DISCUSSION
Dr. Jacob Hvoslof: I would like to ask about the value of lime-water added to the milk. I recently had an experience where I mixed an ounce of lime-water to a pint of milk, as I thought that would improve it. but for some reason or other the baby would not digest his milk. After a while I left the lime-water out, and everything went well. Whether this is a “post” or “propter” I should like to find out.
Dr. O. R. Bryant: In case of an exudative diathesis, where you probably will start solids early, you will also be able to use meat earlier. An infant that does well on solids at six months can probably have meat once a day at fifteen months and show a normal stool.
Dr. S. R. Maxeiner: I would like to ask Dr. Huenekens where he classes eggs and egg albumin.
Dr. C. G. Weston: I have been very much interested in Dr. Hueneken’s paper. I care only for the babies during the three or four weeks after birth; and of late years many of them have passed from me directly into the hands of the pediatrists. I formerly had the babies nursed every three hours, but finding that the baby specialist immediately, on assuming charge, put them on the four-hour schedule, I changed, about a year and a half ago, to that interval; and I thought my troubles would cease, but such has not been the case, and it has been my impression, as well as that of the nurses who have had the care of the infants, that it has made very little difference.
The four-hour schedule is not a new thing in Minneapolis. Many of the older members of this Society may remember that twenty years ago Dr. R. O. Beard always fed his babies in this way.
It seems to me that we should make no hard and fast rules for the feeding of babies, except the one that mother’s milk should be used whenever possible. We should individualize with the babies. If they do well on the four-hour schedule, follow it, as it makes the care of the child easier for the mother; if, however, the child does not get sufficient milk on this interval to properly nourish it, diminish the latter to three hours.
The only way to accurately determine how much milk the nursing infant is getting, is to weigh the baby before and after nursing. One is often surprised at the varying amounts obtained by the same baby at different nursings with no obvious difference in the condition of the breasts. We have had a baby obtain as much as three ounces in the first five minutes of nursing, and at the next feeding take only one or one and a half ounces in twenty minutes.
The green and frequent stools, with evidences of colic, etc., are often found to be due to too much milk, or taking it too rapidly; and the weighing method is the only way to determine this.
I most heartily endorse what Dr. Huenekens said with reference to the importance of encouraging in every way maternal nursing. Many a mother gives up the attempt to nurse her baby on account of some soreness of the nipples or because she has thought she had too little milk to be of any use. Most of these cases may become, by the means recommended by the reader, good milkers, and many a baby’s life may thus be saved.
Dr. E. K. Green: I would like to ask a question in regard to putting babies on cow’s milk. I have adhered very closely to the principle that modified cow’s milk is absolutely the best food for infants, if it is impossible to get mother’s milk, but many times when I have had the opportunity to follow these cases carefully I have had all sorts of stomach and bowel disturbances on cow’s milk until someone would suggest some other food, such as malted milk, or Mellin’s Food, or even condensed milk, which seems to be the farthest from the natural food, and then the babies would get along fairly well. Is this a common experience, or is there something wrong with my method? We have in our own home two children brought up on the bottle, one with malted milk and the other with Mellin’s Food. In both these cases I tried, not only once, but several times to use the modified cow’s milk, but failed absolutely. I would like to know if you consider the fault usually with the modified milk, or does the individual have considerable to do with the case?
Dr. A. S. Fleming: I would like to ask if in the case of the healthy infant the mother’s diet would modify the constituents of the milk otherwise than in the facts stated. For instance, will it modify the character of or the percentage of the sugar, or will any of the aromatic constituents disturb the infant’s digestion?
Dr. M. J. Jensen: Dr. Huenekens dealt with the feeding of the healthy infant only. I would like to ask if it is not true that nearly all infants born alive, are born as healthy and sound as any infant ever is, so far as the functions of its organs and tissues are concerned? Nature frequently decides on producing premature births and “still”-births, rather than running the risk of producing a sick or sickly infant. In young infants it is very often difficult to determine when to classify them as healthy or unhealthy, realizing the conditions of their environment and usual care that is given in the homes.
In regard to the sterilization or boiling of cow’s milk: I do not think that children fed on pasteurized or boiled milk develop as well as those who are fed upon raw milk as it comes from the cow. Dr. Palmer, of Chicago, fed seven hundred children on raw milk during the midsummer months and only lost three of the number. The miserable, atrophied children began to live the moment treatment with raw milk was begun. If the process of milking was carried out in a sanitary manner, or by means of a suction apparatus, then cooled, and placed in sterilized bottles, I believe we would prohibit the development of bacteria, and save the food which exerts so marked a protective influence upon the infant’s organs.
When raw milk free of all objections cannot be obtained, it is sometimes advisable to use another milk product namely, buttermilk.
Dr. S. Marx White: There is just one point I have been thinking about in the discussion on the question of infant-feeding, and that is whether Dr. Huenekens really means us to believe that in practically all cases the mother can furnish sufficient milk for the child. He passed that over in saying that in nine out of ten cases the mother gave as a reason for discontinuing the milk that the milk gave out. Is it not true that in a good many instances the mother needs treatment quite as much as the infant? I do not mean medical treatment, but management. Is it not true that an overworked, tired, nervous, worrying mother is unable to supply sufficient milk for the child? It has been my impression from a very limited experience in this field, that the mental and nervous and physical state of the mother is a very large factor in the production of the milk. When upset and under deleterious influences she is really not a proper producer for the child; and the management of the mother is often quite as important a factor as any other.
Dr. W. H. Aurand: In such cases as Dr. White just mentioned, what are we going to do to increase the supply of milk? Also, I would like to ask Dr. Huenekens if he means to feed to the new-born baby 200 c.c. at a feeding?
Dr. Huenekens (closing): As regards lime-water: I cannot recommend its use. Wherever there is a specific demand for calcium, as in premature infants or spasmophilic cases; or where it may help to produce a firm stool; or, as in diarrheal disturbances, it may be of great value, but in the normal healthy infant it is of no benefit whatever.
Dr. Bryant mentioned the giving of meat in exudative diathesis: His statement that such infants can probably have meat once a day at fifteen months, and show normal stools, is beside the question. A normal macroscopic stool does not necessarily mean that the meat has been digested. However, I am now working on this problem, that is, to determine whether an early solid diet produces an earlier digestion of meat.
I would classify eggs and egg albumin as proteins, and therefore not digestible until the beginning of the third year: but, over and above this, there is danger of anaphylaxis from the absorption of the unchanged egg albumin into the blood-stream.
What Dr. Weston says of the feeding intervals is very interesting. I do not want to be considered an enemy of the four-hour feeding, for I use it wherever possible, and I think it the best interval; but when the infant cannot get enough in that period, we have to choose between two evils. I think the lesser evil is to give the child more milk at shorter intervals, and take the risk of a slightly poorer digestion. We should, also, wherever possible, control the amount of breast-milk by weighing the child before and after nursing. It is highly important to determine whether the baby is getting too much or too little.
As to Dr. Green’s statement, “Modified milk” is a very general term. What is usually meant is milk with a high percentage of fat and a low percentage of sugar, while malted and condensed milk have a high percentage of carbohydrate. In my opinion, if he had used cow’s milk without the addition of cream and with large amounts of cane sugar, he would not have had this trouble. But a large number of children will not do well on this diet. We have special rules for abnormal children with exudative and nervous diathesis.
In reply to Dr. Fleming’s question regarding the mother’s diet and its effect on her milk: What the mother eats has absolutely no effect on the composition of the milk in any way whatever, except perhaps in the percentage of fat. Now-a-days we do not advise any particular foods for the mother’s diet,—anything she likes, and can digest, plus large quantities of fluid;—otherwise there is no single food we advocate—none that will make the milk richer or better, or increase the quantity.
I cannot agree with Dr. Jensen that raw milk is so far superior to boiled milk. Of course, wherever it is possible, we should use certified milk, which does not require boiling; but, if we have inferior cow’s milk contaminated with bacteria, we can boil the milk with very little harm. It is just as well digested, and the food value just as great. There is of course slight danger of scurvy; but that is very easily diagnosed, and very easily cured by a little fresh milk or small doses of orange juice. Where we have inferior milk, it should be boiled in every case.
Dr. White brought up a very interesting point in regard to nervous mothers. Their milk supply is subject to wide fluctuations; but, if the breasts are well emptied at each nursing, they will secrete sufficient milk. I will admit that these cases are difficult to handle, for the infants usually have nervous diathesis, and do not respond well to ordinary food. The one important point is to completely empty the breasts; and that is the only measure we can take to increase the supply of milk.
In reply to Dr. Aurand: I would feed a new-born infant 200 c.c. at a feeding if the milk is sufficiently diluted. The liquid part of the food passes very quickly into the duodenum, so that, before the infant has finished feeding, a part of this quantity has already left the stomach.
In conclusion: We have an opportunity in our infant-feeding to practice the really scientific prophylactic medicine of the future. We can do more in preventing infant-mortality by proper feeding than by any other single measure; and we should encourage mothers to bring their new-born infants to the physician for advice on feeding, and to continue to consult him at longer or shorter intervals during the whole of the first year of life.
THE INEBRIATE [2]
By George H. Freeman, M. D.
Superintendent of the Minnesota State Hospital for Inebriates
WILLMAR, MINNESOTA
[2] Read at the 46th annual meeting of the Minnesota State Medical Association, St. Paul, October 1 and 2, 1914.
The Minnesota Legislature of 1907 passed a bill establishing the Hospital Farm for Inebriates, placing its management under the State Board of Control, and providing for its maintenance by setting aside 2 per cent of the saloon-license money for that purpose. Later, a law was enacted providing for the issuance of certificates of indebtedness; and active construction work soon commenced. The Hospital was opened on Dec. 26, 1912, with Dr. Tomlinson, formerly Superintendent of the St. Peter State Hospital, at its head. Through his untimely death, five months later, Minnesota lost one of her most faithful officials. The principles underlying the work at Willmar, are, with but slight change, those that he so earnestly advocated.
This paper is based upon the study of the patients admitted from the opening of the Hospital until the close of the biennial period, on July 31, 1914,—approximately eighteen months.
Patients are admitted to the Hospital following an examination in a probate court. In such cases there is no expense to the patient’s relatives, except that they are expected to furnish clothing, and a little money for the purchase of tobacco and small luxuries. Voluntary patients are also received following their own application in a probate court. They pay at the rate of $1.00 a day, each month in advance. No distinction is made in the treatment of the two classes of patients, except that a voluntary patient cannot be detained if he wishes to leave. Any resident of Minnesota who is habitually addicted to the use of alcohol, morphine, cocaine, or other narcotics, may be admitted to the institution, provided the history of the patient, as furnished by a probate court, indicates that the man can be benefited by treatment. It is presumed that anyone can be benefited who wants to be, unless afflicted with irremediable chronic disease.
The requirement that the history be furnished, and the ability to refuse admission, have kept out of the Hospital many undesirable individuals who could be cared for only under the discipline of a well-regulated reformatory. However, some, no matter how carefully the history is taken, slip by. The majority of those discharged as not proper subjects, come from that class. As there are no accommodations for individuals suffering with tuberculosis, no one known to be suffering with that disease is admitted. Once in a while a tuberculosis individual gains admittance, but, if not too ill to be released, he is discharged.
During the eighteen-month period, 209 men and 32 women were regularly committed; and 18 men and 3 women were received as voluntary patients. In addition to those classified as voluntary patients, a considerable number have, of their own volition, applied for treatment, and, being unable to pay, have submitted to commitment, in order to obtain treatment for their habit.
There has been a fairly uniform increase in the number of patients received each month, which is gratifying, as showing the need of such an institution and also as an appreciation of the benefit that may be expected. During the last month of the period, twenty-five patients were admitted.
While the causes of inebriety are diverse, it is a significant fact that 182 patients, out of 262, assign associates as their reason for drinking; and observation of their history clearly shows that they have drifted along, drinking now and then and more and more each year. A few assign illness, domestic trouble, or financial worry as a cause for drinking. In only 6 instances was heredity noted. In 132 cases the parents were abstainers.
We have found it impossible to formulate any system of classification of the unfortunates under our care. In order that some idea may be obtained as to the number using alcohol and the various drugs, we have constructed the following table: