DISTURBANCES OF NUTRITION IN INFANTS A. From form represents the commonest type in exclusive breast-feeding. As may easily be understood, it is met with more frequently, and in a more obstinate form, i» infants nursed by a wet-nurse, than in those nursed by their own mother. It is more often present in the first months of life than in older infants on account of the slight development of the function of the digestive organs in the former, and because in many cases a. reciprocal adjustment occurs which leads to spontaneous cure.
The normal course of gastric and intestinal digestion requires that the time necessary for the emptying of the stomach be maintained. This time is necessary for the production of free hydrochloric acid by the gastric glands, which product on the one hand sets a definite limit to the growth of bacteria in this food reservoir, and on the other hand, as we know from the researches of Pawlow and his pupils, acts as a stimulant to the secretion of bile ancl the pancreatic juice. Too fre quent feeding at the breast causes injury, because the stomach, not yet fully evacuated, is filled with a. fresh supply of food, which seizes 'upon the quantity of free hydrochloric acid already prepared, com bines with it, and thus prevents its stimulant action on intestinal diges tion. Thus a vicious circle is produced, because through the intimate physiologic connection between gastric and intestinal digestion every injury affecting the one soon manifests its effects upon the other. Even when the intervals are chosen with proper reg,ard to the time neceasary for gastric digestion, the same results may be eaused by offering too great quantities of breast-milk. In this case, in addition to the taking up of the free hydrochloric acid, a further factor appears in the overdistention of the stomach. This leads to injury to the motility of the stomach, which in turn reacts upon the secretion of the gastric glands, for in this little chemical household all the factors are linked with one another. When both of these evil eonditions are combined, too frequent feeding, and too much at one time, it is very evident that the disturbances will be all the more easily- produced, and will run a severer course.
There are a number of physiologic aids, by means of which the infant tries to ward off these injuries, and which appear as the first symptoms of overfeeding to be perceived clinically. First to be men tioned is the regurgitation of the food. The stomach, overburdened by too abundant or too frequent meals, gives back a part of the food im mediately after taking it, and the milk, unchanged in character, pours out of the mouth immediately after or during nursing, without any visible straining or previous diseomfort. This symptom is met with in ehildren whose appearance and increase in body Nveight are entirely favorable, which must be the origin of the old saying,—"spitting chi/d— thriving child." If no attention is paid to this symptom, as is usually the case on account of the environment of the infant, then diarrhcea appears as a further symptom of defenee. Instead of thc normal two to three movements, there are four to five in twenty-four hours, and their nature points on the one hand to overloading of the bowel, and on the other hand to insufficient utilization of the food resulting from its accelerated passage through the intestine. Finally a lessened oppe lite is associated as a third attempt at natural protection. The child constantly applied to the breast always seizes the nipple well, but lets it go again after a few short sucks, or, if the feeding intervals are regular, it takes less food each tline.
Unfortunately these measures of protection are deceptive in char acter, and their significance is usually misunderstood, because their progress is always apparently favorable, even if not uniform but rather by fits and starts, and ROOD oversteps normal limits. Consequently
they arc insufficient to enforce upon those caring for the ehild a proper understanding of their significance, and thus the evil goes uneeasingly forward, and soon the boundary line of the pathologic is passed over. When this occurs the various symptoms become more marked and more constant. Whereas at first the regurgitation of the gastric con tents only occurred occasionally, and always eonsisted of unaltered milk, it now follows every feeding, and there soon occurs a posipone ment of its time of oceurrence, so that the giving back of the food no longer follows immediately upon its taking, but occurs after a longer interval, froin sorne minutes to half an hour. Moreover the regurgi. tation is accompanied by visible discomfort, and produces an altered milk, which contains larger or smaller ClIrd8, as well as lumps of mucus, floating in a grayish white serum, and is sometimes colored yellow front admixture of bile which has gained access to the stomach. The vomitus bas a strongly sour, and sometimes pungent odor. An equally sour belching frequently occurs in the intervals between the vomiting and causes the infant pain, which manifests itself in discomfort as betrayed by the features, so that instead of the lack of expression of the first weeks of life, its appearance assumes the more or less clear characteristics of suffering. The examination of the gastric contents in this stage shows in the first place a notable slowing of the gastric motility, as, instead of the normal empty conclition after two hours, considerable altered contents are found in the third or fourth hour. The free hydrochloric acid is mainly or wholly lacking, while on the other hand the acids of fermentation, lactic, butyric, and acetic, are found present. The number of microorganisms has become greater, and their varieties more numerous.
The intestine reacts to the lessened stimulus from a smaller or absent hydrochloric acid production, at first mainly by a diminution of its activity, and constipation. Later the pathologically altered gastric contents enter into the intestinal canal, together with the ab normal products of acid fermentation which also alter the conctitions of growth of the intestinal flora. All this causes increased gas production and increased peristalsis. Instead of the normal movement, that golden-yellow, glistening, homogeneous, mushy product with its agree ably sour odor, which two or three times a clay pours out of the anus like syrup out of a bottle and is first discovered on undressing the child, the process of defecation now assumes a much more dramatic charac ter. It is ushered in by restlessness, the entire body starts into ac tivity, growlings and gurglings are heard, and finally, with a loud passage of gas and a vigorous cry, a fluid mass comes out of the rectum as if squirted out of a syringe. This mass on inspection of the napkin appears to be surrounded by a fairly wide watery border, ancl shows larger and smaller white fragments, which here and there are light or dark green, and from it there rises a disagreeable, sour, pungent odor. The test of the reaction gives a higher degree of acidity than is found in the normal movement, Gmelin's test shows abundant bile-pigments, the microscopic examination shows rare fat drops and numerous fat needles and fat clusters (crystallized fatty acids), and the bacteriologic picture shows little deviation from the. normal, and a preponderance of thin Gram-staining rods. Also, green stools may be produced from the very beginning, alternating with the curdy form, or else on standing a greenish coloring of the movement beginning at its outer border may