{748} The infant with this disease is thirsty, and is theref_A system of practical medicine. By American authors. Vol. 2

take more nutriment in the liquid form than it requires for its

sustenance. If nursing, it craves the breast, or if weaned, craves the

bottle, at short intervals to relieve the thirst. No more nutriment

should be allowed than is required for nutrition, for the reason stated

above, and the thirst may best be relieved by a little cold water,

gum-water, or barley-water, to which a few drops of brandy or whiskey

are added.

Since one of the two important factors in producing the summer

diarrhoea is the use of improper food, it is obviously very important

for the successful treatment of this disease that the food should be of

the right kind, properly prepared, and given in proper quantity. I need

not repeat that for infants under the age of one year no food is so

suitable as breast-milk, and one affected with the diarrhoea and

remaining in the city should, if possible, at least if under the age of

ten months, be provided with breast-milk. It can be more satisfactorily

treated and the chances of its recovery are much greater if it be

nourished with human milk than by any other kind of diet. If, however,

the mother's milk fail or become unsuitable from ill-health or

pregnancy, and on account of family circumstances a wet-nurse cannot be

procured, the important and difficult duty devolves upon the physician

of deciding how the infant should be fed. In order to solve this

problem it will be well to recall to mind the part performed in the

digestive function by the different secretions which digest food:

1st. The saliva is alkaline in health. It converts starch into glucose

or grape-sugar. It has no effect upon fat or the protein group. It is

the secretion of the parotid, submaxillary, and sublingual glands,

which in infants under the age of three months are very small, almost

rudimentary. The two parotid glands at the age of one month weigh only

thirty-four grains. The power to convert starch into sugar possessed by

saliva is due to a ferment which it contains called ptyalin.

2d. The gastric juice is a thin, nearly transparent, and colorless

fluid, acid from the presence of a little hydrochloric acid. It

produces no change in starch, grape-sugar, or the fats, except that it

dissolves the covering of the fat-cells. Its function is to convert the

proteids into peptone, which is effected by its active principle,

termed pepsin.

3d. The bile is alkaline and neutralizes the acid product of gastric

digestion. It has no effect on the proteids. It forms soaps with the

fatty acids and has a slight emulsifying action on fat. The soaps are

said to promote the emulsion of fat. Their emulsifying power is

believed to be increased by admixture with the pancreatic secretion.

Moreover, the absorption of oil is facilitated by the presence of bile

upon the surface through which it passes.

4th. The pancreatic juice appears to have the function of digesting

whatever alimentary substance has escaped digestion by the saliva,

gastric juice, and bile. It is a clear, viscid liquid of alkaline

reaction. It rapidly changes starch into glucose. It converts proteids

into peptones and emulsifies fats. While the gastric juice requires an

acid medium for the performance of its digestive function, the

pancreatic juice requires one that is alkaline. This important fact

should be borne in mind, that such a mistake as presenting pepsin with

chalk mixture, or the extractum pancreatis with dilute muriatic acid,

may be avoided.

{749} 5th. The intestinal secretions are mainly from the crypts of

Lieberkühn, and their action in the digestive process is probably

comparatively unimportant, but in some animals they have been found to

digest starch. It will be observed that of all these secretions that

which digests the largest number of nutritive principles is the

pancreatic. It digests all those which are essential to the maintenance

of life except fat, and it aids the bile in emulsifying fat.

One of the most important conferences in pædiatrics ever held convened

at Salzburg in 1881 for the purpose of considering the diet of infants.

Among those who participated in the discussion were men known

throughout the world as authorities in children's diseases, such as

Demme, Biedert, Gerhardt, Henoch, Steffen, Thomas, and Soltmann. None

of the physicians present dissented from the following proposition of

the chairman: That "all the advances made in physiology in respect to

the digestive organs of children only go to prove that the mother's

milk is the only true material which is quantitatively and

qualitatively suited to the development of the child, which preserves

the physiological functions of the organs of digestion, and under

favorable circumstances of growth unfolds the whole organism in its

completeness." All agreed that when the breast-milk fails animal milk

is the best substitute. Henoch, who was one of the conference,

expresses the same opinion in his well-known treatise on diseases of

children, as follows: "Cow's milk is the best substitute for mother's

milk during the entire period of infancy. I consider the administration

of other substances advisable only when good cow's milk cannot be

obtained or when it gives rise to constant vomiting and diarrhoea."

The many infants' foods contained in the shops were considered by the

conference, and, in the words of the chairman, "Now and evermore it is

unanimously agreed that these preparations can in no way be substituted

for mother's milk, and as exclusive food during the first year are to

be entirely and completely rejected." But, unfortunately, we soon learn

by experience that animal milk, although it is the best of the

substitutes for human milk, is, especially as dispensed in the cities,

faulty. It is digested with difficulty by young infants, and is apt to

cause in them diarrhoea and intestinal catarrh. Therefore in the hot

months its use is very apt to act as one of the dietetic causes of the

summer diarrhoea in infants exclusively fed upon it, unless it be

specially prepared so as to more closely resemble human milk. The

frequent unsatisfactory results of its use have led to the preparation

of the many proprietary substitutes for human milk which the shops

contain, and which have been so summarily discarded by the German

conference.

Woman's milk in health is always alkaline. It has a specific gravity of

1.0317; cow's milk has a specific gravity of 1.029. That of cows

stabled and fed upon other fodder than hay or grass is usually

decidedly acid. That from cows in the country with good pasturage is

said to be alkaline, but in two dairies in Central New York a hundred

miles apart, in midsummer, with an abundant pasturage, two competent

persons whom I requested to make the examinations found the milk

slightly acid immediately after the milking in all the cows.

The following results of a large number of analyses of woman's and

cow's milk, made by König and quoted by Leeds, and of several of the

{750} best known and most used preparations designed by their inventors

to be substitutes for human milk, show how far these substitutes

resemble the natural aliment in their chemical characters:

-------------+-----------------------+-----------------------+

| Woman's Milk. | Cow's Milk. |

+-------+-------+-------+-------+-------+-------+

| Mean. | mum. | mum. | Mean. | mum. | mum. |

---------------------+-------+-------+-------+-------+-------+

Water | 87.09 | 83.69 | 90.90 | 87.41 | 80.32 | 91.50 |

Total solids | 12.91 | 9.10 | 16.31 | 12.59 | 8.50 | 19.68 |

Fat | 3.90 | 1.71 | 7.60 | 3.66 | 1.15 | 7.09 |

Milk-sugar | 6.04 | 4.11 | 7.80 | 4.92 | 3.20 | 5.67 |

Casein | 0.63 | 0.18 | 1.90 | 3.01 | 1.17 | 7.40 |

Albumen | 1.31 | 0.39 | 2.35 | 0.75 | 0.21 | 5.04 |

Albuminoids | 1.94 | 0.57 | 4.25 | 3.76 | 1.38 | 12.44 |

Ash | 0.49 | 0.14 | ... | 0.70 | 0.50 | 0.87 |

-------------+-------+-------+-------+-------+-------+-------+

The following analyses of the foods for infants found in the shops, and

which are in common use, were made by Leeds of Stevens's Institute:

_Farinaceous Foods_.

----------------+-------+-------+-------+-------+--------+-------+

| 1. | 2. | 3. | 4. | 5. | 6. |

----------------+-------+-------+-------+-------+--------+-------+

Water | 9.85 | 7.78 | 5.49 | 9.23 | 9.33 | 10.10 |

Fat | 1.56 | 0.41 | 1.01 | 0.63 | 1.01 | 0.97 |

Grape-sugar | 1.75 | 7.56 | Trace.| 2.40 | 4.60 | 3.08 |

Cane-sugar | 1.71 | 4.87 | Trace.| 2.20 | 15.40 | 0.90 |

Starch | 64.80 | 67.60 | 78.93 | 77.96 | 58.42 | 77.76 |

carbohydrates | 13.69 | 14.29 | 3.56 | 5.19 | 20.00 | 4.11 |

Albuminoids | 7.16 | 10.13 | 10.51 | 9.24 | 11.08 | 5.13 |

etc. | 2.94 |erm'd. | 0.50 | ... | 1.16 | 1.93 |

Ash | 1.06 | 1.00 | 1.16 | 0.60 | ... | 1.93 |

----------------+-------+-------+-------+-------+--------+-------+

_Liebig's Foods_.

----------------+------+------+-------+-------+------+------+------+

| Mel- | Haw- | Hor- |bey and| and | Baby | Baby |

| | | | son's.| e's. |No. 1.|No. 2.|

----------------+------+------+-------+-------+------+------+------|

Water | 5.00| 6.60| 3.39 | 27.95 | 8.34| 5.54| 11.48|

Fat | 0.15| 0.61| 0.08 | None. | 0.40| 1.28| 0.62|

Grape-sugar | 44.69| 40.57| 34.99 | 36.75 | 20.41| 2.20| 2.44|

Cane-sugar | 3.51| 3.44| 12.45 | 7.58 | 9.08| 11.70| 2.48|

Starch | None.| 10.97| None. | None. | 36.36| 61.99| 51.95|

carbohydrates | 85.44| 76.54| 87.20 | 71.50 | 44.83| 14.35| 22.79|

Albuminoids | 5.95| 5.38| 6.71 | None. | 9.63| 9.75| 7.92|

etc. | ... | ... | ... | ... | 0.44| 7.09| 5.24|

Ash | 1.89| 1.50| 1.28 | 0.93 | 0.89|erm'd.| 1.59|

----------------+------+------+-------+-------+------+------+------+

{751} _Milk Foods_.

----------------+-----------+-----------+-----------+-----------+

----------------+-----------+-----------+-----------+-----------+

Water | 4.72 | 6.54 | 6.78 | 5.68 |

Fat | 1.91 | 2.72 | 2.21 | 6.81 |

milk-sugar | 6.92 | 23.29 | 6.06 | 5.78 |

Cane-sugar | 32.93 | 21.40 | 30.50 | 36.43 |

Starch | 40.10 | 34.55 | 38.48 | 30.85 |

carbohydrates | 44.88 | 46.43 | 44.76 | 45.35 |

Albuminoids | 8.23 | 10.26 | 9.56 | 10.54 |

Ash | 1.59 | 1.20 | 1.21 | 1.21 |

----------------+-----------+-----------+-----------+-----------+

It is seen by examination of the analyses of the above foods that all

except such as consist largely or wholly of cow's milk differ widely

from human milk in their composition, and although some of them--as the

Liebig preparations, in which starch is converted into glucose by the

action of the diastase of malt--may aid in the nutrition and be useful

as adjuncts to milk, physicians of experience and close observation

will, I think, agree with the German conference that when breast-milk

fails or is insufficient our main reliance for the successful nutrition

of the infant must be on animal milk. Nestle's Food, which consists of

wheat flour, the yelk of egg, condensed milk, and sugar, and which has

been so largely used in this country and in Europe, is probably

beneficial mainly from the large amount of Swiss condensed milk which

it contains.

Although the preference is to be given to animal milk over any other

kind of food as a substitute for human milk, yet even when obtained

fresh and from the best dairies and properly diluted it is very apt to

disagree with infants under the age of one year, producing indigestion

and diarrhoea. The close resemblance in chemical character of cow's,

ass's, and goat's milk to human milk would lead us to expect that

either would be a good substitute for the latter. The fact that the

milk of these animals is apt to cause indigestion and intestinal

catarrh, especially in the hot months, when the digestive function of

the infant is enfeebled from the heat, must be due to the quality

rather than quantity of its constituents. The difference in quality of

the casein of human and animal milk is well known, since that of human

milk coagulates in the stomach in flakes, and that of animal milk in

firm and large masses. The German conference saw at once the importance

of the problem which confronted them--_i.e._ how to modify cow's milk

so that it bears the closest possible resemblance to human milk. They

even discussed the difference of the milk of different breeds of cows,

and the proper feeding and care of cows, but the most important

suggestion made--and one which has already produced good results in

this country and in Europe, and promises to be instrumental in saving

the lives of many infants who by the old method of feeding would

inevitably perish--was made by Pfeiffer of Wiesbaden. I allude to the

peptonizing of milk. The pancreatic secretion digests milk that is

rendered alkaline at a temperature between 100° and 150° F. Milk thus

treated becomes in from twenty minutes to one hour thinner, resembling

human milk in appearance, and if the peptonizing be continued beyond a

certain point, and is more complete, its taste is decidedly {752}

bitter. The process should be watched and the peptonizing suspended as

soon as the bitterness becomes appreciable, for, although more advanced

peptonizing so changes the milk that it is more easily digested by the

infant than when the peptonizing is partial, yet the bitterness which

is imparted to it renders it very disagreeable as a dietetic

preparation. Milk thus prepared closely resembles human milk in

appearance, and its casein is so digested that it is either not

precipitated by acids or is precipitated, like that of human milk, in

flakes. By this process a digested or an easily-digested casein is

produced, instead of the casein of ordinary cow's milk, which produces

large and firm masses in the stomach--masses that the digestive

ferments penetrate with such difficulty that they cause indigestion,

and occur in the stools in coagula of greater or less size. Pfeiffer

pointed out that when peptonized milk is employed "the feces showed

absolutely no trace of the white cheesiness." Milk thus prepared

quickly spoils, and it is necessary to peptonize it in small quantity

and often during the twenty-four hours.

In New York City during the last year peptonized milk has been employed

largely as recommended by Pfeiffer, and with such results as to

encourage its further use. It is now used in the New York Infant Asylum

and New York Foundling Asylum. Five grains of extractum pancreatis

(Fairchild & Co.'s) and ten grains of sodium bicarbonate are added to

one gill of warm water. This is mixed with one pint of warm milk, and

the mixture, in some convenient vessel, is placed in water kept at a

temperature of 100° F. for one hour, when it is placed upon ice to

prevent further digestion. It should be tasted frequently during the

peptonizing process, and if the least bitterness be observed the

process should be suspended before the expiration of the hour. With

some specimens of milk, especially at a temperature of 115° to 120°, a

half hour or even less is sufficient. This artificial digestion is

arrested either by boiling the peptonized milk, which destroys the

ferment, or by reducing its temperature to near the freezing-point,

which renders it latent and inactive, but does not destroy it. I need

not add that placing the peptonized milk on ice is preferable to

boiling it, since we wish the ferment to continue to act in the stomach

of the infant. In the present state of our knowledge of infant feeding,

therefore, we can recommend no better substitute for human milk than

peptonized cow's milk.

Leeds recommended the following formula for peptonizing milk in his

very instructive remarks made before the New York County Medical

Association, July 16, 1884. In order that no mistake might be made, I

wrote to him for his formula, which he kindly sent me. The following is

an extract from his letter: "The formula which I ventured to suggest

for the preparation of humanized cow's milk was as follows: 1 gill of

cow's milk, fresh and unskimmed; 1 gill of water; 2 tablespoonfuls of

rich cream; 200 grains of milk-sugar; 1½ grains of extractum

pancreatis; 4 grains of sodium bicarbonate. Put this in a

nursing-bottle; place the bottle in water made so warm that the whole

hand cannot be held in it without pain longer than one minute. Keep the

milk at this temperature for exactly twenty minutes. The milk should be

prepared just before using."

The object is of course to provide from cow's milk a food which will be

the nearest possible approximation to healthy human milk; and this

{753} appears to be achieved by the peptonizing process. Certainly,

what physicians have long been desiring--namely, some mode of preparing

cow's milk so that its casein will coagulate in flakes like that of

human milk--has been obtained by peptonizing.

It is a common error to expect too much of a new remedy which has a

real value, and we must not expect that all patients not in an utterly

hopeless state will begin to improve as soon as peptonized milk is

prepared for them, or that it is a full and exact substitute for human

milk, so that wet-nurses may be dispensed with. Healthy human milk is

the best of all food for infants under the age of twelve months, and

should always be preferred when it can be obtained, but we claim that

peptonized milk is a most useful addition to the dietetic preparations

for infants, probably surpassing in value the best of those in the

shops. We employ it in the belief that it affords important aid in

curing the dyspeptic and diarrhoeal maladies of infancy. Who first

formulated and recommended the process of peptonizing milk I am not

able to state, but I am informed that Roberts of Great Britain called

attention to it as a means of improving milk at a time antedating the

German conference.

Milk from healthy, properly-fed cows may be prepared without

peptonizing, so as to agree with many infants except in the warmest

weather, but is obviously less easily digested than peptonized milk. It

should be diluted as follows with water boiled so as to free it from

germs: In the first week after birth one-fourth milk with the addition

of a little sugar. The milk should be gradually increased, so that it

is one-third by the end of the fourth week, one-half by the end of the

third month, and two-thirds to three-fourths by the end of the sixth

month. After the sixth month it is still proper to add one-fourth

water, but pure milk may be given. Water increases the urination.

Before peptonizing--which, as we have seen, digests the casein to a

great extent, and changes that which is not digested so that it

coagulates in flakes in the stomach like breast-milk--was resorted to,

it was customary to use a thin barley- or oat-water in place of the

water used for diluting the milk. One heaped teaspoonful of barley

flour to two tablespoonfuls of water make a gruel of proper

consistence. A little farinaceous substance added to the milk by

mechanically separating the particles of casein tends to prevent their

coagulation in large and firm masses. This was the theory which

explained the beneficial action of the admixture. If for any reason

peptonized milk be not employed, milk prepared in the way I have

mentioned, by admixture with a farinaceous substance, is probably the

next best substitute for human milk.

It is very important to determine when and how farinaceous foods shall

be given in this disease. It is well known that infants under the age

of three months digest starch with difficulty and only in small

quantity, since the salivary and pancreatic glands which secrete the

ferments which digest starch are almost rudimentary at that age. The

artificial digestion of starch is, however, easily accomplished. Among

the last labors of the renowned chemist Baron Liebig was the

preparation of a food for infants in which the starch is digested and

transformed into grape-sugar, and thus infants at any age who are fed

with it are relieved of the burden of digesting it. The baron led the

way which has been so successfully followed since in the artificial

digestion of foods. A considerable part of the starch {754} in wheat

flour is converted into grape-sugar by the prolonged action of heat. I

frequently recommend that from three to five pounds of wheat flour be

packed dry in a firm muslin bag, so as to form a ball, and be placed in

water sufficient to cover it constantly and the bag kept over the fire

three or four days. During the nights the fire may go out for a few

hours. At the expiration of this time the external part, which is wet,

being peeled off, the remainder resembles a lump of yellowish chalk.

The flour grated from it gives a decided reaction of sugar by Fehling's

test. Starch is also quickly transformed into glucose by the action of

the diastase of malt, which indeed Liebig employed. If to a gruel of

barley flour, oatmeal, or other farinaceous substance, when hot, a

little of a good preparation of extract of malt, such as that prepared

by Trommer & Co. at Fremont, Ohio, which acts promptly, or by Reed &

Carnrick, be added, it becomes thinner. It is claimed that the starch

is thus quickly converted into glucose; which seems doubtful. It is,

however, so modified that it is apparently more readily digested and

assimilated. Farinaceous substances thus prepared may be employed with

peptonized or other milk. Infants frequently do better with this

admixture than when either the milk or gruel is used separately.

Of the foods contained in the shops which have been most prescribed,

and which have apparently been useful in certain cases, I may mention

those which have been prepared according to Liebig's formula, of which

there are several, the analyses of which I have given, and Nestle's

farina. In the use of those foods which contain no milk, as Ridge's

food, Imperial granum, etc., it is recommended that milk be added,

while for such as contain condensed milk, as Nestle's and the

Anglo-Swiss food, only water should be employed. The Anglo-Swiss food

contains about 60 per cent. condensed milk and about 20 per cent. each

of oatmeal and Russian wheat flour. It gives an acid reaction, unlike

Nestle's, which is alkaline. When Biedert's cream conserve was

announced great expectations were awakened from the fact that the

inventor is an authority in pædiatrics, but, unfortunately, they have

not been realized in this country. Much of Biedert's conserve when it

reaches us is spoiled, and the directions for its use are too

complicated for ordinary family use, since a different mixture is

required for each month of the infant's age. I have employed this food,

but, with Henoch, "could not convince myself that it is more

efficacious than cow's milk." I am informed that the sale of it in this

country has ceased.

Condensed milk is largely used in the feeding of infants. The milk is

condensed in vacuo to one-third or one-fifth its volume, heated to 100°

C. (212° F.) to kill any fungus which it contains, and 38 to 40 per

cent. of cane-sugar is added to preserve it. In the first month one

part of milk should be added to sixteen of water, and the proportion of

water should be gradually reduced as the infant becomes older. The

large amount of sugar which condensed milk, preserved in cans, contains

renders it unsuitable in the dietetic rôle of the summer diarrhoea of

infants. The sugar is apt to produce acid fermentation and diarrhoea in

hot weather. Borden's condensed milk, freshly prepared, as dispensed

from the wagons, contains, I am informed by the agent, no cane-sugar or

other foreign substance, and on this account is to be preferred to that

in the cans. It is cow's milk of good quality, from which 75 to 79 per

cent. of the water {755} has been removed under vacuum. The sole

advantage which it possesses--and it is an important one--is that it

resists fermentation longer than the ordinary milk.

A system of practical medicine. By American authors. Vol. 2 · 第 105 / 184 段

{748} The infant with this disease is thirsty, and is therefore apt to