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OF D I G E S T I V E D I S E A S E S

of 2 minims of a 50 million or a 250 million concentration to 2 minims of a 5 million concentration. (c) The criteria f o r determining the size of each, subsequent, optimum dose of vaccine have been discussed in detail. The size of each dose must be individualized to the patient. P r i o r to each injection, it is essential to determine, (1), whether any temporarily disagreeable reaction occurred following the last injection, and if so, its degree, type and duration, and, (2), whether definite improvement or disappearance of symptoms occurred following the last injection. These facts should be recorded upon a "vaccine sheet" in the history of the patient. The determination of the optimum dose each time is essential for the best therapeutic results. (d) Although no stereotyped schedule of increase of dose can be followed, the schedule or r a t e of increase suitable for a patient with average tolerance for B. coli vaccine has been outlined in detail. The

AND NUTRITION

optimum route for colon bacillus vaccine injection has been discussed. (e) The usual optimum time interval between vaccine injections and the indications f o r increasing or decreasing this interval have been reviewed. (f) The various concentrations of colon bacillus vaccine, actually needed for the practical administration of this type of therapy, have been specified. (4) The proper selection of cases for colon bacillus vaccine therapy, and the careful determination of the proper dose of vaccine at the time of each injection, constitute the two most essential requirements for successful results f r o m B. coli vaccine therapy. REFERENCES 1.

2.

Mateer, J . G., Baltz, J . I., Fitzgerald, J a m e s a n d Woodburne, H . L. : Colon Bacillus Vaccine T h e r a p y - - A s Related to Chronic F u n c tional Diarrhea, Chronic Headache, Chronic "Toxic V e r t i g o " and " U n s t a b l e C o l o n " - - ( N o n - U l c e r a t i v e Colitis). A m . Jour. Dig. Dis. and Nutrlt., Vol. II, No. X, 621-629, 1935. See discussion of above p a p e r by Dr. Leon Schiff.

Infant Feeding---Individualized vs. Routine By I. NEWTON KUGELMASS, M.D. N E W YORK, N E W Y O R K

K constitutes the basis of infants' feedings. MI LProper choice of the milk suited to the particular

infant is indispensable in successful infant nutrition. The g r e a t variety of milks available make such a choice difficult in the individual infant because of unneeess a r y empiricism in practice. More stress has been placed upon the various milks and their properties than on infants and their tolerance. Nutritional knowledge has advanced sufficiently to adapt effectively the required type of milk to the individual infant r a t h e r than the infant to the milk. The type of milk selected requires modification, the procedure of choice depending upon the infant. The resulting formula may meet all the nutritional needs of the infant and yet be unsuited to his digestive tolerance. The theoretical goal in nutrition is the same for all infants but the methods of attaining it necessarily differs with each infant. Goal and method are not only necessary but inseparable in effective infant feeding. Thus, there can be no single formula f o r the universal feeding of infants. The percentage composition of cow's milk mixtures, imitating breast milk, becomes less important than the behavior in the infant's stomach. We have studied the response of various methods of feeding in t e r m s of the infant's eonstitution as a m o r e physiologic basis f o r determining the type of formula indicated. P L A N OF I N F A N T F E E D I N G STUDY Comparative studies of "standard formulae" prepared f r o m various types of milk were made on infants during the first three months of life. The newborns on the service were maintained f r o m birth with the h y d r a t i n g solution given a t two hour intervals ~-From the N~w York City Children's Hospital. This w o r k was aided by g r a n t s f r o m the N u t r i t i o n Research F u n d and the Milk Research Council. Submitted September 29, 1936.

throughout the twenty-four hour cycle and put on the f o r m u l a under study on the second day of life. An effort was made in each case to have the infant nurse and the breast-fed infants were used as controls. Despite the willingness of most mothers to nurse their babies and our insistence in f a v o r of breast feeding, less infants were nursed t h a n is considered good practice. Although theoretically tuberculosis in the mother is the only contraindication to nursing, actually we have found severe p o s t p a r t u m disturbances affecting the mother physically and tempermentally to an extent t h a t made nursing very trying. Breast pumps were tolerated f o r short periods and manual stripping was rejected by m a n y mothers. Whatever the maternal condition the baby was weaned if the quantity of breast milk was less than an average of two ounces per feeding a f t e r the first fortnight. W e a n i n g during the newborn period was instituted for very definite indications and not f o r the purpose of these studies. Many of the infants included in the data nursed f o r a number of days during which time the intake of the special formula was relatively small. But during the baby's stay in the n u r s e r y the intake of the milk mixture was gradually increased until the formula under study comprised the total day's feeding. The infants' progress was under the supervision of research dietetians, Misses Cummings and McMahon and the technical d a t a under Miss Pugsley; all devoting full time to these nutritional studies. Over fifty well newborns were observed serially on each f o r m u l a - - f r e s h , powdered, evaporated and acid milks with breast milk as the control. Careful records were made of the physical status and functional response to the particular feeding. This was continued at home a f t e r the babies were discharged f r o m the nursery and observed subsequently at weekly inter-

KUGELMASS--INFANT FEEDING---INDIVIDUALIZED VS. ROUTINE

241

rants were maintained on a whole milk mixture for three months. It consisted of boiled whole milk with 10% added carbohydrate. The formula was started the second day of life in well newborns with a birth weight over six pounds. Although seven of the group studied had difficult deliveries

vals in a well-baby u n i t w h e r e clinical and l a b o r a t o r y e x a m i n a t i o n s w e r e made. T h o s e i n f a n t s w h o s e m o t h e r s failed to keep a p p o i n t m e n t s w e r e followed up at home by one of t h e d i e t e t i a n s . T h e m o t h e r was p r o v i d e d w i t h t h e special milk used f o r t h e i n f a n t ' s f o r m u l a

Comparative res~zlts on routine and individual formulae

Breast Milk

A g e of I n f a n t s

(Wks.)

1

No. Cases Difficult I ) e l i v e r i e s D u r a t i o n of F e e d i n g

(Days)

Supplements Av. V o l . / F e e d i n g

1 -

Evaporated Milk Formula

Diluted Milk Formula

12

1

1-12

-12

55

54

59

5~

5

7

3

85

SO

OJ&CLO

OJ&CLO

Powdered Milk Formula

I

-12

Acid Milk Formula

1 - 12

60

56

G

5

7

~2

86

85

OJ&CLO

OJ&CLO

OJ&CLO

OJ&CLO

Av. V o l . / D a y F e e d i n g s

4.2

4.2

4.1

3.8

2 too.

5.2

5.4

5.0

5.I

5.3

3 too.

6.0

6.5

6.1

5.9

6.2

(Ozs.) 1 mo.

12

1 -

50 4

OJ&CLO 4.4

4.0

(3,S)

Individualized Formula

35

(Ozs.) 1 mo.

Av. I n t a k e

-12

Whole Milk Formula

5.5 6.5

24

25

25

24

22

26

2 too.

26

27

25

26

26

27

3 too.

30

3~.

31

29

31

33

60

52

66

60

67

70

Cals./Lb./Day

(22)

(56)

Av. Gain Wt. Ozs./Wk.

6.9

6.0

5.9

7.1

6.4

7.1

Av. Gain Ht.

1.0

1.0

1.0

1.0

1.0

L0

1.0

Av. No. S t o o l s / D a y

2.5

3.3

2.5

2.6

2.4

2.7

2.6

% Digestive Disturbances

8

24

12

9

11

10

% Infections

7

9

5

8

10

6

8

90

70

85

88

86

88

95

~

(Mo.)

Successful Feeding

t h u s i n s u r i n g c o n s t a n c y of p r o d u c t and of cooperation. Only n o r m a l well i n f a n t s w e r e included in t h i s series. I t is t h e first t h r e e m o n t h s of t h e f e e d i n g p r o g r e s s of t h e s e i n f a n t s t h a t concerns t h i s r e p o r t . ROUTINE FEEDING OF "STANDARD" FORMULAE IN WELL INFANTS I. Control Series. Fifty-five normal infants were maintained exclusively on breast milk for three months. The breast feeding was started five hours after birth in newborns with a birth-weight over six pounds. Although five of these newborns had difficult deliveries they showed no post-natal manifestations. Orange juice and cod liver oil were introduced the third week. The orange jucie was first given half strength and gradually increased so that two ounces were given by the end of the first month. The 10 D cod liver oil was given five drops a day increasing it gradually until each infant received one teaspoonful a day. The average volume intake was 3.8 ounces per feeding during the first month, subsequent amounts not being determined. Indeed it was difficult to obtain a sufficient number of weighings during the first month to estimate the average volume intake, the accuracy is therefore indetermine for comparison with the equivalent values :for artificial feedings. The average volume intake consumed during the twenty-four hour cycle was accordingly 22 ounces. The average caloric intake was about 56 calories per pound per day. The average gain in weight was 6.9 ounces per week and the average gain in height one inch per month. The average number of stools was 2.5 per day. Three of the infants developed transient upper respiratory infections; four had alimentary disturbances, i.e., one vomited, one had colic and two developed diarrhea. Series II. Whole Milk Form~da. F i f t y - f o u r normal in-

7.3

2

there were no post-natal manifestations. Orange juice and liver oil were introduced the third week. The orange juice was first given half strength and increased gradually so that two ounces were given by the end of the first month. The 10 D cod liver oil was offered five drops a day increasing it gradually until the infant received one teaspoonful a day. The formula was made up for twentyfour hours and divided into six feedings given at four hour intervals during the first month and subsequently into five feedings. The amount offered at each feeding was slightly above that usually taken by infants at each age level. The average volume consumed by an infant was 4.0 ounces per feeding during the first month, 5.2 during the second and 6.0 during the third month, the average volume for the total day's feeding being 24, 26 and 30 ounces respectively. The average caloric intake was about 60 calories per pound per day. The average gain in weight was 6.0 ounces per week and the gain in height was 1 inch per month. The average number of stools was 3.3 per day. There were three cases of upper respiratory infection, one furunculosis and one pyelitis. But thirteen infants showed other disturbances i.e., three vomited, three had colic, one had diarrhea, four were severely constipared, one developed eczema and one had pyloric stenosis. The distribution of alimentary upsets was not uniform at each age level, the greatest proportion being during the first month and the least during the third month: 36% during the first month, 24% during the second and 11% during the third month with an average of 24% for the entire period. Several infants with limited digestive capacities were eliminated from this study during the first month. The most striking feature was the correlation between alimentary tolerance and body build. About 80%

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AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

who showed digestive disturbances were of the lateral type. Apparently the majority of infants of linear body build are able to take undiluted boiled whole milk in amounts adequate to satisfy the appetite without revealing intestinal disturbances. Series IIl. Diluted Milk Formula. Fifty-nine normal infants were maintained on a diluted milk formula for three months. I t consisted of boiled half-strength milk with 10% added carbohydrate. The formula was started the second day of life in well newborns with a birth weight over six pounds. Although three of the group studied had difficult deliveries there were no post-natal manifestations. Orange juice and cod liver oil were introduced the third week. The orange juice was first given half strength and increased gradually so that two ounces were given by the end of the first month. The 10 D cod liver oil was offered five drops a day increasing it gradually until the infant received one teaspoonful a day. The Iormula was made up for twenty-zour hours and divided into six feedings given at four hour intervals during the first month and subsequently into five feedings. The amount offered at each feeding was slightly above that usually taken by infants at each age level. The average volume consumed per infant was 4.2 ounces per feeding during the first month, 5.4 during the second and 6.3 during the third month, the average volume for the total day's feeding being 25, 27 and 32 ounces respectively. The average caloric intake was about 52 calories per pound per day. The average gain in weight was 5.9 ounces per week and the average pain in height was one inch per month. The average number of stools was 2.5 per day. There were three cases of upper respiratory inIection, six cases of alimentary disturbances, i.e., three vomited, two developed colic and one had diarrhea. The distribution ol alimentary upsets was not uniform but in the opposite sense of the group on whole milk formulae. There appeared somewhat more disturbances during the second and third month than during the first. Apparently dilution does not spare infants intestinal disturbances a f t e r the first month. Series IV. Evaporated Milk Formula. Fifty-eight normal infants were maintained on an evaporated milk formula for three months. It consisted of evaporated milk, one to two dilution, with 10% added carbohydrate. The formula was started the second day of life in well newborns with a birth weight over six pounds. Although six of the group studied had difficult deliveries there were no post-natal manifestations. Orange juice and cod liver oil were introduced the third week. The orange juice was first given half strength and increased gradually so that two ounces were given by the end of the first month. The 10 D cod liver oil was offered five drops a day increasing it gradually until the infant received one teaspoonful a day. The formula was made up f o r twenty-four hours and divided into six feedings given at four hour intervals during the first month and subsequently into five feedings. The amount offered at each feeding was slightly above that usually taken by infants at each age level. The average volume consumed per infant was 4.5 ounces per feeding during the first month, 5.0 during the second and 6.3 during the third month, the average volume for the total day's feeding being 25, 25, and 30 ounces respectively. The average caloric intake was about 66 calories per pound per day. The average gain in weight was 7.1 ounces per week and the average gain in height was one inch per month. The average number of stools was 2.6 per day. There were four cases of upper respiratory infection. Five developed alimentary disturbances, i.e., two vomited, one had colic, one diarrhea and one vomited associated with asthma. Series V. Powdered Milk Formula. Sixty normal infants were maintained on a powdered milk formula for three months. It consisted of powdered milk, one tablespoonful to two ounces of water, with 10% added carbohy-

drate. The formula was started the second day of life in well newborns with a birth weight over six pounds. Although five of the group studied had difficult deliveries there were no post-natal manifestations. Orange juice and cod liver oil were introduced the third week. The orange juice ~,as first given half strength and increased gradually so that two ounces were given by the end of the first month. The 10 D cod liver was offered five drops a day increasing it gradually until the infant received one teaspoonful a day. The formula was made up for twentyfour hours and divided into six feedings given at four hour intervals during the first month and subsequently into five feedings. The amount offered at each feeding was slightly above t h a t usually taken by infants at each age level. The average volume consumed per infant was 4.1 ounces per feeding during the first month, 5.1 during the second and 5.9 during the third month, the average volume for the total day's feeding being 24, 26, 29 ounces respectively. The average caloric intake was about 60 calories per pound per day. The average gain in weight was 6.4 ounces per week and the average gain in height was one inch per month. The average number of stools was 2.4 per day. There were five cases of upper respiratory infection including one with otitis media. Five developed alimentary disturbances, i.e., two vomited, one had colic, three developed diarrhea, one of which was secondary to an upper respiratory irttection. Series VI. Acid Milk Formula. Fifty-six normal infants were maintained on powdered lactic acid milk formula for three months. It consisted of one tablespoonful of the powder to two ounces of water, with 10% added carbohydrate. The formula was started the second day of life in well newborns with a birth weight over six pounds. Although seven of the group studied had difficult deliveries there were no post-natal manifestations. Orange juice and cod liver oil were introduced the third week. The orange juice was first given halt strength and increased gradually so that two ounces were given by the end of the first month. The 10 D cod iver oil was offered five drops a day increasing it gradually until the infant received one teaspoonful a day. The formula was made up for twentyfour hours and divided into six feedings given at four hour intervals during the first month and subsequently into five feedings. The amount offered at each feeding was slightly above that usually taken by infants at each age level. The average volume consumed by each infant was 3.8 ounces per feeding during the first month, 5.3 during the second and 6.2 during the third month, the average volume for the total day's feeding being 22, 26, 31 ounces per pound per day. The acid feedings were taken with more avidity a f t e r the first month. The average caloric intake was about 67 calories per pound per day. The average gain in weight was 7.1 ounces per week and the average gain in height was 1 inch per month. The average number of stools was 2.7 per day. There were three cases of upper respiratory infection. Five infants developed alimentary disturbances, i.e., one vomited, two had colic, two diarrhea and the feedings were reduced. INDIVIDUALIZED FEEDING OF "STANDARD" FORMULAE IN WELL INFANTS E v e r y t y p e of f o r m u l a t e s t e d was effective r o u t i n e l y in o v e r 80% of t h e i n f a n t s studied. B u t in each g r o u p t h e r e w e r e always a n u m b e r of n o n - c o n f o r m i s t s . T h e p a r t i c u l a r f o r m u l a was not a d a p t e d to t h e m and t h e y r e a c t e d w i t h a l i m e n t a r y offense. E v e n m o t h e r ' s m i l k yielded its q u o t a of d i g e s t i v e intolerance. T h e diffic u l t y is w i t h t h e i n f a n t in each g r o u p and n o t w i t h a n y of t h e f o r m u l a e tested. It appears improbable t h a t any one type of f e e d i n g will e v e r be u n i v e r s a l l y applicable to all i n f a n t s . T h e five series of r o u t i n e f o r m u l a f e e d i n g s s e p a r -

KUGELMASS--INFANT

243

F E E D I N G - - - I N D I V I D U A L I Z E D VS. R O U T I N E

ated the n o r m a l i n f a n t s f r o m those with l a t e n t cons t i t u t i o n a l disorders. A n d even a m o n g the large g r o u p of n o r m a l i n f a n t s in each series t h e r e we,re differences in the relative tolerance for milk as the first "solid" food. The r a n g e of digestive tolerance is so wide in most i n f a n t s t h a t no a b n o r m a l responses a r e m a n i f e s t clinically with modified milk m i x t u r e s . B u t in i n f a n t s with l a t e n t c o n s t i t u t i o n a l d i s o r d e r s - - d e v e l o p m e n t a l , allergic, n e u r o p a t h i e - - t h e r e is either a low digestive capacity for a n y food or a d i m i n i s h e d tolerance for cow's milk, f r e q u e n t l y below m a i n t e n a n c e r e q u i r e m e n t . Not all these i n f a n t s rebel a g a i n s t " s t a n d a r d " form u l a e because the i n f a n t ' s f u n c t i o n a l d e v i a t i o n s m a y be slow in b e c o m i n g m a n i f e s t . B u t the c o n s t i t u t i o n a l s t i g m a t a p e r s i s t s a l t h o u g h not always p o i g n a n t l y . The r o u t i n e f e e d i n g s u n s u i t e d to these i n f a n t s m a y tide t h e m over the first m o n t h s of difficult a d j u s t m e n t b u t s u b s e q u e n t l y c o n t r i b u t e to the p r e c i p i t a t i o n of t h e i r c o n s t i t u t i o n a l disease. W h a t m a y develop will develop more violently if i r r i t a t e d by i n a p p r o p r i a t e f e e d i n g s f r o m b i r t h . The f e e d i n g of r o u t i n e f o r m u l a e to well i n f a n t s f r o m b i r t h ignores the prevalence of l a t e n t c o n s t i t u t i o n a l d i s t u r b a n c e s . M a n y of these can be recognized early a n d a p p r o p r i a t e f o r m u l a adapted to t h e i r more l i m i t e d digestive capacities. We a t t e m p t e d to d i s t i n g u i s h n o r m a l f r o m d i a t h e t i e n e w b o r n to d e t e r m i n e the type of milk indicated for each i n f a n t individually. I n f a n t s with overt d i s t u r b anees were excluded from this study. Of the forty-five i n f a n t s w i t h diathesis, 65% were allergic, 30% n e u r o pathic and 5% developmental in origin. The i n f a n t s t h a t developed allergic m a n i f e s t a t i o n s showed enough s u g g e s t i o n of l a t e n t allergy to w a r r a n t early adaptation of the formula. The most helpful s i g n was an e r y t h e m a t o u s l i n e a r fold in the p o s t - a u r i c u l a r r e g i o n or b e n e a t h the lobe of the ear, m o r e s t r i k i n g b e n e a t h the left t h a n the r i g h t ear. I n a d d i t i o n the usual prem o n i t o r y expressions of allergy such as a hairless scaly scalp a n d d e s q u a m a t e d dry skin were helpful. W h e n these m a n i f e s t a t i o n s in the n e w b o r n were corrob o r a t e d by a n allergic h i s t o r y in e i t h e r p a r e n t the i n f a n t was considered a p r o b l e m in l a t e n t allergy. N e u r o p a t h i e i n f a n t s were recognized by h y p e r t o n i c m a n i f e s t a t i o n s d u r i n g the first days of life. T h e r e was p r e d o m i n a n c e of the flexor muscles with generalized and c o n t i n u e d spastieity, restlessness, sleeplessness and i r r i t a b i l i t y . I n f a n t s w i t h l a t e n t developm e n t a l d i s o r d e r s were too varied to p e r m i t of a n y single procedure to be of value f o r early diagnosis.

Series VH. Individualized Form~dae. F i f t y normal infants were maintained on individualized formulae for three months. The type of feeding selected was in accordance with the indications of the individual infant. Long lean infants were given 75 calories per pound of body weight per day and lateral infants were given 60 calories. The former were fed concentrated whole milk mixtures, three to one dilution with 10% added carbohydrate, and the later diluted milk mixtures, one to one dilution with the same amount of added carbohydrate. Infants with latent allergy were given evaporated milk, one to two dilution with 10% added carbohydrate, with a caloric intake depending upon their body build. I n f a n t s with hypertonia were maintained on acid milk, one tablespoonful to two ounces of water with 10% added carbohydrate. The formulae were started the second day of life in well newborns with a birth weight over six pounds. Although four of the group studied had difficult deliveries there were

no post-natal manifestations. Orange juice and cod liver oil were introduced the third week. The orange juice was first given half strength and increased gradually so that two ounces were given by the end of the first month. The 10 D cod liver oil was offered five drops a day increasing

Milks indicated for infants I n f a n t Types (392 Babies) Linear (20%)

Medial (25%)

Lateral (55%)

Breast Milk

Breast Milk

Breast Milk

Cow's Milk (3:1)

Cow's Milk (2:1)

Cow's Milk (1:1)

Evaporated Milk (1:1)

Evaporated Milk (1:11A)

Evaporated Milk (1:2)

Powdered Milk (1:7)

Powdered Milk (1:8)

Powdered Milk (1:10)

I n f a n t Diatheses (45 Cases) Allergic (65%)

Neuropathic (30%)

Developmental (5%)

Breast Milk

Breast Milk

Breast Milk

Goat's :Milk

Thick Feeding

Evaporated Milk

Evaporated Milk

Evaporated Milk

Acid Milk

l'owdered Milk

Acid Milk

Vegetable Milk

it gradually until the infant received one teaspoonful a day. The formulae were made up for twenty-four hours and divided into six feedings given at four hour intervals during the first month and subsequently into five feedings. The amount offered at each feeding was slightly above that usually taken by infants at each age level. The average volume consumed per infant was 4.4 ounces per feeding during the first month, 5.5 during the second and 6.5 during the third month, the average volume for the total day's feedings being 26, 27 and 30 respectively. The average caloric intake was about 70 calories per pound per day. The average gain in weight was 7.3 ounces per week and the average gain in height one inch per maath. The average number of stools was 2.6 per day. There were four cases of mild upper respiratory infection and one infant vomited. E V A L U A T I O N OF R E S U L T S W I T H R O U T I N E AND INDIVIDUALIZED FEEDING I. Comparative Intake of Formulae. The i n g e s t i o n of v a r i o u s types of f o r m u l a e was relatiy~|y u n i f o r m in a m o u n t for each g r o u p studied. D u r i n g the first m o n t h the i n f a n t s on b r e a s t milk took such v a r i e d a m o u n t s at each f e e d i n g t h a t the a v e r a g e volume i n t a k e is of little significance in c o m p a r i s o n w i t h artificial feeding. A p p a r e n t l y the effort exerted in n u r s i n g is more of a factor t h a n appetite in d e t e r m i n i n g the volume i n t a k e at a feeding. T h e placid r6le of i n f a n t s on artificial f e e d i n g accounts for the relatively u n i f o r m i n t a k e on the v a r i o u s types of p r e s c r i b e d formulae. I n f a n t s took less of the acid f o r m u l a d u r i n g the first m o n t h b u t once they became a d a p t e d to it t h e y took more of t h a t f o r m u l a t h a n of the others. D u r i n g the e n t i r e period of study i n f a n t s took more of t h e processed milk f o r m u l a e t h a n of the whole milk formula. And those on i n d i v i d u a l i z e d f e e d i n g s consumed more p e r f e e d i n g as well as for the t w e n t y - f o u r h o u r cycle. This is p a r t l y due to t h e fact t h a t more i n f a n t s were

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included in the series who have taken feedings steadily without alimentary upsets. The caloric intake per pound of body weight per twenty-four hours was greater on the more concentrated feedings, the least being with the diluted milk mixtures and the most with the acid and individualized formulae. II. Comparative Tolerance of Formulae. Food tolerance is estimated clinically without quantitative criteria. It is difficult to make comparative estimates of the relative degrees of tolerance for the formulae tested. Quantitatively an infant's tolerance for a food represents the ratio of the maximum amount of the food he can metabolize without resultant disturbances by the maximum amount of that food metabolized by a normal infant of the same age group. We must necessarily deal with maximum rather than with optimum intake in the consideration of tolerance because we do not know what the op*imum of any food is quantitatively for any infant. But we do know that there is a wide range between the minimum and the maximum and that any attempt to exceed the maximum produced a variety of disturbances essentially alimentary in nature. We are, therefore, led to the evaluation of tolerance of various formulae by a negative qualitative method of procedure. Those formulae consumed in the required amounts were considered well tolera£ed if they produced no untoward symptoms while those which produced digestive disturbances apparently exceeded the digestive capacities of the inrants and were considered poorly tolerated. All types of formula were well tolerated, excepting the whole milk mixture during the first month. There were the least number of digestive upsets on the individualized formulae and on the breast feeding throughout the feeding period studied. There were less digesrive disturbances on breast feeding than on fresh milk formulae. Only significant symptoms of digestive disturbances were included in this evaluation of tolerance for much of the minor symptomatology was more an expression of mismanagement than of misfeeding. However, a feature that is frequently neglected in relation to food tolerance during the first three months of life is the increased nervous tone of infants in both breast and bottle feeding. I t is usually alleviated by transient modification of the feeding quantitatively or qualitatively rather than by resorting to sedatives. The number and quality of the stools were not considered diagnostic of the normal range of alimentary function although frequency or abnormal character of stools were deemed pathognomonic of gastro-intestinal disturbance. A striking feature of the two groups on the fresh milk mixtures was the relation between milk tolerance and body build in well infants. During the first two months there was a relatively great preponderance of digestive disturbances amongst those infants who were maintained on the whole milk formulae. E i g h t y per cent of those infants were of the lateral body build. Most of the linear type infants tolerated whole milk mixtures without any disturbances. Apart from food tolerance the caloric requirement from body surface considerations indicates t h a t the linear infants require about seventy calories per pound of body weight while the lateral infants require about fiftyfive calories. This difference in energy requirement appears to parallel their differences in tolerance. It is curious that the high gastric acidity during the first

week of life should not increase the digestive capacities of all infants sufficiently to enable them to tolerate whole milk formulae. But after the second month the percentage of disturbances was parallel to those in the other groups. A significant number of digestive upsets occurred in the group maintained on breast feeding. Excluding disturbances resulting from faulty technique in nursing those that persisted were of the same order of magnitude as in the infants on artificial feeding. The time-honored procedure of analyzing breast milk chemically for the gross constituents is considered irrelevant. Even analysis of the minutae is unnecessary because deficiency disease has a long latent period before inducing disturbances. The difficulty, we believe, is usually with the infant constitutionally and not with the milk chemically. But weaning was nat deemed necessary until supplementary procedures failed to allay the disturbance. The formulae prepared from processed milk were the best tolerated. Off hand, these would appear the most logical for routine use in infant feeding if nursing is impossible but such an approach defeats the very purpose of infant nutrition. The types of feeding that meets with the digestive capacities of the infants is indicated r a t h e r than that which least utilizes digestive mechanisms. It is the newborn's task to adapt to "foreign" f o o d s - - a biologic and therefore a physical necessity. Ability to digest a food is gained by ingesting the food in gradually increasing amounts. The more work the digestive mechanism is made to perform the greater the alimentary efficiency. The indications in normal infant feeding are fresh milk mixtures for the infants that can tolerate them and processed milk mixtures for those with diminished digestive capacities. III. Comparative Nutritional Status. The adequacy of each type of feeding is best determined by the character and rate of growth of the infants of each group. But again growth evaluation is clinical rather than quantitative because we have no absolute standards of the composites of growth for each age level. Average weights and measurements of infants cannot be taken as guides for the developmental progress of an individual infant for the average infant is nonexistent. Developmental progress of an infant can best be evaluated in terms of himself as a standard and the increments of growth accruing at periodic intervals as the individual criteria of satisfactory achievement. These are based more upon clinical judgment than upon mere measurement. They include a variety of external manifestations of wellbeing such as type of facies, color of mucous membranes, condition of skin, quality of subcutaneous tissues, tissue turgor, muscle tone and skeletal characteristics. Even these properties of an infant are, during the first weeks of life, more an expression of his heredity and constitution than of the type of feeding instituted. Each group of infants thrived on the various formulae as on the breast feeding. The greatest gain in weight was in those on individualized feeding and the least on the diluted milk formulae. The infants on breast feeding and on the processed milk formulae gained more rapidly than those on the fresh milk mixtures. The more concentrated the formulae the more rapid the weekly gain in weight. In no group did this necessarily represent mere accumulation of adipose

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milk formulae than of the fresh milk formulae and the maximum was on individualized feedings throughout the period of study. The least number of digestive disturbances was observed on breast feeding and on individualized formulae. 3. The linear type infant required about 70 calories per pound of body weight and tolerated concentrated milk mixtures while the lateral type infant required about 55 calories per pound of body weight and tolerated diluted milk mixtures better. 4. Maximum gains in weight were observed in infants on individualized feeding and the minimum on diluted milk formulae. Infants on breast feedings and on processed milk feedings gained more rapidly than those on the fresh milk mixtures. The gains in height were the same on all types of feeding during the first three months. The incidence of infection was about the same for each group of infants studied. 5. Standard routine formulae were effective in over 80% of the infants studied. The residual nonconformists represented infants with latent constitutional disorders--organic, allergic and n e u r o p a t h i c - with either lowered digestive capacities or diminished tolerance. The early recognition of these types displaced routine by individualized feeding. This group showed the highest percentage of successful infant feeding.

tissue. Despite the high gains in weight there were no manifestations of overfeeding. In fact we have observed no absolute relation between the high gains in weight and quantities of formulae ingested. This applies to both the breast and artificially fed infants. Large lateral infants, for example, with birth weights of about eight pounds made more satisfactory gains on twenty ounces of a formula per twenty-four hours than did the long lean infants with a birth weight of about seven pounds on an intake of twenty-five ounces. But on all types of feedings the gain in height was practically the same at least for the first three months. In each group the incidence of infection was about the same, acquired in most infants from adult contacts. CONCLUSIONS 1. Comparative studies of "standard" formulae were made on 337 infants during the first three months of life with 55 breast fed infants as controls. The formulae consisted of whole milk, half diluted milk, evaporated milk (1 : 1), powdered whole milk (1 tablespoonful to 2 ounces of water), powdered lactic acid milk (1 tablespoonful to 2 ounces of water), each reinforced with 10% added carbohydrate. Each group maintained on a routine formula was compared with a group of 50 infants given individualized formulae. 2. The infants consumed more of the processed

A Case of Trichomonas Hominis Infestation By HORACE W. SOPER, M.D., F.A.C.P. ~ ST. LOUIS, MISSOURI

OFOID (1) points out the difference in the rela-

I~ tive importance of the parasitic protozoa, such as

the intestinal flagellates, and the hematozoa, e.g. trypanosomiasis, leishmaniasis, malaria, etc. The latter group is more catastrophic in its relations to the host than are the intestinal flagelloses. Kofoid believes that the flagellate parasites of the intestines may have more generalized capabilities of tissue invasion than has been hitherto suspected or detected. He states that there is abundant clinical evidence to the effect that they may be harmful when there is a disturbance of the normal bowel condition in the host due to exposure or infection as a result of which the resistance of the host is impaired. Hinklemann (2) reports that 5 c.c. of blood from a human case of diarrhea and intermittent fever, mixed with distilled water and centrifuged, show all the features of Trichomonas intestinalis. Ratz (3) found Trichomonas in the liver of pigeons. The appearance of Trichomonas in pleural transudates and exudates in man as well as the cancers, ulcers, lesions of the mouth, jaw, tonsils, esophagus and stomach also occasionally in liver abscesses is suggestive that it may have tissue invasive powers. The older German gastro-enterologists believed the flagellates to be non-pathogenic, occurring in the feces in most of the chronic diarrheas. ~From the Soper-Mills Clinic. Submitted January 25, 1937.

My experience has been limited to those more commonly occurring in my practice such as Trichomoaas, Chilomastix mesnili, Giardia enterica, Cercomonas and Balantidium coli. Close study of the feces of infected individuals give evidence of a low grade chronic entero-colitis. The treatment of all the flagellates that I have mentioned with the exception of the Giardia enterica is extremely simple. I employ stovarsol 0.25 gram tablet three times a day before meals for a period of three days. I have employed the follow-up method in a large number of cases and I have never known this drug to fail to completely destroy the organisms. The endamoeba coli is also quickly eradicated by this method of treatment. There is no question about the pathogenicity of Giardia enterica. Quite a number of chronic duodenal ulcer patients show Giardia infestation. In my hands patients with Giardia infestation usually show a recurrence about four weeks after the treatment t h a t was used. Jelks (4) recommends transduodenal irrigations of a solution of neo-arsphenamine. Barrow (5) and many others employ stovarsol or carbarsone. Smithies (6) recommends five to ten grains of calomel followed by a saline. This dosage may be repeated in one week's time. The patient is given thymo!