Ernest Watson Cushing.

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ficial feeding could be instilled into the common knowledge of
the people we would have less contention with malnutrition. The
gastro-intestinal disease inaugurated by faulty feeding begins the
way for the invasion of conditions unfavorable to normal nourish-
ment. The indigestion once established is very apt to be a con-
stant source of trouble and when coupled with a feeble resistance
on the part of the child, encourages a chronic condition of in-
testinal indigestion. But if the indigestion — ^marked in the
simple statement of the mother that the food is not agreeing with
it — is corrected at once, malnutrition may be nipped in the bud.
Otherwise the process insidiously goes on and is outlined as fol-
lows: First, a change in the color and frequency of the stools.
The stools are green either when passed or become so a little later;
this shows an alkaline condition of the feces, due to a suppression
of the normal acids. Bacteria, according to Lesage, cause the
change in color. The frequency of the stools is marked, the



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MALNUTRITION IN INFANTS. 49

quantity is lessened, but the discharges are offensive and irritat-
ing. Nervous symptoms soon appear, restlessness, crying, peevish-
ness and sleeplessness. The child wants to be held.

Then even at this stage more complicated nervous symptoms
may appear such as the so-called "inward spasms," a simple
tremor involving the eyelids and extremities. Convulsions, too,
may appear now and often are the first marked symptoms which
decide the parents to call a physician. Confusion in diagnosis
may result because of the nervous symptoms, .as I have seen in
consultation practice. Malnutrition is sure to be in evidence,
however, as the wasting is observed, the child having lost weight
or there has been no gain in weight for a long time. The mother
remarks that she feeds the child often enough and if she is nursing
it at the breast, she is very apt to say that the child constantly
demands the breast or else he never seems satisfied. The very ap-
pearance of the mother will lead to a diagnosis in such cases, as
she is usually an overworked, constantly tired, anaemic individual,
laden perhaps with the responsibilities of other children and the
care of the home. The prostration of the motlier is reflected in
the child and they both together present a striking picture
which enables us to make a pronounced diagnosis. Up to this
stage there may be no marked evidence of structural changes, but
it is very probable that a catarrhal colitis is present, in which case
there is apt to be hyperplasia of the lymph nodules. These symp-
toms are reinforced again by the evidences of impaired bodily
metabolism. The presence of uric acid in the urine is an import-
ant symptom, as Herter says; it is to be taken as an evidence of
destructive metabolism in the nuclei of the cells of the organism
and represents the chemio reaction constituents of the nuclei and
certain poisons. This view sustains the modem physiologic-
chemic belief that uric acid is a terminal product of metabolism
and in itself not a poison in chemic reaction.

Uric acid in the infant, not infrequently in its passage, irritates
the urethra causing the child pain when urinating and on this
account even an infant will not void unless driven to it, because
of the pain which accompanies such evacuation of the bladder.
Or again, the presence of uric acid may cause irritation of the
bladder and so disturb the reflex as to cause constant dribbling of
the urine.

As further evidence of the faulty metabolism, we have other



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60 FRANK PABSONS NORBURY.

symptoms indicating auto-intoxication, viz., the glands are en-
larged — the groin and neck being especially involved. The
patient has now reached that stage of Wasting which Parrott calls
the second stage of gastro-intestinal catarrh. The weight gradu-
ally declines; the child being thin and cadaverous, it has an old
appearance — the skin loses its elasticity, especially around the
gluteal region, over the deltoid and on the thighs. The skin
wrinkles and soon, by the wasting of adipose tissue, it resembles
tissue paper. Th^ child is pale, ansemic; has an offensive breath,
the lips are thin and pale and the eyes look sunken, which ap-
pearance is intensified by the dark circles which are under them.

Blood analysis shows a diminution of the number of red blood
corpuscles and an increase of leucocytes; diminished hemoglobin.
The temperature may be subnormal, as in one of my cases where
it continued so for some time, or when there is a marked increase
of the symptoms of auto-intoxication, it is usual to find the tem-
perature elevated from one to three and even four or five degrees.
The pulse is feeble and rapid (90 to 120) and as exhaustion
supervenes it be(t)mes more feeble and more difiicult to count.
Fenwick calls attention to a fact of interest from the standpoint
of prognosis, that with the approach of death, the action of the
heart becomes slow and often intermits — sixty beats to the
minute has been observed by him in such cases. The respiration
is usually increased and shallow, but becomes of the Cheyne-
Stokes variety, with the increase of exhaustion and the approach
of dissolution. The nervous symptoms are now more pronounced
and are apt to be misleading. Convulsions, local spasm, muscu-
lar rigidity, exaggerated reflexes, transitory paralysis of certain
muscles, mental hebetude, somnolence and coma; spurious
hydrocephalus too may be one of the unique complications.

The convulsions are evidence of the intestinal intoxication.
Herter says, "They are the immediate precursors of a long series
of occasional convulsive seizures to which we cannot give the
name of epilepsy." In some cases it is impossible and
exceedingly difficult to distinguish the action of local ir-
ritants, operating on a reflex arc, from the action of a poison
which through auto-intoxication finds its way into the blood.

A case in point. I saw in consultation a case of profound
malnutrition (infantile atrophy so-called by Starr). I was con-
sulted because of continued convulsions. The child's history



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MALNUTRITION IN INFANTS. 51

in brief was that it was seven months old, of healthy parentage,
nursed by the mother and up to the appearance of convulsions
was considered to be a healthy child. One morning the mother
was awakened early, by the child in convulsions. Forty-five con-
vulsions occurred on this day, when they abruptly ceased, but
reappeared within a few days; in the meantime gastro-intestinal
symptoms appeared in pronoimced form. Nutrition was dis-
turbed. The physician treated the case expectantly, but the con-
dition became more distressing. The loss of weight continued
with an occasional convulsion or series of convulsions to increase
the parents' anxiety. The mother continued to nurse the child.
When I saw the case, the child presented the picture of pro-
found infantile atrophy. I recommended the abandonment of
the mother's milk, the correcting of gastro-intestinal symptoms
and the use of modified milk, beginning in attenuated form and
increasing as the symptoms would permit, inunctions of cocoa-
nut oil, free use of drinking water and proper hygienic care. The
patient recovered after four months' treatment.

The local spasms are usually limited to the motor oculi muscles
but we may have a more general involvement of muscles. The
muscular rigidity and the decubitus noticed by the child burrow-
ing its head into the pillow, the retraction of the head, etc., are
suggestive of meningeal involvement, but these symptoms often
disappear under appropriate treatment. The mental hebetude,
the somnolence and coma indicate a more profound degree of ex-
haustion and intoxication. The mental hebetude may last for
weeks to be followed at last by somnolence, coma and death.
• Pseudo-hydrocephalus, according to Holt, does not show on
post-mortem examination any condition of the brain which
bears relationship to the symptoms. The patient presents the
appearance of hydrocephalus and it is a rare complication. I
was consulted recently by a mother who presented her child
because of hydrocephalus. On examination I found a marked
case of. chronic intestinal indigestion, with malnutrition, or, as
she called it, dyspepsia. The case had been referred to me from
Bloomington, 111.

The hydrocephalus was pronounced and the mental symptoms
confirmed the distinguishing skull conformity. I was loth to
make a diagnosis of acute hydrocephalus, as I found no evidence
of rickets, and as the skull conformation was not of the rickety



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52 FRANK PARSONS NORBURY.

type and as I further remembered what Holt had said as a result
of his post-mortem examination. I made a provisional diagnosis
of pseudo-hydrocephalus and prescribed for the intestinal indi-
gestion. I have seen and had under my care a number of cases of
acute and chronic hydrocephalus, but in none of these did I
notice intestinal complications.

I can understand that true acute hydrocephalus may exist at
the same time as malnutrition, for it is quite probable that the
acute infective process, so conspicuous in gastro-intestinal disease,
may give rise to infection within the cranial cavity, causing acute
meningitis, which is, as Mills truly says, one of the commonest
causes of acute hydrocephalus.

The foregoing symptoms are in brief those found in cases of
malnutrition following intestinal indigestion, which, in fact,
causes fully four-fifths of all cases.

DIAGNOSIS.

The diagnosis of malnutrition, while not necessarily difficult,
yet demands painstaking observation to determine whether or not
some of the diathetic diseases are not the real source of the infirm-
ity. We should not overlook in our inquiry the possibility of kid-
ney, liver, other intestinal disease or malaria to produce a group of
symptoms akin to what we have here delineated. The ordinary
methods of clinical diagnosis should, therefore, be closely fol-
lowed, using laboratory methods and careful daily observation.

PROGNOSIS.

This is not necessarily bad, for if no organic changes have
followed, the prospects for improvement and recovery are en-
couraging, and the little one may grow in strength and develop its
powers without complications if carefully watched. As Holt
says, if the cause can be removed the child will get well. It re-
quires patience, diligence and thorough cooperation of the parent
or nurse to insure success. In giving a prognosis I am. always
guarded and am sure to add that 'Vigilance in this case is the
price of health."

TBEATMEirr.

The treatment has two main objects in view, first, to arrest
wasting, and second, to repair the damage done by the disease.
To this end we should be careful in laying out our campaign of



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MALNUTRITION IN INFANTS. 58

action, to be thorough and exhaust every resource before losing
hope. We cannot rely on drugs except to aid us in promoting
resolution. We must depend largely on the regulation of diet.
If the mother is nursing the babe, abandon the breast at once, or
else employ a wet nurse; but such a substitute is not always satis-
factory, and is usually expensive. In my experience modified
milk is the best substitute feeding we can employ, and when
used on the basis of percentage and carefully followed, we can
build a foundation on which a superstructure of good health can
be raised. As the subject of modified milk will be discussed else-
where on the programme, I shall not enter into the discussion of
its principles. If a baby does not show improvement on this
food, and keeps losing weight, nothing will save it. The atrophy
then has involved the organs of assimilation, and hence their
function, is cut off and death follows. I have used the method
of Meigs in feeding and found it applicable in many cases, but
in my judgment the method of Holt and of Rotch leads iri
thoroughness of scientific principles and practical results. The
bowels should be regulated, and if diarrhoea exists no diarrhoea
mixture should be prescribed. I saw a case in consultation where
a diarrhoea mixture had been persistently used and only served
to intensify the symptoms. Intestinal antiseptics have but a
limited field of action in these cases, but I do not ignore their
usefulness. The subgallate of bismuth and the salicylate of bis-
muth have pleasant effects in allaying intestinal irritation and to
help in overcoming the putrefaction. I feel that the free use of
water, both by irrigation and the mouth, and even the use of
normal salt solution, after the method used in gastro-intestinal in-
fection, should be employed. Elimination is the theory of this
treatment, and it is correct I believe where we have such evi-
dences of auto-intoxication.

I have used freely the local inunction of cocoanut oil, applying
it twice daily over the abdomen, on the thighs, in the axillary
spaces. It promotes nutrition and relieves the harsh condition of
the skin.

Cod liver oil, is should be remembered, has no place in the
treatment of malnutrition, because it leads to fat intoxication and
thus prevents nutrition.

We cannot ignore the percentage basis of infants' food, and
when you disturb this relationship you invite indigestion. It is



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54 O. P. KERNODLE.

on this account that artificial feeding on the "try, try again" basis
is a failure. (1) Fat, (2) proteid, (3) sugar, (4) salts, (5) water
should be combined on a proper percentage basis, the food to b^
modified according to the physical indications and ability to
digest.

Jacksonville, Illinois.



COXSERYATIVE DIETS IX THE FEEDIXG OF THE
SICK AND COXVALESCENTS.*

O. p. KERNODLE, M.D.

The term diet conveys to the mind any and all substances en-
tering the animal organism that give nutrition and sustain life.

And by conservative diets, I wish to convey to the mind a
food whose properties are such that they sustain and conserve
the vital forces and energies from waste and disease. A food,
whose possibilities are so marked and whose composition and
digestibility conforms so closely to the needs of the normal ani-
mal organs, that with the smallest amount of physiological
energy, they may replace the waste material due to disease.

pietetics has a broader and more general field than any branch
of medicine. It is, in fact, the art preservative in healing and all
other sciences are subservient to it.

Hipocrates, saw in food, the first principles of medicine, while
Galen, Celsus, with scores of others following in his footsteps,
reaching higher and farther into its secrets, broadened the scope
with advancing ideas as to the therapeutic values of food.

. The student, eager to grasp all, sought for remedies outside the
realm of nutrition, and the first principles of medicine, as laid
down by the father of medicine, were soon lost sight of; and the
Dark Ages of dietetic medicine have reigned supreme until recent
years.

Diets and feeding have been much neglected by the medical
profession until within the last few years. If you attempt a re-
search through the most elaborate and voluminous libraries you

♦Read before the Medical Association of Missouri at Excelsior
SpriDf^s, May 24, 1898.



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FEEDING OF THE SICK. 56

will find the subject of feeding, not in bound volumes, but in
fragmentary opinions scattered here and there among journals;
and dealt with lightly, as if it did not deserve a place of promi-
nence in medical science.

Even when opinions were ventured, there were grave doubts
in the mind of the author as to the scientific position diets should
have. If you wish to find the commencement of the new era of
dietetic therapeutics, you will have to search closely the writings
of the most recent authors.

Liebig gave diets and food values a new impulse that set the
chemist and physiologist to work, and through the acumen of the
chemist from the laboratories of the learned chemist and physi-
ologist, we have been brought face to face with facts indisputible;
and our knowledge of foods and food values has been broadened;
so that today, diet is the accepted foundation of scientific thera-
peutics.

The question of diet is of vital importance, and is the question
confronting the human family today, in health and in sickness.
It plays the all-important part in reparation and structure build-
ing, sustaining forces weakened by waste and disease, and is
paramount to all other therapeutics.

Medicines are looked upon with less favor as we grow more
thoroughly acquainted with dietetic therapeutics and there is less
inclination or tendency on the part of the profession to prescribe
so liberally medicines and medical compounds. Medicine, whose
vaunted specific properties were once the hobby, is gro\^ng less
in favor with the progressive physician as he studies and becomes
more familiar along the lines of dietetics.

During the past, but little attention has been paid to diet as a
part of medicine; the sick and convalescents were, and are often
now turned over to the cook, after we have prescribed a routine
of remedies.

The first prerequisite to a definite understanding of the uni-
versal adaptibility, as well as the applicability, of the best and
most perfect diet for the sick, is to have a clear idea and definite
knowledge of the customs of the individual in health, as well as
a clear understanding of the chemical composition of food and
food compoimds. It is obvious to the mind of every physician
that there should be certain modifications in the food given
those in health to suit the requirements of the sick; and the



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56 O. P. KERNODLE.

quantity to be given, as well as the quality of the food, should
be in accordance with the conditions surrounding the case.

Formerly the physician was erroneously led into opinions and
practices in feeding the sick, through simple observations, with-
out a definite knowledge of food values, but today the field is
before him with no barriers, and he may choose his diet from
every source; select and reject, until he has within his reach just
what is required.

Too often have we sought exclusively in the physiology of
digestion and nutrition the principles of the study of dietetics.
We may and do find unsolved problems in physiological dietetics
that are far reaching; such as the remote use of certain foods and
drinks, peculiar characteristics of certain elements, producing
certain physiological effects long after use, and being transmitted
from generation to generation the same as family characteristics
and idiosyncracies.

In the study of dietetics, there is much more than simple
physiological conditions to be considered; the peculiar features
of the individual, the mental forces and former habits, also the
beliefs and physical conditions have often to be weighed and
carefully considered.

Often by scrupulously studying the case before us we may
solve what at first seemed a complex problem, simplify the
method of diets and find the task less laborious than we at first
supposed.

We give the name food to all substances introduced into the
human organism that serve as nutrition and sustain life and
give force and energy. These substances are divided into or-
ganic and inorganic principles; they contain all primordial ele-
ments of cell structure and reparation of retrograde metamor-
phosis.

As such divisions, we have in the first, those of first and great-
est importance, the protein principles, "Albuminoid protoplasmic
cell pabulum,'' as Hoffmeister has called them, and non-protein
principles. These principles in their simplicity contain all the
elements of the body, or the body contains in its make-up all
these principles.

Now that our chemical and physiological knowledge has be-
come more exact, we can intelligently appreciate their utility in
their various combinations, as true nutritive agents.



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FEEDING OP THE SICK. 67

!Not to go into detail and bring each article of food
used down to a chemical and physiological test, before definitely
deciding its usefulness, and its proper place in cell structure
building, would be to jeopardize the patient, and destroy it« value
as a food, through unscientific procedures.

The quantitative composition of diets, the atomic construction
of proximate principles entering into them, the results obtained
from each, as well as their respective merits and the high and
low nutritive values, are today acurately understood. We know
which of the proximate principles have heat and energy-yielding
influences, and which enter into the chemical and histological
construction of all fluids, tissues, ferments and glandular
structures of the body, and which are essential constituents in
mechanical energy alone. The physiological Action of these ele-
ments and the chemical laws governing the different classed and
conditions, can be positively demonstrated.

When we apply this knowledge intelligently, and select and
administer the proper food, we produce results almost at will
with a wonderful degree of exactness.

The selection of the most efficacious diets in disease, divided
into their chemical elements, helps us to better understand their
place in restoration of tissues. The inorganic substances all en-
ter the body under their own form, either alone or in combina-
tion with other classes. They are not oxidized or split up within
the system to enter into the chemical formation of other com-
pounds, but uniting mechanically with the proteid groups; in fact
they only act mechanically, and after having served their pur-
pose to the body, pass out with the excrementitious waste, un-
changed.

The organic principles, are oxidized or split up within rhe
system and yield heat and energy; and act as lubricants and
formative bodies, and are eliminated from the body as carbon
dioxide and water.

All the substances irrespective of specific names, mechanically
and chemically united in just proportion, are absolutely essential
to form the fluids, tissues, glands and ferments of the body.

If by any reason there is an abnormal transformation and the
relative quantities are changed, there is marked manifestation in
the excrementitious waste, especially shown in the urine. Allow
me to state, right here, 'That & careful examination of the urine,



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58 O. P. KERNODLE.

will often furnish an exact key to the condition of the system."
We may learn positively by such examinations which foods are
absorbed and serve as nutrition and which are not. Dr. William
Porter^ asserts, "That in connection with the oxidization of
proteid substances, a disturbance in their anabolism not only
changes the relative proportions between the urea and uric acid,
but develops an almost unlimited number of katabolins, some of
which are perfectly inert, while others are as toxic and dangerous
to life as the well known cyanide compound, prussic acid."

The oxygenating capacity of the system is a limited one, yet
it has a moderately wide margin. Quite frequently this margin
is exceeded by eating too freely of all kinds of food; as a natural
sequence, respirations and circulation must necessarily be in-
creased, to prevent'suboxidization, as a defective supply of oxygen
disturbs the metabolism of the proteid bodies, an unlimited num-
ber of katabolins furnishes a rational explanation to all the phy-
siological conditions and systems presenting for treatment. We
are forced to believe that so long as the anabolic processes of the
body are not disturbed by any abnormal agency, there will not
develop any pathological lesion or symptom.

We find in diseased conditions the nutritive powers often over-
taxed, which calls for the practical application of a predigested
food, by which there is a great saving of vital force, which is
a great factor in changing the physiological conditions and mater-
ially assists in perfecting a complete recovery of the sick.

The subject is too broad and deep, and time too limited, to
enter into minute detail of each change that takes place 5u
digestion, yet the principles can be pointed out, and by consult-
ing the tables before us, we may work more to a definite purpose
in perfecting the rapid and complete recovery of the sick.

It is essential to know the heat-producing qualities of a food;
heat is the element that keeps up the equilibrium, and either an
abnormal or subnormal amount changes the ferments and dis-
turbs the anabolic forces of the body. A food, which entering



Online LibraryErnest Watson CushingAnnals of medical practice → online text (page 6 of 77)