The negative results of the microscopic and chemical examinations of milk in certain cases preclude our finding the cause of the disturb ances in the child, and only show, as Epstein pointedly remarks, that our present methods are not sufficient for a certain diagnosis of the abnormalities present. We must therefore with Epstein, Heubner, and others, assume an idiosyncrasy of the infant toward this milk, or perhaps, as I have repeatedly seen, it may be an idiosyncrasy of the mother. Such an assumption can be prove(' with logical certainty, because a change of nurse, all other conditions remaining entirely unchanged, rapidly banishes the disturbances of digestion.
Nordheim discovered that Storch's reaetion was absent in a case of this kind; its significance was rightly disputed by Thiemich. Beside these observations, which are always of enigmatical significance, there are cases in which the mieroseopic and chemical examination of the milk gives positive information. Thus, the presence of numerous so-called fine-granular milk globules is evidence of the bad quality of the food. The condition which is relatively most frequent is the find ing of an abnormally large percentage of fat in the milk, which sur passes all normal fluctuations, and causes a corresponding increase in the movements of the amount of fat which can be recognized macro scopically. Thus, Budin and Michel found 50-115 grams of fat to the litre instead of 35, and the fat content of the stools was 35-65 per cent. instead of 20 per cent. Jemma found 65 grams to the litre. Quintrie and Guiraud have collected nine similar observations. De Rothschild describes several cases of this kind and cites a child observed by Variot and Mery, who showed such severe gastric symptoms that the writers thought of congenital pyloric stcnosis, until a simple change of wet-nurse almost instantaneously stopped the vomiting. The other constituents of milk appear to play a less important part ill this connec— tion, although such cases have been reportecbMarfan, Leviseur and others).
The diagnosis of this condition is always difficult, and is based upon the exclusion of injuries to nutrition in the method of nursing, the absence of an infectious factor, and the possible positive results of the examination of the milk. As a proecdure for the rapid diagnosis of a case of this kind, Marian recommends that the child be taken from the breast for 24 hours and nourished with sterilized cow's milk. II21 provement or cessation of the symptoms during this period points to the breast-milk as the cause. This procedure does not always necessarily attain its end, because many infants, especially young babies, react severely to cow's milk. C'onsequently I would rather recommend the use of the breast of another woman if it can be done.
When the examination shows no qualitative changes in the milk, and when the symptoms do not improve after prolonged observation, a wet-nurse or change of wet-nurse is indicated in the early months of life, and gradual weaning in the later months of life, the latter all the more as the interpolating of cow's milk feedings often has a favorable influence upon the condition.
When an abnornial richness in fat is believed to be the probable cause of the unsuitability of the milk, one can try putting the child to both breasts each time and not allowing it to empty them, in order thus to shut out the last part of the inilk, which is richest in fat. Or, feedings of whey can be interpolated between the breast-feedings, or, in accordance with the proposal of Quintrie-Guiraud, cow's milk can be given alternately with the breast, diluted one half with lime water, and with milk-sugar added in the amount of 35 grams (one ounce) to a litre (pint) mixture.
The other abnormalities, such as increased percentage of casein or of salts, are so infrequent that no general principles of treatment have been established. In individual cases a choice niust be 'mule between change of nurse, weaning, or mixed feeding.
D. From Insufficiency of the Digestive Organs (may result from premature birth, hereditary taint, intra-uterine infection, malfor mations of the digestive apparatus, mechanical obstacles to sucking).
This is not the place to give a complete description of premature infants, consequently I shall limit myself to discussing those factors which constitute the cause of the abnormal course of their digestion, and the occurrences of diseases of nutrition. There can be no serious doubt, even if the evidence is only of an anatomic character, that chil dren who come into the world months before the normal termination of pregnancy, present actual insufficiency in regard to the absorptive and assimilative power of their digestive organs. The defective differentia tion of the secretory elements of the gastric glands, the shortness and width of the intestinal crypts, the embryonic character of the liver structure, the small size of the salivary glands, and so forth, point with certainty to this conclusion. To preserve such infants requires proportionally- more abundant nourishment, as does also their protec tion against loss of heat by radiation, which is especially active on account of the relatively large area of their skin surface, and in conse quence of which more food is required to furnish inereased activity in the functioning of the underlying chemical sources of heat. The fact that the active taking of food by sucking is often impossible, so that feeding by means of milk squirted directly into the mouth or poured in with a spoon, vessel or tube, or even perhaps through the nose, must be resorted to, is a further reason for digestive disturbance, in the form of a reaction on the part of the extremely sensitive orga»isin. Finally, the small capacity of the stomach necessitates an increase in the number of feedings and a corresponding shortening of the intervals in order to give sufficient food. This constitutes a faetor which easily leads to overfeeding, the results of which are more easily brought about, and are much more noticeable in their intensity, in premature infants than in the fully developed. There is a general agreement as to the necessity of supplying an increased number of calories. Thus Budiu states that premature infants must take up to one fourth of their body weight of mother's milk a day in the first ten (lays, and after that require about 20 per cent. of the body weight. Even such strict observers of dietetic principles as Czerny and Keller recommend 110-120 calories per kilo, while Finkelstein recommends 140, and they all with one accord point out the danger of an insufficient amount of food. Czerny and Keller seek to avoid overfeeding by prolonging the intervals and when the amount of milk taken by the child of its own accord is insufficient, they instill the rest artificially, while Budin, Marfan, Finkelstein and others designate 9-12 or even 24 feedings as necessary.