Therapeutics of infancy and childhood

Front matter

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Chap,..'.... Copyright No.

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Preface

Much of what is contained in this work may be claimed as common property. Much of it I have taught before. Indeed, very few books can ever be written that will be entirely new. Pediatrics is not new to-day ; nor was it so when, in 1860, I established the first systematic course, in our country, of clinical instruction in the diseases of children. Having since that time appeared before the medical public with essays and monographs only, I was repeatedly reminded by friends of my obligation to submit to the profession which has afforded me so many facilities and advantages a compact picture of the therapeutics of infancy and childhood as I have it in my mind.

A large part of this work is devoted to diet and hygiene, a good deal also to the consideration of the action of medicines. For, indeed, I believe in medicines. Advancing years and experience during a period of increasing exactness in medical methods have rather strengthened my belief than otherwise. What the knife is to the surgeon, drugs are to the physician. The knife does not make the surgeon, nor do medicines make the physician ; both, however, are indispensable. To employ them with benefit takes skill and experience, both individual and collective, as also judgment and honesty.

Indications for the administration of medicines are furnished by etiology and symptomatology. Both of these occupy a prominent place in this book. Without a diagnosis of the morbid process and of its evolution, and without the appreciation of its influence on the patient, no rational therapy

6 PREFACE.

can be thought of. Consequently I have taken particular pains to offer clear, though brief, statements of differential diagnoses.

I have tried to write a book for those who are sufficiently prepared by previous studies to build their therapeutical measures on the foundation of an exact recognition of the conditions they have to deal with. It is intended for those to whom neither the principles of diagnosis nor the facts of materia medica are mysteries. Therefore I have abstained from ornamenting my pages with numerous recipes. While aiming at accuracy in dosing, I have trusted, as regards the actual writing of prescriptions, to the knowledge and intelligence of the reader. On account of our present period of transition to the metric system, I beg to be pardoned for alternating the old methods with the new.

In view of what I have included within the frame of this volume, it might almost claim the name of text-book. I prefer, however, to call it therapeutics only, intending to emphasize the fundamental truth that everything in medical science, in order to be both scientific and humanitarian, should be conducive to the prevention or to the cure of disease.

The preparation of this book has extended over a long period. The first essays embodied in it were published in the Archives of Pediatries of 1888. As a consequence the reader may discover occasional incongruities, which, however, he will find to be more those of style than of matter.

A. Jacobi.

110 West Thirty-Fourth Street, New York, October, 1895.

Contents

PAGE

I. — Feeding of Sick Children 9

II. — Treatment of the Newly-Born 38

I. Feeding Of Sick Children

Dietetics must be considered a part of therapeutics. The two must always go hand in hand. Sydenham knew the fact that many diseases are removed by a correct mode of living, and nutrition ; and the men who established therapeutical schools on certain positive principles or preconceived ideas, arranged their dietetical and their medicinal and surgical rules on the same basis. Thus, Broussais, among others, while he purged and bled, crowned his work with starvation to such an extent that Graves, in 1843, had to come forward with the declaration that the systematic starvation of the disease ended in the destruction of the patient. It was Chossat, finally, who proved that inanition had many of the symptoms of fever, and that a starvation diet was liable to increase its dangers.

Still, there are no universal rules for feeding, as there are none for medication. There are, however, certain indications which can always be fulfilled in the treatment of individual cases. As intellect and knowledge are required for finding those indications, so there is need of tact and experience to apply and fulfil them. Some of them are plain enough. It is clear that in conditions of great debility there must be no farther reduction of strength ; an irritated cerebrum must not be excited ; hemorrhages, peritonitis, dysentery, perityphlitis require absolute rest; a hyperaesthetic stomach must not be overfed ; a gastro-enteritis resulting from the presence of ferments must do without milk ; convalescence and acute inflammatory fevers must be protected. Still, there are chronic fevers with fair digestion, which permit of generous feeding. All these indications and rules are equally valid for both the adult and the young. Still, the latter have some peculiarities which alter the application of general rules to a considerable extent, for several reasons. Of these I shall mention but a few in this connection. Habits, which play an all-important part in the nosology of adults, such as alcohol, narcotics, sexual abuses, are not observed — unless very exceptionally — in the child. Cardiac debility, which is the constant danger of the senile period, and a frequent one in the adult, is not so frequent in the very young, partly because the heart is larger and more powerful, compared with the rest of the body, and partly because it has not had so much time and opportunity to become diseased. On the other hand, general metamorphosis is very rapid in the young, because of both the rapidity of the vital processes, and the constant necessity of adding to the tissue of the body, besides keeping up the equilibrium. Therefore inanition is not tolerated for a long time. Thus the child cannot long remain without being fed, and, therefore, its digestive organs require permanent attention. Their physiology must be carefully studied in both the healthy and morbid conditions. What the child eats is of but little consequence compared with what it digests. Nor are its subjective sensations the proper guides for the selection of foods or the times of feeding. It is not always true that where there is no appetite there is no digestion. Nor are the pangs of hunger or the temptations of cravings safe counsellors. Nor does the condition of the tongue, to which we are apt to turn as one of our advisers in many of the ailments of the adult, deserve of the same confidence in the young, for the frequent local processes inside the oral cavity are very apt to mislead us.

From the very first month of life a distinct diastatic effect is produced by the oral secretion ; it increases with every month. Even infusions of the parotids, prepared at different times after death, produce the same effect. Infusions, however, of the pancreas taken from the bodies of infants who have lived three weeks, produce no such changes. The diastatic power of the pancreas begins with the fourth week only, and remains feeble up to the end of the first year.

Zweifel experimented with infusions of different glands. That of the submaxillary glands of an infant did not transform starch into sugar, even after the lapse of a whole hour. The effect of an infusion of the parotid of a baby seven days old was distinct after four minutes; however, that of the parotid of a baby which had died at the age of eighteen days, of gastro- enteritis, did not show itself until the lapse of three-quarters of an hour. Nor was a diastatic result obtained by a similar infusion made of the parotids of a baby prematurely born, and one who died of diarrhoea and debility.

It is a remarkable fact that different varieties of starch are not changed by saliva into grape-sugar in the same length of time. In reference to the time required, however, there is no uniformity of opinion. Solera found that the transformation of the starch of the potato was the most rapid. Next came that of Indian corn, next wheat, and the transformation of the starch of rice was the slowest. According to Malay, raw starch changes slowly, boiled starch quickly. According to him, that of the potato required from two to four hours; that of wheat from one-half to one hour; of barley from ten to fifteen minutes; of oats from five to seven minutes; of rye from three to six minutes ; of potato paste five minutes.

It is important to know that the effect produced by saliva persists in the stomach for a period of from one-half to two hours. But it ceases altogether, and starch will no longer be changed into grape-sugar, inside the stomach as soon as the secretion of hydrochloric acid has begun in the digestive process. This is a very important fact, because it shows that the farinaceous food of the infant or child, though it be not masticated, and pass the mouth very rapidly, is still under the influence of the saliva in the stomach, for some time.

Hydrochloric acid is not secreted at once. The first acids in the stomach while digestion is going on are organic, mostly lactic. This is found to be contained in that organ when gastric juice is removed from it in the first period of digestion. Thus in a gastrostomized boy UfFelmann found under normal circumstances, and in the absence of fever, during the first half-hour, lactic acid only ; afterwards hydrochloric acid.* The latter is not met with during fever and a considerable degree of gastric catarrh (and also in dilatation of the stomach

* This agrees with what Ewald and Boas published lately as the result of their experiments also. But they claim to have found hydrochloric acid only, when a decoction of starch alone was introduced into the stomach. Still later Th. ^Rosenheim (Centralbl. f. d. Med. Wiss., November 12, 1887) reports as follows, after the ingestion of fifty grammes of bunn and one hundred and fifty of water : Free hydrochloric acid makes its appearance in the healthy stomach very early, 0.3 p. m. after fifteen minutes, 1.0 p. m. after thirty minutes. This quantity or more is found until the elimination of chyme has been completed. From beginning to end there is lactic acid to a uniform amount, viz., 0.3 p. m. In carcinoma there was but 0.1 p. m. of hydrochloric acid, in hyperacidity 1.0 p. m. In every case and in every period of digestion there was lactic acid. There was less hydrochloric acid (but 0.2 p. m. after an hour) and a fair amount of lactic acid when carbo-hydrates only were taken, no matter whether saliva was admitted to, or excluded from, the stomach.

These data are here added for the purpose of showing that the difficulties of arriving at absolute facts are exceedingly great. Still, the results of the three observers do not differ too much from the accepted doctrine.

resulting from constriction of the pylorus). In these conditions farinacea (amylacea) are taken to advantage, principally because the diastatic effect of saliva is not disturbed.

Some of the main points to be remembered from the foregoing are these :

There is diminution or absence of saliva from the parotid in the very young suffering from diarrhoea and debility. Thus the very young ought to have but little starchy food, or sometimes none at all in these conditions, particularly as the pancreas cannot be relied on for diastatic action in the first weeks.

Whatever saliva, however, has been secreted and is swallowed, continues its action in the stomach as long as there is no hydrochloric acid in it. This in the healthy is secreted only after half an hour or later. In the feverish and catarrhal stomach very much later or not at all. Thus what saliva is present, displays its diastatic action continually. Thus the food craved for and digested is farinaceous. Animal food which requires hydrochloric acid is not wanted, nor is it readily digested.

To discuss here all the functions of the stomach is not necessary. In anaemia, convalescence, particularly in fevers, they are impaired. Both pepsin and hydrochloric acid are wanting. To increase their secretion large quantities of water are required.

Infants' food ought to be mixed with large quantities of water, for reasons given on other occasions, under ordinary circumstances. In diseased conditions of the stomach the free dilution of children's nourishment with water is demanded upon the following additional facts. Only to a certain limit will pepsin be furnished for digestive purposes. Probably a portion of this is not entirely utilized, because a great quantity of water is necessary to assist in pepsin digestion. In artificial digestion albumin often remains unchanged until large quantities of acidulated water are supplied. Without doubt many disturbances of digestion are to be explained by a deficiency of water, certainly many more than are due to an excess of it, for the latter is speedily relieved by rapid absorption.

For the reasons given, I advocate under all conditions a plentiful addition of water to children's food. In this connection I would lay stress upon the fact that, as a rule, small children receive water only as they get it in their milk or milk food. Alike in summer and in winter, it is probable that the fact seldom occurs to a mother or nurse that a child may be thirsty without being hungry at the same time. Certainly many a discomfort and even sickness in a child is conditioned upon the fact that it has been compelled to eat in order to get its thirst satisfied, and often has to suffer thirst because the over-stimulated and injured stomach will take no more nourishment at irregular and too short intervals. There are even normal products of digestion capable of disturbances in the digestive process, chief among which is peptone itself, which is not absorbed unless it be greatly diluted. I have, therefore, considered it necessary in preparing the rules for the feeding of children, which the New York Health Department has annually published and distributed since 1872, to insist upon giving infants who cannot ask in so many words for it, an occasional drink of water, at least during the hot weather. When there is the least ground for the supposition that the drinking-water is contaminated with germs of disease, or where it is unusually hard, it should be boiled before its admixture with children's food, whether the diet be milk or a mixed one. In general it will give greater satisfaction to use the boiled water systematically, even though there be no apparent urgency for it in the cases of very young infants.

There are many other indications for the administration of water in the diseases of the young. In many morbid conditions it is wanting. Perspiration, diarrhoea, general inanition, feverish diseases, diminish its quantity in the tissues and blood-vessels. Thus an inspissation of the blood takes place, thromboses form in the small veins of distant parts or the viscera, in the brain they lead to convulsions and defective innervation (hydroencephaloid), in the limbs to oedema or gangrene. The remedy is water in sufficient quantities. Where the stomach rebels, the hungry lymph-ducts of the rectum will greedily absorb an ounce or much more, injected every hour or two. In many a case life is saved in this manner.

Where general metamorphosis is slow, water in abundance increases the elimination of urea and carbonic acid. Where the urine is scanty and of an undue specific gravity, water protects the kidneys from undue irritation. It acts on the mucous membranes as it does on the external integuments. In laryngitis and bronchitis it liquefies viscid expectoration, in many forms of constipation it acts beneficially by increasing the secretion of the muciparous glands of the intestines. Ice and ice-water, or iced carbonated water, in small quantities, but frequent doses, relieve hyperesthesia of the stomach and stop vomiting. Warm water acts as an emetic, hot water injected into the rectum combats collapse. In this very connection, however, I may allude to what good may be done by abstinence from water. In some forms of acute gastro-enteritis, where vomiting and diarrhoea are excessive, the only salvation is in total abstinence for from four to eight or ten hours. Not infrequently the turning-point in the course of the threatened danger dates from the commencement of what appears to be cruel starvation.

A regular addition to the milk food of infants' and children is that of sugar. Its percentage in the milk of the woman, ass, and mare is larger than that of the cow. Immediately after the milking of the cow the milk-sugar begins to be changed into lactic acid. This process, together with the gradual conversion of fat into acid, is the cause of curdling.

The large amount of sugar in woman's milk, together with its smaller percentage of casein and butter, gives it the peculiar bluish color and furnishes the colostrum, which contains plenty of salts besides, its tendency to loosen the bowels. This property becomes manifest, sometimes, under abnormal circumstances. Thus in the milk of anaemic women sugar is occasionally found to an unusual degree. In their cases the other solid matters may also be diminished, still, this is not uniformly so. The infants, however, suffer often from obstinate diarrhoea.

The conversion of milk-sugar into lactic acid takes place very rapidly. When it takes place in cow's milk this turns sour at once. Not infrequently is it sour from the first ; it has been found to be so in the udder ; in most cases it is " amphoteric," neutral. Thus the question arises what kind of sugar is to be used as the addition to the food of children both well and sick.

Cane-sugar is not so easily transformed. Indeed, it is utilized for the purpose of counteracting the rapid conversion of milk-sugar, and for the preservation of articles of food in general. Trade is not so slow in availing itself of the results of organic chemistry as the profession. Condensed milk remains intact a long time on account of the plentiful addition of cane-sugar, in spite of the original presence of milk-sugar in it. Therefore it is not at all an indifferent matter whether milk-sugar or cane-sugar be added to the food of infants and children. I have always insisted upon the selection of the latter for that purpose.

In the sick the absorption of sugar is slower than in the healthy. Besides, during most diseases, particularly those of the alimentary canal, there is more ferment in the mouth and stomach. Thus but little sugar ought to be given, and never in a concentrated form. Grape-sugar and dextrin are absorbed equally. Cane-sugar, according to Pavy, is partly inverted and partly absorbed. All appear to be changed, when given in moderate quantities, into carbonic acid and water, even during moderate fevers.

In that form of constipation of small infants which depends on a relative absence of sugar and superabundance of casein; in the breast-milk, the addition of sugar acts very favorably.. A piece of loaf-sugar (a teaspoonful or less) dissolved in tepid water (or oatmeal water) must be given before each nursing, and will often prove the only remedy required to regulate the bowels.

The physiological effect of chloride of sodium is very important, no matter whether it is directly introduced through the mother's milk, or added as a condiment to cow's milk, or vegetable diet. Both of the latter contain more potassium than sodium, and neither ought ever to be given, to the well or sick, without the addition of table-salt. A portion of that which is introduced may be absorbed in solution ; another part is, however, broken up into another sodium salt, and hydrochloric acid. Thus it serves directly as an excitant to the secretion of the glands, and facilitates digestion. Therefore during diseases in which the secretion of gastric juice is interfered with, or in the beginning of convalescence, when both the secreting faculties and the muscular power of the stomach are wanting, and the necessity of resorting to nitrogenous food is apparent, an ample supply of salt ought to be furnished. The excess of acid which may get into the intestinal canal unites with the sodium of the bile in the duodenum, and assists in producing a second combination of chloride of sodium, which again is dissolved in the intestines and absorbed. Its action in the circulation is well understood: it enhances the vital processes, mainly by accelerating tissue-changes through the elimination of more urea and carbonic acid.

A very important fact is also this: that the addition of chloride of sodium prevents the solid coagulation of milk by either rennet or gastric juice. Thus cow's milk ought never to be given without table-salt, and the latter ought to be added to woman's milk when it behaves like cow's milk in regard to solid curdling and consequent indigestibility.

Habitual constipation of children is also influenced beneficially, for two reasons : not only is the food made more digestible, but the secretions of the alimentary canal, both serous and glandular, are made more effective by its presence.

A certain amount of fat is digested even in fevers of moderate severity, thus also in typhoid fever. But it is a good rule to rather reduce its quantity, because when infants were fed on cow's milk during capillary bronchitis, the fat in the faeces amounted to forty per cent, of the solid constituents. A few additional remarks will render the subject clearer, and show that it is very easy to give too much fat.

There is a large amount of faeces, although the baby receives absolutely nothing but mother's milk. What has been called detritus in the fseces is not exclusively undigested casein, but principally fat and large masses of intestinal epithelium. This so-called detritus is not soluble in water, acids, or alkalies, but quite soluble in alcohol and ether.

Casein is present only when it has been taken in too large a quantity, or when there is too much free acid in the stomach. In those cases there are large quantities in the fseces.

An important practical application of this fact is the following : As it is true that fat is not completely absorbed, even under the most normal circumstances ; as free fat acids are so easily formed and accumulated; as they are found in moderate quantities, even in healthy babies ; as a surplus is very apt to derange digestion and assimilation, and to prevent the normal secretion of either of the digestive fluids ; as there is a superabundance of fat in the normal food of the nursling, the conclusion is justified that we should be very careful in preparing foods for the healthy or sick. It is very easy to give too much fat. It is hardly probable that there is too little.

Under the head of " Fat Diarrhoea" German journals and a few text-books speak of a diarrhoea, the chief characteristic of which is the presence of a large quantity of fat in the stools.

The normal faeces of the newly-born contain ten or twelve per cent., sometimes more, of fat. In abnormal cases, even when the food does not contain it, the faeces may contain from forty to seventy per cent, of fat.

The microscope reveals in serious cases fat, almost to the exclusion of everything else, sometimes pure, and other times in more or less regular needles. The anatomical condition in fat diarrhoea may vary, but in the majority of cases we have to deal with a simple catarrh of the intestinal tract. There are changes in, and exfoliation of, the epithelium of the small intestine, swelling of the mucous membrane of the duodenum, with obstruction to the flow of the secretions of both liver and pancreas, and such hyperplasia of the mesenteric lymph bodies as to impede the absorption and circulation of chyle. Finally, in a very few instances, anatomical changes were found in the pancreas resembling those which in the adult interfere with the emulsion of fat.

No improvement is possible unless the quantity of fat contained in the food be largely diminished. The administration of cream and the routine treatment with cod-liver oil are equally injurious in these cases.

In feeding the sick no new principles must be sought for. The sick child is still the child, and the physiological laws hold their own under changed circumstances. No new articles of food can be discovered or invented, only the preparation or mixture of those in ordinary use may change temporarily, or a restriction in their number or amount take place. Thus, I cannot undertake to give in full the methods of feeding infants and children. In several previous publications have I done so, and must refer to them. I will only repeat a few rules, leaving the reasons for them to the thoughtful ness or the recollection of the reader.

The principal substitutes for breast-milk are those of the cow and the goat. The mixed milk of a dairy is preferable to that of one cow. Cow's milk must be boiled before being used. Condensed milk is not a uniform article, and its use precarious for that and other reasons. Goat's milk contains too much casein and fat, besides being otherwise incongruous. Skimmed milk obtained in the usual way, by allowing the cream to rise in the course of time, is objectionable, because such milk is always acidulated. The caseins of cow's and woman's milk differ both chemically and physiologically. The former is less digestible. There ought to be no more than one per cent, of casein in every infant food. Dilution with water alone may appear to be harmless in many instances, for some children thrive on it. More, however, appear only to do so ; for increasing weight and obesity are not synonymous with health and strength. Abetter way to dilute cow's milk, and at the same time to render its casein less liable to coagulate in large lumps, is the addition of decoctions of cereals. It has been stated before, that a small amount of starch is digested at the very earliest age. But cereals containing a small percentage of it are to be preferred. Barley and oatmeal have an almost equal chemical composition ; but the latter has a greater tendency to loosen the bowels. Thus, where there is a tendency to diarrhoea, barley ought to be preferred ; in cases of constipation, oatmeal. The whole barleycorn, ground for the purpose, should be used for small children, because of the protein being mostly contained inside and near the very husk. The newly-born ought to have its boiled milk (sugared and salted) mixed with four or five times its quantity of barley-water, the baby of six months equal parts. Gum arabic and gelatin can also be utilized to advantage in a similar manner. They are not only diluents, but also nu-

FEEDING OF SICK CHILDEEN. 21

trients under the influence of hydrochloric acid. Thus in acute and debilitating diseases which furnish no, or little, hydrochloric aeid in the gastric secretion, a small quantity of the latter must be provided for.

Such practitioners and authors who convinced themselves of the ill success often attending the use of milk, or watered milk, commenced at an early period to mix it with MEAT-soups, meat-tea, or egg. Bretonneau reported, as early as 1818, that " tabes niesenterica" disappeared, in the hospital of Tours, from among the children fed on beef-soup and milk. This mixture Vauquelin declared to come nearest to mother's milk of all preparations. The administration of some beef-soup, well made, a cupful every day (mutton-broth when there is a tendency to diarrhoea), is advisable towards the end of the first year. Long before this period, indeed at any time during infancy, it is indicated in cases of early rhachitis, rhachitical constipation, undue adiposity, and retarded teething.

Beef- tea, well made, in a bottle swimming in the water-bath, is still believed by some to be the model food. That it is not so rich in soluble albuminoids as was believed, ought to be generally understood by this time. What, however, it does contain in large quantities, is salts. Thus it is a dangerous article in summer diarrhoea, and must never be administered by itself. When given at all, it ought to be in combination with farinacea, raw albumin (which in this mixture requires very little salt, if any).

Beef-broth is about as nutritious as whey, and no more. But on account of the extractive substances of beef, kreatin and kreatinin, it is more stimulating. The temperature of the body is not raised by it. In gastric irritation, gastritis, and acute dysentery it ought not to be given. Veal-broth is liable to increase diarrhoea, mutton-broth constipation, and is therefore preferable in cases of diarrhoea. A broth of beef, which contains from 1.5 to 2 per cent, of albumin, is made by mixing one part of beef and six of water with a little chloride of sodium and allowing it to stand from ten to twelve hours. Then it is slowly boiled and the whole mass pressed out. Still better is a modification of Liebig's beef-tea, which is obtained by adding one half-pint of water, with six or seven drops of dilute muriatic acid, to a quarter- or one-half of a pound of finely-cut lean beef, stirring it occasionally during two hours, and boiling a few minutes. Beef-juice obtained by pressing out beef after slightly broiling it, contains from six to seven per cent, of albumin. It is slightly acid, and spoils quickly.

The peptonized beef preparations are available both internally and for rectal alimentation. Of the good specimens in the market I have been in the habit of using mostly Leube- RosenthaPs beef solution and Rudisch's (Parke Davis) sarkopeptone. Either may be mixed with hot water or hot broth; a few teaspoonfuls and upwards are valuable additions to the daily food. The former is taken by many undiluted in small quantities; those who object to it because of its strong aromatic taste and odor, will still relish it when quite cold. Valentine's preparation is weak, but very palatable.