160 48. — Irrigation of the no?e 161 51. — Nasal feeding 164 xvi Contents riG. PAGE 52. — Intravenous injections in infancy — tapping the cerebral ventricles 165 53. — Intravenous injection in infancy 166 54. — Caput succedaneum 184 55. — Double cephalematoma 185 56. — Characteristic position of the arm in obstetrical paralysis 190 57. — Obstetrical parah'sis 192 58. — Large umbilical hernia i94 59. — Adhesive strap for umbilical hernia 195 60. — Naevus of the face and neck 198 61. — Complete congenital atelectasis of the left lung. H3'pertrophy of the heart. . 200 62. — Dr. Beth Vincent's apparatus for transfusion 207 63. — Obtaining blood in parraffin treated tube from the donor in transfusion 208 64. — Transfusion in the newborn 208 65. — Congenital cirrhosis of the liver 214 66. — Congenital cirrhosis of the liver 215 67. — Infant premature at the seventh month 231 71. — Feeder for premature infants ■ 234 72. — Colostrom milk 47 73. — Breast pump 251 74. — Sterilizer and thermometer 275 75 — Babcock fat tester 276 76. — Apparatus for homogenizing fat for infant feeding 294 77. — Walker-Gordon laboratory prescription blank 301 78. — Home modification of cow's milk — apparatus 302 79. — Home modification of cow's milk — obtaining the cream 303 80. — Home modification of cow's milk — mixing the ingredients 304 87. — Apparatus for estimating gastric retenfon time 360 88 — Aspiration of the gastric contents 361 89. — Dilated stomach ■ 37i 90. — Dilatation of the stomach 372 91. — Hirschprung's disease — section through colon 374 92. — Congenital dilatation of the colon • 375 93. — Dilatation of the colon 37^ 96. — Worsted truss for nguinal hernia 380 97. — Infantile atrophy 4i4 98 — Infantile atrophy 4iS 107 — Oxyuris vermicular s. Ascaris lumbricoides 5^7 108. — Taenia SOQ DIVISION I THE NORMAL CHILD I. INTRODUCTION Pediatrics is a branch of medicine the importance of which as a special study has gradually come to be more and more generally recognized. It has become a specialty, partly from the same causes which have led to the great increase in specialization in all branches of medicine, but more particularly because of the great number of peculiarities inherent in the manifestations of disease in early life. From the very beginning, the diagnosis and treatment of disease in infants and young children is attended by difficulties not encoun- tered with adult patients. These young patients can give no ade- quate description of their subjective symptoms, and the physician must rely on intimate and profound knowledge of the ways of young children, which can only be gained by long observation, if he will read aright the manifestations before him. Moreover, the most thorough knowledge of normal and abnormal conditions, if gained wholly from observation of adult patients, is of little value in chil- dren, because of the difference in the normal standard. Not only are all the standards by which deviations from the normal are recog- nized different from those of adults, but there is a different standard for each age. Manifestations which are normal at one age, are abnormal at another, and even the anatomic lesions of disease are seen to be modified in the various stages of the child's development. Young human beings must be regarded, throughout their early life, as incomplete. Growth is not merely increase in size, but it is a continuous process of anatomical and functional development, which is not completed until some time after the age of puberty. In early life, arrest, or retardation of the process of normal development may in itself constitute a disease picture; developmental conditions form an important division in the etiology of disease in childhood, but play no part after adult life is reached. The incompleteness of the child's development plays a still greater role in those actual diseases which are produced by conditions out- side the body. It may be true that the same diseased conditions are seen in childhood and in adult Hfe. But their manifestations are greatly modified by the incompleteness of the child's development, and often vary even with the different ages of childhood. Even the 2 The Normal Child reaction to treatment dilTers in the different stages of development. The rules laid down for the diagnosis and treatment of these diseases common both to childhood and to adult Hfe, if gained by a study of adults, cannot hold for children. There is further need for special study and training in pediatrics. Children, in addition to being liable to most of the diseases seen in adults, have also a group of diseases which are entirely their own. Here again, the fundamental cause lies in their uncompleted develop- ment, through which conditions acting upon their bodies from the outside w^orld, which can have no injurious effect upon the com- pleted adult, have a very injurious effect upon the young, unde- veloped child. These young human beings, at each stage of devel- opment, have their own peculiarities of resistance or lack of resist- ance to these conditions. Their treatment must be modified at all times, to correspond to their age, and stage of development. The high rate of infant mortality is still one of the greatest problems of medicine. It is due primarily to no other cause than the lack of resistance to the conditions of its surroundings which exists in the undeveloped infant. Its existence is alone sufficient to point to the need for a special study of the pathology of early life. The fundamental requisite in recognizing the abnormal, is a thorough knowledge of the normal. In pediatrics, a thorough un- derstanding of normal conditions at every stage of development is essential. The distinction between infancy and childhood is neither so artificial nor so arbitrary as it seems at first.. At about the age of two years, certain very important processes of anatomical and functional development become completed. The incompleteness of these functions in the first two years has been an important source of difliculty, and a cause of abnormahty, which later are no longer seen. Hence we refer to the first two years as infancy, and to the later years as childhood. The distinctive fine between childhood and adult life is much harder to draw. It is difficult to say at just what age normal development is finally completed, but the period is arbi- trarily placed at the age of puberty. From birth to the age of puberty, then, is the period through which the development of the normal child must be studied. II. THE INFANT AT TERM A normal infant at birth has a reddened skin, and is covered thickly in many parts by the vernix caseosa, which is removed by the first bath. The description of the newborn infant will be given in two divisions. The first will be a description of a complete physical examination of a normal infant at birth, in the form in which physical examinations are usually recorded in case histories. The second division will be a description of certain features of the infant's internal structure, in the form in which they are recorded in records of post-mortem examinations. This form of description will afford the student a standard of comparison by which he may recognize at once the abnormal, both in physical examination, and in pathological anatomy. THE PHYSICAL EXAMINATION The baby appears well nourished, the body and limbs are well rounded, the cry is vigorous, the extremities are warm, and the grasp of the hands is strong and vigorous. The skin is usually clear, but may be somewhat mottled, and is some shade of delicate pink. The eyes are half open when the baby is awake, and are expres- sionless, of a dull grayish-blue color. The spine is very flexible, and can be twisted and bent at will in any direction. The neck appears short. HEAD — The head appears large in proportion to the body, while the face is quite small in proportion to the cranium. The length and thickness of the hair is very variable. The cranium may be somewhat distorted by the pressure of birth, but these abnormal appearances pass away in a few months. An average circumference of the cranium at birth is t^t, cm. (13 in.). The anterior fontanelle may be somewhat depressed immediately after birth, but is soon on a level with the bones. Its size is variable, but the measurements are usually 2 to 3 cm. in length, by about 2 cm. in width. The frontal suture is usually open in its upper part, and the posterior fontanelle, while open, is often obliterated by overlapping of the bones. MOUTH AND THROAT.— The mucus membrane of the mouth is of a clear pink. The tongue is slightly coated, and comparatively dry. The gums do not completely meet. The soft palate runs backward almost horizontally, descending much less than in the adult. The uvula is rudimentary. 4 The Normal Child THE EAR. — The meatus passing inward, inclines downward, and the membranum tympani is almost horizontal, so that its inspection is difficult. THORAX.^ — The thorax presents a very different appearance from that of the adult. It is much smaller in proportion to the head and abdomen, forming the upper and smaller portion of the egg- shaped trunk. Its whole shape presents a peculiar appearance, which is accentuated by the small shoulders. The sternum is rela- tively much smaller than that of the adult male, and its top is placed relatively higher, while the sides of the thorax are relatively shorter than in the adult. The ribs are more nearly horizontal, and their borders diverge relatively rapidly. The transverse diameter is shorter in proportion to the antero-posterior. THYMUS. — The thymus is present and well developed at birth, but its outline cannot be clearly distinguished by percussion. HEART. — The impulse is visible and palpable rather higher and nearer to the mammary line in the infant than in the adult. The entire position of the cardiac dulness is higher in proportion to the chest walls. The infant's heart is less covered by the lungs than is the adult's. The superficial dulness lies between the left border of the sternum and the mammary line, and the entire area can easily be covered by the tip of the finger used in percussing. The upper border, and the relative dulness are difficult to determine. The heart sounds are still largely of the fetal type, the diastolic pause being absent, and the first sound being much like the second. The rhythm is regular. Murmurs are frequently present at birth, with- out any abnormal significance; only their persistence should attract attention. LUNGS. — The lungs are resonant to percussion, but at birth the resonance is less than in later life. The respiratory murmur is loud and harsh. ABDOMEN. — The abdomen is large in proportion to the thorax. Its physical examination differs from that of the normal adult only in one important particular, namely, in the relatively large size of the liver. Its border is felt fully 2 cm. below the edge of the ribs in the right epigastric and hypochondriac regions, and its upper border of dulness encroaches on the resonance of the right lung to the extent of fully one rib and interspace. The dull area of the spleen is rarely perceptible, but when found corresponds to that of the adult. The border is not normally palpable. The bladder is an abdominal rather than a pelvic organ, but normally gives no dulness in a newborn infant. The Infant at Term 5 TESTICLES. — The testicles are normally found in the scrotum. LIMBS. — The limbs are well formed, and present no features of particular note in newborn infants. The grasp of the hands is re- markably strong. The feet appear flat, but this apparent flatness is due to a pad of fat tissue, and not to any flattening of the arch. HEIGHT AND WEIGHT.— The height and weight are variable. The average height of a newborn male infant is 49.5 cm. (igf in.); in the female it is 48.5 cm. (19^ in.). The weight is still more variable than the height. The average weight for males is about 3,520 grammes (7! pounds), and for females is about 3,290 grammes (7 J pounds). THE SPECIAL SENSES.— Although at birth the eye is anatom- ically perfect, visual perception is not developed. Hearing appears dull during the first few days of life. The sense of touch is well developed. No satisfactory conclusions can be drawn as to taste and smell. The newborn infant passes very little urine. He does not usually perspire. He cannot cry tears. He can have a movement of the bowels, which consists of meconium. Meconium is inodorous, viscid, slightly acid, and of a brownish-black color. It consists of bile constituents and intestinal secretions, and contains mucus, epithelium, and fat drops from the vernix caseosa. At birth, it is sterile. INTERNAL STRUCTURE Among the features in the anatomy of the newborn infant which cannot be perceived by ordinary physical examination, only those will be described which present essential differences from those of adults. BRAIN. — The brain of the newborn infant is proportionately very much larger than in the adult. THE NASO-PHARYNX.— The nasal cavity is relatively long and shallow, and its respiratory portion is very narrow. The opening of the posterior nares is relatively very small. The naso-pharynx is simply a narrow passage running obliquely backward and down- ward from the constricted opening of the posterior nares. The lym- phoid tissue on the posterior wall of the pharynx is well developed, and much richer in absorbents than are the faucial tonsils. The openings of the eustachian tubes are opposite a higher part of the nose than in the adult, although their direction is more horizontal. The ends of their cartilages, which make such prominent folds in the adult, are not developed, so that these prominences do not exist. 6 The Normal Child TEETH. — There are at birth twenty embryo teeth, ten in each jaw, enveloped in their tooth sacs. EAR. — The development of the ear in its several parts is very unequal at birth. The structures of the internal ear and of the tympanic cavity are fully formed at birth, while the external audi- tory meatus is very different in its development from that of later life. The mastoid antrum exists at birth, but the cells are wholly undeveloped. THYMUS GLAND.— The thymus gland exists at birth, is well developed, and lies partly above, and partly in front of the heart. HEART. — The anatomy of the heart at birth, and the changes in the circulation which take place shortly after birth, are so inti- mately connected with the subject of congenital cardiac disease, that their description will be postponed till that subject is discussed. In a baby dying immediately after birth, it would not be abnormal to find an open foramen ovale, or an open ductus arteriosus. LUNGS. — ^The lungs at birth present a very notable difference from the lungs of older individuals. Their chief characteristic is their embryonic type. The alveoH are relatively small in size, and their number is small in proportion to the bronchioles. Their walls are relatively thick, and the connective-tissue stroma is in greater proportion. Blood vessels are relatively abundant, and play a more important role than the lymphatic absorbents. These conditions, while gradually diminishing, persist to a great extent throughout childhood. KIDNEYS. — The kidneys and adrenals are of relatively large size in the newborn infant. The kidneys are markedly lobulated. A prenatal condition called the uric acid infarction exists normally in the kidneys at birth. This shows itself as an orange or light red deposit in the straight tubules, which cause these tubules to appear prominent on section of the organ. This deposit consists of urate of ammonia, amorphous urates, uric acid crystals, and epitheHal cells. The adrenals quite cover the tops of the kidneys at birth. STOMACH. — The stomach at birth is remarkably small, and more tubular than in the adult, the fundus being but slightly devel- oped. It is consequently even more vertically placed, for it is the enlargement of the greater curvature which causes the later obliquity of the stomach'^s axis. Its capacity is about 25 to 30 c.c. The Infant at Term Fig. I ^"■" Stomach, natural size. Infant three hours old. Warren Museum, Harvard University. THE INTESTINE. — The chief pecuharity of the intestine in new- born infants, is that it is much less fixed than in adult life. This difference is most striking in the large intestine, particularly in the cecum, ascending colon, and sigmoid flexure, which show a con- siderable mesentery. The average length of the small intestine is 287 cm. (9 ft. 5 in.); of the large intestine it is 56 cm. (i ft. 10 in,). The total variation may amount to 61 cm. (2 ft.). LYMPHATIC SYSTEM.- oped and active at birth. -The lymphatic system is well devel- BONE MARROW.— At birth, and indeed, throughout the early- months of life, the bone marrow is red. The red color is caused by the numerous injected blood vessels, and is more intense toward the central portion of the bones. III. NORMAL DEVELOPMENT In following the normal development of the baby through the periods of infancy and childhood, those changes will be considered first which appear on physical examination. In a second division will be considered the development of internal structure. NORMAL DEVELOPMENT AS SEEN ON PHYSICAL EXAMINATION THE CORD. — By a process of disintegration the cord separates from the living tissues at the umbilicus, and falls off. This occurs at about the seventh or eighth day. The umbilical scar normally is always depressed. THE SPINE. — The flexibility of the spine gradually becomes less as the infant grows older, although it always remains greater than that of the adult spine. There are at birth no natural curves in the spine except the sacral curve. As the dorsal curve is 'a permanent condition, part of the general curve of the body, it is the develop- ment of the cervical and lumbar curves which are of interest from the point of view of development. The cervical curve is produced by the pull of the muscles of the back of the neck, when the child begins to raise its head. * The child usually begins to hold up its head, only the trunk being supported, during the fourth month. The cervical curve begins to appear at about this period, but is never more than a habitual position, as the convexity of the front of the neck can always be obliterated by changing the position of the head. The lumbar curve is supposed to be caused by the short- ness of the ilio-femoral ligaments. When the child begins to stand, these ligaments tend to incline the body forward, and this tendency is corrected by the contractions of the muscles of the back, which straighten the line of the body by throwing forward the promon- tory of the sacrum. The lumbar curve is first observed when the child is one or two years old, but it is not continually present till some time later, and it can be obhterated until adult life is reached. The surface anatomy of the spine in infancy and childhood pre- sents marked differences from that of adults. In the infant, the back is rounded from side to side, the spine being the center of a more or less continuous curve. The spinous processes are relatively undeveloped, and the laminae overlap less, look more directly back- ward, and are nearer the surface. At three years of age the spine shows a great change which has been coming on since the age of Normal Development 9 eighteen months. The spinous processes now stand out in a prom- inent row, and although the laminae are still near the surface, the back is flatter, and there is some appearance of a median furrow. At six or seven years the spine has made much greater progress toward the adult type, and shows no important differences during the remainder of childhood. THE HEAD. — The head grows very rapidly, especially in infancy. The average circumference at birth is t^t, cm. (13 inches). The growth is most rapid during the first year, the increase in circum- ference amounting to about 12 'cm. In the second year the increase is 2.5 cm., and in the next three years it is 5 cm. After the age of five years, the increase in circumference is very slow, and only 2 or 3 cm. have been added when adult life is reached. The growth of the thorax is so rapid, that the proportion of the head to the thorax becomes equal during the first year. The table shows the relative and proportional growth of the head and thorax du ing childhood. Table i Circumferences of Head and Thorax from Birth to Thirteen Years Birth 33 cm. (13 inches) 31cm. 5 weeks 38 cm. (15 inches) 36 cm. 5 months 42 cm. (165 inches) 41 cm. 9 months 45 . 5 cm. (18 inches) 43 cm. I year 45.5 cm. (18 inches) 47.5 cm. 48 cm. (19 inches) 51 cm. 51 cm. (205 inches) 55 cm. 53 cm. (21 inches) 54 cm. 53 cm. (21 inches) 54 cm. 52 cm. (20I inches) 55 cm. • ■ 54 cm- (21 J inches) 54 cm. 53 cm. (21 inches) 59 cm. 54 cm. (21 J inches) 61 cm. 53 cm. (21 inches) 62 cm. 56 cm. (2 2 1 inches) 63 cm. • - ■ -SS-S cm. (2 1 1 inches) 63 cm. 54 cm. (2 1 1 inches) 66 cm. 2 years 3 " 4 li .s u 6 If 7 11 8 li u 10 a II u 12 u 1-3 u inches) inches) inches) inches) inches) inches) inches) inches) inches) inches) inches) inches) inches) inches) 24I inches) 4f inches) I2t i4i i6i 17 i8| 20| 2l| 2li 2lf 2lf 21J 23I 24 24i 26 nches) The posterior fontanelle becomes imperceptible by the sixth week. The main sutures of the cranium are not usually ossified before the end of the sixth month. The anterior fontanelle appears to grow larger up to the ninth month, and probably grows with the head, although becoming relatively smaller. It appears to remain sta- tionary from the ninth to the twelfth month, and then gradually becomes smaller. Its average time of closing is the nineteenth month, although variations in the time of closure extending from the four- teenth to the twenty-second months are not abnormal. An open fontanelle at the end of the second year may be considered abnormal. The small proportion of the size of the face to that of the cranium 10 The Normal Child gradually grows less. The downward growth of the face is one of the important features of development. The table shows the pro- portions of the face to the cranium in the different periods of childhood. Table 2 Proportions of Face to Cranium AGE FACE CRANIUM Early infancy i to 8 2 years i to 6 5 " I to 4 10 " , I to 3 Adult female i to 25 Adult male i to 2 THE TEETH. — At birth, the twenty embryo teeth, enveloped in their tooth-sacs, are so enclosed in the alveolar processes of the jaws, that nothing but smooth mucus membrane is apparent on the gums above. When calcification of the neck of the tooth begins, elon- gation of the tooth follows, and the tooth is so enclosed that growth can only occur toward the gum, which forms the point of least resistance. This growth probably begins at birth. Pressure of the crown of the tooth causes atrophy of the gum, and finally the tooth pierces the mucus membrane. The various teeth appear at times dependent upon their order of development, which is fairly regular in a normal infant, although variations in the order and time of appearance of the teeth are so common, that they cannot be called abnormal. The first teeth usually appear from the sixth to the eighth month. Early appearance of the teeth is never a sign of disease, and children have been born with teeth. Delayed dentition is usually due to rachitis, but is seen in other conditions, Fig. 2 Five periods of development in the first dentition Normal Development 1 1 such as cretinism, and defective cerebral development. In many healthy infants, no teeth are seen before the tenth month, and den- tition may even be delayed until the fourteenth month without other evidences of any abnormality. The order of appearance of the teeth is shown in the table. Table 3 Temporary Teeth. First Detiiition. Twenty in Number DENTAL PERIODS GROLTS OF TEETH I. 6 to 8 months 2 middle lower incisors II. 8 to 10 months 4 upper incisors III. 12 to 14 months 2 lateral lower incisors and 4 first molars IV. 18 to 20 months 4 canines V. 28 to 32 months 4 second molars The second dentition begins at about the sixth year. The first of the permanent teeth to appear are called the sixth-year molars. They do not replace any of the temporary teeth, but the jaw having grown sufficiently to provide more space, they appear just back of the second molars of the first set. In the seventh and eighth years the permanent incisors replace those of the temporary set. In the ninth and tenth years the bicuspids replace the temporary molars. In the eleventh year the permanent cuspids (canines) replace the temporary, and in the twelfth year the four second molars appear. This completes the second dentition of childhood, twenty-eight teeth, the remaining four molars belonging to adult life. Table 4 Permanent Teeth. Second Dentition. Thirty-two in Number YEARS GROtrPS 6 4 first molars 7 4 middle incisors 8 4 lateral incisors 9 4 first bicuspids 10 4 second bicuspids II 4 canines 12 4 second molars 17 to 25 4 third molars (wisdom-teeth) 12 The Normal Child Fig. 3 8 years VflrrfTTT Eight periods of development in the second dentition THE THORAX.— The thorax, which is insignificant at birth, grows rapidly. The measurements showing the rate of increase in the circumference of the thorax are seen in the table. The circum- ference of the thorax normally remains less or equal to that of the head throughout infancy. Not until the third year does the thorax begin to show a measurement greater than that of the head. With the growth in circumference, there occurs increase in the transverse diameter as compared with the antero-posterior, so that the thorax graduall}^ assumes the elliptical shape which is characteristic of later childhood. At the same time, the peculiarities in the shape of the thorax which are so notable at birth, disappear, and at about the fifth year the infantile type of thorax is no longer evident. THE THYMUS.— The thymus is most developed during the first two years of life. At no time, however, unless the organ is notably Normal Development 13 enlarged, can its dulness be distinguished from that of the heart and great vessels. THE HEART. — Most of the changes in the position of the cardiac impulse, and of the precordial dulness, which have been described as taking place during the development of the infant, are relative, and are due to pecuHarities of the topography of the chest wall, rather than to changes in the position of the heart. That the car- diac impulse in infancy and early childhood is almost invariably found not in the fifth, but in the fourth interspace, is due to this cause. In early childhood the impulse may be found in either the fourth or the fifth interspaces, while in later childhood it is usually in' the fifth. The relation of the impulse to the nipple presents similar variations. In infancy and early childhood it is usually outside the mammary line, and cannot be considered abnormal if less than 2 cm. beyond the nipple. In middle childhood, the im- pulse is in or near the mammary line. In later childhood it is more often seen inside the nipple, and should always be found in this position after the thirteenth year. An important feature in the physical examination of the heart is seen in the position of the area of superficial or absolute cardiac dulness to percussion. In infancy and the latter part of childhood, the right border of absolute dulness is, as in the adult, at the left border of the sternum. In middle childhood it may encroach a little on the sternum, even as far as its middle. The relative or deep cardiac dulness is difficult to determine in young children. WTien found it is proportionately larger than in the adult. Its upper border is at the second interspace, or lower border of the second costal cartilage. On the left it extends to near the mammary line, corresponding to the position of the impulse at the various ages. On the right it follows the right parasternal line. On auscultation, the diastolic pause remains slight or impercept- ible throughout infancy, and the rapidity of the cardiac action is so great, that it is often difficult to distinguish the first from the second heart sound. Normally, however, after the first weeks of life, the first sound becomes louder than the second, and the cardiac cycle can be recognized from this. Murmurs persisting after the first week of life, are abnormal. THE LUNGS.— The percussion note in childhood is more tym- panitic than in the adult, especially under the clavicles, and in the interscapular region behind. There may even be cracked-pot reso- nance under the right clavicle, in healthy lungs. This tympany is due to the relatively large proportion of bronchial to alveolar air space, which persists throughout childhood, although in later child- hood, the lung gradually approaches the adult type. On ausculta- 14 The Normal Child tion, the normal respiratory murmur differs entirely from that of adults. It is of a type generally described as "puerile." The breath- ing is rude, loud, and harsh, and expiration is heard better than in adults. It is often described as resembling the bronchial breathing of adults, but does not resemble it except in the terminology of description. The difference cannot be described, being one of quality, and can only be learned by experience and practice. It is gen- Normal infant seven months old erally stated that this quality of the normal respiratory murmur of childhood is due to the fact that the sounds from the trachea and large bronchi are heard more plainly, because they are not trans- mitted through £0 thick a layer of lung and chest wall. This expla- nation does not seem to me at all satisfactory. If it were true, the sounds would have the quality of bronchial breathing, for we know that in both children and adults, we are hearing in bronchial breath- ing the sounds from the trachea and large bronchi, which are trans- mitted more easily through solidified lung. The normal respiratory murmur of children has not the so-called bronchial quality, I believe Normal Development 15 its loud, harsh quality to be due to the greater size and number of the bronchioles in the child's lung. In later childhood, this pecu- liarity of the breathing gradually diminishes with the development of a greater proportion of alveolar space, as the lung approaches the adult type. Fig. s Normal development at six \'ears THE ABDOMEN. — Throughout infancy, the circumference of the abdomen remains about the same as that of the chest. After the age of two years, the enlargement of the chest causes the abdomen gradually to assume the adult proportion. The abdominal walls in childhood are thinner, and more easily relaxed, than in the adult. THE LIVER. — The liver remains relatively large in infancy and early childhood. In the first two years, the edge can be easily felt about 2 cm. below the costal border in the mammary line. Later, the distance becomes somewhat less, but until the later years of childhood, the edge of the liver can still be felt below the costal border. Only in late childhood does the liver no longer descend 16 The Normal Child below the edge of the ribs in the mammary line, but even at this period, owing to the laxness of the abdominal walls, the edge of the liver can sometimes be felt by pushing the palpating fingers up under the ribs. Fig. 6 Normal development at twelve years THE SPLEEN. — The spleen presents no differences in size or position characteristic of childhood. It may sometimes be felt, by pushing the fingers up under the costal border, but normally is never felt below the costal border, THE LIMBS. — The limbs in infancy are short in proportion to the trunk. Holt has found, from one hundred and fifty observa- tions, that the length of the lower extremities at birth (measuring from the anterior superior spine of the ileum to the sole of the foot), is forty- three per cent, of the length of the body; at five years it is fifty-four per cent., and at sixteen years, sixty per cent. The pad of fat, which gives the infant the appearance of flat-foot, is, accord- ing to Dane, designed to support the arch of the foot until the mus- Normal Development 17 cles are stronger. It is slowly absorbed, and by the fourth or fifth year, the foot presents the same appearance as in the adult. MUSCULAR DEVELOPMENT.— At birth, the strongest mus- cular development is seen in the hands and forearms. Voluntary attempts to grasp objects are seen at about the beginning of the fourth month. The infant should be able to hold up its head with only the back supported, by the fourth month, though sometimes this is seen as early as the end of the second month. It begins to sit alone at between the seventh and ninth months, and creeps at ten months. Soon after this are seen the first attempts to stand, the infant trying to pull himself up with the aid of his nurse's skirts, or of pieces of furniture. It can usually stand at twelve months, and soon after, makes its first attempts at walking. There are wide variations in the age at which the normal infant learns to walk. Some infants learn to walk at twelve or thirteen months, and others, apparently normal, do not walk until they are seventeen or eighteen months old. The average age is fifteen months. MENTAL DEVELOPMENT AND THE SENSES.— The eyes of the infant at birth are sensitive to light; by the end of the second or third week they will follow a bright light. The infant seldom smiles before the fifth or sixth week; he does not recognize objects before the sixth or eighth week. The muscles of the eye in early infancy act irregularly, and coordinate action is not seen until the third or fourth month, and sometimes incoordination is seen for a considerably longer period. The hearing is undeveloped at birth, and for the first few days infants are deaf. The movements of respiration and deglutition cause the eustachian tubes to be cleared of mucus, air enters the middle ear, and the hearing gradually improves After the first month it is very acute, the infant being easily disturbed by noises. Usually by the fifth month the infant will show distinct signs of distinguishing and interpreting particular sounds, and of recognizing individual voices. At this time it may very easily be frightened by loud or unusual noises. The sense of touch, while present, is not very acute at birth, except in the lips and tongue. It develops rapidly, and by the end of the third month, is fairly acute all over the body. Sensibility to pain, while present in infancy, is dull compared with later childhood. The localization of sensory impressions is very imperfect throughout the first years of life. Taste is said to be developed at birth, but I believe its develop- ment is poor during the earlier weeks. It is usually said to be acute throughout the greater part of infancy and childhood, this statement being based on the fact that the child easily detects changes in its 18 The Normal Child food. I believe that taste is only acutely developed in the case of the primary tastes of sweet, sour, bitter, and salt. The foods which it receives during the first year show variations only in these primary tastes. I be ieve that the infant does not perceive flavors, and that this inability to detect variations other than the simplest in the >aste of its food persists through some of the earlier years of child- hood. The infant is very sensitive to the feeling of various foods in the mouth, and it is this sensibility to the sensation of the food which is mistaken for a highly developed sense of taste. Young children do not usually object to the taste of castor oil, unless it has been suggested to them that castor oil has a bad taste. The sense of smell has not been conclusively tested in infancy. This sense is probably present, but develops much more slowly than the other senses. Fine distinctions in odors are not detected until the late years of childhood. SPEECH. ^During the first year of its life the average infant uses its voice merely in crying to express its discomforts or desires. At about the end of the first year it usually begins to enunciate single words, and in the middle, or toward the end of the second year it learns to form short sentences. From this time on, the faculty of talking progresses rapidly, but children do not usually learn to talk connectedly till the third or fourth year. There is great varia- tion in the time when the faculty of speech is acquired. Many children, who understand perfectly, make all their wants known by signs, and who show no other signs of delayed mental development, show a delay of from one to two years in every phase of the develop- ment of the speech faculty. Girls learn to talk earlier than boys. DEVELOPMENT OF OTHER FUNCTIONS.— The function of the lachrymal glands does not usually develop till the baby is three or four months old. The time of its development is variable. Babies have been observed to cry tears as early as the first month. The development of the function of the sweat glands is also very variable. It is occasionally seen developed at birth. Usually, how- ever, perspiration is not seen till the third to the fifth week. The salivary secretion is developed rather slowly in early infancy. There is not much saliva seen in the infant's mouth in the first three or four months of life. THE URINE.— The function of the kidney begins quite early in fetal Hfe, and the bladder has been found to be full of urine at birth. The urine is small in amount at birth, and during the first twenty-four hours it is not uncommon to find little or none passed. The urine which is first passed is usually dark, cloudy, and acid, and contains epitheUal cells and urates and occasionally hyaline Normal Development 19 casts; later it becomes clear, pale, straw-yellow, and usually of slightly acid reaction. Its specific gra\'ity (i.oio at birth) falls in two or three days to 1.003, t»y about the fifteenth day is found to be 1.006, and rises from this time steadily till puberty. By the end of the first week and throughout childhood the amount of urine passed in twenty- four hours is relatively greater than in adult life. This in early in- fancy may be due to the prepDnderance of liquid food, but is in part the result o" the infant's more active metabolism, for the urea is also found to be proportionately increased. According to Foster, the presence of uric and oxalic acid in unusual quantities is a frequent characteristic of the urine of children. It is also stated that the phosphates are deficient, being retained in the body for the purpose of building up the osseous system. The chlorides, sulphates and urinary pigments are less abundant than in the adult. The propor- tion of salts increases as soon as a mixed diet is given and closely approaches the normal proportion for adults. Indican is normally absent in breast fed-infants; in others it is usually absent unless there is a disturbance of digestion. The uric acid infarction, which has been referred to, and evidences of which may last for two or three weeks, consists of urate of ammonium (hedgehog crystals), amorphous urates mixed with uric acid crystals, and some epithelial cells. The variations in the amount of urine which has been com- puted to be passed during the early days of infancy and childhood are very great, as the amount in all probabihty depends very largely on the quantity of liquid ingested, and also upon the activity of the skin and bowels. The difficulties in accurately measuring the amount of urine ex- creted by very young infants are such that few positive statements can be made as to the quantity. It is sufficient to say that it is about ninety cubic centimeters (three ounces) a day for the first few days, and then rises in amount very rapidly. Reitz and Cruse state that during the first few days of life the urine contains more or less albumin, and that this disappears at about the seventh or eighth day, though sometimes, according to Carpenter's work, it may be detected for several weeks. Lesne and Merklen found the freezing point at birth 0° C, at one month —0.13° to —0.35° C, at two months —0.21° to —0.78° C. Sugar is occa- sionally found in the urine of healthy infants during the first two months. The urine sediment of the young infant shows on microscopical examination, mucus, many epithelial cells, crystals of uric acid, urates, and calcium oxalate; also amorphous urates, occasionally a few hyahne casts, and rarely a granular cast. The urine of later infancy and childhood has no microscopical peculiarities. 20 The Normal Child INTESTINAL DISCHARGES.— The contents of the intestine continue to be mixed with meconium for three or four days or a week, the longer time being when the infant is weak and does not nurse well. After this time the infantile discharges, which have a characteristic appearance as distinguished from those of the older child, appear. When the nutrient is human milk, the discharges are of a golden-yellow color, smooth, unformed, of medium consis- tency, showing a large proportion of water, and sometimes changing to a greenish yellow on exposure to the air. If the baby is arti- ficially fed, the movements are normally of a lighter yellow color, and of slightly firmer consistency. They as a rule contain unde- composed bile-pigment and bile-salts, while the older child's and the adult's discharges do not contain the bile undecomposed. The amount of fecal discharge in the first day of life is about forty-five grammes (one and one-half ounces), and increases in the following days to fifty grammes (one and two- thirds ounces). It consists of mucus, fat, epithelial remains, and a slight amount of albuminoid material. In early infancy there are from two to four discharges daily. As the child grows older there are two and finally one in the twenty-four hours. They do not lose their yellow color until amylaceous or al- buminous food is given, when the different shades of brown begin to appear. They are not fully formed until something besides milk is swallowed. Starting at birth, with the sterile meconium, infection by the mouth and rectum quickly occurs, and in a short time many forms of bacteria may be found in the discharges. TEMPERATURE.— The rectal temperature of the newly-born infant varies to a certain extent, lying between 99° F., and 100.5° F. Very soon after birth, as would be expected from the tax which is made on the infant by its surroundings, the temperature shows a slight fall, varying between 98° F., and 99.5° F. By the end of the first week, the normal temperature of the infant is regained, and during the first year, the temperature ranges from 99° F. to 100.5° ^• In the second year, and during early childhood, the temperature is 98.5° F., to 100° F., and in later childhood, the normal temperature is that of the adult. PULSE. — Immediately after birth, the pulse is often quite irreg- ular, but soon becomes perfectly regular in rhythm. The small volume and force of the infant's pulse is proportionate to the small size of a baby as compared with an adult. The rate of the pulse presents the most extreme variations in early life, especially during the first year. It is much affected by nervous influences. The table shows the average pulse rate at the various ages for males; in girls the rate is apt to be somewhat higher. Normal Development 21 Table 5 Pulse-Rate for Males AGE PULSE-BEATS PER MINUTE Early weeks 1 20 to 140 Until 2d year no 2 to 3 years 100 5 to 8 years 90 After the eighth year the pulse gradually acquires the adult rate. RESPIRATION. — The rhythm of respiration in very young in- fants is so easily affected, varying with every disturbance, and even with changes of temperature, that a regular rate of respiration is only seen when the infant is asleep. At all other times the respira- tion is very irregular in rhythm, even when the child is quiet. It may be quite superficial for a few moments, and then quite deep. There are frequent pauses; at times one lung appears to be used exclusively for a brief period. A regular rhythm is not fully estab- lished till the child is two years old. The character of the respira- tion in early infancy is wholly diaphragmatic, and remains mainly diaphragmatic until the sixth or seventh year. From this time on the costal element gradually become , prominent. The rate of respiration is also extremely variable. At birth it is usually from 35 to 45 per minute when the child is quiet. Until the third year it varies from 15 to 40 per minute, and from three to five years, the rate is 20 to 25 per minute. Fig. 7 QUICK PAUSE SLOW QUICK Respiration at birth for one-fourth minute. Awake, but quiet HEIGHT. — The average height of the male infant at term is, according to a large number of measurements about 49.5 cm. (igf inches). Insufficient nourishment and improper food, especially as represented in rhachitic children, seem to retard the growth, while on the contrary, the various fevers seem to increase the activity of growth in length, while decreasing the total weight. In the first three or four months the growth is proportionately rapid to that in the latter part of the first year. In like manner the activity is greater in the first month than in the second, and in the second than in the third, becoming still less in the fourth, fifth and sixth months. Table 6 The average increase for the first month is about 4.5 cm. (if in.) " " " " " second month is about 3.0 cm. (i| in.) " " " " " third to the fifteenth month is about i to 1.5 cm. {\ to J in.) " " « « « flrst year is about 20 cm. (8 in.) 22 The Normal Child Table 6 — Continued The average increase for the second year is about 9 cm. (3I in.) " " " " " third year is about 7.4 cm. (3 in.) " " " " " fourth and fifth years is about 6.4 cm. (af in.) " " " " " fifth to sixth year is about 6 cm. (af in.) The height is about doubled in the first six years, and at fourteen years the final height has usually been attained to within about one- twelfth. The height at different ages in comparison with the weight will be shown in table. 8. WEIGHT. — The normal infant manifests its growth and develop- ment most clearly by increasing in weight. All other signs of dis- turbance of normal development are not at once apparent, but mani- fest themselves slowly. Increase in weight, on the other hand, is a more or less continuous process of development, any disturbance of which manifests itself at once. Moreover, this growth in weight is, of all the processes of development, the one most easily disturbed by all kinds of adverse influences, and therefore is the most valuable and delicate index of health which we have. Of all the data which guide the physician in the care of infants, the records of the weights taken from time to time are the most important. The physician in the wards of an infants' hospital looks first at the weight curves depicted on the charts. In older children, the weight records are less important than in the first two years of life, but nevertheless afford valuable data throughout the period of growth. The weight of the newborn infant is very variable, and can only be expressed by an average. It must be remembered that wherever any figure representing the normal is based on the method of averag- ing normal variations, a deviation from the normal figure in an indi- vidual case does not of itself constitute an abnormality. The limits of weight variation of full term infants at birth are not definitely known, but a birth weight of six pounds or over should be considered within normal limits; a birth weight of under six pounds is strongly suggestive of impaired vitality. The average birth weight for males is yf pounds; for females it is 7I pounds. During the first three or four days of life there is a loss of weight, which is usually designated as physiological. This initial loss of weight often amounts to 9 or 10 ounces. Not all of it is strictly physiological, but only that part of it, amounting to 4 or 5 ounces, which can be accounted for by the passage of meconium. The additional loss is nutritional in origin, and is due to an excess of tissue waste over nutriment. The secretion of the breasts is estab- lished rather slowly, and during the first days of life the infant obtains comparatively Httle food. The nutrition is probably further affected by the tax on the infant's vitality caused by the sudden change in its surroundings. Normal Development 23 By the third or fourth day, when the milk secretion is estabhshed, the normal infant begins to gain continuously in weight. Failure to gain at this time is seen only when the milk secretion is estab- lished unusually slowly, when colostrum milk persists unduly, or when some other cause is present which actually produces a condition of disease. The initial weight is usually regained during the second week. If it is not regained by the third week, we must look for some cause disturbing normal development. In artificially fed infants, the initial weight is often not so rapidly regained as in the breast-fed. During the first year of life, increase in weight is normally con- tinuous, and comparative y rapid. The gain is most rapid during the first three months; in this period the average daily gain is almost two-thirds of an ounce. The gain is not, however, steady from day to day, a large gain on one day being often counterbalanced by a failure to gain on the next day. The rate of gain can best be judged by comparing the records from week to week. In the second three months the gain in weight is not quite so rapid. In the third quar- ter, the rate of gain is the slowest of any of the periods of the first year, and becomes shghtly more rapid in the fourth quarter. The following table shows the average rate of gain in normal infants, in the four quarters of the first year: Table 7 total gain weekly gain grammes pounds grammes ounces First three months 2400 5 180 6.2 Second three months 1920 4 148 5 Third three months 1200 2I 92 3.1 Fourth three months 1320 2f 102 3.5 The figures for the weekly gain represent an average, and are rather larger than are often seen in babies who in every respect develop normally. One should not be worried as to the development of any baby whose weekly gain in weight was 4 ounces for the first three months, 3 ounces for the second three months, and 2 ounces for the last six months of the first year. It is customary to picture the weight development of an infant in the form of a weight curve, such as that shown in the chart. Such a chart represents the average rate of gain of a number of healthy babies. It must not be taken too Hterally in comparison with the weight curve of an individual baby. The rate of gain in individual babies is usually not so steadily continuous as in the ideal infant's weight chart. In many normal babies there are periods when the rate of gain is much less than the average, or in which there is even, for a time, no gain in weight. Such a period of slight gain or of stationary weight is particularly likely to be seen in the third quarter of the first year. In any child there are apt to be 24 The Normal Child Chart i Name, Date of Birth,. Months. 1 Weeks. 13 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 I I I I I I I I I I I -I I I 9 11 13 15 17i 19 21 23 2.'> 27 29 31 33 35 37 39 41 13 45 47 49 51 5fi CO 64 68 72 76 80 8i 88 92 96 1001 04 Weeks. 1 3 6 7 9 H X3 15 IT 19 U 83 85, 27 29 31 33 35 37 39 41 43 45 47 49 5J, §8 fig 64 '^9 78 76 80 64 88 98 96 10010* 0E8IQNE0BY J.P, CROZER GRIFFITH, M.O. Infant's Weight Chart periods when new processes of growth, such as dentition, or new func- tions, such as noticing, walking, or talking, are being rapidly devel- oped. At such times the gain in weight is less pronounced. The weight chart is useful as a general guide for comparison in estimating Normal Development 25 the development of the baby, but it represents an ideal condition, which is often not attained. A further extension of such a method of comparison provides a weight index for estimating the weight development of any infant. This weight index is expressed by dividing the weight of the infant by the weight of the average healthy infant of the same age. If the quotient is multiplied by loo, the result expresses in per cent, the weight development of the baby. This is useful as a general guide, but again, must not be taken too literally as a criterion of normal development, on account of the factor of individual variation. It must also be remembered that babies who are above or below the average at birth, are apt to keep the same relation to the average throughout much of the first year. This is shown in the chart. Inf aat C 5 Chart The middle line "B" represents the weight curve of the average healthy infant. This curve is taken as the constant by which to estimate the weight index of any infant. The perpendicular lines represent the number of pounds the child gains in the four quarters of the first year. The weight index of such an infant is i.o, the weight development loo per cent. The upper curve ''A" represents the theoretical curve of an in- fant weighing 9 pounds at birth, with a resulting weight index of 1.2. If such an infant were to maintain throughout the first year the advantage in weight development with which it starts out in life, its quarterly gains in pounds would be as are indicated in the perpendicular lines. These will be seen to vary considerably from those of the average healthy infant represented in curve "B." In a similar manner curve "C" represents the theoretical weight curve of a 5^ pound-baby, with a weight index of 0.7, and the per- pendicular lines show the quarterly gains in pounds, which would be necessary to maintain throughout the first year the weight devel- opment with which it starts in life. These are seen to be considerably less than those of the average healthy infant. 26 The Normal Child Now, for example, if the infant C and infant A each gain from the sixth to the ninth month 5 pounds, instead of the theoretical gains expressed in the perpendicular lines, one will find by working out the above formula, that the weight index of infant C has been raised to 0.85, a gain of 15 per cent, in weight development; that the weight index of infant A has been raised to 1.30, a gain of 10 per cent, in weight development. In other words, although each infant has gained the same number of pounds in three months, the smaller infant C has gained proportionately 5 per cent, more in weight de- velopment than the larger infant A. It is not to be supposed that every healthy infant weighing above normal at birth and having a weight development above 100 will maintain throughout the first year the same percentage of develop- ment with which it starts out in life; some will and others will not. There is in the majority of cases a tendency for the line of growth of these large infants to dip downward and gradually to approach the weight curve of the average child. On the other hand there is a great tendency for the undersized infants, if properly fed, to grow, relatively to their initial weight development, faster than the average child, and their line of growth tends upward to meet that of the average infant. In judging the effects of feeding upon two such theoretical cases as "A" and "B" in the above example, it is obviously unfair to take the number of pounds gained in each quarter by each infant as the sole basis of comparison. A more exact and scientific method is to indicate their rate of growth in percentages of development. We may thus express with clearness and in easily understood terms their progress either in reference to each other or to the average healthy child. The weight index, then, while not embodying any fixed law of growth may be used to express in definite percentages the variations in weight development of an infant which may occur as a result of natural growth or disease. During the second year the gain in weight is much less constant and steady than in the first year. There is, of course, stationary weight, or loss of weight, with every illness. Also, even when there is no illness, and when the child is developing normally in every other respect, there are periods when the gain is very shght, or when the weight is stationary. Such periods are particularly seen in the summer months; many otherwise normal children, do not gain weight during an entire summer. The rate of growth is apt to be fastest in the autumn and early winter. In the earlier years of childhood, the same conditions of weight devel- opment prevail as in the second year. In the later years of childhood the weight increase is slower, but rather more steadily constant. Normal Development 27 The figures for the average weights and heights of normal chil- dren throughout infancy and childhood are shown in the table. They afford a ready basis of comparison in estimating weight de- velopment, showing the relation of the individual child at all times to the average normal. Table 8 Average Heights and Weights from Birth to Five Years, and of Boston School Boys and Girls, Irrespective of Nationality, from Five to Fourteen Years Boys AGE Girls HEIGHT WEIGHT HEIGHT WEIGHT Centimetres Inches Kilogrammes Pounds Centimetres Inches Kilogrammes Pounds 49-37 1975 3-25 7-15 Birth 48.12 19-25 3-15 6.93 6i «7 24 75 6 5° 14 30 5 months 5912 23 25 6.30 13.86 73 82 29 53 9 54 20 98 I year 74-17 29 07 9.00 19.80 84 55 33 82 13 80 30 36 2 years 82.35 32 94 13-31 29. 28 92 &5 37 06 IS 90 34 98 3 years 90.77 3b 31 15-07 33-15 98 27 39 31 17 27 37 99 4 years 97.00 38 80 16.53 36.36 103 92 41 57 18 04 41 00 5 years 103.22 41 29 17.99 39-57 109 37 43 75 20 49 45 07 6 years 108.37 43 35 19.63 43-18 114 35 45 74 22 20 48 97 7 years 113.80 45 52 21.50 47-30 119 40 47 76 24 46 53 81 8 years 118.95 47 58 23-44 51-56 124 22 49 09 2b «7 59 00 9 years 123.42 4Q 37 25-91 57-00 129 20 51 68 29 62 65 16 10 vears 128.35 51 34 28.29 62.23 133 32 53 33 31 84 70 04 II years 133-55 53 42 31-23 68.70 137 77 55 II 34 89 76 75 12 years 139.70 55 88 35-53 78.16 143 02 57 21 3« 49 84 67 13 years 145-40 58 16 40.21 88.46 149 . 70 59.88 42.9s 94 49 14 years 149-85 59 94 44.65 98-23 In remembering the course of normal weight development, useful figures are the following : An average child doubles its birth weight at five months, and trebles it at fifteen months. At five years its weight is double that seen at the end of the first year, and its weight at five years is doubled at twelve years. DEVELOPMENT OF INTERNAL STRUCTURE In order that the student of pediatrics may recognize certain path- ologic conditions found on post-mortem examination, it is essential that he be familiar with the features of internal structure which are peculiar to early life. The development of those internal parts of the body which at birth show anatomic peculiarities will be traced. The development of function, such as that of the digestive and urinary systems, is also of great importance to the student of pedia- trics. This phase of development is, however, so closely connected with the various gastro-enteric and renal diseases, that its discus- sion will be postponed until these diseases are considered. Anatomic development only will be considered at present. 28 The Normal Child THE BRAIN. — The brain grows rapidly during the first seven years of Kfe; after this age it increases very slowly in weight. The convolutions are not fully developed at birth, and are gradually per- fected as the child grows older. One important anatomical condi- tion in the brain of young subjects is that the dura mater is much more adherent to the skull than in later life. The subarachnoid space also, contains a larger amount of fluid. THE EAR. — At birth there exists in the roof of the middle ear a distinct cleft between those portions of the tegmen tympani which are formed by the petrous and squamous bones. Through this cleft extends a small process of the dura. This cleft closes at about the beginning of the fifth month, becoming the petrosquamosal suture. It does not in early life, appear to play any role in permitting puru- lent processes to extend from the ear into the cranial cavity. The cavity of the antrum is present at birth, but the mastoid process is very slightly developed, there being no mastoid cells. At the end of the first year, the mastoid begins to contain a few pneu- matic cells. It becomes fully developed, resembling the adult mas- toid, at three years. The osseous meatus is not developed until about the fourth year. In introducing the ear speculum at a period previous to the fourth year, the ear should be drawn backward and downward, instead of backward and upward. THE NASOPHARYNX.— The nasal cavity begins to increase in height directly after birth, and its growth is rapid until the begin- ning of dentition. After the completion of the first dentition, the growth is again rapid until the seventh year, during which period takes place the chief increase in breadth, and the growth of the olfactory portion. At the end of the seventh year, the cavity ap- proaches the adult shape, although it still seems broad in propor- tion, and of course has not attained the adult size. The change in the shape of the pharynx is very rapid during in- fancy. It attains the adult shape at about the age of three years. There is little change in the position of the eustachian tubes up to the ninth month. After this, the openings are higher than the floor of the nasal cavity. The pharyngeal tonsil increases rapidly, after birth, and by the end of the third year has a length of eighteen millimeters. THYMUS GLAND.— The thymus is most developed in the first two years of life, but it persists longer than was formerly taught. During its greatest development it is found in the neck as well as in the thorax, extending perhaps 2 cm. (f inch) above the sternum. The thymus extends down the anterior mediastinum, lying on the pericardium in two long lobes on either side of the median line. The Normal Development 29 extent of these lobes is very variable, and the two are not usually symmetrical. I have seen them, even in an infant, so developed that the longer nearly reached the lower end of the sternum; but it is very uncommon for it to reach the diaphragm. These prolongations become thinner as they descend. The thymus is a thick mass behind the first piece of the sternum, where it rests on the top of the heart against the great vessels concealing the innominate veins, more or less of the superior vena cava and the arch of the aorta, and extend- ing back to the trachea. Lower down it extends on either side into the angle between the pericardium and the lungs, or rather pleurae. The time of complete atrophy is extremely variable. I have seen it both present and absent in autopsies at every year from the third to puberty. THE HEART.— At birth, the anatomy of the heart still shows the peculiarities required by the fetal circulation. Functionally, with the tying of the cord and the expansion of the lungs, the circu- lation of the blood immediately changes to the course seen in adults, although a small amount of blood may still pass through the fora- men ovale and the ductus arteriosus. Anatomically the changes are of course not immediate, though they take place fairly rapidly after birth. The ductus venosus becomes a fibrous cord in from two to five days. While the intrauterine function of the eustachian valve ceases immediately, its remains can be found for an indefinite period. The foramen ovale usually is closed by the tenth day, although it is sometimes found open either as a whole, or in its upper portion, at any period of childhood, without any murmur or other physical sign. The ductus arteriosus normally becomes impervious in from four to ten days. The cavities of the umbilical vein, and of the upper parts of the umbilical arteries, are obliterated in from two to five days. As soon as these changes from the fetal condition are completed, the anatomy of the heart differs in no essential particular from that of adults. Its growth is always more or less proportionate to the growth of the child. THE LUNGS. — The age at which the lungs reach their full expan- sion forward is very variable; it is certainly not earlier than the sixth year, and may be much later. There is, of course, a continuous increase in the relative size of the lungs to the heart, which keeps pace with the development of the thorax. The marked anatomical peculiarities seen in the lung of the new- born infant persist almost unchanged throughout the first year. The alveolar walls remain proportionately thick, the connective tissue stroma remains loose, and relatively great in amount, the size of the alveolar air spaces remains small in proportion to that of the 30 The Normal Child Fig. 8 Section of fetal lung at 5 months, showing development of bronchi; no alveoli Section of infant's lung at 10 months, showing increased proportionate amount of parenchyma in comparison with the fetal condition; distended alveoli Normal Development 31 bronchioles, and their number remains relatively small. After the first year, the development of the lung begins gradually to approach the adult type. It has been generally stated that the development is complete by about the end of the fourth or fifth year. I beheve this statement to be only partly true. At this age the size of the alveoli has attained the adult proportion to the bronchioles, the walls of the alveoli have become thin, and the stroma has become firm and binding. But, in my experience, based on a number of observations of children's lungs, the proportion in number of alveoli to bronchioles still remains smaller than the adult proportion, and does not show complete development until toward the end of childhood. THE STOMACH.— Both the position and the shape of the stom- ach change rapidly during the first year of life. The axis of the stomach gradually becomes less oblique, and by the end of infancy reaches the transverse direction seen in older children and in adults. The fundus develops rapidly during the first year, and although it does not reach its full development until late in childhood the tubu- lar shape of the organ soon disappears. The development of the capacity of the stomach is important in connection with the subject of infant feeding. There are two ways of estimating the gastric capacity. One is based on actual anatomic measurements made post-mortem. The other is based on measur- ing the amount of fluid which a normal infant takes at a single feed- ing. There is often considerable discrepancy between the anatomic and physiologic measures of gastric capacity. The following table shows some anatomic measurements at different ages made by Rotch and Holt respectively, and some physiologic measurements made by Rotch and Mosenthal respectively: Birth 1 week . . . 2 weeks . . 4 weeks . . 8 weeks . . 12 weeks. . 1 6 weeks. . 5 months. 6 months. 7 months. 8 months. 9 months. 10 months. 11 months. I year . . . . Table 9 Gastric Capacity in Ounces Anatomical rotch holt I. 20 Physiological rotch mosenthal 90 3-50 4.00 4.80 4.80 ?.6o 32 The Normal Child It will be noted that the figures for anatomic gastric capacity given by Rotch and by Holt are fairly close to each other, those of Holt being in general slightly larger than those of Rotch. The difference in the figures can easily be explained by some minor difference in the technique of taking the measurements. The figures given by Mosenthal for physiologic capacity are much larger than those of Rotch. This can probably be explained on the ground that the babies on which Mosenthal's figures were based were given all the milk they would take, and could take care of, whereas Rotch's figures are based on babies who were thriving on measured amounts without showing signs of hunger. The amounts given to these babies, also, were more or less based on Rotch's anatomic measure- ments. I believe Mosenthal's figures, which show the physiologic capacity to be larger then the anatomic, are better. The reason for the physiologic capacity being greater than the anatomic is ex- plained by recent work on the digestion of milk. It has been shown that coagulation begins during the feeding, and the passage of the fluid portion into the duodenum begins before the feeding is com- pleted. The exact bearing which measurements of gastric capacity have on the amounts of milk to be given at a feeding, will be dis- cussed in the division on feeding. The functional development of the stomach is so closely con- nected with the problems of digestion and nutrition that its con- sideration will be postponed, to be discussed in the division on gastro- enteric diseases. THE INTESTINE.— The growth of the small intestine is so extremely irregular that the widest variations are found at every age of childhood. Its most rapid and constant increase in length occurs during the first two months of life. The variations in the rate and amount of its growth appear to bear no relation to the general development of the child. The position of the cecum is very variable in infants and young children, ranging normally from the lumbar region to the lowest part of the iliac fossa. In the majority of instances its position is higher than in adults, and for this reason the ascending colon is very short. In childhood, especially in infants and young children, the ascending colon very frequently has. a mesentery, being so com- pletely invested with peritoneum as to be absolutely free. Both the caecum and the ascending colon are always much more freely movable in the young child than in the adult. The length and direction of the vermiform appendix are so very variable, that they have no significance. The descending colon usually has no mesentery, but one may be present, especially in early infancy. Normal Development 33 During the first four months of life there is Httle or no change in the length of the large intestine as a whole, but the upper portions grow at the expense of the sigmoid flexure, which at birth has a length of nearly one-half that of the entire large intestine. In the majority of cases, the sigmoid flexure assumes the adult proportion at four months, but sometimes remains relatively very long. After the age of four months, the large intestine increases in length through- out childhood, until the adult length is reached. THE KIDNEYS.— The fetal lobulation of the kidneys observed at birth persists for a variable, but considerable, time. It is usually found at autopsy in children under one year. Evidences of the uric acid infarction usually disappear in about one week, but I have observed them at autopsy in a child three weeks old. BONE MARROW.— Nothing definite is known as to the exact time when the red bone marrow of early life changes to the yellow marrow of a later period. IV. HYGIENE AND CARE OF INFANTS AND CHILDREN CARE OF THE NEWBORN.— At the time of. ligating and cut- ting the umbiHcal cord, the physician should make sure that the newborn child cries lustily. The eyes should be cleansed with sterile water, but the mouth should not be washed. In hospital practice, or if the mother has had a vaginal discharge, a few drops of a two per cent, solution of silver nitrate or ten per cent, argyrol should be instilled into the eyes, before cleansing them with water. The child may then be wrapped in warm flannels, and laid aside, until the nurse has finished the immediate care of the mother. The bath should then be given. The body of the infant should be gently rubbed with olive oil, to soften the vernix caseosa, and then bathed in warm water at a temperature of ioo° F. The stump of the cord and the surrounding parts should be carefully dried, and dusted with sterile talcum, or other dusting powder. The cord should be wrapped in a pad of sterile gauze, and the abdomen should be enveloped rather snugly in a flannel band. The infant should then be examined for malformations or trauma received during birth, after which it may be dressed, and placed in its crib. It should be covered with blankets, and if the extremities are cold, or if the lips and fingers are bluish, hot water bottles covered with flannel should be placed in the crib, care being taken that they do not come in contact with the body. The baby should not be kept in its mother's bed, but should occupy its own crib, in a quiet, dark- ened room. The stump of the cord must be kept dry, and should not be dis- turbed any more than is necessary to inspect it. It usually sepa- rates from the fourth to the seventh day, leaving a red surface, which rapidly becomes covered with epithelium. The umbilicus should be kept dusted with sterile talcum, and should be covered with a small pad of sterile gauze, about one-quarter of an inch thick. The full bath should not be given until after the umbihcal scar has healed. Until this occurs, the infant may be given a daily sponge bath at a temperature of ioo° F. Care must be taken that all the baths at this early period of infancy be given in a warm room. The rectal temperature of the newborn infant should be taken twice daily until the umbihcus has healed. All the intestinal dis- charges should be saved for the physician, until meconium has en- tirely disappeared. The baby need not be weighed until the end of the first week. Hygiene and Care 35 The feeding of the newborn baby is considered in the division on infant feeding. WEIGHING. — Normal babies should be weighed once a week during the first year of life. The weighing is best done at the time the infant receives its daily bath. Infants who are very delicate, or sick, or in whom some change in the feeding has been instituted, should be weighed daily, unless their vitality is so low that they constantly have a subnormal temperature. During the second year, it is also better to weigh most babies as often as once a week, although such frequent weighing is not so necessary as in the first year. Older children should be weighed once a month. BATHING. — Infants and children must be bathed daily. In- fants should begin to have tub baths as soon as the cicatrix of the cord has healed. Theoretically the best time for the tub bath is in the morning, but giving it at this time, in most households, does not fit in so well with the child's general routine. The baby usually has to have its first feeding upon waking in the morning, and often goes out shortly after the second feeding. Also, in many households the rooms are not warm enough to bathe the baby so early in the morn- ing. In most households it is found more convenient to give the tub bath at night, at bed-time, just before the feeding which is given about six o'clock. The baby may have a basin bath in the morning, before its second feeding. Even if no basin bath is given at this time, the infant's face should be washed. The temperature of the bath at the different ages is shown in the table. Table io . " Temperature of the Bath for Different Ages AGE CENTIGRADE FAHRENHEIT At birth 37.8° 100° During first three or four weeks 35 ° 95° One to six months 34 ° 93-2° From six to twelve months 32.2° 90° Twelve to twenty-four months • 30 ° 86° Then gradually reduce in summer to 26.6° 80" In the third or fourth year, if possible, reduce to 23.8° 75° The temperature of the room in which the bath is given should be from 76° F. to 80° F. The nurse should first wash the face in clear water, keeping the body and limbs wrapped up in a warm blanket. The face is then wiped with a soft towel. She should gently cleanse the nose, the corners of the eyes, and the external ears. The nose is especially important, for the infant's vitality is easily aft'ected by occluded nares. The nurse should then soap, wash off, and dry the scalp. 36 The Normal Child Especial care should be paid to the folds of the neck, the axillae, groins, genitals, and anus. The body and limbs having been thor- oughly and quickly soaped, the nurse should gently lower the infant with its face up into the clear water in the bath, being careful not to frighten it or to drop it. After allowing the infant to kick and splash for a few seconds, it is taken back into the nurse's lap and carefully dried with a warm, soft towel. When the skin is perfectly soft, clear, and in a normal condition, no powder is needed. Where there is any slight irritation, which, at times, is liable to occur when the skin has not been kept sufficiently dry, especially if there is a decided redness in the folds of the skin, as of the neck, axillae, or groins, powder may be applied. During the second year, the tub baths at night are continued, but in addition sponge baths in the morning should become part of the general routine. At first, the temperature of the water may be little if any lower than that of the tub baths, but after the end of the second year, an effort should be made to make the morning sponge baths colder. The baths must be very brief. The child should stand in a tub partly filled with warm water, and should be sponged all over very rapidly with the cooler water, for not more than half a minute. It should then be dried by vigorous rubbing. The temper- ature of the water used in giving the morning douche, at first 70° F., is gradually lowered, until the temperature of ordinary tap water is reached. At all times care must be taken that children react thor- oughly from these baths. If at any time, after them, children shiver, look pale, or become slightly blue about the lips, the water used must be warmer, or cold sponging must not be used. In the latter part of childhood, the warm bath at night should be omitted, except occasionally. At this time every morning, the child, standing on a bath mat, should be thoroughly washed with warm water, and may then plunge into a tub of cooler water. The temperature of the cold plunge should be not over 70° F,, and should be as much colder as the reaction of the child will allow. CARE OF THE MOUTH AND TEETH.— The teeth of the young infant should be cleansed each morning, when the morning toilet is made. Too much vigor must not be used in the mouth. Children should be taught to use the toothbrush at the earhest possible moment. A protest should be made against the way in which the nurse, and also others who come near the infant, put their fingers into its mouth on all occasions. It would seem as though the infant's mouth was considered by those who ought to know better as some- thing especially made to be felt. The fingers should always be thoroughly washed before entering an infant's mouth. Hygiene and Care 37 A nurse should be instructed that she is never to kiss the infant on the mouth, or allow any one else to do so. The micro-organisms of disease can well be transmitted in this way. Nor should the baby's hands or fingers be kissed, as they are constantly going into its mouth. CARE OF THE SKIN.— The skin of the young infant is very delicate, and exceedingly liable to irritation. Napkins should be removed as soon as soiled and wet. In very fat infants, or whenever there is the slightest sign of irritation of the skin, some infant powder, containing stearate of zinc, starch, or talcum, should be used, espe- cially in the folds and about the genitals. Intertrigo and eczema are usually due to faulty care of the skin. Children who perspire freely at night, should have the position of the head on the pillow changed occasionally, as facial eczema may be produced by the child's face resting all night on a sweat-soaked pillow. CARE OF THE GENITALS.— In girls, cleanliness is the only requirement. In boys, the prepuce must be attended to, and the best time is the early weeks of infancy. In most cases the prepuce is adherent to the glans, and sometimes it is very long, with only a pin-hole opening. This condition is a marked source of discom- fort and reflex irritation, from accumulation of secretions. When the prepuce is very long, and very tightly adherent, circumcision should be performed. I am not, however, an advocate of circum- cision in all cases. In many cases, where the prepuce is compara- tively short, the adhesion should be broken, and the prepuce retracted daily, with cleansing, and the application of a little vaseline. CARE OF THE HAIR.— Parents do not usually seek the advice of the physician as to whether the child's hair should be cut long or short. In cases where the parents' aesthetic feelings lead them to keep the children's hair long, the physician should point out the sanitary reasons for keeping it short. Long hair makes the children perspire about the head and neck while active, and increases their chance of taking cold while quiet. It makes them hot, uncomfort- able, and restless at night. Short hair causes a better growth of hair in later life. CLOTHING. — In clothing the young infant, there are two impor- tant requisites. The clothing must be sufhciently warm to protect the infant from exposure, and it must be so arranged as to allow the most perfect freedom of motion for the legs and arms, and for the abdominal and respiratory muscles. Young infants have a greater body surface in proportion to their weight than have older children and adults, and this greater surface means greater oppor- tunity for loss of heat by radiation. Also, the heat regulating appa- 38 The Normal Child ratus of the infant is not sufficiently developed to maintain so early a constant temperature under varying conditions of heat and cold. Infants, then, in general, require warmer clothes than older children. The community in general is so thoroughly impressed with the neces- sity of clothing infants warmly, that the tendency is to go to an extreme, and clothe them too warmly. The physician very rarely has to order warmer clothes for the infant, but frequently finds them dressed too warmly, especially during the summer months, and when indoors in winter. The ordinary clothing which the infant wears all the time should be designed to meet the conditions prevailing during the greater part of the time in the particular season of the year. It should of course be lighter in the warmer than in the colder months. It rep- resents a minimum rather than a maximum of clothing, designed so as not to overheat the child, but to keep it sufficiently warm under the conditions usually prevailing. Sudden changes to a colder degree of heat surrounding the child, such as when the child goes out in winter, or when the temperature falls in the mornings and evenings of summer, should be met by extra wraps. On the hottest days of summer, even this minimum of clothing should be reduced, and the baby should be allowed to play and kick in nothing but its band and diaper. The clothes must be loose, so that they do not interfere with the natural activity of the circulation, do not press or bind anywhere, and do not interfere with full muscular activity. All the clothes must be supported from the shoulder, and not from the waist. They must be designed to go on and come off easily. For this purpose it is preferable that they fasten up and down the front rather than the back. The best designed clothes which I have seen for infants are called the "Vanta Vesta." In them all buttons and all safetypins are entirely eliminated. They are fitted with tapes, which are so placed as to fasten them in exactly the best manner, and the tapes can be easily changed to suit the size of the particular infant. Even the diapers are fastened with these tapes. The clothing worn by the infant until the age when it begins to creep, consists of the following articles: The flannel abdominal band is often worn throughout the first year. It is not a necessity, except for the first few months; after this period it should be changed for the knitted band, which fastens to the diaper below. The best material for this band is silk and wool. The diaper is best made of birdseye linen. The shirt is a garment with sleeves and high neck, and is almost as long as the "gertrude" and dress. It should fasten in front rather than behind. It is woven, the best material Hygiene and Care 39 Fig. 9 — Clothing for an Infant First step in the dressing of a baby, showing band, diaper, and stockings Fig. 10 — Clothing FOR an Infant Second step in the dressing of a baby, showing the shirt 40 The Normal Child Fig. II — Clothing for an Infant Third step in the dressing of a baby, showing the "Gertrude" or long flannel petticoat Fig. 12 — Clothing for an Infant n ^ '.^^■hH^^^I^I AHMHlHiF^ ■^ f* ■•^au^MIMI|J|l ^Kh^B i^ - -V "TiiJI w ^^^^^^H rmr^i sB ^^KS^. ii £^I^^H Final step in the dressing of a baby, showing the dress Hygiene and Care 41 being silk and wool. The petticoat, or, as it is usually called, the "gertrude," goes on over the shirt. It has a low neck and no sleeves, is somewhat longer than the shirt, but not so long as the old-fash- ioned ''long clothes" in which the infant's feet were tightly swathed, and preferably fastens in the front. It may be made either of fine flannel, or of woven silk and wool; flannel is less expensive, and fully as satisfactory. The outer garment is the dress, which is made of some soft, white material, and has a high neck, and sleeves. It is of the same length as the gertrude. Many mothers put on a soft lawn gertrude between the dress and the flannel gertrude. The dress is the only garment which the nurse should be allowed to put on over the infant's head. The band, shirt, and gertrude should always be put on over the feet, and if they open in front, the baby may be dressed and undressed very rapidly and easily. The young infant does not need to wear stockings, except sometimes when he goes out in cold weather. There is no objection to short, knitted socks, if the mother wants to use them. The nightdress is a garment made of flannel, or of woven silk and wool, which goes on over the shirt. It should open all up and down the front, and the back should be longer than the front, to permit of its being folded over the feet. When the infant begins to creep, short clothes take the place of the long clothes. The undershirt now takes the place of both the shirt and band. This should have sleeves, and should be made of silk and wool, or a fine all-wool material. The flannel petticoat is made of the same material as in earlier infancy, except that its waist is cotton; it has still a low neck and no sleeves, but is short, goes on over the head, and has no fastenings either in front or behind. Over it goes the white petticoat, similar in design, but made of some soft, white material with a cotton waist. Over these garments go the short dress, with high neck, sleeves, and buttons behind. Stockings must be worn at this period. These are pre- ferably made of wool, and fasten to the diaper. When the child begins to stand and walk, soft kid shoes should be used. Care must be taken that the shoes are of proper shape, adapted to the natural curves of the child's foot. At night the child should wear a regular nightdress, made of soft flannel, with high neck and long sleeves, and buttoned behind. When the child is two or three years old, and often before, the diaper is discarded, and the child begins to wear drawers. At this time the petticoats no longer have the cotton waists permitting them to go over the shoulders, and a new garment is worn, called the waist. The waist has no sleeves, but is supported by shoulder straps, and should fit loosely, especially about the child's waist. Its 42 The Normal Child principal function is to support the petticoats, drawers, and stockings. It is furnished with sufficient buttons at the waist, to permit the petticoats, drawers, and garters to be fastened to it, so that by means of this waist, everything hangs from the shoulders, without any constriction anywhere. SLEEP. — The amount of sleep required by children at different ages varies very much with the individual. The newborn infant sleeps almost continually, waking only for its feedings, and during the first three months, it sleeps twenty to twenty-two hours out of the twenty-four. It sleeps somewhat less, sixteen to eighteen hours, during the second three months. In the second half of the first year, the child should sleep at night from about six p. m. to six a. m., and should have two two-hour naps during the day, one between nine and twelve in the morning, and one between twelve and three in the afternoon. The periods devoted to exercise, amusement, and play should be between six and nine in the morning, and between three and six in the afternoon. The child should always be allowed to sleep as much as it will. The twelve-hour sleep at night should be continued until he is five or six years old. As they grow older, some children develop the habit of waking up earlier in the morning. If this occurs, the hour of their bedtime should not be made later, as this will disturb their routine, and will usually not correct the habit. The habit may often be corrected by making sure that the nursery is kept darkened in the morning. The two day naps should be continued as long as possible, but are usually shortened by the child itself. At one year, the morning nap is usually shortened to one hour, and is given up in the last half of the second year. The afternoon nap should be continued, although children often will not sleep after they are five or six years old. They should, however, still be made to lie down and rest, until they are seven or eight. It is very important that the child be trained from birth in proper habits of sleep. It should never be rocked to sleep, and preferably should not fall asleep in its mother's or nurse's arms, but should be accustomed to be put in its crib alone, in a quiet, darkened room, and to go to sleep of its own accord. All other artificial devices, such as allowing it to go to sleep on the breast, or with a nipple in its mouth should be avoided. Failure to go to sleep properly means noise, light, hunger, indigestion, or wet napkins. FRESH AIR AND GOING OUTDOORS.— Nothing is of greater importance in insuring the normal development of the growing child, and in the prevention of disease, than abundance of pure, fresh air. This prime necessity in the hygiene of early life is more neglected Hygiene and Care 43 than any other, usually through fear of making the children ill by exposure. When children are delicate there is a special tendency to deprive them of the fresh air which they especially need. During the first week or two of life, a baby is very easily dis- turbed by changes in the temperature, and by exposure to cold air. Its nutrition and heat regulating apparatus are not estabHshed, and it requires coddling and warmth. This does not mean that the young infant is not to be kept in well ventilated rooms, but only that it is not to go out doors, nor be exposed to any indoor airing which lowers the temperature of his surroundings below about 70° F. After the first one, two, or three weeks of life, when the regular routine of early Hfe has become estabHshed, we are confronted by the question of providing the infant with additional fresh air, by means of going outdoors, and by means of open windows. The transition from the protected routine of the early weeks, to that of later infancy must never be abrupt, but must be brought about gradually. The proper management of the fresh air problem depends upon the time of year. With infants who are born in the summer months, there is no reason why they should not begin to go outdoors after the first week or two. The infant should then spend as much time as possible in the open air, sleeping outdoors in his carriage in the day time. When indoors, the windows of his room should always be open. In summer, all that is necessary is to guard against the very sudden drops in the temperature which are sometimes seen at our summer resorts. At such times, the infant may continue to go out, unless the tempera- ture falls below 60° F., but extra wraps must be provided. Also, when indoors, he may still sleep with open windows, but if it is so cold that the temperature in his room would fall below 60° F., the windows must not be opened so wide. Only at those hours when the infant is bathed, or is partially undressed and allowed to kick and play, should the windows be closed. Infants who are born in the spring or autumn should not begin to go outdoors until they are at least one month old, and then should not go out when the outdoor temperature is below 60° F. They should at first not be kept out more than ten or fifteen minutes, and the duration of the outing should be lengthened gradually. With infants who begin to go out in the autumn, it is possible to continue to take them out even as the season advances, if care is taken that they be kept in on the colder days, and that they be exposed very gradually to a lower outdoor temperature, so that often they may continue to go out on favorable days all winter. In spring and autumn infants must be gradually accustomed to open windows in their sleeping rooms after they are a month old, 44 The Normal Child precautions being taken against sudden falls in the temperature of their sleeping rooms. ^Vhen infants are born in the late autumn or winter, it is more difficult to provide plenty of fresh air without too sudden a tran- sition. When they are a month old, they may begin to have indoor airings. They are dressed for an outing, and then the windows of the room are opened wide for a few minutes. The minimum tem- perature of the room must be lowered very gradually, while the dura- tion of the airing is very gradually increased. This substitute for an outing may be continued through the winter months, and the child will be ready for an actual outdoor airing with the first fine days of spring. After these indoor airings are instituted, the child may be gradually accustomed to sleeping in a room with open windows, the window at first being opened only the merest crack, and gradually opened more on the warmer nights. When an infant is four or five months old, he should go out doors even in winter. In our middle and northern states, the weather conditions are such that it is not advisable for infants to be taken out every day. When it is very windy and dusty, when there is a snow storm, when the snow is melting, and when the temperature is below 20° F., it is better for the infant to receive his airing indoors. On fine, calm, sunny days, even if fairly cold, he should go out for two hours in the morning, and for two hours in the afternoon, but in winter, should not be out later than three o'clock. The best times for these outings are from ten to twelve in the morning, and from one to three in the afternoon. There is absolutely no objection to an infant sleeping outdoors in his carriage in winter. The nurse should protect his eyes from the direct rays of the sun, and his face from dust and strong wind. Older children should be outdoors as much as possible, being kept in only when the outdoor weather conditions are very bad. As long as an infant spends most of his time in bed while indoors, it is easy to keep the windows of his nursery open, and still protect him from exposure to draughts. When he has grown older, and has reached the age when he begins to creep, stand, walk, and play, this is more difficult in the colder months. The child will play on the floor, and if the window is open, no matter how carefully, and even if a window board is used, there are sure to be cold draughts on the floor. In most cases it is impossible to keep the window of the nursery open, even with a window board, while the child is playing. I am a great believer in an open fire, which is a great aid to ventila- tion, and from the draught of which the child may be protected by not alloAving him to play in a direct line between the window and the fireplace. In any case, the nursery should always be thoroughly Hygiene and Care 45 aired whenever the child is out of it, and before he goes to bed at night. In the day time, if possible, he should be changed from one well, aired room to another. The practice has frequently been adopted in cases where infants were born in summer, and have become accustomed to sleeping outdoors even at night, to continue having them sleep in an outdoor sleeping-porch even in winter. I have seen this practice adopted without harm, and apparently with benefit. Great care must be taken with the coverings, and constant vigilance exercised against sudden changes in the weather. It is so difficult in our northern climate to care for children sleeping outdoors at night in winter, that I do not recommend it until children are at least three years old. The nursery with open window provides enough fresh air for the average baby. After the age of three, I am a great believer in the outdoor sleeping-porch, whenever it can be provided. EXERCISE. — In young infants exercise is obtained by kicking its legs, and waving its arms, and does not require any very special attention. It is, however, a bad plan to allow infants to lie in their cribs all the time. This fault is more often seen in hospitals than in private practice, and sometimes leads to marked impairment of the health of the baby. The babies must be picked up and carried about occasionally and their position should be frequently changed. In private practice it is a good plan, once or twice a day, to take the baby into a warm room, remove its more cumbersome outer clothing, and let it kick about for a while on a large bed. When the babies grow older, and reach the age when they begin to creep, they normally never fail to take sufficient exercise, and sometimes take too much unless they are restrained. By placing them on the floor on a large mattress, or on a large bed, in a warm room, opportunity may be given then to kick and roll about as much as they desire. After babies have learned to walk, care must be taken to prevent them over-exerting to the point of becoming tired. Exercise in the open air is best, but they must not be allowed to walk too far. It is better to wheel them to some desirable spot, and then let them walk or run about for a time which, short at first, is gradually in- creased as they grow older, until finally, between three and five years of age, they walk during the entire outing. For indoor exercise in winter, an exercise pen, which keeps them off the floor, is often useful. In older children, every form of outdoor exercise should be en- couraged. In normal children, none of the usual games and sports are harmful, and opportunity should be given for the children to learn and practice as many as possible. 46 The Normal Child HYGIENE OF THE NERVOUS SYSTEM.— It must be remem- bered that the nervous system is relatively undeveloped throughout the whale of infancy and childhood. The first two years of life constitute the period in which the brain grows more rapidly than during all the rest of the chi'd's Hfe. This rapidly growing brain requires above all things rest and peace, and is especially sensitive to abuse. At all times the nervous system of early life is unstable, and extremely sensitive to stimulat'on and prone to excessive reaction. It is sensitive both to reflex stimulation, and to mental stimulation. To insure normal development of the nervous system, care must be taken at every age that there is present no source of reflex irri- tation. The physician should carefully examine all children who come under his care for evidences of such conditions as phimosis, adherent prepuce or clitoris, adenoid disease, eye-strain, chronic indigestion, and others. The removal of any such possible cause of reflex injury to the nervous system is very important. Mental over-stimulation is still more common as a source of injury to the growing child. It may easily be begun and carried to an injurious extent in the earlier months of infancy, without the mother being aware that any harm is being done. For the young baby, the chief form of over-stimulation which its nervous system receives, is too much or too active entertainment. In most famihes the first baby is the greatest sufferer, from parents at least; but often subse- quent babies are allowed to become the plaything of the older chil- dren. Babies should not be played with much. If possible they should not be allowed to pass their time in rooms where the activi- ties of family Ufe are a constant source of noise, and where they are constantly attracting superfluous attention. A proud mother likes to show off her baby to visitors and friends, who like to hold it, and hand it about, and poke it to make it smile, and talk to it. As it begins to react more and more to its surroundings, by smihng, wrig- ghng, and kicking, these actions are considered "cunning," and more and more efforts are made to bring them forth. All this is very bad for the baby. It is possible to produce in a very young baby an actual condition of nervous exhaustion, which first manifests itself by failure to gain weight, then by loss of appetite, than by restless- ness and poor sleep, the baby jumping at the slightest sound. Even with older infants and children, the nervous system can very easily be over-stimulated to the extent of producing symptoms of harm. Children are sometimes amused by exciting and unusual sights and sounds. Violent romping games, especially at night, and suggesting new and exciting forms of play, are also bad. It is better to allow children to invent their own play, than to play with them too Hygiene and Care 47 much. Moreover, especially when the children are bright and learn easily, their fond parents often delight in teaching them little sayings, or rhymes, at too early an age. This is also too stimulating to the nervous system of the young child, and the brighter the child, the greater the danger. The telHng of exciting stories, or of stories about unfamiliar things which vividly stimulate the imagination, is also bad. Too much adult companionship is often not good for children, espe- cially if new things are taught and suggested. The young child learns best from the companionship of other children of the same age. The type of the individual child should be considered. There is more danger from over-stimulation from teaching, novelty, and excitement in the bright child, than in the dull and phlegmatic child. When they get older, the question of kindergarten and school arises. When a child has reached the age of six years, I believe that kindergarten is a good thing, provided that it is properly managed, with a maximum of play and exercise for the hands and body, and a min'mum of teaching and exercise for the mind and eyes. The chief value of kindergarten, however, is the companionship of other children of the same age. School is the next step after kindergarten. I believe that all children who have attained the proper mental and physical develop- ment, should go to school with other children, and should not have private lessons at home. Private teaching by a governess does not satisfy the very real need for companionship. At just what age a child should begin to go to school, and for how long, are questions which vary with the individual. At no time during childhood should school interfere with the large amount of outdoor exercise which is so essential to proper development in childhood. The hours of the public schools in many parts of this country, with two daily ses- sions, I believe to be too long. The physical development of the child is very important in con- nection with the question of school. It has been shown that a child's capacity for mental work without injury to health, bears a direct relation to his physical development. The difficulty lies in measuring the physical development; height and weight alone can- not form the criteria on which the estimate is based. Everything, all the evidence obtained by careful physical examination, should be considered. Rotch suggested, as the best measure of develop- ment, the successive times of ossification of the carpal bones, and has designed a scheme which he called the ''anatomic index." This has proved a very satisfactory basis in places where large numbers of children have to be grouped and classified according to their stage of development. Some of the dangers and disadvantages of many of our school 48 The Normal Child systems are the following: — In the first place, there is the danger of too long hours. A second unfavorable feature often found in school life, is the fostering of a spirit of competition, by means of marks and prizes. There is another danger which pretty and pre- cocious children in particular encounter, that of becoming "teachers' pets." These children are encouraged to seek promotion, and are shown off, and speak their little pieces whenever visitors are in the school. Many a nervous system has been injured in childhood by the over-ambitious teacher. Precocity in children is always a sign that mental development should be guarded and restrained, rather than fostered. The life of the young child should always be more like the life of the young animal than like that of the adult. Children are little animals, not little men and women. TRAINING AND DISCIPLINE, HABITS.— Children may fre- quently be trained to control the rectum and bladder at a remark- ably early age. Such training should always be begun before the end of the first year of life. The mother should observe at what hour the baby usually has a movement of the bowels, which in most cases follows very shortly after a feeding, and the mother, imme- diately after this particular feeding, should put the baby on a small chamber. Many children learn very quickly to indicate when they want to have a movement. The training of the bladder, while rather less rapid, can be carried out in the same way. Children vary very much as to how quickly they learn to give signs when they want the chamber, but many intelligent children learn so quickly, that in the second year napkins can be dispensed with during the day. While children are very young, no other habits should be taught by training, except the control of the rectum and bladder. During this early period of life, efforts at training should be directed at pre- venting the development of bad habits. The earliest of these habits to appear, and one of the commonest, is crying. The crying habit develops in infants who are picked up and held and petted, or talked to and amused, whenever they cry. The cause of the first crying may have been something really wrong, but if crying is treated by picking up and amusing the baby, the habit will persist after the cause is no longer present. It must be remembered that it is a good thing for the young infant to cry a litt e every day, crying having a beneficial effect in providing exer- cise, favoring peristalsis, and causing deep inspiration and good expansion of the ungs. Too much crying in a well and unspoiled baby, always indicates that something is wrong, or at least, that some cause exists which can be removed. An infant cries from hunger, from indigestion, from fright, from soiled napkins, from HYGIE^^E AND Care 49 inflamed buttocks, from tight clothes. In all cases the crying should not be treated by picking the baby up and diverting him, but a painstaking search for the cause should be instituted, and we should not be satisfied till it has been found and removed. The baby who cries violently, but stops abruptly as soon as picked up, has become an habitual cryer, and has advanced the first step on the road which leads to the '^ spoiled child." Such cases must be treated by a short period of rigid discipKne. If for a few times he is left to "cry it out," he will be cured. Mothers should be assured that this treatment will not injure the baby's nervous system as much as allowing the habit to continue, and that it will not cause either convulsions or rupture. The crying habit is almost identical with another bad habit, that of being held constantly in the arms. A baby should be handled as little as possible, just enough to give it exercise. It should never be allowed to fall asleep in its mother's or nurse's arms. The habit of being held soon develops, and leads to the crying habit Its treat- ment is the same, when developed, but it may always be prevented. Another habit, more inexcusable on the part of the mother or nurse, is that of sucking on a rubber nipple or ''pacifier." Besides deforming the lips and jaws, the pacifier is always unsanitary. Thumb and finger sucking are bad habits of a similar character, and the habit of pulling the ears is sometimes seen. These can be cured by band- aging the hands, and in the case of thumb and finger sucking, putting a solution of quinine on the bandage. All sorts of curious rare habits are sometimes seen in children otherwise normal. One child I have seen recently has a habit of deliberately banging one part of his cranium against the bars of his crib. The training of children in habits of good conduct and behavior, is as important as it is difficult. While they are very young, and unable to understand at all the meaning of right and wrong, it is absolutely useless to use either admonition or scolding. Fortunately, at this age, the properly cared for child will not be able to do very many things which are injurious. If he does begin to do things which are a real menace, such as pulling down table cloths, or putting beans and shoe-buttons into his nose, he must be corrected physically. At this age the baby is precisely like a young animal. Young ani- mals learn the art of selfpreservation through the pain which attends their dangerous acts, and kittens or puppies do not walk into the fire. For young children who are beginning dangerous habits, there is nothing like a good spanking. The mother often fears that the child will dread her instead of loving her, but if the spanking always immediately follows the wrong-doing, and if the punishment is never remitted, but always carried out, this will never occur. 4 50 The Normal Child For oMer children, much depends on a proper method of disci- pHne. When children are old enough to understand commands, they must be trained to be obedient, and discipline must be carried out in the way which will cause the least stimulation to the sensitive nervous system of the young child. All punishment, at this age, should if possible be made to take the form of deprivation of a pleas- ure. The daily life of the young child has by this time become so varied, that some parts of the daily routine are looked forward to and enjoyed more than others. These times of enjoyment should be taken away when the child is naughty. But the great secret of carrying out this discipHne properly, is to make each deprivation appear from the start as the natural and inevitable consequence of the naughty act. Each wrong-doing should be surely followed by its particular deprivation. It is essential that these punishments be never remitted under any circumstances. The mother in her affection, and desire to make her child happy, is strongly tempted to let the child off, if he will "be good next time." This is very bad. The penalty should appear to the child as coming inevitably, through the laws of nature, the mother being unable to prevent it. Once the penalty is remitted, it becomes for the child the arbitrary act of the mother, dependent upon her will, and the child will exercise every form of ingenuity to be as naughty as possible, and yet escape punishment. Parents should of course never show anger, irritation, or annoy- ance in punishing children. They should never under any circum- stances bribe children to be good with rewards or special pleasures; this is of all means the surest to produce the spoiled child. They should never appeal to the child's emotions, by showing grief, or by using the "this hurts me more than you" argument. Many parents beHeve they can disciphne their children by appeaHng to their reason, and by affection alone. This can not be done; the child's intellect is not sufficiently developed to grasp the reasoning, but he assents, and promises, and learns to bribe his mother to overlook naughtiness by showing her excessive affection at times. The neglect of the measures of training and discipline outHned above, leads to the development of the "spoiled child," which is a very distinct type. He is usually bright, precocious, sensitive, with a highly developed mentality; he is very affectionate and demonstra- tive toward his parents. On the other hand he is very naughty, given to tantrums, and violent fits of anger. He refuses to eat what is given him or to do what he is told, and when corrected, tries to frighten his mother by the display of all sorts of terrifying symp- toms. His parents usually beHeve that his temperament and nerv- ous system are so exceptional, that he cannot be properly discipHned without damage to his sensitive organization. As a matter of fact - Hygiene and Care 51 he has almost unconsciously become an adept in managing his par- ents, and getting his own way. Moderate cases of this description can be corrected, if the parents will adopt a proper system of discipline with sufficient firmness. The physician must aid them by assuring them that the symptoms which the child shows under discipline will not ruin his nervous system. Severe cases can only be cured by taking the child temporarily entirely away from his parents, and putting him in charge of a trained nurse. To teach children good manners, nothing more is required than that the parents should use toward the children, and in the family, all the conventional politeness which they would use if strangers were present. THE NURSERY. — This room, in which the child passes so much of its time, should always be adapted to fulfil its hygienic needs. It should be a large room, situated high up, on the second, or third floor. It should have a sunny exposure and large windows high enough from the floor to prevent the younger children continually pressing their faces against the glass to look out, and thus catching cold from the little currents of air which penetrate most window casings. Painted walls are better than papered, and a hard wood floor not highly polished, with a large rug is better than a carpet. The child should have his own bed, made of iron, and painted, with Fig. 13 Infant's bed, Infants' Hospital 52 The Normal Child sides high enough to prevent him from falling out easily. The pillow and mattress should be of felt, folded so as to be soft and com- fortable, and pillow and mattress cases should be used. The mat- tress should be protected by a rubber sheet. The nurse's bed should not be too close. The child should have its own closet, and its own bureau-drawers; the nurse's belongings should be kept in a separate room. The furniture should be simple, not complicated or cum- bersome; stuffed furniture should be avoided. The windows should have both light and dark shades, and only simple musHn curtains. Toys made of woollen material or feathers, or which have colors which can be soaked off by saliva, should not be allowed. Steam heat is not desirable in the nursery. The best means of heat is an open wood fire, and the next best a coal grate. The open fireplace is a great help in securing good ventilation. The window board is useful in securing fresh air, but if the room is always thor- oughly aired when the child is out, the window need not be open when the child is playing, if an open fire is burning. The tempera- ture of the nursery should not be above 70° F. when the child is playing, and should be lower when the child is sleeping. If possible, a bathroom should immediately adjoin the nursery. This can also be used as a room for changing the diapers, and can be kept warm enough at night for this purpose, when the nursery is cold. The diapers should, if possible, never be changed, washed, or dried, in the nursery. NURSERY-]MAIDS.— The first essential of the attendant who cares for the young child is health. She should be free from any suspicion of tuberculosis or sj'philis, and from any catarrhal affections of the mucous membranes. The idea that the child should be taken care of by an old, experienced nurse is a vicious one. The experience of nurses, as a rule, is that of ignorance rather than of intelligence. Every mother, as she is presumably more intelligent than the nurse whom she employs, and is surely more interested in the welfare of her child, should personally supervise and unhesitat- ingly investigate all that the nurse does to the child. The nurse's ideas as to what is needed for the child's hygienic surroundings, food, and clothing can well be dispensed with. The mother, learning from the physician what is best for her child, should give her directions to the nurse and' see that these directions are strictly carried out. A nurse between the ages of twenty and thirty-five is preferable to one who is younger or older. She should be neat, healthy, strong, cheer- ful, gentle, and patient. She should be willing to refer small details of the nursery routine to the mother, as well as those which appear of greater importance. The chief attributes of a good child's nurse, in my opinion, are a desire to obey implicitly the orders which she Hygiene and Care 53 receives from her mistress, and a temperament in harmony with the sensitive nervous organization of her charge. In certain cities, such as New York, Philadelphia, Buffalo, and Boston, schools have been estabHshed for nursery-maids, where the nurses are trained to be servants as well as nurses. PREVENTION OF EXPOSURE TO CONTAGION.— Infants and children are usually guarded from exposure to such well-known contagious diseases as scarlet fever and diphtheria, but no precau- tions are taken against exposure to such conditions as the common cold, influenza and bronchitis, all of which are contagious. Members of a household who have any of these respiratory affections should be quarantined as far as the children are concerned. Some parents believe that children should not be guarded from such contagious diseases as measles and whooping cough, on the ground that they must have them at some time. This is not necessarily true, and children should always be guarded against exposure to these diseases. Whenever children assemble in crowds, especially indoors, the chances of contagion are much increased. The moving picture shows have become very fruitful sources of contagion, and young children should not be taken to them. SUMMER RESORTS.— The physician is frequently consulted as to where the child is to be taken for the summer. In my experi- ence, chiefly gained among children who pass the winter near the sea, our inland mountain summer resorts are far preferable to the sea-shore. Children may advantageously pass part of the summer in the mountains or inland, and part by the sea. A whole summer at the sea-shore should be avoided. It is probable that with children who live inland in winter, the sea-shore resorts in summer would not be open to objection. THE DAILY ROUTINE OF THE NORMAL CHILD.— I have devoted considerable space to the hygiene and care of the normal child. It has come to be recognized that Preventive Medicine is one of the most important, if not the most important, branch of the art of medicine. It is especially important in early life, where a very large proportion of the pathological conditions which develop ma}^ be traced to some violation of, or lack of attention to, the small details of hygiene and care required by the undeveloped condition of the young human being. The modern mother understands the importance of all the little details of care in regulating the environ- ment of the child, and it is on these points mostly that she consults the specialist in pediatrics. She no longer looks to the physician as a writer of prescriptions when the children are ill, but as the expert adviser to whom she can go when she wants to know how to bring up the child in such a way that illness is prevented. The 54 The Normal Child physician must be familiar with every detail of the child's daily hfe, and much of his work is the careful regulation of every detail of the child's environment. This arranging of the daily routine is sometimes very diflficult. It seems hard to make everything fit in right in the course of the day; meals conflict with outdoor airings, and naps with exercise. Many things have to be taken into consideration, such as the nurse's dinner, and other ways of the household difficult to change. As a guide in arranging the daily routine to meet the needs at various ages for food, sleep, and exercise, the following time table is sub- mitted. It is intended to serve, not as an arbitrary rule, but simply as a model, to be modified according to circumstances. Table ii Time Table for the Daily Routine in Infancy and Early Childhood FIRST 6 ■WEEKS 6:00 A.M Feeding 7:30 A.M Morning Toilet 8 :oo A.M Feeding 10:00 A.M Feeding 10:30 A.M. to 12:00 M. Outdoors 1 2 :oo M Feeding 2 :oo P.M Feeding 2:30 to 4:00 P.M Outdoors 4:00 P.M Feeding 5:30 P.M.. Bath 6 :oo P.M Feeding 10:00 P.M Feeding 2:00 A.M Feeding 5 TO 12 MONTHS 6 :oo A.M Feeding 7 :30 A.M Morning Toilet q:oo A.M Feeding 10:00 A.M. to 12:00 M. Outdoors — Nap 1 2 :oo M Feeding 1:00 to 3:00 P.M Outdoors — Nap 3 :oo P.M Feeding 3:30 to 5:30 P.M Play 5:30 P.M Bath 6:00 P.M Feeding and Bed 18 TO 24 MONTHS 7 :oo A.M Feeding 8:00 A.M ; Sponge Bath 9:00 A.M Orange Juice 10:00 to 11:00 A.M. . . .Outdoors II :oo A.M Feeding 11:30 A.M. to 12:30 P.M Outdoors 12:30 to 2:30 P.M Nap 2:30 P.M Feeding .3:00 to 4:00 P.M Outdoors 5:30 P.M Bath 6:00 P.M Feeding and Bed 6 \^^EEKS TO 5 MONTHS 6:00 A.M * Feeding 7 :3o A.M Morning Toilet 8:30 A.M Feeding 10:00 to 11:00 A.M. . . .Outdoors 1 1 :oo A.M Feeding 11:30 A.M. to 12:30 P.M Outdoors 1 :30 P.M Feeding 2:00 to 4:00 P.M Outdoors 4:00 P.M Feeding 4:00 to 5:30 P.M Play 6:00 P.M Bath 6:30 P.M. . . . •. Feeding 9 :oo P.M Feeding 2 :oo A.M Feeding 12 TO 18 MONTHS 7 :oo A.M Feeding 8:00 A.M Sponge Bath 9:00 A.M Orange Juice 10:00 to 11:00 A.M. . . .Outdoors 1 1 :oo A.M Feeding 11:30 A.M. to 12 :30 P.M Outdoors 12:30 to 1:30 P.M Nap 1 :30 to 3 :oo P.M Outdoors 3 :oo P.M Feeding 3:30 to 5:30 P.M Nap 5:30 P.M Bath 6:00 F.M Feeding and Bed 2 TO 6 YEARS 7:00 A.M Sponge Bath 7:30 A.M Breakfast 10:00 to 12:00 A.M. . . .Outdoors 1 2 :oo M Dinner 12:30 to 2:30 P.M Nap 2:30 to 4:00 P.M Outdoors 5:30 P.M Bath 6 :oo P.M Supper and Bed DIVISION II DISEASE IN EARLY LIFE L ETIOLOGY AND CLASSIFICATION The classification of diseased conditions has always presented almost insuperable difficulties for the medical writer. In earliest times diseases were classified upon the basis of their symptoms, or of unscientific, or superstitious theories as to their cause and nature. Later the spread of knowledge concerning pathological anatomy suggested a purely anatomical basis for the classification of disease. Such a basis, however, has proved unsatisfactory for many reasons, chief among which being the fact that many conditions recognizable as diseases present no distinctive anatomical features, and the fact that the lesions of disease bear no definite relation to the cause, symptoms or method of cure. If there were such a relation, classi- fication would be a simple matter. In its absence, attention has been turned more and more toward etiologic factors as the most important conditions differentiating diseased processes from one another, especially since progress in bacteriology has set apart a, large class of diseases as having a demonstrable specific cause. Treat- ment, also, is becoming more and more directed at the causes, rather than at the lesions of disease, and this suggests how advantageous would be an etiologic basis of classification, if it were possible. Unfortunately, it is as yet impossible to classify diseased condi- tions solely upon the basis of their etiology, for two principal rea- sons. In the first place, there is no subject in the scientific aspect of medicine more obscure than that of etiology. The etiology of many recognizable diseased conditions remains wholly unknown. In the second place, a great many diseased conditions which can be recognized as fairly distinct disturbances, are produced by the coin- cident action of a number of different etiological factors. More- over, the same etiologic factor may, at different times, produce wholly different lesions, or disturbances of bodily function, the prob- able explanation of this phenomenon being that there are other coexisting causes which cannot be recognized. Nevertheless, etiology must not be discarded in any attempt to classify disease, but should be used as far as is possible, the defici- ency in our knowledge being eked out by what we know of the essen- tial manner in which various diseased processes are produced. We 56 Disease in Early Life know, for instance, that in some cases the result of the action of a cause or group of causes is a definite anatomic lesion; in other cases the result is a disturbance of the function of a particular organ; in still other cases a disturbance of the entire nutrition and meta- bolism, with or without the formation of toxic substances in the blood. By taking account both of causes, and the various kinds of dis- turbances produced in the body, a basis for the classification of disease may be constructed which will be sufficiently useful to meet the requirements of the present stage of our knowledge. THE CAUSES OF DISEASE The following are the chief etiological factors in disease: 1. Inheritance. 2. The normal lack of development of early life. 3. Unknown internal causes. 4. Mechanical injury from without. 5. External factors in hygiene and environment. 6. Infection. Of these causes, the first three represent conditions existing within the body of the child. The last three represent conditions of en- vironment, acting upon the child's body from without. INHERITANCE is an important, though rather obscure factor. Syphihs is the only disease often directly transmitted from parent to child, though there are rare instances of the transmission of other infections. Inheritance plays its chief part in the transmission of what are commonly called constitutional weaknesses or tendencies. If, as is probable, there is an anatomical basis for these tendencies, it is not recognizable. Lack of resistance to other causes of disease is all we can see, the children being liable to certain infections, or to certain disturbances of function. THE NORMAL LACK OF DEVELOPMENT OF EARLY LIFE has been thoroughly described in the first division of this book. In itself alone, it can not properly be called a cause of disease. It is, however, a very important, if not the most important, etiological factor in connection with other causes acting from without. It explains why children are less resistant to certain conditions of their environment. UNKNOWN INTERNAL CAUSES.— There are certain disturb- ances which occur only at times, and which cannot be traced to inheritance, or to any external cause. The cause may be external, but if so, it has not been discovered. Unknown internal causes are included only as a possible explanation of these conditions. Etiology and Classification 57 MECHANICAL INJURY FROM WITHOUT needs no explana- tion. The effects of blows, of falls, of birth injuries, of foreign bodies in internal structures, of heat, of cold, of irritants, are well known. THE EXTERNAL CONDITIONS IN THE HYGIENE AND ENVIRONMENT OF THE CHILD which can produce disease are, of aH etiologic factors, the most numerous and important. Among them may be numbered improper feeding, unhygienic surroundings, neglect, and indeed any violation of the rules for the proper care of the child. INFECTION means the invasion of the body from without by a living pathogenic parasite. The mode of action of these micro- organisms and the mechanism of defense against them, will be de- scribed in other portions of this book. HOW THE VARIOUS CAUSES ACT IN PRODUCING DISEASE There are three principal ways in which the various known and unknown causes of disease act in the body. 1. By producing faulty anatomical development in intraute- rine life. 2. By producing disturbance of function without primary anat^ omic lesions. .3. By producing primary anatomic lesions. CONGENITAL FAULTS OF DEVELOPMENT.— In the first group the causes are entirely unknown. They may be inherited tendencies, or internal unknown causes, or external conditions acting on the foetus through the mother. This subject is still shrouded in mystery. Our knowledge of embryology tells us only just what phase of development goes wrong in embryonic life. DISTURBANCE OF FUNCTION WITHOUT EVIDENT PRI- MARY ANATOMIC LESION.— This is very common. Such disturbance is usually due to the coincident operation of several causes. Normal lack of development plus inherited weakness, for example, unite with faulty hygiene in producing a disturbance of function. All sorts of combinations and successions of events may exist. Thus the faulty hygienic surroundings of the mother may cause congenital lack of resistance on the part of the child, which permits disturbance of function under conditions which are normal and not injurious to normal babies. In most cases of disturbed function, multiple causes, involving both internal and external fac- 58 Disease in Early Life tors must be sought. Lack of balance between the child's func- tional development and the conditions of his environment is the usual finding. The functions disturbed are various. A single organ, or several organs may be involved. There may be a disturbance of the entire function of nutrition and metabolism. The results of the disturb- ance are very manifold, showing a great variety of manifestations. For example, disturbance of nutrition and metabolism may give rise simply to retardation of growth and development, or to distinct diseases such as rachitis and scorbutus, or to toxemias. Toxemias. — One manifestation of disturbed function is so very striking, and has attracted so much attention recently, that it de- serves special mention, if not a special place in the general classifica- tion of disease. I refer to toxemia. There exist a number of clinical manifestations, some of which can be proved to be due to the formation of toxic substances and their circulation in the blood, and others which can be best explained on this basis even without proof. These toxemias would hold a place in the classification of disease, were it not for the fact that we believe them to be manifes- tations of disturbed function, either of an organ, or more commonly, of the whole metaboHsm. These toxic substances may in turn cause secondary disturbances of function, which brings them into the class of etiological factors. They may even produce lesions, such as are seen in the kidneys in some forms of nephritis, or in the bones in rhachitis and scorbutus. Their mode of action is often not very different from conditions seen in infections, where there is also a toxemia, the only difference being that the toxins are of bacterial and not of metaboHc origin. In this group of functional disturbances are included all condi- tions in which disturbance of function, and not a lesion, is the pri- mary result of the various etiologic factors. Lesions, however, may often be seen in these conditions. For example, improper feeding may cause disturbance of the function of digestion, which in turn causes irritation of the intestinal mucosa, which in its turn eventually may give rise to an intestinal lesion. PRIMARY ANATOMIC LESIONS.— This is a very important manner in which the etiological factors produce disease. It requires little discussion, as this origin of disease is thoroughly understood. The two chief etiologic factors concerned here are mechanical injury from without, and infection. The former produces the various forms of lesion grouped under the general term of traumatic. The second produces a great variety of lesions peculiar to the particular form of infection involved. There is a class of lesions of unknown cause, represented by the new growths. Etiology and Classification 59 THE CLASSIFICATION OF DISEASE Using as a basis both what we know of etiology, and what we know of the mode of action of various causes, the following classi- fication of diseases is suggested, and will be followed in this book: 1. Malformations. 2. Mechanical injuries — a. From external causes — trauma. b. From unknown internal causes. 3. New growths. * 4. Functional disturbances from multiple causes — a. Non-toxic. b. Toxemias. 5. Infections. THE MALFORMATIONS represent the faulty intrauterine de- velopment described above, of which the cause is unknown. It includes all the congenital malformations. THE MECHANICAL INJURIES from trauma need no expla- nation. Those from unknown internal causes are represented by such conditions as hernia and intussusception. THE NEW GROWTHS represent very distinct and pecuhar lesions, of which the cause is still unknown. W^hether the origin of these lesions is developmental, or whether it is to be found in some as yet undiscovered agency acting from without, is for the future to determine. For the present these lesions can only occupy a class by themselves. THE FUNCTIONAL DISTURBANCES trace their position as a separate class of diseases to the essential nature of the disease process, rather than to the nature of the causes, which are multiple. The essential feature is disturbance of function without primary anatomic lesions. Those disturbances in which the manifestations are chiefly chemical, caused by the formation of toxic substances and their circulation in the blood, are grouped under the subdivision of toxemias. Examples of non-toxic functional disturbances are indi- gestion from overfeeding, and enuresis; of toxic functional disturb- ances are spasmophilia, and some forms of nephritis. THE INFECTIONS form the most distinct group etiologically. II. PATHOLOGICAL ANATOMY The peculiarities of the pathology of early life lie in the relative frequency of the different processes rather than in any marked modi- fication of their character. The tissue changes which form the lesions of disease are the same at all ages. In childhood, however, the relative frequency of different kinds of lesions is dift'erent from that seen in adult hfe, and there are more or less characteristic modi- fications in the severity and distribution of the lesions. The varia- tions characteristic of the pathology of early life are most notable in infancy, and become progressively less through childhood, until, at about the age of puberty, adult conditions are reached. Congenital lesions form a comparatively large group in the path- ological anatomy of early life, particularly in infancy. They may be subdi\'ided upon an etiological basis into two classes, one being due to embryonic conditions — abnormahties of fetal development, the other being due to intrauterine disease. Closely connected with these congenital lesions is another group due to trauma sustained during birth. Functional disturbances, without recognizable primary lesions, are comparatively common in early Hfe. The multiple etiology of these conditions has been discussed in the section on etiolog}-. In early hfe, disturbance of function is most common in those organs or. sys- tems of the body which in childhood show a relative backwardness of functional development. Consequently, functional disturbances in early hfe are most commonly connected with the digestive system and nutrition, and with the nervous system. The largest divisions of any work on pediatrics must be those dealing with nutrition, meta- boHsm, and the gastro-enteric tract. The circulatory system in early life is comparatively well-developed, while it contains the tis- sues and organs which, having a mechanical function, show most markedly the effects of the strain of advancing years, and of active abuses. Consequently, functional disturbances of the heart and circulation are comparatively uncommon in childhood. New growths are very much less common in childhood than in adult life. Carcinoma, the most common tumor of later Hfe, is almost unknown in infancy and childhood. Full development and maturity appears to be an essential condition for the occurrence of many varieties of new growth. Thus the fibro-myomata of the uterus, and the cysts of the ovary, so common in adult life, are not seen in childhood. Sarcoma is the most common new growth encountered Pathological Anatomy 61 in childhood, the commonest form being osteo-sarcoma, and sarcoma of the kidney originating in adrenal tissue. Gliomata also are often seen. The inflammatory lesions characteristic of infection are compara- tively common in early life, and form by far the largest group in the pathological anatomy of infancy and childhood. The great liability of children to the group of infectious diseases transmitted by contact, has led to the name of "children's diseases" being applied to this group. The frequency of the contagious diseases in child- hood is, however, probably not chiefly due to an increased suscepti- bility at that period of life. Indeed, infants as compared with older children show a distinct immunity to certain contagious diseases, such as dipthheria and scarlet fever, which may be possibly explained by a partial transmission of immunity from the mother. The rela- tive frequency of the contagious infections in childhood is to be explained chiefly by the fact that these diseases confer an immunity upon the patient, and are not seen in adult life because of the im- munity acquired in childhood. The problem of susceptibility and immunity is, however, very complex, and undoubtedly there exists in the undeveloped tissues of the growing child an increased sus- ceptibility toward certain infections. The mucous membrane of the respiratory tract is particularly liable to infection in early life, and the inflammatory lesions caused by infection are the commonest found at autopsies on children. Pneumonia is very common, and the lungs are rarely found normal at autopsy after an acute infectious disease of long duration. The great frequency of acute inflammation of the middle ear is also a very notable feature in the pathology of infancy and early childhood. The nose, throat, and larynx show about the same susceptibility to catarrhal inflammation as in the adult. The mouth, however^ is peculiarly liable to lesions in childhood, both of infectious and of traumatic origin. There is a marked difference between childhood and adult life in the character of the lesions found in the heart. In infants, prac- tically the only lesions found are of congenital origin. In older children, the heart, both endocardium and pericardium, are partic- ularly liable to the inflammatory lesions characteristic of acute in- fection. The lesions due to chronic endocarditis and its mechan- ical effects, are less common than in adult life. At autopsy, acute endocarditis or pericarditis is the usual finding in cardiac cases. Arteriosclerosis, and the whole group of lesions secondary to vascu- lar changes, which are found in all the organs of the body, and which play so important a part in the pathology of adult life, are almost unknown in childhood. Such conditions are angina pectoris, chronic 62 Disease in Early Life myocarditis, " cardio-renal cases," chronic interstitial nephritis, hemor- rhage into the internal capsule of the brain, and so forth, play little or no part in the pathology of childhood. The nervous system in childhood presents a widely different path- ology from that of adult life. These differences may be summarized as follows: i. The greater frequency of congenital lesions. 2. The greater frequency of some forms of functional disturbance (chorea, epilepsy, pavor nocturnus) and the lesser frequency of others (hys- teria). 3. The lesser frequency of processes showing the pathological anatomy of chronic degeneration. 4. The greater frequency of acute infections. In connection with the last two points, it is notable that such nervous diseases as tabes dorsalis, syringo-myelia, paralysis agitans, and similar conditions are very uncommon in childhood. On the other hand, both meningitis in all its forms, and poHomyelo- encephalitis are much more common in children than in adults. Lesions of the lymph nodes play an important part in the path- ological anatomy of early Hfe. They are affected secondarily to the various inflammations of the mucous membranes, and the result of acute infection is the suppurative inflammation so common in infants, while prolonged chronic infection causes a condition of chronic lymph node hyperplasia. The same condition of chronic hyperplasia is also a very common secondary lesion in the various chronic nutritional disturbances. The thymus plays a part in the pathology of infancy only. The serous membranes are less often the seat of lesions in child- hood than in adult life. Empyema is rather commoner, as is tuber- culous peritonitis, but the other forms of pleurisy and peritonitis are less often seen. The skin in early Hfe is very delicate. Consequently it is very often the seat of lesions caused by infection, or by mechanical irri- tation. The group of lesions seen in adults which represent degen- erative conditions, the results of wear and tear, are not seen in childhood. Certain diseases, chiefly infectious, which occur both in childhood and in adult life, present peculiarities in pathological anatomy char- acteristic of childhood. Notable among these diseases are tuber- culosis, syphiHs, typhoid fever, and rheumatic fever. The lesions characteristic of childhood, and the variations in the pathological anatomy from that of adults, will be described in detail in connec- tion with the conditions in which they occur. III. SYMPTOMATOLOGY AND DIAGNOSIS THE HISTORY The first step in the diagnosis and treatment of a diseased con- dition is the obtaining of the history. Here at once are encountered conditions fundamentally different from those met with in dealing with disease in adults. A child cannot give a description of its symptoms, and consequently the history must be obtained from a parent, nurse, or other attendant. This is particularly the case with very young children, who are not able to describe any symptoms nor to answer any questions, and with children in the first years of life, the entire history of the case must be obtained from the parent. Older children are able to tell their stories, and describe their symp- toms, but their powers of description are often very deficient, and their statements very misleading. Even in older children, the main source of information is the story of the parent, corroborated and assisted by what the children are able to tell. For this reason, subjective symptoms play a comparatively small part in the symp- tomatology of infancy and early childhood, and such as can be ob- tained have to be accepted at second hand. As far as the history is concerned, particularly in young children, the physician is com- pelled to rely on the objective symptoms as observed and reported by another person, usually the mother, whose powers of observation and description are not trained, and are often very inadequate. This tends to diminish the importance of this history in early life. It must not be assumed, however, that the history is not important. The physician must understand the conditions under which it is obtained, and the comparative degree of importance to be attached to the various symptoms reported. It is often supposed by the laity, and even by physicians who are not trained in the diagnosis of disease in early life, that this diffi- culty in obtaining a history constitutes one of the chief difficulties in pediatric practice. It is often said that practice among babies must be especially difficult " because they cannot tell how they feel." It is not true that this constitutes an especial difficulty, but it is rather that it constitutes a need for special training. The pediatrist must become especially practiced in the observation and interpretation of objective symptoms. Moreover, the inability of the patient to tell "how he feels" presents a distinct advantage from certain points of view. The long accounts of feelings pre- sented by sick adults, often exaggerated by the results of prolonged 64 Disease in Early Life auto-suggestion which may even amount to hypochondriasis, are not of much value in diagnosis, and are often actively misleading. In children, the clinical picture is often all the more clear-cut, from the absence of subjective symptoms. In obtaining the history it is well to let the mother tell the story first without cross-examination. When the story is complete, the physician should begin his questioning, not with the family history or previous history, but with the present illness. It is very dis- concerting to a mother, whose mind is earnestly bent on describing clearly the illness of the child, and who has just completed her story, to be immediately asked what her other children died of, and whether there is tuberculosis in the family. Such questions give the im- pression that the physician is merely proceeding by rote, that he is not interested in her story, nor in the real trouble with the child, and they tend to trouble and confuse her. The physician should begin by asking questions on the various points mentioned in the mother's story, with a view to bringing out and defining the various symp- toms. He should then ask the questions necessary for the completion of the history of the present illness. The family and previous his- tory can just as well be obtained after the story of the present iliiness is complete. SIGNIFICANCE OF SYMPTOMS IN EARLY LIFE. In children, as compared with adults, subjective symptoms are less marked, while objective symptoms are more marked. In infants, the symptoms reported by the mother are all objective. It must be remembered that there is often an unconscious tendency on the part of the mother to exaggerate the severity of the objective signs which she has observed. There is also a tendency to interpret them wrongly, and to call things by misleading names. Such symptoms as loss of appetite, loss of weight, vomiting, diarrhea, cough, con- vulsions, restlessness, insomnia, and so forth, are apt to be somewhat exaggerated. On the other hand, such symptoms as dyspnoea, apathy, clouding of the mentality, paralysis, and others, are apt to be insufficiently noticed. In older children, subjective symptoms occur. There is often an un- conscious tendency on the part of both the mother, and the physician. to underestimate the severity and importance of subjective symptoms. Such symptoms are not so varied, nor so common as in the adult. Pain is a much less common symptom in childhood, and in many diseased conditions, it is apparently less severe. When, however, subjective symptoms are present, they are very important in children. THE FAMILY HISTORY.— In the majority of cases, this should begin with the parents. The general health and constitutional vigor of both parents should be ascertained. The diseased conditions having The History 65 most bearing on the child are tuberculosis, rheumatism, syphiHs and alcoholism. The first two should be inquired about specifically. In the case of tuberculosis, the transmission from the parent usually depends rather upon exposure to contagion than upon transmission of the disease directly, or of a hereditary tendency toward the disease. It is consequently advisable not to limit the inquiry to tuberculosis in the parents, but to extend it in such a way as to ascertain if pos- sible, whether the child has ever come into contact with a tuber- culous individual. Neurotic tendencies in the parents should also be ascertained when present. It is usually unnecessary to ask direct questions as to syphilis or alcoholism, unless something in the history of the present illness, or in the physical examination, should suggest the -advisability as to inquiries along these lines. The number of other children living, and their general health, should be ascertained. The number of dead children, and the cause of death, should also form part of the record. Also, in connection with the family history, it is advisable to gain as thorough as possible an insight into all the surroundings of the patient. It is particularly important to find out whether there has been any recent exposure to contagious disease. PREVIOUS HISTORY. — There are four points of importance to be elicited in the previous history of the patient. These are, (i) the circumstances attending birth, (2) the feeding history, (3) the history of development, and (4) the history of previous illness. The Birth. — The physician should first inquire whether the child was premature, or born at full term. The character of the labor should be inquired into, whether natural, instrumental, unduly pro- longed, or attended by complications. Inquiry should be made as to whether the child appeared normal at birth, whether it seemed vigorous, whether it breathed promptly, and whether it took the breast well. The nutrition of the child during the early days of Hfe, and the existence of any symptoms, such as hemorrhage or convul- sions, should be ascertained. The Feeding. — The physician should next ask whether the child was breast-fed or bottle-fed, and if breast-fed, how long breast feed- ing was continued, when partial bottle feeding was begun, and when exclusive bottle feeding was instituted. If the story told by the mother suggests that the illness of the child is in any way connected with nutrition, or if the problem presented is one of feeding, all the data concerning the diet history should be obtained down to the minutest detail. Each method of artificial feeding used should be ascertained, with a full account of just how each food was prepared for the baby, and the various mixtures used in home modification should be translated by the physician into terms of the percentages of the various food elements. The diet of the child after the first 5 66 Disease in Early Life year should be taken up in similar detail. The symptoms exhibited by the child with each change of food should be ascertained. In particular, inquiry should be made as to gain or loss in weight, vomit- ing or regurgitation, the daily number and character of the intestinal discharges, colic and flatulence, and whether the child was satisfied or hungry. These inquiries should be brought up to include the food which the child is now taking. Development. — The best idea of development is to be obtained from the weight record, if there is one. In addition, inquiry should be made as to the appearance of the most prominent landmarks of normal development. For physical development, these are the time and order of appearance of the teeth, and the age at which the child could first hold up its head unsupported, sit unsupported, creep, stand, and walk. Mental development is estimated by the age at which the child could first recognize the mother or nurse, recognize the bottle, seize and handle objects, understand the meaning of words, and speak words, short sentences, and connected speech. Illnesses. — All previous acute illnesses should be noted, particu- larly the acute infections, with the dates. Details as to the dura- tion, severity, and complications of each attack should be obtained It is also advisable to learn whether the child is particularly liable to certain varieties of disorder, particularly those affecting the upper respiratory tract, the digestive system, and the nervous system. Under the first are included frequent colds, tonsillitis, adenoid opera- tions, earache or otitis media, croup, and bronchitis. Under the second are included attacks of vomiting, diarrhea, stomachache, and "bilious" attacks. Under the third are included restlessness, in- somnia, night terrors, convulsions, and chorea. The date of the last successful vaccination should also be ascertained. THE PRESENT ILLNESS.— The details of the present illness are obtained from the story of the mother or nurse, and from the cross-examination of the physician, which deSnes the various symp- toms. The most important point in the history of the present ill- ness is that of duration. The date of appearance and duration of each symptom should be exactly defined, and these details are often not volunteered by the mother, but have to be obtained on cross- examination. The character of the onset of disease in children is one of the most important points in diagnosis, and whether the onset was gradual or abrupt must be carefully ascertained. This can often be done only by asking when the patient was last quite well, and what was the first symptom of illness noted by the mother. The sequence of subsequent symptoms can then usually be clearly ob- tained. Individual symptoms must be analyzed as to their time and mode of onset, frequency, character, severity, and duration. Physical Examination 67 After the story of the mother and the cross-examination analyz- ing the symptoms are finished, it is advisable to conclude the his- tory of the present illness with a few general questions as to the functions of the various physiological systems of the body, which have not been included in the story of the mother or nurse, nor in the physician's cross-examination. The digestive system may be investigated by questions as to appetite, the bowels, vomiting, colic, flatulence and abdominal pain; the respiratory system by questions as to cough, dyspnoea, respiratory obstruction, and pain in the chest; the circulatory system by questions as to shortness of breath, precordial pain, palpitation, and edema; the nervous system by questions as to headache, night terrors, restlessness, insomnia, con- vulsions, and paralysis; the urinary system by questions as to the frequency and amount of micturition, pain on micturition, and the amount and appearance of the urine. Finally, the mother or nurse should be asked what in her opinion is the chief complaint^ the symptom which has mainly caused her to seek medical assistance, and which most requires relief. THE PHYSICAL EXAMINATION If the history of the symptoms in the young child is of less diag- nostic significance than in the adult, the physical examination is of proportionately greater importance. METHOD OF EXAMINING A CHILD.— The method of exam- ining a child is quite different from that pursued with adults. In the first place, the order of examination is different. The child will be either crying or not crying. If it be not crying, it is best to begin with that part of the physical examination with which crying most interferes. Crying interferes most with the palpation of the abdomen, and next with the auscultation of the heart. If the physician is accus- tomed to the examination of children, crying will not interfere with the auscultation of the lungs, but it is sometimes useful to auscult the lungs with the child quiet as well as crying. Consequently, if the child be quiet, it is best to palpate the abdomen, auscult the heart, and then auscult the lungs, at the very beginning of the exam- ination. If the child be crying, these examinations should be post- poned till the end, in the hope that the child will stop crying. The examination of the mouth, throat, and ears should always be post- poned to the end, for if the child be not crying and resisting, this examination will almost certainly cause it to do so. The time which is consumed in the physical examination of a child is important. Prolonged handling of a child, or a prolonged struggle with a resisting child, is very harrowing to the mother. In the adult, the element of time is not so important, but the pediatrist 68 Disease in Early Life must accustom himself to make his examination quickly. Thor- oughness must not be sacr'liced, but a rapid deftness in physical examination is a great asset in dealing with children. This can be gained by practice, and by a thorough knowledge of just how each part should be examined, and just how the child should be held. It is not a good plan with children to make the physical examination before taking the history. The history often brings out informa- tion which will greatly modify the relative time spent in different parts of the physical examination. It is not necessary, for example, to spend a long time on the examination of the heart and lungs in a case which is obviously one of nutrition, nor in the testing of all the functions of the nervous system in a case which is obviously one of infection of the respiratory tract. Sufi&cient attention, how- ever, should be paid to all parts of the examination, to insure that nothing be overlooked. The manner in which the examination is approached by the physi- cian makes a great difference in the handling of a sick child. He should not approach it strenuously, nor tower over it, nor make any parade of preparation. It is best not to notice the child at first, but to talk with the mother. Then the physician may notice and handle the child's playthings. It is often a good plan to give the stethoscope to the child to hold at the beginning of the examina- tion, for if this is done it will not be so terrifying when the time comes to use it. It is also often helpful to perform any act of hand- ling like percussion, or the application of the stethoscope, first on a doll, teddy bear, or even on the mother, before performing it on the child. By smiling and making a sort of game of the examination, a good understanding with the child can often be maintained for a considerable time. If, however, friendly relations cannot be maintained, and the child begins to cry, and resist, all blandishments should be stopped, and the physician should proceed to complete the examination as rapidly as possible. It is often difficult to get mothers to cooperate under these conditions, as they want to avoid using force, and to continue their coaxing methods. At this stage, coaxing is usually of no avail, and the physician should tell the mother exactly what he wants her to do, and just how she must hold the child, and should make her do just what he tells her. This method, though it involves the use of forcible restraint, is much better in the end, as the exami- nation is shortened instead of being prolonged in a confusion of crying, struggling, and coaxing. In many cases, the best position for the child undergoing physical examination is recumbent on a firm surface. The recumbent posi- tion on the back is, however, only essential when the abdomen is being examined, and in an infant, this can be obtained with the Physical Examination 69 child lying across the mother's knees. Placing the child on its back on a table or bed is often more apt to frighten it than if it be examined on its mother's lap, and in many cases it is better to conduct the examination with the child in the latter position. This is especially the case in examinations conducted in the home, where good exam- ining tables are not always available. Examination of a Young Infant on the Mother's Lap. — The naked child is first placed on its back across the mother's knees' and the front of the body is examined. If the child be quiet, the physician begins with the palpation of the abdomen, and follows with the auscultation of the heart and lungs. Then he proceeds to the general examination of the body, and to the examination of the Fig. 14 Proper positijn fur the child when examined in a sitting position cranium, facies, eyes, and neck. Next he completes the examination of the front of the chest and the abdomen, and examines the extremi- ties and reflexes. The child is then turned face down and the back of the chest, the spine, the buttocks, and the anus are exam- ined. The mouth, throat, and ears are examined last. Examination of an Older Infant or Young Child on the Mother's Lap. — The child should sit upon the lap of the mother or nurse, leaning back upon the middle of her body, not held in the 70 Disease in Early Life hollow of one arm. In this position, the physician first notes the points included in the general examination of the body. He next examines the head as far as external inspection and palpation are concerned, which includes the cranium, facies, eyes, and neck, leav- ing the mouth, throat and ears for the end. He then examines the front of the chest, the extremities, and the reflexes. If the child struggles, or attempts to interfere with the examination by grabbing at the stethoscope or at the hands of the physician, the mother should be taught to grasp each of the child's arms firmly just above the elbows, and to hold them close to the sides of the body. When the examination of the front of the body is complete, the child should Fig. 15 Method of holding an infant for examination of the back of the chest be turned with its back to the physician, and held upright if an infant, kneeling if larger, with its head on the mother's shoulder, and her arm around its hips. In this position the back of the chest is examined. The diaper is then removed, and the baby is placed on its back across the mother's knees, for examination of the abdo- men, then turned face down for examination of the spine, buttocks and anus. If the child be too large to lie across the mother's knees, this last part of the examination must be performed on a table or firm bed. Physical Examination 71 Examination Upon a Table.— This is performed in the same manner as with the young child across its mother's knees. If the child struggles or resists, the mother or nurse should stand on the opposite side of the table, and place one hand on the child's two hands, holding them stretched above its head, and pinning them firmly to the table, while the other hand grasps both ankles. If the child is too big to be held in this way, the mother or nurse should stand at the head of the table, and grasping each of the child's hands in one of hers, should hold them firmly to the table close to its sides. This will prevent the child from getting up or turning over, but the physician must be prepared to dodge the kicking heels. It is some- times advisable, in examining the back of the chest, to have the child sitting on the table with its back bent forward, rather than lying upon its face. Fig. 1 6 Position for examination of the throat Examination of the Mouth and Throat.— The child should sit upright on the lap of the mother or nurse, facing the light if a head- mirror is not used, with the light behind if a head-mirror is used. The strongest possible light is desirable. The essential feature of the position for the examination of the throat is that the child shall be held with its back reclining against the middle of the mother's or nurse's body, not in the crook of her arm. The mother then 72 Disease in Early Life grasps both the child's hands in one of hers, and places her other hand on the child's forehead, holding its head firmly against her body. The child's legs are held between the mother's knees. This position leaves both the physician's hands free, which is important when cultures are to be taken. If no culture is to be taken, the physician can use his free hand in helping to steady the head, or in bringing it to the proper angle by pulling slightly forward on the neck. The teeth and mucous membrane of the mouth are first examined, and then the tongue is depressed for the examination of the throat. A young infant can be held for the throat examination with the mother or nurse standing. This permits her to approach close to a window or Hght. The child is swathed in a blanket, and is held with its back against the mother's shoulder, in the position shown in the illustration. Fig. 17 Method of holding an infant for examination of tlie mouth and tliroat This allows the child to be held in a good light close to a v.-indow The various points of importance to be especially noted by a physician in the examination of a child", present certain differences, which should be familiar to every one practicing among children. GENERAL INSPECTION OF THE BODY.— This is accom- phshed by inspection, almost at a glance, and by a rapid palpation of the neck, axillae, inguinal regions, and muscles. It includes the Physical Examination 73 nutrition, size, weight, skin, position of the body, mental condition, lymph nodes, bones, joints, and muscles. The Nutrition, Size and Weight, are estimated by inspection. This first estimate will be confirmed later by weighing and measure- ment. The amount of subcutaneous fat can be judged at this time by inspection and palpation. It is essential that the physician should be familiar with the growth of the normal child in length and weight, as described in the section on Normal Development. The Skin. — The skin should be thoroughly examined for visible lesions. The most significant in early life are eruptions, ecchymoses, desquamation, cicatrices, edema, sclerema, and angioneurotic edema. The color of the skin should be noted for pallor, cyanosis, and icterus. It must be remembered that the color of the skin is not so reliable an indication of anemia and cyanosis as is that of the visible mucous membrane. Edema is recognized by the fact that the swelling is most marked about the eyes, on the dorsum of the feet, on the legs, and on dependent portions, that the color of the skin is normal or pale, that the swelling is not hard nor accompanied by rigidity, and that it pits on pressure. Sclerema is seen only in the newborn, or in very feeble infants, the color of the skin is normal or slightly bluish, the swelHng is hard and accompanied by rigidity, and it does not pit on pressure. Angioneurotic edema is usually circum- scribed, and somewhat pink in color, is often accompanied by itching, and does not pit on pressure. It should also be noted whether the skin is hot or cold, moist or dry, smooth or rough, thin or thick. Rarer lesions sometimes seen in children are emphysema, rheumatic nodules, tumors, moles, and parasites. The bluish-black "mongolian spots," sometimes seen in the sacral and glutial regions, have no diagnostic significance. Position of the Body. — This is often of diagnostic significance, and should always be noted. A child may have a tendency to lie on one side or the other, to lie with the legs drawn up or the limbs in an abnormal position, or the spine may be abnormally curved either forward or backward. Mental Condition. — This is one of the most important points in the physical examination of the sick child. A fairly accurate estimate of the mental condition can usually be made by inspection in the general examination of the body, although at times abnor- malities can only be recognized by the special testing of the condi- tion of the nervous system which is carried out later. The physician should note carefully the child's reaction to its surroundings, and in particular, how it reacts to the examination. Thorough famili- arity with the behavior of normal children at every age is essential. The physician should note whether the child follows his movements 74 Disease in Early Life intelligently, and whether it resists intelligently or mechanically. By watching it closely, he can usually estimate its mental develop- ment, and can recognize the presence of such abnormalities as apathy, stupor, or delirium. The Lymph Nodes. — The cervical, axillary, epitrochlear, and inguinal lymph nodes, may be rapidly examined by palpation, and this can well be done during the general inspection of the body, as it does not usually frighten the child, and is a good preparation for the palpation and percussion which is soon to follow. The lymph nodes are examined chiefly for enlargement, tenderness, and suppu- ration. Enlargement of the lymph nodes may be general or local. It must be remembered that general enlargement of the peripheral lymph nodes in infancy is not of the same significance as in adult life. It occurs in practically all disturbances of nutrition, may in- clude the epitrochlear and occipital nodes, and at this age does not point to syphilis, tuberculosis, or primary disease of the blood. In later childhood, general enlargement of the peripheral lymph nodes has the same significance as in adults. Local enlargement of the peripheral lymph nodes is particularly common in early life. It has the same significance both in infancy and childhood as in adult life. The most common causes are, (i) acute lymphadenitis due to the absorption of toxic products from an infection in the area draining into the nodes involved; (2) acute infection of the lymph nodes themselves, usually, leading to sup- puration; and (3) tuberculosis. The lymph nodes of the neck are by far the most frequently involved in local enlargement, and are almost the only peripheral lymph nodes involved in tuberculosis. The Bones and Joints. — The size, contour, and general appear- ance of the bones and joints can be estimated by inspection during the general examination of the body. If there is nothing in the history to suggest any abnormality of the bones and joints, their routine examination can well be completed at this time. The long bones and joints should be felt, and pressure should be applied. The chief signs to be looked for are deformities, swelling, tenderness, and redness. The significance of these various signs will be discussed under the examination of the extremities. The Muscles. — The condition of the muscles can be estimated by inspection and palpation at the same time as the nutrition and amount of subcutaneous fat are noted. The principal abnormal conditions in the muscles are atrophy, softness, and tenderness. The first is seen in many nutritional disturbances, particularly in those of gastro-intestinal origin. A soft, flabby, relaxed condition of the muscles is seen also in nutritional disturbances, particularly in rickets. Muscular tenderness is most often a sign of over-use. In the back Physical Examination 75 or extremities it is most often seen after over-exercise. Tenderness of the muscles of the abdominal wall is met with after excessive coughing or vomiting. Temperature. — The period of the examination at which the temperature is taken depends on circumstances. If the child is quiet, it is often best to postpone it till the end of the general exami- nation, just before the examination of the throat. It should always be taken either by mouth or by rectum; temperature taken in the axilla or groin cannot be relied upon. Whenever a child is too young to hold the thermometer properly in the mouth, the temperature should be taken by rectum. Fig. 1 8 Obtaining pulse rate in infants Pulse. — This is usually best examined during the general examina- tion of the body, but if the attempt to take the pulse appears to annoy the child, it can well be postponed until later, and taken in connection with the examination of the heart, the limbs, or the taking of the temperature. The points to be noted are the rate, rhythm, volume, compressibihty, and character of the wave. In cases showing signs of circulatory disturbance, the radial pulse should be compared with the ausculted heart sounds, and the capillary pulse should be sought. The normal pulse rate at the different ages is given in the section on Normal Development. It must be remembered that an entirely 76 Disease in Early Life different standard from that of adults must be used in estimating abnormalities of the pulse in early life. Increase in the rate of the pulse is of much less significance in infancy and early child- hood. The rate tends to increase very markedly from compar- atively slight causes, such as exertion, excitement, or any slight disorder. Given any such cause, the absolute rate of the pulse is not very significant. If, however, in any severe disease the rate of the pulse is continually increasing, it points toward an increasing severity of the underlying pathological condition. The ryhthm of the pulse is also very easily disturbed; the pulse is normally irreg- ular in the newborn, and easily becomes irregular from slight causes in infancy and early childhood. The volume and compressibility are more significant as evidence of the condition of the circulation. The Respiration. — The respiration is best observed as a part of the general inspection, and should be examined as to rate, rhythm, and character. The rate varies normally with the age, with the individual, and according to whether the child is active or quiet, asleep or awake. It is therefore difficult to give a standard which is correct for the different ages; an approximate standard is given in the section on Normal Development. Irregularity of the respira- tion, which is so prominent in the newborn, continues normally dur- ing the first two years, and is not significant in infancy. In later childhood, irregularity is more important, and Cheyne- Stokes' types of diagnostic significance can often be recognized. Even in infants a regular irregularity is suggestive. The points to be noted in connection with the character of the respiration, are whether it is painful, shallow, costal, or diaphrag- matic. Painful respiration is betrayed by a contraction of the child's face, and by an expiratory groan or grunt. Shallow respira- tion is not of much significance, as this is a normal form in young children. Also up to the seventh year the respiration is normally predominantly diaphragmatic in character. The relation of inspira- tion to expiration should also be noted. Dyspnoea in early life is of two types, obstructive and non- obstructive. Each of these types may be further subdivided into inspiratory and expiratory. In the non-obstructive type, the respi- ration is increased in rate, and is often labored in character, but is not accompanied by any stridor, or other evidence of mechanical obstruction. It is seen in infections of the lungs and pleura, in disease of the heart, and in certain conditions of toxemia. Although often accompanied by an expiratory grunt, the type is mainly in- spiratory in these conditions, the principal muscular eft'ort being that of inspiration. In some toxic conditions, such as acidosis and diabetic coma, the inspiratory character is so marked that it is Physical Examination 77 called ''air-hunger." Expiratory dyspnoea is seen chiefly in asthma, in which the expiration is labored, and though wheezing is heard, there is no evidence of any localized obstruction. In the obstructive type, there is a stridor, or noise, suggesting the presence of a localized narrowing of the air passages. The location and character of this sound is evidence of the location and character of the obstruction. When the sound is a coarse stridor without musical tone, and appears to come from the throat or nose, the ob- struction is usually in the nose or naso-pharynx. The dyspnoea is usually inspiratory, when the obstruction is due to such conditions as rhinitis, adenoids, or enlarged tonsils, but in retropharyngeal abscess the most marked sound is usually heard during expiration. When the sound is crowing, with a more or less musical tone, the obstruction is in the larynx, and the dyspnoea is of a marked in- spiratory type. Severe inspiratory dyspnoea is further to be recog- nized by inspiratory retraction of the supra-clavicular, intercostal, and epigastric spaces. It must be remembered, however, that in- spiratory recession of the epigastrium is normal in the early months of life. When the stridor comes from the chest, it is usually less marked. The commonest cause is pressure upon the trachea or primary bronchi by an enlarged thymus, or enlarged mediastinal lymph nodes. The dyspnoea is usually of the expiratory type. THE HEAD. — After the general examination of the body has been completed, the physician proceeds to the examination of the various anatomical parts. This should be carried out systematically in a definite order. It is convenient to begin with the head. The Cranium. — The cranium should be examined with reference to size, shape, the fontanelles, the sutures and ossification, the hair, and the superficial veins of the scalp. The absolute size of the head varies with the individual, and the important point is the relative size in comparison with the thorax. The normal relations are given in the section on Normal Develop- ment. The most common cause of enlargement of the cranium is hydrocephalus, and of an abnormally small cranium is microcephalus. The most common abnormalities in the shape of the cranium are those caused by rickets and hydrocephalus. They are recognized by inspection, and will be described in connection with those diseases. Certain deformities resulting from compression during labor are often present at birth, but disappear during the early weeks. There is also a marked congenital asymmetry of the head seen at times, which persists for a number of years, but usually disappears before the child is seven years old. Flattening of the back or side of the head may occur as a result of the child lying too much in one posi- tion. This is easily recognized and corrected. 78 Disease in Early Life The fontanelles are examined by palpation with reference to size, delay in closure, depression, and bulging. An open posterior fonta- nelle after the sixth week, and an open anterior fontanelle after the nineteenth month, are abnormal. Delay in closure, or abnormally large size of the fontanelles is due most commonly to rickets, and next, to hydrocephalus, but is sometimes seen as a pecuharity in normal children. It is well to measure the diameters of the anterior fontanelle; they should not be over 2.5 by 3 cm. Depression of the fontanelle is caused by a decrease in the quantity of intracranial fluid, and is seen chiefly in acute diarrhea, and chronic conditions of malnutrition. Bulging of the fontanelle is caused by increased in- tracranial pressure, and is seen chiefly in meningitis and hydrocephalus, sometimes in brain tumor, brain abscess, and brain hemorrhage. The sutures are examined for failure to close, and for overlapping. Except that the upper part of the frontal suture may normally remain open for a few weeks, any separation of the cranial bones is abnormal. It is seen most often in rickets and hydrocephalus. The cranium should also be examined for cranio-tabes — a softening of the bones of the skull. It is recognized by pressure upon various parts of the cranium with the tips of the fingers. Soft spots are found which give the sensation of tightly stretched parchment. They are found most often about the fontanelles and sutures, and over the occipital and parietal bones. Craniotabes is usually a sign of rickets, but is sometimes seen in syphihs. If it be present at birth, it represents a congenital developmental anomaly rather than rickets or syphilis. The hair is examined as to amount and texture. The fine hair present at birth is not permanent, but is replaced. There is great, variation in the period when this occurs, so that while some babies soon have a thick growth of hair, others remain bald for a consider- able time. Loss of hair on the back of the head is a sign of restless- ness, from whatever cause. Coarse hair should suggest the possi- bility of cretinism. The superficial veins of the scalp are examined for enlargement. This is a constant sign in chronic internal hydrocephalus, and is often seen in syphihs. It is sometimes seen in rickets and other nutritional disturbances. The Facies. — Inspection of the face often reveals abnormal signs. The most important point to be noted is the facial expression, which often gives useful evidence as to the mental condition. The expres- sion may be placid, stupid, anxious, or pinched. There are various types of facies which are difficult to describe, but which are easily recognized from experience. The most familiar is the adenoid facies, characterized by open mouth, and stupid, vacant look, and sometimes Physical Examination • 79 by a flattened bridge of the nose, narrowing of the face toward the chin, prominent upper hp, and obhteration of the naso-labial folds. There is an ''abdominal fades," often seen in severe abdominal dis- orders such as peritonitis or intussusception, which is characterized by a peculiar sunken-eyed appearance difhcult to describe, but easy to recognize. There is also a cerebral facies, seen in patients with severe acute intracranial lesions such as meningitis, characterized by a peculiar staring expression. Facial paralysis is recognized by inspection of the face, but is often overlooked unless the child laughs or cries. In repose, the chief sign is obhteration of the naso-labial fold on one side; on crying, the lessened movement on one side is plainly apparent. The Eyes are inspected for inflammation of the conjunctiva, icteric staining of the conjunctiva, conjunctival discharge, strabismus, nystagmus, and inequahties of the pupil. Inflammation and conjunctival discharge suggest infection, and a purulent discharge should always be examined bacteriologically. Nystagmus .and irregularities of the pupils suggest either disease of the central nervous system, or local disease of the eye. I have often seen nystagmus in albinos. In connection with strabismus, it should be remembered that coordination is not well estabhshed in young infants, and a normal baby does not fix its eyes until it begins to recognize objects at about the age of six weeks, or even somewhat later. In these early weeks, temporary and varying strabismus is of no diagnostic significance. A constant strabismus is suggestive of a congenital abnormality of the muscles of the eyeball. In older infants and children, if strabismus be found, it is necessary to ascer- tain if the condition has been present since birth, in which case it is due to the same local cause. If the strabismus has not been pres- ent from birth, but has developed as a symptom of the present ill- ness, it is important in diagnosis, pointing toward a disturbance of the central nervous system. The pupillary reaction can best be tested at this period of the examination. The test is best performed either by bringing a light from above downward in front of the eyes, or by suddenly snapping on a pocket flash-light held in front of the eyes. The normal reac- tion to light is present immediately after birth. Failure to react suggests disease of the central nervous system. It is useless to attempt to test the reaction to accommodation in infants and young children. The Nose, in routine examination, is investigated by simple external inspection. The most important signs in diagnosis are widening of the bridge of the nose, and discharge from the nostrils. In infancy and early childhood the bridge of the nose is normally 80 Disease in Early Life slightly developed and relatively wide, but a pronounced widening is seen in cretinism and Mongolian idiocy. A nasal discharge in infants as well as children, is usually due to a simple catarrhal rhinitis, and should not suggest syphilis unless other signs be present. A thin, irritating, blood-tinged discharge, especially if coming from one nostril, suggests nasal diphtheria, and a culture should always be taken. A unilateral discharge also suggests a foreign body in the nostril. The Mouth is best examined at the end in connection with the throat, but the signs to be noted are most conveniently described in connection with the systematic examination of the head. The physician should first note whether the mouth is kept open or closed. An open mouth suggests obstruction in the nose or naso-pharynx, most commonly from adenoids, but it should be remembered that young children when deeply interested often keep their mouths open. The physician should next inspect the lips as to their color, and as to the presence of fissures, ulcerations, herpes, and deformities. In infants fissures and ulcerations are suggestive of syphilis; while in older children they are usually due to chapping. Herpes is seen in acute infectious diseases. The most common deformity is hare-lip. The throat stick or handle of a spoon is now inserted between the lips, which are retracted for the inspection of the teeth and gums. The number and arrangement of the teeth are noted, and compared with the normal at that age. The appearance of the teeth, whether carious or deformed, is also noted. Delay or irregularity in the appearance of the first set of teeth is a sign of rickets, but may be only an inherited or individual peculiarity, and should not be attrib- uted to rickets unless other signs of the disease be present. Other disturbances of nutrition do not usually cause delayed dentition, but may cause the formation of imperfect teeth with a tendency toward early decay. The permanent teeth show similar changes if nutrition is disturbed in early childhood. The Hutchinson teeth, characteristic of syphilis, are seen only in the second dentition. In the inspection of the gums, the physician should note their color, and whether they are swollen, spongy, hemorrhagic, ulcerated, or separated from the teeth. Hemorrhagic lesions of the gums are characteristic of scurvy, while the other changes are seen in the various varieties of stomatitis. The tongue depressor is now inserted between the teeth, and the cheek on each side is retracted for inspection of the buccal mucous membrane. Disease signs to be particularly looked for are the redness of catarrhal stomatitis^ the mucous patches of syphilis, the Kop- lik's spots of measles, the eruptions of the exanthemata, and the cJiar- acteristic lesions of thrush, stomatitis herpetica, and ulcerative stoma- Physical Examination 81 litis. There are two appearances in young infants which must not be mistaken for any of the above lesions, namely, Epstein's pearls^ and Bednars aphthae. The former are one or more small white or yellowish-white nodules in the median line of the hard palate near its junction with the soft palate, and are accumulations of epithelial cells. The latter are symmetrical erosions or ulcerations of mechan- ical origin on each side of the hard palate where the mucous mem- brane over the tips of the sphenoidal hamular processes is very thin. The shape of the roof of the mouth should be noted. It is flatter in infancy than in later childhood. While normal variations in the arch of the hard palate are very great, excessive arching is suggestive of obstruction to nasal respiration, the most common cause being adenoids. The tongue is next inspected. The physician should note whether it is pale, red, cyanotic, dry, moist, smooth, rough, or coated. The mouth is normally relatively dry in early infancy. Later the salivary secretion increases rapidly in amount, and until the infant learns to swallow it, drooling is a normal condition. The tongue is nor- mally lightly coated during early infancy. The size of the torgue should be noted. Enlargement and protrusion may rarely represent a congenital malformation, but is more often a sign of cretinism. The tongue may show any of the lesions characteristic of the various forms of stomatitis, and of syphilis. Ulceration of the under sur- face of the tongue about the frenum, as a result of the mechanical irritation of the lower incisor teeth, is not uncommon in infancy. The frenum should also be inspected for tongue-tie. The mucous membrane of the tongue in children may show the peculiar appear- ance of "geographical tongue." Enlargement of the papillae of the tongue is an important sign of scarlet fever. The Throat. — The proper position of the child in the examina- tion of the throat has already been described. If the child refuses to open its mouth, the tongue depressor can usually be worked in gradually from the side, being pushed in little by little when the child cries. It is rarely necessary to pinch the nose. As soon as the depressor is over the tongue, downward pressure will cause the child to open the mouth. It is necessary, in examining the throat, to make the child gag. This cannot be accomplished by pressure upon the front or middle of the tongue, but the depressor is placed on the back of the tongue and pressed downward and forward. The physician should practice his powers of observation so that he sees all there is to see in a brief space of time. In the examination of the throat, all visible portions of the mucous membrane should be inspected for redness, eruptions, exudate, ulcera- tion, and membrane. The localization of any of these signs, whether 6 82 Disease in Early Life upon the soft palate, uvula, pillars, tonsils, or' posterior pharyngeal wall, should be noted. Whenever exudate or membrane is observed, a culture should be taken. Redness alone suggests simple catarrhal pharyngitis, or scarlet fever. Eruptions suggest the exanthemata. Exudate suggests follicular tonsilitis, but is sometimes seen in scarlet fever or diphtheria. Ulceration suggests Vincent's angina, s>T)hilis, or tuberculosis. Membrane suggests diphtheria, scarlet fever, or membranous angina. The physician should note whether the soft palate rises properly when the child gags; failure to do so is suggestive of diphtheritic or bulbar paralysis. He should also note whether the uvula is elon- gated or edematous. The size and appearance of the tonsils should be carefully noted. It should be remembered that throughout childhood the tonsils normally are relatively larger than in the adult. An enlargement of one tonsil, or a pushing of one tonsil toward the median line, is an important sign, suggesting tonsillar or peritonsillar abscess. En- largement of both tonsils suggests tonsillar hypertrophy. The posterior wall of the pharynx is inspected for the swelhng characteristic of retropharyngeal abscess, for the enlargement of the lymph foUicles seen in chronic catarrhal inflammation, and for the excessive muco-purulent or purulent secretion seen in rhino-pharyn- gitis. It must be remembered, however, that retropharyngeal ab- scess is often in\dsible to simple inspection. Therefore, in the exami- tion of the throat, whenever there are any signs of obstruction either to respiration or to deglutition, a digital examijiation should be made. A gag should not be used, as in retropharyngeal abscess the wide separating of the jaws sometimes results in sudden death. The Naso-pharynx. — The naso-pharynx cannot be examined by ordinary inspection. Evidence of disease in this region is obtained from the presence of pathological secretion coming from the nose or seen in the throat, and from evidences of obstruction to the respi- ration. In young children, the naso-pharynx cannot be examined with the mirror. This can be done in some cases in children old enough to cooperate, but in many cases it is impossible throughout childhood. Consequently the physician must depend on digital ex- amination. This should never be undertaken as part of a routine examination, but should be carried out only when it is desired to confirm the presence of adenoids, or when there are signs of respi- ratory obstruction. For digital exploration of the naso-pharynx, the child is held sitting on the nurse's lap, with its left side against her body, and its arms held to its sides. The physician stands behind the child, and with his left hand holds the mouth open, either with the fore- Physical Examination 83 finger, or with a gag if the child be too large. The right forefinger is introduced into the mouth with its dorsum downward. In reaching the naso-pharynx, care must be taken to hook the finger under the soft palate, for if the soft palate be pushed ahead of the finger, a very false impression will be gained from palpation. The Larynx. — Inspection of the larynx is so difficult in children, that laryngoscopy is only undertaken in special cases. Most of the common diseased conditions in the larynx can be recognized by the sound of the respiration, the sound of the voice, and the character of the cough. The E.ar. — Examination of the ears in children is somewhat dis- turbing, and need not be a part of the regular routine in every variety of case. When a satisfactory explanation of the symptoms is found elsewhere, as in a case of gastro-intestinal or nutritional disorder without fever, there is no necessity of examination of the ears. The ears, however, should always be examined as a routine under the following circumstances: (i) When there is fever, or when there are any s}Tnptoms which could be caused by otitis, which are not ade- quately explained; (2) in all acute infectious diseases, and the exami- nation should be frequently repeated in the course of the disease; (3) whenever there are any symptoms suggesting otitis media. It must be remembered that disease of the middle ear in childhood exists more often without symptoms than with them, and cannot be ruled out by the absence of such symptoms as discharge, pain, putting the hand to the head, restlessness, mastoid tenderness, or even fever. The ear is examined with a head mirror and a speculum. A speci- ally small speculum is needed for the examination of an infant's ears. It must be remembered that the direction of the external auditory canal is difi'erent in infants, and that to straighten the canal the ear must be pulled downward and a little forward, instead of upward and backward as in older children and adults. The points to be looked for are reddening of the drum, bulging of the drum, and disappearance of the landmarks. The drum is more horizontal in infancy than later. The Neck. — Among the most important physical signs in early life are rigidity of the neck, tenderness of the back of the neck, and retraction of the head. Examination with reference to these signs should be made with every sick child. The proper method for the physician is to place both hands — one from each side — behind the occipital region of the head. The head is tilted forward and back for rigidity, and then the physician presses on the back of the neck for tenderness. Retraction of the head is recognized by inspection. These signs are by no means diagnostic of meningitis, but suggest meningeal irritation, whether from infection or from toxemia. The 84 Disease in Early Life neck should also be examined with reference to torticollis, spinal curvature, venous fulness, abnormal pulsation, abnormal swellings, and enlargement of the saHvary glands, thyroid, or lymph nodes. Fig. 20 Examination for rigidity of the neck THE CHEST. Inspection. — The chest is examined with refer- ence to size, shape, symmetry, mobility, and deformities. The nor- mal peculiarities of the size and shape of the chest in infants and young children has been described in the section on Normal Develop- ment. The most common deformities of the chest in the first two years of life are due to rickets, and are enumerated under the descrip- tion of that disease. The physician should look in particular for the rachitic rosary, consisting of bead-like enlargements at the junc- tion of the ribs with their cartilages. Flattening of the sides of the chest, flaring of the lower ribs, Harrison's groove, "pigeon breast," "funnel chest," should all be looked for. The last is more often a congenital malformation than due to rickets. Marked deformity of the chest in infants is sometimes produced by certain less common conditions. I have seen it as a very conspicuous feature of con- genital pulmonary atelectasis, and of myatonia congenita. Deformity of the chest in older children is caused most commonly by tuber- culosis of the spine, disease of the pleural cavities, and paralysis Physical Exla.mination 85 or weakness of the muscles. Prominence of the region of the sternum is seen in forms of cardiac disease associated with marked enlarge- ment of the heart. The amount and character of this deformity is valuable as evidence as to the period in life when the cardiac disease was acquired. In congenital cardiac enlargement, the prominence is most marked in the middle of the sternum, the curve receding both above and below. In cardiac disease acquired in early life, the prominence is most marked over the lower part of the sternum. In cardiac enlargement acquired late in childhood, there is usually no precordial prominence. Palpation. — The rachitic rosary is not always evident to in- spection, and should always be sought by palpation. It must be remembered that in thin babies, the line of junction of the ribs with their cartilages is palpable. The rosary is recognized by the fact that the prominence can be felt at the sides of the junction as well as just at the point of junction. THE THYMUS. — The normal thymic dulness in infancy is very difficult to detect. Very light percussion will show slight dulness under the manubrium, which in my experience is continuous with the cardiac dulness, although some writers state that there is a zone of vesicular resonance between. The thymic dulness is said to dimi- nish gradually and to disappear at about six years. Practically, any marked degree of dulness under the manubrium should suggest enlargement of the thymus, but this diagnosis cannot be made with any certainty on routine physical examination. The thymus may normally extend a little above the sternal notch but is not palpable; if it is felt in this region, it is certainly enlarged. THE HEART. Inspection. — The precordia should first be in- spected for pulsation, and the position of the apex beat should be noted. It must be remembered that in early infancy the cardiac impulse is normally rarely visible and is often not palpable. In childhood, on the other hand, the impulse is relatively more distinct than in the adult. The physician should also note the character of the impulse, whether localized or dift'use, faint or forcible. Palpation. — The evidence obtained by inspection as to the car- diac impulse should be confirmed by palpation. In placing the position of the apex beat (which means the point farthest out and down in which the impulse is visible or palpable), the physician should remember the anatomical conditions characteristic of infancy and early childhood. In infancy, the apex beat is normally higher up and farther out than in later life. At this age it is in the fourth interspace, about i cm. (3/8 in.) outside the nipple line. From this point it gradually moves inward and downward, reaching the 86 Disease in Early Life fifth space in the nipple line at about seven years, and coming inside the nipple line before the thirteenth year For purposes of record, it is best to record the position of the apex in relation to the nipple line, rather than to the median line, because the distance from the median line varies with the size of the child. The physician should also confirm by palpation his observations as to the force and character of the cardiac impulse, and should note whether any thrill be present. Percussion. — The outlines of the cardiac dulness are now deter- mined by percussion. The normal outlines at the various ages of infancy and childhood have been given in the section on Normal Development. Both the superficial or absolute dulness, and the deep or relative dulness, should be noted. Many authorities state that the absolute dulness is more difficult to determine than is the relative dulness. In my experience, it is just the other way; the absolute dulness is easier to determine, but is less reliable as evidence of the actual size of the heart than is the relative dulness. It is for this reason that it is better to record both outlines. Percussion in infants and young children should be light and delicate. In determining the left border, the physician should place his finger first on the area between the left nipple and the left border of the sternum, and should percuss toward the left until the tone becomes resonant. In determining the boundary of absolute dulness on the right, he should begin at the same point and percuss toward the right until there is a change of tone. In determining the boun- dary of relative dulness on the right, the physician should begin percussion entirely to the right of the cardiac area, and should per- cuss toward the left until a modification of the resonance is noted. In determining the upper border of dulness, he should percuss from above downward. Auscultation. — In children, auscultation should be performed as in the adult, the most significant areas being those of the apex beat, the middle of the precordia near the left border of the sternum, the base on each side of the sternum, and the lower part of the ster- num itself. The character of the heart sound should be noticed with reference to rate, rhythm, tone, loudness, and relative accentuation or diminution in the different areas. A peculiar character of the first sound, which lacks the booming quality of later life, and resembles the second sound, is normal in early infancy and should be remem- bered. It should also be remembered that in infancy and early childhood, the first heart sound is fainter at the base than in later fife. The pulmonic second sound is normally louder than the aortic throughout the whole of childhood, and for this reason accentuation of the second pulmonic sound is difficult to recognize, and not of Fig. 21 — Xormal areas of dulness to percussion of the front of the chest A. Hepatic dulness B. Superficial or absolute cardiac dulness C. Deep or relative cardiac dulness Thymic dulness in an infant Physical Examination 87 much diagnostic significance. Reduplication of the second sound is also often heard in normal children, and should not be considered pathological unless there are other evidences of cardiac disease. The presence of such adventitious sounds as murmurs and friction- rubs should be carefully noted. With reference to murmurs the following points should be recorded: (i) The region in which they are heard and their point of greatest intensity; (2) their time with reference to the cardiac cycle — systolic, presystolic, or diastolic; (3) their loudness; (4) their character — soft, harsh, or musical; (5) their transmission — whether they are heard in the axilla, back, or over the vessels of the neck; (6) whether or not they replace the heart sounds. It is to be remembered that in the first two or three years of life, murmurs clue to acc|uired cardiac disease are very uncommon. At this age, murmurs are either functional, or represent a congenital cardiac lesion. The physician in considering the relative weight of evidence pointing toward the functional or organic origin of a murmur, should remember that in an infant, if the evidence points toward organic disease, the lesion is usually congenital. The significance of murmurs will be considered in detail in the division on Diseases of the Heart. LUNGS. Inspection. — The observations as to the rate and char- acter of the respiration, and as to the presence or absence of cough, have been made during the general preliminary examination of the body. The ph3^sician should therefore note whether the movement of the chest on both sides is equal, whether there is inspiratory retraction of the intercostal spaces, and whether there is increased circumference of one side with bulging of the intercostal spaces. Palpation. — Palpation over the lungs is used to deterrnine whether there is increase or diminution in the tactile fremitus caused by the voice sounds. This is much less useful in children than in adults^ because in many cases it can only be obtained when the child is crying, and the crying voice sounds are so loud, and the chest wall so thin, that the finer differences cannot be detected. It is also less valuable in diagnosis, especially in young children, as good tactile fremitus is often felt over an effusion. In older children, who are able to speak as ordered by the physician, the results of palpation are more valuable. The tactile fremitus should always be tested, but the physician should not rely too much on its results in young children, as compared with the results of other methods of examina- tion. Rales are often palpable in young children. Percussion. — It is more difficult in infancy and early childhood to recognize changes in the percussion note, than in later childhood. When a young child is crying hard, the resonance of all parts of the lungs is impaired. When, however, a clear difference in the resonance of the two sides is made out, the evidence is just as valu- Disease in Early Life able as it is in later childhood, unless the only abnormality found is slight dulness over the right base. This may be due to the relatively large size of the Uver in infants. Percussion in children should be particularly light and deHcate, on account of the thinness of the chest wall, and the small size of the parts. Strong percussion will produce confusing sounds coming from a distance, and cannot elicit a slight relative dulness. The finger, not a percussion hammer, should always be used. The results of percussion are entirely un- reliable if an infant is lying on its side, because the chest is so com- pressible that the resonance of the lower lung is perceptibly impaired. The infant may, however, be lying on its back, or on its face, may be sitting upright, or may be held upright facing the shoulder of Fig. 22 Percussion of the front of the chest the mother. Even in the latter case, there is some possibihty of compression, and the infant should be transferred to the other shoulder if there is any suspicion of dulness on one side; also, if possible, the arms should be placed in approximately the same position. It is difficult in young children to determine accurately the borders of the lungs, and usually impossible to determine by percussion the mobility of the pulmonary borders. The borders in infancy are about one space higher than in later life. The relation of the various lobes of the lung to the chest wall is practically the sam.e in infancy Fig. 23— Boundaries of the lobes of the lungs from in front Physical Examination 89 and childhood as in adult Ufe. The lines between the upper and lower lobes start from the vertebrae at the level of the spines of the scapulae, pass through the mid-axillary lines at the level of the fourth rib, and reach the borders of the lung at the sixth rib, in the nipple line on the left, in the parasternal line on the right. The boundary between the upper and middle lobes starts on the right at the fourth costal cartilage, runs into the axilla, where it is close above the line separating the upper and lower lobes, and reaches this line at the outer border of the scapula. Fig. 24 Boundaries of the lobes of the lungs from behind The principal points to be noted are relative dulness, flatness, hyperresonance, and tympany. It is useful to remember the follow- ing points characteristic of infancy and childhood: i. The percussion note is normally more resonant than in adults, except in a crying infant 2. The note at the left base is more tympanitic because of the proximity of the stomach, and this tympany may be very marked when the stomach is distended with gas. 3 The percussion note is not higher pitched over the right apex, as in adult life. 4. Up to about ten years of age, there is slight dulness under he inner third of the left clavicle; this is very difficult to elicit in infancy It is very important in early life to distinguish between dulness and flatness on percussion, and this is one of the most important differentiating signs between pu'monary consolidation, and pleuritic 90 Disease in Early Life effusion. Light percussion must be used, because the layer of fluid in children is very thin, and heavy percussion will obtain some pul- monary resonance, even though fluid be present. More important often than the sound obtained by percussion, is the sense of resistance. This can also be elicited by tapping directly on the chest wall with the tips of the fingers, and this method of examination should not be neglected. It is particularly valuable in infancy, at which age an increased sense of resistance is an important diagnostic sign of fluid in the pleural cavity. Fig. 2i, Percussion of the back of the chest Auscultation. — The features to be noted on auscultation in children as in adults are, the character of the respiratory murmur, the vocal resonance, and the presence or absence of adventitious sounds The standard by which abnormality is recognized is, how- ever, so different in infancy and childhood from that of adult life, that there is no part of the physical examination which so greatly requires the special knowledge and training of the pediatrist, as the auscultation of the lungs. The pecuHarities are most marked in infancy, and grow progressively less marked throughout childhood. In children approaching the age of puberty, the adult standard has been reached. The normal pecuHarities encountered in the auscul- tation of infants and children, are due to peculiarities of anatomical Physical Examination 91 development. The principal causes are, the shallowness of respira- tion in early life, and the greater proportion of bronchial air space to alveolar air space in the lungs. The respiratory murmur in infants and young children is higher pitched and harsher than in the adult. If pitch be taken as one of the criteria by which bronchial respiration is recognized, the normal respiratory sound of the young child approaches the bronchial. But the criteria used in recognizing bronchial respiration in^the adult, Fig. 26 Percussion of the apex of the lungs should not be used in childhood, and should be entirely banished from the mind of the physician when he is examining a sick child. Unless he does this, the harsh, high pitched respiratory murmur of early life, which is called puerile, will often be mistaken for bronchial respiration. The recognition of bronchial respiration in children depends in no way upon loudness, harshness, or pitch. It differs from vesicular respiration only in the character of the sound, and in the greater length of expiration. Unfortunately, the latter feature can- not always be recognized. The expiration is frequently replaced by the cry; sometimes in young infants it cannot be heard because the child is breathing very quietly, and when an attempt is made to cause it to draw a longer breath, it begins to cry, and only inspira- tion is audible. Prolonged expiration is a valuable sign of bronchial 92 Disease in Early Life breathing when found, but it is so often not found, that the physician must accustom himself to recognizing bronchial breathing mainly by the character of the sound which is heard on inspiration as well as. on expiration. The character of the sound in the bronchial breath- ing of childhood must be learned mainly by experience. It is diffi- cult to describe. It is high pitched, but so is puerile breathing. It is decidedly not harsh as compared with normal puerile breathing. It can best be described as having a peculiar nasal quality, and as sounding close to the ear as if it came from some point intermediate between the ears of the physician and the bell of the stethoscope. It should be remembered that when the character of the respiration is the same on both sides of the chest, front and back, it cannot be bronchial. In case of doubt, the physician should listen to the respiratory murmur over the second dorsal spine of the vertebrae. In this situation, the breathing is normally purely bronchial, and gives a good standard for comparison as to the quality of the sounds heard in other parts of the chest. The term "increased" is sometimes applied to the respiratory murmur as heard in adults, the meaning being increase in the loud- ness, or intensity of the sound. This term should never be applied to the description of the respiratory murmur heard in childhood. There is no limit to the loudness or intensity of the sound normally heard. When there is a difference in the loudness of the respiratory murmur in the corresponding areas of the two sides of the chest, in the vast majority of cases in childhood, the louder side represents a normal condition, while the fainter side is evidence of a pathological condition. Occasionally, especially in older children, the bronchial breathing heard over the consolidation is louder than the normal breathing heard on the other side. In such a case the breathing might be called relatively increased, but its bronchial character is always plainly apparent. A relative increase in loudness alone, should never be considered abnormal. It is not uncommon for physicians or students unaccustomed to the examination of children, to diagnose lobar pneumonia on the wrong side. The breathing over a consolidation in children is frequently so diminished in loudness that its bronchial character is not recognized, especially if the child is breathing quietly; and the loud, harsh, puerile breathing on the normal side is mistaken for bronchial breathing. Whenever the respiratory sound in infancy is so feeble that its character cannot be determined, the baby must be made to cry and thus take a long -breath. The baby should never be examined when lying on its side, because in this position the compression of the chest will lead to a diminution of the respiratory murmur on the lower side. It should be remembered that bronchial respiration is normally heard over a greater area at the root of the lungs in infancy and early child- Physical Examination 93 hood than in later childhood and adult life. The slightly prolonged expiration heard at the right apex in adults is not found in children. The Vocal TIesonance, like the tactile fremitus, is not so valu- able as diagnostic evidence in childhood as it is in adult life. Chil- dren cannot usually be made to say "one, two, three," or "ninety- nine," as can adults, and vocal resonance can only be obtained when they are crying. The child's cry is so loud, and the chest walls are so thin, that the sound heard on auscultation is often too overpower- ing for an estimate of its character and intensity. A pronounced degree of bronchophany can usually be heard, even when the child is crying. Diminution in the vocal resonance is not only more difficult to detect in young children, but is less constant as a sign of pleuritic effusion, and is often present over consolidation when there is no fluid. In older children the value of the vocal resonance approaches that of adults. In some cases, however, even in infants, a change in the voice sounds on one side can be recognized before any change in the character of the respiration. Rales have the same character, varieties, and significance in children as in adults, and require no detailed description. They are often louder in infancy than in adults. One error frequently made in the examination of the lungs of infants and young children, is the mistaking of rales originating in the nose or naso-pharynx for true bronchial rales. The former are frequently transmitted to the chest, but should easily be distinguished from rales coming from the lungs. Bronchial rales are never exactly alike over both lungs, and are not heard over the trachea or cheeks, whereas rales made in the upper air passages have the same sound over both lungs, the trachea, and the cheeks. Pleural Friction Sounds are very rarely heard in infancy, although pleurisy is not uncommon at this age. The reason for this is unknown. In childhood they have the same significance as in adults, but in my experience, are somewhat less commonly heard. THE ABDOMEN. Inspection.— The abdomen should be in- spected with reference to size, prominence, retraction, shape, irregu- larities of outhne, tension of the wall, the condition of the umbilicus, herniae, superficial veins, respiratory movements, epigastric pulsa- tion, and visible peristalsis. The normal appearance of the abdomen at the various ages has been described in the section on Normal Development. Enlargement of the abdomen is very common in infancy. The most common cause is various disturbances of digestion and nutri- tion, which act in two ways in producing abdominal enlargement. Disturbed digestion may produce an increased formation of gas in the intestine. Enlargement of the abdomen from this cause is seen 94 Disease in Early Life also in older children in chronic indigestion from an excess of carbo- hydrate, the abdomen being enlarged chiefly in the upper portion. In disturbances of nutrition the walls of the intestines suffer with the rest of the tissues and become relaxed, so that even without increased formation of gaB there may be increased accumulation of gas. The enlargement of the abdomen seen in rickets and in most chronic digestive disturbances, is produced in this latter way. In older children enlargement of the abdomen is suggestive of some more serious condition, and the possibility of the same condi- tions in infancy must not be forgotten. Among these causes are ascites, tuberculous peritonitis, enlargement of the liver or spleen, sarcoma of the kidney, and congenital dilatation of the colon. Irregu- larities in outline are suggestive of enlargement of one of the solid viscera, or sarcoma of the kidney. A prominence in the lower por- tion in an infant may be due to a distended bladder. Retraction of the abdomen is usually due to lack of intestinal con- tents, both gaseous and fluid. It is often seen in acute diarrheas, in meningitis, and in conditions characterized by severe vomiting, such as acidosis. It is never due in children to hysteria or lead poisoning. Distention of the abdomen is due to the same causes as enlarge- ment, representing only a greater degree. Inspection of the umbiHcus is particularly important in the new- born. Umbilical herniae are easily recognized. Epigastric herniae are not very rare in infants and young children. Visible peristalsis is a very important diagnostic sign in infancy. When over the epigastrium it is suggestive of pyloric stenosis. Over other parts of the abdomen, it is suggestive of tuberculosis or intes- tinal obstruction. Palpation. — In the general palpation of the abdomen, the points to be noted are the tension and resistance of the walls, and the pres- ence or absence of spasm of the muscles, tenderness, fluctuation, and abnormal solid bodies. Spasm and resistance must be localized, and it must be determined whether they are voluntary or involuntary. If tenderness be present, its seat must be noted, and whether it is superficial or deep. Abdominal tenderness is a less common sign in childhood than in adult life, and is not often seen in disturbances of the stomach or intestine. It should always suggest the possi- bility of some serious condition, such as appendicitis, peritonitis, or intussusception. A sense of fluctuation is often obtained in infants and young children due to the liquid character of the intestinal con- tents, which may be mistaken for ascites. The fluid wave of ascites is obtained as in the adult, and has the same diagnostic significance. It is often difficult to teh whether masses felt in the abdomen are fecal accumulations, or the masses of tuberculous peritonitis, and it Physical Examination 95 is sometimes necessary to repeat the examination after the bowels have been emptied, in order to clear up this point. Percussion of the abdomen is employed mainly to determine the presence of fluid, to determine the character of masses felt, and to map out the outlines of the abdominal organs. The sign of free fluid is dulness in the flanks, shifting with change of position. Care must be taken in interpreting this sign, as in infants and young children the liquid feces tend to gravitate to the flanks, and will give a dulness which shifts with change of position. Very marked shifting dulness, or a fluid wave is necessary for a conclusive diag- nosis of ascites. The Stomach. — Percussion of the stomach is difflcult in infancy and childhood, and the results obtained are unreliable. A dilated stomach, when distended with gas, can sometimes be recognized both by inspection and percussion. Visible peristalsis is an import- ant sign of pyloric stenosis. The Liver is investigated by palpation and percussion. The upper border must be determined by percussion. The lower border in infants and young children is best determined by palpation, as percussion is unreliable on account of the thinness of the edge. The upper border of the liver flatness is at the fifth rib in the right nipple line in infancy. From this point it gradually descends, the adult position being reached at about six years. The lower border in infancy may normally extend 3 cm. (1-1/8 in.) below the costal border in the mammihary line, and 6 cm. (2-1/4 ^^•) below the tip of the ensiform. It is palpable in the mammillary line up to three years, and may sometimes be felt after this time in children with relaxed abdominal walls if the fingers are pushed up under the costal border. The liver in early childhood is easy to feel on account of the thinness of the abdominal waU. It is, however, very often missed, because the physician, not realizing how soft and thin is the edge, and how superficially it lies, palpates too deeply and forcibly. The liver is examined for enlargement, tenderness, and irregu- larity of outline. Examination of the gall-bladder is unsatisfac- tory in early Hfe, but is hardly necessary, as this organ is very rarely diseased in childhood. The Spleen. — Percussion of the spleen is so difficult in early life, on account of the small size of the organ, that it is hardly worth while to undertake it. The outHne may be determined in older children, but palpation of the spleen is so easy in infancy and child- hood that it is better to trust to this method of examination. The spleen should be palpated with the physician on the right side of the patient. Many text-books recommend palpation of the 96 Disease in Early Life spleen from the left side, with the tips of the curved fingers. In my experience palpation from the right is infinitely better. The right hand should be placed almost flat upon the abdomen, with the fingers almost straight. In the child the abdomen wall is so thin, and the spleen is so superficial, that care must be taken not to pal- pate too deeply, for the spleen may thus be pushed down with the abdominal wall without being detected. The extreme tips of the fingers should be placed against the costal border, and then are lightly and quickly depressed. By repeating this operation, drawing the hand forward and back, the spleen will not be missed if palpable. The proper position for the hand is shown in the illustration. The spleen is normally not palpable at any age, except that in infants with lax abdominal walh, the normal spleen can sometimes be felt if the fingers are pushed up under the costal border. When- ever the spleen is palpable below the costal border, it is safe to con- clude that it is enlarged. When there is marked splenic enlargement, forming a large mass on the left side of the abdomen, it is easier in the child than in the adult to recognize the mass as spleen, on account of its very superficial position, and flatness on percussion; moreover, the notch can usually be clearly felt. The Kidneys. — The outHne of the normal kidneys cannot be percussed either in infancy or in childhood. The normal kidney can only rarely be palpated even when the abdominal walls are very thin and lax. If the kidney is palpable, it can be concluded that it is enlarged or displaced. Floating kidneys are very rare in infancy and childhood, and if present, usually represent a congen- ital abnormality Palpable masses in the region of the kidney usually represent tumors, the most common being sarcoma. Congenital cystic kidney, and pyelo-nephrosis are seen at times. Tumors of the kidney are recognized by the fact that they do not move with respiration, and usually show some tympany on percussion, as the colon lies in front of them. Tenderness on deep palpation in the region of the kidney is some- times seen in pyehtis. It should suggest either pyehtis or peri- nephritic inflammation. The Bladder. — In infancy the small oblique pelvis is almost wholly filled by the rectum, and consequently almost all of the bladder lies in the abdominal cavity above the crest of the pubes. Distention of the bladder forms a rounded tumor in the lower part of the abdomen, which lies close to the abdominal wall, and may even reach to the umbilicus. Most of the anterior surface is un- covered by peritoneum. After the child gets upon its feet, the weight of the urine and the anatomical changes in the shape of the ^ ». \ Physical Examination 97 pelvis gradually cause the bladder to assume the adult position, which is reached in middle childhood. This high position of the bladder in infancy and early childhood has caused many bad mistakes in diagnosis. A distended bladder has often been mistaken for ascites, or a new growth. Whenever there is any question of these conditions, the bladder should always be emptied by catheterization. In connection with the examination of the bladder, the groins should be carefully examined. AbnormaHties to be looked for are hernia, hydrocele of the cord, undescended testicles or misplaced ovary, and enlargement of the lymph nodes. The External Genitals. — Inspection of the external genitals should always form a part of the physical examination, particularly in females, and in the newborn. The principal abnormalities to be looked for are malformations and discharge. The commonest mal- formation in females is adhesions of the nymphae. The prepuce is normally adherent to the cHtoris throughout infancy and early child- hood. In males the physician should look for phimosis, undescended testicles, and hydrocele. In infants the glans penis is normally covered by the prepuce, which is adherent. In phimosis the pre- puce is so narrowed that it cannot be retracted. The testicles may be wholly or partially undescended. Tumors of the testes, varico- cele, balanitis, ulcerations, and urethral discharge (in the male), are rare in children. In the female, vulvo-vaginitis is fairly common. It is often of gonorrhoeal origin, but may be due to uncleanliness or some other source of irritation. Whenever there is the least sign of discharge, a bacteriological examination should be made. The Anus. — The buttocks should always be retracted and the anus inspected, particularly in infants. The condition of the skin about the anus should be noted. Fissures of the anus are not un- common in infancy. Hemorrhoids are uncommon in childhood as compared with adult Hfe. Prolapse of the rectum, on the other hand, is common. Ulcers, condylomata, and mucous patches are often found about the anus in syphilitic infants. Fistula, ischio- rectal abscess, and pilonidal sinus are seen at times. The Rectum. — A rectal examination is not necessary unless there is something in the history suggesting its advisability. Whenever there is any question of intestinal obstruction, intussusception, or any obscure condition in the abdominal cavity, a rectal examina- tion should be made. THE EXTREMITIES.— In examining the extremities the physi- cian should keep the following points in mind : Relative size, position, deformities, the shafts of the long bones, the joints, spasm, and paralysis. 7 98 Disease in Early Life Relative Size. — The limbs are normally alike in circumference on the two sides. A difference is more apt to be due to atrophy on one side than to hypertrophy on the other. If any apparent differ- ence be present, it should be confirmed by measurement. Care must be taken that measurements are made in exactly the same place. Differences of less than i cm. are within the limits of error in measure- ment, and should be disregarded. It is also important to determine whether the legs are of equal length. This can only be determined with the child lying on its back. A difference may be an actual difference in length, or due to congenital dislocation of the hip. The latter is recognized by the high position of the trochanter. Position. — Abnormal positions of the extremities are usually due either to temporary muscular spasm or to permanent muscular con- tractures. The details of the examination for spasm will be de- scribed under the examination of the nervous system. A limb is sometimes held in an abnormal position without spasm, the cause being some painful lesion which is more comfortable when the limb is held in this way. The most common cause is arthritis. Deformities — Deformities of the extremities are either congen- ital or acquired. The former variety includes such conditions as club-foot, club-fingers, web-fingers, congenital dislocation of the hip, and a variety of rare gross malformations. The most common acquired deformities are due to rickets, and are enumerated in detail under the description of that disease. There is a sabre-like deformity of the tibiae which is especially character- istic of late syphilis in childhood. It is often mistaken for a rachitic deformity, but occurs later in childhood. The limbs are also deformed in cretinism and chondrodystrophy fetalis. Contractures from disease of the nervous system may cause a condition which is more than an abnormal position of the limbs, and amounts to actual deformity. The Long Bones are examined for tenderness, swelHng, and frac- tures. The most common cause in infancy of tenderness and swel- ling over the shafts of the long bones is scurvy; periostitis, and osteo- myelitis stand next. In older children, scurvy is not seen, and the most common cause is periostitis. Tumors, chiefly osteosarcoma, are seen at times. The fingers should be examined for tuberculous dactylitis. The Joints. — The physician should note the contour of the joints for swelling, should palpate them for tenderness and swelling, and should manipulate them for pain on motion and limitation of motion. It is useful to remember that in infancy acute inflammation of the joints usually represents a septic arthritis, while in older children. ^' II . ?!*»7i x "^ X Physical Examination 99 it usually means rheumatic fever. Chronic inflammation of the joints at any period of early Ufe is most commonly due to tuber- culosis. A traumatic chronic arthritis is not uncommon in children. The chronic "rheumatoid" conditions, osteo-arthritis, and so forth, so often seen in adults, are rare in childhood. THE SPIXE. — The spine is examined best with the patient lying on its face on a flat surface. The points to be noted in connection with the spine are curvatures, mobility, tender points, and spina bifida. The peculiarities of spinal curvature normally characteristic of early life have been described in the section on Normal Development. Curvatures due to disease will be apparent with the patient lying on its face A k}'phosis is most often due to tuberculosis, while a backward curve in children is always suggestive of meningeal irri- tation. The lateral curvatures are common in childhood. The flexibility of the spine is tested by grasping the heels of the infant with one hand, while the other hand holds down the shoulders. The heels are lifted up, and swung in various directions, as shown in the illustration. THE NERVOUS SYSTEM.— Some of the examinations made in obtaining evidence as to disturbance of the nervous system have already been described. It is, however, useful to consider the physical signs of disease of the nervous system together, although the various steps in the investigation are more conveniently made in connec- tion with other parts of the physical examination. The AIental Contrition is estimated during the general examina- tion of the body which precedes the detailed examination of the various organs and systems. It is often advisable, when there is any abnormality in the apparent mental attitude of the child, to make a more detailed investigation of the mental condition. This cannot always be accompHshed at a single examination, and requires more or less prolonged observation. Apathy, stupor, or dehrium will usually be plainly apparent before the examination is finished. Also, pronounced cases of mental impairment, the severer grades of idiocy and imbecility, will not escape notice. It is the milder types of imbecility and backwardness that are not always apparent on a single examination. Much depends upon the physician's powers of observation, and upon a very thorough familiarity with the behavior of a normal child at every stage of development. Paralysis and Spasm.— These signs are most conveniently inves- tigated during the examination of the extremities. Paralysis is often diflicult to detect in young children. Older children, who can cooperate with the physician, will attempt to make various movements as directed, and in them the recognition of paralysis is easy enough. Infants and young children will not do this. The 100 Disease in Early Life motor function of the arms can be tested by offering them things to play with, or showing them something which they particularly like, such as the bottle or a favorite toy. The power of the legs is tested by tickhng the feet, or pricking them with a pin. Sometimes it works well to place a limb in an abnormal strained position, and note if the child moves it back. When a child is unconscious, the only way in which paralysis can be detected is by lifting a limb and then letting it fall, noting the manner in which it drops. A com- pletely paralyzed limb will drop like a dead weight, while if there be no paralysis, the limb will drop neither so promptly nor so life- lessly. Further evidence may be obtained by manipulating the limb and noting the amount of resistance to passive motion. Flac- cid paralysis usually shows a notable difference. It is very important in infancy to distinguish true paralysis from the pseudo-paralysis which comes from failure to use the extremities on account of pain. Evidence of pain can usually be found in the latter condition, and the two conditions can usually be distinguished without causing too much suffering. Spasm is also often difficult to detect in infants. In young in- fants, and in all infants who are notably emaciated^ there is a hyper- tonicity of the muscles which must not be mistaken for contractures of nervous origin. This hypertonicity is most marked in the flexor group of muscles, and often prevents complete extension of the hmbs. When true contractures are present, there is usually a differ- ence in the amount of resistance to passive motion on the two sides. The test for spasm is made by passive motion of the limbs at the various joints. It is often difficult to distinguish voluntary resist- ance from temporary spasm. The former can usually be overcome by rapid repetitions of the same movement, while spasm cannot thus be overcome. When temporary spasm is present, it is important to note the position assumed by the extremities. In early Hfe, spasm is most often due either to disease of the central nervous system, or to hyperirritabihty of the peripheral nerves (Spasmophilia). The Reflexes. — The reflexes to be tested in children as a routine are the pupillary reaction, the knee jerks, and the plantar reflex, and certain special signs. The abdominal reflex is inconstant in child- hood, and the cremasteric reflex is not of much diagnostic signifi- cance. The method of obtaining the pupillary reaction has been described under the examination of the eye. The knee-jerk is often hard to eHcit in an infant. The leg must be relaxed, and great patience is often necessary before a satisfactory test can be made. Too much stress must not be laid upon an absent knee-jerk in an infant, and it is wisest to disregard it as evidence unless there are some other signs of disease of the nervous system. Physical Examination 101 An exaggerated knee-jerk has its full diagnostic significance. The best method of obtaining the knee-jerk in an infant is to place the hand under the lower part of the thigh and lift the knee from the bed or table. The ligamentum patellae is tapped, the foot still rest- ing on the bed, the angle of the leg being varied by moving the knee up and down. Then, if no response is obtained, the knee is lifted so that the foot hangs clear of the bed, and the tapping is repeated. In older children the knee-jerk is best tested with the child in a sit- ting posture, and the leg hanging free. Fig. 29 Testing the knee jerk The plantar reflex is tested in the ordinary manner. In infancy its presence is more often shown by extension than by flexion of the toes. BahinskVs sign is a simultaneous extension of the big toe and flexion of the other toes, and in adults and older children it points toward disease of the higher motor tracts. It has no diagnostic sig- nificance in infancy. Special Signs ^— There are certain special signs of great impor- tance in the investigation of the nervous system in early life. These are Kernig's sign, Brudzin-ki's sign, ankle clonus, the contralateral reflex, Chvostek's sign. Trousseau's sign, and the peroneal reflex. 102 - Disease in Early Life Kernig's Sign consists in a limitation of the extension of the leg upon the thigh when the thigh is at a right angle with the body. Under normal circumstances, when the thigh is at a right angle with the body, the leg can be extended to an angle of 135° at the knee, at least, and in infants often to a greater angle. Kernig's sign is ob- tained when the leg cannot be extended to an angle of 135°. The sign can be tested by placing the thigh at a right angle to the body and attempting to extend the leg, or by holding the leg straight at Fig. 30 Examination for Kernig's sign the knee and bringing the thigh to a right angle with the body, noting how much flexion this causes at the knee. The former method is perhaps a little the better. In very young, or much emaciated in- fants, the muscular hypertonicity must be taken into account. A positive Kernig's sign is almost constant in all forms of menin- gitis except the tuberculous, in which it may or may not be present. It is often positive in conditions other than meningitis, but usually means meningeal irritation of some kind. Brudzinski's Neck Sign.— This consists in a movement of the legs when the neck is flexed forward. Under normal conditions forward flexion of the neck causes no movement of the legs. To test the neck sign, the child must be lying on its back. The physician Physical Examination 103 holds the chest stationary with one hand, and brings the head sharply forward with the other. When the sign is positive, this will cause a flexion of the legs both at the hips and at the knees, or at the hips alone. The movement is sometimes present on one side only. The sign when positive has been regarded by some writers as diagnostic of meningitis. It is certainly seen mainly in meningitis, but is not present in all cases of that disease, and I have observed its presence repeatedly in conditions of meningeal irritation which were proved not to be meningitis. Ftg. 31 Examination for Brudzinski's neck sign Ankle Clonus. — This sign is elicited by lifting the leg a few inches from the table, holding it straight at the knee and making sharp dorsal flexion of the foot upon the leg, the foot being held by the toes. Ankle clonus is present if this causes a rhythmical jerking of the foot back and forth at the ankle. The sign is seen in a great variety of lesions of the central nervous system, affecting the upper motor segment. It usually accompanies spastic paralysis. It is one of the few signs which may be present in meningitis, but which I have never observed in meningismus. The Contralateral Reflex is present when passive flexion of one leg causes a reflex movement of the other leg. The reflex move- 104 Disease in Early Life merit may be identical (flexion), or reciprocal (extension). It is one of the signs of disease of the central nervous system. Chvostek's Sign is tested by tapping upon the facial nerve or its branches where they cross the jaw. Under normal conditions, no contraction of the facial muscles is caused by this procedure, but when the sign is positive there is a contraction which involves either the muscles supplied by the whole nerve, or those supplied by one of its branches. The contraction is observed either about the mouth, about the eye, or about both. It is a sharp, quick contraction which cannot be mistaken for voluntary movement. The sign cannot be obtained when the child is crying. It is sometimes called the facial phenomenon, and the contraction about the eye, caused by tapping the upper branch of the facial nerve is sometimes called Weiss' sign. Chvostek's sign when positive is diagnostic of spasmophilia. Trousseau's Sign. — This is obtained by placing a constriction band about the upper arm near the fork of the biceps. The con- tinued pressure on the nerve trunks normally causes no reaction, but in spasmophilia this often causes the hand to assume the typical spasm of tetany. The sign when positive is diagnostic of spasmo- philia, but its testing is painful, and the diagnosis can usually be made from other signs. It should never be tried in a case of spasmophiha characterized by laryngospasmus. The Peroneal Reflex is obtained by tapping upon the peroneal nerve near the head of the fibula. In eliciting this reflex, a percussion hammer is better than the finger. The sign is obtained when the tapping causes a sharp reflex movement of the foot. A positive peroneal reflex is one of the diagnostic signs of spasmophilia. Sensation. — In older children who are able to answer questions intelligently, sensation may be tested for touch, pain, and tempera- ture, a^ in adults. Testing the temperature sense is however usually unnecessary in children. In young children who are unable to co- operate with the physician, only the sensation of pain can be satis- factorily tested. This is performed by touching the skin with a sharp point and noting whether the child's expression shows pain, or whether it moves the limb out of the way. Special Senses. — For purposes of diagnosis the special senses to be tested are those of sight and hearing. In older children who are able to answer questions intelligently, the tests are made as in adults. In young children, sight is tested by showing the child some object in which it is specially interested, such as the bottle, or a favorite toy. This object is moved from side to side, the physician noting where the patient's eyes follow. In very young babies not old enough to recog- nize objects, the sense of sight is tested by moving a bright light back and forth in front of the eyes and noticing whether the movements Special Methods of Examination 105 of the eyeball follow the light. Another way is to approach the hand rapidly to the eyes, noting whether the child winks. Care must be taken not to draw a wrong conclusion from winking caused by the current of air produced by the movement of the hand. Hearing in young children is tested by making a sudden noise near the ears, and noting whether the child jumps. The test is not always satisfactory in very young babies. SPECIAL METHODS OF EXAMINATION There are certain special methods of examination which frequently have to be performed in children for purposes of diagnosis, but which do not form a part of ordinary routine examination. It is essential that the physician be familiar with the technique of these various operations. LUMBAR PUNCTURE.— This is one of the most important diag- nostic procedures used in infancy and childhood. It is much more frequently employed in children than in adults, because not only meningitis but many conditions simulating meningitis are particu- larly common in early life. There are also other conditions more common in early Hfe in which lumbar puncture is used, such as hydro- cephalus and poliomyeloencephaHtis. The technique of lumbar puncture is comparatively simple, but success depends upon attention to details. Needles are better than trocars for lumbar puncture. The size of the needle should be adapted to that of the child. For very young babies, an ordinary antitoxin needle should be used. For bigger babies and older children, the needle should be larger. Several needles and two test tubes should be boiled, and if the fluid has to be transported for examina- tion, corks to fit the test tubes should be boiled also. The hands of the operator and the lumbar and sacral regions of the patient extending around as far as the highest point of the crest of the ilium, are rendered surgically clean. Tincture of iodine is useful to dis- infect the point over the lumbar spines where the puncture is to be made. ]Much depends upon the proper holding of the patient. An attendant on the opposite side of the patient places one hand under the bend of the knees, and places the other arm about the patient's shoulders. The spine is then flexed by drawing up the knees with one hand and pressing the shoulders forward. Pressure should be made on the region of the shoulders rather than on the neck. It is important that the spine be flexed as much as possible without the use of undue force. An anesthetic is unnecessary in the majority of cases, but should be used when muscular spasm prevents proper flexion of the spine. In some cases in older children the site of the puncture may be rendered insensitive with cocaine or ethyl chloride. 106 Disease in Early Life In many children, however, this procedure appears to cause more discomfort and terror than the puncture itself. The operator takes as a landmark a line drawn between the highest points of the crests of the ihum on each side. This is the upper hmit of safety, and the spinal canal can be entered anywhere below this level without danger of piercing the cord. It is unnecessary to count and locate the lumbar spines by number. The operator should take as his first point of selection the second space below the line described above, which gives him a margin of one space above and below the point first chosen, in case fluid is not obtained at the first attempt. The spaces are located with the forefinger of the left hand. Some Fig. 32 Position for lumbar puncture The dotted line shows the upper limit of safety, below which the puncture must be made operators insert the needle directly in the median line, to pass between the spines, others a little to one side of the median line, to pass be- tween the laminae; in the latter case, the needle must be inclined shghtly toward the median line, so that after insertion the point of the needle will be in the median line. The advantage of the first point of insertion is that the proper direction is much easier to follow, and of the latter point that there is more room for the needle to pass between the laminae than between I ,/ I Special Methods of Examination 107 the spines. I am accustomed to use the latter method, but beheve that both are equally good, the choice depending upon the indi- vidual operator. In either case, the general direction is horizontally forward, and the needle is pressed in until the resistance opposing its progress is felt suddenly to diminish, when the fluid should imme- diately begin to drop or spurt from the outer end of the needle. The fluid is caught in one of the sterile test tubes. The advantage of boiling two test tubes lies in the fact that part of the fluid will sometimes be blood-stained and part clear, and blood- stained fluid interferes somewhat with the diagnostic inferences to be drawn. If at any time the character of the dripping fluid changes from clear to blood-stained, or from blood-stained to clear, the second test tube should be substituted. The amount of fluid to be withdrawn depends upon the purpose for which lumbar puncture is performed. If lumbar puncture is undertaken for diagnosis only, and there are no evidences of intra- dural pressure, not more than 5 c. c. should be withdrawn. If there is evidence of intradural pressure, as shown by spurting of the fluid, the withdrawal should be continued until the fluid drops at a normal rate. If lumbar puncture is properly performed, there should be no dif- ficulty in obtaining fluid in the great majority of cases. Care should be taken that the needle is not pushed in far enough to touch the anterior wall of the spinal canal, as in such a case the fluid will prob- ably be blood-stained, and if the needle enters the tissues in the anterior waH, no fluid wifl flow. On the other hand, care must be taken that the needle is pushed far enough to enter the canal. If the needle strikes bone before entering the canal, it is a sign either that the direction of the needle is not right, or that the spine is not sufficiently flexed to permit the needle to pass between the bones. In the former case, the needle must be entered again with corrected direction; in the latter case, a smaller needle must be used, or increased flexion of the spine must be obtained. A "dry tap," or failure to obtain fluid may be due to several causes. The most common is that the needle has become plugged in passing through the tissues, and the physician should clear the needle by passing in the stylet. It may be also that through some fault of technique, or some peculiar anatomical condition, the needle has not entered the spinal canal. In such a case the puncture should be repeated with corrected technique. If fluid still fails to appear, the intervertebral spaces above and below the one first chosen, should be successively tried. Even when the operator is sure that the needle has entered the canal, a dry tap occasionally occurs; this is due to some peculiar anatomical or pathological cause, which prevents the cerebrospinal fluid from reaching the lumbar portion of the canal, 108 Disease in Early Life or to the fact that the fluid contains fibrin or thick pus, and is thus unable to pass through the needle. After the withdrawal of the needle, the puncture is covered with a Httle piece of sterile absorbent cotton held in place by collodion. EXPLORATORY THORACENTESIS.— This is a most important procedure in the diagnosis of pleural effusion. The point chosen for the puncture should be that which shows the greatest flatness on percussion. When the flatness is extensive, involving the whole lower portion of the pulmonary area, the point of selection should be in the posterior axillary line, at the sixth interspace on the left, and at the fifth interspace on the right. Fluid should always be obtained at these points when the pleural cavity contains free fluid; but in cases of encapsulated fluid, the point for the puncture must be de- termined by physical examination. The needle used in making the puncture should be about one millimeter in diameter. The needle and syringe should be boiled. The child is held firmly in a sitting position, the hand on the side to be punctured being brought up over the opposite shoulder, and the skin is rendered surgically clean. The needle, attached to the syringe is introduced between the ribs, nearer to the upper than the lower border of the rib, in order to avoid injuring the intercostal artery which runs along the lower border. The distance which the needle enters is from i to 2 cm. The entrance into the pleural cav- ity can usually be detected by a sudden diminution in the resistance. The piston of the syringe is then gently drawn, and if fluid be reached it will enter the syringe. If fluid is not obtained, it should not be sought by moving about the point of the needle, but the needle should be withdrawn, and after a second careful physical examination, it should be introduced in another place. After withdrawing the needle upon failure to obtain fluid at any point, it is well to make sure that the lumen of the needle is clear. The wound left by the needle may be covered by a bit of sterile cotton and collodion. In seeking for encapsulated fluid, almost any part of the chest may be safely en- tered, but it is well to avoid the region near the heart. Performed in this way, exploratory puncture is practically without danger, even if the needle enters the lung. EXPLORATORY PUNCTURE OF THE PERITONEAL CAV- ITY.— This procedure is very rarely employed. The diagnosis of ascites should depend upon the results of physical examination, and exploratory puncture is not a safe procedure to determine the pres- ence or absence of fluid. It is only made in cases in which the diag- nosis of ascites is clear, for the purpose of obtaining fluid for bacteri- ological and cyto-diagnostic examination. The syringe, needle, and preparations are the same as for thoracentesis. It is essential that Special Methods of Examination 109 the bladder be first emptied by catheterization. The child should be in a sitting posture, and the needle is introduced half-way between the pubes and the umbilicus. EXPLORATORY PUNCTURE OF THE PERICARDIAL CAV- ITY.— Puncture of the pericardial cavity is also rarely employed for diagnostic purposes. The diagnosis of pericardial effusion should rest on the results of physical examination. In rare cases explora- tory puncture may be made to obtain fluid for examination. The usual purpose, however, of entering the pericardial cavity is the with- drawal of fluid as a therapeutic measure. The technique of this operation will be described in the article on Pericarditis. EXAMINATION OF GASTRIC CONTENTS AND RETEN- TION TIME. — This procedure is of importance in the diagnosis of pyloric stenosis and pyloric spasm. It also often throws light upon gastric digestion, and sometimes reveals the presence of dilatation of the stomach. The apparatus used consists of a soft rubber cathe- ter of a size from 14 to 18 French scale. This is connected by a piece of glass tubing with a rubber tube attached to the nozzle of a glass bulb; to the opposite nozzle of the glass bulb, another piece of rubber tubing is attached. A measured quantity is given at a feeding, and the contents are withdrawn at whatever period after the feeding time it is desired to obtain them. In estimating gastric retention time, it is desirable as a routine to withdraw the contents after one hour, and again after three hours. After one hour, the stomach is usually not empty, but much less should be obtained than was given. After two or three hours, the stomach should be empty. In withdrawing the gastric contents, the catheter is passed into the stomach, and the physician applying his mouth to the tube draws the fluid into the bulb. The amount of fluid withdrawn should always be measured. EXAMINATION BY DUODENAL CATHETER.— The tech- nique of this operation is described under the heading of Spasm of the Pylorus. TESTING THE ELECTRICAL REACTION.— This requires special apparatus. There are a number of good batteries on the market available for this purpose. The essentials are, an appli- ance for reversing the direction of the current, so that the anodal and cathodal reactions may be tested without changing the position of the electrode. There must also be an appliance for measuring the strength of the current used, graduated in milHamperes. The indif- ferent electrode is appHed to the front of the chest or any portion of the body, while the differentiating electrode is applied to the nerve or muscle to be tested. 110 Disease in Early Life LARYNGOSCOPY. — This procedure is mainly used in older chil- dren. The technique is that for adults. OPHTHALMOSCOPY.— This is very difficult in infants on ac- count of the movements of the eyeball. The technique in childhood is the same as in adults. RECTAL EXAMINATION.— This procedure is frequently in- dicated in children, in obscure conditions in the abdominal cavity. The child should be lying on its back. The physician inserts the oiled finger into the rectum, while with the other hand he makes palpation through the abdominal wall. There is no danger in intro- ducing the forefinger into the rectum, even a small baby's, provided that the introduction be made slowly enough to dilate the sphincter. A much greater area may be reached in infants than in older children and adults, and for this reason rectal examination often throws very valuable light on the diagnosis in infants. ROENTGEN-RAY EXAMINATION.— This is by far the most important and valuable of all the special diagnostic procedures used in early life. Owing to the fact that the soft parts in children are less thick, the results of Roentgen-ray examination are more valuable in children than in adults, and in babies than in older children. When- ever possible, Roentgen-ray examination of the chest should be car- ried out in all cases of suspected tuberculosis, or suspected disease of the lungs, pleura, heart, pericardium, or thymus. It should be carried out in all suspected cases of disease of the bones or joints. It is sometimes valuable in intracranial disease. One of the most important uses of Roentgen-ray examination is in the investigation of the gastro-intestinal system. This is carried out by means of the bismuth meal, or the bismuth enema. For the technique of these investigations and the interpretation of their results, the reader is referred to standard textbooks on roentgenology. LABORATORY METHODS OF DIAGNOSIS The importance of laboratory methods of diagnosis in the diseases of early life cannot be overestimated. The laboratory has come to occupy a more and more important place in modern diagnosis. There is, however, a tendency to neglect laboratory methods in the dis- eases of infancy and childhood. This is a very great mistake. In- deed, there are some conditions almost pecuHar to early Hfe, such as for example, pyelitis, in which the diagnosis depends entirely upon the results of laboratory investigation. The laboratory methods of diagnosis which are used in infancy .and childhood, do not differ either in character or in technique Special Methods of Examination Fig. 34 111 Infant, 6 months old. Taken under chloruform from l.iehind. Stomach and large intes- tine distended with gas. i, right lung; 2, left lung; 3, heart; 4, liver; 5, stomach; 6, left kidney; 7, right kidney; 8, ascending colon; 9, descending colon; 10, probably the head of the pancreas 112 Disease in Early Life from those used in investigating disease in adults. The significance and relative importance of the various tests are however in many cases widely different in early life and in adult life. It is for this reason that the tests are here enumerated and described. The tech- nique of the various tests is described for purposes of convenience of reference and of completeness. THE URINE. — The examination of the urine in childhood is often neglected. This is due partly to the impression that the re- sults of the clinical examination of the urine in children are not of such great diagnostic significance as in adults, but mainly to the difficulty of obtaining urine from infants. The examination of the urine should be a routine measure in the investigation of every case of disease in infancy and childhood. Technique for Obtaining the Urine of Infants. — In male infants, the best method of obtaining urine for examination is by the application of a clean test tube to the baby's penis. This is held in place by a strip of adhesive plaster, as shown in the illustration. If the test tube be properly applied and left in place, the urine passed will be collected in the test tube. It is possible by this method to obtain all the urine excreted in twenty-four hours. In female infants, the obtaining of a specimen of urine for exam- ination is more difficult. I am accustomed to use an apparatus like that shown in the illustration. It is simply placed in the proper position inside the diaper, which holds it in place. In many cases it is impossible to obtain immediately a specimen of urine. In such cases catheterization, which is a very simple procedure in female infants, should be employed. Clinical Examination of the Urine. — -The chemical and micro- scopic tests used in the examination of the urine of children do not differ from the tests in adults. For this reason it is, perhaps, un- necessary to describe them. Nevertheless, as there are differences in the relative importance of the various tests in childhood and in adult fife, and also some differences in the diagnostic significance of the tests, they will be briefly described here for purposes of point- ing out these differences, and of completeness. It is important to note the frequency of micturition in all cases. It should be remem- bered that in infants the normal frequency is very great when the baby is awake, the urine often being passed two or three times an hour; in sleep it is retained longer, from two to six hours. After the first two years, the normal time in which the urine is retained during sleep is very variable, and as the child grows older, the frequency by day gradually diminishes. The age at which control of the sphinc- ter of the bladder is attained, is also very variable. Under normal Fig. 35 — Obtaining urine from male infant Laboratory Diagnosis 113 Fig. 36— Apparatus for obtaining urine from a female infant \ . \ \ 1 > 1 1 1 Fig. 37 — Method of collecting urine from a female infant A. Cut rubber finger cot. B. Adhesive plaster for attachment. C. Test tube. D. Apparatus complete 8 114 Disease in Early Life circumstances, the diaper may sometimes be dispensed with as early as one year, and in other cases, not until two years, or even later. The tests may be divided into those which should form part of every routine examination, and those which need only be employed occasionally for a definite purpose. The tests used in the routine examination of the urine will be described first. Physical Character and Reaction. — The color, odor, specific gravity, turbidity, and amount and character of sediment should Fig. 38 Catheterization of a female infant first be noted. The urine of the newly born infant is usually some- what highly colored. During the rest of infancy the normal color is pale in comparison with that of older children and of adults. The normal odor has no peculiarity in infancy and childhood. A strongly ammoniacal odor in infants is seen in some cases of malnutrition and gastro-intestinal disease. Except in the first few days of life, the reaction of the urine in infancy is faintly acid or neutral. In older children it is acid. In the first days of Hfe it is strongly acid, and often shows a deposit of urates or uric acid, which appears as a pink- ish or reddish-yellow stain upon the napkin. The normal specific gravity at the various ages is as follows: Laboratory Diagnosis 115 Table 12 The first two or three days i.oio to 1.012 Fourth to fourteenth day i .003 to i .006 Fourteenth day to sixth month i . 004 to i . 010 Six months to two years i . 006 to i . 01 2 Two to eight years i .008 to i .016 Eight to fourteen years i .012 to i .020 Slight turbidity of the urine is not uncommon in infancy. Under normal conditions it may be due to the presence of mucus, in which case it cannot be entirely removed by filtration, or to the presence of urates. Cloudiness due to urates will disappear on heating. Patho- logical causes of turbidity are phosphates, bacteria, or pathological sediment, which in early life is usually pus. The cause of turbidity should always be determined. Cloudiness due to bacteria is recog- nized by the fact that it is not diminished by ordinary filtration. Phosphates are recognized by the fact that the turbidity disappears when a few drops of acetic acid are added. Pus is suspected from exclusion of the other causes, the suspicion being confirmed by the microscopic examination. Albumin. — For routine use, the best test for albumin is the heat test, which is performed as follows: Filter about 10 c.c. of urine into a test tube, and boil the upper half of the fluid. Add one or two drops of acetic acid (36 per cent.), and boil again. A precipitate which appears on boiling, and persists after the addition of the acid, or which appears on the second boiling, is albumin. Care must be taken not to use an excess of acid. An approximate idea of the quantity of the albumen can be ob- tained from the heat test by allowing the albuminous precipitate to settle, i/ioo per cent, or less causes turbidity but no precipitate. With 1/20 per cent, the bottom of the test tube is covered; i/io per cent, occupies i/io the volume of the column of urine; while 1/2 per cent, occupies 1/3 of the volume; and one per cent, half the column. Albumin amounting to two or three per cent., becomes converted into a compact coagulum. When in the performance of the heat test the addition of acetic acid gives a heavy precipitate which partially clears on boihng, it suggests the presence of the Bence- Jones body (often incorrectly spoken of as albumose) . The presence of this substance is confirmed after filtering the contents of the tube while hot by the appearance of a cloud in the filtrate on cooling. Albumin may be normally present in small amount in the urine during the first days of hfe. Later its presence has the same signifi- cance as in adults. Sugar. — Fehling's test is best for routine qualitative examina- tion. Mix in a test tube 5 c.c. of each of Fehling's two solutions. Boil, and then add slowly 5 c.c. of urine. Separate in two portions 116 Disease in Early Life in two test tubes. Boil one of these portions. If no precipitate appears, sugar is absent; a precipitate may or may not be sugar. Set the other portion aside without further heating. If a precipitate appears, the presence of sugar is confirmed. When the sugar is very small in amount, the precipitate may take from fifteen minutes to several hours in appearing. For the methods by which the presence of sugar is confirmed by other tests, the reader is referred to standard works on physiological chemistry. It is usually stated that sugar may be present in the urine of normal infants during the first two months. This is true, but I have also found it occasionally in the urine of normal infants, or of infants suffering from mild gastro-intestinal disturbances, up to the age of tM^o years. It is very much more frequently absent than present. Creatinin is normally present in the urine of infants, and occasionally is present in sufficient amounts to reduce FehHng's solution. Many writers have mistaken this reduction for sugar. Creatinin can be excluded by shaking the urine with picric acid, filtering, and repeat- ing FehHng's test, which will be negative if the reduction was caused by creatinin. In connection with the appearance of sugar in the urine of infancy, the statement of Grosz is often quoted, that sugar appears if the quantity of sugar given in the food is increased to a certain amount in proportion to the body weight of the infant. In some experimental work performed by Dr. Langley Porter and the writer, the results failed to confirm this statement. We were unable to cause the appearance of sugar, or an increase in the amount of sugar, by giving large amounts of lactose or maltose in the food. For the most accurate quantitative test for dextrose in the urine, such as that with Benedict's solution, the reader is referred to stand- ard works on physiological chemistry. The simplest quantitative estimation for routine use can be made by means of the fermentation test. To loo c.c. of urine of known specific gravity, add one- third of a yeast cake broken into very small pieces. Set in a warm place for twenty-four hours. If at the end of this time there is no reduction with Fehling's solution, take the specific gravity; otherwise continue the fermentation till no reduction is obtained. Multiply the difference in specific gravity before and after fermentation by 0.23 to get the per cent, of dextrose present. Acetone. — The test for acetone should form part of the routine examination of the urine in infancy and childhood. The presence of the acetone bodies is of great diagnostic importance in the dis- eases of early life. Their significance will be considered under Acidosis. To one-sixth of a test tube of urine add a crystal of sodium nitro- prusside. Shake thoroughly until the crystal is dissolved, and then Laboratory Diagnosis 117 add a few drops of glacial acetic acid, shaking again. Pour carefully- down the side of the test tube 5 c.c. of ammonium hydrate. A purple ring where the ammonia meets the urine demonstrates the presence of acetone. Sediment. ^Whenever there is any visible sediment, it should be examined microscopically as a routine. The things to be looked for are pus, casts, blood, epithelial cells, crystals, fat, and bacteria. The following tests need not be made as a routine, but are of occasional value and should be made whenever their need is suggested by the cHnical features of the case. Bile. — The reagent consists of tincture of iodine one part, alcohol fifteen parts. Pour i c.c. of this reagent on the top of the urine in the test tube. A green ring at the junction of the two fluids shows the presence of bile. This test should be performed whenever there is any suspicion of jaundice. Blood is recognized from the color of the urine, and from the ex- amination of the sediment. Blood pigment may be present in solu- tion, as in haemoglobinuria. Its presence is demonstrated by the guaiac test, which will be described under the examination of the feces. Indican. — -To 15 c.c. of urine add 3 c.c. of a 20 per cent, solution of lead acetate. Filter. To the filtrate add an equal volume of a reagent made up of 0.4 gram ferric chloride in 100 c.c. of concentrated hydrochloric acid. Shake for two minutes. Add 3 c.c. of chloro- form and again shake. If indican be present in considerable quan- tity, the chloroform will assume a deep blue color. This is known as Obermeyer's test. An excess of indican in the urine of infants and children is usually significant of acute or chronic intestinal dis- ease. It is more or less a measure of the amount of protein putre- faction going on in the intestine. Indicanuria is also seen in exten- sive suppurative processes without drainage in various parts of the body, such as empyema. Indicanuria is not of very great importance either as a diagnostic measure, or as a measure of the results of treatment in intestinal diseases. It is said to be an important finding in pellagra. DiACETic Acid. — Add a strong aqueous solution of ferric chloride to one-third of a test tube of urine. A Burgundy-red color shows the presence of diacetic acid. If the reaction takes place after the urine has been previously boiled, it is not due to diacetic acid. Diacetic acid is one of the acetone bodies which are found in acidosis. The test is performed whenever acidosis is suspected, or when the routine test for acetone is positive. Whenever diacetic acid is found in the urine, it is probable that /3-oxybutyric acid is also present. Tubercle Bacilli. — To find tubercle bacilli in the sediment, the following technique should be employed: i. Centrifugalize. 118 Disease in Early Life Decant supernatant fluid, dilute with water, recentrifugalize, and make a cover glass preparation from the sediment. This should be spread thinly, and held in the fingers over a flame of a Bunsen burner until dry. Place the cover glass in the forceps and fix by passing three times through the flame. 2. Cover the preparation thoroughly with carbol-fuchsin solution and steam over the flame for half a min- ute. Do not allow the staining solution to dry on the surface of the cover glass, but add more stain if necessary. 3. Wash in water. 4. Decolorize for twenty seconds in 20 per cent, sulphuric acid. 5. Wash in water. 6. Wash in 95 per cent, alcohol for thirty seconds, or until no more color will come out. 7. Wash in water. 8. Cover the prepa- ration vdth Lofiier's methylene-blue solution for thirty seconds. 9. Wash in water, dry and mount. Tubercle bacilH are bright red; nuclei and other bacteria are blue. GoNOCOCCUS. — The technique of staining the sediment of the urine for gonococci is the same as that used in the examination of the vaginal discharge, arid will be described under that heading. EXAMINATION OF THE BLOOD.— For ordinary cHnical ex- amination, blood is obtained from infants and children as in adults. The lobe of the ear is cleansed with water, thoroughly dried, and quickly pierced with a clean surgical needle. Hemoglobin. — For the ordinary estimation of the per cent, of hemoglobin, Tallqvist's scale is sufiiciently reliable. If it be desired to make an accurate estimation, some such apparatus as the Fleischl- Miescher or Sahh must be used. The presence or absence of anemia can be determined by Tallqvist's method. The standard by which anemia is estimated in early life is, however, entirely difi'erent from that used in adult life. The percentage of hemoglobin in the blood is highest in the newly born, and rapidly falls in the first few days of hf e. It is considerably lower than in adult fife throughout childhood, being lowest during infancy, and gradually increasing after the second year up to the age of puberty, when the adult standard is reached. As measured by the adult standard, the lowest normal limit would be represented by 65 per cent on Tallqvist's scale. The usual range in infancy and childhood is from 65 to 85 per cent. Leucocytosis. — The presence or absence of leucocytosis is deter- mined by means of the white count. Draw the blood into the Toma- Zeiss white blood counter up to the 0.5 mark, and then draw in 0.5 per cent, acetic acid up to the 11 mark. ]\lix thoroughly by shaking and revolving the counter. Count all the corpuscles on the ruled field. Clean the slide and make a second count. Add the two counts together, multiply by 100, and the product is the number of white corpuscles per cubic millimeter. Laboratory Diagnosis 119 The normal standard differs notably from that of adult life. Normal variations in infancy are from 8,000 to ij,ooo, and in later childhood from 6,000 to ij,ooo. The Red Corpuscles. — The count of the red corpuscles is made as follows: Draw the blood into the Toma-Zeiss red counter up to the 0.5 mark, and dilute with Gower's solution up to the loi mark. Mix thoroughly by shaking and revolving the counter. Place a drop of blood on the slide of the counter, cover with the glass, and count the corpuscles in twenty-five small squares at each of the four corners of the ruled field, and multiply the total by 8,000, This gives the number of red cells in a cubic millimeter of blood. For greater accuracy it is well to repeat this procedure with a second slide, and take the average. The number of red corpuscles at birth is high, although there is some diversity of opinion as to the actual number. It is between 5,350,000 and 6,000,000. There is an increase in the first two or three days of life, and the count may be from 6,000,000 to 7,500,000. This increase is probably only relative, being due to loss of fluid, and the delay in the establishment of nutrition. After the first few days, the count falls rapidly, reaching the normal figures for infancy at about two weeks. The normal standard for infancy ranges from 5,000,000 to 6,000,000. It gradually falls during early childhood, reaching the adult standard of 4,500,000 to 5,000,000 at about six years. Examination of the Stained Specimen. — Cover glasses should be thoroughly washed with soap and water, and wiped dry. The center of a cover glass held by its edges is touched against the summit of the drop of blood, touching the skin being avoided. Drop the cover glass upon another clean cover glass, allowing the blood to spread evenly between them without pressure. Hold the cover glasses by their edges, and, keeping their faces parallel, draw them quickly apart. When dry, they are ready for staining. No heat is required. Cover the specimen with five drops of Wright's modifi- cation of Leishman's blood stain, for one minute. Add with a medi- cine dropper ten drops of water, and let the diluted stain remain on the slide for two minutes. Wash in water (not running water) until the film has a pinkish color. Dry and mount. The features to be noted in the microscopic examination of the stained specimen, are the following: 1. The relative number of the different varieties of white corpuscles. 2. The appearance of the red corpuscles. The points to be noted are variations in size (makrocytes and mikrocytes), variations in shape (poikilocy tosis) , loss of color (achromia), stippling, abnormality of staining (polychromatophilia) , tendency toward predominance of 120 Disease in Early Life large or small forms, and the presence and relative number of nucleated forms (normoblasts and megaloblasts) . 3. The number of blood platelets. 4. The presence or absence of parasites, particularly those of malaria. Five varieties of white corpuscles are found normally in human blood, and these are classified as follows by Ehrlich: 1. Lymphocytes (Plate XV). These are about the size of a red corpuscle, and contain one large, round, deeply staining nucleus which entirely fills the cell. The protoplasm is not granular and stains faintly or not at all. 2. Large Mononuclear (Plate XV). These cells are much larger than the lymphocytes. They have one large oval nucleus with a broad margin of non-granular, almost colorless protoplasm about it. 3. Transitional (Plate XV). These cells are derived from the last form and are similar in size and color. The nucleus is indented on one side as the result of the beginning of nuclear division. These three varieties are sometimes called basophiles. 4. Polynuclear Neutrophiles (Plate XV). These are round cells, smaller than the large mononuclear, having a peculiar polymorphous deeply staining nucleus. The nucleus is long, irregular or twisted, and when stained often appears segmented. The protoplasm con- tains fine granules which are stained by both the acid and basic stains. 5. Polynuclear Eosinophiles (Plate XV). These are usually about the size of neutrophiles and have a deeply stained polymorphous nucleus. The protoplasm contains granules which are much coarser than those of the neutrophiHc cells, and which stain readily with acid stains. These cells are sometimes called oxyphiles. 6. Myelocytes (Fig. 39). These are round or ovoid cells with one, rarely two, large round or slightly bent nuclei which stain Hght blue. There are two varieties, neutrophilic and eosinophilic. The first has a protoplasm crowded with fine neutrophilic granules. The second contains coarse eosinophilic granules. Myelocytes rarely appear in normal blood, but are much increased in some of the path- ological states. 7. Mast-Cells. — These are coarse, granular basophiles, usually with a trilobar nucleus. The protoplasm with Wright's stain is nearly unstained, with a number of round dark blue spots against a faintly stained background, representing the basophilic granulations. The relative number of these different varieties of white corpuscles is estimated by means of the differential count. The physician should write down the list of the different cells, and then count the corpuscles in the stained specimen, making a mark after each variety of cell. PLATE XV. Culex. (Resting Position.) Anopheles. Anopheles. (Resting Position.) Leitz Oil Inimers. Viz, Ocular No. 3. 1. Normal Hed Corpuscles. 2. Haenmtoblasts or Nucleated Red Corpuscles: a. Normoblasts. b. Mcgaloblasts. 3. Microcytes. 4. Poikilocytos. 5. Lymphocytes nuclear. Lar^e Mononuclear, a. Transitional. Polynucloar Neutrophiles. 8. Poly nuclear Eosinophiles: a. Dwarf Eosinophile. 9. Myelocytes: a. Neutrophilic. b. Eosinophilic. Small Mono- Laboratory Diagnosis 121 At least 250 white corpuscles should be counted, and the number of each variety should be reduced to a percentage of the total number counted. The number of any normoblasts or megaloblasts seen during the count should be noted and recorded, hut should not he included in the total of the count, nor expressed in figures of percentages. A specimen of the method of making and of recording a differential blood count is shown in the following tables: Table 13 Method of Making Differential Blood Count Polynuclearneutrophiles.. WlMrtHMftUrHlfHirHirWItilMlHllHJ rHlMrHltHlWIltiirHllHlMlHifliilHlfHIrao B^Miiies rHlfHimilHllHItHlfHIlHirHlltUlHIl WllHllUlIHllHimiflUrHlM 110 Eosinophiles || 2 Myelocytes ^. [|} 8 250- Normoblasts, ||| j Megaloblasts.....,, [j|j | 6 130 no 2 8 X 100 = 52% X 100 = 44% xioo=.8% X 100=3.2% 250 250 250 250 Table 14 Method of Recording Results of a Specimen Examination of the Stained Specimen DIFFERENTIAL COUNT OF 250 WHITE CORPUSCLES Polynuclear neutrophiles 52. 0% Basophiles 44 . 0% Eosinophiles o . 8.% Myelocytes 3 . 2% 100,0% The red corpuscles showed slight poikilocytosis, and moderate variation in size, ma- krocytes predominating. There was marked achromia, some stippling, and some poly- chromatophilia. During the count were seen — Normoblasts 3 Megaloblasts 6 The blood platelets appeared normal, and no parasites were seen. Peculiarities of the Differential Count in Early Life. — The variations in the percentages of the dift'erent kinds of leucocytes in the blood of infants and young children, according to the age of the child, is most clearly demonstrated by means of chart 3. 122 Disease in Early Life It will be seen from the chart and from the figures giving the total leucocytosis at birth and in the subsequent periods of childhood, that in the first day of Hfe polynuclear leucocytosis exists which decHnes rapidly during the next nine days, and then very gradually until the sixth month, when it begins to mount, and at the end of the sixth year has almost reached the adult level. The lymphocytes, or small mononuclear leucocytes, are, on the other hand, at their mini- mum at birth, and in the subsequent ten days increase with about the same rapidity as the polynuclears decline in numbers. They reach their maximum about the sixth month and then gradually decline to the sixth year, while the polynuclears are proportionately increasing. The chart also shows clearly that the lymphocytosis so characteristic of the early months of life is almost wholly dependent upon an increase In the lymphocytes or small mononuclear cells, the large mononuclear and transitional leucocytes being but httle changed. The eosinophiles show a count somewhat higher than in adults, ranging from two to six or even eight per cent. Their pres- ence in such proportions in early childhood is, therefore, of less significance than in later life. Peculiarities of the Blood Picture in Disease in Early Life. — It is recognized that all the signs by which sickness is shown in the blood of adults are exaggerated in that of children. Their blood is much more sensitive to the action of adverse influences, such as poor air, improper hygienic surroundings, improper food, and numerous other causes, and anemia is much more easily induced. This is especially noticeable in the impoverishment of the blood which follows gastro-enteric disease. Not only is a condition of anemia acquired by these influences, but the development of the blood may be retarded. In this class of cases the blood of a child three or four years old may show no higher development than that of a healthy infant in the second year. Again, the erythrocytes under certain morbid conditions may revert to an earlier type. The function of the bone marrow in infancy is chiefly occupied in the production of the erythrocytes. As the marrow still has at birth many of its fetal characteristics, any strain put upon it by disease makes it much more Ukely to revert to its fetal function, and, therefore, to manufacture and pour out into the circulation the cells which are characteristic of that period. The presence of nucleated red cells, myelocytes and eosinophiles in infancy and early childhood are, therefore, of less significance than in later life. Opinions differ as to the time at which the haema- toblasts disappear in the normal blood of infants. They may be present in small numbers during the first week, but after that their presence is abnormal. In diseased conditions in infancy they appear with much less provocation than in older children and adults. Laboratory Diagnosis 123 Chart 3 showing approximately the relative proportions of the leucocytes from birth to six years. (ADAPTED FROM CHARTS BY CARSTANJe'n.) < - — - - Q - - - - - . Q X I I S Z IE 1- H K " OJ « •* to «> X 1- --.-.. z - ^ ^ I h < UJ >- t- a. < UJ >- z CM < UJ > CO < UJ > I H cc < > I 1- m EC < UJ , > I 1- 7ei% 73;? \ Q8% ^ U% \ 60^ \ ^>v^ 56% \ u<=-^ ^ \^ '53;? i ..f^ 48% \ / \ > iyy^ U% 1 i ^^ 40;? ^ / / / , 36^ / Y ^ / 1 32% t \ / > 38^ ' ,^ 2A% 1 •s ,^"^ 20% 1 W%/ / ^'^v \2i / T ^ ^^ _JRAN Sil'ONAL AN ) LARGE MO^ ONUCLEARS 4.% ^ eosiviOP.H>i- ^ X- ~'^-~^:7 \ --- - In the secondary anemia due to a large number of diseased con- ditions, a diminution in the number of red cells as well as of hemo- globin is more common in infancy and early childhood than later. The chloro-anemia (chlorosis) type, with lower hemoglobin in pro- portion to the red count, is not so common in infancy. It should also be remembered that in all diseased conditions, variations in the size and shape of the red cells are much more easily produced in infancy and early childhood, than later. 124 Disease in Early Lite The white corpuscles are affected in a temporary or permanent manner by many physiological and pathological conditions in the body at large as well as in the blood-forming organs. The most common change from the normal is that of leucocytosis. Leucocy- tosis was originally described by Ehrlich as the presence in the blood of a greater number of white cells than normal for the individual, or a relatively increased number of any variety of white cells, with or without an increase in the total number of leucocytes. Cabot has restricted the term leucocytosis to an increase of leucocytes in which the polynuclear cells predominate, and uses the terms lympho- cytosis and eosinophilia to describe a relative increase of the lympho- cytes and eosinophils . Physiologically, we find a leucocytosis after meals, often called digestive leucocytosis. It is at its height about two hours after a meal, when the number of leucocytes may be increased by 33 1/3 per cent, of the normal number. Pathologically, a leucocytosis accompanies a considerable number of diseases, and seems in a general way to depend upon two factors, the severity of the infection and the amount of resistance in the individual. We find a pronounced leucocytosis in most fevers and in most septic processes. In these cases the increase is almost wholly composed of the polynuclear neutrophiles, which may make up from 90 to 98 per cent, of the entire leucocyte count. The leucocytosis does not depend on the degree of fever, does not always occur with it, and conversely inflammatory leucocytosis may appear before the fever. The diseases which generally show a leucocytosis are pneumonia, pericarditis, endocarditis, pleuritis, erysipelas, acute rheumatism, purulent meningitis, pharyngitis, diphtheria, septicemia, osteomyelitis, scarlet fever, variola, tonsillitis, bronchitis, peritonitis, acute nephritis, certain gastro-enteric infections, some profound anemias whether primary or secondary, leukemia, hemorrhage, malignant new growths, abscess of any kind, including appendicitis, and many skin diseases. The diseases in which the leucocytes are approximately normal are malaria, measles (after the appearance of the efflorescence), typhoid fever, pulmonary tuberculosis (unless there is a secondary infec- tion of other bacteria), rubella, and most cases of epidemic in- fluenza. In tubercular meningitis and peritonitis, leucocytosis may or may not be present. Comparing these two lists it will be seen that there are instances in which the leucocyte count may be of great importance to the physician in making a differential diagnosis. The diagnostic value of leucocytosis in early life is usually stated to be approximately the same as in adult life. In my experience, the value of the white count in diagnosis is not so great in infancy and childhood. Exceptions to the ordinary rules appear to be more numerous. In diseased conditions in infancy and early childhood affecting the Laboratory Diagnosis 125 blood, myelocytes appear more often than in later life. They are usually to be found in all the severe secondary anemias of infancy. There are certain diseases in which there is an alteration in the differential count of the white cells. The lymphocytes are increased in pertussis, syphilis, and in leukemia. An increase in the eosino- philes is seen regularly in leukemia, asthma, with certain intestinal parasites, and in some forms of chronic skin disease. In infancy and early childhood an increase in eosinophiles is not uncommon in sec- ondary anemia, and the count may show ten per cent, without any very obvious cause. THE FECES. — The examination of the feces is in infancy the most important of all the laboratory methods of diagnosis. In older children it is important, but is not necessarily a matter of routine. The stools are examined macroscopically and microscopically. The Macroscopic Examination should include first an observa- tion of the frequency and size of the dejecta, and of their consistency, and form. The color, odor, and reaction should be noted. Abnormal constituents to be looked for are curds, mucus, blood, pus, membrane, masses of undigested food, and intestinal parasites. Frequency and Size. — The normal number of stools in the breast- fed infant is three or four daily. In the bottle-fed, the daily number is less, varying from one to three or four. A certain amount of con- stipation is a normal condition in bottle-fed infants who are otherwise doing well. The size of the stools varies with the frequency. Ab- normally small stools suggest relative starvation. Increase in the frequency of the stools suggests irritation of the intestinal mucosa, such as occurs in various forms of indigestion and infection. Consistency antd Form. — The normal stool of the breast-fed infant is of a soft mushy consistency. In infants fed on cow's milk, the stools are of firmer consistency, and may even be formed. Increase in consistency is seen in constipation. Loose stools suggest irritation of the intestinal mucosa, with increased peristalsis. Color. — In observing the color of the stools, it must be remem- bered that the surface of the fecal mass is easily discolored by con- tact with the air, and the center should be used as a basis for descrip- tion. The color should be recorded as yellow, white, brown, green, or black. The significance of the various colors in infancy is as follows: Yellow stools are seen in breast-fed and bottle-fed infants who are doing well. In the breast-fed the normal color is a golden yellow. In infants who are thriving on cow's milk mixtures, the color is very often lighter yellow, probably because some of the bilirubin is con- verted into hydrobiHrubin, or because there is a slight excess of unabsorbed protein. 126 Disease in Early Life Brown stools are not abnormal, or a sign that an infant is not thriving. Various shades of brown are seen when the amount of protein in the food is high in proportion to the fat. This often occurs when infants are being fed on skimmed milk or whey, or on lactic acid milk or albumen milk. Brown stools are also normal when maltose is substituted for lactose as the extra sugar added to cow's milk modifications. When the infant begins to take a more varied diet, containing starch, beef juice, or broth, the stools assume a brown- ish color. Gray stools are abnormal. A gray color may be due to the pres- ence in the stool of a large amount of fat. While not normal, a gray color is not in itself an indication that the amount of fat should be reduced. A gray color is also seen when bile is absent or insufficient. Green is the most common abnormal color. The shade may vary from a Hght grass green, to a dark green. The darker the green, the greater the pathological significance. A stool which changes from yellow to green after exposure to the air is not abnormal. The abnormal green color is due to the oxygenation of bilirubin into bili- verdin, and this apparently may take place when the stool is either excessively alkaHne, or excessively acid, or as a result of various forms of bacterial activity. Green stools are seen in all forms of indigestion, and are not characteristic of any one type. They are particularly common in acute stages of indigestion from fat or carbohydrate, and in indigestion with fermentation. White stools are due to the presence of an excessive quantity of undigested fat in the form of soaps. They may be soft or hard. White stools are always a sign that the digestion and absorption of fat is not normal, but are not necessarily an indication for cutting down the fat in the food. Black stools are usually due to the giving of bismuth, or iron, or to the presence of blood. Odor. — The odor of the stools depends on the composition of the food, on the completeness of digestion and absorption, and on the degree and variety of bacterial activity. The normal stool has a sour or aromatic odor. In fat indigestion the odor is that of butyric or lactic acid. In carbohydrate indigestion the odor of lactic or acetic acid predominates. Excessive protein, even when not causing indigestion, produces a cheesy or fecal odor. A peculiar musty odor is also suggestive of a relative excess of protein in the food. A very foul or putrefactive odor is seen in some cases of acute indigestion with fermentation, and of infection of the intestine. Reaction. — The reaction of the normal stool is slightly acid. When the relative quantities of the fat and protein are well balanced, it is probable that the normal slight acidity of the stools is maintained Laboratory Diagnosis 127 by the fermentation of the carbohydrate residue which is not ab- sorbed, and that Nature designs that there shall be an excess of carbohydrate to maintain a normal condition of the intestinal flora, and the normal chemical reaction. When the unabsorbed carbo- hydrate residue is in excess, it is never excreted as such, but under- goes fermentation, and consequently the acidity of the stools may be increased. When unabsorbed fat is in excess, there is increased forma- tion of the fatty acids, and the acidity of the stools may also be in- creased. A relative excess of protein will cause increased activity of the proteolytic bacteria whose products are alkaline, and may cause an alkaline stool, which is not necessarily pathological. An excessively acid stool, therefore, is seen in carbohydrate indigestion, and in the acute exacerbations of fat indigestion. An alkahne stool means only a relative excess of protein in the food in the majority of cases, and has no pathological significance. It is, however, occa- sionally seen in cases of indigestion with fermentation due to an excessive activity of bacteria of the putrefactive group. Curds. — There are two kinds of curds found in the stools of an infant. One is primarily composed of casein, the other of fat com- bined with sodium and potassium in the form of soaps. The casein curds are larger, varying in size from that of a bean to that of a pea- nut, and are white or yellowish-white in color. They are tough, cannot be broken up by pressure, are insoluble in ether, and when placed in formaHn become very hard. The fat curds are smaller varying in size from that of a pinhead to that of a pea, and are white, yellow, or green in color according to the color of the stool. They are soft, can be broken up by pressure, are soluble in ether when acidified, and are unaffected by formahn. Casein curds suggest indigestion from a relative excess of protein. Fatty curds always suggest indigestion from a relative excess of fat. Not only that, but fatty curds suggest a degree or stage of fat indiges- tion which is more serious than that characterized simply by an excess of fat in the stools in the form of soaps, and is usually an indi- cation for dietetic treatment. Mucus. — Mucus is present in most normal stools, but in amounts which can only be detected by microscopic examination. In the majority of abnormal stools, an excess of mucus is present, and an amount visible macroscopically is always pathological. Undigested starch may be mistaken for mucus, but is distinguished by the fact that it is stained blue with iodine, and shows a definite structure (starch granules) under the microscope, whereas mucus is not stained, and shows no evidence of structure. An excess of mucus in the stools is caused by any condition which irritates the intestinal mucous membrane. It may be seen in all 128 Disease in Early Life forms of indigestion. A very great excess of mucus, or a stool com- posed mainly of mucus, especially if there is also blood, suggests infectious diarrhea or intussusception. Blood in the stools is always pathological. It can usually be easily recognized on macroscopic examination, but sometimes it is necessary to prove that the appearance seen in the stools is certainly blood. The guaiac test is the best for blood. The reagent consists of ten drops of freshly prepared tincture of guaiac and thirty drops of hydro- gen peroxide. To lo c.c. of stool or other suspected material in a test tube add 2 c.c. of glacial acetic acid and 15 c.c. of ether. Insert a cork, and invert several times. When the ether has separated, decant it, and add the ethereal solution to the reagent. A blue color indicates the presence of blood. When blood appears as a spot or streak of fresh blood on the out- side of a hard stool, it indicates some slight local lesion about the anus, usually a fissure, rather than a hemorrhoid. When the blood is mixed with mucus, but not homogeneously, occurring usually in spots or streaks, it means some form of ileo-colitis, the most common being that seen in infectious diarrhea. When blood is homogene- ously mixed with mucus, it suggests intussusception. When blood occurs without excess of mucus, usually as a tarry mass, it suggests gastro-intestinal hemorrhage from some other cause. Pus, visible macroscopically, means a severe inflammatory condi- tion of the intestinal tract. Membrane is rarely seen, because the patients in whom mem- branous colitis is found post-mortem, usually die before the membrane appears in the stools. It means a very severe inflammation. Undigested Masses of food can sometimes be recognized macro- scopically. Their significance is obvious. Intestinal Parasites. ^ — The commonest in children in northern latitudes are round worms (ascaris) and pin-worms (oxyuris). Seg- ments of the several varieties of tape worms (taenia) are seen at times, usually the beef worm (taenia saginata). Hook worms (un- cinaria) are found in some localities. Other parasites, including the amoebae, are rare. Bile Pigment is a normal constituent of the stools. Its absence is sometimes of great diagnostic significance. The test is as follows: Mix about one-quarter of the stool thoroughly with 100 c.c. of a concentrated solution of corrosive sublimate, and set aside in a cov- ered glass dish for twenty-four hours. All particles containing hydro- bilirubin will have a red color, while those containing bilirubin will be green. Laboratory Diagnosis 129 Microscopic Examination of the Stools. — This is of the first importance in all the nutritional disturbances of infancy. In older children it is often of diagnostic value, but need not be made a rou- tine measure. The examination is divided into three parts as fol- lows: (i) examination of the fresh specimen; (2) microchemical examination for fat; (3) microchemical examination for starch. The feces should be thoroughly mixed in preparation for these examinations, and if hard, should be rubbed together with a Uttle water. Examination of the Fresh Specimen. — A portion of the stool is placed on a slide, covered with a cover glass and put under the microscope. This reveals undigested meat fibres, and such patho- logical elements as pus, blood, eggs of parasites, and so forth. Microchemical Examination for Fat. — A portion of the stool is spread on a glass slide, and mixed with a saturated alcoholic solu- tion of Sudan III. It is then covered with another sHde (a sUde is better than a cover glass) and put under the microscope. Neutral fat drops, and fatty acid crystals, stain red, while soaps do not stain. Next a drop or two of glacial acetic acid is thoroughly mixed with the contents of the sHde. It is better to add the acid by removing the top shde, rather than by letting it run under the edge. The top sHde is reapplied, and the sHde is held over the Bunsen flame until it begins to bubble. This converts the soaps into neutral fat and fatty acids, which appear under the microscope as large stained drops. The amount of fat in the form of soap is estimated from the number of these drops. If the stain with Sudan III before the addition of acetic acid shows fat, it can be determined whether it is neutral fat or fatty acid, by staining another specimen with a dilute solution of carbolfuchsin (i part carbolfuchsin to 4 parts of water). With this solution neutral fat does not stain, fatty acids stain a deep red, and soaps stain a dull rose-red. In estimating the quantity of fat in the form of soap, it must be remembered that under normal conditions all the fat ingested is not absorbed, and that a certain quantity of soaps in the stools is normal. The difliculty in the microchemical examination of the stools for fat lies in determining what quantity shall be termed an excess. With the technique described above the only standard for estimating the amount of fat is the number and size of the fat-droplets in the micro- scopic field, after boiHng with acetic acid. The standard is much influenced by variations in the technique, depending on the quan- tity of feces taken, the amount of its dilution, the length of the boil- ing, and on variations in the rapidity and completeness with which soaps made with different alkaline bases are broken up. Every physi- 9 130 Disease in Early Lite cian must establish his own standard, by adopting a uniform tech- nique, noting the results obtained with numerous babies fed on different quantities of fat, and comparing these results with the macroscopic appearance of the stools. The following may prove useful as a suggestion: 1. Fat droplets crowding field and running together. . . . = large excess 2. Fat droplets numerous in every field = moderate excess 3. Fat droplets few in every field ^ slight excess 4. Fat droplets not in every field = no excess The presence of neutral fat indicates an imperfect digestion of the fat, and usually, but not always, means that the fat in the food is in sufficient relative excess to cause nutritional disturbance. The presence of an excess of fat in the form of soaps indicates that the fat is normally spHt by the digestive ferments, but that it is not normally absorbed, the quantity in the food being in excess in pro- portion to the power of assimilation. Such an excess may or may not cause nutritional disturbance. MiCROCHEMiCAL EXAMINATION FOR Starch. — This of course, is carried out only with the stools of infants and young children who are taking foods containing starch. The staining reagent is Lugol's solution (iodine 2; potassium iodide 4; distilled water 100). The stools are placed on a slide, mixed with this solution, and examined under the microscope. The starch granules stain blue or violet. There are certain microorganisms which also stain blue with this solution, and the presence of these so-called iodophilic bacteria sug- gests a disturbance of carbohydrate digestion. The presence of starch in the stools indicates that the quantity of starch in the food is too great for the digestive power, and that any symptoms of indigestion present are probably caused in part at least by this excess. Bacteriologic Examination. — In the present stage of our knowl- edge, this is very unsatisfactory. Our knowledge of intestinal bac- teriology is very limited, and in comparison with what remains un- known, hardly a scratch has been made upon the surface of this very complicated subject. We know that bacteria, and bacterial activity, play a very important part in gastro-intestinal disturbances, but this subject is still so complicated that it has not afforded any very valu- able methods of laboratory diagnosis. There are certain special tests, such as those for the gas bacillus and the dysentery bacillus, which will be described under infectious diarrhoea. For further methods, clinicians must wait for the research workers, who are making very slow and discouraging progress at the present writing. THE CEREBROSPINAL FLUID.— In the routine macroscopic examination of the cerebrospinal fluid, the points to be recorded are Laboratory Diagnosis 131 the quantity ohtamed, the pressure, the turbidity, and the presence or absence of fibrin formation. The pressure is estimated by the rate and force of the flow through the luniibar puncture needle. Normally the fluid falls from the needle in discrete drops, with an appreciable pause between each drop. If the fluid drops more rapidly, but still in discrete drops, the pressure may be recorded as shghtly increased. If the fluid runs in a continuous stream, the pressure is increased, and if it spurts from the needle, it is markedly increased. The pres- sure may be accurately measured by special apparatus, but this is not necessary in ordinary cHnical work. With regard to turbidity, the fluid is recorded as clear, faintly cloudy, opalescent, turbid, or purulent. In a purulent fluid, a dis- tinct zone of pus settles at the bottom of the test tube. Fibrin Formation is shown by the appearance in the fluid of a gos- samer-like web on standing. In the routine microscopic examination of the cerebrospinal fluid, the points to be noted are the cell count, the character of the cells, and the presence or absence of bacteria. Cell Count. — The estimation of the cell count should be made first, when the fluid is as fresh as possible and before the fibrin clot has had time to form. The fluid in the test tube is thoroughly shaken for one or two minutes. The Toma-Zeiss white blood counter is used, not as in blood examination to obtain a dilution, but simply for purposes of mixing. Glacial acetic acid is drawn into the blood counter to about the 0.5 mark, accuracy not being essential, as the only purpose of the acid is to dissolve any red corpuscles which may be present, and to make the nuclei of the white cells stand out sharply. The counter is then inserted into the cerebrospinal fluid, which is drawn up until the counter is filled. It is then thoroughly shaken for sev- eral minutes, and a drop of its contents is placed on the Toma-Zeiss slide in the same way as for a blood examination. All the cells in- cluded within the ruled field are counted. Ten counts are made in this way, and the sum of these ten counts gives the cell count or number of cells in one cubic millimeter of cerebrospinal fluid. The error caused by the slight dilution with acetic acid is so small that it may be neglected. If, however, the fluid is contaminated with blood, a variable error is introduced depending upom the pro- portion of blood present. If the fluid is only slightly blood-stained, the error is negligible, but if there is evidence that considerable blood has entered the fluid, the results of the cell count are useless for diagnostic purposes. The normal cell count is not over ten cells per cubic millimeter, which is only an average of one cell to each ruled field. Cyto-Dl\gnosis. — During the performance of the cell count, the physician can usually sufficiently differentiate the mononuclear from 132 Disease in Early Life the polynuclear cells to form an estimate of the predominating type. For greater accuracy the differential count may be made upon the stained specimen. A cover glass preparation can be stained with Wright's modification of the Leischman stain, or the differential count can be made on a cover glass which has been stained for bacteria. The results are recorded in percentages of polynuclears and mono- nuclears. Bacteriologic Examination. — While it is advisable to take cul- tures from all suspected specimens of cerebrospinal fluid, the results of the examination of cover glass preparations are more valuable for diagnostic purposes than are the results of culture, because all of the bacteria commonly encountered in the cerebrospinal fluid can be found in cover glass preparations, whereas the diplococcus intra- cellularis is of uncertain growth in cultures. The best method of making a cover glass preparation is to wait until the fibrin clot has formed. This is removed with a platinum loop and is thoroughly rubbed and kneaded upon the surface of a cover glass. If no fibrin clot be formed, the preparation should be made from the centri- fugahzed sediment. For routine examination the best stain is Lof- fler's alkaline methylene-blue. With this the presence and mor- phology of all the organisms which cause meningitis can be deter- mined, except the tubercle bacillus, which requires its special stain. The diagnosis can usually be arrived at with this stain, but for pur- poses of completeness, or in case of doubt Gram's stain should be used on another slide. The diplococcus intracellularis is recognized by its occurrence in biscuit-shaped pairs, the cocci composing a pair lying side by side with reference to their long axis. It is decolorized by Gram's method. The pneumococcus occurs for the most part in pairs, but sometimes in short chains ; in cerebrospinal fluid the chains are rarely more than four cells in length. The cells composing the pairs lie end to end with reference to their long axis. This organism retains the Gram's stain. The streptococcus in the cerebrospinal fluid almost always forms long easily recognizable chains, and shows no tendency to occur in pairs. The staphylococcus is recognized by its typical occurrence in clumps. Both staphylococci and streptococci retain the Gram stain. The bacillus of influenza is the most difficult organism to recognize. Although a bacillus, the bipolar staining is usually so prominent that the appearance of the organism suggests a diplococcus. For this reason the influenza bacillus is often mistaken both for the diplococcus intracellularis and for the pneumococcus. The bipolar dots of the influenza bacillus are smaller than either of these two varieties of cocci. Also in most specimens, while many forms resemble a diplo- coccus, involution forms are usually present. In these involution Laboratory Diagnosis 133 forms the morphology is distinctly that of a bacillus. They do not look like the typical bipolar forms, and are often quite large. As a result of these peculiarities, the impression given by the slide is that of a mixed infection of diplococci and bacilli, which is puzzling unless the tendency to the appearance of involution forms is remembered, when the appearances become an aid in diagnosis. The bacillus of influenza is decolorized by Gram's method. In case of doubt cultures should be made upon blood agar and plain agar, as the influenza bacillus only grows in the presence of hemoglobin. The following points in the bacteriological diagnosis of the cere- brospinal fluid are the results of a very wide experience with cerebro- spinal fluids, and while not strictly scientific, may prove of value: Whenever diplococci are very few and difficult to find, the evidence points toward the intracellularis. Whenever there are many organ- isms included within the leucocytes, the evidence points toward the intracellularis. Whenever diplococci are very numerous, although few are included within the leucocytes, the evidence points toward the pneumococcus. The stain for the tubercle bacillus is precisely the same as that used in the sputum, urine, and other suspected materials. Cover the preparation with carbolfuchsin solution and steam over a flame for thirty seconds, not allowing the staining solution to dry on the glass, but adding more stain if necessary. Wash in water, and then decolorize for twenty seconds with 20 per cent, sulphuric acid. Wash in water, and then wash in 95 per cent, alcohol until no more color will come out. Wash in water. Cover the preparation with Lofiier's methyl ene-blue solution for thirty seconds. Wash in water and mount. Under the microscope the tubercle bacilli are bright red, while the nuclei of the cells are blue. The finding of the tubercle bacillus in the cerebrospinal fluid is often very difficult. If the organism is not found in a preparation made from the fibrin clot, it is advisable to digest the clot in artificial gastric juice, and then centrifugalize thoroughly. The fluid from the bottom of the centrifugal tube is put upon the slide and allowed to dry in air. The following table shows the characteristics of cerebrospinal fluid in some of the most common conditions, in which they are of diagnostic significance. The term meningismus as used in the table refers to a condition of meningeal irritation from a variety of causes without infection. Special Tests. — There are a number of special tests which can be applied to the cerebrospinal fluid, the final value of which is still under investigation. These tests depend upon the fact that in the normal cerebrospinal fluid the amount of protein present is too small to be 134 Disease in Early Lite recognized by ordinary clinical methods, whereas in all inflammations of the meninges there is an increase of protein substances, among which the globulin is most used in tests. These tests have as their chief advantage over the simple routine method of examination described above that they are more delicate. Among the principal ones are to be mentioned Nonne's test, Noguchi's butyric acid test, Lange's colloidal gold test, and Boveri's permanganate of potash test. The technique of these tests is too complicated for ordinary clinical use. At present their chief place is in the research laboratory. They will not be described here, but the reader is referred to recent literature for a description of their technique and diagnostic value. EXUDATES AND TRANSUDATES.— The laboratory examina- tion of effusions into the pleural, peritoneal, and pericardial cavities is often an important diagnostic procedure. Appearance. — First note the appearance of the fluid, and in par- ticular whether it is clear, cloudy, or purulent. The color of serous fluids should be noted, whether pale, straw color, orange, red, or bile stained. The presence or absence of fibrin formation should also be noted. Specific Gravity. — Take the specific gravity of all serous fluids. This is important in distinguishing between exudates and transu- dates. Albumin.- — The fluid should be tested for albumin, and the per cent, of albumin present should be estimated by some quantitative method. It can be estimated roughly from the amount of sediment in the heat test as described for the urine. A more accurate estimate may be made with Esbach's graduated tubes. The Sediment. — The sediment should be examined microscop- ically, and the character of the cells and other bodies should be noted. Cyto-Diagnosis. — Place the fluid in clean centrifuge tubes and centrifugalize thoroughly. Pour off the supernatant fluid by invert- ing the tube, and stir up the sediment in the remaining drops of fluid with the platinum loop. Spread a drop of this mixture on a cover glass and allow it to dry spontaneously without heat. Stain with a fluid made up of Wright's modification of Leischman stain three parts, and pure methyl alcohol one part. The sHde is stained by the method described for the examination of the stained specimen of blood. The same method as for blood is used in making a differential count of the cells. Bacteriological Examination. — Bacteria are stained by the solution used for cyto-diagnosis. In case of doubt as to their mor- phology, another sHde may be stained with Loffler's methylene-blue solution. Further evidence as to the type of microorganism present Laboratory Diagnosis 135 o < ^ =n « c ^ h; — 3 c c c H O <; pa 1> OJ < < < < < ■H u* tM IH t-t >-l ^ z rt rf n! ni rt rt < a OJ ^ _a; ^ OJ 1 ^ 1! Tj "u "o T '•J C 3 3 a 3 a 3 C 1 3 C 2 O O o O O o c C a c C 3 H o O o 3 o O o g ^ ^ S Ph ^ S % o H o 0-3 o Ut 2 O O M 1 " ° S 2 o ■73 ^ tn O "S -^ 9 Ji S OJ fl .3 (Si S 1-1 e o IH 1 .^ u O ^C" 1— 1 -yi C o u 13 t/1 3 3 3 cfi z .^ ^ .^ ^ 'c c C ^ c 3 3 (U OJ •t!^ o < ^ "O -c -d "C H r i.i c r i 2 ;- .<5 c ^ u o r:i o S 3 (Ll > 1 phoid bacillus from twelve to twenty-four hours old. Examine a drop of this cul- ture under the microscope in order to make sure that the bacilli are unclumped and in active motion. Mix nine drops of the typhoid 4. \ M \ ■ is' ^ ' -m ^ Fig. 4c — Scarifying for von Pirquet tuberculin lest Laboratory Diagnosis 139 culture with one drop of blood serum upon one end of the slide. Upon the other end of the slide make a i to 50 dilution by mixing one drop of the i to 10 dilution with four drops of water. Drops of equal size are obtained by using a platinum loop. Cover both the I to 10 and I to 50 dilutions with cover glasses. Make controls in the same way except that the blood serum is omitted. The serum re- action is regarded as positive when before the end of one hour there is complete clumping of the bacilli, and an absolute cessation of motil- ity in both dilutions, the controls remaining unclumped. The re- action is regarded as suggestive but not positive when only the i to 10 dilution is agglutinated. A positive reaction is diagnostic evidence of typhoid infection or antityphoid vaccination. THE VON PIRQUET REACTION FOR TUBERCULOSIS.— The tuberculin reaction and its theory, the various methods of apply- ing it, and its diagnostic value, are discussed in detail under tuber- culosis. For routine use, von Pirquet's cutaneous test is the one to be employed. Wash the skin of the forearm by rubbing with alcohol and ether, and apply two small drops of Koch's old tuberculin undiluted, about 10 cm. apart. A scarifier resembling a tiny chisel which has been sterilized by heating, is used for the inoculation. Apply this first to the skiu between the tuberculin drops and rotate with a boring motion. Repeat this procedure on the skin through each of the tuberculin drops. The boring must be sufficient to remove only the superficial layers of the skin. The blood-vessels of the deeper layers should show through, but blood should not be drawn. As a precaution against rubbing, cover the site of the inoculation with a piece of sterile gauze. A positive reaction is shown by the appearance of reddened areolae about the two points of the inocula- tion, while no reddening is seen about the control. The reaction usually begins within twenty-four hours, reaches its height during the second twenty-four hours, and slowly fades in one or two days. If the areola is less than 5 millimeters in diameter, the reaction should be considered as doubtful rather than positive. In my experience, however, with infants, based oh the results of autopsies, a doubtful re- action usually means tuberculosis. In infants and children a negative reaction has no diagnostic sig- nificance. A positive reaction means tuberculosis in the great rna- jority of cases. CUTANEOUS TEST FOR FOOD IDIOSYNCRASIES.— The technique of this test is exactly the same as that of the cutaneous tuberculous test, except that a small bit of the suspected food sub- stance is used in place of the tubercuhn. Food idiosyncrasies are not rare in infancy. The idiosyncrasy most commonly shown is against some protein food substance, such as lactalbumen, egg albumen, or 140 Disease in Early Life casein. Whenever there is a history of symptoms following the in- gestion of some particular food substance, a cutaneous test should be employed. A positive reaction indicates that the symptoms are caused by a food idiosyncrasy toward the special substance. WASSERMANN REACTION FOR SYPHILIS.— The comple- ment fixation test of Wassermann is of the greatest value in the diagnosis of syphihs in early life. The technique of the test is alto- gether too complicated for routine use, and the test can only be satisfactorily made by one trained in its performance. There are Fig. 41 Obtaining blood for the Wassermann reaction from the longitudinal sinus of an infant however a certain number of laboratories where this test is being habitually made, and in every case of suspected SA^hilis, a specimen of blood should be sent to a Wassermann laboratory for examination. About 10 c.c. of blood should be required for the test, and it is difh- cult to obtain so much blood from infants by the ordinary methods. The best method of obtaining blood from infants for examination is to take advantage of the open fontanelle. The longitudinal sinus which lies immediately under the anterior fontanelle is a very large vein which can be very easily reached. A small Luer syringe and hypodermic needle are sterilized, and the skin over the anterior Laboratory Diagnosis 141 fontanelle is cleansed. A small area may be shaved if there is much hair. The needle attached to the syringe is entered at the posterior angle of the fontanelle exactly in the median line. The needle passes through the skin and dura with a perceptible sense of suddenly lessened resistance. The piston of the syringe is then drawn, and the syringe immediately fills with blood. This method of obtaining the blood is greatly preferable to the gashing of the ear or heel, which was necessary for obtaining enough blood for the Wassermann re- action. My assistant at the Infants' Hospital recently obtained in this way specimens of blood from ten babies in eleven minutes. The specimen in a sterile test tube should be tightly corked before being sent to the Wassermann laboratory. Fig. 42 Injecting diphtheria toxin for the Schick reaction THE SCHICK REACTION TEST FOR IMMUNITY AGAINST DIPHTHERIA. — This test is mainly useful in hospital practice, but it is sometimes useful in private practice in determining whether a prophylactic dose of diphtheria antitoxin is indicated in children with whom there has been exposure or suspicion of exposure to diph- theria. Its value as a reHable test of immunity has been confirmed by the majority of recent investigations, although it is perhaps not finally proved. 142 Disease in Early Life Diphtheria toxin is used for the test. The minimum lethal does of the toxin for a guinea pig weighing 300 grams must be known. This is so diluted that o.i ex. of fluid contains 1/50 of this minimum lethal dose. This is injected with a very small needle, not under the skin but into the skin. If the injection is properly made, it should cause a small raised white looking spot. If the reaction is negative, there is no further discoloration at the site of the injection. If the reaction is positive, the area within twenty-four hours becomes reddened and slightly edematous. This passes off in forty-eight hours, leaving a brownish pigmentation. A positive reaction indi- cates that the individual has less than 1/30 of a unit of natural anti- toxin in I c.c. of blood, and such individuals are to be considered susceptible to diphtheria. A negative reaction indicates that the individual has more than 1/30 of a unit of natural antitoxin in i c.c. of blood, and is immune to diphtheria. The reaction has also a diagnostic value, because children sick with diphtheria show a posi- tive reaction before antitoxin is given. It has been shown that most newly born infants are protected by natural antitoxin, and that about 57 per cent, of children in the first year of life, and 37 per cent of children between two and five years, are immune. THROAT CULTURES.— The chief purpose for which cultures are taken from the throat is in the diagnosis of diphtheria. A cer- tain amaunt of evidence can also be gained as to other infecting organ- isms, not only by the examination of cultures from the throat, but also from examination of cover glass preparations made from the material obtained by swabbing. Cultures should be taken from all cases in which the examination of the throat shows the presence of exudate or membrane. The swab should be appHed to the edge of the membrane and should be drawn rather forcibly across the suspected area. The swab is then rubbed upon the surface of a blood serum culture medium. The culture should be incubated for twelve hours, and then examined by means of cover glass preparations. The best routine stain is Loffler's methy- lene-blue solution. The diphtheria bacillus is recognized by its pecuHar morphology. BLOOD CULTURES.— In a great number of infectious conditions in infancy and childhood, the bacteria enter the blood stream. Cul- tures from the blood are often very valuable in diagnosis, but this method is not employed as much as it should be on account of the supposed difficulty of obtaining blood from infants and young chil- dren under proper sterile conditions. The introduction of the method of obtaining blood from infants from the longitudinal sinus has very much simphfied the technique of blood cultures. Exactly the same Laboratory Diagnosis 143 procedure is employed as in obtaining blood for the Wassermann reaction. In older children with closed fontanelles, the blood can be obtained from one of the veins of the arm, which can be made to stand out by a tourniquette. The blood obtained should be inoculated upon the various culture media, according to the resources of the bacteriological laboratory. For routine use, inoculations should be made in bouillon and upon blood agar. The special method of exam- ining blood cultures for typhoid will be described under that disease. PHENOLSULPHONEPHTHALEIN TEST FOR RENAL FUNCTION. — Within the last few years various methods of testing renal function have been introduced. These tests have appeared to be of notable diagnostic value in many diseased conditions of the kidney. The most useful single test among them is that with phenol- sulphonephthalein. Under aseptic precautions, the patient is given an intramuscular injection of i c.c. of a sterilized solution containing 6 mgm. of phenol- sulphonephthalein. Any urine passed during the next two hours is saved, and at the end of that time the patient is made to empty his bladder, or is catheterized. All the urine collected in this way is made definitely aklaline, and is diluted to make i liter. A standard solution of alkaline reaction, containing 6 mgm. of phenolsulphone- phthalein in i liter, is made up. Some of the urine dilution is put in a test tube, and a series of test tubes of equal diameter are made up containing various dilutions of the standard solution. In this way, by colorimetric readings, the amount of the drug excreted in the urine can be estimated. More accurate results can of course be obtained by .the use of Antenreieth-Konigsberger or other type of colorimeter. With normal renal function, 6o to 8o per cent, of the drug should be excreted in two hours. If the amount is less than this, a disturb- ance of renal function is indicated, and the degree of the disturbance is measured by the amount of the decrease. DIFFERENTIAL DIAGNOSIS When all the evidence which can be obtained from the history, physical examination, and laboratory investigation is at hand, the physician is confronted with the problem of diagnosis. In certain eases, there is something in the evidence which is so positively diag- nostic, that a decision can be arrived at at once. Care must be taken, however, not to base a positive diagnosis upon symptoms or signs whose presence or absence is not absolutely diagnostic. Care must be taken also not to overlook the possibility of more than one pathological condition. In other cases, the evidence obtained suggests only a number of possibiHties, without anything positively diagnostic of any one of 144 Disease of Early Life them. In these cases a differential diagnosis must be made through a careful weighing of the evidence. In making a differential diag- nosis, it is unnecessary to consider every possibihty that could go with every symptom. The best method of arriving at a conclusion is for the physician to select the most prominent symptom or group of associated symptoms, which demand explanation. He should then make a written or mental Hst of all the conditions which could produce this group of symptoms. He should then consider how many of these possibilities can be positively excluded by the different kinds of diagnostic evidence at hand or obtainable. If more than one pos- sibihty be left, he should arrange these alternatives in the order of their probabihty as suggested by the evidence. Care must be taken in excluding possibihties in diagnosis. A dis- tinction must be drawn between cHnical evidence which positively excludes a certain condition, and chnical evidence which is only against a certain condition. The latter class of evidence can only be used in arranging possibihties in the order of their probabihty. When an opinion is formed as to the diagnosis, the evidence should again be reviewed with reference to whether the diagnosis is adequate to account for all the symptoms and signs of disease which are present. If it is not adequate, the possibihty of two things must be considered; one is that some false step in the reasoning has led to a mistaken diagnosis; the other is that more than one diseased condition may be present. The chnical evidence must be reconsidered with a \dew to setthng these alternatives. The abihty to make an accurate diagnosis ui early hfe depends upon the weighing of the clinical evidence. If the standards used in diagnosing disease in adults are used, many mistaken diagnoses will be made with children. The physician must be thoroughly famihar with the anatomy, physiology, and development of the normal child, and with all the pecuharities of the pathology, symptomatology, and diagnostic methods of childhood. IV. PROGNOSIS IN EARLY LIFE The most important factor in the prognosis of disease in early hfe is the age of the patient. The general rule is that the younger the patient, the worse is the prognosis in all the diseases of childhood. It is for this reason that the mortaHty of the first year of life is so high, and that it shows a progressive diminution throughout the re- maining years of childhood. I shall not take time here to review the much discussed question of infant mortality, nor to show in detail the relative frequency of the different causes of death at the different ages. The causes of the high mortality of infancy may be summarized as follows: In the first place, there is the feeble resistance of the infantile organism in general to all the external causes of disease. This feebleness of resistance is shown not only against those external causes which produce disturbance of function, but also against in- fections. In the second place, the feeble resistance of the undeveloped organism may be increased both by inherited conditions and by con- genital faults of development. A third cause is the prevailing ignor- ance as to the hygienic demands of the young organism and the conditions which are essential to its proper health and growth. In the first year of Hfe, gastro-intestinal conditions rank first as a cause of death, with acute respiratory tract infection second, con- genital malnutrition third, and other acute infections fourth. In the second year, diseases of the gastro-intestinal tract still hold first place. It is difficult to draw a distinction between acute infections of the respiratory tract and the acute contagious diseases, because death so often occurs when the former is a complication of the latter. Measles, diphtheria, and pertussis, with their pulmonary complica- tions appear to hold second place, but in my opinion, the statistical figures of infant mortality show altogether too low a proportion for acute tuberculosis and tuberculous meningitis. After the second year, the acute infections rank ahead of all other causes. In considering questions of prognosis, it must be remembered that in general, infants and young children succumb easily to acute con- ditions. They also show much more markedly the effects of chronic functional disturbance. On the other hand, numerous diseases accompanied by organic lesions in early Hfe, show a remarkable possibility of complete recovery as compared with adult life. Many organic conditions which in adults would be permanent can in chil- dren be "outgrown," provided that the patient can be placed under proper hygienic surroundings. This power of recovery from organic 10 146 Disease in Early Life disease is due to the peculiarly rapid metabolism of childhood. There are also a certain number of infectious diseases which are less severe in infants than in adults, owing to certain peculiarities of the anatomy of early life. In children, it is lack of development and peculiarities of func- tional resistance which form the unknown factor in prognosis, just as in adults it is the effects of all abuses, such as alcohol, and vari- ous forms of wear and tear which constitute the unknown factor. The prognosis in any diseased condition can only be estimated from a knowledge of the peculiarities of the particular disease in early life, and from an estimate of the constitutional peculiarities of the individual patient. In children of apparently robust constitution and normal development, the prognosis in those acute diseases which do not tend inevitably to a fatal ending, is fairly good. In children of poor development and poor constitutional resistance, the prognosis is proportionately bad. In chronic functional disturbances, the prognosis depends largely upon the length of time which the dis- ease has existed, and the degree of malnutrition and lowered resistance which has been brought about. In giving a prognosis in early life, the physician must remember two things: One is the liabiUty in infancy to sudden and unexpected death from various unsuspected causes. The other is the liability of infants and children to develop unexpected comphcations. The prognosis of the various diseased conditions as compared with the same conditions in adults, will be discussed in detail in the consid- eration of the various diseases. V. TREATMENT GENERAL PRINCIPLES The one great principle in the modern treatment of disease is re- moval of the cause. This is particularly applicable to the diseases of infancy and childhood. A very large group of the disturbances to which children are particularly hable belong in the class of func- tional disturbances from multiple external causes, and tend toward spontaneous recovery as soon as the causes are found and removed. Not only are these diseases curable through timely removal of the causes, but they are still more easily preventable. A second large group is represented by the infections, in which the cause, while not removable after infection has taken place, is nevertheless also often preventable. Prophylaxis is therefore the most important department of the treatment of disease in early life. There is no more promising field in the whole of medicine than the prevention of disease in childhood. The fundamental principles in preventive medicine are two in num- ber: (i) The removal of the external factors in hygiene and environ- ment which interfere with normal development, and contribute to disease; (2) the prevention of infection. The first principle can be appKed only by the education not only of the medical profession, but also through them of the general public, in the proper hygiene of early life. The second can be reahzed through continued study of the mechanism of infection and the principles of immunity on the one hand, and of such problems as disinfection, sanitation, and quar- antine on the other. In these last problems the public health authori- ties have their great field. When disease has actually occurred, the true diagnostic problem which confronts the physician is not the mere finding of a name for the condition, but the finding of the cause. No name is of any value which does not connote all that is known of etiology, and nothing is worse than for a physician to hide ignorance of etiology and path- ology under vague names like grip, marasmus, rheumatism, bilious- ness, and so forth, which are not based on distinct etiological con- ceptions. Taking refuge in names which have a definite if incorrect signification to the general public may satisfy the parents of our patients, but should not satisfy us, unless we go further, so that our diagnosis suggests all that is known of etiology. It is for this reason that so much stress is laid upon etiological factors throughout this book. 148 Disease in Early Life Modern treatment is primarily aimed, not at the mere relief of symptoms, but at the cause. This does not mean that symptomatic treatment does not have its place. It is obviously our duty to relieve symptoms as far as possible. But symptomatic treatment is longer established, better known, and easier of application than is treatment aimed at causes, and there is danger that we may lose sight of the latter in self-satisfaction at our ability to apply the former. SPECIAL INDICATIONS IN EARLY LIFE The peculiarities of disease in childhood which modify the treat- ment are chiefly due to the incompleteness of anatomical and func- tional development at that period of life. Three groups of conditions besides the acute infections are particularly common in childhood. These are (i) functional disturbance of the digestive system, (2) functional disturbance of the nervous system, and (3) functional disturbance of the general nutrition and metabolism. Even in other diseases, such as the infections, these three varieties of functional disturbance are particularly common as manifestations. The treat- ment required by these three kinds of disturbance is mainly hygienic and dietetic, and consequently these forms of treatment are rela- tively of the first importance in childhood. On the other hand, the great variety of subjective symptoms which demand treatment in the adult are much less common in childhood. Consequently symptomatic treatment directed at such manifesta- tions plays a relatively unimportant part. Moreover, certain im- portant systems of the body suffer less from disease in children than in adults. The chief example of this difference is the heartland circulatory system, which is most damaged by the wear and tear of the adult life, and consequently often calls for symptomatic treat- ment, but which is relatively competent to combat disease in child- hood. Drug treatment plays its most important part in combatting subjective symptoms and circulatory disturbance. The role of drugs is consequently relatively smaller in early life. Treatment may be divided into specific, hygienic, dietetic, and symptomatic. SPECIFIC TREATMENT In the infectious diseases, the first aim in therapeutics has always been to find some remedial agent which will act directly on the cause of the disease. This effort has led to much study of the mechanism of transmission and infection, of the mechanism of defence, and of the comphcated problems of immunity. It has been finally de- monstrated that the human organism has various means of defence against the occurrence of infection, and various means of combatting infection when once it has occurred. These natural methods of Specific Treatment 149 combatting infection are the cause of the self-Hmited character of many acute diseases, and of the fact that in most infections there is a natural tendency toward eventual recovery. The first object of treatment is to hasten recovery — to overcome the infection as quickly as possible. In the search for therapeutic measures which are specific, that is which act directly on the par- ticular microorganism causing the disease, attention was first turned to drugs — chemical agents which when introduced into the body, would kill or injure the microorganisms or prevent their development. The idea of the possible value of drugs in combatting infection was based on the fact that many drugs have a demonstrable pharmacological action, modifying and influencing various bodily functions in vari- ous ways, and as the symptoms of infection are due to a disturbance of bodily function, a drug which caused the opposite effect, which lessened the disturbance of the function, was considered of value against the microorganism causing the trouble. It has been found, however, that in-so-far as the bacterial infections are concerned, there is no drug which can be safely introduced into the body which will act directly on the microorganisms causing the disease, and that consequently , there is no specific drug therapy for the diseases caused by bacteria. It has been supposed that the influence of drugs upon bodily func- tion might be utilized in bringing about recovery, through the finding of drugs which aid the natural methods of resistance, defence, and disinfection. A drug which has such a power would be considered specific. It has been found, however, that the natural methods of recovery from bacterial infections depend upon much more compli- cated biological processes than the simple physiological functions which can be influenced by drugs. The most that drugs can do in infections is to strengthen and support functions whose disturbance threatens a fatal ending before the natural methods of defence have time to act, or to aid in the promotion of the general resistance of the body against adverse influences. The action of drugs in bac- terial infections is therefore in no way specific. The same is true of the various non-medicinal therapeutic measures. Their r61e is the relief of subjective symptoms, the support of threat- ened function, and the strengthening of general resistance. For a true specific therapy in the bacterial infections, we must look further. The study of the natural methods of defence, and of the complicated subject of immunity, has given us two methods of aiding or hastening the natural methods of recovery. These are serum therapy, and vaccine therapy. SERUM THERAPY.— This consists in the introduction into the patient's circulation of the serum of an animal which has been im- munized by inoculations with the bacterium causing the disease. 150 Disease in Early Life Immunological research has demonstrated that one of the methods of defence through which recovery from infection takes place, is the formation in the blood serum of the patient of immune bodies. These immune bodies are of various kinds; some neutralize the toxin formed by the bacteria (antitoxins), others kill the bacteria (bactericidal substances), others prevent the multiplication of bacteria, and others injure the bacteria in such a way that they fall an easy prey to phago- cytic tissue cells (opsonins, or bacteriotropins) . If an animal be inoculated with bacteria, or preparations made from bacteria, under proper conditions, its tissues will be stimulated to the formation of immune bodies, which will be contained in its blood serum. The therapeutic use of such immune animal sera is serum therapy. The most conspicuous example of success in serum therapy is diphtheria. This success led to the hope that a similar specific therapy would be applicable to all the infectious diseases. This hope has not been realized. The immune body in diphtheria is an antitoxin, and it has been found that only in infections with an organism which secretes a soluble toxin as does the diphtheria bacillus, can an effective antitoxic serum be obtained through animal inoculation. The only other effective antitoxic serum is that produced by animal inoculation with the bacillus of tetanus. In the other infections, the organisms do not secrete a soluble toxin, but liberate endotoxins, and the mechan- ism of immunity is much more complicated. Hence serum therapy has made slow progress. The most successful example of serum therapy besides diphtheria, is in epidemic cerebrospinal meningitis. Immune sera have been ob- tained and widely employed against infection with the streptococcus ^ the pneumococcus, the bacillus of dysentry, the bacillus of influenza, and the tubercle bacillus. Most of these sera have given strong lab- oratory evidence of value. Some of them have given some clinical evidence of value, but on the whole, in these infections, serum therapy cannot be said to have proved markedly successful. The reasons for the failure of complete success of serum therapy against the infectious diseases, may be summarized as follows: 1. In some diseases certainly infectious, the specific organism has not been demonstrated. Examples are scarlet fever, measles, rubella, varicella, mumps. 2. Some diseases cannot be sufficiently reproduced in animals to permit the production of an immune serum. Examples, typhoid fever, gonococcus infection. 3. In some diseases immunity depends on tissue reactions of a very complicated nature, in which the formation of immune bodies in the blood serum probably plays a very small part. Example, tuberculosis. Specific Treatment 151 4. In some diseases the specific organism has been so recentl}' dis- covered, that there has not been sufl&cient time to investigate the problem of immunity, and to build a satisfactory foundation for serum therapy. Examples, pertussis, poliomyeloencephalitis. 5. In some infections the specific organism does not represent a single type, but includes a variety of strains, each with its particular immune reaction of varying complexity. Much time will be required for the study and differentiation of these strains and their immune reactions, before an effective serum therapy will become practical. Examples are the pneumococcus, the streptococcus, rheumatic fever. It will be seen from the causes of failure up to the present time, that the outlook for further progress in serum therapy is by no means hopeless or discouraging. The majority of the difficulties are of a character to suggest that they are capable of solution. It is for this reason that among the various fields of medical research, the greatest amount of activity is found in the study of infection and immunity. We must look mainly to the results of this study and research for further advances in specific therapy. VACCINE THERAPY.— This consists in the inoculation of the patient with a bacterial preparation with a view to stimulating the patient's tissues to the production of immune bodies, or to an immune reaction. Immunological studies have demonstrated that when bacteria are killed by heat, the substances contained in the bacterial cells which excite the formation of immune bodies in the patient, are not destroyed. In some instances the injurious endotoxin is not the same as the anti- gens, or substances which excite antibody formation. It is mainly the multiphcation of bacteria in the body which causes harm, and this is prevented by the method of preparation. The majority of vaccines consist of suspensions of dead bacteria in normal salt solution, the dose being measured by the number of dead bacteria given. In using a vaccine, the number of dead bacteria in a certain quantity of the solution must be known, in order to regulate the dose. These vaccines are injected subcutaneously. The tuberculosis vaccine known as tubercuhn is an extract of the tubercle bacillus, and the dose is measured in milhgrams. The vaccine used against small-pox is the living unknown virus of cow- pox, and is inoculated into an abrasion of the skin. The chief value of vaccine therapy is prophylactic rather than curative. The efficacy of the inoculation of bacterial products in producing an active immunity against certain diseases, has been estabhshed beyond the possibiUty of a doubt. Except in the case of vaccination against small-pox, prophylactic vaccination has at present a very small place in pediatrics. It is only under exceptional 152 Disease in Easly Life circumstances of epidemic and exposure that prophylactic inoculation is indicated in childhood. The chief use of vaccine therapy in early hfe is as a curative meas- ure. Vaccine therapy has been tried in almost every known form of bacterial infection. In general, the results have been disappoint- ing. In those general infections, in which there is a profound dis- turbance of the physiology of the entire body, such as pneumonia, typhoid fever, streptococcus and staphylococcus septicaemia, ulcera- tive endocarditis, and the various forms of meningitis, the clinical evidence of good results is not sufficient to justify the routine use of vaccine therapy. There is evidence of a good effect in some indi- vidual cases, but it must be remembered that in these diseases the body is already inoculated and overtaxed with toxic substances, and it is difficult to see how good may be expected from adding to the burden by artificial inoculation. In certain strictly locahzed infections, on the other hand, there is abundant clinical evidence that the infectious process can often be favorably influenced by bacterial inoculations. The most con- spicuous examples are the various localized staphylococcus infections, of which furunculosis is t^^pical. But furunculosis represents really a series of infections, rather than a single one, and the effect of vaccine therapy is probably chiefly as a prophylactic against recurrent in- fection. The more nearly a localized infection approaches a type resembling furunculosis, the more promising is the outlook for vaccine therapy. In other infections, not so strictly localized, but inter- mediate in character between the widespread and Hmited tjqpes, such as pyelitis, gonococcus infection, certain forms of arthritis, and so forth, vaccine therapy must be considered as a possibihty, of which the value is not yet either established or disproved. In the selection of the vaccine, the physician must choose between the employment of an autogenous vaccine or a stock vaccine. An autogenous vaccine is one prepared from a culture taken from the patient and contains the particular strain or t}pe of infecting organ- ism that is producing the disease. The researches of recent years have sho-vvTi that one of the chief elements leading to chronicity and resistance in an infectious process, is a change in the infecting organ- ism by which it becomes less susceptible to the attack of the immune bodies of the host. Artificial active immunization, if it is to be effective, must take cognizance of such elements as bacterial re- sistance and "organ specificity," and consequently a vaccine should be derived from an organism possessing the properties of those con- cerned in the infectious process — an autogenous vaccine. The tech- nique of the preparation of autogenous vaccines varies somewhat with the type of organism concerned, and for the details the reader is referred to standard works on bacteriology. Hygienic Treatment 153 Stock vaccines are prepared from stock cultures. The advantage attending their use is only that they are more easily obtainable. There is evidence that in some types of infection stock preparations are effective. We cannot, however, be sure of the type of infection without a culture, and if a culture is obtainable, the preparation of an autogenous vaccine should be possible. Even if we grant that a correct bacteriological diagnosis can be made from clinical observa- tion, stock vaccines have the further disadvantage that they may not meet the final requirements of the particular strain of organism in the individual case. This disadvantage may be partly overcome by uniting bacteria from different strains of the same species in a polyvalent vaccine. The usual reason however for the employment of a stock vaccine is that the physician is not master of the technique of the preparation of an autogenous vaccine. While their use under certain circumstances may be justifiable, it encourages loose thinking and neg- lect of the fundamental principles on which vaccine therapy is based. The use of ''mixed vaccines," or of non-specific mixtures of the products of bacterial growth, cannot be too strongly condemned. Such "shot-gun" empiricism in matters so important as infection and its treatment is not only wholly unscientific, but stands an excel- lent chance of being actually extremely dangerous. The indication for vaccine therapy and its method of employment will be considered under the various diseases in which it holds- a place as a prophylactic or therapeutic measure. SPECIFIC MEDICINAL TREATMENT.— Failure of drugs as a specific weapon against infectious processes applies to the bacterial diseases only. In infections produced by animal parasites such as protozoa and others, there is evidence that drugs may have a specific value against the pathogenic invader. In pediatrics there are two diseases of this class, malaria and syphilis. The use of quinine in malaria, and of mercury, salvarsan, or iodide of potassium in syphilis, may be considered as specific treatment. HYGIENIC TREATMENT In those diseased conditions which are directly due to faulty hygiene, hygienic treatment may be considered as specific. It holds also a very important place in all the diseased conditions of early life. The resistance of the organism against adverse influences of all kinds, whether they be infections, or whether they be due to con- stitutional peculiarities or external injuries, is largely dependent upon the normal development and general health of the child. Proper hygiene is essential to the proper development of a constitution which is able to resist disease. For this reason hygienic measures have their place in practically all diseases. 154 Disease in Early Liee The details of hygienic treatment have been described at length in the first division of this book under the heading of "The Hygiene and Care of Normal Children." The physician should always devote the greatest pains to discovering whether there are any faults in the hygiene and environment of his youthful patient, and should correct such faults. It is always the first essential to place the patient in proper hygienic surroundings. The particular hygienic measures which are demanded by certain special diseased conditions will be described under the several divisions. DIETETIC TREATMENT A large group of the diseased conditions encountered in infancy and early childhood are due to the relatively low resistance of the functions of digestion and metabolism against adverse influences. In this group, treatment is mainly dietetic, and here, dietetic treat- ment may be considered specific. The susceptibility of the gastro-in- testinal system in early life must be taken into consideration also in all the diseased conditions of childhood, and consequently the proper arrangement of the diet plays a very important part in the therapeu- tics of early life. The details will be considered at length in this book in the divisions on Feeding and on the Gastro-Intestinal Dis- eases. SYMPTOMATIC TREATMENT This is directed at the various functional disturbances which appear as manifestations of disease. It must be remembered, however, that in children the e\'idences of disturbed function are not always an indication for treatment. Symptomatic treatment is indicated under two conditions: (i) When the manifestations of disturbed func- tion are uncomfortable or painful, and (2) when they are harmful or dangerous. The mere fact that a child has fever or a rapid pulse, does not mean that these symptoms are necessarily to be treated. The indications for symptomatic treatment vary with the disease and with the gravity of the s^nnptoms. The remedial measures employed in symptomatic treatment can be roughly classified according to the particular physiologic system whose function is disturbed. Measures directed at the reduction of bodily temperature are called antipyretic. Measures directed at remedying disturbed function of the circulatory system include stimulants and counterirritants. Measures which aid the renal func- tion are called diuretic. The measures directed at the relief of pain are called analgesic, and include the opiates. Disturbance of the function of the nervous system is controlled by the sedatives. Measures designed to aid the general metabolism may be classified as tonics. General Therapeutic Measures 155 The measures employed in the symptomatic treatment of diseases may be classified in another way, according to whether they do or do not involve the use of drugs. They will be described under this classification. THERAPEUTIC MEASURES OTHER THAN DRUGS These play a very important part in the therapeutics of infancy and childhood. HEAT AND COLD. The Ice Bag.— The application of cold is, useful in many conditions. AppHed to the head, it is useful both for the reduction of temperature and for the relief of pain. In other. parts of the body it is often indicated as an analgesic measure, and when applied to the precordia may have some favorable influence on cardiac function. It is useful in many forms of local inflammation. In very young and delicate children it should be used with caution. Cold is usually applied by means of an ice bag. On the head, an ice cap made like a helmet, may be used. On the eyes, cold com- presses are employed, which are frequently changed. The Hot Water Bag. — The appHcation of the hot water bag is useful in symptomatic treatment of pain, particularly when referred to the abdominal cavity. Poultices. — These are useful for the treatment of pain, and in certain local infections in hastening the formation of definite suppura-. tion. The flaxseed poultice, or a poultice made from hot antiseptic solutions may be used. The Hot Pack. — The naked body of the child is covered with towels wrung from water at a temperature of ioo° to io8° F., and is then rolled in a thick blanket. The hot application may be changed every half hour until the required amount of free perspiration is pro- duced. The chief use of this procedure is in nephritis. The Hot Air Bath. — After removal of the clothing, the patient is laid upon the bed with the bedclothes raised about a foot above the body by means of some sort of wicker support. The bedclothing is fastened tightly about the neck of the patient. Hot air from a lamp of some kind is conducted through a tin pipe beneath the bed- clothes. The hot air bath may be continued from fifteen to thirty minutes at a time. Free perspiration will usually be produced in fifteen or twenty minutes. The chief use of this procedure is in nephritis. HYDROTHERAPY. The Hot Bath.— The patient is put into water at a temperature of ioo° F., and the temperature of the water is gradually raised by the addition of hot water to from 103° to 106° F. The body of the patient should be thoroughly rubbed ijvhile the patient 156 Disease in Early Life is in the bath. A thermometer in the bath must be carefully watched. The chief use of the hot bath is in promoting reaction in cases of shock or collapse. The Mustard Bath. — Four tablespoonfuls of powdered mustard are mixed with one gallon of tepid water, and enough water is added to this to make five gallons, at a temperature of ioo° F. The mus- tard bath is useful in cases of shock, collapse, or sudden heart failure, especially in infancy. The duration of the bath should be not more than ten minutes, but it may be repeated in an hour if necessary. The Tepid Bath is given at a temperature of 95 to 100° F. The patient should be left in the bath about ten minutes. This procedure is mainly useful in conditions of irritability of the nervous system, and to promote sleep. It is often more effective than drugs. The Cold Sponge.- — For this purpose equal parts of alcohol and water are used at a temperature from So° to 85° F. The naked child is laid upon a blanket, and the body should be sponged for from ten to twenty minutes, with occasional rubbing of the skin. After the sponging, the child is wrapped in a blanket -without further dressing. This procedure is occasionally indicated in reducing high tempera- ture. Its chief value, however, is in rehe\dng symptoms of irritation of the nervous system in certain diseases. It is less effective, but also less depressing than the cold pack. The Cold Pack.— The naked child is laid upon a blanket, and the entire trunk is enveloped in a sheet \\Tung from water at a tem- perature of 100° F. Ice is now rubbed upon the outer surface of the sheet, first in front, then behind, so that the entire trunk is included. The child is then left in the pack for a varying time, according to the circumstances of the case, during which the rubbing with ice is once repeated. The child is then wrapped in a blanket without removing the wet sheet, and left in this about an hour, when it may be dried and ■v\Tapped in another blanket. This is the most eft'ective means of reducing the temperature in infancy and childhood. It has the advantage of avoiding all shock and fright. It may be necessary to apply heat to the lower extrem- ities while the child is in the pack. . The Cold Bath. — This is sometimes employed as an antipyretic measure, but much less often in children than in adults. The cold pack is to be preferred in most cases. The child is placed in a bath at a temperature of 100° F. The temperature of the bath is then gradually lowered by the addition of cold water to from 80° to 85° F. The body of the child should be vigorously rubbed while it is in the bath, and water should be applied to the head. The bath should be continued for from five to ten minutes, after which the child is removed, dried quickly and rolled in a blanket. General Therapeutic Measures 157 COUNTERIRRITATION. Mustard Paste.— This is made as follows: Take one part powdered mustard and six parts flour, mix with warm water, and spread between two layers of muslin. This is applied to the region where counterirritation is desired, and held in place by a swathe or simple bandage. The effect on the skin should be carefully watched, and the paste should be removed as soon as a decided redness of the skin has been produced. In most cases, this will not take much longer than five minutes. The paste may be made somewhat stronger for older children than for infants. The application of a mustard paste may be repeated as often as every three hours if desired. This is the most efficient means of producing a rapid counter- irritation over a large surface. It is sometimes useful in pulmonary diseases. The Mustard Pack. — The naked child is laid upon a blanket and its body is wrapped in a large towel or small sheet, which has been saturated with mustard water of a strength of one tablespoonful of mustard to one gallon of warm water. The patient is then rolled in a blanket. The pack is continued until a notable redness of the entire body has been produced. The mustard pack is useful in the same conditions as the mustard bath, namely, sudden collapse, great prostration, and internal con- gestion. It is less efficient than the mustard bath, but has the advan- tage of being less disturbing to the patient. The Turpentine Stupe. — Wring a piece of flannel out of water as hot as can be borne by the hand, sprinkle upon it ten or twelve drops of spirits of turpentine, apply directly to the aft'ected part, and cover with dry flannel. Care must be taken in using turpentine stupes in infants, as they easily produce blistering of the skin. The chief use of the turpentine stupe is in abdominal pain, or inflamma- tion, or in abdominal distention. Bleeding. — Venesection is almost never indicated in the diseases of infancy and childhood. Local bloodletting by means of leeches are sometimes useful in certain conditions such as mastoid disease, or thoracic disease with marked dyspnoea and cyanosis. Dry cup- ping may also be employed in some similar conditions. Wet cupping is never indicated in early life. IRRIGATIONS AND SPRAYS. Irrigation of the Colon.— This is one of the most important of all the therapeutic procedures used in infancy and early childhood. Irrigation of the colon must not be confused with enemata. The object is to flush the entire large intestine with fluid, injected as high up as possible. The apparatus required is a fountain syringe holding at least two quarts, four or five feet of rubber tubing, and a soft rubber catheter 158 Disease in Early Life of a size about number 26 French scale. The catheter is connected with the rubber tubing coming frorn the syringe by' means of a bit of glass tubing. In place of the fountain syringe, a fuimel and pitcher may be employed. Double current tubes, or two catheters, one for outflow, the other for inflow, are unnecessary. The syringe is hung about two feet above the level of the child, and is filled with the irrigating fluid, which in routine cases should be normal salt solution. Fig. 43 Irrigation of the colon The child is placed upon its back with the thighs flexed, and the buttocks brought to the edge of the bed or table. A Kelly pad or rubber sheet should be arranged to form a trough leading into a tub or large basin. The catheter is oiled, and the water is turned on and allowed to flow until the cold water in the tube has escaped. The end of the catheter is then introduced through the anus with the water flowing, and is gradually pushed upward as far as possible, usually for a distance of twelve or fourteen inches. The pushing of the catheter is rendered easy by the fact that the running water distends the intestine ahead of the tube. If on account of the peristalsis excited, the catheter turns on itself and comes back through the anus, it must be reintroduced and pushed up again. There is no danger of over-distention of the intestine, as active peristalsis is always ex- o General Therapeutic Measures 159 cited and the water comes back through the anus around the catheter. Usually a pint or more will enter before the fluid begins to return. The irrigation should be continued until the water comes back en- tirely clear, but at least two quarts should always be given. During the irrigation gentle massage of the abdomen will facilitate the reach- ing of the upper part of the colon. After the irrigation, the rubber tube is disconnected and the remaining water is allowed to escape through the catheter. Some is usually retained and passed later. The temperature of the water used in irrigation for ordinary pur- poses should be from 95° to 100° F. It may be varied according to special indications, as when there is high fever, or when there is pain and tenesmus; in these cases colder irrigating fluid is of advantage. In some cases, instead of normal saline solution, plain water or some medicated fluid may be used. Irrigation of the colon should never be used more than twice in twenty-four hours. It is wise for the physician to make sure that the nurse thoroughly understands the technique, as otherwise only a rectal injection will be given. It is often a good plan for the physi- cian to give the first irrigation himself. The essential points are the high introduction of the tube, and the use of a large quantity of water. Gastric Lavage. — Stomach washing is frequently indicated in the diseases of infancy and early childhood, and is one of the most valuable therapeutic procedures which we have. It is not, as is often supposed, attended by shock or prostration in infants, and it is entirely free from danger. The apparatus for stomach washing consists of a soft rubber cathe- ter, a glass funnel attached to a rubber tube, and a glass "window" con- nection between the other end of the rubber tube and the catheter. The child is wrapped up with the arms confined and is held in a sitting position, with a large basin at the nurse's feet. The physi- cian depresses the tongue with the forefinger of the left hand, and with the right hand passes the catheter rapidly backward into the pharynx and down into the esophagus. The passage of the catheter past the pharynx will cause gagging, and for this reason this part of the introduction should be made rapidly. The catheter is now pushed downward more slowly. A second gagging mil usually betray the moment when the catheter passes the cardiac orifice and enters the stomach. The catheter is now passed a little further downward. The en- trance into the stomach is often shown by the escape of curdled milk from the funnel. The distance from the teeth to the stomach varies with the size of the child. It is approximately about ten in- ches, but the physician can usually recognize the entrance into the stomach by the distinct reflex at the cardiac orifice. When the 160 Disease in Early Lite catheter has entered the stomach, the funnel should be raised as high as possible, to facihtate the escape of any gas which may be present, and should then be lowered in order to siphon out any fluid con- tents. The funnel is then raised and warm water at a temperature of about ioo° F. is poured into it from a pitcher. The amount of water varies with the age of the child, and should be approximately equal to the quantity of milk given at a feeding at that age. The funnel is then lowered and the water is siphoned out. This pro- cedure is repeated a number of times until the fluid comes back clear. A number of repeated washings are often required to break up the large curds which sometimes interfere with the flow of fluid. Stomach washing is practically never employed in children over three years old, and is most commonly indicated in the first two years of Hfe. Indications for this procedure will be given under the several diseases in which it is used. Fig. 47 Irrigation of the ear Syeinging the Ears.— This is best performed with a syringe made entirely of soft rubber. The child should be lying on its back in the position shown in the illustration. This is one of the most fre- quent procedures in the therapeutics of early hfe, owing to the very common occurrence of middle ear disease. General Therapeutic Measures 161 Nasal Irrigation. — This may be given by means of a fountain syringe, or with any form of hand syringe which has a soft rubber tip and with which the pressure can be easily regulated. The foun- tain syringe should not be higher than two feet above the child. The patient lies on its side with its mouth open. The irrigation is given through the upper nostril, and then the child is turned on the other side for irrigation through the other nostril. The fluid should return either through the lower nostril or through the mouth. Care must be taken in using the hand syringe not to employ too much pressure, as the fluid may be forced into the eustachian tubes. Fig. 48 Irrigation of the nose Spraying the Nose and Throat. — This procedure is best performed with some form of atomizer. Either aqueous or oily solutions are used, the character of the solution being determined by that of the disease. Gargles. — Gargling the throat is impossible with infants and is only used in older children. The character of the gargle varies with that of the condition in which it is indicated. Syringing the Mouth and Throat. — This is sometimes indicated in children too young to gargle. The child should either be lying on its side, or held in a sitting posture with the head inclined forward. Any form of syringe may be used in this procedure. 11 162 Disease in Early Life INHALATIONS. — These are very useful in various affections of the respiratory tract. They are given in the form of vapor, either plain steam being employed, or vapor from boiling water to which some medicinal agent has been added. In the mildest cases, a bowl of boiling water may be surrounded with a newspaper folded in such a way as to concentrate the vapor, and the child is held over the bowl and allowed to breathe the steam. To be thoroughly effective, how- ever, the patient should be under a tent. Such a tent can be impro- vised in the crib in various ways by means of a sheet. A rubber sheet is often better than an ordinary cotton one. To generate the steam, some sort of croup kettle or vaporizer may be employed, and some efficient and safe means must be devised to conduct the steam from the croup kettle or vaporizer to the tent. Many of the croup kettles on the market are dangerous, but there are some good ones. There are various forms of apparatus for giving medicated inhala- tions. The Cresolene lamp is in common use, but steam inhala- tions with tent and croup kettle are preferable. ENEMATA. — Enemata are used for four purposes, (i) as a means of emptying or cleansing the bowel, (2) as a means of introducing nutriment, (3) as a means of introducing medication, (4) as a means of introducing fluid or of stimulation. Laxative or Cleansing Enemata. — For the purpose of simply emptying the bowel or of cleansing the rectum, the ordinary soap- suds enema is best. In marked constipation when the fecal mass is hard and dry, enemata of olive oil are used — about one ounce, — and they may often be advantageously followed by a soapsuds enema. If an immediate and certain emptying of the bowels is desired, a teaspoonful of glycerin in one ounce of water should be injected for an infant, a larger quantity being used for older children. Nutrient Eneiviata. — Peptonized milk was formerly recom- mended, but I am convinced that the most efficient nutrient enemata should consist of a solution of dextrose (glucose). A six per cent, solution should be employed, and the quantity given at each injec- tion should vary with the age of the child. Young infants will not retain more than one or two ounces, older infants not more than two to four ounces, older children four to six ounces. The interval be- tween the injections should usually be four hours. Medicated Enemata. — The giving of drugs by rectum is often indicated in infancy and childhood, either on account of vomiting or on account of the unpleasant taste. The medicine may be given in water or in gruel. The quantity of diluent used should be the same as for nutrient enemata. With both nutrient and medicated enemata it is useful in infancy to press the buttocks together for half an hour after the injection, to prevent expulsion. 1 General Therapeutic Measures 163 Stimulant Enemata. — These are employed mainly for the pur- pose of introducing fluid into the circulation. Stimulating drugs are best given hypodermically or intravenously. The normal saUne solution may often best be introduced by rectum. Enemata of normal sahne solution may be given at intervals in the same quan- tities as are used for nutrient enemata, the object being to give as much fluid as possible without producing intolerance of the rectum. Another procedure is to give the normal salt solution by means of seepage. A fountain syringe connected by means of a rubber tube with a soft rubber catheter is used. The syringe is hung at an appropriate height above the bed, and is kept warm by being surrounded with some form of thick covering. The solution should be changed when it becomes cold. An attachment is placed upon the rubber tube, by means of which compression of the tube can be varied, and in this way the rate of flow of the solution can be regulated. It may be started at ten drops per minute, but if the patient begins to pass fluid from the rectum, the rate of flow should be decreased, the object being to give as much fluid as can be retained and absorbed. In this way fluid can be given continuously without producing intolerance. GAVAGE AND NASAL FEEDING.-Tn a great number of con- ditions in early life patients are unable or unwilUng to swallow sufficient nutriment. Gavage is a very important procedure in pediatrics. The same apparatus is employed as in stomach washing — • soft rubber catheter, connecting tube, and funnel. The technique is the same as that described for stomach washing, except that it is preferable to have the child lying upon its back instead of in a sitting posture. The catheter is introduced into the stomach through the mouth, and after the funnel has been raised to allow the gas to escape, the food is poured into the funnel. Before withdrawing the tube, it should be tightly pinched in order to prevent any fluid from trickling into the pharynx, and the tube should be withdrawn quickly. The introduction of the catheter through the nose is possible, and was formerly recommended for gavage. The introduction of the catheter through the mouth is preferable, but there are certain cases in which nasal feeding must be used. When gavage is neces- sary in children over two years old, the tube cannot be passed through the mouth without the use of a gag, and then only after much strug- gHng. There are also certain cases in which, on account of opera- tions about the throat or lesions in the throat, nasal feeding is better. MASSAGE.— This is useful in older children in the same condi- tions as those for which it is employed in adults. It is best whenever possible to have a trained masseur. In infancy true massage is not 164 Disease m Early Life often indicated. Massage of the abdomen is occasionally used in constipation. Friction of the skin either with the bare hand or wdth cocoa butter is sometimes indicated in infants. Cod hver oil is widely used for this purpose, but is very disagreeable, and has no advantages over cocoa butter. HYPODERMOCLYSIS.— The introduction of fluid under the skin is often a very valuable therapeutic measure in infancy and childhood. The object is to compensate for loss of fluid, to give addi- No. 51 F ~wi — 1 \ .-«(| Xasal feeding tional fluid, and to stimulate the general circulation. It is an alter- native procedure to the giving of normal salt solution by rectum, and is a preferable method in certain conditions. In other con- ditions, the skin is used in addition to the rectum, or is substituted for the rectum when the latter becomes intolerant. Sterile normal salt solution at body temperature should be employed. It is injected by means of an appropriate syringe and an ordinary antitoxin needle, both needle and syringe being sterilized. Injections may be made between the scapulae, into the skin of the abdomen, or in the lateral thoracic region. The amount injected at one time in an infant should be from one to four ounces, and in an older child from four to six ounces. General Therapeutic Measures 165 INTRAVENOUS INJECTIONS.— This procedure has hitherto been very httle if at all employed in infancy and childhood, princi- pally on account of the difficult technique caused by the small size of the veins. I have recently adopted the plan of employing the longitudinal sinus for purposes of intravenous injection in infants with open fantanelles. This greatly simpUfies the technique, and I have been gradually using intravenous injections more and more in infancy. Drugs — including the various stimulants from which quick action is desired — salvarsan in syphilis, and sodium bicarbonate in acidosis, may be given in this way. It is a most efficient means of intro- FiG. 52 Intravenous injections in infancy — tapping the cerebral ventricles A. Point where the needle is introduced in obtaining blood for examination, and for intraveneous injections and transfusion B. Point where the needle is introduced in tapping the cerebral ventricle ducing normal salt solution rapidly into the general circulation. Nutriment also may be introduced directly into the blood in the form of dextrose by means of this procedure. I have found intravenous dextrose injections of great value in certain cases of extreme inani- tion, atrophy, and malnutrition, and have been able to demonstrate that most if not all of the dextrose thus introduced is actually utilized for the purpose of energy production, only a little if any being excreted in the urine. 166 Disease ix Early Life The technique is simple. If the injection is of a small bulk which can be contained in a small syringe, no more apparatus is required than a sterile syringe and h\-podermic needle. If the injection is of larger bulk, as in the case of normal saHne, sodium bicarbonate, or dextrose injections, a somewhat larger needle must be used, and this is connected with a rubber tube, which in turn is connected \\dth a large syringe. A funnel may be employed instead of a syringe, but a syringe has the advantage that with it the physician can make sure that the needle is actually in the sinus. Fig. 53 Intravenous injection in infancj' Before beginning the injection the entire apparatus is sterilized. Two assistants are required, one to hold the child's head hrmly, the other to manage the syringe. The syringe is filled vdih the fluid to be injected, connected with the tube and needle, and all air is expelled. The region of the fontanelle is sterilized and the physician enters the needle in the median hne at the posterior angle of the fontanelle. The entrance of the needle into the sinus can usually be recognized by a sudden lessening of the resistance. The physician now holds the needle steady while the assistant in charge of the syringe slightly withdraws the piston. If the needle is in the vein, blood will imme- Fig. 49 — Tube feeding, first step ^ m Useful Drugs 167 diately appear at the glass window of the tube. The assistant then reverses the pressure and slowly injects the fluid into the sinus. • Dis- tention of the veins of the scalp is a sign that the fluid is being injected too rapidly. The injection should consume from ten to fifteen min- utes, and the amount injected should be one sixtieth of the infant's body weight. In dextrose injections a 5 per cent, solution is used. USEFUL DRUGS IN INFANCY AND CHILDHOOD The number of drugs used in the treatment of disease in infancy and childhood is comparatively small. It is far better for the physi- cian to understand thoroughly the use of a few drugs than to use many at random. It is essential also that the physician shall thor- oughly understand the action of ever}^ drug used, and that he should never prescribe a drug unless the indications for its use are clear. In considering the indications for drug treatment, it is important to remember the idiosyncrasies of children in general toward drugs, and also to be on the w^atch for individual idiosyncrasy. In giving a drug, the physician should proportion the dose to the age of the patient, and when a drug has been given, he should watch carefully its eft"ect. If the desired eft'ect is produced without toxic symptoms, it is a sign that the dose is sufficient. If toxic effects occur, the drug should be omitted for a time, and when it is resumed smaller doses should be given. If no effect is observed, increase the dose, carefully watching for either a good or a toxic effect. If no effect is then produced, the drug or particular preparation must be changed. In the following list, those drugs which are most important and most frequently used in the treatment of infants and children are indicated. It is assumed that the physician is familiar with the gen- eral description of these drugs and with the facts about their action, elimination, toxic effects, and contraindications. The purpose of the list is mainly to point out the particular purposes for which the drugs are used in early life, to point out any peculiarities which attend their administration to infants and children, and to indicate the doses appropriate at the dift'erent ages. It is extremely difficult to classify the drugs which are most useful in Pediatrics. They cannot well be divided on a basis of their importance on account of the great diversity of the purposes for which they are used. The classification used in the list is not by any means complete. Many of the drugs listed under one heading have also a pharmacological action which would bring them under another heading. The classi- fication is used mainly for convenience, and no efl"ort is made to list them in the order of the frequency of their employment. The doses given are minimum, those with which it is safe to begin. 168 Disease in Early Life STIMULANTS AND DIURETICS.— This group includes drugs whose principal action is upon the circulatory system or upon renal function, and their principal use is in the symptomatic treatment of disturbance of these functions. Caffein. — This is the most generally useful circulatory stimulant in the diseases of early life. It is used particularly in threatening circulatory failure of toxic origin such as occurs in many of the acute infectious diseases. This circulatory failure is usually due as much to vasomotor paralysis as to cardiac weakness, and caffein acts both as a vasomotor and cardiac stimulant. More specific symptomatic indications for its use will be given under the various diseases in which it is employed. It is best given in the form of caffein- sodium-benzoate, or caffein-sodium-salicylate. It is most often used hypodermically, but may be given by mouth. The hypodermic dose is as follows: One to six months, gr. i/8 Six months to two years, gf- 1/4 Two to five years, gr. 1/2 Over five years, gr- I Given every four hours, or as indicated. Digitalis.— This is used as a cardiac stimulant in circulatory disturbance caused by disease of the heart itself. It is almost useless in circulatory weakness resulting from causes outside the heart, and is of no use in the toxic circulatory disturbance of acute infections. Its chief indication is in cardiac insufficiency from disease of the endocardium, myocardium, or pericardium. In children it is more useful in the treatment of chronic than of acute lesions of the heart, and it is particularly valuable in cardiac disease associated with edema, on account of its diuretic action. The usual preparation is the tincture of digitalis (U. S. P.). Indications for its use are very rare in children under one vear. The dose is as follows: One to two years. m. IT Two to five years, m. IV Over five years, m. V to X Given three times a day. It is given by mouth. The following preparations and substitutes for tincture of digi- tahs may be used: Digipuratum, the patented preparation put up in tablets of which each is equal in strength to m. xv. of the tincture. It is expensive. Tincture of strophanthus (U. S. P.). The action is very similar to that of the tincture of digitalis and it is given in the same doses. It should be remembered that the absorption is slow and that twenty-four hours or more is required for the drug to pro- duce a result. Excretion is slow, and action may be cumulative. ^ i W"'^ mmmm 1_ , Fig. 50 — Tube feeding, second step Useful Drugs 169 Camphor. — This is useful as a rapid stimulant in sudden circula- tory collapse. It is given only subcutaneously or intravenously in the form of a lo per cent, solution in oil. The doses of this solution are as follows: One to six months, m. 11 Six months to a year, m. Ill One to two years, m. V Two to five years, m. VII Over five years, m. X Adrenalin. — This is occasionally useful in sudden circulatory col- lapse, especially when of vasomotor origin. The preparation is a one to one thousand solution of adrenalin chloride. Parke, Davis & Company's is a good preparation. It is given only hypodermically or intravenously. The dose is as follows: One to six months, m. I Six months to one year. m. II One to two years. m. Ill Two to five years. m. IV Over five years. m. V Strychnin. — This is used only rarely as a stimulant in early life, in certain particular conditions. Its indication will be noted under the diseases in which it is occasionally useful. It is given hypoder- mically in the form of strychnin sulphate. The dose is as follows: One to six months, gr. i/Soo Six months to one year, gr. 1/500 One to two years, gr. 1/300 Two to five years, gr. 1/200 Over five years, gr. i/ioo to 1/60 The OBROMiN- Sodium Salicylate. — This is a double salt of theo- bromin-sodium and sodium salicylate. "Diuretin" is a trade-name of a similar preparation. It is described in "New and Non-Ofificial Remedies, 1914." Theobromin-sodium salicylate is a diuretic, act- ing directly on the renal epithelium. It is slightly irritating to the kidneys and is contraindicated in acute nephritis. Its toxic effect is vomiting. The chief indication in children is in cardiac disease with edema. To young children who do not mind the bad taste, the drug may be given in solution; to older children it may be given in capsules. The dose is as follows: One to six months, gr. I Six months to one year, gr. II One to two years, gr. Ill Two to five years, gr. V Over five years, gr. V to X Given four times a day by mouth. A substitute having a similar action is the patented preparation known as theocin. It is used in smaller doses, from one-lifth to one- half the quantity of diuretin being given at a dose. 170 Disease in Early Life SEDATIVES. — This group includes drugs whose principal action is upon the nervous system. In it are described drugs which are given for the purpose of quieting nervous excitability, and also drugs other than the opiates which are used for the rehef of pain, or to pro- duce sleep. Sodium Bromide.— The bromides are by far the most generally useful sedatives in infancy and childhood. The sodium salt is to be preferred to the potassium or ammonium salts for use in child- hood. Owing to the fact that the nervous system in early Hfe is particularly hable to disturbance of function, sodium bromide is indicated in the symptomatic treatment of a great variety of condi- tions. It is also indicated in the more pronounced forms of nervous irritability, such as convulsions. It is well borne by children and is proportionately less likely to produce vomiting than in adults. Toxic effects are vomiting, acne, coryza, and somnolence. Sodium bromide is administered in watery solution well diluted. It is given by mouth except in cases where vomiting is present or where swallowing is impossible. Under the latter conditions it is given by rectum. The dose varies somewhat with the purpose for which the drug is prescribed. As a sedative in comparatively mild conditions, the dose is as follows: One to six months, Six months to one year, One to two years, Two to five years, Over five years, given every four hours. When sodium bromide is given for the purpose of checking serious symptoms such as convulsions or vomiting, the doses must be some- what larger, as follows: BY MOUTH BY RECTUM gr. 1/2 gr.I gr. I-x/2 gr.II £:r. Ill to IV gr.I gr.II gr. Ill gr. IV gr. VI to X BY MOUTH BY RECTUM One to six months, Six months to one year, One to two years, Two to five years, Over five years. gr. I-1/2 gr. II-1/2 gr.V gr.VII gr. X to XV gr. Ill gr.V gr.X gr. XV gr. XX to XXX Given as a single dose and repeated as often and in whatever doses as are necessary to produce the desired effect. Chloral. — The chief use of chloral in early life is to check severe convulsions in infancy. It is well borne even by quite young infants. It should always be given in solution by rectum. The dose is as follows : One to three months, gr. I Three to six months, gr. II Six to twelve months, gr. Ill One to two years, gr. V Useful Drugs 171 Trional. — This is occasionally indicated in older children for the same purpose for which it is used in adults, namely, to produce sleep. Insomnia, however, is a symptom which much less often requires treatment in children than in adults, and is usually produced by those forms of nervous over-excitability which are best treated by the administration of bromide. In infants trional is almost never indi- cated, sodium bromide being preferred. Trional is insoluble and is given by being placed upon the tongue and washed down with water. The dose is as follows: Two to five years, gr. II Five to thirteen years, gr. Ill to V Salicylate. — This represents the most useful drug for the rehef of certain kinds of pain in childhood. In addition to being anal- gesic, sahcylate is antipyretic and diaphoretic. It also increases nitrogen ehmination in the urine, acts as a cholagogue, and has some diuretic action. The toxic effects are tinnitus, headache, vomiting, erythema, and in very large doses, drowsiness or dehrium. It is very well borne by children. It is contraindicated in acute nephritis or when there is an idiosyncrasy. The indications for salicylate are rheumatic fever, and various other conditions belonging in the ill-defined rheumatic class which are characterized by pain. It is used for pain in arthritis, peri- carditis, endocarditis, neuritis, neuralgia, and similar conditions. It is an open question whether its action in rheumatic fever is only to reheve pain, or whether it has some actual curative action. There is evidence that it has curative value in some cases of chorea. It is comparatively rarely used in infants, as they do not often suffer from rheumatic fever or from the various forms of pain which are influenced by salicylate. The preparation most commonly used is the sodium sahcylate (U.S.P.). Children do not mind the taste of sodium sahcylate as do adults, and consequently the drug is best given in solution which may be so arranged that one teaspoonful contains the desired dose. It is usually unnecessary to add any vehicle for the purpose of dis- guising the taste. The dose is as follows in rheumatic fever: Two to five years, gr. Ill Five to eight years, ■ gr. V Eight to thirteen years, gr. V to VII Given every hour until relief of pain has appeared, and after this every four hours, unless some toxic effect is produced. For pain in other concUtions than rheumatic fever smaller doses may be sufficient, A common substitute for sodium salicylate is acetylsalicylic acid which is a proprietary preparation sold under the trade name of 172 Disease in Early Life aspirin. In children this has no particular advantage over sodium salicylate. The doses are the same. Phenacetin. — This was formerly a proprietary preparation, but it is now official under the name of acetphenetidinum. It is a coal-tar derivative. Its action is analgesic, antipyretic, mild diaphoretic, and sedative. The toxic effect is circulatory depression, but it is comparatively well borne by children. It is used in a great variety of conditions, rarely as an antipyretic, more often as an analgesic or sedative. Phenacetin has the disadvantage of being insoluble, and is given in tablet form or as a powder. The dose is as follows: One to six months, gr- 1/4 Six months to one year, gr. 1/2 One to two years, gr.I Two to five years, gr. I-1/2 to II Over five years, gr. II to IV Repeated every two to four hours until the desired effect is produced. OPIATES. — Strong objections have been urged against the use of opium in the diseases of early life. It is true that the opiates are less often required in infancy and childhood than in adult life, and this apphes especially to infancy. Nevertheless, cases are frequently encountered in which an opiate is required for the relief of pain. Moreover, small doses of an opiate are the most effective means which we have of controlling excessive cough. Paregoric. — This is the most generally useful preparation of opium for use in young children. Its chief uses are to check cough, check certain forms of diarrhea, and occasionally to control pain. The doses are as follows: One to three months, m. I Three to six months, m. II Six months to one year. m. Ill One to two years, m. V Two to five years, m. X to XX Five to ten years, m. XX to XXX Given every four hours by mouth in a little water. MORPHIN.— This is the best preparation of opium for the control of severe pain. It is not well borne by children and the doses must be proportionately smaller. Morphin is most commonly given hypo- dermically in the following doses: One to three months, gr. 1/1500 Three to six months, gr. i/iooo Six months to one year, gr. 1/600 One to two years, gr. 1/300 Two to five years, gr. i/ioo to 1/48 Five to ten years, gr. 1/48 to 1/24 Over ten years, gr. 1/24 to 1/12 Useful Drugs 173 Repeat when necessary, not sooner than in two hours. When given by mouth the doses must be slightly larger. CoDEiN. — This opium derivative is chiefly employed for cough, or for the treatment of pain. It is less effective than morphin but does not have the constipating effect. The dose is as follows: One to three months, gr. 1/300 Three to sLx months, gr. 1/200 Six months to one year, gr. i/ioo One to two years, gr. 1/60 Two to five years, gr. 1/60 to i/io Five to ten years, gr. i/io to 1/8 Over ten years, gr. 1/8 to 1/6 Given by mouth and repeated when necessary, or every four hours. Dover's Powder. — This is occasionally used instead of pare- goric, and for the same indications. The dose is as follows: One to three months, gr- I 20 Three to six months, gr. i/io Six months to one year, gr- 1/8 One to two years. gr- 1/4 Two to five years. gr- 1/2 to I Five to ten years, gr- II to III Over ten years, gr- III to IV PURGATIVES AND LAXATIVES. Castor Oil (Oleum ricini U.S. P.). — This is the most useful general purgative for use in infancy and childhood. Nothing surpasses it in producing rapid and complete emptying of the bowels. Its chief indication is in various forms of indigestion, especially those characterized by diarrhea. Infants and very young children do not object to the taste, and even older children will often not mind the taste if it has not been suggested to them that the taste is bad. When the taste is objected to, castor oil may be given with orange juice, lemon juice, or brandy. The doses are as follows: First year, i teaspoonful Second year, 2 teaspoonfuls Two to five years, 3 teaspoonfuls Over five years, i tablespoonful Calomel. — This is a purgative and diuretic, but in children is used almost wholly on account of its purgative action. The toxic effects are renal irritation and stomatitis, but the purgative doses used with children never produce these effects. Calomel is useful as a substitute for castor oil when vomiting is present, and is also useful in the treatment of vomiting, as when given in repeated doses it tends to correct reversed peristalsis. It is dispensed in the form of tablets or powders. When tablets are given they should be crushed into powder with the back of a teaspoon, and the powder is given by being floated on the surface of a teaspoonful 174 Disease ix Early Liee of water. In almost all cases calomel is best given to children in dix-ided doses as follows: One to six months, gr. 1/20, even' half hour for ten doses Six months to two years, gr. i/io, every hah" hour for ten doses Two to five years, gr. 1/8, every half hour for ten doses Over five years, gr. 1/4, ever}' half hour for eight doses In infants it is unnecessary to follow the calomel with a saline cathartic. In older children it is well to follow it with a dose of magnesia. Magnesia. — This is the most useful mild laxative for use in infancy and childhood. In the first two years of Ufe the best preparation is PhiUips' milk of magnesia. After two years the best preparation is citrate of magnesia. Milk of magnesia, which is a suspension in water, is used in infancy for two purposes. The first is as a mild measure for the emptying of the bowels. The dose is as follows: One to six months, i teaspoonful Six months to one year, 2 teaspoonfuls One year to eighteen months, 3 teaspoonfuls Eighteen months to two years, i tablespoonful The other use for milk of magnesia is in the treatment of constipa- tion. For this purpose it is better not to give the magnesia in single daily doses, but to give it with every feeding. The dose required varies with the severity of the case and mil be discussed under con- stipation. In children over two years of age citrate of magnesia is the best preparation. The dose is as follows:' Two to five years, oz. 11 Over five years, oz. IV Given usually at bedtime. Magnesium Sulphate. — This is occasionally used in childhood as a hydrogogue purge. Its chief indication is in dropsy, whether of cardiac or of renal origin. It is contraindicated when there is marked weakness, emaciation, or vomiting. The dose in young children is two teaspoonfuls, in older children two to four teaspoon- fuls, given well diluted in water on an empty stomach. Casc-AJRA. — (Fluldextractum Rhamni purshianae, U.S. P.). (Fluid Extract of Cascara Sagrada). This is a mild laxative useful in con- stipation and in a variety of other conditions as a means of keeping the bowels open. It is not so good in the treatment of constipation in infants as in older children. The dose in infants is from one to five drops, in older children from five to twenty drops. It is given in water, preferably at bedtime. Useful Drugs 175 Agar Agar. — This substance swells enormously by the absorption of water, is not digested, does not ferment, and is consequently useful in stimulating peristalsis and sweeping out the intestine. It is used in chronic constipation usually in conjunction with other forms of treatment. The dose is from a teaspoonful to a tablespoonful once or twice daily. Powdered agar agar may be eaten on cereal. Granu- lated agar agar may be eaten mixed with milk or water. There are also agar agar wafers on the market. Russian Oil. — This is liquid paraffin similar to the petrolatum liquidum of the U.S. P. The Russian oil is, however, a more refined product and does not have the yellowish color and unpleasant taste which characterizes American petroleum. It is useful as an intestinal lubricant which passes unabsorbed and undigested through the intestine. It is employed in some cases of chronic constipation. The doses are as follows: Under two years, i teaspoonful Two to five years, 2 teaspoonfuls Five to ten years, 2 to 4 teaspoonfuls Given three times daily after meals. TONICS. Alcohol. — This is well tolerated by children, even by young infants. It has, however, been much abused through being used as a stimulant. The chief value of alcohol in early life is as a tonic, particularly in conditions of malnutrition. It is useful in many chronic conditions, and in acute febrile conditions late in the course of the disease. Alcohol is best administered to children in the form of brandy or whisky. The twenty-four amounts with which treatment with brandy is begun in children are as follows: One to six months, 1/2 teaspoonful Six to twelve months, i teaspoonful One to two years, 2 teaspoonfuls Two to five years, 3 to 4 teaspoonfuls Over five years, 4 to 6 teaspoonfuls This may be given in divided doses with the feedings or meals. Iron. — This is as useful as a tonic in the anemias of infancy and childhood as it is in those of adults. The best preparation for use in the anemias of infancy is the citrate of iron given subcutaneously. An aqueous solution of the citrate is put up in ampules, sterilized, and each ampule contains a single dose. A platinum needle must be used. The dose during infancy is three-quarters of a grain every other day. An alternative preparation for use in infancy is the saccharated carbonate in doses of 5 gr. three times a day. With older children nothing is better than Blaud's pills in doses of 5 gr. three times a day. Arsenic. — This is indicated as a tonic in a variety of conditions encountered in infancy and childhood. It is usually given in the 176 Disease in Early Life form of Fowler's solution (liquor potassii arsenitis, U.S. P.). Arsenic is well borne by children. The doses of Fowler's solution for ordinary tonic purposes are as follows: One to six months, i drop once a day- Six to twelve months, i drop twice a day One to two years, i drop three times a day Two to five years, 2 drops three times a day Over five years, 2 to 5 drops three times a day Given in w^ater after meals. Cod Liver Oil. (Oleum Morrhuae, U.S. P.). — This is a very useful tonic in infancy and childhood, used in a variety of conditions. In the case of infants, the pure oil is to be preferred to an emulsion. The dose is 10 to 20 drops three times a day after meals. To older children any good emulsion of cod hver oil may be given in doses of I to 4 teaspoonfuls three times a day after meals. Malt Preparations. — These are sometimes of value as tonics, particularly in conditions in which cod liver oil is not well borne. Malt extract may also often be advantageously combined with cod liver oil. The dose is i to 4 teaspoonfuls three times a day after meals. Tincture of Nux Vomica. — This is the only bitter tonic which is much used in the diseases of early Hfe. It is especially useful in con- ditions attended with loss of appetite. The dose is as follows: One to six months. m. 1/4 Six months to one year. m. 1/2 One to two years, m. I Two to five years. m. II Over five j^ears. m. Ill to V Given three times a day before meals. It may be combined with water in such proportions that each tea- spoonful contains the required dose. Compound Syrup of the Hypophosphites. (Syrupus Hypophos- phitum Compositus, U.S.P.).— This is occasionally useful as a tonic in older children. The dose is i teaspoonful three times a day after meals. DRUGS USED UNDER SPECIAL INDICATIONS. Sal- VARSAN. — This is a proprietary preparation. Its action is to kiU cer- tain pathogenic organisms in the living body. It may irritate the kidneys or liver, but apparently has no toxic effect for other organs. Its toxic effects are as follows : Signs of renal irritation or diminution of renal function; jaundice; erythema; hyperemia and swelling at the site of the syphilitic lesions; fever developing gradually. The only indication for salvarsan in infancy and childhood is syphilis. Useful Drugs 177 Neosalvarsan has an action like that of salvarsan but less powerful in equal dosage, and with less danger of toxic effects. The dose of salvarsan for an infant is 0.05 gm.; the dose of neosalvarsan is o.i gm. The method of administering salvarsan will be described under syphilis. Mercury. — This is used in early life in the treatment of congenital syphiUs. Mercury is usually given to infants by inunction. Equal parts of unguentum hydrargyri and vaselin are ordered, and an amount the size of a pea is rubbed in daily. If for any reason the inunctions are objectionable, the gray powder (hydrargyri cum creta, U.S. P.) may be given by mouth. The dose is gr. 1/2 three times a day. PoTASSii loDiDUM. — lodide of potash has two actions of impor- tance in the therapeutics of infancy and childhood. These are: i. It causes the disappearance of the tertiary lesions of syphilis. 2. It increases the fluidity of mucus in the respiratory tract. In over doses it causes acne, catarrh of the respiratory organs, gastric dis- turbance, and possibly dehrium. Its chief indications are in tertiary syphilis, in bronchitis with sticky expectoration, and empirically in asthma. lodide of potash is well borne by children, and for tertiary syphihs may be given to older children in the same doses as to adults, namely, 10 to 20 gr. three times a day. In infancy the usual dose iri syphilis is 5 gr. three times a day. As an expectorant the doses are half those given for syphilis. Usually, however, as an expectorant in infancy and childhood, it is better to use as a substitute syrup of hydriodic acid. The doses are as follows: One to six months, 5 drops three times a day Six months to one year, lo drops three times a day One to two years, 15 drops three times a day Two to five years, 20 drops three times a day Over five years, 1/2 teaspoonful three times a day QuiNiN. — This is a specific for malaria. It is well borne by young children and relatively larger doses are required than for adults. The various preparations of quinine, the doses, and the methods of administration will be described in detail under malaria. Hexamethylenamin. — This drug is excreted in an acid urine in the form of ammonia and formaldehyde. The setting free of for- maldehyde acts as a urinary antiseptic. When the urine is alkahne or neutral in reaction, hexamethylenamin is excreted unchanged, and is inefhcient. In such a case the urine should be made acid by the administration of acid sodium phosphate, but this drug should not be administered with hexamethylenamin because they are in- compatible. Hexamethylenamin is especially indicated in pyelitis and cystitis; 12 178 Disease IN Early Life also in typhoid fever, to prevent bacilluria and cystitis. The dose is as follows: One to six months, gr. II three times a day Six months to one year, gr. Ill three times a day One to two years, gr. V three times a day Two to five years, gr. VII three times a day Over five years, gr. X three times a day The drug is given in solution which may be so put up that a teaspoon- ful contains the required dose. It should be given with plenty of water. ''Uro tropin," "formin," and "aminoformin," are proprietary names applied to hexamethylenamin. Sodium Bicarbonate. — This is used in infancy and childhood in a great variety of conditions, among which are the following: (i) In the modification of cow's milk for infant feeding; (2) as an antacid acting locally in certain disturbances of digestion; (3) as a means of making the urine alkahne; (4) as a means of diminishing the acidity of the blood. The dosage and method of administering vary widely with the different purposes for which bicarbonate of soda is used, and will be given under the various indications. Bismuth Subnitrate. — This a mild astringent and antacid, and combines with the sulphuretted hydrogen in the intestine to form a black insoluble sulphate. In childhood it is chiefly used in the treat- ment of certain forms of diarrhea. A good preparation for infants is the milk of bismuth (Parke, Davis and Co.), which can be given in the feedings; each teaspoonful contains 5 gr. of bismuth subnitrate. The doses are as follows: Infants, gr. V. Older children, gr. X. Given every four hours, or repeated after each loose movement. Potassium Chlorate. — This is chiefly used in the treatment of certain forms of stomatitis in infancy and early childhood. Its bene- ficial effect comes from the fact that it is almost wholly excreted with the saliva. When given in over-doses, it is toxic, the symptoms being drowsiness, suppression of urine, cardiac weakness, and sometimes cyanosis. The best method of administering it is to put the entire twenty-four hour amount into a glass of water, and to divide the doses in such a way that they will be given as frequently as possible. The following is the quantity which can be taken in twenty-four hours at the different ages: Under one year, gr. X One to two years, gr. XV Two to six years, gr. XX Six to eight years, gr. XXV Eight to fourteen years, gr. XXX Sweet Spirits of Nitre. (Spiritus aetheris nitrosi). — This is used in infants as a mild diuretic and antipyretic. The doses are as follows : Useful Dr tJGS One to six months, Six months to one year, One to two years, Two to five years, Over five years, m. II m. Ill m. V ra. X m. XV to XX 179 Given every four hours in water. Ipecac. — This drug is used in infancy and childhood chiefly as an expectorant, but occasionally as an emetic. Its chief value is in croup. The best preparation for children is the Wine of Ipecac. Expectorant doses are as follows: One to three months. m. 1/4 Three to six months, m. 1/2 Six months to one year, m.I One to two years, m. II Two to five years, m. Ill Over five years. m. V Given every four hours in a little water. As an emetic or in croup, larger doses are required. Sodium Benzoate. — This is occasionally used in early life, par- ticularly in the treatment of pyelitis. The purpose of its adminis- tration is to make the urine acid. The dose in infancy is i to 5 gr. ; in older children, 5 to 30 gr. It is given in solution. Potassium Acetate. — This is occasionally used in early life, chiefly for the purpose of making the urine alkaline. The doses are the same as those of sodium benzoate. Atropin and Belladonna. — The chief use of this drug in early life is in the treatment of enuresis. The dosage and method of ad- ministration will be described under that disease. Atropin and bella- donna are occasionally used for their action in checking excessive secretion from the respiratory mucous membrane. Atropin is also used with morphin for its counteracting effect. The doses are as follows: For Atropin— One to three months, gr. 1/5000 Three to six months, gr. 1/3000 Six months to one year, gr. 1/2000 One to two years. gr. i/iooo Two to three years, gr. 1/500 Three to five years. gr. 1/300 Five to seven years. gr. 1/200 Seven to ten years. gr- 1/150 Ten to fourteen years. gr. i/ioo For Tincture of Belladonna — One to six months, m. 1/4 Six months to one year, m. 1/2 One to two years. m.I Two to three years. m. II Three to five years. m. Ill Five to seven years, m. V Seven to ten years, m. VII Ten to fourteen years, m.X 180 Disease in Early Life Thyroid Extract. — This is used in infancy in the treatment of cretinism. There are various preparations, among which I have found that of Burrough's and Welcome to be very satisfactory The doses should be at first gr. 1/4 three times a day, and this is gradu- ally increased. Signs of over-dosage are wakefulness, sweating, tachycardia, or rise of temperature. ROUTINE TREATMENT OF AN ACUTE SELF- LIMITED DISEASE In order to avoid needless repetition in the description of the treat- ment of various diseases, the routine treatment of an acute self- limited disease will be described here. It will then only be necessary in the description of the particular diseases of this class to enumerate any special modifications called for by the special etiology and symp- toms of the several diseases. The duty of the physician in an acute self-limited disease may be summarized as follows: 1. The hygienic care of the patient. 2. Directing the diet. 3. Attending to the bowels. 4. The treatment of symptoms. 5. Watching for complications. To these may be added in certain diseases — 6. The establishment of quarantine and the carrying out of proper means of disinfection. Hygienic Care. — Children with an acute self-limited disease should invariably be kept in bed during the entire febrile period, and for a certain time after the fever has subsided. The length of time during which they should be kept in bed after the temperature has come down permanently to the normal varies with the several dis- eases. The sick-room should preferably be one with a sunny exposure. Plenty of fresh air should always be secured at all times. In winter an open fire in the sick-room is very desirable. Every detail of the nursing should be carefully supervised, and good nursing is the prime essential in the treatment of the acute febrile diseases. It is usually best for the child not to walk or be carried to the bathroom, but to remain continuously in bed, using the bedpan. Sponge baths should be given in bed. Plenty of water should be given in all febrile diseases. The management of convalescence is important. The time when the child is allowed to get out of bed depends mainly on the rapidity with which its strength returns, and varies with the character and severity of the disease. It is usually best to keep children in bed for some time after they are anxious to get up, even though recovery Routine Treatment 181 in children is usually rapid. Patients should first be allowed to sit up in bed for an increasing length of time each day. They may then be allowed to sit up in a chair for a little while in their dressing gowns, and if this does not tire them, they may be given their clothes. On the' first day after a child gets its clothes, it should not be allowed to walk farther than from the bed to a chair, and should only be dressed for a short time. As the strength of the child increases, it may be allowed to be dressed for a longer period each day, and to gradually walk about more. When the child shall be allowed to go out doors depends upon the rapidity of the return of strength and upon the prevailing weather conditions. The Diet. — The diet to be given in acute febrile diseases varies somewhat with the type of infection. In breast-fed babies no change should be made from the normal diet, except possibly shght dilution of the breast milk by giving boiled water, or water and hme water immediately before each nursing. In artificially-fed infants, it should be remembered that in acute febrile diseases the digestive power is lowered. Consequently the composition of the food must be adapted to the digestive power of the child by a reduction in the percentages of all the food elements, and fat is especially badly borne in acute illness. On the other hand, the child should be fed up to the limit of its digestive power. The feeding must be carried out on the principle described in the division on Feeding. It is unnecessary under ordinary circumstances to change the amounts given at a feed-, ing and the intervals between feedings. Older children with acute febrile diseases must be fed more fre- quently with smaller quantities than in health, the usual interval being every four hours during the day, and sometimes an additional night feeding is given. Children should always be fed at regular intervals, should never be fed oftener than every three hours, and should never be given milk between feedings when they ask for a drink. The diet should consist mainly of farinaceous food. In children under five years of age, the milk must usually be somewhat diluted with water or lime water. When children do not take milk readily, they may be given Kumyss, beef juice, or broth, as substitutes. Broth and beef juice are also often a valuable part of the routine diet in addition to the milk and farinaceous foods, when they can be digested. Ice cream and jellies are likely to disturb the stomach and should not be given. Raw eggs beaten up with a Httle sherry, a little sugar, and cracked ice are usually taken weh, and form a valuable addition to the diet. Orange juice or grape juice may be given with feedings at which no milk is taken. Among the farinaceous foods, oatmeal and barley gruels are the best. 182 Disease in Early Life The physician should note carefully the total amount of food taken each day. It is undesirable to force food upon children who have marked loss of appetite. In an acute febrile disease, anorexia is Nature's method of protecting the patient against disturbance of digestion. On the other hand, anorexia may be so extreme that an insufficient amount of food is taken. If this occurs only during the first one or two days of the illness, no attention need be paid to it, even if practically no food be taken. If, however, it continues longer than the first two days, forced feeding may be necessary. In such cases gavage must be resorted to. Gavage is most often indicated in infants, but is occasionally required in older children also. If, however, in older children insufficient food is taken on account of anorexia rather than on account of delirium or coma, an effort should be made to increase the amount of food taken by persuasion, before resorting to gavage. The Bowels. — The nurse should be directed to give an enema every other day as a routine, if the bowels do not move. When the physician finds that these enemata are required, he should order a mild laxative to be given daily, provided that it does not upset the stomach. Magnesia, or some mild saline may be used for this purpose. It is usually a good plan to empty the bowels at the onset of an acute febrile disease. For this purpose castor oil is best; if there is vomiting, calomel should be used. The Treatment of Syimptoms. — As there is no specific drug treat- ment for the acute febrile diseases, no drug should be given as a routine. The majority of cases of acute febrile disease in children require no drug treatment whatever. It is, however, very commonly said that it is difficult in private practice to retain the confidence of the par' ents of the patient if no medicine is given. They do not reahze that the hygienic care, nursing, and attention to the diet and bowels are the chief essentials of treatment, and feel that if nothing is prescribed, nothing is being done for the child. In my experience, the old super- stition as to the necessity of medicinal treatment is gradually passing away; the modern mother of the educated classes, in this community at least, often not only knows that routine medicinal treatment is not necessary, but is even apt to judge any physician who uses it as old fashioned and behind the times. I realize, however, that among many classes of people, and in other communities, the parents of sick children demand drugs. In such cases the physician should take care to prescribe nothing which can possibly do any harm. Sweet spirits of nitre in small doses will sometimes satisfy the parents. On the other hand, the physician should watch most carefully for every symptom which does require treatment, or which can be benefited in any way by treatment. When such symptoms arise, the proper treat- Routine Treatment 183 ment should be instituted at once. Even in these cases, however, the various therapeutic measures other than drugs are usually of the greatest value. Complications. — The physician should watch most carefully for the appearance of complications, as they are not uncommon in the acute febrile diseases. An adequate physical examination should never be neglected at any visit. One of the chief dangers in the acute self-limited diseases is the liability to complication, and their early recognition and proper treatment is of the first importance. Quarantine and Disinfection. — The measures used in preventing the transmission of the infection to other persons will be described under the contagious diseases. ROUTINE TREATMENT OF A CHRONIC DISEASE In many chronic diseases it is not necessary for the child to be kept in bed. Whether or not bed is necessary depends entirely upon the patient's strength. Chronic cases should have as much open air treatment as possible, and whenever weather conditions permit, the child should be taken out doors or its bed should be placed out doors. The hygienic measures applicable to chronic diseases are the same as those indicated for the healthy child, with whatever modifications may be demanded by the character of the disease. The same is true of the diet. In my experience, many children with chronic disease are kept in bed too much. DIVISION III DISEASES OF THE NEWBORN I. MALFORMATIONS The commonest diseased conditions seen in newborn infants are the various gross developmental lesions known as malformations. The malformations are so very numerous, that their detailed descrip- tion would occupy much space. Almost any part of the body may be involved. Usually the malformation is external, and its nature is recognizable at once. The only question which confronts the physician is whether the condition is one which offers hope of relief through surgical treatment. Occasionally, the malformation is internal, and gives rise to symptoms of functional disturbance of so vague a character that a diagnosis cannot be made at once. Such cases play an important part in diagnosis. The most important malformations are described in the divisions devoted to the different organs or tracts of the child's body. II. TRAUMATIC CONDITIONS CAPUT SUGCEDANEUM This is a lesion of the scalp, seen in newborn infants, and caused by the mechanical conditions attending labor, especially when pro- FiG. 54 Caput succedaneum. Male, 2 hours old longed. There is an extravasation of serum, or blood, into the sub- cutaneous tissues of the scalp. A swelling is seen, sometimes on one side, sometimes on both sides of the cranium. The tumor is soft Cephalhematoma 185 and flabby, and does not fluctuate. It is at its height at birth, and always disappears spontaneously in the course of two or three days. CEPHALHEMATOMA This condition also is due to an injury received during birth, which causes a rupture of the sub-periosteal blood-vessels. The result is a hemorrhage between the periosteum and the bones of the cranium, which manifests itself as a swelling of the scalp. This swelling is usually not present immediately after birth, but appears in the first three or four days of life. The tumor is soft and fluctuating, reaches a variable size, and is usually situated over one parietal bone, rarely over both. The tumor usually continues to increase in size for about a week, becoming more tense, and may become so large as to cover the w^hole parietal bone. After a stationary period, it begins Fig. 55 Double cephalhematoma. Infant, 4 daj's old to diminish very slowly, becoming softer, and often it does not com- pletely disappear until as late as the fourth month. The skin over the tumor appears unchanged, and there is no tenderness, nor other signs of inflammatory reaction. After the tumor has been present a few days, an elevated ridge presenting a bony edge can be felt sur- rounding the tumor. Cephalhematoma is distinguished from caput succedaneum, in that it is not at its height at birth, but continues to increase in size, is fluctuating, becomes more tense, and does not disappear so rapidly. It is distinguished from abscess of the scalp by the absence of signs of inflammation. In some cases, a cephalhematoma becomes con- -186 Diseases of the Newborn verted into an abscess through infection. In case of doubt, the diagnosis can be settled by aspirating the contents of the tumor with a hypodermic needle under the strictest aseptic precautions. Cephalhematoma disappears spontaneously, and requires no treat- ment other than protection from external injury. When infected, the treatment is that of an abscess. HEMATOMA OF THE STERNO-CLEIDO-MASTOID MUSCLE This condition also is a traumatic birth injury. Either from the violence of the expulsive efforts of the uterus, or from too great vio- lence on the part of the obstetrician, the sterno-cleido-mastoid muscle is torn in such a way that there occurs a hemorrhage into its sheath. Soon after birth it is noticed that the infant holds its head to one side, and when the cause of the torticollis is sought, one sterno-cleido- mastoid muscle is found contracted, and along the tense muscle a small tumor is felt. Sometimes, especially in infants with fat necks, the tumor is difficult or impossible to feel. It is soft at first, and tender to the touch; later it becomes smaller and harder. Efforts to straighten the neck cause crying. The tumor disappears spontaneously, but the torticolHs is apt to persist. It is probable that most cases of torticollis in young infants are due to this cause. No treatment should be employed until after all pain and tender- ness have disappeared, when massage, and gentle manipulations designed to stretch the shortened muscle should be begun. If these measures fail, the child should be referred to the orthopedic surgeon, for treatment by apparatus or operation. INTRACRANIAL HEMORRHAGE ETIOLOGY. — The commonest cause of the intracranial hemor- rhage seen in newborn infants is trauma, the injury being due to the violence attending parturition. Hemorrhage is seen following both operative and normal labor. Everything which increases or prolongs pressure upon the head during labor may be a predisposing cause. Such conditions as difficult or prolonged labor, precipitate labor, di£&culty in extracting the head in breech presentations, and difficult instrumental deliveries, may act as causes. Occasionally intra- cranial hemorrhage is seen as a manifestation of hemorrhagic disease of the newborn. Rare cases may be associated with syphilis, or infec- tion of the newborn. PATHOLOGICAL ANATOMY.— The hemorrhages may occur over the cortex of the brain, or at the base. They are found most frequently beneath the tentorium, usually over the cerebellum, or the occipital lobes of the cerebrum, but hemorrhages over the cortex Intracranial Hemorrhage . 187 are not uncommon, and even hemorrhage into the ventricles has been reported. The extent of the hemorrhage and amount of extra- vasated blood are very variable. There may be a single large clot, or diffuse hemorrhage. The lesion may be confined to one hemis- phere, or extend over both. The extravasation may be beneath the pia mater, or in the arachnoid space between the pia and the dura. The source of the hemorrhage is also variable. In a large propor- tion of cases, lacerations of the tentorium have been found. The blood may come from a laceration of one of the sinuses of the dura from overlapping of the bones, but more frequently, when there is no laceration of the tentorium, the blood comes from one of the large veins empyting into the sinuses, or from the rupture of a small vessel in the pia. SYMPTOMS. — In intracranial hemorrhage, one would expect the symptoms to be those either of increased intracranial pressure, or of cortical irritation. In certain cases such symptoms are present to such a well marked degree, that the picture of a cerebral lesion is very plain. Such cases are frequently asphyxiated at birth, and are only resuscitated after considerable effort. They may show cyanosis, difficult, shallow, or very irregular respiration, bulging fontanelle or slow pulse. They may show twitching of the extremi- ties, or even convulsions, especially in cases which last several days. There may be spasm of the extremities, or paralysis of the face, op of one or more of the limbs, and there may even be a general rigidity or opisthotonus. In these cases the deep reflexes are increased, the pupils may be dilated, or more commonly, contracted, and there may be strabismus or nystagmus. The localizing symptoms of cortical irritation are more frequently seen when the hemorrhage is situated over the cortex. When the hemorrhage is at the base, the symptoms are those of increased pres- sure. In these pronounced cases, showing symptoms of this kind, death may occur within twenty-four hours, and with very large hemorrhages, the children are usually still-born. Nevertheless, pronounced cases giving these distinct symptoms of a cerebral lesion, are comparatively less common than those in which the symptoms are much vaguer, and less suggestive either of increased intracranial pressure, or of cortical irritation. In such types the diagnosis is equally important, but more difficult. The symptoms are frequently not seen at birth, but develop at some time during the first four days of life, usually at about the second day. The commonest and most suggestive symptom is re- fusal to nurse. The babies are pale, and show either restlessness, or seem very dull and stupid, rousing with difficulty. There is often at this time a slight facial edema, which, when present, is a sign of 188 Diseases oe the Newborn great significance. The appearance of refusal to nurse in a new- born baby should always suggest the possibiHty of intracranial hemorrhage, while pallor and facial edema greatly strengthen suspi- cion. Careful examination for cyanosis, disturbed breathing, tense fontanelle, slow pulse, or signs of cortical irritation will often confirm the suspicion, but it must be remembered that localizing nervous symptoms are frequently absent. DIAGNOSIS. — When there are found the symptoms of refusal to nurse, pallor, and possibly facial edema in a newly born baby, intracranial hemorrhage should always be suspected. When in addi- tion are found signs either of increased intracranial pressure, or of cortical irritation, the diagnosis is confirmed. In the absence of these confirmatory signs, the condition should always be suspected. In doubtful cases, lumbar puncture should be performed. If the fluid obtained is bloody, the diagnosis of intracranial hemorrhage is verified, provided that the operator has performed the puncture carefully, and is sure he has not wounded a local blood-vessel. If the fluid is clear, intracranial hemorrhage is not excluded, as only in cases where the hemorrhage is below the tentorium, will the fluid be blood stained. In a case which remains doubtful after a negative lumbar puncture, confirmation of the diagnosis may be obtained by aspiration of the subdural space, as advocated by Henschen. The technic is simple. The aspiration is made through a fontanelle or suture, care being taken not to wound the dural sinuses. The most favorable point is at the lateral angle of the anterior fontanelle. The needle is entered in a direction almost parallel with the surface of the skull, and if blood is not imxmediately obtained, may be carefully swept in various directions. The middle hne must not be crossed on account of the falx. If blood is found, as much may be removed as will flow through the needle. PROGNOSIS. — The prognosis is always serious. Hemorrhages below the tentorium are probably always fatal, as are large hemor- rhages in any situation. Death may not occur for four or five days. When the hemorrhage is situated over the convexity of the brain, and is not too large, the child may survive. In such cases there is always serious damage to the brain, which usually manifests itself later as a cerebral paralysis. The full extent of the damage may not become apparent for a number of years. It follows that in cases in which the signs of cortical irritation are not marked, but in which the signs are those of intracranial pressure, a fatal ending is most certain. TREATMENT.— Prophylaxis is the most important measure available in connection with so serious a condition as intracranial hemorrhage. This is mainly a matter for the obstetrician. It Obstetrical Paralysis 189 must be remembered also that slight and unavoidable degrees of trauma may be followed by hemorrhage. The indications are to shorten prolonged and tedious labor, to avoid compressing the head too violently with the hand through the perineum, and to avoid difficult high forceps operations whenever possible. Aspiration of the clot through the fontanelle or suture will some- times give relief of symptoms. If, when this procedure is under- taken for diagnosis, a considerable amount of blood can be withdrawn, it may be wise to wait before trying anything further. If little or no blood is obtained, the only treatment is by operation. The operative treatment of intracranial hemorrhage of the new- born consists of craniotomy and washing out of the clot. The opera- tive risk is necessarily great, but a certain number of cases have recovered. Out of seventeen cases thus treated prior to 19 14, seven recovered. OBSTETRICAL PARALYSIS ETIOLOGY. — Paralysis in new-born babies is due to trauma received during parturition. It may be one of the symptoms of intracranial hemorrhage, as already described. The form known as obstetrical paralysis, or birth palsy, is caused by an injury to the peripheral nerves. Two types of paralysis are seen, one involving the muscles of the face, the other involving the muscles of the shoulder and upper arm. In the facial type, the injury is usually due to the use of forceps, which press upon the facial nerve, either near the point of exit from the stylo-mastoid foramen, or where it crosses the ramus of the jaw. While pressure from forceps is the usual cause, some cases have been seen in which the forceps were not used. In these cases, it is beHeved that the injury is received from pressure following long arrest of the head at some point in its passage through the pelvis. In the upper arm type, the injury received during labor may be caused in a variety of ways. It is seen more commonly after artificial labor, but may occur when labor has terminated naturally. In vertex presentations, it may be caused by pressure from a forcep's blade which extends down to the neck, by traction upon the head while it is in a rotated position, or by traction with the obstetrician's finger in the axilla. The injury is much more frequent in breech presentations, in which it may be produced by traction upon the shoulder in delivering the head, or by pulling or twisting the arm, especially in bringing down the arms when they are above the head. PATHOLOGICAL ANATOMY.— In facial birth palsy the injury is usually comparatively slight, and consists of exudation produced within the sheath of the nerve bundle by pressure. In the upper arm type, often known as Erb's Paralysis, the injury affects the 190 Diseases of the Newborn nerves which form the brachial plexus, the nerve trunks involved -being usually the fifth and sixth, and sometimes the seventh cervical nerves. In the severer cases, the stretching may result in the rupture of the plexus, or in hemorrhage about the plexus. In milder cases there is hemorrhage within the connective tissue sheath of the cord of the plexus, with a resulting fusiform fibrous swelling. In the mildest cases the lesion is simply exudation within the sheath from stretching of or pressing upon the nerve bundle. The muscles most commonly affected are the deltoid, supra- and infra-spinatus, brachialis anticus, biceps, supinator longus, and probably also the supinator brevis. Fig. 56 Showing characteristic position of the arm in obstetrical paralysis in a girl of 20 months SYMPTOMS.— Facial paralysis and severe upper arm paralysis are usually noticed on the first or second day. Mild upper arm par- alysis may not be noticed for a week. Facial paralysis is recognized by lack of symmetry in the two sides of the face. This is not very apparent when the child is in repose, but it can usually be noticed that the eye on the affected side remains open. When the baby Obstetrical Paralysis 191 cries, the whole side of the face is seen to be affected, the paralyzed side appearing smooth and full, while the mouth is drawn toward the sound side. Nursing is not interfered with, as the lips are Httle used in sucking, and the tongue is not involved. In Erb's Paralysis, the arm hangs limp and motionless, close to the side; the humerus is rotated inward, and the forearm is pronated so that the palm looks outward. It is notable that the movements of the wrist and hand are not affected, nor is the triceps, so that the forearm can be extended, but cannot be flexed. The reaction of degeneration is present in the severer cases. Atrophy usually begins after, a few weeks, but the muscles are comparatively so small, and so covered with fat, that it is usually not perceptible until paralysis has persisted for one or two- years. DIAGNOSIS. — Facial birth paralysis has to be distinguished only from a facial paralysis of central origin. It is extremely rare that facial paralysis is the sole manifestation of intracranial hemor- rhage, and it can usually be easily excluded by the absence of signs of intracranial pressure or of cortical irritation. Moreover, in facial paralysis of central origin the upper segment of the facial nerve is not affected, there is no paralysis of the orbicularis palpebrarum, and consequently the eye can be closed. The upper arm type of obstetrical paralysis is also easily recog- nized. Here again, in a paralysis of central origin, it is extremely rare for the arm alone to be affected. The characteristic grouping of the muscles affected in obstetrical paralysis, together with the absence of the signs of intracranial pressure or irritation, usually make the diagnosis sufficiently clear. The reaction of degeneration, when present, is further proof of the peripheral origin of the paralysis. Erb's Paralysis, however, has at times to be carefully distinguished from surgical injuries received during birth, such as fractures, dislo- cations, or separation of an epiphysis in the shoulder. Careful ex- amination, especially for tenderness, will exclude these conditions. PROGNOSIS. — The prognosis of the facial type of birth palsy is good. Only in cases very rare and very severe, may the paralysis be permanent, or even last for several months. In the majority of cases it disappears without treatment in about two weeks. The prognosis of the upper arm type is very variable, depending on the extent and character of the injury to the nerve plexus, and upon the treatment. As time passes, partial recovery is alwa3''s seen, even with untreated cases. In some cases spontaneous recovery is seen in the course of a few months. Even when recovery does not occur in untreated cases, the flexion of the forearm at the elbow and the abduction of the arm from the trunk are usually regained. Pronation of the forearm, and external rotation of the humerus are 192 Diseases of the Newborn the movements which remain most persistently poor. With treatment begun at the proper time, recovery usually occurs after a time vary- ing from a few months to one or two years. In the majority of untreated cases, and in a few of the severer cases even under proper treatment, the paralysis persists, to a vary- ing degree. Atrophy of the muscles becomes noticeable, especially Fig Obstetrical paralysis in the deltoid, the shoulder droops, and there is a lack of development of the bones of the shoulder girdle as a result of disuse. The arm appears shrunken, and shorter than on the sound side. Contractions in the muscles of the forearm and hand may eventually develop. Finally, in the worst cases, fortunately rare, there is loss of response to either the galvanic or faradic current, and the arm remains com- paratively useless. It is a noticeable feature in this type of paralysis, that even in severe cases, atrophy takes place comparatively slowly. In comparison Obstetrical Paralysis 193 with similar paralysis due to poliomyelitis, there is, as pointed out by Thomas, a notable lack of flaccidity, hypotonia, and atrophy in the affected muscles. This fact is of value in prognosis, as showing that considerable good may be expected in cases which have gone for a long time untreated, if proper therapeutic measures are instituted. The presence or absence of the reaction of degeneration is of some value in prognosis. Its presence points toward a severer type of lesion. TREATMENT. — The earlier treatment of these cases is by mas- sage, electrical stimulation, and educational gymnastics. Treat- ment should be begun at the end of the first month, and should be continued regularly and systematically for many months. Electrical stimulation has always been a conventional part of the treatment of these cases. I have never been able to convince myself that it is of very great value. It has been given up at the Children's Hospital, partly because it is much less effective than the other meas- ures, and partly because the muscles which need exercise the most, namely, the spinati, cannot be reached by electrical stimulation. The treatment by massage and educational gymnastics, as prac- tised by Dr. Thomas of the Children's Hospital, seems to me to be most satisfactory, and I have seen a number of strikingly favorable results from its use. As described by Thomas, the treatment is carried out as follows, consisting of three parts: 1. Passive movements of the joints, shoulder, elbow, wrist and fingers, best done by some one who knows the anatomical possibil- ities and limitations of these joint movements. These movements need to be continued until the arm has entirely recovered. 2. Massage of the gentle kneading form, to stimulate growth, which may be discontinued when the arm keeps up in growth with the unaffected one. 3. Exercises, to induce the child to use the arm voluntarily, which vary with the age of the child. 13 III. NON-TRAUMATIC MECHANICAL DISTURBANCES This group represents certain lesions of a mechanical nature, of which the anatomy and mechanism is understood, but of which the ultimate etiology is unknown. The most common conditions of this group are the various forms of hernia seen in newborn babies. Both inguinal and femoral hernia are sometimes seen at birth, but are not strictly to be classed as diseases of the newborn. There are other mechanical conditions which, while they may be seen at birth, occur more frequently at a later age; examples of such conditions are volvulus and intussusception. UMBILICAL HERNIA This is the only common mechanical condition strictly to be classi- fied among the diseases of the newborn, and even this often does not Fig. cS Large umbilical hernia. Infant 5 months old appear for a considerable time after birth, its development being favored by poor nutrition. When it appears shortly after birth, it is most frequently seen in premature, or congenitally weak infants. There is a soft tumor at the umbilicus, caused by a protrusion of a small part of the abdominal contents through the umbiKcal ring, which is found dilated. The tumor varies much in size, the usual hernia being about half an inch in diameter, but occasionally it may be very large. It rarely becomes strangulated, and is usually not serious. Umbilical Hernia 195 TREATMENT. — In the first two or three months, after the cord has separated, a firm pad should be placed over the navel, kept in place by a rather snug abdominal band. In cases coming under observation at a later period, the pad and band are not enough, and adhesive plaster should be used. A coin or button covered with kid may be placed over the umbilicus, and kept in place by strips of adhesive plaster. I prefer the procedure which we use at the Infants' Hospital, to the use of a coin or button. After the parts are well powdered, and the hernia is reduced, the skin of the abdomen on each side is picked up between the finger and thumb of each hand, in such a manner as to make two vertical folds. These folds are then brought over to the middle line, so that they touch one another over the center of the navel. They may then be held in place by the finger and Fig. sq Adhesive strap for umbilical hernia thumb of one hand, while the other hand applies snugly a broad strip of adhesive plaster. This holds the two folds of skin together over the navel in such a way that they form the pad which retains the hernia. This plaster may be changed every few days, and must be worn for months. Very large herniae, or persistent herniae can only be cured by surgical operation. Operation, however, is seldom necessary. 196 Diseases of the Newborn There is a rare condition of hernia into the umbilical cord, which is entirely different from the commoner umbilical hernia. This is a malformation, due to some fetal defect. It varies in size from a comparatively small tumor to complete eventration in which most of the abdominal organs are in the sack and outside the body. Such severe cases, with complete eventration, are fatal. Milder cases, even though the tumor is quite large and contains a number of coils of intestine, may be cured by surgical treatment. PROLAPSE OF MECKEL'S DIVERTICULUM This is a condition which produces a tumor at the umbiUcus in newborn babies, and with it there is usually an umbiHcal fistula. The tumor is formed by a prolapse of the mucous membrane of Meckel's Diverticulum. Normally the omphalo-mesenteric duct closes completely during fetal life. The duct may however remain patent to a varying extent, the most common finding in such cases being a blind pouch a few inches in length given off from the lower part of the ileum. In rare cases it may be patent at birth throughout its entire extent, and a prolapse of its mucous membrane produces a tumor at the umbiHcus with a fistula at its summit. These tumors are usually small, not larger than a common marble, but may be much larger. They are smooth, of a pink color, and cannot be reduced. A mucous discharge oozes from their surface, and a slight fecal discharge comes from the fistula. Tumors are sometimes seen without a fecal fistula, but microscopic examination shows that their covering is the same as in cases with a fistula, the structure being that of the intestinal mucosa. In other cases, the fecal fistula may exist without a tumor. These fistulae may exist for months or years, may close spontaneously, or be closed by opera- tion. The small tumors most often seen are easily cured by Hgation. The rare large tumors are usually associated with serious malforma- tion of the intestines. IV. NEW GROWTHS While various forms of new growths may be present at birth, their occurrence is so rare, that they constitute pathological curiosities. UMBILICAL GRANULOMA After the cord has fallen off, there is sometimes seen at the umbili- cus a reddish, moist, secreting mass of granulations. This condi- tion is usually due to improper care of the stump of the cord, in which case a mild infection may play an etiologic role. The condition is commoner in hospital out-patient than in private practice. The usual story is that the navel will not heal. The tumor varies in size from the head of a pin to a pea. The discharge is irritating, so that the skin around the umbilicus may be eczematous. A neglected overgrown granuloma becomes a polyp. These polyps are more vascular than the simple granuloma, and have a pedicle. TREATMENT. — The simple granuloma is best treated by one or more applications of a 50 per cent, nitrate of silver solution, and by keeping the part thoroughly powdered with some absorbent powder. Polyps should not be treated by cutting the pedicle and applying nitrate of silver, as hemorrhage is sometimes severe. The pedicle should be ligated, and the polyp, kept freely powdered, will dry up and fall off. NAEVUS This is a congenital new-formation of tissue in the skin; the new- formed tissue may be pigmentary or vascular. ETIOLOGY.— The etiology of naevus, as of new growths in gen- eral, is obscure. None of the theories as to the cause of naevus ad- vanced at various times, have been supported by any proof. One theory is that birth marks are produced by intrauterine pressure; the only evidence in support of this theory is the frequent occurrence of birth marks at the back of the head or neck, and on the face. Vir- chow called attention to the frequency of naevi at embryonic fissures of the skin, where slight irritation might easily give rise to abnormal vascular activity. PATHOLOGICAL ANATOMY.— Various forms of pigmented moles are seen at times, of various shades of brown or black. Some are smooth, some rough and warty, some hairy. 198 Diseases op the Newborn The commoner forms of naevi are vascular, and include the well- known so-called birth marks. They vary in histology, in size, and in appearance, from the small capillary angioma, to the large, dis- figuring "port wine" stain. The appearances vary with the number, and degree of dilatation of the new-formed vessels. True vascular naevi become pale on pressure. Fig. 6o Naevus ot lace and neck in an infant 4 months old TREATMENT. — The smaller pigmented moles are best treated by excision. It must be remembered that metastasis and general sarcomatosis have occasionally followed mechanical interference with certain forms of moles. The same thing, however, occurs with equal if not greater frequency when there is no attempt at excision, and it is probable that children are not so liable to metastasis as adults. Smooth pigmented moles should be left alone, if not in a disfiguring situation. The warty variety, in my opinion, should be excised. Large hairy moles, and vascular naevi, are treated by electrolysis, or multiple puncture. Some small capillary naevi will disappear under the pressure produced by frequent apphcations of collodion (Kerley). The best results in the treatment of vascular naevi, have been obtained by freezing wdth liquid air or carbon dioxide snow. V. FUNCTIONAL DISTURBANCES CONGENITAL PULMONARY ATELECTASIS This condition is one in which the whole or parts of the lung re- main in a fetal condition, air not entering the alveoli. ETIOLOGY. — It is usually stated in textbooks that atelectasis is closely associated with Asphyxia Neonatorum, this statement being based on the fact that infants born dead, or dying as the result of asphyxia show a complete or partial condition of atelectasis post- mortem, and that most cases in which infants die in the first few days of life, and in whom the lesions of atelectasis are found post-mortem, have shown symptoms of asphyxia at birth. I believe, however, that the connection between asphyxia and atelectasis is not so close as is generally supposed. It is a well-known fact that -the expansion of the lung is not normally completed immediately after birth, but is a gradual process, occupying a number of days before complete expansion of the lung is attained. It follows that a certain amount of atelectasis would always be found post-mortem in infants dying in the first few days of life, whether they die from asphyxia, or from any other cause. Further, most of the conclusions upon the cause of atelectasis are based on post-mortem examinations of infants dying in the first few days of hfe, and in these cases asphyxia may well have been the cause of death, or it may have been a symptom of a feeble vitality which was the cause of death. In my experience, infants who survive the early days, and later show the lesions or signs of atelectasis, do not give a history of asphyxia at birth. Atelectasis becomes a pathological condition when it persists beyond the early days of life. The cause is congenital weakness of any kind, such as is seen in premature infants, in congenitally weak or malnourished infants, and in infants suffering from congenital syphilis or cerebral hemorrhage. Anything which impairs the vital- ity of the newborn infant, causes weakened respiratory efforts, and asphyxia undoubtedly may be numbered among the causes of such weakness. In addition to weakened respiratory efforts, in feeble infants there is weakened heart action, leading to pulmonary con- gestion or edema, and the two together form a vicious circle of which atelectasis is the result. Asphyxia is usually due to some intrauterine condition interfering with the placental circulation, such as prolonged labor, the use of ergot in the second stage, pressure on the cord, winding of the cord about the neck, or early separation of the placenta. It is a condition 200 Diseases of the Newborn rarely seen by the pediatrist, its diagnosis and treatment falling more properly to the obstetrician, and it is so adequately described in text- books on obstetrics, that it will not be described here. PATHOLOGICAL ANATOMY.— In infants who are born dead from asphyxia, atelectasis is complete, the lung showing a fetal condition. There are no alveoli, the tissue consisting of closely packed epithelioid cells and blood-vessels, and is recognizable as lung tissue only by the bronchioles with their characteristic epithelium. In infants who breathe at birth, but who die from asphyxia or congenital weakness at any time in the first few days of life, the amount of un- FlG. Complete congenital atelectasis of the left lung. Hypertrophy of the heart expanded lung is very variable, varying to a certain extent with the length of time the child survives. At the borders of completely col- lapsed areas, are areas where some air-containing alveoli are seen, there being a gradual transition to the areas where the lung is completely inflated. Often in the most collapsed areas are found some air spaces. In addition to the fetal condition, there is frequently edema filling the expanded alveoH of the atelectatic areas. The blood- vessels are congested. Congenital Pulmonary Atelectasis 201 In children who survive the early days of life, there is httle evi- dence available as to the pathological anatomy. It is probable that there is a persistence of the fetal condition in more or less extensive areas of the lung. The portions of the lung most frequently involved in congenital atelectasis are the paravertebral and central portions, particularly the area just behind the hilus. The outer portions and borders expand better. The best expanded portions are usually the anterior borders of the upper lobes. The left lung is more frequently and more fully involved than the right. SYMPTOMS.— In the beginning, at birth, the symptoms of atelectasis are the same as those of asphyxia. In other words, a certain amount of asphyxia is frequently present at birth in cases of atelectasis. During the first few days of life the symptoms are those of general feebleness and low vitahty. The infants are somno- lent, do not cry strongly, and do not take their nourishment well. Their faces are pale and expressionless. In the severer cases, the respiration is notably defective, being irregular and shallow, with occasional long pauses followed by a single deep gasping inspiration, after which shallow irregular breathing is resumed. During these deep inspirations, which may be brought about artificially by slapping the child with the hand, or by applying cool water to the chest, crepitant rales may frequently be heard in various parts of the lungs. Sometimes it may be noted that the respiratory movements are not symmetrical, one side of the chest moving more than the other. In the majority of cases of atelectasis physical signs on ausculta- tion and percussion cannot be found. In rare cases there is consid- erable dullness and diminished breathing over a varying area of the lung. The further course of these cases is very striking. The children do not thrive, but seem feeble, gaining very slowly, or not at all in weight, with a tendency toward cyanosis, cold extremities, and sub- normal temperature. Their cry remains notably weak. If they survive the early weeks, they remain smiall and delicate. A child with very slight atelectasis may eventually develop normally, but in these cases, the atelectasis is usually not to be recognized. Occa- sionally a child survives with an extensive atelectasis. Such children remain very much under-sized in both height and weight. I know of one such child, who has reached the age of twelve years. One lung is still almost wholly collapsed, showing dulness and diminished breathing over the greater part of the left chest. The chest wall has sunk in over the collapsed lung, causing a marked deformity of the chest. This patient was very delicate during infancy and early child- hood, but is now strong and healthy, though very much undersized. 202 Diseases of the Newborn DIAGNOSIS. — Any child who dies in the first days of life will show some atelectasis post-mortem. In children who survive the first days, the diagnosis is difficult. If asphyxia has been present at birth, and if the children show impaired vitality with notable disturbance of the respiration, atelectasis may be suspected. It cannot be diagnosed with certainty except in those rare cases which show abnormalities to auscultation and percussion. In a certain number of cases not showing physical signs, the condition will be revealed by roentgen ray examination. PROGNOSIS. — Slight degrees of pulmonary atelectasis are prob- ably compatible with normal development. Such cases, however, are seldom recognized. In the majority of cases the children are very feeble, and in babies born with such low vitality, the mortaHty is very high. A certain number die in the first days of life; others may survive for several weeks. A few cases, even those in which atelectasis has been clearly recognized, survive the early weeks. They remain puny, small, and delicate, and are difficult to rear. A few survive, but even these show backward growth and development TREATMENT.— At birth, the physician should make sure that the child cries strongly, and should see to it that this cry is repeated every day. The various means of resuscitation employed in asphyxia neonatorum is adequately described in works on obstetrics. Feeble infants in whom atelectasis is suspected, should have the treatment for asphyxia continued. During each twenty-four hours, they should be taken from their cribs a number of times, and thoroughly aroused, and should be made to take a number of deep inspirations. This may be brought about in various ways. In the milder cases shaking or slapping, or applying cool water to the face and chest, will suffice. In severer cases they should be dipped alternately into warm and cold baths, as is done in asphyxia. The rest of the treatment is that applicable to any premature, or congenitally feeble baby. They must be kept warm, often with artificial heat in the form of hot water bottles. Sometimes their temperature will remain subnormal unless the "premature jacket" is used, as described for premature infants. They are often too feeble to nurse the breast, yet breast milk is almost an absolute essential to their proper nutrition. In such cases the breast milk must be drawn with a breast pump, and given to the baby with a medicine dropper, or better still, with a Breck feeder. HEMORRHAGIC DISEASE OF THE NEWBORN Hemorrhage in the first few days of hfe is seen in connection with a great variety of recognizable causes. The trauma of birth not infrequently produces a lesion of the blood vessels, but in hemor- Hemorrhagic Disease of the Newborn 203 rhages of simple traumatic origin, there is no tendency for the bleeding to be either unduly prolonged, or uncontrollable, and the purely traumatic origin of the hemorrhage is usually plainly apparent. The recognized infections of the newborn are frequently attended by hemorrhage. In these cases also, the symptomatic nature of the hemorrhage is usually apparent, and the clinical picture is comparable with that sometimes seen in cases of infection in later life, with a tendency to hemorrhage, such as occurs at times in measles, smallpox, and malignant endocarditis. There remains a class of cases in which the hemorrhages are not associated with any other recognizable pro- cess, and in which the bleeding does tend to be both unduly prolonged, and uncontrollable. A very few cases of this character represent manifestations shortly after birth of that particular congenital and hereditary hemorrhagic disease known as hemophilia. Hemophilia, however, is a disease which persists throughout the life of the patient, and the appearance of hemorrhage soon after birth is not a char- acteristic manifestation of the disease, but only accidental, occurring in comparatively few cases. In these cases, if there is traumatic injury sufficient to produce hemorrhage, the hemorrhage attracts attention by its persistent and uncontrollable character. Most cases of hemophilia do not manifest themselves at birth. Finally, we have a class of cases in which prolonged and uncon- trollable hemorrhages occur in newborn babies, and in which the disease is self -limited, the tendency toward hemorrhage ceasing permanently when recovery occurs. These cases, in the present state of our knowledge, are grouped under the term Hemorrhagic Disease of the Newborn. ETIOLOGY. — The etiology of hemorrhagic disease of the new- born is one of the obscure problems of medicine. There are two principal possibilities as to the cause of these hemorrhages. The first is that the bleeding is due to some peculiarity in the tissues of the newborn infant. The second is that it is a manifestation of some obscure infection. Under the first possibility the tissue peculiarity cannot be a permanent defect, because hemorrhagic disease of the newborn is self-limited, and is thus distinguished from hemophilia, in which the probable cause is a permanent tissue defect. The defect in hemorrhagic disease of the newborn, if such a defect exists, must be developmental in origin, a condition incidental to the relative physiological incompleteness of the newborn baby. Such a defective, incomplete condition of the tissues might involve either the blood itself, or the walls of the vessels. Under the other possibility, in which the hemorrhage is attributed to some obscure infection, the immediate cause of continued bleeding is also to be sought in some defect either of the blood itself, or of the 204 Diseases of the Newborn vessel walls. The only difference is that under this theory, the cause of the defect is not developmental incompleteness, but infection work- ing upon the tissues through toxins. The disease is not a very common one. The majority of reports show a percentage incidence of under 2%. Townsend's report from the Boston Lying-in Hospital showed 32 cases out of 5,225 births, or •57%- Green and Swift, in a more recent series from the same hos- pital, report 51 cases out of 4,455 births, or 1.14%. In Prague, Ritter observed 190 cases out of 13,000 births, or 1.46%. The highest record I have seen is 8% out of 740 births. The disease is more frequent in institutions than in private practice. In Green and Swift's series, there was a notable seasonal incidence, the disease being more frequent in the six months from November to April inclusive. IMales are only very sKghtly more frequently affected than females. S}^hilis is asso- ciated with hemorrhagic disease in only a small proportion of cases. PATHOLOGICAL ANATOMY.— There is no constancy in the lesions found post-mortem in hemorrhagic disease of the newborn. In the majority of autopsies nothing is found except the hemorrhages in the various situations, and the consequent anaemia of the organs. The stom.ach and intestines frequently contain considerable blood, but usually show no lesions, except areas of congestion or ecchymosis on the mucous membrane. A few cases have been reported in which ulcers have been found on the gastric or intestinal mucosa. The proportion of these cases is small, and the cause of the ulcers obscure. The changes found in the blood have not been uniform, and have not been thoroughly studied. SYMPTOMS. — The hemorrhage begins usually in the first week of life, and very rarely occurs after the twelfth day. The majority of the infants are two or three days old. The hemorrhages are usually multiple. They occur from a great variety of situations, including the intestine, stomach, mouth, nose, umbilicus, skin, genito-urinary tract, eyes, meninges. In Green and Swift's series, the cases arranged themselves in three distinct clinical groups. The largest group is the sero-mucous, in which the bleeding comes from the mucous or serous membranes. In the second largest group the principal bleeding is from the umbilicus. The smallest group is characterized principally by the formation of subcutaneous purpuric patches or ecchymoses. Table 17 Classification of Green and Sunft's Series Clinical Tj'pe Cases Recoveries Deaths Sero-Mucou? 27 13 14 Umbilical 15 6 9 Purpuric 9 7 2 51 26 2^ Hemorrhagic Disease of the Newborn 205 Usually nothing abnormal is noted until the hemorrhage begins. In the sero-mucous group, the most frequent symptom is hemorrhage from the bowel. The blood is always dark colored, and usually thor- oughly mixed with the feces. Clots are comparatively rare. In cases where there is also hemorrhage from the stomach, blood is vom- ited, usually not in great abundance. The blood vomited is usually dark brown, rarely bright red. In other cases there may be bleeding from the mouth, nose, or conjunctiva. When there is hematuria, the urine is blood-stained, and sometimes contains clots. Occasionally bleeding from the female genitals is severe. The bleeding from the umbilicus is apt to occur somewhat later than the sero-mucous bleeding. It usually betrays itself first by a slight stain on the dressing, though occasionally it begins more pro- fusely. Hemorrhage into the skin is most apt to appear in places exposed to pressure, but many occur anywhere. The amount of the hemorrhage is very variable. Sometimes there is only a continuous oozing; at other times larger amounts of blood are lost. There is prostration, which is often marked from the begin- ning, and there is rapid loss of weight. The temperature may be elevated, or may be normal or subnormal. There is frequently diarrhea. The hemorrhages continue until death or until recovery occurs. In the mild, favorable cases which recover, the duration is usually not more than one or two days. In fatal cases, death usually occurs in three days. Death may result either from the rapid loss of blood, or more frequently, from failure of vitahty. DIAGNOSIS. — It is sometimes necessary to make sure that the dark masses passed from the bowel are blood and not meconium. In such a case one should first examine the discharges microscopically for blood corpuscles, and if they are not conclusively found on account of their disorganization, a chemical test for hemoglobin should be made. Accidental, or traumatic hemorrhages are usually easily recog- nized, and are not persistent. When it is estabhshed that a hemor- rhagic condition is actually present, the causes to be excluded are hemo- philia, and symptomatic hemorrhage in infectious disease of the new- born. Hemophilia is a rare manifestation at birth; males are affected oftener than females in the proportion of thirteen to one; there is usually a history of heredity, particularly in the maternal grand- father; finally the hemorrhage is usually from one situation only. In infectious disease of the newborn, there is usually a persistent fever, and some signs of infection on physical examination, such signs being most frequently found at the umbiHcus. In a few cases the hemorrhage is into some internal organ, and 206 Diseases of the Newborn does not appear externally. In such cases the diagnosis is so difficult, that the disease usually escapes recognition. PROGNOSIS.— The mortality of hemorrhagic disease of the new- born is high. It varies in the reports of different observers, the variations depending on the differences in the severity of the disease at different times, and on differences in the treatment employed. Schloss and Commiskey state that the mortality ranges from 35 to 87 per cent. For all forms of the disease 60 per cent, represents an average mortality. In Green and Swift's series the mortality was 60 per cent, in the umbilical type, 50 per cent, in the sero-mucous type, and 22 per cent, in the purpuric type. In any single case the prognosis depends on the severity of the hemorrhage, the vigor of the child, and the treatment employed. There is no reason for ever giving a hopeless prognosis, for recovery can occur even in the most severe cases. TREATMENT. The most effective weapon against hemorrhagic disease of the newborn is human blood. Favorable results of a con- vincing character have been obtained by the use of whole human blood given both subcutaneously, and intravenously, and by the use of human blood serum. Of the methods of employing human blood, I believe that trans- fusion is the ideal one, because whatever the cause, transfusion re- stores to the infant's circulation all the elements needed for coagula- tion. It further corrects anemia by replacing the cellular elements which have been lost, and dilutes any toxin which may be present to the greatest possible extent. The only objection to transfusion is the difficult technic of the operation when performed on newborn babies. In view of the convincingly favorable reports of Schloss and Com- miskey and others on the subcutaneous use of whole human blood, and those of Welch, confirmed by many others, on the use of human blood serum, these methods of giving human blood deserve a place in the treatment of this disease. I beheve that, as suggested by Vin- cent, a rational combination of all three methods is the best routine treatment which can be employed. In the beginning the hemorrhages are often trivial, or the infant, when first seen, is not yet either severely exsanguinated or prostrated. In this stage, at the first injection, whole blood may be used to save delay. The donor having been obtained, about 60 c.c. of blood should be withdrawn with a sterile syringe and needle from the vein at the bend of the elbow. Of this, from 10 c.c. to 30 c.c, according to the severity of the hemorrhage, should be injected subcutaneously at once. The rest should be set aside to furnish serum for further treatment. In the subsequent injections, this serum may be used, Hemorrhagic Disease of the Newborn 207 and from lo to 30 c.c. may be given every four to eight hours, accord- ing to the course of the case. If the patient, when seen first, is already so greatly prostrated or exsanguinated as to appear in a serious condition, or if the injections of whole human blood, or human serum are not followed by recog- nizable improvement, the safest treatment is by transfusion. Under these circumstances, whenever a surgeon is available who is familiar with the more formidable technic of this operation, direct transfusion should be performed. Fig. 62 Dr. Beth Vincent's apparatus for transfusing. Consisting in paraffin treated tube, com- pression bulb, and needle Transfusion is usually followed by immediate and permanent cessation of the hemorrhages. Whenever the hemorrhages once cease, they are not likely to recur. It should be remembered that cases in which hemorrhage is due to bacterial infection, to syphilis, or to ulcers of the stomach and intestine, are not so favorable for treat- ment with human blood. This may explain the failure of treatment in certain cases. 208 Diseases of the Newborn Fig. 63 Obtaining blood in paraffin treated tube from the donor in transfusion Fig. 64 TRAXSFUSIOX IX THE XEWBORX Injecting blood from a paraffin-coated tube into the longitudinal sinus Hemorrhagic Disease of the Newborn 209 There are other methods of treatment which have not, in my opin- ion, given evidence of value sufficiently convincing to warrant their discussion here. Of these rabbit serum has given the best reports. I believe the only indication for its use would be in a case in which human blood or serum was not obtainable. PR0BLE:\IS and research.— The obscure questions in the etiology and pathology of hemorrhagic disease of the newborn, have been the subject of considerable investigation and experimental research within the last decade. The particular problems at present engaging the attention of investigators are two in number. The first problem is, what are the changes or abnormalities in the tissues which are concerned with this tendency to hemorrhage in newborn babies? The second problem is, what is the cause of these changes or abnormahties? The first problem is intimately connected with the mechanism of the coagulation of the blood, for the tissue defect must involve either the blood, or the walls of the blood vessels. The mechanism of blood coagulation, while still imperfectly under- stood, presents certain known features, interference with which might easily lead to prolonged and uncontrollable hemorrhage. The most generally accepted view of the coagulation of the blood is the follow- ing: Coagulation is due to the action of thrombin (fibrin ferment) upon the fibrinogen of the blood, or to the union of thrombin and fibrinogen. The term fibrin ferment is now not so much used as formerly, because it is doubtful if thrombin is actually a ferment; its mode of action is uncertain. It is fairly certain, however, that thrombin does not exist as such in the circulating blood, but as it appears shortly after the blood is shed, all its constituents must have been present. The mother substance from which thrombin is sup- posedly formed is called prothrombin, and this is supposedly derived from the blood platelets, but it has not been isolated. It is theo- retically supposed to be held neutralized in the circulating blood by antithrombin (antifibrin ferment), which is believed to have the func- tion of preventing the occurrence of an extending coagulum from the passage of thrombin from its original seat of formation. The other substances involved in the formation of the thrombin are the calcium salts normally present in the blood, and a substance called throm- bokinase, which is liberated from the body tissues after injury. This kinase, with the calcium salts, generates thrombin from prothrombin. The mechanism is shown in the following diagram. Prothrombin + Calcium Salts J-Thrombin ] Thrombkinase + [Fibrin Clot Fibrinogen] When all these elements are present in normal proportion, a normal 14 210 Diseases of the Newborn clot is formed. A diminution or absence of any one of them will lead to an inferior clot, or a delayed, or absent clot. If the calcium salts are diminished or absent, it has been found that the coagulation time is prolonged, or there is no clot. If the prothrombin is absent, the onset of the coagulation time will be normal, but the clot will be gelatinous and not firm. If the kinase, or fibrinogen, are dimished or absent, the coagulation time will be delayed, with inferior clot, or the blood will remain fluid. The methods of investigation now in use, are the following: Meas- urements of the coagulation time; studies on the firmness of the clot; studying the effect of adding calcium salts; studying the effect of adding defibrinated normal human blood; studying the effect of the infant's blood on normal blood; artificial extraction of thrombin in pure form. The results of these investigations have not been uniform, and do not point toward the diminution or absence of any one particular factor in cases of hemorrhagic disease of the newborn. The most recent investigations are those of Schloss and Commiskey, and of Schwartz and Ottenburg. In some cases the coagulation time has been found markedly delayed, and there is evidence of an inferior clot. Such cases can be explained on a basis of deficiency of fibrino- gen or of a. general deficiency of thrombokinase. Other cases have been found with coagulation times which are only slightly delayed or are normal. In cases with normal coagulation time, but in which puncture of the skin is followed by excessive bleeding, it is possible that the deficiency lies in the prothrombin. In three of Schloss and Commiskey's cases, however, the coagulation was normal, and there was no bleeding from punctures of the skin, hemorrhage being quickly controlled by a firm well contracted clot. The writers attribute the hemorrhage in these cases to some localized vascular lesion, and believe the lesion may possibly be a local absence or interference with the action of thrombokinase, which is normally liberated upon injury to the vessel wall. There is no well supported evidence that deficiency in calcium salts plays any part in this hemorrhagic disease. The question as to whether the tissue defect, whether it lie in the blood or in the walls of the vessels, is due to incomplete development or to infection is less susceptible of experimental investigation. The argument in favor of the developmental theory, is that the tendency to hemorrhage is seen only in the early days of life, and does not persist. There is, however, a certain tendency to obscure infection which also is only seen in the newborn. Those who believe in the developmental theory point to the absence in most cases of clin- ical, anatomical, or bacteriologic signs of infection. Nevertheless there is an increasing tendency to attribute this disease picture to infection. It is known that hemorrhage is a com- Hemorrhagic Disease of the Newborn 211 paratively common symptom of some well-recognized infections of the newborn. The evidence against the infectious theory is of a purely negative character, while on the other hand, considerable evidence has recently been accumulated tending to substantiate this infectious theory. The disease is most apt to be seen in institutions. Green and Swift have pointed out the tendency of the disease in their series of hospital cases to occur in groups, and believe that this, together with the seasonal incidence, tends strongly to confirm the theory of an infectious etiology. Moreover, a number of observers have isolated bacteria of various kinds from certain of these cases. A certain number of cases show a distinct febrile reaction. The self-limited character of the disease is often brought forward in sup- port of the infectious theory, but goes very well with the theory of incomplete tissue development. We can only look to further investigations for the solution of these problems. The attempt to determine the pathology of the blood in hemorrhagic conditions is beset with numerous obstacles, and it is improbable that the exact causation of hemorrhage in the newborn can be definitely ascertained until the physiologic processes of blood coagulation are more thoroughly understood. It is quite probable that, as in many functional disturbances, several different conditions may be concerned in the etiology, any one of which may be the cause of a particular case of hemorrhage. A number of methods of treatment will be found recommended in the literature of hemorrhage in the newborn, each based on some particular theory of the etiology of the condition, and each with clinical evidence in its support. Among the various measures which have been recommended are the following:— -Injections of gelatine; administration of calcium salts; administration of adrenalin; sub- cutaneous injection of horse serum; subcutaneous injection of rabbit serum. We have seen, however, that no exclusive theory of the pathogenesis of this disease is tenable. Chnical evidence in any single case can be explained by the fact that some cases will recover without treatment. The use of gelatin is entirely empirical, and it has been finally proven to be inert in its power to increase the coagulability of the blood, either in vitro or in vivo. Adrenalin has also been found to be inert, having value only as a local hemostatic. Calcium salts have been found to increase the coagulability of the blood in test-tube experiments, but it has been found that only the ionizable calcium salts of the blood enter into blood coagulation, and these can be only very slightly increased by administering calcium salts to a patient. Deficiency of calcium salts, also, does not appear to play an etiologic role in this particular disease. Of the animal sera. 212 Diseases of the Newborn experiment has shown that horse serum is less potent than rabbit serum, but that rabbit serum is less potent than human serum. ICTERUS NEONATORUM Jaundice is a symptom seen with great frequency in newborn infants. In the majority of cases the jaundice is of so slight a grade, and is characterized by so entire an absence of pathological symp- toms, that it is usually looked upon as representing a physiological process which is normal in the early days of life. This type of jaun- dice is called Icterus Neonatorum. There are, however, a number of other conditions, of true patho- logical nature, which are characterized by the appearance of jaun- dice in newborn babies. These more serious conditions, though rare, must be carefully distinguished from the common icterus neonatorum. In the first place, jaundice is a not infrequent symptom of infection in newborn babies; it is also sometimes, though rarely, a symptom of congenital syphilis. It is the chief symptom of a congenital cirrhosis of the liver, which has been found at autopsy, and of congenital oblitera- tion of the bile ducts. This last condition may represent a congenital malformation, or may represent a late stage of congenital cirrhosis. Catarrhal jaundice, an obstructive form, in which the cause is swelling of the mucosa of the bile ducts, is very rare in newborn babies, but is still a possibility. Finally, certain cases of jaundice have been observed in newborn babies, in which all the above causes were absent, and in which no cause was found. Icterus neonatorum is by far the commonest condition producing jaundice in the first days of life. It has been variously reported to exist in from 40 to 80 per cent, of all newborn infants. ETIOLOGY. — The etiology of icterus neonatorum remains ob- scure, in spite of the fact that it has been the subject of much inge- nious speculation. The most satisfactory explanation is that of Abramow, who considers the jaundice due to an anomaly of secre- tion of the hver cells. Shortly after birth, as the result of the rich supply of blood to the liver, the hepatic cells produce bile more rapidly than it can escape. The bile capillaries at birth are over- filled with a thick and tenacious bile, which obstructs its own flow as it is formed' so rapidly. The bile, consequently, passes into the blood capillaries, and thence into the general circulation. This ex- planation is in accordance with the theory that icterus neonatorum is a physiological and not a pathological process. SYMPTOMS. — The jaundice is not present at birth, but develops usually on the second or third day. It is first noticed on the face and chest, then in the conjunctivae, then on the extremities. It increases PLATE II. Icterus Neonatorum. Red Bone Marrow. Natural Size XP i Yellow Bone Marrow. Three-fourths Natural Size. ^W Erythema Neonatorum. Icterus Neonatorum 213 in severity for three or four days, then rather rapidly disappears. In rare cases it may last longer. The color is usually a pale yellow, but at times is more intense. The fecal discharges are not light col- ored, and contain bile pigment. The urine in most cases is normal, not showing bile pigment, though sometimes the presence of bile pigment can be demonstrated by special tests. There is no en- largement of the liver or spleen, and no rise of temperature. The general condition is not affected; there are no symptoms of indiges- tion, and icteric babies show no tendency to gain weight less rapidly. DIAGNOSIS.— The recognition of the condition is very easy. The absence of all other signs of disease, together with the normal stools, serve to differentiate icterus neonatorum from the other conditions in which jaundice is seen in the newborn. PROGNOSIS. The prognosis is good. TREATMENT.— None is required. PROBLEMS AND RESEARCH.— A number of theories as to the cause of icterus neonatorum have been advanced, and disproved, although references to them are still to be met with in medical litera- ture. Among these disproven theories are the following: — Frank's theory that the cause of jaundice is plugging of the common bile duct with mucous and cast-off epithelium; Birch-Hirschf eld's assump- tion of an edema of Ghsson's capsule; Bouchet's hypothesis of a hepatitis; Epstein's theory of a catarrh of all the bile ducts. Quincke's theory of a patent ductus venosus is improbable. The hematogenic factor in the etiology of icterus neonatorum is still under discussion. The many supporters of this theory assume that there is in the early days of Hfe a countless destruction of erythro- cytes, which produces polycholia and jaundice. This theory has been refuted, the apparent destruction of red blood corpuscles being attrib- uted to an increase in plasma. Still more recently, evidence has been brought forward to show that the destruction of erythrocytes actually does occur. Even if this evidence is true, it only furnishes plausible explanation of the increased bile formation in the early days of hfe, which must otherwise be attributed to a rapid awakening of the function of the hepatic cells. The only experimental work which has been done in this condition is that of Hess, who investigated cases of icterus neonatorum with the duodenal catheter. He found that bile is excreted into the duo- denum very rarely in the first twelve hours of life. In the next twenty-four hours, bile excretion is variable, being profuse in cases with marked jaundice, and scanty or absent in cases not jaundiced. He found that jaundice precedes the excretion of bile into the duo- denum, and is more marked in cases with profuse secretion. Hess believes that the cause of icterus neonatorum is due to the fact that 214 Diseases of the Newborn the mechanism of bile excretion into the duodenum is not well equipped in the earliest days of Hfe. Excess of bile is secreted, whether or not the cause is an increased amount of available hemoglobin. Excre- tion becomes profuse, but not enough to take care of the excess, with resulting congestion of the bile capillaries. CONGENITAL CIRRHOSIS OF THE LIVER, CONGENITAL OBLITERATION OF THE BILE DUCTS These conditions, while described by many writers as separate diseases, are here described together, because the preponderance of evidence points to so close an association between them, that many authorities believe them to be different stages of the same process, and because their clinical manifestations are practically identical. Fig. 65 Congenital cirrhosis of the liver PATHOLOGICAL ANATOMY.— In the majority of the reported cases, there is found at autopsy complete obliteration of some part of the extra-hepatic bile ducts. In the majority of cases the com- mon duct is obHterated, usually down to and including the opening of the papilla of Vater. The obliteration usually also involves the Congenital Obliteration of the Bile Ducts 215 hepatic ducts. The cystic duct may be obHterated, or its lumen may be much narrowed. The obhterated ducts are usually rep- resented by a fibrous cord, but may be entirely absent. The gall bladder is frequently very small, and is sometimes also obhterated, and replaced by fibrous tissue. Accompanying this condition of obliteration of the bile ducts, there are always found marked changes in the liver. The principal lesion is a cirrhosis, of the biliary type, characterized by an increase in con- nective tissue, which is most marked in the region of the portal vessels, but which often occurs to a varying extent dift'usely within Congenital cirrhosis of the liver. Section showing increase in fibrous tissue and invasion of the lobules the lobules. The connective tissue varies in age, in some cases appearing comparatively newly formed, in other cases old and dense. The changes in the liver cells show marked variations in different cases. In some the cells remain arranged in orderly trabeculae, in others some of them are much increased in size, in still others they show marked atrophy or extensive destruction. The bile capillaries are usually much distended and many contain inspissated bile. There are often newly formed bile capillaries to be seen. 216 Diseases of the Newborn Two views are held as to the pathogenesis of the cases in which obhteration of the bile ducts is found. One view regards this lesion as developmental in origin, a congenital malformation. The other view regards the lesion as due to an inflammatory process, leading to fibrous tissue formation and obliteration. It is possible that in some instances the condition may represent a congenital malforma- tion, but such instances are certainly extremely rare. It is probable that in the majority of cases the obliteration of the ducts is due to inflammation. Two views are also held as to the relation of the cirrhotic process in the liver to the obliteration of the bile ducts. One view regards the bile duct process, whether inflammatory or developmental, as primary, and considers the cirrhosis of the liver as a secondary pro- cess. The other view regards the process in the liver, cholangitis and cirrhosis, as primary, and considers that the occlusion of the bile ducts is due to an extension of this tissue reaction down along the large bile ducts. In favor of this latter view is the fact that obliteration of the extrahepatic bile ducts is never found without an accompanying cirrhosis of the liver, but on the other hand many cases have been reported in which precisely the same cirrhosis was found in the liver, but in which the common and hepatic ducts were found patulous throughout their entire extent. While the changes in the liver do not resemble those generally described as occurring after sudden obstruction to the flow of bile, it is usually difficult to tell which process is primary. There is anatomical, evidence on either side, and it is quite possible that either lesion may be the primary one. The two conditions are certainly so closely connected that they cannot well be considered as distinct diseases. ETIOLOGY. — The cause of the condition is unknown, and very possibly varies with the case. Congenital syphiHs is probably not an etiological factor. If we exclude those cases, certainly rare, in which the obliteration of the bile ducts may represent a congenital malformation, the prevailing view is that the inflammatory process is due to the absorption of toxic substances from the mother, and this theory is unafl'ected by the question as to whether the liver or the bile ducts are first affected. This theory is of course, with- out proof. SYMPTOMS. — The most striking symptom is jaundice, which is sometimes present at birth, but which usually develops on the second or third day, and sometimes not until the fourth day. The jaundice increases rapidly, and soon becomes intense, so that the skin appears of a greenish-yellow tint. The stools may or may not be composed of meconium at birth, according to the period of fetal development Congenital Obliteration of the Bile Ducts 217 when the obstruction occurred. Meconium is usually seen, but very soon the dejecta become white or clay colored. In the majority of cases, bile pigment is not to be demonstrated in the stools by a chem- ical test. In some cases, however, bile pigment has been found present, these cases being usually those conditions in which congenital cirrhosis exists without obUteration of the bile ducts. Nevertheless, I have recently seen a case in which no obliteration of the ducts was found at autopsy, with bile pigment constantly absent in the stools, while Hess has recently reported a case with complete obliteration of the common duct, in which the stools contained traces of bile pigment, which proves the possibility of excretion of bile from the circulation through the intestinal wall. The stools always show defective absorp- tion of the fat given in the food. The urine is always dark, and contains bile. The liver and spleen are usually enlarged, although not always, especially in cases where cirrhosis of the Hver is very marked. Hemorrhages may be seen in the early days of life, or late in the course of the disease. The babies lose steadily in weight and strength. Symptoms of indigestion may be present, but are usually notably less marked than one would expect. In fact the general condition, for quite a time after the development of the symptoms, remains much better than would be expected in a condition with such serious lesions. Finally, however, malnutrition becomes extreme, and death occurs from inanition, or from some intercurrent infection. DIAGNOSIS. — Icterus neonatorum is easily excluded in these cases, on account of its mild and brief type of jaundice, and the fact that the stools and urine remain normal. The conditions to be particularly considered in diagnosis are infectious disease of the new- born with jaundice as a symptom, and catarrhal jaundice. When jaundice is a symptom of infection, the temperature is usually ele- vated, and not infrequently high and irregular. The general con- dition is usually more profoundly affected from the start. The physical examination frequently gives definite information as to the source and location of the septic process. The jaundice is often not quite so intense. The most important point, however, is that the movements in sepsis are not light colored, and contain bile. It is more difficult to exclude catarrhal jaundice, although this condition is extremely rare in the early days of hfe. Catarrhal jaundice may show the same intense icterus, with absence of bile in the stools. Even when it is seen early in life, it usually develops at a somewhat later period after birth. In such a case, with com- paratively late development, and with absence of enlargement of the liver, catarrhal jaundice may be suspected. The diagnosis can be confirmed only by the favorable course of the disease. 218 Diseases of the Newborn PROGNOSIS. — The prognosis of congenital cirrhosis and obhtera- tion of the bile ducts is bad. Some cases die in the early weeks; others may survive for several months. Eight months is the longest recorded period of survival. TREATMENT. — Careful feeding is the only treatment which can be employed in these cases. Milk modifications in artificially fed infants should be low in fat, high in protein. In cases in which the diagnosis is fully established by the persis- tence of signs of complete obstruction to the flow of bile, I beheve that a surgical exploration should be considered. Such an operation will probably shorten the life of the baby, if the diagnosis is correct. On the other hand, there is a possibiHty of the jaundice being due to some remediable condition, such as mechanical obstruction of the large ducts from pressure of glands, inspissated bile, or peritoneal adhesions. The absolutely hopeless prognosis makes it justifiable to take advantage of the possibihty, even though remote, of a mistake in diagnosis. PROBLEMS AND RESEARCH.— The problems of the cause of the tissue changes, whether they are due to a malformation, or to the intrauterine absorption of toxin from the mother, and of the location of the primary lesions, are not very promising for experi- mental investigation. Possibly the continued study of pathological material, together with thorough and continued observations on the presence of bile in the duodenum or stools throughout the Hfe of the baby, may eventually give more Hght. The method . of studying the contents of the duodenum by means of the duodenal catheter, as described and practiced by Hess, is particularly worthy of men- tion in this connection. Hess has further called attention to the role of the pancreas in this disease. He finds that the pancreatic duct of Wirsung is frequently obHterated at its opening, when the common bile duct obhteration involves the papilla of Vater, but that the pancreatic ferments may nevertheless be found undiminished in the contents of the duodenum obtained by the duodenal catheter. In these cases the obliteration of the duct of Wirsung is compensated by the presence of the accessory duct of Santorini, and the prog- nosis as to duration of hfe is probably better than in cases in which no accessory pancreatic duct exists. SCLEREMA Sclerema neonatorum is a rare condition, characterized by pro- gressive hardening of the skin and subcutaneous tissues. ETIOLOGY. — Sclerema is seen most frequently in premature or very feeble infants. While it is commonest in the early days of life, it is not exclusively a disease of the newborn, as it may be seen Sclerema 219 at any time in the first few months in infants weakened by malnu- trition, diarrhea, or some acute infection. In the newborn it is most frequently found among those who are born in exceedingly poor hygienic surroundings, and in cold weather. The cause is prob- ably general, a number of factors being involved, such as great feeble- ness with weakness of circulation, loss of fluid from the skin, lower- ing of the body temperature, and hardening of the subcutaneous fat. PATHOLOGICAL ANATOMY.— Although Northrup reported a case clinically topical, in which microscopic examination of the skin revealed nothing abnormal, the majority of writers have reported changes in the skin. These changes, however, show nothing peculiar to the disease, and may not be an essential feature. Various degrees of atrophy of the subcutaneous connective tissue appears to be the chief lesion described. SYMPTOMS. — Soon after birth, spots of circumscribed hardness appear on the skin. These spots soon become diffuse, and the disease, starting, as it usually does, in the feet or the calves of the legs, passes up the thighs to the trunk. It may, however, first appear upon the face and upper extremities, though not commonly. The skin is waxy and ghstening, and is hard and cold; the limbs become thick, stiff, and misshapen. The infant soon grows weak and somnolent, and refuses to take its food; the breathing becomes rapid and superficial, the voice is weak and whimpering, and the pulse small and retarded. The temperature is markedly subnormal and death takes place seem- in glv from inanition. ^b^J DIAGNOSIS. — Sclerema presents so definite a clinical picture, that the diagnosis is usually easy. It must be distinguished from the edema occasionally seen in newborn babies. In sclerema the skin is harder, and does not pit on pressure. PROGNOSIS. — The outlook in sclerema is very bad, because of the grave character of the etiologic factors. It is usually, but not invariably fatal. TREATMENT. — Artificial heat is the most important thing in the treatment. The incubator or incubator-bed must be used. The nutrition must be maintained as well as possible by careful feeding. EDEMA Edema is occasionally seen in early infancy. In a certain number of cases, edema is a symptom of some severe disease, such as septic infection, syphilis of the internal organs, pulmonary diseases, and severe gastro-intestinal disturbances. There is a form to which the name Oedema Neonatorum may be applied, which is not sympto- matic of any recognizable disease process. This edema is seen 220 Diseases of the Newborn most frequently in premature or congenitally feeble infants, and appears usually on the first day of life. The edema appears first in the suprapubic zone, then involves the legs and sexual organs, and is occasionally seen on the backs of the hands. It is never general. There are two stages in its development; in the first the tissue appears overfilled with fluid, but does not pit on pressure; in the second, there are the usual signs of edema with pitting. It lasts usually but a few days; the longest recorded case lasted twenty days. Any deviation from the typical development is suggestive of symptomatic edema from one of the other causes. Edema neonatorum, however, may pass over into one of the other forms. Its prognosis and treatment is that of congenitally feeble and pre- mature infants. VI. INFECTIONS INFECTIOUS DISEASE OF THE NEWBORN The condition described under this name is one of general sepsis in newborn babies in which the infecting microorganisms enter the blood and internal organs of the newborn infant. The infant, even in the early days of Hfe, may suffer from any of the common infectious diseases. The manifestations of these in- fections in newborn infants do not differ in any essential particular from those seen at a later period of life. In addition to the recognized infectious diseases, such as pneumonia, influenza, typhoid, and so forth, there are other infectious conditions seen in the newborn which are caused by the various pyogenic microorganisms, such as the streptococcus pyogenes, the staphylococcus pyogenes aureus and albus, the gonococcus, the pneumococcus, the bacillus pyocya- neus, the colon bacillus, and other rarer forms. These microor- ganisms may form only localized lesions at the portal of entrance, without any general condition of sepsis supervening. Such infec- tions show themselves in the form of abscess formation, cellulitis, and similar lesions, which differ in no essential from the same lesions seen at a later period of life. Omphalitis or inflammation about the umbilicus, and erysipelas are among the most noteworthy of these external infections. Even when the organisms penetrate within the body, they may still give rise to a localized inflammatory process of which the pathology shows no features peculiar to newborn infants. Among these lesions are to be numbered especially peritonitis, pneu- monia and pleuritis, pericarditis, meningitis, gastro-enteritis, osteo- myelitis, and septic arthritis. The clinical manifestations of these conditions are often obscure, so that the diagnosis is rather more difficult in newborn infants. Nevertheless the symptoms do not present any features sufficiently peculiar to the early days of life to warrant their separate description. The localizing signs may be less marked, so that the clinical picture is one of a general infection. On the other hand the presence of a general infection may be masked by the prominence of localizing signs. A general condition of infection, a true bacteremia or pyemia, is a particularly common manifestation of infection in newborn infants. The manifestations of such an infection are so peculiar in the new- born, that they call for a detailed description, and it is to this con- dition that the term Infectious Disease of the Newborn is here applied. ETIOLOGY. — The microorganisms concerned in infectious disease 222 Diseases of the Newborn of the newborn are the pyogenic types already mentioned. Infection occurs when from any source these microorganisms are brought to any of the portals of entry which are open in a newborn child whose resistance is not sufficient to prevent their entrance. I do not beheve that the low general resistance of the newborn infant is so great a factor in the occurrence of infectious disease as is generally stated. If the infant's general resistance to infection were so very low, infec- tion would be relatively much more common. The most important factor is the relatively open condition in the newborn infant of certain portals of entry, particularly the umbihcal wound. It is true that in a large number of cases of infectious disease of the newborn the portal of entry cannot be discovered, but there is httle doubt that in most of these the infection is of umbihcal origin. That every newborn baby has an open wound, which is closely con- nected with the general circulation through the anatomical connec- tions of the umbihcal vessels, is adequate explanation for the fre- quency and pecuharities of this type of infection in newborn infants. At the umbihcus, the stump of the cord is undergoing a necrotic disintegration with which may be associated pyogenic organisms. In the Hgated umbihcal veins are formed thrombi which may easily become infected, and as a result may break down into purulent material. As a result of such a septic phlebitis the infected material may enter the' circulation and produce a general septicemia, while infected emboh may be carried to any organ in the body. All these processes may go on without any lesion being noted at the umbilicus, and therefore it is wise, in any case of infectious disease of the new- born, to regard the umbihcus as the probable portal of entry. There are undoubtedly other portals of entry in certain cases. The organisms may enter through abrasions of the skin or mucous membranes, through the lungs, through the mouth, and in rare instances through the eye, ear, or genital tract. It is probable that even in umbihcal infection, the organisms are not those normally associated with the disintegration of the cord, but that the umbihcal cord is inoculated with organisms of a par- ticularly pyogenic nature. Such inoculation is also the probable means of infection through the other portals of entry. The sources of such inoculation are the vaginal discharges of the mother, unclean hands of nurse or physician, improper care of the umbihcal wound, dirty bath water, dirty clothing, in short, any agent which may carry septic organisms to the portal of entry. In cases of infection through the lungs or intestinal canal, it is probable that infected mucus or liquor amnii may reach these respective portals of entry in the in- fant's first movements of respiration or of deglutition. In rare instances septic infection may be transferred directly from an in- fected mother to the fetus through the placental circulation. Infectious Disease of the Newborn 223 PATHOLOGICAL ANATOMY.— The lesions of infectious disease of the newborn show no essential peculiarities differing from pyo- genic infection at other periods of life. Umbilical arteritis or phle- bitis are the most frequent lesions. The liv^er is the organ which most frequently shows pathologic changes, as one would expect from the frequency of umbilical infection. In the liver there may be suppurative processes, or various degenerative changes. Similar degenerative changes are found in most of the parenchymatous organs, while individual foci of suppuration may have almost any distribution. Hemorrhages are common. Associated with these generally distributed lesions, there are usually also localized lesions, the most common of which is perito- nitis. Pneumonia, pleuritis, meningitis, encephalitis, pericarditis, osteomyelitis, and arthritis are also found. There is a condition in which the particular group of lesions have lead to its description as a separate disease, under the name of Fatty Degeneration of the Newborn or Buhl's Disease. The pathological changes are essentially a parenchymatous inflammation, followed by fatty degeneration of the heart, liver and kidneys, together with multiple hemorrhages in the various organs. Although the nature and cause of this condition are unknown, it was first described before the advent of modern methods of bacteriological study. Both the lesions and clinical features of this disease show no essential differ-, ence from those of pyogenic infection, and it is probable that it merely represents a particular grouping of the lesions in infectious disease of the newborn. SYMPTOMS. — The clinical manifestations of infectious disease of the newborn present great variations. The symptoms due to the various localized lesions seen in these infections are particularly dependent upon the portal of entry, and are often so marked as to obscure the general nature of the disease. The most common mode of onset is seen in the umbilical infec- tions. There is a rather sudden rise of temperature, followed by an irregular septic fever. The temperature curve is very irregular and can only be properly observed by a four-hourly chart. At some periods of the day it may be very high, at others may even be below normal. After a period of such fever, the temperature in some cases may remain permanently below normal. Associated with fever, the two most common symptoms in general sepsis of the newborn are jaundice and hemorrhages. Jaundice is an early and prominent symptom, but is not always present. It is not of the complete obstructive type, bile being found in the stools, as well as in the urine. Purpura is the most common hemorrhagic manifestation; it occurs as a fine petechial rash, or as large, scattered, 224 Diseases OF THE Newborn dark-blue blotches. Hemorrhage from the bowels is also seen at times, and more rarely, there are hemorrhages from the nasal, buccal, or other mucous membranes. The nervous system is usually profoundly affected. There is at first a notable apathy, which rapidly increases into stupor leading to complete coma. Prostration is very marked, and a condition of extreme exhaustion is apt to come on rather rapidly. In other cases, meningeal symptoms, such as restlessness, irritability, twitchings, spasm, paralysis, or convulsions, are present. On physical examination, the liver is usually found enlarged. One looks for localized evidences at the portal of entry, which, as has been already stated, often cannot be found. The umbilicus may be inflamed, the umbilical depression may be filled with pus, or pus may be made to ooze by pressure about the umbilicus. There may be abdominal distention and tenderness, which are an aid to the diag- nosis in umbilical infections where the umbilicus appears normal. On the skin, or on the mucous membrane of the mouth, nose or throat, can sometimes be observed the ulceration or abrasion through which the infection has entered. A great variety of lesions may be seen in these situations. The signs of localized infection are sometimes the most prominent clinical manifestations in infectious disease of the newborn. These signs do not differ essentially from those of the same lesion when not a manifestation of this particular disease. One should look first for signs of peritonitis; then for signs of pneumonia, pleuritis, arth- ritis, osteomyelitis, pericarditis, meningitis, and encephalitis. DIAGNOSIS. — The diagnosis of infectious disease of the new- born presents extreme difficulty, owing to the great variety of the clinical manifestations. When the case presents the clinical syn- drome which may be called most typical, namely, that of septic temperature with jaundice, hemorrhages, and great prostration, the diagnosis is comparatively easy. The other causes of jaundice in newborn babies, namely, icterus neonatorum, and congenital cirrhosis of the liver, are not associated with fever, nor do they show extreme prostration. Catarrhal jaundice often is associated with fever, but is very rare in newborn infants, and the fever is not of a septic char- acter, nor is extreme prostration present. The other causes of hemorrhage in newborn infants, namely, hemophiha and hemorrhagic disease of the newborn, can usually be easily excluded, as in them hemorrhage is practically the only symptom. The most difficult cases for diagnosis are those in which the syn- drome described above is not present, but in which the symptoms of such localized lesions as peritonitis, pneumonia, meningitis, or gastroenteritis are the prominent chnical features. It should be Ophthalmia Neonatorum 225 remembered that such severe symptoms at this period of Hfe are always strongly suggestive of a general sepsis. In all cases, the finding of evidences of infection at the umbilicus, or at any other portal of entry, is a great aid to the diagnosis. Laboratory methods are not of much aid. The blood examina- tion usually shows a marked leucocytosis, but this is of no value in recognizing the general character of the infection. Only by blood culture can the diagnosis of infectious disease of the newborn be definitely proven. The technic of blood culture in newborn infants is so difficult, that, while it has been successfully done in hospitals, it is not very valuable as a routine method of diagnosis. PROGNOSIS. The prognosis is bad. Nearly all the severe cases presenting the typical syndrome of fever, jaundice, and hemorrhage, die. Death may occur within a few days, or may be postponed for a longer period. It is probable that nearly all cases in which there is a general sepsis, or any important visceral lesion, die rapidly. A few cases of apparent umbilical infection recover,but it is probable that in these cases the septic process never became general. PROPHYLAXIS.— That infectious disease of the newborn is pre- ventable, is shown by the great diminution in its occurrence in insti- tutions since the introduction of aseptic methods into obstetric prac- tice. It may be compared to puerperal fever. The majority of cases are caused by the carelessness of some attendant, physician, nurse, or parent, having the care of the newborn infant. The essen- tials are cleanliness of the child's surroundings, and proper care of the umbiHcus. The umbilicus should be treated like any clean, fresh wound. It should be cleansed and dressed with sterile dry dressings. Everything coming in contact with the wound should be sterile. Clean clothes, clean hands, and clean surroundings, are the other essentials. Care should be taken to prevent all excoriation or abrasion of the skin or mucous surfaces. In institutions all septic cases should be strictly isolated. TREATMENT. — The treatment is purely symptomatic. When- ever any locaHzed focus of suppuration open to surgical treatment is present, incision, evacuation, and drainage should be performed. Vaccine therapy with an autogenous vaccine can be tried, if the microorganism causing the disease can be isolated from the blood, or from a localized lesion. There are as yet no favorable reports from its use, and I do not think it offers much prospect of success. OPHTHALMIA NEONATORUM Ophthalmia neonatorum is an inflammation of the conjunctiva of newborn infants. There is a mild catarrhal form occasionally seen, which is caused by any slight irritation of the eyes of the infant. 16 226 Diseases of the Newborn It runs a very mild course, attacks chiefly the palpebral conjunctiva, and usually the only symptoms noted are a slight photophobia and a collection of secretion in the angles of the lids and upon their borders. The usual condition known as ophthalmia neonatorum is a puru- lent conjunctivitis. ETIOLOGY. — The gonococcus is the most frequent pathogenic microorganism in this disease. A few cases are due to other organ- isms, such as streptococci, staphylococci, and pneumococci. In- fection most commonly takes place during birth from direct contact of the conjunctiva with the pus-forming organisms present in the vagina of the mother, who has a vaginitis due to gonococcus or other infection. Occasionally the infection may be carried to the eyes of the infant by the hands of the physician or nurse, or by contaminated linen or other material, and in such cases the infection may take place at a period subsequent to birth. SYMPTOMS. — The disease begins as a redness of the conjunctiva, with a slight discharge from the corner of the eye. This is succeeded with startling rapidity by intense inflammation of the lids. In twenty-four hours the upper lid may become so much swollen as to overhang the cheek and render opening the eye impossible. On separating the lids, a little greenish pus, which may even be tinged with blood, wells up between them. At first the cornea is unaffected, but if the pus accumulates under the edematous lids it soon shows signs of ulceration. In the second twenty-four hours the ulceration may perforate the cornea and evacuate the aqueous humor, thus bringing the iris into contact with the posterior surface of the cornea. The swelling may extend around the eye and well over the forehead and malar prominence, but it does not persist in the latter region very long. All the symptoms disappear slowly, and recovery takes place, except in those cases in which the cornea has been per- manently injured by ulceration. DIAGNOSIS. — The diagnosis of purulent ophthalmia may be easily made from the examination of the eyes. A gonorrheal etiology may be suspected when a very violent inflammation is present, and from the history suggesting gonorrheal vaginitis in the mother. A positive etiologic diagnosis can be made only by bacteriological examination of the purulent discharge. PROGNOSIS. — The earlier the pus appears, the more severe will be the course of the disease, and the more unfavorable the prognosis. Cases seen early and treated properly, terminate as a rule in complete recovery. Neglected cases and very severe gonococcus infections frequently result in corneal ulceration, which may go on to perfora- tion and complete loss of vision. Ophthalmia Neonatorum 227 TREATMENT. — Prophylaxis is the most important part of the treatment of this disease. In private practice, when the mother has no vaginal discharge, all that is required is washing the eyes after dehvery with a weak solution of boric acid. When the mother has a vaginal discharge, or in institutions, Crede's method of pro- phylaxis should be employed. This consists in dropping one or two minims of a two per cent, solution of nitrate of silver into each eye of the newborn infant. As even this has been known to cause a con- siderable amount of irritation, a solution of protargol, or argyrol, ten or twenty per cent., is often used in preference to the silver nitrate. When one eye only has become infected, care must be taken to prevent the spread of the infection to the other eye. This is accom- plished by carefully covering the sound eye with cotton and a bandage. After the disease has once begun, two indications must be kept in mind: (i) To reduce the inflammation, and (2) to prevent the pus from accumulating behind the tightly closed Hds. By far the best way of applying cold to the eye is by compresses of soft pieces of linen cut into small squares. Not more than two thicknesses are to be used at once. These compresses are to be cooled by laying them on a piece of ice or floating them in ice water. They must be constantly changed. To remove the pus, a gentle irrigation, such as can be easily obtained by using a medicine dropper, is sufficient. In the irrigation of the eye one should first turn the child's head a little to the diseased side, and with the fingers of the left hand gently separate the lids as far as possible. Then, holding the dropper with the right hand, irrigate between the lids, directing the stream from the nose. After each irrigation vaseline should be applied to the edge of the lids. This should be done at least every half-hour, day and night, until the swelling has so far subsided as to preclude the danger of any secretion being retained. For irrigation many solutions have been advocated. The most simple, and perhaps the best, is a satu- rated solution of boracic acid, or one of bichloride of mercury in the strength of 0.05 gramme (i grain) to 480 c.c. (i pint) of distilled, water. In addition to the irrigations, a daily instillation of a 2 per cent, silver nitrate solution should be used. In the later stages of the disease, in which all the tissues are relaxed, a solution of nitrate of silver, or still better, of protargol or argyrol, 20 per cent, in strength, painted on the conjunctiva with a camel's-hair brush once daily, is very effective in shortening the course of the disease. TETANUS NEONATORUM This disease differs in no way from tetanus occurring at any other period of hfe. The cause is the same, the bacillus of tetanus, which sometimes finds a portal of entry in the umbihcal wound of new- 228 Diseases of the Newborn born infants. The symptoms, diagnosis, and treatment differ in no essential particular, whether the disease is seen in the newborn or at a later period of life. DERMATITIS EXFOLIATIVA In the year 1878 Ritter gave the first complete description of the disease dermatitis exfoliativa neonatorum. Previous to this date cases of this affection had been reported, but many of them were regarded as some rare or unusual manifestation of pemphigus. Ritter studied and reported the cases which he saw at the Foundling Asylum in Prague from 1868 to 1878. A careful review of Ritter's original observations of these cases has been made by Elliot. The majority of cases were in male infants, and the mortality was found to be 48.82 per cent. The disease is very rare. It occurs rarely before the end of the first week, and usually appears between the second and the fifth week of life. It was found to vary greatly in the in- tensity of its symptoms. In some cases a dry scaly condition of the skin preceded the subsequent lesions, which had apparently lasted after the physiological desquamation of the epidermis had taken place. SYMPTOMS. — The first symptom noticeable in these cases was a diffuse redness, usually over the lower half of the face about the mouth, sometimes, however, beginning in some other portion of the body, and at times being universal from the beginning. This hyper- emia of the skin spread rapidly, and in a few days became universal, the extremities, as a rule, being the last parts affected. The mucous membrane of the mouth and the nose was at times affected, and the conjunctivae usually participated in the hyperemia. The color of the effiorescence varied from a light to a dark purple-red. As the hyperemia extended to new surfaces, those which were first affected began to desquamate. This desquamation at times gave no evidence of exudation, the epidermis being simply thickened, and the loosened epithelium separating easily. At times other lesions appeared, such as milia, and sometimes the horny layer of the skin was raised above an intensely reddened base, and large, irregularly shaped bullae filled with fluid were formed. After the desquamation had taken place the skin recovered its normal condition, occasionally very rapidly, but it remained for some time rough and irritable. In the cases in which there was no exudation a longer time was necessary for the separation and regeneration of the epithelium. Usually the disease was found to run its course in from seven to ten days. Relapses were sometimes observed ten or twelve days after the first attack, but were always mild. In typical cases the process was unaccompanied by any fever or systemic disturbances unless some complication existed. The Infectious Hemoglobinemia 229 functions were normal, and the weight of the infant remained sta- tionary or was even at times increased. The fatal cases resulted either from the intensity of the attack or from some intercurrent affection or sequela, such as furunculosis. This disease is usually recognized as a local septic infection of the skin, and it would seem that it would be easily distinguished from the pemphigus which occurs in the early weeks of life. INFECTIOUS HEMOGLOBINEMIA (Winkel's Disease) Infectious hemoglobinemia is an affection which is met with in newborn infants, usually in the early days of life, and, as a rule, arises as an endemic disease in hospitals. The disease is charac- terized by extreme cyanosis, icterus, hemoglobinuria, somnolence, rapid collapse, and the absence of fever. ETIOLOGY. — The etiology of this disease is obscure. A specific microorganism has not yet been discovered, yet the endemic char- acter of the malady and the changes which are produced in the blood warrant us in supposing that it is an infectious disease. It would be described, not as a separate infection, but as a probable special manifestation of infectious disease of the newborn, were it not for its epidemic character, which suggests a probable undescribed specific infection as a cause. PATHOLOGICAL ANATOMY.— A careful post-mortem examina- tion of Winkel's cases showed that there was cyanosis of the external and internal organs. Except in one instance, no pathological condi- tion of the vessels of the cord was described. The cortex of the kidney was found to be wider than normal, to be of a brownish color, and to present numerous minute hemorrhages. In some places the pyramids were entirely black-red in color, and in other places numer- ous black streaks were found which converged to the papillae. This color was caused by the filling of the straight tubules with granules of hemoglobin. Intact erythrocytes were never found. The blad- der was found to contain greenish-brown urine. The spleen was strikingly enlarged and hard. Its length was about 7.5 cm. (3 inches), and its weight 25 grammes (5/6 ounce). It was black-red in color, and on section the surface was smooth. Microscopic examination showed a considerable accumulation of brownish coloring matter, partly free and partly in the pulp cells. In addition to these appearances in special organs, minute hemor- rhages were found in nearly all the organs, but especially in the pleura, pericardium, endocardium, mucous membranes of the stom- ach and small intestine, and kidney; they were also found in the dura and pia mater and under the capsule of the liver. The lymph- follicles were swollen, especially Peyer's patches and the mesenteric 230 Diseases of the Newborn l3miph-glands. A microscopic examination showed fatty degenera- tion of many important organs, especially the liver, and at times of the muscles of the heart. The bacteriological examinations were, as a rule, negative, especially as regards the tissues of the intestine. Clumps of bacteria were found only once in the Hver and once in the kidney. SYMPTOMS. — The first s3maptoms were generally restlessness and cyanosis, not only of the face but also of the body and extremities, and especially of the back. The color increased progressively until it became a deep blue. To this was added an icteric color, which when death did not occur within twenty-four hours became very marked. The respiration was rapid; the pulse was not especially increased in rate. The rectal temperature never rose higher than 38.1° C. (100.6° F.). The skin generally felt cool. Vomiting and diarrhea occurred in some cases. The most striking symptom was the appearance of the urine. It had a pale brownish color, and was passed frequently, and often with considerable straining. An ex- amination showed that the color was due not to bile, but to hemo- globin. In the sediment were found numerous epithelial cells from the walls of the kidney, granular casts with blood-corpuscles adherent to them, micrococci, masses of detritus, and urate of ammonia. A small quantity of albumin was present. Later in the disease con- vulsions occurred, followed rapidly by death. In other cases besides those of Winckel's in which the blood was examined the condition was found to be one of hemoglobinemia. The percentage of hemoglobin was high, and free hemoglobin was found in the blood-serum, while the erythrocytes were greatly reduced in number, at times amounting to only 1,700,000 or even less. DIAGNOSIS. — The resemblance of this disease to the form of infectious disease known as acute fatty degeneration of the new- born is very striking. Most of the symptoms are common to both diseases. Large hemorrhages are also not uncommon in this dis- ease, but are not so marked as in acute fatty degeneration. The striking points of difference are the presence of hemoglobinuria and the fact that large numbers are affected at the same time in in- fectious hemoglobinemia, while these conditions have not been found in acute fatty degeneration. TREATMENT.— The treatment should be the administration of oxygen and stimulants, and forced feeding by means of a dropper when the infant is too weak to suck. VII. PREMATURE INFANTS APPEARANCE AT BIRTH.— The picture of a premature infant in the early days of Hfe is quite characteristic. Besides its very small size, as shown in the illustration, where the size is compared with the nurse's hand, it shows in varying degrees an absence of the life and vigor which is seen in the fully developed infant at term. It is emaciated, its skin being soft, wrinkled, and showing very little subcutaneous fat. Its head is large, its abdomen broad and^dis- FlG. 67 Infant premature at seventh month. Birth-weight, 1740 grammes. Age, 10 days; weight, 1540 grammes tended, and its limbs puny. According to the stage of its develop- ment it ma}^ or may not have the remains of the hair (lanugo) on its body which was present in uterine life, and in like manner its nails may or may not be well formed. Its face has a senile expres- sion and it is torpid and extremely somnolent. The eyes are closed. Its cry is very feeble. The surface temperature is usually cool, the extremities seldom move. The respirations are very superficial and irregular, often ceasing altogether for a few seconds. The power to suck and even to swallow is often slight. These signs evidently indicate that the vitaHty is very low, and if the weight is below three or four pounds, and the length less than eighteen or nineteen inches, that the functions and organs are not developed sufhciently for use, and that unless unusual care be taken in the treatment of such cases, they will soon die. PROGNOSIS.— The majority of infants born before the comple- tion of the seventh month of pregnancy die within a very short time, although I have seen one or two cases of survival in babies premature in the sixth month. A number of babies premature at the seventh 232 Diseases of the Newborn and eighth months survive, the outcome depending on the vitaHty of the individual baby, and the care with which it is treated. There are a number of factors which make the prognosis very uncertain in every case. Many premature infants have a varying degree of congenital pulmonary atelectasis, which generally lowers their vitaHty and resistance. SyphiKtic infants usually die within a few days. Sclerema is a very unfavorable sign. The best prognostic indica- tion in a premature infant is the temperature curve. If with arti- ficial heat the temperature remains subnormal, or if the curve is very irregular, rising above the normal when the external heat is increased, and falling below the normal whenever it is slightly dimin- ished, the probabihty is that the infant's vitaHty is very low. When the temperature begins to approach the normal line, and to show less irregularity, the prognosis becomes better. The weight curve stands next to the temperature curve as a prognostic sign. A steady gain in weight is a very favorable sign. Many premature infants, how- ever, do not begin to gain in weight for a number of weeks, and yet may survive. It must be remembered that even with the best care, premature infants are Hable to sudden death from no apparent cause. This HabiHty to sudden death is not passed when the infant reaches the period of fuU term, but continues for a number of months thereafter. TREATMENT. — The same measures of care which are indicated for premature infants, are also appHcable to infants who, although born at full term, show the same evidences of low vitality as are characteristic of infants prematurely born. There are three principal points to be considered in the treatment of premature and feeble infants. These are (i) the maintenance of the body heat; (2) the modifications of hygiene and care which are necessary to protect the infant from the deleterious influences of the external world; (3) nourishment. Artificial Heat. — For the maintenance of heat in premature infants, various forms of incubators and brooders have been recom- mended and widely used. My experience with incubators has been entirely unsatisfactory, and I cannot recommend their employment. An "incubator bed'' has given the best results in my hands. This consists in an ordinary infant's crib, padded, and with the lower half covered with a blanket, sufficient space being left at the top for the admission of a plentiful supply of air. The infant is wrapped in cotton. The best means of wrapping the infant is the "premature gown." Such a gown is shown in the illustration. It is made of a thin layer of absorbent cotton, about a quarter of an inch thick, between two double layers of fine gauze. The layers of cotton and gauze are sewed together on the machine, Premature Infants 233 both around the edges, and across in both directions, the lines of stitching being about five inches apart. The dimensions of the gown should be about twenty-six inches in length by twenty-three inches in width. To the top of the body of the gown is attached a hood, made of the same materials. The infant is wrapped in this gown, and laid in the incubator bed. There must be in the bed with the infant some means of supplying artificial heat. An excellent device for this purpose is an electric pad or electrotherm. Just as good results can, however, be obtained by the use of hot water bottles. Earthenware bottles filled mth hot water and wrapped in flannel retain their heat for a long time. One or two of these are placed in the bed alongside the infant. A thermometer wrapped in absorbent cotton is also placed in the bed beside the infant, and the whole, infant, bottles, and thermometer, are covered with a blanket. By changing the water in the bottles at proper intervals, a fairly constant temperature can be main- tained in the incubator bed. Ordinarily with infants of fairly good vitality, the thermometer should register 85° to 95° F.; but the tem- perature which is maintained in the incubator bed must be regulated by the rectal temperature curve of the child. If this shows a tendency to remain subnormal, more external heat will be necessary, and the temperature of the bed should be kept at from 95° to 98° F. Hygiene and Care. — The premature baby must have a constant supply of pure fresh air. For this purpose, the infant must be kept in a room which has some proper communication with the outdoor air, the temperature of the room being maintained by ordinary heating methods. Under ordinary circumstances the temperature of the room should be from 70° to 72° F. Most pediatrists believe that a great mistake has often been made in having the air of the room too warm. Nevertheless, I find that in many cases a warmer temperature is of distinct value provided that the air is kept fresh. When a premature infant in a properly devised incubator bed and in a room of 72° F., still shows a tendency toward constant subnormal temperature, they will often do better if the temperature of the room be kept at 80° F. In a number of cases I have seen premature babies who had not been gaining in weight, begin to gain immediately when they were transferred to a room at 80° F. The probable explanation of this is that they do not have to use so much of their nourishment for the maintenance of their bodily heat, and more food becomes available for tissue building. We have found at the Infants' Hospital that the "80° room" is a valuable measure in the treatment of certain premature and feeble infants. The premature infant should be handled as little as possible. It 234 Diseases of the Newborn should not be bathed, but its body is kept oiled with olive oil. When it is necessary to change the diaper, this should be done rapidly and with as little exposure as possible. The morning and evening tem- peratures should be taken daily, as this record is necessary in regu- lating external heat, and also has a bearing on the problem of nutri- tion. But the taking of the temperature should be attended with a minimum of handling and exposure. The premature infant should also be protected from excessive light and from noise. Fig. 71 Feeder for premature infants (reduced one-half) Feeding.— Breast milk should be used in the nourishment of premature infants whenever possible. Few premature infants are strong enough to take the breast. In the early weeks, a premature infant should be fed as often as every hour, but such frequent nurs- ing has a deleterious effect upon the secretion of the mammary glands of the mother or wet-nurse. Consequently the infant should be put to the breast only every two hours. It will not be able to empty the breast and the remaining milk should be withdrawn by means of the breast pump. In this way, sufficient breast milk can be Fig. 69 — Articles for premature infant Premature Infants 235 obtained for use in the alternate feedijigs when the infant is not put to the breast. When an infant is too feeble to take the breast, as is usually the case in infants born before the eighth month, and with feeble babies born in the eighth month, the infant's food can be obtained by pumping the breasts at the proper intervals. The method of administering milk to a premature baby who is unable to take the breast is important. If the infant is able to swal- low, the milk should be given with the Breck feeder. This consists in a graduated glass tube narrowed at the ends. Over one end is placed a proper sized nipple, and over the other end is placed a rubber compression bulb. The advantage of the Breck feeder over giving the milk with a spoon or medicine dropper is that the sucking reflex is not entirely abolished. There is evidence that the sucking reflex has an important influence upon the digestive function, and with the Breck feeder, even though the baby be unable to suck strongly enough to draw the milk from the bottle, it can make efforts at suck- ing, and can be helped by the pressure made by the nurse upon the rubber bulb. Whenever the infant is so feeble that it is unable to swallow, it must be fed by means of gavage. When, as often hap- pens with premature infants, the mother has not a sufficient supply of milk, a wet-nurse should be obtained if possible. The wet-nurse should always be accompanied by her own infant, and should nurse it, as the requirements of the premature infant will not be suf- ficient to maintain the normal function of lactation in the wet-nurse. The quantity to be given at a feeding to premature infants varies with the age and weight of the child. With a seven months' baby weighing from three to four pounds, one can begin with half an ounce every hour. Changes are regulated by the temperature and weight curves, the composition of the food, the appearance of the movements, etc. Usually after a few weeks the amounts can be increased and the intervals made longer, so that the baby will get an ounce every two hours. This amount will later be further increased in accord- ance with the ordinary principles of infant feeding. When a wet-nurse cannot be obtained, artificial feeding becomes necessary. It is true that the outlook with artificial feeding is not so good as it is with human milk, but the prognosis is not so bad as some writers would lead one to suppose. In all premature infants we have to contend only with congenital weakness of the digestive powers, and such cases are often not so difficult to manage with arti- ficial feeding as are older infants whose powers have been ruined by improper feeding. The amount to be given at a feeding and the intervals between feedings are the same with artificial feeding as when breast milk is used. The composition of the food, however, must be weak. In my experience premature infants have less difficulty in digesting 236 Diseases of the Newborn the fat than the casein of cow's milk, fat indigestion being a partic- ular manifestation of infants who have been improperly fed. Conse- quently, I usually select for a premature infant a whey mixture or split protein formula. An average food to begin with is — Fat, i; lactose, 5; whey protein, 0.75; casein, 0.25; lime water, 20 per cent, of the milk and cream. The methods of obtaining such a food are described in the division on Feeding. Further changes in the composition of the food will depend upon the weight curve and symptoms of the infant, the physician being guided by the general principles of infant feeding. The signs of insufficient nourishment in a premature infant are, failure to gain in weight, constipation, but otherwise good stools, and a persistent tendency toward subnormal temperature. The signs that the food is too strong, or improperly adjusted to the diges- tive power of the infant, are, vomiting, green or undigested move- ments, and failure to gain in weight. •i\: m Fig. 70 — Premature infant in bed Premature Infants Chart 4 237 /\rAJ\r^\ Chart of feeble infant no^ premature, showing the effect of the premature gownZaftd incubator bed The feeding was not changed during the period represented by this chart, which shows the temperature, pulse, respiration, and weight curves. A. Infant admitted to hospital and placed in ordinary bed. B. Infant placed in incubator bed and premature gown. C. Infant taken out of incubator bed and premature gown. W. Weight curve. It will be noted that under ordinary treatment the temperature remained subnormal and there was a steady loss of weight. When no other change in the treatment than putting the baby into the incubator bed and premature gown was made, the tempera- ture rose at once to the normal, and gain in weight was rapid. Later, when removed from the incubator bed, the infant maintained a normal weight but did not gain so rapidly. The artificial heat of the incubator bed enabled this infant to spare food from heat pro- duction and from the effort to maintain a normal temperature, and to utilize this food for tissue building. 238 Diseases of the Newborn Chart 5 .OttMM 43 K 41 6 41 I 40 3 40 3»4 38» 38 3 37 7 37 8 36 e A-f^ f M U UJJ ty *(:yi.JT /ms_;'pl;'l :!:j^'?i^X^ six Maternal Nursing 253 hours for the next twenty-four hours. After this period it should nurse every four hours for another twenty-four hours, and then should begin the regular routine which is to be followed throughout early infancy. The infant will obtain very little food during the first two days of its life, as the secretion of the breast is not yet estab- lished. The object of putting the infant regularly to the breast in these early days, is to stimulate the breast secretion. The sucking of a normal infant is the best possible stimulus to the flow of milk. The infant does not need more food in these early hours of its life. If there were such a need, Nature would supply it. It is not neces- sary nor wise to give an infant sugar solution, nor artificial food during the first forty-eight hours. It does need water to flush out the kid- neys, and one or two teaspoonfuls may be given every two hours. Most babies do not begin to show signs of hunger till after forty-eight hours, and at this time the breast secretion usually begins to be more profuse. If there is still delay, and very little milk in the breast, the bottle must be used temporarily, but every eft"ort should still be made to encourage the mammary secretion, by putting the baby to the breast at proper intervals, and letting him get what he can by sucking. In the bottle feedings, care must be taken to give neither too much nor too rich food. The artificial food should be made very weak, and its strength should be increased slowly if the baby digests it well. A whey mixture is preferable for these early feedings. Two drachms may be given at first, at two-hour intervals, and this amount is increased if the baby is not satisfied. Colostrum is supposed to have a laxative effect. If the bowels have not moved at all at the end of twenty-four hours, one teaspoonful of castor oil should be given. MANAGEMENT OF NORMAL NURSING.— The great essen- tial in the management of breast feeding, is to insure the most abso- lute regularity of the nursing. This must not only be recommended by the physician, but enforced. Infants rapidly tend to form habits, and when they are fed regularly, they soon get into the habit of expecting their feedings at regular times. They will then sleep more, and will only cry and show signs of hunger when their feeding is due. This gives the mother more peace, enables her to plan her work better, and under such happy conditions, she is free from nervous anxiety, and the quality of her milk remains good. Irregularity in nursing is the most common cause of disturbance in the quality of human milk. Such change in the milk tends to produce a greater or less degree of indigestion on the part of the baby. Mothers should be instructed not to nurse the baby before its regular feeding time comes due, even if it cries and seems hungry. On the other hand they must 254 Feeding be told to wake the baby up if it happens to be asleep at nursing time. Under such management the baby soon acquires regular habits. The Intervals Between Feedings. — These are less important than regularity, provided they be not too short. There is consider- able difference in opinion and practice in different parts of the coun- try as to what the nursing intervals should be. The tendency in some locaHties is to use longer intervals, such as four hours. The clinical evidence brought -forward in favor of long intervals is not very conclusive, nor is there evidence based on accurate scientific investigation of the emptjing time of the stomach. Infants can be accustomed to longer intervals, but the process of training them is often troublesome, and there is no proved advantage to be gained. I beHeve the tendency toward long intervals, under present e\ddence, is rather a fad than a practice to be recommended. Indi\adual variation also plays a part, some babies doing better on longer, and others on shorter intervals. The intervals which I am accustomed to recommend are the following: Table 22 Intervals Between Feedings AGE NUIIBER OF FEEDIXGS IN 24 HOTRS NIGHT FEEDINGS INTERVALS First 4 weeks 10 or 8 8 or 7 7 6 6 or 5 I I I I I 2 hours 4 weeks to 3 months 2I hours 2I hours 3 to 6 months 3 hours 3 hours 6 to 9 months 3 hours Q to 12 months 3 hours 3 or 4 hours The feedings, exclusive of the night feeding, are supposed to begin at 6 A. M. and end at 9 or 10 p. M. By night feedings are meant feed- ings given between 9 or 10 p. m. and 6 a. m. This is the only feeding at which an absolutel}- regular hour is not essential, but which can be given when the baby wakes up and cries. If however, the baby wakes up and cries a second time in the night, it is better to give the night feeding at a regular time in the middle of the period, about 2 A. M., in order that the baby shall not form the habit of wanting more than one night feeding. The figures showing night feedings in the table represent the maximum. Generally, the night feeding should be dropped as soon as possible at any age, and as soon as the baby Maternal Nursing 255 iDegins to sleep through the night until within one or two hours of his morning feeding, he should be accustomed to go the whole time without a night feeding. As a baby grows older, the last day feeding, ■or evening feeding, should also be dropped as soon as possible. An alternative between shorter and longer intervals is given at some ages in the table. When a baby has been pre\dously accustomed to shorter intervals, the shorter alternative should be used first, and then later the longer alternative should be substituted. With a baby pre\dously accustomed to longer intervals, or who is under your care from the time of its birth, the longer intervals may be used from the start. The baby should be nursed on alternate breasts at each nursing, if the mother has plenty of milk. If there is any tendency to de- ficiency of milk supply, both breasts should be used at every feeding after the first two morning feedings. The baby should not nurse more than twenty minutes; if he takes longer, it is a sign that some- thing is wrong. On the other hand, if he takes his full supply in less than fifteen minutes, he should be made to take longer breathing spells. A baby gets half his meal in the first five minutes, and one- quarter more in the next five minutes. He should not go to sleep while nursing; if he does, it generally means that the baby is feeble, or that there is too little milk. HYGIENE OF THE NURSING MOTHER.— The essentials in the hygiene of the nursing mother are, freedom from nervous excite- ment and worry, regular habits of life, plenty of sleep, a proper die-, and sufficient exercise. The diet of the nursing mother should not essentially differ from ■what would be considered to be a suitable one for her at any time. There is no special diet which, under all circumstances, is best for all nursing women during the period of their lactation. In the early days of the puerperium there is, as a rule, more danger of overfeeding than of underfeeding the mother. A light and plentiful diet should be given to the mother while she is confined to her bed. This diet should consist of milk, gruels, soups, vegetables, bread and butter, and after the first week a small amount of meat once during the twenty- four hours. When the mother is able to go out of the house again, and has resumed her usual habits, the quality of the diet can be very much increased, and she can have the usual variety of food repre- sented by meats, vegetables, milk, fruits, and cereals. There are no special kinds of food which are contraindicated, provided that the food be kept within the Hmits of the ordinary articles which commonly represent a plain but nutritious diet. It is very important for the nursing mother to have her meals at regular intervals, and during the early part of the lactation to take food somewhat more frequently 256 Feeding than when she is not nursing. The additional meals, as a rule, should be made up of milk or cocoa. There does not seem to be any advan- tage in adding any special beverages, such as beer, malt, or stimulants, to her diet. She should receive as much milk as is compatible with her digestion, and should drink a plentiful supply before retiring at night. Certain vegetables, and sometimes fish, will in individual cases affect the milk and cause discomfort to the infant. We must, then, in every case, seek to determine which article of diet may cause disturbance in the special woman's milk secretion, and eliminate that article. We should, however, be very careful not to exclude this special article of diet from the regimen of a large number of women to whom it might be of benefit rather than of harm, simply because it has affected the milk of a few women. For the average woman a plain mixed diet, with a moderate excess of fluids and proteids over what she is normally accustomed to, will, as a rule, give the best results. Exercise has so constant an influence on the changes which take place in the daily secretion of the milk, that the mother should be encouraged to be out of bed and to walk about her room as soon after her confinement as is possible without injuring her physical condi- tion. Exercise is so important for promoting the proper elaboration and equilibrium of the milk secretion during the entire period of lactation, that it should always be insisted upon, and regular hours for walking should be as definitely arranged during the day as the hours for eating. The exercise must, however, be in accordance with the strength of the special woman, for fatigue has the- same delete- rious influence on the production of the milk as has lack of exercise. EVIDENCES OF NORMAL LACTATION.— In judging of the results of breast feeding in any given case, we must fully appreciate the fact that it is the equilibrium between the digestion and nutrition which constitutes success. A child may digest its milk perfectly and yet drop steadily behind in its weight development. On the other hand, it may make satisfactory gains in weight from week to week, in spite of persistent symptoms of gastric and intestinal indi- gestion. In either case the indications for regulation of the feeding are present. It is desirable to keep careful records of the state of the digestion, and of the weekly gains in weight. A child in whom the equilibrium between digestion and assimilation is well established shows the unmistakable signs of good health. It is free from vomiting and colic. Its sleep is restful and regular. It is always eager to nurse and is satisfied at the end of the prescribed period of fifteen or twenty minutes. It cries only when disturbed by urination, defecation, or hunger shortly before nursing. The movements are regular, one or two a day, smooth, of a Hght-yellow color and mush-like consistency Disturbances of Breast Feeding 257 and slight sour, but not foul or fecal odor. Its weekly gain in weight is regular but varies greatly, according to individual peculiarity. The importance of weight development as an indication of the nutrition of the infant is very great and furnishes us, both in breast and sub- stitute feeding, with the most valuable evidence of all as to the success of the feeding in any particular case. DISTURBANCES OF BREAST FEEDING CAUSES. — In all disturbances of nutrition in infancy there is one factor which is constantly present. This is the relatively undeveloped digestive mechanism of the young infant. The degree to which the digestive power is undeveloped is not fixed and constant in all babies of the same age, but varies in different individual babies. This variation in digestive power, and in food requirement, is so constant, that it may be considered normal. Disturbance of digestion and nutrition is due to lack of balance between the digestive power and requirement of the individual baby, and the food which is given to that baby. The two factors, peculiar- ity of digestive power on the part of the baby, and unsuitable compo- sition on the part of the food, combine to produce the disturbance. In the majority of normal breast-fed babies, the first factor plays very little part. The digestive mechanism of the baby, though un- developed as compared with that of older children, is nevertheless fitted to digest human milk, and will digest human milk, unless for some reason the milk is particularly unsuitable in composition. Ba- bies are seen at times, however, who fail to digest the mother's milk, even when the chemical composition of their food shows no wide variation from the normal average. In such babies we must assume that individual peculiarity of digestive power plays a considerable part. Such babies will usually digest human milk better than any artificial food. Only in very rare instances are babies seen who will digest a cow's milk modification better than human milk. Even in cases where the mother's milk does show a considerable variation from the normal average, individual peculiarity of digestive power may play a part, and the milk may be well digested by another baby. It is best to regard this factor of individual variation in digestive power as constant and normal, and when disturbance of breast feeding is seen, to attribute such disturbance to unsuitable milk. As there is no constant standard for breast milk composition, our conclusion, in disturbance of breast feeding, is that this particular milk is not wholly suited to the digestion of this particular baby. In seeking the cause of disturbed breast feeding, we must look for all the causes which may produce an unsuitable breast milk. The violation of any of the requisites for normal lactation outlined 17 258 Feeding above may be the cause. The commonest is irregular habits of nurs- ing. Worry, nervousness, excitement, overeating, constipation, in- sufficient sleep, insufficient exercise, menstruation, pregnancy, acute illness — any of these may be the cause. In many cases the cause cannot be found; the milk is or becomes either insufficient in quantity or quality, or abnormal in quality, without any apparent reason. In such cases, the cause is to be sought in heredity, and in the condi- tions of the life of our present civilization. Several t\pes of abnormal breast milk are particularly common. Perhaps the commonest is an over-rich milk, high in all the nutritive elements, having a composition of fat 5 or 6 per cent, sugar 8 per cent, protein 2 1/2 or 3 per cent. Such a milk is often seen in well-fed women who take insufficient exercise. Another t}^e of abnormal breast milk is low in fat and sugar, high in protein, having a composi- tion of approximately fat 2 per cent, sugar 5 or 6 per cent, protein 2 1/2 or 3 per cent. Such a milk is often seen in women who work hard and are underfed. A third tx-pe of abnormal milk is very low in fat and sugar, and very high in protein. Its composition approxi- mates fat I to I I '2 per cent, sugar 3 per cent, protein 3 1/2 to 4 per cent. Such a milk is seen in " highly civiHzed " women with over- developed nervous systems. SYMPTOMS AND DIAGNOSIS.— Disturbed breast feeding is recognized by certain symptoms. The babies may have vomiting or cohc, or abnormal movements, or hunger-crying and restlessness, or constipation. Failure to gain, or loss of weight may be the chief symptom, but may be absent. For purposes of practical diagnosis and treatment, cases of dis- turbed breast feeding may be divided into two classes, i. Cases in which the trouble is due to an insufficient breast milk, and 2. cases in which the trouble is due to a bad breast milk. In the first class the milk is insufficient to meet the nutritive requirements of the baby, but does not cause symptoms of indigestion. In the second class the term bad means that the milk is so unsuited to the digestive powers of the baby as to cause symptoms of indigestion. Symptoms of Insufficient Breast Milk. — These are failure to gain, or loss, in weight; hunger-crying, with periods of excessive somno- lence; constipation, with small stools of increased consistency, but otherwise well digested and of normal color. This set of symptoms always means insufficient milk. The milk may be deficient either in quantity or in quality, and for purposes of treatment it is important to determine which condition is present. When the baby seems satis- fied after nursing, but wakes up and cries long before the next feeding time, the milk is apt to be normal in quantity, but of very weak com- position. When the baby is not satisfied at a feeding, wants to nurse Disturbances of Breast Feeding 259 a long time, finally going to sleep on the breast, the deficiency is probably in the quantity. The diagnosis however, cannot be made with any certainty on this evidence. Insufficient quantity may be recognized by the method of weighing the baby before and after nursing. No conclusion can be based on the amount of milk taken at a single nursing, but the baby must be weighed before and after each nursing for a period of twenty-four hours, and conclusions are based on the twenty-four hour quantity of milk taken by the baby. If no deficiency in quantity is found, we may assume that the de- ficiency is in the quality. This diagnosis can be confirmed by a chemical analysis of the milk, which usually shows a marked deficiency in one or more of the food elements. Symptoms of Unsuitable Breast Milk. — The babies show signs of indigestion, such as colic, vomiting, or abnormal stools. In mild cases they may continue to gain weight, even when these symptoms are present; in moderate cases the weight is stationary; in severe cases there is loss of weight. The existence of symptoms of indiges- tion is sufficient evidence for the diagnosis of unsuitable breast milk. The result of analysis may give us some idea as to which element of the milk is excessive, in proportion to the infant's digestive power, but conclusions drawn from such an analysis must not be accepted as too positive, as the peculiarity of the child's digestive power may be so great, that the element shown by analysis to be most excessive may not be the cause of the symptoms. MANAGEMENT OF DISTURBED BREAST FEEDING.— These disturbances of breast feeding are never an indication for weaning. Every effort should be made to correct them before arti- ficial feeding is even thought of. The first step in the management of a case of disturbed breast feeding, is the removal of any possible cause in the hygiene of the mother. The most common cause is irregularity of nursing, and this is the cause easiest to remove. Absolute regularity must be insisted on, and any other bad nursing habit must be corrected. Every detail of the mother's daily hygiene must be scrutinized and all abnormal conditions, such as worry, excitement, improper diet, over-eating, constipation, insufficient exercise, must be removed. Some cause may be found which is not sufficient to indicate weaning, but which cannot be removed, such as menstruation. After the hygiene of the mother has been placed on the best possible basis, a special effort should be made to affect favorably the char- acter of the milk by other means. Such an effort will not always be successful, and the regulation of breast milk by means of diet and exercise cannot be carried to so great an extent as was formerly sup- posed. The following rules may be used as a guide, in such eft"orts: 260 Feeding 1. To increase the total quantity, try to better the mother's physical condition by careful attention to all hygienic conditions. Increase the liquids in the mother's diet, moderately, not to excess. En- courage the mother to believe that she will be able to nurse her infant. Gruel is a good addition to the diet, but malt liquors do no good, and rich cocoa or chocolate should be avoided. It is probable that the special galactogogues mentioned in medical literature from time to time, such as injections of pituitary extract, or corpus luteum, or placenta, do no good. 2. To diminish the total quantity, restrict the fluid a little, diminish the food taken a little, and keep the bowels well open. 3. To increase the total solids, shorten the intervals between the nursing, and try to improve the mother's general condition in every possible way. 4. To diminish the total solids, lengthen the nursing intervals, and increase the food. Additional rules are given in many text books for increasing or diminishing the particular food elements, fat, carbohydrate, and pro- tein. Increasing the protein in the food was formerly supposed to increase the fat in the milk, but it is now believed that there is no relation between the protein in the mother's diet, and the fat in the breast secretion. If a woman is underfed, increased fat in the food will cause increased fat in the milk. If she is not underfed, the fat in her milk cannot be altered by any special dietary regulations. Too much protein in the milk may undoubtedly be caused by insuf- ficient exercise, and also by fatigue, worry, and nervousness. In the treatment, nothing further can influence the protein than by gen- erally correcting all unfavorable hygienic conditions. There is no way of affecting the carbohydrate. When the disturbance of breast feeding is due to unsuitable milk, and the symptoms are those of indigestion, every effort should be made to aid the baby by relieving the symptoms with palliative measures, while waiting for the treatment of the mother to take eft'ect. One of the simplest and most effective of these measures, is to try to dilute the breast milk at each nursing. This is done by giving the baby some diluent immediately before the feeding. Boiled water may be used, or still better, some slightly, alkaline solution, for in the majority of instances, the symptoms of indigestion are due to excessive protein, and the alkalies have a favorable influence in dis- turbances due to protein. From two to four teaspoonfuls each of boiled water and lime water may be given immediately before each nursing, or a weak solution of sodium bicarbonate, i grain to the tea- spoon, may be used instead of the water and lime water. If constipa- tion is present, boiled water with about 10 drops of milk of magnesia may be used. • Disturbances of Breast Feeding 261 After all these measures have been instituted, continuance of the symptoms of indigestion may show that the breast milk is still un- suited to the baby's digestion, and that it cannot be made suitable either through regulation of the mother, or through palliative meas- ures in the baby. In such a case, further treatment depends on whether or not the baby is gaining in weight, for many babies will gain weight on breast milk in spite of showing symptoms of indiges- tion. If the baby is gaining in weight, nothing further should be attempted, as the case is not severe enough to call for artificial feeding. Palliative measures should be continued, and often, as the baby grows older, its digestive power improves, or the composition of the milk improyes, and the symptoms disappear. If the baby is not gaining, or is losing in weight, some artificial food must be given in addition to the breast milk. The baby must, however, not be weaned, and breast milk should still be the basis of its diet. The condition of indigestion is usually one calling for diminution of the total breast milk solids, and this is favored by lengthening the nursing intervals. The baby may now be fed at regular intervals, the breast and the bottle being used at alternate feedings. This tends to improve the breast milk, by lengthening the nursing intervals, without disturbing the child by lengthening the feeding intervals. Under such circum- stances the breast milk frequently improves to such an extent that the bottle feedings may later be omitted. If the symptoms continue, but the baby gains weight, nothing further need be done. If in addi- tion to the persistence of indigestion, there is no gain in weight, the physician should observe carefully whether the symptoms are most marked after the breast, or after the bottle feedings. If the bottle feedings give no lessening of the symptoms, the composition of the artificial food must be changed until improvement is obtained. If the symptoms are relieved by the bottle feedings, then for the first time, the physician should begin to consider passing over from ma- ternal to artificial feeding. Such a change, however, must be made gradually, and the physician must assure himself that the artificial food is well digested, and sufficient to nourish the infant. Even when this is clear, the breast feedings should be dropped out one by one only, until the baby is gaining weight, and as many breast feed- ings as possible should be retained, in spite of their causing some indigestion. The activity of the breast should in the meantime be maintained by pumping, so that the breast milk will remain for the physician to fall back upon, if necessary. Only when it becomes clear that the breast milk is so bad that any given to the baby causes disturbance, and prevents gain in weight, should the breast be dis- carded. When mixed feeding is thus used in these cases of unsuit- able breast milk, the selection of the first artificial food, and any 262 Feeding subsequent changes made in its composition, are to be guided by the principles described under Artificial Feeding. When the disturbance of breast feeding is due to insufficiency of the breast milk, and when the regulation of conditions affecting the mother, and special efforts to increase her milk, have failed to relieve the condition, mixed feeding must be resorted to. The artificial food to be used in such a case should be that which would be given to a normal artificially fed baby of the same age, as described under Artificial Feeding. In insufficiency of breast milk, the bottle feed- ings should not be given to alternate with the breast feedings, but to supplement them. Short nursing intervals tend to increase the quan- tity and total solids of the breast milk, and the intervals must not be lengthened by alternating the breast and the bottle. If the deficiency is in the quantity, its amount may be judged by weighing the baby before and after nursing, and the amount of supplementary food to be given by the bottle at each nursing is to be regulated by the aver- age amount of the deficiency. If the deficiency is in the quality of the milk, the baby must be allowed to take only a part of his feeding from the breast, and the amount which he ought to have should be made up from the bottle. The remaining milk in the breast may be removed by the breast pump, but the breast should not be completely emptied. However, the breast pump will never completely empty the breast. Only as much supplementary artificial food should be given as will enable the baby to gain weight. Deficiency in quality will often correct itself under this treatment, and bottle feedings may be omitted. Deficiency in quantity may correct itself, but usually will not. As much breast milk as the baby can get should always be given, and breast feeding should be continued as long as there is any milk at all in the breasts. WET-NURSING A certain number of mothers are unable to nurse their infants, in spite of every effort on the part of the mother, and care on the part of the physician. In addition to the positive contraindications to maternal nursing enumerated above, many cases are seen, in which there is no milk, or in which the breast secretion soon becomes in- sufficient, and then disappears, or in which the breast milk, in spite of every effort, remains persistently unsuited to the child's digestive power. It is generally supposed that the mother's milk, as a rule, is more likely to be suited to her infant's digestion than the milk of another woman; but we have as yet too few cases where direct investi- gation by means of chemical analysis of the two kinds of milk has been made, to lay down actually as a fact what we can merely grant as a supposition, that an idiosyncrasy in the mother's milk will find an analogue in her infant's digestive powers. The reverse of this proposi- tion has also been held to be true, that at times some peculiarity in Wet-Nursing 263 the mother's milk will make it radically unfit for her infant. The probability is that analyses will show either that these varieties of milk are poor ones, or that the infants have unusually weak diges- tive powers. The fact that every mother cannot provide as good a milk for her infant as can be supplied by another woman finds its analogy in the inability of some Jersey cows to rear their own calves When it has been demonstrated that it is impossible or inadvisable for the mother to nurse her infant, some other food must be sought. If the best possible food for the human infant is the milk secreted by the human breast, then the best possible substitute for the mother's milk is the milk of another woman, and no imitation of human milk made by modifying the milk of an animal will approach the special characteristics of human milk. Upon theoretical grounds therefore, and if we are obliged to take into consideration nothing more than the requirement of supplying the best food for the infant, wet-nursing would be indicated in ever}'- case in which maternal feeding cannot be used. There are, however, certain practical difficulties in wet-nursing. In the first place, in most communities, satisfactory wet-nurses are difficult to obtain, and the supply would by no means meet the demand, if every baby whose mother cannot nurse him were nourished by a wet-nurse. There are obvious inconveniences about the introduction of a wet- nurse into a family, which, while they would quickly be disregarded if the baby's welfare positively depended on a supply of human milk, are very real in many cases. Artificial feeding, while a less favorable means of nourishing babies, is free from such inconveniences, and is successful in a large proportion of cases. It is therefore becoming the custom to use artificial feeding in the majority of cases, and to save the few wet-nurses available in any community for the cases in which artificial feeding is attended by special difficulty. In the selection of a wet-nurse, the physician should see that the woman is healthy, and free from any suspicion of tuberculosis or syphilis.* She should be preferably under thirty years of age, and should be of pleasant personality. Her lungs should be examined, and her skin, glands, teeth, throat, scalp, and eyes should be care- fully inspected. The nipples should be long enough to oft'er no obstacle to sucking. The shape and size of the breasts is no indication as to the amount of her milk. It is of no use to analyze her milk, as the normal standard of breast milk is not definite enough to permit the drawing of conclusions from its composition, as to whether it will meet the baby's requirements. The only way by which we can judge the probable quality of the milk is by the appearance of the wet-nurse's baby. The quantity can be determined by a series of weighings of the baby before and after nursing. * The Wasserman reaction should be tested in candidates for the position of wet-nurse. 264 Feeding It is by no means as essential as was formerly supposed, that the age of the wet-nurse's baby be about the same as that of the baby she is to nurse. After the first month, the changes in the composition of breast milk, are not very important. In an infant from one to six months old, the milk of a wet-nurse whose milk is one to six months old will usually sufhce. In Boston there has been established a Wet-Nurse Directory, con- nected with the Infants' Hospital, of which the object is, on the one hand, to help poor mothers who are obliged to support their babies; through the Directory they can earn money, without being separated from their young infants. On the other hand, the Directory pro- vides wet-nurses for physicians who need breast milk for their cases. The women are examined, and cared for medically by the staff of the Infants' Hospital, and those out of employment are used by the hos- pital. Thus a physician applying to the Directory, is suppUed with a wet-nurse, in whom he can be sure of a plentiful supply of good milk, and that syphilis and all other diseases are excluded. The price paid is fixed by the Directory. WEANING By weaning is meant the discontinuance of breast feeding, and the substitution of some other form of nourishment. Weaning should be allowed for no other reason than for the mother's or baby's best good. It should never be permitted for the mother's convenience, nor for insufficient grounds, such as colic, cracked nipples, menstruation, or mild symptoms of indigestion. Weaning is to be allowed under the following conditions: 1. In the normal course of things, when the baby has reached the age of between lo and 12 months. 2. When the supply of breast milk completely gives out. 3. When the breast feeding is attended by symptoms of indigestion, which are sufficiently serious to cause continual failure to gain in weight, and when every effort to relieve this condition has failed. 4. If the mother becomes pregnant. 5. If the mother has a severe acute or chronic disease. There is a tendency to wean babies upon insufficient grounds, espe- cially to give up breast feeding before the breast milk has completely disappeared, or when breast milk causes comparatively mild symptoms of indigestion. Babies should not be weaned except under the con- ditions enumerated. Whenever possible, weaning should be carried out gradually. Sudden weaning is apt to produce an acute disturbance of digestion. Gradual weaning may be used in all the conditions in which weaning is indicated, except pregnancy or severe illness. The method in which weaning is carried out when the supply of breast milk fails, Weaning 265 or when it is proved finally unsuited to the baby, has been described under the management of disturbed breast feeding. In many cases the breast milk begins to give out at the sixth month, and supple- mentary bottle feedings have to be used, and from this time on, wean- ing may have to be completed at any time. In babies in whom there is no diminution in breast milk, weaning should be carried out between the tenth and twelfth months. With no apparent diminution in the breast milk in a child nine months old or over, a period of several weeks of stationary weight should be the signal for beginning weaning. It is not a good plan to continue breast feeding into the second year, just because the baby is doing well. The late months of lactation require close watching, as there is an increasing liability to sudden disturbance. The prejudice against weaning in hot weather is exaggerated, and babies may be safely weaned in summer, if they are given a pure, properly modified milk. Nevertheless a baby's digestive power is depressed by heat, and if a baby has just reached the age of ten months at the beginning of hot weather, I usually wait until cooler weather begins. The gradual weaning is carried out by means of mixed feeding. First one bottle feeding is substituted for one breast feeding, and then the number of bottle feedings is gradually increased, while the breast feedings are gradually diminished, until the baby passes over wholly to the bottle. The choice of food to be given in the bottle is to be guided by the principles discussed under Artificial Feeding. Many well babies of ten to twelve months can be given whole milk at once. Usually at this age, it is best to begin with a dilution of whole milk with barley water, and if the baby has shown any signs of indigestion, the milk dilution must be weak. The strength of the mixture can be gradually increased until whole milk is reached. In babies who are weaned suddenly because of pregnancy or illness in the mother, or at an earlier age because of symptoms of indigestion or failure of breast milk, the artificial food must be more dilute. Whey mixtures are usually best for very young babies. It is sometimes difficult to get a baby accustomed to the breast, to take the bottle, especially when it has reached the age of ten to twelve months. Feeding sometimes requires much patience and time on the part of both physician and nurse. It is best to have some one other than the mother give the bottle, if possible. It is inadvisable to waste time trying to teach infants from ten to twelve months old to take the bottle; it is better to teach them to drink from a cup, beginning with a spoon if necessary. Forcing, or too much coaxing are objectionable. If the food is offered at regular intervals, and taken away at once if refused, the babies often begin to take it after a time. The mother must be assured that the child will not starve, even if a period of thirty-six or even forty-eight hours elapses. In extreme cases, a few tube feedings may be necessary. III. ARTIFICIAL FEEDING PRELIMINARY CONSIDERATIONS The resort to artificial feeding is usually a matter of necessity. It is the exception, not the rule, for an American mother to be able to feed her infant exclusively on breast-milk for the full twelve months. Supplementary feeding generally begins between the sixth and ninth months and often earlier. The fact that a mother does not nurse her infant is due not so much to her unwillingness from selfish reasons, but to the fact that she is a victim of the artificial conditions of mod- ern life, and cannot nurse because of a deficiency either in the quan- tity or quality of her milk. The great majority of babies fed on substitutes for breast-milk represent cases of failure of breast feeding. Whereas, in exceptional cases, one may solve the problem by securing a competent and reliable wet-nurse, there is not in this country a sufficient number of the class from which wet-nurses are derived to meet the demand made by the 'enormous number of infants whose mothers, for one reason or another, cannot supply their natural food. It is, therefore, not a question as to the relativ^e advantages of breast and artificial feeding, which must be considered, but one- of how best to solve the problem of feeding, by artificial methods, the constantly increasing number of infants who must be reared on the bottle. There is little question that here in America the methods of artificial feeding have been more fully developed along scientific lines than in any other country, but the principles of the modification of cow's milk and per- centage feeding have by no means been generally adopted by the pro- fession as a whole. The scientific modification of milk, and percent- age feeding, are followed for the most part by those whose practice is especially in the line of children. It is owing to the unfamiliarity of the general practitioner with these principles and their aversion to mastering the details of a somewhat difficult subject, that infant mortality in the first year has reached such alarming proportions. The introduction of the proprietary foods has not, and never will, solve the problem of substitute feeding of infants. Fresh, clean, cow's milk must be the basis of successful feeding, and the knowl- edge of the principles by which such milk may be modified in its com- position and adapted to the varying needs of human infants, becomes of vital importance to the welfare of the race. Cow's Milk 267 SOURCE OF FOOD REQUIREMENTS. — Human milk, the food which nature pro- vides for infants, contains certain food elements, which we must assume to be necessary. These food elements are fats, carbohydrates, proteins, and certain mineral salts. The digestion of the infant being fitted to utilize these food elements, any artificial food must contain the same food elements. The fat, sugar, protein, and salts should correspond as closely as possible chemically to the same elements as found in human milk, and should correspond also in their relative proportions. The food which contains these elements in a form most closely resembling those of human milk in their chemistry and proportions is the mammary secretion of another animal. The only animal milk which can be obtained in sufficient quantity for use as a food for infants is the milk of the cow. Further requirements, are that the food must be fresh, clean, free from injurious bacteria, that the number of bacteria be not excessive, that it be free from preservatives, and that it be not skimmed nor diluted. COW'S MILK. The Cow. — The breeds of cows which are con- sidered most desirable for the general purposes of milk production are not the best for use in infant feeding. The most prized breeds are those which give the richest milk, such as the Jersey and Guern- sey cows. These breeds yield a milk which contains a greater quan- tity of fat than the commoner breeds, such as the Holstein. More- over the fat globules in these rich milks are larger than are the globules in the milks from the commoner breeds. One feature in which cow's milk differs most markedly from human milk is the chemical composi- tion of the fats. Cow's milk contains a greater proportion of the volatile fatty acids than does human milk, and this difference is greater in Jersey milk than in the milk of the commoner breeds. Many infants who cannot digest Jersey milk in any modification, can take the milk of the commoner kinds of cows. There is a theory prevalent in some communities, that the milk of one cow is preferable for the nutrition of an infant than the milk of a mixed herd. This is a false theory, and indeed, quite the con- trary is true. The milk of a mixed herd of cows is much more stable in its composition, showing much less variation from day to day, than the milk of a single cow. Also, any single cow is liable to some sudden upset which changes the composition of her milk. An upset in one cow does not manifest itself to any great extent in the mixed milk of the whole herd. Composition of Cow's Milk Compared with Human Milk. — Cow's milk, like human milk, contains fat in the form of an emulsion, and carbohydrate, protein, and mineral salts in solution. The milk 268 ■ Feeding varies in its composition just as does human milk. The variations depend upon the breed of the cow, the methods of feeding, the health of the animal, the season of the year, the stage of lactation, the length of the interval between milkings, the portion of the milk withdrawn, and many other conditions. The analysis of an average good cow's milk is shown in the table, compared with the average human milk. Table 23 Average Cow's Milk Compared with Hitman Milk cow's MILK HUMAN MILK Specific gravity 1.028 to 1.032 1-030 to 1.032 Reaction Amphoteric or slightly acid Amphoteric Fat 4.00 per cent 4.00 per cent Lactose 4.75 per cent 7.00 per cent Protein 3.50 per cent 1.50 per cent Salts 0.70 per cent 0.20 per cent Water 87.05 per cent 87.30 per cent Fat is contained in cow's milk in about the same average amount as in human milk. There is, however, a marked difference in the chemistry of the fat. In both, the greater part of the fat is in the form of neutral fat, although oleic acid is in greater quantity in human milk. The chief difference is that cow's milk contains a greater pro- portion of the lower or volatile fatty acids than does human milk. This difference is very important, because it cannot be corrected by any known method of cow's milk modification. The fat globules, also, are slightly larger in cow's milk. The carbohydrate in both milks is lactose. The only difference is quantitative, cow's milk containing considerably less than human milk. The protein of cow's milk shows both quantitative and quahtative differences, as compared with human milk. The quantity of protein is much greater in cow's milk, averaging 3.50 per cent. The propor- tion of casein to the soluble whey proteids (chiefly lactalbumin) is very much greater. The separation of the different forms of protein is so difficult that chemists are by no means agreed as to the relative proportions of lactalbumin and casein in either human milk or cow's milk. In general, the whey protein and casein in human milk are about equal, or possibly, the soluble protein is in excess. On the other hand, it is generally agreed that in cow's milk the casein is in excess. Some writers place the proportion of casein to whey protein in cow's milk at 4 to i, others at 3 to i. The casein of cow's milk is much more coagulable than is that of human milk. Whereas the human casein is only slightly coagulated with acids, and not regularly by rennet plus acid, the cow's casein is readily coagulated both with acids, and with rennet plus acid. The curd formed in gastric digestion Cow's Milk 269 is tough, and firm, and is much less readily dissolved by the gastric juice. The inorganic salts of cow's milk also show differences as compared with human milk. Their total quantity is more than three times greater than in human milk. There are great differences in the amounts of the various salts in the two milks. The accompanying table was compiled by averaging the observations of a number of writers on this subject. Table 24 Composition of the Ash in Human and Cow's Milk, in per cent (grams per loo grams) Potassium oxide. . Sodium oxide Calcium oxide . . . . Magnesium oxide . Ferric oxide Phosphoric acid . . Chlorine cow s WOMAN S .1720 •0750 .0431 .2117 .0284 .0217 .0346 .0063 .0010 . 0005 ■ 2513 • 0949 .0471 .1428 While all the salts are in larger percentage in cow's milk than in human milk, the relative proportions of the different salts differ greatly. In general cow's milk contains relatively a very large amount of calcium phosphate, while the proportion of potassium salts and iron in cow's milk as compared with human milk is relatively small. There is a great difference in the form in which phosphorus is present in human and in cow's milk. In human milk three-quarters of the phosphorus is in organic combination, while in cow's milk only one- quarter is in organic combination. The iron in neither human milk nor in cow's milk is sufficient to meet the demands in the first year of life; the infant must depend on the iron stored during fetal Hfe. Bacteriology of Cow's Milk. — It is impossible to obtain cow's milk free from bacteria, nor even as relatively free from bacteria as is human milk. Our efforts must be directed toward obtaining milk which is wholly free from pathogenic bacteria and which is as free as possible from the other forms of bacteria not usually harmful. Of the pathogenic bacteria transmitted in milk, the most important is the tubercle bacillus. This organism has been frequently found in milk supplies, and comes from cows diseased with tuberculosis. Opinions may differ as to the exact amount of the danger of acquiring tuberculosis through milk, but there is no doubt that contaminated milk is a possible source of tuberculosis. I believe that the sale of milk from cows showing on physical examination evidences of tuber- culosis should be forbidden by law. Whether or not the sale of milk from cows reacting to the tuberculin test should be forbidden is still an open question. I should advise, for use in infant feeding, only milk from tuberculin tested cows having negative reactions. 270 Feeding Streptococci and other pyogenic organisms may be found in the milk of cows having disease of the udder. These organisms have been shown to be the cause in some cases of gastro-enteric disease. The milk supply should be obtained from a source in which milk from cows diseased in this way is not used. Certain recognized infectious diseases have been traced to milk infection. The diseases known to have been transmitted in this way are, in the order of frequency, typhoid fever, scarlet fever, diphtheria, dysentery, and cholera. The reason that dysentery occupies so low a place in this list, is that the order is based on the frequency with which the infection has been actually traced through the milk. Contaminated milk is probably the usual source of infec- tion with the bacillus of dysentery, but the connection with a definite case of dysentery is less direct, and more difficult to trace. The other bacteria found in milk come from a variety of sources, entering the milk chiefly during the operation of milking. They may come from the hands and clothing of the milker, from the dirt faUing from the cow, from the dust of the stable, and from many similar sources. A great variety of organisms are found in milk. They are for the most part harmless, and it is possible that some of them exercise a protective action by keeping out more harmful forms. Most of them belong to the lactic-acid-forming group, and are concerned in the souring of milk. In too great numbers, it is probable that these organisms may produce changes in the milk which may cause harm to the infant. Certified Milk. — In any locality, the physician should use in infant feeding, the best milk supply which can be obtained. Through the concerted efforts of physicians and others interested in the ques- tions of pubHc health and infant mortahty, attempts have been made in many parts of North America to improve the milk supply. The means used have been various; in some places more or less stringent laws have been passed regulating the conditions of milk production and distribution; in other places milk commissions have voluntarily undertaken to inspect milk supphes, and certify milks which fulfil their requirements, the community being informed of the advantages of milk so certified. In the inspection of milk, one of the chief criteria by which milk supphes are judged, is the count of the number of bacteria contained in the milk. The bacterial count is valuable, not so much because a high bacterial count is necessarily a sign that the milk will harm the baby, as because it is a guide to the general cleanH- ness of the conditions under which the milk is produced. Every physician interested in the subject of infant feeding, should be familiar with the present status of pure milk production. The details of this subject are too voluminous to be incorporated in a Sterilization and Pasteurization 271 text book of this kind, and the reader is referred to the reports of the various milk commissions. In practice, a physician should recommend the use of certified milk whenever possible. When certified milk cannot be obtained, he should be familiar with the available milk supplies in his locality, and with the conditions under which each milk is produced, and should recommend the best. STERILIZATION AND PASTEURIZATION OF MILK.— Cow's milk may be heated in preparation for its use as a food for infants. The object of heating is to lessen the danger of damage to the infant from the bacteria contained in the milk. The term "sterilization" is generally used to designate the heating of milk to a boiling temperature, while the term "pasteurization" is used to designate the process of heating at a temperature lower than boiling. Neither term is satisfactory. Milk is not rendered bac- teriologically sterile by the process of boiling ordinarily employed, and pasteurization is a very vague term, unless it is definitely stated at what temperature and for how long the milk is heated. The Effect of Heat on the Bacteriology of Milk. — The heating of milk at a temperature of 140° F. (60° C.) for twenty minutes will destroy the recognized pathogenic non-spore-bearing organisms, such as the bacilli of typhoid, diphtheria, and dysentery, and the vibrio of cholera. Heating at a higher temperature will destroy these organisms in a shorter time. Many of the organisms of putrefaction are spore-bearing, and their spores are highly resis- tant to heat; some of them have been shown to resist boiling for one hour. Many of the lactic-acid-forming organisms are destroyed by heat, and it has been very generally believed that their destruction favors the development in heated milk of proteolytic spore-bearing organ- isms, which may form highly toxic products. Ayers and Johnson, however, have recently shown that many acid-forming organisms are not destroyed below 168° F. (75.6° C.) and that in milk pasteur- ized at a temperature lower than this, the normal process of souring takes place, though somewhat delayed. No chfference was found in the relative numbers of the acid-forming, and proteol^'tic groups in, pasteurized milk, from that seen in clean raw milk, nor in the rate of multiplication. There is at present no definite evidence to prove that the heating of milk favors the growth of any harmful organisms. The general belief is that the heating of milk has no effect on any bacterial toxins which may already have been produced. This is only partly true. True soluble bacterial toxins are thermolabile, many of them being destroyed at a temperature of 140° F. (60° C). The endotoxins are for the most part resistant to heat. 272 Feeding The general effect of heating milk at 140° F. (60° C.) or orer, may be summarized as follows: The most common pathogenic spore- bearing organisms, including those of specific infections, are de- stroyed, and the total number of bacteria is lessened. In other words, heating brings milk bacteriologically into the same condition as raw milk produced under the most careful and cleanly conditions. The subsequent development of toxin-forming spore-bearing organ- isms is possible, if the milk is not kept at a temperature suf5.ciently cold to inhibit their growth. The Effect of Heat on the CoiiPosiTioN of ]Milk. — The boiling of milk produces a scum upon the surface, and alters the taste and smell of the milk. These changes are not marked at a temperature lower than 158^ F. (70° C). Prolonged boihng changes the color to brown from caramelization of the sugar. Heating at 150" F. (65° C.) for over thirty minutes delays or prevents the rising of the cream. When milk is boiled, some of the mineral salts are precipitated, and the inorganic phosphorus is increased at ^ the expense of the organic compounds. Certain changes are produced in the chemistry of the casein, through which it becomes less easy of coagulation by rennet plus acid, and less readily acted on by the proteolytic digestive ferments. The curd formed in gastric digestion is softer and more flocculent. The soluble lactalbumin is entirely precipitated. The data as to the temperature at which the precipitation of the soluble albumin begins are not in agreement, and there are no satis- factory data as to the temperature at w^hich the other changes begin. Hippius concludes that heating at 149° F. (65^^ C.) for thirty min- utes produces no notable changes in the chemical composition of cow's milk, and the conclusion is probably not far wrong. The evidence as to the efi"ect of heat on the ferments of cow's milk is very inconclusive. It is probable that some of them are destroyed by heat, while it has been shown that others resist various temperatures. The Effect of Heat on the Digestibility and Food \^\lue of Cow's Milk. — The more or less general behef in this country has been that babies fed continuously on cooked milk do not thrive as wxll as babies fed on raw milk. Recently there has been a ten- dency to examine more critically the evidence on which ihis assump- tion is based, with the result that more or less doubt has been thrown upon its truth. The evidence has been derived from three sorts of experiments, first, in artificial digestion, second, on animals, and third, on babies. Artificial digestion experiments have given con- tradictory results, some writers concluding that cooking increases, and others that it diminishes, the digestibility of milk. Animal Sterilization and Pasteurization 273 experiments are mainly in agreement that young animals thrive better on the raw than on the cooked milk of their own species. The experiments on babies have been for the most part clinical and statistical, consisting of comparing the clinical results of raw and cooked milk in the feeding of large series of babies. The results with cooked as compared with raw human milk resemble the results in animals, that the babies do better on the raw milk. The results with raw and cooked cow's milk are open to the objection that clinical and statistical evidence of this kind is apt to be misleading. In general, the majority of investigators have failed to detect any differ- ence in the digestibility and food value of cooked and raw milk. As to the particular diseases of nutrition, there is no conclusive evidence that rachitis is more frequent in babies fed on cooked milk. Scorbutus, on the other hand, has been more generally asso- ciated with the use of cooked food. The evidence in favor of the connection between scurvy and the heating of milk is much stronger than any other evidence as to the value of heated milk. The evi- dence, however, is almost wholly of a clinical and statistical rather than an experimental nature, and evidence of this kind can never be conclusive. In general, the evidence is that in all large series of cases of scorbutus, a considerable proportion of the patients have been fed on heated milk, more often on milk which has been boiled or scalded than simply pasteurized. On the other hand scurvy de- velops at times in babies fed on raw milk, and even in breast-fed babies. This evidence will be considered at greater length when scorbutus is described. That the heating of milk may be a more or less important cause of scorbutus is possible if not probable, but is not proven. Sterilization or Pasteurization. — The higher the temperature at which milk is heated, the greater are. the changes of chemical composition produced. While it is still an open question how great an effect these changes have on the well-being of the infant, it is obviously better to avoid them if possible. The object of heating the milk is to produce the destruction of certain pathogenic organisms, and a diminution in the total number of bacteria. It has been shown that this result can be attained by subjecting the milk to a much lower degree of heat than the boiHng temperature. Therefore pasteurization should be preferred to sterilization. The tempera- ture of the pasteurization should be as low as is consistent with the object to be attained. Pasteurization at a temperature lower than 140° F. (60° C.) is not efficient. At this temperature there is no change in the color, taste, or odor of the milk, and but little change in chemical composition; most ferments and the bactericidal action of milk, are unaffected, while most bacterial toxins and all the patho- 18 274 Feeding genie non-spore-bearing organisms are destroyed. Therefore, when heating is indicated, pasteurization at 140° F. (60° C.) for twenty min- utes should be chosen. Indications for Pasteurization. — Whether or not milk should be pasteurized is a question which must be decided in each individual case. Three factors must be considered in arriving at a decision: i, the source of the milk supply; 2, the season of the year; and 3, the time taken in delivering the milk. With every source of milk supply except the very cleanest, pasteurization should be employed as a routine measure. With such a clean milk supply as, for instance, certified milk, pasteurization should be employed whenever the milk has to be transported for any considerable distance, or when con- siderable time elapses between milking and dehvery. In summer it is always safer to pasteurize, whatever the milk supply; occasionally an exception can be made when a milk is used which is known to be produced and dehvered under the most perfect conditions. In gen- eral, pasteurization should be employed as a routine measure, except wdth the cleanest milk supply, delivered under the most favorable conditions. When an infant does not seem to thrive on pasteurized milk, it must not be at once assumed that the heating of the milk is the cause. Only when other measures have been thoroughly tried, the pasteuriza- tion may be omitted for a time as an experiment. The only risk supported by any real evidence in the use of pasteurized milk is the possible deselopment of scorbutus. Scorbutus is a much less serious danger, than is bacterial infection or intoxication, and if it develops, it is easily cured. Technique of Pasteurization. — It is better to pasteurize milk for each feeding in a separate bottle, than to pasteurize the whole twenty-four hours' food supply in one large receptacle. It is difficult to maintain so large a quantity of milk at the desired temperature for such a length of time as twenty or thirty minutes, and the results bacteriologically have been shown to be not as good as when the milk is pasteurized in smaller quantities. Each feeding should be put in a separate clean bottle which has been boiled, and the bottles should be stoppered with non-absorbent cotton. The bottles are then placed in a dish, which is filled with cold water up to a level with the milk in the bottles. The dish is then placed on the stove and heated until the thermometer suspended in the water reaches 145° F. (62.7° C). The dish with the contents is then removed from the stove, covered with a blanket, and allowed to stand for thirty minutes. At the end of this time the bottles are taken out and quickly cooled in running tap water, after which they are placed on ice, or in a cold place, until used. The Examination of Milk 275 The pasteurizers on the market, designed for home use, are ah good. They are somewhat more convenient, though not more efficient, than the method described. THE EXAMINATION OF MILK.— It is often important or desirable for the physician to determine the composition of milk. In the case of human milk, the analysis occasionally throws some light on the cause in disturbed breast feeding. In the case of cow's milk, it is often important to determine how closely a certain milk used in modifying approaches in composition the milk taken as the basis for calculating percentages. A thorough and accurate analysis of milk Fig. 74 Sterilizer and thermometer Stand lur tubes Sterilizer covered with cozy after removal from heat can only be carried out by an expert chemist. When an expert chem- ist is not available, the physician himself can frequently carry out an analysis of clinical value. The method of analysis is the same for both human milk and cow's milk. The Specific Gravity is obtained by means of any ordinary hydro- meter, graduated from i.oio to 1.040. The Fat. — The estimation of the fat is the most important in clinical milk analysis. The fat can be measured with practically absolute accuracy by means of the Babcock Fat-Tester, or by some similar centrifugal apparatus. Most institutions, and many physi- cians treating many infants, keep this instrument at hand. Its operation is very simple. To a given volume of milk is added a cer- tain amount of sulphuric acid, the quantities varying with the exact model of the machine used. Pipettes for measuring the milk and 276 Feeding acid are sold with the machine. The milk and acid are mixed in a test-bottle with a long graduated neck. The bottles are then whirled in the centrifugal machine at a high speed for five minutes. Hot water is then added to bring the mixture up to the neck of the bottle, and then the bottle is centrifuged for two minutes. Hot water is again added to bring the separated fat up into the graduated neck of the bottle, the machine is again whirled for a short time, and the length of the column of separated fat, as measured on the graduated bottle-neck, is read, the reading giving the per cent of fat in the mixture. Fig. 75 Babcock fat-tester For those who have no Babcock machine at hand, a simpler method of estimation, of approximate accuracy, is by means of Holt's cream guage. This instrument is simply a graduated stoppered tube, which is filled with fresh milk to the zero mark, and is then allowed to stand, corked, at room temperature for twenty-four hours. The reading is taken from the cream line, and three-fifths of this reading is taken as the percentage of fat in the milk. The Protein. — No chemical method of estimating the protein is very satisfactory. The most accurate is that in which the protein is precipitated in the Esbach tube by a solution' of phosphotungstic and hydrochloric acids, the reading being taken at the end of twenty- four hours. An approximate idea as to whether the protein is high or low may be found by considering the known specific gravity in connection with the known percentage of fat. In this estimation we assume that the percentages of sugar and mineral salts in milk are constant; while not constant, these percentages are more constant than those of the other elements. The way in which this approximate conclusion as to protein is made is shown in the table: Sources of Difficulty in Artificial Feeding 277 Table 25 Approximate Estimation of Protein from Known Fat and Specific Gravity SPECIFIC GRAVITY FAT PROTEIN High High = High High Low = Normal Low High == Normal Low Low ^ Low The Carbohydrate and Salts. — These elements of milk cannot be estimated by any simple chemical method. If examination by an expert chemist is not necessary or available, they may be con- sidered constant. The Microscopic Examination of Milk. — This should be part of the routine in the examination of a specimen of milk. Both the cream and the centrifugalized sediment should be examined. In the cream one should look for colostrum corpuscles. In the sediment one should look for dirt, pus, and blood. A few leucocytes are normal, but any excess of dirt, pus, or blood, should cause us to reject the milk. If pus be present, the sediment should be stained for bacteria, and streptococci should be sought. THE MODIFICATION OF COW'S MILK We must now consider the most important part of the subject of the artificial feeding of infants, which concerns the adaptation of cow's milk to the nutritive requirements of the infant. While cow's milk is the only available food which in composition at all approaches the food designed by nature, it is very far from being an ideal baby food. We have seen how greatly its chemical composition differs from that of human milk. That these differences are a very frequent cause of disturbances of digestion and nutrition is a fact proved by years of clinical experience. The existence of such disturbances in babies fed upon cow's milk, has led to a great number of investiga- tions which have been made with the object of discovering whether there are any means by which the digestibility and nutritive value of cow's milk as a food for infants may be increased. THE SOURCES OF DIFFICULTY IN ARTIFICIAL FEED- ING. — There are two factors responsible for the difficulties encoun- tered in the artificial feeding of infants. The first is to be found in the chemical composition of cow's milk, which makes it a less suitable food for infants than is human milk. This may be called the chemical difliculty. The second is to be found in the variation in the digestive powers and nutritive requirements of dift'erent babies. This may be called the individual difficulty. The relative importance of these two factors has been very largely misjudged, not only by the public, but even by the physicians engaged in the very study of the feeding problem. Only in this country has the individual factor in infant 278 Feeding feeding been appreciated, and then only by comparatively few physi- cians. In Europe the entire attention of investigators has been centered upon the chemical factor, and the individual factor has been, and still is, almost entirely neglected, yet it is the individual factor which is really the more important practical source of difhculty in artificial feeding. One great obstacle to advance in our knowledge of the principles of artificial feeding, has been the generally prevalent idea, existing not only in the minds of the public in general, but even in the minds of physicians and of specialists in infant feeding, that there is some- tvhere, yet to be discovered, a bahy food of transcendent value which will solve the problem of infant feeding, and which can be fed success- fully to babies in general. It is possible that in the minds of those who have studied the subject, this idea takes a little different form. Such men will look upon one method of modifying cow's milk as better than another method. To regard one method of modifying cow's milk as better than another, must mean that it is regarded as better for babies in general, and that it is the best method which has been found. This opinion carries with it the idea that there is a best method of modifying cow's milk, and that is only the ideal baby food expressed in other words. The nature of the feeding problem is such that an ideal baby food can never be attained. The factor of individual variation plays too great a part, and we shall never be able to feed babies as a class, nor to find a food or method which will be best for babies in general. The modification of cow's milk which is best for one bab}^ will always be worst for some other. Great advances have been made from time to time in the attempts to solve the chemical difficulty of infant feeding. The most careful and painstaking researches on the physiology and pathology of diges- tion in infancy, on infantile metabolism, and on the effect upon diges- tion and metabolism of various methods of modifying cow's milk have been made. These investigations have given us additions to the sum of our knowledge of these subjects, the value of which cannot be overestimated. Usually the results of each research of this kind has suggested some new practical method by which cow's milk can be modified to greater advantage. There has been an unfortunate tendency to hail each new method of modifying milk suggested by researches of this kind, as the best, if not the ideal method of feeding babies. The new method is regarded not as ranking equally in value with previous methods, but as being a step in advance which will supersede older methods in the feeding of babies. Thus we have passed through successive stages in which modification with whey, with cereal diluents, with various alkalies, with maltose, with lactic acid ferment, with precipitated casein has each in turn been regarded Sources of Difficulty in Artificial Feeding 279 as a better method of modifying cow's milk than its predecessors. Even if the particular investigator has not himself regarded his addi- tion to the methods of milk modification as a new method of feeding which shall supersede others, the readers of his reports have so re- garded it. The way in which the results in practice of any new method of modifying milk have been studied and reported has been such as to perpetuate the idea of its superior value. The new method of feeding is applied to a large series of babies, the clinical results are studied, and a statistical report is published. Such reports are very misleading, because, studied in this way, every new method of modi- fying milk gives good statistical results. The individual variation in babies is so great, that in any series a large number of babies will do well, and a considerable number of babies will do better with the new method of feeding than with any other. This tendency to overestimate the value of the new methods of modifying milk suggested from time to time by research, and to apply them to the feeding of babies in general, has been most unfortunate. There has never been any logical ground for beheving that any one of them is better for babies as a class than any other. Each method is based on some actual discovered fact in infantile digestion and meta- bohsm. Each older method has been in its day just as well supported by clinical and statistical evidence as is the new method. The old facts, if brought out by proper research, remain, and the newly discovered facts are only additional, but do not contradict the older ones. There are babies who do better on one method, and babies who do better on another. We should not discard any method of modifying milk based on some discovered fact about the infantile digestion, simply because some additional fact has been discovered which suggests a different method. We should regard every method of modifying milk based upon adequately demonstrated facts concerning the digestion and metabolism of the infant, as having its own particular value, as being particularly fitted to meet the digestive peculiarities of individual babies. We should regard all such methods as constituting our stock of weapons, which we need to combat the many difficulties springing from the peculiar chemistry of cow's milk, and from the limitless variation in the baby's digestive powers and requirements. We should hail each new research and the practical application to feeding suggested by it, not as a new or better method of feeding babies, but as a new addition to our slock of weapons, a new resource, which will have its particidar use in a problem, the nature of which is such, that we need all the resources at present avail- able, and more. CALORIC REQUIREMENTS AND DIGESTIVE REQUIRE- MENTS. — One of the most important efforts to devise a method of feeding babies in general, based upon research, is that which is some- 280 Feeding times called the caloric method of feeding. This is based on the so-called minimum caloric requirement of a normal baby. A number of infants who were thriving and gaining normally in weight were investigated, and the energy value of the food taken each twenty-four hours was estimated in calories. The quantity of food taken varied with the weight of the baby, and the food required to maintain proper nutrition was measured in terms of calories per kilogram of body weight. From the averages of large series of babies, was deduced the minimum caloric requirement, which represents the minimum number of calories per kilogram of body weight which each baby must receive daily in order to thrive. The Minimum Caloric Requirements. — As estimated in this way the minimum caloric requirement is as follows: Table 26 Mininuim Caloric Requirement Birth- 6 months 120 cal. per kilo 6-12 months 100 cal. per kilo 12-24 months 90 cal. per kilo Protein Requirement. — Protein is that element of the food which is used in the building up of the body tissues, while it is the fats and carbohydrates which are concerned with energy production. From metabolism experiments has been deduced a protein require- ment for the normal baby. The protein requirement thus estab- lished is open to the same objections as caloric requirement, as it is based on the method of averaging variations. I believe, however, that variations are not so extreme, and that the protein require- ment is often a useful guide. It is from i.o to 1.5 grammes of pro- tein daily per kilogram of body weight. Most milk modifications, unless extremely low in protein, more than fulfil this requirement. Caloric Requirement as a Basis for Feeding. — This study of caloric requirement led to the idea that here at least was a definite and satisfactory basis for the artificial feeding of babies. Under this system the physician reckons the minimum daily caloric require- ment from the weight of the baby, and then chooses the food with the primary object of at least meeting this requirement. The amount of fat, carbohydrate, and protein is designed to produce the requisite calories. In case of indigestion, if one element in the food must be reduced, the others must be proportionately increased, in order to maintain the caloric value of the food. Caloric requirement as a basis for feeding, — a caloric method of feeding — is open to numerous very serious objections. In the first place, the figures for minimum caloric requirement were obtained by the method of averaging a given number of observations, which Caloric Requirements 281 method gives a very misleading result whenever individual variation plays much part. The caloric requirement even of normal babies has been shown to be very variable. This variation is still more extreme in sick babies, or with babies in poor condition. Moreover, caloric requirement varies on account of a number of other factors, such as the surface area, and the activity of the baby. Finally, and most important of all, the nutrition of the baby depends upon the quantity of food assimilated, not upon the quantity ingested, and the net caloric value of the food cannot be estimated. In babies with deficient power of digestion, less food is absorbed and utilized, and indigestion does more harm in preventing a child from thriving than anything else. Babies cannot be fed as a class on a caloric basis, because the variation in their power of digesting and absorbing food is too great. Clinical experience has shown the widest extremes, some babies gaining weight on a caloric intake far below the so- called minimum, and others failing to gain on a caloric intake far in excess. Digestive Requirement. — In choosing an artificial food for a baby, our first aim must always be to give the baby a food suited to its power of digestion. Our principal difficulty is in meeting variation in digestive power. We are also confronted by a varia- tion in caloric requirement. Consequently we must assume that every baby has digestive and caloric requirements such that some partic- ular combination of the food elements in milk, modified in some particular way, will be the best food for that baby. Our problem is to find that combination, or at least, if not the best combination, one that will be suitable. To solve this problem, we must consider first all the chemical difficulties in digesting cow's milk, and the methods of milk modification which have been devised to solve these difficulties. Of course the great majority of babies have not such defective powers of digestion as call for any special measures. For such babies, certain general rules for the modification of cow's milk in the prepa- ration of their food, can be stated. The difficult cases call for all our knowledge, and all our resources. Value of Caloric Estimation. — To estimate the caloric value of an infant's food, and to compare it with the theoretical minimum caloric requirement, is a procedure which is often useful in the con- duct of a case where artificial feeding is employed. Sometimes, for instance, we may be in doubt whether failure to gain in weight is due to defective digestion and assimilation, or to insuflicient food ingestion. In such a case, caloric estimation may be a great help. Always, however, the calculation of calories should be used as a check, not as our principal guide. 282 Feeding PERCENTAGE FEEDING.— The world owes to Professor Thomas Morgan Rotch a great debt, for elaborating the theory of percentage feeding, which is now very generally accepted by the leading teachers and writers in America as the basis of the modern scientific feeding of infants. Percentage feeding is often wrongly spoken of as if it were some special method of feeding infants, which is considered by its users as superior to other so-called methods. Those who thus misjudge the theory appear to think that it in- volves some particular formula or set of formulae for the feeding of infants, some special combination of percentages of superior value. Percentage feeding is not at all a method of feeding in the sense that it chooses any particular method of modifying the composition of the infant's food. It is primarily simply a method of recording the characteristics of the food given to the infant. Instead of record- ing the food in terms of mixtures of various ingredients such as cream, milk, lactose, barley water, and so forth, the food is recorded in terms of the percentage of the various elements: fat, protein, lactose, maltose, or starch, etc. contained in these mixtures. Even when a baby is fed on a simple dilution of cow's milk, the record is made in terms of the percentage of fat, lactose, and protein contained therein. The advantage of such a system of record is that it gives a common terminology in infant feeding, and a common basis by which various methods of modifying milk may be compared, both as to theory, and as to practical results. A physician may feed a baby, for ex- ample, on a mixture of milk and barley water, and change the food from time to time by gradually increasing the milk and diminishing the barley water. If he thinks of his food in terms of the relative ounces of milk and barley water, he has no way of comparing his method of modifying milk with other methods; and, if he publishes his results, they will have no value to other physicians until they have estimated just what quantity of the various food elements the baby was getting in that food. To advance in our knowledge of infant feeding, we must be able to compare our results one with another, and must also be able to compare our work with the pub- lished work of others. Such a comparison necessitates a common basis, a universal manner of record. It is the tolerance or intol- erance of the infant for the various food elements, which is the final result in infant feeding. Therefore we must know the amount of each food element given, as recorded in percentage form. As record in terms of percentages became customary, physicians naturally came to think of foods as combinations of percentages of the essential elements, rather than in terms of mixtures of ingredi- ents. The essential thing in choosing a food for an infant is to arrange the quantity and kind of fat, sugar, and protein in such a way as to rtieet the digestive and nutritive requirements of the Modification of Cow's Milk 283 infant. As our knowledge of digestion and nutritive requirements is derived from percentage records, we have come to think first of the percentages we wish to give, and which we record. Then we give the proper directions for obtaining and preparing the food. THE MODIFICATION OF COW'S MILK— THEORY To utiHze all the resources of artificial feeding, the physician must be familiar with every method of modifying cow's milk which is "in good use." Those methods are in good use which are based on adequately proven facts, or on plausible theories, regarding the infantile digestion and metabolism, or which are supported by ac- cepted clinical evidence. In some methods a combination of two or more principles is used. The methods of modifying milk depend- ing on a single principle, which are at present in good use, are ten in number. They are the following: 1. The dilution of milk or cream with the addition of lactose. 2. The addition of starch to cow's milk mixtures. 3. The addition of alkalies to cow's milk mixtures. Of the alka- lies there are three — a. Lime water. b. Sodium bicarbonate. c. Sodium citrate.* 4. The peptonization of cow's milk mixtures. 5. The addition of whey to cream dilutions — the so-called "split protein." 6. The addition of other soluble carbohydrates than lactose to cow's milk mixtures. 7. The addition of the lactic acid ferment to cow's milk mixtures. 8. The addition to the food of precipitated casein. 9. The cooking of cow's milk mixtures. 10. The use of "homogenized" milk mixtures. These various methods may be combined in any variety of ways. A cow's milk dilution may be peptonized, or have lime water or barley water added. Two combinations of principles have been so widely known as methods of modifying milk, that they deserve special mention. They are — 1. "Malt soup" modifications, a combination of maltose, starch, and cooking. 2. Albumin milk, a combination of lactic acid milk and precipitated casein. In order to use to best advantage these various methods of modify- ing milk, it is necessary to know the scientific basis of each one. In * It may be objected that sodium citrate is not really an alkali. In the physiology of digestion it acts in a manner so like the lime water and sodium bicarbonate, that it is most conveniently classified with them. 284 Feeding other words, we must know exactly how each method of modifying affects the composition of cow's milk, what effect such modification of the composition has on the infant's digestion and assimilation, and how the milk is fitted to meet individual variation. The fol- lowing is a summary of the present state of our knowledge of milk modification. MILK AND CREAM DILUTION WITH THE ADDITION OF LACTOSE. — This is the method of modifying cow's milk to which the term percentage modification was first applied. The origin of this method was an effort to produce a cow's milk mixture, the composition of which would approach as closely as possible to that of human milk. The chief difference between human milk and cow's milk is that the latter has a higher proportion of protein as com- pared with fat. In cream the protein is lower in proportion to the fat, and if cream be diluted, the proportion found in human milk may be imitated. For example, the percentage formula of an average human milk is — ■ Fat 4.00 Lactose 7.00 Protein 1.50 and of an average cow's milk is Fat 4 . 00 Lactose 4 . 50 Protein 3 . 50 A cream can be obtained which has an approximate formula of — Fat 8 . 00 Lactose 4 . 00 Protein 3 . 00 If this be diluted one-half with water, the resulting mixture has a composition of — Fat 4.00 Lactose 2.00 Protein i . 50 If now sufficient dry lactose be added to this mixture to make a 5% solution, the resulting mixture will have a formula of — Fat 4.00 Lactose 7.00 Protein 1.50 which is that of an average human milk. It must not be supposed that the above figures are absolutely accurate. They are given only as an example of how the composi- tion of cow's milk may be altered, by dilution and the addition of lactose, to imitate human milk. The actual modification would involve certain fractions, which have been omitted. The modification of cow's milk to imitate an average human milk by no means solved the problem of infant feeding. Certain essential chemical differences remained, such as the composition of the fats and mineral salts, and the relative proportion of soluble protein and casein. Moreover, the imitation of an average human milk did not meet the important factor of individual variation in digestive powers Modification of Cow's Milk 285 and requirements. In this method, of dilution with the addition of lactose, we are by no means confined to the imitation of an average human milk. By diluting creams of various fat percent- ages we may alter at will the proportion of fat to protein. By diluting skimmed milk we may alter at will the percentage of protein without affecting the fat. By adding varying amounts of dry lac- tose, we may alter at will the percentage of lactose. Thus, by this method of diluting in various proportions milks of various fat per- centages, with the use of dry milk sugar, we may alter at will the percentage of fat, lactose, and protein in our food, within very wide limits. There are certain limits to the variety of percentage combinations which we can obtain. Any percentage of fat whatever is possible. The minimum protein depends upon how strong a cream we can obtain. A cream of higher fat percentage can be obtained by cen- trifugal separation than by gravity separation, and the former would give a lower minimum protein. The maximum protein is 3.50, the percentage in undiluted milk. The maximum lactose percentage has no Umit, but the minimum varies with the percentage of protein, as all milk and cream contains lactose. The following table shows the practical limits of milk modification, by this method, with home and laboratory modification, assuming that 16 per cent is the highest fat obtainable in cream by the gravity method. Table 27 Practical Limits of Milk Modification — Minimum Protein, with Varying Fat Percentages Minimum Protein home modification, laboratory, fat percentage gravity cream, 1 6% centrifugal cream, 32% .50 .10 .05 1. 00 .20 .10 ■ I-50 .30 .15 2.00 .40 .20 . 2.50 .50 .25 3 . 00 .60 .30 350 .70 -35 4 . 00 .80 .40 Table 28 Practical Limits of Milk Modification — Minimum Lactose, with Varying Protein Percentages , PROTEIN PERCENTAGE MINIMUM LACTOSE .50 .70 I . 00 I . 40 1.50 2.10 2 . CX3 2 . 80 2-5° 3-5° 3.00 4.20 3-50 4-5° 286 Feeding This method of modifying cow's milk makes no attempt to solve the chemical difhculties involved in the composition of the cow's milk fat and mineral salts and in the high proportion of casein, except by simple dilution. If any of these elements is the cause of trouble, the quantity of that element can be reduced, and if neces- sary, other elements can be increased. The chief value of this method of modifying cow's milk lies in enabling us to meet the factor of indi- vidual variation in digestive power and requirements. It provides us with an almost unlimited number of combinations of the three main elements of an infant's food. The variations in the infant's digestive powers are primarily variations in its ability to digest and assimilate fat, sugar, and protein. Consequently, this method of modifying milk, by which the relative amounts of these elements can be varied at will, is fundamental in infant feeding, and is the basis of all efforts to solve any given problem. MODIFICATION WITH STARCH.— The value of using some cooked cereal preparation as a diluent in cow's milk modification has long been recognized. When a solution of starch, such as is found in diluents like barley water, is present in a cow's milk modifica- tion, the curd formed by the precipitation of the casein in the normal process of digestion, is more finely divided, and is easier of digestion. The action of the starch in preventing the formation of large casein curds is not chemical, but mechanical, due to the colloidal nature of the starch solution. If the starch possesses this colloidal action, there must be some minimum quantity of starch necessary to produce it. This quantity is that necessary to give a sufficient concentration of the starch solu- tion, and it must therefore be proportioned to the total quantity of the food mixture. The minimum quantity necessary to obtain in full the colloidal action of the starch, is .75 per cent. It must be remembered that starch is a readily fermentable carbo- hydrate, and that if it is not spHt by the amylolytic action of the pancreatic secretion, it will ferment. Babies vary in their power of digesting and absorbing starch. It is not known at just what age the amylolytic function develops, as this is probably very variable. The power of starch digestion may be present at birth, or may develop at some subsequent period. It is usually established at six months. Starch indigestion and fermentation is more likely to occur in younger babies. MODIFICATION WITH ALKALIES.— The original basis for the use of alkalies in cow's milk modification was a further attempt to imitate the composition of human milk. It was believed at that time that, cow's milk being acid and human milk alkaline, the addi- Modification of Cow's Milk 287 tion to cow's milk mixtures of 5 per cent lime water would cause them to resemble human milk in alkalinity. It has since been learned that human milk is not alkaline but amphoteric, and that the addition of lime water to cow's milk does not cause it to resemble human milk in reaction. In the meanwhile, however, clinical evidence had been accumulating, which was strongly in favor of the value of lime water in certain cases of difficult digestion. A theoretical explanation of the value of lime water was sought in the fact that many cases of disturbed digestion are accompanied by symptoms suggesting acidity, such as " sour stomach," and acid stools. There is no experimental evidence in support of the theory that the alkalies act by neutralizing the products of acid fermentation, although such action is quite possible, and may explain some cases in which benefit is clinically quite evident. The only positive and scientific data which we have, on which to base our use of the alkalies in infant feeding, is to be found in the work of Hamburger and Slicka, who published the results of an ex- tended study on the action of the alkalies in gastric digestion. The truth of their conclusions has been confirmed by subsequent investi- gators. They have shown that the alkalies combine chemically with the casein of cow's milk, and that as a result of such chemical union, the precipitation of the casein by the rennin and acid of the stomach, is delayed, and the character of the curd is altered. The curd, when thus modified, is easier of digestion by the gastric juice. Further- more, if sufficient alkali be present, the acid of the gastric juice is so neutralized, that the precipitation of the casein is entirely prevented. On this basis, our indication for the use of the alkalies is when we wish to delay curd formation with modification of the curd, or to prevent it entirely. If the alkalies have this action, there must be some definite quan- tity of alkali which gives the action at its best. As the action of the alkali is a chemical one, the alkali entering into actual chemical union with the casein, this optimum quantity of alkali must be in direct proportion to the quantity of casein, with which the alkali combines. As milk and cream both contain casein, and are assumed for practical purposes to contain the same percentage of casein, the quantity of casein in a cow's milk modification varies directly with the quantity of milk and cream in the mixture. The optimum quantity of alkali, that needed to produce the desired result, is, therefore, expressed as a percentage of the quantity of milk and cream used in the prepara- tion of the food. The quantities of alkali which produce the various results which we must have in view when using the alkalies on this basis have been satisfactorily determined by experiment, and are shown in the table. 288 Feeding Table 29 Quantity of Alkali Expressed in Terms of Per Cent of the Milk and Cream TO DELAY CURD FORMATION TO PREVENT PRECIPITATION AND MODIFY THE CURD OF THE CASEIN CURD Lime water 20.00% 50.00% Sodium bicarbonate . . o . 68% i . 70% Sodium citrate 0.20% 0.40% As far as the different alkalies, lime water, sodium bicarbonate, and sodium citrate are concerned, all three have the same general action. They dift'er one from another only in the character of the casein curd formed under their influence. With one alkali the curd is more porous, with another more gelatinous, and so forth. CUn- ically, certain individual cases are found in which some one of the alkalies works best, but there is no guide as to which we shall choose. This work on the alkalies is the only definite basis for their use estab- lished by experimental evidence. In the majority of cases our use of the alkalies should be upon this basis. We should order alkali with a definite purpose, to produce a known result, in the quantity which best accomplishes our purpose, and which is expressed in per cent of the milk and cream in the mixture. There is another basis for the use of the alkalies, not definitely established by experimental evidence, but suggested by chnical results. The work of Hamburger and SHcka is confined solely to the action of the alkalies in gastric digestion. Clinical evidence suggests that the alkalies may have some influence after the food leaves the stomach, possibly by neutraHzing the acid products of excessive carbohydrate fermentation in the intestine. While such influence is not proven, it is sufficiently possible to warrant the use of alkaH on this basis. In such a case, however, the physician should have a definite reason for using alkaH. The amount of alkali used on this basis is not to be proportioned to the milk and cream, for the theoretical action of the alkaH involves no chemical union with the casein. We do not know the amount of alkaH necessary to neutraHze excessive acid fermentation. All we can do is to order alkaH in large excess. In the case of lime water, such an excess would be expressed as about 25% of the total mixture. PEPTONIZATION.— Cow's miUi modifications may be peptonized through the agency of a pancreatic extract obtained from an animal. The object is to effect a pre-digestion of the protein, which is con- verted into peptone by the active ferment trypsin. The amount of peptone formed varies with the duration of the process. If milk is peptonized for ten minutes, only a part of the protein is converted into peptone, and the milk is not altered in taste. If milk is pepton- ized for twenty minutes, most of the protein is converted, and the mixture has a bitter taste. Peptonization represents one method of TOTAL WHEY iCTOSE PROTEIN PROTEIN CASEIN 4-50 3-50 .70 2.80 7 I -50 ■30 1.20 7 I -SO •75 •75 Modification of Cow's Milk 289 overcoming the difficulty presented by the high percentage of protein in cow's milk. With the development of other methods of dealing with protein indigestion, the use of peptonization has become more and more hmited. WHEY MIXTURES. THE SPLIT PROTEIN.— This method of modifying cow's milk is based on a further attempt to imitate Nature. When cow's milk is modified by the method of milk and cream dilu- tion, with the addition of lactose, the relatively high proportion of casein to the lactalbumin and other soluble proteins persists. In cow's milk about four-fifths of the protein is casein, whereas in human milk, only about half is casein. Thus if the formula of cow's milk be expressed in terms of the two forms of protein, four-fifths of the total protein will be casein, and in a cow's milk mixture made by milk and cream dilution with the addition of lactose, designed to imitate human milk, the same proportion will hold. The table shows such a formula compared with human milk. Table 30 FAT Cow's milk 4 Modified cow's milk 4 Human milk 4 The older ideas on the difficulties of digesting cow's milk in arti- ficial feeding laid especial stress on the high casein content of cow's milk as the probable cause. The three methods of modifying cow's milk just described, namely, modification with starch, with alkahes, and with peptonization, were all designed to meet this difficulty presented by high casein. As will be seen from the table, in any formula made with cow's milk, the baby is required to digest much more casein than he would have to digest with the same total amount of human milk protein. The method of modifying with whey was designed to overcome this disadvantage, in another way, by altering the relative amounts of whey protein and casein in such a way as to imitate more closely the relative amounts in human milk. If a cream of high fat percentage be diluted, the protein is much reduced. If, for example, all cream having a composition of — Fat 16 Lactose 4 Protein 3,00 be diluted one to four with water, the formula of the mixture will be — Fat 4 Lactose 1. 00 Protein .75 If this formula be expressed in terms of soluble whey protein and casein it will be — Fat 4 Lactose 1. 00 Whey protein .15 Casein .60 19 290 Feeding Now suppose whey be used as a diluent instead of water. Whey contains no fat, and no casein, but only lactose and whey protein. If the formula of whey be considered as approximately — Fat o Lactose s Whey protein i . oo Casein o and if whey be used as the diluent, and if one-half of the mixture be whey, we have added to our mixture with the w^hey the following- Fat o Lactose 2 . 50 Whey protein . 50 Casein o If we add together the percentages obtained by diluting our cream one-quarter, and making up the remaining three-quarters with whey one half, water one-quarter, we have to add together — Fat 4 Fato Lactose i.oo Lactose 2 . 50 WTiey protein Whey protein ■15 •50 Casein .60 Casein and this gives- - Fat 4 Lactose 3 . 50 Whey protein •65 Casein .60 and if we now add enough lactose to raise the total sugar percentage to 7, we have — Fat 4 Lactose 7 . 00 Whey protein . 65 Casein . 60 which is not far from the formula of human milk. The figures given above are not accurate, but are given as an example of the method by which the relative proportions of whey protein and casein may be altered by the use of whey as a diluent. In this method of modifying cow's milk, we are not confined to the imitation of an average human milk. By using various propor- tions of cream or milk and whey, we can obtain various proportions of fat, whey protein, and casein, and are thus provided with a great number of percentage combinations, fitted to cope with the factor of individual variation in digestive powers and requirements. There are certain limits to the percentage combinations obtainable by the use of whey. The percentage of whey protein in whey is about .90 per cent, and a whey mixture cannot have a whey protein percentage much higher than this. The low limit of casein is deter- mined by the amount of fat required. In general, .90 per cent is considered the upper limit for the whey protein, and .50 per cent the low casein Hmit in home modification, while in laboratory feeding with a centrifugal cream used as a basis, the casein may be reduced as low as .25 per cent. It must be remembered that the primary object of whey modifi- cation is to reduce the casein in the food without reducing the total protein. We can use a food of high nitrogen content, without im- posing the burden on digestion which the high casein of cow's milk Modification of Cow's Milk 291 would otherwise involve. It must further be remembered, however, that such modification would only be useful in cases in which the casein is the cause of digestive trouble. Also, the minimum lactose obtainable with whey mixtures is much higher than with ordinary milk and cream dilution, because the whey used as a diluent in place of boiled water has a high lactose content. The high per- centage of the mineral salts of cow's milk, which is ordinarily reduced by the dilution of milk and cream, is not reduced in whey mixtures, as whey contains a high mineral content. In cases where lactose, or the high salt content of cow's milk might be the cause of trouble, whey mixtures would do harm. On the other hand, the split pro- tein method is the best theoretical method of dealing with casein intolerance, as it is the method used by Nature as exemplified in human milk. MODIFICATION BY THE ADDITION OF SOLUBLE CAR- BOHYDRATES OTHER THAN LACTOSE.— The majority of cow's milk modifications require the addition of a certain quantity of lactose, because the lactose content of cow's milk is low in com- parison with human milk, and is often still further lowered by dilu- tion. The substitution of some other form of soluble carbohydrate for this extra lactose, did not originally spring from the results of any scientific investigation of the infantile digestion and metabolism, but was adopted upon purely empirical grounds. Indeed, this method of modifying cow's milk owes its adoption to the marked success sometimes seen in an individual case, attending the use of some patent baby food. It sometimes happened that a baby fed most carefully on scientific principles, with every kind of milk modi- fication suggested by our knowledge of the subject of artificial feed- ing, would fail to thrive; finally the mother, caught by the lure of some advertisement, or by the suggestion of a friend or neighbor, would try some patent baby food, with the most startling success. Such cases, of course, did not mean that the patent food was a better food for babies than all the resources of scientific feeding, but that it embodied some principle in the modification of cow's milk which was suited to the digestive peculiarities of that individual baby. It is the aim of scientific artificial feeding to contain in its stock of weapons every principle which may bring success in an individual case. It theirefore became necessary to study the principles involved in the various patent foods. This study showed that most of the patent foods are mainly carbohydrate preparations, and that their essential feature is that they contain other carbohydrates than lac- tose, such as maltose, dextrine, dextrose, or cane sugar. Therefore it was obvious that there were babies whose individual peculiarities made them better fitted to utilize these other carbohydrates, and 292 Feeding the substitution of these sugars for lactose had to become one of our stock of resources in deahng with the problem of artificial feeding . More recently, light has been thrown on the probable scientific explanation of the value of a change in carbohydrate. The various carbohydrates usually employed in milk modification are disaccha- rids, differing in the character of the component monosaccharids into which they are split in the course of digestion. Lactose, for example, is spht into dextrose and galactose, saccharose is split into dextrose and levulose, while maltose is split into dextrose and dextrose. These monosaccharids differ in the readiness with which they are absorbed, and in the readiness with which they undergo bacterial fermentation. Dextrose is the substance most easily ab- sorbed, and is, moreover, the only sugar which can be immediately utilized for energy production, without undergoing the process of glycogen-storing in the liver. Galactose and levulose, on the other hand, while less easily utilizable for energy production, are much more readily fermentable. In any case, therefore, in which there was difficulty in digesting and absorbing sugar, or in which there was difi&culty in obtaining from other food elements, such as the fat, a sufficient supply of fuel for energy production, maltose would be the preferable sugar. This explains the good results often seen when maltose is used in cases of severe atrophy. On the other hand. Nature does not provide for the infant the easily utilized maltose, but the more fermentable lactose. There must be a reason for this. Kendall has shown that the normal bac- terial processes in the infant's intestine are those of carbohydrate fermentation, and that a sufiicient supply of fermentable carbohy- drate must remain behind in the intestine, in order to maintain the normal character of .the intestinal flora. It is probably for this pur- pose that lactose is provided by Nature, and under this theory, lactose would be preferable to maltose in babies whose powers of digestion and assimilation showed no very wide deviations from the normal, or in babies whose digestive disturbances are traceable to abnormal bacterial processes. This explanation, while not conclusively proven, is sufQciently satisfactory to serve as a basis for our choice of carbohydrate in feed- ing, and there is no other. Our choice must be made upon this basis, or else empirically without any other guide than chnical experience, which is very deceptive. MODIFICATION WITH THE LACTIC ACID FERMENT.— This method of modifying milk originated from the same idea as gave us the use of starch, the alkalies, the split protein, and peptonization, namely the difficulty in digesting the large tough casein curds which are formed from cow's milk during the process of gastric digestion > Modification of Cow's Milk 293 When the lactic acid bacillus, or any preparation containing its active ferment, is added to cow's milk, part of the lactose is by fermentation converted into lactic acid. This is an artificially produced souring of the milk, much like the natural souring which takes place in milk from the action of other organisms of the lactic-acid-forming group normally present in milk. The lactic acid bacillus and its product are known to be harmless. In the presence of the lactic acid formed in this way, the casein of the milk is precipitated in the form of a curd which is especially finely divided; and easily digested. There is no formation of large curds in the stomach, and lactic acid milk seems to be relatively quite digestible. There are two reasons for using lactic acid milk as a mere feeding method. One is that described, to obtain the casein already pre- cipitated in a finely divided, and easily digested form. The other is that lactic acid milk is relatively low in carbohydrate in proportion to the protein, and may be useful in cases in which carbohydrate is not well tolerated. There is another reason for using lactic acid milk, under which it is not strictly a resource in artificial feeding. This use is based on the influence of the lactic acid bacillus on certain bacterial processes in the intestine, and will be described in greater detail in the division on the gastro-intestinal diseases. To meet this indication it is neces- sary to use a culture of the lactic acid bacillus of known anti-putrefac- tive power, while, if lactic acid milk is used simply as a feeding method, any preparation of the lactic acid bacillus which will form lactic acid may be used. MODIFICATION WITH PRECIPITATED CASEIN.— The use of precipitated casein in infant feeding, is to be traced to the researches and theories of Meyer and Finkelstein. Their original theory ascribed to the carbohydrate of cow's milk, the lactose, a very important role in the production of severe malnutrition and atrophy. In their first publications, lactose was considered quite deadly, while the fats and mineral salts were not absolved from partial blame. To fit their theory, they prepared their celebrated " Eiweiss Milch," or albumin milk. The only new feature in albumin milk was the use of precipi- tated casein. The casein is precipitated with a rennin preparation, washed, ground fine through a sieve, and then is added to some food mixture. The idea underlying its use was originally, to increase the casein content of the food, without a proportionate increase in the lactose or mineral salts. It has been found recently that a good part of the mineral salts remain with the casein instead of going out with the whey. The lactose, however, can be gotten rid of. The casein is in a finely divided form, which is probably easy of digestion 294 Feeding in the majority of cases. The use of precipitated casein does not show very much difference in its probable effect, from the use of lactic acid milk. Only, the possible benefit from the anti-putrefactive properties of lactic acid milk, is not to be expected with precipitated casein. THE COOKING OF COW'S MILK MIXTURES.— The effect of the cooking of cow's milk on the digestibility of the milk has never been determined. There is some evidence that cooking makes milk more digestible, other evidence that it makes it less so. Cooking pro- duces certain changes in the chemistry of the milk which are known, but the relation of these changes to digestion has never been estabhshed, Fig. 76 Apparatus for homogenizing fat for infant feeding It is known that cooking coagulates the lactalbumin, precipitates some of the mineral salts, and produces certain chemical changes in the casein. These changes make the casein less coagulable, and the curd formed with rennet is softer and finer than in raw milk. On the other hand, the casein curd is less readily acted on by the proteoly- tic ferments of gastric digestion. It is probable that in some cases, cooking has a favorable effect. The best established favorable action of cooking, is that seen in cases in which large casein curds are found Modification of Cow's Milk 295 in the stools of the infant. In such a case, the trouble may often be relieved by boiling the milk. HOMOGENIZED MILK MIXTURES.— This is a very recently advocated method of modifying cow's milk. It is based on the fact that many of the most serious cases of atrophy and malnutrition in infancy have been shown to be characterized by inabihty to digest and absorb the cow's milk fat. The difference in chemistry between the fat of cow's milk and of human milk is not affected by any of the methods of modifying milk described above. The homogenizer is a compHcated and expensive apparatus for breaking up fat into the finest molecules, much finer than the emulsion seen in milk. This is done by forcing the fat through the apparatus under heavy pressure. Other fats than cow's milk fat may be used, and thus the unfavorable chemistry of cow's milk fat may be avoided. Those now interested in homogenized milk advocate the use of olive oil, which is added to a milk mixture, and then forced through the apparatus. The olive oil comes out in a form so finely divided as to be supposedly easy of digestion. The method of feeding with homogenized milk is a very newly sug- gested method, and its possible value is as yet unsupported by conclusive evidence. If it be shown in the course of time that it has a value in infant feeding, its use will probably be confined to cases of very resistant difficulty, with inabihty to take as much fat as they require. ALBUMIN MILK. (Protein Milk; Finkelstein's Eiweiss Milch). — This is a modification of cow's milk recommended by Fin- kelstein. The theory underlying its use was originally that the lactose in cow's milk is not well borne in certain cases, and is a frequent source of difficulty in artificial feeding. The original object of Finkelstein's preparation was to secure a food which was low in lactose, and high in protein. The most definite directions were given as to the prepara- tion of this food, which will be described when the subject of home modification is discussed. Albumin milk is essentially a combination of lactic acid milk with precipitated casein. When made according to the prescribed direc- tions it has an average composition of about — Fat 2 . 50 Lactose i . 50 Protein 3 . 00 Salts . 50 The fat percentage is rather variable. Albumin milk was recommended to meet a definite theory as to the etiology of chronic gastro-intestinal disease. The theory has been later much modified and changed. In particular, the original theory held that the lactose in cow's milk mixtures is one of the most frequent sources of danger. This has not been corroborated by other investi- 296 1-EEDING gators. That lactose may, through excessive fermentation, be a cause of indigestion, is undoubtedly a fact, but that it is a serious disturber of metabolism, giving rise to intoxication, is probably not true. This idea was probably borrowed by Finkelstein from some work published by Grosz, later elaborated by Langstein and Steinitz, on sugar elimination in the urine in severe cases of gastro-intestinal disorder. It has been contradicted by the work of later investiga- tors. While there may be cases in which there exists an intolerance of sugar sufficiently severe to call for an amount of sugar in the food no greater than that in albumin milk, it is probable that they are very rare, and do not explain the favorable results obtained by many in- vestigators in using this food. Another theory advanced in favor of the value of albumin milk, was that the high salt content of cow's milk was a source of damage, and that in the precipitated casein used in making Finkelstein's food, the salts are got rid of. This also has been disproved. It has been shown that much of the mineral matter goes over with the casein, and that the salt content of albumin milk is quantitatively but little diminished. The principal respects other than the low proportion of lactose in which albumin milk differs in composition from an ordinary cow's milk modification, of the same fat and protein content, is, first, that the casein is precipitated beforehand in a very finely divided form, and second, that the food contains lactic acid. The favorable results reported from its use must be due to one or both of these features. That both features are of value, is quite probable. That lactic acid milk has a favorable effect on certain fermental processes in the intes- tine, has been fairly well established, although Finkelstein entirely disregarded this as a possible mode of action, in his effort to fit his food to his theory. There is also evidence, that foods containing the casein already precipitated in a finely divided form, are more digestible in certain cases. It must be remembered that the evidence on which the value of albumin milk in infant feeding is based, is of the highly unreliable, statistical kind, obtained by feeding a series of babies on this food, and making a compilation of the various results observed. Almost any method of feeding investigated in this way will give favorable results. The method of studying individual cases, under conditions approaching as nearly as possible those of an experiment, has not been employed. No great effort has been made to determine whether either of the two principles combined in albumin milk, namely, lactic acid fermentation, and the addition of precipitated casein, will not give equally good results, when used separately. No great eff'ort has been made to determine the clinical type of case in which albumin milk works better than other methods. Modification of Cow's Milk 297 That each of the two principles combined in albumin milk is of great value in certain cases, is undoubtedly true. That there are cases in which a combination of these two principles, as realized in albumin milk, is the best method of feeding, is also probable. There- fore these principles, and their combination, must have a place in artificial feeding, among our stock of resources. What is the exact indication for their use remains to be determined. It must be remembered that albumin milk being so widely spoken of as a food, or method of feeding, there is danger of its coming to be regarded as an ideal baby food, as a food or method of feeding of superior value for babies in general, and not as a resource to be used in special cases. If we are to judge by the precedents of other widely advertised methods of feeding, there is danger that the general or indiscriminate use of albumin milk may do harm in the future. This danger is now heightened by the fact that in Europe Finkelstein's albumin milk is a secret, patent preparation, sold by a manufacturing company in sealed cans, and advertised as a baby food. The same company, or its branch, has introduced its sale into this country. It is true that we know enough about the composition of albumin milk to order its preparation in our homes and hospitals, without resorting to the patented form. Is it not better, however, in using and study- ing albumin milk, to consider chiefly the two main features in its composition, and to order them separately, or in combination? We are not confined to making albumin milk according to the original formula, but may combine lactic acid milk with precipitated casein in any proportions we see fit. We can thus use albumin milk, while avoiding the name, and will not be perpetuating the idea of its superior value as a baby food. We can extend our investigations as to its value, by combining its principles with varying amounts of different sugars, and of fat. Like all other methods which have given clinical evidence of good results, albumin milk or the principle it embodies, will probably in the end occupy its definite and particular place among our stock of resources. MALT SOUP MODIFICATION OF COW'S MILK.— This modi- fication of cow's milk was introduced by Keller, as a food to be used in cases of difiicult feeding. Wheat flour is cooked in the milk, and then malt extract is added, and the whole is heated for about five minutes. This food has given clinical evidence that in certain diffi- cult feeding cases, it gives better results than ordinary modifications. It must therefore receive a place among our stock of methods of modifying cow's milk. Malt soup is rich in carbohydrate. Keller believed that through its use, less protein was lost by intestinal fermentation, but this has never been definitely proved. Malt soup is essentially a combination 298 Feeding of three methods of modifying milk already described, namely, modifi- cation with starch, modification with maltose, and the cooking of milk. Furthermore, a certain amount of the starch is dextrinized. We have seen that all three of the methods of modifying combined in malt soup, have their particular favorable action on the digestion of cow's milk. To combine them is probably desirable in certain cases. The dextrinization of the starch in the malt soup is a new element. Dextrinization has been advised as a good method in preparing a food for infants, and dextrinized gruels, made by heating a cereal decoction with thick malt extract, have been employed. W£ have no essential facts in digestion or metabolism to support their use, although they may have a value in certain cases. The evidence in their favor is of the unreHable clinical variety. It seems best to include them under malt soup. HOW THE RESOURCES OF COW'S MILK MODIFICA- TION ARE REALIZED IN PRACTICE Familiarity with the various principles on which the modification of cow's milk is based, is not the only essential in the intelligent arti- ficial feeding of infants. The physician must know exactly how he can utilize in practice the various methods at his disposal, so that any method which he believes to be indicated in an individual case may be employed. PREREQUISITES. — It is essential that the physician should be able to utilize the resources of artificial feeding to their fullest extent. It is undoubtedly true that the majority of babies which he will be called upon to feed, will not require any of the more complicated methods of modifying milk. Simple combinations of milk, diluent, and lactose, are all that is required in these cases. Consequently, many so-called simplified methods of feeding babies have been devised and pubHshed, which give the impression that the artificial feeding of babies is not in reahty a very difficult or complicated problem. The success of such simplified methods, when judged by clinical statistics, is evident, and is to be expected from the comparatively normal digestive powers of the majority of infants. These methods, how- ever, as is well-known, will fail to solve the occasional difficult prob- lems which arise. Knowledge of the methods used in the more difficult cases is essential to their proper treatment, and does not preclude the use of foods of simple composition in comparatively normal cases. The difficult cases are numerous enough to demon- strate that the problem of artificial feeding is not a simple one, nor is it to be solved by simple methods. We must assume that the competent physician must be prepared Milk Laboratories 299 to use every method. Therefore no method of preparing milk modi- fications can be considered which does not fulfil this requirement. THE PATENT FOODS.— There are a number of patent infant foods on the market, which embody principles known to be of value in artificial feeding. Their use has given repeated clinical evidence of the special value of some one of them in certain individual cases. We know that their good results come from the particular principle, such as change of carbohydrate, which they exemplify. We realize that their use as foods for babies in general would never solve the feeding problem, and most of us have seen how great is the harm done by their indiscriminate employment. The question arises, are we not justified in using the patent foods, not indiscriminately, not as general baby foods, but intelligently, in a particular case in which we believe that just the particular modification exemplified by the patent food, is indicated. Used thus inteUigently, it would seem that the patent food would do no harm, and it may be the most con- venient means of realizing the particular feeding resource which we wish to employ. I do not believe we are justified in thus using the patent foods. Whatever their value in individual cases, the fact remains that they are advertised, and sold as general baby foods. As long as they .are thus advertised, their use cannot but help to perpetuate the idea that they are baby foods of superior value. Physicians should avoid perpetuating this harmful idea. Every principle ern- bodied in them can be realized without their use. If we wish to use dextri-maltose, it is better to use some preparation advertised merely as a specially pure form of dextri-maltose, than a preparation con- taining the same dextri-maltose but advertised as a baby food. MILK LABORATORIES.— The object of the milk laboratory is to aft'ord to the physician a means of utilizing every known method of milk modification employed in infant feeding. In this busy age of scientific rational medicine physicians all over the world demand, first, means of saving time, and second, exact methods of work, which in themselves soon become time-savers. In every branch of our art the tendency is growing year by year to systematize the detailed and laborious vv^ork of the individual for the common practical use of the profession at large. The two chief advantages of the milk labo- ratory are, first, the saving of time for the physician, and second, exactness in the composition of the foods prepared for the baby. The physician's time is saved because, thinking of his food in terms of the percentages of the various food elements which he wishes to give, he does not have to calculate the various combinations of in- gredients which will give the required food composition, nor to give to nurse or mother detailed directions for the preparation of the 300 Feeding food. This is done at the laboratory. Exactness is obtained from the fact that the various ingredients used in preparing the food, such as cream, milk, barley water, and so forth, are standardized, and contain exactly the percentages of the food elements demanded by the method of calculation employed. The calculations are of course, exact. In using the milk laboratory, the physician writes a prescription, calling for any food which he wishes to give. He specifies the per- centages of fat, sugar, and protein he desires, states the variety of extra sugar to be used, states, if he wishes, the relative quantities of whey protein and casein. He may order any alkali to be added, may order starch in any amount, may have the food fermented with lactic acid, cooked, pasteurized, dextrinized, or peptonized. He may order albumin milk or precipitated casein. All he has to do is to specify the composition of the food he wants, and the labora- tory puts up this food. These laboratories have been placed under the control of educated, intelligent men in whom we should have the same confidence that we have conceded to the pharmacist, and we can write directions for infants' foods and send them to these laboratories just as, in the treatment of disease, we write our pre scriptions for the division of one drug or the combination of several. As the pharmacist has nothing to do with the various methods of treating disease, so the milk-modifier is simply required to carry out the directions and ideas of the physician, and the laboratory assumes no responsibiHty as to the success or failure of the food. The result attained depends wholly upon the physician's intelligence in the use of the resources of feeding. In addition to carrying out the physicians' prescription calling for a food of a certain composition, the milk laboratory provides a good and clean milk supply, and the modification and dehvery of the milk is carried on under the cleanest conditions. To illustrate the use of the laboratory, a prescription blank from the Walker-Gordon Laboratory is reproduced on the opposite page: It will be seen how all the more ordinary milk modifications can be ordered very simply from these blanks. For some more compli- cated preparations, the physician must give a more detailed descrip- tion of what he wants. The filled prescription calls for a food having a fat percentage of 2, a sugar percentage of 6, the extra sugar being maltose, a whey protein percentage of .75, and a casein percentage of .50. Lime water is to be added in the amount of 20 per cent of the milk and cream. The food is to be pasteurized at 145° F., and delivered in eight feeding bottles, each containing six ounces. The prescription blank is arranged for the use of all the more ordinary resources of infant feeding. When the physician wishes Home Modification 301 Fig. 77 WALKER-GORDON LABORATORIES Fats. I Lactose (Milk Sugar') Maltose (Malt Sugar) Sucrose (Cane Sugar) Dextrose(Grape Sugar) I Starch (b) Dextrinize. (c) Proteids... (d) Peptonize. fWhey.. Casein. (e) Sodium Citrate (f) Sodium Bicarb, (g) Lime Water. . . (h) % of milk and cream. , % of total mixture. . . . % of milk and cream. % of total mixture. . . , % of milk and cream. % of total mixture. . . [ 1 — To inhibit the sapro- Lactic Acid phy tes of fermentation Bacillus 2 — To facilitate digestion of [ the proteids Per Cent 2 Heat at 145°F. Number of Feedings 8. . . Amount at each Feeding 6 . . . ORDERED FOR Address Date 19. Note — See back of pad. . ...M. D. (Over) EXPLANATORY (a) It requires .75 per cent starch to make the precipitated casein finer. (b) One hour completely dextrinizes . the Starch. (c) In case physicians do not wish to sub-divide the proteids, the words "Whey" and "Casein" may be erased. (d) Twenty minutes renders the mixture decidedly bitter. (e) It requires 0.20% of the milk and cream used in modifying to facili- tate the digestion of the proteids; i. e., the formation of a soft curd. 0.40% to prevent the action of rennet; i. e., the formation of tough curd. (f) It requires .68% of the milk and cream used in modifying to favor the digestion of the proteids. 1.70% of the amount of milk and cream used suspends all action on the proteids in the stomach. 1.7% of the total mix- ture gives a mild alkaline food. (g) It requires 20% of the milk and cream used in modifying to favor the digestion of the proteids. 50% of the amount of milk and cream used suspends all action on the proteids in the stomach. 5% of the total mix- ture gives a mild alkaline food. (h) Percentage figures represent the per cent of Lactic Acid attained when the food is removed from the thermo- stat. When the Lactic Acid Bacillus is used to facilitate digestion of the proteids, this is the final acidity, as the process is stopped by heat at this point. When the Lactic Acid Bacillus is used to inhibit the growth of sapro- phytes, the acidity may subsequently increase to a variable degree, as the bacilli are left alive. .25% Lactic Acid just curdles milk. .50% gives thick curdled milk. .75% separates into curds and whey. Walker-Gordon Laboratories 1106 Boylston Street Boston And all Large Cities to use certain special methods of modifying milk, such as albumin milk, modification with precipitated casein, malt soup mixtures, and homogenized fat mixtures, he must transmit to the laboratory more specific directions as to what he wants. The laboratory is prepared to carry out any wishes of the physician in regard to the modification of cow's milk for infant feeding. HOME MODIFICATION.— In many cases, probably the major- ity, a milk laboratory cannot be utilized to obtain the desired milk modifications for the infant. In these cases the food has to be pre- pared at home, by the nurse or mother. To be successful in all cases, the physician must be able to utilize by home modification, all the methods of milk modification available in artificial feeding. This can be done, with less accuracy than at the laboratory, but with 302 Feeding sufficient accuracy for practical purposes. All the methods of modi- fying milk described here except homogenization can be carried out at home, although some of them are rather troublesome and labori- ous, and in some cases, the widest extremes of percentages cannot be obtained. TECHNIQUE OF HOME MODIFICATION The following implements are required: — As many feeding bottles as there are feedings in twenty-four hours; the milk, in quart jars; Fig. 78 ^^S:,. ^ „ - i; . -V ;.• ^ Home modification of cow's milk. Apparatus lactose or other carbohydrate; a pitcher large enough to hold the whole of the mixture; an empty quart milk jar; a graduate, holding one pint; a tablespoon; a teaspoon; sterile cotton or albumin caps to stopper the bottles; a cream dipper. All the implements should be clean, and sterilized by boihng. The lactose is measured with a tablespoon, put in the empty milk jar, and the boiled water measured in the graduate is added while still hot. The jar is then shaken until the lactose is dissolved, and put aside to cool. The top ounce of cream is removed with a tea- spoon, to allow the insertion of the cream dipper without overflow. The rest of the cream, down to the cream line, is removed with the Home Modification 303 cream dipper, and put into the graduate. The excess of cream in the graduate is poured off, leaving in the graduate only the quantity of cream required by the formula.* This is then placed in the pitcher. The skimmed milk remaining in the milk jar is mixed by shaking, and the quantity required is measured off in the graduate, and added to the pitcher. When cool, the boiled water and lactose are poured into the pitcher. The quantities to be given at each feeding are measured off in the graduate, and placed in the feeding bottles. The Fig. 79 Home modification of cow's milk. Obtaining the cream bottles are stoppered, and are then pasteurized, if pasteurization is to be used. (See technique of pasteurization, p. 274.) The bottles are finally placed on ice, until used, when each bottle is warmed and given to the baby. THE CALCULATION OF HOME MODIFICATION The physician using home modification, thinks of the food he wishes to give in the general terminology of the percentages of its component elements. He must be able to translate this percentage formula in to definite directions for obtaining and mixing certain * If the amount of cream obtained from one quart is less than the amount required in the formula, two quarts must be used in obtaining the cream. 304 Feeding ingredients. This involves a certain amount of mathematical cal- culation. A great variety of methods of calculating have been devised and pubhshed. Some of them have a certain time-sa\dng merit, but most of the abbreviated methods are difficult to remember, if not in constant use. The method given here is based on the fundamental mathematical principle involved, from which all abbre- viated methods are derived. Once learned, it is not forgotten. Fig. So Home modification of cow's milk. ^li.xing the ingredients Milk and Cream Dilution with the Addition of ]\Iilk Sugar. — This is the fundamental method by which we vary at will the per- centages of the three principal food elements, the fat, sugar, and pro- tein. Certain ingredients are obtained, and we must calculate the number of ounces of each one, which must be diluted with water to produce the required food. To simplify the calculations, we assume a definite composition for the ingredients used. The formulae thus assumed are by no means accurate, but the calculation of home modifications may be suffi- ciently simplified to avoid very troublesome fractions, and to shorten the process of calculation, provided that the error be not too great. The actual average composition of the milk ingredients most com- monly used in home modification is shown in the table. LACTOSE PROTEIN 4-75 3-50 4 45 327 4 20 305 3 40 2.50 5 CXD 3-55 5 00 3 -65 5 10 0.90 Home Modification 305 Table 31 Average Composition of the Milk Ingredients Used in Home Modification FAT Whole milk 4 ■ 00 10% cream 10. 00 16% cream 16.00 32% cream 32 . 00 Skimmed milk i . 00 Separated milk ("fat free") .25 Wliey 25 The ingredients used are the following: — 1. Gravity cream, which is obtained by taking off with a cream dipper from a quart jar of milk all the cream which rises after eight or more hours' standing. 2. Skimmed milk, which is the milk left in the jar after all the cream has been removed. 3. Dry milk sugar. For purposes of calculation, we assume the following composition for these ingredients: FAT LACTOSE PROTEIN Gravitj' cream 16.00 4.50 3.20 Skimm'ed milk 0.00 4.50 3.20 Dry lactose 0.00 100.00 0.00 The calculation is based on a fundamental mathematical propor- tion, by which all problems in dilution may be solved. The pro- portion is as follows: The quantity of an ingredient : The total quantity o ' the mixture = The per cent of any element in the ingredient: The per cent of that element in the mixture. If this is expressed in algebraic terms, — Let X represent the ounces of the ingredient (ounces required). Let a represent the total ounces of food desired. Let m represent the per cent of any element in the mixture (per cent required). Let n represent the per cent of that element in the ingredient (16% for fat; 3.20% for protein; 4.50% for lactose). Then .v : a = m : n m X = X a . n The ounces of an ingredient required to give a certain percentage is found by dividing the percentage required by the percentage of the element in the ingredient, and multiplying by the total number of ounces in the mixture. Or the percentage required may first be multiplied by the total number of ounces in the mixture, and then divided by the per cent of the element in the ingredient. 20 306 Feeding For example, suppose we wish to calculate the home modification of a food containing — Fat 3 Lactose 6 Protein 2 the baby to have 8 feedings, of 4 ounces each — The total mixture, a, is 32 ounces, the percentage of fat required, m, is 3, and as always, the percentage of fat in our first ingredient, gravity cream, is 16, 3 X = X 32 = 6 ounces of cream. 16 Protein is contained in both the cream and the skimmed milk, and is assumed to have the same percentage in each, namely 3.20. The percentage of protein required being 2.00, 2 X = X 32 = 20 ounces of cream and skimmed milk. 3.20 The cream having been already determined as 6 ounces, the skimmed milk must be — 20 — 6 ounces, or 14 ounces. Before determining the amount of dry lactose needed to bring the lactose percentage up to the required 6%, we must determine what percentage of lactose is added by the milk and cream. The same formula — X : a=^m :n is used, but now x, the number of ounces of the ingredient. is known, the unknown quantity being m, the percentage of lactose in the mixture after dilution of the cream and skimmed milk — If X : a^ m : n m = X n a The percentage given by diluting an ingredient is found by dividing the ounces of the ingredient used, by the total ounces in the mixture, and multiplying by the percentage of the element in the ingredient. Therefore : — 20 5 9 45 . , . „ m = X 4- 50 = X = - — = 3 approximately, 1. e., 3 Vo. 32 . 8 2 16 To determine the ounces of dry lactose needed to give the additional required sugar percentage of 3, we use the original form of the pro- portion, the percentage of sugar in dry lactose being, of course, 100, 3 X = X 32 = .96 or approximately, i ounce. 100 Home Modification 307 In home modification it is troublesome to require the nurse or mother to weigh the sugar on a scale. The common domestic measure, the tablespoon, is usually employed. As a basis of calculation, we consider that, 2 rounded tablespoonfuls of sugar = i ounce. A rounded tablespoon is obtained by gently shaking a heaping table- spoon, until the extra sugar has fallen off. In our calculation, the sugar required being one ounce, we would in our directions call for two rounded tablespoons. The complete directions which we would issue to the mother would be as follows: From a quart jar of milk, on which the cream has "set" (after eight or more hours' standing), remove with a cream dipper all the cream down to the "cream line." This is "gravity cream." The milk left in the jar mixed by shaking is skimmed milk. Mix as follows : Gravity cream, 6 ounces Skimmed milk, 14 ounces Boiled water, 12 ounces Milk sugar, 2 rounded tablespoons The milk sugar should always be dissolved first in the boiled water while the latter is still hot. The steps in the process may be summarized as follows: — - 1. Determine the ounces of cream needed to give the required fat percentage (calculation of x). Divide the percentage of fat required by 16 and multiply by the total number of ounces in the mixture. 2. Determine the ounces of cream plus milk needed to give the required protein percentage (calculation of x). Divide the percent- age of protein required by 3.20 and multiply by the total number of ounces in the mixture. 3. To determine the ounces of skimmed milk needed, subtract the ounces of cream used from the ounces of cream plus milk. 4. Determine the percentage of sugar given by diluting the cream and milk (calculation of m). Divide the ounces of cream and milk by the total number of ounces in the mixture, and multiply by 4.50. Subtract this from the percentage of sugar required, to find the additional sugar percentage needed. 5. Determine the ounces of milk sugar required to give the addi- tional sugar percentage required (calculation of x). Divide the ad- ditional sugar percentage required by 100 and multiply by the total number of ounces in the mixture. 6. Reduce the sugar from ounces to rounded tablespoons by mul- tiplying by 2. 308 Feeding Suppose now we wish to calculate the following formula — Fat 2 Lactose 7 Protein 1.50 the baby to have 8 feedings of 5 ounces each. The steps as enumerated above, would be as follows: 2 1. X 40 = 5 ouncesgravity cream. 16 1.5 1-5 2. X 40 :^ = 18 . 7, or 19 ounces cream and milk. 3.20 . 08 3. 19 — 5 ^ 14 ounces skim.med milk. 19 19 9 178 4. - — X 4.50 = X — = =2.22, or 2% sugar added by the 40 40 2 80 cream and milk. 7 — 2 = 5% additional sugar required. 5 . ■ . ■ 5. X 40 = 2 ounces of dry milk sugar required. 100 6. 2X2 = 4 tablespoons dry milk sugar required. Omitting the preliminary directions for obtaining the ingredients, the directions would be as follows: Gravity cream, 5 ounces Skimmed milk, 14 ounces Boiled water, 21 ounces Milk sugar, 4 tablespoons It is necessary at times to eliminate various troublesome frac- tions of ounces or percentages which occur during the calculation. The error involved in thus eliminating fractions is not very great, and the various errors are very apt to offset one another. It is best to have some definite rule of procedure in eliminating fractions. The following is a good rule: — With fractions involving percentage of fat or ounces of cream, take the nearest quarter per cent or quarter ounce; with fractions involving percentage of lactose or protein, or ounces of skimmed milk or milk sugar, take the nearest half per cent or half ounce. Troublesome fractions may also be eliminated automatically, if we take for our total mixture required some figure easily divisible by other numbers. For instance, if we wish to give 7 feedings of 4 ounces each, we can take for our total mixture 32 ounces, instead of 28. There will only be a waste of 4 ounces, and the figure 32 is much easier to handle in calculating. Similarly, if we wish to give to the baby 7 feedings of 5 ounces each, we can calculate for a mixture of 40 ounces instead of 35, with a waste of only 5 ounces. This use of round numbers has the additional advantage that it provides extra milk to allow for spilling or other accident. Home Modification 309 There are two ways of varying the relation of protein to fat per- centage. We may choose for dilution creams of different fat per- centages, each having a different proportion of protein to fat. Or we may choose for dilution a cream of maximum fat percentage, having the lowest proportion of protein to fat, and may then vary the percentage of protein by adding varying amounts of fat-free (skimmed) milk. The former way has the advantage that the mother or nurse is required to work with fewer ingredients, but the latter way is preferable. Creams of different fat percentages are obtained by taking from the top of the milk a various number of ounces after a various number of hours' standing. In home modification, there is always an error, due to the variations in cow's milk, so that our ingredients never represent the exact percentages which we assume to be their composition. The most essential thing in home modifica- tion is, not that the food shall contain the exact percentages that we wish, but rather, when we change the food, that the new food shall bear an exact relation to the old one. If we are constantly changing our method of obtaining our ingredients, this unknown initial error comes in all over again with each change of food. If we work with two constant ingredients, always obtained in the same way, the error is constant, and no new error is introduced. Fur- thermore, it has been found that the gravity cream obtained by the method described of removing all the cream down to the cream line, is more apt to be close to the assumed fat percentage, and is less subject to variations, than creams of other fat percentages obtained in different ways. Another advantage of using the ingredients de- scribed here, is that they are constant, and the directions for obtain- ing the ingredients when once given to the mother or nurse, hold for all formulae in milk and cream dilution, and do not have to be changed or repeated when the composition of the food is changed. The Calculation of Starch. — Barley water is the usual ingre- dient used to modify cow's milk with a solution of starch. The percentage of starch in barley water varies according to the manner in which the barley water is made. Barley water made according to the directions accompanying most of the barley flour prepara- tions on the market, contains about 1.50 per cent of starch. As the minimum percentage of starch required in a milk modification to give at its best the colloidal action of the starch is .75 per cent, it is obvious that if a barley water containing 1.50 per cent of starch be used as the ingredient, half the mixture must be barley water. As a protein of 1.60 per cent requires half the mixture to be milk and cream, we cannot have half our mixture barley water with a pro- tein percentage higher than 1.60. As we frequently wish to order a higher protein than this, it is better to use as our stock ingredient a barley water having a starch percentage of 3. 310 Feeding Such a barley water may be obtained from any of the barley flour preparations, by giving to the mother or nurse the following direc- tions: — To one pint of water add two level tablespoons of barley flour; boil for twenty minutes; replace the water boiled away with enough water to make up the full pint; strain through three layers of cheese cloth. The calculation is very simple, the same formula being used, as for milk and cream, n being 3. If we want a .75 per cent starch solution, in a 3 2 -ounce mixture, • 75 X = X 32 = 8 ounces of barley water. 3 It is easier to remember that if we are working with a barley water containing 3 per cent of starch, and if we desire .75 per cent of starch in our mixture, one-quarter of the total mixture must be barley water. The Calculation of the Alkalies. — As shown above, the alka- lies should usually be prescribed in definite relation to the number of ounces of milk and cream in the mixture. If we wish to use lime water in the amount of 20 per cent of the milk and cream, we divide the ounces of milk and cream by 5, to obtain the ounces of lime water required in the mixture. If we wish to use lime water in the amount of 50 per cent of the milk and cream, we divide the ounces of milk and cream by 2. It must be remembered that lime water, being a Hquid, and not a dissolved dry, ingredient, enters into the total mixture, and the boiled water, or other diluent must be pro- portionately diminished. In the case of the other alkalies, the calculation is as follows :^j Divide the figure representing the percentage of sodium bicarbonate or sodium citrate required by 100, and multiply by the ounces of milk and cream in the mixture. This gives the alkali required in fractions of an ounce. To reduce to drachms multiply by 8, and to reduce this to grains, multiply the result in drachms by 60. For example, in a formula requiring 5 ounces of cream and 13 ounces of skimmed milk, it is desired to add sodium bicarbonate to delay curd formation in the stomach, and to alter the composi- tion of the curd. The amount of alkali required for this purpose is .68 per cent. Then .68 -4- 100= .0068. .0068 X 18= .1184 ounces. .1184 X 8= .9472 drachms. .9472 X 60= 56.8320 or 57 grains. approximately one teaspoonful. Home Modification 311 As an example of the calculation of both starch and alkali, let us suppose that in the formula calculated on p. 308, we desired to give .75 per cent of starch, and enough lime water to prevent pre- cipitation of the protein in the stomach. The usual directions would be given for obtaining gravity cream and skimmed milk. Further directions would be given for making a barley water containing 3 per cent of starch. The mixing directions would be as follows — Gravity cream, 5 ounces Skimmed milk, 14 ounces Barley water, 10 ounces * Lime water, 9I ounces Boiled water, i| ounces Milk sugar, 4 tablespoons The Technique oe Peptonization. — Pancreatine (Extractum pancreatis) is an official preparation. It acts only in an alkaline medium, and the amount required varies with the protein, and hence with the ounces of milk and cream in the mixture. For each ounce of milk or cream in the mixture, we should use 1/2 a grain of pancreatic extract, and 2 grains of sodium bicarbonate. There are various commercial pancreatic preparations usually in the form of pastes put up in tubes, and usually called peptonizing tubes. These are very convenient, and as the directions as to the quantity accompanying them apply to whole milk, the determination of the amount required in dilutions of milk and cream is easy. They do not require the addition of bicarbonate of soda. The extract and sodium bicarbonate, or the paste, is dissolved in about 4 ounces of the boiled water, which has been allowed to cool. This is then added to the milk mixture, which, in its jar, is set in a vessel of water at a temperature of 107° F, The time varies according to the degree of peptonization desired. The usual time is from seven to ten minutes. Calculation of Whey Mixtures. — The calculation of spHt pro- tein formulae is much like the calculation of milk and cream dilu- tions, except that a new food element, the whey protein, enters into consideration, and an additional ingredient, whey, is used. In the instructions given to the mother or nurse, in addition to the direc- tions for obtaining gravity cream and skimmed milk, we must give the necessary directions for obtaining whey. They are as follows: — To make the whey, use skimmed milk. Add Hquid rennet, or essence of pepsin, or a junket tablet in the proportions of two tea- spoons or one tablet to the pint. Warm to about body tempera- ture (100° F.) and let stand until the curd has soHdified. Break up the curd with a fork or spoon, and strain three times through cloth or fine cheese cloth. Then heat the whey to 150° F. to kill the active rennin. 312 Feeding The average actual percentage formula of whey is — Fat o. 25 Lactose 5. to Whey protein 0.90 Casein 0.00 For purposes of calculation, the formula is assumed to be — Fat 0.00 Lactose 4.50 Whey protein i . 00 Casein 0.00 A further assumption is made for the purpose of simplifying the calculation. A certain proportion of the protein of cow's milk is whey protein, this proportion lying between one-fifth and one-fourth of the total protein. If this fact were taken into consideration in the calculation of whey mixtures for home modification, the mathe- matical diflaculties would be much increased. The small propor- tion of whey protein is disregarded, and it is assumed that all the protein added by the milk and cream is casein. The error involved in this assumption is not very great, and is partly offset by the assump- tion that the whey protein percentage in whey is i.oo instead of 0.90. The various steps in the calculation of split protein formulae are the following: 1. Determine the ounces of cream needed to give the required fat percentage (calculation of x). Divide the percentage of fat required by 16 and multiply by the total number of ounces in the mixture. 2. Determine the per cent of protein contained in this cream dilution (calculation of m). Divide the ounces of cream by the total number of ounces in the mixture, and multiply b}^ 3.20. This protein is considered as being all casein, and represents the minimum casein which can be obtained. If the percentage of casein desired is below this minimum, the formula desired should be readjusted to require the minimum obtainable casein. 3. This third step is omitted, unless the per cent of casein con- tained in the cream is lower than the per cent of casein required. If so, determine the ounces of skimmed milk needed to give the additional casein (protein) percentage required (calculation of x). Divide the additional percentage of casein required by 3.20, and multiply by the total number of ounces in the mixture. 4. Determine the ounces of whey needed to give the required whey protein percentage (calculation of x). Multiply the per cent of whey protein required by the total number of ounces in the mixture. 5. Determine the percentage of sugar given by the cream, milk, and whey (calculation of m). Divide the ounces of cream -f milk -f whey by the total number of ounces in the mixture and multiply by 4.50. Subtract this from the percentage of lactose required to find the additional sugar percentage needed, 6. Determine the ounces of milk sugar required to give the ad- Home Modification 313 ditional sugar percentage required (calculation of x). Divide the additional sugar percentage required by loo and multiply by the total number of ounces in the mixture. 7. Reduce the sugar from ounces to rounded tablespoons by multi- plying by 2. The following example illustrates the calculation of a split protein formula : We wish to give Fat 2 . 50 Lactose 6 Whe}^ protein . 75 Casein . 50 8 feedings of 4-1/2 ounces. In this case, I should assume the total mixture to be 40, instead of 36, in order to avoid fractions. 1. X 40 = 6i ounces gravity cream. 16 6-25 2. ■ — — X 3.20= .50% minimum casein obtainable. 40 In this case, the minimum casein obtainable is just what is required. Therefore the third step is omitted. 4. . 75 X 40 = 30 ounces whey. 36.25 36 9 9 9 81 5. X 4 . 50 = X = X = = 4 per cent of sugar 40 40 2 10 2 20 added by the cream and whey. 6 — 4 = 2% additional sugar reciuired. 2 6. X 40= .8 ounces. 100 7. .8X2^1.6 tablespoons, called i\ tablespoons. The mother or nurse would consequently be told to mix as follows: Cream. 6| ounces Whe}', 30 ounces Boiled water, 35 ounces Milk sugar, i^ tablespoons Calculation of Other Carbohydrates than Lactose. — ISIost of the other carbohydrates are obtainable in dry form. The carbo- hydrate most commonly used is maltose, or a combination of dextrin and maltose. There are a number of preparations of "dextri-mal- tose" on the market which are excellent, and are, I believe, the best form in which to use maltose as the extra sugar in cow's milk modification. These dry sugars are simply used as substitutes for the lactose added to ordinary modifications. In using maltose, the physician does not usually think of a definite percentage of maltose which he wishes to give, but rather of the total sugar, the extra sugar 314 Feeding to be maltose. The relative percentages of lactose and maltose in this total carbohydrate are brought out during the calculation. If we wish to give 6 per cent carbohydrate, extra sugar maltose, when we determine the per cent of sugar added by the milk and cream in the mixture, this represents the per cent of lactose, while the addi- tional carbohydrate percentage required represents the per cent of maltose in the mixture. Some of the carbohydrates used in milk modifications are sold in liquid form. Examples of these are the various malt extracts. When these are used, it is necessary to know the percentage of maltose in the preparation employed. This figure is substituted for the figure loo, in calculating the extra sugar required, and the result is left in fluid ounces, forming a part of the total mixture. Lactic Acid Milk in Home Modification. — The making of lactic acid milk for therapeutic use against intestinal putrefaction will be described elsewhere. In making lactic acid milk as a method of modifying cow's milk for the purpose of infant feeding, any prepa- ration of the lactic acid bacillus, such as lactone tablets, lacto- bacilline, or a bouillon culture of the lactic acid bacillus may be used. When the last is employed, a little of each day's milk, one or two teaspoons, may be added to ferment the milk for the next day. The ferment is added to fat-free milk, which should previously have been steriHzed. If fat-containing mixtures are fermented, the fat globules may fuse together in the form of butter, which may cause indigestion. After adding the ferment, the milk is. allowed to stand in a warm place, the exact temperature not being essential. A little experiment will show how long standing in a given place will suffice to cause souring of the milk with fine precipitation of the casein, without separation of the curd from the whey. When this point is reached, the milk is bottled and put on ice. If it cannot be continuously kept on ice till used, it should be heated to 155° F., in order to kill the ferment. Lactic acid milk thus obtained is considered to have a formula of Fat o Lactose below 4 . 50 Protein 3 . 50 The carbohydrate is very variable, depending on how far the fer- mentation has gone. This food may be diluted in various ways to meet digestive idiosyncrasy. If it be desired to give fat, it is usu- ally better to use alternate feedings of the lactic acid milk and some fat-containing formula, although often a lactic acid milk containing a little cream may be given with safety. Precipitated Casein in Home Modification. — This is obtained as follows: To one quart of skimmed milk add half an ounce of essence of pepsin or liquid rennet, or two junket tablets. Heat to Home Modification 315 about body temperature (ioo° F.), and let stand until the casein has coagulated. Strain off the whey through mushn. The curd is now rubbed through a fine wire sieve. During the process small quantities of water are added to the casein in the sieve. When all the casein has gone through, enough more water is added to bring the quantity of the casein suspension up to lo ounces. This forms the stock precipitated casein solution. The calculation is made as follows: — It has been found that the quantity of casein obtained in this way from a quart is 2.60 per cent of the quart. Ten ounces is very little less than one-third of a quart, and therefore the percentage of casein in the lo-ounce stock solution is represented by 2.60 X 3 or 7.8 per cent, which for pur- poses of calculation is considered to be 8 per cent. If the stock solution contains 8 per cent of precipitated casein, the calculation for obtaining any desired percentage of precipitated casein in any mixture is as follows: — Divide the percentage of precipitated casein required by 8, and multiply by the total number of ounces in the mixture. This gives the number of ounces of the stock solution to be used. Cooking Milk Mixtures. — This procedure requires no specific directions in home modification. The food is simply brought to a boil. It is best to use a double boiler. Homogenized Milk. — This very recent method of modifying milk is not available at present in home modification. It is necessary to resort to a hospital or laboratory possessing a homogenizer. Malt Soup. — The proportions are one ounce (by weight) of wheat flour to ten ounces of milk. The flour is rubbed smooth with cold milk, and the milk and flour are cooked for twenty minutes, and then allowed to cool. In another vessel three ounces of one of the thick malt extracts are dissolved, with 15 grains of potassium car- bonate, in 20 ounces of lukewarm water. This is added to the milk and flour, and the mixture is kept warm for a few minutes, and then boiled for five minutes. After cooling it is ready for use. This mixture has an approximate percentage formula of Fat 1 . 30 Lactose i . 50 Maltose 7 . 50 Protein i . 00 There is also an amount of starch which is very variable, as some of the starch is dextrinized by the malt extract during heating. The essential features of malt soup being the cooking of the flour with the milk and the warming with malt extract, any milk modifi- cation of known composition may be treated in this way. Albumin Milk; Protein Milk; Eiweiss Milch. — Precipitated casein is obtained by the method described under that heading, The amount of water added is up to one pint instead of 10 ounces. 316 Feeding Lactic acid milk is obtained by the method described under that heading, but from whole milk instead of skimmed milk, and one pint is mixed with the casein suspension. Albumin milk thus made has a constant formula, which can only be altered by dilution, or the addition of sugar. . Any combination of percentages, however, can be obtained by combining the 8 per cent precipitated casein solution with lactic acid milk in various proportions. LABORATORY FEEDING AND HOME MODIFICATION; RELATIVE ADVANTAGES AND DISADVANTAGES.— In a discussion of the factors which guide the physician in choosing whether the infant's food shall be prepared at a milk laboratory or at home, it is necessary to state at the outset, that as far as practical results are concerned, there has never appeared to be am^ marked superiority on either side. It appears to be an undoubted fact in the experi- ences of most physicians who have had a large experience wdth both methods, that most infants can be fed with food prepared at home just as successfully as with food prepared at a milk laboratory. This fact appHes to the majority of even the most dif&cult cases, pro- vided that the home modification be properly carried out. The fact that the laboratory employs centrifugalized cream instead of gravity cream' has been urged as an objection to laboratory feeding, on the ground that separated cream is less digestible. No basis has been found for this belief, and it is quite certain that the obtaining of cream by centrifugalization in no way impairs its digestibihty. Accuracy cannot be realized with home modification as with the laboratory. In a food prepared at the laboratory the physician can have the same assurance that the composition of the food is exactly what he ordered, as he has in the case of his drug prescription filled at a reliable pharmacy. That this superiority in the exactness of the percentage formulae has not given evidence of superior clinical results, only demonstrates that such absolute accuracy, while desir- able, is not essential for practical purposes. Successful clinical results are due, not to exactness of the composition of the food given, but to the physician's knowledge of the resources at his command in artificial feeding and of the scientific principles on which these re- sources are based, and to his skill in the diagnosis of the conditions he has to treat, and in the choice among the methods at his disposal. Accuracy is essential for purposes of research. If the physician is interested not only in obtaining good practical results, but also in adding to his knowledge of the relation of clinical manifestations to various quantities of the food elements, or if he is treating cases experimentally with the idea of pubhshing his findings, results based on home modification cannot be used, because of inaccuracy. Calculation of Calories 317 The principal practical advantage in laboratory modification is its convenience. It spares the physician all the trouble of the mathe- matical calculations involved in home modification, and spares the mother or nurse the trouble of obtaining and mixing the ingredients. In any case in which there is any doubt as to the willingness or ability of nurse or mother to modify the milk exactly as directed, under conditions of perfect cleanliness, laboratory modification, if available, should be preferred. Furthermore, laboratory modifica- tion as carried out by the best milk laboratories in this country, insures that the cow's milk used is of the best, although in many places an equally good milk may be secured for home modification. In short, laboratory feeding secures accuracy, convenience, and cleanliness. The practical disadvantage of laboratory modification is the cost of the product; this has to be considered in many families. Som- times the laboratory is available, but is situated at such a distance, that the cost is increased by the expense of transportation. The wishes of the mother, even if founded on prejudice, must sometimes be considered in making a choice. One often encounters the idea that a skillful mother or nurse, whose "heart is in her work," who is in daily contact with "dear little Tommy," and who is famil- iar with his "cunning ways," is less likely to make mistakes than a mere paid laboratory clerk who has never even seen the baby. Such an idea, even if false, calls for sympathy, and if the available milk supply is good, if the mother or nurse is skillful, and if special accu- racy is not desired, home modification may be chosen. In such a case when greater accuracy is desired, the physician can order stand- ardized cream and fat-free milk from the laboratory, and let the interested nurse or mother do the mixing. The physician should not allow himself to be driven to home modification by any such false prejudice as that the laboratory makes mistakes, or that it dispenses some particular kind of food, but should explain that the purpose of the laboratory is the same as that of the pharmacy, to carry out the physician's prescriptions with accuracy, cleanliness, and convenience. Of course, in very many places, the need of a choice does not exist; no milk laboratory is available, and home modification must be employed. When there is a choice, the physi- cian must take into consideration all the circumstances. He must consider the milk supply available for home modification, the finan- cial and geographical situation of the family, the internal conditions of the household, the complexity of the feeding method to be em- ployed, and whether the particular case calls for especial accuracy. CALCULATION OF THE CALORIES.— The estimation of the daily calories per kilogram of body weight, for the purpose of com- 318 Feeding parison with the so-called minimum caloric requirement, is often useful in infant feeding, thou^ its utihty is rather as a check than as a guide. This calculation is made from the known composition of the food expressed in percentages. The "caloric coefficients" are 9.3 for fat, and 4.1 for carbohydrate and protein. This means that one gramme of fat has a value of 9.3 calories, and one gramme of carbohydrate or protein has a value of 4.1 calories. The calcula- tion is made as follows: 1. Multiply 9.3 by the figure representing the percentage of fat and divide by 100. 2. Multiply 4.1 by the sum of the percentages of carbohydrate and protein, and divide by ico. This gives the -caloric value of the carbohydrate and protein in one gramme of food. 3. Add these two results together. This gives the caloric value of one gramme of food. 4. Multiply the food taken in 24 hours, if expressed in ounces, by 30, to reduce to cubic centimeters. Multiply this by the caloric value of one gramme of food. This gives the daily number of calories ingested. 5. To reduce the weight of the baby from pounds to kilograms, multiply the weight in ounces by 30, and divide by 1000. 6. Divide the daily calories taken, by the weight of the baby in kilograms. This gives the daily calories per kilogram of body weight. As an example of this calculation, let us suppose that a baby weighing 9 lbs. 8 oz. is taking daily 32 ounces of a food, of which the composition is represented by the formula fat 2, lactose 6, protein 2. The steps of the calculation are: — 9.3X2-4- 100= .186 Ca. from fat in one gramme of food. 4.1 X 8 -f- 100= .328 Ca. from carbohydrate and protein in one gramme of food. 3. .186 -h .328 = .514 Ca. in one gramme of food. 4. 32 X 30 = 960 grammes of food in 24 hours. 960 X - 514 = 493 .44 calories ingested daily. 9 lbs. 8 oz. = 152, weight of baby in ounces. 152 X 30 -^ 1000 = 4.56, weight of baby in kilograms. 493.44 -H 4.56 = 108, daily calories per kilogram of body weight. CALCULATION OF PERCENTAGE COMPOSITION IN A FOOD OF KNOWN INGREDIENTS.— In order to treat intel- ligently a case of difficult feeding, it is necessary to know all the foods previously used, and how well the baby thrived, and what symptoms it manifested with each food. In order to draw from such a history conclusions which shall serve as a guide in choosing the method of feeding to be employed, it is necessary to know the com- position of each previous food as expressed in percentage. In the history of the case, the previous foods are often described, not as percentage formulae, but as mixtures of ingredients. These mix- Calculation of Percentage Composition 319 tures have to be reduced to a formula representing the composition of the food in percentages of the principal food elements. To reduce mixtures to their percentage formulae requires that we shall know the composition of each ingredient used. Many of the ingredients met with are creams of different fat percentages, or whole milk, or whey. We can only judge the fat percentage of a cream or milk used, by ascertaining the procedure employed by the mother or nurse in obtaining these ingredients. The percentage of fat in a cream or "top milk" varies with the number of ounces removed from the top of the jar. The following table shows the average composition as expressed in percentages, of top milks obtained in various ways, and of the other ingredients most commonly met with in the history of cases of artificial feeding. Table 32 Percentage Composition of Various Ingredients Used in Preparing Food for Infants. Top Milk NUilBER OF OUNCES TAKEN EROM QUART FAT 4 (or less) 20 . 00 6 (or all the cream) 16 . 00 8 1 2 . 00 II 10.00 16 (upper half) 7 . 00 CARBOHYDRATE PROTEIN 4.00 2.80 4.20 305 4-36 3.18 4-45 3-27 4-55 3-41 Other Milks and Creams FAT Whole milk 4 . 00 Skimmed milk i . 00 Separated cream 32 . 00 Separated fat-free milk 0.05 Whey o. 25 Commercial buttermilk 0.50 Fat-free lactic acid milk o . 00 Whole lactic acid milk 4 . 00 Albumin milk 2 . 00 Malt soup with whole milk i • 30 Condensed milk 9.61 CARBOHYDRATE PROTEIN 4 75 350 5 00 3-55 3 5 40 08 2.50 3.60 5 4 4 4 10 06 06 GO 0.90 3.60 3.60 3.60 2 SO 3.00 Q 00 1. 00 54 94 8.01 Other Ingredients FAT Dry carbohydrate o . 00 Malt extract o . 00 Barley water o . 00 CARBOHYDRATE PROTEIN 100.00 0.00 75- 00 0.00 1-50 0.00 At times some one of the widely advertised infant foods has been used in the previous feeding of a baby. These foods are mainly carbo- hydrate, though some of them have evaporated or condensed milk as a basis, which gives them a considerable fat and protein content. The composition of condensed milk appears in the table of ingredients. 320 Feeding Of the 54.94 per cent of carbohydrate contained in condensed milk, 42.91 per cent is cane sugar, and 12.03 per cent is milk sugar. Most of the other infant foods are in dry form. Their composition is shown in the following table, taken from Holt. Table 33 The Composition of the Infant-foods. {Holt) XESTLE 3 FOOD Per cent Fat 5.50 Protein 14 -34 Cane sugar 25 . 00 Dextrose Lactose (milk sugar) . . 6.57 Maltose \ . Dextrins J27.30 Total soluble carbo- hydrates 58.93 Insoluble carbohy- drates (starch) 15-39 Inorganic salts 2 . 03 Moisture ^ . 81 MEL- LEsr's FOOD Per cent 0.24 11-50 60.80 19.20 So . 00 3-59 4-73 C-AiLN- ESKAY's ILALTED RIDGe'S IMPERIAL RICk'S FOOD GR.AXUM Per Per cent cent FOOD Per cent ,16 .82 inLK Per cent 8.78 16.35 49-15 18.80 67-95 3-86 3.06 1 . II II. 81 0-52 1.28 1.80 76.21 0.49 8. 58 1 .04 14.00 0.42 i"38 1.80 73-54 0.39 9-23 FOOD Per cent 7-45 10 The calculation of the percentages in the mixture given to the baby from the known composition of the ingredients, is made from the same proportion as was used in home modification — X : a= m : n In this case, the unknown quantity is ;;z, its value being expressed by X n Divide the number of ounces of the ingredient used by the number of ounces in the mixture, and multiply by the percentage of any element in the ingredient. This is repeated for each food element, and for each ingredient. For example, a mother is preparing her food as follows: — She takes the upper 11 ounces from a quart of milk, and mixes as follows: Cream. 8 ounces Skimmed milk, 10 ounces Lime water, 2 ounces Barley water, 20 ounces Dextri-maltose, 4 tablespoons The total mixture is 40 ounces, and, as will be seen by reference to table 32, the cream is 10 per cent fat. Practical Feeding 321 8 X lo = 2% fat from the cream. 40 10 X I = . 25 fat from the skimmed milk. 40 8 X 3. 27 ^ .65 protein from the cream. 40 10 X 3 • 55 = .88 protein from the skimmed milko 40 8 X 4.45 = .89 lactose from the cream. 40 10 X 5 = 1 . 00 lactose from the skimmed milk. 40 4 tablespoons dextri-maltose -^ 2 = 2 ounces. 2 X 100 =5% maltose. 40 20 X 1 . 50 = ■ 75% starch. 40 2 X 100 ^ . 11% of the milk and cream for lime water. 18 Therefore this food represents in percentages — fat 2.25, lactose 1.89, maltose 5.00, protein 1.53, starch .75, lime water 11 per cent of the milk and cream. PRACTICAL MANAGEMENT OF ARTIFICIAL FEEDING GENERAL PRINCIPLES There are certain general principles which govern the manage- ment of all cases of artificial feeding. Ends to be Attained. — The first object in artificial feeding, which should be kept in view as the principal end to be attained, is to secure the normal development of the infant. The most useful meas- ure of development is the progressive gain in weight which is seen in normal infants, and the absence of which is the most frequent, early and important sign seen in any disturbance. The second object desired in artificial feeding is to keep the infant free from all symp- toms and signs of disturbed digestion. This second object usually goes with the first, as babies who show signs of disturbed digestion do not gain weight normally. Sometimes, however, a baby may fail to thrive without showing recognizable symptoms of disturbed digestion; while conversely, some babies will continue to gain nor- 21 322 Feeding mally in weight, even when digestive symptoms are present. The third object is to develop the digestive powers of the infant. Conditions of the PnOBLEM.^The difficulties encountered in attaining these objects are due mainly to the variation in the diges- tive powers and nutritive requirements of different babies. To meet these difficulties we are provided with the various methods of modi- fying cow's milk which constitute our stock of weapons. The prob- lem is to choose our methods so as to attain the desired object. Suc- cess depends on our knowledge of the tools to be employed, of the principles underlying their use, and the skill with which we choose among them. Feeding a baby is always an experiment. The artificial feeding of infants is not, and never will be, an exact science. We know at the start, only that the baby must be fed on some combination of fats, carbohydrates and protein. We know that this food must be given in proper amounts, and at proper intervals. We know that the milk supply used must be as clean as possible. We must decide whether or not the milk is to be pasteurized or sterilized, and whether we shall employ a milk-laboratory or home modification. The principles which guide us in the decision as to these two last points have already been described. The principles underlying the decision as to the quantity of food to be given each twenty-four hours, and as to the feeding intervals are comparatively simple. The principal problem is to choose the composition of the food. GENERAL CONDUCT OF A CASE OF ARTIFICIAL FEED- ING. — The various steps taken in carrying on a case of artificial feeding are the following: 1. A careful history of the case is obtained. Such a history should include the entire past feeding of the child; if bottle feeding has been used, the composition of each food should be translated into per- centages. The regularity, intervals, and amounts of feeding should be inquired into. The reaction of the child to each food used should be ascertained. In particular, such questions as to whether or not the child gained in weight, whether or not it seemed satisfied or hungry, whether or not the bowels moved properly, should be recorded in detail. All the possible symptoms of indigestion, such as vomit- ing, regurgitation, sour eructation, coUc, excoriated buttocks, should be inquired into. The daily number, and character of the bowel movements should be ascertained. From such a history may often be deduced important facts as to the digestive idiosyncrasy of the baby. 2. The initial food, on which the baby is to be started, is now chosen. The basis of choice is any deductions which have been made from the past history, together with the knowledge and experi- Feeding of Normal Infants 323 ence of the physician in artificial feeding. If the baby has been previously breast-fed, or if the past history is not of such a char- acter as to permit any deductions influencing the choice, the only guide is the age, weight, and apparent development of the baby. 3. The initial food is always a sort of trial formula. The greater the knowledge of the physician, the more apt is the first food chosen to give a good result. It is, however, mainly on the results observed with this initial food, that the further conduct of the case is based. 4. The composition of the food is changed from time to time. The changes are based on the reaction of the baby to the trial formula first chosen. If the baby shows symptoms of indigestion, and failure to gain in weight, changes are made in the composition of the food, with the purpose, first, of obtaining a gain in weight, and second, relieving symptoms. If the baby gains weight, but shows symp- toms of indigestion, the changes in the food are made in the eft'ort to relieve the symptoms. If the baby shows no symptoms but fails to gain, the object of changing the food is to make the baby gain. 5. In artificial feeding, even when a baby is free from symptoms of indigestion, and is gaining weight, we should not rest satisfied indefinitely, but should still change the composition of the food from time to time, with the idea of increasing the burden laid upon the infant's digestive powers, without overburdening them. This is dotie, because one of the principal objects to be kept in view in artificial feeding, is the strengthening of the infant's digestive power. Any function deteriorates when not exercised. In general, it is always best within certain limits to work a baby up to taking a food of as strong a composition as it can digest. 6. The various changes made in the composition of the food should be carried out in such a way as to enable the physician to learn as much as possible about the digestive peculiarities of the baby. It is often best to change the quantity of just one food element at a time, in order to draw conclusions as to the baby's power of digest- ing each one. THE FEEDING OF NORMAL INFANTS There is no such thing as a normal infant with digestive powers and nutritive requirements which conform to any standard. What is meant by a normal infant, is a baby who has previously had no symptoms of indigestion. Babies who have been previously breast-fed, without signs of indigestion, or babies in whom bottle feeding has failed to reveal any weakness of digestive power, or babies who are artificially fed from birth, are considered normal, when the first choice of artificial food is made. They continue to be considered normal when the first artificial food chosen causes no disturbance. In such a case, after having decided as to home or laboratory modification, and as to pasteurization, we must decide 324 Feeding three points; first, the quantity of the food; second, the intervals of feeding; and third, the composition of the food. THE QUANTITY OF THE FOOD TO BE GIVEN.— The most important thing is the quantity to be given in the twenty-four hours. The guide in beginning artificial feeding is the age and development of the baby; the latter is measured chiefly by the infant's weight. Table 34 shows the twenty-four hour quantities in ounces for babies of average weight at different ages. The figures are based on the quantities taken by healthy, breast-fed infants. Big babies require more food than small babies. The guide as to making changes in the quantity after artificial feeding has been begun, is the behavior of the baby. When a baby is not satisfied with the quantity of food given, he shows symp- toms of hunger. Such symptoms may be relieved either by in- creasing the quantity of the food, or by strengthening its percentage composition. Either increase may cause indigestion. If the baby seems satisfied immediately after feeding, but begins to cry and fuss too long before the next feeding is due, the deficiency is more apt to be in the quality of the food, while if the hunger symptoms are seen as soon as he has finished his bottle, increase in quantity is more apt to relieve them. This guide is, however, by no means positive. Generally a baby should be given from the start the full quantity for his weight and age. Then, as a normal baby should preferably have as strong a food as he can digest, the quality should be in- creased first, until he is either satisfied, or begins to show signs of indigestion. Only when the limit in increase in quality is reached should the quantity be raised. The amount of food in ounces to be given at a feeding is the next thing to be decided. It would seem at the first glance that the most scientific basis for determining the quantity to be given at a feeding is the gastric capacity of infants at various ages. Two methods have been employed in estimating gastric capacity. The first is by post-mortem measurements of actual capacity; the second is by measuring the quantity of food taken at a feeding by a healthy breast-fed infant. Both have proved rather unsatisfactory as prac- tical guides. The technique of post-mortem measurements is com- plicated, and the results vary, not only with individual babies, but according to the technique employed. Moreover, it has been clearly shown that the quantity of fluid a baby takes in nursing is not lim- ited by gastric capacity, as a portion of the feeding is passed into the duodenum before the nursing is completed. It would seem that the capacity as estimated by the second method, measuring the quantity taken from the breast, should be a more logical basis for artificial feeding. Here again, however, individual variation plays a very Feeding of Normal Infants 325 important part. Also, the standard for breast-fed babies is not applicable to the artificially fed, who are taking a food less ideally suited to their needs. In general, in determining the quantities to be given in each bottle feeding, the figures on gastric capacity based on post-mortem measurements, should be taken as a minimum, and those based on the quantities taken by breast-fed babies, should be taken as a maximum. Some rule is necessary as a guide in beginning artificial feeding. The important factors are the twenty-four hour quantity, and the intervals between feedings. The quantities given in table 34 have been based on all the various forms of evidence on the subject. They tend to represent minimum, rather than maximum, quantities. THE INTERVALS BETWEEN FEEDINGS.— Artificial feeding does not require any different arrangement of the feeding intervals than that of breast feeding. The subject of the feeding intervals has been already discussed. They are shown in the table — Table 34 QuanlUies and Intervals for Healthy Babies of Average Development NUMBER OF FEEDINGS QUANTITY QUANTITY IN NIGHT AT A IN INTER- 24 HOURS FEEDINGS FEEDING 24 HOURS VALS Premature 24-18 3 |- f oz. 3-18 oz. i-i| hours At term 10 i ^ oz. 5 oz. 2 hours First week 10 i i oz. 10 oz. 2 hours I- 2 weeks 10 i ij- i| oz. 12-15 oz. 2 hours 2 weeks-i month 10 _ i i^- 2 oz. 15-20 oz. 2 hours 1- 2 months 10 i 2 -2^ oz. 20-25 oz. 2 hours 2- 3 months 8 i 3 - 4 oz. 24-32 oz. 2I hours 3- 4 months 8 or 7 i or o 4- 4^ oz. 28-36 oz. 2| hours 4- 5 months 7 or 6 i or o 4^- 5I oz. 30-33 oz. 3 hours 5- 6 months 6 o 5§- 6 oz. 33-36 oz. 3 hours 6- 7 months 6 o 6 - 6| oz. 36-40 oz. 3 hours 7- 8 months 6 o 6 J- 7 oz. 40-42 oz. 3 hours * 8- 9 months 6 o 7- 8 oz. 42-48 oz. 3 hours 9-T0 months 6 o 8 - 8| oz. 48-52 oz. 3 hours 10-12 months 5 o 9 -10 oz. 45-50 oz. 3 hours The table is not intended for arbitrary or literal application, but rather as a general guide. For this reason alternatives in arranging the quantities and intervals have been omitted, in order to make the table as simple as possible. In general, the intervals of feeding, and the quantities to be given at a single feeding should be considered as minimum figures. In other words, the change from 2-1/2 to 3-hour intervals, and the omitting of the night feeding, may often be advantageously made at ages earlier than those given in the table. When this is done, the amount given in the 24 hours should be kept constant, and the quantity given at a single feeding should be proportionately increased. 326 Feeding For example, a baby in the second month is to be artificially fed. The table gives lo feedings of 2 or 2-1/2 oz. each at 2-hour inter- vals, with one night feeding as the proper routine. At any age the night feeding should be omitted as soon as possible. If the night feeding can be omitted, the baby will have nine feedings of 2-1/2 oz. each, which will give him 22-1/2 oz. in 24 hours, which comes within the limits of the quantity he should take in 24 hours. Often at this age, 2-1/2 hour intervals are better. If the baby is fed at 2-1/2 hour intervals with a night feeding, he will get 8 feedings, of 2-1/2 oz., and 20 ounces in 24 hours, and if he does not need a night feeding, he will get 7 feedings, only 1 7-1/2 oz. in 24 hours. In such a case the quantity given at a single feeding should be raised to 3 oz. PERCENTAGE FORMULAE FOR STARTING AVERAGE WELL BABIES. — In choosing the food with which to start artificial feeding, three main principles should be kept in mind. 1. The feeding of normal infants does not require any of the more complicated methods of cow's milk modification. The first method, of milk and cream dilution, with the addition of lactose, usually suffices. The whey modification, however, may often be advan- tageously used in starting newborn or very young babies. 2. The general relation between the quantities of fat, carbohy- drate, and protein, should be based on the relation found in human milk. This means that the food element having the highest per- centage in the formula should be the carbohydrate, with the fat next, and protein last. The percentage of fat should never exceed' 4%, and in home modification, to allow for error, 3.50% is a safer limit. The carbohydrate should never exceed 7% in well babies, nor in sick babies except under the most exceptional circumstances. The protein should not exceed 3-jo%. 3. It is better to begin with a comparatively weak food, which will probably be digested by the infant, even if such a food does not meet the caloric needs of the infant. It is easy to work up from a weak food to a strong one, if necessary. When indigestion has once been produced, it is not so easy to find the right combination. Infants of the saihe age show such variation in their power of digest- ing cow's milk, that if we want the food to produce no symptoms, it is better to begin with a minimum. The table shows the percentage formulae with which artificial feeding may be begun at different ages. In the table the unmodified protein and spht protein are alter- natives. Some very young babies will take a split protein better than an unmodified protein. The probability of advantage is not great enough to make the more troublesome preparation of a split Feeding of Normal Infants 327 Table 35 Formulae for Starting Artificial Feeding PROTEIN PROTEIN IF SPLIT CUNMODI- \VSEY AGE FAT LACTOSE FIEDj PROTEIN CASEIN STARCH First food (after birth) 1 .00 =; .00 0.50 0.75 0. KO 0. 2^ I week-i month. 1.50 J 5 50 75 25 I- 2 months . 2 .00 6 00 I .00 90 25 2- 4 months . 2.50 6 50 I -5° 4- 6 months . 3.00 7 00 1-75 6- 8 months . 3-50 7 00 2.00 0-7S 8-10 months . 4.00 6 50 2.50 0.7s 10-12 months . 4.00 5 50 3.00 1 1.50 T 1 protein formula actually indicated in these young babies. In home modification the minimum casein is not so low as in laboratory mod- fication, and I usually do not order the split protein in young babies when home modification is to be employed. In laboratory feeding, I usually begin babies under two months with the split protein, and then gradually increase the casein and diminish the whey pro- tein, until the composition of unmodified protein is reached. In babies over the age of six months, I usually add starch to the modification. At this age, babies require a comparatively high per- centage of protein, and they can usually digest starch. Therefore, there is no reason why the favorable colloidal , action of the starch should not be taken advantage of. The appearance of the teeth at about the age of six months is Nature's sign that the time is ap- proaching for some other food beside milk. The next addition to the infant's diet is naturally to be starch. The reason that the percentage of lactose is diminished in the formulae given for babies in the last four months of the first year, is that at this age one is beginning to work up the food of the baby from modified milk to whole milk. This is done by increasing the protein and diminishing the carbohydrate, and babies at this age are started on slightly diminished carbohydrate in preparation for whole milk. Table 35 does not represent the strength of the food which should be taken by average well babies at the different ages, but only the formulae for starting them with safety. If these initial formulae cause any symptoms of indigestion, such babies are no longer considered normal, and the future management of artificial feeding comes under the treatment of disturbances of digestion. If the initial formula does not cause symptoms, we should not rest content, even if the baby is gaining in weight, but should increase the strength of the food. The limit of such increase is the digestive power of the infant. But one does not wish to pass this limit and produce symptoms of indigestion. The limit is unknown. There are, however, certain formulae which can usually be taken by the average well baby, on A.CTOSE PROTEIN STA 6.00 0.75 6.50 1. 00 7.00 I -SO y.oo 2.00 7.00 2.50 0. 6.00 3.00 I. 328 Feeding which the baby would have been started if we had not wished to be on the safe side in beginning artiiicial feeding. PERCENTAGE FORMULAE FOR FEEDING AVERAGE WELL BABIES. — This table represents the strength of the food which we should try to give to average well babies, after artificial feeding has been successfully started. Table 36 Formulae for the Feeding of Average Well Babies AGE FAT I week-i month 2 .00 I- 2 months 3 ■ 00 2-4 months 35° 4- 6 months 4 . 00 6- 8 months 4 . 00 7 . 00 2 . 50 o • 75 8-10 months 4 . 00 10-12 months Whole milk with cereal jelly. INCREASING THE STRENGTH OF THE FOOD.— The indi- cations for increasing the strength of the food are three, i. If the baby, being free from symptoms of indigestion, is not gaining, the strength of the food should be increased, provided that the micro- chemical examination of the stools does not show an excessive amount of fat. If the stools show excessive fat elimination, the baby cannot be considered an average normal infant, and the management of such a case is guided by the principles described under disturbances of digestion. 2. If the baby is gaining, but if the strength of the food is below that usually taken by an average baby of that age, the strength of the food should be increased. 3. If the baby, already taking a food of as great strength as is usually taken by a baby of that age, shows signs of hunger, but no signs of indigestion, increase is indicated. In well babies, when increase in the strength of the milk modi- fication is indicated, it should be gradual. It is not necessary, how- ever, to increase only one of the food elements at a time. A slight increase, such as for example, an increase of .50 per cent in the fat and sugar, and .25 per cent in the protein, may be made in all three food elements. If indigestion develops, there is always the previous food to fall back upon. Between the eighth and the twelfth months, the changes in the composition of the food are made with the express purpose of accus- toming the baby to taking whole milk instead of modified milk. The percentages of the food elements should be gradually altered in such a way as to approach those in whole milk. For example, if a baby ten months old is taking a food having a composition of — Fat 3 . 50 Lactose 7 Protein i . 50 Feeding in Digestive Disturbances 329 the change should be somewhat as follows: — 1. Fat 4 Lactose 6.50 Protein 2.00 2. Fat 4 Lactose 6.00 Protein 2.50 3. Fat 4 Lactose 5.50 Protein 3.00 4. Whole milk When a baby goes onto whole milk, the milk sugar usually has to be reduced in greater proportion than the protein is increased. This is compensated for by introducing starch into the food, or by adding some cereal to the diet. In strengthening the food of well babies who are gaining satis- factorily in weight, the changes need not be made oftener than once a week. They are continued until the baby is satisfied, or reaches a food of full strength for his age. If the food is being strength- ened because the baby is not gaining, the changes should be made more frequently, twice a week or every three days. THE FEEDING OF INFANTS HAVING DIFFICULTIES OF DIGESTION. To this group belong infants who have previously shown symptoms of indigestion, and infants in whom the management of the feeding as recommended for normal infants reveals some abnormality of digestive power. In such cases the choice of food is much more difficult, and there is a demand for a wider use of the resources of milk modification. The various digestive disturbances which may arise in the course of artificial feeding are described and discussed, in detail in the division on diseases of the gastro-enteric tract. Cer- tain general principles of treatment having a definite relation to the various methods of cow's milk modification, may, however, be ad- vantageously discussed here. CAUSES OF DIGESTIVE DISTURBANCE.— The manifesta- tions of difficulty in digestion in an infant are due to a lack of bal- ance between the digestive power of the infant and the composition of its food. The food contains fat, carbohydrate and protein, and the digestive idiosyncrasy of the infant is usually manifested against one or more of these food elements. In certain cases, the quantity of food as a whole may be too great for the infant's digestion. Dis- turbances of digestion, therefore, are ultimately traced to fat, car- bohydrate, or protein, or to overfeeding as a whole. SYMPTOMS OF DIGESTIVE DISTURBANCE.— Various symp- toms manifest themselves when digestion is abnormal. Among the most important are vomiting, colic, sour eructation, irritated but- tocks, constipation, diarrhea, abnormal stools, and failure to gain in weight. DIAGNOSIS. — It is often difficult or impossible to know from the symptoms what is the cause of the trouble. If we could 330 Feeding deduce from the symptoms that the difficulty Hes in the digestion of fat, of carbohydrate, or of protein, the choice of the modifi- cation promising the best results would be comparatively easy. The only laboratory method of value available is the micro-chemical examination of the stools. This is invaluable, and should be car- ried out at frequent intervals in every case of digestive difficulty. More valuable than the symptoms in making a diagnosis, are the previous feeding records of the case, including the behavior of the infant under various methods of feeding. From all the evidence, it is often impossible to make more than a guess as to which is the form of indigestion present. The final diagnosis of fat indigestion, carbohydrate indigestion, protein indigestion, and so forth, can often only be made j'rom the results of our own experiments in the feeding of the case. In the meantime we have to treat the case. We wish, as soon as possible, to relieve symptoms and bring about a gain in weight. The only thing we have to go upon is the clinical symptoms, but we must nevertheless choose our initial formula, and our further changes. To do this, it is of value to know what experience has shown to be the best method of guiding the feeding in the face of certain symptoms. CLINICAL TYPES OF DISTURBANCE SEEN IN ARTIFI- CIAL FEEDING. — It is convenient to know what methods of milk modification to try, and in what order to try them, in certain types of cases met with in artificial feeding. The following clinical t\Tpes will be considered: 1. Vomiting the only symptom. 2. Undigested movements the chief symptom. 3. Green or discolored movements the chief symptom. 4. Failure to gain weight the only symptom. 5. Food idiosyncrasy against milk. Vomiting Cases. — This clinical type may be due to indigestion from any one of the three food elements. Usually when carbo- hydrate is the cause of vomiting, there are other symptoms beside. Vomiting alone is most apt to be caused by fat or casein. The vomiting of large curds immediately after nursing points toward the casein. Sour vomiting during the interval points toward the fat. In many cases it remains always impossible to recognize the original cause of the vomiting, because the symptom, once started, is apt to persist after the original cause has been removed. The stomach has been left in such an irritable condition, that the ordinary pre- cipitation of the casein in the stomach, or even the taking of any food into the stomach, will cause vomiting. The micro-chemical exami- nation of the stools for fat is of no value in cases of this type. Feeding in Digestive Disturbances 331 In feeding a case of this type, try first a food with a fat percentage of zero. For example, a formula containing — Fat o Dextri-maltose 6 Proteid i . 50 If the vomiting is reUeved, it is a case of fat indigestion. If vomit- ing is not reHeved, it is either a case of protein indigestion or of habitual vomiting from irritable stomach. In young babies, who have not a long history of vomiting, it is more apt to be due to casein. Even with habitual vomiting which may originally have been caused by fat or carbohydrate indigestion, the precipitating cause is usually the casein. The various methods of milk modifica- tion influencing protein digestion should be tried one after the other, in the following order: 1. A spHt protein formula, such as, fat i, lactose 6, whey protein .go, casein .25. 2. The same with lime water 50% of the milk and cream. 3. Some other alkah, such as sodium citrate. For example, fat I, lactose 6, protein 1.50, sodium citrate .40% of the milk and cream. 4. Lactic acid milk. In making experimental changes in any case of artificial feeding, the changes should not be made oftener than every three days, unless some change produces immediately new symptoms of indigestion. Some cases will do well with small quantities at shorter inter- vals. If all these measures fail, the case is of the obstinate, resis- tant type. As additional measures in cases with vomiting as the chief symp- tom, daily gastric lavage is of great value. I have seen a few cases of this type reHeved by the passage of the duodenal catheter. In cases in which there is vomiting of large curds immediately after nursing, the alkalies often act as a specific. Undigested Movements. — This cHnical type is usually due either to fat, or to protein. The examination of the stools is of the greatest diagnostic value in these cases. If the stools show excessive fat, the treatment is that of fat indigestion; the baby may be started on a formula containing — Fat o Dextri-maltose 6 Protein 2 , 00 and carried on according to the principles described under indiges- tion from fat. If the stools do not show an excess of fat, the various methods of influencing protein digestion may be tried in the follow- ing order: I. The use of starch. Fat 2, lactose 6. protein 1.50. Starch .75 may be given. 332 Feeding 2. The same formula may be boiled. 3. Lactic acid milk, precipitated casein, or a combination may be tried. The alkalies are less valuable in this type of protein indigestion. Green or Discolored Movements. — This clinical type is usually due either to fat or to carbohydrate indigestion. The former diag- nosis may be confirmed by the results of the micro-chemical exami- nation of the stools for fat. The latter diagnosis is often confirmed by the other symptoms of carbohydrate indigestion, namely, vomit- ing, colic, sour eructations, and irritated buttocks. In either case, dextri-maltose is generally to be preferred as the extra sugar. Cases due to fat should be started on some such formula as — Fat o Dextri-maltose 6 Protein i .50-2.00, and the fat increased according to the principles of treatment in fat indigestion. Cases due to carbohydrate should be started on some such formula as — Fat 2 Dextri-maltose 4 Protein i . 50-2 . 00, and the further changes made in accordance with the principles laid down for the treatment of indigestion from carbohydrate. If these measures fail, whether the trouble be due to fat or carbo- hydrate, lactic acid milk, or precipitated casein, or a combination (albumin milk) should be tried next. No Symptoms. — In this type the baby neither vomits, nor shows any marked abnormality in the microscopic appearance of the stools. It simply loses weight, or fails to gain. It is necessary to make sure that the loss of weight does not come from insufficient food. If not, these cases are usually due to fat indigestion. They are best started on a formula containing a low fat, a high protein, and with the extra sugar maltose, such as — Fat o Dextri-maltose 6 Protein i . 50-2 .00 The further treatment is carried on as for a case of fat indigestion. Food Idiosyncrasy Against Milk. — It is very common to hear of cases of infants who supposedly cannot take cow's milk in any form. In the majority of these cases it is not true that cow's milk cannot be digested and assimilated. Most of them are really cases which have some marked peculiarity of digestive power which has defied the ordinary resources of cow's milk modification. There are, however, cases of true food idiosyncrasy against cow's milk. These cases probably represent a condition in which the unsplit cow's milk protein is for some reason absorbed into the cir- culation, and the disturbances caused thereby represent an anaphy- Feeding in Digestive Disturbances 333 lactic phenomenon. Various symptoms are observed in these milk poisoning cases. The commonest symptom-complex is vomiting and urticaria; sometimes diarrhea is seen. The positive diagnosis of the idiosyncrasy against cow's milk can be made by means of the cutaneous reaction. If the skin is abraded in the manner used for the performance of the von Pirquet tuberculin test, and inoculated with milk, a positive reaction will be obtained. In such cases artifi- cial feeding is impossible, as substitutes for cow's milk are unsatisfac- tory. Breast milk should always be obtained. THE FEEDING OF DIFFICULT CASES— The suggestions given for the management of artificial feeding in infants showing difficulty of digestion, will not solve all the problems presented. The formulae given for starting cases of the various clinical tj-pes encountered, are only trial formulae, and even if they reheve the symptoms, often do not meet the nutritive requirements of the infant to an extent sufficient to permit a satisfactory gain in weight. Even after the use of the trial formula considered most available in a particular clinical type, the nutritive value of the food often has to be increased by raising the percentages of some of the food elements. Increasing the quantity of a food element, even of one which has previously been well digested, may cause some new type of indigestion to develop. Thus there are always a certain number of difficult cases which remain to tax the knowledge and resources of the physician. In managing such cases, every eft'ort should be made to reach the ultimate diagnosis. The changes in the food should be made in such a way as to give the physician new information as to the digestive pecuharities of the infant. For this reason it is usually best in such cases, to alter the percentage of only one food element at a time, or to introduce only one new method of cow's milk modification at a time, in order that the deductions based upon the reaction of the infant to the changes shall be warranted. In trying the various available methods of milk modification in these difficult cases, the physician must depend upon his knowledge of the underlying principles of artificial feeding. Success will depend on the skill with which he applies this knowledge to the pecuharities of the case. At all times in the course of a resistant feeding case, the physi- cian knows that breast milk will in all probabihty be the best means of meeting the difficulties with which he is confronted. How soon he shall resort to breast milk depends on the severity of the case, and the availability of a wet-nurse. In a difficult case, the physician must not be wholly guided by the chnical symptoms. There are cases in which the symptoms of 334 Feeding indigestion cannot be relieved at all, or can be relieved only by the use of a food the composition of which is not of sufficient strength to fulfil the nutritive requirements of the infant. Nevertheless in such a case it may be possible to find a combination of food elements on which the infant will gain in spite of the symptoms. Under these circumstances the efforts of the physician to relieve the symptoms should not involve changes in the composition of the food, but should be confined to those methods of milk modification which aim at making the cow's milk more digestible. At some period in the course of every resistant feeding case, it is well to try a compara- tively strong formula without reference to the clinical symptoms. This will sometimes save time that would otherwise be wasted in the effort to render the infant symptom-free. CLINICAL INDICATIONS FOR THE VARIOUS METHODS OF MODIFYING COW'S MILK The subject of difficult artificial feeding has been discussed from the point of view of the clinical symptoms, with suggestions as to the methods employed in meeting the difficulties encountered. It is often convenient to consider the subject in the opposite order, from the point of view of methods of modification, with suggestions as to the clinical indications and contraindications for each. Such a summary is given here, in the hope that it may prove of service to physicians, in their employment of the resources used in artifi- cial feeding. The following are the indications and contraindications for the various methods of modifying cow's milk. 1. Milk and Cream Dilution with the Addition oe Lactose. — This is the fundamental method of varying the quantities of the three food elements. It is indicated in all cases in which some special method, such as split protein or lactic acid milk, is not indicated. It is the basis of the feeding of normal infants, and of cases of fat or carbohydrate indigestion. 2. Starch. — Starch may be advantageously introduced as a rou- tine into the food of well infants in the second six months. The exact age when starch feeding should be begun, cannot definitely be stated. It is best not to use it as a routine before the age of six months. With sick infants, starch is theoretically indicated only in cases of protein indigestion. It is the method of first choice in dealing with protein indigestion in the latter half of the first year. It is more valuable in the type of protein indigestion characterized by undigested movements, than in the form characterized by vomiting. When fat or carbohydrate indigestion is the fundamental condition present, there is usually need to give more protein. Starch is often Indications for Modifying Cow's Milk 335 useful in such cases, especially in the clinical types characterized by undigested movements, or by green or discolored movements. 3. The Alkalies. — The use of lime water as a routine in well babies is no longer considered to be indicated. The alkalies should be used only to meet certain definite indications in disturbances of digestion. The alkalies are most valuable in protein indigestion with vomit- ing. In the particular type in which the vomiting of curds follows very shortly after feeding, an alkali will often immediately relieve the symptoms. In protein indigestion, it should first be given in the amount necessary to delay curd formation and modify the char- acter of the curd; if it fails to relieve the vomiting in this amount, it should be given in the amount which prevents precipitation of the casein in the stomach. The alkalies are also very useful in other forms of indigestion, when vomiting is a prominent symptom. In such cases the vomit- ing often becomes persistent, through irritability of the stomach. The alkali, given in sufficient amount, will prevent the irritation of a sensitive gastric mucosa by the precipitated curd. The alkali may be used in combination with either split protein formulae, or starch-containing formulae. There are no indications for the use of any particular one of these alkalies. In some cases hme water seems to work best, in others sodium citrate, in still others, sodium bicarbonate. One cannot tell beforehand which will work best. In some cases, with green irritating acid stools, an excess of lime water, as 25 per cent of the total mixture, has given clinical evidence of good results. The alkalies have no contraindications, but have not given evi- dence of favorable action in other types of digestive disturbance. 4. Peptonization. — This method of modifying milk constitutes a resource to be tried only in a resistant case, in which other more promising methods have failed. The type of case in which it is occasionally of benefit, is that characterized by persistent vomiting. 5. Whey Mixtures. — In very young well babies, whey mixtures are often of advantage. They enable us to give more protein with- out risk of causing symptoms. Whey mixtures should also be used in the feeding of premature babies. Split protein formulae are indicated in protein indigestion. Pro- tein indigestion is much commoner in young babies than in older ones. The split protein is' the method of choice in dealing with pro- tein indigestion in young infants. It gives the best results in cases characterized by vomiting. In other forms of indigestion it is often necessary to give more 336 Feeding protein to compensate for deficiency in the power of assimilating fat or carbohydrate. In young babies, the increased casein is apt to cause vomiting. The whey mixtures enable us to increase the protein without increasing the casein. In cases of persistent vomiting from gastric irritability at any age, the split protein combined with alkali should be the first meas- ure chosen. The split protein has given no evidence of having any value in those types of indigestion characterized by undigested movements, or by the absence of symptoms other than loss of weight. There are two important contraindications for the use of the split protein. These are, first, acute diarrheas, and second, that type of indigestion characterized by green or discolored movements. Clinical experience has shown repeatedly that these conditions fare badly when fed with whey mixtures. In both conditions, any ten- dency toward intestinal fermentation appears to be increased, pos- sibly because the soluble protein is a favorable culture medium, or because of the high lactose and salt content of the whey. The explanation is not clear. 6. The Carbohydrate. — Lactose is indicated as the extra carbo- hydrate to be added to milk modifications in normal babies, and in all cases with comparatively slight disturbance of digestion. It is indicated in infectious diarrhea due to the bacillus of dysentery, and in the form of acute diarrhea due to abnormal intestinal fer- mentation, with protein decomposition and toxic symptoms. It should be used in all cases in which there is no indication for maltose. Maltose is indicated in very difficult feeding cases, and in severe cases of malnutrition and atrophy. It is part of the routine in the treatment of chronic indigestion from fat. Carbohydrate in- digestion is most frequently seen in cases fed on lactose or on cane sugar; in such cases, maltose is indicated. In some cases, carbohy- drate indigestion develops in babies fed on maltose, usually in exces- sive quantity. In such cases, changing the carbohydrate to lactose is usually beneficial. 7. Lactic Acid Milk. — This is indicated as a therapeutic meas- ure in two forms of diarrhea, — infectious diarrhea due to the gas bacillus, and acute diarrhea with toxic symptoms due to intestinal putrefaction. As a feeding method, lactic acid milk is a valuable resource in certain difficult types. It should be tried in cases of fat indiges- tion, when the usual treatment with low fat, high protein, and mal- tose, is not successful. It is often of value in severe carbohydrate indigestion. It is most useful in the clinical type characterized by green or discolored movements, and should be the first method tried Refusal to Take Food 337 in such types, when the usual methods of modifying cow's milk reveal difficulties. It is usually not well borne when vomiting is a prominent symp- tom, or when habitual persistent vomiting has developed. Precipitated Casein. — This is used only in difficult feeding cases. It is an alternative to lactic acid milk, or may be used in combi- nation with it (albumin milk). The indications for precipitated casein are the same as those of lactic acid milk. Cooking. — This measure has only one definite indication, namely, the appearance in otherwise normal stools of large casein curds. It may be tried in any very resistant case. Homogenized Milk. — The indication for this method is still only theoretical. The method was developed to meet certain resistant cases of fat indigestion, in which the baby cannot through any known method of modifying milk digest and absorb enough cow's milk fat to meet his nutritive requirements. INABILITY OR REFUSAL TO TAKE FOOD FROM THE BOTTLE Certain babies are unable to take their food, or sufficient food, from the bottle, on account of great weakness. In these cases feed- ing must be forced. If the difficulty involves their power of suck- ing, but not their power of swallowing, the food is best given with the "Breck Feeder." This consists of a graduated glass tube, drawn out at one end so as to be small enough to be fitted with a small rubber feeding-nipple. A compressible rubber cap goes over the large end after the tube is filled. The nipple is put in the baby's mouth, and its presence encourages efforts at sucking. If these efforts are ineffectual, the nurse compresses the rubber cap, gently forcing the milk through the nipple into the baby's mouth, and thus helping out his feeble efforts. It is always best to continue the sucking reflex in these cases. If through greater weakness, or unconsciousness, or some other 'cause, the baby is unable to swallow, he must be fed by means of gavage. In some cases, not at all uncommon, babies refuse their food. They are perfectly able both to suck and to swallow, but they do not want the bottle, and resist any efi'ort to make them take it. They may refuse either the whole or a part of a feeding, and may refuse some or all of their daily feedings. This symptom may of course be due to the coming on of one of the common acute diseases. Apart from such recognizable diseases, I have found three common causes for this condition. These are, first, dentition, stomatitis, or any localized sore mouth; second, early scorbutus; and third, the baby may become tired of the taste of his food. Stomatitis and scurvy 22 338 Feeding call for the usual treatment of those diseases. In dentition, apply- ing cold water to the gums immediately before feeding mil often cause the baby to take his feedings better. If the baby is tired of his food, some minor change in the formula wdll often satisfy him; in particular, changing the extra sugar from lactose to maltose, is often completely curative. In some cases of refusal of food, the cause may not be discover- able, or the condition may prove to be not easily remediable. The physician must then decide to what extent he shall allow the baby to refuse feedings without interference. The mother is often much worried by this symptom, and she should be cautioned against tempt- ing the child with food in the intervals between his regular feed- ings. To what extent the child shall be allowed to refuse his feedings depends on a number of circumstances, such as the cause of the condition, the amount of food refused, and the general con- dition of the child. In general, temporary conditions of short dura- tion require no interference. When the condition is of longer dura- tion the child's nutrition must not be allowed to suffer too much. Sometimes one tube feeding will reheve the condition. Usually, when the child's nutrition begins to suffer, I am accustomed to order that the child shall take a certain minimum quantity of food daily. If he has not taken the right proportion of this minimum by a cer- tain hour each day, tube feedings are- to be used to the extent of insuring the taking of the desired minimum. In dentition, acute disease, and similar conditions, the digestive power of the infant is frequently lowered, and his refusal to take his feedings is Nature's way of guarding his digestive system from an overload. Great harm can be done in such cases, by forcing the feeding. IV. FEEDING IN THE SECOND YEAR FEEDING OF HEALTHY INFANTS There is no subject about which so much ignorance prevails, as the feeding of infants during the second year of life. It has become fairly well known that cow's milk has to be carefully modified and prepared for infants in their first year, but as soon as the twelfth month has been passed, and the infants are able to digest whole milk, there seems to be a very prevalent idea that they can digest almost anything. A few children are underfed in the second year, but the great majority are overfed, with badly prepared, unsuitable food carelessly given at improper intervals. The acute diarrheas so prevalent in the summer months^ are very common in infants between one and two years of age, so much so that the "second summer" has come to be a' much dreaded period. The dangers of the second summer are mainly due to improper feeding, and can be entirely prevented by proper management. Among the mistakes most commonly made at this period of life, is the practice of allowing the infants to eat between meals. As long as the feeding of the infant involves the labor of administering the breast or the bottle, mothers are less likely to err in this par- ticular; as soon as the baby is able to take food in its hand, and eat it, this involving no labor on the part of the mother, it begins to get crackers, cookies, or a slice of bread and butter at all times, this being regarded as a legitimate means of keeping it quiet. Not only crackers, but drinks of milk are given between meals, under the idea that drink is not food. As a result of all this, the child begins to take less food at meals, and its feeding becomes a con- tinuous nibbling, which keeps its digestive system in a state of con- stant stimulation, with most ruinous results. Children in the second year should never be allowed to eat between meals. Even the drink of milk, or the "educator" cracker is harmful. A second mistake, is irregular hours for meals, or improper inter- vals between meals. This error is sometimes committed through carelessness, and sometimes in the effort to make some of the infant's meals coincide with those of the parents, so that the infant can come to table, sitting in its "high chair." Beside the tax on the infant's digestive power which such irregularity of feeding intervals entails, the fact that the baby comes to table leads to the practice of giving it "tastes" of the food provided for the rest of the family. The idea that little tastes of these various foods can do no harm, is a very 340 Feeding mistaken one. In this practice the father is usually a more frequent offender than the mother, a father often being very proud that his boy of fifteen months likes the same articles of diet as himself. An- other evil in having the infant take its meals with its parents, is that special care is not devoted to the preparation of the food for the infant, but many articles of diet suited only to the adult are given to the infant under the mistaken theory that if he is healthy, they can do no harm. An infant in the second year should have his meals by himself, at regular and proper intervals. There is no reason why he should not eat with older children, when their feeding time falls at the same hour. The infant's food should be specially prepared for him. If the family cannot manage a separate dietary for their young children and the older members, it is better that the older members should eat what is good for the children, than that the children should be forced to eat what the older members like. One common mistake made in the feeding of infants in their second year, is that they are not given sufficient milk. As they begin to take other foods, some of which they often like better than milk, the quantity of milk in their diet is gradually and often uncon- sciously cut down. Milk should be the basis of the infant'' s diet through- out the second year. The popular idea that many children cannot take milk, has no foundation in fact, food idiosyncrasy against milk being rare. The other articles of diet should always be additional, and should never take the place of milk. Another fault in the feeding of infants is the giving of sweets. This I believe to be one of the commonest, if not the commonest cause of disturbed nutrition in all periods of childhood after the end of the first year. The symptoms of excessive sugar ingestion develop so insiduously, that they are rarely recognized as pointing toward the digestive system. Candy, even at meals, should never be given to infants in the second year. I am inclined to go much farther than this, and do not believe that sugar should be added to the diet at all. It may be true that the majority of children can take reasonable quantities of cane sugar without harm, but sugar is by no means a necessary component of the child's diet. The child gets all the carbohydrate it requires in the lactose of its milk, in the starch of its bread and cereals, and in the fruits which are added later. Sugar can be absolutely dispensed with, without harm. The trouble with sugar is that young children like it, and once having tasted it, want more and more of it. Under these circumstances, it is very difficult to keep it in moderation, for the young child well knows how to get what it likes, and is an adept at bullying its parents into giving it what it likes. Once having tasted sweets, it is very apt to begin to refuse to take its other arti- Feeding in the Second Year 341 cles of diet, and the feeding of the child becomes a struggle, a con- flict in which the child is apt to win. If children do not know the taste of sugar, much trouble is avoided. Underfeeding is sometimes met with in the second year. The commonest cause is keeping the infant too long on the breast only, or on an exclusively milk diet. The various solid articles of diet given in the second year should be added gradually, one at a time, and at first in very small quanti- ties. Sometimes the expansion of the diet list is attended with considerable difficulty. The children refuse to chew and swallow solid foods, and are thoroughly satisfied with milk. In such a case, it is often well for a time for the child to have its meals with its parents or with older children, and to see them eat. Children learn rapidly by imitation. They should be given every opportunity to eat solid food, but should not be forced. Milk, for a time, must be kept in the background, and the more solid articles given first. Often much time and patience are required before they will eat. WEANING FROM THE BOTTLE.— At the beginning of the second year, weaning from the bottle should be started. This is some- times a matter of considerable difficulty, the infants refusing abso- lutely to take milk from a cup. It can only be accomplished by patience. It is best to begin with the early morning feeding, and then gradually to extend the use of the cup to the other feedings. The cup should be offered, and if refused, the bottle should not be given till after an interval of fifteen or twenty minutes. It is advis- able not to begin to add much solid food to the diet until weaning from the bottle has been started. The use of the bottle at the lo P. M. feeding may be continued, for convenience, until this feeding is omitted. Except for this feeding, weaning from the bottle should be completed before the fifteenth month. PREPARATION OF FOODS FOR INFANTS IN THE SEC- OND YEAR. Milk. — In the majority of cases the milk used as the basis of the diet in the second year, does not require modifica- tion. The same precautions should be taken as to the quality of the milk used. The decision as to whether the milk shall be pasteur- ized is to be made on the same grounds as in the first year. Cream should not be given, except in special cases, such as constipation. Zwieback. — -This is somewhat more digestible than bread. The unsweetened variety should always be used. The zwieback made by the National Biscuit Company is excellent. Cereal Jellies. — Oatmeal, four ounces, is added to one pint of water, and boiled for three hours in a double boiler. Enough water is added to form a thin paste when cooking is completed. While 342 Feeding hot, this is forced through, a colander, and a semi-solid mass is formed. Only the regular Scotch oatmeal, not rolled oats or any similar prepa- ration, should be used. Barley jelly and wheat jelly are made in the same way, using barley flour, or cracked wheat instead of oatmeal. Salt should always be added to cereal jellies, but they should be given without sugar. Beef Juice. — Broil a round steak very rare, cut into small pieces, place in a lemon-squeezer or meat press, and press out the juice; add a little salt. Broths. — Take one pound of meat free from fat, and cook for three hours in a quart of water, adding a Uttle water from time to time. When the cooking is completed, there should be a pint of broth. Let the broth cool, remove the fat, strain, and add salt. Scraped Beef. — Broil a round steak very rare. Split the steak, and scrape out the pulp with a dull knife. Cereals. — Oatmeal and hominy should be strained to make a jelly, until toward the end of the second year. Farina, cream of wheat, and wheatena should each be cooked two hours, and need not be strained. All cereals should be cooked with salt, but served without sugar. Egg. — Soft boiled, poached, or coddled are the only ways of pre- paring egg permissible for young children. Junket.— To a pint of milk add one tablespoon of essence of pepsin or liquid rennet, or a junket tablet. Heat to ioo° F. Allow to stand until the curd is set, then place and keep on ice. DIET FROM THE TWELFTH TO THE FIFTEENTH MONTH.^ — The following schedule may be adopted for the feeding of an infant from the twelfth to the fifteenth month: Table 37 Feeding from the Twelfth to the Fifteenth Month FOUR OR FIVE MEALS DAILY 6:30 A.M. (Minimum) Milk, 8 ounces. Zwieback, gradually increasing to one whole piece. (Maximum) Stale bread and butter, one piece, in place of zwieback. 9:00 A. M. The juice of one-half orange. 10:00 A. M. (Minimum) Milk, 8 ounces. Zwieback, increasing to one whole piece. (Maximum) Oatmeal or barley jelly, one tablespoon, increasing to two. tablespoons. Feeding in the Second Year 343 Table 37 — Continued 2:00 P. M. (Minimum) Milk, 8 ounces. Zwieback, increasing to one whole piece. (Maximum) Beef juice, one increasing to two ounces, or beef, mutton, or chicken broth, one increasing to four ounces. Scraped rare beef mixed with stale bread crumbs, and. moistened with beef juice, beginning with one teaspoon, and increasing to a tablespoon. 6:00 P.M. (Minimum) Milk, 8 ounces. Cereal jelly, one increasing to two tablespoons. (Maximum) Zwieback, or stale bread and butter. The first two additions to the child's diet are zwieback and orange juice. I have found zwieback the most digestible form of starch- containing food which can be given at this time. It can be soaked in milk at first, but later the children usually prefer to hold it in the hand and nibble at it. Only a small piece should be given at the beginning, and later increased. During the last part of the first year, babies are weaned from the bottle, or are gradually brought from modified milk to whole milk. While they are still on modified milk, starch should be given in small quantities by using barley water as a diluent in their milk. Zwieback may be given even then, if they are a year old, or seem hungry. In any case, zwieback should be begun when they go onto whole milk, provided that they have teeth. Orange juice may often be advantageously given before the child is a year old. As a routine, it should be begun at one year. The schedule provides for a minimum and a maximum diet at each meal. The minimum diet refers to what is added to the diet in the beginning, the zwieback being given first, and then the cereal jelly at supper. The maximum diet shows the diet reached at the end of the period by gradual additions. The morning cereal should be added first, then the beef juice or broth, then the bread and butter, finally the scraped beef. Many authorities begin to give egg during this period, substituting it for the scraped beef. In my experience scraped beef is less likely to cause disturbance than egg at this period of life. DIET FROM THE FIFTEENTH TO THE EIGHTEENTH MONTH. — The following schedule may be used during this period: Table 38 Feeding from the Fifteenth lo the Eighteenth Month FOUR MEALS DAILY ' 6.30 A. M Milk, 8 to 10 ounces. Zwieback, or bread and butter. 9:00 A. M. The juice of one orange. 10:00 A. M. (Minimum) Milk, 6 to 8 ounces. Cereal (oatmeal or hominy) strained, two to three table- spoons, with milk. Zwieback, or stale bread and butter. (Maximum) Egg, one (soft boiled, poached, or coddled). 344 Feeding Table 38 — Continued 2 :oo P. M. (Minimum) Milk, 6 to S ounces. Beef Juice, or mutton, chicken, or beef broth with rice or stale bread broken in. Scraped rare beef with bread crumbs, one tablespoon. Bread and butter. (Maximum) Stewed prune pulp, baked apple, or apple sauce. 6:00 P. M Milk.. Bread and butter, or bread and milk. Cereal, (farina, cream jjt wheat, or wheatena), one increas- ing to three tablespoons. The only new articles not added to the maximum diet of the pre- ceding period, are the egg, the cereal instead of cereal jelly at supper, and the fruit. The cereal and egg may be added first, but the fruit should be tried very cautiously. DIET FROM THE EIGHTEENTH TO THE TWENTY- FOURTH MONTH. — The following schedule may be used during this period: Table 39 Feeding from the Eighteenth to the Twenty-fourth Month FOUR ILEALS DAILY 7 :oo A. M Milk, 8 to 10 ounces. Bread and butter. Cereal. Egg. 9:00 A. M Orange juice. II :00 A.M. (Minimum) Milk. Bread and butter. Chicken, beef, or mutton broth with rice or stale bread. (Maximum) Custard, or cornstarch, or plain rice pudding, or junket. 2 130 P. M. (Minimum) ]Milk. Bread and butter. Scraped beef, or the heart of a lamb chop cut up fine, or chicken. Baked apple, or apple sauce. (Maximum) Spinach, or squash, or stewed carrots, or mashed cauliflower. Baked potato added toward end of the second year. 6:00 P. M Milk. Cereal. Bread and butter. Certain changes in the arrangement of the meals are made in this schedule, in preparation for the child having later three prin- cipal meals daily. Babies at this age are apt to sleep later in the morning, and the first meal becomes a regular breakfast at seven o'clock. The second meal is made relatively light, and the third meal will later become the dinner. The new articles should be only gradually added to the diet. Potato should not be given before the twenty-first month, and sometimes cannot be digested till the end of the second year. Feeding ix the Second Year 345 FEEDING IN DIFFICULT CASES The tendency to chronic digestive disturbance and malnutrition has not been outgrown when the infant reaches the second year of its life. Its digestive apparatus is still relatively undeveloped, and requires the most digestible foods. While the number of cases of difficult nutrition met with in the second year is smaller than in the first, such cases are by no means uncommon. Some of them are seen in infants whose nutrition has been a matter of difficulty from birth, and who have been brought through the first year only by the exercise of the greatest care. Others have had their digestive power badly damaged by improper feeding. Still others enter the second year apparently normal, and with every promise of normal development, but soon after weaning begin to do badly. The factor of individual variation in digestive power still plays an important part in the second year. A diet which is exactly suited to the majority of infants may be wholly unsuitable to an infant with impaired digestive power. Infants may enter the second year with impaired digestive power, and although given an average diet, may yet be relatively overfed. On the other hand, many of the cases of difficult nutrition in the second year entered this period of Hfe with normal digestive power, and their trouble is due to inju- dicious feeding after weanmg. It is often difficult in a given case to say which factor predominates, weakness of digestive power, or faulty feeding. There are two clinical types of chronic disturbance which are especially common at this period. In the first, the symptoms are very insidious, and do not point very directly at the digestive appa- ratus. In these cases, loss of weight is not marked, but the children become generally run down; they become pale, and their muscles become flabby. Loss of appetite is a prominent symptom. There is often a chronic cough, which, with the other symptoms, leads the parents to suspect tuberculosis. In other cases of this t\^e, attacks of abdominal pain are a prominent feature. These patients usually have coated tongues, prominent abdomens, and clay colored stools. The cause of this type is relative overfeeding with carbohydrate. It is the type of indigestion seen in the candy eaters, or in children who eat an excess of sweets. In some children any sugar in the diet may be an excess and cause this clinical picture to develop. In other children, no sugar may be given, but the carbohydrate foods may be in relative excess. Children, who, on taking solid food, take too little milk, or children who eat between meals, are common sub- jects of this t>'pe of nutritional disturbance. This type is not really difficult, or resistant to proper treatment. The difficulty lies in recognizing it. All sugar should be cut out of 346 Feeding the diet, and the carbohydrate should be reduced to a minimum. I usually cut out all cereals, the diet being milk, beef juice, scraped beef, a little bread or zwieback, and in older babies, egg. Small doses of tincture of nux vomica are often of service in combating the persistent refusal to take food, which is sometimes a trouble- some feature in these cases. The second type is much more resistant and difficult to treat. First there is only failure to gain in weight, then increasing loss. Sometimes these cases may even go on to severe atrophy. The symptoms of gastro-intestinal disturbance are not marked. The stools are often abnormal in color, but are usually large, smooth, and rather dry, with, a peculiarly foul odor. Microchemical examination usually reveals a deficiency in the absorption of the fat. The babies having this disorder are apt to be very irritable and cross, and this is increased when more food is given. They often have a slight fever, which disappears when their diet is restricted. The cause of this condition is overfeeding. The original damage cannot usually be traced to any one food element. Cases of this type are seen most frequently in children who have been overfed in all respects, who have a highly varied diet, including tastes of rich foods. The disease manifests itself in a general deficiency of diges- tion and absorption, which appears most striking in the case of the fats. Carbohydrates also are poorly borne. This type of disturbed nutrition is difficult to treat. When the diet is restricted, the infants may be freed from the irritability and slight fever, and the character of the stools may improve, but they lose weight rapidly. When additions are made to the diet, the symptoms return, without gain in weight. The main principle of treatment is restriction of fat and carbohydrate. To what extent this shall be carried depends on the severity of the case. In a severe case of this type, all carbohydrate foods, such as bread, zwieback, and cereals, must be prohibited, and milk must for a time be stricken from the diet, which consists of beef juice and scraped rare beef. Many cases improve on this diet, but it cannot be continued long. Some cases seem to become worse. The next addition is maltose, given first in 6 per cent solution. Then fat-free milk containing 6 per cent maltose is added. The rest of the treatment is the very gradual adding of fat to the milk, and starch to the diet, proceeding very slowly and cautiously, with frequent examinations of the stools. Occasionally a definite intolerance toward fat or protein of cow's milk, like that seen in the first year, occurs in the second year. In such cases the milk must be modified as in the feeding of similar cases in the first year. V. FEEDING AFTER THE SECOND YEAR The diet after the expiration of infancy, gradually approaches that of the adult. It must be remembered, however, that during the entire period of childhood, the digestive functions remain un- developed in comparison with the adult. Therefore throughout childhood certain kinds of food, which lay the greatest tax on the powers of digestion should be avoided. As the child grows older, the diet should be gradually enlarged, but must always be restricted. Many parents believe that children need a great variety in their diet. This is not true, but restrictions are difficult, if too much variety has once been allowed. The following table shows in a form convenient for reference, the foods which are allowed, and those which are forbidden during the greater part of childhood. Of course, toward the end of childhood, the restrictions can be gradually relaxed. Table 40 Diet List for Children ALLOWED Milk Cream Stale bread Graham bread Crackers and biscuits Eggs (not fried) Cooked cereals Butter Plain soups Beef juice Beefsteak Roast beef Roast lamb Mutton chop Chicken Fish, baked or boiled Potatoes (not fried) Rice Spinach Asparagus tips Stewed celery String beans Carrots Fresh peas Squash Mashed cauliflower Boiled onions Junket Custard Cornstarch pudding Rice pudding (without raisins) Ice cream (rarely) Oranges Baked apples FORBIDDEN Tea Coffee Cocoa Soda water Hot bread and rolls Griddle cakes Sweet cakes Ready-to-serve cereals All fried food Ham Pork Sausage Salt fish Fried fish Corned beef Dried beef Meat stews Meat dressings Kidney Liver Goose Duck Fried potatoes Cabbage Raw or fried onions Tomatoes Beets Egg plant Green corn Lettuce Cucumbers Raw celery Radishes Salads 348 Feeding Table 40 — Continued Apple sauce Candy Stewed prunes Pies Peaches Tarts Pears All pastry Grapes (without seeds) Preserves Nuts Dried fruits Raw apples Bananas Many authorities believe that four meals should be given daily during the third year, and even until the sixth year. I beUeve that with most healthy children, three meals are better. The children have better appetites, digest better, and their daily schedule of exercise, airing, and naps, is more easily arranged. Nevertheless, especially in the third year, many children will thrive better, if a light lunch be given at about 3 or 3.30 P. M. With dehcate children, this light fourth meal often has to be continued until the seventh year. This lunch should consist of a glass of milk, and some crack- ers, or a cup of broth and zwieback. The meals for the earlier years of childhood should be arranged ■as follows: Breakfast — 7 to 8 A. M. Cereal with milk; eggs; bread and butter, or biscuit and butter; a drink of milk. On certain days a lamb chop or some hashed chicken may be sub- stituted for the egg. Dinner — 12 o'clock. Soup or broth; meat, or when meat is given for breakfast, fish or egg; potato; vegetable; bread and butter; baked apple, apple sauce, or prunes; milk. Supper — 5.30 to 6 P. M. Cereal; zwieback or bread and butter; junket, custard or pudding; milk. DIVISION V DISEASES OF THE GASTRO-ENTERIC TRACT The diseases of the gastro-enteric tract may, with certain sHght moditications, be classified according to the plan based on etiology described in Division II. CLASSIFICATION OF THE DISEASES OF THE GASTRO-ENTERIC TRACT I. MALFORMATIONS II. TRAUMATIC MECHANICAL INJURIES 1. Foreign bodies 2. Corrosive gastritis HI. MECHANICAL CONDITIONS OF INTERNAL ORIGIN 1. Stenosis of the pylorus 2. Spasm of the pylorus 3. Dilatation of the stomach 4. Contraction of the stomach 5. Dilatation of the colon 6. Intussusception 7. Volvulus 8. Hernia 9. Fissure of the anus 10. Hemorrhoids 11. Prolapse of the rectum IV. NEW GROWTHS V. NERVOUS DISTURBANCES 1. Nervous vomiting 2. Nervous diarrhea VI. DISTURBANCES OF DIGESTION (FUNCTIONAL DIS- TURBANCE FROM MULTIPLE CAUSES) 1. Indigestion from excess of food as a whole 2. Indigestion from excess of the various food elements a. Fat b. Carbohydrate 350 Diseases of the Gastro-Enteric Tract c. Protein d. Mineral salts 3. Indigestion with fermentation VII. INFECTIONS 1. Infectious diarrhea a. Dysentery bacillus b. Gas bacillus c. Other organisms 2. Cholera infantum 3. Gastritis 4. Proctitis 5. Appendicitis VIII. UNCLASSIFIED 1. Constipation 2. Incontinence of feces 3. Peptic ulcer 4. Intestinal worms / u fe I. MALFORMATIONS Developmental malformations of the stomach and intestines are comparatively rare. A malposition of the stomach may be met with in various places, one of which is in the thoracic cavity. They are very rare and are of anatomical rather than of clinical interest, as the diagnosis can scarcely be made during hfe. Malformations of the stomach are represented by a narrowing of either the cardiac or pyloric orifice of the stomach or by a constriction in various parts of the ventral cavity (hour-glass contractions). MALFORMATIONS OF THE RECTUM.— From the cHnical point of view, malformations of the rectum are the most important developmental lesions of the gastro-enteric tract. This lesion is usually spoken of as imperforate anus, but several different condi- tions may be present. In one variety the intestine is normal to the lowest extremity of the rectum, but there is a persistent cutaneous septum closing the opening. This form is very easily curable by surgical operation. In the second form, the anus and the lower part of the rectum are normal, but a short distance up there is a membrane separating the lower part of the rectum from the upper. This condition can be recognized by inserting the finger in the anus, when the bulging of the distended rectum can easily be felt. This form also is easily cured by surgery. In a third form the rectum terminates in a blind pouch at a variable distance from the anus, the lower part being represented only by a fibrous cord. This condition can only be remedied by surgical operation, and is much more serious. There may also be stenosis of the rectum, without complete occlu- sion, giving rise to symptoms of stricture. Some of these cases are curable by dilatation. MALFORMATIONS OF THE SMALL INTESTINE.— These, while not very common, present a great variety of lesions. The lesion may be either atresia or stenosis, and may be situated at any single point, or may be multiple, situated at many points. The lesions are most often situated in the upper part of the small intes- tine. Atresia is rather more common than stenosis. The lumen of the intestine may be obliterated at a circumscribed point, or for a considerable distance, the obliterated portion being represented by a fibrous cord. The intestine above the point of obstruction is 352 Diseases of the Gastro-Enteric Tract always found much distended, while the intestine below is collapsed, and usually somewhat atrophied. The symptoms of these malformations appear soon after birth, and are those of intestinal obstruction. In atresia, fecal movements are not passed, and the duration of Hfe is rarely more than a week, being shorter, the higher the obstruction. In stenosis, the patient may live for several months. The diagnosis is comparatively easy, as in a case of marked intes- tinal obstruction in a newborn baby showing nothing abnormal about the anus, malformation of the intestine is the only probable cause. The nature of the obstruction, whether stenosis or atresia, and its situation, can be recognized by taking a roentgenogram after a bismuth meal. The condition is usually beyond the range of surgi- cal interference. Meckel's Diverticulum. — This is the remains of the omphalo- mesenteric duct. Usually it exists as a blind pouch given off from the ileum about a foot above the ileo-caecal valve, having a length up to two or three inches, and communicating with the intestine. In this form, it causes no clinical symptoms. In some cases the extremity of the pouch may continue into a fibrous cord, which may be free in the abdominal cavity, or may be attached to the umbilicus. In the latter case, it may compress a coil of intestine, leading to obstruction or strangulation. This may occur either in infancy or in later hfe. The tumor at the umbilicus caused by Meckel's Diverti- culum when it remains pervious, has been described under Diseases of the Newborn. Malpositions of the intestine are met with in infants when there is a transposition of the abdominal organs, or when portions of the intestine are found involved in other gross malformations, in which they may be entirely outside the abdominal cavity. II. TRAUMATIC MECHANICAL INJURIES FOREIGN BODIES It is common for young children, especially those between the ages of one and four years, to swallow various objects. There is the very greatest variety in the articles thus swallowed, including everything that the young child can reach and put into its mouth. The most common articles swallowed are buttons, coins, pins, pebbles, marbles, and detached parts of toys. Sharp articles as well as smooth ones may be swallowed. Sometimes the articles swallowed lodge in the pharynx or esophagus, but in the majority of cases they pass into the stomach, and on through the intestinal canal. Foreign bodies usually cause very slight if any injury to the gastro-enteric tract. Sharp bodies may cause slight hemorrhage in the throat at the time of swallowing, and from the rectum at the time of passage. Impac- tion and perforation, while possible, are exceedingly rare. SYMPTOMS. — In the majority of cases, even with sharp and angular as well as smooth bodies, there are no symptoms whatever. Occasionally, at the time of swallowing there may be an attack of choking and pharyngeal pain, and with sharp bodies there may be pain as well as hemorrhage at the time of passage past the sphincter ani. While the body is passing through the intestine, there may be some colicky pain. The time required for a foreign body to traverse the gastro-intestinal tract is usually from three to ten days. DIAGNOSIS. — Owing to the absence of symptoms, the diagnosis cannot be made on any basis other than the story of the parent, which may be reliable, but which also may be a false alarm. The diagnosis can only be made positively by X-ray examination, which should be made in every case, if possible. PROGNOSIS. — Parents should be reassured, and told that only in the most exceptional cases is the swallowing of a foreign body a cause of harm. Even a sharp, open safetypin will usually go through without symptoms. TREATMENT. — The diet should contain an abundance of those articles of food which leave a large residue, such as coarse cereals, bread, and green vegetables. The stools should be carefully watched for the passage of the foreign body. No emetics or cathartics should ever be given. Surgical interference should never be considered, unless definite localizing symptoms have developed. 23 354 Diseases of the Gastro-Enteric Tract '* HAIR BALL " IN THE STOMACH This condition is also caused by the swallowing of foreign bodies, but is clinically quite distinct from the condition described above. It is caused by a habit sometimes seen, especially in nervous or excitable children, of pulling off and swallowing such substances as hair, wool, fur, or shreds of clothing. The commonest substance is hair from the patient's own head. These substances may be vomited or may pass through the gastro- enteric tract, and be passed from the bowel like other foreign bodies, and this is what usually occurs in infants, with whom the quantity swallowed is usually small. In older children, the hair, or similar substance, may accumulate, forming a ball, most often in the stom- ach, but rarely in the intestine. The condition is most often seen in girls, on account of their long hair. The habit may continue imtil quite large tumors have been formed, which may even attain a weight of several pounds. SYMPTOMS.— Usually the first thing noted by the parents in these cases is the tumor. Sometimes there is vague gastric dis- turbance. Epigastric pain is more common than vomiting. DIAGNOSIS. — The diagnosis is not often made until operation is performed. The tumors have been mistaken for cancer, a dis- placed spleen or kidney, impacted feces, and tuberculosis of the mesenteric lymphnodes. TREATMENT. — The mass must be removed by operation in most cases. There are a few recorded instances of disappearance of the tumor and subsequent passage of the ball, after catharsis. The outcome after operation is favorable. CORROSIVE GASTRITIS The lesions in this condition are caused by the swallowing of strong irritants. The most common are carbolic acid, and the caustic alkalies. PATHOLOGICAL ANATOMY.— \\Tien strong caustics are swal- lowed, the most extensive lesions are usually found in the pharynx and esophagus, the muscular spasm of these parts usually preventing all but a small quantity of the caustic from reaching the stomach. In the stomach the lesions are usually found on the summits of the rugae. Their character varies from slight superficial necrosis of the mucous membrane, to deep ulceration, or even perforation, the variations depending on the amount and concentration of the caustic, and whether the stomach was full or empty at the time of swallow- ing. There is usually marked congestion of the mucous membrane Corrosive Gastritis 355 about the ulcers, and often considerable extravasation of blood. If death does not occur very speedily, evidences of intense inflammation are found. SYMPTOMS. — The chief symptoms are pain and a sense of con- striction, and vomiting, which takes place almost immediately. The vomitus usually contains blood. Examination of the mouth and throat usually shows greyish or whitish lesions on the mucous mem- brane. When the lesions in the stomach are severe, collapse develops rapidly, and death occurs from shock. In milder cases there is continued pain and vomiting, with epigastric tenderness, and there may be diarrhea with bloody mucous stools. In infants, death usually occurs within a few days, even in the milder cases. In older children, recovery may occur, to be later followed often by cicatricial contraction and deformity of the stomach. TREATMENT. — The first indication in treatment is to admin- ister the proper chemical antidote for the substance swallowed. Washing out the stomach with the tube should be avoided. Sooth- ing- mucilaginous or oily fluids should be given, such as olive oil. Later, milk or albumin water should be given. III. MECHANICAL CONDITIONS OF INTERNAL ORIGIN HYPERTROPHIC STENOSIS OF THE PYLORUS This is a condition characterized by hypertrophy of the circular muscular fibres of the pylorus. It is probably always congenital in origin, although it is likely that the amount of muscular hypertrophy may increase after birth. The congenital nature of the disease might suggest its classification under the malformations, but it is not a condition resembling the malformations which can be traced to definite anomahes of fetal development, and its results are of a purely mechanical nature. ETIOLOGY. — The etiology of pyloric stenosis is unknown. Two theories have been advanced: first, that the hypertrophy is the result of muscular spasm, and second, that it is a developmental abnormahty. The first theory assumes that in those cases in which the symptoms appear very soon after birth, the muscular spasm occured during intra-uterine hfe. The chief evidence in favor of the first theory is the late development of the S3miptoms seen in some cases. That muscular spasm during fetal Hfe is the cause is improbable, and the late development of symptoms sometimes seen may be explained on the ground that when the stenosis is partial, it may not be sufficient to cause symptoms unless complicated by spasm, which may develop late as the result of indigestion. The frequent occurrence of very marked cases in newborn babies is strongly in favor of the second theory, and the weight of opinion regards pyloric spasm as a congenital anomaly. Pyloric stenosis occurs more frequently in boys than in girls, and is fully as common in breast-fed babies as in the artificially fed. PATHOLOGICAL ANATOMY.— The disease has a definite path- ological anatomy, on which alone its certain diagnosis can rest. The h^-pertrophy is chiefly in the circular layer of muscle fibres at the pylorus, which layer is usually two or three times its normal thick- ness. This thickening is due to an increased number of fibres, rather than to the presence of fibres of increased size. The layer of longi- tudinal fibres is usually of normal thickness. The mucosa is some- what thickened, particularly in its longitudinal folds, and the sub- mucosa may be sHghtly thickened. Macroscopically, in marked cases, the lesion appears as a hard, whitish tumor at the pylorus, resembling an oHve in size and shape. Pyloric Stenosis 357 In milder cases, there may be thdckening about the pylorus, with- out a definite tumor. There is great variation in the effect of the hypertrophy on the lumen of the pylorus. In some cases the pyloric orifice is completely occluded at birth, no gastric contents being permitted to pass into the duodenum. In other cases, representing the most common type, complete occlusion is not present at birth, but develops in the course of a few weeks. In still less marked cases, the narrowing of the lumen is less extreme, and complete occlusion never occurs. Slight narrowing may possibly be compensated by the growth of the pylorus with age, or may at any time later give rise to symptoms. Autopsies on infants previously operated on for pyloric stenosis, have shown no tendency toward diminution of the hypertrophy. There is usually some hypertrophy of the muscles of the walls of the stomach, especially in the region of the pylorus. There is almost always some dilatation of the stomach, which may become very marked, especially in cases of incomplete occlusion, in which there is a long duration of the obstruction. There is sometimes some dila- tation of the oesaphagus. There are no inflammatory lesions. SYMPTOMS. — The characteristic symptoms of h3rpertrophic steno- sis of the pylorus are vomiting, constipation, and loss of weight. Vomiting is the first symptom noted. It may begin in the earliest days of life, but usually does not appear until the beginning of the second week. It may not appear until still later, but rarely fails to develop before the end of the first month. In the beginning there is nothing to distinguish the vomiting from that seen in indi- gestion, but in typical cases it soon becomes forcible and explosive, and the gastric contents may be shot out of the mouth to a distance of several feet. The vomiting usually occurs soon after the taking of food, but in some cases it may not occur until toward the end of the interval between feedings. In many cases, the vomiting is seen after every feeding, but sometimes several feedings may be retained, and later expelled together. The vomiting does not appear to be accompanied by pain, but often there are evidences of dis- comfort, as shown by the baby's squirming and drawing up its knees, in the interval between the feeding and its expulsion. The vomitus at first consists only of the food taken, more or less digested accord- ing to the time after feeding; later it may contain mucus, but does not contain bile, except in the rarest cases. The babies are hungry, take their food readily, and are willing to try it again right after vomiting. The vomiting is not often permanently influenced by changes in the composition of the food, but quite often changes in the milk modification given are followed by an improvement in the vomiting which proves to be only temporary. This feature is often 358 Diseases op the Gastro-Enteric Tract misleading as to the diagnosis, the temporary responses to dietetic treatment leading the physician to believe that the vomiting is caused by indigestion. In some cases of partial occlusion, in which the symptoms develop late, and are complicated by spasm, there is a more permanent response to changes in the composition of the food, the babies doing better on one food than on another, and this tends still more to obscure the diagnosis. Constipation appears early in pyloric stenosis. In severe cases, with complete occlusion of the pyloric orifice, the stools contain no normal fecal material, and resemble meconium in appearance. In milder cases, with only partial obstruction, the stools contain fecal matter, and are not notably abnormal in appearance, although very small in size. Loss of weight is an important symptom. In cases with com- plete or marked obstruction, loss of weight is constant and pro- gressive, becoming more rapid as time goes on. Eventually the baby shows all the signs of starvation, with marked emaciation, pinched face, and dry skin. In cases with partial obstruction, loss of weight occurs eventually, but there may be long periods during which with careful feeding, the weight curve remains stationary, or shows only very gradual decline. The diagnosis is made more diffi- cult in cases of partial obstruction by this feature. Physical Examination. — The important points on physical ex- amination are: i, visible peristalsis, 2, palpable tumor, and 3, delayed emptying time of the stomach. Early in the course of the disease, when vomiting has recently begun, inspection of the abdomen usually shows nothing abnormal. Later, prominence or ballooning of the epigastrium, and peristaltic waves running from left to right, are seen when the stomach is full. In examining a case of suspected pyloric stenosis, the physician should have a feeding given. Immediately after the feeding, the abdomen should be bared, and the physician should watch the epi- gastrium. Prominences are formed, about half the size of an egg, which successively run slowly across the epigastrium from left to right, and disappear. If this visible peristalsis does not appear, the physician should try stroking the epigastrium with the fingers, or applying a towel wet in cold water, or a piece of ice. These meas- ures will usually elicit the phenomenon when it is present. Some- times dilatation of the stomach may be made out from the size of the area involved in the visible peristalsis. A tumor may be felt in most cases with marked or complete ob- struction, and in some cases with partial obstruction. The situation of the tumor is not constant, but its most common situation is a little to the right of the median Hne, and about midway between lU Fig. 82 — Pyloric stenosis with complete occlusion RoentKeno";ram taken four hours after bismuth meal Pyloric Stenosis 359 the tip of the ensiform cartilage and the umbilicus. At times it is high up under the edge of the liver, or low down near the level of the navel. If visible peristaltic waves are present, the tumor may often be found where they disappear. The tumor feels hard, and is about the size of the tip of the thumb, or of an olive. Id examining for tumor, the physician should palpate first when the stomach is empty before the feeding is given ; again when the stomach is full while watching for visible peristalsis, and again during the relaxation which occurs after vomiting. The tumor may be best felt at any of these times, but is most often best felt immediately after vomiting. If there are other strong evidences of pyloric sten- osis, but no tumor felt, an examination should be made with the baby under an anesthetic. In pyloric stenosis the tumor never varies in size. Delayed emptying time of the stomach may be recognized by two methods of examination: — i, by roentgenograms of the stomach taken after a meal containing bismuth; 2, by aspiration of the stom- ach contents with a stomach-tube at various periods after feeding. In routine practice, it is best to take three roentgenograms, the first, immediately after the giving of the bismuth meal, the second at the expiration of two hours, and the third at the expiration of four hours. In normal cases, with a dilute milk given as the basis of the bismuth meal, the first plate should show that the passage of some food through the pylorus into the duodenum has already taken place. The second plate, taken after two hours, should show either an empty stomach, or very little bismuth in the stomach, most of the meal being in the intestine. The third plate, taken after four hours, should show the stomach empty. In cases of hypertrophic stenosis with complete occlusion of the pylorus, the test meal remains in the stomach until it is vomited, and none of the plates shows any passage of bismuth into the intestine. In cases of partial obstruc- tion, the first plate shows the passage of very little or no bismuth into the duodenum, the second plate shows the passage of a little, most of the meal remaining in the stomach, while the third plate still shows part of the meal in the stomach. The advantage of this method of investigation is that it gives positive evidence as to whether the pyloric obstruction is complete or partial, and gives a permanent record of the delay in the emptying time. Its disadvantage is that sometimes the bismuth in the meal causes a shght delay in the empty- ing time in cases in which conditions at the pylorus are normal. To measure the emptying time with the stomach tube, an appa- ratus should be employed similar to that shown in the illustration. This consists of a soft rubber catheter, size 21 F., a glass bulb with two glass prolongations at opposite sides to serve as nozzles, and a funnel attached to a rubber tube. At the end of two or four hours 360 Diseases of the Gastro-Enteric Tract after a feeding, the catheter is passed into the stomach, the nozzle of the bulb is inserted into the catheter, and the physician sucks through the other nozzle of the bulb. If curds in the stomach ob- struct the end of the catheter, the physician attaches the rubber tube to the nozzle of the bulb, and pours in water through the funnel, then lowering the funnel and withdrawing the gastric contents by siphonage. When siphonage ceases, aspiration should be tried again. All water used should be taken from a measured amount in Fig. 87 Apparatus for estimating gastric retention time a graduate, and all fluid obtained from the stomach should be put into this graduate, which will then show, as an excess over the original quantity contained in the graduate, the quantity obtained from the stomach. Little or no residue should normally be obtained after two hours, and none after four hours. This method has the advan- tage of avoiding the delay in the emptying time sometimes caused by bismuth, and it sometimes shows the retention of several feedings and dilatation of the stomach. It does not, however, throw definite light on whether the obstruction is complete or partial. DIAGNOSIS. — In well-marked cases of hypertrophic stenosis of the pylorus, with complete occlusion of the pyloric orifice, the diag- nosis is very easy. In marked cases, the symptoms usually begin Fig. 83 — Pyloric stenosis wilii [):irti;il occlusion Roentgenogram taken immediately after bismuth meal and showing a very little bismuth in the intestine Fig. 84 — Pyloric stenosis with partial occlusion RoentRcnogram of the same case taken four hours after bismuth meal, showing passage of the food into the intestine, and retention of a portion in the stomach. Pyloric Stenosis 361 within a few days or weeks after birth, and vomiting beginning at this period of Hfe, having no relation to the composition of the food, or occurring in breast-fed babies, should always arouse in the physi- cian's mind the suspicion of pyloric stenosis. The projectile char- acter of the vomiting, the marked constipation with meconium-like stools, the visible gastric peristalsis, and the palpable tumor, all make up an unmistakable picture. In these pronounced cases the tumor can usually be found, if carefully sought, but not always. The finding of the tumor is not necessary in these cases for the mak- ing of a positive diagnosis, but when a tumor is not found, the diag- nosis should always, if possible, be confirmed by a roentgenogram taken after a bismuth meal. Fig. 88 Aspiration of the gastric contents. Apparatus used in estimating gastric capacity and retention time In cases in which the clinical picture is less pronounced, repre- senting usually a condition in which the muscular h\T)ertrophy at the pylorus causes only a partial stenosis, but not a complete occlu- sion of the pyloric opening, the diagnosis is often more difficult. In such cases the condition must be differentiated from muscular spasm of the pylorus, from indigestion, and from habitual vomiting. Spasm of the Pylorus. — The diagnosis between hypertrophic 362 Diseases of the Gastro-Enteric Tract stenosis of the pylorus with partial obstruction, and pyloric spasm is often extremely difficult. The distinction between these two conditions has not always been well maintained in the literature of the subject, nor by some surgeons, who have classified as h5^er- trophic stenosis only those cases in which a tumor was found, or in which the obstruction was complete. The only truly scientific distinction is based on pathological anatomy, spasm of the pylorus showing no abnormal condition of the tissues at the pylorus. Every case in which there is any hypertrophy of the circular muscular layer, should be classified as hypertrophic stenosis, whether or not there be a palpable or visible tumor, and whether or not the obstruc- tion be complete. Both conditions, stenosis and spasm, may show the same mode of onset. Vomiting may be explosive in both; it may be tem- porarily relieved by dietetic treatment in partial stenosis, while in spasm it may at times be resistant to dietetic treatment. The symptoms of constipation, loss of weight, visible peristalsis, and delayed emptying time of the stomach are common to both con- ditions. There is occasionally, though not often, a palpable tumor in spasm, while in mild cases of stenosis a tumor is often not found. Nevertheless, the differentiation of the two conditions is essential in prognosis and treatment. The presence of a typical palpable tumor is strongly in favor of hypertrophic stenosis, and is usually conclusive proof of the diag- nosis. Tumor is occasionally present in spasm, but the tumor of spasm is smaller and cord-like in feel, and is apt to vary in size during the examination. The absence of a palpable tumor after careful and repeated examination, is evidence against stenosis, but does not exclude it. The following points are evidence only in differential diagnosis, and none of them is positively diagnostic. Marked and persistent constipation points toward stenosis, although in mild cases of ste- nosis with partial obstruction, constipation may not be more marked than in spasm. If the baby is breast-fed, it points toward stenosis, because pyloric spasm is very uncommon in breast-fed babies. When the symptoms develop soon after birth, especially in babies who are properly fed, it is in favor of hypertrophic stenosis. Rapid and permanent improvement in the symptoms, under regulation of the diet with carefully modified milk, or with any of the particular resources of infant feeding, is in favor of spasm, while resistance to proper treatment is in favor of stenosis. This evidence is by no means positive, as cases of hypertrophic stenosis are often complicated by spasm, and respond to a certain extent to dietetic treatment, while some cases of spasm are resistant. Roentgenograms after a bismuth meal do not help in the differential diagnosis, as in both spasm and Fig. 85 — Pyloric stenosis with pailial occlusion Roentgenogram taken two hours after Insmuth nicil, showing dilatation of the stomach. Fig. 86 — Pyloric stenosis with partial occlusion Same case taken four hours after bismuth meal Pyloric Stenosis 363 stenosis with partial obstruction, , there is delayed emptying-time. At times the investigation of the emptying-time by X-ray, or by the stomach tube, reveals evidence of dilatation of the stomach. This is strongly in favor of h^'pertrophic stenosis as dilatation is very rarely seen in spasm. The absence of evidence of dilatation is not against stenosis, and throws no light on the diagnosis. In spite of these various forms of evidence, the differential diag- nosis between a slight or moderate degree of hypertrophic stenosis, possibly complicated by spasm, and spasm, without organic tissue- change, remains extremely difficult in many cases. The symptoms, and evidence are often very confusing, and have led to an effort to find a more exact method of investigation. Diagnosis by Duodenal Catheter. — I have recently adopted the pas- sage of the duodenal catheter, as recommended by Hess, as a means of investigation in obstructive conditions of the pylorus, and believe it to give most valuable evidence in the differential diagnosis of h}^ertrophic stenosis and spasm. In Hess's method, a long and- very flexible catheter was used, which was introduced with a meal, the end of the catheter being eventually carried through with the food into the duodenum. The advantage of such a tube is that it is usually carried sufiiciently far into the duodenum to permit the flow of bile, which is certain proof of its passage through the pylorus. The disadvantage of such a catheter is that it often requires consider- able time to enter the duodenum, and does not permit so accurate an estimate of the size of the pyloric orifice as does a somewhat stifi'er tube, which enters the duodenum impelled by the pushing of the operator. We have been using at the Infant's Hospital ordinary soft rubber urethral catheters of graded sizes, these tubes being quite long enough to enter the duodenum, though not long enough always to obtain bile. Repeated controls made by filling the tubes with bismuth, and taking a roentgenogram after passing the catheter, have shown that in normal cases, or in cases of pyloric spasm, these tubes speedily enter the duodenum, and these controls have convinced us that it is quite easy to recognize the moment when the catheter passes the pylorus. The catheter is passed as is the ordinary stomach tube, but more slowly, the physician watching carefully for the various reflexes which mark its progress. When the end of the tube passes along the throat, the pharyngeal reflex is shown by the gagging and cough- ing of the baby. While the tube is passing through the esophagus, the baby is comparatively quiet, but a second gagging reflex is ob- served, and a slight sense of resistance is felt, when the tube passes the cardiac orifice of the stomach. After the tube enters the stom- ach, resistance diminishes, and at this time gastric contents may be 364 Diseases of the Gastro-Enteric Tract expelled, or may be aspirated, through the tube, and if the catheter is released by the physician's fingers it tends to come back at the baby's mouth. The catheter is passed slowly on until a slight sense of resistance is encountered, when it is held firmly in situ, with con- tinued sHght pressure. During this period, the baby again shows marked evidence of discomfort, squirms, cries, and may again gag or vomit. This is the pyloric reflex. Suddenly the resistance relaxes, as the tube passes the pylorus, and now if the catheter is released by the physician's fingers, it will not tend to come back. More- over, suction with the bulb through the catheter obtains either no contents, or a small amount of bile. When the catheter enters the duodenum, the baby ceases to squirm and gag, and becomes per- fectly comfortable. A gush of gas from the catheter also often marks the entrance into the duodenum. The following table, based on the work of W. W. Howell, associate physician at the Infants' Hospital, shows the various sizes of catheter which should normally pass the pylorus: Table 41 Sizes of Catheter, French Scale, Which Should Pass the Normal Pylorus at Various Ages. (Howell) Birth to 2 months 13 or 14 F. 2 to 6 months 15 or 16 F. .6 to 12 months 17 or 18 F. I to 2 3^ears 18 to 22 F. In spasm of the pylorus, there may be some delay in the passage of the catheter past the pylorus, but the baby will always take a cathe- ter of a size normal for its age. In hypertrophic stenosis of the pylorus, either the catheter cannot be passed into the duodenum at all, or only a catheter of a smaller size than that normal for the age will pass. Also the pyloric reflex is diminished or absent. The autopsy and operative findings have, up to the present, con- firmed the accuracy of the evidence obtained by the duodenal catheter in pyloric stenosis. The following table shows the results in the cases diagnosed at the Infant's Hospital since this method has been in use: Table 42 Cases Diagnosed by Duodenal Catheter TYPE OF CASE NO. OF CASES TREATMENT " MORTALITY Marked obstruction 8 Prompt operation 0% Partial obstruction 3 Delaj^ed operation 100% Partial obstruction i Dietetic treatment 100% Partial obstruction 3 Prompt operation 0% Spasm 16 Dietetic treatment 0% The eight cases of marked obstruction were given prompt surgical treatment. In the next four cases of partial obstruction, the diag- nosis was not clear, resting only on the evidence of the duodenal Pyloric Stenosis 365 catheter, and the surgeons were unwilHng to interfere promptly, beHeving that they might be cases of spasm. All were fatal, and in three in which necropsies were done, hypertrophic stenosis was found. In the other three cases of partial obstruction, the evidence of the duodenal catheter was accepted, prompt operation was done, stenosis was found, and all recovered. All the cases in which the duodenal catheter excluded hypertrophic stenosis recovered without operation. Indigestion. — Marked cases of pyloric stenosis with their dis- tinctive symptom-complex, are easily distinguished from cases of indigestion with vomiting. In every case in which, in an infant, vomiting is the main symptom, the possibility of pyloric stenosis should be considered, and its special symptoms should be sought. Indigestion is uncommon in breast-fed babies, and never shows explosive vomiting, visible peristalsis, severe constipation, tumor, or any marked delay in the emptying time of the stomach. In indiges- tion, roentgenograms occasionally show some retention of food in the stomach for a longer time than normal, but the plate taken immediately after the bismuth meal shows that the food begins at once to leave the stomach in normal amounts. The passage of the duodenal catheter is normal. Habitual Vomiting. — This is a condition sometimes seen in babies, in which vomiting frequently occurs after feeding without other signs of indigestion. In this condition there is no constipa- tion, no loss of weight, no visible peristalsis, no palpable tumor, and no delay in the emptying time of the stomach. PROGNOSIS. — In cases of hypertrophic stenosis of the pylorus, with marked obstruction, or complete occlusion, the prognosis with medical treatment is hopeless. Death from starvation will surely occur within a few weeks. The prognosis in cases with partial ob- struction is also bad under medical treatment. The babies may live for a considerable time, but usually die eventually either from starvation, or from some intercurrent affection. There are many cases on record of recovery under medical treatment of cases of mild pyloric stenosis. In these cases, however, the diagnosis was not based on any accurate means of investigation, and all of them are open to the suspicion of having been really cases of pyloric spasm. There is no evidence that organic stenosis tends to diminish, and in my experience, the prognosis with medical treatment is event- ually bad. The prognosis with operation varies according to the time when the operation is performed, and the skill of the operating surgeon. The prognosis has appeared to be better in cases of marked or com- plete obstruction after operation, than in cases of slight obstruction. 366 Diseases of the Gastro-Enteric Tract This I believe to be due mainly to the fact that in marked cases the diagnosis is made with more certainty, and the operation per- formed more promptly, than in less marked cases. Cases of partial obstruction after operation apparently undergo a more stormy con- valescence than cases of complete obstruction, but this may be due to the fact that in the former, symptoms have often had a long dura- tion, and the stomach has become more irritable. In the hands of a surgeon thoroughly accustomed to operating upon these cases, and upon babies, the prognosis is good, unless the operation has been too long delayed. TREATMENT. — Prompt surgical operation is indicated in all severe or pronounced cases in which the diagnosis is supported by the finding of a tumor or by evidence of complete obstruction as shown by X-ray. In cases of partial obstruction in which no tumor can be made out, dietetic treatment may be tried, and if the baby responds, it may be continued as long as the baby is doing well. If, however, the symptoms recur, or the baby begins to lose weight, or does not begin to gain after one or two weeks' trial, and if the diagnosis is supported by the evidence of the duodenal catheter, no further time should be wasted with dietetic treatment. The operation to be chosen should depend on the experience of the operating surgeon. Posterior gastroenterostomy has been the procedure most employed, and has given very high percentages of recovery in the hands of some surgeons. Various forms of pyloro- plasty have been recommended and performed by various surgeons, with good results. Recently, Dr. James S. Stone at the Children's Hospital, has obtained good results from simply spHtting the muscle of the pyloric ring down to, but not through, the mucous layers. This operation has the advantage of taking much less time than the others, but has not yet stood the test of time as has posterior gastroenteros- tomy. The choice of operation is less important than is the skill and training of the operator. The operation should be performed as soon as possible after the diagnosis is made. Often, however, the babies are in very poor physical condition, which diminishes the Hkelihood of their standing the shock of so severe an operation. In cases of partial obstruc- tion, careful feeding for a day or two may bring about improvement in the general condition, and I have found that if the duodenal catheter will pass, the babies may be fed through it with great ad- vantage, showing marked improvement in one or two days. In cases of marked obstruction, no longer delay than twenty-four hours of preparation should be given. During the period of preparation, salt solution should be given by rectum, and, if the general condition is poor, also subcutaneously. We have recently at the Infant's Pyloric Spasm 367 Hospital obtained excellent results from intranvenous injections of destrose solution. The stomach should be washed out just before the operation. More salt solution should be given after the opera- tion. The feeding after operation is important. It may be begun as soon as the baby recovers from the anesthetic. The best food is human milk, at first diluted with three parts water, the strength being rapidly increased. If human milk is not available, feeding should be begun with whey, to which cream is gradually added in amounts sufficient to give first fat .50%, then fat .75%, and then fat 1.00%. The amount at first should be one drachm every hour, the amounts being increased and the intervals lengthened as rapidly as possible. The conduct of the case soon becomes that of any case in which chronic vomiting has been present, and is carried on in accordance with the principles of infant feeding. If the disease has existed for some time, the quantity of food cannot be increased so rapidly. Occasional vomiting is not a contraindication to in- creasing the food, but the stools should be carefully watched. SPASM OF THE PYLORUS In this condition, obstruction occurs from a spasm of the muscles of the pyloric ring. It is more common in infancy than is hyper- trophic stenosis of the pylorus, and has often been mistaken for it. It is probable that most of the cases in which recoveries from hyper- trophic stenosis of the pylorus under medical treatment have been reported, were really cases of spasm. Pyloric spasm is distinguished from pyloric stenosis by the fact that in the former there is no con- dition of pathological anatomy at the pylorus. Spasm may compli- cate organic hypertrophy, but such cases are classified as stenosis. ETIOLOGY. — The etiology of pyloric spasm is very obscure, and is very probably multiple. The principal etiological factors men- tioned by the various writers on the subject are, i, nervous hyper- irritabihty, 2, hyperacidity of the gastric juice, and 3, mechanical irritation from indigestion. The first theory is based on the evidence that the condition is apparently most common in nervous and excit- able infants of neurotic heredity. The second theory is based on that fact that often favorable results follow treatment directed at neutralizing hyperacidity. The third theory is based on the evi- dence that in the majority of cases some disturbance of gastric diges- tion precedes or accompanies the condition of spasm, the spasm itself being caused by the influence of the products of indigestion on the normal muscular hyperirritability characteristic of early life. It is probable that all three factors may play a part. In my opinion, the third, that of indigestion, is so important, that spasm might be 368 Diseases of the Gastro-Enteric Tract regarded as one symptom of indigestion, appearing particularly in nervous infants. SYMPTOMS. — The symptoms of pyloric spasm are much like those of the milder cases of h3rpertrophic stenosis. The condition is most common in artificially-fed babies, and the patients are usually of an irritable, neurotic type. Vomiting is the first symptom; it may appear shortly after birth, but usually does not appear for several weeks, or even for several months. The vomiting often becomes projectile. It is almost never completely relieved by any change in the composition of the food, although there may be some improvement. The vomitus may or may not show evidences of indigestion, and the quantity vomited does not ordinarily exceed the amount of the last feeding. In mild cases vomiting is the only important symptom, although there may be some tendency to constipation. In more severe cases, constipation is more marked, although the stools always show some fecal residue. Visible peristalsis is often present. In rare cases, a tumor may be felt at the pylorus, but the tumor is smaller and thinner than that of hypertrophic stenosis, and during palpation may often be felt to appear and disappear under the finger. Roentgenograms after a bismuth meal, or aspira- tion with the stomach tube, shows exactly the same delay in the emptying time of the stomach as is seen in hypertrophic stenosis, but the X-ray plates never show evidence of complete occlusion. DIAGNOSIS. — Spasm of the pylorus must be differentiated from hypertrophic stenosis of the pylorus, indigestion with vomiting, and habitual vomiting. Hypertrophic Stenosis. — The differential diagnosis of pyloric stenosis and pyloric spasm has been fully considered under the head- ing of the former disease. The duodenal catheter, of a size normal for the age of the baby, will always pass in pyloric spasm. Indigestion. — In indigestion there is usually some evidence in the vomitus, the vomiting is rarely projectile, and visible peris- talsis is not seen. The most important evidence in doubtful cases is gained by investigating the emptying of the stomach, the begin- ning of which is never delayed in indigestion, but is always delayed in pyloric spasm. Habitual Vomiting. — In this condition the vomiting usually occurs when the baby is picked up, moved, or is active. The vomit- ing is never projectile, constipation is not marked, there is no visible peristalsis, and no delay in the emptying time of the stomach. PROGNOSIS. — The ultimate prognosis of these cases is very good; almost always eventual recovery occurs. The cases, however, Pyloric Spasm 369 often require long treatment, the symptoms persisting for many- weeks, or even months. TREATMENT. — The treatment of pyloric spasm consists in care- ful regulation of the diet, the giving of alkalies, gastric lavage, and the passage of the duodenal catheter. The best food is human milk. When infants must be artificially fed, the food given must be low in fat, not more than .50% at first, because excessive fat tends to delay the emptying time of the stom- ach. The caloric value of such a food is low, and cannot be made up by any marked increase in carbohydrate, without danger of causing carbohydrate indigestion. The protein should be increased, but the casein curds of cow's milk may act as irritants to the irrit- able pyloric ring; consequently whey mixtures are indicated. A formula of fat .50, lactose 6.00, whey protein .90, casein .40, lime water 50% of the cream, is a good one to begin with. If the symp- toms are relieved, but there is no gain in weight, the fat must be gradually increased, and later the casein may be increased. I have found that in many cases of pyloric spasm, sodium citrate, in the amount of .40% of the milk and cream, works better than lime water. In obstinate cases, sodium bicarbonate, 1.70% of the milk and cream, may be tried. The intervals between feedings should be longer than the emptying time of the stomach, as measured by X-ray or stomach-tube inves- tigation. The amount given must be varied, until it is found on what quantity the baby does best. Daily lavage with water or a weak bicarbonate of soda solution may be tried. It may help at times, but in the majority of cases it does no good. Flaxseed poultices to the epigastrium have ap- peared to help some cases. I have had the best results in spasm of the pylorus with the duodenal catheter. It should at first be passed once daily, and one feeding may thus be given directly into the duodenum. As the symiptoms improve, the catheter is gradually passed less often, and finally its use may be omitted. It is possible that there may be cases of pyloric spasm sufficiently severe and resistant to require surgical intervention. I have yet to see a case in which the diagnosis was confirmed by the duodenal catheter, which did not eventually do well under medical treatment. PROBLEMS AND RESEARCH.— In the last ten years various studies on the physiology of gastric digestion have included the mechanism of the opening and closing of the pylorus. The pyloric reflex is probably closely connected with the subject of spasm of the pylorus. Cannon has shown that on the gastric side of the pylorus, when the material is acid, the valve tends to open, and when alkaline 24 370 Diseases of the Gastro-Enteric Tract to close. On the duodenal side an alkaline reaction allows the valve to open, and an acid reaction causes it to close. Cowie and Lyon have found that this opening and closing reflex could be demonstrated in infants. If the food were too strongly alkaline, the opening reflex would be delayed, and the food would remain longer in the stomach. ""This is opposed to the theory on which use of alkali in pyloric spasm is based, namely, that the alkalies in diminishing casein curd forma- tion, allows the liquid contents to pass the pylorus more readily. Cannon, on the basis of his experiments, believes that mechanical factors have little or nothing to do with the opening and closing of the pylorus. If this explanation is true, it would be possible to exaggerate the condition of spasm, by giving too much alkali, and our use of alkali would theoretically have to be based on chemical analysis of the gastric contents. DILATATION OF THE STOMACH ETIOLOGY. — A moderate dilatation of the stomach is rather more common in infancy than in older children. The higher degrees of dilatation are rare. It may rarely arise from some obstructive con- dition, such as a stenosis of the pylorus, but in most cases is the result of errors in feeding. It is more apt to occur when the infant is not nursed, unless especial care is taken to give it the quantity of food which is adapted to its age and gastric capacity. When the infant is nursed, the breast seems to provide the amount of food which is suitable. Dilatation from errors in feeding may be caused by the fact that the food is not adapted, either in quality or in quan- tity, to the needs of the individual infant. When the quality is at fault, the nutrition of the tissues of the stomach is interfered with, and its w^alls become weak, and are thus more easily distended by the gas which results from the abnormal changes in the food. In this way dilatation occurs. This class of cases is notably represented in rachitis, in which dilatation of the stomach takes place very readily. When the quantity of the food is not properly adapted to the size of the stomach, dilatation can take place in even a healthy infant, so that the careful regulation of the amount of food which is given at each feeding during the first year of life is most important. PATHOLOGICAL ANATOMY.— The pathological condition which exists in cases of gastric dilatation is well represented in Fig. 89. SYMPTOMS. — The symptoms of dilatation of the stomach are essentially those of chronic indigestion. Vomiting is quite frequent, and continues until the stomach has been entirely emptied, when a period of rehef comes, to last until fresh irritation arises from another Dilatation of the Stomach 371 supply of food. Abdominal pain, flatulence, and general discom- fort are prominent symptoms. Rapid loss in weight and emaciation also occur. In rare cases, in young infants, convulsions may arise, apparently due to the reflex disturbance which is produced. When a dilatation is of a high grade, the vomiting may occur only after considerable intervals, and the amount vomited is greater than that Dilated stomach. Rachitic infant, 7 months old. (Actual size) of a single feeding, and may be very laTge. In dilatation of the stomach, the greater curvature is so much increased and depressed below the level of the pyloric orifice that a pouch is formed. The food, collecting in this pouch as though it were at the bottom of a well, has to be practically pumped, by the contraction of the muscular walls, up to and through the pyloric orifice. The already weakened 372 Diseases of the Gastro-Enteric Tract stomach thus has to perform work for which it is not fitted, and finally is relieved by spasmodic vomiting. When only the small amount of food adapted to their normal gastric capacity is given to young infants whose stomachs are dilated, a large space of empty stomach is left above the level of the liquid which has entered the stomach. This creates a feeling of emptiness and general discom- fort, so that the infant appears to be hungry when, in fact, it is only suffering from the feeling of incomplete filling of the stomach. Dilatation of stomach. Age 6 years Physical Examination. — On inspection the abdomen is seen to be distended and tense, and on percussion to be highly tympanitic in its upper part. Succussion is not an especially valuable diag- nostic sign in dilatation of the stomach. Succussion is so frequently found in many conditions, and is so likely to be confounded with that which occurs in the colon, that it cannot be relied upon. The Dilatation of the Stomach 373 outlines of a normal stomach when it is somewhat distended vary so much during infancy that the results of percussion are often very misleading. When, however, the tympanitic resonance is found to extend below the line of the umbilicus, we may suspect that we are dealing with gastric dilatation, but even then it is uncertain whether it is the gastric tympany which we have obtained. In infancy the cardiac end of the stomach is so sHghtly developed that any great increase in the area of gastric resonance on the left side is an im- portant aid in making the diagnosis. DIAGNOSIS. — The differential diagnosis is to be made chiefly from dilation of the colon. In many cases when the colon is dilated it is impossible to determine whether the stomach is also dilated, since under these circumstances the colon can almost completely cover a largely dilated stomach. The most important diagnostic symptom is the vomiting of exces- sively large quantities of food. The positive diagnosis of the condi- tion is based on the result of a roentgenogram taken after a bis- muth meal. PROGNOSIS. — If the dilatation is due to congenital stenosis of the pylorus the prognosis is that of stenosis. In other cases the prognosis depends upon whether the condition arises from improper amounts of food or from some disease, such as rachitis. In the former class the prognosis is good, and the stomach under a proper regulation of the diet soon assum^es its natural size. In the second class it is good, although as a rule, the stomach will remain more or less distended until the disease which causes the dilatation has been cured. TREATMENT. — If the case is an obstinate one, lavage is an important part of the treatment. In many cases, however, good results are obtained simply by regulating the quaHty and quantity of the food. When the food is first given in the proper amount it will not fill the stomach nor satisfy the demands of the infant. Under these circumstances the infant will be very restless, and will often cry almost continuously from the time of one feeding until the next. The nurse must be made to understand that these signs of discom- fort are liable to last for a number of days, until the stomach has more nearly resumed its normal size, and that an additional supply of food must not be given to the infant simply because it cries for more. CONTRACTION OF THE STOMACH In certain cases the capacity of the stomach is decidedly dimin- ished. The diminution in size, as a rule, depends upon a lack of use, such as occurs in infantile atrophy. Sufficient food to fill 374 Diseases of the Gastro-Enteric Tract the stomach is not taken, and in this way the stomach is not called upon to perform its normal work. In cases, also, in which there is continuous vomiting, this same lack of use may produce a diminu- tion in the size of the stomach. These cases are of pathological rather than of clinical interest, as they can seldom be diagnosticated, and their treatment is essentially that of the especial disease to which they are secondary. DILATATION AND HYPERTROPHY OF THE COLON (Hirschprung's Disease.) (Idiopathic Dilatation of the Colon.) This disease consists in a very marked condition of dilatation and hypertrophy of the whole or of a part of the large intestine. Fig. 91 Hirschprung's Disease. Section through the colon showing enormous widening of the muscular layers, particularly of the muscularis mucosae ETIOLOGY. — The etiology of the condition is unknown. The most widely held theory is that it is a primary congenital malforma- tion. Some writers beheve that it may in some cases at least, rep- resent a secondary or acquired condition, due to some slight and hardly recognizable obstruction. The sigmoid flexure of infants is normally longer than that of adults, and it is conceivable that in an especially long one, kinks might occur, which would lead to accumu- lation of feces and gas, to dilatation, and eventually to compensatory Hirschpruxg's Disease 375 h}'pertrophy. Or, the cause of the stoppage might be in the rectum. Against the theory of a secondary etiology is the fact that the symp- toms usually appear very soon after birth, and that in the cases which have come to autopsy, no constriction has been found in the lower part of the intestinal canal. There must be some lack of motility, or an incomplete power of contraction, to explain why, with congenital hj-pertrophy of the muscular layers, the intestines are incapable of expelling their contents. Fig. 92 Congenital dilatation of the colon. (Hirschprunir's Disease) PATHOLOGIC.\L ANAT0:MY.— The condition is recognized by its characteristic pathological tissue changes. These may involve the whole of the large intestine, or only a part. The lesion macro- scopically shows as a dilatation and lengthening of the colon, with marked thickening of its walls. ^Microscopically, the principal lesion is a marked h^-pertrophy of all the muscular layers, the thickening 376 Diseases of the Gastro-Exteric Tract of the muscularis mucosae being especially conspicuous. Secondary ulceration of the mucous membrane is. often found post-mortem. SYMPTOiMS.- — The chief symptoms are distention of the abdo- men and constipation. Both symptoms appear very sooil after birth. The constipation is very obstinate, and patients have been Fig. 93 Dilatation of colon. Male, 12 years old known to go as long as two weeks without a movement of the bowels. The distention of the abdomen soon becomes very extreme, but may temporarily disappear entirely if the bowels are emptied by vigorous treatment with enemata, and purgatives. Visible peristalsis is pres- ent at times. Nutrition suffers to a variable extent. Emaciation may become severe, or may not be marked. At times attacks of more acute obstruction may occur, with colic and vomiting; at other times there may be attacks of diarrhea, the movements being foul, and often y Fig. 94— R()C'nlgcn(),i,rram of conKcnijal flilatal,ion of Mic colon taken aflcr rectal injections of bismuth The distention of the sigmoid flexure is clearly shown Fig. 95— Roentgenogram of congenital dilatation of the colon taken after a rectal injection of bismuth The enlargement of the sigmoid flexure and transverse colon is clearly shown Hirschpruxg's Disease 377 containing pus and blood. Death may occur from collapse in an acute attack, from peritonitis, or from some intercurrent affection. DL\GNOSIS. — The condition should be suspected whenever there is a history of obstinate constipation and enlarged abdomen existing from birth. The diagnosis is confirmed by taking a roentgenogram after filling the colon through the rectum, with a suspension of bismuth. PROGNOSIS. — Most cases die in infancy. In a few cases, the patients have lived to adult life. TREATMENT. — Medical treatment is only palliative. It con- sists in the removal of the accumulated feces, and in the prevention, as far as is possible, of reaccumulation. Enemata, frequently re- peated, should be first used, and after as much emptying as possible has been eft'ected, purgatives are used. Surgical treatment offers the only hope of permanent cure, but the disease is so uncommon that statistics of its results are not yet available. An artificial anus has been made with temporary benefit. The ideal operation is removal of the colon, or of the portion involved in the lesion. The operation is a very dangerous one, is attended by severe shock, and will probably always have a high mortality. Never- theless, in \aew of the bad prognosis of the disease, I believe operation should be recommended in marked cases. It is a good plan to operate in two stages. At the first operation the anastomosis between the sound portions of the bowel above and below the lesion is made, and a part of the bowel is stitched to the abdominal wall, so that if acute obstruction occurs, an artificial anus may be easily made. At the second operation, the hypertrophied colon is excised. The results depend upon the amount of colon involved. If the lesion extends down to the rectum, the outlook is not so good as when there is sound tissue available for anastomosis above and below the lesion. INTUSSUSCEPTION Intussusception is a condition in which a part of the intestine is invaginated into another part. Under these circumstances there is an outer layer of intestine within which is the part of the intestine forming the invagination. Only a small portion of the intestine may be invaginated, or it may extend from the ileo-cecal valve to the rectum. Small invaginations are frequently found at the post- mortem examinations of infants and young children. These prob- ably take place during the death-struggle, as no pathological condi- tion is found in connection with them. This form is usually mul- tiple and in the small intestine. The form of intussusception which occurs during fife is chiefly a disease of infancy, but is very rare under 378 Diseases of the Gastro-Enteric Tract three months, and is most common from the third to the twelfth month. At this age the large intestine is shorter in relation to the small intestine than in the adult, while the mesentery is relatively longer, and thus allows much greater latitude for misplacement, especially of the cecum and colon. It may occur in later childhood in rare instances. ETIOLOGY. — The etiology of intussusception is obscure, but it is probably directly due to increased local peristalsis. Nothnagel has shown by experiments on animals that intussusceptions are formed by an irregular action of the muscular layers of the intestinal wall. In infants, it is probable that intussusception is produced in the same way. The disease is commonest in poorly nourished chil- dren. While the condition is not a common one, it is the most frequent form of acute intestinal obstruction seen in infancy and childhood. PATHOLOGICAL ANATOMY.— The pathological anatomy de- pends upon the tightness of the constriction and the length of the time from the beginning of the obstruction. In some cases the in- carcerated portion of the intestine is so little constricted that the bowel remains pervious. In other cases the constriction is so great that the tension of the intestinal capillaries quickly becomes extreme, and hemorrhage occurs, and inflammation, with resulting adhesions, is apt to follow rapidly. The intestine may not only be invaginated, but may be bent on itself, an important point to remember in regard to treatment. SYMPTOMS. — The symptoms of intussusception are usually acute, though often at first rather obscure. Often the first thing noted, is a condition resembing surgical shock. The principal symp- toms are pain, vomiting, and bloody stools. The onset is usually with pain and vomiting, though occasionally the bloody movements are noted first. The pain is paroxysmal, resembling a very severe colic, and it is present in the majority of cases, though it may be absent. The vomiting is most severe at the onset, but usually con- tinues throughout the attack and may become stercoraceous in some cases. There may be one or two fecal stools passed at the begin- ning, but soon they consist of mixed blood and mucus resembling currant jelly in appearance, and no more fecal matter is passed. The mind is clear, and in young infants the face is often tranquil between the paroxysms of pain, so that on looking at the infant it would scarcely be supposed that a serious condition was present. Later, however, the face grows haggard and the eyes become sunken. During the first twenty-four to forty-eight hours, and even longer, the infants will often take their food quite readily. Tenesmus is Intussusception 379 at times present. There may be fever, especially when inflammation has occurred. The pulse is usually quickened. These symptoms all vary, and depend on the amount of the invagination. In some cases these are the only signs which indicate that there is abdominal disturbance. In most instances, however, either at once or within a few hours, a tumor can be felt in the abdomen. The tumor is the most important sign. It may be felt in various parts of the abdo- men, and may often be felt by rectal examination. It has even been found protruding from the anus. DIAGNOSIS. — The chief points in the diagnosis of intussuscep- tion are the occurrence of discharges of blood, vomiting, abdominal pain, and the detection of an abdominal tumor. In these cases a careful rectal examination should always be made, for a tumor can often be found in this way when an external examination has failed to detect it. I have seen intussusception mistaken for infectious diarrhea. An important diagnostic point is that in infectious diar- rhea, the mucus is streaked or spotted with blood, while in intussus- ception the mucus and blood are homogeneously mixed. No case with a history of blood in the stools should be allowed to pass with- out either an actual inspection of the discharges, or a careful abdom- inal and rectal examination. PROGNOSIS. — Without treatment the prognosis is unfavorable, though there are a certain number of recoveries by spontaneous reduction, or rarely by sloughing of the invaginated portion of the intestine, which is then passed by the rectum. If death takes place, it usually occurs about the third or fourth day, or at any rate within a week, after the incarceration is complete. When the incarceration is not complete the infant may live for many weeks, and in older children in rare instances the disease may become chronic. TREATMENT. — The treatment of intussusception, when the diagnosis has been definitely made, should be immediate, as in no other disease does a delay result in more serious consequence. Food and cathartics or laxatives are contra-indicated. Immediate lapa- rotomy is indicated in all cases. Attempts to reduce the intussus- ception by hydrostatic pressure are too uncertain, and may cause unwarranted delay. The results of operation depend on how early in the course of the disease it is performed. If it is performed early, the surgeon can often easily reduce the invagination, and the intes- tine may not show such serious signs of damage as to require resec- tion. In such cases, the prognosis is much better. If the operation is performed later, not only will the patient's general condition be worse, but adhesions will have formed, and resection will be necessary. 380 Diseases oe the Gastro-Enteric Tract VOLVULUS By volvulus is meant a twisting or bending of the intestine. This condition is more apt to occur in early life than later, possibly because of the greater proportionate length of the mesentery at this time, which allows the intestine greater latitude of motion. It occurs either by itself or in connection with intussusception, from which it is to be differentiated by the absence of blood and mucus in the discharges. HERNIA The most common form of hernia encountered in early life is the umbihcal hernia of infancy, which has been described in the Division on Diseases of the Newborn. Inguinal hernia is sometimes seen in Fig. Worsted truss for the treatment of inguinal hernia in infants infants. It is usually easily reducible, but protrudes again when the infant cries. A truss made of a skein of worsted which is anchored by being passed around the waist, and then passed through the groin and about the thigh, will often suffice to keep the hernia in place until spontaneous recovery occurs. If the hernia resists this simple treatment, it becomes essentially a surgical affection. Prolapse of the Rectum 381 FISSURE OF THE ANUS This condition is seen both in infants and children, and is not very uncommon. The usual cause is constipation. The passage of a large, hard stool causes a tear, and when this is repeated, healing is prevented. External trauma, such as careless use of a rectal syringe, or the scratching caused by pin-worms, may cause a similar tear, but these fissures usually heal readily, unless the cause is repeated. The fissure is a linear ulcer, which may be situated at the muco- cutaneous junction, or a short distance from it. The chief symptom is pain, which accompanies defecation, and continues for some time afterward. The patients dread a movement of the bowels, cry as soon as the impulse comes, and often resist the impulse so that chronic constipation results, a condition which makes the fissure worse. A young child usually refers the pain to the abdomen, or some neigh- boring part, rather than to the anus. The diagnosis is easily made by inspection of the anus. TREATMENT.— The fissure should be touched with the solid nitrate of silver stick, and the applications should be repeated every two days until the lesion heals. The parts should be kept clean, and constipation should be prevented. If these measures fail, the sphincter must be stretched under anesthesia. HEMORRHOIDS Hemorrhoids are rarely met with in infancy and early childhood, although they can occur. The chief cause, as in adults, is chronic constipation. The treatment of the constipation is the important thing in childhood. This, with the ordinary local measures, such as the application of cold compresses after stool, careful reduction, and the application of astringent ointments, usually suffices for a cure. Operation should not be necessary in early life, unless the condition is neglected. PROLAPSE OF THE RECTUM In this condition either the mucous membrane of the rectum, or the entire rectal wall, protrudes beyond the sphincter. It is a condition seen almost exclusively in early life. It is most common in the second and third years, but may be seen in younger infants and in older children. * ETIOLOGY. — The cause of the frequent occurrence of prolapse in early life is the lack of muscular support about the anus at that age. It is often seen in atrophied infants. The exciting cause is 382 Diseases of the Gastro-Enteric Tract straining at stool, and consequently the condition is met with both in constipation, and after diarrhea with tenesmus. Straining at stool is at times excited by reflex irritation, and prolapse of the rectum may be a symptom of phimosis, or of stone in the bladder. SYMPTOMS. — The prolapse usually occurs when the child has a movement of the bowels. It is usually easily reducible, but tends to reappear with each bowel movement, and in pronounced cases may come down at other times. The appearance of the tumor varies with the severity of the case. In mild cases there is simply a protruding fold of mucous membrane surrounding the anus. In the majority of cases, there is quite a large tumor of a deep, purplish- red color, which bleeds easily. DIAGNOSIS. — The appearance of the protruding tumor at the anus is characteristic. In rare cases intussusception shows a similar protrusion, but in prolapse all symptoms of acute intestional obstruc- tion are absent. PROGNOSIS. — The eventual prognosis is good, but the disease is often obstinate, and requires prolonged treatment. TREATMENT. — Each time that the tumor prolapses, it should be bathed with ice water, and then carefully reduced with the oiled fingers, the central portion being pushed back first. After reduction a strip of adhesive plaster three inches wide should be applied in such a manner as to hold the buttocks tightly together. The child should be kept in bed for the first week of the treatment. Later, it should be made to lie down for about .half an hour after defecation. Children who have graduated from the diaper, should never be allowed when at stool to sit upon a chamber, or low chair, or upon a water-closet seat the opening of which is of adult size. They should have their own chair, with a small opening. The underlying condition should be treated. Constipation should be treated at first by enemata, and then by mild laxatives sufficient to keep the stools semi-liquid, but not so strong as to produce active purgation. The tenesmus accompanying diarrhea may be relieved by small injections of ice water containing tannic acid. Supposito- ries containing opium may be necessary in more severe cases. Occasionally, in long-standing cases, reduction is difficult. It may be facilitated by applying a two per cent solution of cocaine. In the most resistant cases the tumor should be touched with the paquelin cautery, making a series of radial linear markings about an inch apart. IV. NEW GROWTHS New growths in the gastro-enteric tract are very rare in infancy and childhood, and are mostly confined to the myxomatous polypi of the rectum. Polypus of the rectum is more common in early life than at any other period. Hemorrhage from the rectum, when not due to con- stipation, diarrhea, or fissure, usually arises from polypi. A careful examination for this growth should be made when rectal bleeding is frequent or large. Rectal polypi are of various sizes, and may be myxofibromata or adenomata. The surface of the polypus is usually smooth, and the pedicle is often long and thin. The diag- nosis is easily made by a digital examination. The treatment is either to twist or cut off the polypus. The growth is not apt to recur. V. NERVOUS DISTURBANCES ETIOLOGY. — The functions of the digestive tract may be dis- turbed by influences acting through the nervous system. The result of such influences is a secondary disturbance of function. Both the secretory and mechanical functions of the digestive system may be affected. When the secretory functions are disturbed, the result is indigestion, and the symptoms are indistinguishable from those of indigestion. Consequently, nervous disturbance is only one of the many causes concerned in the production of indigestion. When the mechanical functions of the gastro-enteric tract are disturbed, the results are quite characteristic, and both the symptoms and treat- ment are sufficiently distinct from those of indigestion to require separate description. The easily irritated nervous system of the young child renders it particularly liable to react to various external stimuli. There is variation in the excitability of the nervous system in different indi- vidual children. The tendency to reaction may be increased by errors in the infant's care and routine, such as noisy surroundings, too much attention, and stories or games of too exciting a character. These errors produce over-irritability and over-exhaustion of the nerve centers, which become liable to abnormal reaction. The exciting causes acting through the nervous system to produce gastro-intestinal symptoms, are various. The most common are extremes of heat and cold. In infants that is the most common factor, and the usual result is diarrhea. In such cases, the over- heating of the baby affects the nerve centres, and the abnormal influences transmitted to the nervous mechanism of the intestine cause increased peristalsis, without there being any indigestion. The condition is somewhat analogous to a mild heat-stroke, and indeed, in heat-stroke or heat-exhaustion, diarrhea of a similar character is frequently seen as a symptom. Part of the prevalence of acute diarrhea in the summer months is due to this cause, and nervous diarrhea is one of the forms included under the vague heading of " summer diarrhea," although it is the least common and least serious form. Cold also may produce an acute diarrhea through nervous influences, both in infants and older children. A sudden chilling of the surface of the body, such as occurs when a child is exposed to a cold draught, falls into the water, or even is exposed to a sudden change of temperature without proper modifi- cation of the clothing, will at times produce an acute diarrhea. Nervous Vomiting and Diarrhea 385 In indigestion the local nervous mechanism of the intestine is stimulated by its abnormal contents, and diarrhea results. Pro- longed stimulation from indigestion may lead to local overexcitability of the nervous mechanism governing peristalsis, and such a condi- tion may remain after the indigestion has been cured by proper dietetic treatment. The result is a continuing diarrhea which is not due to indigestion, but is of nervous origin, which clinically resembles the nervous diarrhea from other causes, except that it is more chronic, and which requires entirely different treatment from the diarrhea caused directly by indigestion. Such a condition of nervous diarrhea may also follow infectious diarrhea. Excitement and fright may disturb the gastro-intestinal function through the nervous system in the same way as extremes of heat and cold. In excitable children, vomiting is often produced by fright and excitement. Nervous disturbances occur both in breast-fed and bottle-fed infants. SYMPTOMS. — ^The two chief symptoms of nervous disturbances of the gastro-enteric tract are diarrhea and vomiting. NERVOUS DIARRHEA.— In nervous diarrhea the stools are increased in number and diminished in consistency. An infant usually has from five to nine loose movements daily. The appear- ance of the stools is normal in every way, except for the more watery consistency. The color and odor are normal, and they do not con- tain curds, undigested masses, mucus, nor blood. The diarrhea may cease spontaneously after one or two days, or, as a result of con- tinuing irritability of the nervous mechanism governing peristalsis, the diarrhea may continue. There may also in infants be an ele- vation of the body temperature at the onset in cases produced by heat, but this usually falls to the normal in twenty-four hours. In older children, especially in the cases produced by cold, there is often a sudden attack of colic, with borborygmus, followed by one or two forcibly expelled loose movements. The attack usually ceases spontaneously unless the children are over-fed. In the type pro- duced by heat there is simply a tendency to frequent loose movements. There is a somewhat more chronic form of nervous diarrhea, which is the type caused by the increased peristaltic irritability left behind after some form of indigestion or infection. This form is quite common, and the symptoms are characteristic. It is marked by the occurrence of an immediate movement of the bowels every time an infant is fed. The mother often reports that " everything he eats goes right through him." The number of movements in twenty- four hours is about equal to the number of feedings, and the physi- cian should suspect this condition in healthy-appearing children, when the number of movements in twenty-four hours is six, seven, 386 Diseases of the Gastro-Enteric Tract or eight, and should inquire if the bowels move with each feeding. This form of nervous diarrhea is produced by the feeding entering the stomach and duodenum, and causing a stimulation of peristalsis which is exaggerated by the condition of the nervous mechanism. The stools in this type are like those of the more acute form, loose, but otherwise normal in appearance. NERVOUS VOMITING.— This condition is occasionally seen in children with excitable, high-strung nervous systems. The precipi- tating cause is usually emotional excitement. Vomiting occurs sud- denly, without nausea or straining, and is usually not repeated. The vomitus consists of the food last taken, and shows no evidence of indigestion. The condition reminds one of the vomiting seen in high bred puppies. DIAGNOSIS. — The diagnosis of nervous diarrhea depends chiefly upon the character of the stools, which show no evidence of indi- gestion, fermentation, or infection. The moving of the bowels with each feeding is a fairly characteristic symptom, but the diag- nosis should not be made without actual inspection of the stools. PROGNOSIS. — The prognosis of both nervous diarrhea and nervous vomiting is good. In some cases, without proper treatment, nervous diarrhea may continue for a considerable time, and may lead to some loss in weight. TREATMENT. — In the acute type of nervous diarrhea, infants should be given a dose of castor oil, one teaspoonful in the first six months, two teaspoonfuls after the age of six months. After the castor oil, the next three or four feedings should be withheld, boiled water being given instead. The object of the castor oil is not so much to empty the bowel, as to produce a maximum stimulus to peristalsis, after which, if food be withheld, peristaltic irritabihty is lessened. During the period of withholding food, bismuth sub- nitrate may be given, in doses of five grains every four hours, and should be continued after feeding is resumed, if there is still any tendency to loose movements. If the diarrhea resists this treat- ment, paregoric should be given as in the more chronic type. In the form of nervous diarrhea due to increased local peristaltic irritability, in which the bowels tend to move after each feeding, small doses of opium act almost like a specific. In this more chronic type, an initial dose of castor oil is not indicated, but paregoric should be given in small doses proportioned to the age of the child. The quantities to be given every four hours at the different ages are the following: — In the first three months, mi; in the second three months. Mil ; in the second six months, mv; in the second year, mx ; after the second year, mxv to xxx, according to age. Nervous Nervous Vomiting and Diarrhea 387 diarrhea is the only form of diarrheal disease in which any opium preparation should ever he part of the routine treatment. Its action in checking peristalsis is specific for this type. In cases in which there is any doubt as to the diagnosis of nervous diarrhea, or any suspi- cion that any indigestion, fermentation, or infection may be present, it is safer not to use paregoric, as in such conditions diarrhea should not be checked. Bismuth may be used in place of paregoric in the doubtful cases. It is less effective than paregoric. In older children, nervous diarrhea may be treated in the same way as in infants. The condition is not so persistent, and usually is reheved by castor oil and the withholding of food. If the diarrhea tends to continue, bismuth is safer than paregoric, as the inspection of the movements does not give such certain information as to ab- sence of indigestion as it does in infancy. Nervous vomiting requires no treatment other than the correc- tion of any faults of hygiene which may be contributing causes of nervous over-excitability. VI. DISTURBANCES OF DIGESTION Disturbances of digestion constitute the most common and im- portant division of the diseases of the gastro-enteric tract in infancy and childhood. GENERAL ETIOLOGY.— A disturbance of digestion may be caused by some single etiological factor, or may be the result of a number of etiological factors acting together. Also, the etiological factors which act in different cases may be entirely different. The physician must be fully familiar with this manifold etiology. Lack of Development. — The great frequency of disturbances of digestion in early life can only be attributed to differences of anatomy and physiology in the child and in the adult. The digestive system of the child, as compared with that of the adult shows a relative lack of development, chiefly in function, though partly in structure. It is true that the functional development of the infantile gastro-enteric tract is designed for and suited to the digestion of human milk. Nevertheless, it is relatively undeveloped, and consequently sensi- tive to the action of other etiological factors, such as improper regi- men of nursing, variations in the breast milk through improper regimen of lactation, errors of hygiene, and other external influences. When the food is not human milk, but is something else, for the digestion of which the infantile gastro-enteric tract is not designed, the factor of lack of development becomes all the more important. The lack of development due to age alone, may be regarded as the constant underlying factor in the disturbances of digestion. It does not act alone, but is the cause whereby other etiological factors pro- duce disturbance in children when they would produce no disturb- ance in adults. Inherited Individual Variations in Digestive Power. — The functional power of digestion is not constant. A number of babies cannot digest the same food because they are of the same age or weight. As suggested in the division on Feeding, there is unlimited variation in the digestive powers and nutritive requirements of dif- ferent individual babies and young children. It is impossible to say how much of this variation is inherited, and how much is ac- quired. There can be no doubt, however, that part of it is inherited, because babies of the same age, under the same hygienic surroundings, and with the same food, often show dift'erent digestive powers and nutritive requirements. It is probable that inheritance plays an important part in the power of the digestive apparatus with which Etiology of the Disturbances of Digestion 389 a baby is equipped at the start of life. Indeed it would be remark- able if it were not so, and the so-called constitutional factor is be- coming constantly more and more important in our conceptions of etiology. Faulty Hygienic Surroundings. — The individual variation in digestive power and nutritive requirements is further increased by the different hygienic surroundings encountered by infants and children. Most of the violations of the rules of hygiene which are requisite for the proper development of young human beings, can react on the digestive system, and are, perhaps, more apt to exercise their unfavorable influence there than in any other part of the body. Bad air, insufficient fresh air, insufficient sleep, improper clothing, faulty care of the mouth and teeth, overstimulation of the nervous system, all these have an effect on the power of digestion. It is easy to see that with a varying inheritance and with varying hygienic surroundings, there can be no limit to the individual variation in the powers of digestion. Sudden External Influences. — The digestive power may be suddenly lowered by influences from outside the body. Whereas faulty hygienic surroundings produce a continual chronic condition of lowered digestive power, these suddenly acting influences produce a temporary or acute lowering of digestive power. The most com- mon of these sudden disturbing influences acting from outside are heat, cold, and exhaustion. In the division on Nervous Disturb- ances of the Gastro-enteric Tract, we have seen how heat can act in deranging the mechanical function of the digestive canal. It can also derange the secretory function, and the result of such derange- ment is indigestion. Extremely hot weather, especially under faulty hygienic conditions, produces a rapid lowering of digestive power. Sudden changes of temperature, sudden chilling of the body, and physical exhaustion, may have the same efTect. These suddenly acting external influences have a great deal to do with many of the cases of acute indigestion which are so common in early life. Disease. — Disease in other parts of the body may exercise an unfavorable influence on the digestive function at all ages, and is particularly liable to do so in early life. Acute diseases will cause a sudden lowering of digestive power very similar to that caused by the external influences just described. Chronic disease will cause a chronic lowering of digestive power very similar to that caused by faulty hygienic surroundings. The Food. — The etiological factors which we have considered up to this point have to do with the digestive powers of infants and children. The most important of all etiological factors, however, is the character of the food given, and tJie manner of its giving. The diges- 390 Diseases of the Gastro-Enteric Tract tive system of the infant is designed for human milk, but, under modern conditions of Hfe, the quahty of human milk is not always what 'it should be. Faulty inheritance, faulty hygienic surroundings, sudden disturbing influences from outside, and disease — all these factors may act upon the mother as well as upon the child. The result of their action on the mother may be an acute or chronic dis- turbance of the function of lactation, leading to a sudden and tem- porary, or gradual and continual, abnormal change in the quality of the breast milk. This may either alone or in conjunction with other etiological factors, produce acute or chronic disturbance of digestion in the infant. Nevertheless, so much more perfectly adapted is human milk to the digestive apparatus of infants, than is any other food, that disturbances of digestion are very much less common in breast-fed babies than in the artificially fed. When the food given to an infant is not human milk, it is a foreign body, as far as the physiology of the infantile digestion is concerned. That such food is a foreign body does not mean that it is necessarily incapable of digestion. Whether or not it is properly digested de- pends largely on its composition. If it is carefully prepared, in accordance with the principles described in the Division on Feeding, it will often be digested as well as if it were not a foreign body. Nevertheless, it is never as good a theoretical food as is human milk, and no matter how carefully it is prepared, one or more of the fac- tors described above, such as inherited weakness of digestion, external disturbing influence, faulty hygiene, or disease, may cause an inability to digest a food which is essentially a foreign body. It is for this reason that disturbances of digestion are so much more common in artificially fed infants, even when the composition of the food is carefully regulated. When the composition of an artificial food is not carefully regu- lated in accordance with the principles described in the Division on Feeding, it is much more apt to act as a foreign body, and hence, not to be properly digested. In some babies, the constitutional power of digestion is so good, that even with food not of proper quality, disturbance of digestion does not occur. More often, how- ever, if some grave offense against the principles of feeding is com- mitted, indigestion will result. In older children, whose diet is more varied, the same principles apply. The quality of the food given may be good, carefully regu- lated in accordance with the proper principles of feeding, and yet the other factors influencing the power of digestion may cause dis- turbance. On the other hand, in children with good digestive power, the quality of the food may be so improper, that indigestion may be produced, and in older children the opportunity for dietetic errors is very great. Etiology of the Disturbances of Digestion 391 Not only is the quality of the food important, but also the manner of its giving. If it be given in excessive quantity, the difificulties attending its digestion are exaggerated, and indigestion may result. Simple overfeeding is one of the commonest causes of indigestion. If the food be given at irregular and improper intervals, this also, is likely to result in disturbance of the function of digestion. It is often difficult to draw a distinction between the food as a factor in disturbed digestion, and the various factors which lower the digestive power. It is a disturbance in the relation of the food given to the digestive power which causes the disease. The cause may lie chiefly or wholly in the food, or chiefly or wholly in the digestive power of the individual child. Bacteria. — The role of bacteria in the disturbances of digestion is one of the unsettled problems in the nutritional diseases of in- fancy. The intestinal canal is normally the home of a great variety of bacteria, belonging for the most part to the class of saprophytes, or at any rate, leading a saprophytic existence, and deriving their nutriment from the food contents of the intestine rather than from the tissues of the host. A certain amount of bacterial fermenta- tion is therefore constant and normal in the intestinal canal. The most generally accepted theory is, that under normal conditions, the numbers of the various varieties of microorganisms are so balanced one against another, that bacterial fermentation not only does no harm, but is possibly a condition essential to proper digestion. It has been shown that in vitro, the growth of many of the varieties of bacteria found in the intestine may be influenced favorably or unfavorably by changes in the chemistry of the culture media on which they are grown. It is probable that a similar eft'ect may be produced in the intestinal canal by changes in the chemistry of the food. Such changes in the chemistry of the food which enters the intestine may be produced by overfeeding with the different food elements, fat, carbohydrate, or protein, or by indigestion in the stomach or intestine. The result of changes in the chemistry of the food would be a disturbance of the normal bacterial balance, an excessive predominance of certain varieties of bacteria over other varieties, and an excess of some particular kind of fermentation. It is conceivable that the same condition of bacterial fermentation of a particular kind might be produced by the introduction from without in the food, of a large number of bacteria belonging to one of the varieties normal to the intestine, or by the introduction of a smaller number of some variety which is not a normal inhabitant. The relative importance of disturbance of the bacterial balance from' changes in the chemistry of the intestinal contents, and from the introduction of bacteria from without, is not known. The evidence 392 Diseases of the Gastro-Enteric Tract is in favor of the greater importance of changes in the chemistry of the intestinal contents, and if this is so, abnormal bacterial changes are secondary to other forms of indigestion. PATHOLOGY. How the Various Etiological Factors Pro- duce Disease. — Disturbance of digestion results from lack of bal- ance between the digestive power and the food given, with or without the added factor of abnormal bacterial fermentation. The changes produced by this lack of balance, with or without fermentation, are for the most part chemical. Symptoms of the disturbance are pro- duced in three ways. They are the following: — 1. Irritation of the mucous membrane. 2. Disturbance of metabolism. 3. Absorption of toxic products. Irritation. — The irritation of the mucous membrane in indiges- tion may be purely mechanical. If a young child eats a quantity of pickles or cucumbers, it is not any chemical change in the food which produces the trouble, but the mechanical irritation of a sub- stance which in the dehcate stomach or intestine of early life, acts as a foreign body. Similarly, if an excessive quantity of casein is not digested, the curds may produce symptoms by mechanical irritation. Very often,, however, it is the chemical changes in the food con- tents which, in indigestion, produce irritation of the mucous mem- brane of the gastro-enteric tract. Excessive bacterial fermentation also may result in the formation of products which are not absorbed, but act purely as chemical irritants. It is impossible to separate the chemical changes produced in the food by pure disturbance of the chemistry of digestion, from those produced by abnormal bac- terial fermentation. The anatomical changes produced by the irritation of the mucous membrane in indigestion are unimportant, and bear no constant relation whatever to the etiological factors involved. Very often there are no macroscopic changes whatever. There may be conges- tion of the mucous membrane, excessive secretion of mucus, or some desquamation of the epithelium. In a few cases of long-standing, or cases in which mechanical irritation was excessively severe, there may be folHcular, or even ulcerative, ileo-colitis, the lesions resemb- ling those seen in -the infections. Disturbance of Metabolism. — The most important effect of indigestion is disturbance of the general metabolism of the body. One of the most important steps in advance in the progress of our knowledge was the recognition of the fact that the function of diges- tion cannot be considered apart from that of the general metabolism. It is to European writers that we chiefly owe this advance. For a Pathology of the Disturbances of Digestion 393 long time they have been classifying functional disturbances of the gastro-enteric tract under the general heading of disturbances of nutrition.* The relation of general metabolic and nutritional dis- turbances to particular food elements led in Europe to the wide- spread acceptation of the idea of a chemical "food injury." The changes in the metabolic processes of the body which are produced by disturbed digestive function, are as yet very imper- fectly understood, and are the subject of much scientific investig- tion at the present day. They are not recognizable by any anatom- ical changes. The most important fact which has been established is that these disturbances of metabolism vary according to which of the food elements is most concerned in indigestion. Disturbance of metaboHsm may be produced by failure of absorption, by the absorption of abnormal chemical products, and by the excessive secretion into the intestine of chemical substances belonging in the circulating blood. The exact nature of the various disturbances is probably very compHcated. The first and principal result of dis- turbed metaboHsm, is disturbance of the general nutrition of the body. A second result is the production of a toxemia, which may be due to a relative increase of some substance normally held in proper balance, or to the formation of toxic metabolic products. The important point to remember is that the disturbances of meta- bolism and their results, produced by indigestion, vary according to the food ele7nent which is in relative excess. Fermentation. — It is probable that every change in the chem- istry of the intestinal contents is accompanied by some abnormality of bacterial life, — some degree of fermentation. It is when the symptoms produced by bacterial fermentation come to dominate the clinical picture, that bacterial processes become important. The products of abnormal bacterial fermentation can act in two ways in producing sj^mptoms. The first is by simple irritation of the mucous membrane of the gastro-enteric tract, and in this way the manner of action is similar to that of the abnormal chemical pro- ducts of digestion, when they irritate the mucous membrane, and the symptoms produced are also similar. The second mode of action is seen when the products of bacterial fermentation, instead of being only locally irritant, are actuall}^ toxic. Their absorption then produces a toxemia, the symptoms of which are much like those of the toxemia sometimes produced by disturbance of the general body metabolism. When bacteria enter the tissues of the intestine, or produce definite lesions, the condition is classified, not under disturbances of diges- tion, but under infection. * Cf. Czerny-Keller. Des Kindes Ernahrung, Ernalirung^krankheiten und Ernah- rungstherapie. 394 Diseases of the Gastro-Enteric Tract CLASSIFICATION OF THE DISTURBANCES OF DIGES- TION. — It is obvious that the disturbances of digestion cannot be classified upon the basis of their pathological anatomy, as in them there are no lesions characteristic of the various causes and pro- cesses. Classification upon the basis of symptoms, is entirely un- scientific. In spite of the manifold etiology, our efforts at treat- ment are directed at removing the cause, and the essential etiologic factors which we have to combat are, relative overfeeding, and bacterial fermentation. We have seen that the disturbances of metabolism produced by indigestion vary with the particular food element which is in relative excess, while an excess of food as a whole may produce indigestion from simple irritation. In some cases, excessive bacterial fermentation dominates the clinical picture. Upon this basis, the following classification was adopted by the Pediatric Department of the Harvard Medical School.* Classification of the Disturbances of Digestion 1. Indigestion from an excess of food. 2. Indigestion from an excess of an individual food element. a. Fat. b. Carbohj'drate. c. Protein. d. Salts. 3. Indigestion with fermentation Finkelstein's Classification. — The disturbances of nutrition associated with, gastro-intestinal symptoms have been looked upon by Finkelstein from a point of view differing somewhat from that on which the above classification is based. His ideas have been so clearly and forcibly expressed, that they have occupied a large place in recent pediatric literature, and have strongly appealed to many pediatrists. For this reason, a brief discussion of his grouping of these nutritional disorders, and of its relation to the classification used in this book, may be useful to some readers. The basis of Finkelstein's classification is the way infants react to food, and the various groups into which he divides infants are based upon their apparent functional capacity. He deduces his theories as to etiology, and the nature of the metabolic disturbances produced, from the reaction to feeding. Finkelstein divides nutritional disorder into four stages, or de- grees, as follows: i. Bilanzstoriing (disturbed equilibrium) ; 2. Dys- pepsie; 3. Dekompbsition; 4. Intoxikation. In the first stage caused by lowered tolerance for fat, that of dis- turbed equilibrium, there is a failure of the normal gain in weight, and fluctuations in the weight curve continue, until either an ad- justment occurs between the food given and the digestive power, or * Morse and Talbot. Diseases of Nutrition and Infant Feeding. The Macmillan Co. 1915. Classification of the Disturbances of Digestion 395 until a more serious stage supervenes. The temperature variations are wider than normal. The tolerance for food is reduced, and attempts to attain a gain in weight by giving more food are not successful, and may produce more serious symptoms. In the second stage, that of dyspepsia, which comes on when the first stage is not ended by proper adjustment, definite symptoms of indigestion are present. The cause is the development of intolerance for carbohy- drate. Diarrhea is the most common symptom, and the stools are green, and contain mucus. There is moderate loss of weight in this stage, and occasional elevation of temperature. The toler- ance for food is still further reduced, as is shown by the fact that attempts to give more food aggravate the symptoms. In the third stage, that of decomposition, the loss of weight is rapid and marked, the temperature is usually subnormal, and the stools are of bad character. The tolerance for food is reduced to a minimum. It should be remarked that when Finkelstein uses the term decomposi- tion, he does not refer to bacterial decomposition of the food in the intestine, but to the decomposition of the tissues of the body which occurs as a result of the food intolerance. The fourth stage, that of intoxication, is reached when there is a complete break-down of all the processes of nutrition, an advanced failure of metaboHsm, with the formation of toxic products. Valuable Features of Finkelstein's Theories. — The various groups described by Finkelstein undoubtedly represent clinical t^^^es commonly seen in mild, moderate, and severe disturbances of nutri- tion. We owe Finkelstein a great debt of gratitude for so vigor- ously calling attention to the fact that a "food injury" causes a disturbance of the entire metabolism of the body. He points out clearly that under certain conditions, the tolerance for certain food elements may be so greatly lowered that even very small quantities may be injurious, and may produce through disturbance of metabol- ism, certain severe symptoms which are in no way dependent upon the action of bacteria. The first three stages represent conditions with which we in this country have long been familiar, though pos- sibly under different names. The description of the fourth stage, that of intoxication, is particularly valuable. We have been too prone in this country to attribute toxic symptoms in nutritional disorders to the results of bacterial processes only, whether of infec- tion or of fermentation. It is, I beheve, a valuable correction to our views, to realize that intoxication can also be produced entirely by disturbance of metabolism. Objections to Finkelstein's Classification. — The principal objection to Finkelstein's classification is that it entirely excludes the other ways that indigestion may cause symptoms, namely, by simple 396 Diseases or the Gastro-Enteric Tract irritation, and by permitting abnormal bacterial fermentation. He regards the protein of cow's milk as practically incapable of pro- ducing injury, yet we know that in young babies, the casein may be the cause of symptoms. The reason he regards the protein as innocuous is that it does not produce severe disturbance of meta- boKsm, but probably acts either by simple irritation, or by producing a disturbance of the bacterial balance. He regards the fat and carbohydrate as mainly responsible for the severer grades of intol- erance. While this is true to a large extent, some of the conclu- sions as to the manner in which the carbohydrate at least causes injury, have not been justified. His entire description of nutritional disorders would apply to what I shall describe as indigestion from excess of fat. The entire exclusion of bacterial fermentation is probably not justified. The relative roles of chemical food injuries affecting metabolism, and bacterial fermentation, are still an unsettled ques- tion, lacking convincing evidence. It is probable that both processes find an important part to play in nutritional disorders. "Alimentary Intoxication." — I cannot leave the subject of the views of Finkelstein and his followers, without some further dis- cussion of the condition described by him as "alimentary intoxica- tion." The condition is familiar to every one, although marked differences of opinion exist as to its cause, and consequently as to the name to be applied to its description. It is characterized by diarrhea and toxic symptoms. Restlessness, sleeplessness, and signs or irritation of the central nervous system are common; frequently stupor comes on, which may deepen into coma. As Howland has pointed out, respiratory symptoms are often present, especially toward the close of the disease. Such symptoms vary from a slightly in- creased ventilation of the lungs to very marked dyspnea. Post- mortem the lesions found are very slight. There are three views as to the cause of this symptom-complex. The first is that of Finkelstein, already mentioned, that the symp- toms are due to intermediary products of metabolism, which are im- perfectly elaborated, and are toxic. He regards the condition as an end stage, in a progressive failure of nutrition. A second view regards the symptoms as due to a relative acidosis. This view is based on the chemical investigation of the disease, first undertaken by Czerny and Keller, which showed that in children with severe watery diarrhea the ammonia content of the urine was much increased. No abnormal acids could be found to account for this, and the acetone bodies are not usually present in any quantity in the urine. Steinitz first showed that there is a great loss of bases, particularly sodium, by the alimentary tract, and that as a result Classification of the Disturbances of Digestion 397 of this a relative acidosis occurs, ammonia being produced or de- flected from its normal role in forming urea, to unite in the urine with the acids which are in relative excess in the blood. This theory has been strengthened by some recent work of Rowland and Mar- riott, who, investigating toxic cases of diarrhea, especially those with dyspnea, found evidence of acidosis as shown by a diminution of the carbon dioxide tension of the alveolar air. They confirmed this evidence by investigations of the acidity of the blood by two methods. They also found in these cases an increased tolerance for alkali, such as is seen in other forms of acidosis. The third view regards the symptoms as due to the absorption from the intestine of toxic fermentation products. This view regards abnor- mal bacterial activity as the primary cause of the diarrhea, and as the chief cause of the symptoms. It is probable that all three theories are true. The toxic condi- tion called alimentary intoxication, is undoubtedly a symptom-complex, not a disease in itself, and can be produced in various ways, by various causes. The theory of a relative acidosis does not concern itself with the original cause which produces the diarrhea, but applies only to the manner in which the symptoms are produced. A rela- tive acidosis is a result of a disturbance of metabolism, and the only question is whether the disturbance leads to the formation of toxic intermediary products, or to a relative excess of acid through loss of alkali. There is no doubt that the latter can occur, that in cer- tain cases, especially those characterized by dyspnea, the symp- toms are a manifestation of acidosis. I believe that in cases with severe watery diarrhea, it is more probable that the symptoms are produced by a relative acidosis than by the intermediary products of metabolism. Such cases are, however, usually acute. Toxic symptoms are often seen in cases of a chronic type, occurring toward the end of a long history of nutritional disturbance. While diarrhea occurs in these chronic cases, it is not so severe as in the acute ones. While the toxic symptoms in this type also may be due to a relative acidosis, I believe that we cannot exclude the possibility that toxic intermediary products of metabolism may also be a cause. The third view, that the symptoms are due to the absorption from the intestine of the toxic products of abnormal bacterial activity, brings into sharp contrast two distinct forms of thought as to gastro- intestinal disease which are prevalent among the pediatrists of this country. One might be termed the chemical view-point, which re- gards all the functional gastro-intestinal diseases such as are classified here as disturbances of digestion, as chemical, both in origin and effects. Chemical food injury, and the resulting chemical disturb- ances of metabolism account for everything. Bacterial processes are neglected. The other view-point might be called the bacteriological, 398 Diseases of the Gastro-Enteric Tract in which an important role is assigned to abnormal bacterial fermentation. I believe that both views are made too exclusive by their sup- porters, and that both factors, the chemical and the bacteriological, play an important part. I believe that the chemical men have gone too far in minimizing the importance of bacteria. On the other hand, we in Boston have always been inclined toward the bacteriological view-point, probably also too exclusively. The following is my personal opinion as to the condition some- times described as alimentary intoxication. It is a symptom-complex having a varied etiology. When it occurs in the course of chronic forms of indigestion, or as an end symptom of a chronic severe nu- tritional disturbance, it is to be explained on chemical grounds. The symptoms are produced by some chemical disturbance of meta- bolism, which is caused by some form of relative overfeeding ("food injury"). The chemical disturbance of metabolism which produces the symptoms may be a relative acidosis, especially if diarrhea be prominent and severe, or it may be a break-down of the intermediary metabolism with the formation of toxic products. When the symp- tom-complex occurs as an acute manifestation, occurring most often in summer, and apparently independent of relative overfeeding, it is to be explained on bacteriological grounds. The symptoms may be produced either by the absorption of the toxic products of fer- mentation, or by a chemical disturbance of metabohsm caused by the diarrhea. In the former case, the toxins are probably due to the activity of proteolytic microorganisms. In the latter case, the disturbance of metabolism is probably due to the loss of mineral salts in the stools which occurs in severe diarrhea, and is a relative acidosis. This view is explained by the following diagram: Chemical Food Injury. (In chronic cases.) Abnormal Bacterial Fermentation. (In acute cases.) [Disturbance of j Intermediary Metabolism \[ fFormation of Toxic Products . (Diarrhea. Loss of I Alkaline Bases fFormation of I Toxic Products [in intestine Relative Acidosis \ I Intoxication (Absorption 1 [Toxic Products J GENERAL SYMPTOMATOLOGY.— The principal symptoms associated with disturbances of digestion are vomiting, abnormal stools or diarrhea, loss of weight, and at times, toxic symptoms involving the nervous system. There is no definite grouping of the symptoms associated with any particular etiologic type of digestive disturbance. Diagnosis of the Disturbances of Digestion 399 DIAGNOSTIC METHODS.— We can only rely to a limited extent upon the grouping of the clinical symptoms in making a diagnosis. The most valuable diagnostic procedure available is the examination of the stools. This gives very valuable information at times, as to which food element in excess is producing the symptoms. The technique of this examination has been described in the general section on diagnostic methods. The information derived from the examination of the stools is not often conclusive, and one must rely on some other means of arri\dng at a conclusion. The most valuable diagnostic indication is often the reaction of the child to the food given. We cannot always form any conclusion as to this point when we first see a case of dis- turbance of digestion. A careful history of the case should always be taken, which should include a description of each food previously given to the child, and of all the symptoms which were present during the period of its administration. Particular inquiry should be made as to vomiting, its frequency and character, as to the daily number and character of the stools passed, as to loss of weight, as to irrita- tion of the buttocks, as to abdominal distention. In order to form conclusions, it is advisable to translate each food given into the terms of its composition as expressed by the percentages of the various food elements. In this way we can know just how much fat, how much and what kind of carbohydrate and protein, were given with each food. With a knowledge of the composition of each food given, of the manner of its giving, and of the symptoms which attended its use, we can often form preliminary conclusions as to the probable type of indigestion with which we have to deal. We then start our treatment on the basis of these conclusions, the first food which we order being considered a sort of trial formula. From this time on we must be guided by the reaction of the infant, as shown by its symptoms and weight curve, and by the results of frequent examinations of the stools. Although abnormal bacterial fermentation is probably the cause of the symptoms in certain cases, yet we have as yet no bacteriological technique by which such processes may be definitely recognized. Our diagnosis here must rest upon the clinical picture, and upon the results of treatment. GENERAL PROGNOSIS.— The prognosis of the disturbances of digestion varies with the type of indigestion present, and with the severity of the case. GENERAL TREATMENT.— The general principle of treatment in the disturbances of digestion is the removal of the cause. The treatment varies somewhat according to whether the disorder is of an acute or of a chronic character. In acute cases, we try first to 400 Diseases of the Gastro-Enteric Tract remove from the gastro-intestinal canal the offending products of indigestion. This is effected by the use of purgatives, enemata, or high irrigation of the colon. We then rest the gastro-intestinal canal, and finally begin the administration of a food which we beheve the patient can digest properly. In chronic cases, the treatment is mainly dietetic from the start, supplemented by the correction of faulty hygienic surroundings. The complete withdrawal of food is not advisable in the treatment of chronic cases. In feeble, atrophied infants even temporary starvation may be highly dangerous. The methods of feeding employed vary with the particular type of case. Drugs have very little place in the treatment of either acute or chronic disturbances of digestion, in early life. The so-called "diges- tants," such as hydrochloric acid, preparations of pepsin, or pan- creatic extracts, are entirely unnecessary. Pepsin, hydrochloric acid, and rennin are never deficient in the gastric secretion, and the pan- creatic ferments are destroyed in their passage through the stomach. The only medicinal agents of frequent value are the purgatives, the best being castor oil and calomel. Castor oil is indicated in begin- ning the treatment of all acute cases with diarrhea, calomel being substituted if the oil is vomited. Calomel is indicated in beginning the treatment of acute cases in which vomiting is the principal symptom. There are certain symptoms which occur in several, or in all forms of indigestion, the treatment of which requires a brief dis- cussion. Vomiting. — Calomel in divided doses should be given at the onset of an acute attack of vomiting. If the vomiting continues after the stomach is rested, sodium bicarbonate, in doses of 2 grains to a tea- spoonful of water, will sometimes help. None of the drugs advocated for the treatment of vomiting in adults, should be used in children. Even bismuth should not be used. Theoretically, bismuth acts by lessening the irritability of the gastric mucosa. In children, vomiting is Nature's eft'ort to get rid of undesirable, undigested food. Bismuth usually will not help the vomiting, and if it does help, it is only masking a symptom which should serve as a guide to the proper dietetic management of the case. Vomiting, when chronic, is best treated by changes in the compo- sition of the food. Sometimes, however, as a result of prolonged irritation from some form of indigestion, the stomach becomes so irritable that it rejects the food even after the cause of indigestion has been removed. Even in cases of this kind, all medicinal treat- ment is usually totally ineffective. The best measure which can be employed, especially in an infant, is daily gastric lavage. When vomiting is so severe that the child is threatened with starvation, General Treatment of Disturbance of Digestion 401 rectal feeding should be instituted, and the irritable stomach should be given a prolonged rest. Feeding through the duodenal catheter is a very valuable resource in some cases. DiARRHEA,^ — -The diarrhea caused by the various forms of indi- gestion is an effort on the part of Nature to rid the body of offending material. Consequently, all measures aimed at checking the diar- rhea are contraindicated. The treatment is that of the cause, and varies with the cause. The drugs particularly to be avoided are the astringents and the opiates. I have entirely given up the use of bismuth in the diarrhea caused by any form of indigestion. A prolonged investigation of the results of the routine use of bismuth, extending through eight years' summer service at the Infants' Hospital Outpatient Clinic, has convinced me that bismuth is of no value in lowering the mortality, lessening the severity of the- diarrhea, or shortening its duration. There were individual cases which appeared to improve under bismuth, but the statistics as a whole showed no favorable action, and it is probable that the apparent improvement was an instance of coincidence rather than of cause and effect. There was, however, no evidence that bismuth does any harm. The injury to the body caused by diarrhea comes from three things, I, loss of fluid, 2, loss of food elements, 3, irritating or toxic products of the indigestion. The checking of diarrhea may dimin- ish the first two causes of injury, but will dangerously increase the third. The loss of fluid can be made up by the giving of fluid by rectum, subcutaneously, or intravenously. The loss of food elements can be made up by careful regulation of the diet. Colic. — This is really the only symptom requiring special treat- ment in infants. It will be relieved by removal of the cause, but often the relief is not immediate. Also when nutrition is progressing favorably, and colic is the only symptom of indigestion, it is often better to treat the colic symptomatically, and not to change the composition of the food. For colic the most effective measure is to give the baby a quarter or a half of a soda mint tablet dissolved in a tablespoonful of hot water. Hot applications to the abdomen will often help. If these measures are not effective, the physician may try a few drops of essence of peppermint, or of brandy, in the same amount of hot water. If this fails, and if the attack is severe, an enema should be given. Only in the most severe and resistant cases is it ever necessary to resort to a few drops of paregoric. Colic is sometimes due to the swallowing of air during nursing. The symptoms can be prevented if from time to time during nursing the baby is held upright and patted on the back until the swallowed air escapes. 26 402 Diseases or the Gastro-Enteric Tract INDIGESTION FROM AN EXCESS OF FOOD ETIOLOGY. — This condition occurs when the food given to an infant or child is too much for its digestive power. The food may be either excessive in quantity, or too rich in quaHty. The dis- turbance may be acute or chronic. Acute Ikdigestion from overfeeding occurs when there is a sud- den disturbance in the balance between the digestive power and the food. Such a condition can occur either from some sudden change in the quantity or composition of the food, or from some sudden lowering of the digestive power without change in the food. In breast-fed babies the various etiological factors influencing lactation, such as disease or emotional excitement, may cause a sudden change in the composition of the breast milk, which occasion- ally may be enough to cause indigestion. In artificially fed babies a change of milk supply, or of the composition of the food, may similarly cause indigestion. Under indigestion from excess of food must also be grouped those cases in older children produced by overeating — "overloading the stomach," as it is sometimes called, — and by the eating of some particular article of diet, such as pickles, cucumbers, hot bread, cake, rich fried things, which is unsuited to the digestive power of a child of that age. Similar articles, un- suited to the digestive power, are sometimes given even to babies. Many cases of acute indigestion have been produced by giving to babies "a httle taste" of some article of diet from the adult table, such as a bite of banana, a bit of candy, or a little piece of cake. Acute indigestion is not always produced by some dietetic out- rage. There may be no indiscretion in the food given to a child, and yet a sudden disturbance of digestion may occur. In such cases the indigestion results from a relative excess of food, and the imme- diate cause must be looked for among those etiological factors which produce a sudden lowering of the digestive power. Among the commonest are heat, cold, emotional excitement, fatigue, and disease. Heat, or sudden changes of temperature in hot weather, are the commonest of these causes. Many of the cases of acute diarrhea of the milder type, occurring in the summer months, are produced in this way, and even in breast-fed babies these mild acute disturb- ances are comparatively common. Chronic Indigestion from an excess of food occurs when there is a continual disturbance of the relation between the food and the digestive power. The food may be too great in amount, may be too rich, or may be given too frequently. The condition is uncom- mon in breast-fed infants. It is more common in the artificially fed, but nevertheless, chronic indigestion from overfeeding as a whole is infinitely less common than is chronic indigestion from an exces- Indigestion from an Excess of Food 403 sive amount of one or more of the individual food elements. It would seem that in chronic indigestion, even if originally produced simply by an excess of food, the digestive power soon begins to dis- tinguish amongst the various food elements, and to show more marked intolerance toward certain ones. SYMPTOMS. Acute Indigestion. — In acute indigestion caused by a relative excess of food, there are two common clinical t}^es, one characterized by vomiting, the other by diarrhea. In the first type there is a sudden attack of vomiting. The vom- itus is not characteristic; in infants it is usually sour, and contains curds. When the attack is caused by some improper article of diet, this appears in the vomitus. If the case is not properly treated, and the vomiting continues, the vomitus may contain bile. The vomiting is not repeated more than a few times, unless feeding is continued. Water is usually not vomited. The failure to with- hold food, especially if food be given soon after vomiting, may cause the symptoms to be continued indefinitely, so that all food, and sometimes even water, may be vomited. The vomiting is accom- panied by nausea, and is often preceded by eructations of gas, and a general appearance of discomfort. There is no elevation of tem- perature, no constitutional disturbance, and no other important symptoms. The stools are not characteristic. In some cases there may be an accompanying diarrhea, but this is not common. In the second type there is an acute attack of diarrhea. The movements are loose, rather large in amount, and vary in number from six to twelve in the twenty-four hours, and are usually free from much odor. They are not characteristic but may show evi- dences of indigestion of any or all of the food elements. Their color is a mixture of yellow, brown, and white, and they have a generally undigested appearance. They may contain some recognizable im- proper article of diet, entirely undigested. There may also be a light greenish color, but the deeper shades of green are not often seen. The stools may be either acid or alkaline in reaction. There may be a small amount of mucus, but blood is seldom present, except in cases in which the attack has lasted a long time. It may be present in rare cases in which some particularly irritating article of diet has been taken. Abdominal pain and vomiting may or may not be present, usually not. The temperature as a rule is normal or only shghtly raised, and the slight fever sometimes seen is of brief duration. As a rule, there is moderate loss of weight. The duration of the attack depends on the treatment, and may be much prolonged by continued giving of a relative excess of food. Chronic Indigestion. — The symptoms of chronic disturbance of the balance between the food and the digestive power are vomiting. 404 Diseases or the Gastro-Enteric Tract an increased number of stools, loss of appetite, colic, eructations of gas, and a failure to gain in weight, or a moderate loss. The vomiting is usually not seen after every feeding. The vomitus and stools are not characteristic, and may show evidences of indigestion of any or all of the food elements. When vomiting is the most pronounced symptom, the bowels may be constipated. The babies are often fussy and do not sleep well, but fever and constitutional disturbance are absent. DIAGNOSIS. — The acute type with vomiting must be distin- guished from vomiting as a symptom of disease elsewhere, and from recurrent vomiting. Most of the diseases having acute vomiting as a symptom are acute infections, and can be excluded by the absence of fever and other physical signs. Tuberculous meningitis sometimes begins with vomiting, before fever or any characteristic symptoms are present. It is distinguished from acute indigestion by failure to react promptly to treatment. Recurrent vomiting is character- ized by the facts that no dietetic cause is ever discoverable, that there has often been a previous similar attack, that the vomiting usually continues to occur when only water or even no food at all are given, and that the urine always shows a strongly positive reac- tion for acetone even at the beginning of the attack. The acute type with diarrhea must be distinguished from other conditions in which acute diarrhea is or may be the most prominent symptom. The most common are nervous diarrhea, acute indi- gestion with fermentation, and infectious diarrhea. Nervous, diar- rhea is excluded by means of the character of the stools, which in indigestion always show some abnormality suggesting disturbed digestion, but which in nervous diarrhea are loose but otherwise normal in appearance. The distinction between the acute diarrhea of indigestion from relative overfeeding, and the acute diarrhea of fermentation, is often very difficult, because a sharp line cannot be drawn between the two conditions. It is probable that all but the mildest cases of simple indigestion are accompanied by a certain amount of abnormal bacterial fermentation in the intestinal con- tents. The symptoms of the two conditions are very similar. The distinction has to be a very arbitrary one, based mainly on the greater severity of the symptoms in acute indigestion with fermentation. The presence of fever, constitutional symptoms, or other evidences of toxemia, would lead the case to be regarded as one of fermenta- tion. If these symptoms are absent, very frequent green or watery stools, possibly showing a frothy appearance characteristic of exces- sive fermentation, or having a very foul odor, would also suggest a process more severe than simple indigestion. In infectious diarrhea there is persistent fever, and the stools show the early appearance Indigestion from an Excess of Food 405 of excessive mucus, or of mucus and blood, while in simple indiges- tion there is no persistent fever, and excessive mucus or blood are uncommon signs, appearing late in the course of the disease. The chronic type of indigestion from an excess of food is distin- guished from the chronic types due to indigestion from the various elements, by the comparative mildness of the symptoms, the absence of characteristic stools, the absence of a reaction to feeding showing intolerance for a particular food element, and the ready response to treatment. PROGNOSIS. — The prognosis of indigestion due to relative over- feeding is usually good. In the type characterized by acute diar- rhea, the disease may pass over into the type due to excessive bac- terial fermentation, or even into infectious diarrhea. Usually, however, it yields readily to proper treatment, as do the acute vomit- ing and chronic types. TREATMENT. Acute Indigestion.— The essentials of treat- ment are, to empty the gastro- ntestinal canal of undigested residue, to rest it, and then to give a food which shall be within the child's power of digestion. In the type characterized by vomiting, calomel should be given, in small divided doses. Calomel is preferable to castor oil whenever there is much vomiting, because it not only empties the intestine, but in divided doses tends to overcome the tendency to reversed peristalsis in the stomach which is causing the vomiting to continue. It tends to start peristalsis in the right direc- tion throughout the gastro-intestinal canal. One-tenth of a grain may be given every half-hour, for five doses to a baby under six months, and for ten doses to a baby between six months and three years ; one-quarter of a grain every half -hour for eight doses may be given to older children. The calomel need not be followed by a cathartic, if the bowels move. In the type characterized by diarrhea, castor oil is preferable to calomel. One teaspoonful may be given to an infant in the first year, and two to an infant in the second year. From the time the calomel is started or the castor oil is given, no food should be allowed for a certain period, although water can be given. In vomiting cases, and in breast-fed babies with diarrhea, food should be withheld for the next two to four feedings, varying with the severity of the case. In artificially fed babies with diar- rhea, food should be withheld for at least twelve hours. Boiled water should be given at the regular feeding time. In older children, with vomiting, only the next meal should be wholly omitted, but if there is diarrhea, it is safer to withhold food for twelve hours. When feeding is resumed, the quantity of food given should at first be far below the normal. In breast-fed infants, the breast may 406 Diseases of the Gastro-Enteric Tract be given for five minutes at the first feeding, for ten minutes at the second, and for fifteen minutes at the third. The breast milk should be diluted by the giving of two teaspoonfuls each of boiled water and lime water immediately before each nursing. This should be continued for some time if there is reason to believe the attack was caused by a change in the character of the milk, and then gradually omitted, unless symptoms recur. In artificially fed infants, who have been previously doing well, the food should be diluted with boiled water and a little lime water. In diarrheal cases, a one-quarter dilution should be given the first day, a one-half dilution the second, a three-quarters dilution the third, and full strength the fourth, unless symptoms tend to recur, when one must proceed more slowly. It is well to boil the milk for the first few days. In vomiting cases, the strength of the food may be increased more rapidly, if no vomiting recurs. In older children, feeding may be begun with boiled milk diluted with barley water, which is increased in the same way, and then other articles are gradually added to the diet. If in an acute case, vomiting continues, the physician should try giving sodium bicarbonate gr. ii in a teaspoonful of water five minutes before each feeding. If diarrhea continues, the whole treatment must be repeated, with a longer period of withholding food, a weaker food at the resumption of feeding, and a slower increase. In my experi- ence, bismuth is of no value in diarrhea of this type. Astringents and opiates are positively contraindicated. Chronic Indigestion. — In chronic cases, and in acute cases which have shown any symptoms of indigestion before the acute attack, no cathartic is necessary, but a new dietary must be given. If the quantity of food is excessive, it must be cut down. If the quantity is not excessive, the food must be weakened. It is best to bring the strength considerably below that which would be suitable for an average normal baby of the same age. The food must be reduced in strength until the baby is free of symptoms; then, if the gain in weight is not satisfactory, it must be gradually strengthened. If symptoms recur before a proper gain in weight is attained, it is probable that there is intolerance of some particular food element, and the physician must determine the t>'pe, by increasing the food elements separately. In older children, cases of simple indigestion from an excess of food will usually do well when the dietary errors which have caused the condition, are corrected. Indigestion from an Excess of Fat 407 INDIGESTION FROM AN EXCESS OF FAT DIGESTION AND METABOLISM OF FAT.— The disturbances due to a quantity of fat in the food too great for the child to prop- erly carry out its digestion and absorption, involve the entire meta- bolism. It is necessary, therefore, in order to understand this form of indigestion, to know something of the normal digestion and meta- bolism of fat, and of the effects of a relative excess. The subject of infantile metabolism is one of the most complicated in the whole domain of pediatrics, and one on which much scientific research work is being at present carried on. The recent literature of the subject is enormous, and while many facts of varying value have been added to our knowledge, the problems involved still remain very obscure. A review attempting to cover what is known of the digestion and metabolism of fat, would take up too much space for a general work on pediatrics. Only the very briefest summary of the facts most essential to the reader will be attempted. Importance of Fat. — Fat is a food element of the greatest im- portance to the infant on account of its high caloric value. It is used as a source of energy — a fuel, and it is difficult, in the feeding of an infant, to make up for a deficiency of fat by increasing the carbohydrate and protein in the food. There are wide variations in the tolerance for cow's milk fat. Digestion of Fat.— While there is a gastric fat-spHtting ferment in the infant, it is probably of very little importance in digestion. The principal digestion of fat is carried out in the intestine, the processes being the same as in the adult. The fat is subdivided by the alkaline salts of the intestinal secretions, and split by the fat- splitting ferments. As a result fatty acids are formed, which com- bine with the alkaline carbonates to form soaps. In the presence of these soaps, the fat is subdivided into still smaller particles. Nearly all of the fat in the food is split, and the weight of evidence suggests that neutral fat cannot be absorbed, and that splitting is a necessary preliminary to absorption. Absorption of Fat. — The form in which the fat is finally ab- sorbed is not definitely known. There is much difference of opinion as to whether the fat is absorbed as fatty acids, as soluble soaps, or as insoluble soaps. The fat enters the blood stream, where it has been demonstrated by the ultramicroscope. In health, with a normally arranged diet, in babies of normal digestive power, the absorption of fat is extremely good. It is prac- tically as good in babies fed on cow's milk as in babies fed on human milk, and the amount absorbed is usually over 90%, and may be as great as 98%. The absorption of fat is lessened in infants with soap stools, and there is a still greater loss of fat in the stools of 408 Diseases of the Gastro-Enteric Tract babies having a diarrhea, whether such a diarrhea is caused by excessive fat, or by some other form of indigestion, such as that from excessive carbohydrate. Fat in the Stools. — Fat is normally present in the stools, in the form of soaps. Practically all of this fat comes from the food, not from the intestinal secretions. The amount of fat normally present in the stools is very variable. In the first few days of life it is very large, as much as 50% of the dried stool, and it gradually diminishes as the babies grow older. The usual amount in later infancy lies between 14 and 25%, although it has been found as high as' 42% in babies apparently normal. Microscopic examinations of the stools for fat consequently have little value in showing excess in the early weeks of life, but in later infancy, they have more value. Efeect of Excessive Fat. — When the amount of fat in the food is in relative excess, either from an excessive amount of fat and normal digestion, or from a normal amount of fat and diminished powers of digestion, there may be an effect on gastric function. It has been shown that an excess of fat has a direct effect on the empty- ing-time of the stomach, retarding it, and leading to gastric stagna- tion, or at times even to selective retention of fat. An excess of fat also delays the secretion of hydrochloric acid and consequently re- tards the occurrence of the pyloric opening reflex, and the closure of the cardiac orifice. Regurgitation or vomiting would naturally result from this action. In the intestine, the eff'ects of excessive fat depend on various factors, among them being the relative amounts of casein and carbo- hydrate in the food, which influence the intestinal flora. When the casein is in relative excess, the prevalent bacteria belong to the putrefactive group, and the result of protein decomposition is that the intestinal contents remain alkaline. Under these conditions, the fatty acids formed from the splitting of the neutral fat combine with the earthy alkahes to form the so-called "soap stools," and calcium and magnesium are lost from the organism. When the car- bohydrate is in relative excess, the acid-forming bacteria predominate, the stools are acid, and the fat combines with sodium and potassium, forming soft, fatty curds. The interference with fat absorption when ''soap stools" are formed, and the consequent disturbance of metabolism, is com- paratively slight, and may or may not be suiflcient to cause a failure to gain, or a loss, in weight. (C/. Finkelstein's Bilanzstorung.) When soft, fatty curds are present, with loss of sodium and potas- sium, the interference with absorption, and the consequent disturb- ance of metabolism are probably greater, and loss of body weight usually results. (C/. Finkelstein's Dyspepsie.) Indigestion from an Excess of Fat 409 In diarrhea there is much loss of fat in the stools, and a type sometimes seen is characterized by acid stools. There is a question whether such a diarrhea results from the irritation of an excessive amount of the lower fatty acids in the intestine — a fatty diarrhea from primary fat indigestion — or whether the diarrhea is caused by some other form of indigestion, such as that from carbohydrate, in which there is increased peristalsis and loss of fat. Probably both conditions can occur. In this condition there is much disturb- ance of metabolism, the tissues of the body are drawn upon to fur- nish the needed fuel, and loss of weight is rapid. (C/. Finkelstein's Dekomposition.) The loss of alkaline salts, especially sodium, may be so great as to cause a relative acidosis, with an excess of ammonia in the urine. In the extreme condition of malnutrition known as infantile atro- phy, or marasmus, there are usually evidences of diminished power of digesting and absorbing fat, as is evidenced by the voluminous literature of the metabolism of this condition. Metabolism experi- ments cannot prove definitely, however, whether infantile atrophy is the cause or the effect of diminished power of digesting and ab- sorbing fat. It seems very probable that in most cases it is an ■effect rather than a cause. Toxic symptoms may develop in the course of fat indigestion. (C/. Finkelstein's Intoxication.) It is not established whether they are due to the relative acidosis sometimes present, or to the toxic products of an extremely disordered metabolism. They are prob- ably not due to absorption of lactose, as was originally suggested by Finkelstein. ETIOLOGY. — With all the known facts about the results of a relative overfeeding with fat, the first cause of a diminished power to digest and absorb fat is not definitely known. Of course, in cases grossly over-fed with fat, the cause of the symptoms is clear, but in cases in which there is present a diminished power of digesting and absorbing comparatively small amounts of fat, the question arises, what is the first cause of this diminished power. We know that in the normal baby the power of taking care of cow's milk fat is good. Yet cases of fat intolerance are seen mainly — almost en- tirely — in artificially fed babies. The question is unsettled. There are various theories. One is that the first injury comes from the chemical composition of the fats in cow's milk, which differs some- what from that of the fats in human milk. Another is that it is the different salt content of cow's milk which causes the first trouble. Still another is that the first injury to digestion and metabolism comes from an excess of carbohydrate, and that this injury lessens the power of digesting and absorbing fat. 410 Diseases of the Gastro-Enteric Tract In any case, whatever the first cause, the condition with which we are confronted is an intolerance toward fat. SYMPTOMS. Clinical Types in Artificially Fed Infants. — The majority of cases of fat indigestion occur in artificially fed in- fants, and therefore the symptoms seen in babies fed on cow's milk will be described first. In the previous history there is often a long story of various symptoms attending various attempts at feeding with artificial food. Sometimes indigestion from fat is seen in very young babies; these are cases which either are grossly overfed with fat, or which have a marked individual intolerance toward fat. More often, indigestion from fat is met with in babies who are somewhat older, and who have a history of previous gastro-enteric disturbance. This previous history may or may not suggest that fat was the cause of the trouble. Often there is a previous history of gross overfeeding with carbohydrate, and symptoms of carbohydrate indigestion. The three principal symptoms of fat indigestion are vomiting, abnormal stools, and failure to gain in weight or, more often, progres- sive loss. There may also be flatulence, colic, and loss of appetite. There may be slight irregular fever, or occasional rises of tempera- ture. The condition is essentially a chronic one. Acute symptoms may arise in the course of a case of indigestion from fat, but are obviously an acute exacerbation in a case which has shown symp- toms of chronic disturbance of digestion for some time. There are four important clinical types in indigestion from fat. These types are characterized respectively by i, vomiting, 2, soap stools, 3, stools containing soft, fatty curds, and 4, loose, green stools. In the first type, vomiting is the principal symptom. It represents the effect of excessive fat in causing delayed emptying time of the stomach with a selective retention of fat. The vomiting does not occur immediately after feeding, except sometimes in long-standing cases, but occurs in the middle or toward the end of the interval between feedings. The vomitus is acid in reaction, and has a strongly sour odor due to the presence of butyric and other fatty acids. It usually contains small, flaky curds. The stools in this type are not characteristic macroscopically, and on micro-chemical examination do not regularly show the presence of an excessive quantity of fat. The frequent failure of the stools to show evidences of excessive fat is due to the fact that the excess is vomited and does not pass through the intestine. Vomiting may occur occasionally in the other chnical types, but in this first type, vomiting is practically the only symptom, except, of course, the loss of weight. In the second type, the clinical appearances of indigestion are not very marked, so that, unless particular notice be taken of the char- acter of the stools, it seems difiicult to account for the failure of the Indigestion from an Excess of Fat 411 infant to gain in weight. The stools macroscopically appear well digested, and are not loose. In color they are usually white, gray, or grayish-yellow, and in size and consistency they are large, hard, and dry. They may have a glistening appearance when mechanically spread upon the napkin. The appearance of the stools in this type is sometimes suggestive, but often does not differ sufficiently from that seen in babies who are doing well to be diagnostic. They rep- resent the "soap stools," in which the fat is in combination with calcium and magnesium. Microscopically, the stools show an ex- cessive amount of fat in the form of soap. Loss of weight is usually slight in this type, and there may only be failure to gain. In the third type, the most common in severe cases, the stools contain many small, soft curds. They may contain considerable mucus also. These stools represent the type in which the fatty acids have combined with sodium and potassium. Sometimes the fatty curds may be so numerous as to give the stool the appearance of curdled milk. Occasionally the stool may be creamy in color and consistency, this representing an excess of neutral fat. Micro- scopically in this third type, the stools show an excess of fat in the form of soap, with or without the presence of free fatty acid. Oc- casionally neutral fat is present. Loss of weight is apt to be marked in this t\^e. In the fourth type the stools are loose, green, and strongly acid. They are apt to cause marked irritation of the buttocks. The fat is in combination with the alkahne salts, and there is usually also free fatty acid. The stools in this type closely resemble those in indigestion from an excess of carbohydrate, or in indigestion with fermentation. In fat indigestion, however, stools of this kind usu- ally represent a somewhat acute exacerbation, supervening upon one of the preceding types. Microscopically the stools show an excess of fat in the form of soap, free fatty acid, and occasionally, some neutral fat. Loss of weight is usually extremely rapid in this type. Reaction to Feeding. — In indigestion from an excess of fat, when the quantity of fat in the food is reduced, an improvement occurs in the clinical symptoms. The amount of reduction necessary to bring about this improvement varies with the degree of fat intol- erance present in the particular case. Sometimes it is necessary to withdraw cow's milk fat wholly from the food, in order to relieve the signs of indigestion. The only exception to the improvement in the clinical symptoms usually following reduction of fat in the food, is seen in the type characterized by vomiting. In this type, the vomiting sometimes continues, even after all fat is excluded. This occurs because the stomach has become so irritable, that the mechan- ical stimulus from the coagulation of the casein, or even from the mere presence of food in the stomach, is sufficient to cause vomiting. 412 Diseases of the Gastro-Enteric Tract This fact should be remembered, as otherwise the continuance of the vomiting greatly obscures the diagnosis. In comparatively mild cases, in which complete exclusion of fat is not necessary for the relief of symptoms, the babies are able to gain weight when the fat in the food is reduced. In other more severe cases, the babies begin to gain in weight only when the fat in the food is completely excluded. Often the gain in weight under both these conditions may be maintained for a considerable time. Usually, however, as these babies improve, their caloric requirements eventually rise, and they become unable to gain in weight unless the caloric value of the food is increased. In comparatively mild cases, after the digestive system is rested, fat can now be increased in the food, or added to the food, in an amount sufficient to maintain a gain in body weight without causing indigestion. In more difficult cases of fat indigestion, the reduction of fat, or exclusion of fat, necessary for the relief of symptoms, does not per- mit a gain in weight. In such cases, an attempt is made to raise the caloric value of the food by increasing the quantity of carbo- hydrate and protein. There are, however, limits varying with the individual, beyond which the carbohydrate and protein cannot be increased without danger of producing serious symptoms of indi- gestion. The carbohydrate is best fitted to assume the role of the fat as a source of energy, but an excess easily produces indigestion, and carbohydrate indigestion tends greatly to increase the intol- erance toward fat. While increase in the protein is less dangerous, this food element is very uneconomic as a source of energy. There- fore, in serious cases of indigestion from an excess of fat, a certain amount of fat is necessary for proper metabolism, yet cannot be utihzed, and we are confronted by the difficult situation of inability to give fat with inability to attain a gain in weight without it. When, in such cases, the amount of fat in the food is increased, the reaction is often deceptive. The addition of fat after complete exclusion, or increase in fat if exclusion was not complete, is often followed by an immediate response in so far as gain in weight is concerned. The babies begin to gain most satisfactorily, and clinical :symptoms of indigestion often do not reappear at once. The stools may take on the macroscopic appearance of ''soap stools," and may even show microscopically an excess of fat in the form of soap. Such stools, however, are not incompatible with continued gain in weight, and the macroscopic appearances may gradually improve, while the microscopic excess of soap may gradually diminish. On the other hand, in these cases, after a variable period of gain in weight, there may occur a sudden appearance of symptoms of indigestion such as vomiting, stools containing fatty curds, fatty diarrhea, or marked increase of soap in the stools, and in such an acute exacerbation, all Indigestion from an Excess of Fat 413 the gain in weight which has been accumulated may vanish within twenty-four or forty-eight hours. Such a sudden reappearance of the signs of fat intolerance is often, for abbreviation, called a fat "blow-up." These "blow-ups" may be serious, accompanied by toxic symptoms, such as high fever, or collapse with subnormal temperature, rapid, deep respiration, restlessness or stupor, and cherry-red lips. The cause of the toxic symptoms is a marked dis- turbance of metabolism, probably an acidosis, as there is increased ammonia excretion in the urine. A fat "blow-up" may be fatal. The management of a case of severe fat indigestion is often very difficult, because the clinical warning of the approach of a "blow-up'* is often very slight. The finding of excessive fat in the form of soap in the stools of a baby who is gaining satisfactorily in weight, is not necessarily the sign of an approaching "blow-up," and if the fat is reduced, the gain in weight will probably cease. If, however, as a result of several micro-chemical examinations of the stools, the quantity of fat is found to be increasing, it is probable that trouble is approaching. Other symptoms indicating an approaching "blow- up" are the reappearance of, or increase in, the vomiting; the ap- pearance of stools containing soft, fatty curds, or of loose, green,, acid stools; the appearance, on microscopic examination, of neutral fat in the stools; a sudden loss of weight, unexplained by clinical symptoms. Clinical Type in Breast-fed Infants. — ^When the quantity of fat in breast milk is excessive, the principal symptoms are vomiting, abnormal stools, and failure to gain, or loss, in weight. The vomit- ing occurs in the intervals between feedings, and the vomitus is often sour, usually without curds, but sometimes containing a substance resembling melted butter. The stools contain small soft curds, are usually acid, and may irritate the buttocks. They are either green in color, or have an oily, glistening appearance. Typical "soap stools" are very unusual. The loss of weight is usually moderate. Loss of appetite, flatulence, and colic, may be present. The symp- . toms are usually not severe. Clinical Type in Older iNFANTS.^There is a peculiar clinical type, particularly seen in the second year of life, in infants who are no longer on an exclusively milk diet. There is usually nothing in the history to suggest overfeeding with fat, or indeed, with any particular food element. There is, however, usually a history of general overfeeding, these cases occurring in infants whose diet has been increased too rapidly, and has become too rich and varied. This should properly produce symptoms of indigestion from an excess of food as a whole, but these symptoms have been overlooked. The occasional acute attacks of indigestion which may have occurred 414 Diseases of the Gastro-Enteric Tract have been attributed to accidental or temporary causes, rather than to persistent overfeeding, and the only marked chronic symptom is undigested stools. The stage of indigestion from simple overfeeding is consequently passed without attracting attention, and the repeated injuries from overfeeding cause the digestive system to show intol- erance toward fat. The symptoms are continued slight fever, restlessness, irritability, and failure to gain in weight. Symptoms pointing directly toward the digestive system are not marked, and although the stools are abnormal, their character does not attract the attention of the child's mother. The stools macroscopically are apt to be large, hard, and dry; microscopically, whenever there is fat in the diet, the stools show excessive fat in the form of soap. If fat is cut out of the diet, the stools improve, and the fever and irritability disappear, but the child is still unable to gain in weight, or actually loses. When fat is added to the diet, the symptoms reappear. Fig. 97 Infantile atrophy. Female, i>2 years old Epeect of Fat Indigestion on Nutrition and Metabolism. — The principal effect of defective power of digesting and absorbing fat, is shown by a general failure of nutrition, which is principally manifested in loss of body weight. The continuous loss of calcium and magnesium in the stools which occurs in many cases, may pro- duce a disturbance in the salt metabolism. There are two particular manifestations of such disturbance seen in two distinct types of malnutrition to be described in the next division, namely, rachitis and spasmophilia; fat indigestion is a frequent contributing cause of both of these. The effect of acute exacerbations in producing an acidosis, has already been described. Sometimes the disturbance of metabolism may be very marked, and the continued loss of weight may lead to the severe condition Indigestion from an Excess of Fat 415 of malnutrition known as "marasmus," or "infantile atrophy." While other forms of indigestion may lead to this condition, the most common is indigestion from excessive fat. The prominent feature of this condition is the progressive and extreme loss of weight, especially of the subcutaneous adipose tissue. The skin is dry and wrinkled, and hangs in folds on the bones, giving the appear- ance of a living skeleton or advanced old age. The bones of the head frequently overlap and the anterior fontanelle is usually de- pressed. The extremities are cool. The abdomen soon becomes sunken. The tongue is dry and usually reddened. The pulse is feeble and usually rapid. The temperature is normal, or more com- monly subnormal, but in some cases is raised. The respirations are generally normal. Although secondary anemia is quite a prominent condition, extreme pallor is not usual. In some cases, although the skin is pale, the blood count shows an increase in hemoglobin and red blood corpuscles, due to concentration of the blood. There is no characteristic change in the leucocytes. The appetite is usually lessened, but may be at times voracious. Fig. 98 Infantile atrophy. Female, 9 months old DIAGNOSIS. — The diagnosis of indigestion from a relative excess of fat depends mainly on two clinical features, first, the reaction of the patient toward the quantity of fat given in the food, and second, the character of the stools. These features have been described under symptoms. There are, however, a number of types in which diag- nosis is particularly difficult. The type in which vomiting is the principal symptom must be distin- guished from a number of conditions in which vomiting is a prominent symptom. Pyloric stenosis and spasm are excluded by the absence of their peculiarly characteristic symptoms, such as visible peristalsis, delayed emptying time of the stomach, and so forth, and by the presence in the vomitus of signs of indigestion. Indigestion from overfeeding may cause vomiting, but the symptom is easily relieved by reduction in the strength of the food, without the occurrence of 416 Diseases of the Gastro-Enteric Tract loss of weight. Indigestion from carbohydrate may cause vomiting^ but there are usually also loose, green, acid, irritating stools, with much gas, and the vomiting is relieved by changing the quantity or variety of carbohydrate in the food. Furthermore the vomitus has not the butyric acid odor characteristic of indigestion from fat. In indigestion from protein, the vomiting usually occurs soon after feeding, the vomitus usually contains large curds, and has no butyric acid odor. In fat indigestion, the confirmation of the diagnosis often depends on the improvement in symptoms following reduction of the fat in the food. In some cases, in which the stomach has become very irritable, no improvement follows when fat is excluded from the diet. In such cases it is difficult to make a diagnosis. One can suspect fat indigestion from the previous history, and this is the commonest cause of such resistant cases. The type characterized by soap stools is sometimes difficult to recog- nize. The indigestion is not conspicuous macroscopically, and a practical problem which frequently arises is this, — is failure to gain in weight a sign that the infant needs a food of higher caloric value,, or a sign that it is getting too much fat for its powers of digestion. The result of the micro-chemical examination of the stools is inval- uable in setthng this question, and is the principal guide in directing the treatment. The type characterized by soft, fatty curds is the one most t}^ical of fat indigestion, and the easiest to recognize. The diagnosis is confirmed by the finding of an excess of soap, often with free fatty acid in the stools on microscopic examination, and by the reaction of the patient toward attempts to feed fat. The type characterized by loose, green, irritating movements is difii- cult to distinguish from indigestion from carbohydrate, and indiges- tion with fermentation. The results of the micro-chemical exami- nation of the stools are not conclusive, as an excessive amount of fat may be eliminated in the diarrhea caused by both carbohy- drate indigestion and fermentation. Indigestion from carbohydrate is, however, quickly relieved by a change in the quantity or variety of the carbohydrate, while in fat indigestion the symptoms are only reHeved by a reduction of the fat. In indigestion with fermentation the diarrhea is usually much more severe than in fat indigestion, and it is not reHeved by a reduction of the fat. In older infants the diagnosis rests entirely upon the results of the micro-chemical examinations of the stools for fat, and upon the effect of the attempts- to give fat. Infantile atrophy due to fat indigestion must be distinguished from similar conditions of malnutrition produced by such diseases as tuberculosis, syphilis, and other forms of chronic indigestion. The first two are excluded by absence of their characteristic diag- Indigestion from an Excess of Fat 417 nostic features. It must be remembered, however, that fat intol- erance is frequently seen in chronic tuberculosis. PROGNOSIS. — The prognosis of indigestion from an excess of fat is very variable. There are the greatest extremes of variation in the degrees of fat intolerance encountered, in the length of time the symptoms have persisted, and in the degree of malnutrition which has been reached. The prognosis depends upon all these factors. As the degree of fat intolerance cannot be estimated until treatment has been attempted, it is impossible for the physician to give a prog- nosis when he first sees a case. In general, in artificially fed infants, indigestion from fat is the most resistant and difficult to treat of all the chronic forms of indi- gestion, and the acute exacerbations which occur from time to time are decidedly dangerous, and may be fatal. When the intolerance toward fat is not marked, and the baby is able to gain with a reduced quantity of fat in the food, the prognosis is good. When, however, the baby shows a higher caloric requirement than can be given him without the production of symptoms of fat indigestion, the outlook is less encouraging. With proper treatment, most of these cases eventually recover, if malnutrition has not become extreme, and if no intercurrent acute disease supervenes, but the physician must recognize that he has a long and arduous struggle before him. In the type described above as occurring during the second year in infants taking a more varied diet, the prognosis is good for eventual recovery, but much patience is needed, and many months are often required. Neither the physician nor the parents must expect either an immediate or a rapid gain in weight, and often the best treatment is that which results in no gain in weight for weeks or even months. In breast-fed babies the prognosis is usually good. TREATMENT. In Artificially Fed Infants. — The principle of treatment is to reduce the quantity of fat in the food to a point at which it will be within the infant's powers of digestion and ab- sorption. This necessarily reduces the caloric value of the food, which must be made up by some increase in the carbohydrate or protein or both. The amount by which the fat must be reduced depends on the severity of the case. Some estimate of the degree of intolerance for fat can often be made from a careful study of the previous feeding of the infant. Even in apparently mild cases it is not wise to begin with more than 2 per cent of fat. In severe cases, i per cent is better, and in any case suffering from acute symptoms, such as diarrhea or intoxication, it is best to cut out the fat entirely. The carbohydrate should not exceed 7 per cent; if there is any suspicion 27 418 Diseases oe the Gastro-Enteric Teact of previous carbohydrate indigestion, it should not exceed 5 or 6 per cent. As to the kind of extra carbohydrate to be added, whether lactose or maltose, I beheve dextri-maltose to be better in general in cases of fat indigestion. This is because maltose is less fermentable than lactose, is more easily absorbed, and is all absorbed in the form of dextrose so that it can be more immediately utihzed for purposes of energy production without having to go through the process of glycogen-storing in the liver. Babies with fat intolerance cannot usu- ally digest more fat when maltose is used than when lactose is used, except in some cases where the fat intolerance has been increased by coexistent carbohydrate fermentation. They can, however, often gain weight on a lower percentage of fat when maltose is used instead of lactose, the reason probably being that with maltose more carbo- hydrate is absorbed and utilized. Sometimes, however, maltose will cause indigestion and the babies will do better on lactose, but this is rare. The maltose may be given in the form of dextri-maltose, or of a malt extract. The former is preferable for routine use as it is less laxative. The protein should be from 1.5 to 2 per cent at the start. The split protein should not be used, as, with our present knowledge of the subject the giving of a large quantity of the whey salts should be avoided. If the baby is able to gain in weight on the first food given, the formula should not be changed, for a time at least. It must be remembered, however, that while the resting of a function leads to recovery and increase of functional power at first, too prolonged rest tends to weaken it. The power of digesting fat can be weak- ened by too prolonged use of a food low in fat content. Conse- quently, even if babies are gaining weight, cautious efforts should be made from time to time to increase the quantity of fat in the food. Such increases should not exceed 0.25 per cent at a time, and should always be controlled by careful examinations of the stools. When a baby is unable to gain in weight on the first food given, or when after a tem.porary gain, the weight becomes stationary, or begins to decHne, the question arises as to whether the inability to gain is due to too low caloric intake, or to the fact that the amount of fat in the food is still excessive. Obviously, if all fat has been cut out, failure to gain must be due to a food too low in calories. If some fat is being given, the question is settled by the symptoms, and particularly by the results of the examinations of the stools. If s>Tnptoms still persist, or if the stools still show fatty curds, or micro-chemically a large excess of fat, the fat must be still further reduced, or cut out entirely. It is essential that at the beginning of treatment the signs of fat indigestion be eliminated. Indigestion from an Excess of Fat 419 Frequent careful examinations of the stools are essential to the proper management of a case of indigestion from excess of fat. Such an examination should be made as a matter of routine, on the second day after every change in the composition of the food, and at other times, every two or three days, until the feeding has become estab- lished. After this a micro-chemical examination should be made once a week. When the physician is convinced that symptoms of fat indigestion have been eliminated by reduction of the fat, and that failure of the patient to gain in weight is due to an insufficient caloric intake, he should first increase the carbohydrate and protein. The carbohy- drate may be raised to 7 per cent, and the protein gradually to 2.5 or 3 per cent, symptoms of indigestion being carefully watched for. Such symptoms are a sign that the limit of tolerance for that par- ticular food element has been passed, and that its quantity must be reduced. If the raising of the carbohydrate and protein within the limits of tolerance do not permit a steady gain in weight, then the fat must be increased. Increase in the quantity of fat must always be grad- ual, not more than 0.25 or 0.5 per cent at a time, and should be care- fully controlled by the results of the micro-chemical examinations of the stools for fat. When, after the increase in the fat, the baby finally begins to gain in weight, no further increase should be made. Even with the baby gaining in weight, the stools should be carefully watched. The mere presence of an excess of fat in the form of soap in the stools is not a contraindication to leaving the baby on the formula on which he is gaining. In such cases, a fat "blow-up" may be ap- proaching, or the baby's digestive powers may be gradually adjust- ing themselves to the quantity of fat which is being given. If, however, the amount of fat in the stools is increasing, and especially if the macroscopic appearance of the stools is becoming worse, or if any other symptoms of fat indigestion reappear, then the fat must again be reduced for a time, even if gain in weight temporarily ceases. A case in which a gain in weight cannot be attained and main- tained under the above outline of dietetic management, comes into the category of a resistant case. Resistant Cases. — The most satisfactory food in indigestion from a relative excess of fat is human milk. Owing to the difficulty in this country of obtaining wet-nurses, human milk cannot be used to any great extent, and comparatively mild cases will often do fairly well with artificial feeding. In any case, however, in which attempts at artificial feeding have shown that the infant belongs to the class •of resistant cases, a wet-nurse should be obtained whenever possible. Moreover, with any case which at the time of beginning treatment 420 Diseases of the Gastro-Enteric Tract is already in a condition of extreme malnutrition, it is better not to waste time with attempts at artificial feeding, but to use a wet-nurse at once, provided one can be obtained. Even if a baby cannot be put entirely on human milk, any amount of human milk which can be obtained is a very valuable adjunct to the treatment. The man- agement of resistant cases under artificial feeding must be described here, because human milk cannot always be obtained. Albumin milk has been widely recommended in the treatment of cases of severe malnutrition. In my experience, babies with fat indigestion cannot take more fat when albumin milk is substituted for ordinary mixtures. Some babies, however, will do better and will gain weight on a lower quantity of fat when albumin milk is used. This is probably due to the form in which the protein is given in albumin milk. The combination of precipitated casein with lactic acid milk, which constitutes albumin milk, is in my experience not essential. In a resistant case I order definite quantities of fat, car- bohydrate, and protein, as before, merely providing that the protein shall be added in a precipitated form in the percentage wliich I wish to give. The quantities of the various food elements may then again be varied in various ways in the effort to attain a proper gain in weight without symptoms of indigestion. Some individual babies appear to do better on lactic acid milk than on precipitated casein. Therefore, if precipitated casein fails, lactic acid milk may be tried. There is no proven method of modifying cow's milk by which the tolerance for fat can be actually increased. The new method of using homogenized olive oil described in the division on feeding, has given some evidence of increasing the power to digest and absorb fat in resistant cases. This method of modifying milk has not yet become generally available, but offers some future promise as a weapon in resistant cases of fat indigestion. One type coming under the heading of resistant cases is that char- acterized by vomiting, in which the stomach has become so irritable and intolerant that the vomiting does not cease even after fat is wholly cut out of the food. In such cases it is probable that the immediate exciting irritant is casein, and the various methods of modifying cow's milk, which aim to make the casein more digestible, should be tried in turn. I have obtained the best results with sodium citrate, given in the amount of 0.4 per cent of the milk and cream; but other alkahes may be tried. The addition of 0.75 per cent starch will sometimes help. Daily gastric lavage is an im- portant adjunct to the treatment in these cases. In some resistant cases, if the physician can reconcile himself to a period of loss of weight, or failure to gain, while keeping the quan- tity of fat in the food very low, and thus avoid symptoms of fat Indigestion from an Excess of Fat 421 indigestion or a fat "blow-up," he will often find that in time the tolerance for fat will have improved and that the patient will finally begin to do better. Treatment of a Fat "Blow-up." — A fat "blow-up" is an attack of acute indigestion from excess of fat. Its symptoms have been described. In such a case, if human milk can be obtained, it should be utilized. If it cannot be obtained, all fat should be cut out of the food. Heaters and stimulation are sometimes required. I have obtained a remarkably good response in certain desperate cases of acute fat indigestion, by the intravenous injections of three or four ounces of a 5 per cent dextrose solution. I am convinced that the sugar will not cause an intoxication, nor add to the toxic symptoms, when given in this way, and that much, if not all of it, is utilized for actual energy production. Treatment of the Type Seen in Older Children. — The general principles of treatment of the type of fat indigestion which occurs in the second year of life, and sometimes in the third or fourth, are much like those used in the treatment of the younger artificially fed infants. The difference is that the physician has at his disposal an increased number of forms in which he can give carbohydrate and protein. The treatment consists in continual minute regulation of the diet, the idea being to give as much carbohydrate and protein as can be given without producing indigestion from an excess of those food elements. The fat must be kept reduced to a point where an excess does not appear in the stools. Under such treatment the children often will not gain for a considerable time, but if patience be exercised, eventually the tolerance for fat will rise, and as soon as they can take a sufficiency of fat, they will begin to gain. The giving of fat must be closely controlled by micro-chemical examina- tions of the stools. In beginning the treatment of such cases, skimmed milk with the addition of some extra dextri-maltose should form the basis of the diet. Other carbohydrate and protein articles of diet should be added, according to the age of the infant. Eventually the cream should be gradually added to the milk. Treatment in Breast-fed Infants. — The disturbance of diges- tion caused by an excessive quantity of fat in breast milk, is usually easily corrected. If the mother has been eating an excessive amount of fat, this should be reduced. Ordinarily, however, the mother has been eating too much in general, rather than too much fat. The amount of her food as a whole should be reduced, and the amount of exercise which she takes out doors should be increased. In the mean- time, the duration of nursing should be shortened, so that the breast may not be completely emptied; it is known that the last milk con- tains more fat. The breast milk may be diluted by the giving of 422 Diseases of the Gastro-Enteric Tract boiled water immediately before each nursing, and this should be continued until the hygienic regulation of the mother has produced a reduction of the fat in the milk. Sometimes, if the duration of the nursing is shortened, it is necessary also to shorten the intervals between feedings, in order that the baby may get enough food. PROBLEMS AND RESEARCH.— The most important problem connected with indigestion from an excess of fat in the food has to do with etiology. The normal baby, when studied experimentally, appears to show no particular difficulty in digesting and absorbing cow's milk fat. On the other hand, babies with a weakened diges- tive power appear to show a special intolerance for cow's milk fat, while the fat of human milk is digested with much greater ease. The question to be solved is whether the inability to digest cow's milk fat is a particular manifestation of general congenital weak- ness of digestive power, or whether it develops as the result of the abuse of the digestive system through faulty methods of feeding. If the latter, what particular errors in feeding are most hkely to pro- duce a diminished power of digesting fat? We only know that an amount of fat too great for the infant's powers of digestion and metabolism causes functional disturbance of digestion and metabolism. We do not know why comparatively small amounts of cow's milk fat often constitute a relative excess. We do not know whether the reason lies in the chemical composition of cow's milk fat, which differs from the fat of human milk, whether it lies in the different salt content of cow's milk, or whether the primary injury comes from some other form of indigestion, which so damages the digestive function, that cow's milk fat cannot be digested. Possibly all these factors play a part. We have learned that inability to digest fat works a far-reaching injury upon nutrition and metaboUsm. Nevertheless, the mechanism of the absorption and metabolism of fat is still very imperfectly understood, and the complete nature of the disturbances caused by an excess is still unknown. We must look to further studies on metabolism with improved technique, and to further advance in physiological chemistry, for the solution of these problems. INDIGESTION FROM AN EXCESS OF CARBOHYDRATE DIGESTION AND METABOLISM OF CARBOHYDRATE.— A summary of the known facts as to the digestion and absorption of carbohydrate is necessary for an understanding of the disturbances caused by a relative excess. Role of the Carbohydrate. — The carbohydrates have two im- portant functions in digestion and metabolism. Their principal use is similar to that of the fat, in that after absorption they serve not Indigestion from an Excess of Carbohydrate 423 as tissue builders, but as sources of energy. The caloric value of the sugars and starches is the same, and is less than that of the fat. A second function of the carbohydrate is exercised in the intestinal canal itself. This function will be described later. Chemistry of the Carbohydrate. — The carbohydrates most used in infant feeding are the three soluble sugars and starch. The three soluble sugars are lactose, or milk sugar, maltose, or malt sugar, and saccharose, or cane sugar. Maltose is not used in its pure form, on account of its cost. The various commercial prepa- rations of maltose are combinations of maltose with various dex- trins, but as in digestion dextrin is converted into maltose, the chemistry is practically the same. These three sugars are all disaccharids, that is, combinations of two simpler sugars called monosaccharids. They may, by the action of ferments, be split into their component monosaccharids. The table shows the composition of the three disaccharids most used in the food of infants and young children. Table 43 Chemistry of the Sugars Lactose Saccharose Maltose Dextrose + Galactose Dextrose + Levulose Dextrose + Dextrose Starch is broken down by the action of ferments into various forms of dextrin, and the dextrin is finally converted into maltose. Digestion of the Carbohydrates. — Although an amylolytic ferment is present in the saliva, even of the new-born infant, salivary digestion is unim.portant in infancy. The carbohydrates are but little acted upon in the stomach, and pass quickly into the intestine, where they encounter the various digestive ferments concerned in their splitting. These are chiefly lactase which spHts milk sugar, invertin which splits cane sugar, maltase which splits malt sugar, amylase which breaks down starch. These ferments are present from birth. They split the carbohydrates into their component monosaccharids . Absorption and the Metabolism of the Carbohydrates. — The carbohydrates, in their more complex disaccharid forms cannot be utilized in metaboHsm. If milk sugar be injected into the circula- tion, it will all be excreted in the urine. If cane sugar be injected, about 65% will be excreted in the urine, and the rest into the intestinal canal. Consequently, the carbohydrates must be absorbed in the form of monosaccharid. The monosaccharids after absorption are taken up by the portal vein, then converted into glycogen, and are stored in that form. 424 Diseases of the Gastro-Exteric Tract Glycogen is stored mainly in the liver, but somewhat in other parts of the body. \Mien the carbohydrate is needed for energy produc- tion, the glycogen is reconverted by the maltase in the blood into dextrose, in which form it is utilized. The final products of carbo- hydrate combustion are carbon dioxide and water. The normal amount of dextrose in the blood is one-tenth per cent. Not all the carbohydrate given in the food can be assimilated. Various figures have been given on the Hmits of assimilation of the difl'erent sugars. These figures are not in any way an accurate measure of the percentage of sugar which can be absorbed and utihzed. They are based on the amount of sugar which can be given to babies without the appearance of sugar elimination in the urine. In my experience, an excessive amount of sugar is not often shown by sugar elimination in the urine. There is no way of esti- mating the proportion of sugar which is not absorbed, because the sugar is not ehminated in the stools in any measurable form. Sugar is not found in the stools, except in diarrhea or other exceptional conditions. The sugar which is not absorbed is broken down b}^ the bacteria of the intestine into a great variety of fermentation products, among them being lactic, butyric, acetic, and succinic acids. Carbohydrate Fermentation in the Intestine. — It is probable that Nature does not intend that aU the carbohydrate in the food shall be absorbed, but designs a certain proportion of it for fermen- tation in the intestine. All the disaccharids are fermentable. It is probable that a certain amount of fermentable carbohydrate is neces- sary for the maintenance of a normal condition of the intestinal flora. It is the normal bacterial fermentation of the excess of carbo- hydrate in the food which keeps the reaction of the intestinal canal acid. Furthermore, it has been shown that an adequate amount of carbohydrate in the food makes the digestion of the protein more complete. This is probably because the normal intestinal bacteria five preferably upon the carbohydrate, and do not attack the protein. The carbohydrates dift'er in the readiness with which they are broken down and absorbed. Maltose is the one most quickly broken down, and consequently is the least fermentable. Lactose is the one least rapidly broken down and absorbed, and is consequently the sugar best fitted to provide a food for the normal bacteria of the intestine, to maintain an acid reaction, and to spare nitrogen. It is probably for this reason that Nature provides that the sugar in human milk is lactose, and that it is as large in amount as seven per cent. Effect of an Excess of Carbohydrate. — As sugar is destined to play a dual role in digestion and metabolism, one being absorption and assimilation, the other being fermentation, it might be expected Indigestion from an Excess of Carbohydrate 425 that an excess of sugar would have two possible effects, one exercised upon the general metabolism, the other exercised locally upon the intestinal function. Many writers have described the eft'ect of the excessive absorption of sugar. It has been believed that sugar may cause fever and intoxication, and this view has been widely held. In the light of the most recent work on the subject, however, it appears that the gi^ang of an excessive amount of sugar in the food is not followed by fever, intoxication, or any other specific eft'ect upon metabolism. It is probable that either the excess is not ab- sorbed, or, if there is increased absorption, all of the sugar is nor- mally utilized. The effect of excessive ingestion of carbohydrate is probably con- fined to the intestinal canal. There is an increase in bacterial fer- mentation beyond the normal. The result is a marked increase in the acidity of the intestinal contents, which increase may involve the whole or only a part of the canal. The increased quantity of acid acts as an irritant to the intestinal mucosa, and this results in an increase of peristalsis. The irritating food is thus removed from the bowel. The nutrition of the child is interfered with, because not only is carbohydrate lost to absorption, but the increased peris- talsis carries out large amounts of fat, protein, and salts which would otherwise be retained and absorbed. Another effect of the excessive fermentation which results from a relative excess of carbohydrate in the food, is the formation of an excessive amount of gas. This may cause abdominal distention, and, extending backward, it may carry irritating acid products into the stomach, and thus cause vomiting. An excess of starch may act in the same way. Starch is broken down slowly, but the maltose which is formed is quickly absorbed. Starch may, however, undergo fermentation, with the formation of irritant acids. While lactose is theoretically the most readily fermentable of the carbohydrates, cases are seen in which excessive fermentation appears to take place more easily with cane sugar, or even with maltose. These cases are probably explained by variations in the prevalence of various varieties of intestinal bacteria. ETIOLOGY. — Indigestion from carbohydrate is caused by the gi\dng in the food of a quantity of carbohydrate too great for the digestive power of the child. The individual variation in the power of sphtting and absorbing carbohydrate met with in different infants and children is due to the causes described under the General Etiol- ogy of disturbances of digestion, x^ctual overfeeding with carbo- hydrate is, however, relatively more important in this condition than is weakness of digestive power. 426 Diseases of the Gastro-Enteric Tract In breast-fed babies indigestion from an excess of sugar is ex- tremely uncommon. In artificially-fed babies the disease is compara- tively common, and it is one of the commonest forms of indigestion seen in older children. In artificially-fed babies overfeeding with carbohydrates is a com- mon fault. It is particularly encountered in babies fed on one of the patent foods. Most of the patent foods which are added to cow's milk mixtures are composed mainly of carbohydrate. These foods are advertised as being particularly beneficial to babies, and mothers are often tempted to increase the quantity of infant food added to the milk, beyond the limits of the physician's order or of the directions accompanying the food, in the hope of increasing the beneficial action. Condensed milk is also frequently associated with carbohydrate indigestion, on account of its high cane-sugar content. There are variations in the susceptibility of infants to overfeeding with carbohydrate in general, and to the several forms of carbohy- drate. Some babies can digest maltose better than lactose or starch, while others can digest lactose or starch better than maltose. The limit of carbohydrate tolerance is extremely variable in different babies, and cannot be categorically stated. In general, it is not advisable to give more than 7 per cent of sugar in the food of an infant, nor more than 1.5 per cent of starch to an infant under one year of age. At times an extreme degree of intolerance toward car- bohydrate in general, or to some particular sugar, most often lactose, is encountered. In older children overfeeding with cane sugar is the most common cause of carbohydrate indigestion. Candy eating is the most frequent form of over-indulgence, but sometimes the eating of an excessive amount of sugar in cocoa or on cereals, or the eating of too much cake or dessert, will cause indigestion in children who are not given much candy. Occasionally, particularly in the second year, indiges- tion is caused by a badly regulated diet, in which there is a relative excess of starchy food. When babies graduate from the breast or bottle, the first articles of diet added are the starch-containing foods. The babies often like these foods so much that they do not take enough milk, thus increasing the carbohydrate in their diet at the expense of the fat and protein. Frequent eating between meals, especially the nibbling of crackers and cookies, is a very common cause. SYMPTOMS. In Artificially-fed Infants. — The symptoms caused by a relative excess of carbohydrate in the food may be acute or chronic. They are due to the fermentation of unabsorbed carbo- hydrate. In the acute cases there is less relation between dietary indiscretions and the symptoms than in chronic cases. It is difficult to say in a case primarily acute, whether the symptoms are due to Indigestion from an Excess of Carbohydrate 427 actual overfeeding, or to some bacterial condition in the intestine which causes a sudden increase in fermentation. In cases primarily acute, bacteria play an extremely prominent part, and the border line between indigestion from overfeeding with carbohydrate, and indigestion with fermentation is not a distinct one. It therefore seems best to describe cases of intestinal fermentation which are primarily acute under the heading of Indigestion with Fermentation, and to confine the clinical description of Indigestion from an Excess of Carbohydrate to cases which are chronic, with possible acute exacerbations. It is mainly in the latter class of cases that a clear history of carbohydrate excess can be obtained. In general the symptoms are the same, whatever the particular carbohydrate which is in relative excess. There are, however, some symptoms which are particularly marked with excess of a particular carbohydrate. The general symptoms of carbohydrate indigestion are vomiting, abnormal stools, excessive gas formation, and loss of weight. The vomiting does not usually occur after every feeding. It does not usually take place right after feeding, but in the interval be- tween feedings. The vomitus is acid in reaction, and may have the characteristic odor of lactic, acetic or butyric acids. Vomiting is a frequent but not a constant symptom, and is never the sole symptom, as it sometimes is in fat indigestion, but is always accom- panied by abnormal stools. The most prominent symptom of carbohydrate indigestion is the passage of characteristic stools. In mild cases the stools are usually somewhat looser than normal, but are not very loose, and are only slightly increased in frequency. In more severe cases, or in acute exacerbations, the stools are loose, or even watery. The stools are usually green in color, the shade varying from light to dark, but in indigestion caused by the maltose-dextrin preparations, they are often dark brown. They may contain mucus. They are very acid, and have an acid odor; sometimes the distinctive odor of lactic, acetic, succinic, or butyric acid can be distinguished. These acid discharges are very irritating to the buttocks, and excoriation of the buttocks and genitals is one of the commonest signs of indiges- tion from an excess of carbohydrate. Loss of weight may be absent in the mildest cases. It is marked in the severer cases in which the stools are more frequent and loose, and is very rapid in acute exacerbations with an actual diarrhea. Flatulence, colic, abdominal distention, and the passage of quan- tities of gas from the rectum, are symptoms often seen in carbohy- drate indigestion. Fever and intoxication are described by most writers as occasional symptoms of indigestion from an excess of carbohydrate. I have 428 Diseases of the Gastro-Enteric Tract never seen a case in which I could attribute these symptoms definitely to an excess of carbohydrate in the food. They are common symp- toms of indigestion with fermentation, but proof is lacking that in cases showing these symptoms, the fermentation involves the car- bohydrates, or that the fever is due to the carbohydrate fermentation. The follomng are the main peculiarities of the symptoms caused by the various carbohydrates: — Lactose is the sugar most likely to produce acute symptoms. The stools are practically always green and very irritating. Flatulence and colic are less prominent. Cane sugar differs from lactose mainly in being less likely to pro- duce acute disturbance. Babies are apt to gain weight on cane sugar, but become pale and flabby. The maltose-dextrin preparations rarely produce acute exacerba- tions. The stools are often dark brown rather than green, and often have a very acrid odor. Vomiting is apt to be more promi- nent. The vomitus often has the odor of butyric acid. Flatulence and colic are more common. Starch produces chronic symptoms only. Vomiting is rarely seen. The stools are much less abnormal, and may even be constipated, dry, brown, and alkaline in reaction. When looser they are brown, and resemble mucus in appearance. They are only slightly acid, have slight if any acid odor, and are not irritating to the buttocks. The principal symptoms of indigestion from starch are colic, which is usually very pronounced, flatulence, and abdominal distention. The babies may gain in weight, but are flabby and pale. That the indigestion is due to starch may easily be recognized by the examina- tion of the stools. The iodine test may be positive macroscopically, and is always recognizable as positive microscopically. Indigestion from an excess of carbohydrate may produce the extreme condition of malnutrition described as Infantile Atrophy. This is particularly the case in infants who have suffered from fre- quent acute attacks, such as will be described under Indigestion with Fermentation. In chronic cases, while the original cause may be carbohydrate indigestion, when infantile atrophy has developed, there is usually also an intolerance of fat. In Older Children. — The type of disturbance from an excess of carbohydrate in older children has been formerly described under the name "Chronic Duodenal Indigestion," because the fermenta- tion occurs mostly in the duodenum, and upper part of the small intestine. The principal subjective symptoms are loss of appetite, abdominal pain, nausea, particularly in the morning, cough, and frontal headache. The principal objective symptoms are bad breath, coated tongue, bad teeth, pallor, loss of weight, prominent abdomen, and clay-colored stools. Indigestion from an Excess of Carbohydrate 429 The children are brought to the physician usually without suspicion on the part of the parent that the condition is connected with diges- tion, or due to improper feeding. Some cases are brought on account of loss of appetite, and failure to gain in weight. These may be the only symptoms. When in addition to these symptoms pallor and cough are present, the parents often suspect tuberculosis. Other cases are brought for "nervousness" or worms. These children are nervous, fretful, subject to headaches, pick their noses, and grind their teeth at night. More than half the cases believed by parents to be suffering from worms have this form of indigestion. In still other cases appendicitis is suspected, because abdominal pain, usu- ally referred to the region of the umbilicus, is the most prominent symptom, and is often associated with morning nausea, though rarely with vomiting. The symptoms vary greatly, and different combinations are present in each case. Loss of appetite is the com- monest symptom; nervousness, abdominal pain, and cough stand next. On physical examination the most constant sign is a prominence of the abdomen in the upper portion. Usually the tongue is coated; often the breath is bad, and the teeth decayed. When cough is present, examination of the throat will reveal enlargement of the lymphoid follicles of the posterior pharyngeal wall. The complexion is pale, sometimes sallow, but the blood does not usually show a marked reduction in hemoglobin. The patients are apt to be nervous, fidgety, very bright mentally, and take a pronounced interest in the conversation when questions of diet are touched upon. In the earlier and milder stages of this disease the stools are not characteristic. In typical cases they are clay-colored, and contain considerable mucus. In pronounced cases they consist of clay- colored balls, coated with mucus. In Breast-fed Infants. — Excess of sugar in breast milk is a very rare condition. The symptoms are similar to those caused by an excess of lactose in artificially-fed infants, but are milder in degree. The principal symptoms are sour vomiting, colic, flatulence, light- green and irritating stools, and sometimes, slight loss of weight. DIAGNOSIS. In Infants. — The diagnosis is based mainly upon the clinical picture, which is more characteristic in this form of indi- gestion than in any other. The acid stools, often loose and green, with the occasional sour vomiting, is fairly characteristic. Irrita- tion of the buttocks is the most important diagnostic sign. This may occur in acute exacerbations of indigestion from fat, but in such cases the micro-chemical examination shows excessive soap, and usually, fatty acids. The diagnosis is often greatly strengthened by a definite history of carbohydrate overfeeding. It is finally confirmed by the immediate 430 Diseases of the Gastro-Enteric Tract improvement which takes place when the carbohydrate in the food is changed in kind, or reduced in amount. In Older Children. — The diagnosis in older children is easily made, if the condition is not forgotten. Whatever the story told by the mother, whether suggesting tuberculosis, appendicitis, or nervousness, the physician can usually by questions eUcit other symptoms characteristic of carbohydrate indigestion. Careful and thorough cross-examination is often required to reveal the existence of over-indulgence in sweets, as mothers are sometimes so bent upon proving that the child has some serious, obscure disease, that they resent inquiries as to candy and cake, and conceal or minimize the dietary indiscretions. Circuitous paths must sometimes be employed in questioning, which will often lead to pennies received from a neigh- bor for running errands, or to visits to a grand-parent. Sometimes only a history of insufficient milk, too much starchy food, or eating between meals can be obtained. Of course the physician, before coming to a final conclusion, must make a thorough physical examination, in order that some more serious condition, such as tuberculosis or appendicitis, may not be overlooked. Usually he will find some of the characteristic signs of carbohydrate indigestion, such as prominent abdomen, coated tongue, or bad breath. If the characteristic clay-colored stools are present, the diagnosis is certain. PROGNOSIS. — Except in the acute types to be described under Indigestion with Fermentation, the prognosis of indigestion from a relative excess of carbohydrate is good. Artificially-fed infants react promptly to proper treatment. When the intolerance involves one particular form of carbohydrate only, the feeding is particularly easy. Even when there is an intolerance of all forms of carbohydrate, the necessary reduction of the carbohydrate in the food can usually be compensated by comparatively shght increases in the fat and protein. Occasionally difficulty will be encountered in babies having a comparatively low fat or protein tolerance, in whom indigestion from one of those elements may be produced. Any marked degree of intolerance toward fat greatly increases the difficulties of treat- ment. Occasionally a case of extreme carbohydrate intolerance is encountered, which makes the quantities of fat and protein required for nutrition too much for the child's digestive power. In these difficult cases the prognosis becomes that of fat or protein indigestion. The power of digesting carbohydrate is recovered slowly, weeks or even months being often required. It is, however, recovered more rapidly than the power of digesting fat. In the type seen in older children the prognosis is very favorable. In no digestive disturbance is so prompt and satisfactory a response Indigestion from an Excess of Carbohydrate 431 to proper treatment seen, provided that the directions of the physi- cian are faithfully followed. It is necessary, however, that great care in the supervision of the diet be exercised for a long time, if recurrence is to be prevented. TREATMENT. In Artificially-fed Infants. — If an infant is suffering from acute symptoms, with an actual diarrhea, it is advis- able to begin the treatment with a dose of castor oil, followed by a period of complete rest during which only water is given. In chronic cases, the treatment is dietary from the start. The first step is to change the kind of extra sugar added in modifying the milk. If milk sugar or cane sugar has been used, a maltose- dextrin preparation should be substituted. If maltose has been used previously, the change should be to lactose. The total percentage of carbohydrate in the food should never be more than 7%, and it is usually better to begin with 5% or 6%. The fat may be 2%, 2.5%, or 3%, according to the age of the child, and the protein 1%, 1.5%, or 2%. If changing the kind of sugar used relieves the symptoms, the child will often gain weight and progress normally without further change. If the symptoms are relieved, but the child does not gain in weight, the fat and protein must be gradually increased, .25% at a time, until either a gain in weight is attained, or symptoms of fat or protein indigestion develop. If changing the kind of sugar added to the food does not relieve the symptoms, there is an intolerance toward sugar in general. The amount of sugar must now be reduced to a total in the food of 3% or 4%. If this does not relieve the symptoms, the extra carbohy- drate must be cut out entirely, which will leave in the food only the quantity of lactose contained in the milk used in obtaining the re- quired protein percentage. If symptoms of carbohydrate indigestion still persist, it is evidence of an extreme degree of sugar intolerance, and must be treated as a resistant case. When, after the quantity of sugar in the food is reduced sufficiently to cause a relief of symptoms, the infant is unable to gain in w^eight, it is usually a sign that the caloric value of the food is too low. The fat and protein must now be gradually increased, until a satisfactory gain in weight is attained. If the extra carbohydrate has been cut out entirely, increasing the protein will necessarily cause a correspond- ing increase in the percentage of the lactose in the food, as more milk is used. If this produces symptoms of carbohydrate indiges- tion, the case comes into the class of resistant cases. If increasing the fat and protein in the food produces symptoms of fat or protein indigestion before a satisfactory gain in weight is obtained, the case is also of the resistant class, but its further management is guided by 432 Diseases of the Gastro-Enteric Tract the principles used in the treatment of indigestion from excess of fat or protein. Resistant cases of indigestion caused purely by the excess of car- bohydrate, are those in which the quantity of lactose contained in the amount of cow's milk needed to furnish the required amount of protein, is too great for the infant's powers of digestion. In these cases the protein is best given in the form of precipitated casein, which permits the total exclusion of lactose for the time being. (See Di\dsion on Feeding.) Such a formula as fat 2.00% — -sugar 0% — protein 1.5% to 3.5% can thus be given. Later a maltose-dextrin preparation may be gradually added to this mixture, raising the sugar percentage 1% at a time. Sometimes in babies showing marked evidences of carbohydrate indigestion, time will be saved if the infants are put at once on lactic acid milk, which is comparatively low in lactose and high in protein, or on a precipitated casein mixture, in which the carbohy- drate may be made still lower, or on a combination of the two (albu- min milk). This may allow more protein to be given at the start, without the production of indigestion. In the resistant cases in which fat or protein indigestion complicate the efforts to treat indi- gestion from sugar, this same measure is the first which should be employed. In cases which have reached a condition of extreme malnutrition, and present the picture of Infantile Atrophy, no time should be wasted with artificial feeding, if human milk can be obtained. The Type Seen in Older Children. — In this essentially chronic type, if the dietary indiscretion has been over-indulgence in cane sugar, this food element must be whoUy excluded from the diet. Parents must be told that the children are to have no candy at all, and no sugar in or upon any article of food. Starches must not be excluded, but in marked cases, they must be reduced to a minimum. The diet should consist of milk, cereal without sugar, meat soups, meat, fish, eggs, bread, and green vegetables. The only dessert allowed should be fruit cooked without sugar. The green vegetables, and those low in starch, such as spinach, asparagus, cauliflower, and string beans are preferable to the starchy vegetables such as peas and lima beans. Very little potato should be allowed in mild cases, and none in severe ones. If the child is too young for so varied a diet, the diet appropriate to its age should be modified upon the same principle — exclusion of sugar, and limitation of starch. If the symptoms apparently have been caused not by an excess of sugar, but by an improper balance between starch and the other food ele- ments, the physician should order a reduction in the amount of starch-containing food, and see that the full quantity of milk appro- Indigestion from an Excess of Protein 433 priate to the diet of a child of that age be given. Also, whatever proteins and fats are permitted by the age of the child should be given. It is essential that eating between meals be absolutely prohibited. The "piece of cracker" and even the "drink of milk" are harmful. The chief difhculty encountered in carrying out this treatment is refusal on the part of the child to eat. A child of two to four years is an adept at bullying its mother into giving what it wants. Firm- ness is required on the part of the mother. She should keep putting before the child at meal times what it should have, and should neither coax the child, nor show any notice of whether it eats or not. If at any time between meals the child complains of being very hungry, the mother must not be moved by any tears or entreaties to give it food. Finally the child will always yield, and the battle is won, but if the mother once gives in, the difficulty will be endless. The treatment of this form of chronic indigestion is much helped by the giving of tincture of nux vomica before meals, in doses usually from one to five minims, according to the age of the child. Consti- pation, if present, must be combatted by appropriate treatment. In Breast-fed Infants. — The symptoms may be temporarily re- lieved by giving the baby a Httle boiled water immediately before each nursing, and shortening the nursing time a Httle. If the mother has been eating an excessive quantity of sugar, this should be cor- rected. If she has not been eating too much sugar, it is probable that she has been eating too much in general. If the total amount of the diet is reduced, and if she takes more exercise in the open air, the excessive sugar in her milk will quickly disappear. PROBLEMS AND RESEARCH.— The question of how much carbohydrate is assimilated is still unsolved. There are many un- solved problems in carbohydrate metaboHsm, for the solution of which we must look to future metabolism work. The most import- ant practical problems in carbohydrate indigestion are connected with the subject of intestinal bacteriology and fermentation. These will be discussed at greater length under the heading of Indigestion with Fermentation. INDIGESTION FROM EXCESS OF PROTEIN DIGESTION AND METABOLISM OF PROTEIN.— A summary of the known facts as to the digestion and absorption of protein is necessary for an understanding of the principles of infant feeding, and of the effects of a relative excess. Role of the Protein. — Protein is the only food element abso- lutely essential not only to the growth of the child, but also to the continuance of hfe itself. Nitrogen is the chemical element used in the formation of new tissue, and in the replacement of the daily 28 434 Diseases of the Gastro-Enteric Tract wear in the tissues of the body, and protein is the only food element which contains nitrogen. No matter how great the number of calo- ries, protein cannot be replaced by other food elements. Every baby has a minimum daily protein requirement, which varies with the individual, particularly in sick babies, but which in general lies between 1.5 and 2 grams per kilogram of the body weight. The adult needs protein only for the repair of tissue waste ; the baby needs protein not only for the repair, but for growth. In the adult the demand for maintenance of the nitrogen equilibrium is powerful, but not so imperative as the demand for fuel, and if the food is in- sufficient in caloric value, protein will be sacrificed and nitrogen will be lost. It is not so with the growing child. The imperative demand is for growth, and if the food is insufficient in caloric value, the baby will continue to utihze protein for growth, will retain nitrogen and sacrifice other tissue elements for fuel as long as possible. Thus an infant, at the expense of its general nutrition, will grow in length while losing in weight. Protein can, however, be used for energy production. Its caloric value is the same as- that of the carbohydrate, but only between one-quarter and one-third is given off as heat. Consequently, pro- tein is very uneconomical as a fuel, and the products of its combus- tion throw a difficult burden on the organs of elimination. It is probable that the products of rapid protein combustion may some- times be toxic. Under normal conditions, the role of protein as a source of energy is small. The mineral salts in the food are also necessary for the building up of the body tissues. They are necessary for the proper retention of nitrogen, and the salt content of the food probably has a very marked influence on the storage of nitrogen. The influence of the carbohydrate in the food on the retention of nitrogen has been men- tioned in connection with the metabolism of carbohydrate. In spite of its high caloric value, fat does not spare nitrogen. Digestion of the Protein. — The ferments necessary for the diges- tion of the protein are all present and active at birth. The pepsin of the stomach, in the presence of hydrochloric acid, spHts the pro- tein into albumoses and peptones. The trypsin of the pancreatic juice, and the erepsin of the small intestine further split these prod- ucts into polypeptids, and finally into amino-acids. Absorption and Metabolism of the Protein. — The protein is absorbed in the form of amino-acids, circulates in the blood in that form, and is reconstructed by the body cells into the various comph- cated constituents of the tissues. These are disintegrated as a result of cellular metabolism, and are excreted chiefly by the kidneys. Indigestion from an Excess of Protein 435 There are a number of end products, the most important of which are urea and ammonia. Under normal conditions the protein of the food is almost all broken down and absorbed, the nitrogen of the feces being derived almost entirely from bacteria. The weight of experimental evidence is in favor of the conclusion that the retention of nitrogen is equally good in breast-fed and arti- ficially-fed infants, and also equally good in sick and healthy infants. Consequently, inabiHty to digest sufficient protein, if the amount needed be given in the food, is not a factor in the nutritional disturb- ances of infancy. Effect of an Excess of Protein. — There is no conclusive evi- dence that the giving of an excess of protein produces any injurious effect upon metabolism through excessive absorption. It is probable that in the adult excessive protein absorption can produce an injuri- ous effect, but in the child, the excess is either not digested and ab- sorbed, or is normally utilized. The principal effect of excessive protein in the food is confined to the gastro-intestinal canal. The disturbance is chiefly caused by the casein. When the quantity of casein given in the food is too great, the curds formed in the stomach by the action of the rennin are large and tough, and difficult of digestion. The undigested curds may act as irritants to the gastric or intestinal mucous mem- brane, causing increased peristaltic action and vomiting. It is possible that an excessive amount of whey-protein may cause a disturbance of digestion. If so, we know little about the nature of the disturbance produced. Foods containing an excessive amount of whey-protein, contain also an excessive amount of lactose and salts. The digestive disturbance seen in such babies usually takes the clinical type of carbohydrate or fat indigestion, and in most instances it is probably caused by lactose or salts. It is possible also that the whey-protein is a particularly favorable culture medium for some of the intestinal organisms belonging to the putrefactive group, and this may explain some of the disturbances seen in babies fed on whey mixtures. The disturbances will be described under Indigestion with Fermentation. Protein and Anaphylaxis. — The disturbances sometimes caused by cow's milk have been attributed to the foreign protein contained in that food. The connection between cow's milk and anaphylaxis has been an interesting field for speculation and experiment. There is no doubt that occasionally a baby is seen who has an idiosyncrasy toward cow's milk, reacting in a manner which makes it very prob- able that the disturbance is an anaphylactic phenomenon caused by the cow's milk protein. 436 Diseases of the Gastro-Enteric Tract ETIOLOGY.^ — Indigestion from excess of protein in the food occurs both in breast-fed and in artificially-fed infants. It is the only form of digestive disturbance seen in breast-fed infants which is at all common. The protein in breast milk is often excessive during the early part of lactation. The probable cause of this excess is that the mother has not yet resumed her normal life, and the equilibrium of her milk has not become established. Most of the causes exercising a deleterious effect upon lactation are more apt to influence the protein-content of the milk than that of the other food elements. Such factors as anxiety, nervousness, fatigue, or lack of sufficient exercise, may all cause an increase in the percentage of protein in the milk. Whether or not the excessive protein-content produces symptoms of indigestion in the baby, depends upon the digestive power of the individual infant. Both in breast-fed and in artificially-fed infants, protein indigestion is most apt to occur in the earlier months, when the digestive power is relatively undeveloped. In babies who are fed on cow's milk mixtures, if the principles of artificial feeding are followed, and if ordinary modifications are used, indigestion from an excess of protein is comparatively rare. When the milk is not properly modified, and when consequently an excessive quantity of protein is actually given, indigestion may be produced, especially in the younger infants. Symptoms referable to protein indigestion are often seen in babies whose digestive power has been injured by overfeeding, or in babies who are given an exces- sive quantity of protein to compensate for a difficulty in digesting fat and carbohydrate. SYMPTOMS. In Breast-fed Infants. — The symptoms seen in breast-fed infants are chiefly vomiting, colic, and abnormal stools. Vomiting is comparatively uncommon; when it does occur, it usually takes place shortly after nursing. The vomitus is not of sour odor, and does not contain the tough curds seen in babies who are fed on cow's milk. Colic and flatulence, on the other hand, are almost constant symptoms, and are often very annoying. The stools are usually increased in number and are looser than normal. Instead of the golden-yellow characteristic of the stools of the normal breast- fed infant, the color in indigestion from protein is a brownish-yellow, and sometimes it is green. Fine curds and considerable mucus are often present. In reaction the stools are usually alkaline, but may be slightly acid, they are not irritating to the buttocks. The odor of the stools is not characteristic. The weight curve may be sta- tionary, or there may be a slight loss. Often, however, a baby even with marked symptoms of protein indigestion, will continue to gain in weight. In Artificially-fed Infants. — The same general symptoms are Indigestion from an Excess of Protein 437 seen in artificially-fed infants, namely, vomiting, colic, abnormal stools, and loss of weight. Vomiting is much more common; it is not seen in every case, but it is usually present in cases severe enough to produce much disturbance of nutrition. The vomiting is apt to occur very shortly after feeding, and the vomitus usually contains large curds, which may be soft, or very tough and leathery. The vomitus has very little if any odor. Colic and eructations of gas are usually present, and are often quite marked. In the majority of cases the number of stools is not increased, and their appearance is normal, except for the presence of large tough curds. In some cases the stools are slightly increased in number, and are looser in consistency, with a brownish color and a pecuUar sticky appearance when manipulated. The stools of protein indi- gestion are usually alkaline in reaction. Their odor is musty or slightly foul. Loss of weight in protein indigestion is usually comparatively sHght. In the type characterized only by the presence in the stools of large casein curds, nutrition is usually not disturbed at all. DIAGNOSIS. In Breast-fed Infants. — The disturbance caused by excessive protein in breast milk is difficult to distinguish from the disturbance caused by irregular or too frequent nursing, on the basis of the chnical symptoms alone. When a breast-fed baby is nursed properly at regular intervals and still has symptoms of indigestion, the probability is that it is the protein which is excessive in the breast milk. Fat indigestion is excluded by the micro-chemical examination of the stools, and carbohydrate indigestion by the absence of acid, irritating discharges. In Artificially-fed Infants, the most important diagnostic symp- toms are the vomiting of large curds, the passage of large, tough curds in the stools, or the existence of brownish, sticky, musty fecal discharges. Indigestion from an excess of fat is excluded by the absence of excessive soap in the discharges; and carbohydrate indi- gestion is excluded by the absence of characteristic acid, irritating movements. The most difficult form of indigestion to exclude is that caused by an excess of food as a whole. When a reduction in the total amount of food given is not followed by clinical improve- ment, and when the symptoms of fat and carbohydrate indigestion are absent, it may be concluded that the protein is the food element at fault. PROGNOSIS. — In breast-fed babies the prognosis is very favor- able, provided that the cause of the excess of protein can be removed. Proper regulation of the hygiene of lactation will remove the cause in the majority of cases. In some cases, the mother's mode of life cannot be properly regulated, and in other cases there is so marked 438 Diseases of the Gastro-Enteric Tract an abnormality of secretion that the protein in the milk will con- tinue in excess in spite of proper regulation of the mother's life. In these cases the prognosis becomes that of artificial feeding in general. In artificially-fed babies the prognosis of a primary protein indi- gestion is very good. The resources of artificial feeding directed toward making the casein of cow's milk more digestible are so numer- ous that good results can usually be obtained by the use of one of them. It is only when protein indigestion is caused by an effort to compensate for some other digestive difficulty by increasing the protein that the prognosis becomes more doubtful. TREATMENT. In Breast-fed Infants.— The breast milk should be temporarily diluted by giving the baby one or two tea- spoonfuls each of boiled water and lime water immediately before each nursing. The mother's diet and mode of life should be regu- lated in accordance with the principles described in the Division on Feeding. She should be prevented from overeating, from fatigue, and from taking insufficient exercise, and should be reheved as far as possible from worry and anxiety. Increasing the length of the intervals between the nursings will often prove of marked assistance. In Artificially-fed Infants. — In the earlier months of infancy the measure of milk modification best fitted to meet difficulty in digesting the protein is the use of a whey mixture. The fat and carbohydrate may be ordered in percentages adapted to the age of the infant, usually about 2% fat, and 6% total carbohydrate. The maximum whey-protein percentage and minimum casein percentage possible should be used — usually about .80% whey-protein and .40% casein. If centrifugal cream from a milk laboratory is used, the casein percentage may be reduced still lower. This treatment is particularly successful in cases characterized chiefly by the vomiting of large curds. In older infants the first step is reduction in the amount of protein in the food, care being taken not to diminish it below the minimum protein requirement of 1.5 to 2 grams per kilo- gram of body weight. If this does not relieve the symptoms, a whey mixture may be tried in older infants also. If this method of modifying the milk is not successful, the further treatment depends somewhat upon whether the chief symptom is the vomiting of large curds, the passage of large curds in the stools, or the passage of brown, sticky, musty stools. When vomiting is the chief symptom the physician should try the addition of one of the alkalies, — lime water, sodium bicarbonate, or sodium citrate, — to the milk modification. These alkalies should be added in the amounts sufficient to prevent the precipitation of the casein in the stomach, — for lime water 50% of the milk and cream ^ Indigestion from an Excess of Protein 439 for sodium bicarbonate 1.7% of the milk and cream, for sodium citrate 0.4% of the milk and cream. The alkalies may be added either to whey mixtures or to mixtures containing unmodified protein. Usu- ally with the alkalies it is best to use the latter. The amount of protein should not be below the average normal minimum protein requirement. If the alkalies are not successful, the physician should try the addition of starch in the amount of 0.75% of the milk and cream. If this is ineffective, he may try giving the protein in the form of precipitated casein, or in lactic acid milk. When the chief symptom is the presence in the stools of large casein curds the following methods are apphcable: — i. Boiling the milk. 2. The addition of starch in a cereal diluent. 3. The addition of one of the alkalies. 4. The giving of protein in the form of pre- cipitated casein, or in buttermilk, or in a combination of the two (albumin milk). 5. Peptonization. It is difficult to say which of these measures will prove most effective in a given case. In infants over sLx months old, the use of a cereal diluent is the method of choice, and if this is not completely successful, the milk may be boiled in addition. In younger infants, boiling should be tried first, and then a cereal diluent may be added. If these measures are unsuccessful, the alkahes may be tried, and the precipitated casein methods kept for a last resource. Peptonization is rarely required. In the type characterized by loose, brown, musty stools, all pro- tein should be excluded from the food for a period lasting from 24 to 48 hours. Casein should then be added little by little. Resistant cases of protein indigestion are usually not encountered except when an effort is being made to treat some other form of indigestion by substituting protein for whatever food element is not tolerated. In indigestion from excess of fat particularly, it is often necessary to give a large amount of protein. Vomiting is a most prominent symptom in these resistant cases, and is usually difficult to treat, because prolonged irritation of the gastric mucosa has made it intolerant toward casein precipitation. These cases will tax all the resources enumerated above as applicable to protein indigestion. PROBLEMS AND RESEARCH.— The amount of research work which is being done in infantile digestion and metabolism in general, is so enormous that it is difficult to indicate particular aspects of the subject in which we may look to the near future for addition to our knowledge which shall be of practical value. Among the un- settled questions are the following: — i. Can the feeding of excessive protein produce disturbance of metabolism through excessive ab- sorption? 2. Are the disturbances in digestion which are often seen in babies fed on whey mixtures due to the whey-protein, or are they 440 Diseases of the Gastro-Enteric Tract due to lactose or salts? 3. What influence does the feeding of exces- sive protein have upon intestinal bacteriology? 4. What role does anaphylaxis play in the disturbance seen in babies fed on cow's milk? In connection with the question as to whether excessive protein absorption can cause disturbance, it is interesting to note some experiments of Holt and Levene, who produced fever in babies by giving a (synthetic) food containing 6% of casein. They called attention to the resemblance between this fever and that produced by Vaughn, by the parenteral injection of protein. Their food, however, contained so large a quantity of mineral salts that it is possible that the salts may have been the cause of the fever. There is some evidence that disturbances of digestion in babies fed on cow's milk may be an anaphylactic phenomenon. Various experiments have shown that when a foreign protein is introduced for the first time into the gastro-intestinal canal of infants, there is a reaction in the body similar to that obtained in active sensitiza- tion and immunization. The present stage of the theory is that, in very young babies, or in sick babies, the cow's milk protein may pass through the intestinal wall without digestive splitting, and may produce the sequence of sensitization and immunity. The relation of this phenomenon to the disturbances of digestion is not very definitely established, except in the peculiar instance of cases showing individual idiosyncrasy toward cow's milk, which are accompanied by such symptoms as urticaria. INDIGESTION FROM AN EXCESS OF MINERAL SALTS PROBLEMS AND RESEARCH.— There is no form of indiges- tion which has been definitely associated with an excess of salts in the food. The important part played by the salts in metaboHsm is well known, and it is probable that they play a part in the digestion and metabolism of the other food elements. It is possible that a relative excess of salts may be a contributing factor in the etiology of indigestion from fat, carbohydrate, or protein. It is even possible that in certain cases the primary injury to the digestive power may come from an excess of salts, but that we are only able to recognize the disturbance when manifested in inability to digest some other food element. Present day investigation is concerned with just such problems as the influence of the salts in digestion, and their role in metaboKsm. Advances in the knowledge of this subject are to be looked for in the near future, and therefore a review of some of the leading known facts about salt metabolism is advisable in any dis- cussion of the subject of indigestion. Role of the Salts. — The role of the salts in metabolism is similar to that of protein, namely, the repair of tissue waste, and the build- Indigestion from an Excess of Salts 441 ing of the new tissue required for growth. The salts are consequently essential not only for growth, but for the continuance of life itself. Metabolism of the Salts. — Both human milk and cow's milk contain a sufficient amount of all the salts needed for normal meta- boUsm in a growing infant, except iron. Both are deficient in iron, and anemia would quickly develop in an infant were it not for the iron stored in the liver during fetal hfe. The part played by the salts in digestion is very complicated, and very little is known of it. They are absorbed from the intestine, and may be re-excreted into the digestive canal; the digestive juices contain salts. There are undoubtedly reactions between the salts and the organic food elements, but these are very complicated, and little is known of the subject. The differences in the salt content of cow's milk and human milk have been discussed in the division on Feeding. It is known that cow's milk contains more ash than human milk, and in what salts the excess lies. It is known that the breast-fed infant absorbs about 80% of the salt content of its food while the artificially-fed infant absorbs from 43% to 78%. A larger amount of the salts is retained in the early months of infancy when growth is most active, than in the later months. Salt retention is better in breast-fed than in artificially-fed infants, in the former, according to Hoobler, between 40% and 50%, in the latter between 0% and 43%. It is probable that the low retention of salts sometimes seen in artificially-fed in- fants, is due to indigestion, as it is known from Talbot and Hill's experiments that in certain conditions with diarrhea there may be an actual loss of salts from the body. The salts are ehminated partly in the urine and partly in the feces. About one-third has been found to be ehminated through the feces when human milk is the food, while one-half is thus elim- inated with cow's milk. Disturbances of Salt Metabolism. — It is known that in nutri- tional disturbances there are very marked changes in the metabolism of the salts. These may vary from slight diminution of retention to such excessive loss of the alkaline salts that a relative acidosis may develop. Problems Awaiting Solution. — Knowing that the salts are concerned in digestion, we assume that a relative excess can cause a disturbance of digestion. There is, however, very little definite evidence. We know that a large quantity of sodium chloride given to a baby may produce a rise of temperature, but only when there is also produced some disturbance of digestion, and therefore no definite effect of the excess of salt is proved. The problems are, can an excess of salts produce a primary disturbance of digestion, 442 Diseases of the Gastro-Enteric Tract and what influence does an excess have on the digestion of the various food elements? Furthermore, what are the more compUcated dis- turbances of salt metabolism seen in severe nutritional disturbances? Practically, in any obstinate form of indigestion, in a baby fed on cow's milk, we can try the effect of diminishing the salts. INDIGESTION WITH FERMENTATION (Fermental Diarrhea) This is a condition in which the most prominent disturbance of the digestive function is caused by excessive bacterial fermentation in the intestinal contents. The term fermentation is used, not in the limited sense in which it is sometimes used to describe carbohy- drate fermentation only, but in its broad sense to describe all the results of excessive bacterial growth and activity. As bacteria are normal inhabitants of the intestinal canal, there must at all times be fermentation taking place there. The bacteria live upon the same food as their human host. A certain proportion of the food ingested is not absorbed, but remains behind to support the microscopic inhabitants of the intestine. We have already seen, in considering the subject of indigestion from an excess of carbohy- drate, that Nature furnishes in the normal food of infants an excess of a fermentable carbohydrate which is comparatively slowly split and absorbed. This leaves behind sufficient sugar to support bac- terial life, and is probably a condition necessary for the maintenance of a normal intestinal bacteriology. It is probable that the amounts of the food elements which are not digested and absorbed must be properly balanced, one against another, in order that normal condi- tions of fermentation shall prevail. When there is indigestion, this balance is disturbed, and consequently the conditions of bacterial fermentation in the intestine become abnormal. It is probable therefore that a certain amount of abnormal fermentation accompanies many cases of indigestion. If this is the case, what is the distinction between simple indigestion and indigestion with fermentation? In simple indigestion abnormal fermentation is only a contribut- ing factor in producing the symptoms of disease. It is not extremely excessive, and does not dominate the clinical picture. The relation of the symptoms of indigestion to relative overfeeding, whether with food as a whole, or with one of the individual food elements, is a prominent feature of simple indigestion. In indigestion with fer- mentation, abnormal bacterial activity is so excessive that it pro- duces the symptoms which dominate the clinical picture. The rela- tion of the occurrence of disease symptoms to a relative overfeeding with food as a whole, or with any one food element, is usually not obvious. The disease appears primarily as a bacterial condition, Indigestion with Fermentation 443 and the manner of its occurrence suggests a variety of concurrently acting causes, among which dietary indiscretion does not necessarily play the chief part. Indigestion with fermentation is not the only disturbance pro- duced in the intestinal canal by bacteria. There is another con- dition, which will be described under the name of Infectious Diar- rhea. The distinction between these two conditions is a somewhat arbitrary one, since both are caused by bacteria. In indigestion with fermentation the organisms concerned all belong to the group of saprophytes, and are capable of producing the same fermentation outside the body. In infectious diarrhea most of the organisms con- cerned are true parasites, requiring a host for their development. In indigestion with fermentation the bacteria do not attack nor seriously injure the tissues of the host; they live on the intestinal contents, and any lesions produced in the intestine are comparatively slight, due to the irritation of their products. In infectious diarrhea the bacteria either directly attack and live upon the tissues of the host, or their products are more markedly injurious; in either case serious lesions are produced in the intestine. Nevertheless the distinction between the two conditions is not very sharply drawn on the etiological side, and must be regarded as somewhat of a con- cession to the demands of the clinical picture. ETIOLOGY. — In almost no aspect of scientific medicine is our knowledge so deficient as in intestinal bacteriology. The subject is so enormously complicated, and its investigation is attended by such excessive technical difficulties, that at the present day we can- not say that more than a beginning has been made in its study. The greatest difficulty is that probably no real light on the subject is thrown by the examination of the fecal bacteria. There is a certain amount of evidence which associates certain varieties of bacteria, such as the butyric acid bacillus, the bacillus putrificus, the bacillus perfringens (Tissier), and the colon bacillus, with fermental diarrhea. The studies of Kendall on bacterial metabolism are interesting and suggestive in connection with this subject. He divides bacteria into three groups, as follows: — i, obligate carbohydrate fermenters, which must have a sufficiency of carbohydrate in order to develop; 2, obligate protein splitters (putrefactive group), which must have protein; (3), facultative organisms, which can live on either carbo- hydrate or protein, but which normally ferment carbohydrate. The products of excessive carbohydrate fermentation are only locally irritating, although disturbance of metabolism, toxic symptoms, and acidosis may be produced as the result of the loss of water, salts, and food elements caused by the diarrhea. The products of exces- sive protein putrefaction may be actually toxic, and may produce 444 Diseases of the Gastro-Enteric Tract symptoms after absorption. The normal condition is one of fairly even balance, carbohydrate fermentation predominating; the facul- tative group subsist on carbohydrate. Carbohydrate fermentation may be in excess, and produce the symptoms. On the other hand protein putrefaction may be in excess, either through the introduc- tion from without of obligate putrefiers, or from the facultative organisms attacking the protein. The actual exciting causes which lead to excessive abnormal bac- terial fermentation in the intestine, are not clearly understood. Probably a number of factors are concerned, some operating in one case, others in another. The disease is most common in the first two years of life. It is extremely rare in babies whose food is human milk. There is no disease in which seasonal influences play so prominent a part, the disease being comparatively rarely seen in the winter and spring, but being very common in the summer and early autumn. Its great prevalence lasts until November. The prevalence of the disease in artificially-fed infants, and in the hot months of the year, has led to the conclusion that the exciting cause is usually contaminated milk. In hot weather there is in- creased opportunity for the development in milk of abnormal organ- isms, particularly of types belonging to the putrefactive group. In spite of the attractiveness of the theory, bacteriological examinations of milk supplies have failed to afford much evidence of its truth. There is no doubt that the introduction of abnormal organisms in milk is one of the exciting causes of indigestion with fermentation, but it probably does not play a part which is in any way exclusive. Indigestion with fermentation can occur in infants who are fed from a milk supply known to be of the best, and even in infants fed on milk which has been pasteurized or sterilized. In such cases we must look to some disturbance of the digestive function as the precipitating cause of the disease. Even with the little which we know about intestinal bacteriology, it is easy to conceive how a sud- den disturbance of the digestive function might alter the quantity and quality of the fermentable food residue in the intestine, in such a way as to markedly disturb the bacterial balance and permit exces- sive abnormal fermentation. Nevertheless, the acute and often severe disturbances which characterize indigestion with fermenta- tion are rarely associated with overfeeding with a particular food element. Overfeeding with carbohydrate will produce signs of ex- cessive acid fermentation, but usually not the severe acute disturb- ance which is often seen in summer when there has been no dietary indiscretion. Relative overfeeding with the different food elements is common at all times of year, and cannot account for the preva- lence of indigestion with fermentation in hot weather. Indigestion with Fermentation 445 In all forms of indigestion in which excess of food plays a part, the excess is relative. Sometimes the precipitating factor is actual overfeeding, while at other times it is a sudden lowering of the diges- tive power. We have seen already that the latter factor is par- ticularly likely to produce acute disturbance, and that the most common cause of sudden lowering of the digestive power is heat. We know nothing about what actually takes place in the intestine under such circumstances, nor whether the changes produced in the intestinal contents differ from those produced when the cause is actual excess of food. It is possible, if not probable, that the changes produced when the digestive power is suddenly lowered are different, and are of such a character as particularly to disturb the bacterial balance, and to cause excessive fermentation. Such a theory would account for the prevalence of indigestion with fermentation in sum- mer, and would make it the same in etiology as many cases of indi- gestion from excess of food as a whole, with the additional bacterial element. PATHOLOGICAL ANATOMY.— In indigestion with fermenta- tion, the anatomical changes seen in the intestine are comparatively shght. In the majority of cases coming to autopsy, all that is seen is a congestion of the blood-vessels of the mucous membrane. In some cases a mild catarrhal inflammation is seen, with increased formation of mucus, and a little cellular exudation. One prominent feature of the disease is that there is no relation between the severity of the anatomical changes and the severity of the clinical symptoms; In the most severe cases, with pronounced toxic symptoms, no ana- tomical changes may be found in the intestine, while some catarrhal inflammation may be present in cases which cHnically are of the mildest character. In very severe cases the tissues of the body in general are drained of water. There may also be degenerative changes in the parenchy- matous organs, particularly in the liver and kidneys. Necrosis is the lesion I have seen most often in the liver. Otitis media, bronchitis, bronchopneumonia, and pyelitis are often seen as secondary complications in severe cases. SYMPTOMS.— This disease is usually acute. The constant symptoms are diarrhea and loss of weight. Other symptoms often, seen are fever, vomiting, and symptoms of toxemia aft'ecting the nervous system. The severity of the clinical manifestations is very variable. Even in mild cases, however, the diarrhea is usually more severe than in indigestion from an excess of food. The Mild Type. — In the mild type of the disease, the diarrhea is the principal symptom. The infant begins suddenly to have frequent loose movements. The number of movements in twenty-four hours 446 Diseases of the Gastro-Enteric Tract may vary from eight to twenty or thirty. The appearance of the stools varies according to whether the process is one of carbohy- drate fermentation, or of protein putrefaction. Usually in the mild type, the symptoms are due to an excess of the acid forming organisms, and consequently the stools are green in color, acid in reaction and odor, and irritating to the buttocks. They are usually watery in consistency, are sometimes frothy in appearance, and often contain small, soft, fat curds, or a considerable amount of mucus. Vomiting is uncommon in this comparatively mild type. Loss of appetite is usually present. There may be a moderate febrile reac- tion in the beginning of the attack, but the temperature rarely goes above ioi° F., and the fever rarely persists for more than one or two days. Toxic symptoms are absent. Loss of weight is always present, varying with the severity of the diarrhea; it may be marked, even in comparatively mild cases. The Severe Type. — In the severe type the severity of the diar- rhea may not be any greater than in the mild type. In some cases, however, the diarrhea is much more severe, the bowels moving so frequently that the number of movements in twenty-four hours is not counted. In these cases, whenever the infant is changed, a watery stain is found on the napkin. The stools are usually very watery, though occasionally they may have a more fecal consis- tency. They are often frothy. In color they may be green, brown, or yellowish-brown. The color of the stools is not necessarily an indication of whether the organisms producing the disease belong to the carbohydrate-splitting group, or to the protein-sphtting, putre- factive group. It is probable that severe cases can be produced by both types of organisms. Brown, dark-brown, or yellowish-brown stools suggest proteolytic bacterial activity, but it is probable that green stools may also occur in putrefactive conditions. If the stools are acid in reaction and odor, irritate the buttocks, and contain mucus, the evidence points toward abnormal activity of the organisms which ferment carbohydrate. If the stools are alkaline, with a foul, putrid odor, and contain neither curds nor mucus, the evidence points to abnormal activity of the proteolytic group. The value of this evidence has not, however, been conclusively proved by bac- teriological investigation. In the severe type vomiting may be present or absent, moderate or severe. It is in no way characteristic. Fever is usually present at the beginning of the attack. The elevation of temperature may be moderate, or, in severe cases, it may reach 104° F. in the first twenty-four hours. Fever rarely persists for more than a few days, and in many severe cases, as the disease progresses, and before the other symptoms have improved, the temperature may be persistently Indigestion with Fermentation 447 subnormal. In some cases a subnormal temperature is the rule after the first twenty-four hours. In other cases moderate fever may persist for a week or more. Loss of weight is always rapid and severe. The urine is usually diminished in quantity. A leucocytosis, usually not over 20,000, is usually present. It is not characteristic, as it may be either higher, or absent entirely. Toxic symptoms are frequently seen in severe cases of indigestion with fermentation. These symptoms may be produced either by the absorption of the products of protein putrefaction or by the chemical disturbances of metabolism caused by the loss of water, salts, and food elements. This disturbance is probably most often a relative acidosis. The most common severe symptom in indigestion with fermenta- tion is marked prostration. The infant may appear excessively feeble, with cold extremities. Collapse may occur at any time. These patients have a peculiar hollow, sunken appearance of the eyes, a sort of "abdominal expression" resembling that seen in gen- eral peritonitis. They take Kttle notice of their surroundings, and may be actually comatose. Their hmbs feel markedly relaxed. In this stage the temperature is very apt to be subnormal. In other cases there are signs of toxic irritation of the nervous system. Marked restlessness is common, and muscular twitchings are often seen. Even convulsions may occur. The nervous symp- toms may be those of meningeal irritation, with rigidity of the neck, retraction of the head, inequality of the pupils, exaggerated knee- jerks, Kernig's sign, Brudzinski's neck sign, and so forth. Any symptom characteristic of meningitis may be present. In some cases there may be excessive vomiting. The temperature is variable in this stage; it may be subnormal, moderate, or, in some cases, there may be hyperpyrexia. In severe cases death may occur at any period of the disease, usually with all the signs of collapse and circulatory failure. In cases which recover, relapses are fairly common in hot weather, even in infants who are carefully fed. Infants who have survived fre- quent acute a'ttacks of indigestion with fermentation present toward the end of the summer a fairly characteristic picture. They are greatly emaciated, presenting the picture of infantile atrophy. Their skin feels dry and wrinkled. They have a subnormal temperature— - and cold extremities. The buttocks are irritated; their eyes are hollow and sunken. Such cases are liable to collapse and death at any time. DIAGNOSIS — There are two conditions characterized clinically by acute diarrhea, from which indigestion with fermentation must be distinguished. These are indigestion from an excess of food as 448 Diseases of the Gastro-Enteric Tract a whole, and infectious diarrhea. It is known that a certain amount of bacterial fermentation occurs in simple indigestion, and the dis- tinction is mainly one of degree. In simple indigestion the diarrhea is not severe, fever is usually absent, toxic symptoms are absent, loss of weight is less marked, and the stools are undigested. The movements in simple indigestion may be somewhat green in color, but they are not watery, frothy, or foul, and contain curds or un- digested masses. In infectious diarrhea there is fever and toxic symptoms, but the character of the stools is wholly different. They consist mainly of mucus, or at least contain an excessive amount of mucus, and often contain specks or streaks of blood, and sometimes pus. They do not show much evidence of fermentation. The fever in infectious diarrhea is usually much more persistent, though the initial tem- perature is often not so high. The forms of indigestion caused by relative overfeeding with the various individual food elements may at times have diarrhea as a symptom, but those forms are essentially chronic, and the diarrhea only appears as a temporary phenomenon in a case which has been exhibiting chronic symptoms. Carbohydrate indigestion is the form showing the greatest tendency to diarrhea, but in cases giving a defi- nite history of carbohydrate overfeeding, the diarrhea is not so severe as in the primary type classified as indigestion with fermentation. In any case occurring in summer, with the sudden appearance of severe diarrhea, and watery, green, or foul stools, acute indigestion with fermentation is the most probable diagnosis. No satisfactory method has been worked out by which the- diag- nosis of indigestion with fermentation can be confirmed by a bac- teriological examination of the stools. With the methods of exami- nation at present available, the stools show no constant or char- acteristic bacteriological findings. Cultural methods are only of value in excluding infectious diarrhea. PROGNOSIS. — The frequency of occurrence, and the severity of indigestion with fermentation is variable in different* parts of the country. In any one locality the frequency and severity of the disease vary greatly in different summers. I have known summers when I have seen more deaths from indigestion with fermentation than from infectious diarrhea. The prognosis depends greatly on the treatment. Mild cases may easily be converted into severe ones by improper treatment, and severe ones may be made fatal. With proper treatment the prog- nosis of mild cases due to excessive fermentation of carbohydrate is very good. In severe cases, with toxic symptoms, the prognosis is always grave. It is especially serious in the type characterized Indigestion with Fermentation 449 by dark brown stools with a foul or musty odor. When severe cases survive the first three or four days they usually recover from that particular attack. Recurrence often occurs in hot weather, unless the greatest care be taken; unless faulty hygienic surroundings can be corrected recurrence is almost certain. An infant may survive several attacks, and finally succumb to an attack occurring in the autumn. Bad treatment greatly increases the gravity of the prog- nosis. I have seen a single dose of paregoric in a comparatively mild case followed by death from toxic symptoms within a few hours. TREATMENT. Routine.— The first step in the treatment of every case of acute indigestion with fermentation is to empty thor- oughly the intestinal tract. Castor oil is the best purgative which can be used for the purpose. One teaspoonful may be given to infants in the first three months, two teaspoonfuls from three to eighteen months, and three teaspoonfuls to older infants. Children should take from a dessertspoonful to a tablespoonful, according to age. If the castor oil is vomited, calomel should be given, to babies in the first year in doses of one-tenth of a grain every half hour for ten doses, and in the second year in doses of one-fourth of a grain every half hour for six doses, and to older children in doses of one- fourth of a grain every half hour for eight doses. Two hours after the last dose, two or three teaspoonfuls of milk of magnesia should be given. From the time of giving the castor oil, or of beginning the calomel, the giving of all food should be stopped for from twelve to twenty- four hours. If food be given, the emptying of the intestine will be useless, and the castor oil or calomel might just as well not have been given. Many mothers have learned that castor oil is good routine treatment for acute diarrhea, but have not learned that to be effective it must be followed by a period of withholding food. During this period water must be given freely, in a quantity at least equal to the quantity of fluid which the baby would take if it were receiving its ordinary food. The water may be given in the bottle or from a cup, as preferred by the child, and may be either warm or cool, according to the taste of the child. If sufficient water be not taken, it must be given with a spoon, and if there is still difficulty in getting in the desired quantity, it must be given through a tube. It may be sweetened with saccharin, if taken better that way. The length of the period of withholding food should not be more than twenty-four hours. When lactic acid milk is available, it need not be more than twelve hours. If for any reason lactic acid milk cannot be used in the treatment of the case it is usually better not to give milk in any form for a second twenty-four hours. During this period barley water may be given. 29 450 Diseases of the Gastro-Enteric Tract After twelve hours, usually, feeding should be begun with lactic acid milk made, if possible, from a culture of the lactic acid bacillus which has known anti-putrefactive properties. The lactic acid milk should be made from fat-free, or skimmed milk, and should not be heated after the process of "ripening," in order that living bacilH may be given. Lactic acid milk may be tried first undiluted. If it causes vomiting, or if curds appear in the stools, it may be diluted. Basis for Treatment with Lactic Acid Milk. — I beHeve lactic acid milk to be by far the best routine treatment for cases of fer- mental diarrhea. The object to be attained by treatment is the inhibition of abnormal bacterial activity, and the restoration of normal bacterial conditions in the intestinal canal. The abnormal bacteria cannot be completely removed by purgatives, and will con- tinue to ferment all food given, unless combatted in some other way. Intestinal antiseptics are absolutely useless, because they cannot be given in doses large enough to kill the bacteria without injuring the patient. The offending microorganisms cannot be removed by irrigations of the colon, because they are situated mainly in the small intestine, and the fluid in a colon irrigation does not go above the iliocecal valve. There are two ways in which the abnormal bacterial activity which is causing the disease can be checked. One is by the intro- duction into the intestinal canal of microorganisms antagonistic to the offending micro5rganisms. The other is by altering the chem- ical composition of the food in such a way as to provide a culture medium unsuitable for the abnormal fermentation which is present. Many years ago Tissier showed at the Pasteur Institute at Paris, that the bacillus bifidus, an organism normally present in the intes- tine, has an inhibitory action on the bacillus perfringens, which he found in certain abnormal conditions. The B. bifidus, however, being an anaerobe, was not suited to cultivation for therapeutic purposes, and Tissier advocated the use of the lactic acid bacillus in fermental diarrhea. Since then, considerable evidence of the value of the lactic acid bacillus in inhibiting the development of various microorganisms has been brought forward. Metchnikoff demon- strated its value in inhibiting the growth of many of the saprophytes of putrefaction. Not only is it effective against the B. perfringens, and other bacilH of the gas-forming group, but there is evidence that it is effective against many proteolytic types, and against the B. acidophilus. If it were possible in fermental diarrhea to know just what type of microorganism was causing the disturbance we would know just when to use the lactic acid bacillus. This is impossible with our present diagnostic methods. We know, however, that protein putre- faction is one dangerous form of bacterial activity. We cannot be Indigestion with Fermentation 451 certain in any case whether the disturbance is caused by proteo- lytic or by carbohydrate-sphtting organisms; if by the latter, carbohydrate is contraindicated, and protein should be given. It would not be safe, however, to give protein, unless we could guard against a possible increase in proteolytic bacterial activity. By giving a food containing great numbers of living lactic acid bacilli, we can prevent excessive proteolytic activity through the antago- nistic action of that organism. Lactic acid milk not only contains great numbers of lactic acid bacilli, but is relatively low in carbo- hydrate and high in protein. It is therefore an ideal food for the treatment of a condition in which we can never be sure of the exact character of the abnormal bacterial processes in the intestine. If the case is one of protein putrefaction, the lactic acid bacilli will antagonize the proteolytic organisms, and bring about a normal bacterial balance, while the carbohydrate in the food and the protein, protected from attack, will nourish the patient. If the case is one of excessive carbohydrate fermentation, we are using a food rela- tively high in protein and low in carbohydrate, which is just what is needed. The only reason for using a lactic acid milk which does not contain fat is that in the presence of lactic acid the fat globules tend to run together in the form of butter, which is difficult of digestion. If the best results are to be obtained, it is essential that a culture of the lactic acid bacillus be used in ripening the milk which is of known antiputrefactive value. There are many strains of the lactic acid bacillus, and all are not of equal value for therapeutic pur- poses. There is evidence that the so-called Bulgarian bacillus is a valuable strain, but other strains have been isolated which have given evidence of equally strong antagonistic action against various organ- isms. It is best if possible, always to use a strain of which the anti- putrefactive action has been tested. The lactic acid bacilli should be given alive, in some fluid medium. They are, in my experience, not as effective when some dry prepara- tion in tablet form is used, as when bouillon cultures are used. The bacilli may be given directly to the patient in the form of bouillon cultures, but in my experience it is much better to use either butter- milk, or ripened modified milk. The latter is really the most rational method, as it allows the chemical composition of the food to be fitted to the digestive requirements of the individual infant. The advantage of giving lactic acid bacilli in the food rather than in the form of bouillon cultures is, first, that in the former way greater numbers of the bacilli are administered; second, that more lactic acid, which itself has an antagonistic action against certain forms of abnormal bacterial activity, is present; third, that the protein is already precipitated in a very finely divided form, being consequently 452 Diseases of the Gastro-Exteric Tract easier of digestion; and fourth, that the ripening process lowers the percentage of carbohydrate by converting some of the sugar into lactic acid. It is obvious why ripened milk given for the treatment of fermental diarrhea must not be boiled or pasteurized after the addition of the culture. Alterxatr^e Treatmext. — In case treatment with lactic acid milk is either not available, or fails to be followed by a favorable result, the only way in which abnormal bacterial fermentation can be inhibited is by making some change in the character of the food. In selecting a food for these cases the physician must form an idea from the clinical symptoms as to whether the abnormal fermentation involves the carbohydrate-sphtting group of organisms, or the pro- teolytic. Unfortunately such a conclusion can never be positive, until some method of accurate bacteriological diagnosis is discovered. It is, however, the only available basis of treatment, as the changes which are made in the composition of the food depend on which form of fermentation is present. In this disease therapeutic progress has outstripped progress in diagnosis. When the cUnical evidence, green, acid, irritating stools, and so forth, points toward excessive abnormal carbohydrate fermentation, the milk should be modified as for the treatment of carbohydrate indigestion. . The food should be low in carbohydrate, not more than 3% or 4%, and maltose is usually preferable to lactose as being less fermentable, unless the baby has been previously fed on a food containing maltose. The percentage of fat should also be low, 1% or 2%, because excessive carbohydrate fermentation often leads to great difficulty in digesting fat, and to the disturbance of metabolism caused by fat indigestion. The percentage of protein should be high, 2% to 3%. When the clinical evidence, browm, musty or foul stools, and so forth, points toward excessive protein putrefaction, the percentage of protein should be low, at first not more than 0.5%. The per- centage of carbohydrate should be high, 6% or 7%, and the extra sugar added should be lactose, not maltose. The fat may be from 1% to 2%, In very severe cases, obviously due to proteolytic organ- isms, when lactic acid milk is not available, or has failed, all protein should be excluded for twenty-four hours, and the infant may be fed during this period on a 6% lactose solution. Theoretically, if the organisms are of the butyric acid forming type, the fat in the food should be very low. Such a condition is difficult to recognize chnically. If, however, the stools should have a distinct butyric acid odor, fat should be entirely excluded from the food, and the carbohydrate should be low in percentage. CoNTRAiNDiCATioxs IN TREATMENT. — In the feeding of cases of Indigestion with Fermentation 453 acute indigestion with fermentation, certain foods should not be used. Prominent among the contraindicated foods are whey, whey mixtures, albumen water, and beef juice. Whey and whey mixtures are high in lactose content, and are therefore bad if the abnormal fermentation should involve the carbohydrate. In conditions of protein putrefaction, whey, albumen water, and beef juice all seem to increase markedly the severity of the symptoms. This is very probably because the soluble albuminous protein contained in these foods is a more favorable culture medium for proteolytic organisms than is casein. Another reason for avoiding albumen water and beef juice is that there is some evidence that in acute diarrheal con- ditions the foreign egg and beef protein may pass unchanged through the intestinal wall, and may sensitize the baby. The opiates and astringents are positively contraindicated at the onset of fermental diarrhea. The checking of the diarrhea at this time by any such method necessarily leads to accumulation of fer- mentation products, and may greatly increase the toxemia. The use of opium will be spoken of in the treatment of certain severe types. Treatment of Resistant Cases. — ^When treatment with lactic acid milk fails to bring about an improvement in the symptoms of fermentation, the failure is probably due to one of three causes. I. The lactic acid milk may cause protein indigestion manifesting itself in vomiting or curdy stools. 2. The carbohydrate in the lactic acid milk may not be sufficiently low to inhibit sugar fermentation. 3. The lactic acid bacilli may not have an effective inhibitory action against the organisms causing the abnormal fermentation. In the first condition the lactic acid milk must be given diluted. If dilution is not successful, the milk must be modified as described above under alternative treatment. The second condition is. suggested when the stools continue to be green, acid, and irritating to the buttocks. In such a case a com- bination of lactic acid milk and precipitated casein, such as albumin milk, should be tried. This retains the advantages of lactic acid milk, while permitting further reduction of the carbohydrate. Car- bohydrate can be almost entirely excluded by the use of precipi- tated casein. The third condition is suggested by a continuance of the original symptoms. Albumin milk may be tried. If it is unsuccessful, the case should be treated with ordinary milk modifications as described above under alternative treatment. Dietetic After-treatment. — ^When the symptoms due to fer- mentation have been promptly relieved, the baby will sometimes gain in weight rapidly. This is due to increased water retention, the drained tissues re-supplying themselves with water. A very rapid 454 Diseases oe the Gastro-Enteric Tract gain in weight, or gain in weight without rehef of symptoms, should always be looked upon with suspicion, as it may be due to edema. Some infants will gain in weight for a considerable time on lactic acid milk or on albumin milk. In such cases the diet should not be changed until the patients begin to show a failure to gain properly in weight. Many infants, in spite of relief of symptoms, will not gain on lactic acid milk. Failure to gain on lactic acid milk, or on albumin milk, means usually a deficiency of fat, of carbohydrate, or of both fat and carbohydrate. In albumin milk, the fat and carbohydrate can be increased by the addition of cream and sugar in proportions sufficient to gradually raise the percentages of those food elements. When lactic acid milk has been used, it is better not to add the cream and sugar to the lactic acid milk, but to begin with alternate feedings of lactic acid milk and some ordinary milk modification. Gradually the lactic acid milk may be dropped, and the diet may be arranged in accordance with the ordinary principles of feeding. If indigestion develops the food must be modified to meet the indications. If recurrence of fermentation develops, the treat- ment must be begun over again, and the return to a normal diet must be more cautious. Treatment oe Alimentary Intoxication. — In cases showing the symptom-complex often described as "alimentary intoxication" some modifications of the routine treatment must be made. If the infant has been having severe diarrhea for a considerable time, with very frequent watery stools, and a retracted abdomen, the intestines are already as empty as they can be made, and a purgative may in- crease the loss of water and salts, and possibly act as an additional irritant, without any compensating benefit from the removal of fer- menting food residue. In this condition, therefore, the preliminary emptying of the bowel should be omitted. The rest of the routine treatment in feeding should be followed, but feeding with lactic acid milk may be begun at once. In these toxic cases it must be remembered that the symptoms may be due to two causes, one being the absorption of toxic products from the intestine, the other being the occurrence of a relative acidosis from loss of alkaline bases. (See diagram, p. 398.) We rely on the antagonistic action of the lactic acid bacilli to relieve the first form of toxemia, and its effect is sometimes very striking, especially in cases caused by the activity of the proteolytic t3^e of organisms. In the second form of toxemia the indications are to check the excess- ive loss of salts in the stools, and to neutralize the relative acidity of the blood. In either case the severity of the disease is much increased by the loss of water from the tissues. In all severe cases, with toxic symp- Indigestion with Fermentation 455 toms or collapse, one of the chief therapeutic indications is to supply the tissues with as much fkiid as possible. The giving of fluid by- mouth is often much interfered with by vomiting or by a continuance of the diarrhea, and fluid must therefore be suppHed in other ways. It may be given by rectum, continuously by the drop method. (See Division II, section on General Therapeutics.) The fluid is often not well retained and absorbed when given by this method. Fluid may be given subcutaneously when not retained by rectum. At times however, in very sick infants, its absorption is very slow. In the most severe cases it is best given intravenously. Not more than four ounces of fluid should be given intravenously at any one adminis- tration to a baby under one year. In cases in which the toxic symptoms are not relieved soon after feeding with lactic acid milk is begun, or in which the symptom-com- plex is strongly suggestive of a relative acidosis, an alkali is indicated. The symptoms suggesting an acidosis are severe watery diarrhea of the acid-carbohydrate type, concentrated urine full of ammonia, and any dyspnoea. Sodium bicarbonate may be given by mouth in doses of 40 to 60 grains (3 or 4 grams), half an hour before each feeding. When the sodium bicarbonate produces digestive disturbance, is not retained, or when, on account of the severity of the case, sure and quick action is desired, sodium bicarbonate should be given intra- venously, in doses of 5 or 6 grams (60 to 90 grains), diluted with 4 ounces of water. The injections should be repeated, as indicated by the reaction to the treatment, and by the symptomjS. I have entirely discarded the subcutaneous method of giving bicarbonate of soda. It is likely to produce necrosis of the tissues, and in infants, the use of the longitudinal sinus has made the technique of intra- venous injections so extremely easy, that I have adopted the intra- venous route whenever I wish to give fluid or medication quickly. For a description of the technique, the reader is referred to Division II, p. 166. When the diarrhea does not quickly respond to dietetic treatment, opium is the only drug which will check the excessive loss of water and salts. It has always been taught that opium is very dangerous in fermental diarrhea. If the symptoms are due to the products of excessive fermentation opium is dangerous, as the checking of peris- talsis leads to the increased retention and absorption of toxic pro- ducts. In a case of alimentary intoxication, however, when the bowels are empty, and when either no food is being given, or a food designed to antagonize excessive fermentation, the diarrhea may have become habitual, and the loss of water and salts may be a more serious menace than is toxic absorption. Therefore, in a resistant case, with continued severe diarrhea, large watery stools, retracted abdomen, and toxic symptoms suggesting a relative acidosis, opium 456 Diseases of the Gastro-Enteric Tract may be cautiously tried. It is best given in the form of paregoric, in small doses proportioned to the age of the child, a few drops being given after each loose stool. Treatment of Special Symptoms. — The special symptoms re- quiring treatment are collapse, toxic nervous irritation, and excessive vomiting. When severe prostration and collapse occur, the best stimulant is fluid. In infants it is best given intravenously, into the longi- tudinal sinus. Normal salt solution may be used, or, if the baby has shown symptoms suggesting acidosis, sodium bicarbonate should be given in sterile water, as described for the treatment of alimen- tary intoxication. I beHeve the collapse in many cases is due to failure to absorb enough energy-producing food. Infants in collapse need fuel as weh as water and alkah. I have recently tried giving dextrose intravenously in cases of this kind. A quantity equal to one-sixtieth of the body weight of the child of a five per cent dextrose solution may thus be given. In some cases some of the dextrose is excreted in the urine, but in my experience part of it is always actually used for energy production, and in some cases it has all been used, none having been excreted in the urine. The use of dextrose may be combined with sodium bicarbonate. Other stimulants which may be used in collapse are adrenaHn, in doses of 1 to, 5 minims intravenously, strychnine subcutaneously in doses of i/iooo to 1/200 of a grain, caffeine sodium-benzoate or salicylate in doses of 1/8 to 1/2 a grain subcutaneously, and camphor in oil in doses of i to 2 grains intravenously. Alcohol is contra- indicated in collapse. For the toxic nervous symptoms, such as restlessness or signs of meningeal irritation, sodium bromide is the best drug. It is best given by mouth in doses of 5 grains, repeating in two hours as often as is necessary to control the symptoms. If the fontanelle is bulg- ing, lumbar puncture will often give relief. Ice bags to the head should not be used unless there is high fever, and then cautiously. For excessive vomiting the stomach should be washed out with a solution of sodium bicarbonate, one teaspoonful to a pint of water. This may be repeated daily. Little else can be done for this symp- tom, as nutrient enemata will not be retained. VII. INFECTIONS INFECTIOUS DIARRHEA The distinction between indigestion with fermentation and infec- tious diarrhea has been discussed under the former disease. Etio- logically it is not a very definite one, because both diseases are caused by bacteria. In infectious diarrhea the bacteria, instead of developing only in the intestinal contents, enter the intestinal wall, and produce definite lesions of the tissues. It is probable also that in infectious diarrhea, as in many other infections, bacteria may actually penetrate the blood vessels and enter the general circulation. The chief distinction, however, is one of pathological anatomy. It has been urged against the distinction, that in numerous cases in which the bacillus dysenteriae was actually demonstrated as the cause, there was little anatomical change other than slight hyper- plasia of the lymphatic tissue of the intestine. This condition fre- quently occurred in the report of Flexner and Holt on the dysentery bacillus. It is, however, only found associated with dysentery in- fection in cases which succumb very rapidly, before there is time for the formation of pronounced lesions. On the other hand, in the cases of the type described as acute indigestion with fermentation, the disease can run a long course without the production of demon- strable intestinal lesions. Infectious diarrhea has been frequently described under a different terminology, being called ileo-colitis. The basis for this terminology is the lesions produced in the intestinal mucosa. The lesions, how- ever, are not peculiar to infection with the various forms of bacteria which cause the clinical picture of infectious diarrhea, but are seen in other diseases of known etiology. An ileo-colitis occurs in typhoid fever, in tuberculous disease of the intestine, and sometimes even as the result of prolonged irritation from some form of indigestion, or from the taking of some particularly irritating article of food. The term ileo-colitis therefore can only be properly used to describe, a certain form of pathological anatomy in the intestine which may be produced by various causes. For the association of the lesions of ileo-colitis with a more or less definite form of infection, and a very definite symptom-complex, infectious diarrhea is the best avail- able term. ETIOLOGY. The Bacteria. — The microorganisms which have been associated with infectious diarrhea are the following: — i, the 458 Diseases of the Gastro-Enteric Tract various strains of dysentery bacillus; 2, the gas bacillus and similar organisms; 3, the streptococcus, in various strains; 4, the bacillus pyocymieus; 5, a few other organisms in rare cases. There is no doubt that the bacillus of dysentery is the most fre- quent cause of infectious diarrhea. Its etiological connection mth the disease has been proven beyond any question. The various types or strains of the dysentery bacillus need not be described here. The original Shiga type, first described by Shiga as causing the ordinary acute dysentery of Japan, has been found in this country in acute cases of summer diarrhea. The Flexner t}^e is the com- monest in temperate chmates. In a report from the Philippines, Ohno has shown that there are at least fifteen varieties of bacillus dysenteriae, all closely related to one another both in morphology and pathogenicity. The bacillus of dysentery cannot usually be demonstrated in the stools of normal infants. The few cases in which it has been found in normal stools can be explained on the ground of a recent previous attack of diarrhea. The bacillus of dysentery, in one of its strains, has been found in as large a propor- tion as 90% of all cases of infectious diarrhea, in some investigations. The figures in different reports depend greatly on the skill of the investigators. The proportion of cases of infectious diarrhea due to this organism probably varies in different locahties, and probably also varies in difi'erent summers in the same locaUty. The etiologic role of the gas bacillus is based on the fact that in certain epidemics, or at least in certain localities in certain sum- mers, large numbers of gas bacilh have been found in the stools of infants showing the chnical picture of infectious diarrhea, while the dysentery bacillus was not found. The etiologic importance of the gas bacillus is not, however, estabHshed with absolute certainty. It may frequently be found in the stools of infants who do not show the S3anptom-complex characteristic of infectious diarrhea. From this it has been argued that the gas bacillus is not a cause of the disease, but that its presence in infectious diarrhea is merely acci- dental. The same argument, however, would apply to the pneumo- coccus in pneumonia, as it is frequently found in the sputum of normal individuals. In the two summers when the gas bacillus was so frequently found associated with the infectious diarrhea prevalent in Boston, it was difficult to doubt that it was the cause of the disease. It was found in great numbers in the stools, and when its numbers diminished, or when it disappeared, there was a coincident relief of symptoms. There is no doubt that the gas bacillus, and similar organisms may frequently be present in the stools of babies who have not infectious diarrhea. It is also strongly probable that at times these organisms may develop, invade the tissues, and produce lesions. The prevalence of gas bacillus infection, and indeed of any Infectious Diarrhea 459 particular type of intestinal infection, probably varies in different localities, and in different summers in the same locality. The streptococcus has been found definitely associated with cer- tain epidemics of infectious diarrhea. It has in certain cases been demonstrated in the tissues. The bacillus pyocyaneus, and a few other organisms, have been found associated with the lesions of the disease in rare individual instances. Causes of Infection. — The manner in which infection occurs in infectious diarrhea is not definitely known. Presumably the bac- teria are taken in by the mouth, and consequently, we look to con- taminated food as the vehicle of infection, particularly milk. It is known that milk can be the vehicle of infection, but it is not proven in just what proportion of cases it actually plays this part. The bacilli may also be carried to the mouth in water, on the hands, or on objects put in the child's mouth. There is, however, some evi- dence that the mere entrance of the pathogenic microorganisms into the intestine, or their presence there, does not necessarily suffice to cause actual infection. By infection is here meant invasion of and multipHcation in the tissues. The various bacteria may lead a purely saprophytic existence, without invasion. There is a marked difference of opinion among authorities as to the circumstances which cause actual infection to take place. One view is that a sHght lesion of the intestine, such as might be caused by a previous digestive disorder, is essential. The other view also regards a previous diges- tive disorder as important, but holds that it acts by altering the chemical composition of the food contents in the intestine, in such a way as to produce a culture medium favorable for the develop- ment of the organisms. Whatever the final mechanism of infection it is probable that the introduction of organisms from without is the most important factor. It is probable also that the precipitating cause for the actual infection of the tissues is some condition in the intestinal contents, such as indigestion, which provides increased opportunity for bacterial development, or some lowering of the resistance of the tissues against infection. Given such favorable conditions, the introduction of bacteria from without might easily lead to infection, or infection might take place from organisms pre- viously introduced. Infectious diarrhea is most common during the hot months of the year. This may be explained in three ways: — first, that hot weather favors the development of microorganisms outside the body, in milk and other food; second, that it is in hot weather that indigestion, with resulting disturbance of the character of the intestinal contents most frequently occurs; third, that hot weather can produce a marked lowering of resistance against infection. The relative importance of these possible factors is not known. 460 Diseases of the Gastro-Enteric Tract Infectious diarrhea is most common in artificially-fed infants and in young children. The period when it occurs most frequently is that between six months and two years. It is not, however, by any means a disease confined to infants and young children. It is fre- quently seen in older children, and may even occur in adults. PATHOLOGICAL ANATOMY.— The lesions found are very varied. The variations in the severity of the tissue changes depend upon two factors, first, the severity of the infection, and second, the duration of the infection before death occurs. The slightly marked pathological tissue changes are found in feeble infants who succumb to a comparatively mild infection, or in patients who succumb almost immediately to a severe infection. The more marked lesions are found in patients w^ho resist a severe infection for a considerable time. In the milder cases there may be only catarrhal inflammation of the mucosa. In the cases which die rapidly from a severe infec- tion, there may be only shght h}"perplasia of the Ijonphatic tissue. In other cases, in which the duration of hfe has been longer, there is very extensive h}^erplasia of the sohtary foUicles and Peyer's patches. In this type there may be only a few small ulcers on the h}^erplastic l}Tiiphoid tissue, or there may be extensive ulceration. In more severe cases not immediately fatal, there may be a super- ficial necrosis of the whole mucosa. FinaUy, there may be an ex- tensive pseudomembrane, consisting of necrotic tissue, leukocytes, and bacteria, but ^\ith little or no fibrin. The lesions are usually Hmited to the colon and the lower portion of the ilium. They are ordinarily most marked in the colon. There is usually some hyperplasia, and slight congestion of the mesenteric lymph nodes. There are often degenerative lesions in the liver and kidneys. Secondary infections, such as otitis media, bron- chitis, bronchopneumonia, and pyeHtis, due to diminished resistance, are seen at times. SYMPTOAIS. — The principal symptoms are diarrhea, fever, toxe- mia, and rapid loss of weiglit. Typical Cases. — The onset is usually acute. In some cases symptoms of some form of indigestion precede the symptoms of infection. Occasionally the symptoms of infection develop after a preceding diarrhea characteristic of indigestion or fermentation. Usually, however, there are no premonitory s}Tiiptoms. Diarrhea is ordinarily the first symptom. The first evacuations consist of fecal matter, but in typical cases, mucus and blood soon appear. Soon after this, sometimes in a few hours, sometimes not for one or two days, the stools become mainly composed of mucus and blood, with little or no fecal matter. The mucus may be white, but is often stained green or brown. The amount of blood is very Infectious Dla.rrhea 461 Fig. 99 Non-ulcerative follicular inflammation. Simple hyperplasia of lymph-follicles. Female, 3 years old. Warren Museum, Harvard University 462 Diseases of the Gastro-Exteric Tract Fig. ioo Colitis follicularis non-ulcerative. Male, 2 years old. ^Museum of the College of Physicians and Surgeons, New York Infectious Diarrhea Fig. ioi 463 Inflammation of follicles and surrounding p;uL^ n\ i olun. Ihe process has gone on to necrosis. Female, 3 months old. Warren Museum, Harvard University 464 Diseases of the Gastro-Enteric'^Tract Fig. I02 Pigmented follicular ulcers of colon. Chronic catarrhal ulcerative follicular colitis. Museum of the College of Physicians and Surgeons, New York Infectious Diarrhea Fig. 103 465 (.'01 it is follicularis non-ulccrati\'a 30 466 Diseases of the Gastro-Enteric Tract Fig. 104 Pseudo-membranous colitis. Cliild, iH years old. Museum of the College of Ph^'sicians and Surgeons, New York Infectious Diarrhea Fig. 105 467 Acute ulcerative catarrhal colitis. Female, 3 months old. Museum of the College of Physicians and Surgeons, New York 468 Diseases of the Gastro-Enteric Tract Fig. io6 Ileo-colitis ulcerativa follicularis. Infant, i6 months old._ Museum of the College of Physicians and Surgeons, New \ork Infectious Diarrhea 469 variable; sometimes only specks of blood are seen, while in other cases the mucus is profusely streaked with blood, and in still other cases there is considerable blood-stained mucus. The blood never is homogeneously mixed with the mucus, as in intussusception, but there is always some mucus which is not blood-stained. While blood is present in the great majority of cases, there are occasionally cases which have been found to be caused by the dysentery bacillus, in which no blood appeared in the stools. Pus cells can usually be found microscopically; macroscopically pus may never be seen, or may appear after a few days. Membrane is only present in the sever- est cases. The stools usually have very little odor, unless there is membrane or much pus present, when they may have a putrefactive odor. The reaction of the stools is not constant, but in the majority of cases it is alkaline. The number of stools passed in twenty-four hours is very variable, and bears no definite relation to the toxic severity of the case. The number may vary from twelve to forty or more in twenty-four hours. When the evacuations are frequent, the stools are usually very small, often consisting of no more than a small stain of mucus and blood. Fever is a constant symptom of infectious diarrhea. The tem- perature usually runs between ioo° F. and 102° F., but may be several degrees higher. The temperature curve does not usually show marked exacerbations and remissions. It is a fairly accurate measure of the progress of the infection, tending to rise when the patient gets worse, and to come down when the patient is improving. The fever persists throughout the active stage of the disease. Toxic symptoms are present in the severer cases, absent in the milder ones. Various factors may produce the toxemia. It may be due to the absorption of bacterial endotoxines, and that this cause certainly plays a part is strongly suggested by the fact that in dysen- tery infection, agglutinins and bacteriolysins are formed in the blood. The toxemia may be caused by the loss of water and salts, as in fermental diarrhea, but the case symptoms do not usually suggest a relative acidosis. It is probable that in dysentery infection, at least, the toxemia is mainly of bacterial origin. The commonest manifestation of toxemia is a clouded mentality, the patients being dull, and reacting very little to their surround- ings. In severe cases their stupor is deeper; they may be com- pletely comatose and relaxed. At any time in these severe cases marked prostration or sudden collapse is liable to occur. There may be toxic symptoms referable to irritation of the central nervous system. Restlessness, twitching of the extremities, and sometimes even convulsions may occur. The signs of meningeal irritation may be so marked as to suggest a meningitis. Any of the so-called meningeal symptoms, such as rigidity of the neck, retrac- 470 Diseases of the Gastro-Enteric Tract tion of the head, inequaHty of the pupils, exaggeration of the knee- jerks, Kernig's sign, and so forth, may be present. Abdominal pain is a common symptom, and appears early in the course of the disease. It appears to be most severe when the patient is having an evacuation of the bowels. Tenderness of the abdomen is almost never seen; occasionally there is slight tenderness along the course of the colon, but involuntary muscular spasm is almost never present. The abdomen is markedly retracted in the majority of cases. Occasionally, however, there may be abdominal distention. The liver and spleen are occasionally enlarged, but this condition is not common enough to be in any way characteristic. Tenesmus is frequently present, and may be a particularly annoy- ing symptom. Prolapse of the rectum from the constant straining is not uncommon. Vomiting is not a prominent symptom in typical cases. It is often absent, and when it does occur, it is not usually severe enough to be troublesome. The appetite is usually very much impaired, and it is often difficult to get patients with infectious diarrhea to take sufficient nourishment. Loss of weight is very marked. The urine is diminished in quantity and concentrated. Casts, and a small amount of albumen are often present, pointing toward degen- eration of the renal epithelium. Sugar is usually not found in the urine, unless a large amount is being given in the food, and even then not constantly. The blood usually shows a leukocytosis. The white count is ordi- narily about 2o,,ooo, but may be higher. In some cases, particularly very severe ones with marked toxemia, the white blood count may be normal, or even diminished. Atypical Cases. — The most common atj^ical symptom-complex seen in infectious diarrhea is the very mild one. In this t5^e, the diarrhea is not severe, and the appearance of the stools is not char- acteristic. The daily number of evacuations may be very little in- creased, there being sometimes no more than four to six bowel move- ments in twenty-four hours. Blood may be wholly absent, mucus may not be excessive in amount, and fecal matter may be present throughout, and may present appearances suggesting various forms of indigestion. Abdominal pain and tenesmus are absent in this mild type. Fever, however, is usually present and continued, even though moderate. Some mucus visible macroscopically, is usually constantly present in the stools. Another atypical symptom-complex is seen in very severe cases, which end fatally before characteristic symptoms have had time to develop. These cases resemble severe cases of acute indigestion with fermentation. With or without premonitory symptoms of indiges- tion, severe diarrhea develops, accompanied by high fever, and marked Infectious Diarrhea 471 toxic symptoms. The stools are watery, and do not contain blood, or excessive mucus. Severe prostration, followed by collapse and death end the disease, usually within twenty-four hours. Cases of this type, even on post-mortem examination, resemble fermental diarrhea in that they show very little pathological change in the intestinal mucosa. They are recognized as a type of infectious diarrhea only because the dysentery bacillus has been found in great numbers in the intestinal discharges. Other cases are atypical only in the exaggerated severity of some particular symptom. Hyperpyrexia is seen occasionally. In rare cases, vomiting is excessive. In other cases, meningeal symptoms are unusually pronounced. DIAGNOSIS. — In typical cases of infectious diarrhea the symp- tom-complex is so characteristic, that little difficulty attends the diagnosis. The only other condition characterized by stools con- taining blood and excessive mucus, is intussusception. Atypical cases, however, may be mistaken for simple indigestion from overfeeding, for indigestion with fermentation, and for meningitis. Intussusception begins usually with abdominal pain and symptoms of more or less shock, whereas infectious diarrhea begins with frequent loose movements, abdominal pain not being so prominent, and shock- being absent. In both conditions the first stools contain fecal matter; in infectious diarrhea, while some stools may consist entirely of mucus- and blood, other stools contain some fecal matter. In infectious diar- rhea the mucus and blood appear somewhat earlier in the stools, and diarrhea is usually a more prominent symptom. In intussusception the blood and mucus are homogeneously mixed, all the mucus being blood-stained, often resembling currant jelly; in infectious diarrhea there is always some unstained mucus, and the stools do not have the currant jelly appearance. Fever may be present or absent in intussusception, while in infectious diarrhea it is always present, and is usually higher than in intussusception. The abdomen in infec- tious diarrhea is usually retracted, and on palpation, involuntary muscular spasm is never present. In intussusception, the abdomen is usually somewhat distended, and involuntary muscular spasm is often present. In infectious diarrhea no tumor can be recognized either by abdominal palpation or by rectal examination; in intussus- ception a tumor can often be found, although the absence of a tumor does not positively rule it out. The important thing to remember is, that in order not to overlook intussusception, a diagnosis of infectious diarrhea should never he made without an actual inspection of the stools, and a careful examination for tumor. Simple indigestion from relative excess of food manifests itself very often in summer by an acute diarrhea. It is sometimes difficult to 472 Diseases of the Gastro-Enteric Tract distinguish very mild infectious diarrhea, in which the daily number of stools is not very large, and in which blood is absent and mucus small in amount, from acute diarrhea due to simple indigestion. The chief differential feature is the fever, which is always constantly present, even though moderate, in infectious diarrhea, and is never constantly present in indigestion. Nevertheless, in many of these mild cases of infectious diarrhea the diagnosis is not made for a considerable time, the physician making repeated careful physical examinations in the effort to account for the fever by finding some disease process outside the intestinal canal. In such cases the diag- nosis can sometimes only be made by means of a bacteriological examination of the stools. In other cases the correct diagnosis is finally suspected when the patient responds to the treatment for infectious diarrhea. There is a form of intestinal disturbance which can only be classi- fied under simple indigestion, which is occasionally seen when some very unusually indigestible and irritating substance is eaten. I have seen it produced in babies by the giving of such things as green corn, pickles, and cucumbers. In this condition diarrhea may occur with mucus and blood in the stools. It is distinguished from infectious diarrhea by the absence of fever, the history of some gross dietary indiscretion, and the rapid response to treatment. Indigestion with fermentation is very difficult to exclude in certain cases of infectious diarrhea. The difficulty of diagnosis occurs both in the very severe type of infectious diarrhea in which death occurs before characteristic stools have developed, and also in the mild type in which blood does not appear in the stools. Diarrhea, fever, wasting, and toxic symptoms are seen in both conditions, and a positive diagnosis is often impossible. When the amount of mucus in the stools is large, the evidence points toward infectious diarrhea. The most important point in differential diagnosis is the character of the temperature curve. In fermental diarrhea, the temperature is usually higher at the onset, and falls in one or two days; it often reaches the normal before the symptoms are relieved. In infectious diarrhea, the temperature may not be so high at the onset, but is more steadily maintained, and some fever persists throughout the active stage of the disease. In many cases, however, a positive diag- nosis can only be made by a bacteriological examination of the stools. There are cases in which stools resembling infectious diarrhea, and containing mucus and blood, are seen after prolonged simple indi- gestion, or prolonged indigestion with fermentation. These cases are often misleading. They are recognized by the absence of fever. Meningitis is suspected when the signs of meningeal irritation are pronounced. When severe diarrhea with characteristic discharges are present, the meningeal symptoms are easily explained by the Infectious Diarkeiea 473 intestinal infection. When the intestinal symptoms are not marked, or when characteristic stools have not developed, the diagnosis may be doubtful. In such cases a lumbar puncture will settle the diagnosis. Bacteriological Examination of the Stools. — A practical, speedy, and fairly accurate method for determining the presence of the gas bacillus is the "stormy fermentation" test. Litmus milk or sterile fat-free milk is inoculated with a loopful of feces, heated to 80° C. in a water bath for twenty minutes, and then incubated twenty- four hours. If no spores are present, there will be no growth in the tube, and the milk will be unchanged. If the spores of a gas form- ing bacillus such as the bacillus Welchii are present the milk will show a tough clot, permeated with gas holes and often "driven" against the side of the tube or to the surface of the media; there will be marked acid formation, the fluid residue will be compara- tively clear, much of the casein will be dissolved and the culture will have a distinct odor of butyric acid. The isolation and identification of the dysentery bacillus is not always an easy matter. Only material from very recently passed stools should be used. A suspension of the feces in bouillon is first made, the amount used being a variable quantity. If there be macroscopic pus present in the stool, one loopful to a small tube of bouillon may be used; two or more loopfuls of mucus may be used when no pus is found. One should attempt in all cases to secure pus or mucus for the suspension. This emulsion should be streaked by means of a glass rod over Endo-plates (prepared from a 2% agar), and the plates incubated from sixteen to twenty-four hours. Suspi- cious colonies will appear as small, circular, translucent, bluish-gray drops, not causing discolorization of the media. Bouillon tubes are inoculated from such colonies and incubated six hours. Then stab- cultures are made in three tubes of Hiss' semi-solid media, one con- taining lactose, one glucose, and one mannit, litmus being added as an indicator. They are incubated twelve hours and then examined for motility, and for gas and acid production. The organisms should be small, gram-negative bacilli, non-motile, forming acid from dex- trose, and not acting upon lactose, nor forming gas. The formation of acid from mannit will further differentiate the organism of the so-called mannit-fermenting group of dysentery bacillus (Flexner type). Agglutination tests may then be done with those bouillon tube cultures, in which the organisms have resembled the dysentery bacillus. The serum is obtained from the Rockefeller Institute for Medical Research and is prepared only for the mannit-fermenting strains. It should be diluted to 1/500 and the test made by mixing in small tubes i c.c. of the serum and i c.c. of the culture, the fluid diluted i/iooo; a control with normal saline is made in each case. The agglutination tubes are incubated two hours, and then set in 474 Diseases of the Gastro-Exteric Tract a cold glass jar for twelve to twenty-four hours. Sometimes the phenomenon can be determined at the end of the incubation; by observing through a hand lens the formation of small fiocculent masses. Usually it is necessary to wait until the masses have set- tled, after the tubes have remained some hours in the ice-chest. Here, if the test be positive, the masses are seen clinging to the sides of the tubes, or forming a sediment at the bottom, the rest of the tube being clear as compared with the control, which is cloudy. PROGNOSIS. — Infectious diarrhea is the most serious of aU the acute diarrheal diseases of early life. The mortality varies greatly in different localities, and in different summers. In a series of cases studied at the Infant's Hospital in Boston, including only 82 cases, the mortahty was 14.5 %. In the report of Flexner and Holt, in- cluding only cases in which the bacillus of dysentery was found, the mortality ia 207 cases was 35%. From the beginning of a case of infectious diarrhea, the prognosis should always be guarded. Older children have a better chance than infants, but the end can never be definitely predicted. Death may foUow early in the course of the disease, but occurs most commonly in the second week, and may be delayed for a longer period. In the cases which recover, improvement is usually seen by the end of the first week, or by the beginning of the second. In some cases, however, no improvemient may be seen for several weeks. The disease tends to run a rather long course, improvement is slow, relapses are com- mon, and the management of the feeding is difficult. The presence of symptoms of severe toxemia is a serious prognostic sign. TREAT^SIEXT. PRELniiXARY. — The first step in the treatmient of a case of diarrhea is to cleanse the intestinal tract of accumulated mucus, and fermenting food products. This is best accompHshed by means of castor oil, which is the most thorough and least irritating of the cathartics. One teaspoonful may be given to infants in the first three months, two teaspoonfuls from three to eighteen months, and three teaspoonfuls to older infants. Children should take from a dessertspoonful to a tablespoonful according to age. If the castor oil is vomited, calomel should be given, to babies in the first year in doses of one-tenth of a grain every half-hour for ten doses, and in the second year in doses of one-fourth of a grain every half-hour for six doses, and to older children in doses of one-fourth of a grain every half-hour for eight doses. Two hours after the last dose, two or three teaspoonfuls of milk of magnesia should be given. From the time of giving the castor oil, or of beginning the calomel, the giving of all food should be stopped for from twelve to twenty- four hours. During this period water must be given freely, in a quantity at least equal to the quantity of fluid which the patient Infectious Diarrhea 475 would take if it were receiving its ordinary food. The water may be given with the bottle, or from a cup, as preferred by the child, and may be either warm or cool, according to the taste of the child. If sufficient water be not taken, it must be given with a spoon, and if there is still difficulty in getting in the desired quantity, it must be given through a tube. It may be sweetened with saccharin, if taken better that way. The length of the period of withholding food should not be longer than twenty-four hours. The Feeding. — The diet in infectious diarrhea is difficult to pre- scribe. All wTiters agree that the management of the feeding is a matter of the greatest importance in the treatment of the disease. Nevertheless, the most diverse views as to what the diet should be are advanced by various authorities. The two principal views on the diet are diametrically opposed. According to one view the diet should be high in fermentable sugar and low in protein. Ac- cording to the other view the diet should be high in protein and comparatively low in sugar. In addition to these two opposed views, some authorities believe that the food should be very low in fat content, while others advocate feeding with such substances as albu- men water, beef juice, and whey. The view that the diet should be chiefly carbohydrate is based on certain bacteriological studies. The bacillus dysenteriae, the strep- tococcus, and the other organisms except the gas bacillus which have been associated with infectious diarrhea, have been shown to belong to the facultative group which, when living on carbohydrate, pro- duces harmless products, but which in the absence of sufficient car- bohydrate attacks the protein, with the formation of toxic products. Further, the products of carbohydrate fermentation have a certain inhibitory action on the development of the bacillus of dysentery. Those who believe that these facts about the cultural peculiarities of the dysentery bacillus should be the basis of treatment, advocate beginning feeding with a 5% or 6% solution of lactose in barley water, and gradually adding protein by means of the addition of fat-free milk. The advocates of this view also recommend attack- ing the bacilli which have entered the tissues by means of a dextrose solution given intravenously. The objections to this theoretical basis of dietary treatment are numerous. In the first place, even when an excessive quantity of lactose is given in the food, practically none is excreted in the feces. The unabsorbed excess is all destroyed by the fermentation of the normal intestinal bacteria, and this destruction certainly takes place in the upper part of the intestinal canal, above the colon which is the chief seat of the disease. Consequently, it is probable that no sugar reaches the dysentery bacilli. Even if lactose did enter the 476 Diseases of the Gastro-Enteric Tract colon and lower part of the ileum, or even if the products of lac- tose fermentation are inhibitory toward the development of the bacillus of dysentery, the organisms which are causing the disease are not in the intestinal contents, but have penetrated into the tissues, where they can easily find all the protein they need. As to the giving of dextrose solution by intravenous injection, it is difiicult to see how it can have an effective action against the bacilli which have penetrated the tissues. The evidence shows that the dextrose is rapidly utihzed or excreted in the urine, and consequently very little if any can reach the microorganisms, which are already sur- rounded by protein tissue. It seems to me that this theoretical basis for the feeding of infec- tious diarrhea, while attractive, involves too great an assumption as to what goes on inside the body. Proof is entirely lacking that the conditions which influence the development of the bacteria in vitro can be in any way reproduced within the body of the host. The advocates of the opposing view believe that the food should be high in protein, and many of them recommend albumin milk in the feeding of infectious diarrhea. This view is based on the un- doubted fact that the dangers from the casein of cow's milk have been greatly exaggerated. It is also based on Finkelstein's theory of the dangers of carbohydrate in severe gastro-intestinal disorders — the idea of sugar intoxication. The objection to the view is that it takes a disease which is admittedly bacterial in origin, and then for its treatment applies a theory which attributes gastro-intestinal disease exclusively to chemical causes. It is certain that the theory of sugar intoxication has been disproved. The advocates of albumin milk have shifted their ground by attributing the dangers of car- bohydrate — the so-called "pyrogenic action" of sugar — to increased carbohydrate fermentation. But why the necessity of attributing the fever to the sugar in a disease manifestly caused by bacteria, of which the products on any culture medium are toxic? The advo- cates of low carbohydrate, however, do not in general make the same distinction between fermental diarrhea and infectious diarrhea which is made here. There is no doubt that protein is necessary for the metabolism of children with infectious diarrhea as well as for that of children in general. The favorable results of feeding with albumin milk can easily be explained by the fact that this food is easily digestible. It is comparatively low in fat and sugar, and the casein is in a finely divided and easily digested form. The view that fat should be excluded from the food, or should be very small in amount, is based on the difficulty of digesting and absorbing fat in severe gastro-intestinal disorders. It is partly due to the effect of the Finkelstein teaching, which fails to distinguish clearly between the break-down of metabolism and nutrition which Infectious Diarrhea 477 occurs as a final result in a chronic disturbance of digestion, and a primary bacterial infection such as I believe infectious diarrhea to be. I believe that the difficulty of absorbing fat, and the consequent disturbance of metabolism, has been greatly exaggerated in con- nection with infectious diarrhea. The view that such foods as whey, albumen water, and beef juice should be used in infectious diarrhea is based on the theory that in these foods the soluble protein is more easily digested than the insoluble casein, and that consequently these foods leave less residue to act as irritants to the inflamed mucus membrane. This same theory once dominated the treatment of typhoid fever, but has now almost entirely been relegated to oblivion in that disease. There is at present little disagreement as to the ordinary digestibility of casein, while there is considerable evidence pointing toward possible danger from the albumins. It is a very significant fact that the advocates of all these views are enthusiastically in favor of their particular theory of treatment, and report superior results from its use. This I think strongly suggests that in infectious diarrhea, no particular dietary treatment based on theoretical grounds is of special value. The results seem to be about equally good or bad, whatever theory of diet is put into practice. I have, in my own wards tried alternately the high sugar treatment, and albumen milk, and have never seen the slightest evidence that the one method is superior to the other in the treat- ment of infectious diarrhea in general. / do 7tot believe that altera- tions in the diet to fit any theory have any specific influence on the progress of the infection. How, then, shall we feed cases of infectious diarrhea? I believe that the feeding should be governed by the same principles as govern the feeding of any acute infection, such as, for instance, typhoid fever. Indeed, infectious diarrhea seems to me to be much more closely related to typhoid fever than to the simple disturbances of diges- tion, or to indigestion with fermentation in the intestinal contents. It is only in the latter disease that the composition of the food is all-important in its influence on the actual processes which cause the disease. In infectious diarrhea, as in typhoid fever, the symptoms are caused by true parasites, which invade the tissues, produce lesions, produce toxins, and against which the host elaborates im- mune bodies. Diseases of this kind recover, not by alterations of the chemical contents of the intestine, but through the development of resistance on the part of the patient. Our aim in feeding, there- for, in infectious diarrhea as in any acute disease, should be to nourish the patient as well as possible, in order to increase his power of resistance against infection. How this aim is carried out in practice depends on the digestive 478 Diseases of the Gastro-Enteric Tract peculiarities of the particular case. In infants the disease is com- plicated by various forms of digestive disturbance, and our manage- ment of the feeding should be that of any difficult case of infant feeding. We give the infant what we think it can digest, and alter the composition of the food to meet the indications as they arise, guided in our changes by the character of the stools, and the various symptoms of indigestion. In older children dilute milk, soluble carbohydrate, beef juice, and albumin water all have their place. As convalescence approaches, gruels may be added. One exception to the theory of treatment outlined above should be noted. There is a probability that the symptoms may be caused by the gas bacillus. It has been shown by Tissier and others that the lactic acid bacillus inhibits the growth of the strain of gas bacillus known as the bacillus perfringens. There is evidence that the favor- able effect of the lactic acid bacillus can be realized in the intestine. Therefore, theoretically, the lactic acid bacillus should be given to cases of gas bacillus infection. Unfortunately, however, as explained under Diagnosis, we can never be sure when the symptoms are due to the gas bacillus. The finding of a positive test for gas bacilli in the stools is not positive proof of their etiological importance. Still, fat-free milk ripened with a known strain of lactic acid bacillus is a digestible food, and would not be contraindicated in dysentery infection. It differs from the widely recommended albumin milk only in having a lower protein and fat content, and a slightly higher carbohydrate content. If, therefore, the simple test for gas bacilli in the stools is posi- tive, I believe it is best to begin feeding with lactic acid milk. This may be continued until it fails to produce either a negative gas bacil- lus test, or an improvement in the symptoms after a few days. When ripened milk fails, or when the gas bacillus test is negative, the case should be treated as dysentery. In beginning artificial feeding in infection with the dysentery bacillus, or with other organisms of the same class, the food should be weak at first. To an infant, the first formula given after the twenty-four hours of water diet should be — Fat, I %— Lactose, 5% — Protein, .50%. The food should be gradually strengthened according to the prin- ciples laid down in the division on feeding. ■ If ordinary cow's milk modification does not seem to give favorable progress, albumin milk may be tried. To an older child, dilute boiled milk may be given, and the strength of the mixture is to be gradually increased. Extra sugar may be added. Later whey, and albumin water may be added to the diet, and still later, the cereals. Routine Treatment. — Irrigation of the colon is a very useful Infectious Diarrhea 479 procedure in infectious diarrhea, and should be part of the routine treatment in every case, unless it appears seriously to distress or disturb the patient. The object of the irrigation is to remove from the wall of the colon as much as possible of the adherent mucus, and thus to favor the elimination of bacteria, toxic products, and the products of the inflammation of the tissues. The object is not to promote healing, nor to kill the bacteria, as neither astringent nor antiseptic solutions can be used in a strength sufficient to pro- duce appreciable effects. Physiological salt solution is the best for irrigation in the acute stage. It should be given once or twice daily, but not oftener than twice. The technique of colon irriga- tion has been described in Division II. When the case tends to become prolonged or chronic, with the continued presence of blood and pus in the stools after the fever and toxic symptoms have dis- appeared, healing injections may be tried. A solution of silver nitrate is best for this purpose. Silver nitrate injections should be preceded by an irrigation of the colon, given in the ordinary manner, except that sterile water should be used instead of normal salt solu- tion, because sodium chloride forms an insoluble salt with silver nitrate. After the irrigation a 2% solution of silver nitrate should be injected in a quantity varying from one-half a pint to a pint, according to the age of the baby. After the injection the tube should be withdrawn, and the patient left to expel the solution at leisure. These injections may be repeated daily, or every second day. If they cause discomfort the silver nitrate may be washed out with. normal salt solution, and the next injection should contain' silver nitrate in weaker solution. The stools passed immediately after a silver nitrate injection may contain more blood, pus, and necrotic material than usual. There is, however, considerable evi- dence that these injections improve the character of the later stools, and hasten the healing processes. The benefits to be expected from either colon irrigations or silver nitrate injections are not great enough to warrant their use when they are seriously depressing or disturbing. The only drug of possible local value in infectious diarrhea is one of the salts of bismuth. The theoretical action of bismuth is that it forms a protective and soothing coat on the inflamed mucous mem- brane. My own experience has never been able to convince me that bismuth does any real good, in the acute stage at least. In the chronic stage some cases have appeared to do better when bismuth has been used. The subcarbonate of bismuth, or the milk of bis- muth are better preparations than the subnitrate, on account of the possible danger of nitrate poisoning from the latter. The dose should be five to ten grains every two hours, or in every feeding. The various so-called intestinal antiseptics, such as salol, and 480 Diseases of the Gastro-Enteric Tract similar drugs, are of no value in infectious diarrhea. They cannot be given in doses large enough to injure bacteria without greater injury to the patient. If it is impossible to induce the baby to take a sufficient amount of water, or if water or food given through a tube is vomited, fluid must be supplied in some other way. Normal salt solution may be given through the bowel by means of seepage, and even when there are frequent intestinal discharges, considerable fluid may be absorbed. If sufficient fluid is not absorbed when given by rectum, salt solution may be given subcutaneously. In very severe cases, fluid may be given intravenously. The value of alcohol in infectious diarrhea is a matter about which opinions differ. The preponderance of modern opinion denies to alcohol any stimulant value in the treatment of disease. In infants and children, however, who are suffering from prolonged infections accompanied by nutritive disturbance, I believe alcohol to be of value as an easily utihzable source of energy. I beheve it should be given in infectious diarrhea, to an infant, in doses of lo to 20 drops of whiskey diluted with water, and to older children in somewhat larger doses proportioned to the age of the child. Treatment oe Special Symptoms. — The special symptoms re- quiring treatment in infectious diarrhea are in the order of frequency of occurrence, pain and tenesmus, marked prostration, collapse, toxic nervous irritation, excessive vomiting, and hyperpyrexia. When abdominal pain and tenesmus are present, hot stupes or compresses should be appHed to the abdomen. Injections of starch solution may be tried in the effort to relieve tenesmus. The solu- tion for injections should be made by adding two teaspoonfuls of starch and five drops of tincture of opium to two ounces of water. They are often so rapidly expefled, that they cannot be of much benefit. The only eft"ective method of controlling pain and tenesmus is by the use of opium. It is best given in the form of paregoric, 'in small doses proportioned to the age of the child. From five to twenty drops may be given to infants, repeated often enough to relieve the pain and tenesmus, and to check excessive peristalsis. For marked prostration, stimulation is required. Except in acute emergencies, strychnin is the best stimulant, given in doses of from i/iooo to 1/200 of a grain. In place of strychnin, caffein-sodium benzoate may be used in doses of from 1/8 to 1/2 of a grain. For coflapse the best stimulant is fluid. In infants it is best given intravenously, into the longitucUnal sinus. Normal salt solution may be used. I believe that marked prostration and collapse in many cases are due to failure to absorb enough energy-producing food. Infants in coflapse need fuel as well as water and alkali. I have recently tried giving dextrose intravenously in cases of this kind. Infectious Diarrhea 481 Four ounces of a 5% solution of pure dextrose may thus be given. In some cases some of the dextrose is excreted in the urine, but in my experience part of it is always actually used for energy produc- tion, and in some cases, it has all been used, none having been excreted in the urine. I have never seen either the mythical "sugar fever" or toxic symptoms follow dextrose injections provided that pure dextrose is used. Other stimulants which may be used in col- lapse are adrenalin, in doses of one to five minims intravenously, caffein-sodium benzoate or salicylate in doses of 1/8 to 1/2 a grain subcutaneously, and camphor in oil in doses of one to two grains intravenously. For the toxic nervous symptoms, such as restlessness or signs of meningeal irritation, sodium bromide is the best drug. It is best given by mouth in doses of five grains, repeated in two hours as often as is necessary to control the symptoms. If the fontanelle is bulging, lumbar puncture will often give relief. Ice bags to the head should not be used, unless there is a high fever, and then cautiously. For excessive vomiting, the stomach should be washed out with a solution of sodium bicarbonate, one teaspoonful to a pint of water. This may be repeated daily. Little else can be done for this symp- tom, as nutrient enemata will not be retained. For hyperpyrexia, hydrotherapy is greatly to be preferred to any form of medication. The coal-tar products are not advisable in infants and young children on account of their depressing effect. Sponge baths of water and alcohol in equal parts at about 90° F. are usually the best measure that can be used to reduce the temperature. Hyperpyrexia is a rare symptom in infectious diarrhea. SUMMARY OF THE DISTURBANCES OF DIGESTION AND INFECTIOUS DIARRHEA The disturbances of digestion and infectious diarrhea all belong to the same group, in-so-far as symptoms, diagnosis, and treatment are concerned. A summary of the principal features of this group of diseases, which may prove useful to the student, is given in table 44 : One of the difficulties in the diagnosis and treatment of this group of diseases is the frequent similarity of the symptoms seen in condi- tions which differ widely in etiology. Our treatment, however, must be specifically fitted to the cause of the condition, and it is for this reason that these diseases are classified upon an etiologic rather than upon a symptomatic basis. Nevertheless, these conditions pre- sent themselves in the form of rather definite symptom-complexes. It is essential for the physician to know just what the etiological conditions are which can produce the symptom-complex with which 31 482 Diseases or the Gastro-Enteric Tract to Z o u 3 3 13 ^ en c ^ =3 « <: H o O z o <: Q o en- o.-ti .s.s Severe diarrhea, fever and toxic symptoms. No blood or excessive mucus in stools T3 O O o > a ^^-i tn *^ 3 ^^ oj 13 }-< OJ Ph h w o (u T5 en S M O en O >> (-! 1> o 3-s o £? o «^ i) o < en s 3 en ° S bC en en en W) en o 2 >^ ^2 St3 a c3 en s ^2 _r >> Qt3 3 « C (J 5^ ■11 SI j2 3 '3 g 3 < OJ 3 u < c z c fi !^ > E- < e <: o >■ a < z E E- C Ph Z c e < E- z ft IS P! < < Q e/i H U w c 5 Infectious Diarrhea 483 he is confronted. A table, therefore, showing the relation of the most prominent symptom which presents itself to the etiologic classi- fication of these diseases, may prove useful for reference. Symp- tomatically, the conditions which present themselves may be di\^ded into acute and chronic. There are four rather definite clinical pictures encountered in acute cases. In the first, vomiting is the only symptom, the physi- cian being called upon to treat an acute attack of vomiting. In the other three clinical pictures the principal symptom is acute diarrhea, the t}^es differing according to the character of the stools. The second clinical t}'pe is characterized by stools of undigested appear- ance, containing curds and undigested masses. The third type is characterized by watery, green or brown stools. The fourth type is characterized by stools which contain blood and mucus. In the two last types toxic symptoms may be present. The relation of these four clinical types to the etiological classification of this group of diseases is shown in table 45 : Table 45 Symptom-complex in Acute Cases a7id Causes Vomiting only symptom Indigestion from excess of food Diarrhea, imdigested stools Indigestion from overfeeding Diarrhea, watery, green, or brown stools Indigestion with fermentation Diarrhea, blood and mucus in stools Infectious diarrhea The cHnical t}^es which present themselves in chronic cases are also rather definite, but have a much less definite relation between the symptoms and the disease which causes them. In the first type, vomiting is the only symptom. The second type, frequently encountered, shows no symptom other than loss of weight, the stools being macroscopically of approximately normal appearance. In the third type, the stools are hard, dry, and of a whitish or yellowish- white color. In the fourth type the stools are of approximately normal consistency, but are green in color. In the fifth type the stools are rather looser than the normal, but not so loose as in acute diarrhea, and are of a green color. In the sixth type the stools are undigested, containing curds, or undigested masses. The relation of these cfinical types to the etiological classification is shown in table 46: Table 46 Symptom-complex in Chronic Cases and Causes [Indigestion from excess of food Vomiting only symptom j Indigestion from excess of fat [indigestion from excess of protein Loss of weight. Stools macroscopically normal. /Underfeeding \Indigestion from excess of fat 484 Diseases of the Gastro-Enteric Tract Table 46 — Continued Hard, dry, whitish or yellowish stools Indigestion from excess of fat Green stools, normal consistency. f Indigestion from excess of food \lndigestion from excess of carbohydrate Loose, green stools f Indigestion from excess of carbohydrate \lndigestion from excess of fat [Indigestion from excess of food Undigested, curdy stools ^Indigestion from excess of fat [Indigestion from excess of protein PROBLEMS AND RESEARCH IN DISEASES OF THE DIGESTIVE TRACT This field in pediatrics is of the highest importance and is the sub- ject of the most bitter controversy. The lack of distinctive path- ology, cases of varied symptomatology showing at autopsy prac- tically the same findings, makes a, classification along these Hnes most difficult. For the same reason the etiological factors are not clear. Chemical and bacteriological agents are both concerned and the question of the importance of the part that each plays is, un- fortunately, decidedly an unsettled one. The work of the Rockefeller Institute and later work on the Boston Floating Hospital by Ten Broek seems to have definitely established the fact that there is a real dysentery among other alimentary path- ological conditions. In nearly every case in which pus and especially blood is present in the stools, the organism of dysentery can be iso- lated from the movements and agglutination tests on the blood will show a positive reaction to the organism later on in the course of the disease. (From a paper by Ten Broek and Norbury, as yet unpubHshed.) This applies only to the condition known as infectious diarrhea in the vicinity of Boston. It may be found to apply to other locaHties also, but at present, no sufficiently thorough work has been done. Although it is probable that other organisms, the streptococcus, colon bacillus, etc., may play a part, it is not probable that it is an extensive one, as an excitant of dysenteric conditions. It is the symptom-complex, called by some authors Fermentative Indigestion and by others Intoxication, that is the cause of so m.uch difference in pediatric thought along these lines. On the one hand are found the supporters of the bacterial origin of this condition, on the other hand are those who consider the injury primarily a chemical one, soon becoming systemic. The one group holds that the bacteria already present may increase under certain conditions, or that masses of bacteria may be introduced with the food, and that their products are toxic and irritating, causing the general pros- tration and the diarrhea. The other group believes that a chemical injury may occur to the epithehal cells of the wall of the intestine Cholera Infantum 485 and by raising their permeability to toxic chemical products, allow these bodies to enter the blood stream. In this case the injury would be a "food injury" and if bacteria or other products were involved, it would be a secondary affair. It is true that Steinitz has found that h>'perpermeability exists for certain enzymes (diastase and maltase), and that Lust has noticed the same reaction for protein bodies, in these cases. ]Moro has shown in animals that an endogenous infec- tion of the small intestine does not cause hyperpermeability of its walls to protein. In intoxication many organisms which are usually present are found in increased numbers. It may well be that their virulence is increased by the varied culture media off'ered to theiji; Passini has been able to show, in vitro, that the "gas bacillus" may, under certain food conditions, manufacture a powerful toxin. There have also been attempts to show that the colon bacillus is found in in- creased numbers, so as to cause a characteristic appearance in stained cover glass preparations from the stools in these cases. Both theories are suh judice. It seems reasonable to believe in the possibility that both may be responsible for this very obscure condition, each under different circumstances. It seems probable that more than one condition is described under the head of A limen- tary Intoxication. With regard to the "gas bacillus" one may say that more work must be done before it can be estabHshed as an etiological factor. Its increase under certain conditions may be purely secondary, as increase in the bacterial flora is a common occurrence when the function of the intestine is impaired. It is of such common occur- rence in the intestinal tract as to justify its being considered a fairly normal inhabitant of those parts. CHOLERA INFANTUM This name is appHed to a very definite symptom-complex, the etiology of which is entirely unknown. It is possible that the disease may be caused by some particular type of fermentation process in the intestinal contents, or even that it may be due to some pecu- liar form of food poisoning. Nevertheless, the definiteness of the clinical picture, and the character of the symptoms strongly suggest that it is an acute specific infection. The disease is a very rare one. In Boston, I have only seen one or two cases which fulfilled the description of the condition. The term cholera infantum is, however, very generally wrongly applied to severe cases of acute indigestion with fermentation. ETIOLOGY. — If there is a specific organism in cholera infantum, it has not been found. The disease occurs only in the first two 486 Diseases of the Gastro-Enteric Tract years of life, and in its development is probably closely associated with the food, for it has been noticed that infants who are fed ex- clusively on breast-milk, are not liable to be attacked by it. It is also significant that the disease occurs only in hot weather. PATHOLOGICAL ANATOMY.— The pathology of cholera in- fantum has not yet been satisfactorily determined, but it seems to be a non-inflammatory disturbance of the whole gastro-enteric tract, without any gross lesion beyond a desquamative catarrh, and some- times hyperemia of the mucous membrane. SYMPTOMS." — The onset of cholera infantum may be sudden, but, as a rule, it is preceded by some form of gastro-enteric disturb- ance, which, by causing an irritation of the mucous membrane, renders the infant vulnerable. When, however, the disease has once gained a foothold, the development of the symptoms is very rapid. After a variable but generally short period of restlessness and apparent abdominal discomfort, the infant begins to vomit. The vomiting is either accompanied or quickly followed by profuse diar- rhea. After the stomach and intestine have been emptied of the food which may happen to be in them at the time of the onset, the vomitus and the diarrheal discharges are chiefly serous; and it is this watery consistency of the discharges which especially charac- terizes the disease. As a rule, the discharges are odorless, and con- sist of serum mixed with epithelial cells and many bacteria. Although the disease is more likely to attack weak and debilitated infants, yet it occasionally attacks those who are healthy and robust. It may run its course to a fatal issue in from twenty-four to forty-eight hours. The extremities soon become cold, the skin is palHd or even cyanotic, and the face pinched. The abdomen may at first be a little distended, but is soft, and soon becomes retracted. The pulse is rapid and difficult to count. The respirations are somewhat rapid and superficial. The temperature of the entire surface of the body is low, but the deep rectal temperature is high (103°, 104°, or 105° F.). The thirst is great and is a very prominent symptom. The fonta- nelle very soon becomes depressed. The urine is very scanty and sometimes suppressed. It is concentrated, highly acid, almost always contains albumin, and often casts and blood. Nervous symptoms, such as twitching of the arms and great restlessness are present. Rapid emaciation takes place, and all the symptoms increase in severity. At first the infant whimpers, but soon it becomes Hstless, falls into a stupor, or may have convulsions. The infant may die in this stage, which closely resembles the algid stage of cholera Asiatica. The disease appears to be self-limited, and if the infant survives the first two or three days a crisis comes, the skin becomes less cool and of a better color, the vomiting and diarrhea becomes less Cholera Infantum 487 frequent, and finally it is left with a slight amount of simple diar- rhea and occasional vomiting. These symptoms may become chronic, in which case the infant finally dies of exhaustion or from an attack of one of the other gastro-enteric diseases, to which it is left very susceptible. DIAGNOSIS. — The diagnosis of cholera infantum is not difficult if the characteristic symptoms are borne in mind; these are rapid onset, constant vomiting, frequent serous discharges, intense thirst, high rectal temperature, low surface temperature, collapse, depressed fontanelle, sudden loss of weight, and distressed, restless expression, suggesting speedy death, all developing in from twenty-four to forty- eight hours. It is distinguished from fermental diarrhea by the serous nature of the intestinal discharges, and by the constant high rectal temperature. PROGNOSIS. — The prognosis is bad. The more violent the attack, the higher the temperature, the less the vitality, and the warmer the weather, the worse is the prognosis. When the infant has survived the very acute symptoms which appear in the first two or three days, the prognosis is more favorable. TREATMENT. — Cholera infantum is so formidable in its attack that it must be treated most energetically if we hope to succeed in saving the infant's life. The indications for treatment are (i) to assist the effort which nature is making to free the stomach and intestine from the poison which is in them; (2) to restore the surface circulation, which is so seriously interfered with; (3) to supply water to the tissues, which are being drained to so grave an extent; and (4) to support the strength until the disease has run its course. The poison seems to act with especial virulence on those portions of the economy where it is most concentrated, — namely, the stomach and the intestine. We therefore have at first extreme irritation of these parts, which causes increased peristalsis, and later vasomotor paralysis, with great transudation of serum. This condition of the gastro-enteric tract is to be especially borne in mind during the whole course of our treatment. In this disease we should not attempt to use any remedy which works slowly. The condition of the mucous membrane is in all probability such that absorption of drugs does not take place readily. The administration of drugs is, therefore, contra-indicated, for they may later, when absorption is being restored, prove fatal by their cumulative action. During the acute stage of the disease the diges- tive functions fail to act, and therefore food of any kind will be only an additional source of irritation. Early in the attack, and when the vomiting has not caused much prostration, the stomach should be thoroughly washed out with warm Diseases of the Gastro-Enteric Tract water and the intestine should be irrigated. If the rectal tempera- ture is very high, cold water may be used for irrigation. When the vomiting has continued for some time and there is prostration with great thirst, the infant should be allowed to suck sterilized, ice-cold water from the bottle. At first nothing else should be given by mouth. The infant should be placed at once in a warm pack. This should be done by wrapping it to the chin in sheets wrung out of water at least as hot as 38° C. (100.4° F.). It should then be enveloped in a hot blanket. This procedure should be repeated as often as the infant shows signs of collapse or much cyanosis and coldness of the skin. This is the best method that we know of to restore the surface circulation. While the infant is in the hot pack, water can be given freely by the mouth and, if necessary, small and frequently repeated doses of stimulants, unless they appear to excite vomiting, in which case they should be given hypodermically. If the vomiting and diarrhea continue to be excessive after this treatment, small doses of morphine, 0.0006 gramme (i/ioo grain), and atropin, 0.00008 gramme (1/800 grain), for an infant a year old, can be tried hypodermically. The effect should be carefully watched, and the dose repeated if necessary. The feeding and stimulation of these cases should be carried out as described for severe cases of infectious diarrhea. The giving of fluid subcutarieously or intravenously is of special importance. GASTRITIS Gastric infection is extremely rare, and in frequency of occurrence presents a marked contrast with that of intestinal infection. ETIOLOGY.— Improper feeding, with its resulting gastric indi- gestion, is the predisposing cause, infection probably resulting from increased vulnerability of the gastric mucus membrane. The nature of the infection is variable, but, with the exception of its occurrence in connection with such diseases as tuberculosis and diphtheria, the streptococcus is probably the most frequent organism present. PATHOLOGICAL ANATOMY.— The lesions found in infectious gastritis may be divided into (a) catarrhal, (b) ulcerative and (c) pseudomembranous gastritis. Catarrhal gastritis shows hyperemia of the mucous membrane, hypersecretion of mucus, small punctate hemorrhages and slight thickening of the mucous coat. The undigested food remains longer than normal in the stomach and is mixed with an excess of mucus. Microscopically the changes are confined mainly to the mucosa and consist of degeneration, infiltration in places with round cells Gastritis 489 and at times loss of surface epithelium. Rarely, in chronic cases, there is more marked infiltration and an increase of the connective tissue. Ulcerative gastritis is extremely rare. The ulcers are usually follic- ular, numerous, vary from mere dots to 1/4 inch in diameter, and usually involve only the mucosa. Pseudomembranous gastritis is still more rare. In this condition there is a grayish or greenish adherent false membrane, consisting microscopically of fibrin, granular matter, epitheHal cells, and detritus. There is round-celled infiltration of the mucosa, submucosa, and sometimes even of the muscular coat. This form is usually accom- panied by ulcerative gastritis. SYMPTOMS.— Of the different forms of gastritis, the catarrhal is very much the most common. There are no pecuHar symptoms by which the ulcerative and pseudomembranous varieties can be recognized \dth any certainty. Acute Gastritis. — The symptoms of acute catarrhal gastritis resemble at the onset those of acute indigestion. There is nausea, vomiting, thirst, loss of appetite, and usually some prostration. Fever is always present, whereas it is usually absent in indigestion. Abdominal tenderness is present. The continuance of the symptoms, particularly those of fever, vomiting, pain, and tenderness, is the basis for the diagnosis of acute gastritis. The temperature is usually moderate, 37.7°-38.8° C. (ioo°-io2° F.) after the onset. There may be constitutional symptoms at the onset. There is usually frothy mucus in the vomitus, which is sometimes streaked with blood. DIAGNOSIS.— Gastritis is so rare a disease in early Hfe, that the diagnosis is not often made. It is much commoner for cases of indigestion to be WTongly diagnosed as gastritis than for cases of gastritis to be overlooked. The symptoms are much like those of indigestion, with vomiting as the principal manifestation. Fever and tenderness over the epigastrium, which are characteristic symp- toms of gastritis, are practically never seen in indigestion. Those forms of indigestion which have fever are characterized usually by diarrhea or abnormal movements rather than by vomiting, and diar- rhea is usually not present in gastritis. The diagnosis depends on the coexistence of vomiting, continued fever, epigastric pain and tenderness. PROGNOSIS.— Attacks of acute catarrhal gastritis, even when properly treated, are apt to last for from three to seven days. When not properly treated they may be prolonged or chronic gastritis may develop. When properly treated the prognosis is good. 490 Diseases of the Gastro-Enteric Tract TREATMENT. — The treatment of acute gastritis is much Hke that of acute indigestion with vomiting. The initial administration of calomel should, however, be omitted. It is necessary also that food be withheld for a longer period, and in severe cases nothing should be given by mouth for several days. Whenever it is neces- sary to give no food by mouth for more than twenty-four hours, rectal feeding should be instituted.. The patent may be given from four to six ounces of peptonized milk, or of a 6% dextrose solution every four hours, by rectum. A little salt solution may also be given by rectum between the nutrient enemata. If the child is very thirsty, iced soda water in very small doses may be given by mouth, unless it appears to increase the vomiting. The time when feeding by mouth should be resumed, must depend upon the circumstances of the individual case. In general, food by mouth should not be given until a marked improvement has appeared in the symptoms. Albumin water or whey are good preparations for beginning feeding. Later, a very weak milk modification con- taining lime water, or sodium bicarbonate, should be given. The strength of the food is gradually increased according to the digestive requirements of the individual. When serious symptoms, such as prostration and collapse occur, the general measures which are used are like those in similar conditions. PROCTITIS Proctitis is an inflammation of the rectum, and may be acute or chronic. It is usually coincident with inflammation of the colon, but may occur alone as the result of trauma or the extension of inflammatory processes around the anus. SYMPTOMS. — The symptoms are essentially pain, traces of blood mixed with mucus, and tenesmus. DIAGNOSIS. — The diagnosis from reflex inflammatory conditions is made by direct inspection. TREATMENT.— The treatment is to keep the child in bed, to keep the feces soft with laxatives, to cleanse the rectum, and, ac- cording to the especial lesions, use astringents or soothing injec- tions. Where there is pain or tenesmus, suppositories of opium are indicated. APPENDICITIS Appendicitis occurs at all ages, and is not especially a disease of early life. Only the pecuUarities of the disease as seen in children will be described here. ETIOLOGY. — Inflammation of the vermiform appendix in chil- dren is most frequent between the ages of five and fifteen years, Appendicitis 491 and is not of uncommon occurrence. It is very rare under two years. Several cases have been reported as early as seven weeks. Boys are more often attacked than girls, in about the same propor- tion as in adults. Little is known as to the predisposing or exciting causes of an attack. Foreign bodies are infrequent, despite the general opinion, and although the presence in the appendix of fecal concretions, often resembling seeds and stones of fruit, is very com- mon, their exact relation to the inflammation is not clear. Intes- tinal worms, both lumbricoid and the oxyuris, have been found within the appendix and presumably have been the inciting cause. Direct trauma, as from a blow in the abdomen, is sometimes a definite exciting cause. The prevailing opinion is to consider the process an infectious inflammation, though no specific organism has been shown to cause it. On the contrary, cultures of the colon bacillus alone, or mixed infections of the colon bacillus associated with the streptococcus, pneumococcus, staphylococcus albus or aureus, the bacillus aerogenes, and certain undetermined anaerobic organisms are found. The transformation of the appendix into a closed tube is to be considered as a consequence rather than a cause of appendicitis. PATHOLOGICAL ANATOMY.— The pathological "conditions oc- curring in the course of an appendicitis are exceedingly varied, and will only be outlined. In the early stages of a purely appendicular lesion, the appendix is in normal position and may show only slight swelling and congestion. Usually it is voluminous from extensive infiltration of its walls, very turgescent, and often shows spots of ecchymoses with intense congestion of the peritoneal coat. In more advanced stages the mucosa is soft and granular, sometimes gela- tinous, with ecchymoses and ulcerations. The muscular coats are thickened and their fibres often separated by minute or extensive accumulations of pus. All these changes may develop in from twenty-four to thirty-six hours after the onset of symptoms. Per- foration and gangrene of the appendix, in part or in whole, are simply further steps in the inflammatory process, and are especially likely to occur in children. The inflammation is rarely confined to the appendix, but by ex- tension involves the peritoneal coat of the appendix and the peri- toneum itself. The subsequent course is very variable. The pro- cess may remain local, and lead to a peri-appendicular inflammation, in which the appendix, cecum, and end of the ileum are shut oflf from the rest of the peritoneal cavity by adhesions, with or without the formation of pus; or the infection may spread directly from the appendix to the general peritoneal cavity, with the production of general septic peritonitis. The location of the pus in cases of abscess formation depends to some extent upon the location of the appendix, 492 Diseases of the Gastro-Enteric Tract in which there is considerable variation. It may be either iliac, pre-rectal, sub-umbiUcal, retro-cecal, or lumbar in its disposition. A most malignant form of general peritonitis may follow a simple parietal appendicitis without perforation or gangrene of the appendix, and give rise to a clinical picture more suggestive of septicemia than of peritonitis. A simple appendicitis, sometimes called catarrhal, may produce so much thickening of the walls and infiltration of the submucosa with leucocytes, and subsequent formation of granulation tissue, as to cause an obliteration of the lumen of the appendix. If the lumen is completely obHterated, it may render the patient immune to subsequent attacks, but if only partial, it favors the collection of pockets of pus and cyst formation, and the organ is then a constant source of danger. SYMPTOMS. — In many cases the symptoms of appendicitis in children are like those of appendicitis in adults, presenting the familiar picture of abdominal pain, localized tenderness, muscular rigidity, and distention with vomiting and fever. This adult type is most common in older children, and presents comparatively Httle diffi- culty in diagnosis. In younger children, the clinical manifestations of the disease are often very atypical, and present the greatest diffi- culties in diagnosis. The younger the child, the more irregular is the onset and course likely to be, and the greater the difficulty in recognizing the nature of the disease. The atypical features of the disease may be summarized as fol- lows: Pain, while usually present, is often indefinite and hard to recognize. It often appears to be paroxysmal in character, attacks of crying coming at more or less regular intervals. It is often not definitely referred to the right ihac region, or even to the right side, but is referred at different times to various parts of the abdomen. In infants restlessness and irritabihty may be the only sign of pain, or there may be frequent attacks of cr5dng. When these manifes- tations occur in paroxysms, with quiet intervals, it is particularly suspicious. Tenderness on abdominal palpation is often still more difficult to recognize than pain. Young children cannot cooperate with the examining physician in saying when palpation hurts them, and the examiner must judge by the facial expression and actions of the patient. Young children often resist examination strenuously, or, if nervous and sensitive, shrink from the slightest touch. Even when they are old enough to answer questions, their repUes may be misleading. When evidences of pain on palpation are found, the tenderness often cannot be localized. When localized tenderness is found, it is often not situated in the right ihac region, but high up Appendicitis 493 on the right side, near the Hver, or nearer the centre of the abdomen. I have seen cases in which tenderness appeared to be entirely absent. Muscular rigidity is often equally difi&cult to determine. In young children it is often necessary to divert the attention from the exami- nation, and this can only be accomplished by the exercise of tact and patience. When the physician can be sure that real invol- untary spasm of the muscles of the abdominal wall is present, it is a sign of great importance. Even when the examination is satis- factory, muscular rigidity may be absent. Often the only evidences of tenderness and muscular rigidity are a disinclination on the part of the child to move the trunk or lower extremities, or signs of pain when the patient is moved. Sometimes the right thigh, or both thighs, are held rigidly flexed. Abdominal distention may be present or absent. When present in connection with other symptoms, it is an aid in diagnosis. Fever in children is apt to be higher than in adults, and high fever in con- nection with any abdominal symptoms, but unaccompanied by diar- rhea, is very significant. There are many exceptions, however. While some fever is almost always present, the temperature may be very moderately raised. Constipation is usually present, but may be absent, and diarrhea is sometimes seen. There is usually a poly- morphonuclear leukocytosis, the white count being about 20,000. Acetonuria is usually present early in the disease. Of all the symptoms of appendicitis in early life, vomiting is the most common. In insidious cases the symptom-complex is vomiting, fever, and paroxysmal crying. The other symptoms and signs are confirmatory when present, but are often absent, or difficult to recognize. Course of the Disease. — When the clinical picture of appen- dicitis in children resembles that seen in adults, the course and ter- mination of the disease are also like those of adults. The symptoms may improve after a few days, and recovery may take place, to be followed by another attack after a number of months. In other cases the symptoms may either slowly or rapidly increase in severity, with continued vomiting and fever, rising pulse and temperature, increasing abdominal distention and rigidity, and increasing pros- tration. In such cases death occurs as a result of general perito- nitis in from four to eight days. In the atypical types, so common in younger children, the course of the disease is much more irregular. The indefinite clinical picture may persist for several days. Only comparatively slight vomiting, moderate fever, and indefinite evidences of pain may be present after the onset. The child is fretful, wants to be let alone, and resists examination so that definite tenderness cannot be made out. Pros- tration is not marked, and the child may not seem very ill. Never- 494 Diseases of the Gastro-Enteric Tract theless, under these circumstances gangrene or perforation may occur without preliminary warning. The child now begins to get worse, either gradually or rapidly, and begins to look seriously ill, while the pulse rate rises, prostration increases, and abdominal dis- tention becomes marked. At operation, a gangrenous appendix and general peritonitis may be found, or a locaHzed appendix abscess. DIAGNOSIS. — ^Abdominal tenderness is the sign of greatest diag- nostic significance in children, when it can be obtained. It is not a common symptom in infants and young children, and is not seen in the acute disturbances of digestion or in infectious diarrhea. Be- side appendicitis it is seen most often in intussusception and lobar pneumonia. Intussusception is excluded by the other pecuHarities of its symptom-complex, such as bloody intestinal discharges, and the finding of a definite rounded tumor. The diagnosis between appendicitis and early lobar pneumonia is often very difficult. Pneu- monia is much more often mistaken for appendicitis than vice versa. In appendicitis the rate of respiration is not so much accelerated as in pneumonia, vomiting is a more pronounced and persistent symptom, and the abdominal tenderness, while it may not be local- ized in the right iHac region, is usually accompanied by involuntary muscular spasm, which sign is absent in pneumonia. The diagnosis may be in doubt until the signs of pneumonia appear in the lungs. Paroxysmal ' pain, continued vomiting, and increasing prostration point toward appendicitis. In those cases in which abdominal tenderness cannot be made out, the diagnosis is often still more difficult. It usually depends on the combination of fever, vomiting, constipation, pain, especially if paroxysmal, and the absence of any evidence of other adequate cause for the symptoms. I have seen appendicitis in which fever, vomiting, and acetonuria were the main symptoms, mistaken for acidosis until after general peritonitis had developed. PROGNOSIS. — The prognosis depends largely upon how early the diagnosis is made and the skill of the surgeon who is called for consultation and operation. Cases undoubtedly recover in many instances without operation, but the extreme gravity of the results of an extension of the inflammation to the peritoneum, and the realization that this accident may occur at almost any time, even in the cases which are apparently running a mild course, render general statistics of little value in the consideration of an individual case. We should not lose sight of the fact that in infancy we see most frequently the very severe and acute forms of the disease, and there is the special tendency to perforation and gangrene and extension to the peritoneum, with its very serious consequences. Appendicitis 495 TREATMENT. — I believe that every case of appendicitis in children should be operated upon as soon as the diagnosis is made. The danger of delay is greater in children than in adults, because the disease may be so much more insidious in its onset and course, that gangrene, perforation, and peritonitis may occur with very little warning. Consequently, if the diagnosis of appendicitis can be made, or if it is even suspected, the surgeon should be called in immediately. If the diagnosis is fairly clear, no time should be wasted with blood counts, or with observation of the progress of the case. The opera- tion should be promptly performed. I have seen serious mistakes made in waiting too long by surgeons who were more familiar with the disease as it manifests itself in adults than in children. There is no medical treatment other than that which is purely symptomatic. Absolute rest in bed, irrespective of the severity of the symptoms, is of first importance; local appHcations of ice should be used to control the pain, or, if the child objects, as is frequently the case, hot fomentations should be tried. Cathartics and laxatives should be avoided, and the bowels moved by enemata. Blisters should not be used. Opium is strongly objected to by surgeons as tending to mask the symptoms; if it can be avoided, it is far better to do so; but very small doses, sufficient to keep the patient from excessive pain and fairly quiet, are probably in children a lesser danger than that which would be caused by hours of pain, crying, and intense restlessness. VIII. UNCLASSIFIED DISEASES Under this heading will be considered certain conditions which cannot be classified under any of the foregoing groups, because their etiology is either unknown, or exceptional, or very varied. CONSTIPATION Constipation is a condition in which the number of stools passed is less than the normal, or in which the consistency of the stools is greater than the normal. It is not a disease, but a symptom. To recognize constipation one must be familiar with the normal number and consistency of the intestinal discharges in the various periods of early Hfe. During the first year of life, the normal daily number of evacuations is two or three in breast-fed infants, and one to three in the artificially-fed. The consistency is normally somewhat greater in the artificially-fed, but should not be so great as to cause any evidences of discomfort on passage. In the second year the normal number of discharges daily is one or two, and in later childhood one is the usual number. ETIOLOGY.— The causes of constipation are very numerous and varied, and often the condition is due to the joint action of several causes. It is difficult to make a satisfactory classification of the various kinds of constipation, and the various etiological factors involved. The following classification, while not logically consistent in every respect, is convenient for reference in the diagnosis of a given case. Table 47 Causes of Constipation [Heredity 1 . Constitutional i Thyroid insufficiency [Backward development [Long colon 2. Mechanical | Intestinal lesion [Obstruction from pressure [Fissure of anus 3. Reflex (spasmodic) -^Hemorrhoids [Large, hard stools 4. Partial paralysis fOpium \Acute infectious disease 5. Dietary. Too weak food Too little fat Excess of fat Heating of milk Too little solids Constipation 497 Table 47 — Continued 6. Muscular weakness (atonic) Prolonged indigestion Malnutrition Rachitis Lack of exercise Abuse of laxatives Lack of proper training Constitutional Causes. — There is no doubt that certain children have a constitutional tendency toward constipation, which often appears during early infancy. There are so many instances in which constipation is seen in both parent and child, without other obvious cause, that it is probable that heredity plays some part. Neverthe- less, the possibihty of coincidence cannot be overlooked, and it is probable that the part played by heredity is a minor one. Thyroid insufficiency is a possibility which must not be forgotten in infancy. In a marked case of cretinism, the cause of the constipation would not be overlooked, but in many cases the characteristic stigmata are slight or absent. It is probable that a relative backwardness of the functional development of the digestive glands, such as the liver and intestinal glands, may be a contributing cause in some cases in young infants. With the exception of insufficiency of the thyroid, the causes in this group can neither be recognized, nor removed, and must be regarded as representing an underlying constitutional factor, which in the case of heredity is permanent, and in the case of backward development is temporary. The treatment of constipation from thyroid insufficiency is that of cretinism. Mechanical Causes. — The large intestine, especially the sigmoid flexure, in the infant is relatively longer than in later life, and has a proportionately longer mesentery. This allows more opportunity for bends and kinks, and may be a constant contributing cause in the constipation of infancy. In some cases, the colon may be abnor- mally long. There may be a congenital lesion involving some portion of the intestine, such as a partial stenosis, a Jackson's membrane, or peritoneal adhesions resulting from some inflammatory process before or after birth Such adhesions are not very rare in post-mortems of infants. Hirschprung's disease is a recognized mechanical cause of constipation. Moreover, some lesion not directly involving the intestine, such as tumor, may cause mechanical obstruction from pressure. Some of the mechanical causes, such as tumor and Hirschprung's disease, may be recognized by physical examination. Usually, how- ever, the recognition of a mechanical cause for constipation depends on the examination of roentgenograms taken after bismuth meals and bismuth rectal injections. Some mechanical causes cannot be diagnosed. 32 498 Diseases of the Gastro-Enteric Tract Reelex Causes. — Mechanical irritation, usually in the rectum or at the anus, may produce a spasm of the musculature of the intes- tinal walls. This is the so-called spasmodic form of constipation. It is seen in such conditions as fissure of the anus, or hemorrhoids. The passage of large, hard stools is perhaps the most frequent cause of spasmodic constipation. The other causes of constipation must be sought in explanation of the hard stools. The reflex causes of constipation are recognized by examination. PARTLA.L Paralysis. — Constipation may be caused by a paralysis of peristalsis, coming not from muscular weakness, but from impaired innervation. This is the probable explanation of the symptomatic constipation seen in acute infectious disease. The same sort of con- stipation is seen as the result of the administration of opium, usually in the form of paregoric or some ''soothing syrup." The possi- bihty of this cause must always be remembered. Sometimes a nurse may be giving some form of opium to quiet the baby without the knowledge of the parents. In acute infectious disease, the cause of the symptom is obvious. The recognition of opium depends on the history, or on the detective investigation of the physician. Dietary Causes. — This group includes causes which are far com- moner than any of the foregoing. In infants the commonest dietary cause is insufficient food. The milk may be insufficient in quan- tity, or may be too weak in composition. This cause is met with both in breast-fed infants and in the artificially-fed. The infants are constipated, because the soHds of the food are so completely absorbed that not enough residue is left to form the normal amount of feces. Constipation may also occur when the food contains insufficient fat. The fat forms the principal bulk of the feces in infants, and if the carbohydrate and protein be completely absorbed, there is not enough fecal matter. An excess of fat is, however, a more common cause of constipation in artificially-fed infants. In this instance the bulk of the stools is not diminished, nor is the number of discharges, but the stools are large and hard. The Hght yellow or gray color, and occasional dry, crumbHng consistency of the "soap stools" have been described under indigestion from an excess of fat. An excess of starch in the food may cause constipation, but in this instance the symptom is due to muscular weakness from the effects of prolonged fermentation. In older children constipation may be seen in indi- gestion from an excess of sugar, but this form is also due to muscular weakness, and will be described in the next group. The heating of milk, especially if the milk be boiled or sterilized instead of pasteur- ized, may be a cause of constipation, but this cause is less common than is generally supposed, and has never actually been proven. Constipation 499 In older children constipation may be caused by a faulty diet. One fault, seen mainly in the second year, is the giving of too much milk. A baby of this age is sometimes so fond of milk that it is given more than it should have, or the mother is fearful that solid food will cause digestive disturbance, and believes that milk is "safer." A baby in the second year should not take more than forty ounces of milk in the twenty-four hours. Another dietary fault in older children is the giving of an insufficient amount of cereal, cooked fruit, and green vegetables. The dietary causes of constipation are recognized by a careful and painstaking inquiry into every detail of the child's diet. Muscular Weakness. — Muscular weakness is not a primary cause of constipation, but a condition secondary to a variety of causes. This is the well-known "atonic" form of constipation, which is one of the commonest encountered in early life. The essen- tial condition is a weakness or atony of the muscles of the intestinal wall. Weakness of the muscles of the abdominal wall is not infre- quently an accompanying condition and contributing factor. Prob- ably the commonest cause is prolonged indigestion, especially when due to an excess of carbohydrate. While carbohydrate indigestion in infants produces loose movements from the irritating products of fermentation, the excessive gas formation and intestinal distention causes an atony of the intestinal muscles, which will later result in constipation. This is especially common in the carbohydrate indi- gestion of older children. Moreover, in many chronic digestive disturbances, and in many other chronic diseases, malnutrition, involving all the tissues of the body is a common condition. The muscles of the intestinal wall and the abdominal muscles are involved in this general wasting, and muscular atony is the result. One form of disturbed nutrition, in which atonic constipation is very common, is rickets. Lack of exercise leads to general muscular atony, and the muscles of the intestine are also involved. This cause is not confined to older children, for infants are often kept too quiet, and not allowed to kick and use their limbs. Another cause is lack of training. While still in infancy, children can be taught to empty the bowel at a regu- lar and proper time, and this training should be carried out as early as possible. With older children it is essential that the child be not allowed to wait until the spirit moves him to evacuate the bowels, but that he should be made to go to the water closet at a regular time each day, preferably after breakfast in the morning. If this is not done, children will often develop constipation through neg- lecting their bowels, as they allow their various absorbing interests to make them postpone going to the water closet even when they feel the impulse. Muscular atony will in time follow such neglect. 500 Diseases of the Gastro-Enteric Tract The atonic form of constipation can be recognized only from a very careful history of the case, including every detail of the child's daily Hfe. SYMPTOMS. — The general symptoms caused by constipation in children are indefinite, variable in kind and severity, and sometimes entirely absent. In infancy, the only symptom may be signs of general discomfort, irritabihty, and sometimes sleeplessness. The trouble may sometimes be recognized only by the straining and effort which accompanies defecation. In some cases flatulence and colic are the most prominent symptoms. In older children the most prominent symptoms are either a tendency to headaches, or abdom- inal pain and cUscomfort. In both infancy and childhood, a coated tongue and bad breath are frequent symptoms. None of these symptoms is peculiar to constipation, nor in any way diagnostic. There are often no general symptoms, and this is particularly likely to be the case when the constipation is due to atony of the lower part of the intestine. Pain is almost always present in the spasmodic form, and is usu- ally present in the type characterized by the passage of large, hard stools. In this type streaks of blood with the feces are not un- common. DIAGNOSIS. — Constipation being a symptom, its diagnosis is of course obvious. The important thing is the diagnosis of the etiology of the condition. This depends on a thorough knowledge of all the various possible etiological factors. It demands a very careful history, which should include every detail concerning the child's diet, habits, and daily hfe. A most thorough physical ex- amination, which should usually include a rectal examination, should be made in every case. Roentgenograms, taken after a bismuth meal, or a bismuth enema, constitute an important diagnostic pro- cedure, and should be employed in every case in which the etiology is not immediately obvious. PROGNOSIS. — The prognosis of constipation depends on the etiological factors involved. In some cases due to easily removable causes, such as improper diet, or the use of opium, the prognosis for immediate improvement is good. Such causes as insufiicient exercise, lack of proper training, and the abuse of laxatives are removable, but when they have resulted in the development of the atonic form of constipation, the process of recovery is much slower, and while the eventual prognosis is good, considerable time is often required before improvement is noted. The prognosis of constipation secon- dary to other diseases is that of the causative condition, but here again, if such causes as malnutrition or prolonged indigestion have resulted in the atonic form of constipation, recover}" is comparatively Constipation 501 slow. In cases in which heredity plays an important part, the ten- dency toward constipation is more persistent, but even in such cases, backward development usually plays some role, and the tendency may be outgrown in time. In cases due to a lesion of the intestine, the prognosis depends on the possibiUty of removing the cause. TREATMENT. Removal of the Cause.— The treatment of constipation is removal of the cause, or treatment of the cause. Such causes as heredity, and backward development cannot, of course, be removed or treated. On the other hand, such causes as cretinism and the abuse of drugs can be quickly remedied. Such mechanical causes as anatomical lesions involving the intestine, can only be remedied, if at all, by some radical surgical operation. When consti- pation is due to the long infantile colon, only time and growth can remove the cause. Both fissure of the anus and hemorrhoids are easily cured in childhood; during the treatment the stools must be kept soft with some mild laxative. In the type of spasmodic consti- pation due to the passage of large, hard stools, the first cause is dietetic, and the treatment is that of the cause. The treatment of the symptomatic constipation seen in acute infectious diseases is described under the diseases in which it occurs. It consists in the use of enemata, or of mild laxatives. In infants with acute infectious disease, the bowels can be kept properly open with magnesia. In older children, sodium phosphate, cascara, or phenolphthalein, are required. Constipation due to recognizable dietary errors is easily remedied by removal of the cause. When the cause is some under- lying chronic disease, such as prolonged indigestion, malnutrition and rickets, the treatment is that of the cause. Such causes as lack of exercise, lack of training, and the abuse of laxatives are removable. Dietetic Treatment. — In many cases of constipation, the cause cannot be immediately remedied, but the underlying disease requires prolonged treatment. In other cases, while the cause can be re- moved, its removal is not followed by immediate relief of symptoms. This is particularly true when the constipation is of the atonic type. It becomes necessary to treat the constipation in the meantime. The treatment of constipation is mainly dietetic. The measures employed to improve a weak breast-milk have been described in the division on Feeding. In artificially-fed infants, changes may be made in the composition of the food, with a view to finding the combination of the food elements best suited to the needs of the individual baby. The food may be cautiously strength- ened in composition, while signs of indigestion are carefully watched for. It is not, however, a good plan, in a baby who is digesting well, and gaining weight, to make much change in the composition of the 502 Diseases of the Gastro-Enteric Tract food. It is particularly dangerous to increase the quantity of cow's milk fat in the food, simply for the purpose of treating constipation. Only in cases where the baby is getting less food or less fat than he can digest, is it safe to make much increase. The feeding of an infant is guided by his digestive peculiarities, and there is compara- tively little room for treating the constipation of infancy by dietetic measures, beyond the correction of an error. In some cases the substitution of a maltose-dextrin preparation in place of lactose will have a good effect on constipation. For this purpose the malt ex- tracts are better than the dry dextri-maltose preparations. Orange juice may be given to infants in the second half of the first year. Also, at this age, oatmeal water or oatmeal jelly may often be advantage- ously substituted for barley water. In the second year there is more scope for dietetic treatment. The amount of milk may be slightly reduced, but cream should not be substituted, because while the giving of more cream will improve the constipation, it may cause indigestion in a very insidious way. The slight reduction in milk should be made up by an increase in the amount of sohd food. The coarser farinaceous foods are valuable as peristaltic stimulants. Graham bread should be substituted for white bread, graham crackers may be substituted for zwieback, and oatmeal should be the preferred cereal. Meat broths and beef juice are valuable on account of the laxative effect of their salts and ex- tractives. Fruits are valuable, but only the juice should be given until the child is over fifteen months. Between the fifteenth and eighteenth months baked apple, apple sauce, or prune pulp may be given daily. Toward the end of the second year a Httle of the green vegetables, such as spinach, string beans, and asparagus may be cautiously tried. In older children the quantity of milk may be reduced, and also the quantity of starchy food. Graham bread should be used, and bran biscuits are often valuable. Meat and broth may be given freely. One of the green vegetables should be given every day. Cooked fruit of any kind should be given, but raw fruit not until the child is over three years of age. Care must be taken, however,, not to produce indigestion by the giving of too much fruit and coarse food. Plenty of water should be given between meals. It is often a good plan to give a half a glass of some sparkling water, such as Apollinaris, an hour before breakfast. Other General Measures. — It is essential that regular habits in connection with the evacuation of the bowels be established. Even in babies, training is not difficult. The baby should be put in a properly constructed chair at a regular hour each day, and a sup- pository made from a roll of paper dipped in sweet oil, or a soap suppository, should be inserted to supply a local stimulus. As soon Constipation 503 as the habit is established, the suppositories should be omitted, or the baby may easily become dependent on them. Older children should be trained never to neglect an impulse to evacuate the bowels and should be made to go to the water closet every morning imme- diately after breakfast. Massage of the abdomen is useful as a routine treatment, but should not be relied on without other measures. It should be given for five minutes just after the child goes to bed, and just before it gets up. The hand should not be oiled, and the skin should not be rubbed, but the hand and abdominal wall should roll together over the deeper structures. Medicinal Treatment. — Laxatives must be used, when other measures do not suffice. The best laxative for an infant is milk of magnesia, and it is often required, because of the limitations of dietetic treatment at this age. It is better not to give the milk of magnesia in a single daily dose, but to divide the daily amount so that it is given in all the food taken by the infant. In a breast- fed infant, the magnesia may be given in a teaspoonful of water im- mediately before, or during, each nursing. In an artificially-fed baby, the magnesia may be put into every bottle. The daily amount to begin with should be a teaspoonful, and this should be so divided that a baby receiving six feedings should have ten drops of milk of magnesia put into every bottle, or given before each nursing. The number of drops thus given in each feeding should be increased or diminished according to circumstances, until just the right quantity is found to cause a daily normal evacuation of the bowels. The minimum amount which will produce this effect should always be used, and as the constipation improves, an effort should be made to reduce the amount of magnesia till it can be omitted altogether. The advantage of giving milk of magnesia in this way is obvious. Any laxative in a child, when given in single daily doses, produces a maximum stimulus, and tends to make the patient dependent on the drug. When milk of magnesia is given in the food, the effect is to make all the food more laxative, and this is just Uke dietetic treatment, and is just the result which we wish to obtain in infants. This method of administering milk of magnesia may also be used in the second year. When a daily amount of two or three teaspoon- fuls given in divided doses in the milk fails to produce a satisfactory result, sodium phosphate should be substituted. It should be given divided in the same way m the milk, the twenty-four amount being sixty to ninety grains. When both milk of magnesia and sodium phosphate fail to pro- duce the desired result, the child is usually over eighteen months old, and the variety of its diet makes dietetic measures more effec- tive, so that it is less necessary to give the laxative in the food. In 504 Diseases of the Gastro-Enteric Tract cases of this kind, and in older children in general, the two best lax- atives for chronic constipation are phenolphthalein and cascara sagrada. Here again it is preferable to give the laxative three times a day with the meals, but often a satisfactory result cannot be obtained in this way. In such cases, the laxative should be given at bed- time. The dose of phenolphthalein is from one to three grains, and of cascara from one-half to two grains, or from five to twenty drops of the fluid extract. Olive oil, in doses of a teaspoonful three times a day, is some- times useful both in infants and in older children. Agar agar is useful in older children who pass hard, dry stools. It should be given finely divided, in doses of one to three teaspoonfuls three times a day. In some cases of atonic constipation, a combination of aloin, extract of nux vomica, and strychnine, in small doses appropriate to the age of the child, is very valuable. It may be given as a tonic, and if it does not sufiice to overcome the constipation, cascara or phenolphthalein may be given in addition. To a child two or three years old, the combination may be aloin gr. 1/24, ext. nux vomica gr. 1/24, ext. belladonnae gr. 1/48. The medicinal remedies to be especially avoided in the chronic constipation of early Ufe are castor oil, calomel, senna, compound liquorice powder, and rhubarb. All of them cause too violent a stimulation of peristalsis, and are not adapted for prolonged use, as they tend to increase the tendency toward constipation, and to make the child dependent upon medicine. They are adapted only for temporary use, in such conditions as acute disease. Even when cascara or phenolphthalein are used in chronic constipation, a con- stant effort should be made to reduce the amount of laxative. With the other measures, and treatment or removal of the underlying cause, this will usually be possible. Suppositories. — Suppositories are best adapted to the form of constipation in infancy in which the weakness is low down in the intestine. This form can be recognized by the immediate passage of a large movement whenever a suppository is used. Treatment with suppositories should be confined to this form of constipation, and should not be used for atony of the upper bowel. Infants be- come dependent on suppositories just as easily as upon drugs. Gluten suppositories are the least irritating. Soap suppositories are allow- able, but glycerin suppositories should never he used in chronic consti- pation. I have seen more cases of chronic constipation caused by glycerin suppositories, than by the abuse of any laxative. Enemata. — These are not advisable in the treatment of chronic constipation in general. They are, however, useful in constipation due to a temporary cause, such as the symptomatic constipation Intestinal Worms 505 of acute disease. The ordinary soap suds enema is the best in such cases. When the stools are very hard and dry, an injection of an ounce of sweet oil at bedtime may facilitate their passage. Cases of fecal impaction are rare in children, but cases are sometimes seen in which there is a great deal of hard fecal accumulation, the bowels not having moved for several days! In such cases, an injection of an ounce of sweet oil may be given, to be followed in half an hour by a soap-suds enema. It is sometimes necessary to cause an immediate emptying of the lower bowel by means of an enema. Under such circumstances an enema of two teaspoonfuls of glycerin in an ounce of water, is very efl&cient. Glycerin enemata are strongly contraindicated in chronic constipation. INCONTINENCE OF FECES Incontinence of feces is a condition in which the fecal move- ments occur involuntarily. This may be due to inabiUty to control the sphincter ani, or to loss of power of the sphincter itself. The first class of cases, due to disease or injury of the spinal cord, or to absence of reflex sensation, is rare. The second class is due to an atonic condition of the sphincter. The treatment of the first class of cases is essentially that of the disease in which it occurs. The treatment of the second class is illustrated in the following cases: A boy, eleven years old, much overworked at school, had been made to study a number of languages, and allowed to take only a very limited amount of exercise in the open air. He completely lost control of the sphincter ani, and became very anemic and weak. Nothing abnormal was found on a physical examination. The boy was. taken from school, relieved entirely of his studies, and kept in the open air most of the day. Under this treatment, in addition to the administration of tartrate of iron and potassium, he improved rapidly, and in two months was entirely well. Another boy, seven years old, came to the Children's Hospital, with a history of incontinence of feces lasting over a year. He illustrated the condition of incontinence from habitual constipation, as the incontinence was found to depend on the stretching of the rectum by impacted feces. The rectum was emptied by a dose of castor oil and an enema each day. At the end of a week the boy had ceased to have involuntary fecal movements, and has since continued well. INTESTINAL WORMS The worms which are found in the intestines of infants and chil- dren are the same as those which occur in older patients. The only ones, however, which are common and important enough to be described are the oyxuris vermicularis (pin-worm) , the ascaris lunibricoides (round worm), the taenia solium, and the taenia saginata or mediocanellata (tapeworms). OXYURIS VERMICULARIS The oxyuris vermicularis is a minute worm, which looks like a little piece of white thread. The female is from 1/4 to 1/2 inch in length. The male is about one-third as large, and has a tail 506 Diseases of the Gastro-Enteric Tract rolled into a spiral. Their development takes place in the large intestine, and the mature worms deposit their eggs in the rectum. The eggs enter the intestine through the mouth, and children are very apt to reinfect themselves by carrying the eggs on the fingers or under the nails to their mouths. These worms sometimes exist in large numbers, and their develop- ment is so rapid that it is often difficult to dislodge them completely. The most common symptom of the oxyuris is an intense itching about the anus. The sleep of the child is disturbed by this irrita- tion, and various nervous symptoms develop in children who are infested with this parasite. Thus incontinence of urine sometimes results. In girls the parasite, by migrating from the anus to the vulva, may cause a vulvo-vaginitis. DIAGNOSIS. — The diagnosis of the presence of these, as of other intestinal parasites, can be made only by finding the worms or their ova in the intestinal discharges. When they are suspected, an enema of clear water should be given. If the parasites are present, they will be dislodged, and careful inspection will disclose their presence. Whenever there are symptoms of reflex irritation in the neighborhood of the anus or the genital organs, the oxyuris should be suspected and sought for. The parasites can often be found in the fecal dis- charges, and in some cases they can be seen by simply stretching open the anus and examining the mucous membrane of the rectum, especially if this be done when the child is in bed at night. TREATMENT. — Although most of the worms are in the rectum, yet they also infect the upper parts of the intestine, and therefore sometimes cannot be reached by enemata. In many cases enemata of salt-and-water are sufficient to produce a cure, but in some cases the salt, even in small amount, is so irritating that it cannot be used. Infusions of quassia may also be employed as enemata. One of the most effective methods of dislodging the parasite is to give every evening at bedtime an injection of 60 c.c. (2 ounces) of sweet oil. This is allowed to remain in the rectum for five or six minutes, and a large enema of water is then used to wash out the oil, which usually carries with it the parasites from the lower colon and the rectum. Care must be taken in regard to cleanhness, so as to prevent reinfection. When this treatment is not sufficient, lozenges of santonin, 1/6 to 1/2 grain, according to the age, may be given two or three times daily. Every two or three days a cathartic, such as castor oil or calomel, should be given. Care must be used in giving santonin not to produce symptoms of poisoning, such as gastro-enteric irri- tation, dizziness, and yellow vision. The occurrence, however, will not be common if in each case the effect of the drug on the child is Intestinal Worms 507 carefully watched. Serious symptoms, such as convulsions, have been caused by a lack of care in using this drug in young children. Under this treatment, aided by high rectal injections, the worms can in most cases be eradicated. I have, however, met with very intractable cases in which months and even years had elapsed before treatment of any kind was successful. In such cases temporary relief can be obtained by giving the child each night, or two or three times a week, a small enema of oil. Fig. 107 Oxyuris vermicularis. Ascaris lumbricoides ASCARIS LUMBRICOIDES The ascaris lumbricoides is a long, cylindrical, yellowish- white or reddish-yellow worm, pointed at both extremities. The male is distinguished from the female by the fact that it is smaller and is always rolled upon itself, while the female is straight. The length of the male is from 4 to 7 inches, and that of the female from 6 to II inches. The eggs of this worm are oval in shape, 0.075 mm. long and 0.058 mm. wide. When they are first passed they are 508 Diseases of the Gastro-Enteric Tract almost transparent, but they soon become yellowish and opaque. These eggs are not developed within the intestine, but pass out with the feces. They are very tenacious of life, and may develop under favorable circumstances after many years. The embryos are de- veloped outside of the body, and reach the intestine with the drink- ing water, where they develop into the mature worm. The habitat of the worm is usually in the small intestine. It may, however, pass through the rectum either with the feces or alone, and may migrate into the stomach, esophagus, or nose. Sudden death has resulted from the entrance of these worms into the air-passages. They may also at times enter the common and cystic bile-ducts, and they have even penetrated farther and caused abscess of the Hver. There is no danger of their perforating a normal intestine, but when ulceration has been present perforation has occurred. SYMPTOMS. — There are no especial symptoms produced by this worm, and we can diagnosticate its presence only by seeing it or by finding the eggs in the fecal discharges. The worm may in some instances produce a feeUng of discomfort or even colic in the region of the umbiUcus. Neither of these symptoms, however, can be depended upon, and an anthelmintic is required to determine whether the parasite is present. In certain cases convulsions in children have been followed by the passage of a lumbricoid worm. This, however, cannot be accepted as conclusive evidence that the convulsion was dependent upon the worm. TREATMENT.— The most efficacious treatment of this form of parasite is in the form of santonin, which should be given in the same doses and with the same caution as have been already described in speaking of the treatment of the oxyuris. Instead of santonin, the freshly prepared fluid extract of spigeHa and senna in doses of 1/2 drachm for a child two years old, and i drachm for older chil- dren, can be given two or three times a day, care being taken not to produce too much irritation. The oil of chenopodium, 2 to 3 minims, on sugar, for a child two or three years old, and 8 or 10 minims for older children, can also be given. A cathartic should be used in connection with these drugs, as well as with santonin. TAENIAE— (TAPEWORMS) The forms of taenia which most frequently occur in children are the taenia solium and the taenia mediocanellata. The taenia solium has a slight projection at the apex of its head, around which are a series of hooks, and below which are four sucking-disks. The taenia, mediocanellata, or beef tapeworm, is the variety which occurs most frequently in children. It has a blunter head than the taenia solium, Intestinal Worms 509 and does not have the circle of hooks. These worms vary in length from 20 to 50 feet. There is nothing especial to be said concerning these worms, and we refer to them merely because at times they occur in early life. They are never met with in nursing children when breast milk forms the exclusive diet. There is reason to sup- pose that raw beef juice may carry the eggs of the taenia. There are no especial symptoms produced by this worm, and the diagnosis is made entirely hy finding the segments in the feces. There is no especial danger from the presence of the tapeworm. Fig. 108 Taenia. I, without head; II, with head TREATMENT. — The treatment employed in expelling this worm is the same in children as in adults, but we should be very careful not to irritate too much the sensitive gastro-enteric mucous membrane of the young child. The child should first be treated with laxatives, so as to free the intestine. Food should be withheld from the early 510 Diseases or the Gastro Exteric-Tract evening until as late as possible the next day. An anthelmintic should then be given, followed in one or two hours by a cathartic. This usually results in the expulsion of a large mass of segments. Great care should be taken to prevent the head from breaking off before it is expelled. If the head remains, the worm grows again and the treatment has been useless. The anus should be carefully dilated during the expulsion of the worm. Sitting on a vessel of hot water seems to help to prevent the head from breaking off. There is no anthelmintic which I have found pre-eminently suc- cessful in expelHng the taeniae. One of the most harmless is the alkaloid pelletierine from pomegranate. The tannate of the pelle- tierine can be given to a child from three to five years old in the dose of from i/6 to 1/2 grain. As dizziness and headache are some- times complained of, it is well to have the child kept in bed and lying down until the effect of the anthelmintic has passed off. The oleoresin of male fern may also be used. The dose is 1/4 to 1/2 drachm. The cathartic which is most useful in these cases is Epsom salt, 2 to 4 drachms. It is hardly worth while to mention the other numerous anthel- mintics which have been recommended, as they are usually ineffi- cient. If the head of the worm is not obtained and if a considerable por- tion of the segments is discharged as a result of the treatment, it is desirable to wait a few months before making a second attempt to expel the parasite. The reappearance of segments in the stools indicates that the growth of the worm is sufficient to justify another attempt to dislodge it. End of Volume I i Date Due ' ^ RJ45 D92 1917 Dunn "^'l Pediatrics