Special Eeport Series, No, i^tibg (Council MEDICAL RESEARCH COUNCIL RICKETS The Relative Importance of Environment and Diet as Factors of Causation: an Investigation in London BY H. CORRY MANN, O.B.E., M.D. m .^ ^^mm^'^ .^ LONDON PUBLISHED BY HIS MAJESTY'S STATIONERY OFFICE 1922 Price 2s. 6d. net imttm Cornell University Library RJ 396.M28 Rickets: the relative importance of envi 3 1924 000 324 255 ^ribg (ttouncil MEDICAL RESEARCH COUNCIL RICKETS The Relative Importance of Environment and Diet as Factors of Causation: an Investigation in London BY H. CORRY MANN, O.B.E., M.D. LONDON PUBLISHED BY HIS MAJESTY'S STATIONERY OFFICE 1922 Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000324255 MEDICAL RESEARCH COUNCIL The Viscount Goschen, C.B.E. {Chairman). William Graham, LL.B., M.P. The Rt. Hon. F. B. Mildmay, M.P. (Treasurer). SiK Frederick W. Andrewes, D.M., F.R.S. Professor T. R. Elliott, C.B.E., D.S.O., M.D., F.R.S. Henry Head, M.D., F.R.S. Professor F. G. Hopkins, D.Sc, F.R.S. Major-General SiB William B. Leishman, K.C.M.G., C.B., F.R.S. Professor D. Noel Paton, M.D., F.R.S. Sir Cuthbert S. Wallace, K.C.M.G., C.B., F.R.C.S. Sir Walter M. Fletcher, K.B.E., M.D., Sc.D., F.R.S. (Secretary). 15 York Buildings, Adelphi, W.C. 2, (5474) Ps. 51939. Wt. 30958. 347/1294. 1500. 11/22. O.U.P. EICKETS THE RELATIVE IMPORTANCE OF ENVIRONMENT AND DIET AS FACTORS OF CAUSATION : AN INVESTIGATION IN LONDON BY H. CORRY MANN, O.B.E., M.D. CONTENTS PAGE Ikteoduction 6 I. Social Gokdiiions . 9 A. Income 9 B. Kent 12 C. Housing 13 D. Fresh air and exercise 20 E. Distinctions of race 20 II. The Healthy Non-rachitio akd the Rachitic Child .... 21 III. NoN-RAOHiTio Cases 23 A. Selected as healthy babies without signs of rickets ... 24 B. In rachitic families 31 C. Which developed rickets 33 IV. ElOKETS 36 (1) Dietetic Factors . , 38 A. Fat deficiency with carbohydrate excess 38 B. Breast-feeding 45 C. Unsuitable diet owing to money shortage in the home ... 50 D. Carbohydrate excess 54 (2) Factors other than diet 59 E. Diathesis 59 F. Ante-natal influences 6^ G. Gastro-intestinal disorders • ^? H. Post-infective malnutrition . . 70 I. Prematurity 74 V. Delayed Ossifioatioh ''& VI. CoNCLtrsiOHS 78 A. General conclusions • . . 78 B. Detailed conclusions . . . . . . •' •' .80 Appekdioes 1-9 • .'■''. . ■ .88 INTKODUCTION DuEiNG the summer of the year 1906, as physician to out-patients at the Evelina Hospital for Children in Southwark, London, I started an attempt to prevent the onset of rickets by means of a routine method of infant- feeding. The method which was adopted, and which was continued without intermission during eight years until the summer of 1914, was that of feeding throughout infancy with undiluted citrated milk. As every one knows who has em- ployed this form of hand-feeding for babies, the plan is immensely successful, for fully 95 per cent, of the cases can be fed in this way provided that a certain caloric value for the total milk intake is used as a guide and that the milk feeds are not sweetened by additional cane sugar. Simplicity in the preparation of the feeds and avoidance of dirt contamination are additibnal' advantages in dealing with children who live in poor homes and among slum surroundings. The vast majority of babies who were fed by this method {vide Appendix 1) were found to be either of average or above normal weight and length at the age of 18 months, and they subsequently developed in normal manner. A certain number of the minority showed delayed ossification of the fontanelle, their teeth erupted at a later date than is usual, they were subnormal in size and in weight for age, but they did not develop rachitic deformities, the long bones remaining straight without enlargement of epiphyses, and by the age of seven or eight years, apart from subnormal height and somewhat thin bones, they were found to be healthy and active children (OTc?e Appendix 3, T. G. and H. G.). All the case papers had notes of total income, housekeeping money, the occupation of the wage-earners, rent and weekly charges for the home, the number of rooms occupied, type, and locality. At that time I had no idea of publishing the notes, though three papers had already appeared in the Guy's Hospital Gazette dealing with the value of whole milk feeding in a poor district where casual labour is so common. It was pointed out that the records would be of value in assessing the relative importance of environment and diet as causative factors in the production of rickets or scurvy, and when the Medical Research Committee started their programme of investigations I was asked to continue this work and to collect further datfa on the subject of rickets. A preliminary report was sent in dealing with 330 cases collected prior to March 1915, and details of diet and observations on home conditions were recorded. The work was then interrupted by the war, as I proceeded on foreign service, but up to that time conditions had remained unchanged, both as regards food quality and food supply* and also as regards housing conditions.. These earlier records, therefore, which are summarized separately (wcie Appendix 3), refer to pre-war times, and except in a few instances no actual measurements were made of the rooms occupied, but I visited myself over 100 homes, making notes and drawing general conclusions as to environment. During the war the findings of Professor Noel Paton's workers in Glasgow were published (Med. Res. Com. Special Report No. 30), and stress was laid in that report upon the importance of air-space owing to the presence of 32 per cent, deficiency among rachitic as compared with non-rachitic families. There had been no obvious indication of such a deficiency among my own cases before the war — many of them were living in homes in the suburban outer ring of London, every house provided with a garden — but the point raised by the Glasgow workers could not be neglected, and since my work was resumed in London in April 1919 due , attention has been paid to it, careful measurements have been taken of all the rooms occupied both by the families of the rachitic children and those of the healthy controls, so that the report of the London findings on this question could be compared accurately with that of Glasgow. Methods of Investigation and Material. — The same type of schedule has been employed continuously, both before and since the war, but the details of housing conditions were enlarged, so as to include in the later records the measurements of all rooms occupied by the families who were under observation — both rachitic and healthy. The majority of the cases live in London on the Surrey side of the river within an area which extends eastward from Westminster Bridge for three miles to the Surrey Commercial Docks a,nd south- ward from Southwark Bridge for 2^ miles, but as with the pre-war series certain of the families live in a much wider district, which is bounded by Dartford on the east (18 miles from London), by Ashford on the south (60 miles from London), and Surbiton on the west (12 miles from London). A few cases come from the north side of the river, living in London boroughs, namely, Acton and Chiswick — ^west, Kilburn — north-west. Stoke Newington — north, Shoreditch, Whitechapel, Bethnal Green — east. Most of these were attending as out-patients at the Evelina Hospital when first seen, another group are in attendance at various welfare centres in London, and a considerable number were attending the put-patient department at Guy's Hospital and were examined there by kind permission of the House Committee and Staff of the hospital. The rickets cases which have been under observation have been divided into the following clinical groups : — (1) Severe deformities with marked enlargement of the epiphyses. (2) Slight deformities with prominence of the epiphyses. (3) Prerachitic type — having delayed closure of the anterior fontanelle, delayed dentition, and X-ray changes typical of rickets at the epiphysial line. (4) Delayed ossification without other signs of rickets. The non-rachitic cases were obtained in the following way : — (1) Healthy children — between the ages of 6 months and 15 months — first seen at their homes while a visit was being paid to another member of the same family. (3) Babies born in the homes of rachitic children which were already under observation for the purpose of this inquiry. (3) Healthy children — between the ages of 6 months and 15 months — who were found in the out-patient departments of the Evelina Hospital or of Guy's Hospital. The non-rachitic cases were under observation for at least nine months, the great majority until the age of eighteen months, and very many until the age of two years. The new-bom babies were under observation for at least twelve months, very , many for eighteen months. The details of the home and its environment have been obtained in a routine method both for the rachitic children and the non-rachitic by the same two lady visitors, who are expert in social work of this kind and who in addition are trained nurses with special knowledge of children's diseases, of massage, and of midwifery, for which they hold diplomas or certificates. They were each responsible for their own cases, and while keeping to the schedule made their reports, recording fully their impressions of the homes in their own words. Clinical examinations were made by me both at hospital and at welfare centres. At the first visit to hospital a clinical examination and inquiry lasting at least half an hour was made ; the mother or other guardian was then told the objects of the investigation and her co-operation was invited. Leading questions as far as possible have been avoided, and particular attention has been paid to voluntary statements both as to inherited methods of feeding and individual idiosyncrasies of diet among various members of a family, such statements being subsequently confirmed or amended at the home-visits or later visits to hospital. Whenever by reason of unemployment of the wage-earner or insufficiency of wages it was found that the income of the home was insufficient, either for general purposes or for a diet advised at hospital, immediate help was given with food until such time as the local agencies for relief could offer co-operation, recommendations for the latter assis- tance being provided by the visitor. Every possible eflfort was made to ensure that the visits were in every sense of a friendly character, that they were not regarded by the parents as inspections involving the possibility of censure, of the loss of lodgings or of tenants, or of prosecution in a magistrates' court, the visitors carefully disclaiming any such intentions. Furthermore, there was no attempt made to enforce the diet which had been ordered at hospital ; it was very often found that, for various reasons, the treatment \yhich had been advised there had not been carried out. 9i and care was taken to record the diet which was actually being used rather than to attempt any amendment on the lines which had been previously advised at the hospital clinic or welfare centre. In a few instances where it was found that the visits were not appreciated or that the parents objected to the detailed inquiries into their home-life no attempt was made to continue them, and such information as was obtained has not been included in this report because of the possibility of the notes in question being unreliable. In the vast majority of cases the visitors were welcomed, and in a considerable number of , instances where actual relief was supplied to necessitous families the parents, in return, gave active assistance to the investigations. I. SOCIAL CONDITIONS. A. Income. The families which have been studied belong to the same social class in the great majority of cases, owing to the fact that the district in which most of the homes are situated is inhabited largely by wage-earners who are engaged in waterside or casual labour. For many of these during the winter months of the year unemployment is the rule rather than the exception, and during their period of unemployment they obtain relief in one of the following ways : (a) By the use of savings made during that period of the year ' when employment is more regular. (6) By pawning articles of furniture and clothing. (c) By loans from relatives. (d) By the income derived from married women's labour. (e) By loans from local moneylenders, the usual rate being to borrow ten shillings at the beginning of the week and to repay ten shillings and ten pence at the end of the week. (f) By the provision of fresh or dried milk either at half rates or free through the agency of Maternity, or Infant Welfare Centres, (g) By ' loan clubs '. ' (h) By poor law relief in the form of food. (i) By unemployment insurance pay — this last only in operation since the war. During the first year of the investigation — April 1919 to April 1920 — wages were tending to rise, and in some instances — e.g. the railway men and the dockers^there was a considerable rise. During the second year — April 1920 to April 1931 — owing to in- creasing unemployment or to part-time work, to absence of overtime and also owing to an actual fall in wage, the tepdency has been for the income to fall. These variations have been studied and allow- ance has been made for them in the case of families who have been under observation during the whole period of two years and a half. 10 During the last six months of the work, owing to the coal strike, there was a great increase in the number of families who were receiving relief both in the form of food and as unemployment pay, every industry being aflfected adversely. For this reason both income and diet became very variable ; during one week both funds and food might be satisfactory, and during the next fortnight the family would be living on borrowed money or unemployment dole and food of poor quality. Mr. T. W. Russell, Senior Clerk in the Statistical Department of the Medical Research Council, has taken a great deal of trouble in assessing the income per head and making averages of income where the wage was variable. These figures have been arranged under three headings: (1) Rickets with deformity. (3) Prerachitic cases — early signs. (3) Non-rachitic cases. Vide Table I. As some of the non-rachitic cases were born or living in homes where there were also rachitic children under observation, it has been thought advisable to include tables which deal only with ' Controls ', that is to say, non-rachitic infants in whose homes no rachitic children were found. Vide Table II. Figures are given for 324 cases of rickets and 273 non-rachitics (including 144 controls) for whom an accurate value could be placed. In 70 cases of rickets and 58 non-rachitics (including 33 controls) definite information was either unobtainable or owing to irregular employment it was impossible to assess it. These tables show first of all that both rachitic cases and controls have been drawn from the same industrial class, the three tables of income per head being very similar. In London it is customary for the mother, out of her housekeeping allowance, to pay all charges under the headings of rent, fuel, includ- ing gas and coal, 'club' subscriptions, and insurance premiums. There is considerable variation in the weekly amounts so paid out, and owing to casual labour payments are often deferred by agree- ment until the wage-earner is again in full work. Such weekly payments for a family including four children would commonly average : Rent, 10s. Coal, 3s. 3d. Gas, 7s. ' Clubs ', 2s. Insur- ance premiums, 2s. Total, 24s. Sd. (average in 1920). It was found — both as a result of the investigation and from con- versation with Various social workers — that in such a family of four children with .both parents alive, if the housekeeping money was 40s. weekly then the mother had the greatest difficulty in meeting her expenses — even in summer time — and the food was of poor quality, including condensed milk of a cheap brand. This forty-shilling standard for a family of six has proved a reliable guide throughout the inquiry, for although the maximum index number was reached in April 1920 (total Index Number 352-9), the summit for food being in May 1920 (305-9) and for materials in March 1920 (386-9), there was little real fall in retail prices until December 1920, by which date the rise in rent values had almost reached the present level, so little relief for the house- keeper was actually experienced until June 1921, when, however, unemployment was widespread (Food values, &c., Index, vide Appendix 4). 11 II •lis 8 go ^^3 I §• grt rH lO M -H ■* «■"! to (M ■* 05 lO TH Si « o ^ s »■ o "^ ;rHCOC010!00;ilO--4-^OSWQOO(Mi-tT-HT-(«0(M ■ e S 1^ a s I T3 S ■s.s 03 *V a S !^ in ^ a sis e> P S ■43 t. I* g CO 3 js M fk •§ c e &s § S ^ ® ^ : 2 » :i-l :i-l : iH (M cq 1-1 U5 1-1 ;i-( ;th(M ;^ 1 g o 05 ;CqiOG a a CDS ^ =8 o i 1 ■« 1; * ■e •< i- >; >* 1*1 g ooioixM eq 1 ■* ai s E-t e« a M sis ji-ti-HCqcoi-Hcqcocq-r-i CM i-lT-liHrHTHTHTHi-liHT-l(MOqO«ICTWICq(MCq(N °^ a e s rHiHiH(Mi-(t-((N^i-l ■ . . •! C3 IS S '^ a ■» 02 W '^ > J 2 p 3 ^ SS ^ O <9 M I 12 It will be noticed that below the level of income six shillings per head (vide Tables I and II) there are 38 rickets cases and 13 control cases. All of these 13 control cases, however, were attending Infant Welfare Centres and in receipt of ' invisible assets ' in the form of fresh milk or dry milk at ' special rates ' or possibly a ' free supply ' for considerable periods. Of 30 cases — controls — which are at the six shillings per head level a considerable number were obtaining the same advantages, which meant that a pound of dried milk could be obtained at the price of 2s. or 2s. Sd. per pound as against the price of 3s. or Ss. Sd. per pound in the open retail market, or the supply was ' free '. There has been widespread evidence of the immense importance of this scheme of milk distribution as a preventive factor of rickets for these control cases of necessitous families many of which include cases of rickets among the older children. The rachitic child, on the other hand, does not frequent Welfare Centres, and the cases of rickets which arise among infants who remain under the regular supervision of a Welfare Centre are very few in number, other factors being responsible for failure. Table II. Controls (vide paragraph 2, page 10.) Showing condition of Father's employment and Housekeeping Allowance. Income per Head. Segular. Cases. Casual. Cases. No particuiars of employment. Cases. Total Cases. 3/- 3 10 _ 13 6/- 18 16 2 36 ■9/- 33 9 1 43 - 12/- 24 5 1 30 15/- 8 1 2 11 18/- 6 1 _ 7 21/- + 2 - 2 4 ffo particulars of 13 14 6 83 Housekeeping Allowance Total 107 56 B. Rent. 14 177 During the period of two and a half years under review the rents of tenements and lodgings have increased by 50 to 60 per cent. These increases took place more especially during the year 1920, for when work on rickets was resumed in April 1919 the rents which were then paid were almost the same as before the war, although there had already been a considerable rise in wages, and local rates had already increased. The following details refer to a typical Southwark home : A two-story house of nine rooms and two sculleries— occupied by three families — seventeen persons in all, one family living on each floor. The family who are under observation have three rooms and a scullery on the second floor. They have lived there for thirty years, within half a mile of London Bridge. Rooms : Kitchen. NW. 10 ft. 6 in. x 7 ft. 10 in. x 7 ft. 10 in. height. One window 2 ft. 10 in. x 4 ft. 2 in. 13 Scullery. NE. 6 ft. in. x 4 ft. 3 in, x 7 ft. 10 in. height. One window 2 ft. 2 in. X 8 ft. 8 in. . W.C. Off scullery. Window ventilation 1 ft, x 1 ft. Front bedroom. WSW. 12 ft, 4 in. x 13 ft, in.x 7 ft. 10 in. height. Two windows 3 ft. 5 in. x 4 ft. 3 in. each. A sunny room. Grandmother and three childrfen sleeping in. Back bedroom. NE. 11 ft. 6 in. x 8 ft. 6 in. x 7 ft. 9 in. height. Window 3 ft. 2 in. X 4 ft. 2 in. Grandfather and uncle sleep- ing in. Front. Side street of average width. Open at both ends. Airy, not enclosed. Back. ' ' A yard with fowls, and back premises and yards of other houses. Remarks. Good rooms. Clean. Through ventilation, back to front. Rent in 1891 . . 6a. 6d. weekly, „ „ 1919 . . 7s. 6d. .„ „ Xmas 1920 . .lis. 4,d. „ July 1921 , . lis. lOd. „ C. Housing. The almost complete absence of empty houses and flats for working-class people as a result of the cessation of house-building operations during the war had the effect of maintaining housing conditions in an unchanged state while the investigation has been in progress. In fact, very little house-tmoving indeed has taken place during the past two years, and it has therefore been possible to watch the development of bpth rachitic children and controls living side by side in the same streets, in the same houses, and even in the same rooms over a prolonged period and vtnder un- changed conditions of air-space and environment which would not have been found before the war. Strange as it may seem in view of a widespread opinion as to the prevalence of overcrowding in poor districts, an opinion which has been freely disseminated by the press, we have found little indication of gross overcrowding among the homes visited, and nothing approaching the standard of congestion which has been suggested as prevalent. In most of the houses, inhabited in many cases by two or more families, the index of population stands at that of two persons per room, and in many instances it is Ipwer. It may be said that the absence of empty houses has produced inconvenience for the .labouring classes rather than insanitary conditions. As a result of previous medical and social work during a period of twenty-one years in the district in. question, and comparing espgoially the pre-war with the post-war conditions, the following conclusions may be drawn : (a) Housing shortage at the present time produces an economic disability in that a labourer is not able to live near his 14 work and to move into a new district with a change of labour to that district. This results in money being spent on travelling to work which would otherwise be spent on food. (&) Children of opposite sexes above the age of puberty are sleeping in the same rooms. (c) Young mai;Tied couples have been compelled to. remai,n living with their parents, being unable iq find new rpoms., (d) Before the war it was exceedingly common to find iii the homes of families of this class a parlour or sifcting-ropm in addition to a kitchen. This room has disappeared, as it is probably occupied by a lodger or, other tenant, and as a result the furniture and household belongings of three or four rooms are now crowded into the floor space provided by only two or three rooms, and the latter overcrowded rooms are sometimes imperfectly cleaned on this account. Housing details have been collected under the following head- ings : < , , , Table in. Type of dwelling* This return. shows that rachitic childi'en and non-rachitics are living in similar surroundings and in quarters of the same class, about 60 per cent, of each occupying rooms in one- or two-story houses which line the usual variety of side street. Table IV and IV A, Total air-space of the rooms, flat, tenement flat, or house occupied. This return shows that the conditions are almost identical, complete records having been made for about 360 cases of rickets and 310 non-rachitics. In some of the homes of the non-rachitics other rickety children were found; a separate table is therefore shown dealing with ' Controls ', that is to say, non- rachitic children in whose famihes there were no rachitic subjects (Table IV A.) Table V and Va. This return gives details of the air-space per person of the bedroom in which the rachitic or non-rachitic child was sleeping. The ' Controls ' are tabled separately (Table V a). The three series of figures — percentages — ai-e very similar. 45 per cent, of rachitic cases, 44 per cent, of non-rachitics, and 38 per cent, of controls have less than 300 cubic feet per person. Table VI. The size of the family. The number of children born. There are no difi'erences of note. The number of children born is smaller than was found to be the case in the studies upon rickets which were made in pre-war years (330 cases). In 53 per cent, of the rachitic cases and in 55 per cent, of the non-rachitic only three children had been born. There has been considerable evidence that measures to prevent conception or to procure abortion are practised more commonly than was the case prior to the wai-, and the statement was made not infrequently that income would not permit of increase in the size of the family. A further reference is made to this point under the 15 8 T^ *? ^ ^ '^ . o db w i> ■^ ^ -^ lO (M -^ N It* ^ W ^ OT i-H I l> O ^ <-< ;m CO 2 rH CO "O IN ; i? lO ooo M B . ■ 0| ««, CO ■ ' CM rH tH r-t z> i> CO CO iH o : ; 3» A Cue 1^ CO rH ■ • •« !S5 g •oo ^ "so lO S '^ O QO C5 O tH Cl 4 <0 rH rH > <» S5h £ S r-^ ^ S Eh -S • CO "s-l (N 1-5 f-a tij 1—1 "1 •« H J ca '^,_tCO®eOM Cfl Si^CO00C0QOC>COi« coce CO a 8 coeoS=o«>o35ool>0005©iHCilC0'^»O«C'C*00 91 S I- 9 « H {N M o 16 O r? S ^ r3 . 80 '-I 00 -^ i-H 5- CO « i-O « S t?-* to o> IN o -^ o CO A us ^ rt so « ,-H I— I Eh "^ a, KZ. •« »-^ OS -^ (M 02 & ^ (^ 'i' ^1 ^1 1-^ 1-^ O < g| «>Smg«S°°"^"="='""g «5^ ■s oooooooo ^ 03 .g , '^oosc5cocq 1-^ 17 l« o o eq (N T-i ^ 1-1 I t- I 1-1 O . )z; ■^OOWOOTr^COOStMCa iH ^ r-i 1-H ^ 10 la ^ <1 > pa gOJi-H00«O<»I>00CT00 |l> |- W CO T-H ' OS <^ m" (^ 1 g 1— 1 :< > III K w (I4 1-1 (a ^ o H g oaoit>-^(M»OOiCOCO i-H iH M ^ 10 [^ tH la 10 Cq ^ I I «., > o o o o o o o - > o o o o o o o t M CO ^ 10 ?0 l> 00 .2 " M i-( (M CO -I* »0 O I> 00 OS Or-CdCO'^iiiitnO c 5474 18 S eO-i#«DI>eoiM(M .Bs s ^ IN . m "OCT 1^ Uv CO CO ^^ r^ ^^ o- o lo : T-t ^ I 5^ »; o : f CO ^ 1 M -S eo O <3> lO '^ '^ .goo --I •r-O .Si Ol0CpO!D«D0S'-7* iH CQ (M ?D OS OS CO CO CO CT ■s 1 « CO a -03 ffl 0) £ CO S2 'j^ « ■!-< u-S »^ . .^ w ■+■3 11 1^ Od t. 00 lO CO o .:3 s o o « S •^ 1 ^. ^ lO O o COIN " (M "t2 -w 5 (M i- 5^ Ell S OS^OCOCMCO O 2 rt«(M ;" : I i-:i <1 a g 00 CO 1-1 ■ CO (N <3 ^-^^ 1^ 5£^-<00»^COO> CO (M CO IM CI I (N a § to N •* o « a 3 o "-loq i-i o .5 ^dC0-*U3— t^OOCJOT =2 "3, S t. o i3 9 O .2^ to °' CO rt (M CM t> T 6 IN CO 00 CO CO I 1-H o 00 ^ IS 00 ; o ;i-( CO ^ "ift CO P § o-S Sj o OD At g MSB! 3.;3 .a "^ .3 3 Oft 5b ' 5 e a S M). b2 20 heading of 'Ante-natal deficiencies' with regard to the incidence of rickets. Table VII. Number of children alive. There are no differences of note to be observed between the two groups. In both instances the families are smaller than in pre-war days. Table VIII. Nature of father's employment. There are no differences to be observed between the two groups, but it should be mentioned that under the heading of' regular work ' are many instances in which the labourer is working ' part time ' owing to the trade depression which began in October 1920. Table IX. Occupation of mother. The advantage rests with the non-rachitic cases in that the mother in nearly 80 per cent, is living continuously at home, whereas with the rachitic cases in only 66 per cent, was she living at home. In ten other instances there was a good deal of evidence to give rise to suspicion that her constant attention was not given to the care of a rachitic child, but definite information could not be obtained. ' Controls ' have been tabled separately in all the above tables. D, Fresh aie and Exercise. There has been no indication that the rachitic cases as distinct from the controls have suffered to a greater degree from the want of fresh air. Absence of fresh air and sunshine lead to anaemia in a child who is kept at home, and the marked pallor is recognized at once. Moreover, 60 per cent, of the families who have been under observation occupy rooms in rows of small houses mostly of one or two stories which Une side streets not subject to heavy traffic. The street is the playground for all ages, and as the climate of London is mild usually for at least eight months of the year, the habit of the child is to be in the roadway rather than in the house. It is perhaps only on the upper stories of high tenement bviiidings that any tendency has been observed to keep children indoors. Many rachitic children can be found in summer-time with sun- burnt faces. As soon as the family possesses a child of ten they become great wanderers, and Southwark out-patients — in loco parentis complete with babies — have been found in Hyde Park, over two and a half miles from their homes, during fine weather. Anaemia undoubtedly delays recovery from rickets, and even with an adequate diet improvement is slow or delayed for those who are cursed with the misfortune of a mother engaged in married women's labour. E. Distinctions of Race. The particular area of London which has been the district where by far the greater part of the investigation has been made is inhabited almost entirely by people of British and Irish stock there being a considerable percentage of the latter. Six Italian 21 families, one Dutch, and ten Hebrew have been the only foreign element. The South waterside differs in this matter very much indeed from the East End of London, though in one street of Rotherhithe which borders the Surrey Commercial Docks may be seen the fair-haired and blue-eyed Scandinavian type whose fathers are sometimes unknown sailors from the Norwegian timber ships. Racial characteristics must not be forgotten, for it is possible that the small and slowly-growing infant of southern Italy or Malta is more easily protected from and less prone to develop rickets than the larger and more rapidly-growing child of a more northern climate. II. THE HEALTHY NON-RACHITIC AND THE RACHITIC CHILD A comparative study has been made of the methods of feeding adopted for the healthy children employed as ' control ' cases, and for the rachitic children up to the age when signs of rickets first appeared. For both groups of cases a considerable percentage show certain dietetic features which are constantly recurring throughout the series, and if careful notes are taken of individual diets, of the family diet sheet, and of the housekeeping portion of the total wage upon which the quality of the food on the table depends, such findings would be the experience of any one working at a children's hospital in any large town. The quality of the diet is bad and the fat-carbohydrate balance of the diet is wrong more often as a result of money shortage than of ignorance and careless feeding. That cases of rickets do occur under other circumstances, under conditions where the home is well found and comfortable is undoubted, but they are relatively infrequent if the investigation includes all classes of industrial life in a wide area. The cases have, therefore, been grouped under headings indicative of causative factors in order to show the percentage incidence. In reviewing the dietary I have not adopted the family budget system which was used by Miss Margaret Ferguson in Glasgow. This system is a method which may be of value in studying the industrial £ets of adults, but when dealing with children the conclusions may be fallacious, more especially when those children, as in the case of rickets, are between the ages of six months and two years. Children are quite peculiar in their individual likes and dislikes in matters of food, and individual members of a family often show rooted objections to certain items of diet. These idiosyncrasies are nearly always conquered as the child passes beyond the fifth birthday, but in some children in spite of disciplinary measures they remain throughout life, and this may be due to failure in assimilation of certain forms of protein, carbohydrate, or fat. I myself was an elder member of a family including eight children, and I well remember how very much the individual members as children differed as regards the quality of food eaten. In many such cases conclusions based upon a ' family budget ' of diet are bound to be 23 misleading. Furthermore, rickets is a complaint which shows itself by symptoms appearing during a certain dietetic period m a ctiiM s life, namely, between six months and eighteen months ; cases which occur earlier or later than this age period are rare. JJurmg tnat period is the change from liquid to solid food. In most cases me change occurs without incident— the baby often taking a personal interest in hastening the alteration. But whereas the child takes readily almost without exception to solid forms of carbohydrate, especially potato, sugar and bread, there is often an intervalbetore the change from liquid milk fat to solid meat fat, such as dripping, is allowed by the baby, and in some instances the interval extends to a matter of years. Again, even in the quality of solid fat and in the method of cooking marked idiosyncrasies are shown at this period of life. As a general rule fats which tend to liquefy at ordinary air temperature are taken more readily, and the lower the melting- point the better they are tolerated. Digestive failures are responsible for some differences, and such failures are sometimes forgotten, undue importance being attached to the presence of a ' vitamin ' rather than to the digestive powers of the individual for a particular article of food. These discrepancies in the quality of the diets do not appear when only family budgets of food are studied, and for the above reasons I have not followed the Glasgow method of investigation, but each family has been carefully worked through, the individual peculiarities of each child, and often of the parents as well, have been recorded both for healthy controls and for the cases of rickets. Tables have been drawn up indicating the type of diet employed for the Eon-rachitic and rachitic cases. The classification has been arranged under twelve headings on broad lines without any detailed particulars as to the quality of the food and the length of time during which the diet was employed, the main features only being indicated, but approximately the length of time of feeding under the different categories is the same. For full details see the tables concerned. The non-rachitic eases have been subdivided into : (1) Controls, whose homes were visited repeatedly. Measurements of the rooms and details of the environment were recorded. (2) Other non-rachitic cases who were imder constant supervision, but the rooms of the home were not measured and the details of the house were incomplete. (3) Non-rachitic cases born in families where one or more rachitic children were already under observation, with records of the home conditions. These are entered in a separate table (vide p. 31). These tables show that when the matter is considered without any detailed examination there are obvious differences between the rachitic babies and the non-rachitic babies. Only 31 per cent, of the former and 77 per cent, of the latter have been fed upon breast- milk, fresh milk, or dried milk. Such findings authorize the further examination of both non- rachitic and rachitic cases in detail in so far as the methods of feeding are concerned. 23 Non-rachitic Gases. 242. 1. Breast-feeding . 2. Breast and fresh milk 3. Brea»t and dried milk 4. Fresh milk 5. Dried milk 6. Dried and fresh milk 7. Fresh milk and foods 8. Condensed sweet milk 9. Breast and condensed milk 10. Breast-milk with foods 11. Mixed methods . 12. War shortages . (a) Controls. (6) Other non-rachitics. Totals. Per cent. 31 13 44 18.1 \ 52 14 66 27.2 32 18 50 20.6 77.8 8 Nil 8 33 I per cent 11 Nil 11 4.5 8 Nil 8 3.8 1 1 2 0.8 4 2 6 2.4 i 10 12 22 9-0 21.6 4 2 6 2.4 per cent 16 3 19 7.8 , Totals 177 65 242 Rickets. 533 Cases. Totals. Pel- cent. 1. Breast-feeding 591 11.0 2. Breast and fresh milk 54 10.1 3. Breast and dried milk 16 8.0 4. Fresh milk 16 8.0 5. Dried milk 2 0.3 6. Dried and fresh milk . 3 0-5 7. Fresh milk and foods . 19 3.5 8. Condensed sweet milk 61 11.4 9. Breast and condensed milk 101 18-9 10. Breast-milk and foods 7 1.3 11. Mixed methods ' . 120 s 22.5 12. War shortages . 75 14.0 31-4 per cent. 68.1 per cent. ' Includes 37 cases of feeding with poor breast-milk (see page 46). * Mixed methods. The diet was at first good and the baby made progress ; subsequently the method of feeding was changed and the food was of poor quality with little fat and excess of carbohydrate. ' Includes 51 cases of prolonged breast-feeding with a diet of poor quality (see page 47). III. NON-KACHITIC CASES Total 428-1-8 = 436. These have been arranged in three main groups : A. Cases which from the first were regarded as healthy children and were supervised as such, coming under observation at various ages from birth to 18 months — mostly between the ages of 6 months and 12 months. These have been subdivided into two groups : (1) True controls — the homes of which were studied in detail (177 cases). (2) Other non-rachitics (65 cases) . . . Total 242 cases 34 B. Cases which were born in families where one or more rachitic children were already under ol^ser^f" ,„„ „^^^^ , . _ . TotaL lob cases C. Non-rachitic cases developing rickets . • Total 8 cases The methods of feeding which were employed for the various cases in these three groups will now be described m detail. A. NoN-EACHiTic Cases. Selected as Healthy Babies WITHOUT Signs of Rickets. 242 cases. Methods of feeding— ^^. Thus : 1. Breast-feeding to 8 or 9 57 cases. 42 cases. 40 cases. 33 cases. ._ _ _ months of age, then ordinary food including one pint of fresh milk minimum .....•••• Breast-feeding for short periods, then ' Glaxo ' or 'Ambrosia', then fresh milk and a diet with adequate fat . . . . • Breast-feeding to 12 months of age, very little food otherwise up to that date ...... Breast-feeding for short periods with fresh milk or dried milk, then fresh milk or dried milk (six methods) ......... 4 a. Breast-feeding with occasional feeds of fresh milk, later ' Ambrosia ' (or ' Glaxo ') .8 cases. 4 6. Breast-feeding, then citrated whole fresh milk and malt . . .4 cases. 4 c. Breast-feeding, then fresh milk and barley water or fresh milk and groats 6 cases. 4c d. Breast-feeding with 'Glaxo', then Benger's food with fresh milk, later fresh milk alone and a satisfactory diet 4 cases. 4e. Breast-feeding, then 'Glaxo', then Nestl^'s sweet milk, then fresh milk 10 cases. 4/. Breast-feeding with a fresh milk- cream-sugar mixture . . .1 case. (Total 33 cases). Breast-feeding to 9 or 12 months of age with additional feeds of Nestle's sweet milk and a general diet afterwards with adequate fat (three methods) 20 cases. 5 a. Breast-feeding to 12 months of age, with occasional feeds of Nestle's sweet milk 8 cases. 25 5 b. Breast-feeding to 10 months of age, then Nestld's sweet milk and a general diet with dripping. Weaned at about the age of 12 months . 11 cases. 5 c. Breast-feeding alone to 6 months of age, then breast-milk with alternate feeds of Nestl^'s sweet milk to 9 months, then fresh milk §xx daily and the house diet of variable quality 1 case. (Total 20 cases). 6. Breast-feeding for short periods with patent foods and fresh milk as extra feeds (five methods) . . 8 cases. 6 a. Breast-feeding with additional feeds of fresh milk and AUenbury No. 3 food, then citrated whole unsweet- ened fresh milk . . . .4 cases. 6 6. Breast-feeding to 6 months, then extra feeds of fresh milk and Neave's food to 10 months of age, thereafter an adequate diet with fresh milk . 1 case. 6 c. Breast-feeding to 3 months of age, then fresh milk with Ridge's food to the age of 10 months, then an ordinary diet with §xx fresh milk daily ...... 1 case. 6 d. Breast-feeding with ' Glaxo ' to the age of 6 weeks, then fresh milk and barley water, then fresh milk gxx daily, malt and Ridge's food, then an ordinary house diet with |xx fresh milk . . . . .1 case. 6e. Breast-milk feeding with diluted fresh milk to the age of 5 weeks, then Allenbury No. 1 and No. 2 foods until the age of 6 months, then Allenbury No. 2 with fresh milk §xxv daily to the age of 7 months, then citrated fresh milk, undiluted and unsweetened . . 1 case. (Total 8 cases). 7. Breast-feeding, then Nestld's sweet milk, then a general diet including dripping and fresh milk (four methods) ....... 9 cases. 7 a. Breast-feeding to 3 months of age, then Nestl^'s sweet milk from 3 to 12 months of age, then an adequate diet with fresh milk . . . . 6 cases. 36 7 b. Breast-feeding was given throughout to the age of 24 months, dripping with other food was started from the age of 10 months, and Nestl^'s sweet milk from 14 months, after which age a good diet was given with little breast-milk ■■■ ''*^®- 7 c. Breast-feeding to the age of 6 weeks, then Nestle's sweet milk to 8 months, then skim condensed milk (Goat brand) and a diet including dripping to 20 months, then fresh milk and an adequate diet 1 '^^^^• 7d. Breast-feeding to 6 weeks of age, then Nestle's sweet milk to 8 months of age, then fresh milk and an ade- quate diet 1 case. (Total 9 cases). 8. Fresh milk and dried milk (six methods) . . .20 cases. 8 a. Fresh milk and barley water to 8 or 12 months of age, then an adequate diet with fresh milk, gxx daily . 8 cases. 8 6. 'Glaxo', then eitrated whole milk unsweetened . . . . -2 cases. 8c. 'Glaxo' throughout the first year, and then continued with an adequate diet .5 eases. 8 d. ' Glaxo ' to the age of 9 months, then fresh milk and groats and an adequate diet 3 cases. 8 e. Citrated whole fresh milk unsweet- ened, then 'Ambrosia ' and an adequate diet . . .... 1 case. 8/. Fresh milk, then 'Glaxo' and an adequate diet subsequently with ' Glaxo ', one pound weekly . . 1 case. (Total 20 cases). 9. Fresh milk, adequate quantities with Savory and Moore's food to the age of 12 months, then an adequate diet with fresh milk, one pint (minimum) daily . 1 case. 10. ' Glaxo ' adequate to the age of 8 months, then fresh milk §x daily with additional feeds of Nestle's sweet milk and an ordinary house diet of variable quality in an industrial home of poor station ... 1 case. 11. N&tle's sweet milk for various periods, then 'Glaxo' or fresh milk and an adequate diet (six methods) . 11 cases. 11 a. Nestle's sweet milk to 4 months of age, then ' Glaxo ' to the age of 12 27 months, and an adequate diet after- wards with ' Glaxo ' or fresh milk . 3 cases. 116. Nestl^'s sweet milk to 3 months of age, then Nestle's sweet milk with fresh milk gxv daily to the age of 10 months, then an adequate diet including dripping, bacon fat, and §x fresh milk daily . ... 1 case. lie. Nestle's sweet milk with olive oil (3j was added to each bottle) to the age of 12 months, then a general diet with Nestle's sweet milk . , 1 case. lid. Nestle's sweet milk and butter with barley water to the age of 7 months, then ' Glaxo ' and an adequate ordi- nary house diet . . . 1 case. lie. Nestle's sweet milk to 8 months of age, then fresh milk and an adequate diet . ., . ... 3 cases. 11/. Nestle's sweet milk to 8 months of age, then an adequate diet, including fats, and Nestle's sweet milk . . 2 cases. (Total 11 cases). Note. — In fifteen cases, among 242 non-rachitics, the mother was engaged in married women's labour. The following are additional details from certain of the above case-papers which present interesting or unusual features : Method 2. A. F. No. 111. Baby boy, sixteen months : weight 17 lb. 4 oz. Breast-feeding alone to the age of seven months, when the child was weaned with the advice of the Welfare Centre and fed by ' Glaxo ' to the age of ten months, after which date he received a pint of fresh milk daily with a general diet to which cod liver oil i5iij daily was subsequently added. He was a ' back- ward ' child in many ways. Dentition delayed — 4 teeth at sixteen months, 7 teeth at twenty monthsj and subnormal in height and weight for age. He did not develop even early X-ray signs of rickets. He suffered from epidemic diarrhoea at nine months (September 1919) and measles with bronchitis at eleven months. The parents after his birth were under treatment for syphilis, receiving injections of N.A.B. In October 1919 the mother had a miscarriage. Method 3. L. M. No. 207. Baby girl. Breast-feeding alone to the age of twelve months, and continued until the age of fifteen fnonths with an adequate fat diet including butter. After that date the diet included margarine, occa- sionally dripping, and one pint (average) of fresh milk daily. She was small- weight for age at fifteen months, but improved considerably after fifteen months of age, until at 2A years the height was 33 in. and weight 23 lb. 8 oz. Denti- tion was delayed — 14 teeth only at two years. The fontanelle had closed at twenty-one months. During the second year she received 3iij cod liver oil daily for about four months. No signs of rickets were found at any time. Gr. P. No. 381. Baby girl. Breast-feeding alone to the age of nine months, and subsequently continued to the age of fourteen months with adequate fat in the diet. After that age the diet included half a pint of milk daily in tea (not a very thirsty child), and dripping at least three times weekly, as ther child was ' very fond of it and would eat it in handfuls '. During the first year the mother often gave the child bacon fat to suck ' as is her practice with all 28 her children ', and bacon fat was not discontinued during the second year No • signs of rickets developed, and there have been no cases among nme chilcUen wlo have all been fed in the same way. &. P- walked at ten "^o"*^!,- Xelle tion-flrst two teeth at four months. Twenty teeth at two J^^^^Xj^f^^'^l^ closure at eighteen months. Weight 24 lb. 6 oz. at two years ^nd height d^m Stem height? 19 in. The home isl poor one. Income ^fe-.^eeW^ for parents and nine children, two boys helping. Bent, 8s. weekly 'standing , for tour rooms. Fourteen years in residence. Insui-ance 2s. weekly, coal 6s. oa. yee^iy, gas 3s. Sa. weekly. One room let at 3s. Total : Thirteen persons in five rooms and a wash-house. Five children are sleeping in one bed in a room lu it. 1 1 m. X 8 ft. X 7 ft. 6 in. height. Window : 2 ft. 8 in. x 4 ft. 2 in. Method 4 d. The four cases in this sub-group were all oases of primary infantUe dyspepsia, who were hospital in-patients and out-patients tor some months, receiving special forms of food such as peptonized milk and Benger a food, both of which preparations were valuable owing to digestive troubles in the early months of life. They eventually made satisfactory progress,^ tat percentage being gradually increased as tolerance for milk improved. Signs of rickets did not develop. G. P. No. 342. Baby boy. 10 lb. 4 oz. at four months, 9 lb. 4 oz. at six months, 10 lb. 6 oz. at seven months, 11 lb. 5 oz. at eight months, 13 lb. 11 oz. at nine months, 16 lb. 4 oz. at ten months, 20 lb. 6 oz. at twelve months. Height, 31 in. at eighteen months, 32 in. at two years. Weight, 271b. 8 oz. at two years. Dentition delayed— 2 teeth at eleven months, 14 teeth at two years. Benger's food employed at first, then Benger's food alternating with 'Ambrosia', later fresh milk and an adequate diet including butter and dripping. No signs of rickets developed. Normal height and weight at three years of age. G. B. No. 314. Baby girl. Weights : 8 lb. 2 oz. at three months, 18 lb. at five months, 14 lb. at nine months, 15 lb. at ten months, 17 lb. 8 oz. at eleven months, 19 lb. at twelve months, 23 lb. 4 oz. at nineteen months. Height : 29f in. at fifteen months, 31J in. at 2^^ years. Dentition delayed — 3 teeth at eleven months, 10 teeth at sixteen months, 14 teeth at twenty-one months. Breast-feeding was given alone to the age of seven weeks. Then secretion began to fail, and for a fortnight extra feeds of Nestle's sweet milk were given. From nine weeks of age breast-feeding with ' Glaxo ', and later with fresh milk. Weaned at eleven weeks and fed with a fresh milk-sugar-water mixture. From three months undiluted citrated milk employed. Improve- ment to five months of age. Then troublesome vomiting followed by febrile symptoms and intolerance. Subsequently fed with peptonized milk, then Benger's food, then Benger's food and ' Glaxo ' No. 1, then Benger's food and ' Glaxo ' No. 2, then Benger's food and ' Glaxo ' full strength, then fresh milk citrated and an adequate diet with fresh milk later. No sign of rickets developed. Somewhat subnormal height and weight for age. Method 4 e. Ten cases in this group are interesting owing to the fact that secretion of breast-milk failed or the amount of breast-milk proved inadequate for the child, who subsequently showed intolerance for either fresh milk oi ' Glaxo ' when fed by hand using normal standards of fat percentage. They were therefore fed for various periods with varying strengths and quantities of Nestle's sweet milk until tolerance for fresh milk-fat became established, when substitution of fresh milk and other forms of fat in a general diet was gradually made. None of these cases developed signs of rickets. They received constant supervision either as in-patients or out-patients at the EveHna Hospital, in order that the fat-carbohydrate balance of the diet should be corrected at the earliest possible date. Examples : \^-f ??.■ ^.ni B^^y ,^°y- Breast-feeding employed to the age of three weeks, fed by Glaxo to the age of six weeks. Not thriving. From six weeks to ten months of age fed successfully with Nestle's sweet milk and barlev water From ten months of age fed with fresh milk §xx to gxxx daily and anadeauate diet including butter, dripping, and bacon fat. Dentition was delayed some what. 12 teeth at eighteen months of age. Normal height and weight at twenty-two months of age. ° 29 Gr. P. No. 468. Baby boy. Breast-feeding employed to the age of two months, when the child was weaned as he was not thi'iving. Suffering from a primary dyspepsia. Hand-feeding with ' Glaxo ' attempted until the age of ten weeks. Failure. From ten weeks to eight months of age fed with Nestl^'s sweet milk successfully ; fresh milk introduced gradually and used entirely after the age of eight months with a diet containing adequate fat. Weight : 16 lb. 4 oz. at nine months of age. Satisfactory progress subsequently. No signs of rickets. E. T. No. 494. Baby girl. Breast-feeding employed alone for ten days and then secretion began to fail. From ten days to five weeks of age breast-feeding was continued by night and bottle-feeding with Nestle's sweet milk by day. From five weeks to five months of age bottle-feeding with Nestle's sweet milk was continued as an attempt to feed the child with fresh milk failed at the age of six weeks owing to vomiting. Weight at five months, 9 lb. 9 oz. From five months to twelve months the baby was fed with undiluted citrated fresh milk — unsweetened — vdth a steadily rising weight. At twelve months of age the weight was 19 lb. 4 oz. The child took very little solid food until the age of twelve months. Subsequently satisfactory progress with a general diet including butter, dripping, and gix fresh milk daily. L. W. and T. W. No. 265 A, 265 b. Twins, boy and giri. Breast-feeding alone was employed until the age of four months, but as they were not thriving alternate feeds of Nestle's sweet milk were started and continued until the age of ten months, when dripping and other food from the house table was allowed. Both babies were weaned at the age of fourteen months, and after that age received a general diet including dripping, occasionally bacon fat, margarine, and Nestle's sweet milk — rarely §x to §xx fresh milk daily. Dentition— of both children — was somewhat delayed : 6 teeth at fifteen months of age. T. W. fontanelle open. L. W. fontanelle closed at fifteen months. Both children measured the same length, 28 in. at one year, but L. W. was two pounds heavier, and had always been the heavier child. T. W. died of broncho- pneumonia at the age of sixteen months. L. W. continued to make satisfactory progress with a general diet including dripping and Nestle s sweet milk, no fresh milk included in the diet except in an occasional milk pudding. Height, 32 in. Stem height, 20 in. Weight, 27 lb. 19 teeth at two years of age. Satisfactory progress subsequently. Neither child developed signs of rickets. B. W. No. 367. Baby boy. Breast-feeding alone was employed until the age of three months, when additional feeds, two daily, of Nestle's sweet milk were given. The mother was engaged in married women's labour and the child was weaned at four months of age. After that date he was fed entirely by bottle with a mixture of ' Cow and Gate ', Nestle's sweet milk, and Maryle- bone cream to the age of twelve months. Thereafter he had a satisfactory diet including fresh milk §xx to §xxv daily. Weight, 24 lb. at eighteen months. Height, 31^ in. Dentition not delayed. 2 teeth at six months, 8 teeth at twelve months, 16 teeth at nineteen months. Subsequent progress satisfactory. No signs of rickets. Method 5 a. In this group breast-feeding was practised to the age of twelve months, but for various reasons additional feeds of Nestle's sweet milk — vaiying quantities — were given. Eight cases. G. T. No. 189. Baby boy. He is one of a family of six children who have never suffered from rickets, and who have all been fed in the same way. Breast- feeding alone is given for three months, and then the mother has found that the children are not satisfied, so bottle-feeds of Nestle's sweet milk are given, according to scale, alternating with breast-feeds until the age of twelve months. From the age of twelve months a general dietary with Nestle's sweet milk is provided. 'The mother said that she believes in fat for children, and even when they are babies often holds meat fat in their mouths for them to suck ' (voluntary statement). Margarine or butter with suet and bacon fat are constant items of diet during the second year. Dripping is frequently on the table. G. T. made satisfactory progress up to the age of two and a half years, when he was a fine, well-grown child. Height : 34 in. at 2^ years. Dentition : 4 teeth at fourteen months, 14 teeth at twenty months, 20 teeth at 2^ years. He never showed any signs of rickets. 30 Method 5 b. In this group breast-feeding was practised for about the usual period, and when the child was weaned sweetened condensed milk '^^\"^^"' but the balance of the diet in the matter of fat deficiency was corrected by tne use of additional fat in the form of dripping, butter, bacon, cod liver oil, suet, and eggs. Such cases should be compared with those occurring under the heading ' Rickets, fat deficiency with carbohydrate excess ' (q. v.) where con- densed sweetened milk being the milk food in use no additional fat is added to the diet. The undermentioned examples under this heading.^5 b may be quoted : F. W. No. 438. Baby boy. A small baby at birth weighing 5 lb. He was breast-fed to the age of nine months. The mother's health was good, she was never short of food, she did not take extra milk herself during lactation, but occasionally, perhaps once a week, she took stout. The boy was weaned at nine months of age and subsequently fed on Nestle's sweet milk and the house diet, which included milk pudding made with fresh milk, at least three times weekly. At twelve months his weight was 16 lb. 5 oz. Height, 27 in. Stem height, 17^ in. Not thriving, liable to diarrhoea (September 1920). Dentition, 8 teeth. No excess gas formation in the intestines. From the age of twelve months dripping and meat-gravy together with fresh milk pudding became regular items of diet. Sweetened condensed milk was continued. A small amount of cod liver oil was given with malt, 3ij t.d.s. ( = 3ij cod liver oil daily). Rickets did not develop. There were no X-ray signs of rickets at either nine months or twelve months of age. At 1 }§ years : Height, 30 in. Stem height, 18 in. Weight, 25 lb. Twenty teeth present. He was an active, somewhat thin, child. The same diet with sweetened condensed milk was continued. No fresh milk was used. M. T. No. 187. Baby girl. Breast-feeding alone was employed until the age of four months, when the child weighed? lb. 1 oz. and had lost 1 lb. during the preceding six weeks. From four months to six months breast-feeding was continued with a small amount of malt and cod liver oil. 3vj daily (= oij cod liver oil daily). There was plenty of breast-milk but the child did not thrive. At six months she was weaned and fed upon Nestle's sweet milk with cod liver oil (3iv daily) and at once made marked improvement. From the age of nine months until fifteen months she received mutton broth, an egg daily, bread and margarine besides the Nestle's sweet milk and cod liver oil. Improvement continued. Dentition : 2 teeth at eleven months, 6 teeth at twelve months, 8 teeth at fifteen months, and 16 teeth at twenty-two months. The fon- tanelle was hardening from the age of eleven months, and closed at nineteen months. Walking alone at fifteen months. From eleven months of age addi- tional fats were introduced, including dripping, bacon fat, and margarine 4 oz. weekly. Nestle's sweet condensed milk continued. Heights : 27| in. at eleven months, 31i in. at twenty-two months, and stem height 19| in. Signs of rickets did not develop. Method 6. This group— eight cases -includes the clinical reports of children who failed to digest milk fat during the early months of the first year, and who also in some cases showed some intolerance for carbohydrate until the age of about eighteen months. On this account they were regular hospital out- patients, either at the Evelina or Guy's Hospital, and malt or malted foods were employed for varying periods with diluted milk. The balance of the diet fat-carbohydrate ratio, being restored at the earliest possible date. None of these children developed signs of rickets, though they were subnormal in height and weight for age with a delayed closure of the fontanelle. Thus : Method 6 d. M. D. No. 240. Baby boy. Method of feeding vide suora 6 d Dentition : 4 teeth at fifteen months, 11 teeth at twenty moiths, 13 teeth at twenty-one inonths 14 teeth at 24 months. Fontanelle closure at twenty-one months. Heights: 28 in. Stem 17^ m. at fifteen months, 30 in. at twenty months. Weights: 9 lb. 5 oz. at six months, 10 1b 11 n? at r,;«„ i-wyni-y 12 lb. 6 oz. at^leven months, 16 lb. at fifteen months ani 22 T 12 nf 't' twenty-two months. Signs of rickets did not develop. ■ ■I'i oz. ai Method 7. Nine cases. These cases are somewhat similar tfl t>,n««> described under Method 5 (q.v.), but in the latter instance breast-feedin= r o ., Family History. Diathesis. Details of the home. Approach. Back premises and surroundings. Type. Separate house. Rooms in a house. Flat. Tenement flat. situation. Basement, ground floor or higher floors. In residence for : Lodgers or not. Sanitation. W.C. Flush in order. Well kept or otherwise. Situation. Oreneral cleanliness. Ventilation. Aspect. Sunshine or not. Total rooms in house. Number of persons. Total rooms occupied. Number of persons. Sleeping arrangements. Air-space of all rooms occupied. Air-space per person. Air-space of sleeping room. Air-space per person. Window-space of all rooms ;occupied. ' ' Rent, and rent increase. ' Other weekly payments : Fuel, gas^ insurances, club subscriptions, d^bts outstanding. General observations. i:.i Reports from -Welfare Centre, LC.A.A. or C.0,&. /:: m Notes of the Case under observation. Method of feeding from birth. General condition at birth. Delivery at term or premature. Intercurrent infection. General progress. Clinical notes. Dietaiy. Treatment. Records of height and weight. Health of other children in the family. APPENDIX 9. The following details of the composition of certain Infant Foods mentioned in the foregoing pages are taken from a table in Food and the Principles of Dietetics, by Robert Hutchison, M.D., P.R.C.P. (3rd edition, Arnold). Allenbury No. 1. For children below the age of three months. Desiccated cow's milk from which the excess of casein has been removed and a certain proportion of soluble vegetable albumin, milk sugar and cream added. No starch present. Half an ounce in three ounces of water for a child aged three months. Percentage composition : Proteids 9' 7, fat 14-0, carbohyd. .66-85, mineral matter, 3-75, water 5-7. Allenbury No. 2. For children of the age of from three to six months. Resembles Allenbury No. 1 but contains some malted flour in addition. No starch present. One ounce in six ounces of water for a child aged six months. Percentage composition : Proteids 9-2^ fat 12-3, carbohyd. 72-1, mineral matter 3-5, water 3-9. Allenbury No. 3. A mixture of wheat flour and malt. When prepared accord- ing to the directions it still contains some unaltered starch, Designed for children above the age of six months. One tablespoonful (about one ouncq), a teaspoonful of sugar, and three tablespoonfuls of cold water ; mix and add half a pint of boiling milk and water (equal parts). Percentage composition : Proteid 9-2, fat 1-0, carbohyd. 82-8, mineral matter 0-5, water 6'5. Bidge's Food. A baked flour containing only 3 per cent, of soluble carbo* hydrates, the remainder being starch. Recommended to be made with milk or water. Made with water alone is totally insufiicient food. Percentage Com- position: Proteids 9-2, fat 1-0, carbohyd. 81'2, mineral matter 0-7, watei- 7-9, 98 to Ridge's Food, but recommended to ige composition : Proteids 10-5, fat 1-0, Neave's Food. A baked flour similar be made with milk and water. Percentage composition carbohyd. 80-4, mineral matter 1-6, water 6-5. Savory and Moore^s Food. Composed of wheat flour with the addition of malt. When prepared according to directions, most, but not all, of the starch is converted into soluble forms (chiefly dextrins). One or two tablespoonfuls (equals from one ounce to two ounces) to be mixed with two or three table- spoonfuls of cold milk or milk and water, and J pint of boiling milk or milk and water to be added. Percentage composition : Proteids 10-3, fat 1-4, carbohyd. 83-2, mineral matter 0-6, water 4-5. Milo Food. A mixture of desiccated Swiss milk, baked wheat flour, and cane sugar (30 per cent.). Contains about 15 per cent, of starch. Percentage com- position: Proteids 14-0, fat 5-2, carbohyd. 75-3, mineral matter 1-9, water 3-6. Sweetened condensed milk (NestU's). A recent analysis, June 1921 (P. E. King, B.Sc, P.I.C.), gives: Total solids 76-0 per cent., including: Proteids calculated from nitrogen 8-93, fat 10-4 ; milk sugar 13-0, cane sugar 40.3, ash 2-10, acids calculated as lactic acid 0-5. Free from boi-acic preservative. During the process of manufacture cane sugar is added to the heated milk and the mixture is then condensed by boiling under reduced atmospheric pressure. The dilu- tion of this condensed product, as practised by the purchaser, varies greatly {vide p. 42). Skimmed condensed sweetened milk (' Goat ' Brand). A recent analysis, June 1921 (P. E. King) gives : Total solids 71-85 per cent., including— Proteids calcu- lated from nitrogen 10-45, fat 0-40, milk sugar 15-11, cane sugar 41-52, ash2-75, acids calculated as lactic acid 0-78. Contains a trace of boracio preservative. This form of condensed milk is used among the poorest families {vide p. 42). ' Glaxo.' A dried milk from pasture-fed cows. It has the composition : Pats 25-5, proteids 22-9, carbohydrate- 41 -9, mineral matter 5-5, moisture 3-2. ' Ambrosia.' Another dried milk manufactured by a similar process and of very similar composition. ACKNOWLEDGEMENTS The original work which was undertaken in connexion with rickets was made possible owing to the action of the Committee of Management of the Evelina Hospital for Children, who placed funds at my disposal for the purchase of fresh milk on behalf of necessitous mothers and infants of the Southwark and Rotherhithe districts in South London. A Lady Visitor was also provided to superintend the relief and to report upon the condition of the homes. This policy was continued when I started work for the Medical Research Committee in 1914, and permission was obtained to open a clinic for the observation and treatment of rickets, the hospital authorities providing the nursing staff, the facilities of the hospital dispensary and other details required for a large out-patient department. In 1919 when the work was resumed after the war further help was obtained from the House Committee of Guy's Hospital, who gave leave for the investi- gation to be continued there as well. This co-operation was made possible through the great kindness of my friends on the staff of Guy's Hospital, who allowed me to examine and collect information concerning the cases of rickets attending their out-patient services. In particular I am indebted to : Dr. H. W. Barber, physician to the Skin Department, Dr. H. C. Cameron, physician to the Children's Department, Mr. T. B. Lay ton, surgeon to the Throat Department, and Mr. W. H. Trethowan, surgeon to the Orthopaedic Department. This extension of the field of work allowed a rapid collection of cases which could be studied before there was any appreciable change in the economic conditions. From Dr. 6. B. Milson, Medical Ofiicer of Health for Southwark, and from Dr. K King-Brown, Medical Officer of Health for Rotherhithe, much help was obtained in the provision of milk for necessitous mothers and for the children 99 of those homes where the wage-earners were unemployed or in temporary difficulties owing to illness. No delay was expeiienced in obtaining help for urgent cases under these conditions, and there was every indication that the control of relief work of this character was in capable hands in both Southwark and Rotherhithe. By permission of the Superintendent of Lambeth Infirmary I was able to examine and obtain details of some interesting oases of rickets in that institu- tion, Dr. Gr. F. Stebbing, Senior Medical Officer, and his colleagues giving valuable help to the investigation. I am much indebted to the Medical Officers of a great many Welfare Centres in South London who sent cases of rickets and other forms of malnutrition in childhood to the Evelina Hospital for the purpose of diagnosis and treatment. Many interesting and unusual oases were added to the records in this way. I was also enabled to visit several of the Welfare Centres and examine the children in attendance, besides obtaining information of local industrial conditions. The Medical Research Council provided me with the help of three expert Lady Visitors : Miss Evelyn J. Densham, R.R.C., formerly Assistant Matron, Guy's Hospital. Miss Joan Lyons, R.R.C. formerly Sister Mary, Guy's Hospital. Miss Hilda M. Vine, formerly Sister Charity, Guy's Hospital. In addition to an expert knowledge of nursing and social work, they are endowed most happily with an immense capacity for tact and friendliness, which has been responsible for the complete records of house-to-house visiting as well as for the efficient maintenance of working relationships between home, Welfare Centre, and hospital. February, 1922. ^tibg Council MEDICAL RESEARCH COUNCIL (Formerly Medical Research Committee, National Health InsuranceJ. LIST OF PUBLICATIONS December 1922 The following publications relating to the work of the Medicdl Research Council can be purchased through any bookseller, or directly from H.M. Stationery Office, at the following addresses : Imperial House, Kingsway, London, W.C. S, and 38 Abingdon Street, London, S.W. 1 ; 37 Peter Street, Manchester; 1 St. Andrew's Crescent, Cardiff; 23 Forth Street, Edinburgh. Annual Keforts or the Medical Research Committee : — No. 1. 1914-191S. [Cd. 8101.] Price %d., post free 4Jd. [Cd. 8399.] Price S\d., post free 5d. [Cd. 8836.] Price 6d., post free Id. [Cd. 8981.] Price id., post free 6d. [Cmd. 412.] Price 6d., post free id. Annual Reports or the Medical Research Council : — 1919-1920. [Cmd. 1088.] Price 9rf., post free 11 A 1920-1921. Price 3». M., post free 3s. 8^rf. No. 2. 1915-1916. No. 3. 1916-1917. No. 4. 1917-1918. No. 5. 1918-1919. Special Report Series Tuberculosis : No. 1. First Report of the Special Investigation Committee upon the Incidence of Phthisis in relation to Occupations.— The Boot and Shoe Trade. Price Sd, post free id. No. 18. An Investigation into the Epidemiology of Phthisis Pulmonalis in Great Britain and Ireland. Parts I and 11. By John Brownlee. Price Is. 3d., post free Is. Sd. No. 22. An Inquiry into the Prevalence and Aetiology of Tuberculosis among Industrial Workers, with special reference to Female Munition Workers. By Major Greenwood, and A. E. Tebb. Price Is. 6d., post free Is. 7id. No. 33. Pulmonary Tuberculosis : Mortality after Sanatorium Treatment. By Noel D. Bardswell, and J. H. R. Thompson. Price 2s., post free 2s. Sid. No. 46. An Investigation into the Epidemiology of Phthisis in Great Britain and Ireland, Part III. By John Brownlee. Price 2s. 6d., post free 2s. Sd. No. 67. Report on Artificial Pneumothorax. By L. S. T. Burrell and A. S. MacNalty. Price 2s. 6d., post free 2s. 8ld. Cerebro-spin&l Fever : No. 2. Report of the Special Advisory Committee upon Bacteriological Studies of Cerebro- spinal Fever during the Epidemic of 1915. Out of print. No. 3. Bacteriological Studies in the Pathology and Preventive Control of Cerebro-spinal Fever among lie Forces during 1915 and 1916. By M. H. Gordon ; Martin Flack ; P. W. Bassett-Smith, and T. G. M. Hine and W. J. TuUoch. Price Is. 6d., post free Is. 8Ji. No. 17. I. A Report upon the Seasonal Outbreak of Cerebro-spinal Fever in the Navy at Portsmouth, 1916-1917. By Paul Fildes, and S. L. Baker. II. The Treatment of Cerebro-spinal Meningitis by Antimeningococcus Serum at the Royal Naval Hospital, Haslar, 1915-16-17. By G. P. Adshead. Price 2s. 6d., post free 2s. 9d. No. 50. Cerebro-spinal Fever. Studies in the Bacteriology, Preventive Control, and Specific Treatment of Cerebro-spinal Fever among the Military Forces, 1915-19. By M. H. Gordon, and others. Price 4s., post free 4s. S^d. 474 •* Special Report Series — contmued. Dysentery : Reports upon Investigations in the United Kingdom of Dysentery Cases received from the Eastern Mediterranean. No. 4. I. Amoebic Dysentery and the Protozoological Investigation of Cases and Carriers. By Clifford Dobell. Price Is., post free 1». 2d. No. 5. II. Report upon 878 Cases of Bacillary Enteritis. By L. Rajchman and G. T. Western. Out of print. No. 6. III. Report upon recovered Cases of Intestinal Disease in the Royal Naval Hospital, Haslar, 1915-16. By Paul Fildes, and others. IV. Report upon combined Clinical and Bacteriological Studies of Dysentery Cases from the Mediterranean. By S. R. Douglas, and L. Colebrook. Price is, 6d., post free 4s. Sd. No. 7. V. Report upon 2,360 Enteritis 'Convalescents' received at Liverpool from various Expeditionary Forces. By E. Glynn, and others. Price 6s., post free 6s. ^d. No. 15. A Study of 1,300 Convalescent Cases of Dysentery from Home Hospitals : with special reference to the Incidence and Treatment of Amoebic Dysentery Carriers. By Clifford Dobell ; H. S. Gettings ; Margaret W. Jepps ; and J. B. Stephens. Price Is. 3d., post free Is. id. No. 29. A Contribution to the Study of Chronicity in Dysentery Carriers. By W. Fletcher, and Doris L. Mackinnon. Price 9d., post free lOJti. No. 30. An Investigation of the Flexner-Y Group of Dysentery Bacilli. By S. H. Gettings. Price Is., post free Is. Ijd. No. 40. Studies of Bacillary Dysentery occurring in the British Forces in Macedonia. By L. S. Dudgeon, and others. Price 3s., post free 3s. 2d. No. 42. A Study of the Serological Races of the Flexner Group of Dysentery Bacilli. By Sir F. W. Andrewes, and A. C. Inman. Price 2s., post free 2s. Sd. Alcohol : No. 31. Alcohol — Its Absorption into and Disappearance from the Blood under different conditions. By E. Mellanby. Price Is. , post free Is. IJd. No. 34. The Influence of Alcohol on Manual Work and Neuro-muscular Co-ordination, By H. M. Vernon. Price 2s., post free 2s. IJd. No. 56. The Effects of Alcohol and some other Drugs during Normal and Fatigued Conditions. By W. McDougall, and May Smith. Price l».,postfree Is. l^d. Venereal Diseases: No. 23. An Analysis of the Results of Wassermann Reactions in 1,436 Cases of Syphilis or Suspected Syphilis. By Paul Fildes, and R. J. G. Parnell, Price 2s. , post free 2s. l^d. No. 41. I. An Investigation into the Ultimate Results of the Treatment of Syphilis with Arsenical Compounds. By Paul Fildes and R. J. G. Parnell. II. A Clinical Study of the Toxic Reactions which follow the Intravenous Adminis- tration of ' 914'. By R. J. G. Parnell and Paul FUdes. Price 2s., post free 2s. l^d. D '''fr. Unsuspected Involvement of the Central Nervous System in Syphihs. By Paul Fildes ; R. J. G. Parnell ; and H. B. Maitland. Price Is., post free Is. lid. No. 47. The Accuracy of Wassermann Tests, applied before and after death, estunated by Necropsies. I. The Wassermann Test appUed before death. By H. M. Turnbull. Price 2s. 6rf. , post free 2s. Sd. No. 55. I. Results of the Examination of Tissues from Eight Cases of Death following Injections of Salvarsan. By H. M. Turnbull. i„d; t '"™ence of Salvarsan Treatment on the Development and Persistence of PriM 3s osVfr 3 ^^ Measurements of Agglutinins. By E. W. Ainley Walker. ''^^%^Jthods,^o^l-IY f''^ ^'^^'""'^"'^'^ (Committee and of the OommUtee upon Pathological Rickets : No. TntTodurtorl"Hyoriraf'tf/°^ Economic Factors in the Causation of Rickets, with an o^tl^'txp'Lmett^rm^^^^^^^ Reports of the Salvarsan Committee ■ ^an*d*bliL^lTd^i„tttLrot^5^^^^^^^ Is. l|