Perhaps the question may arise of the propriety of placing under the heading of diseases of nutrition, a condition of the child which is simply that of hunger. For my part I believe that to do so-is thor oughly justified, because in the first place the disturbances arising as a result of insufficient feeding, if they persist over a certain time, can lead to severe changes in the body, and can make it susceptible TO secondary infection of various kinds. And in the second place symp toms appear as a direct consequence of insufficient, food which cause relief by making the taking of food difficult or impossible.
A pardonable digression may here be made to the subject of the physiology of nutrition. The newborn infant usually takes on the first day of its life either no food, or very little, and also the amount of colostrum taken before the appearance of regular lactation is very little, so that we reckon regular nutrition as beginning on about the fifth day. This of course holds good only for infants nursed at the mother's breast. .Marfan gives a table, showing the average amount of food taken in 24 hours and the quantity at each feeding, which is taken from the observation of healthy and thriving infants. The figures are perhaps somewhat high, and the intervals rather short, but neverthe less they serve as an approximate standard, especially if the intervals are reduced to the three hours customary with us.
According to Czerny-Keller the 24 hour amount of food taken by the healthy breast-fed infant in the early weeks is about one-fifth of the body weight. Front the middle of the first three months to the middle of the second three months it falls to one-sixth and one-seventh of the body weight. From six months on it remains at one-eighth of the body weight.
In children with healthy digestion nursed by a healthy mother there occurs a constant 9Cl?.11 'in the body weight averaging 25-30 grams a day. tinder such conditions, the duration of nursing is from ten to at most twenty minutes. In the early months the child when satisfied falls asleep at the breast, to wake up only for its next feeding, while older children if they do not fall asleep, let go of the nipple with a marked expression of satisfaction, and pass the time till the next feeding in quiet content and serene humor. The movements normally formed and golden yellow occur two to four times a day; the abundant .secre tion of urine, the rosy tint of the skin, the firmness of the flesh, the abundant subcutaneous fat, and the formation of the typical fatty folds in certain parts of the body, are further signs of thorough nutri tion and normal development.
In the insufficiently nourished breast-fed infant, such as drinks enough milk to build up its body substance to some extent, but in which, for instance, the claily gain in weight is only 10-15 grams instead of the average, there is less development of the subcutaneous fat, so that such infants appear thin and lack the plump outlines of the young baby. The abdomen, which under normal conditions shows a rounded outline, is flat, often actually somewhat indrawn, the move ments occur at most twice a day, their amount is relatively small, their consistency somewhat harder, their color rattier approaches a dark yellow ochre than the golden yellow of the normal milk stool. The passage of urine, which in thoroughly nourished infants occurs 10 to 15 times in 24 hours and which always makes a widespread spot on the napkin, is much restricted in frequency and amount, and the duration of nursing appears prolonged over the normal.
From these cases near the border line, various transitions lead to the more or less complete condition of inuaition. This is charac terized by the fact that the child, after the physiologic loss of the first few days, instead of showing a constant and lasting gain in weight from the end of the first week on, remains at first stationary in weight, or shows up and down oscillations, till finally a slight but constant loss becomes established. He then appears thin, the abdominal wall is notably indrawn (Czerny-Keller), and the fontanelle is slightly de pressed. The movements are notably constipated, often only two or three a day, at times occurring only by means of artificial aids, and are dark brown or greenish black in appearance, their sticky consist ency reminding one of meconium. The amount of urine is reduced to a minimum so that the child when undressed is almost always found dry. Weighing shows us that the amount taken at a feeding is of small value, and that the total amount of milk taken in 24 hours is far behind the normal figures mentioned above. Also the drinking of such chil dren is very characteristic, although we must convince ourselves that it is not due to some malformation in the buccal or nasal cavities hin dering sucking. They lie for a long time at the breast, and make periodi cal sucking movements, but one can not hear the sound of swallowing which in normal infants occurs after every few sucks and is evidence of the passage into the stomach of the milk collected in the mouth (Tarnier and Chantreuil, cited by Bidoult). Moreover, no drops trickle down from the corners of the mouth, and the expression of the face does not show satisfaction.