COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64088189 QP246 . Ad8 A clinical report on RECAP ApKlAN.CE k C^jINICaL REPORT OB THI HUMj H :■■ . ST'S MILK Q?1*U M^ Columbia ^nitjer^itp College of ^fjpSitians anb gmrgeons TLibvaxv Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons (for the Medical Heritage Library project) http://www.archive.org/details/clinicalreportonOOadri :ases Or By VANDERPOEL ADRIANS formal Histology, College of Ph) .NCE, A.M., F.C.S. c 5 s J* A CLINICAL REPORT ON THE CHEMICAL EXAMINATION OF TWO HUNDRED CASES OF HUMAN BREAST MILK. BY VANDERPOEL ADRIANCE, M.D., Assistant in Normal Histology, College of Physicians and Surgeons, AND JOHN S. ADRIANCE, A.M., F.C.S., Analytical Chemist to the Nursery and Child's Hospital, and the New York Infant Asylum; Member of American Chemical Society, and of the Society of Chemical Industry; Fellow of the American Association for the Advancement of Science, etc. The observations on the cases reported in this article were compiled by Dr. Vanderpoel Adriance while resident physician at the Nursery and Child's Hospital; simultaneously Mr. John S. Adriance made the chemical determinations of the milks in the laboratory of the same institution. The milks were pumped between 8 and 9 a.m., placed in a clean bottle, and taken to the laboratory before any chemical decomposition could set in; and in almost every case the analysis was completed before night- fall. It would be preferable in each case to report the analysis of the entire pumpings of one breast, but as this seemed impractic- able, our analyses represent the middle milk, the mother being instructed to nurse her infant for two minutes before pumping the sample. The Nursery and Child's Hospital offers especial facilities for the study of this subject. Many of the children are born in the institution, and those that are not have an accurate history taken at the time of their admission. Notes and weights are recorded daily during the first two weeks of life, and subse- quently once a week, so that a complete record is kept for refer- ence. The fact that a large number of the children are perfectly well is of great value, as it admits of the establishment of a normal standard for the purpose of comparison. The cases reported were under the daily observation of the resident physician. Careful notes were taken of the mother's history, as well as the child's. The cases have been divided into 2 Adriance: Chemical Examination of Breast Milk. normal and abnormal. The normal ones are selected, only a clean record on both mother's and infant's sides justifying such classification. A clean record implies, on the part of the mother, a good general condition, and on the part of the child, no im- mediate sickness or gastro-intestinal symptoms, and a weight record which corresponds approximately with the weight chart constructed by Holt. During the later months of lactation, how- ever, it is normal for a child to gain weight less slowly, and if nursing is continued too long, an actual loss may occur. In order to ascertain the normal milk of this period, all the cases were included, unless some wide variation was observed; a loss of weight pure and simple at this period being insufficient to define its abnormality. In this period are also included infants not entirely breast-fed. To appreciate the abnormal, we must start with some knowl- edge of the normal. This is as true of the chemical analysis of human milk as of other subjects in medicine, and in judging of the results of milk analysis, some physiological standard must be set with which we shall be enabled to compare our results. Human milk has in its composition fat, carbohydrate, proteids, salts, and water. The first four represent the solid constitu- ents, and the water represents the vehicle by which they are offered in liquid form. These constituents exist in a more or less definite proportion to each other, and yet we cannot say that all milks are alike, for they vary greatly, and although we never have more than the above-mentioned constituents, these are markedly variable. Still some standard is necessary, and we may roughly state that normal human breast milk can be represented by figures included between certain extremes. The fat varies from 3 to 4 percent., carbohydrate from 6 to 7 percent., proteids from 1 to 2 per cent, and the salts can be represented by .20 per cent. The total solids amount to 12 per cent., while the water, the complement of the total solids, is 88 per cent. In tabular form the percentages would appear thus: Fat. Carbohydrate. Proteids. Salts. Total Solids. Water. 3-4 6-7 1-2 .20. 12. 88. In our list we have 120 normal cases,* extending from the second day of lactation into the fifteenth month. The analyses are recorded below in chronological order. We regret that no *The average age of these mothers was twenty-five years; fifty-five were multiparas, sixty five primipara;. Adriance: Chemical Examination of Breast Milk. NORMAL CASES. Mother. < 1- a S < Q < > O O X Q < £ u H £ O X < < < O 1/) * ~s~7 < t/5 < < 0. < O f- £ '9 2 Days. 3-77 5-39 3-3' •27 !2. 7 8 87.2. 29 2 s. 3d. 1.034 1 97 6.58 2.04 •24 IO.84 89.15 20 I s. 3d. 1.030 4 52 5.86 2-37 .26 I3.O3 86.96 27 4 s. 4 d. 2 24 6.44 1.91 .27 10.88 89.11 20 1 G. 4 d. 1.031 2 80 6.36 2.25 .26 1 1.69 88.30 21 2 A. 5 d. 6 54 5.36 3-37 .28 '5-54 84.45 37 6 G. 5d. 1.033 3 00 6.56 .66 ■25 10.48 89-53 18 1 G. 5 d. 1.030 2 53 6-37 1.85 .28 1 1.02 88.95 29 2 G. 6d. 1.035 2 64 6-74 1.81 .28 11.49 88.50 20 1 G. 6 A. '•037 2 80 6.83 2.13 ■25 12.02 87.97 26 6 s. 6d. 4 35 5-93 2.00 .20 11.48 88.32 29 2 G. 6d. 3 81 6.75 1.84 .26 13.70 86.28 23 2 G. 6d. 4 3° 5.38 2. 79 •23 12. yi 87.28 24 1 A. yd. 1.030 3 74 6.09 2.15 •34 12.35 87.64 '9 1 A. 7 d. 2 93 6-55 2.yo .20 .2.38 87.61 37 6 G. yd. 1.033 2 27 6.8y 1.41 .20 io.y6 89.23 23 2 G. yd. 1.026 4 06 5-93 2.10 .26 12.34 87.65 29 2 F 8d. 3 '4 6.50 1.90 .18 "•74 88.24 24 2 G. 8d. 2 05 6.39 2.10 •24 10.81 89.18 35 7 S. 9 d. 4 76 6.00 1.50 .19 .2.46 87-53 '9 G. 10 d. 2 64 6.62 1.70 •23 11.19 88.80 37 6 G. 10 d. 1.034 2 84 6.38 1.84 •23 11.30 88.68 25 1 A. 11 d. 4 74 7-'4 2.10 13.99 86.00 3° 1 G. 11 d. 1.030 2 29 6.03 2. 12 ■24 io.y2 89-27 34 1 A. 12 d. 3 '7 6.94 2.66 .10 ,2.87 87. .3 23 2 A. 12 d. 1.030 3 32 6.y6 1.62 .21 11.93 88.06 23 2 A. 12 d. 1.030 2 52 6.62 1.80 .22 11.18 88.S1 20 1 A. 13 d. 1.030 5 58 6.20 2.13 .19 14.09 85.90 20 2 A. i 4 d. 1.030 5 01 6.6y 1.30 .20 13.19 86.80 30 1 G. ■ 5 d. 1.032 3 73 6.yy 1.38 .22 12.15 87.84 3° 1 G. 15 d. 1.032 4 48 6.54 2.47 .26 '3-74 86.25 18 1 A. 15 d. 1.030 5 26 6.39 1.79 .22 13.69 86.30 20 1 G. 16 d. 1.030 4 29 6.52 ^■93 .20 12.95 87.04 29 2 G. 16 d. 1 .030 3 '5 6.54 .69 •'7 10.57 89.41 21 2 A. 16 d. 5 84 6.94 1.73 .21 14.71 85.28 '9 1 A. 16 d. 1.032 5 3' 6. 1 1 1.30 •23 12.97 87.02 '9 2 A. , 9 d. 1.032 4 79 6.89 1.15 .21 13.06 86.93 '9 2 A. 24 d. i.02y 5 61 6-77 1.19 .20 '3-79 86.20 '9 2 G. 24 d. 1.029 3 77 6.89 2.69 .20 .3.56 86.43 20 2 A. 26 d. 1.023 5 21 5-35 1.81 .28 12.66 87.32 29 2 G. 26 d. 1.032 94 y. 12 '•35 .20 ii. 63 88.^4 20 1 G. 26 d. 1.030 5 26 7.05 1.66 .22 14-19 85.80 27 2 G. 29 d. 1.033 1 85 6.90 '■34 ■25 10.36 89.63 18 1 G. 31 d. 1. 03 1 2 46 6.98 1.25 .21 10.95 89.04 39 2 F. 31 d. 4 52 6.83 2.02 .21 13.60 86.39 18 1 A. 3, d. 1 77 6.49 1-33 .16 9-75 90.23 20 2 A. 1 m. 4 d. 1.031 2 56 683 '•57 •'7 11.14 88.85 * S, scant. G, good. A, abundant. F, fair. Adriance : Chemical Examination of Breast Milk. Normal Cases (Continued). Mother. i- x S < ■ < < < >- O X Q c/i i ui > < | u H s - 2 X < < < O D on < i/) < < !_ < O £ 29 2 G. 1 m. 7 d. '•94 6.91 86 .14 9.86 90.13 26 F. 1 m. 10 d. 1.033 2.27 7.25 1 28 •'9 I I. OI 88.98 3 2 4 A. 1 m. 14 d. 1.035 2.48 6.57 2 01 .18 I I.27 88.72 2 3 2 G. 1 m. 17 d. 1.030 4.08 6.91 1 44 •'9 12.61 87.38 31 F. 1 m. 17 d. 4.22 5.64 1 81 ■'5 ,..83 88.16 26 2 G. ! m. 19 d. 2.86 6.98 1 21 •'5 I 1.21 88.78 '9 A. 1 m. 21 d. 3.28 6.59 1 45 .16 11.53 88.46 20 A. 1 m. 23 d. 4.10 6.59 2 56 •'7 '3-43 86.56 3 2 A. 1 m. 28 d. 4-5.3 6.69 1 35 .19 12.75 87.24 29 2 G. 2 m. 1.029 3-'5 6.99 1 00 ■'9 1..36 88.63 23 2 G. 2 m. 1.035 3-44 6.69 1 43 .16 12.03 87.Q6 2 5 2 A. 2 m. 5 d. 3.24 6.54 1 22 •'7 11.18 88.81 51 F. 2 m. 12 d. 4-47 5.50 1 78 .26 12.03 87.96 20 F. 2 m. 12 d. 4.00 6.08 2 08 .21 12.37 87.62 2 3 G. 2 m. 17 d. 1.027 5.26 6.92 1 07 ■>9 '3-47 86.52 2 5 A. 2 m. 2i d. 2.66 6.62 1 57 ■'5 11.05 88.94 2 4 2 A. 2 m. 22 d. 3-4' 7.51 1 00 .18 12.81 87.I7 34 A. 2 m. 27 d. 3- '5 6.06 1 83 •17 1 1 .22 88.77 35 4 A. 2 m. 30 d. 1.026 3.69 6.81 1 36 .18 12.06 87-93 '9 F. 3 m. 3d. 5.11 6.64 i 55 .18 13.50 86.49 3» F. 3 m. 4 d. 6.78 5-94 ' 4' .19 14.31 85.67 29 F. 3 m. 5 d. 3.83 6.85 2 06 .22 12.97 87.O2 G. 4 m. 1.030 3.86 7.02 1 63 .20 12.71 87.28 A. 4 m. 1.029 3-'5 7.03 60 •14 10.96 99.02 3° 3 A. 4 m. 10 d. 4-94 6.68 42 ■'5 12.21 87.78 2 4 G. 4 m. 15 d. 4.10 5.99 1 94 .18 12.22 87.77 18 A. 4 m. 23 d. 1.030 '-35 6.48 1 18 ■•7 9.19 90.8O 21 G. 4 m. 23 d. 5.83 6.18 1 89 ■'7 14.09 85.9O 2 3 A. 4 m. 23 d. 1.027 3.38 6.85 37 -'7 10.77 89.22 24 2 A. 4 m. 23 d. 4.87 6.66 1 47 ■'4 13.17 86.82 24 G. 5 m. 1 d. 2.01 6.99 2 60 •13 11.73 88.26 G. 5 m. 12 d. 2.30 6.19 1 4' .16 10.07 89.92 2 3 A. 5 m. 14 d. 3.88 7-95 ' 57 .18 13.58 86.42 28 5 G. 5 m. 14 d. 1.80 7.24 1 27 .19 10.49 89.49 28 2 A. 5 m. 21 d. 1.31 7.71 1 01 .09 10. 12 89.88 27 2 G. 5 m. 23 d. 1.029 2.45 7.04 1 02 .20 10.73 89.26 27 2 G. 5 m. 23 d. 1.028 3.96 7.04 1 '7 .20 12.38 87.67 24 A. 6 m. 5-43 6.87 1 1 1 .16 13.62 86.37 24 A. 6 m. 10 d. 1.025 7.61 6.69 81 •'7 15.31 84.64 26 2 G. 6 m. 23 d. 4.41 7.03 1 68 .20 '3-34 86.65 2 3 A. 7 m. 5-79 6.14 1 63 .20 '3-77 86.22 21 F. 7m. 17 d. 1.034 2.38 <"6.9i 1 05 •'5 10.50 89.48 21 A. 7 m. 19 d. 1.031 3.66 6.88 1 40 .18 12.15 87.84 28 2 A. 7 m. 25 d. 4-93 6-55 98 ■•3 12.61 87.38 21 G. 7 m. 26 d. 4.02 6.79 7' .18 1 1.69 88.30 20 G. 7 m. 2g d. 1.033 i.59 7-05 69 .21 9-57 90.42 26 G. 8 m. 1.032 6.08 7.20 89 .16 '4-34 85.65 28 2 G. 8 m. 10 d. 3. 11 7-33 98 ■'5 1 1.60 88.39 Adriance : Chemical Examination of Breast Milk. Normal Cases {Continued). Mother. * ■ ,5 < a < O 1 1/5 >- < s- X < < O 00 < t/i < < (J £ L < £ 37 2 G. 8 m. 24 d. 1.022 4-77 6.66 54 ■ 15 12.14 87.85 28 5 G. 8 m. 27 d. 1.034 4 60 7 09 57 .16 12 52 87 47 3° 3 F. 8 m. 28 d. 1.030 3 54 6 70 1 30 .10 I 1 63 88 36 28 2 A. 9 m. 7 d. 1.030 1 99 7 04 69 .16 9 87 90 12 28 2 G. 9 m. 16 d. 1 9' 7 18 1 °5 .14 10 32 89 67 29 3 G. 9 m. 15 d. 4 9° 6 99 83 .16 12 8q 87 10 24 1 G. 10 111. 17 d 4 92 6 64 1 07 .16 12 82 87 17 28 2 G. 10 m. 18 d 4 78 6 09 61 ■'7 12 26 87 73 20 F. 10 m. 22 d 1.033 1 95 7 59 23 .21 9 98 90 01 25 F. 1 1 m. 1 d. 6 45 7 1 1 93 •'3 '4 65 85 34 24 G. 1 1 m. 9 d. 3 09 6 21 1 25 ■23 10 80 89 '9 28 2 A. 1 1 m. 10 d 4 80 7 20 34 ■'4 12 49 87 50 2? G. 11 m. 18 d 6 '7 6 34 48 ■14 13 14 86 85 28 G. 11 m. 19 d 3 43 6 99 2 28 ■14 12 86 87 '3 26 G. 1 1 m. 20 d 3 57 6 79 ' '7 ■ 15 1 1 69 88 3° 20 F. 1 1 m. 21 d 1.028 3 00 6 9 1 80 .16 10 92 89 07 28 G. 1 1 m. 22 d 3 00 5 64 2 3' ■•'4 1 1 1 1 88 88 19 F. 12 m. 13 d 3 23 6 92 1 25 ■>3 1 1 55 88 43 30 F. 12 m. 14 d 4 44 7 '9 39 .14 12 15 87 84 28 G. 12 m. 17 d 6 59 5 81 1 52 ■'5 '4 1 1 85 88 24 G. 12 m. 18 d 3 49 5 96 1 86 .19 1 1 52 88 47 20 F. 12 m. 28d 1.030 5 34 7 06 09 .21 12 75 87 24 34 2 G. 13 m. 8 d. 2 53 7 33 65 ■'3 10 65 89 34 3° G. 14 m. 5 d. 4 46 7 '5 76 .16 12 53 87 46 20 G. 14 m. 15 d 1 .030 4 1 I 7 42 48 ■>5 12.20 87.79 determination of the milk of the first day after delivery could be made; notwithstanding many attempts, sufficient milk for that purpose could not be obtained at that time, nor could a speci- men be obtained later than the fifteenth month. Our thanks are due to Dr. Samuel Lambert, Dr. J. J. Hull, Dr, A. M. Thomas, and Dr. L. E. Holt, of the Medical Board, for their kind co-operation and permission in allowing the publica- tion of our results, and to Drs. Thomas and Holt, who permitted us to report the milks from their private cases, which were analyzed by us. The reaction was uniformly alkaline. The number of cases reported hardly warrants a determination of a standard to which all human milk should conform. The averages can only be con- sidered as approximations, but such approximations will help us in studying the cases in hand, and, above all, to appreciate the Adriance : Chemical Examination of Breast Milk. subsequent consideration of abnormal cases. The number of cases is unevenly distributed in the various periods. When each group of cases is viewed in connection with the others, an aver- age curve for each constituent can be determined, representing its amount at any time during lactation. TABLE SHOWING AVERAGES OF NORMAL CASES AT DIFFERENT PERIODS OF LACTATION. No. OF Cases. Period of Lactation. Spec. Grav. Fat. Carbo- HYDR. Proteids. Sa LTS. Total Solids. Water. i 2 Days. 3 77 5-39 3-3' 27 12.98 87.21 2 3d. 1.032 3.24 6.22 2.20 25 ...98 88.05 2 4 d. 1 .03 1 2 52 6.40 2.08 26 11.28 88.70 3 5d. 1. 031 4 02 6.09 1.96 27 12.35 87.64 5 6 a. 1.036 5 58 6-31 2.1 1 24 .2.48 87.77 4 7 d. 1.029 3 25 6.36 2.09 25 n.96 88.03 2 8d. 2 59 6.44 2.00 21 11.27 88.71 I 9d. 4 76 6.00 1.50 ■9 .2.46 87-53 2 io d. 1.034 2 74 6.50 1.77 23 11.24 88.74 2 u d. 1.030 3 5 1 6.58 2. 1 1 24 12.35 87.63 3 12 d. 1.030 3 00 6.77 2.03 18 11.99 88.00 i i 3d. 1.030 5 58 6.20 2.13 '9 14.09 85.90 i 14 d. 1.030 5 01 6.67 1.30 20 13.19 86.80 8 3 wks. 1.031 4 61 6.59 '•55 21 12.98 87.01 9 4 wks. 1.029 3 7' 6.71 1.63 21 12.30 87.7. IO 2 m. 1.032 3 22 6.70 '•54 17 11. 65 88.33 10 3 m. 1.029 3 65 6.60 1.49 '9 : 1.96 88.02 3 4 m. 5 24 6.48 1.67 20 '3-59 86.36 8 5 m. 1.029 3 93 6.61 1.31 16 11.91 88.07 7 6 m. 1.028 53 7.17 '•43 16 11.30 88.70 3 7 m. 1.025 5 81 6.86 1.20 18 14.09 85.90 6 8 m. 1.033 3 73 6.72 1.08 '7 11.71 88.27 5 9 m. 1.029 4 43 7.00 .86 '4 12.45 87.54 3 10 m. 1. 030 2 93 7.07 .86 '5 11.03 88.96 3 1 1 m. 1.033 3 88 6.97 .64 18 1 1.69 88.20 8 12 m. 1.028 4 '9 6.65 1.18 '4 12.21 87.77 5 13 m. 1.030 4 62 6.59 1.02 16 12.42 87-57 i 14 m. 2 53 7-33 •65 '3 10.65 89.34 l 15 m. 1.030 4 28 7.28 .64 15 12.36 87.62 We have grouped and averaged these figures according to the period of lactation. During the first two weeks the changes are so rapid and so marked that the average was taken for every day, but only once a week during the third and fourth weeks, and subsequently but once a month. Fat. The easiest way to appreciate the changes in this constitu- ent is to study its up and down course in the accompanying chart. Adriance : Chemical Examination of Breast Milk. 7 This demonstrates the fact that the amount of fat at successive periods is widely variable. At the same time there is no definite reason to account for this peculiarity, which is not shown by the other ingredients of human milk — the sugar increasing, and the proteids and ash decreasing steadily during the progress of lactation. A study of the accompanying chart will show the very marked variability of this ingredient. This chart does not represent the analyses of one woman's milk at successive periods of lactation, and should not lead to the inference that any one woman's milk will vary to such a surpris- ing degree. It does show, however, that in a series of 120 cases the percentage of fat is far from being a constant figure. The amount of fat, then, cannot be represented by a regular curve, as we shall find later is the case with the carbohydrate and proteids, yet some average figure must be adduced to repre- sent the fat, and as this cannot be done by the days, weeks, or months of lactation, the figures must be obtained at differ- ent intervals, evenly distributed throughout the entire period. This has been done by taking the average of our list of 120 nor- mal milks, which is 3.83 per cent. This figure should be remembered as the average normal amount of fat, and can be accepted for any time from the colostrum period to the end of lactation. From this figure, however, wide variations are to be expected. Among our normal cases are milks containing as high as 7.61 per cent., and as low as 1.31 per cent, of fat. There is a rough relationship between the amount of fat and proteid, the proportion being 3 to 1. This ratio must not be considered as a hard and fixed one, which will determine whether a milk is to be classed as normal or abnormal, for although it expresses an average, it does not pertain to all cases. If at any time the pro- teids are found in excess of the fat, it often means that the proteids are above their normal amount. This is more apt to occur during the colostrum period than at any other. Carbohydrate. The carbohydrate, or milk sugar, is a singularly constant constituent, and represents more of the total solids than all the other ingredients together. It steadily increases from the begin- ning to the end of lactation, but this increase is so slight, in com- parison with its large amount, as to be recognized with difficulty except by averaging many cases. We see from Chart II. that it Adriance: Chemical Examination of Breast Milk. o v. ^}- "1 ^ •» N \ ff> ■^ K> "-V > N ^> h •* W ^1 \ Ul Ul 4- w >- < y f O / 2 - Q N S J NO 'o r -- V <*■ M / P| \ ' VI * \ | K> K U1 •> < •*- "3 > «2 - s in CO N \ v3 i N 4: * < ^ to H M N ^ at? H =6 E < « o 0- ra C >- & «J I « 3 5 ™ E OS p o Adriance: Chemical Examination of Breast Milk. z o S <*- to •< £ / o f ^ •>, J tJO N VO 4) * < ^ to k •=*- \ to I \ > < A * n ■'i ) / £ L o i cn > 00 Y -r N / ■4 ( i !n ; f + / «i — — = ; j N WD *< ^ •a " °" i-s 3 E '5 5s 12 Adriance: Chemical Examination of Breast Milk. h o t £ «*. > «j 3< £ < ** m <» / f N / / >« h ^1 J ^ <*- K 1 tf| \ \ H K u > * f K) i > < 5 s \, *i ^- > £ o 51 (D N \J (n (' + V to H H o «o o fa N> vc ** "*■ ao-c c b- 5 Adriance: Chemical Examination of Breast Milk. 13 Calcium phosphate, 23.87 Calcium silicate, . . . - . . . . 1.27 Calcium sulphate, ....... 2.25 Calcium carbonate, . . . . . . . 3.77 Potassium carbonate, ...... 23.47 Potassium sulphate, 8.33 Potassium chloride, ...... 12.05 Sodium chloride, . . . . . . . 21.77 Iron oxide and aluminum, ..... .37 100.00 Like the proteids, the salts diminish slowly but steadily from the beginning. On the second day they average .27 per cent., but this figure falls, till in the fifteenth month it is only .14 per cent. (Chart IV.) Total Solids. The total solids are composed of all the elements we have considered — namely, the fat, carbohydrate, proteid, and ash; and any variation in these constituents should be shown in the total solids. The average amount of fat, we have shown, is 3.83 per cent., and this has been accepted as our standard through- out, so that it will cause no variation. The ash, represented by only a fraction of 1 per cent., is so small as to be practically thrown out of consideration. We must look to the carbohydrate and proteid, then, for any change in the amount of the total sol- ids. These, however, very nearly compensate each other, as the sugar increases and the proteid decreases steadily during lac- tation, thus acting as balances to each other. So the total solids remain very constant, when lactation is considered as a whole, but nevertheless show variation from month to month, as the chart demonstrates. The average for the total solids is 12.20 per cent, until the seventh month. After this it suffers a gradual de- cline until, at the fifteenth month, it is 1 1.50 per cent. (Chart V.) Water. The water is the complement of the total solids, and as the latter decrease, the former increases, so that during the last months there is a slight gain. Specific Gravity. The average specific gravity is 1.030. The proteids and fat are the chief determining agents of the specific gravity. Any in- crease in the fat lowers the specific gravity, and any decrease 14 Adriance: Chemical Examination of Breast Milk a: ■z Q i / «1 c - — / v. vj v. / \ / 51 < r to — i b N \0 ti ■<*■ M *i \ <4 14 * y \ ^ 1 >■ < =*- *? ^ 5 <■. ■•>, o --. > W) w <*< — °* 2: t? 5! 55 Adriance: Chemical Examination of Breast Milk. \4 11.59 88.41 15 m. 1.030 3 83 6.96 63 '4 1 1.50 88.50 So far we have considered the general changes taking place in mother's milk during lactation as a whole, but there are two periods which deserve our especial attention; these are com- monly known as the colostrum period and the later months of lactation. 1 6 Adriance : Chemical Examination of Breast Milk. Colostrum Period. The characteristics of the milk of this period are: (i) The presence of colostrum corpuscles. Normally these corpuscles persist in the milk from seven to ten days. (2) Laxative property upon the infant. (3) Yellow color of the milk, which is marked at first, fades gradually, and disappears about the same time as the colostrum corpuscles. (4) Chemical characteristics. It seems to us that the chemical analysis of the colostrum milk is of greater importance, as a characteristic of the milk of this period, than any of the others just mentioned, and that it is insufficient to say that the colostrum corpuscles are the sine qua- non, upon whose disappearance the milk ceases to belong to the colostrum period. Arbitrary as it is, we have considered the colostrum period as covering the first two weeks. During the first days, when the breasts are assuming their functional activity, we should expect irregularities in the secretion which would not occur later when the function is established. It is not infrequent to find the fat very high during this period, or, on the other hand, very low. The sugar is lower on the second day than at any other time, but rises steeply, and at the end of two weeks its curve has traveled well upward. The proteids, as already remarked, pursue just the opposite course, being higher on the second day than at any other time, but fall rapidly during the first few days, and less rapidly subsequently. From 2.77 per cent, on the second day, it goes to 1.7 per cent, on the four- teenth day. This excess of proteids during the colostrum period is of great importance, as we shall see in the consideration of ab- normal milks. The ash, like the proteids, is higher at this time than at any other. Examples to show the changes during the first part of lacta- tion. Mother 20 years of age, primipara. 3 days. 6 days. Fat, . . . 4-52 Carboh., . . . 5.86 Proteids, . . . 2.37 2.13 Salts, 26 .25 Total Solids, Water, 6 days. 26 days 4.29 5.26 6.52 7.05 1.93 1.66 .20 .22 12.95 14.19 87.04 85.80 Adriance: Chemical Examination of Breast Milk. 17 Mother 19 years of age. Grav. ii. 2 days. 10 days. Fat 3.77 2.64 Carboh., 5.39 6.62 Proteids, .... 3.31 1.70 Salts, 27 .23 Total Solids, . . . 12.78 11.19 Water, . . . . 87.21 88.80 Mother 23 years of age. Grav. ii. 6 days. 1 mo. 17 days. Fat, ..... 4.30 4.08 Carboh., 5.38 6.91 Proteids, .... 2.79 1.44 Salts, 23 .19 Total Solids, .... 12.71 12.61 Water, . . . . . 87.28 87.38 The Later Months of Lactation. During the later months, when the function of lactation is preparing for cessation, certain changes are to be expected. The quantity of fat still shows marked variation. The sugar, gradu- ally increasing from the beginning, continues to increase. The proteids, the exact opposite of the sugar, have been gradually decreasing, and continue to decrease. The total solids, which remained constantly at 12.20 percent, till the seventh month, begin to show a slight decrease at the eighth month, falling to 1 1.50 per cent, at the fifteenth month. The quantity of ash is now very small, as it has been steadily diminishing from the start. Examples of milks during the later months of lactation. Mother, 34 years; grav. ii. ; good supply. 13 mo. 8 days. Fat, . . . . . 2.53 Carboh., ..... 7.33 Proteids, . . . . . .65 Salts, . . . . . .13 Total Solids, .... 10.65 Water, . . , , ,89.34 Adriance: Chemical Examination of Breast Milk. Mother, 30 years Fat, . Carboh., . Proteids, Salts, ; primipara; fair supply. \2 mo. 14 days. • 4-44 7.19 • -39 .14 Total Solids, Water, 12. is 87.84 Influences Causing Variations Outside of the Period of Lactation. Outside of the period of lactation there are influences which affect the milk. Clinical experience has taught that in selecting a wet-nurse, a primipara is preferable to a multipara, and the age to be preferred is between twenty and thirty. Ludwig states that the milk of multipara; contains less fat than that of primi- para;, and that women between twenty and thirty years of age have less proteids, sugar and salts, but more fat in their milk, than women between thirty and forty years. In considering these questions, it will not do to average a number of these cases, and to classify them without regard to the other influences. The comparison of the milk of primipara; and multipara; must be made only at corresponding periods of lactation. This has been done in the following lists of twenty-three primipara; and twenty-three multipara;. The extremes of lactation, that is, be- fore the fifteenth day and after the ninth month, were excluded. The average period of lactation of both classes is three months. The average age of mothers is twenty-five years. Fat, Carboh., Proteids, Salts, Total Solids, . . 12.41 12. 11 12.20 Water, . . 87.57 8 7- 8 7 8 7- 8 ° By comparing these figures, we see that the milk of the primipara; of this period of lactation is richer in fats, proteids, salts, and total solids, than average milk; the sugar, however, is Average of 23 primiparae, third month. Average of 23 multipara;, third month. Computed average for third month. 4.06 3.67 3.83 6.52 6.85 6.72 I.6l '•35 I.48 .18 •17 ••7 Adriance: Chemical Examination of Breast Milk. 19 less abundant. The milk of multipara; is just the reverse. Such being the case, we are selecting primiparae as wet-nurses with justice, for we are obtaining a richer milk. To ascertain the correctness of preferring the milk of a wet- nurse between twenty and thirty years of age, a number of ob- servations have been made upon equal numbers of primiparae and multipara;, and at the same average period of lactation. No considerable difference has been detected. If any exists, it will be demonstrated only after consideration of a larger number of cases. Although we cannot prove that a wet-nurse between twenty and thirty years of age offers a better milk, still a young woman is more likely to be healthy than one who is older, and, taking all things into account, will be more desirable in the house- hold. The great law of variation is so active in determining the character of human milk, that its scientific study is rendered difficult. No sooner had a classification of cases been attempted, than differences arose which seemed at first insignificant. These demonstrated the individual idiosyncrasy of the children. One would thrive on one kind of milk, and another on another. What would be detrimental to one child, would prove healthy food for another. Sometimes the chemical analysis showed results which differed widely from the average, and yet the in- fant maintained good health. It is exceptional for the infant to maintain good health under these conditions, and yet the milk is debarred from being classed as abnormal. The following analyses are given as examples of what differ- ent children thrive on: Mother, 29 years; grav. ii. ; good supply. Infant, female; birth weight, 8 lbs. 2 oz. (3670 grammes); 6 days old, weight, 7 lbs. 1 1 oz. (3480 grammes). Fat, ..... 4.81 Carboh., ..... . . 6.75 Proteids, . . . . 1.84 Ash, . . . . . .26 Total Solids, .... 13-70 Water, . . . . .86.28 20 Adriance: Chemical Examination of Breast Milk. Mother, 19 years; grav. i. ; supply abundant. Infant, female; birth weight, 8 lbs. 7 oz. (3840 grammes) ; 7 days of age, weight, 8 lbs. 2 oz. (3684 grammes). Fat, . . . . . 2.93 Carboh., . . . . .6.55 Proteids, . . . . 2.70 Ash, . . . . . .20 Total Solids, .... 12.38 Water, ..... 87.61 Mother, 20 years; grav. i. ; supply good. Infant, female; birth weight, 5 lbs. is oz. (2690 grammes); 16 days of age, weight, 6 lbs. 10 oz. (3000 grammes); spec. grav. 1.030. Fat, ..... 4.29 Carboh., . . . . .6.52 Proteids, . . . . 1.93 Salts, . . . . . .20 Total Solids, .... '2.95 Water, ..... 87.04 Mother, 27 years of age; grav. ii. ; supply good. Infant, male; birth weight, 6 lbs. 9 oz. (2970 grammes) ; 29 days of age, weight, 10 lbs. 8 oz. (4761 grammes); spec. grav. 1.033. Fat, ..... 1.85 Carboh., . . . . .6.90 Proteids, . . . . 1.34 Salts, . . , . . .25 Total Solids, . . . 10.36 Water, ..... 89.63 Mother, 21 years; grav. i. ; good supply. Infant, male; birth weight, 6 lbs. 9 oz. (3070 grammes) ; 4 months, 2} days, weight, 17 lbs. 13 oz. (8070 grammes); very fat. Fat, ..... 5.83 Carboh., . . . . .6.18 Proteids, . . . 1.89 Salts, . . . .17 Total Solids, .... 14.09 Water, . . . . . 85.90 Adriance : Chemical Examination of Breast Milk. 2 1 Mother, 24 years; primipara; good supply. Infant, male; birth weight normal; 5 months, 1 day. old, weight, 13 lbs. 8 oz. (6122 grammes). Fat, ..... 2.01 Carboh., . . . . .6.99 Proteids, . . . . 2.60 Salts, . . . . .13 Total Solids, .... 11.73 Water, ._ . . . 88.26 In these cases there are great variations in the constituents, yet in none was any disturbance of nutrition observed. Another reason why no strictly scientific classification of the cases could be made was the fact that the same woman's milk varied at dif- ferent times; and it was not to be expected that the analysis of one milk would hold good for the following, or even that the morning's analysis would correspond with that of the evening. Mother, 21 years; primipara. Infant, 2 months, 23 days. Fat, . Carboh., . Proteids, Salts, Total Solids, . Water, Even different parts of the same nursings differ. If we divide the pumpings from the same breast into three equal parts, keep- ing first, second and third portions separate, we shall find differ- ences as follows : Fore Milk. istCase. 2d Case. 3d Case. Average. Fat, Carboh., Proteids, Salts, Total Solids, Water, IO A. M. 4 P. M. 4.4O 2.00 6.93 6.64 2.06 •47 ■23 •'5 I3.66 9.28 86.33 90.70 3.66 1.98 1. 19 2.27 6.82 6.56 7.00 6.79 1.45 .58 .56 .86 .16 .12 ••5 .14 12. 1 1 9.26 8.95 10. 1 1 87.88 90.73 91.04 89.88 22 Adriance: Chemical Examination of Breast Milk. Middle Milk. ist Case. 2d Case. 3d Case. Average. Fat, . . . 4.40 2.00 1.99 2.79 Carboh., . . 6.93 6.64 7.04 6.87 Proteids, . . 2.06 .47 .69 1.07 Salts, . . .23 .15 .16 .18 Total Solids, . 1 3.66 9.29 9.87 10.94 Water, 86.33 90.70 90.12 89.05 Strippings. Fat, 5.11 3.12 2.78 3.65 Carboh., 6.92 7. 1 1 6.93 6.99 Proteids, 1. 00 .72 •95 .89 Salts, .20 •17 . 12 .16 Total Solids, . . 13.25 11. 14 10.79 n -73 Water, . . 86.74 88.85 89. 20 88.26 From these figures it will be seen that the fat and total solids represent a larger per cent, in the middle milk than in the fore milk, and in the strippings than in the middle milk. The aver- ages also show a rise in the carbohydrate, but regarding any changes in the other constituents, our number of cases is not sufficient to warrant drawing any conclusions. § Harrington has determined the same increase in the fats and total solids in cows' milk. The samples from the two breasts also show a variation, the milk taken at the same time from the right and left showing ap- parent differences, as the following cases will illustrate: Right breast. Left breast. Spec. gray. 1.032. Spec. gray. 1.032 Fat, Carboh., Proteids, Salts, Total Solids, Water, 3-73 3.48 6.77 6.54 ..38 2.47 .22 .26 12. 15 '3-74 87-53 86.25 Adriance: ChemicalExamhiaiion of Breast (Milk. 23 Right breast. Left breast. Spec. grav. 1.030. Spec. grav. 1.030. 2.52 6.62 3-32 6.76 1.62 .21 11.93 Right breast. ^eft breast. Spec. grav. 1 .029. Sp '.c. grav. 1.027 3-77 5.6l . 6.89 6.77 2.69 I. 19 .20 .20 13.56 '3-79 . 86.43 86.20 Fat, Carboh., Proteids, Salts, Total Solids, Water, Fat, Carboh., Proteids, Salts, Total Solids, Water, Each one of these cases shows variations which are apparent, and in some cases quite marked. We know that the quantity and quality of the milk depend largely upon the demand for it, and especially upon the character of the nursing. If the infant is hearty, and nurses vigorously, the quantity is increased and the quality improved. The next case is the milk of a woman who nursed her own healthy baby from the right breast, and a poor, miserable foster- child from the left breast. The foster-child labored under the disadvantage of its weakness, and being nursed irregularly and grudgingly. Right breast. Left breast. Spec. grav. 1.028. Spec. grav. 1.029. Fat, .... 3.96 2.45 Carboh., .... 7.04 7.04 Proteids, . . . 1.17 1.02 Salts, .... .20 .20 Total Solids, Water, 12.38 87.61 10.73 80.26 The next analysis is that of a woman who had but one func- tionating breast, the other having been dried up at three weeks on account of a cracked nipple. Adriance : Chemical Examination of Breast tMilk. Right breast. Fat, . . . . . 3. 1 1 Carboh., . . . . . 7.33 Proteids, .... .98 Ash, . . . . .15 Total Solids, . . . . 1 1.60 Water, ..... 88.39 The baby is eight months, ten days old, perfectly healthy, and above the normal weight. The case demonstrates that one healthy breast can provide enough good milk for an infant's nourishment. Among our cases are those of mothers who are nursing only their own children, those who are nursing their own and half nursing a foster-child beside, and those nursing two children. After careful analysis and compilation of these cases, no evidence was found to show that increased frequency of the nursings modified, in any way, the character of the milk. A review of the foregoing observations leads to the following conclusions: (1) The fat shows no constant changes during lactation. Its most marked characteristic is its variability. (2) The carbohydrate, on the second day of lactation, is low, but rises rapidly during the first few days. This increase con- tinues, but less rapidly, up to the end of lactation. (3) The proteids pursue a course the reverse of the carbo- hydrate. (4) The salts diminish similarly to the proteids. (5) The total solids are represented by 12.20 percent, till the later months of lactation, when they decrease steadily. (6) The colostrum period has low carbohydrate, with a tendency to increase rapidly, and high proteids and salts, with a tendency to decrease rapidly. (7) The milk of the later months of lactation shows a de- ficiency in proteids, ash, and total solids. (A study of Abnormal Milks will be reported in the next number.) * Beitrage zur Physiologie der Muttermilch und ihren Beziehungen zur Kinderunahrung. — Jarb. f. Kinderh., Leip., 1883, n. F. xx., 359-402. f Ueber Veranderungen der Frauenmilch und des Colostrums bei Krankheiten der Wochnerinnen. — Arch. f. Gynaek., Berl., 1894, xlvi.. 342- 357- X Rotch's Pediatrics. § Rotch's Pediatrics. Adriance: Chemical Examination of Breast Milk. 25 Abnormal Milks. Under this head have been classified only those milks which have shown themselves abnormal by their effect upon the child, or have been found by chemical analysis to differ materially from average milk. Chemical analysis alone, however, offers no cri- terion, for in many cases, as has been previously stated, the infant adapts itself to its conditions, and thrives on a milk which one should suppose ill adapted for food. To secure a healthy milk, the mother should have: (1) A good constitution. (2) Healthy environment. (3) Simple, nutritious diet with enough albumenous food. (4) Regular exercise in the open air. These, with the exception of the first mentioned, are simple hygienic conditions which every mortal should enjoy, but on a nursing woman they have a definite influence, not only on her health, but on her milk, and in this way a disregard of them is as harmful to the infant as to the mother. A woman with a wast- ing disease cannot yield a nutritious milk, and a woman whose general condition is below par is liable to dry up prematurely. A robust woman offers the best milk. Under the head of environment comes a happy home life with a minimum of worry. Nervousness of any kind causes a rise of the proteids, and if the woman is constitutionally nervous, this may cause such a constant rise as to make the milk unfit for a food. A woman in our wards could not live happily with her neighbors, and frequently indulged in heated argument with marked show of temper. After these quarrels her child was always upset for a day or two. A simple, nutritious diet, with a proper allowance of meat, is necessary, as it keeps up the gen- eral tone of the milk. The milk of an underfed woman shows a reduction in total solids. A lack of meat reduces the fats and total solids, and on the other hand, an excessive meat diet raises the fats too high. A judicious amount of exercise in the open air is necessary, for it is a general tonic to the milk. When the milk is scanty, a little exercise often restores the proper amount; and the baby who has been crying from hunger, and lagging behind in weight, improves in a wonderful manner. A lack of exercise allows the proteids to increase. On the other hand, excessive exercise wor- ries and tires out the mother, and acting like other untoward 26 Adriance : Chemical Examination oj Breast Milk. nervous influences, results in the production of too large an amount of proteids, causing the same result as if exercise had been neglected. Each one of these conditions, if nicely regulated, is a source of good; on the other hand, their abuse or neglect is sure to result only in injury. Moreover, the regulation of these condi- tions varies according to the idiosyncrasy of different women, and in each case it must be determined just how much of each is required. In some cases it is only by repeated examinations of the milk and rearrangement of the manner of life that a satis- factory condition is reached. Excessive Fats. In judging from the chemical analysis alone, without regard to the effect of the milk upon the child, we should often wrongly judge the fats to be in excess, as we have already stated that this constituent is subject to great variation, and that an unduly large amount may occur at any period of lactation; there is no partic- ular time when this condition is to be expected. A large amount of fat may tax the digestive system too severely, and is often followed by spitting up after nursing, vomiting, or by intestinal symptoms. Such disturbances, if allowed to persist, are natur- ally followed by lack of nutrition and a loss of weight, which must receive treatment. This consists mainly in cutting down the amount of albumen in the mother's diet, until the per cent, of fat in the milk agrees with the child ; but should this be carried too far, it results in a general impoverishment of the milk in all its solids, with a reduction of the total solids, so that although we have corrected the excess of fats, the nourishing properties of the milk are impaired, and the nursing infant loses weight from partial starvation. A deficiency of fat never causes any intestinal symptoms that we have been able to determine. It is generally considered that a deficiency of fat causes constipation, but this we have not proved. Constipation has more often seemed to be due to an insufficiency of milk, or an insufficiency of total solids, so that not enough is left to pass through the alimentary canal as waste material. A fine child, doing nicely, continued to gain, and kept above normal weight till three months of age. The character of the milk is shown by the accompanying analysis. Mother, 27 Adriance : Chemical Examination of Breast Milk. 27 years; grav. ij. ; healthy; good supply. Infant, male; birth weight 6 lbs. 9 oz. (2970 grammes) ; when 29 days old, weight 10 lbs. 8 oz. (4761 grammes). Spec. grav. 1.033. Fat, ..... 1.85 Carbohydrates, .... 6.90 Proteids, . . . . 1.34 Salts, ..... .25 Total Solids, . . . . 10.36 Water, . . . . .89.63 At three months the infant began to vomit, have green move- ments, and to cry with colic. Still he continued to gain weight, though more slowly than normal, until the fifth month, when it was found that his weight was beginning to fall off. He con- tinued to vomit and cry, while the bowels were in worse condi- tion. He seemed really sick. Analysis at five months: Spec. grav. 1.022. Fat, . . . . . 8.44 Carbohydrates, . . . .6.15 Proteids, . . . . .91 Salts, . . . . . .17 Total Solids, .... 15-69 Water, . . . .84.90 The analysis of the milk explained the source of trouble. There was a decided change from the milk we had analyzed on the twenty-ninth day. Then the fats were but 1.85 percent., but now they had run up to 8.44 per cent. This quantity of fat is so very unusual and excessive that there was no hesitation in blaming it for the child's condition, and steps were immediately taken to correct it. First of all, as a general regulator, the mother was told to take a walk in the fresh air every day, and to stop eating meat and eggs altogether. Two days later the milk showed a marked improvement in the baby, and four days later the fat had fallen to 3.40 per cent., the specific gravity to 1.029. There was no more vomiting, and the movements were yellow and well 28 Adriance: Chemical Examination of Breast Milk. digested. This proved that our treatment had been well directed. The child, however, continued to lose weight and to cry, although he had no gastro-intestinal symptoms or physical signs of disease. Three weeks after the last analysis another ex- amination was made, which showed the following result. Analysis at five months, twenty-two days: Spec. grav. 1.051. Fat, ..... 1.66 Carbohydrates, . . . . 7.25 Proteids, . . .. . .61 Salts, . . . . . .19 Total Solids, .... 9.72 Water, . . . . .90.27 We now found that, through a misunderstanding, the mother had continued to desist from albumenous diet completely. Asa result, although the child had no intestinal symptoms, he did not receive enough nourishment, and consequently did not be- gin to gain weight normally until this mistake had been recti- fied. This case demonstrates how an excess of fat may be cor- rected, and how the treatment must be used properly, and not carried too far. Rotch, of Boston, has said that the amount of fat in the milk can be controlled by the amount of nitrogenous material in the mother's diet. The treatment in the following cases was not in- dicated, but was prescribed to prove or disprove his statement. Mother, 19 years; grav. ij. ; healthy; good supply. Infant, female; birth weight, 7 lbs. 9 oz. (3430 grammes); 6 days old^ weight, 6 lbs. (2734 grammes). Analysis at six days: Spec. grav. 1.033. Fat, ..... 2.)^ Carbohydrates, . . . .6.49 Proteids, . . . . 1.23 Salts, . . . . . .24 Total Solids, .... 10.31 Water, , , , . .89.68 Adriance : Chemical Examination of Breast Milk. 29 The infant cried a great deal, vomited, and had green and undigested movements. The milk did not suggest anything out of the ordinary, but to determine if we could increase the amount of fat at will, the mother was put upon an albumenous diet of eggs for breakfast, meat for dinner and supper, and meat broth between times. The vegetables were limited. The child's condition remained about the same, and in two days the fats had increased to 4.20 per cent., and the specific gravity had fallen to 1.029. For six days this diet was kept up. The infant still cried a great deal at night, and the movements continued green, although the weight increased. The milk was analyzed on the twelfth day, and showed the fat still high. Analysis at twelve days: Spec. grav. 1.027. Fat, 4.57 Carbohydrates, .... 6.00 Proteids, . . . . 1.77 Salts, . . . . . .23 Total Solids, .... 12.59 Water, . . . . . 87.40 The diet was then discontinued, and one lacking in albumen- oids was substituted. After twelve days, a third analysis was made. Analysis at twenty-four days: Spec. grav. 1.029. Fat, . . . . . 3.77 Carbohydrates, . . . .6.89 Proteids, . . . . 2.69 Salts, . .• . . . .20 Total Solids, . . . . 13.56 Water, ..... 86.43 The child was now in good condition — healthy, above weight, and sleeping well — while the fat had fallen as we had desired. The fat had increased and diminished as we had antici- pated with the administration and withdrawal of the meaty diet respectively. }o Adriance: Chemical Examination of Breast Milk. Another case demonstrates the same point. Mother, 20 years of age; grav. ij. ; healthy; abundant supply- Infant, male; birth weight, 6 lbs. 12 oz. (3070 grammes); 21 days old, weight, 8 lbs. 10 oz. (391 1 grammes). Analysis at twenty-one days: Spec. grav. 1.030. Fat, ..... 6.61 Carbohydrates, . . . .6.20 Proteids, . . . . .94 Salts, . . . . . .19 Total Solids, .... '3-9^ Water, ..... 86.03 Two days after this analysis was made the mother was put on albumenous diet to see if the fat could be kept in excess. When twenty-seven days of age, or four days after the change of diet, another analysis was made. Analysis at twenty-seven days: Spec. grav. 1.023. Fat, . . . . . 5.21 Carbohydrates, .... 5.35 Proteids, . . . . 1.81 Salts, ..... .28 Total Solids, .... 12.66 Water, . . . . .87.32 This shows the fat in excess, although it had fallen some, but changing to non-albumenous diet, a marked difference was noted; in six days the fats had fallen to 2.56 per cent. Analysis at one month, four days: Spec. grav. 1.031. Fat, ..... 2.56 Carbohydrates, . . . .6.83 Proteids, . . . . 1.57 Salts, . . . . .17 Total Solids, . . . . n. 14 Water, . . . ... 88.85 Adriance: Chemical Examination of Breast Milk. 31 Excessive Proteids. The proteids are apt to be excessive under certain conditions, These conditions are a lack of exercise, too rich a diet, and nerv- ousness. Excessive proteids occur frequently during the first days of lactation. When excessive, they show themselves by interfering with the infant's digestion, the symptoms of which are vomiting and frequent movements of the bowels, which may contain curds of undigested proteid. The movements are some- times green and sometimes yellow, the green movements being more frequent during the first days of nursing. The baby suffers from colic, and on account of the disturbance of the digestive organs, there may be a disturbance of nutrition sufficient to cause a loss of weight. We shall consider the treatment of this condition during the first days of lactation later, but for the pres- ent will speak of the treatment in general. The treatment of this condition is both prophylactic and cura- tive. Its most constant cause is lack of exercise. A woman of sedentary habits, especially if her diet is too rich, should be ad- vised to take a suitable amount of exercise, regulation of this function being the most reliable factor in reducing the proteids. By drinking a larger amount of water, the mother can dilute her milk so that the total solids, and consequently the proteids, will be represented by a smaller per cent., or the milk may be pumped and diluted with water directly, when it can be fed from the bottle. Mother, 29 years; grav. ij. ; healthy; good supply. Infant, female; birth weight, 5 lbs. 8 oz. (2500 grammes); at 3 months of age, weight, 12 lbs. 4 oz. (5556 grammes). Analysis at three months: Spec. grav. 1.034. Fat, 1.38 Carbohydrates, . . . .7.19 Proteids, . . . . 2.72 Salts, . . . . . .16 Total Solids, . . . .' u-43 Water, 88.55 For ten days the infant had frequent yellow and undigested stools. There had been no vomiting, but the child cried a great deal with colic. The foster-child was in the same conditon. jj2 Adriance : Chemical Examination of Breast Milk. This case shows, both in the case of the mother's child and the foster-child, the usual results of a milk with high proteids. The next case demonstrates some principles in the treatment of excessive proteids, which Rotch has shown consists in regula- tion of the exercise. Mother, 23 years; grav. i. ; nervous constitution; poor gen- eral condition; good supply of milk. Infant 1 month prema- ture, and under weight at birth, but at 1 month, 7 days of age it weighed 6 lbs. (2721 grammes). Analysis at one month, seven days: Spec. grav. 1.035. Fat, . . . . . 4. 13 Carbohydrates, . . . .6.79 Proteids, .... 2.06 Salts, ..... .26 Total Solids, .... 13.23 Water, . . . . .86.76 The infant had been having five or six green movements with curds every day since birth. The mother had taken no ex- ercise, was losing sleep, and was very nervous. This case showed high proteids, as we shall find later is the case in pre- maturity. The mother was in such poor condition, it was feared that exercise would be an injury rather than a help. Still fresh air was necessary, and driving each day was recommended. She was advised to eat meat but once a day, instead of three times, and to drink large quantities of water. Six days after the inauguration of the treatment, the child, though much improved, still suffered from indigestion. Move- ments were frequent, but the curds had diminished to small flakes. Child had gained six ounces in the four days. This im- provement in the stools was due to the diminution of the pro- teids, as seen in the following analysis. Analysis at one month, thirteen days: Spec. grav. 1.031. Fat, ..... 4-38 Carbohydrates, . . . . 7. 10 Proteids, . . . . 1.66 Salts, ..... .24 Total Solids, .... 13.37 Water, ... .86.62 Adriance : Chemical Examination of Breast Milk. 33 During the following week the movements became less fre- quent, and there was a gain of one ounce daily. One month after the beginning of treatment the movements still contained a few fine curds, but were reduced in frequency to the normal number, while the child's weight had increased two pounds, twelve ounces. Excessive Proteids During the Colostrum Period. In normal cases we have found the proteids highest during the colostrum period. This excess influences the color of the stools. After the four days during which the infant is passing meconium, the stools become brown or brownish green. After this the color of the stools may change to the yellow of a normal infant's stool, or it may continue green, or green alternating with yel- low, for several days. In an older child such a green color of the stools often indicates an excess of proteids in the milk, which requires treatment. In the stools of infants of this age a green color so often exists that it demands no treatment, unless accom- panied by other symptoms of disease. It is to be considered simply the natural consequence of the high proteids in the milk of this period. If it becomes more marked, curds appear in addition to the green color of the stools. The movements be- come increased in frequency, and there may be vomiting, with rise of temperature. Such a hard strain upon the new-born infant during the first days of life may change into a toxic gastro- enteritis, with feeble, rapid pulse and cyanosis, which is difficult to differentiate from a septic condition of the system. Mother, 24 years of age; grav. i. ; healthy; good supply of milk. Infant, male; birth weight, 7 lbs. 12 oz. (3520 grammes) ; 4 days of age, weight, 6 lbs. 13 oz. (3100 grammes). Fat, . . Carbohydrates, Proteids, .... Salts, .... Total Solids, .... Water, .... The high proteids in this case upset the infant, and showed in frequent green and undigested movements, uric acid stain 3.12 4-93 3-. 49 .24 11.82 88.17 34 Adriance: Chemical Examination of Breast Milk. upon the napkins, and an afternoon temperature of 103 . At the end of one week the disturbing proteids had fallen to 1.85 per cent, and after another week of no treatment the green in the stools disappeared, and the child began to improve. Mother, 31 years; primipara; fair general condition; fair sup- ply of milk. Infant, male; weight at birth, 8 lbs. 12 oz. (3960 grammes); five days old, weight, 7 lbs. 12 oz. (3420 grammes). Fat, ..... 2.83 Carbohydrates, . . . .4.80 Proteids, . . . . 3.24 Salts, ..... .39 Total Solids, . . . . 11.30 Water, . . . . .88.69 Fed on the milk represented in this analysis, the infant lost steadily, and had very bad movements. This general condition failed, and on the twelfth day the circulation was poor, the face dusky, and the child was in as miserable a condition as if the system were poisoned. On the twelfth day he was taken from the mother and put upon a woman's breast, whose child was older and doing nicely. The stools and general condition imme- diately improved, and in ten days the child had improved so much that it was hoped he could digest his own mother's milk, even if the proteids had not become normal. This was tried. The milk was not analyzed at this time, but it apparently agreed with the child, and one month, seventeen days after delivery the child was still doing well, and the analysis showed a marked reduction in the amount of proteids. Analysis at one month, seventeen days: Fat, ..... 4-22 Carbohydrates, . . . .5.64 Proteids, . . . • 1.81 Salts, . . • • -15 Total Solids, . . . . n.83 Water, 88.16 Adriance: Chemical Examination of Breast Milk. 35 Any extra worry or nervousness may increase the amount of proteids during the first days of lactation. The following case illustrates this point. The infant had colic and bad movements. Mother, 24 years; primipara; healthy; abundant supply; excessively nervous, and at times hysterical. Infant, male; weight at birth, 6 lbs. 8 oz. (2940 grammes) ; 7 days old, weight, 6 lbs. 5 oz. (2860 grammes). Spec. grav. 1.030. Fat 3.74 Carbohydrates, . . . .6.09 Proteids, . . . . 2. 1 5 Salts, . . . . . .34 Total Solids, .... 12.35 Water, . . . . .87.64 Prematurity. In every case of prematurity in which we have had an oppor- tunity to analyze the milk, we have found distinguishing charac- teristics. The variations of the colostrum period are present, but exaggerated in the proteids. This increase in the proteids ex- tends over a longer interval than in ordinary colostrum milk, and is not easily dispelled. It consequently taxes the delicate diges- tive organs of the untimely-born infant for a longer time than is usual. The sugar, the complement of the proteids, is low at this time. The cases reported were all one month premature. Cases One Month Premature. 2 days. 3 days. 7 days. Spec. grav. 1.032. Spi ;c. grav. Spec. grav. 1.031 Fat, . . I.83 2.48 2.68 Carbohydrates, 5-55 5.38 5.38 Proteids, . 3.18 2.91 3.08 Salts, .27 .23 .26 Total Solids, . . 10.83 I I.04 1 1.42 Water, 89. 16 88.95 88.57 36 Adriance: Chemical Examination of Breast Milk. Analysis of the same case at successive times : 4days. 17 days. 1 mo., 10 days. Spec. grav. Spec. grav. Spec. grav. 1.030. Fat, . . . 3.39 3.32 3.3} Carbohydrates, . 5.02 4.43 6.64 Proteids, . . 4.90 3.88 1.71 Salts, . . .31 .26 .10 13.66 86.32 1 1. 91 88.08 11.79 88.20 5 days. Spec. grav. 1.030. . 2.S8 16 days. Spec. grav. 1.027. 3.29 5.99 6.O9 • 2.37 I.90 .27 .22 . I 1 .20 88.79 11.47 88.52 Total Solids, Water, Fat, Carbohydrates, Proteids, Salts, Total Solids, . Water, The last two cases, analyzed on successive days, not only demonstrate an excess of proteids during the first days, but also that in prematurity this excess shows a tendency to persist longer than usual. We have known the proteids to remain over 2 per cent, into the second month of lactation. Premature chil- dren are naturally delicate, and ill adapted to stand this extra strain so early in life. Treatment at the Colostrum Period. The treatment of excessive proteids during the colostrum period is difficult. Naturally during child-bed the mother's diet must be limited, and exercise upon which we ordinarily rely for reducing the proteids is impossible. The milk can be pumped, diluted with water, and fed from the bottle; or it can be diluted by the administration of large quantities of water to the mother. In some of the less severe cases, less frequent nursing will prove of benefit, taking water from the bottle in the intervals. This condition is usually temporary, and will adjust itself in a few days. In cases of prematurity, as it is hard to say how long this difficulty will persist, it is often wise to give the infant to a Adriance : Chemical Examination of Breast Milk. 37 wet-nurse whose milk has been demonstrated to be good by its effect upon her child and by analysis. In the meantime the mother's breast should be stimulated by pumping, so that the secretion will not dry up, but in time serve as a proper food. We have had very good fortune in the management of pre- mature babies in our institution. Much of our success was due to careful nursing, but recognizing the excessive proteids, the treatment was regulated accordingly, and no doubt deserves a large part of the credit. Abnormalities Toward the End of Lactation. The most marked changes in the milk in the later months of lactation are a reduction of the proteids and total solids. These seem of little importance, but are not to be lightly considered. The diminution in the proteids is the natural forerunner of the cessation of lactation, and means that the milk is deteriorating; on the other hand, if the proteids are high, lactation will prob- ably continue for some time. The fats, certainly, are no criterion of the condition of the milk; neither is the sugar, but a proper amount of proteids in the milk indicates its tone is good. The physiologists tell us that fats and carbohydrate can be made in the human body, but that proteids cannot be, so that they have to be taken in as such. A scanty amount of proteids then means that the nursing infant will have to get along as best it can under unfavorable conditions. We have observed many such cases, and been led to think that at this time the proteids are the backbone of the milk, and really represent its nourishing properties better than any other guide which we at present possess. This condition, forced upon the child, causes a general weakness of the constitution, which results in anaemia, fretfulness, a falling below the normal gain in weight, delayed dentition, and proneness to gastro-enteritis. The latter symptom may not appear till some time after we have begun the tardy process of weaning. As a rule the first sign of approaching danger is a tendency to gain weight more slowly than normal. A healthy infant should gain from four to eight ounces weekly for the first six months, and from two to four ounces weekly during the second six months. If the child's weight falls below this standard for any length of time, or is sta- tionary, or there is a positive loss, we should try to find the cause at once. It may be that the infant is getting insufficient 38 Adriance: Chemical Examination of Breast €Milk. milk. This can be determined by weighing before and after each nursing. The milk should be analyzed, and if the total solids and proteids are found low, their absence must be supplied. Treatment of Normal Cases in the Later Months of Lactation. The hygiene of the mother's life must be carefully regulated. On account of certain deficiencies which we have seen occur normally in human milk of this period, certain additions must be made to the diet. By the seventh or eighth month the infant's pancreas is functionating so well that we can rely upon it to con- vert starch, and some carbohydrate, such as barley gruel, should be given in addition to the milk. On account of the lack of pro- teids, we must give a substitute of some form of animal food. In this way a deficiency in the mother's milk can be partially supplied. Weaning should begin at the ninth month, and in the early stages of this process we should use a modified milk containing low proteids, taking care not to force upon the infant's digestion an amount of cow's proteids equal to or greater than that which the mother has been offering, for it is known that the proteids of cow's milk form a tough curd, which are indigestible in compari- son with human proteids. The number of bottle feedings and the amount of proteids should be gradually increased. Under this treatment, even if the child continues to lose weight for a time, we can feel that the stomach is gradually becoming accustomed, and eventually will be able to digest a stronger diet. At any rate we shall have the satisfaction of keeping the child from gastro-enteritis, to which its constitution would be particularly susceptible at this time. Management of Abnormal Cases in the Later Months of Lactation. If the mother is anaemic, a tonic containing iron is indicated. Holt has shown that malt increases the total solids in human milk, and we have found its use very beneficial at this time. The form we have used has been Maltine. The mother's diet should be increased with the addition of cow's milk. A good form in which to prescribe the latter is a milk punch. Exercise in the fresh air is important. Antiseptic massage of the breast Adriance : Chemical Examination of Breast (Milk. 39 for its local stimulating effect was used on A. M. Thomas' serv- ice at the hospital. In the later months of lactation we cannot hope to bring the original tone back to the milk, but we can hope to keep it from degenerating further till the child has been weaned. Mother, 20 years; primipara; healthy; fair supply. Infant, male; birth weight, normal; 11 months, 25 days of age, weight, 17 lbs. 4 oz. (7824 grammes). Fat, . . . . . 2.24 Carbohydrates, . . . .6.86 Proteids, . . . . .36 Salts, . . . . . .13 Total Solids, . . . . 9.59 Water, . . . . .90.40 The infant was very anaemic, and had been losing weight for two months. This case shows the usual result of protracted nursing, but all milk does not show such degeneration, for some mothers retain their milk in its strength till much later in lacta- tion, and in such cases nursing can be continued longer. Milk Degenerating Earlier in Lactation. Changes in the mother's milk due to preparation for the ces- sation of lactation may begin at any time when the mother's health is so poor as to affect the milk. Many mothers are never able to nurse their children for any length of time, as the milk dries up prematurely. Under such conditions we find the same chemical changes that would normally occur later in lactation; or this condition of the milk may persist for many months, and the infant suffer from lack of food, while the mother, perhaps misled by her abundant supply, is at a loss to account for the fail- ing health of her baby. Under such circumstances, a better prognosis can be given than later in lactation, for the mother may be so influenced by treatment that the milk is brought up to its standard. Mother, 19 years; primipara; poor general condition; scant supply. Infant, male; birth weight, normal; 7 months, 6 days of age, weight, 10 lbs. (4535 grammes). Poor, delicate, anaemic child, subject to bronchitis. Has been under weight since one month of age. 5.6 1 6.89 .63 •17 40 Adriance : Chemical Examination of Breast Milk. Fat, ..... Carbohydrates, Proteids, .... Salts, .... Total Solids, . . . . 1 3. 32 Water, . . . . . 86.67 This milk showed low proteids, which often exist in a poor milk, even when the total solids are not below the normal. Mother, 24 years; primipara; fair supply. Infant, male; birth weight, above normal; weight kept above normal till 2 months of age, and since then has gained less slowly; 4 months, 27 days of age, weight, 13 lbs. 8 oz. (6122 grammes). Spec. grav. 1.050. Fat, 3.95 Carbohydrates, . . . .7.45 Proteids, . . . . .34 Salts, . . . . ..15 Total Solids, . . . . 11. 91 Water, ..... 88.08 Mother, 35 years; grav. iv. ; nursed second child for five months, when the milk dried up; nursed third child three months, when milk dried up. At this lactation had an abund- ant supply, but was run down. She nursed her own infant, and a foster-child beside. Own infant, female; birth weight, 8 lbs. 8 02. (3854 grammes) ; 2 months, 13 days old, weight, 8 lbs. 12 oz. (3968 grammes) ; much under weight. The weight had been falling off rapidly for three weeks, but the child did not seem sick, had no vomiting or bowel trouble, and on physical exami- nation nothing was discovered but craniotabes. There were no other sign of rickets. Analysis at Analysis at Analysis at 2 mos., 13 days. 2 mos., 20 days. 2 mos., 28 days. Spec. grav. 1.030. Spec. grav. 1.030. Spec. grav. 1 .026. Fat, . . . 3.00 3.78 3.69 Carbohydrates, . 6.97 7.06 6.81 Proteids, . .75 .15 1.36 Salts, . . .18 .16 .18 Total Solids, 10.90 11. 15 12.06 Water, . . 89.09 88.83 87.93 Adriance: Chemical Examination of Breast Milk. 41 The chemical examination of the milk disclosed the diagnosis of this case. The proteids and total solids were low. Nothing was done for a week, and the child continued to fail. At the end of a week another analysis was made, and the proteids had fallen very low, although the total solids had risen 25 per cent. The mother was told to walk in the fresh air every day, and given a tonic containing iron, arsenic and strychnine, a tablespoonful of Maltine three times a day, and extra milk and milk punches. At the end of eight days a decided change for the better, both in the mother's condition and in the child, took place. The child had gained fourteen ounces, and was doin'g nicely. The analysis showed a good milk, instead of the poor milk of eight days previous. Mother, 22 years; primipara; thin, and very nervous; fair supply; complains of lack of appetite. Infant, birth weight, 8 lbs. 8 oz. (3854 grammes); 2 months, 16 days of age, weight, 14 lbs. (6350 grammes). 2 mos., 16 days. 2 mos., 25 days. Spec. grav. 1.033. Spec. grav. 1.035. Fat, . . . . . .67 1.36 Carbohydrates, . . . 7.14 7.25 Proteids, . . . . .93 .21 Salts, . . . . .22 .17 Total Solids, . . . 8.95 9.01 Water, . ... . 91.04 90.98 The infant was doing well, but the analysis was made be- cause the mother was so much worried and pulled down. From the observation of many previous cases which had presented a similar chemical condition, it was believed that the milk was likely to dry up at no distant date. Nine days later the milk was analyzed again, and showed further reduction in the proteids. By this time the mother thought her milk was flowing less freely, and extra modified milk was given the infant. The mother continued to worry, and five days later the breasts secreted so little milk that the baby was put entirely upon the bottle. This proved to have been wise, for in three days the breasts were entirely free from milk. Two weeks later the mother was in bed with nervous prostration. Low proteids and total solids may persist for some time, but when their reduction is rapid, it is a warning that lactation may 42 Adriance : Chemical Examination of Breast Milk. cease unless proper treatment is inaugurated. An insufficient diet may lower the tone of the milk, reducing the proteids and total solids, but unlike the milk preparing for the cessation of lactation, its tone is promptly restored when the diet is in- creased. Summary. (ij Excessive fats or proteids may cause gastro-intestinal symptoms in the nursing infant. (2) Excessive fats may be reduced by diminishing the nitro- genous elements in the mother's diet. ' (3) Excessive proteids may be reduced by the proper amount of exercise. (4) Excessive proteids are especially apt to cause gastro- intestinal symptoms during the colostrum period. (5) The proteids, being higher during the colostrum period of premature confinement, present dangers to the untimely-born infant. (6) Deterioration in human milk is marked by a reduction in the proteids and total solids, or in the proteids alone. (7) This deterioration takes place normally during the later months of lactation, and unless proper additions are made to the infant's diet, is accompanied by a loss of weight, or a gain below the normal standard. (8) When this deterioration occurs earlier, it may be the forerunner of the cessation of lactation, or well-directed treat- ment may improve the condition of the milk. 321 Lexington Avenue. mm COLUMBIA UNIVERSITY This bqok is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28<638)M50 'QP246 ■A. clim'^oi Ad8