air was heard entering the lungs easily, the heart sounds were tumultuous and loud and the precordium heaved with the force of the beats, with which the feebleness of the radial pulse contrasted strongly. The mind seemed perfectly clear. The whole attitude and the symptoms suggested pain connected with the heart, an angina pectoris; so a hypodermic injection of morphin (gr. 1/12) was immediately given, and in twenty-five minutes the patient was asleep. In the absence of murmurs, what the pathological cardiac lesion was could only be conjectured beyond a decided hypertrophy, with some degree of dilatation. Although there was no generalized nor local edema, failing compensation was doubtedly present, as shown by the high hemoglobin count, above the maximum figure of 120 per cent. on the Dare scale, and the high count of the red cells, the figures for which were fortunately not recorded. The attacks of pain were also looked on as due to an acute dilatation of the different chambers of the heart, more particularly of the auricles following that of the left ventricle, which seemed overworked in a vain attempt to overcome some great resistance to the general circulation.

The attacks were subsequently controlled in the severity of the pain by the use of morphin, a hypodermic at the onset being followed by relief in a few minutes, but the frequency remained the same, and an alarming one occurred on the seventh day after admission, with cessation of respiration for a short time.

Fever was present every day, of an irregular type, the morning temperature being usually normal and the evening showing a rise to 103° or 104°, until the tenth day after admission, when it rose to 107-4° just before death.

At the autopsy, aside from a hypostatic congestion of the lungs. and anemic infarcts in the spleen and left kidney, the main interest centered in the thymus, which was decidedly enlarged, and in the heart, which extended 472 cm. to the right and 642 cm. to the left of the midsternal line; its dimensions were 92 cm. long, 712 cm. wide, and 3 cm. thick, and it weighed 115 grams. Careful search failed to disclose any trace of the pulmonary artery, but there was a great deficiency of the interventricular septum, and the ventricular wall, especially on the left, showed decided hypertrophy. The absence of the pulmonary artery and the appearance of the endocardium explained the absence of murmurs during life and the inability to diagnose the condition.

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DISCUSSION. DR. JACOBI. The nutrition of the lungs in these cases takes place by dilated bronchial arteries coming from the aorta. They take the place of the ramifications of the pulmonary artery, which is absent or stenosed. Life in such cases may be prolonged, as the writer has said. I published such a case in the ARCHIVES OF PEDIATRICS some ten years ago. The patient was twenty-nine when he died and he died only of very copious pulmonary hemorrhage. I believe that these cases are not very rare, and most of them are diagnosticable, as the writer says. There is a loud systolic murmur in many that extends all over the heart, by no means in all. The fact that the two ventricles are alike is simply the same as we have at birth—then the two are alike, normally. The circulation remains fetal, as it were, and the two ventricles remain alike.




Boston, Mass.

Since the year 1891, when the attention of physicians was first turned to the methods of laboratory feeding, a great deal has been accomplished year by year in perfecting more precise methods of dealing with the nutrition of early life, the object always being kept in view of placing the subject of feeding in as simple and practical a way as possible before the medical profession and the laity. I have thought it worth while, after these seventeen years of careful study of the subject, to present to you what has been accomplished, and what a wide range of resources the modern laboratory methods provide. During the development of the question of percentage feeding, I have frequently been impressed with the difficulties which physicians have told me they met with when they found that they were not able, in some special case, to accomplish by these modern methods the favorable results they said they saw apparently follow the use of the various patent and proprietary foods. Notwithstanding these reports, to which I have always listened attentively and endeavored to explain in some rational way, I cannot but feel that there is nothing, after all, so mysterious in the at times successful use of these foods. The subject essentially deals with the nutritiur the infant as effected by all known food stuffs. The food stuffs which make up practically all possible foods can be classiħed under three headings—fats, carbohydrates and proteids. Any other substances which are used in concurrence with these food stuffs, such as water, mineral salts, alkalies and ferments, are merely added to facilitate the digestion of the above-mentioned compounds of food. However much, as special students of infant feeding, we may each know regarding the use of these three classes of food stuffs, there is no doubt that physicians, in general, as well as the public who employ these physicians, know very little about the vital

principles of physiological chemistry, which are so interwoven with the whole question of infant feeding. The majority of physicians, for instance, after having made up their minds that they wish to carry out in their practice the principles which were first enunciated by those who believed in the exact method of feeding provided by the milk laboratories, have continued to prescribe on the same routine lines. They have done this without having taken the trouble to inquire whether the earlier ideas on the subject have changed or improved, or whether through means of the laboratories the latest advances in the physiological chemistry of digestion can practically be made use of in every-day practice, in cases where the infant is fed from laboratory products and by laboratory methods. On the prescriptions which emanate from the laboratories it has, indeed, for many years, been explained how the different classes of proteids can be prescribed and used, but this is about all, with the exception of writing for the various food compounds in percentages, that has been accomplished. I have, therefore, thought that the time had come when, for the convenience of physicians in general, the possibilities of what can be accomplished by a new and more advanced prescription card should be explained. I have also thought that besides writing for the percentages of fat, lactose and proteids, as has heretofore been done, we might go further and introduce, by means of an explanatory prescription blank, various new foods, thus showing the physician not only how to write for each food, or the various combinations of the food stuffs, but also to inform him what this writing of prescriptions really means. In order to do this satisfactorily, we should each one of us understand what possibilities there are in prescriptions. If these possibilities are understood, physicians will soon see that the use of the patent foods is entirely unnecessary, for even granting that success may follow their use, we must allow that none but the three classes of food stuffs above mentioned can be used, and that there is no new or unexplained virtue which they contain. The key to the whole question is that we should first understand what the constituents of these foods are. We should next investigate why, from their own peculiar combinations of food stuffs, the various patent foods are at times apparently superior in their results to the recognized laboratory combinations.

This has already been done, and now all combinations of food

can be obtained at the laboratories according to the individual practitioner's preference.

Beginning with the investigation of the fats, although we know it is the quality of the fat, as well as the quantity, which makes its use successful in the feeding of an individual infant, yet the only variation besides the percentage which it is possible to obtain at the present time is by using the cream from different breeds of cows, for it is well known that the quality of the fats differs markedly in different breeds. Thus, if we take as examples the creams from Holsteins and Jerseys, a number of differences can be noted. The emulsion of the fat is finer in the Holstein than in the Jersey; is much less easily disturbed, and is restored much more readily. It has not only been found that the calves of Jersey cows thrive better on the milk of common cows than on that of their own mothers, but that in the feeding of pigs a milk poor in fat has been found to be the best. The question of high or low fats in infant feeding I shall not enter into here, as I believe that each infant must have the percentage of fat given to it which is adapted to its own peculiar fat digestion; that the successful use of fats depends upon the knowledge of the individual physician of the especial case rather than on invariably using high or low percentages, and that, so far as the nutrition of the infant is concerned, a gradually increasing percentage of fat, according as it can be adapted to the digestion, is indicated, always enunciating that a percentage of fat higher than 4 is only necessary in very unusual cases. So many opinions have been expressed by physicians in regard to the method of obtaining cream for percentage use, and so much prejudice has been shown as regards the use of centrifugal cream, that it may be well to state that gravity cream, as well as centrifugal cream, can always be obtained at the laboratories, and that quite a number of physicians are accustomed in writing their prescriptions to signify their wish that in writing for their percentages of fat, it is to be understood that gravity cream should be used.

There are a number of variations possible and practical in the use of the different carbohydrates, and I have, therefore, thought it worth while to put in prescription form the various carbohydrates, such as lactose (milk sugar), maltose (malt sugar), sucrose (cane sugar), dextrose (grape sugar), and starch. The explanation of many of the successful results in infant

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