. CORNELL UNIVERSITY LIBRARY David Albert Hauck Endowment PRINCIPLES AND CONDITIONS OF ARTIFICIAL FEEDING. Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924098811213 ON THE PRINCIPLES AND EXACT CONDITIONS TO BE OBSERVED IN THE ARTIFICIAL FEEDING OF INFANTS: THE PROPERTIES OF ARTIFICIAL FOODS : AND THE DISEASES WHICH ARISE FROM FAULTS OF DIET IN EARLY LIFE. A SERIES OF LECTURES DELIVERED IN THE POST GRADUATE COURSE AT ST. MARY'S HOSPITAL, AND AT THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND STREET, I887 BY W. B. CHEADLE, M.A., M.D.Cantab., F.R.C P. PHYSICIAN TO ST. MARY'S HOSPITAL AND CO-LECTUKER ON CLINICAL MEDICINE IN ST. MARY'S MEDICAL SCHOOL J CONSULTING PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN. FOURTH EDITION. LONDON : SMITH, ELDER, & CO., 15 WATERLOO PLACE. 1896. [Ail rights reserved PREFACE TO THE FOURTH EDITION THE Lectures have been further revised and amended, and a few slight additions have been made,^ chiefly to the chapters treating of Rickets and Scurvy. 19 Portman Street, London, W. November 9, 1895. PREFACE TO THE THIRD EDITION The text has been revised throughout and some corrections made, as well as numerous additions which have been suggested by later experience. These relate chiefly to the qualities of cow's milk and its preparations '; the effect of various diluents upon it ; the use of peptonised and pancreatised foods, and the influence of their prolonged use on the de- velopment of the scorbutic state. 19 Portman Street, London, W. October I, 1894. PREFACE TO THE SECOND EDITION THE present Edition has been revised throughout, and some new matter added to the text, more particularly with regard to the sterilisation of milk, the relation of eruptions of the skin to diet, and other points of practical interest. The results of the analyses of human milk hitherto made differ so widely in the amount and relative proportions of many of the elements that a fresh de- termination of these has been thought desirable, and this has been ably carried out for me by my friend and colleague Dr. Luff. The results are based upon the examination of samples from twelve different subjects, each constituent being estimated positively, not by difference. The most recent and improved processes have been adopted, especially in the deter- mination of the proteids and the fat, and the results viii ARTIFICIAL FEEDING OF INFANTS are no doubt the most exact and reliable yet attained. The proportions for cow's milk have also been cor- rected by later analyses than those originally adopted, and the figures throughout revised in accordance with the corrected standards. Dr. Luff has also completed his previous analyses of the various foods by deter- mining the amount of lime and of phosphoric acid. For this valuable and indispensable aid in organic analysis I tender my most cordial acknowledgment. My best thanks are also due to Dr. Hope, the Senior Physician to Queen Charlotte's Hospital, and to Dr. W. A. Bond and Dr. E. H. Brock for their kind offices in procuring the necessary supply of human milk. 19 Portman Street, Portman Square, W. May 21, 1892. PREFACE TO THE FIRST EDITION The reason and purpose of these Lectures are suffi- ciently set forth in the introductory portion, and I have here only to express my cordial and sincere thanks for much kind and valuable help received from many sources. I am especially indebted to my friend and colleague at St. Mary's, Dr. Arthur Luff, for the accurate and repeated analyses of milk and various other foods and preparations which he has made for me ; to Mr. Arthur Savory and Mr. Ekin for similar service ; and to the makers of various articles of diet for information freely and generously supplied. 19 Portman Street, Portman Square, W. /««« 14, 1889. CONTENTS LECTURE I. THE SCIENTIFIC PRINCIPLES UPON WHICH ARTIFICIAL FEED- ING SHOULD BE BASED, AND THE EXACT CONDITIONS TO BE OBSERVED IN THE COMPOSITION, PROPERTIES, AND QUANTITY OF INFANTS' FOOD. Introductory — Importance of the subject — The lack of precise knowledge— Examples of common errors — Exact conditions essential to a diet of full nutrition — The elements of food — The purposes which they serve — The proportion in which these elements must be combined— The standard proportions differ in the case of adults and of infants — The amount of proteid and of fat greater in the latter — Argument from pro- portions in human milk, and from gross amounts consumed — Condition I. The standard scale of proportions must be ob- served — Condition II. An antiscorbutic element essential : Present in certain foods, absent in others — Condition III. The total amount of aliment must be sufficient : Quantity required : Argument from breast supply : from amount of elements con- sumed : Varies within certain limits — Condition IV. Food must contain a certain proportion of animal element : Reasons for this— Condition V. Food must be in a form suited to the special physiological state of the digestive functions in infancy : Food should be of the same kind at every meal : Adapted to imperfect power of digesting starch : This the chief ingredient of most artificial foods : The carbohydrate element to be in the form of dextrine, maltose, or grape-sugar : Inability of infants' digestive power to deal with large solid or semi-solid' masses, or hard fibre — Condition VI. Food must be fresh and sound, free from taint of sourness or decomposition — Summary RAGE xii ARTIFICIAL FEEDING OF INFANTS LECTURE II. ARTIFICIAL FOODS — THE VARIOUS FORMS OF MILK AND ITS PREPARATIONS. PAGE Brief summary of conclusions reached in the previous lecture — Advantages of wet-nurse — Difficulties in the way — Table of proportion of elements in various kinds of milk — Preparations of cow's milk— Asses' milk one of the best substitutes for human milk— Its advantages and disadvantages— Cow's milk diluted with water — Nutritive value of different degrees of dilution — Two parts milk to one part water essential to full nutrition — The real difficulty of cow's milk due to the character of the casein, not to excess of solids — Comparison of the casein of cow's milk with that of other kinds of milk — Its massive coagula — Experiments— Expedients for remedying this coarse coagulation — Dilution — Boiling — Barley water— Lime water — Bicarbonate of soda — Peptonised milk — Qualities of the various preparations considered — Objections raised to boiled milk considered — Its advantages — Arrest of contagion from this source — Sterilised milk — The process — Condensed milk : its good and bad qualities — Goat's milk — Artificial human milk 41 LECTURE III. ARTIFICIAL FOODS — continued. GLUTEN FOOD — THE MALTED FOODS — OTHER FARINACEOUS FOODS — BEEF-TEA PREPARATIONS— RAW MEAT JUICE — ESSENCES OF MEAT. Summary of conclusions reached in the previous lecture — Develop- ment of the child's power of digesting milk — Necessity for supplementing the milk with other food in certain cases — Table of nutritive values of various artificial foods and prepa- rations — Bread jelly or gluten food — Mode of preparation — Insufficient alone — With milk — With meat juice and cream —Nutritive value of these preparations— Farinaceous foods — Conditions under which they are admissible — Deficiency of fat and of antiscorbutic element — To be regarded as adjuncts or accessories only — Their value — They add nitrogenous and car- CONTENTS xiii l'AGE bohydrate elements and salts — Malted foods; of two classes — Examples — Their insufficiency alone — Nutritive values of the various forms — When mixed with water only — When mixed with a due proportion of milk, or other animal elements— Ob- jections which have been raised to the use of these foods — The proper place of these foods in infant feeding — Pan- creatised food — Distinction between pancreatised food and a malted food — Advantages and dangers of predigested foods — Reasons — Foods which are neither malted nor pancreatised— Their composition— Useful for older children as additions to milk — Entire wheat flour — Arrowroot — Cornflour — Rice — Prepared barley — Tapioca — Sago — Oatmeal — Malted foods with desiccated milk — Composition — Their insufficiency alone — Other accessory foods — Meat juices and essences — Beef tea — Analysis — Small percentage of proteid — Poor in structural materials — Unsatisfactory results as a food for children— Veal broth — Raw meat juice — Mode of preparation — High nutri- tive value and digestibility— Analysis— Raw meat pulp — Mode of preparation — Patent meat juice— Its analysis and uses — Meat essences — Analysis — Their place as a food — The meat peptones — High nutritive value — Their special uses . 78 LECTURE IV. DISEASES WHICH RESULT FROM ERRORS OF DIET, AND THEIR TREATMENT — DYSPEPSIA, DIARRHCEA, CONSTIPATION, STO- MATITIS, ANEMIA, ATROPHY. Food disorders of two classes : (1) Those resulting from irritation of the alimentary tract ; (2) Those arising from defective nutri- tion — Class I : Dyspepsia, gastro-enteric catarrh, choleraic diarrhoea, constipation — Dyspepsia in hand-fed children — In sucklings— Its symptoms — Causes— Most common in hand-fed children— The prime error— How it is to be avoided— Danger of cow's milk and water— Importance of boiling— Of sufficient dilution— Gastro-intestinal catarrh— Something more than mere indigestibility necessary to set up severe forms, viz. de- xiv ARTIFICIAL FEEDING OF INFANTS composition — Conditions under whichit arises — Danger greater in hot weather and warm climates — Mortality from this cause — Various degrees of gastro-enteric catarrh — Symptoms — Effect of loss of fluid on the body — Post-mortem appearances — Treatment — Broad principles on which treatment should be based — Diet — Non-fermenting — Non • irritant — Nutritive — Various modes of attaining this — Stimulants — External warmth — Bismuth — Opium — Ipecacuanha — Grey powder — Their ac- tion and effective combination —Chronic diarrhoea — Peristalsis too readily excited — Treatment — Constipation — Treatment by diet and simple laxatives — Thrush — Occurs chiefly in hand- fed children - The fungoid growth — Symptoms — Follicular stomatitis — Ulcerative stomatitis — Treatment — Atrophy — Due to many causes— Atrophy from too scanty food — From food deficient in certain elements — Atrophy from vomiting and diarrhoea— From imperfect digestive power— Cases in illustra- tion — Ana;mia — Food one of the factors — Forms of food ancemia — Aneemia of starch-fed children — From deficiency in animal element of food— From defective digestive power — Treatment : Iron and arsenic, raw meat juice, sunlight, pure air — Eruptions of the skin — Eczema — Urticaria — Lichen urticatus . . . 125 LECTURE V. DISEASES WHICH RESULT FROM ERRORS OF DIET, AND THEIR TREATMENT — continued. Rickets. Occurs chiefly in first two years of life — The affection of the bones — Type of the rickety child — Bone defects not the sole lesion — Other constitutional peculiarities — Affection of muscles — Aneemia — Night-sweats— Tendency to catarrhs '--The nervous system shares the general malnutrition — Its higher excitability — Laryngismus — Tetany — Convulsions —Symptoms may be slight — Signs which should excite suspicion — Rickets largely a food disorder — Usually several factors— Influence of inheri- tance — Of syphilis— Of want of air and light — Rickets may CONTENTS xv PAGE arise where all points of hygiene are good except food— This the most constant factor — Evidence of the connection of rickets with defect of diet — Occurs chiefly in hand-fed children — Im- munity of children at the breast — Artificial production of rickets in animals — Experiments of Guerin and Tripier — Experience at the Zoological Gardens— Theory of its dependence on lack of lime — Experiments of Chossat and Wegner — The lactic acid theory — Evidence from the simplest cases — Fat most probably essential — Importance of proteid — Of phosphate of lime — Re- markable results of change of diet in arrest of rickets in young animals — Influence of other causes — Vomiting and diarrhoea — Varieties of rickets according to causes at work — Starvation ' rickets — Syphilitic form — Cranio-tabes — Enlargement of liver and spleen — Large rickets — Rickets in sucklings — On diet of cow's milk — Explanation — Foetal rickets — Congenital form — Late rickets — The common form of food rickets — An emi- ' nently preventable disease — Treatment by diet chiefly — Value of cream and raw meat — Mode of preparation of the latter — Cod-liver oil — Recovery favoured by ftesh air and sunlight — Case I. Typical example of severe rickets : Chief symptoms : Remarkable family history : The prevalence of the .rachitic state explained by the regimen : Faults of feeding aggravated by want of light and air : Treatment : Recovery without any change in hygienic conditions except food— Case II. Rickets arising under exceptionally perfect general hygienic conditions : Food only defective : Effect of faulty diet mitigated by hygienic conditions : Treatment by antirachitic diet : Recovery — Case III. Rickets occurring under ordinary favourable hy- gienic conditions : Food alone faulty : Condition of patient : History ; Recovery under proper feeding .... 166 LECTURE VI. SCURVY, OR SCURVY-RICKETS. Infantile scurvy— Identification of the disease — The acute rickets of German authors — Records of the disease in England— The characteristic symptoms of scurvy — The condition set up by xvi ARTIFICIAL FEEDING OF INFANTS PAGE privation of certain constituents of fresh food — The disease cured by the supply of these— Scurvy occurs in young children in all degrees of severity— Mortality — The symptoms corre- spond closely with those met with in adults — Occasional variation in the condition of the gums and in pyrexia — Other symptoms and morbid anatomy identical — The cause the same — Examples of children's diet producing scurvy — The disease cured as in adults by antiscorbutics — Example showing ex- treme rapidity of recovery — Case I. Typical scurvy in a child of 1 6 months — Severe symptoms accompanying rickets : Die both rachitic and scorbutic : All other hygienic conditions ex- cellent : Value of milk and potatoes in a child's dietary : Rapid effect of antiscorbutic diet, all other conditions being un- changed — Case II. Scurvy in a child IO months old : Symp- toms : Concurrent rickets. Food : Effect of antiscorbutic diet: Brief account of recent cases — Case III Scurvy in a boy of 14 months : Full series of scorbutic symptoms : Concurrent rickets : Previous regimen : Difficulty in feeding : Death on fourth day from haemorrhage into the lung : Post-mortem ap- pearances — Case IV. Patient aged 13 months : Well-marked signs of scurvy : Concurrent rickets : Previous feeding : Effect of full antiscorbutic diet — Case V. Persistent hsematuria in a child 12 months old : Other symptoms suggestive of scurvy : Cachexia : Syncopal attacks : Spongy gums : Haemorrhages : Periosteal swellings : Concurrent rickets : Previous feeding : Difficulty in feeding : Recovery — Case VI. A child 9 months old : Previous diet : Great tenderness of legs and inability to run, supposed to be rheumatic : Periosteal swelling : Other signs of scurvy doubtful : Subsequent occurrence of extensive haemorrhages under the lower eyelids : Immediate improve- ment on addition of certain elements to former food — Scurvy on peptonised and pancreatised foods — The association of rickets with scurvy — Explanation — The tenderness of limbs in rickets possibly scorbutic — Necessity for bearing in mind the frequent association of the two diseases — Conclusion .... 208 INDEX 237 LECTURE I THE SCIENTIFIC PRINCIPLES UPON WHICH ARTIFICIAL FEEDING SHOULD BE BASED, AND THE EXACT CONDI- TIONS TO BE OBSERVED IN THE COMPOSITION, PROPER- TIES, AND QUANTITY OF INFANTS' FOOD Introductory — Importance of the subject — The lack of precise know- ledge — Examples of common errors — Exact conditions essential to a diet of full nutrition — The elements of food —The purposes which they serve — The proportion in which these elements must be com- bined — The standard proportions differ in the case of adults and of infants — The amount of proteid and of fat greater in the latter — Argument from proportions in human milk, and from gross amounts consumed — Condition I. The standard scale of proportions must be observed — Condition II. An antiscorbutic element essential : Present in certain foods, absent in others — Condition III. The total amount of aliment must be sufficient : Quantity required : Argument from breast-supply : From amount of elements consumed : Varies within certain limits — Condition IV. Food must contain a certain proportion of animal element : Reasons for this — Condi- tion V. Food must be in a form suited to the special physiological state of the digestive functions in infancy : Should be of the same form at every meal : Adapted to imperfect power of digesting starch : This the chief ingredient of most artificial foods : The carbohydrate element to be in the form of dextrine, maltose, or grape-sugar : Inability of infants' digestive power to deal with large solid or semi-solid masses, or hard fibre— Condition VI. Food must be fresh and sound, free from taint of sourness or decomposi- tion — Summary. B ARTIFICIAL FEEDING OF INFANTS REASONS FOR THE CHOICE OF THIS SUBJECT I SHALL make no apology, gentlemen, for the subject of these lectures, trite and commonplace as it may- seem to be ; and for these reasons : In the first place, because difficulties connected with this question of the feeding of infants are amongst the most common of the many troubles which beset the ordinary practitioner, and are con- stant sources of worry, of anxiety, and not unfre- quently of discredit. Owing to many different causes a very large number of children cannot be suckled by their mothers, or transferred to wet-nurses, and must be brought up by hand. The mother dies or falls into ill-health, or has no supply of milk, or is too closely occupied to attend to her child. A wet-nurse is expensive, troublesome, often difficult to obtain, and in a vast majority of cases practically out of the question. There is no alternative but artificial feed- ing. So. that this question has constantly to be faced. In the second place, a large proportion of the diseases of early life, some of the most fatal, and some of the most lasting in their influence, have their origin in errors of diet. EXACT CONDITIONS TO BE OBSERVED 3 It is not merely a question of overcoming a passing difficulty, or of effecting temporary benefit, but one which largely affects the whole future of the child. IMPORTANCE OF THE QUESTION AS A MATTER OF NATIONAL HYGIENE It is, therefore, of immense practical importance as a matter of national hygiene. Of the four great external conditions which influ- ence the development of the young organism — food, air, heat, and sunlight — food is one of the most potent. Of course the intrinsic condition, original consti- tution, played upon by these external conditions, is the other great and prime factor. In some individuals there is a high capability for development, in others the organism is originally so weak and faulty that it is incapable of reaching any great degree of strength and perfection. But the peculiarities of original con- " stitution may be largely modified by external influ- ences. The feeble and imperfect body which, under adverse conditions, would fall still lower, or dwindle and die, may, by favourable conditions, be fos- tered into some degree of vigour and stability ; the well-made body of rich possibilities may, under evil 4 ARTIFICIAL FEEDING OF INFANTS conditions, be degraded, and grow stunted and de- formed, while under favourable surrounding influences it will develope into the highest perfection. THE LACK OF PRECISE KNOWLEDGE ON THE SUBJECT A third reason which has influenced me is the discovery that there is a lack of correct and precise knowledge on this subject, not only amongst students, but amongst medical men in active practice also ; and even more than this, a great deal of positively erroneous belief, and of mistaken practice founded upon it. The main cause of this serious deficiency is to be found, I think, in the fact that the subject is neglected in our medical schools. It is either not taught there, or only in vague generalities and in desultory fashion. No accurate and scientific expo- sition of it is to be found in the ordinary text-books. The materials of knowledge exist, but they are scattered about in the pages of works on physiology and on hygiene. And thus, when the student enters upon the actual work of his profession, he has no certain data to guide him. He lacks accurate knowledge (i) of the physiological laws which govern the needs and COMMON ERRORS 5 powers of an infant, with their variations in health and disease ; and (2) of the exact nutritive value of the various materials adapted for artificial feeding. And so the method followed is too often routine and mere rule of thumb. The exact nutritive value of the food chosen and its relative digestibility is not estimated ; if one kind does not agree, another is substituted haphazard, not because its ingredients are known to be accurately adapted to the special needs of the particular child, but because some other child appears. to have done well on it, possibly under quite different conditions — with different constitution, of. different age, of different digestive power, in a dif- ferent state of health. , EXAMPLES OF COMMON ERRORS Thus, to give examples from actual experience, I have seen a delicate little infant, with a stomach whose powers were utterly unequal to digesting the coarse heavy curd of cow's milk, which set up vomit- ing and purging, forthwith put on goat's milk. Now, goat's milk is excellent food for children ; it contains more cream than cow's milk, and almost the same proportion of casein. But the casein coagulates in equally heavy masses, and therefore goat's milk 6 ARTIFICIAL FEEDING OF INFANTS was quite unsuited to meet the particular difficulty in the case, and the change, instead of doing good, made matters worse than before. Again, I have seen too frequently — the most common mistake of all, perhaps — a puny, bloodless child, with incipient rickets, eminently suffering from want of animal proteid and fat, owing to its inability to digest cow's milk, placed upon a purely farinaceous diet, with the result of causing still further deteriora- tion, and inducing scurvy in addition to rickets. Such instances, gentlemen, I might multiply almost indefinitely. But these will suffice to indicate the evils which arise from the imperfect appreciation of physiological laws in relation to diet, and of the properties of the materials available for artificial feeding. THE EXACT CONDITIONS ESSENTIAL TO A DIET OF FULL NUTRITION I pass on now to the first point in the considera- tion of this subject, viz. the exact conditions essential to be fulfilled in the diet of a child in order that it may afford perfect nutrition. And here, before I proceed further, I must ask your indulgence. In order to place the question clearly before you, I shall , EXACT CONDITIONS TO BE OBSERVED 7 be obliged to state many things which you probably know already. If, however, we are to follow out readily what we have before us for consideration, it is necessary, I think, to refresh our memories with the groundwork ; and the time thus spent in brightening the recollec- tion of elementary facts will not be lost. THE MATERIALS REQUIRED AND THE PURPOSES WHICH THEY SERVE First, then, the body requires a constant supply of materials for various essential purposes. In a full- grown person the chief of these are the repair of structures, many of them undergoing constant, un- ceasing change and as unremitting self-repair ; the supply of secretions requisite for vital functions, as the juices which effect digestion, for example ; and also as fuel to be burnt in the body for the generation of heat, and of force or energy for every movement and action and operation of organic life. In children there is a need for materials for another grand purpose in addition, viz. for the struc- ture and development of new parts. The existing tissues have to be kept in repair, just as with adults, but what may be called building 8 ARTIFICIAL FEEDING OF INFANTS materials are also required for making the new tissues of the growing structure. So that a child requires certain materials in larger proportion than an adult. While a mature adult can thrive upon a limited assortment of food elements, provided that it contains combustible enough for the supply of energy, and enough of other materials for the secretions and for the repair of waste and wear, the child requires a more varied assortment, containing, in addition to the ordinary essential elements, certain special ingre- dients necessary for the original structures of fresh growth. Some of these new structures — as the mineral portion of bones, for example — are permanent, and require little or no repair afterwards. THE ESSENTIAL, ELEMENTS OF FOOD — FIVE CLASSES Now, the essential elements of food, I may be per- mitted to remind you for a moment, are of five chief •classes. I. The nitrogenous elements, characterised by the presence of nitrogen, the chief of which are the albuminates or proteids, found most largely in animal EXACT CONDITIONS TO BE OBSERVED 9 foods. Of these the albumen of egg, the casein of milk, the syntonin of muscle, and the gluten of wheat are examples. 2. The hydrocarbons or fats. 3. The carbohydrates, of which starch and sugar are the chief forms. 4. Mineral elements, of which the salts of lime, especially the phosphate and carbonate, potash, soda, iron, are the chief. 5. Water, the most general and largely used of all. FOR PERFECT NUTRITION FOOD MUST CONTAIN ELEMENTS FROM EACH CLASS It has been ascertained by numerous observations and experiments that, in order to afford perfect nourishment to the body, food should contain materials drawn from each of these five groups. A man may get on for a time without one or other, perhaps, such as the carbohydrates or the fats ; but not continuously. For perfect health all must be combined. For a little child, even more than for an adult, it is essential that food should contain elements from each class. io ARTIFICIAL FEEDING OF INFANTS WITH CHILDREN, AS WITH ADULTS, PROTEIDS RANK FIRST IN IMPORTANCE And with children, as with adults, the nitrogenous elements or proteids rank first in importance. They are used for the structure of brain, nerve, muscle, and gland. Protoplasm, the centre of life and energy in every individual cell, is formed of nitrogenous matters, and nourished out of them. Every structure in the body in which any form of force is manifested is nitrogenous. Nitrogen is indeed essential to every vital process. Deprived of it, every function of the body languishes. All vigour and power dwindle and die out. It is clear, then, that if a sufficient supply of nitrogenous material or proteid is of the first import- ance to mature adults, it is- still more essential in the case of children with growing bodies, who require this material for new structures, in addition to that necessary for the routine work of maintaining the existing structure. EVIL EFFECTS OF WANT OF NITROGEN Deficiency of this element of nitrogenous food shows its evil mark quickly : the child's growth is EXACT CONDITIONS TO BE OBSERVED n interrupted ; it becomes flabby and soft of muscle, pallid, feeble ; vigour and vitality, and the power to resist disease, decline. THE HYDROCARBONS OR FATS SECOND ONLY TO PROTEIDS The second group, the hydrocarbons or fats, are inferior in importance only to the preceding. Fat, like the nitrogenous protoplasm, appears to form a necessary part of every cell, enters largely into the structure of brain, and nerve, and the marrow of bone, and it is stored up in all nooks and corners of the frame. Probably its chief office is to serve as fuel — burnt in the body just as oil is burnt in a lamp or coal in a furnace. Thus is supplied the heat required to keep up the temperature of the body to the standard necessary for vitality of the fluids and solids of which it consists, and thus also is supplied chiefly the force (converted from its co-relative, heat) for every action and motion and function of the organism. 12 ARTIFICIAL FEEDING OF INFANTS THE EXTREME IMPORTANCE OF FAT IN THE DIET OF INFANTS In the case of infants, again, it is obvious that this element of food, fat, must be of the very highest im- portance. It is wanted for the generation of heat and energy so largely called upon in the period of early growth. It is wanted for every tissue formed and forming, especially for brain and nerve cell, and for the marrow cells. 1 In children who are fed upon a deficient amount of fat the bony structures are imperfect and slow of growth ; in a word, deficiency of fat in the food is one of the chief factors in the production of rickets. THE USES OF CARBOHYDRATES The next group of elements, the carbohydrates, of which starch and sugar are the representatives, do not appear to be used directly in tissue-formation, al- though theyare present in the form of glycogen (grape- sugar) and inosite (or muscle-sugar) in certain organs 1 It is probable, I think, in view of the imperfect tissue-formation which results from a deficiency of fat in the food of children, that all used for structural purposes is derived from that supplied from without in food as fat — not fat manufactured in the body, as it is so largely from the carbohydrates, and by the splitting up of albuminous com- pounds, and which is used for combustion, or stored up in adipose tissue. EXACT CONDITIONS TO BE OBSERVED 13 and fluids of the body. The carbohydrates in food are largely converted into fat, and thus serve for combus- tion ; and also in the form of invert sugar, perhaps, as a lighter kind of fuel than the more highly carbona- ceous element, fat. These elements, then, appear to possess less intrinsic value than the preceding, the proteids and the fats. Certain races of men, such as the Esquimaux, who live almost entirely on animal food, get little or none — except from fruits in the short arctic summer, or in the form of lichenin in Iceland moss — and yet retain their health. The children, however, get carbohydrate in infancy in the form of the sugar in their mothers' milk. Seeing how largely carbo- hydrate is present in ordinary food, and how plenti- fully it is supplied to infants in their natural diet, milk, this element is probably essential to the perfect nutrition of the adult organism, and certainly to that of the growing organism. THE IMPORTANCE OF THE MINERAL ELEMENTS IN CHILDHOOD The mineral constituents of food, which form the fourth group of elements, are many of them essential to life at every age, but some far more important to children than to grown persons. H ARTIFICIAL FEEDING OF INFANTS Iron, salts of lime, magnesia, potash, and soda are essential to bodily nutrition at all ages and in every phase. , VALUE OF SALTS OF LIME AND MAGNESIA IN CHILDHOOD The phosphate of lime appears, indeed, to be necessary to every tissue. Probably no cell growth can go on without the earthy phosphates. Even the lowest forms of life, such as bacteria and fungi, cannot grow if deprived of them. 1 But there is an additional and special need for these salts of lime and magnesia in childhood for the building up of permanent structures, such as the mineral part of bone, which probably require little or no repair afterwards. Water, again, is essential to all for the solution and carriage of peptones from the stomach to the blood stream, for the liquefaction of the blood and of the secretions, and for the restora- tion of tissue. But more is needed in proportion by the infant organism for the building up of new tissues, four-fifths of which consist of water. t With infants, therefore, as with adults, it is essen- tial that food should comprise a sufficient amount of 1 rarkes's Manual of Hygiene, 4th ed. p. 176. EXACT CONDITIONS TO BE OBSERVED 15 ingredients from each of these five groups: proteids, hydrocarbons, carbohydrates, minerals, water. RELATIVE PROPORTIONS IN WHICH THE ELEMENTS FROM EACH CLASS SHOULD BE COMBINED Then comes the question, since these are the materials required by the growing body of the child, and such being their relative importance, how much proteid does a child require? How much fat? How much starch, dextrine, or sugar ? In what proportions should these ingredients be present in the food ? PROPORTIONS IN THE CASE OF ADULTS Now, it has been ascertained by numerous experi- ments that in order to keep an adult body in perfect health the various essential elements should be com- bined in the following proportions : Nitrogenous elements or proteids (albumen, casein, &c.) I -co part Hydrocarbons (fats) . . . • , ■ O'6o ,, Carbohydrates (starch, dextrine, sugar, &c.) . ' 3-00 parts Salts 0-23 part Water 15-17 parts 20 - 00 i6 ARTIFICIAL FEEDING OF INFANTS Or, raising the proportions to so much in ioo, or a percentage : ' Proteids 5-00 Fats . 3'°° Carbohydrates 15-00 Salts 1 -IS Water 75'8S ioo-oo Should, then, the proportions for a child, be the same as for grown persons ? The answer is unmis- takably in the negative. The proportions should not be the same. PROPORTIONS DIFFERENT IN THE CASE OF IN- FANTS — EVIDENCE FROM PHYSIOLOGY — THE MILK STANDARD The evidence afforded by physiology and the evidence obtained by actual observation agree on this point, and are absolutely conclusive. First, the evidence from physiology. Milk contains everything essential for the forma- tion and nourishment of the child during the first months of life, out of which, without addition of 1 Moleschott's table quoted by Parkes, confirmed by numerous other experimenters sufficiently closely ; by Pettenkofer and Voit, Von Ranke, Playfair. EXACT CONDITIONS TO BE OBSERVED 17 other food, it can grow into complete perfection, just as an egg supplies every material out of which the chicken is formed complete, with bone and flesh and feathers. Human milk, therefore, may be taken as the type- food for an infant, and the proportions of the differ- ent ingredients found to be contained in it may be taken as the standard of an infant's food when arti- ficially made. The analyses of human milk show, however, considerable variation. That of Payen, which long remained the standard, gives Proteid (casein and albumen) • 3-35 Hydrocarbon (fat) ■ 3-34 Carbohydrate (lactine and salts) . • 377 Water • 89-54 A later one by Gorup-Besanez : Proteid (casein and albumen) Hydrocarbqn (fat) Carbohydrate (lactine) Salts Water .... 3 - 924 2-666 4-364 0-138 88-908 More recent analyses still by Kbnig, Forster, C \Y 1 8 ARTIFICIAL FEEDING OF INFANTS Meigs, Harrington, and others, collated by Rotch, 1 give the following approximate results : Proteid I to 2 Fat 3 t° 4 Lactine ...... 7 Salts 0-2 Water 87 to 88 All these analyses of human milk agree with regard to the high percentage of fat in proportion to carbohydrate and to proteid, as compared with the standard proportions of these elements in the diet of an adult previously given. In Payen's the fat is as nearly as possible equal to the carbohydrate, instead of only 1 : 5, as with adults ; and it is equal to the proteid, instead of only 3 : 5, as with adults. The figures of Gorup-Besanez make the propor- tion of fat 1 : 2, as compared with only 1 : 5 for adults, and with regard to the proteid it is nearly 2 : 3, instead of only 3 : 5, as with adults. In the more recent analyses collated by Rotch, 1 the proportion of fat to carbohydrate is from 3 or 4 : 7, as compared with only 1 : 5 in the case of adults ; and 3 or 4 : 1 or 2 of proteid, instead of only 3 : 5 in adult diet. Although, however, these various analyses exhibit clearly in each case the essential 1 Keating's Cyclopcedia of Diseases of Children, vol. i. p. 275. EXACT CONDITIONS TO BE OBSERVED 19 differences in the relative proportions of the different elements in the standard children's diet of human milk as compared with the proportions in the stand- ard for adults, it will be seen that there is considerable difference in the actual amounts of each element given by the various analysts. In view of this dis- crepancy, Dr. Luff has at my request made careful analyses of twelve different samples 'of human milk. Every element has been estimated directly by the latest and most exact method. In no case has the amount of an ingredient been estimated by mere difference, as has been the general practice in pre- vious analyses. This, therefore, may be taken as the most exhaustive, exact, and reliable estimation yet achieved, and I have adopted it as the standard ; the proportions are as follows : Human Milk (Dr. Luff's analysis). Proteid 2-35 Fat 2-41 Lactine 6 39 Lime ....... -019 Phosphoric anhydride .... -026 Other constituents of ash . . . -295 Water 88-51 100 -ooo Here again the fat is to the carbohydrate as 1 : 2^ instead of 1 : 5, as in adult diet, and more than equal to proteid, instead of 3 : 5 only. c 2 2o ARTIFICIAL FEEDING OF INFANTS This altered proportion of elements and predomi- nance of fat in an infant's diet as compared with that of an adult is a most significant and important fact constantly disregarded or overlooked in the actual practice of feeding children. EVIDENCE FROM GROSS AMOUNTS OF EACH INGREDIENT REQUIRED AT DIFFERENT AGES Further, there is the evidence of actual observation as to the gross amounts of each ingredient required at different ages — evidence distinct from the inference drawn from the analogy of human milk. Investigations conducted at Munich show that the smallest amount of food compatible with health at different ages is as follows : l Age Nitrogenous elements Fat Carbohydrates Child under i^ year 20 to 36 grms. 30 to 45 grms. 60 to 90 grms. Child from 6 to 15 years 70 „ 80 „ 37 » 5° .. 250 ,,400 „ Man (moderate work) . 118 grms. 56 grms. 500 grms. Woman (mode- rate work) 92 .. 44 ,. 400 „ Old man . 100 „ 68 ,, 35° ., Old woman 80 „ 5° .. 200 ,, 1 Landois and Stirling, Human Physiology, vol. i. p. 481. EXACT CONDITIONS TO BE OBSERVED 31 We see that for children the proportion of fat to carbohydrates is 30 grammes (fat) to 60 grammes (carbohydrates), or 45 to 90, according to age, i.e. exactly as 1 : 2, the precise proportion found to exist in the standard food, milk. For the adult it is 56 ; 500, or about 1 : 9 only. LARGE GROSS AMOUNT OF FAT REQUIRED BY A CHILD AS COMPARED WITH AN ADULT Further proof of the large amount of fat required by a child in proportion to that necessary for a grown person is shown by this table of gross amounts. For a little child under i^ year the total required in 24 hours is estimated at 30 to 45 grammes. For a grown man in 24 hours, 56 grammes. Or, roughly, for the tiny infant from half to three- quarters as much fat is necessary in food in 24 hours as for a full-grown man. Then, again, the proteid should be in larger pro- portion to the carbohydrate than in an adult diet, as 3^ : 4, or nearly equal, instead of 1 : 3 only. Similarly, the gross amounts show that The proportion of proteid to carbohydrate for a child is 20 : 60 = 1 : 3 or 36 : 90 For an adult it is as .... 118 : 500= 1 : 5 nearly 22 ARTIFICIAL FEEDING OF INFANTS THE RELATIVE PROPORTION OF THE DIFFERENT ELEMENTS NECESSARY IN INFANTS' FOOD DE- DUCED FROM THE PRECEDING EVIDENCE The outcome of this may be summed up thus : Taking Dr. Luffs analysis of human milk as the final standard, the proportion of fat to the other elements, viz. the proteids and the carbohydrates, should be very much larger than in the food of adults, i.e. the fat should be rather more than equal to the proteid (2 - 4i : 2"3S) instead of only as 3:5, and the fat again should be to carbohydrate as 1 : 2\ (2"4i : 6-39) instead of as 1 : 5 only, as in the food of adults. And in the same way the proteid should be in higher proportion to the carbohydrate, 1 : 2§ instead of 1 : 3. The proportions essential in infants' food, thus deduced, may be stated broadly thus : Proteid 2\ Fat 2\ Carbohydrate . . . - 65 THE ESPECIAL IMPORTANCE OF A FULL PROPOR- TION OF FAT IN THE FOOD OF INFANTS The existence of this large proportion of fat in the standard food, milk, is conclusive as to its great EXACT CONDITIONS TO BE OBSERVED 23 importance. A similar proportion obtains in the milk of all animalsj not in human milk only. There can be no doubt that fat serves some most vital purpose in the nutrition of young growing animals. What that precise end may be we are not quite certain, but, as I pointed out, fat is largely concerned in all cell growth, and is probably vital to the perfect formation of bone. I wish to lay especial stress upon the paramount importance of a due proportion of fat in the food of infants, because it is a point most imperfectly recog- nised by the majority of medical men who direct the feeding of young children. In spite of the significant fact that milk is a rich emulsion of fat, little children are constantly placed on artificial foods which are almost destitute of this vital element ; or are fed upon milk from which the fat in the form of cream has been more or less com- pletely removed, such as ' skim ' milk or partially skimmed milk, or fresh milk diluted with ' skim ' milk, or condensed milk made from ' skim ' milk or, at any rate, milk containing a deficient amount of cream. Proteid is commonly deficient also, but usually in less glaring and extreme degree. 24 ARTIFICIAL FEEDING OF INFANTS STANDARD PROPORTIONS OF THE DIFFERENT ELEMENTS FOR INFANTS We may then lay down as a first proposition that children's food should contain the different elements in these proportions. Taking the latest and most reliable analysis of human milk by Dr. Luff, the pro- portions of different elements are, for an infant — Proteid .... 2-35 Fat 2-41 Carbohydrate 6-39 Lime .... •019 Phosphoric anhydride . ■026 Other constituents of ash •295 Water .... . 88-510 ioo-ooo as compared with the standard for adults — Proteid ...... 5-00 Fat ....... 3 *oo Carbohydrates ..... 15-00 Salts . . . . . . .1-15 Water . . . . . ■ 75 '85 ioo-oo Whatever kind of artificial food we use, then, it ought to contain all the elements in the proportions EXACT CONDITIONS TO BE OBSERVED 25 of the first of these tables, not in the proportions of the standard for adults. How little this grand first rule is regarded you will see presently. IN ADDITION TO THESE ELEMENTS IN STANDARD PROPORTIONS, THE PRESENCE OF THE ANTI- SCORBUTIC PROPERTY IN KOOD IS ESSENTIAL TO HEALTHY NUTRITION There is another quality in food essential to the healthy nutrition of infants, in addition to the due proportion of the different elements, the antiscorbutic property. As you know, it is found that, in the case of adults, every dietary must contain a certain amount of fresh food, or scurvy follows. The exact nature of the ingredient which confers the antiscorbutic power has not been ascertained with certainty : but it is known to be contained especially and abundantly in fresh vegetable juicesi and has been inferred to consist in a combination of organic acids with potash. 26 ARTIFICIAL FEEDING OF INFANTS THE ANTISCORBUTIC ELEMENT PRESENT IN FRESH MILK Now, children fed on fresh milk never get scurvy except when the quantity is extremely small, or in the very rare instances where the mother who is suckling her child becomes scorbutic. This shows that where the antiscorbutic element is present in the food of the milk producer, it is transferred with other properties to the milk. Nursing mothers who get scurvy from the lack of antiscorbutic food cannot transfer the essential element to the milk, and their infants may become scorbutic. Fresh milk, therefore, possesses, in addition to the other essential elements, this mysterious antiscorbutic element, which in an ordinary diet is chiefly supplied by fresh vegetables. Thus milk becomes an absolute and complete com- pendium of all essentials of food. It is perfect in all points. It would seem, however, as I shall show later, that the antiscorbutic power of milk is not great, so that it requires to be taken in quantity to be effectual ; and that condensed milk loses something of this spe- cial virtue. The antiscorbutic element is present in fresh meat — especially in raw meat — as we should expect it to be in the flesh of herbivorous animals, EXACT CONDITIONS TO BE OBSERVED 27 and as proved by Dr. Rae's experience in the Arctic regions, and my own. THE ANTISCORBUTIC ELEMENT ABSENT FROM ALL FARINACEOUS FOODS On the other hand, it is absent from all farinaceous food. If, therefore, the child cannot be fed on milk, the antiscorbutic element must be specially supplied to the artificial food substituted for the milk. This is a vital point, essential to full health, yet its im- portance is most inadequately recognised in practice. 1 We may, then, put this down as the second essential condition of an infant's food, viz. that it should contain the antiscorbutic element. Such, then, being the materials which an infant's food ought to contain, and the proportions in which the chief elements should be present, the next ques- tion to be dealt with is, How much food altogether must be given, combined in these proportions ? THE GROSS AMOUNT OF FOOD REQUIRED This is a more difficult question to answer with precision than the previous one with regard to pro- ' Some years ago I published a series of cases of true scurvy, as I shall have occasion to show later, arising in hand-fed children from this 28 ARTIFICIAL FEEDING OF INFANTS portions. But an approximate answer may be offered. It is found from experiment x that each breast of a woman with a full flow of milk secretes on an average about 50 to 60 grammes, = 1^ to 2 oz., every 2 hours. This would give for the two breasts 100 to 120 grammes, =3 to 4 oz., every two hours, or 1,200 to 1,440 grammes, =387 to 46'$ oz., in 24 hours. But this, you will observe, is merely the average yield when both breasts are emptied, and at different stages of lactation. The child does not empty both breasts each time of suckling — only one at first : hence it would not draw the whole 38 oz. probably, but much less. THE AMOUNT VARIES ACCORDING TO THE STAGE OF LACTATION And then the amount yielded varies according to the stage of lactation. At first the milk is much less than at a late period of suckling. It has been calcu- lated that a mother's breast yields 1 pint of milk dur- ing the 24 hours for the first few weeks, and that this cause, and these observations have since been confirmed by my col- league, Dr. Barlow, and by numerous others, and are now, I think, fully accepted. 1 Lamperiere, Comptes Rendus, 1850, vol. xxx. p. 172. Lamperiere's results are the average of 67 experiments. EXACT CONDITIONS TO BE OBSERVED 29 quantity gradually increases, until in the later months it reaches 3 pints. This, then, may be taken as the standard of quantity. ANOTHER BASIS OF CALCULATION FROM GROSS AMOUNT OF EACH ELEMENT Taking, now, another basis of comparison, viz. the gross amount of each element of food required, obser- vations ' show, as noted previously, that a child under 1 \ year requires at least — Proteid . . . 20 to 36 grammes = 310 to 558 grains Fat 30 „ 45 „ =465 „ 697 „ Carbohydrate . 60 ,, 90 „ =930,, 1,395 » Now, i pint of human milk yields, according to Dr. Luffs analysis — Proteid 215 grains Fat 231 „ Carbohydrate . . . . 613 „ 2 pints yield — Proteid 430 grains Fat 462 „ Carbohydrate .... 1,226 ,, 3 pints yield — Proteid 645 grains Fat 693 „ Carbohydrate .... 1,839 „ 1 Landois and Stirling, Results of Investigations of the Munich School, 1. c. vol. i. p. 482. 30 ARTIFICIAL FEEDING OF INFANTS So that, to provide the gross amount of elements necessary, from I to 3 pints of human milk would be required ; or of cow's milk rather less, with sugar added. 1 This would give a slight deficiency of all elements for the smaller measures. The yield of mother's milk is probably the best guide — better than these estimations of gross quantities of each element, which are based upon too wide a range of age, viz. from birth to 1 \ year, to be exact for young infants who get milk food only. But the general result agrees sufficiently well with that obtained previously by calculating the breast yield to give it additional certainty. There is, no doubt, considerable variation in the amount which is essential, according to the size and vigour of the child and the nutritive richness of the milk, and judgment must be used in adapting the quantity in individual cases. GROSS AMOUNTS ACCORDING TO AGE We may take it as a general rule, then, that any- thing materially under I pint of human milk, or its 1 One pint cow's milk contains— Proteid 394 grains Fat 315 Carbohydrate . . . .431 EXACT CONDITIONS TO BE OBSERVED 3 r equivalent, would be insufficient for full nutrition, even for the first month of life, and we may safely say that for the first month the child should have the equivalent of 1 2 to 20 oz. of human milk ; in the second month the equivalent of 20 to 26 oz. ; in the third month the equivalent of 24 to 30 oz. ; in the fourth month 30 to 35 oz. ; later, 35 to 45 oz., or more. Or, putting it another way, at first 1 £ to 2 oz. every 2 or 2% hours, gradually increased to 3 oz. every 3 hours after the first month, and the quantity augmented so as to give the amount calculated as necessary for each month of age. 1 THESE QUANTITIES NOT ABSOLUTE These quantities are not to be taken as absolutely and arbitrarily fixed. They will require to be varied within the limits named, according to the capacity of the child and its peculiarities, but will serve as a starting-point and safe guide at the outset. 1 According to the observations of Rotch (Annual of Univ. Med. Science, vol. iv. 1888, p. 260), the stomach of an infant five days old has a capacity of 25 c.c, or about 6 \ fluid drachms. The capacity increases rapidly at first, so that it reaches 62-5 c.c, or about 2 oz. by the end of the fourth week, then advances more slowly, reaching 80 c. c. , or about 7.\ oz. by the end of the third month, and go c.c, or about 2| oz. by the end of the fifth month (Frolowsky, quoted by Rotch) ICeating's Cyclopadia of Diseases of Children, vol. i. p. 273. 32 ARTIFICIAL FEEDING OF INFANTS The child's stomach acts in some degree as an indicator of quantity. If it is overfilled, the excess is readily rejected. If, after the meal, craving still remains, the child cries for more, sucks its fingers, is restless and complaining. With the data I have given, and watchful obser- vation of the child's condition as to overloading of the stomach, and satisfaction of appetite, aided by a regular record of weight (the increase should be 2 to 4 oz. per week, or more) — a most important help — the necessary quantity will be estimated with suffi- cient exactness ; and, indeed, this matter of quantity is much less important than the proportion of the elements. It is in great degree self-regulating. FOOD MUST CONTAIN A DUE PROPORTION OF ANIMAL MATTER Another condition which must not be overlooked in an infant's artificial diet, but a principle too often neglected is that it should contain a due proportion of animal matter. It is difficult to supply sufficient nitrogenous matter in vegetable food, which con- tains it in small proportion ; and it is practically impossible to obtain sufficient fat from vegetables, for in the available forms, such as the farinaceous EXACT CONDITIONS TO BE OBSERVED 2,2, preparations, it is present in smaller proportion still. Even maize, the richest of all grains in fat, contains only 7 per cent, and that, with the requisite dilution of 7 to 1 6 parts of water, would be far below the necessary standard. But apart from this difficulty it is doubtful whether, even if these ingredients could be supplied in vegetable form in sufficient quantity, they would be efficient for nutrition. Milk, the type food, is entirely animal. Animal tissues are probably most easily formed from animal materials, and little children brought up on vegetable food alone are soft, flabby, anaemic, rickety, and, if the food is solely farinaceous, scorbutic. Yet most artificial foods are entirely vegetable. We may un- hesitatingly, I think, affirm the fourth Rule : That it is an essential condition that an infant's food should not be purely vegetable, but should contain a due proportion of animal matter. THE FOOD MUST BE OF A FORM SUITED TO THE PHYSIOLOGICAL CONDITION OF THE DIGESTIVE FUNCTION IN INFANCY The next point upon which I must insist is this : That the food should be of a form suited to the physio- logical condition of the digestive function in infancy. D 34 ARTIFICIAL FEEDING OF INFANTS It must be remembered that the digestive organs have only just come into use, and are designed solely to deal with the bland and easily dissolved nutriment of the mother's milk. THE FOOD SHOULD BE OF THE SAME KIND AT EACH MEAL There is another special condition connected with the digestive function of young infants, and that is that it is adapted to deal .with food in one form only — and the same form at every meal — a child at the breast gets milk only, the same milk always at each feeding ; so, in artificial feeding, the food should be the same each time. This is constantly overlooked — and the child given milk at one time, farinaceous food another, animal broth at a third. .This is an error, and often a source of digestive trouble. The necessary ingredients should be combined in proper proportion and given together. SPECIAL FEATURES OF THE DIGESTIVE FUNCTIONS IN YOUNG INFANTS — DEFICIENCY OF DIASTATIC FERMENT— INABILITY TO DIGEST STARCH During the early months of life young animals, and human infants amongst them, have little power EXACT CONDITIONS TO BE OBSERVED 35 of digesting starch. It appears that in new-born children the parotid gland alone contains the diastatic ferment ptyalin. It is developed in the submaxillary gland at the earliest at two months, and during this time there is indeed little saliva secreted. It begins to flow after the second month, but not freely until the eruption of the teeth. 1 Moreover, the diastatic ferment is likewise absent in the pancreatic secretion for the first two months of life. It is not fully developed until a year old. 2 An infant, therefore, has at first small power of digesting starchy food. In its natural food, milk, there is no starch ; the carbohydrate is in the form of lactine, or sugar of milk. The starch is converted into sugar in the mother beforehand. Yet, although nature has not endowed infants with the power of dealing with starch, and it cannot, therefore, possibly be a proper element of food, most artificial foods, with profound indifference to physiological teaching, have starch for their chief ingredient. 1 Landois and Stirling, from various authors— Zweifel, Korowin, &c vol. i. pp> 293, 294. 2 Landois and Stirling, vol. i. p. 344. ' The pancreas of new-born children contains trypsin, which acts on proteids, and the fat-decom- posing ferment, but not the diastatic one.'— Zweifel. 'A slight diastatic action is obtained after two months, but the full effect is not obtained until after the first year.' — Korowin. D 2 36 ARTIFICIAL FEEDING OF INFANTS INABILITY TO DIGEST LARGE MASSES A second notable deficiency in the digestive power of infants is the inability to deal with large masses of solid or semi-solid matter. Neither the solvent virtue of the digestive juices nor the feeble muscular power of the stomach is equal to this. They can only digest solids in a state of minute sub- division. This is seen in the disorder produced by cow's milk, when large coagula of curd are rejected by the stomach undissolved, or passed unchanged by the bowels. In the same way the insoluble cellulose and woody fibre of the coarser vegetable products are irritating and injurious. FOOD MUST BE FRESH AND SOUND — FREE FROM ALL TAINT OF ACIDITY OR DECOMPOSITION And, lastly, the sixth essential condition : The food must be fresh and sound, free from all taint of acidity or decomposition. The stomach of a little child has a very delicate and sensitive reflex organisation, and is extremely intolerant of food which is in a state of fermentation or is affected by the least trace of decomposition. EXACT CONDITIONS TO BE OBSERVED 37 Probably the products of such changes are ab- sorbed and act injuriously on the nervous system when carried there in the blood stream, as well as locally upon the mucous membrane of the alimentary canal. THE DANGER OF FERMENTATION CHANGES IN COW'S MILK Cow's milk is a constant source of danger in this way. As soon as it has been drawn from the cow it immediately commences to undergo change. The minute light oil-globules disseminated through the liquid rise to the surface as cream. Milk absorbs oxygen, and begins at once to give off carbonic acid from the decomposition of the nitrogenous matter. 1 This sets up fermentative change in the lactine by the aid of the bacterium lactis, lactic acid begins to form and causes the coagulation of the casein. The cream, which has previously risen to the surface, disappears. Other micro-organisms probably in like manner set up fermentations which result in the formation of acetic and butyric acid. The pro- ducts of these changes of fermentation are highly irritating, and the sensitive. reflex apparatus is pro- 1 Hoppe-Seyler, quoted by Parkes. 38 ARTIFICIAL FEEDING OF INFANTS foundly disturbed by them. Violent vomiting and diarrhoea are set up by food in a state of sourness and fermentation — consequences always serious, often fatal. This, and the presence of masses of undigested curd or dense food in the stomach and intestine fermenting there, are indeed the two chief causes of choleraic diarrhoea, so deadly to infant life — the Cholera Infantum of the American physicians, es- pecially rife in hot climates, where decomposition proceeds most rapidly, and infants' food is most readily tainted by it. PRIME NECESSITY FOR EXTREME CLEANLINESS Hence the prime necessity for extreme cleanliness in all utensils used for infants' food — milk cans, bottles, cups — and also the wisdom of boiling milk as soon as it is received, so as to stop at once all further changes of fermentation. Milk once boiled remains much longer free L from sourness ; it is practically sterilised. Of this point I shall now take leave once for all. You are, no doubt, alive to its importance, which is, indeed, in these days pretty generally re- cognised. EXACT CONDITIONS TO BE OBSERVED 39 SUMMARY OF ESSENTIAL CONDITIONS To sum up ; the six essential conditions to be observed in the diet of infants, then, are these : I. The food must contain the different elements in the proportions which obtain in human milk, viz. : Proteid Fat . Carbohydrate Salts . Water 2 '35 per cent. 2'4I » 6-39 »» °"34 >j 88-51 j» I OO 'OO II. It must possess the antiscorbutic element. III. The total quantity in 24 hours must be such as to represent the nutritive value of 1 to 3 pints of human milk, according to age, viz. : Proteid . 225 to 675 grains Fat . • 231 „ 693 „ Carbohydrate ■ 613 „ 1,839 . .» 40 ARTIFICIAL FEEDING OF INFANTS IV. It must not be purely vegetable, but must contain a large proportion of animal matter. V. It must be in a form suited to the phy- siological condition of the digestive function in infancy. VI. It must be fresh and sound, free from all taint of sourness or decomposition. THE VITAL IMPORTANCE OF OBSERVING THESE CONDITIONS I would urge you, gentlemen, to ascertain accu- rately in all cases that the food you order for a child satisfies these six essential conditions. In the next lecture I hope to show how far these same essential conditions are met by the artificial foods in ordinary use, and how they may be satis- factorily secured in actual practice. 41 LECTURE II ARTIFICIAL FOODS— THE VARIOUS FORMS OF MILK AND ITS PREPARATIONS Brief summary of conclusions reached in the previous lecture — Advan- tages of wet-nurse — Difficulties in the way — Table of proportion of elements in various kinds of milk — Preparations of cow's milk- Asses' milk one of the best substitutes for human milk — Its advan- tages and disadvantages — Cow's milk diluted with water — Nutritive value of different degrees of dilution — Two parts milk to one part water essential to full nutrition — The real difficulty of cow's milk due to the character of the casein, not to excess of solids— Com- parison of the casein of cow's milk with that of other kinds of milk — Its massive coagula — Experiments — Expedients for remedying this coarse coagulation — Boiling — Barley water — Lime water— Bi- carbonate of soda — Peptonised milk —Qualities of the various pre- parations considered— Boiled milk with barley water or lime water preferred — Objections raised to boiled milk considered — Its advan- tages — Arrest of contagion from this source — Sterilised milk— The process — Condensed milk : its good and bad qualities — Goat's milk — Artificial human milk. RECAPITULATION OF POINTS ESTABLISHED IN THE PREVIOUS LECTURE In the previous lecture, gentlemen, I endeavoured to trace out the exact conditions which should be 42 ARTIFICIAL FOODS observed in the composition and amount of infants' food. First, the proportions in which each element should be contained, laying especial stress, you may remember, upon the necessity for a sufficient supply of fat and a sufficient supply of proteid, and the high value of these elements — points constantly dis- regarded. Secondly, that it must contain the antiscorbutic element, another essential condition constantly over- looked, with disastrous consequences. Thirdly, the total quantity in 24 hours should be the equivalent of 12 to 20 oz. of human milk for the first month, running up by gradual in- crease to 35 or 45 oz., or even to 60 oz. at 8 or 10 months. I pointed out to you, however, that there must be considerable variation in quantity, according to the capacity and constitution of the child. This mere question of quantity in great measure settles itself. I do not wish to attach prime import- ance to exact observance of standard quantity. If the child gets too much, it is sick. If too little, it is restless and crying with hunger. Remember, if the proportions of food are right, the quantity may be easily adjusted, beginning, as a standard for the first EXACT COMPOSITION AND PROPERTIES 43 month, with 1^ oz. to 2 oz. every two hours, or every two and a half hours. The fourth essential point on which I insisted was that the food should not be purely vegetable, but must contain a due proportion of animal matter. And first, because sufficient fat could not be supplied in vegetable form, and sufficient proteid with diffi- culty ; and secondly, because, even if this were possible, it is doubtful whether the vegetable fats and proteids are equally as efficient for the formation of growing tissues as the same elements from animal sources, while the carbohydrates in the form of starch are used with difficulty, and are not so effective as sugar of milk or its analogues. Fifthly, I urged the importance of the foods being adapted to the digestive powers of an infant and of uniform kind at each meal. 1 showed how this con- sideration was constantly neglected in the early use of farinaceous foods, the young child having little or no power of digesting starch for the first few months of life, owing to the small amount of the diastatic ferment in the saliva, the paucity of the salivary secretion until the teeth appear, the entire absence of the diastatic ferment from the pancreatic juice during the first two months, and its imperfect development until the end of the first year. I alluded 44 ARTIFICIAL FOODS also to the necessity of giving the same form of food at each meal, as the child gets it when on breast milk only, and to the inability of the gastric digestive apparatus to deal with solids in mass ; how they must be in a state of minute subdivision to enable the child's stomach to grapple with them, and how in- soluble vegetable matter, such as cellulose, and woody fibre of the coarser products, oatmeal or brown flour, are irritating and injurious. And lastly, I stated how intolerant the delicate and sensitive alimentary canal of an infant is of the slightest taint or sourness and decomposition in food. HOW THESE ESSENTIAL CONDITIONS CAN BE BEST FULFILLED Such, then, being the conditions to be observed in the provision of artificial food for an infant, let us see how they can be best fulfilled with the materials at disposal. If the mother is unable to suckle her child, the best substitute for the mother's milk is the milk of some other woman, whose child has been born about the same time, and whose milk, therefore, is in a similar state of development. A good wet-nurse usually saves all further trouble. EXACT COMPOSITION AND PROPERTIES 45 But the expedient of a wet-nurse cannot always be adopted. It may not be possible to find a satis- factory one at the moment, or the expense may be too great for the parents' means, or the addition to the establishment too inconvenient, and the child must, of necessity, be brought up by hand. ARTIFICIAL FEEDING PERFECTLY SAFE WITH DUE CAKE AND PROPER KNOWLEDGE I believe that, by proper management and pre- cautions, all difficulties of the transfer from the breast to artificial feeding may be got over with absolute safety, and in all respects satisfactorily, so that the child shall escape gastric troubles and shall thrive. And here let me notice for a moment a popular prejudice which exists against hand feeding and suckling combined. A superstition still survives amongst nurses and matrons that the cow's milk and the mother's milk do not agree, as if they quarrelled in some curious way within the child's body, and fought it out there to its great discomfort and damage. But this is a pure fallacy. The cow's milk may disagree with the child, but not the mother's milk, if it is healthy. All that the child can get of this is pure gain — half a loaf is better than no bread. The fact of the child having so much of the best and 46 ARTIFICIAL FOODS most nourishing food will in no possible way interfere with its power of digesting cow's milk. It may be that the child has not digestive power enough to deal with cow's milk ; but this is all the more reason why it should have as much mother's milk as it can get, which it is able to digest. If it cannot digest cow's milk, other food must be given. Of this I shall speak presently. But it cannot be stated too strongly that a healthy mother should suckle her child, even if only able to give it a partial supply, to be supple- mented by artificial means. ASSES' milk as a substitute for human milk One of the best temporary substitutes for human milk is asses' milk. It is, as you will see by Table I. (page 47), much weaker in every ingredient except in sugar, but it is of an extremely fine curd and easily digested. The chief objection to it is that it is somewhat laxative. The difficulty of its being weaker in proteid and fat may be got over for a time by giving a somewhat larger quantity. It would re- quire twice as much to make it equivalent to human milk. And it is not satisfactory as a permanent food for this reason. 1 Moreover, the question of expense 1 I have noted more than once that children do not thrive vigor- ously on asses' milk after the first few months. I have had recently EXACT COMPOSITION AND PROPERTIES 47 w M < a z < Q Z a o 5 > f- 1 w z 3 B « B s. ft. fa O a m z o z o H « O o. o c4 B s O z & o a _w in :-"*> 1 | v6 o 1 -*■ ■3-m ' in 00 8 - o 8 w 10 §£"2 « b ON 00 U Q S3 E q J'W u £ 3 *0 op p p p p b o M •-< •-• W '- , is a- VO W r^ 00 o b o IB S- 2 in CO 00 ■s-. a j* iO N ■*■ 00 O « > O U ro n lO o 8 K en « #8 Dilut with part water 2 mi! on P ON t 7i- p ON iluted th an qual antity water 1^ 00 ON w P p b lb £« Si- Em S M G^g* ON T3(, M|- vo t*<. * 1^1 in vo vo ro r-H, p b o Dilut with part wate 7^- M in ON ^ 3 1^ to * -a- 1 in O o 1 ■* fO* ' 00 a o z OVVO *n 3* S J 3 m " ON , pn * ro | O O « m o as J « M VO oo o o J2.C S S '%* . 5 2 J ) 4 a s .3 "« in to ^ g"S c o men) carbons or f / Lactine es \ Cane su Lime Phosphoric anhydr Other constituents • 13 MO. a u ■3 ° 55 albu Hydro Carbo- hydrat 3,3 St H s -s 48 ARTIFICIAL FOODS and supply again come in. It is not always possible to obtain asses' milk— except in London, where there are regular establishments for its supply — and its price is in most cases prohibitive. IN THE MAJORITY OF CASES COW'S MILK DILUTED WITH WATER THE BEST AVAILABLE SUBSTITUTE So that in the vast majority of instances we are compelled to fall back upon cow's milk — either cow's milk diluted with water or mixed with some prepa- ration of farinaceous food — and the most common expedient, the thing first tried, is cow's milk diluted with water. PROPORTION OF MILK TO WATER It is found that for a child under a month old, or even for an older child at first, it is not safe to give a stronger solution than I part of cow's milk to 2 parts of water, with the addition of a little sugar. And this is the strength usually adopted. With a very young infant — under one month — it is not safe to begin with more than i to 3, and at first the milk should be peptonised in both cases. under my care a child brought up entirely on asses' milk until one year old. It was apparently fairly well, but white, flabby, and delicate. On cow's milk and water, with raw meat juice, it has become firm and rosy, and has gained weight with extraordinary rapidity. EXACT COMPOSITION AND PROPERTIES 49 Now, a reference to Table I. will show you at once that cow's milk thus diluted, 1 to 2, is weaker in every constituent than human milk. It would only contain 1*458 proteid, i'i66 fat, and i'^6j lactine. Thus a much larger quantity would have to be given than the 12 to 20 oz. of human milk we have seen to be required to bring up the total amount of nutriment to the proper standard. It has been shown in the first lecture that a child would require for the first month nearly 20 oz. of cow's milk daily to furnish the requisite amount of alimentary material. 1 Just consider what this means. It means 60 oz., or three pints of this mixture of 2 parts water to 1 of milk — a quantity quite out of the power of a small infant to take in and retain. As a matter of fact, however, the child gets on very 'well, as far as nutrition is concerned, for a short time with 12 to 20 oz. of this dilution, if it digests it thoroughly. 1 Bouchut's calculation (Journal Officiel, 1870, Nov. 23) comes very near this. He estimated that a child requires — For the 1st month 10 meals per diem of 2 oz. cow's milk „ 2nd ,, 7 ,, ,, 6 ,, ,, 3 rd » 7 .. >. 8 „ „ 4* .. 7 » >. 10 ,, „ 50 ARTIFICIAL FOODS ADDITIONS TO INCREASE THE PROPORTION OF PROTEID, OF FAT, AND OF SUGAR If nutrition flags at all, the proteid element may- be increased by the addition of raw meat juice, and the fat by the addition of cream enough to bring them up to the standard proportions per cent, respectively. Then the strength of the dilution may be cautiously increased until equal parts can be digested, which gives a proportion, as you will see from the Table, of proteid, 2-187; f at > V 7A9\ su g ar > 2-201. The proteid is nearly sufficient, the fat deficient (nearly 1 per cent.), the sugar deficient (more than 4 per cent.). The sugar must be increased, and the total quan- tity of food given be increased also, to keep up a sufficient supply. Then the child thrives until the proportion can be still further increased, as the di- gestive powers advance, to 2 parts of milk and 1 of water ; or raw meat juice may be given to increase proteid, cream to increase fat. This, viz. 2 parts of milk to 1 of water, would give: proteid, 2-916; fat, 2-332 ; sugar, 2-934 j which contains a more than suffi- cient proportion of proteid, and almost a sufficient amount of fat, which is a great point ; and although the carbohydrate element is largely deficient, this can EXACT COMPOSITION AND PROPERTIES 51 be remedied by adding 3^ per cent, of sugar to make up for the want of lactine. Pure cow's milk should never be given before the sixth month. ALL CHILDREN DO NOT THRIVE ON COW'S MILK EVEN WHEN APPARENTLY DIGESTING IT WELL Yet, as Kehrer has pointed out, it is only a por- tion of the children brought up on cow's milk in the ordinary way that thrive really well. These are children who have good constitutions and great digestive power. Some are behindhand in growth and development ; they possibly do not get quite enough, or digest quite enough, for full nutrition. At the period of dentition they are more flabby, anaemic, and weakly than those, brought up at the breast. And the faeces show constantly a quantity of undi- gested casein and fat, and this is probably the key to the defective nutrition. Yet they often gain on the sucklings later. Their alimentary organs learn to digest difficult substances better, and they meet the strain of change of diet, when put on more solid food, more easily than the less tried digestive organs of the breast-fed child. SJ 52 ARTIFICIAL FOODS TWO PARTS OF MILK TO ONE OF WATER, WITH l\ PER CENT. OF SUGAR ADDED, FULFILS MOST OF THE ESSENTIAL CONDITIONS The diluted cow's milk, with sugar added, at any rate as soon as the sufficient strength of 2 parts milk and 1 water is reached, would seem to satisfy all the essential conditions. It contains nearly the true proportion of each element ; it possesses the anti- scorbutic property. The gross amount of nutriment will be sufficient ; it is animal ; and it can be kept sweet and good, so as to satisfy the sixth condition. YET A GREAT AND REAL DIFFICULTY STILL REMAINS — IT LIES IN THE INFERIOR DIGESTI- BILITY OF COW'S MILK The real difficulty, however, does not lie in the inferior nutritive value of the cow's milk and water, although this may retard development at first. It lies in the fact that cow's milk is much less digestible than human milk. Some children cannot digest cow's milk, even in this diluted form, or indeed in any degree of simple dilution compatible with fair nutri- tion. In extreme instances the weakest solution sets up colic, vomiting, diarrhoea. EXACT COMPOSITION AND PROPERTIES 53 IT FAILS TO SATISFY THE FIFTH CONDITION The point in which it fails and is unsatisfactory is the fifth condition. It is not perfectly suited to the digestive powers of an infant ; its solids are too massive. WHY COW'S MILK IS MORE DIFFICULT OF DIGESTION THAN HUMAN MILK The reason that cow's milk is so much more difficult of digestion than woman's milk does not depend, as commonly supposed, upon the fact that it contains more solids, especially casein, but upon the peculiarly firm and massive character of the curd when coagulated by the gastric juice— as it is, of course, the moment it enters the stomach. 1 The addition of water largely modifies this. It makes the casein less in proportion, and renders the clots smaller ; but it does not alter its nature. 2 1 Recent experiments by Dr. Stawell, of Melbourne, go to show that the curdling ferment, rennet, acting in an acid medium, is the active agent in producing coagulation, and not the hydrochloric acid in the gastric secretion. (Australian Medical Journal, Aug. 15, 1893, pp. 386-88.) 2 The casein of cow's milk would appear to have a different chemical composition, its atoms differently grouped from those of human milk. 54 ARTIFICIAL FOODS THE DISTINCTIVE CHARACTERS OF THE CURD IN THE DIFFERENT KINDS OF MILK — EXPERIMENTS IN ILLUSTRATION The distinctive character of the casein of cow's milk, of goat's milk, and of ewe's milk, as compared with that of human milk and of asses' milk, can be shown at once by experiments with artificial di- gestive fluid. The casein of human milk is thrown down in extremely minute flocculent granules, readily dissolved by additional fluid ; while the casein of cow's milk is cast down in great masses, and is not dis- solved by the addition of more fluid. Further, if human milk and cow's milk be placed in two glasses side by side with a small quantity of digestive fluid and kept at a temperature of ioo° — i.e. artificially digested — the solid curd of cow's milk takes a very much longer time to dissolve than the minute light flocculi of human milk. Anyone curious to do so may satisfy himself as to the difference in coagulability of the two milks by a more simple experiment still. Add a little dilute acetic acid or vinegar to cow's milk, and also to a sample of human milk. In the latter the acid produces little appreciable change. It remains uniformly liquid ; or at most an EXACT COMPOSITION AND PROPERTIES 55 extremely minute, light, flocculent curd is alone pre- cipitated. In the former it leads to the immediate formation of large masses of coagulated casein. Goat's milk and ewe's milk behave in the same way as cow's milk, while asses' milk and that of the mare resemble human milk in this respect. 1 The true secret of the difficulty with which cow's milk is digested by infants, then, is the massiveness and insolubility of the coagulated casein. EXPEDIENTS FOR RENDERING THE CASEIN C0- AGULA SMALLER AND MORE FLOCCULENT — BOILING This fault, however, may be largely modified, and the casein rendered more flocculent by certain expe- dients. The fact that boiled milk agrees better than fresh milk with children prone to diarrhoea has long been known. Nurses say that it is constipating. Rather, it should be said, that it is less laxative. The expla- nation lies partly, no doubt, in the fact that boiling arrests decomposition, which so quickly commences, and that thus development of the irritant products which excite intestinal action is arrested. But this is 1 Hydrochloric, sulphuric, and nitric acids produce similar results to acetic acid on the two kinds of milk. 56 ARTIFICIAL FOODS not the sole reason of the less laxative character of boiled milk. There is another, viz. that the effect of boiling is to make the curd coagulate in somewhat smaller masses. It produces less irritation, being less liable to ferment because it is practically tempo- rarily sterilised, and also because it is more quickly digested. Dilute acetic acid, or vinegar, added to boiled cow's milk which has been allowed to grow cold, no longer produces the massive coagula characteristic of fresh cow's milk, but somewhat smaller and lighter curd masses, although still much larger and coarser than those of human milk. 1 THE ADDITION OF BARLEY WATER Another device is to add barley water to the milk. Barley water is presumed to act by mechanically separating the casein, so that it coagulates on addition of acid in minuter flocculi than those of boiled milk. Barley water has, moreover, the advantage of adding something to the nutriment in its mucilaginous property. 1 Rotch's experiments, however (Keating's Cyclopedia of Diseases of Children, vol. i. p. 308), showed no difference in the coagulability of boiled and unboiled cow's milk, and he obtained finer curd with simple boiled water than with barley water, lime water, or other so-called attenuants. EXACT COMPOSITION AND PROPERTIES 57 THE ADDITION OF LIME WATER A more favourite plan still is to add lime water to the milk, with the view of rendering the curd more easily soluble, and of neutralising acidity. According to my own observations, lime water has some effect in causing the casein to coagulate on ad- dition of acid in smaller masses, but it is less efficient in this respect than barley water. THE ADDITION OF SOLUTION OF BICARBONATE OF SODA Another efficient plan is to add a little bicarbonate of soda, 3 grains to each ounce of milk. This is a much more powerful antacid than lime water. The result on adding acetic acid is to get a fine curd fairly flocculent. DEGREE OF DILUTION THE MOST IMPORTANT FACTOR In all these cases, however, the amount of dilution appears to be a more important factor in the pro- duction of fineness of curding than the nature of the diluent. 1 1 Further careful experiments upon this point have recently been made by Dr. Barrett, of Melbourne, in conjunction with Dr. Wood 58 ARTIFICIAL FOODS CONDENSED -MILK Condensed milk again, if properly diluted, is more digestible than fresh, unboiled cow's milk. This is due to the fact that the process of heating which it undergoes alters and lessens the coagulability of the casein. On the addition of acid it coagulates in lightish masses, coarser than those of human milk, or the mik mixed with barley water or lime water, or carbonate of soda, but vastly different from the great clots of fresh cow's milk. PEPTONISED MILK In peptonised milk a few fine coagula only should form on addition of acid. The casein is converted into soluble peptone. The various forms of milk of which I have yet and Dr. Stawell. The results are thus summed up by Dr. Barrett, in a letter which he has kindly addressed to me. ' The net result of our work is that none of the diluents attenuated clot more efficiently than pure water. In Savory and Moore's food and Mellin's food, when made up with milk and water, casein was precipitated rather more finely than in milk and water alone. These experiments were made by the addition of acetic acid. Dr. Stawell made further experiments with gastric juice drawn from a child's stomach, the results of which he sums up thus : " Simple dilution had a marked effect in lessening the size of the clot of cow's milk formed in the stomach ; that the addition of foreign material did act as an attenuant to the size of the clot, but not to the extent generally supposed." ' {Australian Medical Journal, Aug. 15, 1893, pp. 387-88.) EXACT COMPOSITION AND PROPERTIES 59 spoken, in respect of easy digestibility of curd, appear to rank thus : 1. Peptonised milk. 2. Cow's milk with barley water. 3. Cow's milk and lime water. 4. Cow's milk with bicarbonate of soda. 5. Condensed milk. 6. Boiled cow's milk, undiluted. 7. Fresh cow's milk, undiluted. THE BEST METHOD OF GIVING COW'S MILK — PEPTONISED MILK If, then, it is decided to give cow's milk, as will be the case in the vast majority of instances — for various cogent reasons — how is it to be given ? Shall it be peptonised, or rather pancreatised ? DILUTE PEPTONISED MILK, THE BEST AND SAFEST TO COMMENCE WITH Milk peptonised by pancreatic ferment, which emulsifies the fat as well as peptonises the casein, and properly diluted with water at first, agrees ex- cellently ; there is only a small proportion of casein unchanged to peptone, so there is no curd difficulty. 1 When a young infant is first placed on artificial 1 Casein 0-96 per cent. Peptone *. 1-88 „ (Dr. Vieths's analysis, kindly supplied by the Aylesbury Dairy Co. ) 6o ARTIFICIAL FOODS food, peptonised milk and water is the best and safest substitute for human milk in the first instance, if asses' milk cannot be obtained. Peptonised milk contains, of course, the same amount of nutriment as unpeptonised milk. But although peptonised milk is satisfactory as far as di- gestibility and nutrient value are concerned, there are reasons against its continued use. It is an excellent preparation for temporary use at first, or in special cases of illness, but it is not fitted to be the permanent diet of a healthy infant. The chief reason is that the continued use of pre- digested food weakens the digestive power of the stomach, which becomes enfeebled by want of exer- cise of its proper function. This objection is a most serious one, and prohibitive of its use as a permanent food. Peptonised milk does excellent service as a temporary food, or as a transition food between human milk and cow's milk, in gastro-intestinal dis- turbance, but it cannot be safely given for more than a few weeks. I have more than once seen scurvy arise upon peptonised milk, both fresh and condensed. One difficulty in the use of peptonised milk is its bitter flavour, so that some children refuse it altogether. fc This difficulty, however, rarely arises with very EXACT COMPOSITION AND PROPERTIES 61 young infants, with whom the process is of most importance. When peptonised milk is given, there- fore, the peptonising process should be gradually reduced, both by lessening the quantity of the pep- tonising agent, and also by shortening the time during which the process is continued. By using peptonising powders this graduation can be effected with great ease and certainty. Or the same end may be attained by mixing unpeptonised milk with the peptonised in gradually increasing proportion, beginning with a teaspoonful only in each bottle. It is most important that the change should not be abrupt, a child's stomach resents sudden changes. Beginning, then, with dilute peptonised milk and water, what is to be substituted for it, since it is not fitted for a permanent food ? In any case the substi- tution must be gradual. The progressive reduction of peptonisation, or the admixture of fresh milk and water in increasing amount, will leave the child eventually upon the proper diet of milk diluted with water according to age. MILK WITH SOLUTION OF BICARBONATE OF SODA The preparation of milk and water, with the addition of a little bicarbonate of soda, yields a flocculent curd, and the bicarbonate of soda is 62 ARTIFICIAL FOODS valuable for its power in neutralising acidity. As Sir W. Roberts has pointed out, lime water only contains about half a grain to the fluid ounce, and no less than six ounces of lime water would be required to be equivalent in antacid power to an ordinary dose of 10 grains of bicarbonate of soda. If the addition of an alkali is desirable, solution of bicarbonate of soda, 6 grains to the ounce, is better than lime water, especially when the bowels are constipated. I have frequently used it for long periods with most satisfactory results. As a rule, however, it is not necessary for permanent feeding. There remain boiled milk mixed with water, milk mixed with barley water, milk mixed with lime water, condensed milk, and, of course, plain fresh unboiled milk diluted with pure water. FRESH MILK AND WATER, THE RISKS WHICH ATTEND ITS USE The last, fresh milk and water, is the one most commonly resorted to. I suppose that nine children out of ten are put upon this in the first instance, yet I think anyone who has seen these massive coagula of fresh cow's milk, when acted upon by an acid such as I have shown you, would be rather uneasy about the result when this plain milk and EXACT COMPOSITION AND PROPERTIES 63 water came into contact with the gastric juice in the child's stomach. Remember, moreover, how readily milk unsterilised by boiling enters upon acid fermentation. And such apprehension of disturbance would very frequently be justified. How often do we see vomiting, and purging, and griping, and diarrhoea result from the administration of this mixture. I think it may be safely affirmed that this reckless and almost universal practice of placing infants — and especially very young infants — abruptly and without preparation upon fresh cow's milk and water is one of the most fruitful causes of the serious food troubles of childhood, and a most prolific source of disease. THE MILK SHOULD BE BOILED — OBJECTIONS RAISED TO BOILED MILK The risk ought always to be avoided. Let me advise you to adopt another plan. In the first place, always have the milk boiled, so as to render it temporarily sterile, prevent souring, and render the coagula of curd lighter and more digestible. This is the first grand rule I would lay 64 ARTIFICIAL FOODS down, and it should be an invariable rule. Nurses will fight against it, and mothers object, perhaps, for there is a common prejudice against it ; they say it is less nourishing and that it is ' binding,' and that the children don't like it. Well, as to the first objection, there is just this much truth in it, that the milk loses by boiling exactly the small amount of soluble albu- men which rises as scum to the surface. With cow's milk, where the casein is in excess, this is no great disadvantage. Yet that there is a slight loss of good digestible proteid must be allowed. 1 As to the second objection, that it is constipating, there is also some truth. As I pointed out before, the smaller curd masses, and the absence of acidity from incipient fermentation, render it less provocative of peristalsis and of secretion from the intestine than fresh milk. But this is a fault which may be easily remedied by the addition of a small quantity of fluid magnesia or carbonate of magnesia to each bottle, and later by the addition of some food which is laxative, as a malted food, for example. The last objection, viz. that children don't like it, does not apply to children who are given it from the first. They know no other, and take to it kindly 1 According to Dr. Winter Blyth this coagulable albumen is equal in amount to about one-fifth of the casein. EXACT COMPOSITION AND PROPERTIES 65 enough. It is true that children who have been already accustomed to fresh milk will sometimes refuse it boiled ; that is a different matter. Never let any- thing but boiled milk be used in the nursery from the first, and there will be no difficulty afterwards. THE ADVANTAGES OF USING BOILED MILK — STERILISATION — DESTRUCTION OF GERMS OF FERMENTATION The first great advantage gained by boiling milk is its sterilisation. It is a curious fact, as has been well- pointed out by Dr. Jeffries, 1 that while older people are chiefly fed on sterilised, i.e. cooked, food, infants are fed on food peculiarly adapted by its composition and fluid state to afford a favourable nidus for the develop- ment of bacteria. Human milk has been proved by Professor Escherich to be absolutely sterile when first drawn from the breast. Sir Joseph Lister has shown in like manner that cow's milk as it comes from the udder is sterile, and that it quickly becomes infected after- wards in various ways, as from the hands of the milkers, the air of the cowshed, or the vessels into which it is drawn. Now, the process of boiling milk 1 ' Sterilisation of Milk and Food for Infants,' American Journal of Medical Science, May 1888. F 66 ARTIFICIAL FOODS sterilises it, destroying, according to Dr. Townsend, 1 ' not only the putrefactive bacteria, but changing and driving off tyrotoxicon, one of the poisonous ptomaines produced by these bacteria.' DESTRUCTION OF GERMS OF INFECTIOUS DISEASES Another great advantage in using boiled milk is the protection thereby afforded against infection. It has been proved beyond question, by a series of con- clusive and striking investigations, that the specific poisons of typhoid fever, scarlatina, and diphtheria, are communicated through the agency of milk, and it further seems to be proved, by a series of remarkable cases of exemption, that these specific poisons are rendered inert by heat at the boiling-point. 2 Dr. Henry showed this with respect to scarlet fever ; and there is evidence that in the epidemic of typhoid which broke out in the neighbourhood of Wimpole Street some years ago, and was traced to milk infection, those households escaped in which the milk was boiled. This was also the case in the Harewood Square 1 Quoted by Rotch, Cyclopedia of Diseases of Children, vol. i. p. 3 00 2 Dr. Rissell finds, at the Glasgow Hospital for Infectious Dis- eases, that toiling clothes is sufficient to disinfect them thoroughly. EXACT COMPOSITION AND PROPERTIES 67 epidemic of scarlatina, traced to milk infection ; all who drank boiled milk escaped. 1 Mr. F. W. Par- sons, of Wimbledon, informs me that this was also the case in the epidemic there. Again, in the epidemic of diphtheria at Ealing, which was traced to milk infection, those families who boiled their milk enjoyed complete immunity ; and I have ob- served generally that those households where all milk is boiled enjoy a singular freedom from infec- tious diseases. Further, there is evidence that that scourge of infancy, tuberculous disease, or at any rate abdom- inal and general tuberculosis, can be communicated through milk. M. Ollivier recently brought before the Academy of Medicine an instance of infection of the kind, where six girls fell victims to tuberculosis 'derived from milk drawn from a cow whose udder was the seat of extreme tuberculous lesions. Probably a far more common source of infection of milk than the cow's udder, however, are the germs which enter it from air and dust to which it is exposed. Taking even phthisis alone, seeing how rife it is, the freedom with which sputum loaded with bacilli is everywhere distributed, the proved infectiousness of dried sputum, and the constant exposure of the 1 Vide B. M. J., Jan. 30, 1886. 68 ARTIFICIAL FOODS excellent culture medium, milk, to infection in this way, it can hardly be doubted that ingested milk is frequently the channel by which the disease is com- municated. The extraordinary liability of children to abdominal tuberculosis would be thus explained. We may then lay it down as a safe and wise rule that in all cases where the milk supply is not private, and its conditions fully known, all milk for use in the nursery should be boiled immediately upon its arrival in the house. OTHER METHODS OF STERILISING MILK — THEIR VALUE Since the importance of using sterilised milk for the feeding of infants has been recognised, various forms of apparatus have been devised by Soxhlet and others for the purpose of effecting sterilisation, either by immersion in boiling water, or by exposure to steam, and its preservation in hermetically sealed vessels. Milk completely sterilised by several ex- posures to heat in this way at intervals of a day — so as to effectually destroy spores as well as bacilli — and hermetically sealed, will keep sweet for many weeks, and this device is most valuable for long journeys or ocean voyages. EXACT COMPOSITION AND PROPERTIES 69 OBJECTIONS TO THESE METHODS — BOILING SUFFI- CIENT FOR ORDINARY USE For ordinary use, however, such elaborate process is, I believe, quite unnecessary. Simple boiling for a few minutes is amply sufficient. Professor Leeds believes that milk may be rendered practically sterile by heating to 68° C. or 155 F. for six minutes with- out any important diminution of its digestibility. And then it is possible that prolonged exposure to great heat may impair the nutritive value of the milk. There can be little doubt, as will be seen later, that the process of condensing milk destroys to some extent its antiscorbutic property ; and two cases have been reported to me by my friend Dr. Ford Anderson, in which well-marked scurvy followed the use of sterilised milk and fully dextrinised artificial food for several months. In numerous other cases, however, no evil result of the kind was observed by him, and the children appeared to thrive. Possibly a difference in the duration of exposure to heat or in the quantity of milk taken may have deter- mined immunity or non-immunity. Fresh milk even is not a powerful antiscorbutic. The experience of 70 ARTIFICIAL FOODS Dr. Davis at the Philadelphia Hospital ' showed that although the use of sterilised milk cured and pre- vented gastro-enteritis, nutrition did not improve, and the infants died in two or three weeks of malnutri- tion. 2 Those removed to a different atmosphere and given fresh milk rapidly improved. Yet other ob- servers report most favourably. My own experience is that, although sterilised milk answers admirably for a time, children kept on it throughout eventually lose firmness of flesh and vigour, and do not thrive into robustness. I am convinced that the process impairs the value of the nitrogenous element in some degree. THE WATER SHOULD ALSO BE BOILED The water with which milk is diluted for infant use should be boiled also. Its hardness, where excessive, as in London water, for example, is thus reduced, and any active contagion it may contain is thus destroyed, while other organic impurities are rendered innocuous. The milk may be made more digestible still by mix- ing it with barley water instead of plain water, which is presumed to act mechanically by separating the coagulating casein into smaller molecules. Or lime 1 American Journal of Medical Science, June 1891. 2 Ibid. EXACT COMPOSITION AND PROPERTIES 71 water may be added in the proportion of 1 part in 1 2. Lime water is effective in moderating coagulation, as you will see from the specimen to which acid has been added. The objection to it is that it favours constipation. When this occurs, a solution of soda bicarbonate of 6 grains to the ounce may be sub- stituted for the lime water. Boiled milk diluted with thin barley water is, on the whole, the best form for young infants, after the peptonising process advis- able at first has been gradually reduced to vanishing- point. THE USE OF CONDENSED MILK — ITS ADVANTAGES — OBJECTIONS TO ITS CONTINUED USE Under certain circumstances, where fresh cow's milk does not agree well, or when it cannot be pro- cured fresh and good, as on sea voyages, for example, or on long journeys, condensed milk may be used. The advantages of condensed milk are that it keeps perfectly, that it is always at hand sound and good, and that, as we have seen, the casein is rendered more digestible than that of fresh cow's milk. One mistake commonly made in feeding young infants on condensed milk is that of making the solution too strong at first. The directions on the 72 ARTIFICIAL FOODS label state that for infants 7 to 14 parts of water are to be added. But this is far too concentrated for a child at birth, or during the first month at any rate, to begin with. I have found by experience that it is not safe to give it, in early infancy, of greater strength at first than a dilution with 24 parts of water. This, of course, as you will see by the Table, is far too weak — only about one-quarter the strength of human milk — to give sufficient nutriment for long. It must, therefore, be steadily increased until the dilution of 1 in 10 or 1 in 7 is safely reached. The objections to the ordinary condensed milk are that it contains a large excess of sugar, much of this being in the form of cane sugar, added for the purpose of preserving it. As a matter of physiological necessity, the cane sugar has to be converted into grape sugar before it can be absorbed. In the meantime it is liable to ferment ; lactic acid is formed, which sets up irrita- tion of the stomach, flatulence, and discomfort. The excess of sugar also tends to make children fed on condensed milk wax fat out of all propor- tion. I remember that it was alleged some years ago by some practitioner, in whose mind I think theory EXACT COMPOSITION AND PROPERTIES 73 outbalanced observation, that this excess of sugar actually became a cause of diabetes. But this statement has not been confirmed by subsequent experience. 1 DEFICIENCY OF ANTISCORBUTIC ELEMENTS IN CONDENSED MILK There is, however, another point. The antiscor- butic property of milk is greatly impaired by this pro- cess of condensation. I have seen a child of 1 1 months old, fed from birth entirely upon condensed milk, who developed spongy gums and tenderness of bones, clearly scorbutic, and which disappeared entirely on change to antiscorbutic diet of fresh milk and potato pulp. In addition to this I have met with four cases of infantile scurvy on a sole diet of condensed milk and farinaceous food. 1 The objection to condensed milk on account of excess of sugar has been in great measure overcome by the preparation of 'unsweet- ened' condensed, milk. This, however, in the proportions of I of milk to 3 of water, the amounts stated, gives a mixture somewhat below the standard of ordinary cow's milk — viz. Solids, not fat . . . . . 8-54 Fat . . . , . . . 2-oo Water 89-46 Total ioo-oo (Dr. Luff's analysis.) And there is in my mind some doubt as to the perfect safety from sour- ness of milk thus prepared without excess of sugar. 74 ARTIFICIAL FOODS DEFICIENCY OF CREAM IN CONDENSED MILK Moreover, cream is greatly deficient — and you will see by the Table of Proportions (Table I.) that when condensed milk is diluted with only 7 parts of water the proportion of fat is only 1 - 6, about one-half that of human milk — much too small to be safe or satisfac- tory. 1 Hence, not unfrequently, especially in the case of children with feeble digestive power, who cannot take a solution of full strength, the child, although fat enough, not only becomes soft of muscle and pallid, but actually soft in bone and rickety. THE QUALITY AND USES OF GOAT'S MILK Goat's milk is highly nutritious, richer in fat than cow's milk, and therefore excellently adapted for young children in this respect. It is often procurable, and may be used with advantage where extra rich- ness of diet is advisable. But it is no whit more digestible than cow's milk. The casein coagulates in the same large masses, and it must therefore be treated in exactly similar fashion for very young 1 It is stated that the skim milk of butter factories is used largely in the manufacture of condensed milk (Dr. Wood, Australian Medical Journal, July 15, 1893). The milk is thus lacking in what is, for c hildren, the most important constituent. EXACT COMPOSITION AND PROPERTIES 75 children — viz. peptonised and diluted at first, and then boiled and barley water or lime water added. INABILITY OF SOME CHILDREN TO DIGEST COW'S MILK Some children — a not inconsiderable proportion indeed — one is constantly being confronted with such cases — appear to be unable to digest diluted cow's milk of a strength sufficient to support life. With even a dilution of 1 part of milk to 3 of water, they are sick, bring up undigested curd, are griped and flatulent, constantly crying with pain and discomfort are restless and enjoy little sleep, suffer from diar- rhoea as well as from colic. If nothing be done, the vomiting and purging go on and increase, and may lead to a fatal issue. The child becomes pallid, lean and flabby, with wrinkled, loose, hanging skin, wastes away to a mere skeleton, and, if no change be made, dies eventually of inanition. ARTIFICIAL HUMAN MILK A successful device in many cases is to put the child upon what is called artificial human milk. This is prepared by first removing all the cream by skim- 76 ARTIFICIAL FOODS ming, after the milk has stood some time. ■ Then the remainder is divided into two equal portions. From one all the casein is removed by rennet, i.e. converted into whey. The other portion is then mixed with the whey and the whole of the cream added. This preparation will therefore contain all the lactine, all the cream, but only half the quantity of casein.' It will thus be nearer in composition to human milk than cow's milk, containing sufficient proteid and some excess of fat. But it is not abso- lutely identical with human milk ; although the pro- portion of proteid is nearly the same, 2 the curd is unchanged in nature. It is still, as ascertained by experiment, coarsely coagulable cow's milk curd, although less massive than that of undiluted cow's milk. The fat is in larger proportion than in human milk, and the lactine rather less. This is probably an advantage, and some children who are able to digest only a limited amount of cow's milk casein do remarkably well on it. A few who are quite intolerant 1 Proteid ...... 2-57 Fat 4-45 Sugar 5-02 See Table I., page 47. 2 As the child grows older the proteid element should be increased by removing the curd from one-third of the milk only, instead of from one-half, as at first. This would raise the proportion of proteid to 3-6 per cent. , or more than equal to that of human milk. EXACT COMPOSITION AND PROPERTIES 77 of this form of casein cannot take even this dilute mixture. CAUTIONS WITH REGARD TO ITS USE There are two warnings I would give with regard to humanised milk. In the first place it will not keep long. After a time the cream separates with some curd in great clots, and does not easily mix again. I have twice seen children dangerously ill from taking artifi- cial human milk which had been sent a long distance and had changed in this way. If the dairy where it is manufactured is not within reasonable distance, have it made freshly at home. The second caution I would give is that its use should not be continued too long, and for two reasons. In the first place, the reduced amount of casein is insufficient for a child more than 6 or 7 months old — at this age ordinary cow's milk should be gradually substituted for it. I have seen several cases of serious falling off in nutrition from the too prolonged use of humanised milk. And, secondly, the antiscorbutic property is seriously impaired by the process — at least as carried out commercially. I have met with more than one instance of infantile scurvy on a sole diet of so-called humanised milk continued without change for several months. I must defer the consideration of farinaceous foods and meat juices to the next lecture. 78 ARTIFICIAL FOODS LECTURE III ARTIFICIAL FOODS — continued GLUTEN FOOD — THE MALTED FOODS — OTHER FARINACEOUS FOODS — BEEF-TEA PREPARATIONS— RAW MEAT JUICE ESSENCES OF MEAT Summary of conclusions reached in the previous lecture — Development of the child's power of digesting milk — Necessity for supplementing the milk with other food in certain cases — Table of nutritive values of various artificial foods and preparations — Bread jelly or gluten food — Mode of preparation — Insufficient alone— With milk — With meat juice and cream — Nutritive value of these preparations — Farina- ceous foods — Conditions under which they are admissible — Deficiency of fat and of antiscorbutic element — To be regarded as adjuncts or accessories only — Their value — They add nitrogenous and carbo- hydrate elements and salts — Malted foods ; of two classes — Examples — Their insufficiency alone — Nutritive values of the various forms — When mixed with water only — When mixed with a due proportion of milk, or other animal elements — Objections which have been raised to the use of these foods— The proper place of these foods in infant feeding— Pancreatised food— Distinction between pan- creatised food and a malted food -Advantages and dangers of predigested foods — Reasons — Foods which are neither malted nor pancreatised — Their composition — Useful for older children as addi- tions to milk — Entire wheat flour — Arrowroot — Cornflour— Rice - Prepared barley — Tapioca — Sago — Oatmeal — Malted foods with desiccated milk— Composition — Their insufficiency alone — Other accessory foods — Meat juices and essences — Beef tea — Analysis — EXACT COMPOSITION AND PROPERTIES 79 Small percentage of proteid — Poor in structural materials — Unsatis- factory results as a food for children — Veal broth — Raw meat juice — Mode of preparation— High nutritive value and digestibility — Analysis — Raw meat pulp — Mode of preparation — Patent meat juice — Its analysis and uses — Meat essences — Analysis— Their place as a food— The meat peptones — High nutritive value — Their special uses. BRIEF RECAPITULATION OF THE POINTS ESTA- BLISHED IN THE PREVIOUS LECTURE In the last lecture, gentlemen, I explained to you the properties and special characters of the various kinds of milk, the different methods of preparing them, their nutritive value, and the qualities which deter- mined the relative ease or difficulty with which their casein could be converted into peptone by the diges- tive fluids of an infant. I showed you, I think, that without doubt the great difficulty which children have in digesting cow's or goat's or ewe's milk does not, as generally sup- posed, lie in the fact that these contain a greater amount of solids than human milk. That could be easily remedied, of course, by the addition of water. This inferior digestibility of cow's milk is due to the character of the casein, some difference in its chemical composition, in the arrangement of its molecules, so that, when in contact with the gastric juice, it coagu- lates in massive clots, which are in striking contrast 8o ARTIFICIAL FOODS TABLE SHOWING THE PROPORTION PER CENT. OF THE DIFFERENT CONSTITUENTS Elements of Food s of Proteids — = "r Fats Nitrogenous of Hydrocarbons ui a- «« Lactine or Sugar of Milk . Grape Sugar Carbohydrates of J Maltose , various forms \ Dextrine - I Starch v Cellulose . Lime . . • # ■ Phosphoric anhydride Other ash . Water . Total . 2'35 2-41 6-39 Pure Jelly "019 ■026 ■295 88-51 2 73 0*50 Total _ Carbohy- ' drates I5"24 'OS •29 ■17 8l "02 Bread Jelly I* o a 0-74 0T3 Total Carbohy- drates 4'i5 ■08 ■05 94-84 X O 'E * BE; a) o T C "« O 2-705 1-695 Total Carhohy- drates 5-618 •149 >'643 1:11 .2-Q •sal 2'7II 3*632 Total Carbohy- drates ="953 '13 'ii EXACT COMPOSITION AND PROPERTIES 81 II IN CERTAIN ARTIFICIAL FARINACEOUS FOODS AND PREPARATIONS Malted Food partially dextrinised Pure Food d c * « ofa IS ■g-s •a .8 MaltedFood more highly dextrinised Pure Food * "S fe iS if 2 * ass" •ssas - ^8 *sa = ° s ■"> I «*«--? ■PsS2 -a SauJ Malted Food with desiccated Milk Prepared Entire Wheat Flour i3 1 H W s Pure Flour 10-78 64*12 1-36/ 15 '35 i'o8 Total Carbo- hy- drates 77-28 42 ■40 4'37 074 0-05 2-723 2*009 Total Total Carbo- Carbo- hydrates hydrates 3'75 04 •04 95'37 6*2X1 •16 ■168 88*619 5*43 o'i6 2*187 9-62 4'75 Total Carbohy- drates 87*12 14 •71 2-68 376 3*946 ■4 •175 91*341 80 "o ■30 •38 '71 4*22 0*641 0*316 Total Carbohy- drates 5 '335 °3 •043 93 '6i5 1 20Z o*594 Total Carbohy- drates ■04 *°5 •08 8-005 13*15 Starch 50 '59 '33 82 ARTIFICIAL FOODS to the minute, light, flocculent coagula of human milk. The latter, of course, as may be shown by actual ex- periment, quickly and easily dissolved by the gastric juice ; the former only after a considerable period. In the meantime the casein, thus unconverted, begins to set up fermentation, and irritant acids are formed, with the usual disastrous effects upon the alimentary canal of the child. I then described various devices for rendering the casein coagula lighter, smaller, and more flocculent ; such as boiling, peptonisation, and the addition of barley water or lime water, or solution of sodium bi- carbonate, the combination of boiling with barley water or an alkaline solution being the most satisfac- tory and effectual, after the first initiation on dilute peptonised milk. Further, I affirmed, you may remember, that some very young children are unable to take cow's milk in any form, at any rate at first, even when its character is favourably modified after the manner I have described. For these it is necessary either to get a wet-nurse or adopt asses' milk, or to abandon all milk for a time, and substitute other food until digestive power strengthens. EXACT COMPOSITION AND PROPERTIES 83 THE SUBSTITUTION OF OTHER FOOD FOR MILK A TEMPORARY EXPEDIENT ONLY And here I would impress upon you that this expedient is only a temporary measure to overcome a difficulty for the time, and again urge the para- mount necessity of advancing gradually to a food which comes up to the standard of nutritive value in all ingredients, and which fulfils, indeed, all the several essential conditions laid down in the first lecture. THE PLAN TO BE ADOPTED WHEN THERE IS INTOLERANCE OF COW'S MILK The safest plan, perhaps, with children who ex- hibit extreme intolerance of dilute cow's milk, fresh, boiled, or condensed, or even artificially humanised, is to stop milk in any of these forms altogether for the moment, and to continue for a time peptonised milk and water, or peptonised condensed ' milk of the strength of 1 to 16, or asses' milk, if it can be obtained. Asses' milk and peptonised condensed milk are both expensive foods. Another satisfactory plan is to adopt some other 1 This can be obtained ready prepared at certain leading chemists. G 2 84 ARTIFICIAL FOODS food as a basis, to which milk may be gradually added, increased as the child's digestive power developes. THE CHILD'S STOMACH TO BE GRADUALLY TRAINED TO DIGEST COW'S MILK The child's stomach may be educated to the digestion of cow's milk by careful training and man- agement. If the process is sufficiently gradual and cautious, it is always successful in the end. Diluted peptonised milk may be used in this way, the peptonising process being gradually reduced, or milk and water added to the peptonised food in gradu- ally increasing proportions, as previously explained (p. 61) ; or bread jelly, prepared after the formula suggested many years ago by Dr. Churchill, of Dublin, may be given — the simplest and cheapest material, and one of the best for this purpose. MODE OF PREPARING BREAD JELLY Take a thick slice of bread (4 oz.), two or three days old, so as to be dry and sweet, and of seconds flour (since this is richer in proteid and phosphates than the finest white flour), place it in a basin of cold water and allow it to soak for six or eight hours. It is then to be taken out, and all the water squeezed EXACT COMPOSITION AND PROPERTIES 85 out of it. The object of this first soaking is to clear away the lactic acid formed in fermentation> and all other peccant matters. The pulp is then placed in a pint of fresh water and gently boiled for an hour and a half. The object of this prolonged boiling is to thoroughly break up the starch corpuscles, and to promote the change of starch into dextrine and grape sugar. The thick gruel thus made is strained, rubbed through a fine hair sieve, and allowed to grow cold, when it forms a fine, smooth, jelly-like mass. This should be freshly prepared night and morning, for it will not keep long. Enough of the jelly is then mixed with warm water, previously boiled, to make a food of the con- sistence of thin cream (about one full tablespoonful to 8 oz. of water), so as to pass readily through the bottle ; a little white sugar may be added. THE COMPOSITION AND PROPERTIES OF BREAD JELLY — WHEREIN IT FAILS TO FULFIL THE ESSENTIAL CONDITIONS Now the composition of this, as ascertained by actual analysis, is shown in the Table ; and, diluted as I have stated, you will see that it is far too weak alone in every element except carbohydrate to form a 86 ARTIFICIAL FOODS satisfactory food. It would fail in every one of the first four essential conditions. Thus (Table II. p. 80) one tablespoonful diluted with 8 oz. of water con- tains — Proteid 074 Fat ....... 0-13 Carbohydrate 4 P I5 Lime. ...... "01 Phosphoric anhydride .... -08 Other ash -05 Water 94'84 Total ..... 100 -oo 1. It would therefore not contain the elements in due proportion: 2. It would not contain the antiscorbutic element. 3. The nutritive value of the amount possible to be taken by a child would necessarily fall far short of the standard, except in carbohydrate. 4. And it would contain no animal element. REQUIRES THE ADDITION OF SOME ANIMAL MATERIAL — THE MODE OF PROCEDURE These deficiencies must be remedied by the addi- tion of an animal element supplying the requisite supplement of proteid, fat, and the antiscorbutic property. This may be done by adding boiled milk. The quantity should be extremely small at first, especially EXACT COMPOSITION AND PROPERTIES 87 if the child has already shown intolerance of cow's milk — two teaspoonfuls of boiled milk, or even one only, to the 3 oz. or half bottle. The milk may be gradually increased every few days as the child is found able to digest it, the stools being carefully examined for sign of undigested curd. Thus the child may be gradually advanced to the requisite quantity of milk. ANALYSIS OF BREAD JELLY WITH DUE PROPORTION OF MILK Bread jelly mixed with water, equal parts of milk and water, i.e. 3 oz. jelly ( = one full tablespoonful) to 4 oz. milk and 4 oz. water (Table II. p. 80) — Proteid 2705 Fat . 1-695 Carbohydrate 5 -6 18 Lime -08 Phosphoric anhydride . . . -II Other ash "149 Water 89-643 Total ioo-ooo Peptonised milk may be added at first, instead of boiled milk, and the quantity increased more rapidly. This food, you will see, when made with half milk and half water, comes fully up to the standard in proteid, is rich in lime salts, but is decidedly de- ficient in fat, and in less degree in carbohydrate. 88 ARTIFICIAL FOODS BREAD JELLY FOOD WITH CREAM AND RAW MEAT JUICE IN PLACE OF MILK — ANALYSIS In cases where there is absolute intolerance of cow's milk, the animal element, the additional proteid and fat, and the antiscorbutic property, may be supplied by raw meat juice and cream. It will be seen from Table III., given subsequently in p. 1 14, that raw meat juice is nearly double the strength of human milk in proteid, and more than double in nitrogenous matter if extractives be in- cluded. 1 A reference to Table II. (p. 80) will show that bread jelly with 4^ parts of the solution in water ( = five tablespoonfuls), \\ part raw meat juice ( = six teaspoonfuls), \ part cream ( = two teaspoonfuls) contains in each 100 parts Proteid and extractive . . .2711 Fat .. . . ■ . . . . 3-632 Carbohydrate 2 -953 1 Raw meat juice . 4 to I water and extracted by pressure. Nitrogenous 1 Proteid . 5 -I l_g. 2 elements J Extractive . 3'l j Cream contains — Fat 46 Casein, milk-sugar, and salts . . 5 Water 49 Total 100 (Dr. Luff's analysis.) EXACT COMPOSITION AND PROPERTIES 89 In this mixture there is an ample amount of proteid and of fat, but a deficiency of carbohydrates. The latter may be remedied by the addition of a little sugar. VALUE OF THIS COMBINATION AS A SUBSTITUTE FOR MILK This combination as a substitute for milk is of great value ; the bread jelly is extremely bland ; the raw meat albumen is most digestible as well as nutritious, and the cream supplies the necessary fat. When it is thought desirable, as the child's diges- tive power developes, to raise the strength to a high standard, somewhat in excess of human milk, the amounts stand thus : 4 parts bread jelly mixture with water only, + 3 parts raw meat juice, + \ part cream, + £ part sugar. The composition of this mixture is — Proteids 3-894 Fats 3-068 Carbohydrates 4'338 Salts 0-343 Water ., 88-357 Total .... ioo-ooo 9 o ARTIFICIAL FOODS A SOURCE OF DANGER ATTENDING ITS USE It must be borne in mind, however, that there is one source of danger in using this food, and that lies in the liability of the raw meat juice to undergo de- composition. To be safe it should be freshly prepared twice a day, as also the bread jelly, and kept in a cold airy place. The cream should also be obtained fresh night and morning. Lastly, the meat juice must not be added to the food when hot, or the albumen is coagulated and its special digestibility thereby de- stroyed. THE FARINACEOUS FOODS — NOT TO BE REGARDED AS COMPLETE FOODS, BUT AS ACCESSORIES OR ADJUNCTS ONLY I now come to the consideration of the other farinaceous foods, useful only, and to be used only, like the preceding, as adjuncts or accessory foods for the purpose of addition to milk or other animal elements. Farinaceous foods cannot be regarded as complete foods sufficient in themselves ; the deficiency in fat, the absence of animal matter, and of the antiscorbutic element, absolutely disqualify them as sole foods. It behoves the medical practitioner not to order these EXACT COMPOSITION AND PROPERTIES 91 foods loosely and at haphazard, but to make himself acquainted with their composition, to satisfy himself as to which of the classes hereafter described they belong, and their fitness for the exact case which he has in hand. MAY BE USED AS ADDITIONS TO MILK AND WATER WHEN ONLY A WEAK SOLUTION IS TOLERATED Now, as appears clearly from the Table, and as I think I made plain to you in the last lecture, cow's milk and water in the proportion of 1 part of milk to 2 of water is vastly below the standard of human milk in nutritive value, and this deficiency exists in all three chief elements — proteid, hydrocarbon, carbo- hydrate. Even half and half, you see, although containing sufficient proteid, is far below the standard in fat and in carbohydrate. As I demonstrated to you, it is only when the proportion of 2 parts of milk to 1 of water is reached that it approaches the necessary standard in fat, containing then a slight excess of proteid but still short of carbohydrate. 92 ARTIFICIAL FOODS THE PROPORTION OF COW'S MILK TO WATER REQUIRED TO BRING IT TO THE STANDARD OF HUMAN MILK This point is a most important one. Remember, then, that feeding by cow's milk and water is not satisfactory, unless the child can digest a solution so strong as 2 parts of milk to one of water, or can take an increased quantity of the more diluted kind sufficient to bring up the gross amount of the different elements to that yielded by the regulation quantity of human milk, which I gave you before. If this cannot be done — and constantly the child cannot take enough of cow's milk alone to yield the required amount of nutriment — the deficiency must be made up by addition of fresh ingredients. The standard proportions must be reached, if not by milk alone, then by milk with additions. The deficiency of carbohydrate is usually remedied by the addition of sugar, but that of proteid and fat remains. VALUE OF ARTIFICIAL FARINACEOUS FOODS AS SUPPLEMENTS TO ANIMAL FOOD Now, as I have said, the value of the artificial farinaceous foods consists really in their being supple- EXACT COMPOSITION AND PROPERTIES 93 ments to animal foods. They are not to be regarded as sole foods or even as chief foods, yet if the child cannot take cow's milk more than 1 part to 2 or equal parts, then farinaceous foods supply additional nutriment in digestible form. They supply additional proteid, they supply additional carbohydrate, but they supply hydrocarbon in infinitesimal degree only. ELEMENTS SUPPLIED BY THE ADDITION OF ARTI- FICIAL FARINACEOUS FOODS — THE FORM OF PROTEID AND CARBOHYDRATE These artificial foods, then, are to be regarded as a means of supplying an additional amount of carbo- hydrate and some additional proteid. The proteid, in the form of gluten, appears to be digested and assimilated by the child's stomach with ease. The carbohydrate element is in some in the form of starch, in others converted, or in process of conversion, more or less completely into dextrine, maltose, or grape sugar. Now starch, I need hardly remind you after what I have said previously, is a form of carbohydrate, which infants have only the most limited power of digesting, and its use in its simple unchanged state is most objectionable in the case of very young chil- 94 ARTIFICIAL FOODS dren. It gives rise to acidity, flatulence, and is to a great extent useless as food, because unassimilable. For a child's use it should either be converted into maltose or grape sugar, or the process at least set in motion to be carried on to completion in the duo- denum and small intestine. THE ELEMENTS WHICH GIVE VALUE TO ARTI- FICIAL FARINACEOUS FOODS — PROTEID AND DEXTRINE, OR MALTOSE As a general proposition it may be affirmed that these foods are admirable in proportion to the amount of nitrogenous matter they contain, and in proportion to the conversion of the starch through some of the stages into sugar. Some medical men object to the use of these foods altogether. I think they are undoubtedly in error. Such foods have their place as adjuncts to milk. For the proteid supplied is a valuable addition ; and if the carbohydrate is in the form of dextrine, maltose, or grape sugar instead of starch, this is far better than the cane sugar used to sweeten foods for this latter is more liable to ferment during the process of digestion, since it has to be changed into grape sugar before it can be assimilated. The EXACT COMPOSITION AND PROPERTIES 95 maltose or grape sugar, ready made, can be absorbed at once. Moreover, the mixture with milk appears to favour mechanically the formation of smaller curd masses, and thus increase its digestibility. THE PRINCIPLE OF A MALTED FOOD The principle of a malted food, first suggested by Liebig, is the conversion of starch into sugar, and there are numerous preparations now manufactured on this principle. Malt meal is mixed with wheaten meal, and the action of the diastase in the malt upon the starch of the wheaten meal, at a certain heat, changes it chemi- cally ; first into dextrine, then into maltose, and then into grape sugar. MALTED FOODS — TWO CLASSES— I. PARTIALLY DEXTRIN ISED Malted foods may be divided into two classes ac- cording to the extent to which the process is carried. In the first, the finest wheaten flour is mixed with malt flour, but the process of conversion into sugar is only carried to a slight extent. The process is set in motion again actively on mixing with water for use. The starch is then converted very rapidly, 96 ARTIFICIAL FOODS partly in the cooking, partly in the child's stomach. In the course of 10 or 15 minutes after mixture with warm water, only the merest trace of starch can be discovered. You will see, from Table II., that this food contains in the form of flour only 1 per cent, of sugar, 107 of dextrine to 6\' 12 starch, and at first sight this would appear unsatisfactory. But the work of conversion goes on quickly in the prepara- tion for use, and the food is transformed into a sugar food instead of a starch food. PREVIOUS DIGESTION OF STARCH AND CONVER- SION INTO DEXTRINE AND SUGAR PHYSIOLOGI- CALLY RIGHT Now I wish to draw your attention to this point. The process of converting the starch into dextrine and grape sugar artificially is not weakening and demoralising to the child's digestive functions like the peptonising and pancreatising process. It is physiologically correct that the conversion of starch should take place outside the child's stomach. The diastase of the malt only does for the child what the mother does for her infant, viz. convert starches and sugars into lactine before they are supplied to the child in the mother's milk. With the other processes EXACT COMPOSITION AND PROPERTIES 97 it is different. Peptonizing digests proteids alone. Pancreatising, on the other hand, digests not proteids only, but starches and fat also. This office of digest- ing proteids and fats the child's stomach and intestine are fitted to do for themselves. Tou will note also that malted food has a high proportion of proteid elements in the form of the gluten and albumen of the wheat flour and of the barley. This richness in proteid is of course a valu- able property, and it appears to be due partly to the choice of wheat flour rich in gluten, partly to the starch in the malt being used up (after conversion into sugar) in the germinating growth. The little buds are of course removed in the riddling of the malt, the result of this removal being to leave the malt meal with less of the starchy element in propor- tion to the proteid or nitrogenous element, i.e. to leave it with a high proportion of proteid. MALTED FOODS ABSOLUTELY INSUFFICIENT ALONE — POINTS IN WHICH THEY FAIL TO FULFIL THE ESSENTIAL CONDITIONS But as a sole food, made with water only, a. malted food is of course absolutely unsatisfactory. I have at this moment a patient, a child of 12 months, suffering H 98 ARTIFICIAL FOODS from severe scurvy, brought up entirely upon food of this kind without the addition of milk. Pure fari- naceous foods, as I have shown you, cannot contain everything necessary for the full nutrition of an infant. The absence of both animal and antiscorbutic element would alone disqualify them. As you will see from the Table, such food is defi- cient in every ingredient except the carbohydrate ; even in mineral matter, but notably and especially in fat. ANALYSIS OF A MALTED FOOD MADE WITH WATER ONLY The analysis of a sample of one of these malted foods diluted with 15 parts of water, according to directions, yields only (Dr. Luffs analysis) — Proteid ...... 0-74 Fat o-oj Carbohydrate 375 Salts . . . . . . . 0-09 Water ...... 95 -37 Total ..... ioo-oo WITH THE ADDITION OF MILK Mixed, however, with due proportions of fresh milk and water (in this case J\ parts of milk and j\ parts of water), it becomes a highly satisfactory food in most respects ; the gluten and albumen in the EXACT COMPOSITION AND PROPERTIES 99 flour, added to the casein of the milk, bring up the proportion of proteids to a little above the normal standard, 2723 as compared with 2*35. The carbo- hydrate is sufficient, 6 - 2ii as compared with 6-39, and it is in the most desirable form of dextrine and grape sugar from the food and lactine from the milk ; the lime salts are in excess, T 1 lime and - i6 phosphoric anhydride, as compared with - oiq and 026 respec- tively in human milk, a good fault, improving the food in bone-making material. This mixture with milk is, however, still deficient in fat, though not to any great degree — 2*009 as compared with 2-41 (i.e. less than \ per cent). To make the food absolutely up to standard in this element, a minute amount of cream should be added (about five drops to each two ounces of food), or the proportion of milk raised to rather more than half. This would bring up the proportion of fat to the required amount, the proteid being somewhat in excess. USE OF PARTIALLY DEXTRINISED MALTED FOOD This form of malted food partially dextrinised agrees perfectly in most cases with children over three months, and those brought up on it with the proper addition of milk are firm-fleshed, lively, and vigorous. It sometimes, however, proves laxative, loo ARTIFICIAL FOODS and is not suitable to very young infants. For these the bread jelly, with milk or raw meat juice and cream, is far preferable ; or a more perfectly dextrin- ised food, with milk ; or artificial human milk. II. MALTED FOOD HIGHLY DEXTRINISED The second form of malted foods differs from the preceding chiefly in this, viz. that the process of conversion of starch is completed in the first prepara- tion of the food flour ; not a trace of starch remains. It is all changed into dextrine and sugar. According to the analysis of one of these foods the proportion of nitrogenous element is lower, viz. 5-43 only. There is also an inferiority in fat — a remarkable one, 01 6 only as compared with 0-313 in the other malted food — -due possibly to the process of preparation, by which the soluble portions are chiefly retained, the other parts being strained off. ANALYSIS OF HIGHLY DEXTRINISED MALTED FOOD MIXED WITH WATER ONLY— WITH THE ADDI- TION OF MILK Mixed with water only, it fails in all points, as will be seen by reference to Table II. Mixed with equal parts of milk and water, it is still somewhat EXACT COMPOSITION AND PROPERTIES 101 below the standard in fat, in nitrogenous element, and in carbohydrate. But duly enriched in fat and pro- teid by the further addition of milk, or of raw meat juice and cream, it forms an excellent food, the total absence of starch being its especially favourable fea- ture. For this reason it is better suited for very young infants than the other class of malted food. PREDIGESTED FOODS — PANCREATISED FOOD — CHANGES EFFECTED BY THE PANCREATIC FERMENT Another form of food largely used now is pan- creatised food. I have no actual analysis of it ; but it is made of the best wheat flour, containing a high proportion of proteids, probably about 12 per cent., the proportion which obtains in the finest wheaten flours, and in most of the foods made from them. Mixed with a due quantity of pancreatic ferment, the starch is converted into dextrine and grape sugar, as with the malt process. But there is a further change. The pancreatic secretion acts also on proteids, converting them into peptones, and upon fats, emulsifying them. Now this, I must again insist, at once usurps a proper function of the infant's digestive organs. It is not their physiological function to convert starch into 102 ARTIFICIAL FOODS sugar, but it is their physiological function to convert albuminoids or proteid into peptones, and to emulsify fats. Pancreatised food of this kind, being always pre- pared with milk, has the essential animal element. It is nutritious and easily digested ; an excellent form of nourishment for a weakened or invalid stomach. It is often of great service as temporary or additional food in sickness and debility, but it is found to be lacking in antiscorbutic properties. CAUTION AS TO THE USE OF PREDIGESTED FOODS — IMPAIRMENT OF DIGESTIVE FUNCTION, ANAEMIA, SCURVY, RESULT FROM THEIR PROLONGED USE All predigested foods, however, infallibly debili- tate and demoralise a healthy stomach after a time by relieving it of work which it ought to do for itself. They are, therefore, not fitted for permanent use, and especially as a regular food for little children whose digestive powers require to be developed and improved — not impaired. Moreover, they fail to impart full nutrition after a time, and the antiscor- butic property is certainly injured by the process. I have now seen a considerable number of children under a year old, who have been brought up en- tirely upon these predigested foods. They conform EXACT COMPOSITION AND PROPERTIES 103 curiously to one type. They are large, fat, soft, flabby, white — not markedly rickety in bone, but late in teething, given to sweat profusely, prone to laryngismus and convulsions. Many became scor- butic, with swollen gums and periosteal swellings and tenderness. A significant feature in these cases was the difficulty which attended the attempt to place them on ordinary milk food, which caused vomiting and diarrhoea when given in quantity, and the change had to be carried out very gradually. Simple peptonised milk and peptonised condensed milk are open to the same grave objections. Children fall off and fail to thrive after a time when kept on these foods alone, and the difficulty of getting the child's stomach to deal with ordinary milk foods arises, as in the former case, and is sometimes almost insuperable. Moreover, I have seen in a large number of cases genuine scurvy supervene not only on a diet of peptonised milk continued for four or five months, but on pancreatised farinaceous foods made with milk. All predigested foods, even those made with fresh milk, should only be used temporarily to tide over a difficulty for a week or two, and then gradually re- placed by natural diet. 1 1 Sir W. Roberts found that in the case of a kitten fed on pre- Io4 ARTIFICIAL FOODS If a predigested food is given, the farinaceous part should be gradually replaced by some ordinary food, such as a malted food, or finest prepared entire wheat flour, which may be mixed with it in increas- ing proportions, the pancreatised food being reduced in like ratio, but the proportion of milk retained. Or some other home peptonised or pancreatised food may be given, and the degree of peptonising agent and time of digestion gradually reduced to nil. Peptonised milks may be modified by reducing the degree of digestion in the same way, or more easily, perhaps, by the gradual substitution of boiled milk and water, which may be mixed with the peptonised form in slowly increasing quantity. OTHER FARINACEOUS ARTIFICIAL FOODS — UN- MALTED FOODS — THEIR PREPARATION AND PROPERTIES Other farinaceous preparations largely used are made from good flour which has been heated at high temperature, with the object of breaking up the starch and partially converting it into dextrine. digested food exclusively, there was no marked loss of health, yet this kitten fell behind another fed on ' simple milk ' in body weight, and he suggested that some atrophy of unemployed glands might be the cause of this failure of nutrition. Exactly the same result follows in the case of children, with the addition of loss of digestive power, marked anaemia, and eventually scurvy, if the diet be continued for a long period. EXACT COMPOSITION AND PROPERTIES 105 But this is evidently imperfectly effected ; the infusion gives but slight indication of dextrine. Unmalted Farinaceous Food Proteid 12-3 Starch (and dextrine) . . . .69-0 Ash 1-06 Moisture 9-45 So that such foods must be looked upon as chiefly starch, with, like all other farinaceous prepara- tions, a deficient amount of proteid, and almost desti- tute of fat. They are less suitable than the malted foods as a diet for young infants in having unchanged starch instead of dextrine. A food of this kind, prepared with water alone, would be of very faulty nutritive power. It would contain less than 1 per cent, nitrogenous matter, a trace of fat only, and carbohydrate in the form of starch ; no animal element, no antiscorbutic element. I have lately seen a child suffering from scurvy as well as rickets, brought up on a food of this kind alone without the addition of a sufficient quantity of milk or its equivalent. Mixed with a due proportion of milk, it forms a satisfactory food for children after the first few months, when they have gained the power of digest- ing starch. But it is unsuitable for young infants. io6 ARTIFICIAL FOODS BAKED FLOUR — ITS PROPERTIES Baked flour, like the patent unmalted farinaceous foods, is prepared upon this principle of partially con- verting starch into sugar by heating at high tempera- tures. It corresponds very closely with the preceding in the proportions of proteid and of starch which it contains, and yields little dextrine. It is essentially starchy food, not suited for very young children. Mixed with a sufficient amount of milk it forms satis- factory food for the later months of infancy. ENTIRE WHEAT FLOUR — ITS SPECIAL VALUE One of the best of the unmalted flour foods is entire wheat flour, prepared by Chapman's process. In this the inner portion of the husk of the wheat is separately ground down to finest powder, and added to the white flour. The mixture contains the whole of the mineral matter, and the whole of the proteids. The objection to it is that it contains a slightly larger amount of cellulose than ordinary flour, and, of course, the starch is unchanged. Much can be done in this latter direction by long boiling, but even with this improvement it cannot be EXACT COMPOSITION AND PROPERTIES 107 accepted as a suitable food for very young infants. Its virtue lies in its richness in phosphates and in proteid. 1 ONE GREAT DEFECT OF ALL FARINACEOUS FOODS IS THAT THEY CONSIST MAINLY OF CARBO- HYDRATES, GENERALLY IN THE FORM OF STARCH Let me remind you again that the grand defect of all farinaceous foods is that they consist mainly of carbohydrates, and generally in the form of starch. As I pointed out to you, Nature gives conclusive evidence against starch as such — the infant's type- food, milk, contains no starch — and yet these prepa- rations consist chiefly of starch. The starch should at least be partially changed into dextrine and sugar, and then the artificial fari- naceous preparations form useful additions to milk or other animal aliment. 1 At my suggestion a malted food is now prepared from this entire wheat flour. Its greater richness in phosphates and proteid renders it especially valuable, and it is thus rendered available even for infants too young to digest it in unmalted form. 108 ARTIFICIAL FOODS THE EVIL OF FARINACEOUS FOODS NOT SOLELY DUE TO PRESENCE OF STARCH, BUT TO DE- FICIENCY OF FAT AND PROTEID, OF ANIMAL MATTER, AND THE ANTISCORBUTIC ELEMENT Bear in mind, further, that the chief evil of fari- naceous food does not lie in the mere positive quality of the presence of starch only, as commonly believed, although this is a grave fault, but rather in negative qualities : in the deficiency of proteid, in the still greater deficiency of fat, in the entire absence of all animal element, and of the essential antiscorbutic property. HOUSEHOLD FARINACEOUS PREPARATIONS — THEIR PROPERTIES And more defective even than the patent foods, in this respect, are certain household farinaceous materials often made use of. Arrowroot, for example, is almost pure starch, and cornflour is little more, the maize from which it is prepared having been robbed of some of its most nutritious ingredients to render the flour white and attractive. These substances are largely given — especially EXACT COMPOSITION AND PROPERTIES 109 cornflour — chiefly by the poor ; possibly because they make a smooth, gelatinous fluid which looks the very ideal of a light digestible food. ILL EFFECTS OF A DIET OF THIS KIND Children fed on this soon grow pallid, thin, and feeble. Yet their appetites are voracious ; they are always hungry, always crying for food. In spite, however, of the large quantity they consume, they grow thinner and thinner, and die of atrophy, not so much from any over-dose of starch, although that, of course, they digest imperfectly, as from the want of life-giving, tissue-making proteid and fat. They are starved to death in the midst of plenty. For little children arrowroot and cornflour are the poorest and least useful of foods. Prepared barley, sago, tapioca, rice, are open to the same objection in varying degree. Oatmeal is more nutritious, as containing more albuminate, fats, and salts, but it is unsuitable for young infants on account of the large amount of coarse vegetable fibre which it contains. no ARTIFICIAL FOODS THE PATENT FARINACEOUS FOODS WITH A DESICCATED ANIMAL ELEMENT ADDED And now I turn to preparations which are not purely farinaceous, but contain some animal element in addition. Such foods would appear at first sight to be com- plete. They are composed of flour duly malted and dried milk ; and therefore, from their composition, should contain ample proteid and fat, and a due pro- portion of animal matter. THESE FOODS NOT SUFFICIENT WITHOUT ADDI- TION OF FRESH ANIMAL ELEMENT They are not, however, complete and sufficient for perfect nutrition in themselves alone. They do not supply everything necessary to life, and growth, and health. For full nutrition it is essential that some fresh animal element should be given in addition. The reasons for this conclusion are as follows : From the analysis given in Table II. you will see that when prepared for use, one tablespoon ful to five of water, it is below the standard in proteid, and ex- tremely deficient in the proportion of fat, as compared with human milk. Moreover, it contains a consider- able excess of carbohydrate element, some of which EXACT COMPOSITION AND PROPERTIES in is cane sugar. When prepared for very young infants, viz. one tablespoonful to ten of water, it will be only half the strength. Malted Food with Desiccated Milk — Pure food Mixed with 5 parts water Mixed with 10 parts water Proteid Fat . Carbohydrate (starch, cane sugar, dextrine) Salts .... Water 9-62 475 80-02 i-39 4-22 1-202 o-954 10 -025 0-174 88-oos 0-641 0-316 5-335 0-093 93-625 Total ioo-o 100 -o 100 -o In theory this form of food is attractive, and it possesses useful qualities. It usually agrees well with the children's stomachs ; they are free from sickness, flatulence, or food diarrhoea, are extremely comfort- able, and do well on it for a time. THESE FOODS DEFICIENT IN CERTAIN ELEMENTS Yet these foods, although of good digestible materials, have too low a proportion of animal matter, especially of proteids and fat, lack the antiscorbutic property, and therefore cannot supply fully and permanently the ingredients essential to the perfect structure of tissues. 112 ARTIFICIAL FOODS WARNING WITH REGARD TO THE USE OF THESE FOODS ALONE Children brought up on dried foods alone, with- out any addition whatever, are apt to become pallid, flabby, deficient in robust vitality, rachitic, and even scorbutic. A fresh animal element must be added. For experience shows further that these dried foods are defective, not only in proteid and fat, but also in the antiscorbutic property. This, you will remember, is present in fresh milk, and largely deficient in condensed milk. It would seem that the process of desiccation impairs that property in the milk, and its nutritive power in other respects, perhaps, also. Scurvy has constantly been observed to arise on a prolonged and continuous diet of dried food alone ; many cases of the kind in my own ex- perience and numerous others are recorded. We must conclude, therefore, that, although sound and digestible, dried foods require to be supplemented by fresh animal material, such as milk, or cream, and raw meat juice. They need these additions to bring them to the standard required for a regular and per- manent food. EXACT COMPOSITION AND PROPERTIES 113 MEAT TEAS, JUICES, AND ESSENCES — THEIR PROPERTIES AND VALUE I pass on now to certain other accessories of food, which are frequently given in addition to milk and farinaceous preparations. I mean the various forms of meat teas, juices, and essences. BEEF TEA — ITS COMPOSITION AND USES The one in most common use is beef tea. Yet beef tea is, after all, a poor food for little children, and I have been much struck with the very- small amount of advantage they appear to obtain from it. The children do not gain hardness of flesh and freshness of colour on it. If you look at Table III. you will, I think, see the explanation of this. You will be surprised, perhaps, to see how little proteid it contains, even when made in the best way by previous soaking in cold water. BEEF TEA POOR IN AMOUNT OF PROTEID Beef tea made in the ordinary way yields — Proteid 0-82 Extractives 2-09 Fat o-co Salts 078 Water 96*31 I 114 ARTIFICIAL FOODS W M o rt < > £ <; Ui < H H < H W ri I; R. D H > rri H U < a a < o tu s o u (3 z, is o a Essence of Beef. (Dr. Luff's analysis) y in f*j , tj-oo Ctf op N w N -- vb b m w 8 Patent Meat Juice (Dr. Luflf's analysis) H m in v>r*. oj as ps | op n is is* '•& ' b 00 ri « « m m p b Raw meat juice made by mincing beef-steak, soaking one bour, and forcibly expressing. 4 oz. meat to 1 oz. water. (Messrs, Savory and Moore's analysis) t Total nitrogenous elements L 8-2 0-7 91-1 p b Beef tea made by soak- ing one hour in cold water, then stewing down. 1 lb. beef to make 1 pint. (Messrs. Savory and_ Moore's analysis) Total nitrogenous elements 1-021 I 2-8 4 1-82) o-88 96-28 p b Beef tea made in the ordinary way by stew- ing down in an earthen jar. 1 lb. beef to make 1 pint. (Messrs. Savory and Moore's analysis) Total nitrogenous elements 0-82 \ l 2 ' 91 ^2-09] 0-78 96-31 8 d B V 5 Proteids Nitrogenousex- tractives, kreatin, &c. . Non - nitrogenous extractives . Fat Salts . Water . 3 H EXACT COMPOSITION AND PROPERTIES 115 Beef tea made by the more approved method, viz. soaking first one hour in cold water, yields — Proteid 1-02 Extractives 1-82 Fat ....... o - oo Salts ....... o-88 Water 96-28 So that it still contains a low percentage of proteid. There is also rather more than the same quantity of inferior nitrogenous matter — extractive — but it is a question yet unsolved how far these products are usable for tissue construction. They are probably of greatly inferior importance to albumen. DETERIORATIVE EFFECT OF HEAT UPON NUTRI- . TIVE VALUE OF ALBUMEN The coagulation of albumen by heat, or the effect of heat upon the other constituents, appears to lessen the value of these substances for the child. At any rate, the use of beef tea in cases of debility, anaemia, and atrophy yields much less satisfactory results than a smaller amount of raw meat juice. I constantly find the best results follow the substitution of the latter for the former in the case of growing children. n6 ARTIFICIAL FOODS VEAL BROTH— ITS LOW NUTRITIVE VALUE Veal broth, which was much used by the practi- tioners of the last generation as a food for infants suffering from gastric disturbance, is, like all broths, a poor food for structural growth, weak in proteids, and not over rich in extractive. It is far inferior in nutri- tive value to any of the other meat preparations — has no advantage, as far as I know, in point of digesti- bility. You may, without hesitation, dismiss it from your list of infants' foods. RAW MEAT JUICE — ITS HIGH NUTRITIVE VALUE AND DIGESTIBILITY Raw meat juice is the most easily digested and restorative of all animal foods ; the most valuable of all nitrogenous preparations for children. As I have previously shown, it may be given freely as a sub- stitute for the casein of milk. BEST MODE OF PREPARING RAW MEAT JUICE Raw meat juice should be prepared by mincing finely the best rump steak, then adding cold water in the proportion of one part of water to four of meat. 1 Mutton or chicken may be substituted for beef when desirable. EXACT COMPOSITION AND PROPERTIES 117 This should be well stirred together, and allowed to soak for half an hour, cold. The juice should then be forcibly expressed through muslin by twisting it. This process is the result of many experiments made for the purpose of ascertaining the best means of obtaining meat juice of the highest nutritive value. The result is far better than that obtained by Liebig's process with the addition of hydrochloric acid. It is, moreover, nearly equal to juice obtained by simple pressure without water — a most tedious and unsatisfactory method. ITS COMPOSITION Analysis Proteid (albumen) . • S' 1 1 „ Extractive . . . 3., } 8"* total n.trogenous element. Salts .... 07 It is, as you will see from the Table, extremely rich in proteid, viz. 5 - i per cent. In addition to this there are 3-1 of extractives, equal to 8 - 2 total nitro- genous matter, and a large proportion of salts, 07. THE SPECIAL QUALITIES OF RAW MEAT JUICE So rich in albumen is it that it coagulates in a solid mass on boiling. And this material is what the child wants for structural purposes and for active iiS ARTIFICIAL FOODS vital processes ; not inferior extractives, such as form nearly the whole nitrogenous material of beef tea and broths. Mixed with milk it does not coagulate it — the taste is hardly perceptible in the mixture. When diluted in this way or with any watery solution it coagulates on addition of digestive fluid in small light flocculi. And these delicate atoms are artificially digested by the pepsine ferment much more rapidly and easily than albumen coagulated by boiling, as in beef tea. 1 Raw meat juice, too, besides these two virtues of richness in proteid and easy digestibility, has a rich proportion of salts, and must contain the antiscorbutic element in more active form than cooked beef tea. Experience shows that raw meat is far more anti- scorbutic than cooked meat, and cooked fresh meat than salted meat. Raw meat juice is without doubt the best material 1 Dr. Luff has kindly tested this point for me. He finds that with pepsine ferment albumen of raw meat is fully peptonised, Uncoagulated in 40 minutes Coagulated ,,140 ,, But with the pancreatic ferment the time for full solution was nearly the same for both, but slightly less for the coagulated form. Uncoagulated albumen .... 160 minutes Coagulated 150 „ EXACT COMPOSITION AND PROPERTIES 119 for supplying proteid to the food of children who cannot digest a sufficient amount of the milk proteid casein. MODE OF GIVING RAW MEAT JUICE — QUANTITY TO BE GIVEN As much as 2 to 3 oz. of the juice may be given in 24 hours, if necessary, in place of milk casein. The proper plan is to give the quantity equivalent in nutritive value to the casein of the milk for which it is substituted. This can always be calculated by the aid of the tables of proportion previously given. 1 Even a larger quantity may be given when little other food can be taken. And here let me interpose a caution. Especial care must be taken to have raw meat juice fresh. It does not keep well, and should be prepared afresh at least twice a day. RAW MEAT PULP Raw meat pulp, obtained by scraping the soft muscle elements from the fibre, may be substituted for the juice in the case of children 12 months old and upwards. It must not be minced, but scraped. 1 For example of proportions see p. 80. 120 ARTIFICIAL FOODS Mincing includes, of course, the hard tendinous portions, which are not easily digested uncooked.- The albuminous pulp is more digestible raw than when coagulated by cooking, but the tendinous portion, on the contrary, less so : 2 oz. of pulp may be given to a child a year old — more even, if this be the sole nitrogenous food. DANGER ATTENDING THE USE OF RAW MEAT A possible source of danger lies in the introduction of the cysticercus of tapeworm. I have seen four instances of this only out of a very large number of cases. In each instance the parasite was got rid of without serious harm, and I think the balance of good was largely in favour of the raw meat. In each case the raw meat probably saved the child's life. Moreover, the risk of ingestion of the cysticercus is small if only the finest quality of meat is used for the purpose. It is astonishing how firm, and hard, and muscular children become on this food. Yet since tapeworm has never, as far as I know, followed the administration of raw meat juice, it is wiser to make use of it in preference to the pulp. In the juice the cysticerci are probably removed by the fine muslin through which it is strained. EXACT COMPOSITION AND PROPERTIES 121 ' PATENT MEAT JUICE — ITS COMPOSITION AND PROPERTIES Another valuable preparation for young children is patent meat juice. It mixes well with milk and other foods, does not coagulate the casein of milk, does itself not coagulate with heat or acid, and has marked reviving and restorative power. Yet you will see from Table III. that it contains a very minute proportion of proteid, with an enormous amount of extractive and a large proportion of salts. It must owe the restorative and nutrient properties which it undoubtedly possesses in high degree to these last two elements. Patent Meat Juice Proteids Nitrogenous extractives Non-nitrogenous extractives Salts .... Water Total Dr. Luff's analysis) a trace IS'93 H'95 10-85 58-27 SUITED FOR TEMPORARY USE ONLY From its small proportion of proteid it is only suited' for temporary use in conditions of exhaustion and debility, not for a permanent item, of food like raw meat juice. It agrees with children — even small 122 ARTIFICIAL FOODS infants — remarkably well. I have given it freely to children almost from birth with great advantage. MEAT ESSENCES — THEIR QUALITIES AND VALUE Meat essences are less concentrated than meat juice, although they are of great value in certain cases as a stimulant and restorative, and are, in some de- gree, directly nutritious. These essences can be taken by children freely without producing any digestive disturbance. As you will see from t;he Table of analyses— Meat Essence (Dr. Luff's analysis) Proteids a trace Nitrogenous extractives .... 6 '85 Non-nitrogenous extractives . . . 0-23 Salts 1-14 Water .9178 Total ioo-oo — it contains little proteid, but chiefly extractives. Yet it has its place as a useful means of giving easily assimilated nitrogenous matter in cases of severe or protracted illness. The absence of proteid, however, renders it, like patent meat juice, insufficient for permanent use as a child's food. EXACT COMPOSITION AND PROPERTIES 123 MEAT PEPTONES — THEIR HIGH NUTRITIVE VALUE Preparations of meat peptone differ from the two preceding. They are not only restorative but in the highest degree nutritious, and of special value in certain cases of extreme feebleness, atrophy, and anaemia. A meat peptone yields, on actual analysis, no less than 71 per cent, of proteid and 84 extractive, or in all 794 of nitrogenous elements — Meat Peptone Proteid (diffusible peptones) . . .71-0 Extractive 8-4 Fat 17 Salts 3"4 Water 15-5 Total ioo-o — a large amount of salts, 34, and a fair propor- tion of fat, 17. The proteids are in the form of peptones, immediately assimilable Without further preparation. This is an advantage when digestion and assimilation are faulty. These foods are then extremely rich in nitrogenous matter, and are most valuable nutrients and restora- tives. 124 ARTIFICIAL FOODS USE OF PEPTONES OF MEAT I have used them occasionally for children, and, as with adults, the results are most satisfactory. The meat peptones are, however, not very pleasant in flavour, and it is often difficult to get children to take them. Another objection to their continued use is that which applies to all predigested foods. It tends to weaken digestive power by rendering the exercise of it by the stomach not only unnecessary but impos- sible ; and peptones, therefore, are unsuitable as a regular food, although of the highest value as a tem- porary resource in serious illness, where digestive power is failing or deficient. 125 LECTURE IV DISEASES WHICH RESULT FROM ERRORS OF DIET, AND THEIR TREATMENT — DYSPEPSIA, DIARRHCEA, CONSTIPA- TION, STOMATITIS, ANiEMIA, ATROPHY Food disorders of two classes: (I) Those resulting from irritation of the alimentary tract ; (2) Those arising from defective nutrition — Class I : Dyspepsia, gastro-enteric catarrh, choleraic diarrhoea, constipation — Dyspepsia in hand-fed children — In sucklings— Its symptoms— Causes — Most common in hand-fed children — The prime error— How it is to be avoided — Danger of cow's milk and water — Importance of boiling — Of sufficient dilution — Gastro-intestinal catarrh — Something more than mere indigestibility necessary to set up severe forms, viz. decomposition — Conditions under which it arises — Danger greater in hot weather and warm climates — Mortality from this cause — Various degrees of gastro-enteric catarrh — Symptoms — Effect of loss of fluid on the body — Post-mortem appearances — Treatment — Broad principles on which treatment should be based — Diet — Non-fermenting— Non-irritant — Nutritive — Various modes of attaining this— Stimulants — External warmth — Bismuth— Opium — Ipecacuanha — Grey powder — Their action and effective combination — Chronic diarrhoea— Peristalsis too readily excited — Treatment — Constipation — Treatment by diet and simple laxatives — Thrush — Occurs chiefly in hand-fed children — The fungoid growth— Sym- ptoms — Follicular stomatitis — Ulcerative stomatitis — Treatment — Atrophy — Due to many causes — Atrophy from too scanty food — From food deficient in certain elements — Atrophy from vomiting and diarrhoea — From imperfect digestive power — Cases in illustration — Anaemia — Food one of the factors — Forms of food anaemia— Anaemia of starch-fed children — From deficiency in animal element of food — 126 DIET DISEASES OF EARLY CHILDHOOD From defective digestive power — Treatment: Iron and arsenic, raw meat juice, sunlight, pure air — Eruptions of the skin — Eczema — Urticaria — Lichen Urticatus. FOOD DISORDERS OF TWO CLASSES : I. DISEASES PRODUCED BY IRRITATION OF THE ALIMEN- TARY TRACT OR ABSORPTION OF POISONS ; 2. DISEASES ARISING FROM DEFECTIVE NUTRI- TION The disorders which result from errors of diet in young children may be divided at once into two great classes. 1. The diseases produced by irritation of the alimentary canal by decomposing or indigestible articles of food, or absorption of poisonous matters produced by different ferments ; and, 2. Those arising from defective nutrition, from the want of sufficient food, or more often from a defi- ciency, not in the gross amount of food, but in certain elements of food, a defect of quality rather than quantity. In the first class are such diseases as dyspepsia, stomatitis, thrush, gastro-enteric catarrh, the more severe forms of choleraic diarrhoea or cholera infantum, and the contrary condition of constipation. Under the second class come such disorders as anaemia, atrophy, rickets, scurvy. DYSPEPSIA 137 It is clear that some of these disorders of the second class — general constitutional conditions — may be sequels to the former, and directly produced by them. Anaemia, atrophy, and rickets may result, and constantly do result, from the deficient preparation of nourishment for assimilation in dyspepsia, or in the rejection of it, or the draining of it away by vomiting and diarrhoea. But in such cases they are consequences— not immediate accompaniments — and may well be considered apart. In many cases there is no perceptible ailment of this kind — no vomiting, or diarrhoea, or dyspepsia — yet the child grows anaemic, atrophied, or rickety, from simple deficient supply of assimilable food of the right proportions. It will be convenient to take the class of diseases due to direct irritation or organic poisoning by pro- ducts of fermentation first in order. DYSPEPSIA IT MAY OCCUR EVEN WITH BREAST MILK The commonest and simplest of these is dyspepsia. Few children brought up by hand escape alto- gether, and many suckled at the breast of the mother or wet-nurse suffer in minor degree. 128 DIET DISEASES OF EARLY CHILDHOOD In some instances, indeed, the mother's milk has disagreed so much in this way, causing colic, flatu- lence, with incessant crying and restlessness, and disturbed nights from pain, that it has been found necessary to wean the child, and place it upon boiled cow's milk and water. This was done with the best and happiest results in one instance I remember well : there was peace from that moment. The child became free from all pain and discomfort, and throve apace. Microscopic examination of the mother's milk showed numerous large granular corpuscles, appa- rently the epithelium of the lacteal gland acini, imper- fectly changed persistent colostrum corpuscles.' No other fault could be detected in the milk. Possibly the difficulty of digestion arose partly from gulping it down too rapidly, with ingestion of air. DYSPEPSIA FROM HUMAN MILK RARE But such extreme dyspepsia from human milk is 1 Formerly it was supposed that the cells of the acini underwent fatty degeneration, and thus produced the fatty granules of the milk. It is more probable, however, from the observations of Strieker, Schwarz, Partsch, and Heidenhain, that the cells of the acini manu- facture the fatty granules, and their protoplasm eliminates them, at the same time forming the clear fluid part of the milk. — Landois and Stirling, vol. i. p. 462. DYSPEPSIA 129 rare. I have met with only one other instance where the child was unable to digest the milk of a sound mother whose health was not disordered, although cases in which that of a wet-nurse proves unsuitable are by no means very uncommon. , MORE COMMON WITH BOTTLE-FED CHILDREN This trouble of food dyspepsia then arises some- times with children who are nourishing on the whole- some milk of a healthy mother or wet-nurse ; not often, and most rarely in extreme degree. But most commonly with bottle-fed children ; with them it may be of any degree of severity, from slight discomfort to violent colic, vomiting, and diarrhoea. SIMPLE INFANTILE DYSPEPSIA — SYMPTOMS The signs of imperfect digestion in an infant are usually palpable enough. After the meal the child becomes evidently uncomfortable ; it is restless, cries, draws up its legs, brings up wind, eructates a certain amount of food, keeps hiccoughing, or actually vomits curded masses ; or the pain may be so severe that the child kicks and screams violently. Sometimes there comes that blueness round the mouth, twitching of face, and contraction of the lips which nurses call K 130 DIET DISEASES OF EARLY CHILDHOOD inward convulsions, so graphically described by Dr. West. 1 ' The child lies as if asleep, winks its imperfectly closed eyes, and gently twitches the muscles of its face — a movement especially observable about the lips, which are drawn as though into a smile.' If this condition increases, the child breathes with difficulty, its respiration seems for a moment almost stopped, and a livid ring surrounds the mouth. Presently, it brings up a quantity of flatus, is relieved, and after a time, with much nursing, walking about, and coaxing, at last goes off to sleep. I believe this disturbance of circulation and respiration is due to the pressure of a gas-distended stomach upon the heart. Many children suffer from marked gastric discom- fort after almost every meal, are constantly crying and restless, and wear out both mother and nurse by ceaseless fretfulness ; and this may be the case with- out any serious vomiting, or diarrhoea, or obvious malnutrition. CAUSES AND TREATMENT OF THIS FORM OF DYSPEPSIA All these troubles may be avoided if proper means be taken at the outset, and even if they do 1 Diseases of Infancy and Childhood, p. 41. DYSPEPSIA 131 arise, they can soon be arrested by appropriate treat- ment and management. If the child is at the breast, the cause of discom fort may be the too rapid gulping down of milk from a freely flowing breast, or the mother's food may have been such as to render the milk of an irritating nature. She may have been taking acid fruits or wines, or some medicine which affects the child. Faults such as these are easily rectified. The milk-flow can be moderated by pressure of the fingers on the nipple, the mother's diet regulated, and with a few doses of alkaline carminative mixture imme- diately after feeding, acidity and flatulence will be relieved, and the child will be put at ease. Thus, TREATMENT BY DRUGS I£ Sodae bicarb, gr. iij., spir. ammon. aromat. 111 j., spir. chloroformi tiij., syrupi mx., aquae anethi 3J. ; for a child one month old. The doses usually given are too small. Bismuth and prepared chalk may be added where there is much pain, or when there is diarrhoea ; or prepared chalk may replace the carbonate of soda, and magnesia may replace the soda if there is consti- pation. i 3 2 DIET DISEASES OF EARLY CHILDHOOD In certain extreme cases, as I have stated before, the human milk from some cause, possibly the pre- sence of colostrum corpuscles, or, in the case of a wet- nurse, from the milk being in too advanced a stage for the infant — the nurse having been delivered earlier than the mother of the infant she is to suckle, and therefore her milk, being too plentiful and too caseous, disagrees hopelessly. DIET In such cases the best plan is to wean the child at once on to diluted peptonised milk ; or on to the bread-jelly food, or dextrinised food, with a small quantity of boiled cow's milk, steadily increased as the child's digestive power improves. If the cow's milk cannot be digested, peptonised milk may be added instead, or properly diluted raw meat juice and cream may be substituted. In the meantime, the child's stomach must be soothed by a mixture of soda, aromatic spirits of ammonia, and dill water, such as that previously mentioned. THE DISASTERS OF HAND FEEDING AVOIDABLE But it is the bottle-fed children who are the greatest sufferers, and it is with hand feeding that DYSPEPSIA 133 mistakes are chiefly made, and difficulties stirred up which might and ought to be avoided. I am convinced that these difficulties and disasters of hand feeding need never occur. An infant can be safely placed upon artificial food, without any serious gastric disturbance arising, if the food is carefully adapted to its powers at the outset. THE MISTAKE USUALLY MADE AT THE OUTSET It is at the outset that the fatal error is usually made. It is the first step which is usually so produc- tive of trouble. The great causes of irritation are, as you know, indigestible masses of casein fermenting in the alimentary canal, or indigestible starch which undergoes lactic fermentation. Sometimes, perhaps, the lactic fermentation of cane sugar, or milk which is more or less sour from commencing decomposition before it is taken, is the source of irritation. THE DANGER OF THE COMMON PRACTICE OF USING UNBOILED MILK AND WATER The common practice, as I reminded you before, is to put the infant at once upon unboiled cow's milk and water, either half and half, or 1 part of milk to 2 134 DIET DISEASES OF EARLY CHILDHOOD of water, with perhaps some lime water added. The child has flatulence, hiccough, and cries and tosses with all the tortures of colic ; or it is sick and purged, its stomach irritated by solid curd and distended by the gases disengaged from the fermenting coagula. Or the child is given starchy food, with or without milk, and in like manner suffers from flatulence and colic, due to lactic fermentation of the starch which it is unable to properly convert into grape sugar, while the cane sugar added increases the difficulty and acidity. The pancreas has too great an amount of carbohydrate to reduce, and this ferments in the intestine probably as well as in the stomach. I repeat that these consequences are all preventable. The point is so important that you will forgive me for again enforcing the rules I have laid down before. PLAN TO BE FOLLOWED IN WEANING INFANTS IN ORDINARY CASES — BOILED MILK AND BARLEY WATER In the first place, never put the child when it is first weaned upon unboiled cow's milk and water. Boil the milk and add boiled water or thin barley water. In the second place, carefully gauge the child's DYSPEPSIA 135 digestive power by making the solution of milk suffi- ciently dilute at first, 1 part of boiled milk to 3 of boiled water to begin with, instead of 1 to 2, as usually adopted. The strength can be gradually increased. If condensed milk be used, begin with it suffi- ciently dilute, 1 part to 24 at first, instead of the usual 1 in 10 or 15. FOR VERY YOUNG OR VERY DELICATE INFANTS, BREAD JELLY AND MILK, OR PEPTONISED MILK If the child is very young (under 3 months), or exceptionally delicate, or if other children of the same parents have had difficulty in digesting cow's milk, do not attempt to put it on cow's milk and water ; place it at once on bread jelly, with small doses of milk, slowly increased until the necessary standard of nutrient value is attained. As a rule, I find the safest plan in all cases is to begin with bread jelly or highly dextrinised malted food, of the second form described (p. 100 and Table II. p. 80), with a tea- or dessert- spoonful of boiled milk only to the half-bottle. Or, better still, put the child on dilute peptonised milk, gradually lessening the amount of peptonisation. One of the best preparations for temporary use for a brief 136 DIET DISEASES OF EARLY CHILDHOOD period is the condensed peptonised milk, which may be very gradually replaced by mixing ordinary milk and water with the condensed milk in increasing pro- portion until entire substitution is effected. WARNING AGAINST LOOSE PRACTICE AND COMMON ERRORS But do not adopt the usual plan, of making the child ill first with plain cow's milk and water, and then endeavour to remedy the fault by wild, hap- hazard, unintelligent changes to other milk, or to this artificial food or the other, without regard to diges- tibility or nutrient value. A child of three months old, recently brought to me, had been placed on thir- teen different foods in succession as a matter of mere blind experiment. The result was, I need hardly say, most disastrous. I constantly find this loose practice. A child which cannot digest cow's milk is put upon some equally difficult food, or on a purely farinaceous diet without any animal element. A cautious, watchful procedure at first, beginning with a sufficiently dilute food, peptonised for a time if necessary, will, I think, infallibly prevent all serious trouble in weaning even the very youngest and most delicate infant ; remem- DYSPEPSIA 137 bering always to raise the strength of the food to the standard proportions. Do not be content without this. A food may agree perfectly well, and yet be entirely unsatisfactory from defect in nutritive value. Test all food by the data given in the previous lectures. FURTHER GRAVE CONSEQUENCES OF FOOD DIS- ORDERS IN INFANCY — INFLAMMATION OF THE GASTRO-INTESTINAL MUCOUS MEMBRANE But these faults in the diet of infants, especially during the first few months of life, frequently produce much more grave consequences than mere dyspepsia! The constant irritation of the gastro-intestinal tract by indigestible food causes, first hyperaemia, and then catarrhal inflammation of the mucous mem- brane, and this may be in any degree, from slight sickness and diarrhoea to that incessant vomiting and purging which constitutes acute inflammatory diar- rhoea, or cholera infantum. FATALITY OF GASTRO-ENTERITIS Gastro-enteritis forms one-third of the whole number of infantile disorders — a most deadly disease, which it is of the utmost importance to arrest in its first onset. r38 DIET DISEASES OF EARLY CHILDHOOD In some mild cases, and in chronic cases, mere indigestibility of food may be, and often is, the sole cause. Sometimes the influence of rank food taken by the milch cow may give an irritant character to the milk. THE MOST SEVERE FORM SET UP BY FOOD IN STATE OF FERMENTATION But to set up gastro-enteritis in its severest and most fatal form, I believe something more than mere indigestibility of food is required. The most potent cause is souring and decomposition of food, and this usually results from neglect of scrupulous cleanliness in utensils in which food is kept, or even keeping it too long before using, especially in hot weather, or in foul air ; near a drain or sink, for instance, or in an ill-ventilated room. Milk is a constant source of danger in this way ; it readily takes up dangerous organic poisons, and, as I showed in the first lecture, soon undergoes change. THE CAUSES WHICH GIVE RISE TO FERMENTATION The merest trace of sour milk or other food will set up fermentation in a whole bottleful. Sometimes, I believe, the decomposition is started by keeping the DYSPEPSIA 139 food during the night gently heated in food-warmers. This favours fermentation. Further, it is to be remembered that with a food which, like milk, so easily undergoes fermentative change, undigested clots retained in the alimentary canal under the conditions of heat and moisture so favourable to all forms of fermentation and putrefactive change, decompose with extraordinary rapidity. So that the irritant poison may in these cases be actually developed inside the child's body, not introduced ready-made from without. SOURCE AND NATURE OF THE POISONOUS MATERIALS Whatever the active agents of disturbance may be, whether the products of the lactic and butyric fermentations, or other products of decomposition., such as ptomaines or the liquid products of bacteria, food in this state of change is profoundly irritating to a child's gastro-intestinal mucous membrane. That it is the decomposition of food which gives rise to these irritating products is supported by the fact of the extreme prevalence and deadliness of choleraic diarrhoea in hot climates, where decomposition pro- ceeds so rapidly. i4o DIET DISEASES OF EARLY CHILDHOOD PREVALENCE OF GASTROENTERITIS IN HOT CLIMATE AND SEASONS In the United States, for example, it is far more deadly than in England. According to Dr. Lewis Smith, 1,500 deaths occur from it every year in New York alone. A large number of cases reported as ' marasmus ' are probably due to the same cause. 1 It rages especially in the summer season. Dr. Lewis Smith shows further that it occurs chiefly in young children, and is most common about the period of weaning ; and, most significant fact, the younger the child the more likely it is to be affected, if bottle-fed. In the New York Charity Hospital, before wet- nursing was adopted, a large proportion of foundlings died of entero-colitis during the first and second months. Few survived to the age of six months. 2 Similar disastrous results have followed bottle-feeding in the French foundling hospitals. Again, the warmer the season the greater the danger. In America the mothers dread the second summer after the child is born. In New York nearly every infant taken from the breast between April and 1 Diseases of Children, 2nd ed. p. 594. 2 Of. tit. p. 599. GASTRO-ENTERITIS 141 October becomes affected with diarrhoea, which if not inflammatory in its commencement soon becomes so. Moreover, hilly districts are comparatively free, .On low grounds the disease is rife. 1 This all goes to show that heat, damp, foulness, favouring decomposition and perhaps poisoning of food, act as septic agents, so that we must take indi- gestibility of food and decomposition, or fermentation, as the two great factors in the production of gastro- enteric catarrh in all its degrees. THE DIFFERENT FORMS OF DIARRHOIA There are a great number of varieties of diarrhoea described — simple diarrhoea, non- inflammatory diar- rhoea, inflammatory diarrhoea, entero-colitis, choleraic diarrhoea, cholera infantum, dysenteric diarrhoea. This multiplication of names has led to much con- fusion, and is not warranted by either the clinical characters of disease or its morbid anatomy. WITH THE EXCEPTION OF THE DYSENTERIC FORM THE DIFFERENCE CHIEFLY ONE OF DEGREE With one exception, viz. dysenteric diarrhoea, the differences are those chiefly of degree. Catarrhal disturbance and inflammation of the mucous lining of 1 Lewis Smith, Diseases of Children, p. 595. ' 142 DIET DISEASES OF EARLY CHILDHOOD the alimentary canal occur in every degree of intensity, from the slight disturbance produced by irritation of a little undigested food, to the violent and extreme choleraic disturbance set up by the poisons of decom- position. Some difference is traceable according to the portion of the canal chiefly involved, but the varieties shade into one another indefinitely. The symptoms and the lesions vary in acuteness, severity, and extent, according to the nature and degree of virulence of the cause which sets them up. And so you may have gastro-enteritis of every grade from a simple diarrhoea to cholera infantum. There is probably a difference according as the disorder is set up by local irritation of undigested or irritant food acting directly upon the mucous lining, or is due to the central action of a septic poison absorbed into the blood. Yet this probably has a local irritant action also, and it is impossible to distinguish except by degree, the more severe cases being, I imagine, septic always. DISTINCT CHARACTERS OF DYSENTERIC DIARRHOEA OR CATARRHAL COLITIS Dysenteric diarrhoea has distinct characters of its own. It is characterised by the passage of mucus GASTRO-ENTERITIS 143 and blood, by straining, with fever and some vomiting at first, but there is no copious colliquative diarrhoea constant and incessant. We may then make two distinct forms of infantile diarrhoea : TWO DISTINCT FORMS OF INFANTILE DIARRHOEA 1. Gastro-enteritis. 2. Dysenteric diarrhoea, or catarrhal colitis. Of dysenteric diarrhoea I shall say nothing here, for it is not properly a food disorder, but, according to my observation, in the case of children at any rate, usually the result of a definite chill, a catarrhal in- flammation of the large intestine analogous to that of the bronchi in bronchitis. GASTRO-ENTERITIS — ITS SYMPTOMS The first symptom is usually moderate diarrhoea, four to six actions in the twenty-four hours. Yellow stools first, then greenish, like chopped spinach — offensive, acid. The child is feverish, fretful, cries or screams, draws up its legs, moves restlessly in pain with stomach-ache ; usually there is little sickness for a day or two at first ; then vomiting begins, of sour, curded, undigested food. In cases of extreme severity, 144 DIET DISEASES OF EARLY CHILDHOOD however, vomiting sets in at once, with purging. In such cases often the very smallest quantity of food, even water, is instantly rejected. The bowels act every hour, perhaps, or even several times an hour; the stools become more and more serious and colour- less. The child may be dead in two or three days. EFFECTS OF THE INCESSANT DRAIN OF FLUID AND NUTRIMENT The continuous draining off of food, and especially the loss of liquid, by the incessant vomiting and purging, causes the child's tissues to shrink. It dwindles rapidly, remarkably. This rapid shrinking in fulness and size is striking and characteristic. The cheeks become hollow, the eyes sunken, the skin wrinkled, the fontanelle depressed. The subcutaneous fat, so plentiful in a plump, healthy child, rapidly disap- pears. The sunken cheeks and eyes, the pinched features, give it a most ghastly, unnatural look, like a death's head. Later the eyes become bleared ; there is puriform secretion between the lids. More strange and significant still, the eyes and mouth remain open during sleep, due to loss of tonicity and contractile power in the orbicularis palpebrarum and GASTRO-ENTERITIS 145 orbicularis oris — a sign of extreme muscular feeble- ness. The muscular weakness is further evidenced by the quietness of the patient. It lies still, exhausted ; with eyes half open, taking little notice, in contrast to its former active restlessness. The constant drain, again, produces pallor. The red corpuscles decline ; the vessels are half empty. The deficiency of haemoglobin, the failing circulation, and the want of combustible food, cause coldness of extremities and chilliness of surface. The pulse grows small, frequent, threadlike (120 to 130, 140, 160). The temperature becomes subnormal — at first it may be 100 to 104 or even 105 — but it falls after a few days to 96 or 97, if the drain continues. The tongue, coated at first, becomes dry and red. SUPERVENTION OF HYPOSTATIC PNEUMONIA — OF ' SPURIOUS HYDROCEPHALUS ' Hypostatic pneumonia may arise and add a fresh danger to the crisis. There may follow also the con- dition known as spurious hydrocephalus. The child becomes drowsy, almost insensible ; the pupils re- spond no longer to light, and the child dies exhausted or convulsed. 146 DIET DISEASES OF EARLY CHILDHOOD TENDENCY TO SUDDEN COLLAPSE In some instances sudden collapse comes on when improvement appears to have set in, and death takes place quickly and unexpectedly. Twice within the year have I seen this sudden change for the worse set in, when the case seemed to be proceeding hopefully. In each instance the child was beginning to take food, the vomiting had ceased, the diarrhoea was subsiding. Then came on pallor, coldness of extremities, unconsciousness, and death in the course of three or four hours. The prognosis in these cases, therefore, must always be most guarded. MORBID CHANGES The morbid changes found on post-mortem examination are vascularity of the mucous mem- brane, with swelling and infiltration, thickening, excess of mucus coating the surface, softening, and occasionally small superficial ulcers. The glands are tumid, enlarged. The solitary glands, those of Peyer's patches, and the mesenteric glands are affected in a similar manner. The brain is exces- sively anaemic. GASTRO-ENTERITIS 147 TREATMENT — GENERAL PRINCIPLES ON WHICH IT SHOULD BE BASED The rule of first importance is, always to arrest infantile diarrhoea as soon as possible. The broad principles on which treatment should be based are these : 1. Stop all food which favours fermentation and acidity, or causes irritation by indigestibility. 2. Neutralise acidity developed by fermentation. 3. Soothe the irritability of the stomach and intestine, and stop the excessive peristalsis. 4. Sustain strength and repair -the loss of fluid through the excessive liquid drain by easily digested nutritious food. 5. Assist further the depressed circulation and heat production by stimulants and by external warmth. DETAILS OF TREATMENT — DIET — COMMON ERRORS — PLANS TO BE ADOPTED In the first place, then, stop at once the cow's milk, or whatever irritant food has produced the dis- turbance. Give no cow's milk until the symptoms largely abate. But do not commit the common, fatal 148 DIET DISEASES OF EARLY CHILDHOOD mistake of putting the child on mere barley water, or arrowroot and gelatine, or veal broth, except for a short time at first. This may agree, but it is starva- tion diet ; the danger is of death by exhaustion and collapse. Give food that will stay on the child's stomach, but let it be nutritious and stimulating also and given in small quantities at a time. This end may be attained in one or two different ways. WET-NURSE If the child is very young, a wet-nurse should be obtained if possible, and the baby allowed to suck small quantities only at a time. If it cannot or will not take the breast, milk may be drawn off and given with a teaspoon, or asses' milk may be given in like manner. BREAD JELLY AND PEPTONISED MILK Another plan, which in my experience has been most successful, is to place the child on bread-jelly food, to which a small quantity of peptonised milk has been added ; or weak peptonised milk alone may be used. GASTRO-ENTERITIS 149 FOOD TO BE GIVEN AT SHORT INTERVALS IN SMALL QUANTITIES The food should be given frequently in small quantity, one or two teaspoonfuls only, every hour or half-hour. When the sickness abates, half a tea- spoonful of Brand's essenee, or 10 drops of Valentine's meat juice in a teaspoonful of water with a little white sugar, should be given in addition, every 2 hours. THE USE OF STIMULANTS — MODE OF ADMINISTRATION — QUANTITIES The best pale old French brandy should be added in the proportion of half a teaspoonful to a table- spoonful of food every 2 to 4 hours, according to the degree of feebleness and collapse. 1 The doses usually prescribed are too small, and their effect spoilt by over-dilution. It is no use putting 10 drops in a bottleful of food. 1 5 to 10 drops every 4 hours for a child 1 month old. 10 ,, 20 „ ,, „ 2 months old. 20 „ 30 „ „ „ 3 „ 3° » 40 „ ,, „ over 3 „ . OO ,, ,, ,, ,, 4 M Brandy is an excellent sedative for children as well as a stimulant. It probably acts favourably also by helping to arrest fermentation. When opium is given at the same time, it is necessary to bear in mind that brandy has a narcotic action, which, added to that of the other drug, may cause too great drowsiness. ISO DIET DISEASES OF EARLY CHILDHOOD CAUTIOUS INCREASE IN FOOD AS THE SYMPTOMS SUBSIDE When the sickness has completely ceased for at least 24 hours, more nutritious food may be cautiously ventured upon, such as the raw meat juice and cream> added in small quantities to bread-jelly or highly dextrinised artificial food, and gradually increased to the standard proportion. If cow's milk is resumed, take care that it is boiled immediately it is brought into the house, and begin with a weak dilution in barley water, or add it to the other food in small quantity. Above all, see to the cleanliness of vessels, and the purity and freshness of the food given. SUPERVENTION OF COLLAPSE If the collapse is great, give at once an enema of peptonised beef jelly, or beef tea if the other is not at hand at the moment ; with brandy, a dessert- spoonful to an enema of 2 oz. ; and place the child in a warm bath. The application of external warmth is essential. You will find that the body temperature has fallen far below the normal ; the child has not the means of keeping up its body heat by internal combustion. GASTRO-ENTERITIS 151 Wrap it in warm flannels, give it a hot bottle in bed ; or one to the feet and one on each side if the collapse and coldness are great. In extreme cases repeated hypodermic injections of sterilised water, or intra- venous injections of saline solution, appear to have saved life by restoring quickly the lost fluid. TREATMENT BY DRUGS TO RELIEVE VOMITING In such cases much may be done by drugs as well as by diet and warmth. If the sickness is great, give grey and Dover's powders. For an infant under 3 months, £ to, £ grain of Dover's powder, with \ grain grey powder every 3 hours ; for a child over 6 months, £ grain of each every 4 hours. TO RELIEVE DIARRHOZA — VALUE OF BISMUTH — OPIUM If diarrhoea be the most urgent symptom, and the sickness not so extreme as to prohibit liquid medicine in larger volume, give bismuth. I would impress upon you that the liquid preparations of bismuth are very ineffectual for this purpose, and the small doses of nitrate usually given of little use. Large doses of the insoluble nitrate are essential, or .smaller doses very frequently repeated : 5 or 6 or even 152 DIET DISEASES OF EARLY CHILDHOOD io grains of the nitrate may be given every 4 hours. With this, opium and ipecacuanha ; £ to \ or \ a drop of liq. opii sedativus, according to age, with 2 or 3 drops of ipecacuanha wine in 2 teaspoonfuls of water ; or the bismuth may be given in powder com- bined with Dover's powder. To this mixture may also be added with advantage prepared chalk, 3 or: 5 grains, or bicarbonate of soda to neutralise the acid formed by fermenting food. USELESSNESS OF MERE ASTRINGENTS Mere astringents alone are of little use. But de- coction of hsematoxylum may be used as the basis of the mixture if the flux is watery and excessive. The great drugs, however, are bismuth, in full doses, to soothe the mucous tract by local action ; opium (with caution), to lessen peristalsis and reflex irrita- bility ; ipecacuanha, to ease the inflamed membrane by aiding secretion ; or grey and Dover's powder, in frequent doses, for similar purposes. CHRONIC VOMITING AND DIARRHOEA— TREATMENT Sometimes, when the disorder is subacute, the diarrhoea and vomiting, especially the former, tend to become chronic. The mucous membrane not only secretes too freely, but its. reflex apparatus remains so GASTRO-ENTERITIS— CHRONIC FORM 153 sensitive, that the contact of food excites vermicular .action. Thus the induced peristalsis of the intestines may cause the bowels to act every time food is taken. These conditions should be treated by bismuth and opium, or grey and Dover's powder, and most careful dieting on unstimulating food, such as peptonised milk, or raw meat juice and cream food. The con- tinued use of small doses of opium is essential to the permanent cure of this peristaltic hyper-excitability, the ' lientery ' of the old authors. CHRONIC CONSTIPATION — TREATMENT It is more difficult to trace constipation to errors of diet than the opposite condition of diarrhoea. It is common in healthy, milk-fed children, due perhaps in part to great uniformity of food, or food of too un- stimulating a character, which leaves little debris be- hind. It is a condition easily remedied by simple saline laxatives and appropriate diet. I have so fully stated my views on this subject in lectures published in the ' Lancet ' ( 1 886), that I shall not touch further upon it now, except to remind you of the two main points in treatment. They are that the saline laxative should be given for some time continuously, not intermittingly, and that it should be mild and unstimulating. 154 DIET DISEASES OF EARLY CHILDHOOD THRUSH — ITS CHARACTERS — TREATMENT Another common affection which is liable to supervene on improper feeding is thrush. This is characterised by the presence of milk-white patches, due to the development of a fungus, which grows upon the mucous membrane of the mouth and tongue, and spreads sometimes to the oesophagus, and even to the stomach and intestine in rare cases. 1 ITS RELATION TO FUNGOID GROWTH The fungus occasionally springs up upon what appears to be healthy mucous membrane in the case of very young infants. But it flourishes most luxuri- antly where the membrane is inflamed and its secre- tions disordered. Its growth is favoured by the acid reaction ; the decomposing or soured milk adhering to the inflamed membrane forms a congenial soil for this, as it does apparently for various other low forms of life. THE GRAVE FORM OF THRUSH Grave cases of severe thrush are usually sequent upon chronic diarrhoea, vomiting, starvation, or other 1 The O'idium albicans of Berg ; it has lately been classified with the moulds, and as identical with the mould of wine. THRUSH AND STOMATITIS 155 disease ; most frequent of all after gastro-enteric catarrh from food irritation in bottle-fed children. In such cases there is dryness and injection of the mouth ; the tongue looks rough, red, and dry ; the papillae are vascular and prominent, there may be superficial ulceration — thick patches of white fungoid growth adhere to the tongue, the inside of the cheeks and lips, and the roof of the mouth. Very often in these cases the first thing noticed by the mother or nurse is that the child refuses food. It dreads the pain caused by contact with the tender mouth. Re- member, then, always to examine the state of the mouth in every case where the child refuses food. The bowels are loose and discharges acrid, excoriating the nates. STOMATITIS — THE DIFFERENT FORMS Not unfrequently thrush is complicated or added to stomatitis, either aphthous or follicular stomatitis, or often, amongst the poor, ulcerative stomatitis. The former, follicular stomatitis, is an inflammation of the mucous follicles of the mouth characterised by the presence of small round ulcers, the size of a pin's head ; the latter, an erosion of the mucous membrane 156 DIET DISEASES OF EARLY CHILDHOOD along the edges of the gums and cheek, due to im- paired vitality of tissue. 1 All these conditions — thrush, follicular stomatitis, ulcerative stomatitis — are closely connected with errors of diet ; the first two due to irritant food, the latter to gravely defective nutrition ; and I men- tion them briefly in order to draw attention to this connection, and because they are all curable by similar means. TREATMENT OF THE VARIOUS FORMS OF STOMATITIS First, regulate the diet. Stop all pure starchy foods and in extreme cases ordinary cow's milk, sub- stituting peptonised milk with malted food or Valen- tine's meat juice ; or raw meat juice, with cream and water. Give chlorate of potash and bark internally. 2 Locally, each time after taking food, paint the patches 1 I omit gangrenous stomatitis, which, although probably due in part to feeble vitality of malnutrition, is usually directly set up by pre" ceding measles, or other exanthem. 2 I), Pot. chlor. . . . . gr. iij. Ext. cinchona: liq. . . . m.x. Syrupi 5ss. Aq. ad 5ij. For a child I year old. ■ STOMA TITIS—A TROPHY 1 57 of fungoid growth or ulcerations with a solution of borax and chlorate of potash, of each 10 grains to the ounce, using a soft camel's-hair brush. This solution is more effective than the glycerine of borax, or borax and honey. Or a solution of glycerine of tannic and glycerine of carbolic acid, \ a drachm of each to the ounce, may be applied in the same way. The most effective drugs are borax, or weak tannic and carbo- lic acid locally ; chlorate of potash internally. These^ with bark, full feeding, and brandy or wine if necessary, good fresh air and favourable hygienic conditions, will usually soon effect a cure. ATROPHY — ITS CAUSES Another common result of defective feeding is atrophy. Now atrophy is due to very many causes ; to con- genital syphilis, to prolonged pyrexia, to tuberculous disease, and so on. But it is very constantly asso- ciated with errors of diet, notably when food in gross amount is too scanty — starvation — and it is a fre- quent result of food vomiting and diarrhoea. 158 DIET DISEASES OF EARLY CHILDHOOD SIMPLE ATROPHY FROM FOOD VOMITING AND DIARRHOEA — TREATMENT I have now (April 1887) under my care in the Children's Hospital a child 8 months old, reduced to a mere skeleton by vomiting and diarrhoea, induced by careless feeding with cow's milk in the workhouse. It is getting rapidly fat and strong upon peptonised milk and raw meat pulp. SIMPLE ATROPHY FROM DEFICIENCY IN IMPORTANT ELEMENTS OF FOOD — TREATMENT Simple atrophy often follows mere deficiency of the most important elements of food, proteid and fat, as in the wasting of starch-fed children. The want of proteid and fat apparently lessens the vital power essential to growth and nutrition, by causing failure of protoplasm in each cell, so necessary for every vital process of the body. This is remedied by the addition of animal food, milk, or meat juices, and the substitu- tion of a malted food for the starch, with perhaps cod- liver oil, or cream if possible. Occasionally atrophy supervenes in children brought up on good cow's milk, owing to their im- perfect power of digesting it, although there may be ATROPHY 159 no vomiting or diarrhoea at any time. Of this, the following case forms a good example : SIMPLE ATROPHY FROM DEFICIENT POWER OF DIGESTING COW'S MILK — CASE IN ILLUSTRATION An infant, aged 4 months, was brought to me on January 5, 1887. It had been weaned at 3 months and put on cow's milk and water ; at first 1 part to 2 parts of water, since raised to 1 to 1. After weaning, the child had a good deal of vomiting of curd, no diarrhoea, but constipation. The bowels now act every day, but the stools are dry, light-coloured, and contain undigested curd. The child is occasionally sick. It is always hungry, takes food eagerly, and sleeps well. But it gets thinner and thinner. It was on account of this steady loss of weight that the child was brought to me. There was no abnormality discoverable in chest or abdomen on careful exami- nation. The child's skin was mottled, healthy ; it was not very flabby, but extremely thin, and the fonta- nelle was widely open. Here was evidently a case in which the cow's milk was not digested and assimi- lated, and also the gross amount was somewhat less than the standard quantity. 160 DIET DISEASES OF EARLY CHILDHOOD TREATMENT OF THIS FORM The only change I made in treatment was to have the milk boiled and given with the bread-jelly food ; - 2\ oz. of milk, with an equal quantity of food every 3 hours. This amounted to I pint of cow's milk ; in addition one tablespoonful of raw meat juice was given instead of milk in one bottle. I prescribed no medicine whatever. The improvement which followed was immediate and most striking. The gain in weight for the first fortnight was only 2 oz., then 4 oz. every week, then 1 1 oz. The milk was increased and the food further thickened, and in the next month the child gained 2 lbs. 4 oz., or an average of 9 oz. per week. Then Chapman's flour was substituted for the bread jelly, and the next month showed a gain of 2 lbs. 1 3 oz., or an average of \\\ oz. a week. The child is now, at 8 months, the picture of robust health, big, hard-fleshed, rosy. SLIGHT ATROPHY FROM PROLONGED DIET OF ASSES' MILK — CASE IN ILLUSTRATION I have lately had under my care a child, M. L., who became atrophic, flabby, and anaemic when fed on asses' milk up to a year old. The gradual substitution ANAEMIA 161 of cow's milk, with some raw meat juice and malted food, at once caused rapid gain of weight, firmness of flesh, and increase of colour. In the course of three weeks that child gained 37 oz., or an average of 12^ oz. per week. ANEMIA — ITS CAUSES Another common result of faults in diet is anamia. Anaemia of course results from many varied causes — from organic disease, from foul air or lack of fresh air, and in London, notably, lack of light ; it is also> let me remind you, a constant feature of rickets and scurvy. ITS CONNECTION WITH DEFECTS OF DIET But anaemia of a simple kind is often seen in children who are apparently fat and well, but yet in reality imperfectly nourished. It occurs notably in those who cannot take or are not allowed a sufficient amount of fresh animal food, i.e. of fresh milk or some equivalent. INFLUENCE OF STARCH DIET IN PRODUCING ANAEMIA — OF DESICCATED FOODS— OF PRE- DIGESTED" FOODS Anaemia is present in all starch-fed children, and in those brought up on the vegetable foods, when M 1 62 DIET DISEASES OF EARLY CHILDHOOD given alone, or with too small an amount of fresh milk. It is seen even in children brought up on farinaceous foods which contain a dried animal element, unless fresh milk or raw meat juice be given in addition. The anaemia may be partly due in the latter case to the altered character of this animal element. Experience shows that by desicca- tion milk loses some antiscorbutic property, and it would seem that its power of making red blood — its haemic virtue — is in some degree impaired likewise. Similar results follow the prolonged use of peptonised or pancreatised foods. Children fed on cow's milk or asses' milk are occa- sionally anaemic, owing, in some instances, to causes apart from food, but in others, I think, owing to imperfect digestion and assimilation of the nitro- genous casein. TREATMENT — DRUGS — DIET — RAW MEAT JUICE Iron and cod-liver oil are excellent remedies, and to these minute doses of arsenic may be added in severe cases. But far better than all drugs in mo'st cases is an addition to the animal element of food in the shape of raw meat juice or pulp. The improvement which ANAEMIA 163 follows the administration of raw meat in such cases is most remarkable. Possibly the haemoglobin it con- tains in abundance is directly used in the formation of new red blood corpuscles. Abundance of fresh air in the day, and especially in sleeping rooms at night — a point constantly wofully neglected — pure hygienic surroundings, and sunlight, are other powerful agents in the cure of the anaemia of childhood. DISEASES OF THE SKIN A number of eruptions of the skin which occur in childhood have been attributed to the influence of food ; notably eczema, urticaria, and lichen urticatus. In the case of eczema, a diet containing a large amount of sugar, even an exclusively milk diet, has been credited with the production of- the disease. For my part, I have never been able to satisfy myself of the connection sufficiently to class eczema as a diet disease, although I have in several instances seen cases of severe infantile eczema apparently greatly benefited by the substitution of raw meat juice and cream for milk and saccharine farinaceous prepa- rations. With regard to urticaria, and that modification of it, the mixed eruption of wheals and papules so 1 64 DIET DISEASES OF EARLY CHILDHOOD common in young children — lichen urticatus — there can be no question as to the influence of diet as a factor. It appears to act by way of reflex irritation. The irritation of the intestinal mucous membrane by certain articles of food is reflected on to the cutaneous surface. Certain drugs, and many acrid or indigestible materials, will set up urticarious erup- tions — as copaiba, salicylic acid, quinine, shell-fish, tomatoes, and onions, for example. In the case of children, however, the most common agents in the production of urticaria and lichen urticatus are the irritant matters of retained faeces in constipation, especially in conjunction with foods containing materials which are absolutely insoluble in the digestive juices — fruits such as figs and prunes, and jams containing hard seeds and skins — oatmeal, brown bread, and the like. Accordingly lichen urticatus is especially met with in children who suffer from con- stipation, to whom such things are given largely with the view of provoking the action of the bowels, often with the result of provoking an urticarious eruption instead. This is more particularly the case if the device, as most often happens, proves ineffectual. The constipation is one factor, the accumulation of insoluble debris of food another. Such cases must be treated by removing from the diet list all ANAEMIA 165 materials which are irritating or indigestible, notably those of which I have spoken, and the steady daily administration of alkaline saline aperients to neutral- ise acidity and promote free action of the bowels. If this is not sufficient, cascara may be added, but the more stimulating purgatives are inadmissible. The itching skin may be soothed externally by baths and lotions of bicarbonate of soda and borax, or of resorcin. 166 DIET DISEASES OF EARLY CHILDHOOD LECTURE V DISEASES WHICH RESULT FROM ERRORS OF DIET, AND their treatment {continued) Rickets Occurs chiefly in first two years of life — The affection of the bones — Type of the rickety child — Bone defects not the sole lesion— Other constitutional peculiarities — Affection of muscles — Anaemia — Night- sweats — Tendency to catarrhs — The nervous system shares the general malnutrition — Its higher excitability — Laryngismus — Te- tany — Convulsions— Symptoms may be slight — Signs which should excite suspicion — Rickets largely a food disorder — Usually several factors — Influence of inheritance — Of syphilis— Of want of air and light — Rickets may arise where all points of hygiene are good except food — This the most constant factor — Evidence of the connection of rickets with defect of diet — Occurs chiefly in hand-fed children — Immunity of children at the breast — Artificial production of rickets in animals — Experiments of Guerin and Tripier — Experience at the Zoological Gardens — Theory of its dependence on lack of lime — Experiments of Chossat and Wegner — The lactic acid theory — Evi- dence from the simplest cases — Fat most probably essential — Import- ance of proteid— Of phosphate of lime — Remarkable results of change of diet in arrest of rickets in young animals — Influence of other causes — Vomiting and diarrhoea — Varieties of rickets according to causes at work — Starvation rickets — Syphilitic form — Cranio-tabes — Enlargement of liver and spleen — Large rickets — Rickets in suck- lings — On diet of cow's milk — Explanation — Fcetal rickets — Con. genital form — Late rickets — The common form of food rickets — An RICKETS 167 eminently preventable disease— Treatment by diet chiefly— Value of cream and raw meat — Cod-liver oil — Recovery favoured by fresh air and sunlight — Case I. Typical example of severe rickets : Chief symptoms : Remarkable family history : The prevalence of the rachitic state explained by the regimen : Faults of feeding aggravated by want of light and air : Treatment : Recovery without any change in hygienic conditions except food — Case II. Rickets arising under exceptionally perfect general hygienic con- ditions : Food only defective : Effect of faulty diet mitigated by hygienic conditions : Treatment by anti-rachitic diet : Recovery — Case III. Rickets occurring under ordinary favourable hygienic conditions : Food alone faulty : Condition of patient : History : Recovery under proper feeding 1 RICKETS ONE of the most interesting and remarkable of the disorders which result from the faulty feeding of young children is the condition of rickets. Its occur- rence is limited almost entirely to the first two years of life, in children fed entirely by hand, or after weaning. It is not my intention in the present lecture to describe all the morbid changes found in the bones and tissues. These are given in detail in all the text-books, and to these I must refer you. What I desire to do is to give a broad clinical picture of rickets and its aetiology in relation to food, and to this I shall chiefly confine myself. The affection of the bones, so striking and so obvious, has given this characteristic of the rachitic 1 68 DIET DISEASES OF EARLY CHILDHOOD state undue prominence and importance, and rickets has been in danger of being regarded as simply a morbid state of the bony structures, leading to cer- tain deformities and defects of the osseous skeleton. It has been thus defined in leading text-books on medicine until quite recently, and it is still classed under diseases of the bones. It is something far more than this. RICKETS NOT MERELY AN AFFECTION OF THE BONES You are no doubt familiar with the type of the rickety child : the square projecting forehead, the open fontanelle, the beaded ribs, the enlarged ends of the long bones, and their soft yielding structure producing deformities such as the pigeon breast, the depressed ribs, the protuberant belly, the curved arms and clavicles, the bowed legs or knock-knees, the contracted pelvis ; the delay in the appearance of the teeth and their early decay ; the relaxed ligaments producing the yielding ankles and the knock-knee, and the curved spine. But these palpable defects of the bony framework do not comprise the whole morbid condition. The name of rickets ' is perhaps 1 Trousseau speaks of 'riquets,' an old Norman word applied to RICKETS 169 unfortunate, as tending to identify the pathological condition with bone changes alone. OTHER TISSUES AFFECTED AS WELL AS THE OSslbuS SYSTEM For there are distinct deviations from the normal healthy constitutional state in other organs and functions which are less prominent, yet more impor- tant, than the bone faults. The lymphatic glands generally become enlarged, sometimes also the liver and spleen ; the lungs partially collapsed by the pressure of the depressed chest wall, with compensa- tory emphysema and perhaps a friction patch upon the heart and a pressure murmur there. AFFECTION OF THE MUSCLES Moreover, the rickety child suffers from general constitutional debility in various forms. It is soft- fleshed and flabby, the muscular feebleness being often so great that it cannot sit upright ; is unable to walk perhaps until it is two years old or more. This deformed persons. Glisson first adopted the term * rickets ' from the common name given to the disease in the West Country, where it was first observed. He subsequently adopted the term ' rachitis ' from pax's, the spine, which he thoteht was the first part affected. 170 DIET DISEASES OF EARLY CHILDHOOD feebleness is indeed so extreme in some instances that the child is supposed to have paralysis. I have several times been consulted with regard to para- plegia in a child, when the affection turned out to be nothing but the muscular debility of rickets, and the patient was restored to full walking by appropriate diet and cod-liver oil. This feebleness of muscle as well as softness of bone interferes seriously with the action of the intercostals in respiration, and becomes a serious factor when bronchitis supervenes. ANEMIA — SWEATING— TENDENCY TO CATARRH OF MUCOUS MEMBRANES There are other constitutional signs too — anaemia, profuse night-sweats, and a remarkable tendency to catarrh of all mucous membranes ; of the bronchi, and of the intestine, so that bronchitis is set up on slight cause, and diarrhoea is a constant symptom. Moreover, the lungs are injured by collapse and compensating emphysema, the mechanical result of the giving way of the soft chest walls in respiration. THE NERVOUS SYSTEM INVOLVED The nervous system suffers, too, from the general malnutrition. A peculiar excitability and instability of the reflex motor system arises, which is evidenced RICKETS 171 by the special liability to convulsive disorder, viz. laryngismus stridulus, or spasm of the glottis, tetany, or carpopedal contractions, i.e. tonic spasm of the hands and feet ; and general convulsions. SLIGHT DEGREES OF RICKETS LIABLE TO BE OVERLOOKED These various signs and symptoms are not all present together, and the absence of the most pro- minent — as, for instance, curving of the long bones — sometimes leads to the existence of the disease being entirely overlooked. This is especially the case with the children of the better class, amongst whom slight cases are by no means uncommon. Now and again the signs are extremely unobtrusive, limited perhaps to an abnormally open fontanelle, some back- wardness in teething, a little enlargement of the ends of the long bones, slight contraction of the chest antero- laterally, and maybe a just perceptible curving of the legs, or a laxness of knee or ankle ligament causing genu valgum, or weak ankles. But with this a distinct anaemia, a general softness of flesh, sweating about the head at night, a notable tendency to catarrh, both bronchial and intestinal, trouble in teething, and not unfrequently attacks of laryngismus. 172 DIET DISEASES OF EARLY CHILDHOOD SYMPTOMS SUGGESTIVE OF SLIGHT RICKETS If a child has marked predisposition to mucous catarrh, or protracted, or late, or painful dentition, or attacks of laryngismus, however slight, always ex- amine carefully the bony structure for evidence of rickets there. Now this general fault of constitution affecting bone, muscle, nerve, and mucous membrane, which is known by the term rickets, is largely a food disorder. FACTORS CONCERNED IN THE PRODUCTION OF RICKETS There are, I believe, generally several factors concerned in the production of rickets. Defects of diet, food disorders, causing prolonged vomiting and diarrhoea, foul air, want of light and general mal- hygiene, congenital syphilis, inherited tendency — all may play a part. But these factors are not all in action in every instance. Is any one of them efficient alone ? Is any one of them constantly present? INHERITED TENDENCY To begin with the last. Although some statistics have been given to show that rachitic parents tend to RIPKETS 173 have rachitic offspring, I have seen nothing to confirm this. Rickets dies out with childhood, and is not likely to be transmitted. I believe the sole influence of heredity is the transmission of a weakly constitution in some instances ; that inheritance is not a constant factor seems proved by the fact that the children of perfectly healthy parents become rickety. CONGENITAL SYPHILIS In the next place we may, I think, be quite certain that rickets is not a simple expression of congenital syphilis, as M. Parrot contended. In many cases the history is absolutely beyond suspicion, and the children bear about them none of the well- established signs of congenital syphilis. The eruption, the snuffles, the pegged teeth, the keratitis, the linear scars, are alike wanting. And conversely, many cases of congenital syphilis are not rickety. It is clear that syphilis is not a constant factor. The cases in which it does play a part have very special features, of which I shall speak presently. Congenital syphilis modifies rickets, it does not create it. 174 DIET DISEASES OF EARLY CHILDHOOD MALHYGIENE AS A FACTOR Again, conditions of general malhygiene are not constant factors in the production of rickets. Many cases arise where the patients are under excellent sanitary conditions as far as air, and light, and cleanliness, and warmth are concerned. A child may enjoy all these to perfection, and yet become rickety in marked degree. We see this constantly in children of perfectly healthy well-to-do parents, amongst whom rickets is by no means uncommon. It is impossible to say in such cases that faults of hygiene of this kind are concerned, and these examples, where so many of the causes commonly credited as essen- tial to the production of the disease are absent, throw great light upon its aetiology. They simplify the problem, and help to distinguish the essential from the non-essential. INFLUENTIAL BUT NOT ESSENTIAL The truth is, that these general conditions of malhygiene connected with air, and light, and clean- liness, and warmth, are not essential factors always present, but favour the production of rickets by degrading nutrition ; they are generally at work, too, RICKETS 175 in the most extreme cases, but they are not essential. I have never seen a child develope rickets in the most unhealthy surroundings if properly fed and free from food disorder. THE ONLY CONSTANT FACTOR IS THE FOOD FACTOR The only constant factor, always present, is the food factor. Sometimes it is the only factor. The chief cause, this fault of diet, is the commonest, the most potent, and dominant of all. This much is, I think, well established : the vast majority of cases of rickets arise directly in connection with food. THE QUALITY RATHER THAN THE QUANTITY OF THE FOOD AT FAULT The first fact which comes out with regard to the relation of food to the production of rickets is, that it is a question of quality rather than quantity — of special fault of nutrition, not a general fault of nutri- tion. A child may be in the last stage of atrophy, and yet not rachitic. It may be fat and gross, and yet extremely rachitic. 176 DIET DISEASES OF EARLY CHILDHOOD CHILDREN AT THE BREAST RARELY AFFECTED The second point to be noted is that it occurs almost entirely amongst children brought up by hand, or after weaning. It does not appear in children at the breast, except in special instances where the milk is insufficient or defective, as from special debility of the mother or from prolonged lactation. I think it may be affirmed broadly that children feeding well on a full supply of good breast milk up to the age of 8 or 10 months do not become rickety during the time of suckling. Even with congenital syphilis at work, the suckling does not become rickety. Dr. Barlow and Dr. Lees l found that in eleven children with cranio-tabes who were brought up entirely at the breast, not one showed the smallest sign of rickets. Elsasser, who first described cranio- tabes, noted a similar absence of general rachitic signs. If these children do become rickety, it is later — after weaning. ON THE OTHER HAND, CHILDREN FED CHIEFLY ON FARINACEOUS FOOD CERTAINLY BECOME RICKETY I think it may also be affirmed broadly, on the other hand, that children fed almost entirely on ' Path. Trans, vol. xxxii. p. 330. RICKETS 177 farinaceous food, even if taking it well, without apparent drawback, as certainly become rickety. We see these experiments made daily before our eyes with uniform result. THE SPECIAL ASSOCIATION OF RICKETS WITH AN ARTIFICIAL DIET IS STRONGLY SUPPORTED BY RESULTS OF OBSERVATION AND EXPERIMENT ON THE LOWER ANIMALS— GUERIN'S EXPERI- MENTS The artificial production of rickets by Gu6rin, who substituted meat for the mother's milk, although impugned by the later experiments of Tripier, has been remarkably confirmed by the experience at the Zoological Gardens in London. The lion whelps weaned early and put upon a diet of raw flesh only, invariably became rickety in such extreme degree that it has been found impossible to rear them. MR. BLAND SUTTON'S OBSERVATIONS AT THE ZOOLOGICAL GARDENS Mr. Bland Sutton, the hon. pathologist, informs me that the young monkeys, deprived of their mother's milk and fed entirely upon vegetable food; became rickety. The most remarkable case observed N 178 DIET DISEASES OF EARLY CHILDHOOD was that of two young bears who were fed exclu- sively upon rice, biscuits, and raw meat, which latter they licked but hardly ate, and who died of extreme rickets. That the condition is a true rachitis there can, I think, be no doubt. There is the same mus- cular feebleness, the same bending of bones, the same general debility ; and the identity of the bone changes has been established by the observations of Mr. Sutton, who has so ably investigated the morbid anatomy of the disease. THEORIES AS TO THE EXACT NATURE OF THE DIET FAULT — THE INFLUENCE OF WANT OF LIME SALTS Various theories have been put forward as to the exact nature of the diet fault productive of rickets. The first which naturally suggested itself was that the bones being obviously soft and deficient in mineral matter, a want of lime salts in food was at the bottom of it. Chossat and Milne-Edwards produced curvature of the bones in pigeons and dogs by privation of the earthy salts ; these results are, however, impugned by the later experiments of Friedleben, 1 who found that, although atrophy 1 Vide Fagge, Path. Trans, vol. xxxii. p. 318. RICKETS 179 follows, the characteristic features of rachitic bone are wanting. Wegner, however, claims to have produced rickets by administration of phosphorus and priva- tion of lime salts at the same time. And the amount of lime salts in rickety bone is below normal. MERE DEFICIENCY OF LIME NOT THE SOLE FACTOR Yet that mere want of lime, in the form of hydrate- or carbonate, is not, per se, the essential cause of rickets, is proved by convincing evidence. First, the fact that rickets is common in limestone districts where the drinking-water is heavily charged with lime, and the children must necessarily take abun- dance of it. In my native town, situated in one of these districts, goitre and rickets were both extremely common. Moreover, many children of the better class who become rickety have had lime water regularly added to their food. Secondly, the fact that the foods upon which children are especially liable to become rachitic, the farinaceous foods, are rich in lime and phosphoric acid. Dr. Luff has tested this point for me, and the results of his analyses are given in Table II. So that the presence of lime salts in abundance in the food will not prevent the develop- 180 DIET DISEASES OF EARLY CHILDHOOD merit of rickets, nor is deficiency of lime salts in food usually associated with it, but rather, on the contrary, an ample supply. These earthy salts are present in sufficient quantity in most articles of an infant's diet. If the earthy salts were grossly deficient in food, the soft condition of bone would no doubt be favoured by the lack of this material ; but, as a matter of fact, they are actually abundant. THE LACTIC ACID THEORY OF RICKETS Another theory, suggested by the special associa- tion of rickets with farinaceous food, is that lactic acid is the evil agent. Starch, imperfectly digested, ferments, and lactic acid is formed in excess ; this is supposed to unite with the lime about to be deposited in the bones, and carry it off in soluble form ; or, according to a later theory of Heitzman, by irritating the ossifying tissue and provoking growth when the necessary lime was wanting for the structure. Heitzman found lactic acid in the tissue of rickety animals, and claims to have produced rickets by the administration of lactic acid. RICKETS 181 FACTS WHICH NEGATIVE THIS HYPOTHESIS But against this hypothesis there are these weighty facts : first, that rickets arises in children who have no apparent disorder of digestion to favour lactic acid formation, who digest the starch or dextrine or maltose, assimilate it, and wax fat on it ; and, secondly, the fact that if the food on which the child has grown rickety be continued, without other change than the addition of certain elements which are deficient, the child gets well. Moreover, if lactic acid did exist in the blood, it would be neutralised by the alkali there, so that clearly the starchy element is not directly harmful. TWO ELEMENTS DEFICIENT IN THE FOOD OF RICKETY CHILDREN, VIZ. ANIMAL FAT AND PROTEID — POSSIBLY, ALSO, PHOSPHATE OF LIME Now if we take cases of the. simplest kind, viz. those of the children of healthy parents, born healthy, and brought up under perfect hygienic conditions as far as air, light, cleanliness, and warmth are con- cerned, who become rickety, we find these constant features — they have been brought up by hand, and 1 82 DIET DISEASES OF EARLY CHILDHOOD the artificial food on which they have been fed is uniformly deficient in certain elements, viz. animal fat and proteid. How sadly wanting are these vital ingredients in the foods in common use I have shown in my earlier lectures ; and the evidence is set forth in Tables I. and II. Possibly deficiency of earthy phosphates may be a factor of some influence also in certain cases, although, as I have shown, it cannot be an essential because it is not a constant one. ANIMAL FAT THE MOST ESSENTIAL ; — EVIDENCE OF THIS Animal fat is the most essential element. The abundance of it in the type food milk, which is a rich emulsion of fat, as I showed you before, indi- cates its high importance in the nutrition of the young organism. The occurrence of rickets in a child brought up on skim milk, all other hygienic conditions being unimpeachable, which came under my personal observation, seems to indicate that pri- vation of fat alone is sufficient. The acknowledged curative power of cream and cod-liver oil affords further evidence in the same direction. Fat is pre- sent in every cell, and animal fat, introduced as fat from without, is probably essential to vigorous cell- life and structural power. RICKETS 183 IMPORTANCE OF THE PROTEID ELEMENT — CLINICAL EVIDENCE OF ITS VALUE The deficiency of animal proteid in these ricket- producing foods is probably of an importance second only to the absence of fat. It is true that the pre- sence of proteid in abundance will not prevent rickets. The experiments of Guerin and the experience of the Zoological Gardens prove this. Yet it may be an im- portant aid in addition to the fat, and, as a matter of clinical experience, rickety children improve much more rapidly if they are given raw meat or its juice in addition to cream or cod-liver oil, than on the latter alone. The nitrogenous element, as I have urged before, is essential to the nutrition of proto- plasm — the indispensable active agent in all vital processes — and probably benign or injurious in action according as the other materials are present or absent. VALUE OF PHOSPHATE OF LIME Phosphate of lime appears to be present in every tissue, and there are grounds for believing that no cell-growth can go on without it ; in rapidly growing cells it is present in large amount. The lowest 1 84 DIET DISEASES OF EARLY CHILDHOOD forms of life, even, will not grow without earthy- phosphates. 1 The dependence of rickets on the deficiency of these three elements of food would explain something more than the mere bone changes ; it would equally explain the imperfect nutrition of brain and muscle and nerve structure, which no theory of mere excess of lactic acid or lime salts would account for. It explains, moreover, why rickets is so prevalent in large towns and dense populations, where milk is scarce and dear, deprived of cream and watered, and the poor driven to feed their children on the cheaper farinaceous foods. DEFECT IN DIET ALONE SUFFICIENT TO PRODUCE RICKETS — EVIDENCE OF THIS IN THE CASE OF ANIMALS That defect in diet alone is sufficient to produce rickets, and that these three elements, fat, proteid, and earthy salts, are some or all of them chiefly con- cerned, is strikingly shown by the recent experience at the Zoological Gardens, to which I have already alluded. As I told you, many young animals become rickety there, and it had been found impossible to rear the young lions from this cause ; they invariably died, and died from extreme rickets. 1 Parkes' Hygiene, 4th ed. p. 176. RICKETS 185 EXPERIENCE AT THE ZOOLOGICAL GARDENS — DIET ON WHICH YOUNG ANIMALS GROW RACHITIC The lion whelps were fed solely upon the flesh of old horses, almost entirely destitute of fat. The bones were found to be proof against the teeth even of adult lions, and those of the cubs were powerless against them. About once a week they had goat's flesh, which is about the fatness of venison. So that in this case, again, animal fat and earthy phosphates would be de- ficient. The food of the young bears who became rachitic on biscuits and rice, and that of the young monkeys fed chiefly on bananas and fruits, would be deficient in the same elements. The feeding of the last litter of lion cubs was commenced in the usual way. The dam had very little milk, which ceased entirely at the end of two weeks, and they were then put on horseflesh alone as before ; they became extremely rickety, and one died. THE REMARKABLE EFFECT OF A CHANGE OF DIET ALONE Then, at Mr. Bland Sutton's suggestion, the diet was changed. The meat was continued, but in 1 86 DIET DISEASES OF EARLY CHILDHOOD addition to it, milk, cod-liver oil, and pounded bones were given. No other alteration whatever was made in any way. They were kept in the same dens with the same amount of air, and the same light and warmth as before. The change which followed was remark- able. In three months all signs of rickets had dis- appeared, and they grew up perfectly strong and healthy and well developed. It was a unique event in the history of the Society. You will observe that no change was made in the conditions of existence except in feeding only, and the change in the food consisted practically in the simple addition of fat and bone salts. This is a most striking and crucial experiment in the production and prevention of rickets, and seems to be absolutely conclusive as to the chief points in its aetiology. DIET EFFICIENT ALONE TO PRODUCE RICKETS — OTHER FACTORS USUALLY ENGAGED ALSO — SYPHILIS — VOMITING — DIARRHOEA Ordinary rickets can be set up by a rachitic diet, and cured by an antirachitic diet, as certainly as scurvy can be caused by a scorbutic diet and cured by an antiscorbutic diet. RICKETS 187 Do not forget, however, that there are generally- other factors engaged in the production of rickets in addition to the food factor. Bad air and want of light lower vitality, syphilis seriously impairs nutrition, and in many instances these agents probably aggravate and emphasise the disease. But far more potent still are chronic vomiting and diarrhoea in the production of rickets ; but these latter act practically as food factors, since they no doubt produce their effect by draining off nourishment. And it is to be noted that the loss would fall chiefly on the proteid and fat, which require time for digestion before they can be absorbed, whereas the carbohydrate element, sugar of milk, is already in a state of solution, and fit to pass at once into the circulation. EFFECTS OF THESE FACTORS IN MODIFYING RICKETS The disease is undoubtedly modified by the action of other factors. It is probably only developed in its most extreme degree when the food defect is aggra- vated by generally bad hygienic conditions, or by syphilis, and exhibits a variety of forms according to the particular cause or combination of causes which give rise to it. When rickets is produced by chronic vomiting 188 DIET DISEASES OF EARLY CHILDHOOD and diarrhoea, when it is merely a part of general starvation, and when it is the result of congenital syphilis, the child is usually small, puny, wasted. We have a small rickets. In the case of syphilitic rickets there are further distinctive features : thinning of the flat bones of the skull, the cranio-tabes of Elsasser, and projections on the frontal and occipital bones — the so-called cranial bosses. These, I am convinced, are most common and most marked in syphilitic cases ) although they are also met with in cases of simple rickets in which there is no reasonable presumption of syphilitic taint. Dr. Barlow and Dr. Lees ' found a certain history of syphilis in 47 per cent, and Dr. Baxter found 75 per cent, clearly syphilitic. I think that it may eventually turn out to be the case also that the enlargement of the liver and spleen, which is found in certain instances, described by Sir W. Jenner and Dr. Dickinson, is a syphilitic change, not a true rachitic change, although this point has not been actually established. Dr. Gee states that he can find no difference between the enlargement of spleen found in rickets and that found in ague and syphilis, a pure fibroid change. 2 1 Path. Soc. Trans, vol. xxxii. p. 223 et seq. 3 St. Barth. Hosp. Rep. vol. iv. p. 78. RICKETS 189 THE RICKETS OF FAT CHILDREN Contrasted with these cases of rickets accom- panied by wasting are those in which the child is plump or even excessively fat. This occurs in a con- siderable proportion of cases— notably in those in which the disease is the result of mere deficiency of certain elements of food. The children get abund- ance of carbohydrates — starch and sugar to make fat. When, some twenty years ago, there was a great baby show held at Greenwich, the prize baby, who won its honours by virtue of its weight and size, was brought to me in the out-patient room at the Chil- dren's Hospital in Great Ormond Street on account of bowed legs and arms and muscular feebleness, and I found that it was suffering from well-marked rickets. It was a starch-fed child, excessively fat. RICKETS IN BREAST-FED CHILDREN — EXPLANATION I have said that rickets occurs in breast-fed chil- dren after weaning only, except in rare instances, where the mother is sickly and feeble, or has suckled the child into the second year, and the milk has thus become deteriorated in quality. In one interesting case which came under my own observation, rickets 190 DIET DISEASES OF EARLY CHILDHOOD was developed at six months in a child at the breast in this way. The mother became pregnant while suckling, and apparently a large portion of the nutri- ment which should have gone into the milk was diverted to the foetus in utero. This was born strong and healthy and plump, while the infant at the breast dwindled into puny rickets. RICKETS ON A DIET OF SKIM MILK Again, I have seen rickets arise on a full diet of cow's milk. This needs some explanation. A very extreme case of the kind came under my observation, in which the child was fed abundantly on cow's milk, and apparently digested it thoroughly. The parents were a coachman and his wife, living in the country, and they told me that they were allowed an unlimited supply of milk from the dairy at the Hall. This at first was a great puzzle. But on further investigation I discovered that the milk thus bounteously given was skim milk, i.e. milk with the cream removed. The child had nothing but this and farinaceous food ; it practically got no animal fat. In every other respect the conditions under which the child lived were exceptionally good. I have already instanced this as an instructive experiment showing the effect RICKETS igi of simple deprivation of animal fat upon the pro- duction of rickets. RICKETS ARISING ON A DIET OF GOOD COW'S MILK But, further, rickets appears occasionally in chil- dren fed on good cow's milk of a strength containing all essential elements in standard proportion. This occurs when the child is unable to digest it in suffi- cient quantity, as evidenced by the appearance of curd and fat in the stools. It happens also when the milk produces vomiting or diarrhoea, and the nutriment is drained off: the result is the same as if an insuffi- cient amount had been given. Yet this can be pre- vented in the vast majority of cases, and, as a rule, it ought to be prevented. RICKETS AS A RESULT OF VOMITING, DIARRHOXA, AND MALHYGIENE Sometimes, no doubt, rickets is the result of a drain on nutrition, such as vomiting and diarrhoea produced by causes unseen or uncontrollable at the time, or by a combination of conditions of mal- hygiene. Such cases are- exceptional, and in nearly every instance which came under my observation the faulty state might have been prevented. 192 DIET DISEASES OF EARLY CHILDHOOD FCETAL RICKETS— CONGENITAL RICKETS The so-called festal rickets observed in the bodies of some stillborn children is now generally allowed to be a condition allied to cretinism. With regard to congenital rickets, I think it possible that it may occur. The feebleness of health and malnutrition of the mother might well cause rickets in utero, and indeed the observations of Lauro, Kassowitz, and Schwarz seem conclusive as to its occasional occurrence in varying degree. LATE RICKETS — CASE IN ILLUSTRATION There is another form of the disease which de- serves a passing mention, viz. late rickets. Occasion- ally bone changes occur — curvature of the long bones, contraction of the thorax and beaded ribs, in children long past the ordinary rickety period of the first two years of life, to which, as a rule, the disease is so strictly limited. A curious case of this kind came under my care a few years ago, in a boy nearly 10 years of age. The disease had only commenced to show itself nine months before, yet it was already so advanced that the patient had become unable to stand. The ribs were beaded, the chest walls driven RICKETS 193 in, the ends of the tibiae much enlarged. There was pain and tenderness of the knees, but no rise of temperature. The case was clearly not one of food rickets. Antirachitic diet, cod-liver oil, and steel wine were given, but the patient grew worse instead of better. Iodide of potassium was then tried, and remarkable improvement followed for a time, and the condition was thought to be syphilitic, although there was no positive evidence of this. Eventually the child went out, and subsequently died of bronchitis. A cast of his distorted limbs and body is now in the museum of the hospital. That this case was one of true rachitic change in the bones was subsequently almost certainly proved on post- mortem examination, 1 and similar instances have been recorded by others. Yet the whole pathology of these cases is very obscure, and requires investigation. ORDINARY RICKETS A PREVENTABLE DISEASE The ordinary form of rickets, with which we are concerned, being due so largely to faults of feeding, aided in many cases by other conditions of bad hygiene or by the cachexia of congenital syphilis, is clearly a preventable disease. I will not go so far as 1 Vide Path. Trans, vol. xxxii. p. 391. 194 DIET DISEASES OF EARLY CHILDHOOD to say that rickets ought never to occur as a result of artificial feeding, but it should, at least, be extremely rare. THE OCCURRENCE OF RICKETS IN MOST CASES A GRAVE REFLECTION UPON THOSE RESPONSIBLE FOR THE CHILD'S DIET A careful observance of the essential conditions as to the proportions of the different ingredients in an infant's food, its quantity, digestibility, and other points laid down in the first of these lectures, would reduce the disease to very small dimensions. Its occurrence is too often a grave reflection upon medical man, or nurse, or mother, under whose directions the diet of the child has been regulated. There ought to be little rickets to cure, but since it exists, how is it to be treated ? TREATMENT OF RICKETS — DIET OF MORE IMPORTANCE THAN DRUGS As it is due to fault of diet chiefly, so it is to be cured by diet adapted to remedy the deficiencies of previous feeding. And here I find fault with the common practice in these cases. Far too much RICKETS 195 reliance is placed upon the mere giving of drugs, cod-liver oil, chemical food, lime, iron. Dosing with these remedies is often the sole treat- ment. We starve the infant of fat in its daily food, and try to make up for this by drenching it with cod- liver oil afterwards. The remedies I have named are useful, but they are by no means of the first importance in the treat- ment of rickets. CREAM — COD-LIVER OIL Cod-liver oil supplies the deficiency of fat in the food in satisfactory form, but cream is equally efficient. The other important element, the nitrogenous pro- teid, must likewise be supplied by additional animal food. RAW MEAT JUICE. Proteid may be added in the shape of casein if the child can take more milk, but many children cannot digest a sufficient amount, and the best substitute, as I have shown in an earlier lecture, is raw meat juice or raw meat pulp. The mode of pre- paration of these I have already explained. 1 1 Lecture III. pp. 1 16-120. 196 DIET DISEASES OF EARLY CHILDHOOD LACTO-PHOSPHATE OF LIME I doubt very much whether the administration of lime salts in the form of drug has really any influence on the affection, although I would make a reservation, perhaps, in favour of the lacto-phosphate. Certainly lime water is quite ineffectual. Earthy salts are contained sufficiently in milk, and raw meat, and cream. On a diet in which these are leading ingredients, a rickety child grows rapidly strong, firm, and hard in bone and muscle, loses its pallor and night-sweats, and feebleness and tendency to con- vulsion. It becomes vigorous, lively, and robust to a degree that no amount of chemical food, or salts of lime, or iron, or cod-liver oil alone can bring about. DRUGS USEFUL ADJUNCTS, BUT TOO MUCH RELIED UPON IN THE TREATMENT OF RICKETS Drugs are, however, useful adjuncts in certain cases, although children are generally overdosed with cod- liver oil, syrup of phosphates, and chemical foods ; I more often stop them than order them. Syrup of iodide of iron, which is a favourite remedy, is harmful rather than beneficial. Iodine is depressant, and, moreover, its persistent administration has occa- sionally given rise to iodic purpura. Cod-liver oil RICKETS 197 must be given in. default of cream or good milk, if it does not prove too laxative. More important still are fresh sea or mountain air, sunlight, and an outdoor life. They materially aid vigorous nutrition, and hasten recovery. Where these cannot be obtained, I constantly find that a mere regulation of diet is in itself sufficient to effect the required transformation, although perhaps more slowly. CASE EXHIBITING ALL THE CHIEF SYMPTOMS OF EXTREME RICKETS, AND ILLUSTRATING THE EFFICACY OF PROPER DIETING The following case admirably illustrates rickets in all its leading features, and exhibits forcibly the efficacy of proper dieting. In December 1883 I saw, in consultation with Dr. Spence, a child of 1 1 months. The parents were small but prosperous tradespeople in Soho. The patient was a thin, miserable, white-faced baby, with projecting forehead, flabby muscles, widely open fon- tanels, pigeon-breast, beaded ribs, and enlarged ends of the long bones. It bad no teeth ;. at this age it should have had five or six at least. The child had, in a word, all the signs, of well-marked rickets. It 198 DIET DISEASES OF EARLY CHILDHOOD had had repeated attacks of sickness, and constant diarrhoea : no food seemed to agree with it. It was anaemic, chill ; its temperature persistently subnormal. I was asked to see it, however, chiefly on account of attacks of spasm of the glottis. These were so severe and prolonged occasionally as to bring the child to the verge of suffocation. They were brought on by the smallest excitement, but, as is usually the case, they were most intense on first waking in the morning, or when induced by crying or laughter. On examining the child more minutely, the thumbs were seen to be tightly drawn towards the palm, which was arched longitudinally, the fingers adducted and overlapping each other — the typical so-called accoucheur's hand of tetany. The feet were arched and the toes flexed. The dorsum of each foot was much swollen, as if dropsical, but there was really no oedema, the swelling being due probably to pressure of the contracting muscles, yet not sufficient to produce effusion — the condition often produced by a tight bandage. The child was constantly crying with the pain of cramp, when the spasm was most intense. Twitching of the orbicularis and levator anguli oris could be induced by scratching the skin over the pes-anserinus. The attacks of laryngismus had lately been increasing in severity. RICKETS 199 A SIGNIFICANT FAMILY HISTORY The family history of the patient was remarkable and highly significant. The parents had had five children born alive, all strong, plump, and apparently healthy, yet of these five, three died early. The first had general convulsions at 3 months, and died in an attack of laryngismus at 6 months. The second died at 6\ months, of diarrhoea and wasting — no laryngismus or convulsions. The third is still alive and fairly well, but she was weakly as an infant, and had two convulsions when teething. The fourth had croup when 4 months old — probably catarrhal laryngitis — and died at the age of 1 year and 10 months, from general convul- sions. The fifth was the youngest, who came under my observation in the condition I have described. So that four out of the five children had convul- sive seizures, and the one who escaped convulsions had diarrhoea and atrophy. What is the explanation of this remarkable pre- disposition to convulsion ? Was it an inherited tendency — a congenital nervous hypersensibility ? There was no family zoo DIET DISEASES OF EARLY CHILDHOOD history of neurotic disease or constitution. The parents were strong, healthy people of the middle class. No, the tendency was not inherited, it was acquired — developed by defective nutrition. The story of their manner of life, and the food on which they had been brought up, afforded an ample expla- nation of their constitutional state. THE INFLUENCE OF HAND-FEEDING — LACK OF ANIMAL FAT AND PROTEID The children had all been brought up by hand. The mother, closely engaged in business, could not give time to suckle her children. They were fed chiefly upon cornflour, a patent farinaceous food made without milk, and arrowroot. They had very little milk, for cow's milk disagreed with all of them, and caused vomiting and diarrhoea. No other animal food was given to make up for the want of milk. So two of the canons laid down in my first lecture were broken. The food did not contain proteid and fat in due proportion. It did not contain an ample amount of animal matter. RICKETS 20 1 CARBOHYDRATES THE CHIEF ELEMENTS OF THEIR DIET It was a diet almost purely vegetable, consisting of little but starch and sugar; a food in which the carbohydrates were the chief elements, largely in excess, and the fat and the nitrogenous proteids almost absent. The carbohydrate was, moreover, in the form the least available for infants, viz. starch : cornflour and arrowroot are almost pure starch. So these little children were starved, although fed abundantly. They suffered grievously from want of fat and nitrogenous food. Thus not only were bones soft and rickety, muscles flabby, the blood short of red corpuscles, but the nerves and nerve centres grew unstable, hypersensitive, ready for convulsive spasm on small irritation. Such was the explanation of the tendency to convulsive disorder exhibited by four out of the five children. The only one which did not suffer from convulsion in some form died of diarrhcea and atrophy, doubtless a food disorder like- wise. The youngest, our patient, had slightly better fare than the elder children. The parents had risen in the world a little, and the mother was able to find time to nurse her baby, but her supply of milk was 202 DIET DISEASES OF EARLY CHILDHOOD t very scanty. So this child, too, had cornflour, bread and butter, and various farinaceous foods, but no cow's milk, which did not agree. The child's appetite was ravenous ; it had constant diarrhoea and frequent vomiting. TREATMENT FOR THE CONTROL OF LARYNGISMUS — FOR THE CURE OF THE RICKETY STATE The treatment adopted was first to relieve the laryngeal spasm by chloral (gr. £) and bromide (gr. 4) given every four hours, and thus, by soothing the nervous system and guarding against the danger of convulsion, to gain time for the cure of the rickety atrophic condition which was the prime source of the nerve disorder. To this end the diet was changed to one of animal food chiefly, with fat and abundant nitrogenous matter ; 2 oz. of raw meat pulp daily, boiled milk diluted with one-third water, entire wheat flour. When the diarrhoea declined, cod-liver oil was given to make up for the deficiency of fat in the food, and lacto-phosphate of lime, which, I am inclined to think, has a beneficial influence on the rachitic fault. The laryngismus at once declined, fits were less frequent (two or three in the week instead of ten or RICKETS 203 twelve a day) and less severe, the tetanoid spasm relaxed, and complete recovery quickly followed. When I saw the child six months later she was plump, hard-fleshed, robust, and had got five teeth without trouble or disturbance. THE CASE CURED BY THE ADDITION OF ANIMAL FAT AND PROTEID TO THE FOOD The preceding case affords an example of the disease in its most severe and complete form. The food defect was extreme, and no doubt the most potent cause at work. The action of this had been intensified by want of fresh air and of sunlight. The house was in a crowded district, and the dwell- ing-rooms were dark and not well ventilated. Yet it is significant that, as in the case of the young lions, the addition of certain ingredients of food alone was sufficient to cure, the other conditions remaining absolutely unchanged. In the next case which I shall give, however, the surrounding conditions were very different. They were indeed perfect as far as air, light, clothing, and cleanliness were concerned. 204 DIET DISEASES OF EARLY CHILDHOOD EXAMPLE OF RICKETS OCCURRING UNDER PER- FECT SANITARY CONDITIONS, WITH THE SOLE EXCEPTION OF DIET The patient was 2 years and 10 months old, the child of wealthy parents of high social position, brought up in a great country house, and enjoying air and light freely, both indoors and out. It was brought to me on account of general feebleness of health. It was pallid, spiritless, and soft-fleshed. It had sweating about the head, the fontanelle was not quite closed, the bones of the margin thickened, the forehead projecting, the ribs beaded, the ends of the long bones enlarged. The legs were knock-kneed, one tibia slightly bowed, the ankles yielding, the teeth already decaying. THE CAUSE OF RICKETS IN THIS INSTANCE THE FOOD FAULT ONLY The history was this. The child had been brought up entirely by hand, for the first six months on con- densed milk, and then cow's milk was given. This, however, did not agree ; it was frequently vomited, and could only be taken in small quantity. There RICKETS 205 had been no diarrhoea, but constipation throughout. Lately the child had had 1 pint of milk, bread and butter, fish or meat or beef-tea once daily, stewed fruit, no milk puddings. THE TREATMENT BY DIET The treatment consisted of 2 oz. of raw meat pulp daily, milk puddings made with prepared entire wheat flour, and an increased allowance of milk. No medicine was given except some carbonate of magnesia daily, to relieve the chronic constipation. Firmness of flesh and colour quickly returned ; the relaxation of ligaments and softness of bone went no further, and the child grew healthy and strong without drawback. In this case the food defect, the lack of milk or equivalent animal food, was the sole cause to be dis- covered. The diet failed to fulfil the essential con- ditions ; it was clearly deficient in fat and proteid and the animal element. The child got rapidly well directly this defect was remedied. The ill effects of the defect of diet were mitigated, no doubt, by the generally favourable hygienic conditions, instead of being aggravated by evil sanitary conditions, as in the case I first related to you. 206 DIET DISEASES OF EARLY CHILDHOOD ANOTHER EXAMPLE OF SIMPLE FOOD RICKETS Let me now give an example of rickets occur- ring under the ordinary favourable conditions of middle-class life in a good house in the suburbs of London. In this instance, again, the only fault to be dis- covered was connected with the food. In all other respects the child was well managed and well cared for. I was asked to see it on account of general debility. A number of different medical men in the country had already been consulted, and all had agreed that the child was weakly and backward, but that it had no special ailment of any kind. It was 2 years and 4 months old, yet the anterior fonta- nelle was still widely open, and it had only twelve teeth. It was extremely pigeon-breasted, had beaded ribs, enlarged wrists, the arm bones were bent, the legs knock-kneed. It had profuse head sweats, and suffered from frequent catarrhs. The history was this. The child had been suckled up to three months, then cow's milk was tried. It did not appear that this disagreed, but condensed milk was found to be less troublesome, especially in hot weather, and so it was substituted. Of this it had RICKETS 207 only one pint of the ordinary dilution. In addition bread and beef-tea only. TREATMENT BY DIET The treatment consisted in two pints of fresh cow's milk boiled, raw meat pulp, with prepared entire wheat flour. Syrup of lacto-phosphate of lime and cod-liver oil were given at first, but for a few days only, since they seemed to cloy appetite, and the child rapidly recovered without medicine, quickly becoming firm- fleshed and robust. 208 DIET DISEASES OF EARLY CHILDHOOD LECTURE VI INFANTILE SCURVY, OR SCURVY-RICKETS Infantile scurvy — Identification of the disease — The acute rickets of German authors — Records of the disease in England — The charac- teristic symptoms of scurvy — The condition set up by privation of certain constituents of fresh food — The disease cured by the supply of these — Scurvy occurs in young children in all degrees of severity — Mortality — The symptoms correspond closely with those met with in adults — Occasional variation in the condition of the gums and in pyrexia — Other symptoms and morbid anatomy identical — The cause the same — Examples of children's diet producing scurvy — The dis- ease cured as in adults, by antiscorbutics — Example showing extreme rapidity of recovery — Case I. Typical scurvy in a child of 16 months — Severe symptoms accompanying rickets : Diet both rachitic and scorbutic : All other hygienic conditions excellent : Value of milk and potatoes in a child's dietary : Rapid effect of antiscorbutic diet, all other conditions being unchanged — Case II. Scurvy in a child 10 months old: Symptoms: Concurrent rickets. Food: Effect of antiscorbutic diet — Case III. Scurvy in a boy of 14 months : Full series of scorbutic symptoms : Concurrent rickets : Previous regimen : Difficulty in feeding : Death on fourth day from haemor- rhage into the lung : Post-mortem appearances — Case IV. Patient aged 13 months : Well-marked signs of scurvy : Concurrent rickets : Previous feeding : Effect of full antiscorbutic diet — Case V. Persistent hematuria in a child 12 months old : Other symptoms suggestive of scurvy : Cachexia : Syncopal attacks : Spongy gums : Haemorrhages : Periosteal swellings : Concurrent rickets : Previous feeding : Difficulty in feeding : Recovery Case VI. A child 9 months old : Previous diet : Great tenderness of legs and inability to run, supposed to be rheumatic : Periosteal SCURVY 209 swelling : Other signs of scurvy doubtful : Subsequent occurrence of extensive haemorrhages under the lower eyelids : Immediate im- provement on addition of certain elements to former food — The association of rickets with scurvy — Explanation — The tenderness of limbs in rickets possibly scorbutic — Necessity for bearing in mind the frequent association of the two diseases — Conclusion. SCURVY There is still another morbid condition met with, in children dependent on faulty diet, and usually, al- though not invariably, associated with rickets, namely, scurvy, of which I spoke incidentally in my first lecture, when laying down the canons of correct feeding. The subject is one in which I take great interest, since I was, I believe, the first to identify the disease in this country, to demonstrate its exact nature, and to trace with precision its source in a scorbutic diet. THE IDENTIFICATION OF THE DISEASE IN CHILDREN AS TRUE SCURVY It appears from the researches of Dr. Barlow ' that isolated cases of similar character had been noted in Germany from 1859 to 1873, by Moller, Bohn, Hirschsprung, and Senator, as examples of acute rickets, and one in 1873 ver y briefly by Ingelev, as 1 Med. Chir. Trans. 1883. P 210 DIET DISEASES OF EARLY CHILDHOOD infantile scurvy. The first case observed in this country appears to have been one recorded in the ' Pathological Transactions,' by Mr. T. Smith, in 1876, under the provisional title of hemorrhagic periostitis, but the condition was not recognised as scorbutic. In 1878, in a clinical lecture published in the ' Lancet,' I gave an account of three cases observed during the preceding year, which I identified as true scurvy occurring in young children, associated with rickets, and dependent upon the absence of the neces- sary antiscorbutic element in their food. I recorded other cases of like kind subsequently in 1879, 1 and again in 1882. 2 In 1 880, Dr. Dickinson observed cases of hematuria in children which he recognised as scorbutic, due to defect of diet, and described in his work on ' Renal and Urinary Diseases.' Similar cases attracted the attention of Dr. Gee in 1 881, who described them in 'St. Bartholomew's Hospital Reports ' under the designation of osteal or periosteal cachexia. In 1883, Dr. Barlow, in an exhaustive paper read before the Royal Medical and Chirurgical Society, gave the history of eleven cases of infantile scurvy which had come under his own care, and twenty others collected from various sources. Dr. Barlow's conclu- 1 Brit. Med. Journ. 1879. * Lancet, July 15, 1882. SCURVY 211 sions fully confirmed my own as to the nature of the affection and its causation. In the same year Mr. Herbert Page brought a case of subperiosteal haemor- rhage before the Medical and Chirurgical Society, which he judged to be probably scorbutic. In addition to much valuable matter relating to the clinical features of the disease, Dr. Barlow gave a full account of its morbid anatomy, and proved how exactly the lesions found in infantile scurvy correspond with those found in the sea scurvy of adults. For this portion of the subject especially I would refer you to his paper, which is published in the sixty-sixth volume of the ' Medico-Chirurgical Trans- actions.' Within the last few years numerous cases have been recorded by various observers in America and on the Continent, and the pathology of the disease as set forth by myself and Dr. Barlow has been, I think, generally accepted. As many as 106 cases were reported to the New York Academy of Medicine at the beginning of last year (1894). THE SYMPTOMS OF SCURVY Scurvy, as ordinarily observed in adults, is cha- racterised by progressive anaemia, accompanied by 212 DIET DISEASES OF EARLY CHILDHOOD a cachectic earthy complexion, marked muscular debility, mental apathy, and depression. Before long, however, more characteristic signs develope : petechial spots appear on the skin, then larger superficial, and deep-seated extravasations of blood, giving rise to puffy swellings on the periosteum, in the muscles, especially at the anterior aspect of the legs, the popliteal spaces, and flexures of the elbows. Haemor- rhages also take place in the subcutaneous connective tissue, as in the loose tissue below the eyelids ; or in parts exposed to pressure or slight injury, showing as discoloured bruise-like patches. The limbs become tender and painful, the ankles cedematous. Often albumen and sometimes blood appears in the urine. But the most characteristic feature of all, and the one which serves especially to distinguish scurvy from purpura and all other diseases, is ithe condition of the gums ; they become soft, livid purple, spongy, and sometimes so swollen as to protrude from the lips in lobulated .masses, hiding the teeth altogether. They bleed freely, soon begin to ulcerate or slough, and the decaying blood imparts a horribly ;fetid odour to the breath. The teeth become loose and frequently fall out ; bruise-like extravasations and even unhealthy ulcers ^follow the least injury, or even the rough pres- sure of handling. The temperature is normal or sub- SCURVY 213 normal, except in case of haemorrhages into the lung or pleura, when inflammatory changes are set up. If the scorbutic state continues, there comes increasing debility, a tendency to syncope on exertion, often of extreme danger, haemorrhages from the stomach, bowels, or lungs. Unless the condition be relieved, death takes place at the close of some weeks or months by sudden syncope, or gradual asthenia, or the supervention of some acute- inflammation. Such is a picture of scurvy in the adult. THE CONDITION DESCRIBED TRACED TO SIMPLE DEFINITE CAUSES There is nothing more certain in pathology than that scurvy is produced absolutely and invariably by want of certain constituents of food. These are pro- bably organic acids, such as citric, malic, tartaric, in combination with potash. Whatever their exact nature,: however, they are known to be contained abundantly in fresh vegetable juices, in fresh raw meat, and in milk ; and as the privation of these elements produces the disease, so. their free supply absolutely and quickly cures it. The effect of scorbutic diet is increased by want of light, of air, and defective hygiene ; and, on the 214 DIET DISEASES OF EARLY CHILDHOOD other hand, the curative influence of antiscorbutic diet is aided by fresh air and sunlight. SCURVY OCCURS IN CHILDREN ALSO IN ALL DEGREES OF SEVERITY — THE MORTALITY IN CHILDHOOD Now scurvy, as I have shown, is met with in children, and in all degrees of severity. Sometimes it is developed in its most extreme and dangerous form. Seven out of the thirty-one cases in Dr. Barlow's list were fatal. I have seen twenty cases. Of twelve of these I have accurate knowledge, and out of ten which were under my own care, one only was fatal. The child was in a condition of extreme debility, took food with great difficulty, and died three days after admission into hospital from haemorrhage into the lung. 1 PERIOD OF CHILDHOOD AT WHICH SCURVY OCCURS These cases of scurvy, like rickets, occur as a rule in infancy, the period of bottle-feeding. In Dr. 1 Since the above was written in 1889, I have seen a large number of cases in addition, both in hospital and in private, making forty in all, under my own immediate observation and care. Of these only two have proved fatal, including the one mentioned in the text. The other, also a hospital case, was admitted with a large subperiosteal swelling on the femur supposed to he an abscess, treated surgically, the scorbutic condition not being recognised at the time. No private case — and these form the large majority — has ended fatally. SCURVY 215 Barlow's thirty-one cases, twenty-five were under 2 years. In my series of cases, all but four occurred in patients under 2 years, i.e. the period of diet of narrow range. When the child grows older, the diet becomes more varied and scurvy rarely occurs. THE SYMPTOMS CORRESPOND WITH THOSE OBSERVED IN ADULTS The spongy bleeding gums, which present such a notable feature of scurvy in adults, are usually remarkable enough in children. This sign may be absent in cases arising before the eruption of the teeth ; the sponginess being found chiefly in the neighbourhood of teeth which have been cut, or just above the pushing teeth not yet through. In some instances the condition was represented by small sub- mucous ecchymoses only. This is consistent with the occasional absence of sponginess of gums in certain cases of scurvy in adults, where the teeth have pre- viously fallen out. Occasionally in children, when teeth are present, the gums show no perceptible change in the early stage of the disease, and in slight cases there may be only cachexia and periosteal tenderness of limbs. Pyrexia appears to be more common in children than in adults, but depends probably, as in adults, 2i6 DIET DISEASES OF EARLY CHILDHOOD upon the amount of haemorrhage, and the consequent presence of inflammatory change or septic absorption. For the rest, the earthy pallor, the anaemia, the muscular feebleness, the listlessness, the tendency to syncope, the oedema, the haemorrhages, the albumi- nuria or haematuria, tenderness, and swelling of the limbs both in muscle and periosteum, are the same. 1 The morbid anatomy of the disease in children cor- responds with the morbid anatomy of scurvy in adults. WITH CHILDREN, AS CERTAINLY AS WITH ADULTS, THE CAUSE CAN BE TRACED TO SCORBUTIC DIET In no instance have I seen the disease arise in an infant at the breast, or when fed on an ample supply of good cow's milk. Oatmeal and water, bread and water, various patent farinaceous and desiccated foods, peptonised milk, condensed milk, sterilised milk, ' humanised ' milk, pancreatised farinaceous food and milk, German sausage, bread and butter and tea, beef- tea, gravy and bread, in most cases with no fresh milk at all, in a few with a very small amount only, are the dietaries on which I have seen scurvy develope, and, latterly, most often on the peptonised and pancreatised foods now so much in vogue. And in these cases in 1 In one case which came under my care, the periosteal swelling and tenderness were limited to the malar bone. The copdition of the gums, hawever, afforded conclusive evidence as to its nature. SCURVY 217 children again, as with adults, the improvement which immediately follows the administration of anti- scorbutics is one of the most remarkable facts in the whole range of medicine, and a convincing proof of the condition being a true scurvy. How almost incredibly rapid this change is in some instances may be judged from the following circumstance. A CHANGE TO ANTISCORBUTIC DIET FOLLOWED BY RAPID RECOVERY— CASE IN ILLUSTRATION A child suffering from well-marked scurvy was admitted into the Children's Hospital under my care. The spongy swelling of the gums was such a con- spicuous and typical feature, that I determined to have a sketch made of it ; and I went the same evening to the late Dr. Westmacott, a skilful artist in this line, to ask him to make the drawing for me. The day chanced to be a Friday ; the following days, Saturday and Sunday, were not convenient, and it was agreed that the matter should be postponed until Monday. The child had been at once placed upon an antiscorbutic diet of potato pulp, fresh milk, and raw meat. On the Monday, or in three days' time, the child had wonderfully improved in strength, and the swelling of the gums had subsided to such a degree that the sketch had to be abandoned as useless. 218 DIET DISEASES OF EARLY CHILDHOOD CASE I. — TYPICAL SCURVY IN ITS EXTREME FORM DEVELOPED ON A DIET OF FARINACEOUS FOOD AND BROTH The special and striking features of infantile scurvy in a typical form are well shown in the follow- ing instance, the case which first disclosed to me the true nature of the affection. The patient was a child 16 months old, born of middle-class, well-to-do parents, living in a large house in St. John's Wood, seen in consultation with Mr. Sumner in January 1877. It presented a very striking appearance. Large purple gelatinous-look- ing masses protruded from between the lips, and gave the child the appearance of being engaged in sucking pieces of raw flesh. On examination these projections were seen to be the gums swollen to this extreme degree, livid and bleeding. These projec- tions, I learnt, had been still greater, having been partially excised by the medical attendant, who thought they interfered with feeding. The mucous membrane of the roof of the mouth was similarly swollen, livid and spongy, the swelling being so great as almost to be in contact with the tongue, and oozing with blood. The breath was horribly offen- sive, the odour that of carrion. The complexion SCURVY 219 was anaemic, earthy ; the skin harsh and unhealthy- looking. There were some purpuric blotches on the limbs, which were tender on being handled, and the legs cedematous, but no muscular or periosteal swellings could be detected. The muscles were flabby, and so feeble that the child could not sit up, but fell over immediately on being placed upright. It had all the characters of extreme rickets in skull, and long bones, and chest. DETAILS OF THE CHILD'S DIET Its history was this : The child was born stout and healthy, and con- tinued so until the end of the first six months ; dur- ing that time it was suckled, and had in addition oat- meal and water, condensed milk being also given for a short period at first only. This was discontinued after three months, as it was thought to disagree. At the end of six months the infant was weaned, and fed entirely upon oatmeal and rusks made with water, no milk ; at ten months some mutton broth was given in addition. This diet was continued without any change until the sixteenth month, so that from the sixth to the sixteenth month, i.e. for ten months, this unfortunate baby had no milk, no 220 DIET DISEASES OF EARLY CHILDHOOD meat, no potatoes — nothing but oatmeal, rusks, and water, with a small quantity of broth. THE DIET A RICKETY DIET AS WELL AS A SCORBUTIC DIET On such a diet the child was certain to become rickety. The food was almost destitute of animal fat, and greatly deficient in proteid, lacking the animal element almost entirely. But the diet was something more than a rickety diet ; it was a scurvy diet. It contained no antiscorbutic element, no fresh milk, no fresh vegetable, no fresh meat. Most children get a certain amount of fresh milk — which, although not a powerful antiscorbutic, and sometimes ineffective in small quantity, is a per- fect antiscorbutic when taken in sufficient quantity — until they are able to take solid food, at any rate ; and then they almost invariably get potatoes, one of the best antiscorbutics. This child had neither, and scurvy developed. PREVIOUS TREATMENT — ITS INEFFICACY Chlorate of potash and bark had been given, and subsequently syrup of the iodide of iron. The swell- ing of the gums, however, increased, with occasional SCURVY 221 haemorrhage from the mouth ; and alum and glycerine were applied locally. This, however, failed to have any effect. The swelling of the gums grew still more extensive, until the whole of the mucous membrane of the upper and lower jaw seemed to be involved, and the bleeding became more profuse. The treat- ment was then changed to perchloride of iron and cod-liver oil internally, and glycerine of tannin was applied to the fungous excrescences. The local application reduced the swelling to some extent, but the child grew weaker in spite of iron and cod-liver oil, and became unable to sit upright. Feet and legs began to swell, dyspnoea came on with stridulous respiration, especially during sleep, occasionally de- veloping into paroxysms of laryngismus. TREATMENT BY ANTISCORBUTIC DIET — RAPID RECOVERY The treatment now advised consisted in simply placing the unfortunate little patient upon antiscor- butic food : fresh milk, fine potato gruel, 1 and raw 1 Prepared by rubbing thoroughly steamed floury potato through a fine sieve, and beating this up well with milk until it is smooth and of the consistence of thin cream. A teaspoonful of this may be added to each bottle at first, and the amount gradually increased to a dessert- spoonful, or even a tablespoonful, if it is found to agree. Well-boiled carrots may be used in the same way. 222 DIET DISEASES OF EARLY CHILDHOOD meat. Fresh milk, as I previously stated, is clearly not a potent antiscorbutic, and although sufficient to prevent scurvy when given in full quantity, will not always prevent it when taken in small amounts only. It fails accordingly to remove the scorbutic condition with quickness and certainty when given alone. It. is necessary, therefore, to add to the food some more active agent, such as potatoes, carrots, or a vegetable juice, such as orange juice, or broth in which vege- tables such as carrots and potatoes have been boiled and strained out, with raw meat juice in addition. The child had been taking cod-liver oil and per- chloride of iron for some time without benefit. The only change made was to substitute steel wine for the perchloride, with some glycerine and 5 grains of bro- mide of potassium to relieve the laryngismus. The child remained at home until convalescent. No change of any kind was made in the conditions of life except in the diet. Improvement at once followed, uninterrupted recovery took place, and in the course of a few months the child was running about strong and well. SCURVY 223 THE FOOD FAULT THE ONLY CAUSE OF THE DISEASE In this case there could be no doubt as to cause. All hygienic conditions were excellent, except one. The child was well clothed, lived in a large, well- ventilated house, and had abundance of fresh air. The only fault was the absence of antiscorbutic and antirachitic elements from the diet, and the disease was cured at once by their free supply. CASE II. — SCURVY DEVELOPED UPON AN EXCLU- SIVE DIET OF FARINACEOUS AND DESICCATED FOOD — SYMPTOMS Let me give you another out of many striking instances which have come under my personal notice. The patient was an infant 10 months old, the off- spring of parents in prosperous circumstances, living in a healthy suburb of London. The child from birth had been well housed, clothed, and cared for — brought up, indeed, under highly favourable sanitary conditions in most re- spects. Yet it was a miserable object, emaciated, anaemic, cachectic, with dry earthy skin, the muscles 224 DIET DISEASES OF EARLY CHILDHOOD flabby and soft. It was so feeble that it could not sit up or even lift its head up for an instant, but lay perfectly limp, almost motionless. Although hardly able to move its limbs, it was extremely restless and irritable, fretful, wakeful, never sleeping more than half an hour at a time. It cried out when touched, being evidently tender everywhere, most tender of all, however, in the right leg, which was greatly swollen just above the ankle. The swelling was seated partly in the periosteum of the tibia, and partly in the anterior tibial muscles. There was a similar swelling, but smaller, on the left tibia. Both ankles were cedematous. There were no petechial spots. The gums of the upper jaw in front were greatly swollen, and of a deep livid purple, bleeding, spongy, protruding between the lips. The lower gums were slightly swollen also, and marked by ecchymoses. THE PATIENT RICKETY AS WELL AS SCORBUTIC The child was rickety. Both the lower arm bones were much curved, the ribs beaded, the joints enlarged, the chest laterally compressed, the fonta- nelle widely open. Careful examination of the chest and abdomen showed no sign of tuberculosis or SCURVY 225 enlargement of organs. The temperature was barely 98° There was a considerable quantity of albumen in the urine. The child took food greedily, had no vomiting or diarrhoea, yet, in spite of this, became more feeble and pallid daily. The history was this : DETAILS OF FEEDING The child was suckled for the first two months, then partly weaned, and fed in addition on a patent farinaceous food with desiccated milk. It throve well until it was five months old, then suffered from a severe attack of vomiting and diarrhcea, which was attributed to sunstroke. This continued for several' days, during which time it was fed on arrowroot and isinglass only. When the symptoms ceased it was again put on the same farinaceous and desiccated food, and had been fed on that solely ever since. It had grown steadily worse from the first. Here, then, was a case of undoubted scurvy developed upon a diet of arrowroot and isinglass with farinaceous and dried milk food. No fresh milk was given in addition. As I told you, other cases of scurvy supervening on this diet have been recorded. The child was now put upon potato pulp, raw meat juice, and milk. No medicine of any kind was Q 226 DIET DISEASES OF EARLY CHILDHOOD prescribed. Recovery took place with extraordinary- rapidity. The child is now robust and hearty, the picture of perfect health. THE DIET RICKETY AS WELL AS SCORBUTIC Here, again, the diet had been scorbutic as well as rickety, and immediate recovery followed the change of food alone, without any assistance from medicine, or any other remedial agent of any kind. The child remained at home, no condition being changed except the food. I could relate many other cases of like kind, but I shall content myself with a brief summary of four which have come under my care, viz. two in the Children's Hospital and two in private. They illus- trate one or two points of special interest. CASE III. — SCURVY DEVELOPED ON BREAD AND WATER DIET The first of these is that of E. L., a little boy of 14 months, admitted to the Children's Hospital on January 25, 1888, for extreme cachexia, emaciation, and debility. The child was wizened in appearance, had scattered haemorrhagic blotches on the body, SCURVY 227 notably on the eyebrow and round the right eye. There were two sloughing sores on the inner margin of the right thigh. The gums were spongy, swollen, and blue. The scrotum was cedematous and covered with eczematous eruption. There were no periosteal or muscular swellings. No albumen was found in the urine. The only signs of rickets were an open fontanelle and slight beading of the ribs ; no enlargement or curvature of long bones, or collapse of chest wall. DETAILS OF FEEDING The account given of the feeding was this : The child had been brought up by hand ; always vomited when given milk and water, so that bread soaked in water had been given, and for the last three weeks nothing else. Raw meat juice, peptonised milk, and potato pulp were ordered, but the child took food with great difficulty, the attempt to swallow giving rise to cough and return of food through the nose. No improvement took place, and the child died on the fourth day after admission. This is the case previously mentioned as one of two under my own immediate observation which ended fatally. Q2 228 DIET DISEASES OF EARLY CHILDHOOD Post-mortem examination disclosed extensive haemorrhage into the lungs, the whole of the lower lobe, and >part of the middle lobe on the right side, and part of the lower on the left side being solid from extravasated blood. There was bloody fluid in the pleural cavity. Numerous small haemorrhages were found under the serous membranes of all the chief organs of the thorax and abdomen. The bronchial and mesenteric glands were infiltrated with extra- vasated blood. CASE IV. — SCURVY DEVELOPED ON EXCLUSIVE DIET OF FARINACEOUS AND DESICCATED FOOD The next case is that of a child, H. H., aged 13 months, admitted into the Children's Hospital in April 1888. It was brought for tenderness and swelling of the legs immediately below the knees, but the child seemed tender all over, and cried on being handled ; the skin was tense and shiny over the swollen parts, and there were numerous petechial haemorrhages on the surface of the legs. The gums were swollen, purple, and spongy. The signs of rickets were a widely open fontanelle, large square head, and beaded ribs. The temperature was normal, the urine free from blood and albumen. SCURVY 229 The condition was clearly one of true scurvy, of no extreme severity. The state of gums had been noticed coming on for three months, but the tender swellings of the legs had commenced only three weeks before. DETAILS OF FEEDING The child had been brought up by hand from six weeks old, on farinaceous and desiccated food, without the addition of any fresh element, up to 11 months. From that time it was said to have had a pint and a half of cow's milk thickened with fine oatmeal. The father was a dairyman, and said he suspected the milk of being adulterated. In this case the late addition of milk to the food no doubt saved the child from any extreme symptoms, which commenced with spongy gums a month before the change was made, although, as I have stated before, milk is not a powerful antiscorbutic, and it failed to cure. RAPID RECOVERY ON ANTISCORBUTIC DIET The child was at once put on raw meat juice, milk, and potato pulp, and the result was remarkable. In four days all the petechiae had disappeared, the 230 DIET DISEASES OF EARLY CHILDHOOD blueness of gums had gone, although some swelling remained, and the tenderness and swelling of the legs had greatly subsided. The child took food freely, and at the end of three weeks was discharged absolutely well. CASE V.— SCURVY DEVELOPED ON A SOLE DIET OF FARINACEOUS FOOD AND CONDENSED MILK The next case is an unusually interesting one The patient, a child of 1 2 months old, was sent to me from the country in January 1888, as a case of obstinate and unexplained hsematuria. When the mother brought the child into my room I saw that it was extremely pallid and cachectic, and lay very limp and helpless in its mother's arms. She told me that its limbs were tender, that it cried when they were touched, and that the flesh bruised on handling. It was feeble, drowsy, and listless, and it became panting, breathless, and so faint on the smallest exertion that they were frightened, and thought it would die. About a month ago the urine became dark like blood. I found it loaded with blood and albumen. The child had once or twice passed blood with the stools. SCURVY 23 r THE CHILD ALSO RACHITIC The fontanelle was unduly large, the ribs beaded, and the wrists a little enlarged, showing a slight degree of rickets. The gums were dark and spongy, and there were distinct swellings on the front of each tibia, which were very tender ; the feet were cedema- tous, and there was a large bruise in the right iliac region. DETAILS OF FEEDING The history was this : The child had cow's milk and water up to three months. Then it had an attack of diarrhoea and vomiting, attributed to the milk. This was accord- ingly stopped, and it was put on a malted farinaceous food with a small quantity of condensed milk, viz. one small teaspoonful to three bottles of food. RECOVERY ON ANTISCORBUTIC DIET The only treatment ordered was, as before, dietetic. No medicine was given, but raw meat juice, cream, potato gruel. The case proved a little difficult. The stomach had become so sensitive that the child was frequently sick after the richer 232 DIET DISEASES OF EARLY CHILDHOOD food, and it was found necessary to reduce the quan- tity of cream, and give half a bottle of food only every two hours. Yet, in spite of this drawback, the limbs were already less tender, the gums less swollen, there were no fresh bruises, and the urine was only slightly discoloured with blood. In a fortnight all trace of blood and albumen had disappeared from the urine. The meat juice and cream were increased gradually, and milk added. In less than a month the child was well and playing about. In this case, again, the food defect was clearly sufficient to cause scurvy. Condensed milk, as I told you before, is of slight, or even doubtful, antiscorbutic virtue. One- third of a teaspoonful in each bottle would be utterly inadequate. The rapid recovery on antiscorbutic diet, again, was a convincing proof of the nature of the malady. CASE VI. — SCURVY DEVELOPED ON AN EXCLUSIVE DIET OF FARINACEOUS AND DESICCATED FOOD The last example which I have to relate is also of special interest, since the child appeared so unusually well-nourished that at first I was doubtful whether the condition was really scorbutic after all. This was, however, unmistakably proved before long. SCURVY 233 The patient, P., a child of 9 months old, was sent to me on the nth of April, 1888, by my friend Dr. Liveing, on account of great tenderness of the limbs. It had suffered from eczema almost from birth, but this had disappeared under treatment. The child lay with its legs drawn up, quite motion- less ; the least attempt to straighten the legs or offer to touch them caused it to cry out. The periosteum of the tibia was obviously swollen, and extremely tender. There was a faint bruise on the right cheek, near the ear. The gums looked a little dark in colour, and slightly swollen ; but they could not be positively identified as spongy. There was no albu- men in the urine. The child was plump and of fair colour. The signs of rickets were, however, distinct : the fontanelle was widely open, the size of a florin ; the teeth showed no sign of appearing, and the ribs were well beaded, but this was all. The child had been fed entirely upon farinaceous and desiccated food, without the addition of any fresh element. I had little doubt that the disease was scurvy, but the absence of any decided sponginess of gum, and, more still, the tolerably fresh complexion and healthy look of the child, made me hesitate to give a positive diagnosis. 234 DIET DISEASES OF EARLY CHILDHOOD RAPID RECOVERY ON ANTISCORBUTIC DIET Antiscorbutic elements, viz. potatoes, milk, and raw meat juice, were added to the food. No medi- cine was given except a few doses of grey powder with Dover's powder, to check slight diarrhoea from which the child was suffering. The scorbutic nature of the case was speedily confirmed by two pieces of evidence. In the first place, a violent fit of crying produced copious extravasation beneath each lower eyelid, so that the child appeared at its next visit, to my great satisfaction, with two tremendous black eyes ; and, secondly, it got rapidly well on the anti- scorbutic diet. The food was clearly lacking in antiscorbutic elements, and it is significant that recovery imme- diately followed the simple addition of potatoes and fresh milk and meat juice to the previous dietary. SCURVY ON PEPTONISED AND PANCREATISED FOODS, AND UPON SO-CALLED ' HUMANISED ' MILK Since these lectures were first written I have met with a number of instances of severe infantile scurvy supervening upon a sole and prolonged diet of pre- digested food — peptonised milk, and patent pancrea- tised farinaceous food made with milk, and also upon SCURVY 235 a prolonged diet of ' humanised ' milk. I mention this because no clinical example has been included in the above list of cases. It is clear that the process of peptonising or pancreatising in some way impairs the virtue of the antiscorbutic element in milk, and that the ' humanising ' process, at least as carried out com- mercially, has a similar deteriorating effect. RICKETS A USUAL ACCOMPANIMENT OF SCURVY — REASON FOR THIS All the cases of scurvy I have seen have exhibited some evidence of rickets. In some instances, how- ever, it has been very slight, and I doubt whether it is an absolutely invariable or essential accompaniment. Obviously, from the origin of both conditions in fault of diet, they are extremely likely to be produced together. 1 MANY CASES OF RICKETS PROBABLY SLIGHTLY SCORBUTIC On the other hand, I think it highly probable that many rickety children are also scorbutic in some degree, although the distinctive signs of scurvy, such as spongy gums and haemorrhages, may be wanting. 1 Since the above was written cases have been observed in which no sign of rickets could be made out clinically or post mortem. 236 DIET DISEASES OF EARLY CHILDHOOD The tenderness of bones and muscles often present in rickets is very suggestive of this. It is reasonable to suppose that a slight degree of scurvy should arise together with rickets on artificial foods, since they are usually lacking in the antiscorbutic and antirachitic elements together. I call your attention to the point in order that you may bear it in mind in your treatment of rickets, and direct the child's diet so that the antiscorbutic element is fully represented. This concludes, gentlemen, what I have to say on the diet and food disorders of early childhood. As I stated at the outset, the subject may seem to be commonplace, but its practical importance is great. If I have assisted you to an accurate knowledge of it, you will, I think, allow hereafter that I have not spent your time and mine in vain. 237 INDEX Acids, experiments with, on the coagulation of various milks, 54-58 Anaemia, causes of, 161, 162 ; a constant feature of rickets and scurvy, 161 ; treatment, 162, 163 ; remedies, 162, 163 Animal element, food must con- tain a due proportion of, 32, 33, 40, 43 ; not contained in fari- naceous foods, 86, 90, 98 Antiscorbutic element, essen- tial in artificial food, 25-27 ; exact nature of, not known, 25; deficient in farinaceous foods, 27, 98 ; probable nature of, 213 ; causes rapid recovery from scurvy, 217, 221, 229, 231, 234 Arrowroot, almost pure starch, 108 ; totally inadequate as a food, 109 Artificial feeding of infants, exact conditionsto be observed, 1-40; the necessity for, 2 ; practical importance of, 3 ; neglect of the subject in the medical schools, 4 ; examples of common errors in, 5, 6 ; physiological facts in relation to, 6-8 ; essen- tial elements of food, 8-25 ; standard proportion of the ele- ments, 24 ; quantity of food to be given, 27-32 ; value of a regular record of weight, 32 ; a vegetable diet insufficient, 32, 33, 40, 43 ; necessity of abso- lute cleanliness, 38 ; perfectly safe with due care and know- ledge, 45 Artificial food, conditions essen- tial to full nutrition, 6-27 ; necessity of material for repair and for structure of new parts, 7 ; the five essential constituents of, 8-16 ; must contain elements from each class, 9, 14, 15 ; nitrogenous elements of first importance, 10 ; effects of de- ficiency of nitrogen, 10 ; de- ficiency of fat a cause of rickets, 12 ; special need of salts of lime and of magnesia, 14 ; human milk the type, 17, 39; large amount of fat necessary, 21 ; frequently almost destitute 2 3 8 ARTIFICIAL FEEDING OF INFANTS of fat and deficient. in proteid, 23 ; standard scale for the ele- ments in, 24, 42 ; must corre- spond to this scale, 24 ; the antiscorbutic element essential, 25-27, 39, 42 ; amount to be given and times of giving, 27-3 1 ; a necessity of a due pro- portion of animal matter, 32, 4°> 43 ! generally almost en- tirely vegetable, 33 ; should be suited to the physiological con- ditions of infancy, 33 ; chiefly starch, 35 ; must be fresh and sound, 36,40, 44 ; use of highly dextrinised, in gastro-enteritis, 150 Artificial human milk. See under Milk Asses' milk. See under Milk Atrophy, defective nutrition a cause of, 109, 126 ; due to many causes, but mostly to errors of diet, 157 ; typical cases and their treatment, 158- 161 - Bacteria, putrefactive, in milk, destroyed by boiling, 66 Baked flour contains much starch and little dextrine, 106 ; mixed with ample milk, good for older children, 106 Barley, prepared, inadequate as a food, 109 Barley-water, effect of adding, to fresh cow's milk, 56 ; to boiled milk, 71 ; to goat's milk, 75 Beef-tea, poor results of, as a child's food, 113 ; constituents of, 113, 114, 115; inferior to raw meat juice, 115 Bicarbonate of soda, effect of adding, to diluted cow's milk, 61 Bismuth in treatment of diarrhoea, ISI-IS3 Boiling, a safeguard against milk infection, 65, 66, 67 Brand's essence in gastro-enteritis, 149 Brandy as a stimulant in gastro- enteritis, 149 ; quantity and mode of administration, 149 ; with peptonised beef jelly as enema for collapse, 150 Bread jelly or gluten food, con- stituents of, 80; mode of pre- paration, 84, 85; deficient in certain elements, 85, 86 ; alone, insufficient, 86 ; addition of boiled milk necessary, 86 ; with peptonised milk, 87 ; nutritive value of various preparations of, 87-89 ; raw meat juice and cream required to supply defi- cient elements, 88 ; with boiled milk as a substitute for human milk in dyspepsia, 132, 135 ; in gastro-enteritis, 148 ; in atrophy, 160 Carbohydrates, essential in food, 9 ; not directly used in tissue-formation, 12 ; of less importance than nitrogenous elements and hydrocarbons, 13 ; proportion of, necessary in INDEX 239 infants' food, 15-24 ; excess of, in malted food with desiccated milk, 1 10, ill. See Starch, and Sugar Casein of cow's milk, massive coagula of, 53, 55; experi- ments on, with acid, barley- water, and lime-water, 56, 57 ; converted into soluble peptone by peptonisation, 58 Chapman's flour in atrophy, 160 Cholera infantum, 38, 126, 137, 141, 142 Cod-liver oil in the treatment of aneemia, 162 ; with cream, curative power of, 182 ; in the treatment of rickets, 195 Collapse, sudden, in gastro- enteritis, 146 ; peptonised beef jelly and brandy enema to be given, 150 Condensed milk. See under Milk Constipation, 126 ; how caused, 153 ; treatment, 153 Convulsions, 'inward,' 130 Cornflour, consists of almost pure starch, 108 ; totally inadequate alone as a food, 109 Cow's milk. See under Milk Cream, addition of, to diluted milk in imperfect nutrition, 50 ; sometimes deficient in con- densed milk, 74 ; addition of, to bread jelly, 88 ; and to malted foods, 99, 101 ; with raw meat juice as a substitute for human milk, 132 ; in the treatment of stomatitis and thrush, 156; in the treatment of rickets, curative power of, 182, 195 Dextrine preferable to cane sugar, 94 ; conversion of starch into, in malted food, 95, 96, 100 Diarrhoea, induced by sour and fermented food, 38 ; choleraic, 38, 126, 141 ; deadliness of, in hot climates, 139 ; common in young children at weaning, 1 40 ; great mortality from entero-colitis in New York Charity Hospital and French foundling hospitals, 140 ; few children in New York weaned between April and October escape it, 140, 141 ; varieties of, 141 ; differ chiefly in degree, 141 ; inflammatory and non- inflammatory, 141 ; dysenteric, 141 ; characteristics of, 142 ; not properly a food disorder, 143 ; chronic, 152; treatment, 152 ; grave cases of thrush usually sequent to, 1 54 ; a constant symptom of rickets, 170. See Gastro-enteritis Diet, errors in, cause of disease in childhood, 2 ; farinaceous, induces scurvy in rickety children, 6 ; conditions of, essential to full nutrition, 6 ; vegetable, inefficient, 32, 33 Digestion, artificial, effects of, on various milks, 54 Diphtheria epidemic at Ealing from milk infection, immunity of 240 ARTIFICIAL FEEDING OF INFANTS households using boiled milk, 67 Diseases, infectious, germs of, destroyed by boiling, 66 Diseases of childhood, arising from errors in diet, 2, 126 ; two classes of — produced by irritation of alimentary canal, and arising from defective nutrition, 126 ; some of second class results of the first, 127 ; dyspepsia, I27-137 ; gastro- enteritis, I37—IS3 ! chronic form of, 152; thrush, 154; stomatitis, 155— 157 ; atrophy, 157-161 ; anaemia, 161 ; erup- tions of the skin, 163-165 ; rickets, 166 ; scurvy, 208 Diseases of the skin. See Skin diseases Dover's powder in treatment of gastro-enteritis, 151-153, 234 Dyspepsia, 126 ; bottle - fed children the chief sufferers, 127, 129, 132 ; suckled chil- dren suffer in a minor degree, 127 ; severe case caused by mother's milk, 128 ; boiled cow's milk and water sub- stituted with success, 128; such extreme cases rare, 128 ; some- times milk of wet-nurse a cause, 129 ; simple infantile, symptoms of, 129 ; appearance of the child, 129, 130 ; some chil- dren suffer after every meal, 130; causes of, 130; how remedied, 131 ; treatment by drugs, 131 ; causes of human milk disagreeing, 132 ; the food to be substituted, 132; errors in diet causing the disease in hand-fed children, 132-134; results all preventable, 134 ; precautions to be observed, 134-137 Eczema, 163 Entero-colitis, 140, 141 Entire wheat-flour, constituents of, 81 ; process of preparation, 106; advantages of, 106; ob- jections to its use, 106 ; un- suited for very young infants unless malted, 107 Essence of beef. See Meat essence Farinaceous foods, alone, cause scurvy in rickety children, 6, 27 n. ; lack the antiscorbutic element, 27, 90, 105, 108; preparations of — table of con- stituents, 80, 81 ; the animal element absent, 90, 98, 105, 108 ; deficient in fat, 90, 105, 108 ; insufficient as a diet, 90, 105, no; nutritive value of, 92 ; to be regarded as adjuncts only, 92, 107; valuable in proportion to richness in nitrogenous elements and conversion of the starch, 94 ; predigested, 101 ; objec- tions to their use, 102, 103 ; unmalted, chiefly starch food, 104, 105 ; entire wheat-flour, 106 ; baked flour, 106 ; grand defect of all kinds of, 107 ; household preparations, 108 ; arrowroot and cornflour, 108, INDEX 341 109 j barley, sago, tapioca, rice, and oatmeal, 109 Fats. See Hydrocarbons Fermentation, germs of, in milk, destroyed by boiling, 63-66 Flour. See Baked Flour, and Entire wheat-flour Food, essential elements of, 8 ; nitrogenous elements, 10 ; hy- drocarbons or fats, 1 1 ; carbo- hydrates, 12 ; mineral elements, 13 ; Water, 14 ; proportion of the elements, 15-25 ; standard proportion for adults, 15 ; a different proportion for chil- dren, 16 ; smallest amount compatible with health at differ- ent ages, 20 ; for infants, should be the same at each meal, 34 Food-warmers, a cause of fer- mentation, 139 Fruits, seeds, &c, of, productive of skin diseases in children, 164 Gastroenteritis, 126 ; various degrees of, 137 ; causes of, 138- 143 ; milk a great source of danger, 138 ; symptoms of, 143-145 ; effects of loss by vomiting and purging, 144 ; the pulse and temperature, 145 ; complications : pneumonia, spurious hydrocephalus, and convulsions, 145 ; danger of sudden collapse, 146 ; examples of sudden collapse, 146 ; post- mortem changes, 146; treat- ment, 147 ; irritant food to be stopped, 147 ; the diet to be substituted, 148-130 j treatment in cases of collapse, 1 50 ; im- portance of warmth, 1 50 ; the most efficient drugs, if sickness excessive, 151 ; if diarrhoea the most urgent symptom, 151 j mode of action of drugs in, 152 Gastro-intestinal disturbance, pep- tonised milk an excellent food during, 60 Gluten food. See Bread jelly Goat's milk. See under Milk Hematuria, Case of, in scurvy, 230 ; due to defect of diet, 210 Hydrocarbons or fats, essential in food, 9 ; the source of heat and force, 1 1 ; necessary for forma- tion of tissue and bony structure, 12 ; deficiency of, a cause of rickets, l2;proportionrequisite, 15-25 ; large amount of, re- quired by infants, 21-24; arti- ficial foods frequently almost destitute of, 23 ; contained in maize in excess of all other grains, 33 ; deficient in diluted milk, 49, 50 ; in condensed milk, 74 ; in gluten food, 86 ; and in some malted foods, 100 ) deficiency of, a cause of atrophy, 158 ; and of rickets, 182 ; func- tion of, in nutrition, 182 Infants, large amount of fats re- quired by, in food, 17-24 ; fed only on vegetable food rickety and scorbutic, 33 ; food should R 242 ARTIFICIAL FEEDING OF INFANTS be given in the same form at every meal, 34 ; deficiencies in digestive powers of, 34, 35, 43, 75, 79 ; sensibility of stomach of, 36 ; six essential conditions in the diet of, 39 ; do not all thrive on cow's milk, 51 ; fed on condensed milk grow unduly fat, 72 ; inability of, to digest starch, 93 ; effect on, of starchy foods, 109 Ipecacuanha in treatment of diarrhoea, 151, 152 Iron, 14 Lactic acid theory of rickets, 180 Lichen urticatus, 163, 164 Lime phosphates, function of, in nutrition, 183 Lime, salts of. See Salts of lime Lime-water, effect of adding, to cow's milk, 57, 70, 71 ; to goat's milk, 75 Magnesia, salts of, 14 ; special need of, in children's food, 14 Maize, richest of all grains in fat, below the standard as a food, 33 Malted food preparations, consti- tuents of, 81 j principle of, 95 ; nutritive value of, 95-101 ; two forms of, 95 ; the first form : partially dextrinised, 95 ; con- version of starch into dextrine in, 95, 96, 100 ; rich in proteid, 97 ; unsatisfactory as a sole food, 97 ; analysis of, made with water, 98 ; should be mixed with milk and water, 98 ; the second form : highly dextrin- ised, 100 ; very deficient in fat, 100 ; specially suitable for young infants, 101 ; contains excess of carbohydrate, no ; with desiccated milk, deficient in certain elements, no— 112 ; constituents of, III; its nutri- tive value, in ; insufficient alone as a food, in, 112; value of, highly dextrinised, in weaning, 135 ; in atrophy, 161 Meat essence, 122; taken well by children, 122 ; analysis of, 122 ; insufficient as a permanent food, 122 Meat, fresh, a valuable antiscor- butic, 26 Meat juice as a remedy in gastro- enteritis, 149 ; in stomatitis and thrush, 156 Meat peptone, preparations of, 123 ; nutritive value of, 123 ; analysis of, 123 ; valuable as a temporary food for enfeebled stomachs, 124 ; debilitating effect of continued use, 124 Meat teas, juices and essences, 113-124; table of composition of, 114; beef-tea, 113, 114, 115 ; veal broth, 116; raw meat juice, 116-119 ; raw meat pulp, 119; patent meat juice, 121 ; meat essences, 122; meat pep- tones, 123 Milk, asses', as a temporary sub- INDEX 243 stitute for human milk, 46 ; objections to it, 46, 48 ; not suited for a permanent food, 46 ; analysis of, 47 ; difficulty of obtaining, 48 ; compared with other milks, 54 ; as a sub- stitute for cow's milk, 82, 83 ; in gastro-enteritis, 148 Milk, condensed, less antiscor- butic than human milk, 26, 232 ; analyses of pure and diluted, 47 ; more digestible than fresh milk, 58, 71 ; use of, 7 1 ; amount of dilution ne- cessary, 72, 135 ; excess of sugar in, 72 ; objections to its use, 72, 73 ; ' unsweetened,' 73 n. ; scurvy caused by, 73 ; deficient in cream and fat, 74 ; when made from skim milk, lacking in the most important constituent, 74 n. ; danger of ansemia and rickets from a diet of, 74 Milk, cow's, vomiting caused by, in delicate infants, 5 ; com- pared with human and other milks, 30, 54, 55 ; consti- tuents of, 30, 47 ; quantity re quired by infants at different ages, 30, 48, 49 J dangers of, 37 ; sour, produces vomiting and diarrhoea, 38 ; analysis of, 47 ; diluted with water, 47-50 ; proportion of water to be added, 48-50, 135 ; not to be given undiluted before sixth month, 51 ; less digestible than human milk, 53, 55 ; insolubility of the casein of, 54 ; this modified by boiling, 55 ; experiments on casein of, with acids, 56 ; ex- periments of Rotch, 56 n. ; of Barrett, Woods and Stawell, 53 k., 57 «■ ; dilution with bar- ley-water, 56, 7°; effect of bicarbonate of soda on, 57, 61 ; importance of the degree of dilution, 57 ; effect of adding lime-water, 57, 71 ; common mode of using, 62, 133 ; boiling the safest plan, 63, 134 ; popu- lar objections to boiling, 64 ; boiled less laxative than fresh : how remedied, 64 ; advantages of boiling, 65 ; boiling sterilises, 65 ; boiling gives immunity in epidemics and other diseases from milk infection, 66-68 ; other methods of sterilising milk : value of, and objections to, 68 ; substitutes for, 83 ; with bread jelly, 87 ; boiled, substituted successfully for human milk in severe dyspep- sia, 128, 132 ; readily takes up organic poisons, 138 ; cases of rickets on a diet of skim, 190 ; ordinarymilk, 191 ; small power as a curative agency in scurvy, 222, 229, 235 Milk, desiccated, with malted foods, 110-I12; desiccation impairs antiscorbutic property and nutrient power, 112 Milk, ewe's, contrasted with other milks, 54 Milk, goat's, excellent as a food for children, 5 ; unsuited in cases of curd vomiting, 6 ; 244 ARTIFICIAL FEEDING OF INFANTS analysis of, 47 ; compared with other milks, 54, 55, 74; nutrient value of, 74 Milk, human, contains everything essential, 16, 26; analyses of, 17-19 ; the standard for artifi- cial food, 17 ; constituents of, 17-19, 29, 47 ; proportion of fats to carbohydrates higher than in adult food, 18-20 ; children fed on, do not get scurvy unless mother scorbutic, 26 ; amount of, at different stages of lactation, 27, 28 ; con- tains no starch, 35 ; contrasted with other milks, 54, 55, 76 ; sometimes a cause of dyspepsia, 127, 132; case of rickets on a diet of, 189 Milk, human, artificial, composi- ion of, 47, 76 ; mode of pre- paration, 76 ; compared with breast milk, 76 ; its value as a food, 76 ; dangers connected with its use, 77 ; occurrence of scurvy on a prolonged use of it. 234 Milk, mare's, contrasted with hu- man milk, 55 Milk, peptonised, 48 ; contains nocoagula, 58 ; excellent, when diluted, as a temporary food on which to wean young infants, 59, 60, 132 ; reasons against its con- tinued use, 60, 103 ; pepto- nisation to be gradually dimi- nished, 61, 84 Milk, peptonised, 60 ; as a sub- stitute for cow's milk, 83 ; liability to scurvy from a pro- longed use of, 103, 234 ; as a substitute for human milk in dyspepsia, 132, 136 Milk, skim, rickets on diet of, 190 ; use in manufacture of condensed, 74 «. Milks, the popular fallacy about mixing, 45 ! experiments with acids on the digestibility of, 54-58 ; order of digestibility, 59 Mineral elements of food, 9 ; of more importance for children than for adults, 13 ; the earthy phosphates, 14 ; special need of magnesia and salts of lime in children's food, 14 ; requisite proportion of, 15-25 Nitrogenous elements, 8 ; in importance, 10 ; speci- ally essential to' children, 10 ; effects of deficiency of, 10 ; pro- portion of, necessary in food, 15-25 ; frequently deficient in artificial food, 23, 32 ; below the standard in diluted cow's milk, 49, 5° ! an d in bread jelly, 86 ; malted food rich in, 97 ; proportion of, in pan- creatised food, 1 01 ; in beef- tea, 113,114, 115 ; in raw meat juice, 114, 117 ; deficiency of, a cause of atrophy, 158 ; and of rickets, 182, 183 ; func- tion of, in nutrition, 10, 183 Oatmeal, its nutrient value, INDEX 245 109 ; scurvy caused by a diet of, 216, 219 Opium in treatment of diarrhoea, I5I-I53 Fancreatised food, proportion of proteid in, 101 ; mode of preparation, 101 ; suitable to a weak stomach, 102 ; de- bilitating to a healthy stomach, 102 ; deficient in antiscorbutic properties, 102 ; not fitted for a permanent food, 102 ; scurvy supervening upon prolonged feeding on, 103, 216, 234 Patent meat juice, 121 ; analysis of, 121 ; nutrient properties, 121 ; suited for temporary use in exhaustion and debility, 121 ; useful in early infancy, 121, 122 Peptonised milk. See under Milk Phosphate of lime necessary to cell-growth, 14 Potash, 14 Potato pulp as a remedy in scurvy, 73, 221, 229, 231, 234; mode of preparation, 221 «. Predigested food. See Pancrea- tised food Proteid. See Nitrogenous elements Raw meat, value of, in scurvy, 213. See also Raw meat juice Raw meat juice, effect of, in im- perfect nutrition, 50 ; with bread jelly, S8-90 ; nutritive value of, 88, 89, 116, 117, 118; precau- tions necessary in using, 90 ; composition of, 114, 117; most digestible of all animal foods, 116; mode of preparation, 116; best substitute for milk proteid, 116, 119 ; analysis of, 117 ; rich in albumen, 117 ; and in salts, 1 18 ; quantity to be given, 119; care necessary as to freshness, 119 ; with cream, as a substitute for human milk, 132 ; in sto- matitis and thrush, 156 ; in atrophy, 158, 160, 161 ; in anaemia, 162 ; value of, in rickets, 1 195 ; in scurvy, 222, 229, 231, 234 Raw meat pulp, mode of prepara- tion, 119; more easily digested thai) cooked meat, 120 ; quan- tity to be given, 120 ; the question as to danger of tape- worm, 120 ; value of, in rickets, 195, 2°5 Rice, inadequate as a food, 109 Rickets, farinaceous diet in, produces scurvy,. 6 ; deficiency of fat in food a cause of, 12 ;., induced by a vegetable diet, 33 ; defective nutrition a cause of, 127.; anaemia a constant feature of, 161 ; limited almost entirely to the first two years, 167 ; and to hand-fed children, 167, 176 ; type of the rickety child, 168 ; condition of the bony skeleton, 168 ; constitutional features, 168-171 ; symptoms not always all present, 171 ; hence some- times overlooked, 171 ; bones should be examined in doubt- ful cases, 172 ; largely a food 246 ARTIFICIAL FEEDING OF INFANTS disorder, 172 ; effects of in- herited tendency, 172; congeni- tal syphilis modifies but does not produce the disease, 173 ; may arise under excellent sani- tary conditions, 174; defect of diet the only constant factor, 175 ; rare in children at the breast, 176; specially associated in lower animals with artificial diet, 177 ; its artificial produc- tion : experiments of Guerin and Tripier, 177 ; confirmed by ex- perience at the Zoological Gardens, 177 ; identity of the animal disease with the human, 178 ; theory as to nature of the diet fault, 178 ; experiments of Chossat, Milne-Edwards, Fried- leben, and Wegner, 178, 179 ; want of lime not the essential cause, 179 ; the lactic acid theory, 180 ; evidence against the theory, 181 ; the diet theory, ] 81 .; uniform deficiency of cer- tain elements, 182 ; animal fat the most essential, 182 ; proteid the next in importance, 183 ; function of the phosphates, 183 ; % the whole pathology explained by want of these elements, 184 ; recent experience at the Zoologi- cal Gardens : a conclusive ex- periment, 184-186 ; can be caused and cured at will by diet, 186 ; other causes, 187 ; form of, varies according to special cause, 187 ; starvation rickets, 188 ; syphilitic form, features of, .188 ; Urge form, 188, 189 ; in ' breast-fed children, 189; on cow's milk diet, 190, 191 ; explana- tion of, 191 ; sometimes due to a drain on nutrition, 191 ; fcetal rickets, 192 ; congenital rickets possible, 192 ; late rickets, 192 ; treatment of, 193 ; ordinary rickets a preventable disease, 193; drugs not the chief reme- dies, 194 ; treatment of, 194, 202, 203, 205, 207 ; value of raw meat juice, 195 ; import- ance of fresh air and sunlight, 197 ; typical cases of rickets, 1 97-207 ; scurvy often associ- ated with, 209, 235 ; import- ance of considering this in the treatment of rickets, 236 Sago, inadequate as a food, 109 Salts of lime, 14 ; special need of, in children's food, 14 ; influence of the want of, on rickets, 17S, 179, 180, 182-184 Scarlet fever, from milk infection, boiling a safeguard against, 66, 67 Scurvy, infantile, or scurvy- rickets, liability to, from continued use of predigested foods, 103, 234, 235 ; defective nutrition a cause of, 126 ; anaemia a constant feature of, 161, 211 ; a food disorder often associated with rickets, 209 ; identification of the disease, 209, 210 ; arises from a scorbutic diet, 216; re- corded cases of, 209-21 1 ; symp- toms of the disease, 21 1- 213; INDEX .247 cured by fresh vegetables, milk, and raw meat, 213 ; occasion- ally met with in a dangerous degree, 214; occurs as a rule in infancy, 214 ; infantile and adult symptoms agree, 215 ; examples of diet which develope the disease, 216 ; rapidity of recovery on antiscorbutic diet, 217; typical cases, 217-234; treatment, 220-222, 225, 226, 229, 231, 234 ; many cases show evidence of rickets, 235 Skin diseases, the influence of food on, 163 ; eczema as a diet disease, discussed, 163 ; urti- caria and lichen urticatus, their cause and treatment, 163-165 Soda, 14; solution of bicarbonate with milk, 57, 61 Spurious hydrocephalus following gastro-enteritis, 145 Starch, indigestibility of, 34, 35, 93 ; to be avoided in early infancy, 35 ; not contained in human milk, 35; chief ingredient of artificial foods, 35 ; should be converted into grape sugar, 94 ; process of conversion . into detxrine in malted food, 95, 96, 100 ; effects of starch food on children, 109 Sterilised (boiled) milk, advan- tages of, 65-69 ; other methods, 69 ; objections to, 69, 70 Stomatitis, 126 ; follicular and ulcerative, 155 ; treatment, 156, 157; gangrenous, 156 ». Suckling, partial,- better than none, 46 Sugar, diluted cow's milk deficient in, 50 ; excess of, in condensed milk, 72 ; also in malted food with desiccated milk, no, in Syphilis, congenital, sometimes a factor of rickets, 173, 187, 188 Tables : percentage of elements in various milks and milk pre- parations, 47 ; in certain arti- ficial farinaceous foods and pre- parations, 80, 81 ; in meat juices and essences, 114 Tapioca, inadequate as a food, 109 Thrush, 126, 154; characteristics of, 154; severe cases always sequent upon some other dis- ease, 154; treatment, 156, 157 Tuberculosis, communicated through milk, and its preven- tion, 67 Typhoid, from milk infection, immunity of households where milk boiled, 66 Unmalted farinaceous food, composition of, 105 ; insufficient alone, 105 Urticaria, 163 Veal broth, low nutritive value of, 116 Vegetable diet, insufficiency of, 3 Z > 33. 4°. 43 5 children fed on, feeble and rickety, 33 24« ARTIFICIAL FEEDING OF INFANTS Vegetables, fresh, valuable in scurvy, 213 Vomiting, chronic, 152; treat- ment, 152; grave cases of thrush sometimes sequent to, J 54 Water, an essential in food, 9 ; uses of, in the system, 14 ; pro- portion of, necessary in food, 1 5-24 ; proper quantity to be added to cow's milk, 48-51, 92, 135 ; to condensed milk, 72, 135 ; should be boiled when used with milk, 70 Wet-nurse, advantages of, 44 ; in case of gastro-enteritis, 148 Wheat-flour. See Entire wheat- flour PRINTED BY SP0TT1SW00DE AND CO., NEW-STREET SQUARE LONDON SMITH, EL DER, & CO.'S PU BLICATIONS. A MOST USEFUL BOOK IN EVERY FAMILY. Twelfth Edition. With numerous Illustrations. Demy 8vo. lis. 8d. HOUSEHOLD MEDICINE: Containing a Familiar Description of Diseases, their Nature, Causes, and Symptoms, the most approved Methods of Treatment, the Properties and Uses of Remedies, &c. .Expressly adapted for Family Vbb. By JOHN GARDNER, M.D. This work is a complete * Domestic Medicine,' treating of Hygiene, the symptoms of Diseases, and best mode of Treatment ; Diet and Food for the Healthy and Sick ; Guide in Accidents and Emergencies ; many Prescriptions and Recipes of great value. No work will be consulted more frequently by any family possessing it. On the RELATION BETWEEN DIABETES and FOOD, and Its APPLICATION to the TREATMENT or the DISEASE. By AKTHUK SCOOT Dokrix, M.D.Ertin., M.D.Dnrh., Member of the Clinical Society of Loudon; lute Lecturer on Fureii-ic Medicine and Examiner in Medicine in the University of Durham, &o. &c. Crown 8vo. 5s. The DOMESTIC MANAGEMENT of CHILDREN. ByP.M.BRAiDwooD, M.D., Burgeon to the Wirra.1 Hospital for Sick Children. Crown 8vo. 2s. fid. On CHOREA and other ALLIED MOVEMENT DISORDERS of EARLY LIFE, by the late OcTAVlUt. Si'URBES, M.D. (Cantab.;, F. R.O.I'., Physician to the Westminster Hospital. Crown 8vo. 7a. Sd. B\f the same Author. On CHOREA and WHOOPING COUGH. Crown 8vo. 3*. U. The CAUSES and PREVENTION of PHTHISIS. By Arthur Ransome, M.D., M.A., F.R.S., Honorary Physician to the Manchester Hospital for Consumption and Diseases of the Throat. With Charts and Maps. Crown 8vo. b$. GOULSTONIAN LECTURES on the NATURAL HISTORY of PULMONAKY; CONSUMPTION. Uy A. B. SHEPHERD, H.A.,jM.D., E.K.U.P. With Illustrations. Demy 8vo. 16*. The INFLUENCE of CLIMATE on the PREVENTION and TREAT- MENT of PULMONARY COaSUMtTlCN. Lectsoniau Lectures fur 1876. By Cuarles Theodore Williams, M.A., M.D. Oxou., F.R.C.P., Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. Crown 8vo. bt. CROONIAN LECTURES on the HYGIENIC and CLIMATIC TREAT- MENT of CHRONIC PULMONARY PHTiilSIti. DeJivered at the Royal College uf Pnysieians. By Hehmanh Webbe, M.D,, Fellow of the College; Physician to the German Hospital. Crown 8vo. 5s. On BACILLARY CONSUMPTION : its Nature and Treatment in the True First Stage. By Houauk Dobkll, M.D., &c, Consulting Physician, late Senior Physician, Royal Hospital lor Diseases of the Chest, London, &c. 8vo. clotu, 6s. 6rf. A PRACTICAL TREATISE on DISEASES of the LUNGS, including the Principles of Physical Diagnosis and Notes on Climate. By the late Wai/ter Haylr Walshk, M.D. Fourth Edition. Revised and much Enlarged. Demy 8vo. 16$. The CURATIVE EFFECTS of BATHS and WATERS : being a Handbook to the Spaa oi Europe. By Dr. J. brtAUN. With a Sketch on the Balneo- therapeutic and Climatic Treatment of Pulmonary Consumption by Dr. L. Rohden, An Abridged Translation from the Third German Edition, with Notes. By Hermann Weber, M.D., F.R.C.P. Loud., Physician to the German Hospital. Demy 8vo. 18i. London : SMITH, ELDEK, & CO., 15 Waterloo Place. SMITH, ELDER, & CO.'S PUBLICATIONS., A TREATISE on the SCIENCE and PRACTICE of MIDWIFERY. By W. S. Plavfaiu, M.D., F.R.C.P., Physician-Accoucheur to HX and R.H. the Duchess of Edinburgh ; Professor of Obfetetric Medicine in King's College ; Physi- cian for the Diseases of Women and Children to King's College Hospital ; Consulting Physician to the Gpneral Lying-in Hospital, and to the Evelina Hospital for Children ; late President of the Obstetrical Society, of London ; Examiner in Midwifery to the University of London, and tn the Royal College of Physicians. 2 vols., demy 8vo. Eighth Edition. With 197 Illustrations and 6 Plates, 28a. * These volumes take position in the highest rank of obstetric works.' Lancet. * We need scarcely say that we recom- mend it to practitioners, teachers, and students. Ibis second to no similar treatise in our language.' Edinburgh Medical Journal. A SYSTEM of OBSTETRIC MEDICINE and SURGERY. Theo- retical and Clinical. For the Student and Practitioner. By Robert Barnes, M.D., Consulting Obstetric Physician to the St. George's Hospital, &c. ; and Fancourt Bahnes, M.D., Consulting Physician to the British Lying-in Hospital. The Section on Embryology contributed by the late Professor Milnes Marshall. Complete in 2 vol?., with numerous Illustrations, 8vo. Vol. I. 18s. Vol. II. 20*. * The book needB but to be read to be appreciated. The illustrations are nu- merous and well executed, contributing materially to the usefulness of the work. The book is well '' got up," handy in size, and will unquestionably prove a valuable companion, whether to the student acquir- iug knowledge of obstetrics, or to the busy practitioner anxious to keep pace with the times.'— British Medical Jourkal. A MANUAL of MIDWIFERY for MIDWIVES. By Fancourt Barnes, M.D. ,M.R.C.P. ; Consulting Physician to the British. Lying-in Hospital, &c. Sixth. Edition. With, Illustrations. Crown 8vo. 6*. The EVOLUTION of the DISEASES of WOMEN. By W. Balls- Headlev, M.A., M.D. Cantab., P.R.C.P. Lond. ; Lecturer on Midwifery and the Diseases of Women at the University of Melbourne ; Honorary Physician to tbe Women's Hospital ; President of the Section of Obstetrics and Gynaecology at the Intercolonial Medical Congress, Sydney, N.S.W.. 1892; late President of the Medical Society of Victoria, &c. With numerous Illustrations. Demy 8vo. 16s. 'The book contains much that teresting, and a great deal of sonnd advice on tbe treatment of gynecological dis- ease.' — Edinburgh Medical Journal. * Should be studied by all who have to deal with the diseases peculiar to women. . It is in our opinion calculated to give the student a clearer insight into perhaps the most difficult branch of medical prac- tice than any other single work on the subject.' Australian Medical Gazette. A SYNOPTICAL GUIDE to the STUDY of OBSTETRICS : being an Aid to the Student in the Class-room, in Private Study, and in Preparing for Examinations. By Robert Barnes, M.D., Consulting Obstetric Physician to St. George's Hospital, &c. Crown 8vo. Zs. CLINICAL and PATHOLOGICAL OBSERVATIONS on TUMOURS of theOVARY/, FALLOPIAN TUBE, and BROAD LIGAMENT. By Albak H. G. Doran, F.R.C.S., Assistant-Surgeon to the Samaritan Free Hospital, formerly Anatomical and Pathological Assistant to the Museum of the Royal College of Surgeons o£ England. With 32 Illustrations. 8vo. 10s. fid. GENERAL and DIFFERENTIAL DIAGNOSIS of OVARIAN TUMOURS, with Special Reference to the Operation of Ovariotomy, and Occasional Pathological and Therapeutical Considerations. By Washington L, Atlee, M.D. With 39 Illustration p. 8vo. 20s. The QUESTION of REST for WOMEN DURING MENSTRUATION. By Marv Putnam Jacobi, M.D., Professor of Materia Medica in the Women's Medical College, New York. With II lustrations. Demy 8vo. 12s. London : SMITH, ELDER, & CO., 15 Waterloo Place. SMITH, ELDER, & CO.'S PUBLICATIONS. A TREATISE on SURGERY: its Principles and Practice. By T. Holmes, M.A. Cantab., F.R.C.S., Consulting Surgeon to St. George's Hospital ; Memb. Associe de la Soc. deChir.de Paris. Fifth Edition. Edited by T. Pickering Pick. Surgeon to, and Lecturer on Surgery at, St. George's Hospital ; Senior Surgeon, Victoria Hospital for Children ; Member of the Court of Examiners, Ttoyal College of Surgeons of England. With 428 Illustrations. Royal 8vo. 30s. * Mr. Pick has revised the whole book most thoroughly, has carefully brought it up to date, and has incorporated a great deal of the modern teaching in pathology and practical surgery. . . . We are sure that this edition will largely add to the great reputation which this text book has for a long tune had.' — Lancet. ' This edition may fairly claim to have been brought thoroughly up to the level of the most recent knowledge, and no doubt will retain the place which this favourite handbook has gained as one of the standard treatises on surgery.' British Medical Journal. DICTIONARY of PRACTICAL SURGERY. By Yaeious British Hospital Surgeons. Edited by Christopher Heath, F.R.C.S., Hulme Professor of Clinical Surgery in University College, London ; Surgeon to University College Hospital ; Member of the Council and Court of Examiners of the Royal College of Surgeons of England. In 1 vols, comprising 1,864 pages. Third Edition. Eoyal 8vo. 32 s., bound in cloth ; or, in half -morocco, marbled edges, 425. * The Dictionary will Btand undoubtedly as one of the most trustworthy works of reference published in modern times upon practical surgery, and will form a valuable and almost essential occupant of the prac- titioners' library.* London Medical Record. * Altogether the work is a credit to the energy of authors, editor, and publisher, aDd will rank highly wherever British surgery ia consulted, and wherever the English language is understood. All its contributors aie to be congratulated upon its appearance.' British Medical Journal. An INDEX Of SURGERY : being a Concise Classification of the Main Facts and Theories of Surgery for the Use of Senior Students and others. By C. B Keetlbt, F.R.C.8., Surgeon to the West London Hospital, and to the Surgical- Aid Society. .Fourth Edition. Crown 8vo. 10s, 6d. * Mr. Keetley's work fills a gap that has long existed in the educational literature * Will, we trust, for many years be kept up to the imperious demands of surgical progress. The system of arrangement is just what the system in such a publication should ever be, purely alphabetical, and the text is written in as elegant and intel- ligible English as can be expected in con- densations and abridgments.' Britis h Medical Journal* of surgery. Previous attempts have been made to produce a book of the same cha- racter, but, compared with the " Index," they have all been crude and ineffectual.' Medical News. The SURGERY Of DEFORMITIES. A Manual for Students and Practitioners. By Noble Smith, F.R.C.S. Edin., L.K.C.P. Loud., Surgeon to the City Ortbopiedic Hospital, and Surgeon to the All Saints' Children's Hospital. With 118 Illustrations. Crown 8vo. 10*. 6rf. 'The woodcuts show very practically the points which they are intended to illus- trate, and materially help the reader. We can recommend this as one of the most practical, useful, and able handbooks of Orthopaedic Surgery/ British Medical Journal. * This is a sound practical guide to the treatment of bodily deformities, based evi- dently upon personal observation and ex- perience. . . . We can cordially recommend the work as a guide to busy practitioners, who will find in it ju*t what they want clearly set forth and illustrated.' London Medical Record. London: SMITH; ELDEK, & CO., 15 Waterloo Place.. SMITH, ELDER, & CO.'S PUBLICATIONS. ANTISEPTIC SURGERY : its Principles, Practice, History, and Resulth. By W. Watson Cheyne, M.B., P.R.C.S., Assistant- Surgeon to King's College Hospital, and Demonstrator of Surgical Pathology in ICing's College. With 145 Illustrations. 8?o, '21s. 'In the volume before us Mr. Cheyne has made a very valuable addition to sur- gical literature. The intimate professional relations of Mr. Cheyne with Professor Lister give a special importance and value to this work ; for while Mr. Lister's results and views have hitherto been published only fragmentarily in journals and .trans- actions of learned societies, Mr. Cheyne's book affords a trustworthy and complete statement of them.' — Lancet. DISEASES of the BONES : their Pathology, Diagnosis, arjd Treatment. By Thomas Jones, P.RC.S. Ener., B.S. Lond., Surgeon to the Manchester Royal Infirmary ; Lecturer on Practical Surgery in the Owens College, Victoria University; Consulting Surgeon to the Children's Hospital, Pendlebury, Manchester. With 7 Chromo-hthographic Plates, 9 Etchings, and 77 Woodcuts. 8vo. 12s. 6d. MANUAL of the ANTISEPTIC TREATMENT of WOUNDS. For Students and Practitioners. By W. Watson Cheyne, M.B., F.R.O.S., Assistant- Surgeon to King's College Hospital, Surgeon to the Paddington Green Children's Hospital, &c. With Illustrations. Crown 8vo. 4.v. ad. A SYSTEM of SURGERY : Pathological, Diagnostic, Therapeutic, and Operative. By Samuel D. G-boss, M.D., LL.D., D.C.L. Oxon. Sixth Edition, greatly Enlarge! and thoroughly Revised. With upwards of 1,600 Illustrations. 2 vols. 8vo. £3. 10s. The DESCRIPTIVE ATLAS Of ANATOMY. A Representation of the Anatomy of the Human Body. In 92 Koyal 4w>. Plates, containing 550 Illus- trations. Introducing fcieitzmann's Figures, considerably modified, and with many Original Drawines from Nature. By Nublk Smith, F.R.C.S.Edin.L,B.O.P. Lond.; Surgeon to the City Orthopaedic Hospital, and Surgeon to the All Saints' Children's Hospital. Bound iu hale leather, 25«. ' Certainly one of the most remarkable publications of the day. The great ad- vantage which it presents is that all the attachments of bones, the arteries, veins, &c, are copiously lettered and described in situ ; and the arteries aud veins are coloured. The book is one of great utility and merit, and reflects credit on the artist, and also on those who have produced it.' British Medical Jouhnal. A DIRECTORY for the DISSECTION of the HDMAN BODY. By John Clkland, M.D., F.R.S., Professor of Anatomy in the University of Glasgow. Third Edition, thoroughly revised by John Yule Mackay, M.D., Senior Demonstrator of Anatomy in the University of Glasgow. Pep. 8vo. is. Gd. A HANDBOOK of OPHTHALMIC SCIENCE and PRACTICE. by Henry E. Juleb, P.K.U.S., Oputhalmic Surgeon to at. Mary's Hospital ; Surgeon to the Koyal Westminster Ophthalmic Hospital ; Consulting Ophthalmic Surgeon to the London Lock Hospitals. Second Edition, Revised, with numerous Illustrations. 8vo. 21s. * Altogether the book is one of which I * A very good and reliable work, which we are able to speak in terms of unqualified represents satisfactorily the present state approval.' — British Medical Journal. | of ophthalmic science and practice.* Lancet. London : SMITH, ELDEE, & CO., 15 Waterloo Place. SMITH, ELDER, & CO.'S PUBLICATIONS. A TREATISE on the THEORY and PRACTICE of MEDICINE. By the late John Stbr Bmstowe, M.u. Lond., Fellow and formerly Censor of the Royal College of Physicians ; Senior Physician to, and Joint-Lecturer on Medicine at, St. Thomas's Hospital ; President of the Society of Medical Officers nf Health ; Examiner in Medicine to the Boyal College of Surgeons ; formerly Examiner in Medicine to the University of London, and Lectttrer on General Pathology and on Physiology at St. Thomas's Hospital. Seventh Edition. 8vo. 21*. ' The busy practitioner will be able by its perusal to keep abreast with the great progress which scientific medicine bas made within the past few years, and for which he has neither the time nor frequently the opportunity to consult larger treatises, monographs, and journals. The style of the work is plain and lucid ; though con- densed it is never bald. As an accurate and praiseworthy guide it is of the highest order of merit.' — Boston Medical and Surgical Journal. An INDEX of MEDICINE : a Manual for the use of Senior Students and others. By Seyaiour Taylor, M.D., M.R.C.P., Senior Assistant-Physician to the West London Hospital. ' Dr. Seymour Taylor may certainly be 1 and the book may confidently be recom- congratulatedontbe success of his labours. J mended to those for whom it Is intended.' He has produced exactly what be desired, | Lancet. CLINICAL MANUAL for the STUDY of MEDICAL CASES, Edited by James Finlayson, M.D., Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary. With Special Chapters by Prof. G-airdnbr on the Physiognomy of Disease ; Dr. Alexandkr Robertson on Insanity; Dr. Joseph Coats on the Throat; Prof. Stephenson on Disorders of the Female Organs ; and Dr. Samson Gemmell on Physical Diagnosis. Third and Cheaper Edition, Revised, with Illustrations. Crown 8vo. 85. 6cf. An INDEX of SYMPTOMS as an AID to DIAGNOSIS. By Ralph Winnington Leftwich, M.D., late Assistant- Physician to the East London Children's Hospital. Pep. 8vo. 5*. *** Each Symptom is followed by an Alphabetical List of Diseases in which it occurs. ' So far as we bave tested this little I serviceable in its suggestirenesa . . . book it appears to be remarkably free [ altogether a little book of undoubted from errors, and to be likely to be very | novelty and utility.' — Lancet. A MANUAL Of GENERAL PATHOLOGY. By Joseph F. Payne M.D., F.R.O.P., late Fellow of Magdalen College, Oxford ; Physician and Joint- Lecturer on Pathological Anatomy at St. ThomaB's Hospital ; Examiner in Pathology in the University of Oxford ; late Examiner in Medicine to the Royal College of Surgeons of England, &c. With Illustrations. Crown 8vo. 12j. 6d. The FUNCTIONS of the BRAIN. By David Febbieb, M.D., LL.D., F.R.S., Professor of Forensic Medicine, King's College ; Physician to King's College Hospital ; Physician to the National Hospital for the Paralysed and Epileptic. Second Edition, Rewritten, with many new Illustrations. 8vo. 18a. * No scientific medical man's library can author's own work, as well as those of be said to be complete without Dr. Ferrier's other observers of repute.*— Lancet. book, which contains the records of the London : SMITH, ELDEE, & CO., 15 Waterloo Place. SMITH, ELD ER, & CO.'S PU BLICATIONS, The LOCALISATION of CEREBRAL DISEASE. By David Ferbikr, M.D., F.R.S., Assist ant-Physician to King's College Hospital ; ProfeFsor of Forensic Medicine, King's College. With numerous Illustrations. 8vo. Is. Gd. A COURSE of PRACTICAL HISTOLOGY. By Edward Albert Schafek, Assistant-Professor of Physiology, University College. With numerous Illustrations, Crown 8vo. 10s. 6d. the ground covered by this treatise will find that he bus not only gained a mastery over the modern methods of microscopical investigation, but a sound knowledge of the several structures of which the body is * '—Lancet. ' We are very much pleased with Mr. Schafer's book. It is clearly written, ■veil and originally illustrated, and pos- sesses the merit of being both concise and complete. In conclusion we may say that any student who has gone fairly over ATLAS of HISTOLOGY. By E. Klein, M.D., F.R.S., Lecturer on Histology at St. Bartholomew's Hospital Medical School, and Noble Smith, F.R.C.S. Edin., L.R.O.P. Lond., &r\, Surgeon to the City Orthopcedic Hospital, and Surgeon to the All Saints' Children's Hospital. A complete Representation of the Microscopic Structure of Simple and Compound Tissues of Man and the higher Animals, in carefully executed coloured engravings, with Explanatory Text of the Figures and a Concise Account of the hitherto ascertained facts in Histology. Royal 4to. with 48 Coloured Plates, bound in half-leather, price £4. 4s. ; or in 13 Parts, price 6s. each. MANUAL of PATHOLOGICAL HISTOLOGY. By Ooknil and Raxvier. Translated by authority from the New and Re-written French Edition, with the original Illustrations. Vol. I. Histology of the Tissues. Demy 8vo. 21j. "Vol. II, Special Pathological Histology. Lesions of the Organs. Part I. Demy Svo. 12s. Part II. Demy 8vo. 16j. ( We may safely recommend the work I studied by many to whom the original as the foremost text-book of its class, and was a closed book.* — Lancet. we are certain that it will now be widely j ELEMENTS of HUMAN PHYSIOLOGY. By Dr. L. Hermann, Pro- fessor ot Pmsiology in the University of Zurich. Second Edition. Entirely recast from the Sixth German Edition, with very copious Additions and many Additional Woodcuts, by Arthur Gamgee,H.D., F.R.S., Brackenbury Professor of Physiology in Owens College, Manchester, and Examiner in Physiology in tha University of Edinburgh. Demy8vo. 16$. ELLIS'S DEMONSTRATIONS of ANATOMY : being a Guide to the Knowledge of the Human Body by Dissection. Eleventh Edition. Edited and Revised by G. D. Thane, Professor of Anatomy, University College, London. With 252 Illustrations. Small Svo. 12*. Gd. ILLUSTRATIONS Of DISSECTIONS. In a Series of Original Coloured Plates, the size of Life, representing the Dissection of the Human Body. By G. V. Ellis and G. H. Ford. Imperial folio. 2 vols, half-bound in morocco, £6. 6$. May also be had in Parts separately. Parts 1 to 28, '6s. Gd. each * Part 29, 5s. f "With these plates, and such as these, by his side, the learuer will be well guided in his dissection; and, under their guid- ance, he may safely continue his study when out of the dissecting room. With such plates as these, the surgeon will be fully reminded of all that is needful in anatomy when engaged in planning an operation.'— Medical Tmes. London : SMITH, ELDEE, & CO., 15 Waterloo Place. SMITH, ELD ER, & CO.'S PUB LICATIONS. VERTEBRATE EMBRYOLOGY. A Text-book for Students and Practitioners. By the late A. Milnes Marshall, H.D., D.Sc., M.A., F.R.S., Professor in the Yictoria University ; Beyer Professor of Zoology in Owens College ; late Fellow of St. John's College, Cambridge. 'With, numerous Illustrations. 8vo. 21*. ' The book is welcome, and we do not doubt but that it will obtain the popularity which it so well deserves. The care and accuracy with which it has been written will render it most useful to the student and to the teacher.' — British Medical Journal. 'Will be extremely useful to all teachers and students of bioloery. ... an eminently practical treatise.' — Nature. A JUNIOR COURSE Of PRACTICAL ZOOLOGY. By the late A. Milnes Marshall, M.D., D.Sc, M.A., E.R.S., Professor in the Victoria Univer- sity ; Beyer Professor of Zoology in Owens College ; late Fellow oE St. John's College, Cambridge. Assisted by C. Herbert Hurst, Ph.D., Lecturer in the Yictoria University ; Demonstrator and Assistant- Lecturer in Zoology, Owens College, Manchester. Fourth Edition, Revised by 0. Herbert Hurst. With Illustrations. Crown 8vo. 10s. Gd. 1 A most successful and Important book. . . . The illustrations are excellent, reflect- ing the greatest credit upon all concerned. . . It is provided with an exceedingly good index, and presented in a form demand- ing our sincere thanks.'— Nature. A GUIDE to THERAPEUTICS. By Robert Farquharson, M.P., M.D, Bdin., F.R.C.P. Lond., late Lecturer on Materia Medica at St. Mary's Hospital Medical School, &c. Fourth Edition. Thoroughly Revised. Crown 8vo. 7s. 6d. THERAPEUTICS : its Principles and Practice. By H. C. Wood, M.D., LL.D., Professor of Materia Medica and Therapeutics and Clinical Professor of Diseases of the Nervous System iu the University of Pennsylvania. Being the Ninbh Edition of ' A TREATISE on THERAPEUTICS,' Rearranged, Re- written, and Enlarged. 8vo. 18*. OCULAR THERAPEUTICS. By L. De Wecker, Professor of Clinical Ophthalmology, Paris. Translated and Edited by Litton Forbes, MA., M.D., F.R.G.S., late Clinical Assistant, Royal London Ophthalmic Hospital. With Illustrations. Demy 8vo. 16s. A PRACTICAL TREATISE on the DISEASES of the HEART and GREAT VESSELS; including the Principles of their Physical Diagnosis. By the late Walter Hatle Walshe, M.D. Fourth Edition, thoroughly revised and greatly enlarged. Demy 8vo. 1 Gs. AUSCULTATION and PERCUSSION, together with the other Methods of Physical Examination of the Chest. By Samuel Gee, M.D. With Illustrations. Fourth Edition. Pep. 8vo. 6s. HANDBOOK of MODERN CHEMISTRY, INORGANIC and Or- ganic. By the late Meymott Tidt, M.B., F.C.S., Professor of Chemietry and of Medical Jurisprudence and Public Health at the London Hospital ; one of the Official Analysts to the Home Office ; Medical Officer of Health for Islington ; late Deputy Medical Officer of Health and Public Analyst for the City of London ; Master of Surgery, &c. Sic. Second Edition. Revised and Enlarged. Demy 8vo. 18*. The ELEMENTS of PHYSIOLOGICAL and PATHOLOGICAL CHEMISTRY. A Handbook for Medical Students and Practitioners. By T. Cbanstoun Charles, M.D., F.C.S., &c, Master of Surgery ; Lecturer on Practical Physiology, St. Thomas's Hospital, London ; late Medical Registrar, St. Tbomas'B Hospital, &c. &c. With 38 Woodcut Illustrations and 1 Chromo-lithograph. Demy 8vo. 12s. 6rf. London : SMITH, ELDEE, & CO., 15 Waterloo Place. WORKS by the late Prof. JOHN MAR SHALL, F.R.S. THIRD EDITION. Imperial 8vo. price £i. iij. td. ANATOMY FOR ARTISTS. By the late JOHN MARSHALL, F.R.S., F.R.C.S. Professor of Anatomy, Royal Academy of Arts ; late Lecturer on Anatomy at the Government School ot Design, South Kensington : Professor of Surgery in University College, London ; Senior Surgeon to the University College Hospital, &c. &c. Illustrated with 220 Original Drawings on Wood, by J. S. Cuthbert. Engraved by J. & 0. Nicholls. BY THE SAME AUTHOR. Folio, price 8s. in wrapper ; or in portfolio, price 9,1.- A RULE OF PROPORTION FOR THE HUMAN FIGURE. Illustrated by JOHN S. CUTHBERT. FOURTH EDITION. 4to. with folio Atlas, iu. 6d. A DESCRIPTION OF THE HUMAN BODY : ITS STRUCTURE AND FUNCTIONS. Illustrated by Physiological Diagrams. Designed for the use of Teachers in Schools, and of Young Men destined for the Medical Profession, and for popular instruction generally. " The Work contains 260 quarto pages of Text bound in cloth, and 240 Coloured Illustra- tions, arranged in 11 folio Plates, measuring 15 inches by j\, in a limp cover. iprepareD for tbe department of Science an& 2lrt. A SERIES OF LIFE-SIZED ANATOMICAL DIAGRAMS. Specially adapted for Schools of Art and Art Students. Seven Diagrams, Life-size on paper, 7ft, by 3ft. gin. Each sheet sold separately, price 12$. 6d., coloured in fac-simile of the Original Drawings ; or £1. is. each, mounted on canvas, with rollers, and varnished. Explanatory Key, price is. To Teaohers and Students of Artistic Anatomy this Series of Diagrams will be invaluable. Suspended on the walls of the lecture room or studio, they will not fall to secure, through the medium of the ejge, that familiar acquaintance with the principal points in the osseous and muscular systems so indispensable to the Art Student. PHYSIOLOGICAL DIAGRAMS. Eleven Diagrams, Life-size, each on paper 7ft. by 3ft. gin., coloured in fac-simile of the Originals. 12.1. td. each sheet ; or mounted on canvas, with rollers, and varnished, price £1. is. each. Explanatory Key, price is. For the present Edition each subject was re-drawn on the zinc, and, under the supervision of the Author, important additions were made to the series, so as to render it as complete as possible and consistent with the present state of Science. %* An Illustrated Prospectus of the Diagrams will be sent post free on application. London : SMITH, ELDER, & CO., 15 Waterloo Place.