Dr. Aldert Smedes Root’s address to the Johnston County Medical
Society, presented April 5, 1921
Three thousand infants under two years of age die of
diarrheal diseases in North Carolina each year. Our State has stood for years
and still stands among the very first of all the states in her high infant mortality.
Typhoid fever and smallpox have practically been eliminated
from our midst. Hook-worm disease no longer menaces the health of our
communities. Diphtheria is beginning to be controlled by the prophylactic
treatment with toxin-antitoxin. And yet the deaths from summer diarrhea, greater
in numbers than all these diseases combined, remains practically the same year
in and year out with little, if any, improvement.
In seeking the effective measures which might be instituted
to combat this infant scourge, let us for a moment consider those factors which
are responsible for its prevalence. Let us consider first he predisposing
causes and attempt, if possible, to remove these.
The most important of these by far is the state of health of
the infant. In no other disease is the survival of the fittest so clearly
exemplified, in none does the weakling have so poor a chance. The first duty,
therefore, which devolves upon us physicians is to keep the baby physically
fit. By what means and the institution of what measures can this best be done? Holt says that “Less than 5 per cent of the
serious cases of diarrhea are amongst the breast fed, and fatal cases amongst
the exclusively breast feed are really rare, no matter how bad the surroundings
or how ignorant the mothers. This being true, that 95 per cent out of every 100
cases of diarrhea occur in bottle fed babies, it is obviously our first duty to
keep the baby upon the breast for the first year, and if this be a physical
impossibility to make every attempt to have the mother partly nurse the infant
through this period.
In order to do this, premature weaning must be discouraged
and measures for the maintenance of breast milk encouraged. Too many babies
come under observation who because of vomiting and failure to gain or because
of two frequent stools with mucus and curds and failure to gain, have been
taken from the breast and placed wholly upon artificial feedings.
I am sure that a very large number of these babies could
have been nursed had the hours of nursing been properly regulated, the milk
which may have contained a high fat percentage diluted by giving water or lime
water immediately before the breast, and other simple measures. Again, too many
babies are weaned completely when complimentary feedings from the bottle could
have been given. The maintenance of the breast supply is of paramount
importance, nor are the means to this end fully appreciated and preached by the
medical profession. I do not mean that the profession does not appreciate the
value of breast milk, for Dr. Sedgwick’s statistics show that 80 per cent of
the wives of physicians nurse their babies three months or longer, but the
average physician does not go into the minute details and give the
encouragement so often needed by these nursing mothers. The key-note of success
in the maintenance of breast milk depends upon two factors: first, the complete
emptying of the breast and secondly, the stimulation of the breast glands by
nursing the baby at regular intervals. As to the complete emptying of the
breast at each nursing, any one who has been reared upon a farm knows that
unless the cow is milked “dry” and the udders are stripped to express all of
the milk the quantity of milk will decrease day by day in proportion to the
incompleteness of the milking. This principle obtains equally well in the human
being.
….
What is the next most important step in keeping the baby
physically fit? The answer is to give him, when it become necessary, artificial
feedings which are well balanced in the three elements of food which are
necessary to maintain growth and development, namely fats, carbohydrates
(sugar), and protein. None of the proprietary foods will answer this purpose,
especially is this true of condensed milk, easily the most popular of them all.
It is inexpensive, easily prepared, obtainable from almost any drug store, and
upon it babies frequently gain in weight. This gain is due to the high
percentage of sugar in the formula, binding water to the tissues. These babies
are in reality water-logged. They are flabby, pale and pasty and their muscle
tissue small in amount. And this is what we would expect, for protein is the
only element of food which repairs tissue waste and from which the red muscled
are formed, and the amount of protein in such mixtures is far below the requirements
of the baby.
The fat content is equally as low as the protein, and it is
in the functions of fat to supply energy, heat and body fat.
The vitality of these babies fed upon such low fats and
protein and high sugar mixtures and their resistance to diseases is upon such a
low plane that they become a rich soil for bacterial invasion, and when this
occurs they literally wilt as a tender flower under the summer sun.
In prescribing such mixtures here again I would not
incriminate the rank and file of the medical profession, for all too often they
are recommended by an elderly matron in the community who probably has “raised”
two children and lost four, and hence is thoroughly conversant with the very
need of ever baby.
If we, ourselves, could universally realize and make the
laity do the same, that the best substitute for breast milk is properly
modified and sterilized clean cow’s milk or should this not be obtainable,
properly modified dry milk, then our babies would certainly be more physically
fit and more able to resist ravages of “summer diarrhea.” That period of life
existing between the end of the nursing age and the beginning of school life
has been appropriately called the “neglected age of childhood.” It is just as
important that these children should have well regulated diets and I would like
to call your attention t the fact that the Bureau of Infant Hygiene, operating
under the State Board of Health, has for distribution to any mother who may
need them, suitable diet lists from the age of 12 months to 6 years.
Other predisposing causes of summer diarrhea of far less
importance may be briefly mentioned. It is surprising how many babies are
permitted to wear the abdominal band and even some woolen undershirts during
the summer months. The reservoir of the
blood in the body is in the splanchic vessels of the abdomen and the humid heat
retained by these garments must surely overheat the blood and often causes a
reaction. Such reactions might easily pave the way for an intestinal infection.
Could we not lessen the effect of summer heat by clothing the infant in the
lightest possible fashion and by sponging him with cool water several times a
day?
Unhygeinic conditions in the home, where flies swarm and
where the importance of thorough sterilization of bottles and nipples is not
appreciated, will always be a difficult problem. We must preach and continue to
preach screening against flies, against the use of unsanitary “pacifier,” and cultivate
patients in going into the minutest details of milk preparation and its care.
I cannot refrain from mentioning in this paper a few of the
flagrant errors in the treatment of infectious diarrhea which have been handed
down from generation to generation. One of these is the daily purge by castor
oil or calomel which is so frequently resorted to. If the initial dose, which
should be given at the very onset, continues to be repeated, we are surely
“adding fuel to the fire.” Another common practice is to keep the baby upon
nothing but barley or rice water, or broths for days. The food value of these
is practically nil, while the tissue waste in the disease is enormous. After
the first 12 to 24 hours of starvation, food should be given, low in fat, low
in sugar and relatively high in protein. This indication is met by diluted
skimmed milk mixtures, buttermilk mixtures, and best of all, lactilic acid or
protein milk. No other food is so generally appropriate as this latter and I
should sincerely like to see this community lead the way among the smaller
towns in the State in devising plans whereby this produce could be made
available for such cases during the spring and summer months.
A third criticism of every-day method of treating summer
diarrhea is the administration of drugs. If we could realize that the treatment
is practically altogether dietetic, that no drug has any specific action, that
they serve in the majority of cases merely to upset the stomach, it would
surely be a step forward. There is one exception. I believe that in every case
sodium bicarbonate should be given to combat the relative acidosis brought
about b y the loss of bases through the stools. I am firmly convinced that
colonic irrigations once or twice daily will do more toward controlling the
frequency of bowel movements than any of the drugs in the Pharmacopoea. The diarrhea is life-saving and if opiates are given
so that this is checked, the poisons are pent up and the prognosis in any given
case made bad.
Can we not then, as a body of earnest medical brothers working
shoulder to shoulder, lower our high infant mortality rate by encouraging
maternal feeding and the maintenance of breast milk, but eschewing the use of
proprietary foods but rather seeing to it that the baby is placed upon a
well-balanced diet, by preaching sanitation, by properly clothing the infant
and finally by recognizing each one of us that the disease is constitutionally
one which depends almost solely upon the proper dietetic measures for its care.
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