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, 1913

, Vol. VIII

ent.

tion, especially in the houses of the poor. genital syphilis or pyloric stenosis, be presA point of less moment is an absence of that constant leaking of the napkins, which occurs when diluted milk is used.

Limitations and Disadvantages. It is -It is not claimed for whole citrated milk that it is a panacea for all the digestive disturbances to which infants are prone. There are certain very exceptional children who from earliest infancy cannot take milk in any form. To them milk seems to act as a poison, producing symptoms of serious toxemia. There are others, a small proportion I believe, whose powers of digesting the fats of cows' milk are restricted. In these cases citrated, whole milk is contra-indicated, for what these infants need is reduction of fat-content. The discovery that the curds passed by the bowel consist largely of fats and soaps, is not necessarily an evidence that fat indigestion is the important factor to be treated, for if the protein coagulum be tough and firm, the fat globules are entangled in its meshes, much as blood corpuscles in a thrombus, and in this way the fat splitting ferments are placed at a disadvantage, render the curd soft and flocculent, and the fatty pellets will disappear from the motions. Milk in any form is unsuitable for the epidemic diarrhea of the Summer months. There are also some few babies who may truly be said to be born to die. Without presenting any gross lesions, they resist all methods of feeding and gradually sink from inanition. These subjects of "abiotrophy" are often born at the end of long families, or when the mother is getting on in years, and are not endowed with sufficient vital force to live. Failures in feeding by this method, as by any other, are due to be met with too, if organic disease, such as con

One of the disadvantages which are said. to attend undiluted citrated milk is that it engenders constipation. I have not been able to convince myself that this is the case, although it is true that the motions are more bulky. Nearly all the babies whom I have watched who have suffered from constipation were similarly affected before the citrated milk was begun. Urticaria and erythematous rashes have been produced when sodium citrate has been given in excess, but never, in my experience, when used in the proportions here recommended. A rational objection to whole milk is that more protein is given than is present in human milk, and therefore more than the infant needs. One can only say that it does no harm when the curd difficulty is overcome by citration. The size of the motions indicates that some of this is passed, but I have no data as to the ratio between the amount of protein utilized and that excreted, nor how this compares with the same ratio when diluted milk is given.

Results. The progress in weight and strength of the infants fed by this method fully justifies the claims which have been made for it. I have now watched some hundreds of infants reared on citrated whole milk, and am convinced of its value. The failures are surprisingly few, and very rarely has another method been substituted with advantage. On the other hand, time and again I have replaced other methods by it with success. Rickets, gastric dilatation, general hypotonia and that puffy and pasty appearance so commonly seen in babies fed on diluted milk do not develop. On the contrary the muscles are particularly strong and firm.

Another occasion for citrated milk is at the time of weaning in the case of children who have been breast-fed. It may be substituted gradually for the breast, first using 2 grains to the ounce of milk, and then one. The sodium citrate may afterwards be omitted. Such a gradual transition from breast milk to cows' milk safeguards the baby from the dangers to which a sudden change subjects it.

To test its efficacy for children who are undersized and losing weight by other methods of feeding I have performed the following experiment: Marasmic infants. were taken consecutively. Each was weighed on the first examination and again a week later, no alteration being made in the diet. At the end of the week they had lost weight. Whole citrated milk was substituted and subsequently their weights were charted at first weekly, afterwards every 2 or 3 weeks. In this way 80 consecutive cases of marasmic infants were studied.

When first seen 30 were being fed on cows' milk and barley water, and 4 on cows' milk and boiled water. One was receiving milk, lime water and cream. In one case, the milk was being peptonized, and in another humanized. Seven were being fed on condensed milk, in one case supplemented by sanatogen, in another by in another by Empress wheaten flour. Patent foods were being given in eleven instances and had previously been given in seven more. Altogether 17 varieties of patent foods had been tried in these cases. In one instance albumen water only was being used. Twenty-one were losing weight on the breast, in one case supplemented by condensed milk, in another by nursery biscuits.

The poor state of nutrition of the cases when first seen could be gauged best by

the weights at the time. Four weighed under 5 pounds, their ages being 3, 4, 8 and 10 weeks respectively. Ten others weighed 6 pounds or under, their ages varying from 5 weeks to 3 months. The lightest baby weighed 4 pounds and was 3 weeks old. All weighed below the average and had been wasting when first given whole citrated milk. Three, according to the mothers' statements were brought because they were given up by their doctors, and in one case a death certificate had already been promised.

The results were very gratifying. All gained in weight. This was especially surprising seeing that previously all had wasted and on very many kinds of foods. I heard of only one fatality. This was that of a very ill-developed, undersized child who first attended, age 2 months and weighing 8 pounds and 2 ounces. For fifteen weeks he gained an average of 3.53 ounces weekly, but died of epidemic diarrhea in September. Other members of the family had diarrhea also. In one case the citrated whole milk was supplanted by another preparation. According to the mother it was being pumped up whilst condensed milk was retained, and as the child was not progressing I allowed the condensed milk to be given temporarily and afterward lost sight of the patient. It is important that the presence of thrush was coincident with the want of progress.

In a third case the citrated milk was given as a means of assisting breast feeding, and after a month was unnecessary. Three were the subjects of rickets. One of these had rickets before coming under treatment; one had as well as rickets, congenital syphilis, hernia, phimosis and bronchitis. The remaining 74 cases were well and healthy when last seen. Five de

, 1913

, Vol. VIII

veloped diarrhea and vomiting in the Summer months, from which they recovered. There was no case of gastrointestinal disturbance apart from zymotic diarrhea sufficiently severe to cause loss of weight.

OBSERVATIONS ON BREAST

FEEDING.

BY

DAVID FORSYTH, M. D., D. Sc., (Lond.) F. R. C. P. (Lond.) Physician to the Evelina Hospital for Sick Children; Physician to Out-Patients Charing Cross Hospital.

London, Eng.

Compared with the great strides that have been taken in the last half-century in artificial methods of feeding, not a great deal has been done to extend our control over nature's method. Even the quantity of human milk needed by an infant is still uncertain, though the opinion is sometimes heard that the whole matter can safely be left to nature-an attitude hardly to be found in other spheres of scientific inquiry. Certain it is that nature often conducts the business only indifferently well and sometimes very badly; yet, on these occasions, what trustworthy remedy is available? With no means of increasing or modifying the natural supply, bottle-feeding is the first and only resource when an infant fails to thrive on breast-milk.

What little is accurately known of the subject is largely drawn from a comparatively few observations on the consumption of breast-milk. Most of these, however, are merely estimates of the size of single feeds the so-called "test-meals"-and the daily total is calculated (with what accuracy will be considered later) by multiplying the size of the test-meal by the num

ber of the daily feeds. In only a few cases have the observations been continued over any length of time, the most systematic attempt on this larger scale having been made. in 1911, by Pritchard, Carter and Pitt, who estimated all the feeds of a number of babies in St. Marylebone Workhouse until the 21st day after birth; and their results stand as a guide to breast-feeding among the poorest classes. But, as they are careful to point out, their figures must not be taken as applicable to a better social class. Yet, so far as I am aware, no continuous observations on infants of this class have been made; no doubt the practical difficulties are considerable, since the experiment necessitates weighing a baby some score of times every day and at all hours of the day and night-an undertaking which not every mother would approve of.

In these circumstances, the following observations which I made four years ago would seem worth placing on record. They comprise a continuous estimate of the consumption of breast-milk by an infant of the better class from the 5th day after birth, when the supply of maternal milk began, until the 49th day, when the child was removed from London. No other nourishment was given, and the mother had every advantage in the way of food, nursing, etc., which is customarily available for those whose circumstances are easy.

During the period of the experiment 413 breast-feeds were given, the daily number varying from 7 to 11 and averaging 9. Immediately before each meal the infant was put in the scales and again immediately after, except on a few occasions when for one reason or another, no record was made. Altogether, in the seven weeks he was weighed 799 times. A special balance registering up to 20 kilos and turning

1See their paper (Lancet, 1911, II, p. 677) for such references as are to be found.

MEDICINE

Series

at 5 grms. was used, the records at first being in English but subsequently in metric

measure.

To begin with a summary of the results covering the whole period, the total consumption of milk from first to last was just under 24 litres (2 galls. 5 qts.). If the composition of human milk be taken as 12.7 parts solid per centum, these 24 litres will have contained 3.048 kilos (6 lbs. 11 ozs.) of sugar, fat, protein and salts; and, on the foundation of this nourishment (plus oxygen, of course) the child built up an additional body-weight of 1.025 kilos (2 lbs. 4 ozs.)-i. e. from 3.685 kilos (8 lbs., 2 ozs.) to 4.710 kilos (10 lbs., 6 ozs.).

The amount of milk consumed week by week is set out in the following table, the last column showing the daily average in each week.

TABLE I. Total Milk

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Week

Daily Average

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Week

I

55 cc. (2

ozs)

2

125 cc. (41⁄2 ozs)

7 cc. (14 oz)

3

125 cc. (41⁄2 ozs)

7 cc. (14 oz)

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I

7 cc. (14 oz)

With regard to these averages it is necessary to add that the actual daily consumption by no means always lay near the average, the difference between the largest and smallest daily totals in any given week varying considerably. Thus, in the 2nd week this variation was from 380 c.c. (131⁄2 ozs.) to 600 c.c. (21 ozs.), and in the 3rd week from 420 c.c. (151⁄2 ozs.) to 495 c.c. (171⁄2 ozs.). In the next week it reached its maximum-a difference of 60%-as the following figures show:

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So large a feed in the second week as 125 c. c was unexpected, but it was registered twice in that week-once on the 10th day and again on the 13th-while on the 11th a feed, nearly as large, of 110 c. c. (4 oz.) was taken. Similarly, in the 3rd week a feed of 125 c. c. was taken on the 18th day, and one of 110 c. c. on the 20th. These figures are suggestive when contrasted with the reputed capacity of an infant's stomach; thus it is commonly held that the size of a bottle-feed in the second week should not exceed 50 c. c. (34 oz.), and in the 3rd week 55 c. c. (2 oz.). And yet, in the case under observation, 29 of the 66 second-week feeds were 2 ozs. and over (12 of them being 3 oz. and over), and 19 of the 72 third-week foods were 21⁄2 ozs. and over (7 being 31⁄2 ozs. and over).

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, 1913

, Vol. VIII

Series

[graphic]

Chart showing consumption of milk and rise in body weight.

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