'^^feNv- Inf ant FceOiing LOUIS FISCHER, M.D. i*i^l-«l-«i5«. m^ Book. jil 5 Z. Gopyiightl^^.. COPYRIGHT DEPOSIT. T?r INFANT-FEEDING IN ITS RELATION TO Health and Disease LOUIS FISCHER, M.D. Visiting Physician to the Willard Parker and Reception Hospitals of New York City ; Attending Physician to the Children's Service of the New York German Poliklinik ; Former Instructor in Diseases of Children at the New York Post-graduate Medical School and Hospital, etc., etc. ; Fellow of the New York Academy of Medicine. Containing 52 Illustrations, with 23 Charts and Tables, Mostly Original SECOflD EDlTIOfl Philadelphia F. A. DAVIS COMPANY, PUBLISHERS 1901 THE LIBRARY OF CONGRESS, Two Coptes Received SEP. 30 1901 Copyright entry CLASS •^ 3 Q <1 «^^ _ c .i; hich is easily done. Bicarbonate of Soda in Milk. The addition of the bicarbonate of soda to milk for its preservation has hitherto been tolerated by the police, but the Council of Hygiene of the Seine has condemned the practice, as it is not free from danger. The trans- formation of the sugar of milk into lactic acid gives rise, in milk so adulterated, to a lactate of soda, Avhich is purgative, and is thus a cause of diarrhoea in young children. Under these conditions the Council considers that the addition of the bicarbonate of soda to milk, which is an aliment of the first order and very often pre- scribed for invalids and children, should neither be authorized nor tolerated.^ Soda is also added to milk sometimes to delay the souring process. The prohibition of this chemical may be viewed in the light of a stultification when we consider the large amount of bicarbonate of soda that is used at the present day in one of the popular methods of feeding ^ Hospitals-tidende, R. 3, B. 8, S. 1089; Medical and Surgical Reporter, February 13, 1892, page 277. « Lancet (London), February 11, 1888. MILK-SUGAK. 35 infants. I think it is no less reprehensible on the part of the physician than it is on the part of the dairyman.^ MiLK-SUGAE. Process of Mahing. — The milk is collected and al- lowed to stand for several hours in cooling vats; then it is conveyed to a large tank, to he coagulated. Various substances are used to hasten the coagulation. According to Flint/^ vinegar, cream of tartar, muriatic acid, and sour milk can be used to produce coagulation, but, of course, rennet is the most popular and most commonly used agent. This, as we all know, is the fourth stomach of the calf. The directions given for preparing rennet are as follow: ''Care must be taken not to use too much water in cleaning; wiping lightly with a moistened cloth until it is clean is the better way. If then blown up like a blad- der and hung up and dried, it will retain its power for coagulating milk for years." Pieces of this rennet are steeped in warm water, and the solution from it is added to the milk and then the milk is raised to a temperature above 100° and kept at that until coagulation takes place. Then the whey is drawn off, and this whey is evaporated by boiling to one-fifteenth of its original mass. This is dipped out into a tub, where the sugar will crystallize in -twenty-four to forty-eight hours. These crystals are known as ^^sand"; this sand is put into sacks, from which the water drains off. The sand is again boiled in water to a sufficient concentration, and the sugar is allowed to crystallize in sticks. It will thus be seen that many. of the other crystallizable bodies contained in milk would be included in this crystallization, as w^ell as the alkaloids or ptomaines. ^E. E. Brush, M.D., in the Journal of the American Medical Association, November 23, 1889. " "Milk-cows and Dairy-farming." 36 INFANT-FEEDING. The use of milk-sugar has increased notably during the last few years, in the feeding of children, through the recommendations of Soxhlet and Eeubner. It is not gen- erally known, however, that under some circumstances the milk-sugar of cheaper sorts may be contaminated by the presence of bacteria, derived from the milk from which it is made. In repeated examinations the author has found a large number of bacteria, and among them those which lead to the formation of gas: a form particularly feared because of its power to decompose milk. If such milk-sugar be added to sterilized milk it quickly curdles it; if, also, a small quantity of such sugar be added to a sterile milk, and subjected to the usual sterilizing methods for twenty or even forty minutes it is not as certainly rendered free from germs as is the case with ordinary milk. Enough germs, however, are destroyed so that the milk Avill not spoil until the second or third day. With the Soxhlet method of preparing the milk it was found that a very impure milk-sugar could be used without harm, provided the milk was used up within twenty-four hours. It was quite another matter when, as the author found, certain vendors of sterilized milk added the pow- dered sugar after the sterilization process. Through the addition of the impure milk-sugar, countless germs were introduced into the sterile milk, and, since the milk is only slightly warmed before feeding, they enter the ali- mentary canal of the child', where they may produce the very evils one has sought to avoid. Under such circum- stances the use of the relatively-sterile beet- or cane- sugar is preferable. From this is derived the practical rule that cheap grades of milk-sugar should be avoided in the prep- aration of the food of infants, or at least that they should be used only before a careful sterilization of the milk. (H. Neumann. ^^) "Berliner klinische Wochensclirif t ; American Medico-Sur- gical Bulletin. MILK-SUGAK. 37 Dr. E. E. Brush/2 of Mount A^ernon, N. Y., says that "one of the faults of physiological chemists is that they make no distinction between a substance existing in a natural condition and that substance eliminated and iso- lated by chemical means. Thus, the sugar of milk of com- merce and the sugar of milk as it exists in that fluid are regarded by the chemists as one and the same thing. Hence, the physician has been led into the error of think- ing that as the sugar in milk is that designed by nature as the best saccharine nutrient, therefore the isolated sugar must fulfill the same function. This is not the truth. Sugar of milk in that fluid is all assimilated, and the milk-sugar of commerce, when added to baby food, is eliminated both by the kidneys and bowels. This I have demonstrated by numerous experiments. I have never found sugar present in the urine or faeces of babies fed at the breast. On the other hand, in three cases of infants fed in twenty-four hours with 3 ounces or more of mixt- ures containing commercial milk-sugar (as in Meig's mixture), I have always found sugar in the urine and faeces, demonstrated by Fehling's test." Impurities in Milk-sugar. — J. 0. Braithwaite^^ states that the new United States Pharmacopoeia methods of testing milk-sugar do not suffice, because they consider only the contents in grape-sugar and cane-sugar. He found in a great number of samples a disproportionately high residue of ash, which coagulates milk when the latter is heated to nearly the boiling-point. This is a serious defect, since milk-sugar serves now mainly as a material for preparing artificial food for infants. The author found the ashes, in several samples, to consist chiefly of magnesium; he found lime in one sample; and concludes that, during the preparation of the sugar, magnesium ^- Journal of the American Medical Association, July 5, 1890. "London Pharm. Journal, April 14, 1894. 38 INFANT-FEEDING. carbonate and lime had been used for neutralizing the acid solution, and that, during crystallization, magnesium lactate had crystallized out with the milk-sugar. The author confirmed, by way of experiments, the well-known fact that many metallic and earthy salts coagulate milk, and that magnesium lactate does so also, even in milk- sugar to which 0.5 per cent, of the salt had been admixed. He proposes that the pharmacopoeias restrict the amount of ash from milk-sugar to 0.25 per cent, as a maximum. Bacteria in Milk-sugar. — Prof. Albert E. Leeds^* states that all the samples of pulverized milk-sugar coming from drug-stores and which he had examined gave an abundant crop of bacteria when definite weights dissolved in sterilized water were submitted to ordinary gelatin- peptone culture; and the presence of bacteria as a com- mon impurity in lactose, to be looked for and avoided by the chemist and the druggist, was sufficiently demon- strated.^* "Journal of the American Chemical Society; Oil, Paint, and Drug Reporter, August 31, 1896. CHAPTEE YIII. Bacteeia of the Ixtestixe. Theee are a great many bacteria found in the in- testine. These are present in a normal infant^ as well as in an infant suffering from a gastro-intestinal dis- order. A great many of these bacteria are, therefore, non-pathogenic. Miller, who carefully studied the various micro-organisms in the mouth, found that most of them could again be found in the intestinal canal. He also found that certain germs possessed diastasic properties, and were capable of producing lactic-acid fermentation in the milk-fseces of nurslings. Escherich found two germs, the one he called ^'bac- terium lactis aerogenes (or bacterium aceticum, Bagin- sky)'' and the other the bacterium coli commune. In the meconium he found proteus vulgaris, streptococcus coli gracilis, and bacillus subtilis. bacteriu^i coli co^nirxE (escheeich). Obtained by Emmerich (1885) from the blood, vari- ous organs, and the alvine discharges of cholera patients at Xaples; by Weisser (1886) from normal and abnormal human fteces, from the air, and from putrefying infusions; by Escherich (1886) from the faeces of healthy children; since shown to be constantly present in the alvine dis- charges of healthy men, and probably of many of the lower animals. Found by the writer in the blood and various organs of yellow-fever cadavers in Havana (1888 and 1889). Numerous varieties have been cultivated by different bacteriologists, which vary in pathogenic power and to (39) 40 INFANT-FEEDING. some extent in their growth in various culture-media; but the differences described are not sufficiently charac- teristic or constant to justify us in considering them as distinct species. Morphology. — Differs considerably in its morphology as obtained from different sources and in various culture- media. The typical form is that of short rods with '* te„. "IMf Fig. 9. — Bacterium Coli Commune. rounded ends, from two to three microns in length and 0.4 to 0.6 micron broad; but under certain circumstances the length does not exceed the breadth — about 0.5 micron — and it might be mistaken for a micrococcus; again the prevailing form in a culture is a short oval; filaments of five microns or more in length are often observed in cult- ures, associated with short rods or oval cells. The bacilli are frequently united in pairs. The presence of spores has not been demonstrated. In unfavorable culture- media the bacilli, in stained preparations, may present un- BACTERIUM COLI COMMUNE. 41 stained places, which are supposed by Escherich to be due to degenerative changes in the protoplasm. Under cer- tain circumstances some of the rods in a pure culture have been observed by Escherich to present spherical, unstained portions at one or both extremities, which closely resemble spores, but which he was not able to stain by the methods usually employed for staining spores, and which he is inclined to regard as "involution forms.'' The bacillus stains readily with the aniline colors usually employed by bacteriologists, but quickly parts with its color when treated with iodine solution — Gram's method — or with diluted alcohol. Biological Cliaracters. — An aerobic and facultative anaerobic, non-liquefying bacillus. Sometimes exhibits independent movements, which are not very active. One rod of a pair, in a hanging-drop culture, may advance slowly with a to-and-fro movement, while the other fol- lows as if attached to it by an invisible band (Escherich). The writer's personal observations lead him to believe that, as a rule, this bacillus does not exhibit independent movements. Does not form spores. Grows in various culture-media at the room-temperature — more rapidly in the incubating oven. Grows in a decidedly-acid medium. In gelatin plates colonies are developed in from twenty-four to forty-eight hours, which vary considerably in their appearance according to their age, and in differ- ent cultures in the same medium. The deep colonies are usually spherical and at first are transparent, homogene- ous, and of a pale-straw or amber color by transmitted light; later they frequently have a dark-brown, opaque central portion surrounded by a more transparent periph- eral zone; or they may be coarsely granular and opaque; sometimes they have a long-oval or "whetstone" form. The superficial colonies difi^er still more in appearance; very young colonies by transmitted light often resemble little drops of water or fragments of broken glass; when 42 INFANT-FEEDING. they have sufficient space for their development they quickly increase in size^ and may attain a diameter of three to four centimetres; the central portion is thickest, and is often marked by a spherical nucleus of a dark- brown color when the colony has started below the surface of the gelatin; the margins are thin and transparent, the thickness gradually increasing toward the centre, as does also the color, which by transmitted light varies from light-straw color or amber to a dark brown. The outlines of superficial colonies are more or less irregular, and the surface may be marked by ridges, fissures, or concentric rings, or it may be granular. The writer has observed colonies resembling a rosette, or a daisy with expanded petals. Escherich speaks of colonies which present star- shaped figures surrounded by concentric rings. In gelatin stick cultures the growth upon the surface is rather dry, and may be quite thin, extending over the entire surface of the gelatin, or it may be thicker, with irregular, leaf-like outlines and with superficial incrusta- tions or concentric annular markings. An abundant de- velopment occurs all along the line of puncture, which, in the deeper portion of the gelatin, is made up of more or less closely-crowded colonies; these are white by re- flected light, and of an amber or light-brown color by transmitted light; later they may become granular and opaque. Frequently a diffused cloudy appearance is ob- served near the surface of the gelatin, and under certain circumstances branching, moss-like tufts develop at in- tervals along the line of growth. One or more gas-bubbles may often be seen in recent stick cultures in gelatin. Upon nutrient agar and blood-serum, in the incu- bating oven, an abundant, soft, shining layer of a brown- ish-yellow color is developed. The growth upon potato differs considerably, according to the age of the potato. According to Escherich, upon old potatoes there may be no growth, or it may be scanty and of a white color. In BACTERIUM COLI COMMUNE. 43 milk at 37° C, an acid reaction and coagulation of tlie casein are produced at the end of eight or ten days. In the absence of oxygen this bacillus is able to grow in solu- tions containing grape-sugar (Escherich). In bouillon it grows rapidly, producing a milky opacity of the culture- liquid. The thermal death-point of Emmerich's bacillus, and of the colon bacillus from f£Eces, was found by Weis- ser to be 60° C, the time of exposure being ten minutes. The writer has obtained corresponding results. Weisser found that when the bacilli from a bouillon culture were dried upon thin glass 'covers they failed to grow after twenty-four hours. These results give confirmation to the view that the bacillus under consideration does not form spores. Pathogenesis. — Comparatively small amounts of a pure culture of the colon bacillus injected into the circu- lation of a guinea-pig usually cause the death of the ani- mal in from one to three days, and the bacillus is found in considerable numbers in its blood. But, when injected subcutaneously or into the peritoneal cavity of rabbits or guinea-pigs, a fatal termination depends largely on the quantity injected; and, although the bacillus may be ob- tained in cultures from the blood and the parenchyma of the various organs, it is not present in large numbers, and death appears to be due to toxaemia rather than to septi- caemia. Mice are not susceptible to infection by subcu- taneous injections. Small quantities injected underneath the skin of guinea-pigs usually produce a local abscess only; larger amounts — two to five cubic centimetres — fre- quently produce a fatal result, with symptoms and patho- logical appearances corresponding with those resulting from intravenous injection. These are fever, developed soon after the injection, diarrhoea, and symptoms of col- lapse appearing shortly before death. At the autopsy the liver and spleen appear normal, or nearly so; the kidneys are congested and may jDresent scattered punctiform ec- 44 INFANT-FEEDING. chymoses (Weisser). According to Escherich, the spleen is often somewhat enlarged. The small intestine is hyper- semic, especially in its upper portion, and the peritoneal layer presents a rosy color; the mucous membrane gives evidence of more or less intense catarrhal inflammation, and contains mucus, often slightly mixed with blood. In rabbits death occurs at a somewhat later date, and diar- rhoea is a common symptom. In dogs the subcutaneous injection of a considerable quantity of a pure culture may give rise to an extensive local abscess. Varieties. — Booker, in his extended studies relating to the bacteria present in the faeces of infants suffering from summer diarrhoea, has isolated seven varieties "which closely resemble bacterium coli commune in morphology and growth in agar, neutral gelatin, and po- tato, but by means of other tests a distinction can be made between them.^^ These are described as follows: — "Found in two cases of cholera infantum and the predominating form in one serious case of catarrhal en- teritis. "Morphology. — Eesembles bacterium coli commune. "Growth in Colonies. — Gelatin: Colonies grow luxuri- antly in gelatin, and thrive in acid and sugar gelatin equally as well as in neutral gelatin. In the latter the colonies closely resemble, but are not identical with, the bacterium coli commune. In acid gelatin they differ very much from bacterium coli commune. The colonies spread extensively, and are bluish white, with concentric rings. Slightly magnified, they have a large, uniform, yellow central zone surrounded by a border composed of per- pendicular threads placed thickly together. Sometimes a series of these rings appear, with intervening yellow rings. "Agar: The colonies are round, spread out, and blue BACILLUS '^E*' OF BOOKER. 4:5 or bluish white. Slightly magnified, they have a pale- yellow color. ^'Stah Cultures. — Gelatin: In sugar gelatin the sur- face growth has a nearly-colorless centre surrounded by a thick border, with an outer edge of fine, hair-like fringe; the growth along the line of inoculation is fine and deli- cate. In neutral gelatin the growth is not so luxuriant as on sugar gelatin; on the surface it is thick and white, with a delicate stalk in the depth. "Agar: Thick white surface growth with a well- developed stalk in the depth. "Potato: Luxuriant yellow, glistening, moist, and slightly-raised surface, with well-defined borders. ^'Action on Mill'. — Coagulated into a gelatinous coag- ulum in twenty-four hours at 38° C, and into a solid clot in two days. ^^MWk-Litmus Reaction. — ]\Iilk colored blue with lit- mus is changed to light pink in twenty-four hours at 38° C. The pink color gradually fades, and by the second or third day is white or cream color, with a thin layer of pink on top. The pink color extends in a few days about one-half down the clot. '^Temperature. — Grows best about 38° C. "Spores have not been observed. ^'Gas-production. — Gas bubbles are produced in milk; not observed on potato." BACILLUS E OF BOOKEK. "Found as the predominating form in two cases of dysentery, one of which was fatal and the other a mild case. ''Morpliology. — Eesembles bacterium coli commune. "Grotvtli in Colonies. — Gelatin: The colony growth varies considerably with slight difference in the gelatin. In 10-per-cent. neutral gelatin the colonies resemble 46 INFANT-FEEDING. those of bacterium coli commune. On the second or third day^ when the colonies have just broken through the sur- face and are spread out^ it is impossible to distinguish one variety from the other, but as the colonies grow older a difference can generally be recognized. In sugar and acid gelatin the colonies have a clear centre with white border. Slightly magnified, a uniform brown centre sur- rounded by a brown zone composed of fine, needle-like rays perpendicular to the border. After cultivating for a few generations on acid and sugar gelatin the colonies cease to develop, and either grow in very small colonies or do not grow at all. The activity is regained if culti- vated on neutral gelatin. "Agar: Colonies are large, round, and have a mother- of-pearl appearance. Slightly magnified, a uniform yellow color. "Stal) Cultures. — ^Agar: Luxuriant, nearly colorless surface growth, with well-developed stalk along the line of inoculation in the depth. "Potato: Grolden-yellow, glistening, slightly-raised surface, with well-defined borders. '^Action on Milk. — Milk becomes gelatinous in twenty- four hours at 38° C, and in a few days a solid coagulum is formed. Milk colored blue with litmus is reduced to white or cream color in twenty-four to forty-eight hours at 38° C, with a thin layer of pink at the top of the culture. The pink color gradually extends lower in the coagulum. '^^Temperature. — Thrives best at about 38° C. "Spores have not been observed. "Gas-production. — Occurs in milk, but not seen in po- tato cultures. "Belation to Gelatin. — Does not liquefy gelatin. "Fesemhlance. — Eesembles bacterium coli commune and bacillus "d,^^ differing from the former in the charac- ter of the colony growth on acid and sugar gelatin and in BACILLUS "f" of BOOKEK. 47 ceasing to develop in these media after several genera- tions. It differs from bacillus ^d' in this latter respect." OF BOOKER. "Found in one case of cholera infantum and one case of catarrhal enteritis. "Morpliology. — Resembles bacterium coli commune. ^'Groivth in Cohmes. — Gelatin: It is difficult to dis- tinguish the colony growth from the bacterium coli com- mune. There is often a ditTerence in the colonies planted at the same time and kept under similar conditions^ but it is not very marked nor always the same kind of differ- ence. The tendency to concentric rings is greater in this variety. The colonies develop somcAvhat better on neutral and sugar gelatin than on acid gelatin. "Agar: The colonies are large^ rounds and bluish white. Slightly magnified, a light-yellow color. ''Stab Cultures. — Gelatin: The culture is spread over the surface and has a mist-like appearance; in the depth along the line of inoculation is a delicate stalk. "Agar: Thick, luxuriant, white surface growth, with a well-developed stalk along the line of inoculation in the depth. "Potato: Bright-yellow, glistening, moist surface, with well-defined borders, and but slightly raised above the surrounding potato. ''Action on Milk and Litmus Reaction. — Milk is coagu- lated into a solid clot in twenty-four hours at 38° C., and in forty-eight hours is reduced to white or cream color with a thin pink layer on top. "Gas-production. — Gas-bubbles arise in milk cultures, but they have not been observed on potato cultures. "Temperature. — Grows better at 38° C. "Spores have not been observed. "Relation to Gelatin. — Does not liquefy gelatin. 48 INFAJfT-FEEDING. ''Besemhlance. — • It closely resembles bacterium coli commune and Brieger's bacillus in the character of its growth upon different media, but is readily distinguished from both, as is also Brieger's bacillus from the bacterium coli commune, by the following differential test recently made known by Dr. Mall: Yellow elastic tissue from the ligamentum nuchas of an ox is cut into fine bits and is placed in test-tubes containing water with 10-per-cent. bouillon and 1-per-cent. sugar, and sterilized from one and one-half to two hours at a time for three consecutive days. Into this is inoculated two species of bacteria, one of which is the bacterium under observation, the other a bacillus found in garden earth. The latter bacillus is anaerobic; grows in hydrogen, nitrogen, and ordinary illuminating gas; in the bottom of bouillon; in the depth, but not on the surface, of agar stab cultures, and not at all in gelatin stab cultures. It has a spore in one end, making a knob bacillus. Different species of bacteria — streptococcus Indicus, tetragenus, cholera, swine plague, bacterium lactis aerogenes, bacterium coli commune, Brieger's bacillus, and a number of varieties of bacteria which I have isolated from the faeces — were inoculated with head bacillus into the above-described elastic-tissue tubes. The tubes inoculated with Brieger's bacillus de- velop a beautiful purple tint, which started as a narrow ring at the top of the culture, gradually extending down- ward and deepening in color until the whole tube has a dark-purple color. This color-reaction began in five to fourteen days, and was constantly present in a large num- ber of tests. Tubes inoculated with bacillus T gave a much fainter purple color, which was longer in appearing and never became so dark as with Brieger's bacillus. "Tubes inoculated with the other species of bacteria above mentioned gave no color-chauge and remained simi- lar to control. Bacillus T also shows a slight difference from bacterium coli commune in coagulating milk and BACILLI "g'' and "h" OF BOOKER. 49 reducing litmus more rapidly, and appears to produce more active fermentation in milk. Like Brieger's bacillus, the gelatin colonies more frequently show a concentric arrangement than those of the bacterium coli commune/' OF BOOKER. "Found in one case of serious gastro-enteric catarrh. It was not in large quantity. ^'Morphology and Biological Characters. — In mor- phology, character of growth on agar, gelatin, and potato, it resembles bacterium coli commune. ''Action on Milk and Litmus Reaction. — Milk is not coagulated, and milk colored blue with litmus is changed to pink in a few days, and holds this color. These charac- teristics distinguish it from the bacterium coli commune. ''Gas-production. — Not observed in milk or potato cultures. "Relation to Gelatin. — Does not liquefy gelatin.'' BACILLUS "h" of BOOKER. "Found in one case of mild dysentery, not in large quantity. "Morphology. — Eesembles bacterium coli commune. "Growth in Colonies. — Gelatin: In plain neutral gela- tin the colonies resemble those of bacterium coli com- mune. In sugar gelatin the colonies are white and spread extensively. Slightly magnified, they have a round, dark centre surrounded by a yellow, loose zone with an outer white rim; later the whole colony has a uniform yellow color and is not compact. "Agar: Colonies are white, round, and large. Slightly magnified, they are brownish yellow. "Stab Cultures. — Nothing characteristic in gelatin and agar. 50 INFANT-FEEDING. ^'Potato culture is yellow, dry, and slightly raised, with well-defined borders. ^'Action on Milk and Litmus Reaction. — Milk is coagu- lated into a solid clot in two days at 38° C. Milk colored blue with litmus is changed to pink in twenty-four hours. '^Gas-production. — Occurs in milk; not observed on potato. '^Belation to Gelatin. — Does not liquefy gelatin." "Found in two cases of cholera infantum and one of catarrhal enteritis. "MorpJiology. — Eesembles bacterium coli commune. "Growth in Colonies. — Gelatin: In neutral gelatin the colonies cannot be distinguished from those of bacterium coli commune. In acid gelatin the colonies do not spread so extensively as those of bacterium coli commune, and they have a decided concentric arrangement; a wide white centre surrounded by a narrow, transparent blue ring; and outside of this a white border. Slightly magnified, the colonies have an irregular, yellowish-brown centre, mottled over with dark spots and surrounded by a light- yellow ring bordered by a brownish-yellow wreath. "Agar: Colonies are large, round, and bluish white. Slightly magnified, a light-brownish-yellow color. "Stah Cultures. — Gelatin: In sugar gelatin the sur- face growth is extensive; nearly colorless; and has a rough, misty appearance. In the depth is a delicate growth. In plain neutral gelatin the surface growth is bluish white, thick, and not so extensively spread; the growth in the depth is also thicker. "Potato culture is moist, dirty-cream color, has raised surface and defined border. "Action on Millc. — Milk becomes gelatinous in twenty- four hours at 38° C., and a solid clot in two days. Milk BACTERIUM LACTIS AEROGENES. 51 colored blue with litmus is changed to pink in twenty-four hours^ and reduced to white^ with a pink layer on top, in two days." BACILLUS "n" of BOOKER. "Found in large quantity, bu.t not the predominating form, in one case of chronic gastro-enteric catarrh (ex- tremely emaciated). ^^Morpliology. — Eesembles bacterium coli commune. ^^ Growth in Colonies. — Gelatin: In neutral gelatin the colonies are spread out and have a frosty, or ground-glass, appearance. The centre is blue and border white, but both have the ground-glass appearance. Slightly magni- fied, the central part is light yellow and the border brown, wdth a rough, furrowed surface. In acid gelatin the white border is wider and the surface is rougher. "Agar: Colonies are round, blue, or bluish white, and spread out. Under the microscope tliey have a light-yel- low color. "Sfah Cultures. — Gelatin: Has a rough, nearly color- less surface growth, and a thick stalk in the depth along the line of inoculation. "Agar: Thick white surface growth, with well-de- veloped stalk in the depth. ^'Action on Milk and Litmus Bedction. — Milk remains liquid and milk colored blue with litmus is changed to pink. ^^Gas-production. — Not observed in milk or potato cultures. ''Belation to Gelatin. — Does not liquefy gelatin. "Spores have not been noticed."^^ BACTERIUM LACTIS Ai^ROGENES. Synonym. — Bacillus lactis aerogenes (Escherich). Obtained by Escherich (1886) from the contents of ^= Sternberg's "Manual of Bacteriology," 1892. 52 INFANT-FEEDING. the small intestine of children and animals fed upon milk; in smaller numbers from the faeces of milk-fed children, and in one instance from uncooked cows' milk. Morphology. — Short rods with rounded ends, from 1 to 2 microns in length and from 0.1 to 0.5 micron broad; short-oval and spherical forms are also frequently observed, and under certain circumstances longer rods — 3 microns — may be developed; usually united in pairs, and occasionally in chains containing several elements. In some of the larger cells Escherich has observed un- stained spaces, but was not able to obtain any evidence that these represent spores. This bacillus stains readily with the ordinary aniline colors, but does not retain its color when treated by Gram's method. Biological Characters. — ■ An aerobic (facultative an- aerobic), non-liquefying, non-motile bacillus. Does not form spores. Grows in various culture-media at the room- temperature — more rapidly in the incubating oven. Upon gelatin plates, at the end of twenty-four hours, small, white colonies are developed. Upon the surface these form hemispherical, soft, shining masses which, examined under the microscope, are found to be homogeneous and opaque, with a whitish lustre by reflected light. The deep colonies are spherical and opaque, and attain a consider- able size. In gelatin stick cultures the growth resembles that of Friedlander's bacillus; i.e., an abundant growth along the line of puncture and a rounded mass upon the surface, forming a "nail-shaped" growth. In old cult- ures the upper part of the gelatin is sometimes clouded, and numerous gas-bubbles may form in the gelatin. Upon the surface of nutrient agar an abundant, soft, white layer is developed. Upon old potatoes, in the incubating oven, at the end of twenty-four hours a yellowish-white layer, several millimetres thick, is developed, which is of paste- like consistence and contains about the periphery a con- BACTERIUM LACTIS AEEOGENES. 53 siderable number of small gas-bubbles; this layer in- creases in dimensions^ has an irregular outline, and larger and more numerous gas-bubbles are developed about the periphery, some the size of a pea; later the whole surface of the potato is covered with a creamy, semifluid mass filled with gas-bubbles. On young potatoes the develop- ment is different; a rather luxuriant, thick, white or pale- yellow layer is formed^ which is tolerably dry and has Fio'. 10. — Bacterium Lactis Aeroeenes. irregular margins; the surface is smooth and shining, and a few minute gas-bubbles only are formed after sev- eral days. Pathogenesis. — Injections of a considerable quantity of a pure culture into the circulation of rabbits and of guinea-pigs give rise to a fatal result within forty-eight hours. In his first publication relating to "the bacteria found 54 INFANT-FEEDING. in the dejecta of infants afflicted with summer diarrhoea/' Booker has described a bacillus which he designates by the letter "b/' which closely resembles bacillus lactis aerogenes and is probably identical with it. He says: — ''Summary of Bacillus 'b.' — Found nearly constantly in cholera infantum and catarrhal enteritis, and generally the predominating form. It appeared in larger quantities in the more serious cases. It was not found in the dysen- teric or healthy fseces. It resembles the description of the bacillus lactis aerogenes, but the resemblance does not appear sufficient to constitute an identity, and, in the ab- sence of a culture of the latter for comparison, it is con- sidered a distinct variety for the following reasons: Bacil- lus 'b' is uniformly larger, its ends are not so sharply rounded, and in all culture-media long, thick filaments are seen, and many of the bacilli have the protoplasm gathered in the centre, leaving the poles clear. There is some difference in their colony growth on gelatin, and in gelatin stick cultures bacillus ^b' does not show the nail- form growth with marked end-swelling in the depth. In potato cultures the bacillus lactis aerogenes shows a differ- ence between old and new potatoes, while bacillus 'b' does not show any difference. "Bacillus ^b' possesses decided pathogenic properties, which were shown both by hypodermic injections and feeding with milk cultures." CHAPTEE IX. COLOSTEUX. CoLOSTEu:\r is found in the breast of a woman several hours after birth. It resembles milk^ but is a much thinner fluid. It is always the forerunner of a healthy normal secretion of breast-milk^ which usually appears on the third day after the birth of the infant. Colostrum is the earliest milk^ very thin and watery ,°m9&fM Colostrum- corpuscles Fig. 11. — ^From a Drop of Milk on tlie Third Day after Deliv- ery, kindly Furnished by Dr. H. L. Collyer, showing Co- lostrum-corpuscles. The specimen drawn by Dr. Julian W. Brandeis. (Zeiss Ocular 4, dd Lens.) in color^ very rich in salts, with decided purgative proper- ties, saving all useless castor-oil, honey, and butter and all sugar-water, with which mothers and nurses delight to experiment. According to Baginsky, colostrum contains large quantities of serum-albumin, is also very rich in fat and colostrum-corpuscles, and contains a large quantity of (55) 56 INFANT-FEEDING. salts. The last two ingredients are supposed to be the cause of the laxative action of the colostrum. Immunity by Beeast-milk. It is a well-known fact, and one that has been brought out most prominently by Brieger and Ehrlich and Baginsky, that immunity can be conferred on a child by nursing the milk of its mother. This question has also been studied with reference to conferring immunity in infectious diseases, and H. Neumann has found that im- munity can be conveyed to an infant by the agency of breast-milk. The Two Mammary Glands. The two mammary glands of the same woman may yield somewhat different milk, as shown by Sourdat and later by Brunner. Also the different portions of milk from the same milking may have different compositions. The first portions are always poorer in fat (Parmentier, Peligot, and others). According to THeritier Yernois and Becquerel, the milk of blondes contains less casein than that of bru- nettes: a difference which Tolmatscheff could not sub- stantiate. Women of weak constitutions yield a milk richer in solids, especially in casein, than women with strong constitutions. According to Vernois and Becquerel, the age of the woman has an effect on the composition of the milk, so that we find a greater quantity of proteids and fat in women 15 to 20 years old and a smaller quantity of sugar. The smallest quantity of proteids and the greatest quan- tity of sugar are found at 20 or from 25 to 30 years of age. The milk with the first-born is richer in water — with a proportionate diminution of the quantity of casein, sugar, and fat — than after several deliveries. The influ- witch's milk. 57 ence of menstruation seems to slightly diminish the milk- sugar and to considerably increase the fat and casein. Witch's Milk. Witch's milk is the secretion of the mammary glands of newborn children of both sexes immediately after birth. This secretion has, from a qualitative stand-point, the same constitution as milk, but may show important dif- ferences and variations from a quantitative point of view. Schlossberger and Hauff, Gubler and Quevenne, and von Gesner have made analyses of this milk, and give the following results: 10.5-28 p. m. proteids, 8.2-14.6 p. m. fat, and 9-60 p. m. sugar. The newborn human infant almost constantly se- cretes a fluid in the mammas, and adult males have not only secreted milk, but that in abundance enough to suckle. Females, also, both human and animal, occasion- ally secrete milk without having been previously pregnant. With regard to the milk secreted by infants, there is some doubt about its real nature. Kollicker does not view it as a true milk, but considers its appearance connected with the formation of the mammary glands. Sinety, on the other hand, upon anatomical grounds considers it a true lacteal secretion. It probably is a sort of imperfect milk, loaded with leucocytes, and this is the more likely as Yollard^^ notices that it frequently ends in abscess. Schlossberger gives an imperfect quantitative anal- ysis of a sample of milk obtained by squeezing the breasts of a newborn infant, a male. In the course of a few days about a drachm was obtained. The following was the result of the analysis: — ^*^ '"Traite des Maladies des Enfants nouveau-nes/' third edi- tion, 1837, p. 717. 58 INFANT-FEEDING. Water 96.75 Fat 0.82 Ash 0.05 Casein, sugar, and extractives 2.83 Sugar-reaction strong. The most complete analysis we possess of sucli milk is by von Gesner: — Milk-fat 1.456 Casein 0.557 Albumin 0.490 Milk-sugar 0.956 Ash 0.826 Water 95.705 Total solids 4.295 Joly and Filliol have recorded the case of an old lady, 75 years of age, who suckled successfully her grand- child. Similar instances have been recorded in dogs, and we fortunately possess one or two analyses which show that the fluid is certainly milk. Thus, Filhol and Joly give the following analysis of the milk derived from a bitch which had no connection with a male: — Specific gravity 1.069 Total solids 29.00 Fat 2.20 Sugar 0.32 Albumin 23.20 The ash, on analysis, gave the following percentage: Chloride of sodium 65,10 Chloride of potassium 3. 88 Calcic phosphate 27.75 Sodic phosphate 1.40 Sodic carbonate 1.87 Traces of magnesia and other phosphates. meist suckling childrex. 59 Men Suckling Children. Men before now have suckled children. Humboldt relates the case of Francisco Lozano, whom he saw, and whose case he carefully investigated; and it appears estab- lished that this man did secrete from his breasts a nutri- ent fluid, on which his infant son lived for many months; it is said, indeed, a whole year. The curious in such mat- ters may consult the references given farther on.^'^ " 1. "Untersucliimg der sogenannte Hexenmilcli." J. Scliloss- berger, Annalen der Chemie imd Phamiaeie, B. 87, 1852. 2. Robert Bisliop of Cork: letter concerning a man who gave suck to a child. Phil. Trans., 1741, No. 461, page 813, etc. CHAPTER X. Breast-milk. AccoKDiNG to Pfeiffer, human milk contains, several days after the birth of the baby, a large quantity of albu- min, salt, and a small quantity of fat. He also found Fig. 12. — This Illustration was Drawn by Dr. J. W. Brandeis from a Drop of Breast-milk Taken from a Wet-nurse Em- ployed in the Author's Family. It Represents a Beautiful Emulsion of Evenly-Divided Fat-globules. Note the Reg- ularity of their Size. that, tlie longer the period of nursing, the smaller the quan- tity of albumin, which, in the eleventh month, sinks (60) BREAST-MILK. 61 quite low. There is also a decrease in the quantity of salts, whereas the amount of sugar steadily increases. The fat varies constantly. According to Johannessen, the quan- tity of albumin in the first six months is 1.192 per cent.; in the next six months 0.989 per cent.; and at the end of the year 0.907 per cent. Breast-milk varies according to the length of time that it remains in the breast, and also the length of the nursing period; so it has been shown that the first milk taken at the beginning of the nursing act is the poorest in nutrient value, whereas the last milk is richest in fat. The longer the milk remains in the glands of the breast, the more will the solid substances of the same be ab- sorbed, so that only a watery solution remains. If suck- ing is commenced, this stimulation soon changes the char- acter of this watery milk, so that normal milk will soon be secreted. Forster studied the chemical constitution of the first, middle, and the last portions of milk from a nursing woman, with the following result: — In one hundred parts he found: — First Portion of the Nursing Act. Water 90.24 Nitrogenous substances 1.13 Fat 1.70 Sugar 5.56 Ash 0.46 The quantity examined was 33.1 grammes. Second Portion [during the Nursing). Water 89.68 Nitrogenous substances 0.94 Fat 2.77 Sugar 5.70 Ash 0.32 The quantity examined was 33.1 grammes. 62 INFANT-FEEDING. Third Portion {at the End of the Nursing Act). Water 87.50 Nitrogenous substances. 0.71 Fat 4.51 Sugar 5.10 Ash 0.28 The quantity examined was 37.3 grammes. From a study of the foregoing tables we find a de- crease of nitrogenous substances during the course of the nursing^ a steady increase in the amount of fat, and an unvarying percentage of sugar. Thus, it is apparent that, in order to submit a specimen of ireast-milh to a chemical examination, it is necessary to stimulate the secretory functions of the mammary glands by putting the child to the breast at least two minutes; thus an even milk can be procured. If this rule is overlooked, then we shall find proportions in the chemical components of milk which might otherwise be entirely different. The most recent chemical analysis of breast-milk shows that in a hundred parts there are Solids 11.5 Liquids 88.5 Of the solid constituents there is Casein 1.2 to 1.03 Albumin 0.5 Fat 0.8 to 4.07 Milk-sugar 6.0 to 7.03 Ash 0.2 to 0.21 The above is the chemical examination of a good average breast-milk. I again call attention to the fact, however, that not only does the milk vary in different women, but it also varies in the same woman during one single nursing act. The albuminoids of milk consist of real casein, lact- albumin, globulin, and opalisin. This latter body has only BREAST-MILK. 63 recently been discovered by A. Wroblewski, and more re- cently by Schlossmann. Phosphorus exists in milk as nuclein-phosphorus. Wittmaack has demonstrated the fact that the phosphorus in woman's milk exists as an organic nitrogen compound in the casein. According to the examination of Stolasa, lecithin contains a larger quantity of phosphorus in woman's milk than in cows' milk. The specific gravity of breast-milk varies from 1.026 to 1.036. SPECIMEJ^ OF BREAST-MILK EOR CHEMICAL EXAMINATION^. After the third, possibly tlie fourth, day the average healthy woman secretes milk that gradually becomes nor- mal in quality and quantity, depending on her general condition. It is usual for an infant to lose some weight during its first week of life, owing to various physiological changes, added to which is, no doubt, the deficiency in the quality and quantity^ of its food. It is a safe plan, and one that I have always urged, if at all possible, to send a specimen of breast-milk to a chemist and sub- mit the same to a chemical analysis. In some women a specimen can be examined when the baby is one week old; in others it is better to wait until the end of two weeks. We then would have a proper working basis, and know just how much fat, carbohydrate (sugar), and albuminoids — including proteids — we are feeding. Noting the weight of the child, its sleep, its digestion, color and frequency of its stools, we can easily see in one week how much the infant has gained in weight, and its general condition. To take a specimen, it is advisable to have all utensils absolutely clean; hence the following plan would be sug- gested: Boil an ordinary one- or two- ounce bottle in water, to which a piece of baking soda has been added. 64 INFANT-FEEDING. for about one-half hour. Then place the bottle in plain water and boil again for a half-hour. Then turn the bottle upside down, and allow it to drain and dry. In this manner we can completely sterilize the inside of the bottle and avoid contamination. Withdraw a sample of breast-milk by means of a breast-pump. One which has served the author very well is known as the Florence breast-pump, and has a glass mouth-piece. (See illustration. Fig. 15.) Another form is an English breast-pump, having a rubber bulb. Compressing this bulb, we can suck about an ounce or more in from five to ten minutes. This milk is to be poured into the bottle, and well corked, and set in a re- frigerator, but not on the ice. Milk will keep for many hours in this way. My plan has been to inform the chem- ist the day previous to submitting the sample, so that it Pro- Human Milk. Fat. TEIDS. Sugar Ash. Authority. Normal lElks. Average . 2.90 3.07 5.87 0.16 A. W. Blythe. Average 3.68 1.70 7.11 0.20 Marchand. Average 2.67 3.92 4.37 0.14 Vernois & Becqnerel. Average 3.52 2.01 5.91 Hammarsten. 14 analyses from same woman . 2.53 3.42 4.82 0.23 Simon. Mean of 6, aged 23-33 years . . 3.82 2.04 5.93 0.42 H. Gerber. Average 3.55 1.52 6.50 0.45 Chevalier & Henry. From woman aged 18 .... 3.20 2.39 6.83 0.29 J. Bell. From woman aged 33 2.99 2.51 6.51 0.30 J. Bell. 4 days after deliv- ery . 4.30 3.53 4.11 0.21 Clemm. 9 days after deliv- ery . 3.53 3.69 4.30 0.17 Clemm. 12 days after de- livery . . 3.34 2.91 3.15 0.19 Clemm. Average of 84 samples . 4.13 2.00 6.94 0.20 Leeds. Average of 107 samples . 3.78 2.09 6.21 0.31 Konig. BREAST-MILK. 65 can be withdrawn from the breast early in the morning — at about 8 a.m. — and sent to the laboratory at once. The result of the analysis can be received on the evening of the same day or on the following day in all instances. A point worth noting is that the very first milk — known as the foremilk — should not be used^ but the infant should be allowed to suck at the breast for about two minutes before pumping the sample. After this the breast-pump should be applied for five minutes to procure the so-called middle milk for examination; then the infant can again be put to the breast to finish the so-called end of nursing or to suck the strippings. CHAPTEE XI. Beeast-feeding. DuEiNG the first month feed every two hours, but never oftener. During the second month^ every two and a half to three hours. N"ever disturb a child from its sleep to be nursed; so that the rule should be to leave the baby rest as long as it appears satisfied. This rule applies to healthy chil- dren only. In sickness special feeding rules are required. If the child thrives, gains in weight, then it is advisable in the interest of the mother and child to have an interval of from seven to eight hours at night; thus Bouchut ad- vises feeding betv/een 10 and 11 at night and commencing the morning meal at 6 a.m. If the child is restless, then turn the child from side to side; in other words, changing its position and giving it 1 or 2 teaspoonfuls of boiled water will frequently satisfy it and prolong its sleep. Time foe Feeding. From Birth At 1 Month 2 TO 4 4 TO 6 6 TO 9 Months Old. 9 Months UNTIL 1 Month UNTIL 2 Months Months Old. Months Old. UNTIL IYkar Old. OLD. Old. 6 A.M. 6 A.BI. 6 A.M. 6 a.m. 6 A.M. 6 A.M. 8 A.M. 9 A.M. 9 A.M. 9 A.M. 9.30 to 10 A.M. 10 A.M. 10 A.M. 11 A.M. 12 Noon. 12 Noon. 1.30 to 2 P.M. 2 P.M. 12 Noon. 1 P.M. 3 P.M. 3 p.m. 5.30 to 6 P.M. 6 P.M. 2 P.M. 3 P.M. 6 P.M. 6 p.m. 9.30 to 10 P.M. 10 P.M. 4 P.M. 5 P.M. 9 P.M. 9 P.M. 6 P.M. 7 P.M. 12 Mid- 8 P.M. 9 P.M. night. 10 P.M. 11 P.M. 12 Mid- night. The first three or four days after birth require special feeding methods: — (66) BKEAST-FEEDIXG. 67 On the clay of the birth, the exhaustion of the mother and presence of colostrnm. besides the normal deficient quantity of food in the breast^ demand large intervals of rest; thus for the first three days (unless the milk-supply is profuse) putting the infant to the breast once every six hours would be sufficient; if, however, the supply of milk is ample, then we can follow the table given above and nurse the infant every two hours. SUGGESTIOXS FOE BEEAST-FEEDIXG. The mother or wet-nurse should always sit upright, be it at night or during the day, while nursing the infant. Danger of Suffocation. — A great many cases are on record where the mother or wet-nurse has fallen asleep while nursing, and smothered the child. For this reason it is important that the infant should sleep in its own crib or bed, and should never sleep with its mother or nurse. Shall o.n Infant Beceive lut One or Both Breasts for One Meal? — This depends on the infant's appetite. Some infants appear satisfied after nursing from one breast, and will let the nipple go and fall asleep. Light tapping on the cheeks of the infant will awaken it, or the with- drawal of the nipple from the infant's mouth will fre- quently arouse the child to continue its nursing. If, how- ever, an infant will not renew its nursing, and still con- tinue to sleep, and if the infant has nursed steadily for ten minutes, then the sleep should not be disturbed. Length of Time for Kursing. — A good plan is to note the time when the nursing act commences and stops. No infant should nurse longer than 20 minutes, whereas fre- quently 10 minutes or 15 minutes will suffice. If an in- fant nurses more than 20 minutes, say 30 or 1:0 minutes, then we may be sure that the breast-milk is deficient in quantity, and a specimen should at once be submitted for a proper chemical examination. 68 INFANT-FEEDING. Mixed Feeding. When there is a deficiency in the quantity of breast- milk, bnt the quality is good, then it is advisable to feed the infant alternately with breast-milk and bottle-milk. At the same time, it is advisable to direct attention to the mother's general condition, and see if we cannot tone her up, and thus improve both quality and quantity of her milk. Frequently a subnormal or ansemic condition re- quires iron; in other cases a day's outing to the sea-shore or to the country, with moderate exercise, will stimulate and increase the flow of milk. It is well to try some galactagogues. Among them the author has found an albumin diet (meat, milk, and eggs) and a preparation known as nutrolactis in tablespoonful doses before meals to have acted very well in some cases. Grandin and Jarman, in their text-book on obstetrics, recommend the strong infusion of galega officinalis when the flow of milk is scant. This is to be ordered in tablespoonful doses three or four times a day. Every drop of breast-milk is so precious that no infant should be deprived of it, and wise is the physician who will insist on giving all the breast-milk when there is deficient lactation, and supplying the de- ficiency by giving a proper diluted milk- or cream- mixture, adapted for the age and weight of the infant. Do Drugs Taken hj a Nursing Woman Affect the Bahj During the Nursing Period? — Physiological experiments have frequently demonstrated the fact that a great many drugs can be given to an infant through its mother's milk; thus, opium and morphine and narcotics in general do affect the nursling when the drugs are taken by the mother. Baginsky calls attention to this fact in his text- book on "Diseases of Children": "Alcohol, when taken by the mother, is transmitted through the milk, but not in very large quantities. The following is a list of drugs which have been found in milk; The purgative principles STERILITY OF HUMAN MILK. 69 of rhubarb, senna, and castor-oil; the metals antimony, arsenic, iodine, bismuth, lead, iron, mercury; the volatile oils, like copaiba, garlic, and turpentine; also salicylic acid, and the iodides and bromides.'^ Do not give cocaine, chloral, atropine, or hyoscyamos. Care is to be used with the following: Digitalis, antipyrin, and ergot. An un- pleasant flavor can be imparted to the breast-milk by the mother or wet-nurse eating onions, turnips, cauliflower, or cabbage. Microbes m the Milk of Nursing Women. EingeP^ examined the milk of 25 women, 13 of whom were healthy. With minute precaution to insure accuracy, he found the milk sterile in only 3 cases; he obtained the white staphylococcus in 17, the yellow in 2, the two together in 1 case, and in 2 instances he found the white staphylococcus together with the streptococcus. As the microbes could not be due to genital infection, the idea was suggested that they might come from the child^s mouth, the white staphylococcus having been, in fact, found on the child^s tongue. But having examined the milk of a woman who had not been suckling, but whose nipples had been disinfected, Eingel still found the staphylococcus. Sterility of Human Milk. Honigmann finds that human milk obtained with all antiseptic precautions from 73 breasts of 64 nursing women was only sterile, when duly cultivated, in 4 cases. In the remainder staphylococcus albus was present, and in 44 cases the staphylococcus aureus; while in 3 in- stances other bacteria — a bacillus and a sarcina — were ^^ Miinch. med. Wochenschrift^ No. 27 ; British Gynaecological Journal, xxxvi; Brooklyn Medical Journal, August, 1894. 70 INFANT-FEEDING. found. The number of germs varied from 1 to upward of 9000 in a cubic millimetre. These observations are of interest in reference to the occurrence of thrush in chil- dren^ to the origin of which they may furnish a clew, and also to the liability that children, while suckling, present to suppuration after wounds accidentally or intentionally inflicted. {Lancet.) Fat-globules. Woman^s milk has larger fat-globules than cows' milk. Their number, according to Bouchut, is 1 to 2 millions in 1 cubic centimetre. It has less inclination to turn acid; therefore it does not coagulate distinctly. Additional Foods During the Nursing Period. Flour-Ball Feeding. — When an infant nursing at the breast is six months old certain additions to the food can safely be made; thus, for example, the white of a raw Qgg can be given every second day, and on the alternate day several teaspoonfuls of a meat- soup (beef or chicken) in which barley, farina, or sago has been boiled and strained. This method of feed- ing can be kept up until the child is seven or even eight months old, and then a small piece of zwieback can be al- lowed every day. As this is hard, children like to nibble on it, for it seems to soothe their gums. If the bowels are in a good condition, then a few teaspoonfuls of a very light wheat-flour ball can be given every few days. Flour ball can best be made by following the directions given by Dr. Edwin Eosenthal (paper read before the Pennsylvania State Society, May 18, 1898, entitled ''Some Points on Infant-feeding"); he says: "I use the following formula, and I can claim as much good results therefrom as from any form of modified home-made food. It is known as the flour-ball food, commercially imperial granum. It is made ADDITIOXAL FOODS DUEIXG NUESING PERIOD. 71 as follows: Plain wlieat-floiir is boiled in a bag for five hours, then dried, broken open, the rind rejected, and then grated into a powder. I take of pure milk, mixed and scalded, 1 pint; of sterile water, 1 pint; of the boiled flour, a heaping tablespoonful, a bit of cinnamon-bark (sometimes to give some flavor with certain children), and a pinch of common table-salt. The milk is placed on the fire and heated; the flour is rubbed to a fine paste with the water, and then added to the milk. The cinnamon is added, and then it is brought to the boiling-point, taken from the fire, the salt added (not sufficient to taste), and the whole is then placed on the ice. It is then heated again when used. Two ounces every two hours is given to a child one month old. It is increased V2 ounce every month, while the water is reduced 1 ounce every month. The milk is added to keep the quantity up to the 2 pints. I have with this method seen some very surprising results, and feel no hesitancy in recommending it.^^ Tlie Addition of Hydro chloric Acid to Food. — The indiscriminate use of dilute hydrochloric acid is a prac- tice that is to be condemned. We know that hydrochloric acid passes through the body unchanged, and in being- excluded by the kidneys frequently irritates the same. A point to note is that HCl is formed in the stomach from the chlorides in the circulation of the blood. It appears, therefore, quite plausible to add salt to the infantas food (ordinary table-salt: NaCl), which is likely to be trans- formed into HCl in the infantas stomach. The Feeding of SicTc Children. — The method of feed- ing here is entirely different from feeding in health. J^o definite rules can be laid down as to the quantity or the quality, or the interval required for feeding; for example, if an infant suffering with dyspepsia will vomit, and have large, cheesy curds in the stools, and have anorexia, such an infant requires food that is far more diluted with water than heretofore. If, let us say, an infant, two months old, 72 INFANT-FEEDING. suffer with dyspeptic disturbance, and receives 2 parts of milk and 3 parts of water, such an infant should be given 1 part of milk with 3 parts of water, to see if the dys- peptic condition cannot be modified. If no improvement is noted after several days of such feeding then it is wise to substitute barley-water instead of plain water, and thus see if the digestibility of the casein cannot be im- proved. If, however, no improvement is noted, then a good plan is to resort to predigested foods. It is in this class of cases that peptonized foods are so advantageous; but, if milk is badly borne, then it should be diluted with dextrinized gruels. The Diet of a Nuesing Mothee. Immediately after the birth of the child the ex- hausted condition of a woman following labor will cer- tainly call for rest; hence sleep is imperative, after which some form of stimulation is required. This can best be accomplished by giving at intervals of several hours good wholesome food, as broth of chicken, or beef-broth, weak tea, or strained gruel. It is unnecessary to state that each woman's case and her former habits must be taken into consideration; and thus, if the labor has been normal, the nourishment will certainly stimulate the flow of milk. Great care, however, must be given to the usual irritable stomachs in this condition, and, if warm liquids are not Avell borne, then cold drinks, like buttermilk, koumiss, mat- zoon, or iced tea, should be employed. In some instances ice-cream will aid nutrition and allay gastric irritability. If the pelvic condition is normal, then it is wise not .to give solid food for the first three days, but, rather, stimulate the milk-glands by giving meat-broths, farinaceous gruels, and by all means milk. Zwieback soaked in milk or in tea is highly nutritious and easily digestible. Other nutri- tious foods are calf s-foot jelly and chicken-jelly. After the third day — if the pelvic organs are normal THE DIET OF A NURSING MOTHER. 73 — it is wise to consider the action of the bowels. If the bowels have not moved by this time^, then buttermilk added to the diet or some stewed prunes or baked apples or stewed peaches, or grapes, will aid in establishing a movement of the bowels. If the milk is scanty and the bowels have not acted, then the best remedy is a large tablespoonful of castor-oil, modified to suit the taste by the addition of either orange- juice or lemon-juice, or by adding several drops of the ordinary spirit of peppermint. After the bowels have been evacuated and the general condition warrants it, then a diet consisting of the following is indicated: — Breakfast, 7 to 8 a.m. Hominy and Milk. Grapes. Farina and Milk. Soft-Boiled Eggs. Rice and Milk. Poached Eggs. Oatmeal and Milk. Eggs on Toast. Germea and Milk. Coffee and Milk. Cream of Wheat and Milk. Tea and Milk. Some Stewed Prunes, Figs, Cocoa and Milk. or Peaches. Toast and Butter. Stewed Apples. Stale Bread (2 days old), Oranges. with Butter. I do not advise meat nor fish in the morning, unless the nursing mother has always been accustomed to this form of diet. Lunch, 12 to 1 p.m. Some soup, made from meat, either veal, beef, mut- ton, lamb, or chicken, containing also some rice, barley, farina, sago, or hominy; it should not be highly seasoned, and should not be strained. Fish, boiled or fried, and all shell-fish, particularly 03'Sters, are very nutritious during the milking period. If the appetite warrants it, then a piece of steak or 74 INFANT-FEEDING. chop^ roast beef, chicken (white meat only), or raw chopped meat, with bread and butter, is very nutritious. Some fruit. Evening, 6 to 7 p.m. A bowl of Oatmeal Gruel. Junket. Some Oysters (stewed). Cup of Tea. A drink of Milk. Eggs, if desired. Farina Pudding. Meat, if in the habit of eat- Eice Pudding. ing it in the evening. Cornstarch Pudding. For Thirst. — Cool, filtered water or the alkaline w^aters, like Seltzer and Apollinaris. If the milk is scanty, the flow can be stimulated by drinking a cup of hot broth, made from beef, chicken or veal, lamb or mutton, several minutes before putting the child to the breast. Alcoholic Di'inks. — If a woman is in the habit of drinking beer or wine, then it is unwise to discontinue the use of alcoholics in moderate quantities, while she is nurs- ing. I have seen a great many women, whose flow of milk was scant, who immediately secreted an abundance of milk after partaking of a glass of beer or ale or porter with their meals for several days. Beer has a decided laxative effect, and this in itself is rather an advantage for those nursing mothers having a tendency to constipation. So, my rule, therefore, would be to insist on abstinence from wine and beer unless the patient has been in the habit of taking it formerly. THINGS TO BE AVOIDED BY A NUESING WOMAN. Onions. Large quantities of pota- Garlic. toes. Cabbage. Butter and Fat moder- Powerful Salts (Eochelle, ately. Glauber, Epsom). Candies and too much Ethereal Oils. Sweets. CHAPTER XII. AYet-xuese. If the infant's own mother cannot nnrse her child^ then we can and shonkl try to secure a wet-nnrse. The wet-nnrse nmst be carefnlly examined, as well as her child, for the presence of syphilis. I beg to refer to a short paper on this subject, published in the American Medico-Surgical Bulletin in January, 1894. 1. Xever have a baby fed by the milk of its mother if the latter suffer with general debility or tuberculosis. Extremely nervous mothers should not nurse their babies. Syphilitic babies (hereditary) can only be nursed by their own mothers, owing to the risk of infecting the wet- nurse. In such cases very frequently the life of the child is dependent on its being nursed by its mother. The following general rules may be noted: — (a) The return of menstruation is no contra-indica- tion to the continuation of nursing. (b) The moment a woman is pregnant nursing should be stopped. (c) Children should not be nursed at night unless for some special reason. (d) AA'eaning should take place gradually, and only in the eighth to the tenth month. (e) It is understood that weaning should not be com- menced during the hot summer weather. The main factor in determining the time of weaning is "weighing. ^^ Children must be weaned when, although in perfect good health, they remain below normal weight. (/) Prolonged nursing will induce rachitis. 2. If, for various reasons, a child cannot be nursed by its own mother, we then resort to the wet-nurse. ('5) 76 INFANT-FEEDING. (a) She must be carefully examined as to her phys- ical condition; tuberculosis, all chronic disorders and dis- eases would prevent proper nursing. Hereditary nervous troubles, epilepsy, or syphilis would exclude nursing. (&) It is a good point to try to procure a wet-nurse suckling a child about as old as the one we wish her to nurse, although it is quite common to find nurses who have older children than the one they wish to nurse and to find the latter doing well. (c) The proof of the usefulness of the wet-nurse is the condition of the baby after some time. If the child thrives, it will increase in weight. Hence scales must be frequently used. DIET OF A V^^ET-NURSE. The diet given for a nursing mother can also be used as a guide in choosing the diet for a wet-nurse. The greatest care, however, must be bestowed on the Marnier of Living. — If a wet-nurse was a former serv- ant, or worked out-of-doors and is suddenly taken into this new mode of life and given charge of a baby, she must have proper exercise, or else such wet-nurse will very soon secrete milk which will be totally unfit for an infant, and, as a result, the child will probably have severe colic and irregular, cheesy stools; will vomit excessively; and will not gain in weight sufficiently. It is, therefore, important to try and adapt a wet-nurse to the same condition as ex- isted prior to her pregnancy; so that both her manner of living and, chiefly, her diet shall not be different. Proyer Rest. — To be equal to her task a nurse must be given plenty of sleep, if it is at all possible. Adriance, in the Archives of Pediatrics, says: — 1. Excessive fats or proteids may cause gastro-intes- tinal symptoms in the nursing infant. 2. Excessive fats may be reduced by diminishing the nitrogenous elements in the mother's diet. CHANGING INGREDIENTS IN WOMAN'S MILK. 77 3. Excessive proteids may be reduced by the proper amount of exercise. "i. Excessive proteids are especially apt to cause gastro-intestinal symptoms during the colostrum period. 5. The proteidSj being higher during the colostrum period of premature confinement, present dangers to the untimely-born infant. 6. Deterioration in human milk is marked by a re- duction in the proteids and total solids, or in the proteids alone. 7. This deterioration takes place normally during the later months of lactation, and, unless proper additions are made to the infant's diet, is accompanied by a loss of weight, or a gain below the normal standard. 8. When this deterioration occurs earlier, it may be the forerunner of the cessation of lactation, or well- directed treatment may improve the condition of the milk. Methods of Changing the Ingredients in Woman's Milk. Eotch gives a condensed table for these changes as follows : — • To l7icrease the Total Quantity. — Increase the liquids in the mother's diet, especially milk (malt-extracts may be helpful), and encourage her to believe that she will be able to nurse her infant. To Decrease the Total Quantity. — Decrease the liquids in the mother's diet. To Increase the Total Solids. — Shorten the nursing intervals, decrease the exercise, decrease the proportion of liquids, and increase the proportion of solids in the mother's diet. To Decrease the Total Solids. — Prolong the nursing intervals, increase the exercise, and increase the propor- tion of liquids in the mother's diet. 78 INFANT-FEEDING. To Increase the Fat. — Increase the proportion of meat in the diet. To Decrease the Fat. — Decrease the proportion of meat in the diet. To Increase the Proteids. — Decrease the exercise. To Decrease the Proteids. — Increase the exercise up to the limit of fatigue for the individual. It is wise in all cases of disturhed lactation, whether in maternal or wet- nursing, to make efforts in accordance with these rules to produce a milk that is suitable for an infant who is not thriving, before changing to any other method of feeding. Wet-nuesing. It is an established fact that the best possible food for an infant is breast-milk. Where the mother of an infant is prevented from nursing her child, the next thing to be considered is wet-nursing. That nursing a child is an advantage to the mother is a well-known fact, inas- much as it influences the contraction of the uterus and stimulates the circulation. Contrary to the belief that nursing a child is detrimental, and contra-indicated in women whose lungs are weak and who have a tendency to the development of tuberculosis, it does them no harm, and, indeed, seems to do them good. This state- ment is borne out by the experience of Dr. Heinrich Munk, of Karlsbad, Austria, a specialist for diseases of women. In Austria the State supports public institutions for lying-in women. They are kept there and confined gratis, and remain about fourteen days. They are admitted into these hospitals in the last months of pregnancy. Vienna usually has about 300 women on hand. Prague constantly has 100 women in this condition, who are utilized for the purpose of instruction to physicians and midwives. In Prague there are about 3000 women confined an- TTET-XURSIXG. 79 nually, and these women are put into the foundling- asylum. There they remain until they procure a place as a wet-nurse or as long as their services are needed in the asylum. ^\'hen wet-nurses are taken from the foundling- asylum^ it is a frequent occurrence to have those remain- ing therein nurse at least two children, and frequently, three, at one time. In this manner they dispense gradu- ally with these wet-nurses without hurting the remaining children. Many children die, some of them intrapartum in operatiA'e confinements, and the women (mothers of such children) are then utilized for wet-nursing. It is a rule to keep the children in the asylum until they have attained a little OA'er four kilogrammes (about 9 pounds), and they are then put out for further feeding (artificial feeding), for which the city pays about 15 florins a month ($5.00). The children remain usually until they are six years old, and are then giA^en hack to their own mothers. Many of these children die, others are adopted by those who have reared them, but the greater portion are taken back by their own mothers. In Vienna there are about 10,000 confinements annually in the public institution. There are a great many cities in Austria — like Innsbruck- Olmutz, Brunn, Linz, and Klagenfurt — where there are at least 200 confinements* annually. In Vienna a Avet- nurse receives 30 florins per month, for which she is sent (railroad expenses paid) to whomever requires her services. She is taken on trial for fourteen days to see if she is adapted for her place. A wet-nurse can be procured by sending a telegram and a money-order any day during the year. The customary wages are from 12 florins upward per month. Each wet-nurse is carefully examined by the professor before she is sent away. A great many families do not care to take a wet-nurse from an asylum, as they are usually women in the lowest walks of life, and prefer, therefore, to take a woman who has been married. For this purpose there are wet-nurse 80 INFANT-FEEDING. agencies, duly licensed. These will supply wet-nurses, and usually take orders in advance; thus a wet-nurse may be reserved. Such wet-nurses cost much more, and those from one special region — Iglau in Mahren — receive from 20 to 50 florins monthly. The empress took for her own use a wet-nurse from Iglau (a married woman), and the Princess of Bulgaria took a wet-nurse from Iglau for her last child. Not only Iglau, but the whole region, is renowned for its excellent quality of wet-nurses. The Bohemian and Mahren nurses have very good mammae. They seem to love the children intrusted to them. While it is a rule that a wet-nurse should be taken for a baby of the same age as that of her own, frequently wet-nursing of an infant at birth by a wet-nurse whose baby is three months old has not been followed by any bad results. In New York we are at a decided disadvantage re- garding wet-nurses. As no licensed agencies exist, a few people having so-called influences procure wet-nurses by friendship, or something similar, from superintendents and house physicians where obstetrical work is done. Thus we find ourselves at the mercy of some people who traffic in wet-nurses for a fee, usually five dollars, and who do not stop at anything to attain their own selfish ends. Time and again have I sent for a wet-nurse to an agent who, instead of giving me a healthy wet-nurse, tried to induce me to use women having colostrum-milk for an infant in which such milk would have proved disas- trous. In another instance, only recently, I procured a wet- nurse from an agent who sent me one 17 years old, who had had a premature birth, "evidently an abortion," and whose milk was typical thin w^ater, with here and there a fat-globule, when examined under the microscope, WEANING, AND FEEDING AFTEK WEANING. 81 At other times some of the finest specimens of wet- nurses have also been procured from the same agent. It is a pity that we have no municipal control for what the writer considers one of the most valuable forms of adjuncts to our maternal feeding, and in the same manner such control would regulate the supply to such unlimited number that modern arrogance on the part of the wet-nurse would probably disappear. The prices paid in New York are from twenty to thirty dollars per month and board, and this price pro- hibits many an infant from securing the benefits of Nature's food. Let us hope for municipal regulation. Weaning, and Feeding fkom One Yeak to Fifteen Months. A¥eaning should take place gradually between the eighth and tenth months. In some instances it is ad- visable to commence weaning a child much sooner. For example, when there is a deficiency in the supply of milk or owing to ill health of the infant's mother. This I have already mentioned in the section on "Mixed Feeding." Weaning is imperative when the infant's mother is pregnant, although it is advisable to use great caution if it occur in midsummer. In a case of this kind the better plan would be to have a specimen of the breast-milk ex- amined by a chemist, and, if the same be found deteri- orated in quality, then the judgment of the physician must prevail as to the advisability of continuing or dis- continuing the nursing. My rule has been not to wean during the summer months. The main points have already been mentioned in this chapter under "Wet-nurse." Weaning should not be attempted suddenly. Thus, it is better to commence weaning gradually, by withdraw- ing the breast in the morning and substituting a bottle 82 INFANT-FEEDING. for that meal. Following this meal we can again nurse the child at the breast for two feedings^ and substitute a bottle for its third meal instead of the breast. In this manner we can feed the child with a bottle in the morning, to be followed in three or four hours by the breast, then at the next feeding again nurse the child, and this to be followed in three or four hours by the bottle: — 8.00 A.M Bottle. 11.30 A.M Nursing. 3.00 P.M Nursing. 6.30 P.M Bottle. 10.00 P.M Breast. In this manner we can see just how the food is as- similated, and also study the individual peculiarities of the baby. Some children are very hard to wean, and it will require great tact and patience to successfully cope with this condition. I recently saw a child in consultation which, on being removed from the breast, absolutely re- fused to take the bottle, and when fed with a spoon the child would spit out its food. After three or four days of this unsuccessful weaning the physician attempted more heroic methods, and insisted on isolating the child from the wet-nurse for twelve consecutive hours. This infant refused to take food even after that time, and then it was that I was summoned. We decided to give pep- tonized milk alternating with peptonized yolk of egg by means of rectal feeding. Thus, 1 ounce of milk and 1 ounce of starch-water were injected, followed by the pep- tonized yolk of egg added to the starch-water four hours later. This method of feeding can be found described in detail in the chapter on ^^Eectal Feeding," and also in the chapter on "Feeding in Diphtheria Intubation Cases." Thus we aimed to sustain life and avoid starva- tion. The rectal feeding was continued for two days more, when the child suddenly took the bottle. WEANIJSTG, AND FEEDING AFTER WEANING. 83 In some cases forced feeding by gavage will be found useful. If the child holds its jaws firmly /the catheter can be introduced through the nasal passage^ as described in the section on "Xasal Feeding.^' I was called to see a perfectly healthy child^ about 9 months old^ whose mother told me that "he would not take the breast." She was greatly chagrined, but all efforts at nursing him proved futile. The infant had weaned himself. Such cases of "self-weaning" are very rare. AFTEE-WEANING DIET. When weaning is successfully accomplished, then great care must be exercised, owing to the change in diet. It will be found that the slightest error in overfeeding or too frequent feeding will be rewarded by a severe attack of dyspepsia and the usual gastric disturbances, such as vomiting and fermentation in the stomach, causing diar- rhoea and possibly colic. It will therefore be very neces- sary to exercise good judgment in the choice of both quality and quantity of food during the first month or two after weaning or until the stomach adapts itself to thig new way of feeding. The amylolytic function now being thoroughly developed, we can safely give cereals. TIME OF FEEDING. Excepting in rare instances, after a child is weaned it should not be fed oftener than once in four hours. The best time for feeding would be about 6 a.m., 10 a.m., 2 P.M., 6 P.M., and 10 p.m. if the child is awake. This would give eight hours rest, and healthy children can be trained to sleep that amount. The first bottle after sleeping should consist of 8 84 INFANT-FEEDING. ounces of pure cows' milk.^^ This would be the 6-a.m. feeding. Four hours later^ or at 10 a.m.^ the infant should re- ceive the white of a raw egg fed with a spoon from a wine- glass immediately before its bottle^ which consists of: — Cows' milk 5 ounces. Barley-water 2 ounces. At 2 P.M. our next feeding should consist of 8 ounces of pure cows' milk. I usually permit the infant to nibble on one-half piece of the ordinary zwieback. The evening meal at 6 p.m.: — Cows' milk 6 ounces. Barley-water 2 ounces. The last feeding at 10 p.m., if the child is awake, or at midnight should consist of 8 ounces of pure cows' milk. When milk is brought from the dairy there is a thick layer of cream on the top of the milk, which should be thoroughly mixed with the milk by shaking the bottle so that the infant receives a thoroughly-mixed milk contain- ing the same quantity of cream in each feeding. The milk should be mixed and the barley-water added to it. It is then poured into thoroughly-clean bottles, which are stop- pered with ordinary cotton stoppers. This can be found described in detail in the chapter on "Sterilization." This food is to be steamed for twenty minutes and then allowed to cool by placing the bottles in a refrigerator, but not on the ice. When ready for use each bottle is to be warmed to a temperature of about 100° F. for the feeding. If constipation follows the use of this diet, then a good plan is to substitute 2 ounces of oatmeal-water instead of the barley-water above mentioned. When the stools are regular and the child appears to be quite pale, then great ^® The best milk obtainable in this city is undoubtedly milk received in bottles direct from the dairy the same day of milking. WEANING, AND FEEDING AFTEK WEANING. 85 good can be accomplished by adding 2 ounces of almond- milk instead of the oatmeal- or barley- water. The prepa- ration of almond-milk can be fonnd described in the "Dietary/^ to which I beg to refer my readers. If a se- vere form of constipation, with cheesy curds in the stools, exists, then the milk should not be steamed, but fed in the "raw state.^' It is self-understood that it should be warmed to the body-heat before feeding to the infant. Instead of giving the white of egg every day I substitute either 1 or 2 ounces of a good beef-soup or chicken-soup or beef-tea and expressed steak-juice, and feed this quan- tity immediately before the 10-a.m. bottle of milk. No distinct change of food will be necessary until the child is twelve or fifteen months old, when I am in the habit of giving either ^/^ saucer of oatmeal-gruel with some butter or some hominy and butter in addition to a morning bottle. In the evening when the child arrives at this age a half-dozen teaspoonfuls of junket can be fed before the evening bottle of milk. When a child is over one year or about fifteen months old, instead of giving water for thirst I frequently give prune-water made by boiling good fleshy prunes in water for one-half hour and straining off the liquid. When oranges can be procured, one or more teaspoonfuls of orange-juice can be given with advantage. Apple-sauce can also be given. Thus, my plan consists in giving each one of these foods on different days. Just at this period the addition of several tea- spoons of Mellin's food has been found very beneficial. Owing to gastric derangements, it will be found necessary to frequently discontinue milk entirely. At such times the use of the milk-foods — such as Nestle's food and Mellin's food — has proved very beneficial. When diluting milk with cereals like barle3^-water, rice-water, sago- water, flour ball and water, it is always better to dextrinize the diluents. This dextrinization has a decided effect on the casein, inasmuch as it splits up the curd, rendering it 86 INFANT-FEEDING. finely flocculent as it is found in human milk, and it is especially indicated in the period of weaning after the stomach has been accustomed to breast-milk and is sud- denly forced to digest cows' milk containing a more rub- bery and heavier casein, or curd. Diet After the Peeiod of Weaning. The following dietary is for a child from one and a half to three years old, the heartiest meal to be at noon. BREAKFAST. Hominy Farina Oatmeal ( With milk, suo-ar, Cream of wheat ( and butter, Germea A¥heaten grit Sliced Apples (Raw), with Cream. Sliced Bananas with Cream. Oranges or Fleshy Prunes. Peaches with Cream. Grapes or Grape-jelly. Baked Apples or Apple-sauce. Drink of Raw Milk (warm). Toast and Butter or AVlieat Bread and Butter and Drink of Water. A Soft-Boiled Egg or Poached Eggs. Cocoa with milk. No Tea or Coffee. NOON MEAL. Soup made with lentils or split peas, meat, and vege- tables, — but not highly seasoned, — which soup can be thickened by the addition of sago, farina, barley, or rice, the last to be omitted if severe constipation exists. FEEDING AFTER WEANING. 87 Fish broiled, white meat only. Eaw scraped steak on crackers. Small chops or piece of broiled steak: top sirloin or tenderloin. White meat of chicken (breast). f Spinach. Mashed Potatoes. Some vegetables > .2 02 1 02 -d 1 DETECTIOX AND ADDITION OF PEESERVATIYES. 117 phenol is added and the mixture poured npon strong sulphuric acid contained in a test-tube^ a bright-crimson color appears in the zone of contact. This color is still readily seen with 1 part of formaldehyde in 200^000 of water. If there is more than 1 part in 100,000 there is seen above the red ring a white, milky zone, while in stronger solutions a copious white or slightly-pink, curdy precipitate is obtained. This reaction has an advantage over the one previously referred to, as it is obtained with formaldehyde solutions of all strengths, while the blue color of milk is not obtained with milk containing much formaldehyde. Salicylic acid is not very much in vogue as a milk- preservative. It can easily be detected by Pellet^s method: 200 cubic centimetres of the milk are diluted with an equal measure of water, heated to 60° C. and treated with 1 cubic centimetre of acetic acid and an excess of mercuric nitrate free from niercurous salt. The salicylic acid is extracted from the filtered solution by agitation in ether and recognized by evaporating a little of the ethereal solution to dryness and testing the residue with ferric chloride, which gives a violet color with salicylic acid. Pearmain and Moor, in describing the bacteriology of milk, say that it usually contains a large number of bac- teria derived from the external surroundings of the cow. Where these are unclean, the number may reacli three or more millions per cubic centimetre. These can, ^^for experi- mental purposes," be completely separated by filtration through Pasteur tubes, the tubes being cleaned at short intervals. A thin, watery serum constitutes the filtrate, the whole of the fat being arrested with the organisms, so that milk cannot therefore be freed from organisms for practical purposes by any known system of filtration. Milk can be curdled by ferments even in the absence of an acid reaction. The most notable ferment is rennet, ob- tained from the stomach of a calf. Hueppe first pointed 118 INFANT-FEEDING. out that such ferments are conveyed by many different bacteria which precipitate the casein in the presence of a weakly-acid, amphoteric, or even neutral solution. The numerous tyrothrix bacilli isolated by Duclaux, the bacil- lus pyocyaneus, yellow sarcina, and particularly the organ- isms described by Fliigge/° characterized by their capacity to peptonize milk, belong to this class. Cohn^^ produced the precipitation even by means of bacteria, whose vegetative capacity had been completely abolished with chloroform, thus showing that the fermentative action was due to a substance independent of the metabolic products of the organism. These substances have been isolated by Cohn and others. They are destroyed in most cases at from 65° to 75° C. Some ferments, however, as, for example, that described by Gorini in association with the bacillus prodigiosus, resist as much as an hour's ex- posure to 70° or 80° C, and require at least half an hour's exposure to 100° C. (or 212° F.) for their destruction. It is practically inevitable that milk, as delivered from the cow, should contain a number, and usually a very large number, of bacteria. The extent of their presence is, however, affected by many circumstances, of which some are also indications of unwholesomeness or danger. Many of the organisms which are capable of causing disease do so by producing toxic decomposition-prod- ucts from the milk. Their vegetative capacity increases greatly with rise of temperature, and it is therefore an essential condition of sanitary milk-production and espe- cially of the designation of a milk as suitable for children that it should be kept at a low temperature during the whole of the interval between being drawn and being con- sumed. Yellow milk is said to be colored by the bacillus ^° Zeitschrift filr Hygiene, xvii, page 272. ^^ Centralblatt fiir Bacteriologie, ix, page G53. DETECTION AND ADDITION OF PEESERVATIVES. 119 synxanthus of Schroter, tlie color being removed by acids and restored by alkalies. Salty milk is stated to occur only in connection with inflammation of the udder. It is to be detected not only by its taste and its high percentage of ash^ but by its low percentage of milk-sugar. Its specific gravity is 1.027 to 1.029. According to Klenze^, 2.4 per cent, of small de- posits of calcium carbonate in the milk-glands may give rise to sandy milk. Curious results have been noted by Scheurlen/^ in experimenting with bacteria in milk. He found that milk can be freed from bacteria by the opera- tion of a centrifugal machine. He also noted that, of the large majority of bacteria contained in milk, three-fourths went into the cream on being centrifugalized, and the rest stayed in the separated milk, and the same result was ob- tained by merely leaving the milk stand. These results held good not only for the ordinary milk bacteria, but also for anthrax, typhoid, and cholera. The tubercle bacillus only remained to a small extent in either the milk or the cream, and the large majority was ejected under the cen- trifugal influence. The biological commission on milk- supply held under the auspices of the British Medical Journal for 1895, reported the following: 1. That all milking be carried on in the open air, the animal and operators standing on a material which is capable of being thoroughly washed, such as a floor of concrete or cement. Such a floor could be easily laid down in any convenient place which can be found. The site chosen should be removed from inhabited parts as far as possible, and should be provided with a plentiful water-supply. Only in this way does it seem possible to avoid the initial con- tamination with the colon bacillus. 2. That greater care should be expended on the personal cleanliness of the cows; the only too familiar picture of the animal's hind- "^ Arbeiten a. d. k. Ges. Amt., vii, 1891. 120 INFANT-FEEDING. quarters, flanks, and side being thickly plastered with mud and faeces is one that should occur no longer. It would not be difficult to carry out this change. Indeed, in the better managed of our large dairy companies^ farms such a condition no longer prevails, but in the smaller farms it is but too frequently met with. 3. That the hands of the milker be thoroughly washed before the operation of milking is commenced, and that after once being washed they be not again employed in handling the cow, other- wise than in the necessary operation of milking. Any such handling should be succeeded by another washing in fresh water before again commencing to milk. 4. That all milk-venders^ shops should be kept far cleaner than is often the case at present; that all milk-retailing shops should be compelled to provide proper storage accommo- dation, and that the counters, etc., should be tiled. The Breed of a Cow. Some breeds yield quantity, others quality. Hol- steins produce the most milk; Alderneys and Jerseys yield the most fat; shorthorns give the most casein and sugar. The average capacity of a cow's udder is about 5 pints, and the annual yield of milk is about 600 gallons. Time and Stage of Milking. Cows are usually milked twice a day, the morning milk usually being larger in quantity and poorer in qual- ity. The milk which is first drawn is known as the fore- milk, and contains very much less fat than that last drawn, known as the strippings. This is due to a partial cream- ing taking place in the udders. Dishonest dealers have often taken advantage of this fact in adulteration cases to have the cows partially milked in the presence of ignorant witnesses, the resulting milk consisting largely of the foremilk. cuedling of milk and diluents. 121 Age of Cow. Young cows give less milk, while cows from four to seven years old give the richest milk, and less milk is given wdth the first calf. They give the largest yield, ac- cording to Fleishmann, after the fifth until the seventh calf; after the fourteenth calf they yield, as a rule, no more milk. The poorest milk is yielded during the spring and early summer; the richest during the autumn and early winter. If cows are worried or driven about, the quality and quantity of the milk are reduced. If they are kept warm and well fed, both quantity and quality are naturally increased. Effect of Alkalies on Milk. By running milk through a centrifugal machine a product known as ^^separator slime" is produced, which is analogous to mucin. A decided difference in viscosity is noticed between milk before and after running it through a centrifugal machine. This "separator slime" swells up and forms a viscid jelly with lime-water or alkalies. Milk to which alkali is added is decidedly more viscous than milk that is slightly acid, and is so undoubtedly because of the action of the alkali on the mucin of the milk. Curdling of Milk and Diluents. Milk of all animals may be separated into two classes. Those that form a soft curd with rennet and those that form a hard curd with rennet. Woman^s milk is in the first class and cows' milk in the second. The conditions favorable for the formation of hard curds of cows' milk are body-heat and the presence of rennet and lactic or other acid. The rennet forms a clot of the milk, the heat causes the lactic bacteria to grow in the curd, and the acid causes the curd to shrink and become leathery. Adding alkalies 122 INFANT-FEEDING. to the milk neutralizes the acid, but the bacteria will keep making more lactic acid as long as any sugar is present. Diluting milk with water does not prevent tough curds forming, but diluting with gruels does prevent the contraction of the curds. This has been proved beyond dispute, both experimentally and clinically. Albuminoids in Cows' Milk. That there are differences in the amounts of the albu- minoids occurring in human milk is proved by the fact that, while Professor Leeds found a variation of 0.85 to 4.86, Professor Meiggs asserts that there was but 1 per cent. Konig, an earlier analyst, makes the variation from 0.85 to 4.86. Some of these results give as high a per- centage of albuminoids in woman's milk as we find in cows' milk, and I have no doubt in my own mind that the time and habit of extracting the milk has a deal to do with the amount of occurring albuminoids. In other words, when milk is extracted every two hours or less, it cannot contain as much of the cell-material as milk from the same source extracted at intervals of twelve hours. This latter is riper and it is the non-uniformity of the tis- sue which causes all the difference in the different oc- curring albuminoids. We know that during the incuba- tion of eggs casein is developed from egg-albumin. This illustrates the ripening of albumin. Furthermore, take an egg just laid by the hen, and boil it, and you will find im- mature albumin in it; that is, after boiling, instead of being thick and firm, like an older egg, much of it is milky. If boiled a few hours later, all the albumin will coagu- late perfectly, because it has had time to ripen. There is no doubt that the albuminoids in milk from healthy ani- mals are all cell-transformations, not an exudate, as are undoubtedly the fats and salts, because these latter we can influence by the food very plainly, but in health the al- buminoids are constant without regard to food, while dur- ALBmrmoiDS in cows' milk. 123 ing menstruation, pregnancy, and other conditions, not- ably febrile disturbances, we find the fats and salts not materially affected, but the albuminoids decreased, in- creased, or totally changed, as in the case of colostrum. The casein, besides heing I'iper in cows' mill', by reason of its stronger growth, is intended by Xature to coagulate into a hard mass, because it is the product of a cud-chewer for the nourishment of a cud-chewer, and the reason why it does not always coagulate in the infant's stomach as it does in that of the calf is that the latter animal's stomach secretes a principle called chymosin; this is the principle that curdles cows' milk, and it operates either in an acid or an alkaline medium. Pepsin luill not coagulate milk, and hence the hard coagulum of cows' milk that sometimes forms in the infant's stomach is due to acidity of that organ, and this acidity is not always the fault of the stom- ach, hut of the milk itself. The variations in the chemistry of the albuminoids found in cows^ milk would not be sur- prising to anyone if he would examine into the condition of some of its mammai^ sources. Thus it will often be found, on dissecting a cow's udder, which I always do when making an autopsy on a cow, that there are old cicatrices, one or more quarters of the udder intensely inflamed, sometimes a mammiferous duct clogged with a calculus or a clot of fibrin. Besides these pathological conditions, the mammary gland is subject to benign and malign infil- trations, bacillary tubercular deposits, and eruptive dis- eases of the skin involving the gland and ducts. There- fore, that fibrin, serum, and albumin, in various forms, are found in the cows' milk is not surprising, and it can safely be assumed that any variation in the albuminoids from the normal casein can be ascribed to sickness on the part of the animal. We next come to the salts contained in milk, and it is remarkable how few analyses have been made to deter- mine the salts or minerals that are contained in this fluid. 124 INFANT-FEEDING. Heidlen^s analysis, copied everywhere, seems to be the only exhaustive one of the salines in cows' milk made dur- ing the present century. It seems to me in this case, too, that it is time for the chemist to teach us something more. There probably never was a time, in our era, at least, when milk was attracting so much attention as now, and still all our chemists are content with the total solids, fats, albuminoids and sugar — just what the butter-makers and cheese-makers want to know. From this much-quoted analysis of cows'-milk salts we learn that milk contains in various proportions the phosphates of lime, magnesia, and iron; the chlorides of potassium, sodium, and iron; and free soda. Robin gets from human milk, in addition to the fore- going, carbonate of lime and soda, phosphate of soda, sul- phate of soda, and potash. We have no means of knowing how constant is the occurrence of any of these salts in milk or under what conditions they are modified; we do know, however, from the experiments of Fehling, that many of the drugs administered to the milking female are excreted in the milk. Therefore, we can safely assume that the saline constituents occurring in milk are influenced both by the health and food of the animal. That the phos- phates are craved for hj the milking cow is evidenced by the habit of chewing old bones and the like, and that there is a lack of this element of food is not to le wondered at when we see herds of milking cows pastured on old, worn-out lands; the practical farmer knows that exhausted pasture- lands need, more than anything else for their rejuvenes- cence, the phosphates, and we know that in our nutrition we need them also. The land on which a cow is pastured will indicate pretty fairly what we may expect to find in her milk as salts. We have all noticed the excessive growth of sorrel on exhausted land, and can it then be a subject of wonder that some kind of a vegetable acid should be found in the milk of animals that are obliged to include this variety of food in their summer-rations 125 and sour ensilage or spoiled brewery grains in their winter-feed? Theodore Hankel's discovery of citric acid in cows' milk to the amount of 0.9 and 1.1 grammes per litre is just what might be expected. Sugar, I think, in milk has always been overestimated as to its nutritive value, because we know that carnivorous animals do not secrete sugar to any appreciable extent, according to chemists. When we see a small slut nursing seven or eight puppies and keeping them all fat, and in a thriving condition, we can easily imagine that sugar is not a necessary element of food, for the canines excrete no sugar in their milk. We see that the gross result of con- densed-milk feeding with an excess of sugar is harmful. Brush maintains that pure cane-sugar is the ideal addition to cows' milk. Prof. L. B. Arnold, an authority on dairy matters, says that, when milk will not properly nourish an infant, then it is not the cows' milk that is at fault, but it is either a pathological condition of the cow or improper food or care, or the conditions through which the milk has passed on its way from the cow to the infant. The average temperature of a cow is 102 V2° ^^ (Brush). This is certainly a peculiarity of the cow. An- other peculiarity is the constant employment of her gen- erative functions: she is always milking or pregnant, and both the uterus and the mammary glands are employed al- most constantly at the same time. Her nervous system is more subject to severe shocks, and she is a delicate creat- ure. As regards the average income from a cow, it is about $20.00 a year to the producer. This is about 7 cents a day, from which the dairyman has to buy food and pay for labor. In order to make a profit the dairyman must utilize every drop of milk, whether the animal giving it be sick or well. It is, therefore, very common to find that all the cheap foods, such as brewery grains, distillery slops, and the refuse from starch-factories enter largely into the 126 INFANT-I'EEDING. food from which our babies' supply of milk is produced. Brush maintains that^ in personal inspections of small dairies near New York City^ the sole, article of diet was swill. One of the means employed for removing the stable odors of milk is by adding nitrate of potash, commonly known as ^^saltpeter." With this drug a substance re- sembling nitroglycerin is formed. It is strange that the toxic effects of nitroglycerin are similar to those of tyro- toxicon. Brush believes that the ideal dairy for supplying in- fant-food should be composed entirely of spayed cows, and thus one constant source of nervous function of dis- turbance would be eliminated. He believes that these animals are much more quiet in disposition, they give a more constant and uniform supply of milk, and seem to enjoy a more even degree of health than the cow who is occasionally bulling and becoming pregnant when giving milk. The author has certainly had very good results with Brush's milk, and, although it is somewhat expensive, he has found it well adapted for the home-modification of infants' food. CHAPTER XYII. Cream. When food contains too little fat, or its equivalent (cream), we have fat-starvation, which is soon manifested by symptoms of rickets. One of the earliest symptoms of rickets is constipation, showing deficient muscular tone: a distinct atony of the bowel. This can be remedied by the addition of fat or cream to the food. Some children are benefited by giving them codliver-oil, butter, or olive-oil. Some authors advise giving fried bacon to very young children; thus it is plain that each one desires to remedy the deficiency of fat in his own manner. In buying cream from small milk-stores one can make a rough guess at the proportion of fat in cream by its thickness. A 50-per-cent. cream at the ordinary tempera- ture of the room runs from a jug slowly and in a thick stream, almost like thick mucilage, whereas a 16-per-cent. cream runs almost as freely as milk. This is, however, a crude way of estimating the difference between poor and rich cream. It is a very important point to know exactly what percentage of cream we are using, for such mixtures like Biedert's, in which 1 ounce of cream is mixed with 3 ounces of water, may agree very well when we use a 16- or 20-per-cent. cream, but might be disastrous if we use a cream containing 40 per cent, of fat. Such infants would not tolerate this rich cream, and might have troublesome vomiting. CREAM FOR HOME-MODIFICATION. Ordinary Cream. — This is made by setting milk at night and skimming it in the morning; it is called grav- ity, or skimmed, cream, and contains 16 per cent, of fat. (127) 128 INFANT-FEEDING. Twelve-per-cent. Cream. — Obtained in the city by using equal parts of ordinary (20 per cent.) centrifu- gal cream and plain milk. In the country we must use 2 parts of ordinary skimmed, or grayity, cream (16 per cent.) with 1 part of plain milk, or by taking the top layer of milk after it has stood five or six hours^ by means of siphoning. Eiglit-'per-cent. cream is obtained in the city by dilut- ing 1 part of centrifugal (20 per cent.) cream with 3 parts of plain milk; in the country, by using 1 part of gravity cream and 2 parts of plain milk, or by using the top layer of milk that has been standing five or six hours, and siphoning it off. Top-milk is obtained directly from fresh milk by the so-called *^^gravity process. ^^ Cream contains a great deal of fat, usually three-fifths of cream is fat; this floats on the surface of the watery milk. If a quart bottle of the average city milk is put into ice-water or upon ice in the refrigerator, and removed after four or five hours, we can skim off from the top about 10 ounces of an 8-per- cent, cream; after six hours about 6 ounces of 12-per-cent. cream. This I shall speak of as top-milk. Frequently, instead of skimming the cream, the lower portion is si- phoned off, leaving the cream in the glass bottle. When cream is removed by a centrifugal machine, it is known as centrifugal cream. It can be separated much more quickly than so-called gravity cream, which must rise naturally and slowly from milk that is allowed to stand. HOW TO PROCURE CREAM. Set aside the ordinary quart bottle of milk on the ice for several hours (from six to eight hours) to allow the cream to rise. After the cream has risen draw the milk from the bottom of the bottle; this can be accomplished by means of a siphon. To make the siphon get a piece of glass tubing 21 CREAM. 129 inclies in lengtli and a quarter of an inch in calibre. This can be procured in every drug-store. German glass is less liable to crack than American glass. If the glass tubing is longer than 21 inches make a small scratch in it, after measuring off 21 inches, with a three-cornered file; then grasp the glass tubing between the fingers and opposing thumbs of both hands, having the thumb-nails touching on the side of the glass just opposite to the scratch. On attempting to bend the glass tube it will break smoothly across, and if there are any sharp edges they can be smoothed by rubbing them down with the file. To bend the glass tube to the Y shape, hold it in the flame of an ordinary gas-jet or alcohol-lamp for a few moments, twirling the glass rod until it softens suffi- ciently to allow it to be bent to the required angle. The tube should be warmed gradually at first, and then put right into the flame. It is better in bending the glass to make one arm of the siphon a few inches longer than the other. In using the siphon hold it with the angle down, fill it with water and close the long arm with the tip of the finger, then keeping the finger applied to the long end, turn the siphon with the angle up, and introduce the short arm into the bottle of milk, letting it rest upon the bot- tom. On removing the finger, the milk will flow through the tube, and continue to do so until the bottle is empty. It is, therefore, necessary to watch the layer of cream, so that the siphon can be lifted out of the bottle just before the cream reaches it. There will thus remain in the milk- bottle all of the cream and a small portion of the milk, the latter depending upon the expertness of the person using the siphon. TO PASTEUEIZE THE CREAM. Take a clear glass bottle having a neck not very wide; fit into the same a perforated cork with a chemical ther- 130 INFANT-FEEDING. mometer registering up to 212° F. The bnlb of the ther- mometer should come within half an inch of the bottom of the bottle. The cream is put into the bottle, and the cork carrying the thermometer is inserted; the bottle is then placed in a pot containing a couple of inches of warm water and allowed to heat on the stove. The ther- mometer should be watched until it reaches 160, taking care that it does, not go above 170. When the ther- mometer has reached this point, set the pot back on the stove where it will cool off, and allow it to remain there for twenty minutes. At the end of this time substitute a plug of absorbent cotton for the cork containing the ther- mometer. Great care must be taken to keep the absorbent cotton dry. Cream thus prepared is pasteurized, and will keep sweet and fresh for twenty-four hours without being kept on ice, and all that is necessary in removing a portion from the bottle is to be sure that the cotton plug does not become moist, or, if it should, to replace it with a dry piece at once. TO CLEAN THE GLASS SIPHON. It is advised to fill it with water immediately after using it, and the ordinary tube-brush having eighteen inches of wire added to it will permit thorough cleansing. Nothing, however, will be found as good as thorough boil- ing in plain water to which a pinch of soda has been added. Modification of Milk. It has been shown previously that the percentages of fat in woman's and in cows' milk are about the same, that the quantity of sugar is rather lower in cows' milk, and that the quantity of casein and albumin is greater in cows' milk, as is also that of the ash. Experience has shown that cows' milk must be diluted before it can safely be fed to infants. Simply diluting the milk reduces the CREAM. 131 percentages of fat and sugar too much; so the practice of adding cream and sugar has arisen, but the processes that have been advocated for obtaining the desired additional quantities of fat and sugar have been too complicated for general use. The top 9 ounces of a quart of milk on which the cream has risen will be about three times as rich in fat as the whole milk, the top 15 or 16 ounces will be about twice as rich as the whole milk, while the other ingredi- ents remain about the same as in whole milk. For babies under 3 months of age the top 9 ounces of a quart of milk on which the cream has risen should be diluted from 3 to 10 times and 1 part of sugar added to 25 parts of food. For babies 3 to 6 months old the top 16 ounces of a quart of milk on which the cream has risen should be di- luted 2 or 3 times and 1 part of sugar added to 25 or 30 parts of food. For babies 6 to 9 months old the top 20 ounces of a quart of milk on which the cream has risen should be di- luted Y2 to 1 time and 1 part of sugar added to 50 parts of food. An even tablespoonful of granulated sugar equals V2 ounce. By following this method the infant commences on weak mixtures that show about the same composition and variations as mothers^ milk and gradually takes food richer in casein until plain milk is reached. The diluents used are water, gruels, or dextrinized gruels, which are simply ordinary gruels the starch of which has been converted into soluble forms, leaving the cellulose and proteids of the cereal in a finely-divided state. The effect of the different diluents will be men- tioned farther on. 132 INFANT-FEEDING. Milk-sugar Solutions. 1. Take 1 ounce of milk-sugar and 20 ounces ] of water, and dissolve. | This makes about a Or 1 even tablespoonful of milk-sugar and J- 5-per-cent. sugar 7 ^/s tablespoonfuls of water, and dis- solution, solve. 2. Dissolve 1 tablespoonful of milk-sugar in ] 6 V2 ounces of water. [ Makes a 6-per-cent. Or 1 ounce of sugar is to be dissolved in [ sugar solution. 16 ^/a ounces of water. J 3. Dissolve 1 ounce of sugar in 14 ounces of ] water. [ Makes a 7-per-cent. Or 1 even tablespoonful in 5 V2 ounces of { sugar solution, water. 4. Dissolve 1 ounce of sugar in 12 V2 ounces of water. [ Or 1 even tablespoonful in 12 V2 ounces of [ , . water. Makes an 8-per- ^ y cent, sugar solu- of 1 Makes a 10-per- 5. Double the strength of above milk-sugar I , , (Formula No. 1). | tTol" '''^^' '' "" ADDITION OF SUGAR TO MILK. In order to render milk palatable^ sugar must be added in some form; hence cane-sugar or milk-sugar has been advised. Jacobi insists on the addition of cane- sugar, and he agrees with Bieclert, who uses it in his cream-mixture. That cane-sugar certainly has some virtue can be seen by the fact that it is used extensively as a preservative in the manufacture of condensed milk. Cane-sugar. — Cane-sugar, being far sweeter than sugar of milk, it is advisable to use V2 the quantity that would ordinarily be used for sweetening with milk-sugar. Cane-sugar is advised in the treatment of constipation; frequently we find breast-fed babies who suffer constipa- tion, the cause of which is deficiency in sugar. In such cases giving ^/^ lump or about V2 teaspoonful of cane- ALKALINE SOLUTIONS. 133 sugar dissolved in a teaspoonful of sterile water (ordinary boiled water), and this given immediately before putting the baby to the breast, will make up the deficient sugar and frequently modify a distressing constipation without resorting to drugs. Cantra-indi-cations to the Use of Sugar. — There are a great many conditions in which the addition of sugar is not only contra-indicated, but absolutely harmful. For example: If an infant suffers with colic and has sudden attacks (paroxysms) of pain which disturb the infantas sleep, such an infant will be found with its legs drawn up to its belly, and besides it will utter shrieks while crying. The stools will be usually green and sour smelling, and the ab- domen will be found greatly distended with gas from fer- mentation, and frequently the infant will have violent eructations. Such an infant usually receives an excess of sugar. The treatment of such a case is the absolute dis- continuance of sugar in the food. HOW SHALL V7E SWEETEN? If constipation has accompanied the infant's fer- mentative condition and has also preceded this attack of colic, then I advise adding glycerin to the milk. It has a very sweet taste and a pronounced laxative effect. Dose of Glycerin. — For some children half a teaspoon- ful of glycerin added to each bottle will suffice; for others, I frequently use 1 teaspoonful to each bottle, rarely more. Glycerin has a pronounced antifermentative effect; being an oil, it is indicated in children requiring the addition of fat. It certainly has decided nutritive properties. SOLUTIONS USED EOR EENDERING COWS' MILK ALKALINE. Lime-water is the alkali usually selected for neutral- izing the acidity in cows' milk. It acts by partly neutral- 134 INFANT-FEEDING. izing the acid of the gastric juice, so that the casein is coagulated gradually and passes, in great part, unchanged into the intestine, to be there digested by the alkaline secretions. As it contains only ^/ ^ grain of lime to the fluidounce, the desired result cannot be attained unless at least a third part of the milk-mixture be lime-water. Instead of lime-water, 2 to 4 grains of bicarbonate of sodium may be added to each bottle, or, better still, from 5 to 15 drops of the saccharated solution of lime. This solution is made in the following way: — IJ Slaked lime, 1 ounce. Refined sugar, in powder, 2 ounces. Distilled water, 1 pint. Mix the lime and sugar by trituration in a mortar. Transfer the mixture to a bottle containing the water, and, having closed this with a cork, shake it occasionally for a few hours. Finally separate the clear solution with a siphon and keep it in a stoppered bottle. BicarljonaU-ofSoda S'Olution {Baking-soda). — Take 1 grain of soda bicarbonate to V2 ounce of water. Or 1 drachm of soda bicarbonate to 1 quart of water. This is the proper strength used for diluting milk. Quantity to he- Used. — One tablespoonful of the last- named solution equals in strength 1 tablespoonful of ordi- nary lime-water. Both lime-water and soda-bicarbonate solution should be kept in very clean, well-stoppered bottles and in a cool place. CHAPTER XVIII. Water. Or all the necessities of an infant, water stands out most prominently. It will aid materially in clearing the mouth and gums and in quenching the thirst. It is cer- tainly diuretic, and water given regularly is one of our best laxatives. It is a good rule, and one that I insist upon, namely: to instruct every mother and nurse that a child, young or old, must receive water several times a day. Quantity. — An infant up to the first month shall re- ceive several teaspoonfuls of plain sterile (boiled) water, which has been allowed to cool, but by no means ice-water. This drink of water is best given either immediately after nursing or feeding or as soon after the feeding as possible. It is not necessary to awaken the child to give it a drink, but if it is not time for feeding and the infant is restless, a few spoonfuls of cool water will frequently com- fort it. When we desire to modify constipation, then water will be a most important factor, especially so when large, cheesy curds are found in the stool. Instances will be found in which some children will refuse water; then the slightest addition of a few grains of granulated (cane-) sugar will prove advantageous. Older children, over six months old, can, if properly de- veloped, take hold of a glass and be guided in the drinking or sipping of a wineglassful of water. I advise giving at least 3 wineglassfuls of plain sterile (boiled) water per day, especially during warm weather. The free dilution of children's nourishment with (135) 136 INFANT-FEEDING. water is demanded upon the following additional facts: Only to a certain limit will pepsin be furnished for di- gestive purposes. Probably a portion of this is not en- tirely utilized. A great quantity of water is necessary to assist in pepsin digestion. In artificial digestion albumin often remains unchanged until large quantities of acidu- lated water are supplied. Without doubt many disturb- ances of digestion are to be explained by a deficiency of water/ certainly many more than are due to an excess of it, as it is so quickly absorbed. CHAPTEE XIX. BOTTLE-FEEDIXG, OR HaXD-FEEDIXG. Cleanliness. — The most important point to remember is that everything used in connection with "hand-feeding^^ mnst be scrupulously clean. To sterilize milk in a filthy bottle^ or to put milk contaminated with stable filth or dirt from the udder of a cow, or milk containing pathogenic bacteria, into an abso- lutely clean bottle, is surely repulsive. Therefore, my first proposition is: "clean every- thing that is associated with infant-feeding,^' from the milking of the cow, the surroundings of the cow, until the food is ready to be fed to our infants. This necessarily implies quite an amount of work, which I shall try to detail later on. Amount to le Fed. — Ssnitkin (investigations at the Children's Hospital of St. Petersburg, quoted by Eotch) makes the following rule: "The greater the weight, the greater the gastric capacity." Ssnitkin's table of calculation shows that one one- hundredth of the initial weight should be taken as the figure with which to begin the computation, and to this should be added one gramme for each day of life. Initial Weight. 3000 Gm. 4000 Gm. 5600 Gm. Illusteatiox of Ssxitkin's Rule. Early Days. At 15 Days. At 30 Days. 30 Gm. 30 + 15 = 45 Gm. 30 + 30 = 60 Gm. (About 1 oz. ) (About U oz.) (About 2 oz. ) 45 Gm. 45 + 15 = 60 Gm. 45 -f 30 = 75 Gm . ( About li- oz.) ( About 2 oz. ) ( About 2.^ oz. ) 60 Gm. 60 4- 15 = 75 Gm. 60 + 30 = 90 Gm. (About 2 oz. ) (About 2h oz.) (About 3 oz. ) (137) CHAPTEE XX. Feeding-table and Cream-mixtures. Age. lNTERVAI,S OF Feeding. Number OF Times IN 24 Hours. Average Amount Each Feeding. Average in 24 Hours. 1st week .... 1st month . . . 2d month . . 3d and 4th mos. 5th and 6th mos. 2 hours 2 hours 2^ hours 3 hours 3 hours 10 8 8 7 6 10.. 1.} to 2 OZ. 3 to 4 OZ. 4 to 5 OZ. 6 to 7 oz. 10 oz. 12 to 16 oz. 20 to 30 oz. 30 to 35 oz. 34 to 40 oz. The above is the feeding-table of George C. Car- penter (London). biedert's cream-mixtures. The following fornHilas are from the fourth edition of his book on "Infant-feeding," published in 1900: — Casein. Fat. Sugar. Per Cent. Per Cent. Per Cent. Formula. Cream. Water. MiUc-sugar. 3Iilk. I. II. III. IV. V. VI. 4 oz. 4 oz. 4 oz. 4 oz. 4 oz. 12 oz. 12 oz. 12 oz. 12 oz. 12 oz. 8 oz. Cream. Milk. Wafer 1st mo. 2d mo. 3d mo. 4th mo. 5th mo. 6th mo. (138) 5iv. No. No. No. No. No. No. Sxvj. 5x1]. No. No. No. No. 5viij. 4.} dr. 4^ dr. 4.^ dr. 4J dr. ^dv. 3 dr. 3iim- siigar. 5SS. No. No. No. No. ^iiss. 2 oz. 4 oz. 80Z. 12 oz. 24 oz. 0.9 1.2 1.4 1.7 2.0 2.5 Casein. 2.5 2.6 2.7 2.9 3.0 2.7 Is equiv alent to Is equiv alent to alent to Is equiv- alent to Is equiv- alent to Is equiv- alent to Fat. Sugar. Per Cent. Per Cent. Per Cent. 1.0 2.4 1.4 2.3 2.6 3.2 2.6 2.7 2.9 3.0 3.0 3.8 3.8 3.8 3.8 3.7 4.0 CEEAM-MIXTUEES. 139 The latter are known as Biedert's cream-mixtures, and are quoted by A. Jacobi.^^ According to recent milk-analyses^ it is necessary to take 6 per cent., which is equivalent to 5 V2 drachms of sugar, to 12 ounces of water. It has also been shown that cane-sugar in the same quantity as milk-sugar can be used. In using Formula 5, especially if an infant is constipated, it is advisable gradually to substitute milk for the water; thus we take away 1 ounce of water^ and add 1 ounce of milk, until our formula is: — Cream. Siigar-ivater. Milk. 4 ounces. 4 ounces. 20 ounces. and gradually arrive at a whole-milk feeding; in other words: give pure cows^ milk undiluted. Biedert claims that frequently diluted cows' milk was not well borne, especially on weak stomachs, and the change to the cream- mixture resulted in decided benefit. Moreover, he believes that the cream-mixture is assimilated far better than the diluted milk-mixtures not containing cream. Thus he claims that the cases of constipation alter- nating with diarrhoea and lastly mucous enteritis are those in which the cream-mixture will render satisfaction; but he advises that a definite rule must prevail regarding the amount of fat contained in the cream, and further- more that an 8- to 10-per-cent. cream be used. BIEDERT S DIRECTIONS FOR MAKING HIS CREAM. From 1 to 2 quarts of milk are put into a broad jar (glass) on the ice, for no longer than two hours. He then removes with a flat spoon from 3 ^/g to 7 ounces of the thin white creamy layer over the bluish mass of milk. In removing the above quantity a small portion of the milk 'Therapeutics of Infancy and Childhood. 140 INFANT-FEEDING. will be remoYed with it. In cases of severe constipation Biedert insists on removing pure cream. The above Formula I is for the first month, Formula II is for the second month, Formula III is for a child from three to four months, Formula IV is for fourth to fifth month. Formula V is for the sixth to seventh month, and Formula VI is for the eighth to tenth month. It is self-understood that, while feeding, the general condition of the child is the criterion, and thus we shall frequently be compelled to change the formula for indi- vidual requirements, some infants requiring far more cream than the above-mentioned formulae give them for their age and their weight, whereas the great majority will require a modification of far less cream than the above-given formulae for their age and weight. CHAPTER XXI. Home-modification of Milk. coit's decimal method (tuttle, gallaudet). This is the simplest and easiest-worked method of home-modification yet suggested. It is based on the metric system^ and all the calculations are made in deci- mals. Three solutions are required: 1. A decimal (10 per cent.) cream, or superfatted milk for introducing the fat. 2. A saccharated (10 per cent.) skimmed milk for intro- ducing proteids not carried by the cream. 3. A standard (10 per cent.) sugar solution for introducing the lactose not carried by the cream or the skimmed milk. Solutions 1 and 3 only are required when the proteid percentage is small. As the child grows older, and a higher proteid percentage is necessary, solution 2 is required also. Decimal cream is produced by allowing a quart of ordinary fresh milk from a mixed herd to stand on ice for fifteen hours, and at the end of this time one-fifth of it is taken from the top. This averages 15 per cent, of fat, and loses about ^/^ per cent, each of sugar and proteids. If to this we add '^/^ its volume of water, a decimal cream is obtained, analyzing: 10 per cent, of fat, 2.33 per cent, of proteids, and 2.66 per cent, of sugar. From this the following formulae, showing the amounts of proteids and lactose coincidently introduced with any definite fat-per- centage, are easily deduced: — Decimal cream in introducing 4 per cent, of fat also introduces 1 per cent, of proteids and 1 per cent, of lac- tose. Decimal cream in introducing 3.5 per cent, of fat also introduces 0.8 per cent, of proteids and 0.9 per cent. (141) 142 INFANT-FEEDING. of lactose. Decimal cream in introducing 3 per cent, of fat also introduces 0.7 per cent, of proteids and 0.8 per cent, of lactose. Decimal cream in introducing 2.5 per cent, of fat also introduces 0.6 per cent, of proteids and 0.7 per cent, of lactose. Decimal cream in introducing 2 per cent, of fat also introduces 0.5 per cent, of proteids and 0.5 per cent, of lactose. Saccharated skimmed milk depends on the fact tliat skimmed milk analyzes 4 per cent, of proteids and 5 per cent, of sugar. Five per cent, more of lactose is added simply for convenience of calculation. This means adding 1 ounce^ by weighty of lactose to 20 ounces of skimmed milk. Our solution then analyzes: proteids^ 4 per cent.; and lactose, 10 per cent. If we wish to add 1 per cent, of proteids, we use one-fourth of the total food required from solution 2; if 0.5 per cent, of proteids, one-eighth, etc., always remembering that we introduce coincidently two and one-half times as much sugar. The formulse here de- duced are also plain: — Amount of food in cubic centimetres x ^/g (saccha- rated skimmed milk) adds proteids, 0.5 per cent.; and lac- tose, 1.25 per cent. Amount of food in cubic centimetres X V4 (saccharated skimmed milk) adds proteids, 1 per cent.; and lactose, 2.5 per cent. Amount of food in cubic centimetres x ^/g (saccharated skimmed milk) adds pro- teids, 1.5 per cent.; and lactose, 3.75 per cent. Amount of food in cubic centimetres x ^/s (saccharated skimmed milk) adds proteids, 2 per cent.; and lactose, 5 per cent. Standard sugar solution is prepared by dissolving 10 per cent, of lactose in sterile water, or 2 ounces, by weight, in 20 ounces of water. In calculating formulge four facts only are necessary: the quantity of food required; the percentage-formulae required; that the standards, except the proteids, are 10 per cent.; and the quantity of other constituents intro- duced with the standards. HOME-MODIFICATION" OF MILK. 143 With these facts in mind, all that is necessary further is to reduce the quantity expressed in ounces to cubic centimetres by multiplying by thirty, and to multiply this product by one-tenth of the constituent to be introduced. Examples with and without the introduction of extra pro- teids will be given: — SixGLE Feeding. Fat. Frofeids. Sugar. Per Cent. Per Cent. Per Cent. Quantity, 2 oz. Formula desired ..... 2.0 0.50 6.00 Oz. 2X30 = 60 c. cms. X 0.2=12 corns. decimal cream, adds 2.0 0.50 0.50 Leaves 0.0 0.00 5.50 Oz. 2X30 = 60 c.cms. X 0.55 = 33 c.cms. sugar solution, adds 5.50 Working formula: 12 c.cms. decimal cream. 33 c.cms. standard sugar solution. 15 c.cms. water. 60 c.cms. One Day's Food. Fat. Proteids. Sugar. Per Cent. Per Cent. Per Cent. Quantity, 35 oz. Formula desired . . . 4.0 1.0 6.50 Oz. 35 X 30=1050 c.cms. X 0.4 = 420 c.cms. decimal cream, adds . .... . . 4.0 1.0 1.00 Leaves 0.0 0.0 5.50 Oz. 35 X 30 = 1050 c.cms. X 0.55 = 577.50 c.cms. sugar solution, adds .... 5.50 Working formula: 420.00 c.cms. decimal cream. 577.50 c.cms. standard sugar solution. 52.50 c.cms. water. 1050.00 c.cms. One Feeding. Fat. Proteids. Sugar. Per Cent. Per Cent. Per Cent. Quantity, 5 oz. Formula desired ... 4.0 1.50 7.00 Oz. 5X30 = 150 c.cms. X 0.4 = 60 c.cms. decimal cream, adds 4.0 1.00 1.00 Leaves 0.0 0.50 6.00 Oz. 5 X 30 = 150 c.cms. X i = 18.75 c.cms. skimmed milk, adds ... 0.0 0.50 1.25 Leaves . . 0.0 0.00 4.75 Oz. 5 X 30 = 150 c.cms. X 0.475 = 71.75 c.cms. sugar solution, adds 4.75 144 INFANT-FEEDING. Working formula: 60.00 c.cms. decimal cream. 18.75 c.cms. saccharated skimmed milk. 71.25 c.cms. standard sugar solution. 150.00 c.cms. General Rules for Bottle-feeding. Age of Child. Frequency OR Interval, OF Feeding. Number of Feedings in 21 Hours. Average Amount for Each Feeding. Average Amount in 24 Hours. From its birth until it is 1 month old. 2 hours. 10 1 ounce. 10 ounces. 1 month until 2 months. Every 2h hours. 8 I2- some- times 2 ounces. From 12 to 16 ounces 2 to 4 months old. Every 3 hours. 6 or 7 From 3 to 4 ounces. From 18 to 24 ounces. 4 to 6 months old. Every 3 hours. 6 5 or 6 ounces. 30 or 36 ounces. 6 to 9 months old. Every 3^ to 4 hours. 5 8 ounces. 40 ounces. 9 to 12 months old. Every 4 hours. 5 8 ounces. 40 ounces. 1 Rules for Feeding. F'or a Child at Birth. Formula 1. — The newborn in- fant's food should consist of: — Home-modification. To make this formula, we take of Fat 1.0 Sugar 5.0 Proteids 0.75 Reaction alkaline. Cream 2 ounces. Milk 2 ounces. Lime-water 1 ounce. Water 15 ounces. Milk-sugar 67* drachms. The above formula (1) is to be divided into 10 feed- KULES FOR FEEDING. 145 ings of 1 ounce each, or 30 cubic centimetres each, and should be heated for 20 minutes to 167° F. The cream must contain at least 10 per cent, of fat. This is known as a decimal cream, and can be referred to under the heading of "Cream for Home-modification." Child 1 Month. Formula 2. — Formula for Home Use. Take of Fat 2.0 Cream 4 ounces. Sugar 5.0 Lime-water 1 ounce. Proteids 0.75 Water 15 ounces. Lime-water . .5.0 Milk-sugar 67* drachms. The above quantity is to be divided into ten feedings, and heated for 20 minutes to 167° F., and the infant to be fed once every two hours. In Formula 2 we have added more cream and purposely left out the milk. If the in- fant thrives on this mixture, then we can substitute 1 ounce of milk instead of 1 ounce of water. After the end of the second month the quantity of food can be increased if the infant's appetite, sleep, stools, and general condition warrant it. Thus, instead of feed- ing a bottle of Formula 2, we simply add 1 ounce of milk for the third month to Formula 2. At 4 Months. Formula 3. — Formula for Home Use. Take of Fat 3.5 Cream 7 ounces. Sugar 6.5 Milk 1 ounce. Proteids 1.5 Lime-water 1 ounce. Lime-water . . 5.0 Water 11 ounces. Milk-sugar 6 V* drachms. Divide into eight bottles; heat as above to 167° F.; feed every three hours. 146 INFANT-FEEDING. From 9 to 12 Months. Formula 4. — Formula for Home Use. Fat 4.0 Cream 8 ounces. Sugar 7.0 Milk 7 V2 ounces. Proteids 3.0 Lime-wat^f.. Proteids, 0.8 fo. Sugar, &fc. 3. 6th-llth week. Fat, 3^. Proteids, 1 fc . Sugar, 6 fo . 4. 11 wk.-omo. Fat, 3^ ^ . Proteids, l>^fc. Sugar, 7 fo . 5. 5th-9th mo. Fat. 4 ft. Proteids, 2fc. Sugar, 7 fc . 6. 9tli-12th mo. Fat. 3J>^^. Proteids, 2^ ft . Sugar, 33-2 f* • Milk Milk Milk Milk Milk Milk Cream Cream Cream Cream Cream Lime-water Lime-water Lime-water Water Water Water Lime-water Milk-sugar Lime-water Milk sugar Water Water Cream Milk-sugar Milk-sugar Barley-gruel Milk-sugar Gr. sugar \ The method of using the apparatus is extremely simple. Having decided upon the formula to be used, that panel is to be observed to the exclusion of all the others. The respective ingredients are then poured into the vessel, to the line below the designated substance. Thus, milk-sugar is put in first (or, in its absence, gran- ulated; and the line with the cross shows to what point the latter should be used), then the water, lime-water, cream, and milk in the order shown. The whole is then stirred, and the result will be a milk whose formula is at :materna home-modifier. 151 the top of the panel. The milk used with the apparatus should be good average milk. The cream should be the light centrifugal cream as obtained in bottled milk (16-20 per cent.). The water should be hot, to dissolve the sugar. The barley-gruel should be prepared in the usual way with Robinson's or ordinary barley. According to the age and size of the child, the vessel must be filled once, twice, or three times to obtain the Fig. 20. quantity requisite for the twenty-four hours^ feeding. The pouring into bottles and sterilization are then done as usual. Full directions, including a schedule for the twenty-four hours' feeding at the various periods of the child's growth, accompany the apparatus, which is simple, accurate, and economical, making properly-modified milk of practical value obtainable in places where it has hitherto been impossible to get it. The materna is adapted for home use only when the 152 INFANT-FEEDING. physician notes results. To intrust an apparatus of this kind into the hands of a mother or nurse not conversant with the difference in the percentage of fat contained in cream is not only wrong, but will prove disastrous to the infant so fed before many weeks are over. The author recently saw a case of dyspepsia brought about by feeding in this careless manner. On the other hand, the appa- ratus will serve as a guide to those physicians whose train- ing in percentage-feeding requires occasional assistance. CHAPTEE XXII. Sterilized Milk. E. Gr. Freeman, M.D., in a paper read before the Academy of Medicine, New York, May 11, 1893, says, of sterilization, that, when milk is sterilized at 212° F. (100° C), absolute sterilization is not obtained, but the milk is rendered less digestible than it is in the raw state, and physicians who have used sterilized milk as a regular food find that often infants so fed do not thrive. This clinical experience chemists state is occasioned by the many modi- fications produced in milk by this temperature of 212° F., the starch-liquefying ferment being destroyed, the casein being rendered less coagulable by rennet and therefore being acted upon slowly and imperfectly by pepsin and pancreatin, and the milk-sugar being destroyed; these chemical changes begin to be marked when a temperature of 176° F. (80° C.) is reached, and become more marked as the temperature becomes higher. In the Medical Age, September 25, 1893, it is stated that Dr. Fayel, of Caen, France, says boiled milk is more or less indigestible, and is in no respects safer than un- boiled milk; the temperature at which milk boils is in- sufficient to destroy microbes, and the milk is therefore not sterilized, while its density is increased by the boiling above that which is suitable for infant-digestion. In the Therapeutic Gazette, October 16, 1893, is a translation from a communication to the Societe de Mede- cine de Lyon, by Crolas. Crolas concludes that boiling milk relieves the milk of small quantities of butter, but has no action whatever upon the casein or lactose; that the boiling increases the quantity of soluble phosphates. (153) 154 INFANT-FEEDING. He therefore believes that boiled milk as an article of food is equivalent, if not superior, to unboiled milk. At the meeting of the 'New York Academy of Medi- cine, Section in Pediatrics, May 12, 1892, Dr. A. Jacobi, in the discussion upon infant-foods, made the following points: — It was a great error to suppose that sterilized milk was anything like human milk; it required just as much modification as though it were not sterilized. Alkalinity in cows' milk was always suspicious, for it was evidence that it had been "doctored." The most dangerous alkali was bicarbonate of soda, for in milk thus treated the ptomaine-producing germs develop best. While pepsin was sometimes useful, he objected to its indiscriminate use; without an acid it was inert. Sugar was required in an artificial food, but he did not believe that milk-sugar was best. There was a close relationship between milk-sugar and lactic acid. The change from one to the other was very rapid. Some lactic acid was necessary for proper digestion, but an over- quantity produced hyperacidity and indigestion.^^ Excerpt from an address at the Eleventh Inter- national Congress, Eome, Italy, April 4, 1894, by A. Jacobi, M.D.: — "I shall only dwell upon two articles which have taken an improper hold on the imagination of medical men and have almost been raised into subjects of super- stitious veneration. The use of milk-sugar in the place of cane-sugar in children's food, to any extent beyond what there is in cows' milk or its exclusive employment is a source of acid gastric catarrh, which afterward requires medicinal correction; it is transformed into lactic acid beyond need and proves a detriment, to the full conviction of all those who will give the subject proper attention. 88 Virginia Medical Monthly, June, 1892. CHANGES IN MILK CAUSED BY BOILING. 155 Thoughtful experience is as valuable an objective addition to our knowledge as a mere chemical or theological theory. "Next in order is sterilized milk, on which hundreds of thousands of babies are now being fed to the exclusion of everything else. Nobody would teach nowadays the feeding on unchanged or unmixed cows^ milk to babies as a proper course to take, — as a substitute for mothers' milk. But sterilized milk has been looked up to as an ob- ject of faith and treated as a pope among foods, infallible. To feed babies exclusively on sterilized milk has become the rage since it was recommended by gentlemen of the highest possible standing in science, but, as far as I know, little conversant with the art of treating well and sick in- fants. I speak so bluntly because I love babies, one and all. "Sterilized milk — pasteurized is inferior to it — is su- perior to unchanged cows' milk, still not human. Of 7 cases observed this winter of infantile scurvy, — a nutri- tive disorder as far as we can make out, — there were 3 that had been fed, 2 exclusively, 1 for several months, on sterilized cows' milk."^^ The Chemical and Physiological Changes in Milk Caused by Boiling."*^ Milk consists of a multitude of cells suspended in serum. The cells are fat-cells, which form the cream; the remaining cells are nucleated, and of the nature of white blood-corpuscles. The serum consists of water, in which is dissolved milk-sugar and serum-albumin, with various salts, and, chief of all, casein. The cells, with the excep- tion of the fat-corpuscles, are all living cells, and they re- tain their vitality for a considerable time after the milk is drawn from the mammary gland. ^^ Medical Record, May 19, 1894. *° J. L. Kerr, M.D., CM., F.R.S.E., in the British Medical Jour- nal, December, 1895. 156 INFANT-FEEDING. There is reason for supposing that, when fresh milk is ingested, the living cells are at once absorbed without any process of digestion, and enter the blood-stream and are utilized in bnilding np the tissues. The casein of the milk is digested in the usual way of other albuminoids by the gastric juice, and absorbed as peptone. There is also absorption of serum-albumin by osmosis. The chemical result of boiling milk is to Mil all the living cells and to co- agulate all the albuminoid constituents. Milk after boil- ing is thicker than it was before. The physiological results are that all the constituents of the milk must be digested before it can be absorbed into the system; therefore there is distinct loss of utility in the milk, because the living cells of fresh milk do not enter into the circulation direct as living protoplasm, and build up the tissues direct, as they would do in fresh, un- boiled milk. In practice it will have been noticed by most medical practitioners that there is a very distinctly appre- ciable lowered vitality in infants which are fed on boiled milk. The process of absorption is more delayed and the quantity 'of milh required is distinctly larger for the same amount of growth and nourishment of the child than is the case when fresh milk is used. Pasteukization of Milk. Heating milk to 75° C, as is done by many of the methods, does not sterilize, for the spores of the bacillus subtilis can withstand this temperature for several days. The spores will resist the temperature of 100° C. (212° F.) for six hours. Upon heating to 110° to 120° C. (230° to 248° F.) the milk will be thoroughly sterilized, but such heating causes a browning of the milk, and the cream- cells are apt to be broken and the fat or butter will rise to the surface.*^ ^ Molt-Zeitung. STEEILIZED XILK. 157 Pasteurization with a temperature between 70° and 80° C. (158° to 176° F.) destroys tubercle bacilli and, ac- cording to Tan Geiins, destroys also the typhoid bacillus, the cholera bacillus, and the pneiimococciis of Friedlander, and also most of the ordinary milk germs, and does not injure the milk.^^ Sterilized Milk. Sterilized milk is, according to Marr,^^ as badly borne in children's dyspepsias as ordinary milk, for, even when sterilized by Soxhlefs apparatus, milk is still prone to de- composition, and hence favors the decomposition-proc- esses present in the diseased digestive tract. Dr. B. Bendix** studied the question as to the rela- tive value of sterilized and unsterilized milk. In a paper recently published he arrives at the following conclusions: Sterilized and unsterilized milk have an equal value in nourishing both sick and well children. The change in taste and odor caused by the sterilization is no cause for the refusal of the same by infants, as sterilization destroys both the pathogenic bacteria, as well as the bacteria caus- ing fermentation and decomposition; so he believes that it is the duty of every physician to insist on substituting sterilized milk v-hen breast-milk cannot be had. and, as he believes that sterilization does not cause difficulty of digestion, he prefers the latter to pasteurized milk. Koplik^^ studied the comparative value of sterilized, pasteurized, and other milks, and found that some weeks pasteurized milk and other weeks a sterilized milk would show advantages which, however, would hardly decide for or against either method of preparing the food. The *2 Medical Record, July 2, 1892. ^ London Medical Recorder. ^ Jahrbucli fiir Eanderheilkunde, 38. *' Xew York Medical Journal, April 13, 1895. 158 INFANT-FEEDING. author believes that it is rather the food that should be looked after than the method of feeding it. Sterilization of Milk at 212° F. for Thirty Minutes. method of sterilizing (soxhlet method). Bottle-cleansing. — Always cleanse the bottles thor- oughly before using if they are new bottles. It is a good plan to give them one good washing by adding a pinch of common washing-soda to each bottle, boiling for at least five minutes in this soda-water, and then boiling for at least a quarter of an hour in ordinary water. The bottles are then turned upside dov/n to allow the water to drain off. I then insert a large stopper consisting of non-absorbent cotton (ordinary cotton, from a dry-goods store, which is non-absorbent, is far better than the white absorbent cot- ton). The neck of the bottle is stoppered at least three- quarters of an inch. Bottle-baking. — If we wish to dry them hurriedly^ then several of these bottles can be placed in a large fry- ing-pan with a piece of pasteboard between each bottle, and baked thoroughly dry for about a half-hour. This not only dries them, but baking them really sterilizes them. Place the bottles — previously filled with milk or the feeding mixture — in the rack, and set the rack in the sterilizing chamber, and cover up tight with the lid and hood. Fill the reservoir (pan) two-thirds full of water and place the apparatus over a moderate fire for one hour. If the milk is just from the cow, 40 or 50 minutes are suffi- cient (20 minutes for heating and 20 or 30 minutes for sterilizing). The sterilizer may be used on a gas-stove (turned low), kerosene-stove, or upon an ordinary cooking-stove; if over the last, the griddle should not be removed. You STEKILIZATION OF MILK. 159 can tell by a bubbling sound that the sterilizer is working all right. If the water is not bubbling with regularity in- side, you need more heat. It must not be pu.t on the fire Fig. 21. without water in the reservoir, and the water should never be allowed to get lower than one inch from the bottom. With proper attention as to the quantity of water in the reservoir no further care need be given to the appara- 160 INFANT-FEEDING. tus^ or to the contents of the chamber, for the prescribed time. It is not necessary to place the bottles on ice after removing them from the sterilizer, but all bottles should be put into a refrigerator until taken out for feeding, leav- ing in the cotton plugs until it is feeding-time. The di- rections sent out with some sterilizers, that milk will keep for days, implies that infantas milk may be prepared for several days at once. To this I decidedly object. A great Fig. 22. many authors have pointed out cases of Barlow's disease due to milk which had been sterilized and not used for a very long time. Before feeding, the bottle is to be prop- erly warmed by putting it into a small measure or bottle- holder and heating it with alcohol or gas to about the body-temperature of 98° or 100°. Immediately before using shake the bottle, so as to mix the cream and the milk, which invariably separate in a refrigerator; remove the cotton and draw on the nipple. CHAPTER XXIII. Pasteueized Milk. Booker states that certain germs may not be harm- ful to the baby, if introduced into its body, but are in- jurious to the milk. For example, bacillus lactis aerog- enes. These germs are destroyed at a low temperature. Booker does not believe that the disturbances claimed to be caused by the sterilization of milk are warranted; nor does he belieye that sterilized milk per se causes scurvy. Freeman states that high-temperature sterilization causes chemical changes in milk: — Change in taste at 70° C. (158° F.). Chemists note changes at about 80° C. (176° F.). Freeman believes bottle-food to be a predisposing cause of scurvy. He states that a low temperature, pro- longed, acts as well in destroying pathogenic germs as the action of a high temperature for a short time. Fie advises 68° C, equivalent to 155° F., for 30 minutes, followed by rapid cooling. Such a temperature wull destroy the germs of diphtheria, typhoid, and tuberculosis, and other germs, proved by the inoculation of a plate at laboratory tempera- ture, showing no growth after twent3^-four hours. Free- man does not believe that our present dairy can furnish a raw milk which is absolutely safe as an infant-food, be- cause, he says, milk must be obtained by pressure on the teats of a cow, and these teats hang beneath an udder, which is covered with hair, and from the belly of the cow, wdiich is also covered with this same hair covering. More- over, this portion of a cow is particularly liable to be soiled wdth dirt, as it comes in contact with the ground when the cow lies down. Its hairy covering, moreover, (161) 162 INFANT-FEEDING. holds the dirt, which is gradually shaken out by friction. If the cow has loose stools, these run down the inner sur- face of the thigh and the posterior portion of the udder. The contamination dries on the udder, in the air, and during milking is apt to fall as dust in the pail. More- over, the milk-ducts of the cow may contain many bac- teria, although usually contamination from this source is not very great. Freeman further says: "The milkman's hands are almost never clean. His hands are employed in handling manure, and in attending duties involving contamination. Occasionally they are used during the day in waiting on some one sick with a contagious disease, and, when such is the case, the consumers of the milk are apt to suffer." The author read a paper by Prof. Adolf Baginsky, on "The Milk-supply in the Kaiser and Kaiserin Fried- rich Children's Hospital in Berlin," before the Section on Diseases of Children, at Atlantic City, in June, 1900, wherein Baginsky says that, before milking a cow, the stable is cleaned with a damp cloth. All the dirt is re- moved, and finally the stable is cleaned with water. Prior to milking, the Swiss milkmen are compelled to thor- oughly cleanse themselves, giving especial attention to their hands. These are cleaned with soap and brush. Great stress is laid on washing the udder of each animal with warm soap-water, and drying with clean cloths. In this manner the infection with hair and stable-dirt is pre- vented. The milk is not allowed to remain in the stable until all the cows are milked, but as soon as a pail is filled it is at once removed to the dairy, thus preventing the danger of contamination with bacteria, which are found in the air of the stable, and which are very hard to destroy by sterilization. These are the bacteria of the hay- and potato- bacillus groups. Another vital point is that warm milk easily absorbs the various stable-odors, and fre- quently has a distinct "stable-flavor." PASTEURIZED MILK. 163 If what Freeman claims might happen^ — namely: the introduction of filth, manure, and faecal matter into the milk during the milking process, — then it seems to me that such milk should be discarded entirely, for it is hardly conceivable that sterilizing or pasteurizing can modify milk contaminated in such a manner. Following the precepts of Professor Baginsky at Berlin, the main point is to insist on the strictest ^''stable-hygiene,^^ and thus try to sterilize everything pertaining to the cow, the stable, and the utensils, and in this manner seek to obtain. Fig. 23. — Author's Choice of Feeding-bottle. by the strictest attention to cleanliness, ^^a strictly-clean milk.^^ Directions for Pasteurizing Milk. — Pasteurization is really sterilization at a temperature of 167° F. Experi- ence has shown that the bacteria usually found in milk and those which would be harmful for an infant can be destroyed by subjecting milk to a temperature of 167° to 170° F. for 15 to 20 minutes. For this purpose Freeman has constructed his pasteurizing apparatus (see Figs. 24 and 25), which, however, is rather expensive, although ex- 164 INFANT-FEEDING. tremely useful. The author has used it and has been well pleased with the result. Freeman^s pasteurizer consists of a metal pail into which a rack is placed holding the bottles exactly as is found in the ordinary sterilizing apparatus. This metal pail is partly filled with water up to its first groove, and the water heated to the boiling-point. Until the water is brought to the boiling-point, the bottles are not intro- duced within the kettle. The bottles, previously filled with the required mixture of the infant's food, are held in readiness, and, when the water boils in the metal pail, the lid is removed, the rack with the bottles placed on the Fiff. 24. inside of the metal pail, and the heat turned off, or the pail is removed from the fire. The process consists in allowing the water to cool, whereby the bottles and the milk get warm for a period of 30 to 45 minutes. After 45 minutes, the lid is again removed, the metal pail con- taining the bottles of milk is taken to a water-trough or sink, and the cold-water faucet, over which a piece of rub- ber pipe is fitted, is turned on, and the water permitted to flow on the inside of the pasteurizer. In this way there is a gradual displacement of the warm water by this cold water, until the water is all cold. After the bottles are sufficiently cooled, they should PASTEUEIZED ^IILK. 165 be remoYed to the refrigerator. The rapid cooling of the bottles is as important as the pasteurization by the heat. Pasteurized milk should be kept no longer than twenty- four hours. "We can pasteurize in other ways with any ordinary sterilizing apparatus. Thus, the Arnold steam- sterilizer (see Fig. 21). leaving the hood off. can be utilized for this purpose. To be sure that we are attaining the cor- rect temperature, we can insert a special thermometer, which is made for sterilizing bottles. It can be procured from any chemist or from the Arnold Sterilizer Company. Fio-. 25. To pasteurize with any ordinary sterilizer, set a thermometer into one bottle and put the sterilizer on a brisk fire until the thermometer reaches 170° F. Then remove to the back of the stove, take out the ther- mometer, stopper the bottle that contained the same, and cover with a hood or the lid of the tin pail for fifteen minutes. Then fill the inside of the pail with hot water around the bottles as near to the top as possible, remove to the sink, and allow a stream of cold water from the faucet to displace the warm water. A point worth noting is that the cold water must not be allowed to splash on the hot bottles, otherwise it will crack them. It usually 166 INFANT-FEEDING. takes about ten minutes to gradually displace the hot water in the tin pail or kettle used as a sterilizing cham- ber^ after which the bottles of milk are to be placed in a refrigerator and left there until ready for use. It is understood that each bottle is to be warmed to about a body-temperature of 98° to 100° immediately before feed- ing. In a letter recently received by the author Prof. Victor Vaughan says he does not believe that milk is ren- dered more digestible by sterilization or pasteurization. He thinks that if milk could be obtained under complete aseptic precautions, sterilization, as a preparation for in- fant-feeding, would not be necessary. However, either sterilization or pasteurization is imperative when market milk is used, because this is seldom or never obtained under aseptic precautions. Some people have an idea that it matters not how filthy a milk is, or how many germs it may contain, if it be pasteurized or sterilized it becomes a fit food for children. This is not true, because, in the first place, even prolonged boiling does not kill the spores of all bacteria; and, in the second place, the chemical poisons produced by certain germs are not altered by the temperature of boiling milk. After milk has been either sterilized or pasteurized it should be kept at a low tem- perature before being fed to the child. This should be regarded as a necessary procedure in the preparation of infant-food. The fact that milk in which the colon germ has already grown abundantly cannot, by any process of sterilization or pasteurization, be rendered fit food for children should be emphasized. The toxin of the colon hacillus may le heated to 180° C. (356° F.) for half an hour without having its poisonous properties diminished. If clean milk be obtained and pasteurized at from 155° to 158° C. and then kept at a low temperature until fed to the child, it furnishes the best food which it is possible for us to obtain under ordinary circumstances. CHAPTER XXIY. Tyndallizatiox. Whex milk is subjected to a temperature of 212° F. for from 15 to 20 minutes on three successive days^ such process is called tyndallization. When such a procedure is instituted^ we certainly obtain the "absolutest sterility jpossible^^ of the milk. Such milk, however, is not adapted for infant-feed- ing, owing to the changes brought about by this continued application of heat in rendering the albuminoids and salts contained in the milk more difficult to digest. Milk subjected to this tyndallization has all the dis- advantages of a prolonged sterilized milk or milk-mixture. My experience is decidedly in favor of avoiding such con- tinued heating of milk, and I am sure that many cases of scurvy can be traced to the lack of fresh albumin and casein assimilated. It is certainly peculiar that in spite of the experience of many noted men, the author has recently seen a decided improvement in a child suffering with scurvy when the food was changed from sterilized milk to a raw-milk mixt- ure, the milk-mixture being merely warmed to a feeding temperature. Barlow's disease can frequently be traced to improper feeding, especially when mothers are permitted to use their experience in making up their own feeding-mixtures. Children are more frequently starved than will be ordi- narily admitted, and, were it possible to examine the food given to the average infant and compare it with a. stand- ard breast-milk suited for the age of the infant, we would soon learn that our crude methods resulted in positive (167) 168 INFANT-FEEDING. harm, the result of which years of proper medication and feeding will hardly be able to remedy. The vital point to remember is to get the child prop- erly started, and we must not be discouraged if onr first feeding-mixture is not properly digested or assimilated. In such instances we will soon learn which elements of our food require more proper modification and elimination, especially so if the stools are studied. Tyndallization will permit milk to be kept for months, and is just such milk which, fed to weakened chil- dren, will ultimately cause Barlow's disease or its allied conditions. While in Berlin several years ago I was given milk which had been sterilized six months previously. While it is true the taste did not betray the length of time that the milk had been kept, it can be easily seen that cer- tain chemical changes will develop, altering the character of the food. It is my belief, founded on extensive experience, that sterilized milk, continually fed, to the exclusion of raw milk and raw beef-juice, will ultimately result in rachitis or scurvy. CHAPTEE XXV. N^IPPLES AND Bottles. Attention to this portion of the feeding apparatus is very important, as the cause of sore mouth and tongue and gums can frequently be traced to a filthy nipple. Fig. 21). Such infections can be easily avoided in the following manner: The nipples are to be boiled for about ten or fifteen minutes in a so-called nipple-sterilizer (see illus- tration, Fig. 30), placed in a tin pail of plain water to which a pinch of salt has been added. After boiling in this manner the nipple should be put into a tumbler of (169) 170 INFANT-FEEDING. plain, sterilized (boiled) water and allowed to soak until it is time to use it. It is advisable to boil every nipple im- mediately after removing it from the feeding-bottle by Fig. 28. Fig. turning it inside out, placing it in the sterilizer, and steaming it for 15 or 20 minutes. In this manner all pathogenic bacteria are destroyed, and all particles of milk NIPPLES AND BOTTLES. 171 which adhere to the rubber are removed. Such nipples will not be the cause of stomatitis or other infectious mouth disorders. The choice of a nipple is another important matter. My preference has always been for a black-rubber nipple, and it is a very wise point to use a nipple no longer than one week; in other words, old, worn nipples are useless for the proper management of infant-feeding. Black rub- ber is softer than white rubber; most white rubber is sup- posed to contain lead; hence a decided reason for not using it. Nipples Recommended. — One of the best nipples made is the so-called anticolic nipple. This nipple has a ball- shaped top, which enabks a baby to take a firm hold; it has three small holes, which give an easy flow of milk, and regulate a slow meal. Nipples having very large open- ings, which will permit a baby to finish a 6- or 8-ounce bottle of food in five or six minutes, are useless, and this gulping of food is really the cause, or one of the causes, -of infantile colic. Another nipple I have used, but it is much harder to clean, and, unless all precautions for steriliza- tion are carefully noted, this nipple should not be used; yet, in the hands of the intelligent or where we have a trained nurse, it can be safely recommended. It is called the "Mizpah." The nipple has also a very small puncture; so that the baby gets the food slowly. The "Swan Bill" nipple or the long French nipple I do not like, nor have I noted results as good as with the above-mentioned kinds. Ventilated Nipple. — A nipple very highly spoken of is the ventilated nipple made by Ware, of Philadelphia, which has a small opening or valve on the side, and, as the milk is drawn in from the bottle, it permits air to enter, thus preventing a vacuum from being formed. It is also supposed to be non-collapsible, and is highly recommended by those that have used it. The only objection — already 172 INFANT-FEEDING. offered — is that all nipples must not only be practical for use, but must be capable of thorough sterilization. Odor of Nipples. — Children will object most decidedly Fig. 30. — Nipple-sterilizer. to nipples having any odor or taste; hence it is a good plan to boil every new nipple before using it. Tlie nipple-sterilizer (see Fig. 30) is a very convenient "-'^k Fiff. 31.— Bottle-brusli. little arrangement made by Ware, of Philadelphia, and resembles a coffee-strainer with a lid. It is neat, cheap, and serves its purpose admirably for the sterilization of the nipple. Fiff. 32.— Bottle-brush. The loUle-brusli has a long handle and bristles for cleansing the bottles. This brush should be used before the bottles are put in the soda solution, and serves for NIPPLES AND BOTTLES. 173 cleansing the inside of the feeding-bottles. It is self- understood that the brush can itself harbor bacteria and particles of milk removed while cleansing. It is therefore Fia-. 33. important that the brush should be thoroughly boiled in a washing-soda solution after each use. Fiff. 34. Feeding-bottles. The long 8-ounce feeding-bottle, or so-called feeding- tube, which is illustrated, is certainly a unique bottle for feeding; as it has no corners and no useless rims, besides 174 INFANT-FEEDmG. being smooth on the inside^ it can be very easily cleaned. All bottles having angles and depressions should be avoided. The boat-shaped bottle is also very good, but much harder to clean. My preference has always been for two kinds of bottles: 1. Those holding four ounces and graduated on one side in both ounces and tablespoons. This saves quite Fig. 35. — Baby-comforter, Not Advised by the Author. some time and trouble. 2. Bottles holding eight ounces and divided off into 16 tablespoonfuls or 8 equal ounces. Exactness of Ounces. — It may not be out of place to ask each physician to insist on having the graduated ounces on an infant's feeding-bottle measured with an accurate graduate, obtainable at every drug-store. In many instances the author noted feeding-bottles wherein the ounces were very unequal, and in one particular bottle the eight graduated ounces on the bottle held twelve ounces. Long Ruhher Tubes. — Most prominent pediatrists agree that the long rubber tubes are a convenient place for harboring micro-organisms, and they have been uni- versally condemned. CHAPTEK XXVI. Dextrinized Gruels. We have preyiously referred to the method of making flour ball, in the section on "Additional Foods during the Xnrsing Period." In some instances, especially where di- gestion is subnormal, beneficial results will follow the dextrinizing of infant-foods. Thus, the starch of the gruel is held in solution, and the remaining cellulose and pro- teids of the cereal are left to act on the curds. Method of Dextrinizing. — Prepare the wheat-, barley-, oatmeal-, or rice- flour by adding a tablespoonful of the same to a pint of water, adding a pinch of salt, and boiling the same for from fifteen minutes to one hour. This will make a gelatinous solution, and hence the name of barley- jelly, rice-jelly, oatmeal- jelly, or wheat- jelly. We allow this jelly to cool, and w^hen cool enough to be tasted we can add a diastase, such as cereo; or taka-diastase, made by Parke, Davis & Co.; or the Forbes diastase. When a small quantity of this diastase is added to the jellies above mentioned, they lose their thickness, and become very thin. They can easily be strained through cheese-cloth, and some water added to make up for the loss by evapora- tion during the boiling. This jelly, or gruel as it is some- times called, made from either barley-, rice-, wheat-, or oat- jelly, is to be used with the milk after the diastase is added. In certain diseases, where milk is not well borne, such as dyspepsia (dyspeptic vomiting) or in summer com- plaint, where the giving of milk is prohibited, feeding the dextrinized gruels for several days will be found, not only very useful, but very healthful. In making this dex- trinized gruel, small particles will be seen floating, which settle out upon standing. These particles consist of the (175) 176 INFANT-FEEDING. cell-walls and the proteids of the cereal^ and cut the curds of the milk into fine pieces, when the cnrds begin to shrink under the combined action of rennet and acid. In iising this diastase we aim at breaking up the tough curd in cows' milk by purely-mechanical means. Henry D. Chapin {Journal of the American Medical Association, July 14, 1900) says: "The next important step is to get the cows' milk as nearly as possible in the same physical condition as mothers' milk. The diluent I prefer to use is a wheat-, barley-, or oatmeal- gruel, the starch of which has been digested or dextrinized by the action of diastase. A heaping tablespoonful of flour, made from a cereal, is boiled with about a pint and a half of Avater for fifteen minutes. It is then removed from the stove and set in cold water for about three minutes to cool it. When it is sufficiently cool to taste, a teaspoonful of a preparation of diastase is added, which renders the gruel thin and watery. This makes about a pint of gruel, con- taining the starches in soluble form, while the cellulose, or skeleton of the cereal, acts as a most effective attenu- ant of the curd. These digested gruels render the milk- curd porous, and also provoke the secretion of the digest- ive juices. As diluents, they are a great improvement on water. Most of the thick malt-extracts are sufficiently active in diastase to produce the desired effect." The writer, however, prefers the employment of diastase itself, without any of the other malt ingredients, as being both speedy and efficient. It can either be produced cheaply at home or purchased at the nearest drug-store. A simple decoction of diastase may be made as follows: A table- spoonful of malted barley-grains is put in a cup, and enough cold water added to cover it, usually two table- spoonfuls, as the malt quickly absorbs some of the water. This is prepared in the evening and placed in the re- frigerator over night. In the morning the water, looking like thin tea, is removed by a spoon or strained off, and DEXTKIXIZED GRUELS. 177 is ready for use. About a tablespoonful of this solution can be thus secured^ and is very active in diastase. It is sufficient to dextrinize a pint of gruel in ten to fifteen minutes. Preparations of diastase are made by a number of chemists: Forbes; Parke, Davis & Co.; Horlick, and others. There is now obtainable an active glycerite of diastase known as cereo, which is specially made for the purpose of dextrinizing gruels. The author has seen very good results follow the ad- ministration of any and all of the malt-extracts now in our market during the past summer, in those critical cases of summer complaint in which subnormal digestion existed. Frequently the administration of a teaspoonful of malt-extract to an infant immediately before feeding was not only relished by the infant on account of the pleasant taste of the malt, but certainly aided in the assimilation of the food. Earely was more than 3 teaspoonfuls of malt ordered during twenty-four hours. Such preparations like maltine and also maltzyme gave very good results. The malt-extract of Parke, Davis & Co. has a very pleasant flavor and seems well borne. Frequently, when expense proved an important item, sufficient dextrinization of foods could be procured with these malt preparations above cited. It is claimed that, while most malt preparations de- teriorate on standing or if exposed too long, cereo will keep indefinitely. PART II. CHAPTER XXVII. Feeding of Infants in Incubatoks. When we consider that the usual viability of a child is placed at twenty-eight weeks of intra-uterine gestation, then we can see how vastly different the method of feed- ing must be from that of a child born at term, or a so- called ^^full-born child/^ Method of Feeding. — The size of the child precludes the taking of an ordinary-sized nipple, and hence various measures have been tried, the most successful of which has been, according to the author's experience, feed- ing with a small medicine-dropper at intervals of two hours, the quantity varying with the age of the infant. It is a good plan, considering the capacity of the infant at term to be 1 ounce, to recognize the deficiency in the development of not only the size and capacity of the stomach, but also its lack of digestive function. Hence my plan has been to commence feeding by giving two teaspoonfuls of milk diluted with two teaspoonfuls of sugar- water; no lime-water and no salt added. A prematurely-born baby is necessarily doomed with- out proper food, and there are so many other factors to be considered during its life in an incubator, such as its ventilation, its bodily warmth and cleanliness, that too much stress cannot be laid on the value of its food. With- out breast-milk, therefore, I feel justified in saying: I have yet to see the premature infant that will survive, and hence I advise procuring breast-milk, containing no colostrum-corpuscles, from a woman having a child any- where from two or three weeks to several months old, and (178) FEEDING OF INFANTS IN INCUBATOES. 179 diluting this breast-milk, as stated above, with a solution of cane- or milk- sugar. Voorhees**^ says: ^'Eegarding the care of premature babies in incubators, we have relied mainly on diluted breast-milk, and have only employed cows' milk in weak proportions when it was impossible to obtain the former. In our opinion, our results would have been much poorer without the help of mothers' milk.*' In rare instances, where infants are very weak, and seem to doze and will not swallow, a 'No. 7- American Tie- mann & Co. rubber catheter, having a velvet eye, can be attached to a long rubber tube about one foot in length and ending in a little funnel, holding several ounces. (See illustration. Fig. 38.) With this funnel and catheter forced feeding — so-called gavage — can be performed. With the infant lying flat on its back, push the catheter slowly, but forcibly, through the mouth as far against the pharynx as possible, and continue to push the tube from the pharynx into the oesophagus and the stomach. In all, from five to seven inches, rarely more, will be nec- essary to reach the stomach. The milk, properly di- luted with an equal quantity of milk-sugar solution, can then be allowed to flow into the stomach, and the catheter must then be very quickly withdrawn. Such feeding should be repeated once in four, five, or six hours, de- pending on the requirements of the case. Each infant is a law unto itself, and hence no cast-iron rule can be laid down, but each individual case should be studied sepa- rately and its requirements met as indicated. Thus I have found in a premature infant, born at seven months, that 6 drachms was enough for one feeding, and this was well borne once in three hours. The food consisted of equal parts of breast-milk and milk-sugar water. This feeding was continued for one week, when the child cried Archives of Pediatrics, May, 1900. 180 INFANT-FEEDING. very miich^ and, on attempting to satisfy it, the infant swallowed 1 V2 ounces. We then alternated each feeding by giving a large meal of 1 V2 ounces followed by a small meal of 6 drachms, and fed in this manner every two hours until the child was three weeks old. We then gave 1 V2 ounces of food every two hours. The child's stool was quite good; it soiled from two to three napkins every day, and, when it was very restless, we gave it from 2 to 3 teaspoonfuls of boiled water, which seemed to satisfy it. I would urge the necessity of giving plain, sterilized water freely to all infants living in an incubator. The in- ci eased temperature of its surroundings calls for it; so does also the necessity for eliminating through skin, bowels, and kidneys. Dangers of Feeding. — A'^ery small quantities of food should be used in gavage — feedings of the mouth or when feeding through the nose. No more than 4 to 6 drachms should be used, and thus we can feel our way. It is a good point to remember that, the pharynx being very sen- sitive, the irritation of the tube in passing into the stom- ach may provoke regurgitation of some of this food, and frequently vomiting will be produced. In such instances, if the posterior nares or the pharynx is filled with food, the infant can easily suck some of this fluid during an inspira- tion into its trachea, and start up a pneumonia in the same manner as is done during the course of a child having a tube in the larynx in the treatment of laryngeal stenosis. Eectal feeding for premature infants is rarely called for, but it can and should be tried if the infant will not swallow and the forced feeding through the mouth or nose is unsuccessful. In such instances use very dilute milk, thoroughly peptonized, — the same proportions, how- ever, as have been stated previously, namely: V2 niilk and V2 water. The formula for rectal feeding should be: I^ Breast-milk, V2 ounce. Starch-water, ^A ounce. FEEDING OF INFANTS IN INCUBATORS. 181 Add contents of 1 Faircliild peptonizing tube, and in- ject this quantity Avith an infant's rectal syringe. (See illus- tration, Fig. 39.) The starch-water is made by taking 2 teaspoonfuls of ordinary starch and mixing it with ^/ ^ teacnpful of warm water (not boiling water) and making a milky mixture of the same. This starch-water should be made fresh for each feeding. It is advisable to feed about once every six hours with the above solution. Cleanse the rectum thoroughly by washing with V2 pint of lukewarm, Castile-soap water to remove all fseces ten minutes before the nutrient fluid (peptonized milk) is injected. PREMATUEE INFANTS (GRIFFITH). Premature, Birth. — A child may be born in the seventh or eighth month of pregnancy, or even earlier, long before it is quite ready to live outside of the mother's body, and when it weighs not more, perhaps, than two and a half or three pounds. We need not necessarily despair of the life of a baby, however unpromising it seems at first. Children born at six and a half months have grown up strong at last, although it is not often they survive if born before the seventh month. The great need of such a baby is heat, and the maternity hospitals employ an apparatus, called a couveuse, hrooder, or incubator, espe- cially devised to supply it. (Fig. 36.) For family use, a couveuse may be bought at the instrument-makers, or hired from some of them. This is, perhaps, better, as the apparatus is costly. But with an increased degree of at- tention w^e may get along fairly well without it. If a premature baby is bathed at all after birth, the tempera- ture of the water should be 102° F., and the greatest care should be taken, while drying, to see that the child is not chilled. It should be made very warm by swaddling it in raw cotton, head and all, leaving only the face exposed, wrapping it about with a blanket, and tying it around with 182 INFANT-FEEDING. a roller bandage. Hot bottles should be placed on each side of it as it lies thus wrapped up in the bed, and fresh ones be substituted frequently. A very convenient method is to place the child in a baby's bath-tub half-full of raw cotton in which numerous hot bottles have been concealed. The child's only clothing consists of a diaper and a shirt. The room should be kept warm, and espe- cially so when this human bundle is unwrapped for its bath. After bathing, it should be rubbed with sweet oil and be rolled up again in fresh cotton. Often it is better to omit all bathing, and simply to rub with the oil. These premature infants lose considerably more in proportion to their birth-weight than babies at term. This is due to their immature digestive tract; also to the fact that they are almost invariably intensely jaundiced. They gain very slowly, and, if at the end of two or three weeks they have reached their birth-weight, they have done unusually well. In some of the babies the color is poor from the be- ginning, and at any time they are especially liable to at- tacks of cyanosis. For these conditions a little slapping to cause a good cry or the administration of oxygen will dissipate the blueness. Often a few drops of brandy in hot water every two or three hours will prevent further trouble. One must be very sure, however, that nothing has been aspirated into the larynx. A great danger in the care of these babies is their susceptibility to infections. The incubator itself is a great germ-carrier, and should be regularly disinfected. The weakness of the lungs and gastro-enteric tract makes the infants especially vulnerable. Unless the air is fil- tered, dirt is carried in continuously; consequently the streptococcus, staphylococcus, and pneumococcus are al- ways present, seeking an avenue of entrance. Through the skin in eczematous spots or in areas of irritation, at the navel; through the eyes, nose, mouth, larynx, lungs. FEEDING OF INFANTS IN INCUBATOKS. 183 stomach, and rectum the bacteria can gam admission. To prevent infection the most carefnl cleansing is necessary, of both the incubator and the baby. Undonbtedly most of the deaths of onr cases conld be traced to this source. Finally, in the carrying out of the above essentials in the proper management of the premature infant, we re- quire the most patient and painstaking attention on the part of the nurse, and upon her conscientiousness depends the chance of its survival. Besults. — The statistics are taken from 2314: births which occurred at the Sloane Maternity Hospital. Four hundred and ten of these babies were prema- ture, but of these 74 were still-births, which include mac- erated foetus, and still-born babies of cases of placenta prsevia, accidental haemorrhage, eclampsia, and the like, leaving 336 for treatment. Among these cases were a set of triplets, and there were 18 pairs of twins; 85 were treated as infants at term, and of these 4 died, — a mortality of 4 V^ per cent.; 145 were put in cotton, and of these 12 died, — a mortality of 8 per cent. Some of this class should have been placed in the incubator, but for lack of room it was impossible; 106 were incubator babies. These are divided into two classes: 1. Those that died within four days of birth. 2. Those that lived longer than four days. Twenty-nine of the incubator babies died within four days. All of these but 3 were more or less asphyxiated at birth; 9 were breech cases, and of these 5 were difficult extractions; 3 after an accoucliement force in placenta prsevia. The rest were vertex presentations, but of these 2 were forceps deliveries; 6 were under 7 months of uter- ine gestation; 22 were between 7 and 8 months along, and 1, 8 ^/4 months. The etiology of the premature labor was an endo- metritis in 14; syphilis in 2; albuminuria in 1; placenta 184 ii^-i^ANT-i^EEDiiTa. praevia in 3; accidental haemorrhage in 1; persistent vomiting in 1; twin in 1; violence in 1; and in 4 the labor was induced. The largest baby weighed 5 ^/^g pounds; the smallest 2 Vie pounds. Only 5 infants lived over twenty-four hours; 24 were in such poor condition at birth that they survived only a few hours. In 16 autop- sies were held, and in all of these there were marked atelectasis; in 7 haemorrhages of some degree, either into the brain or into the serous membranes; in 2 the foramen ovale was still patent. Seventy-seven incubator infants survived the first four days; 51 were children of primiparae, 27 of whom were out of wedlock; 3 infants were under 7 months of gestation, 8 were over 8 months along; 9 were breech presentations; 1 a transverse and the rest vertices; 2 were of triplets associated with albuminuria; 18 were in twin deliveries, associated with albuminuria or hydram- nios. The cause of the premature labor was endometritis in 27; syphilis in 4; phthisis in 2; albuminuria in 7; ac- cidental haemorrhage in 1; placenta praevia in 1; in 2 the labor was induced for albuminuria and eclampsia; 1 was a Caesarean section; another an ectopic gestation; the cause of the rest was unknown. Seven were delivered by for- ceps; 2 by a version; 1 by accouchement force; 1 by Cae- sarean section, and the ectopic gestation by a laparotomy; 12 were slightly asphyxiated at birth; 9 moderately so, and 5 deeply asphyxiated; 2, after one and a half hours' work of resuscitation, were put in the incubator head downward, and their condition was so poor that they were expected soon to die, but they left the hospital gaining in weight; 5 weighed less than 3 pounds; 38 between 3 and 4 pounds; 33 between 4 and 5 pounds; 1 over 5 pounds; the average weight was 3 ^-/^g pounds. During their in- cubator-life 28 had one or more attacks of atelectasis. All but 10 were more or less jaundiced. The initial loss of the infants was from 1 to 17 ^/2 ounces; the average was FEEDIXG OF IXFAXTS IX IXCUBATOES. 185 7 ounces. These figures are not quite correct^ as the babies Tvere weighed at different interrals^ some on the Fio-. 36. 186 INFANT-FEEDING. fifth day, some on the seventh day, and others not till the fourteenth day. The period of loss was from five to twenty-two days, the average, eleven days; 10 lost steadily till death; one baby was in the incubator only three days, while another lived there eighty-two days. The average time was nine- teen days. Some were removed early to make room for others who needed the place more urgently. Only 3 of the 77 cases vomited. The stools were nor- mal in 32. One was discharged from the hospital as early as the eleventh day, and others also too soon at their mothers' demand. One was 89 days old; the average was 24 days. In 16 diluted breast-milk was supplemented, at times, with a mixture of cows' milk and water, with Russian gelatin and lactose. In 10 a 1, 6, 0.33 modification was used. In all the rest diluted breast-milk was relied upon. Twenty-seven never nursed at the breast; of these, 12 died. A few nursed as early as the third or fourth day two or three times a day. Others not for three weeks, and one not till the sixty-eighth day. Of the 77, 13 died in the hospital: a mortality of 16 per cent. The cause of death was atelectasis and bronchitis in 7, acute asphyxia from a curd in the larynx in 1, syphilitic pneumonia in 1, cerebral haemorrhage in 1, gastro-enteritis in 3, and a patent foramen ovale and ductus arteriosus in 1. The condition of 3 was poor at the time of discharge, fair in 24, and very good in 37; 32 were above their birth-weights, and 57 were gaining in weight. To letters written about January 1, 1900, no answer was obtained from 28. Thir- teen were reported as having died, 1 of these lived four- teen months, 1 nine months, 1 four and one-half months, 3 lived two months, 6 lived six weeks, 1 only a month. Five of these died at the Nursery and Child's Hospital and 2 died at Bellevue Hospital. They were bottle-fed, and the probable cause of death was gastro-enteritis. FEEDING OF INFANTS IN INCUBATORS. 18^ Twenty-one were found to be alive and doing well. Some had nursed and the others were bottle-fed. The oldest baby was twenty-two months, and almost all were good, healthy children. One baby at seven months weighed 16 pounds. It weighed 4 ^/^g pounds at birth, and nursed from its mother after leaving the hospital. The ectopic and the Caesarean babies were in beautiful condition. At the Sloane Tarnier. Charles. Sloane Hospital Per Cent. Hospital, not Counting Incubators. Per Per those which Cext. Cent. Died in a Few Hours. Per Cent. Saved at 6 months. 16 10 Saved at 6h niouths. 3G 20 22 6G Saved at 7 months. 49 40 41 71 Saved at 7.t months. 77 75 75 89 Saved at 8 months. 88 70 91 The incubator here described (see illustration, Fig. 36) is the one used at the Sloane Maternity Hospital. There are a great variety of these incubators, but the one made by the Kny-Scheerer Company in this city will answer all requirements. Owing to its expense, the manu- facturers will lend an incubator for a nominal sum per month. CHAPTER XXYIII. Aerated Milk. Aeration of Milk. — Milk when drawn from the cow contains a certain amount of dissolved gases. These gases contain more or less of what is known as animal odor, the amount of this odor depending very largely upon the physical condition of the animal at the time the milk is drawn. Sometimes the amount is very slight and scarcely noticeable; at other times it is so great as to be extremely offensive. These gases and the accompanying odor are easily removed from the milk by exposure of the milk to the air during the process of cooling, and to this extent aeration of the milk is an advantage. Various forms of aerators and combined aerators and coolers have been devised, many of which are simple and effective, and the best results follow their use. In order to secure these results by aeration, however, it is necessary that the ap- paratus used for aeration should expose the milk thor- oughly to the air, should not be cumbersome, and should be simple and easily cleaned; moreover, the process of aeration should always take place in the purest atmos- phere possible. Certified Milk. Dr. H. L. Coit organized a medical commission in Newark, N". J., which has made agreements with the dairy- men compelling them to look after the details pertaining to the food, the selection of the cows, and — most particu- larly — the handling of the milk. All this is under the supervision of the Medical Commission. A veterinary surgeon is employed for the inspection of the animals. In (188) CERTIFIED HOLK. 189 like manner a chemist and bacteriologist see that the milk is kept to the standard requirements of composition and purity. The milk is delivered in bottles, which are labeled '^Certified Milk." This plan has proved to be very suc- cessful, and certainly deserves imitation. CHAPTEE XXIX. Infant-foods. There have been a great number of infant-foods and seemingly a great variety placed upon the market and ex- ploited by the makers as suitable for the artificial feeding of infants. These infant-foods may be broadly classified under two heads of (A) infant-foods in which cows' milk desic- cated is a constituent, and (B) infant-foods to be used with and as adjuncts to fresh cows' milk. Fig. 37. — Feeding-cup, after Period of Weaning. The infant-foods of which dried milk is a constituent are made from cereals and cows' milk. The milk is desic- cated in the process of manufacture, and these foods are commonly known as dried-milk foods, although in this class of foods milk-solids constitute but from one-eighth to one-fourth the substance of the foods, the balance con- sisting of matters derived from cereals. In some of these foods the starch of the cereals is untransformed, and they may be termed farinaceous dried-milk foods. In others (190) IXFAXT-FOODS. 191 the starch of the cereals has been transformed into dex- trin and maltose^ and they may be termed malted dried- milk foods. All attempts to preserve whole cows' milk by evapo- rating it to dryness have been failures; the fat of desic- cated milk soon acquires a rancid flavor, and the caseous matter does not properly dissolve in water, as the drying process destroys its colloidal condition. In the dried- milk foods the caseous matter of the cows' milk is inti- mately mixed with the other ingredients, but its colloidal condition has been destroyed, and it is in the form of fine, hard, granular particles, very sparingly soluble in water. The group of infant-foods used as adjuncts to cows' milk are either farinaceous foods, made from cereals and consisting largely of unconverted starch; or malted foods, also made from cereals, but having the starch transformed into soluble maltose and dextrin. As fresh cows' milk is, without doubt, the best generally-available material for the artificial feeding of infants, the foods of the latter class, used for the modification of fresh cows' milk, are more in accord with physiological principles than are the dried-milk foods. Of the large number of infant-foods that have been put on the market, it is our purpose to describe a few commonly-known foods. In order to judge fairly of the nutritive value of an infant-food and its resemblance to woman's milk, it is necessary to know its composition after its preparation for the nursing-bottle according to the directions of its manufacturer, and the analyses that accompany the following descriptions are of the foods pre- pared for use for infants six months of age as per direc- tions on the packages. The published analyses of woman's milk show the great variability of its composition, especially as re- gards the percentages of proteids and fats. The analysis of woman's milk used in the following tables is by Dr. 192 INFANT-FEEDING. Luff, adopted as the standard by Cheadle. It agrees closely with Leeds's analysis, excepting as to the fat, which is given by Luff as 2.41 per cent, and by Leeds as 4.13 per cent.; the latter amount seems too large, as it exceeds considerably the published averages of a number of observers. nestle's food. Nestle's food is a farinaceous dried-milk food of Class A. According to the manufacturers, it is made "from the richest and purest cows' milk, the crust of wheaten bread, and cane-sugar," and is a "form of modified milk." "N'o cows' milk is to be added to Nestle's food; nothing but water, and that water is boiled.'^ Upon examination, unconverted starch and cane- sugar are found to be its principal constituents, amount- ing to about 70 per cent, of the whole. The directions for preparing Nestle's food for the nursing-bottle, for in- fants six months old, are to use 2 level tablespoonfuls of the food to V2 pint of water; mix the food with enough warm water to make a smooth paste that will pour, add the rest of the water and boil in a sauce-pan, stirring con- stantly until it thickens and a milky foam appears on the top. Composition of Nestle's Food," when Prepared as Above. Woman's Milk. Water 92.76 88.51 Salts 0.13 0.34 Proteids 0.81 2.35 Fat 0.36 2.41 Starch 1.99 Cane-sugar 2.57 Maltose, dextrin, etc 0.44 Milk-sugar 0.84 6.39 Keaction alkaline. Reaction alkaline. " According to Chittenden. INFANT-FOODS. 193 The thick condition of the mixture is owed mainly to the insoluble starch present. The total carbohydrates therein (5.84 per cent.) are somewhat less than the carbo- hydrate, milk-sugar (6.39 per cent.), in woman^s milk; it is to be noted that, of this amount, 1.99 per cent., or about one-third, consists of insoluble starch. The fat is nearly one-sixth and the proteids are about one-third of the amounts in woman's milk, and over one- half of the proteids is insoluble, owing to the colloidal condition of the milk-casein having been destroyed by drying during manufacture. horlick's malted milk. This is a malted dried-milk food of Class A, stated on the circulars to be composed of pure, rich cows' milk com- bined with an extract of malted grain, and not to require the addition of cows' milk. Its makers claim that, by special treatment with their new agent, plant-pepsin, the casein, or cheesy part, of the cows^ milk is kept from form- ing large and irritating curds in the stomach. This food is very nearly soluble in water, as its prin- cipal constituents are the soluble carbohydrates — maltose, dextrin, and milk-sugar. The drying process has de- stroyed the colloidal condition of the caseous matter of the milk, and it is in the form of finely powdered, hard particles, sparingly soluble in water. The directions for preparing the food for an infant six to twelve months of age are to dissolve 4 to 6 tea- spoonfuls in V2 pint of water. Composition when pre- pared by using 6 teaspoonfuls of food to V2 V^^^ ^f water: HorlicTc's Malted Milk^^ Woman's Milk. Water 92.47 88.51 Salts 0.29 0.34 Proteids 1.15 2.35 According to Chittenden. 13 194 mFANT-FEEDING. Fat 0.68 2.41 Maltose and dextrin 4.20 Milk-sugar 1.18 6.39 Reaction alkaline. Reaction alkaline. The proteids, fat^ and carbohydrates are all less than in woman^s milk, the proteids being not quite one-half and the fat not quite one-third of the amounts in woman's milk. The amount of milk employed must be very small in proportion to the cereal constituents, since the mixt- ure, prepared as above, corresponds to a dilution of 1 part of good cows' milk with about 4 parts of water. MILKINE. This is a malted dried-milk food (Class A). Its makers state it is a complete food ready for immediate use by the addition of water, and the only prepared food that combines the nutritive elements of meat, milk, and cereals. In this malted dried-milk food, beef-extract is com- bined with cereal extractives and dried milk. Soluble car- bohydrates are its principal constituents, forming nearly three-fourths of the product. The proteids are sparingly soluble. The directions for preparing milkine for an infant three to six months of age are to dissolve 1 to 2 dessert- spoonfuls of food in a breakfastcupful of water. Composition when prepared with 2 dessertspoonfuls in a breakfastcupful of water: — Milkine. Woinan's Milk. Water 92.78 88.51 Salts 0.23 0.34 Proteids 0.92 2.35 Fat 0.43 2.41 Maltose, dextrin, etc 4.74 Milk-sugar ■ 0.90 6.39 Reaction alkaline. Reaction alkaline. I^TFANT-FOODS. 195 The total solids are hardly two-thirds of the amount in woman's milk. The fat especially is greatly deficient, being only abont one-sixth of the amount in woman's milk, and the proteids are but two-fifths of the amount in woman's milk. A dilution of 1 part of good cows' milk with about 7 parts of water will contain about the same amount of milk as milkine prepared as above. CEREAL MILK. Cereal milk is a malted dried-milk food (Class A). It is stated by its makers to be a complete food, cooked and ready for use with the simple addition of water, and to be made from the purest Yermont dairy-milk, the finest wheat-gluten flour, the best barley-malt, and milk-sugar. Cereal milk in general appearance very much re- sembles the other malted dried-milk foods, but it contains a much greater percentage of milk-sugar, showing that this substance is used in its manufacture, as claimed. The directions for preparing it for use are to mix 1 teaspoonful of cereal milk in a teacupful of hot water for infants under three months of age or for a very deli- cate child. For older and stronger children 1 to 2 tea- spoonfuls of food are to be used to each cupful of water. Composition w^hen prepared by using 2 heaping teaspoon- fuls of food to a teacupful of water:— Cereal Milk. Woman's Milk. Water 92.52 88.51 Salts 0.16 0.34 Proteids 0.69 2.35 Fat 0.30 2.41 Maltose, dextrin, etc 4.73 Milk-sugar 1.60 6.39 Keaction alkaline. Reaction alkaline. The total of soluble carbohydrates as above is prac- tically the same as in woman's milk; the amount of pro- 196 INFANT-FEEDING. teids is less than one-third the amount in woman's milk, and abont one-half is insoluble in water. The amount of fat is one-eighth the amount in woman's milk. The small amount of fat indicates that the cereal extractives and milk-sugar make up the bulk of the solids of this food, and that a dilution of 1 part of good cows' milk with 11 parts of water would be the counterpart of the above mixture as to the amount of milk therein. v^ampole's milk-food. Wampole's milk-food is a malted dried-milk food (Class A). Its makers state that it is made from malted cereals, beef, and milk, and when mixed with warm water it is immediately ready for use; no other preparation necessary. This dried-milk food is very nearly soluble in Avater, owing to the soluble carbohydrates being so large a con- stituent. A little less than one-half of the proteids is in- soluble in water. A small amount of beef-extract has been combined with the cereal extractives and dried milk. To prepare it for an infant six months to one year of age, the directions are to dissolve 4 to 6 teaspoonfuls of the food in 6 ounces of hot water. Composition when prepared by dissolving 6 teaspoonfuls in 6 ounces of water: Wampole's Milk-food. Woman's Milk. Water 88.59 88.51 Salts 0.46 0.34 Proteids 1.58 2.35 Fat 0.73 2.41 Maltose, dextrin, etc 7.65 Milk-sugar 0.99 6.39 Eeaction alkaline. Reaction alkaline. Compared with woman's milk it is seen that the car- bohydrates are considerably in excess, and the proteids and fat are deficient, the fat especially, it being less than one-third the amount in woman's milk. INFANT-FOODS. 197 One part of good cows' milk diluted with about 3 ^/o parts of water would be analogous to the dilution of milk in Wampole's milk-food prepared as above. IMPERIAL GEANUM. Imperial granum is a farinaceous food to be used as an adjunct to cows' milk (Class B). Its makers state that it is a solid extract derived from very superior growths of wheat^ nothing more. It ap- pears to be made as claimed from wheaten flour and to be mainly composed of torrefied starch. For an infant six months of age it is to be prepared by cooking 3 ^/ ^ teaspoonfuls of food in 31 ounces of water and 20 ounces of milk. Composition when prepared as above: — Imperial Granum.*^ Woman's Milk. Water 91.53 88.51 Salts 0.34 0.34 Proteids 2.15 2.35 Fat 1.54 2.41 Starch 1.22 Maltose, dextrin, etc 0.58 Milk-sugar 2.71 6.39 Reaction alkaline. Reaction alkaline. The total of solids contained is one-quarter less than in woman's milk; the carbohydrates are nearly one-third less than the amount in woman's milk and it should be observed that 1.22 per cent., or about one-fourth of them, consist of starch; there is only a slight deficiency in the amount of proteids, but a considerable deficiency in the amount of fat. By using more milk or milk and cream and less water than above employed the percentages of fat, proteids, and soluble carbohydrates would be in- creased. *^ According to Chittenden. 198 INFANT-FEEDING. Its very large proportion of starch forms the principal objection to this food. The presence of unconverted starch causes the thick condition of the mixture. ESKAY^S ALBUMENIZED FOOD. This food is to be prepared with cows^ milk (Class B). Its makers state that it contains the more easily digested cereals, combined with egg-albnmin. Eskay's albnmenized food consists largely (about 88 per cent.) of carbohydrates; the soluble carbohydrates, mostly milk-sugar, are about 50 per cent., and the insolu- ble carbohydrates, mostly starch, are a little less than 40 per cent. On account of this proportion of starchy matter in the dry food, it may be termed farinaceous. The makers, however, claim that in the process of manufacture the starch-granules are almost entirely disintegrated, and when the food is prepared with milk according to directions the percentage is said to be not over 1 ^/o to 2 per cent. An analysis of the dry food shows that it contains about 9 per cent, of proteid matter, but when prepared according to the six months' formula it analyzes about 2.55 per cent. The egg-albumin is said to be first combined with sugar of milk in such a thorough manner that the particles are finely subdivided, and no firm, hard coagulum can therefore take place in the stomach. The particles retain their identity, and do not coalesce; so that in the finished preparation the egg-albumin is suspended throughout the v/hole mixture in very fine particles, which are easily di- gested, because the gastric juice acts by contact, and, the smaller the particles, the greater the effect of the gastric juice. No claims are made by the manufacturers for its solubility, but for its ease of digestion and its nutritive value. The directions for preparing it for an infant six months of age are to take INFANT-FOODS. 199 2 ^/o tablespoonfuls of food. 1 pint of hot "water. 1 pint of rich cows' milk. When prepared as above^ using rich cows' milk, con- taining abont 6 per cent, of fat, their analysis shows that it contains: — Eskay's Alhumenized Food. Woman's Milk. Fat 2.96 2.41 Proteids 2.55 2.35 Carbohydrates 6.13 6.39 Milk-sugar 5.07 Insoluble carbohydrates 1.06 Reaction alkaline. Reaction alkaline. mellin's food. Mellin's food is a malted cereal food (Class B). This food is stated by its makers to be a soluble dry extract from wheat and malt, for the modification of fresh cows' milk. The carbohydrates therein are in the form of dextrin and maltose, and constitute abont 80 per cent, of the food; the proteids amount to about 10 per cent., and are derived from the cereals. Mellin's food is almost com- pletely soluble in water. It is especially noticeable that this food does not contain any starch. The directions for preparing this food for use for in- fants six months of age and over are to dissolve 2 heaping tablespoonfuls of food in ^/^ pint of hot water and ^/^ pint of cows' milk. Composition when prepared as above: — Mellin's Food.^° Woman's Milk. Water 88.00 88.51 Salts 0.47 0.34 Proteids 2.62 2.35 According to Chittenden. 200 INFANT-FEEDING. Fat 2.89 2.41 Maltose, dextrin, etc 2.73 Milk-sugar 3.25 6.39 Reaction alkaline. Reaction alkaline. In total solids this food differs but slightly from woman's milk, and in the various constituents its simili- tude to woman's milk is remarkably close. Of the carbo- hydrates the maltose and dextrin are a little less in amount than the milk-sugar, and the total carbohydrates (5.98 per cent.) are only slightly less than the amount in woman's milk. The manufactu.rers of Mellin's food present many formulas for preparing the food for use to meet various indications. The following formulas are given with the analyses of the respective milk-modifications: — FOEMULiE AND ANALYSES FOE PeEPAEING MeLLIN'S FOOD. For Infants ahout Tioo Montlis Old. Mellin's food, 6 tea- spoonfuls (level). Milk, 6V2 fluidounces. Water, 9 V2 fluidounces. Gives this composition: r Water 93.40 I Salts 0.35 I Proteids 1.69 1 Fat 1.53 Carbohydrates (no starch) 3.03 LoiD Proteids. Mellin's food, 2 table- spoonfuls (heaping). Milk, 4 fluidounces. Cream, 1 V2 tablespoon- fuls. Water, 12 fluidounces. Gives this composition : r Water 91.50 Salts 0.37 Proteids 1.45 Fat 2.50 I Carbohydrates (no starch) 4.18 INFANT-POODS. HigJi Fat and Low Proteids. 201 Mellin's food, 3 table- spoonfuls (heaping). Milk, 4 fiuidounces. Cream, 2 tablespoonfuls. Water, 12 fluidoiinees. Gives this composition: r Water 89.36 Salts 0.45 I Proteids 1.65 i Fat 3.00 Carbohydrates (no starch) 5.54 PEPTOGENIC MILK-POWDEE. This product is stated by its makers to be an article containing milk-sugar and a digestive ferment capable of acting on casein^ offered for the preparation of an arti- ficial infant-food. McGill states: "It is not, in the strict sense, a food. Its professed object is so to change the composition of cows^ milk as to render this comparable to human milk. This it seeks to do by introducing milk- sugar and small quantities of albuminoids.'' According to McG-ilFs analysis, it is composed almost entirely of milk- sugar (96.60 per cent.). The following analysis is by Leeds, and is taken from a circular of the makers. Composition of ^Tiumanized milk" prepared as di- rected, using 4 measures of peptogenic milk-powder with ^/o pint of milk, ^/^ pint of water, and 4 tablespoonfuls of cream: — Eumanized Milk. Woman's Mill-. Water 86.20 88.51 Ash 0.30 0.34 Proteids 2.00 2.35 Fat 4.50 2.41 Milk-sugar 7.00 6.39 Peaction alkaline. Peaetion alkaline. Chittenden's analysis of this m.ost identical with the above. 'humanized milk" is al 202 INFANT-FEEDING. The proteids of the cows' milk undergo a change in the peptonizing process, being converted chiefly into par- tial peptones, and in this form they cannot be said to re- semble the proteids of woman's milk, which have not been acted upon by a proteolytic ferment. CHAPTER XXX. Pkofessok Gaertner Mother-milk. In a paper entitled "The Clinical A^alue and Cliem- ical Results'' the antlior published a paper in the Medical Becord, December 11, 1897. This new food has now been used about five years in Europe, and is the outcome of the scientific endeavors of Professor G-aertner, of the Uni- versity of Vienna. The first paper was published by Gaertner in the TJierapeutische WocJienscJirift, May 5, 1895. A few months before, January, 1895, Gaertner, in an address before the Vienna Scientific Society, explained the mode of preparation and the results obtained with his new modification of cows' milk, for such the mother- milk of Gaertner really is. Professor Gaertner, in the preparation of his food, has aimed to overcome what has been the great difficulty in infant-feeding — namely: to reduce the excess of casein by a scientific process without the addition of chemicals. To achieve this result he employs a machine called a separator or Pfannhaiiser centrifuge, which makes four thousand or eight thousand revolutions per minute. The apparatus consists essentially of a drum of steel, which re- volves on its axis. This drum is filled with equal parts of fresh cows' milk and sterilized water. The mixture con- tains approximately the same amount of casein as human milk, for cows' milk undiluted contains about twice as much casein as human milk. The mixture is next poured into the centrifuge and the speed of the drum is carefully regulated, so as to separate the mixture contained therein into (1) a creamy (fatty) milk and (2) a skimmed milk. The two portions so separated are then led off separately by suitable openings in the centrifuge. (203) 204 INFANT-FEEDING. The analysis of each of these portions shows that the creamy milk has the same quantity of fat as is found in human milk^ while about 2 per cent, of the casein is con- tained in the skim-milk^ and the remainder, about 1.7 per cent., remains in the creamy milk. The chemical com- position of fat milk is shown in the following table: — Proteid. Fat. Sugar. Ash. Fat milk 1.76 3-3.5 2.5 0.35 Human milk 1.03 3.5 7.03 0.21 Cows' milk diluted with one- half water 1.76 1.6 2.5 0.35 If, now, 3 or 4 grammes of milk-sugar be added to every 100 cubic centimetres of fat milk, the percentage of sugar is brought up to the level of sugar in human milk. This addition is made before sterilizing. The fat milk has the advantage over the diluted milk of having "a higher percentage of fat"; it also curdles more slowly than diluted milk and the curd forms a more flocculent precipitate. According to Escherich, the following amounts should be used at different ages of infancy, feeding every two to four hours: — Infants under 2 weeks. .. . 500 c.cms. (17^/2 S) in 9 feedings. Infants 3 to 4 weeks 750 c.cms. (26 5) in 8 feedings. Infants 4 to 8 weeks 1,000 c.cms, (35 B) in 8 feedings. Infants 3 to 4 months. . . .1,250 c.cms. (42 S) in 8 feedings. Infants 5 to 6 months. . . .1,500 c.cms, (50 B) in 7 feedings. Escherich gives in detail his experience in feeding with fat milk fifty infants in a hospital, including rickety and tuberculous children. He has certainly met with marked success. Some cases have been under observation for six months. His article is published in extenso in Mitteilungen des Verehm der Aerzte in Steiermark, No, 1, 1895. GAERTNEE MOTHER-MILK. 205 Baginsky^^ mentions Gaertner milk as a new form of food introduced. In our country Jacobi^^ states that Gaertner milk is applicable to the majority of infants who require cows' milk appropriately prepared. During the past summer I proposed to test the effi- cacy of Gaertner milk. With this in view I have subjected the milk to a very rigid test^ inasmuch as the time chosen, from June to October, was the heated term, which is the worst for milk digestion, and the hygienic conditions of the infants were those found in the average tenement- house, too well known to need description. The guides for ascertaining the degree of assimila- tion were the following factors: — 1. The child's general condition, as manifested by its appearance, appetite, and sleep. 2. The presence or absence of gastro-enteric disturb- ances, such as vomiting, colic, restlessness. 3. The condition of the stools, constipation or diar- rhoea, the number of stools in twenty-four hours. 4. The gain in weight; weekly observations. The nurses or mothers were instructed to note the amount of food taken and the number of stools in twenty- four hours. We submitted the stools passed in twenty-four hours to Mr. Herman Poole, our chemist, whose chemical re- port is appended. Thus we have tried to ascertain how much proteids, fat, sugar, and salts were taken, how much absorbed, and how much was voided in the faeces without having taken part in metabolism. The following cases will serve to illustrate the method pursued in attempting to solve the problem be- ^^ "Lehrbuch der Kinderkrankheiten," fifth edition, pages 35 and 36. ^^ "Therapeutics of Infancy and Childhood," page 508. 206 INFANT-FEEDING. fore us and the results obtained as regards the efficacy of the milk: — Case I. — Dorothy Shattuck, a prematurely-born child, the labor having occurred in the middle of the eighth month of gesta- tion. For three weeks after birth the child's mother fed her on Borden's "eagle brand" condensed milk, and then, being discour- aged with the results, gave the child to the care of Mrs. Turnure, who brought her to the clinic. For the past week she had fed the child on malted milk and a mixture of milk, cream, and barley- water. June 16, 1897, the little patient first came to us at the German Poliklinik. She stated that the child had been getting worse, was extremely irritable, slept badly, had had persistent vomiting and diarrhoea, with six and more watery stools daily. It also had a hacking cough. Status prwsensx An extremely-emaciated child, twelve weeks old, weighing 6 pounds and 12 ounces. The head is of normal shape; the face has a peculiar, senile expression; the fontanelles are open, but do not bulge. The scalp is of a reddish color, with here and there a furuncle. The face has a sallow, earthy color; the eyes are kept closed most of the time. The thorax is not de- formed; the ribs are not beaded; the thoracic skeleton is sharply outlined; the skin is dry, yellowish. The upper extremities show thick epiphyses; thin, flabby, bluish skin; cold, weak hands; and thin, atrophic long bones. The reflexes are diminished, the grasp is weak. The abdomen is full and pendulous, the abdominal walls are very thin, the intestines are distended with gas. The skin in the groins is flabby; there are no dilated veins and no hernise. The buttocks and genitals are covered with an erythematous rash (intertrigo); the anal reflex is normal; rectal temperature, 99° F. The lower limbs are similar to the upper — thin bones, thick epiphyses, atrophic muscles, bluish dry skin. The scapulae project behind; the spine is not deformed; the whole appearance is one of extreme atrophy. The tongue has a white coating; gums normal; fcetor ex ore. There are swollen glands in the inguinal region and furuncles on the thighs. The child drinks water with avidity; a peculiar, lactic-acid smell is exhaled from the body. Diagnosis: Athrepsia, catarrhus gastro-entericus, rachitis. Treatment: (a) Hygienic: Daily baths; cleanliness in the mouth, clothing, bottles, nipples. (6) Dietetic: The sole diet, Gaertner's mother-milk. Three cans (one- third litre in each) in twenty-four hours; beginning with a few ounces at a time, and increasing the dose gradually until 8 GAERTNER MOTHER-MILK. 207 ounces are given at one mealj of which there should be six in twenty-four hours: i.e., every three hours in the day-time and at longer intervals at night. (c) Medicinal: None. An iiTigation with hot water was used to wash out the colon and rectum before the diet was begun. June 23d^ the child took the milk at first reluctantly; the first doses were vomited at once. The nurse persisted, however, and her efforts were rewarded, for in a few hours the baby began to take the milk in larger quantities and to retain it well. The vomit- ing and diarrhoea stopped — three stools daily. The child was quiet, and slept twelve to sixteen hours out of twenty-four. Looked cleaner and brighter. June 26th, The general condition is the same; bowels reg- ular, tongue clean, complexion more natural. On July 14th the weight was 8 pounds and 3 ounces, a gain of 1 pound and 10 ounces in two weeks; 26 ounces in fifteen days equals 1 ^A ounces daily gain. The milk was continued in the same quantities; a fresh supply was furnished at the clinic on every visit. The child was seen two or three times every week, July 29th. Weight, 8 pounds and 10 ounces. Gained 7 ounces in fifteen days, or V2 ounce daily out of the 48 ounces of milk con- sumed. August 4th. Had an attack of vomiting and diarrhoea, which was relieved by one dose of castor-oil. There are three or four stools daily, August 7th. Milk continued as usual. The child looks bright; face smooth and of a natural color. Sleeps well, appetite good. August 14th. For the last two days there is vomiting fol- lowing an attack of cough. Child takes her food well; mucous rales on both sides of the chest; temperature, 101° F.; diagnosis of bronchitis. A teaspoonful every three hours of mistura glycyr- rhizae composita, to which some belladonna had been added, relieved the cough. September 4th. The child has a normal temperature, cough is stopped, general condition is good, digestive organs are in good order. The child was not seen until September 20th. Weight, 10 pounds and 14 ounces. The child is still taking the milk, and ap- pears to enjoy very good health. Case II. — Abraham Friedman^ 1 year old, was fed at the 208 INFANT-FEEDING. breast for the first seven weeks of his life. Since then he had been receiving condensed milk. On July 3d was first seen at the Ger- man Poliklinik, with the history of diarrhoea, twelve greenish stools a day, vomiting once or twice daily. On examination, a pale, bloated child; skin flabby, smooth, and dry; fontanelles open, dentition retarded, ribs beaded, abdo- men pendulous, limbs weak, and bones very thin. Weight, 17 pounds and 10 ounces. Diagnosis: Gastro-enteritis, rachitis. Treatment: An irrigation of colon and rectum with a deci- normal saline solution; 5 grains of betanaphthol-bismuth every three hours. Diet: Gaertner milk, three or four cans daily, at intervals of three hours. On July 7tli the general condition is better, no vomiting, two or three stools a day. July 14th. The condition remains the same. July 29th. No diarrhoea, no vomiting; has two stools a day. August 7th. The child's weight is 20 pounds and 10 ounces. September 3d. The child receives^ in addition to the mother- milk, soup and rice. The general appearance is better; two stools daily of a brownish-yellow color. The child was discharged cured. Case III. — Abraham Bassick, 7 months old, first seen at the dispensary July 21st. Previous history: Born at term; for the first three days after birth he received the breast, and then he was fed on condensed milk. The child has an erythema intertrigo and lichen tropicus. Now suffers with diarrhoea, vomiting, and colic. Child is considerably emaciated, and weighs 8 pounds and 14 ounces, including his clothes. Diagnosis: Athrepsia infantum. Prognosis doubtful. Treatment same as in Case I. Feeding: Number of cans daily, three; number of meals per day, six; at night, two. Clinical results: The child increased in weight; the condi- tion of the gastro -intestinal tract seemed to improve while he was taking this form of food; there was no vomiting nor diarrhoea for the first three days after the commencement of the feeding. The child was infected with measles on August 9th, and was removed from our observation. The child died of pneumonia, August 16th. Case IV. — Grace Bliss, 2 months old, was first seen August 14th. Mother had a number of miscarriages and lost several chil- GAERTNEE MOTHEE-MILK. 209 dren; has had several still-born children, some covered with an eruption. The present child was born at term, weight not known; has been nourished at the breast until to-day. For the past two weeks the child has been restless, cries a good deal; coughs, has coryza; also has eructations and passes a great deal of wind; three or four greenish slimy stools a day. The examination shows a large, square head, thick epiphyses, distended abdomen, beaded ribs, flabby skin. There are no erup- tions, and their existence previously is denied. The temperature is normal; no enlarged glands. Weight to-day, 11 pounds; the child has been losing weight gradually. Diagnosis: Athrepsia, rachitis, lues congenitalis. Treatment : The breast-feeding is to be alternated with Gaert- ner milk, one to one and one-half cans daily. The child was seen every other day until August 28th. Gen- eral condition good, takes the milk readily, there is much less colic, the child seems more contented and more quiet; stools are yellowish and appear more normal in consistence. On September 1st the child's weight was 11 pounds and 11 ounces: a gain of 11 ounces in two weeks. The child has been watched during the month of September, and has received small doses of calomel — Vio grain three times a day for its lues — besides a bichloride bath, 1 to 10,000, every third or fourth night. We consider this case very much improved. Case y.-^Mary Burghardt, a premature child, born at the eighth month of utero-gestation. Mother reports that it weighed about two pounds {sic). It was first seen on the 1st of August. During the first week of life the child appeared fairly well, slept quietly, and took the breast without any signs of discomfort. The child is now eleven days old; we are told that it coughs, moans, and cries when touched. There are frequent soft stools. The child is about one and one-half feet long, and weighs three pounds. The mother states that she has lost several children in their infancy and had several miscarriages. Examination: The head is of normal shape, with the soft bones and open fontanelles at this age. The face has a senile ex- pression, but the skin is of normal color. There is no eruption; there are no beaded ribs. The upper extremities are very thin, the hands cold, the feet cold. The veins are enlarged; the abdomen is distended, tympanitic on percussion. The mother states that the skin of the lower half of the body came off in large scales a few days after birth. The skin is dry and shrunken. Temperature, 101.6° F.; pulse, 138. 210 INFANT-FEEDING. Treatment: Irrigation; calomel, Vio grain t. i. d. Gaertner milk, 2 ounces every three hours. The diagnosis of the case was congenital syphilis and athrepsia infantum. The child was reported considerably improved, but it was thought advisable not to increase the quantity of milk until the 28th of August, when the child received V2 ounce more at each feeding. The child was watched during the month of September, and is considerably improved to-day. Weight, 4 pounds and 9 ounces on September 25th. Owing to the coolness of the limbs, inunctions of oil were given every day following the bath, and the child's body was wrapped in cotton-wool. Besides the above cases we have had fifteen patients to whom Gaertner milk was given since the beginning of June last. In some cases it was necessary to add sugar to the milk, as many children objected to the taste. In one case (Case III) no deductions can be made, owing to the child^s infection with measles and pneumonia result- ing fatally. Cases I and V serve as splendid illustrations for the proper determination of the value of this food, as both were syphilitic and prematurely-born children. The other two children (Cases II and IV), although much stronger at the commencement of the treatment, im- proved very rapidly. We sometimes diluted the Gaert- ner milk with equal parts of barley- or rice- water, and if this latter mixture was not retained, then the Gaertner milk was discontinued. In the above cases the milk was borne very well, and is continued up to the present day. Although our experience is not so large as that of Professor Escherich, we feel that we can in- dorse both his statements and those of Professor Gaertner. The assimilation of this form of food, judging from the stools, is equal to that of any other modified milk. The German journals assert that rickets and scurvy can be prevented by using this milk. As our observations GAERTNER MOTHER-MILK. 211 have not been carried on long enough^ we cannot yet cor- roborate this. As we frequently notice that some children show a distinct idiosyncrasy when given milk^ so it was in one case in which neither cows' milk, nor modified milk, nor breast-milk, nor Gaertner milk was tolerated. That child fared best on malted milk, properly diluted. Con-elusions. — The small amount of proteid matter contained in the milk appeared to be vei^ easily as- similated in the cases above mentioned. Case I is a splendid illustration of a tolerance of this form of feed- ing, when neither cows' milk, condensed milk, nor malted milk was retained. We felt greatly encouraged, especially in the very hot July days, to find this baby gaining in weight, for it must be remembered that this child, in our city with poor hygienic surroundings, gained, from the end of June to the 14th of July, 26 ounces in fifteen days. Case II, suffering from summer complaint about the same time, early in July, made very rapid progress, and while it could not digest a dilution of one-third milk and two-thirds barley-water without passing six or eight stools a day, fared very well on the Gaertner milk. Case III was under observation from July 21st until August 9th, and, although progressing favorably, unfortu- nately contracted measles and died. Case TV, an emaciated child, had been receiving breast-milk, which did not satisfy it. It frequently nursed from thirty to thirty-five minutes at the breast. The child's mother insisted on nursing it, and thus we gave mixed feeding, alternating the breast-milk with the Gaertner milk. Thus the child has received from two to three cans of milk per day, without showing any evidences of colic, and without having gastric or enteric disturb- ances. The treatment has been continued for over two months. Case y, the prematurely-born child with congenital 212 INFANT-FEEDING. syphilis^ was certainly one which was well adapted for the trial of this form of feeding. When she was first seen there were thick, cheesy stools, which, after the gastro- intestinal tract had been cleaned and feeding changed, showed an entire cessation of the colicky symptoms. When commencing this treatment, the child having pre- viously fed on cows' milk, I ordered all milk to be stopped, and fed the child on barley-water and rice-water for three days, after which I gave Gaertner milk, 1 ounce every three hours on the first day, 2 ounces every three hours on the second day, 3 ounces every three hours on the third day. Considering the syphilitic condition and the fact that it was a premature child, the increase of 3 pounds and 7 ounces from August 11th until September 25th, during a period of six weeks, speaks for itself. In conclusion I desire to thank Dr. George Saxe and Dr. McConville, Dr. de Hart, and Dr. Emil Joel for kind and valued assistance. CHEMICAL KEPORT, BY HERMAN POOLE, F.C.S. The chemical examinations were made with the idea of working out some connection between the substances ingested and those excreted. To this end the milk fed was analyzed, and from this the quantity of each con- stituent fed to the child daily was determined. The fseces were also examined so as to ascertain the quantity of un- digested fat and casein voided. The results of both sets of analysis are given below, the fasces examinations being tabulated and plotted for the better elucidation of the facts. Tlie Milk. — The milk used in feeding the children contained the following: Fat, 3.05 per cent.; casein, 2.09 per cent.; milk-sugar, 6 per cent. Specific gravity, 1.0275. Eeaction, faintly alkaline. When cold, part of the fat separates out, forming a GAERTNER MOTHER-MILK. 213 layer on the top of tlie liquid. On being warmed and thoroughly shaken^ this is completely emulsified and dis- tributed through the fluid. Its appearance is that of a good^ rich milk; in taste a little sweeter than ordinary cows' milk; and it is more liquid and mobile. Each can contained Vg of a litre, or 20.34 cubic inches, weighing nearly 9 V2 ounces. Of this there was: Fat, 0.289 ounce; casein, 0.198 ounce; milk-sugar, 0.569 ounce; total, 1.056 ounces. Each child consumed from three to four cans of the milk per day, and hence used: 0.867 to 1.156 ounces of fat; 0.594 to 0.792 ounce of casein; 1.707 to 2.276 ounces of milk-sugar. The milk was perfectly sterilized, a can remaining open for five days without thickening or showing acidity. The can analyzed had a shot of solder in it, which was perfectly bright, showing no chemical action and conse- quently no solution of lead. Tlie Fceces. — The chemical examination of the faeces was made with a view of obtaining, as nearly as possible, the percentage of undigested fat and casein. To this end the nurses were instructed to deliver at the laboratory three times a week the napkins used during the previous twenty-four hours. They were put into cigar-boxes and kept in them until examined, which was on the day of re- ceiving them. In some cases they were in very good con- dition, but many times they were dry and hard, the de- posit adhering so firmly to the cloth that it was almost impossible to remove an amount sufficient for analysis and have it free from adherent cotton-fibre. This was espe- cially the case when cotton flannel was used, as was fre- quently done. In all cases except No. 1 (ShattUck) the weight of the faeces given is below that actually voided; in case No. 2 as much as 25 per cent, can be added to the amount given; with ISTos. 3 and 4 at least 50 per cent., and on 214 INFANT-FEEDING. some days the amount obtained for analysis was not one- half of that actually voided. The amount of moisture was, of course, much influ- enced by that of the liquid excretion, which naturally varied considerably. Still, to avoid necessity of laborious analysis, the hypothesis was adopted that the amount of moisture absorbed from the faeces by the cloth was equal to that added by the liquid excretion. In some cases I think this was correct; in others it is doubtful, especially when the fasces as voided were very thin and the napkin had evidently been kept long enough to become dry. This was a matter very hard to regulate, and must be accepted as found. The physical appearance did not vary very much in individual cases, except in times of intestinal disturbance. After a few days the cloths of Case I would have the fasces in a single mass, and of such consistence that over 90 per cent, of it could be easily removed. While the child was suffering from an attack of the diarrhoea, as shown by a rise in the curve, such a condition could not, of course, be expected. There was a decided improvement in the color in each case, changing from a dead clayey appear- ance to a more or less decided yellow, with occasionally a greenish tinge. When dry, as was sometimes the case, the color was uniformly brown or dark brown. In most cases the faeces at first were very thin and spread all over the cloth, but after a time this character changed and they became firmer and more aggregated. Some of the cases were so poorly taken care of that no mention need be made of the condition, as it was hardly possible to obtain a sufficient quantity for satisfactory examination. With one exception the smell was uniformly very faint and not of an offensive character. The exception is the case of the Bassick child, which was fed with egg- albumin in addition to the milk. One of the other cases GAERTNER MOTHER-MILK. 215 showed a faint skatol odor twice, but in none of the others was it noticed, while in this case there was not sufficient skatol to admit of separation. On many days the lactic- acid odor was not perceptible, although litmus-paper showed a faint acidity. The reaction was almost uniformly acid, not strong at any time, and not measurable except in very few in- stances, and in these only to a very small fraction of a per cent. (0.005), as determined with decinormal ammonia solution. On some days no change in moistened test- paper could be observed after fifteen minutes. No de- cided alkaline reaction was found except once, and this was in a dried sample, the reaction of which may have been influenced by the urine present. The quantity in the same case did not vary very much. When a very large figure is given there was evi- dently an accumulation of two days, as was shown by the physical character. As mentioned above, in some cases I was not able to remove more than half of the total, and, of course, the amounts given do not fairly represent the quantity. This is true with all cases except Case I, which will average within 10 per cent, of the total voided. It is impossible to impress the kind of people from whom these were obtained with any idea of care in this regard, and the cloths brought to me show it. Eemarks analogous to those made regarding the amount of excretion apply as well to the water contained. Still, a fair average can be found and will probably be near the correct one. In most cases I was obliged to put all together, w^et and dry, to have sufficient for analysis, and this at times caused an abnormal number to appear as the water-content. This is notably the case with the Bassick child, in which the water-content dropped on one day to 20 per cent., the cloths being practically dry. It was also noticed, in regard to this one, that in this in- stance the ordinary strong smell was absent. 216 INFANT-FEEDING. In each case the quantity of fat and casein decreased after the milk was used, and remained at a lower per- centage. This does not apply to the Bassick case; and, in fact, this case was amenable to no law but that of uni- form filth. Whenever a temporary sickness occurred the percentages would rise, and with the Shattuck child this rise also occurred nearly simultaneously with her being taken to Staten Island, where, although she was reported in good health, the percentages kept higher than when she was in the city, and on her return to the city they fell again. Still, in none of these cases of rise in percentage did it reach that point which was attained at the be- ginning of the experiments. No notice is taken, in these results, of the quantity of fat which exists in the fseces combined with calcium, iron, alumina, etc., as insoluble soaps. These have undergone some change in the system, and only the undigested or unchanged fats which were soluble in ether were determined. The methods used for determining the fat and casein were those mentioned in my paper read before the Ameri- can Chemical Society at Detroit in 1897. The faeces were dried at 90° F., then at 110° C, and the ether ex- tract taken. This ether extract, containing also choles- terin with fat, was saponified with alcoholic potassa and the cholesterin taken up with ether. The fat-acid soap was then decomposed by hydrochloric acid and the fat determined. The residue from the ether extraction was then treated with water and with alcohol. This residue, containing undigested casein and epithelial cells from the intestinal tract, was digested with diluted hydrochloric acid for ten to twelve hours, and this solution used to determine the nitrogen by the Kjeldahl method. Casein was consid- ered as being 15 per cent, nitrogen. Of course, these metliods may be open to objections, but I know of no better ones, and after trying several others decided that they would suit the investigation and GAERTNER MOTHER-MILK. 217 its requirements the best, and I actually believe that the true state of affairs has been shown better than it would have been by any of the methods previously used: The following tables show the results of the exami- nation, giving the date of receiving the faeces, the general appearance, consistence, reaction, quantity in grammes that could be removed from the cloth, and the percentages of water, fat, and casein obtained by the methods given above. The percentages of cholesterin are not given, al- though they were, of course, obtained. They did not run in a uniform proportion to the fat, being at times very much larger than at others. (See pages 219 to 221.) Discussion of the Curves. — The curves are made by using the days of the month as abscissas and the per- centages as ordinates. The zero-point at the intersection of the axes is then the date of the commencement of the experiment on the line of the abscissas and per cent, on the line of the ordinates. (See page 222.) The Shattuck curves: The curve of the casein per- centage runs very even until the latter part of July, the time when the child was taken out into the country. While she was there her health was reported good, ex- cept at the middle of August, when she had an attack of diarrhoea, which lasted some time. This is plainly shown on the curve, both casein- and fat- lines responding to the conditions. Why the curves rose about July 29th is not explained. The fat-curve made a decided downward movement from the beginning, and, except for the fluctu- ations due to intestinal troubles, remained low; in all cases it remained lower than it was at its inception. This curve, like that of the casein, tends upward about July 29th, and does not return to its former low figures. The Friedman curves: With these curves, as with the Shattuck ones, the effect of the feeding is shown by a downward movement. The two lines run closer together than in the Shattuck case, and both respond to the diar- 218 INFANT-FEEDING. rhoea which commenced August 1st and was at its height at about the 17th. The fat-curve seemed to respond more quickly to changes in the intestinal tract than did that of the casein, and at times no change in the casein could be determined when a marked one in the fat was evident. At other times, however, from some cause, the casein showed a change not to be noticed in the fat. The curves of the other cases are not plotted, as they were soon discontinued, and the data obtained were not considered sufficient. At the time I experimented with this mother-milk it w^as sold and delivered in tin cans. At that time I dis- tinctly told the manufacturer that milk must be fresh and must be delivered daily in bottles. Milk of this descrip- tion, in which the proteids are mechanically reduced, forms an ideal food, and no doubt some future manufact- urer will reap the benefit of milk prepared in this manner and freshly sold in carefully-sterilized bottles. Thus, we can account for the success attained by Professor Escherich as well as by Professor Gaertner and others, as theirs is a milk prepared daily, and delivered in bottles. Some in- teresting editorials in various medical journals followed the publication of my article on Gaertner mother-milk. To those who are interested I should advise reading an editorial in Pediatrics, January 15, 1898, and also an edi- torial in the Atlantic Medical WeeMij, January 15, 1898. An editorial in the Woman^s Medical Journal, January, 1898, published in Toledo, Ohio, is worth repeating. Here is the article as published: — "There has been no greater advance in preventive measures than in the reahii of infant-feeding. Where substitution of pabulum other than mothers' milk is necessary, we have for ages been at our wits' end for a desirable food. "In our research we have tried all sorts of grains and foods — and cows' milk has been incorporated in them, with small suc- cess. We all are only too familiar with the poor results that accrue GAERTNER MOTHER-MILK. 219 si -£^cooci oi cc t6 c^i ?c <>i c^i oi ci d CO CO CO CO CO o o o ,^ ^ ^ -^ ^ CO o o t^o?:^xc;oo q lt: -^i ?! ?5 o -3 o C! CD CI t- u': cc ^6 X c; ut ut' L'^ 1-H re 1-! i-< ic d — ^ c; CO l> :oj:-l-t-;s;c:oo UO i> o lO O t^ i> O CO CD CO ^^^ , ^ o o o o o o o CO o 5 5 o c; X t^ o K -3 X X o o -^^ T--' CO 1— * X I- o -^ c-j oi CO C5 X yi '^ d ci d 1--: X C^j C> lO l-^ (M c^} c) r: :>) r-^ ^: JO CC^-rH UO CO Ci r-( ^Oi < OCiOOrt^iO^i' 'S 'S '3 o ai "E3 S s 2;-> ss' -t^ . • "i^ o c3 1-1 ;?; ^ >^ i So . . . . >5 33 :« 72 _. (D V2 a] l^: : • • j:;» Ph i=H P. 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C CO LO O CO CO s as ^ H a !^ Tti LC Tf lO J> i i-H ^£^ K! 2£^^ IS iS!^ ^ ^ M 1 4 H 1 5>:g CO O O O CO t- 2^5 00 '^ CO lO CO 00 -^\6\6 t^ CD id CD »■ . . . o o -^ Ti ^ &X) ;|1 1 1 i > O O c3 c3 c3 -^I^P^ PR ^ &0 bjo 2 '^ d o ■ § • o fl S ii "= • -^.^ - = l -i^'^'a^ ni ^ ^il^ ,_r-^ o ^ ="a.2^.sss g.^^ o OcEjH^;^t» ^4JCC o 02 PHco « >j . . . . j H >H pq;>H>^ <| S .• • A- Arc '^ '^ r- :3 ';3 CJ ^ O CO 00 o ^ ^ -— ' 1^ (M O^ C P ^ ^ fi s ^ f^ h-5 Hj H5H5<^ J CO CO ^' 125 O M < 111 p c; fl a; a; a; ji o . 1 ill e4 o Ph < ■ 5c ^ ^ ^ 1 -t3 -t^ ^ti 05 M M Si 13 222 INFANT-FEEDING. fe ^"f ^'f ^ :? 5 ^ sa- -£ 5 ^ S _4i . / JI / IT „IL / ' : IT ^ I 7 4--.^ ' t7 rr T"" II z: I- u y ) L\^ T _.t_K t 7 y. ij- »- y L 7 '" t t ~ X i I ~ X I ± t I ^ ± J_X IT " > ! , i: ^ 1 : _ , t~ > : ^ J H 1 rn j:' ";i X " i -i i n ^ 5 Ij s " t -z J i 4 :• jt it T TIT I ^jt z: r \ L4 ^ -4- -t r " \ir HI " J t . "1' jli ± -A ^i "^ V-t X-T- X -^ 4lil ::x :i :: q 5- -- - t -t^- -^ i- " ==:ii=t--="t=^-t= J L " Tl ^~ li tit J * - i " ■■ 223 from cows' milk, and the sequelae that present themselves after a diet of this substance. But finally practical measures are instituted and tangible results ensue. "We are all more or less familiar with the proper method of preparing milk, but we are sorry to say that the average mother is appalled at the machinery which is essential to the proper prep- aration of baby's food. "In the larger cities this may be secured correctly prepared, but in the country and village the lack of proper machinery is an insurmountable obstacle that confronts us. "It must be admitted that much has been done, and steril- izers that are simple produced; but to prepare milk according to the latest chemical research is beyond the paraphernalia of the average practitioner. "What we need is a simple, handy method of eliminating the casein from cows' milk^, and the man or woman who produces it will be a benefactor to the race. "Louis Fischer, Professor of Diseases of Children in the New York School of Clinical Medicine, has made some very satisfactory and encouraging tests with milk prepared by Gaertner's method, and the results are good; so there is no doubt about the value of Gaertner's method; but how is the doctor in the country to pre- pare such a milk? "The milk used by Dr. Fischer was as follows: — "Fat, 3.05 per cent.; casein, 2.09 per cent.; milk-sugar, 6 per cent. Specific gravity, 1.0275. Reaction, faintly alkaline. "When cold, part of the fat separates out, forming a layer on the top of the liquid. On being warmed and thoroughly shaken, this is completely emulsified and distributed through the fluid. Its appearance is that of a good, rich milk; it tastes a little sweeter than ordinary cows' milk; and it is more liquid and mobile. "Each can contained Vs of a litre, or 20.34 cubic inches, weigh- ing nearly 9 V2 ounces. Of this, there was: Fat, 0.289 ounce; casein, 0.198 ounce; milk-sugar, 0.569 ounce. Total, 1.056 ounces." Backhaus's Milk.^^ The following method is employed in the production of this food. The milk from different breeds of cows is mixed and passed through a centrifuge, to separate the " Archiv fiir Kinderheilkunde, B. 26, H. 5 and 6. 224 INFANT-FEEDING. cream from the milk and to remove any impurities that might have gained access to the milk, notwithstanding the great care used in handling. Three grades are pro- duced: two for infants, the third representing full milk in its composition. After separating it from the cream the milk is exposed to the action of a mixture of rennet, trypsin, and sodium carbonate, which are combined in such proportions that the trypsin will have converted at the end of thirty minutes 30 per cent, of the casein into soluble albumin. By this time the action of the rennet coagulates the balance of the casein and thus arrests the action of the trypsin. The temperature of the mixture is now raised to 80° C. (176° F.) by the introduction of steam into it. At this temperature it is kept for five minutes. At the end of this time it is strained through cloths and mixed with half its volume of water, one-fourth its volume of cream, and the necessary amount of sugar of milk. It is finally put up in bottles holding 125 grammes (about 4 ounces) and sterilized. The second grade, for older children, is obtained by mixing equal parts of milk and w^ater with half the quan- tity of cream and with milk-sugar. This is put up in quantities of 200 grammes (about 6 ^/\ ounces). The third grade, in bottles holding 300 grammes (about 10 ounces), represents cows' milk in composition, modified by the above-mentioned process. The composi- tion of the three grades is given as follows: — Fat 3.1 3.2 3.3 Sugar of milk 6.0 5.4 4.8 Casein 0.6 1.8 3.0 Albumin 1.0 0.3 0.5 Ash 0.4 0.4 0.7 The milk has been tried at the Wiener allgemeine Poliklinik by Friihwald in a scries of twenty cases, the histories of which are given by the author. With the ex- LAnMANN'S VEGETABLE-MILK. 325 ception of six, these children have been under observation for more than two months. When first seen the children were all suffering from different forms of digestive dis- turbances, and from malnutrition; some were suffering from severe marasmus, and most of them passed through some other disease while they were under observation. Three of the infants took the breast in addition to the Backhaus milk for periods of two and three weeks, when they, too, had to be put on the artificial milk entirely. The children took about six bottles of No. 1 up to four weeks, seven to eight to the end of the second month. From the middle of the third month the second degree was gradually substituted, while No. 3 was used only in the case of an older child. A daily gain was observed of from 18 to 30 grammes (about ^/^ to 1 ounce). In private practice and in healthy children a gain of 50 grammes (about 1 ^/o ounces) not rarely happens. The milk keeps well. Lahmann's A^egetable-milk. In Europe, and recently also in our country, the feed- ing of infants has been enriched with a new product; thus^ Dr. Lahmann believes that the great panacea is feeding- infants wdth milk which he designates as "vegetable- milk." It resembles a thick jelly, and is made by Hewwel & Yeithen, Cologne. His theory consists, in brief, in sub- stituting nuts and almonds, w^hich are rich in albu- min and fat, instead of cereals to dilute milk, his idea being that an emulsion, wdiich is digestible and supposed to be rich in albumin, is doubtless better than pure water or a thin starch-paste. In order to add food-salts, which are not supplied by this means, he extracted them from leaf vegetables, which are rich in food-salts, and added some sugar-syrup. In this manner he believes to have made a preparation which he states is, chemically, equal to human milk; and full of nutritive value. His idea is 226 INFANT-FEEDING. that the interposition of plant-albumin (conglutin) par- ticles, which coagulate with difficulty between the coagu- lating casein masses, would increase their digestibility by breaking them up, and that the digestion of the plant- albumin and oil, as w^ell as of the sugar and food-salts, would present no difficulty. Stutzer, of the University of Bonn, reports thus: The vegetable milk is distinguished from children's food by the absence of starchy substances. In common with Biedert's cream-mixture, the vegetable-milk contains con- siderable quantities of fat in an emulsified condition. It differs from the cream-mixture in the way it is prepared, and in its other qualities. Chemical Analysis. Fat 34,72 per cent. Plant-casein and similar nitrogenous con- stituents 12.00 per cent. Sugar and plant-dextrin 31.02 per cent. Salts 1.64 per cent. Water 20.62 per cent. My own personal experience has been rather favor- able with the use of the vegetable-milk, inasmuch as an emulsion of almonds and nuts was used to dilute the curd of cows' milk. Thus, equal parts of vegetable-milk with cows' milk were taken by an infant for several months, and it was very well assimilated. Not only did the child gain in weight, but the bowels were in a fair condition, and the infant remained strong. My experience, however, is too limited as yet to give a positive opinion. Condensed Milk or Condensed Cream. Hundreds of infants are fed with condensed milk. This has its reason: — First: The readiness with which condensed milk is obtained, CONDENSED MILK OR CONDENSED CEEAM. 227 Second: The great cheapness of this article. Third: The ease with which the feeding-mixture can be prepared. Jacobi says that some manufacturers use pure cows' milk; others find it in accordance with the health of their bank-accounts to use skimmed milk. Quantity of Sugar in Condensed Milk. — Milk sold in our city for immediate use contains about 12 to 15 per cent, of sugar. Milk to be kept for an indefinite length contains as much as 50 per cent, of sugar. These varia- tions show how serious it is to use the same quantity of con- densed milk all the time and from different sources with such an enormous variation in the quantity of sugar. Kehrer — quoted by Jacobi — states, regarding it, that it increases the formation of lactic acid. Fleischman states that it gives rise to thrush and diarrhoea; Daly, that it fattens them (?), but gives rise to rachitis. The worst specimens of rachitis and spinal rickets are seen in my clinic in condensed-milk babies. And still in discussing my paper on infant-feeding (read by invita- tion before the Society for Medical Progress, April 11, 1896), and which was published in extenso in Pediatrics for July 15, 1896, we find Dessau, with a large infants' ex- perience, still advocating the constant use of condensed milk as an infant-food. In traveling, when good fresh cows' milk cannot be obtained, then I permit the use of condensed milk, but for a few days or for a week only, as on the ocean steamer, where cows' milk cannot be had. My experience among hundreds of children seen in my Children's Service at the German Poliklinik and also at the service at the West-Side German Dispensary during these last ten years has been that children so fed have rickets; that they are predisposed to the infectious dis- orders; that they have less resistance and far less vitality, especially in combating such diseases as pneumonia or 228 INFANT-FEEDING. diphtheria; that they have tendencies to hernias and de- formities, owing to the softer condition of their muscles and bones; that they invariably suffer with constipation, alternating with diarrhoea; that their dentition is delayed, compared with other methods of hand-feeding. Thus summing it up, I cannot approve of this method at all. So condensed cream will be lauded by the mother whose baby is well, and again the same food will be con- demned by the mother of an infant whose rickety head, bones, and muscles are founded on an impoverished diet of condensed milk. We can account for the rickety child, but we cannot account for the healthy one on the same food. The directions on the tin of the Anglo-Swiss Con- densed Milk Company's Milkmaid Brand of condensed milk are, for newborn infants, add 14 parts of water; as the child grows older, gradually use less water, but never less than 7 parts. The analyses of all these condensed milks are of the milk diluted with both 7 parts and 14 parts of water — the two extremes. Gail-Borden Eagle Milkmaid Brand. Brand. With? With 14 With 7 With 14 Pts. Water. Pts. Water. Ptp. Water, Pts. Water Water 88.18 93.59 89.10 94.09 Ash 0.36 0.19 0.29 0.16 Proteids 1.50 0.82 1.31 0.71 Fat 1.70 0.92 1.18 0.64 Cane-sugar 6.00 3.25 6.59 3.57 Milk-sugar 2.26 1.23 1.53 0.83 'NestWs Smss Milk. _ With 7 With 14 Romans Milk. Pts. Water. Pts. Water. Water 87.95 93.46 88.51 Ash 0.25 0.14 0.34 Proteids 1.51 0.82 2.35 Fat 2.14 1.16 2.41 Cane-sugar 5.81 3.15 Milk-sugar 2.34 1.27 6.39 BUTTERMILK. 229 The foregoing brands of condensed milks are consid- ered to be among the best upon the market. Buttermilk. Ballot recommends buttermilk as an infant-food. He cooks a tablespoonful with a tablespoonful of wheat-flour for a few minutes and adds 15 grains of sugar to the same. In cases of diarrhoea he substitutes rice-flour instead of wheat. Buttermilk is composed of :— Water 90.62 Fat 1.25 Milk-sugar 3.38 Nitrogenous substances 3.78 Lactic acid 0.32 Salts 0.50 Buttermilk contains lactic acid. If allowed to rise spontaneously so that it can be "skimmed" off, we have, even in low temperatures, several acids formed, believed to be lactic acid and fatty acids. When milk is skimmed it has a specific gravity of 1.035 to 1.037 and contains:— Water 90.63 Nitrogenous substances 3.06 Fat 0.97 Milk-sugar 4.77 Salts 0.75 The author has seen decided benefit from skimmed milk, and from the above chemical composition it can be readily seen that it contains some nutritive properties. It is naturally unsuited to the requirements of an infant; in fact, it is, as Jacobi puts it, very decidedly "objection- able." It is more adapted for a child after the period of weanins". 230 infant-feeding. Cocoa. Dr. H. Cohn/* in describing the chemical value of cocoa as nourishment, states his belief that it is overrated, and denies the value of the same. He bases his statement on the poor method of assimilation, owing to the large quantity of fat Avhich could be removed by chemical process. Cocoa also contains 5.5 per cent, of tannic acid. Besides, the albuminoids are converted, by the process of roasting, into a very indigestible product. About the tannic acid, he says that it precipitates the digestive ferments, and unites with the albuminoids into insoluble compounds, causing the constipating factor. According to his experiments, only one-half of the 16,6 per cent, of the albuminoids are absorbed, and, in order to give the human body enough cocoa to have a sufficient quantity of proteids, it would be necessary to feed at least somewhat over 2 pounds daily, provided cocoa alone was given for nourishment. Ice-cream and Water-ices. Ice-cream and water-ices are very grateful to a fever- ish child. When milk and cream are refused they will be greedily taken. These preparations will alleviate the pain on swallowing in the case of diphtheria. They contain considerable nourishment, but must be given in modera- tion. Nausea and vomiting may frequently be controlled by them. ^* Zeitschrift fiir physiologische Cheiiiie, xx, 1, 2. CHAPTEE XXXI. Laboratoey Modification of Milk. In an article published by the author in Pediatrics, July 15, 1896, the following appears: — ^'It is now several years since a Walker-Gordon Milk- laboratory Avas established in Xew York. The feeding of infants is based on mixing the ingredients in such com- bination that, when combined, they should resemble cer- tain chemical formulae of breast-milk at various ages. "Blanks are given the physician, w^hich are filled out according to the child^s age and weight, calling for a definite percentage of fat, milk-sugar, proteids, water; and prescribing of feedings, the amount of each feeding, the percentage of alkalinity, and the length of time in which the mixture is to be sterilized or pasteurized. This would be a practical method, and appeals to the physician at first, but it is necessary to familiarize one's self with the mysteries of this method before one can properly judge of its merits. I have given modified milk a careful trial in my private practice; it is too expensive for either dispensary or hospital cases." One of the first symptoms encountered was constipa- tion, which could not be relieved; in five children fed ex- clusively on modified milk, the constipation was so severe that the formula was changed many times: we added more cream, and still more cream, until we finally abandoned the feeding by this method. The following case will illustrate what has been said: N. R., a healthy female, was put, soon after birth, on modi- fied milk. October 14th: Fat, 2.0; milk-sugar, 5.0; albuminoids, 0.75; lime-water, ^/ig. Eight feedings; 2 ounces in each. October 17th: Constipation. Fat, 2.5; milk-sugar, 6.0; albu- min, 1.0; lime-water, Vie- Nine feedings; 2 V" ounces in each. (331) 233 INFANT-FEEDING. October 27th: Fat, 3.0; milk-sugar, 6.0; albuminoids, 1.0: lime-water, Vie; barley-jelly, Vis- Ten feedings; 3 ounces in each November 5th: Fat, 3.5; milk-sugar, 6.0; albuminoids, 1.0; lime-water, ^/le; barley-jelly, Vis- Ten feedings; 3 ounces in each November 17th: Fat, 4.0; milk-sugar, 6.0; albuminoids, 1.5 lime-water, V20; no barley. Ten feedings; 3 ounces in each. November 19th: Curded stools, dyspeptic diarrhoea. Fat, 4.0 milk-sugar, 6.5; albuminoids, 1.0; lime-water, Vao- Ten feedings 3 ounces in each. The child did not increase in weight, had a rectal temperature of 100°, slightly-furred tongue, vomited curds, had greenish stools containing undigested particles of fat and true casein and large masses of mucus. The diagnosis of dyspepsia infantum was made; hand-feeding was stopped, the child's alimentary tract was cleaned by giving cascara sagrada, and a proper wet-nurse was secured. The infant at this time was about 6 weeks old. The child nursed very well, and after a few days the stools were normal, both in consistency and color. The infant gained steadily from 4 to 6 and sometimes 8 ounces per week, until she was 7 months old, when suddenly the w^eight remained stationary. The child w^as bright and cheerful, but I deemed it necessary to have the milk of the wet-nurse examined by a competent chemist; a specimen of the same was secured in the usual manner described by me in a pre- vious section on "Method of Obtaining Breast-milk for Chemical Examinations." This specimen was examined for the author by John S. Adriance, the chemist of the Nursery and Child's Hospital, who reported the following: — Fat 2.000 per cent. Sugar 7.431 per cent. Proteids 0.882 per cent. Ash 0.162 per cent. Total solids 10.475 per cent. Water 89.525 per cent. Specific gravity at 70° F.. . .- 1.0316 Reaction alkaline. In the chemical result above given it is very evident that a deficiency in the proteids exists; hence it accounted, not only for the stationary weight, but for the late dentition. The child did not gain an ounce in one month. We discharged the wet-nurse. The following food was ordered: — LABOEATOEY MILK. 233 Milk 3 ounces. Cream 2 teaspoonfuls. Oatmeal-jelly 3 ounces. Lime-water 1 drachm. Milk-sugar 1 teaspoonful. Salt 1 pinch. Sterilize the above and feed every three hours^ the above quantity being for one feeding. After the infant had taken this food for G days it was cheer- ful, had had one and two yellow stools daily, and gained 6 ounces in 6 days. The above case Avill illustrate: — 1. That the child was decidedly dyspeptic while taking its modified milk for at)out 6 weeks. 2. That for about 6 months the infant thrived very well on the milk of a wet-nurse. 3. That the stationary weight of the infant and the chemical examination of the milk of the wet-nurse showed deficient pro- teids, which accounted for this non-increase in weight and the late- ness in dentition. 4. That a proper milk-mixture, which agreed very well, suited the requirement of this infant, and emphasizes the fact that we must individualize in each and every case. It is impossible to make an emulsion like milk from its component parts by a synthetic process. Let it there- fore be distinctly understood that, once a milk-emulsion is broken up, as is done in centrifuging milk and removing the cream, mixing the whole will never restore the uni- formity of the emulsion that existed prior to this division. Time and again have I examined a drop of milk under the microscope and found an unevenly-divided emulsion of modified milk, resembling colostrum-milk. The macro- scopical examination of modified milk will always show a large amount of butter-fat swimming on top of each bottle of milk when it is cool. If this fat is part of the formula prescribed, then the modified milk does not contain its original amount of fat, and much more must be pre- scribed, to allow for the separation of the same. Hence 234 INFANT-FEEDING. it would seem that the percentage portion of the food must necessarily be incorrect. I am in accord with Jacobi/^ who says^ speaking of laboratory-fed babies: — ^^Only one observation struck me in many cases: the formation of the muscles and particularly of the bones appeared to be slow. The teeth came a number of weeks or even months too late; the cranial bones turned slightly soft in not a few instances; in many such cases I had to add animal broths or juice before the usual time. In two, when I tried phosphorus (elixir phosphori), it was rejected; in all others it was well borne and useful.^' Jacobi further states, in speaking of the difference between Walker-Gordon and Gaertner mother-milk, that the latter is patented, the former is not. It is a well- known fact that Walker-Gordon milk is patented. Dr. A. Worcester,^^ speaking of the modified-milk question, calls attention to the lately-patented Walker- Gordon process; so also has Dr. Baner,^^ of New York, and many others. In the Indian Lancet, editorially, May 1, 1898, we read the following: "We confess that we cannot agree with the writer of a paper, Dr. D. J. Evans, of the Montreal Foundling Hospital, in what appears to us to be his wholesale distrust of the provision made by Nature for the needs of infancy. We cannot but think that his process errs by overelaboration of those simpler measures by which, with some judicious help in times of difficulty, she has, on the whole, very successfully reared the race of man through countless generations." In a paper published by Eotch^^ we find the following: "I would plead in the name of common humanity, as ■'^ "Therapeutics of Infancy and Childhood," page 38, second edition. ^^ Boston Medical and Surgical Journal, September 19, 1895. " New York Medical Journal. ^^ Boston Medical and Surgical Journal, November 23, 1893. LABORATORY MILK. 235 well as in that of the intelligence and scientific reputa- tion of our profession, that this representative body of American physicians should, in its endeavor to advance the general subject of infant-feeding, record itself as op- posed to the use of patent or proprietary food of every description/^ Further on, in the same paper, the author states: — "We should, in fact, remember that the nutriment which we are endeavoring to copy, far from being a cheap product, is, on the contrary, a very expensive one." Dr. Louis Starr^^ gives a critical review of his clinical study with laboratory-milk for the last few years. He states: — • "With all the above advantages, laboratory-milk is theoretically the most perfect substitute for normal human milk that science has yet devised. But unfortu- nately clinical experience, in my own practice at least, does not bear this theory out. "The following is a generalization of the results of over two years' study of the use of laboratory milk-food in substitute feeding: — "These results may be classified under three heads, viz.: — "(a) The satisfactory, — embracing the very excep- tional cases of perfectly-healthy children who have been continuously fed upon laboratory-milk, from, or shortly after, birth up to the time of beginning a mixed diet. I have seen but three of these in as many years. "(b) The partially satisfactory, — including cases, much greater in number than the preceding class, in which laboratory-milk was used for a considerable period — six months to a year — without producing active illness, but gradually inducing health conditions necessitating a change of food. Of this class I have seen sixteen cases. ^® Archives of Pediatrics, January, 1900. 236 INFANT-FEEDING. "(c) The "Linsatisfactory. The instances of this group are by far the most numerous, and in it, in my experience, may be placed the vast majority of infants fed upon laboratory-milk after the first eight weeks of life. It em- braces those eases in which laboratory-milk feeding must, of necessity, be discontinued on account of the onset of some acute disorder of undoubted dietetic origin. My cases in this class number thirty-five. "The unhealthy conditions referred to in the second class present a very uniform group of symptoms, viz.: pallid, dry skin; dry, lustreless hair; flabby, soft muscles; indifferent appetite; inactive — not decidedly constipated — bowels, with clay-colored evacuations; light-colored urine; listlessness and disinclination to play; peevishness and restless sleep — in a word, the features of malnutrition. With the muscle-flabbiness there is not always emaciation, but the two conditions are often associated and the little sufferer is both weak and puny, and the observant mother states: T do not know what is the matter with my child; he is not ill, but he does not seem to thrive and is not like other healthy babies.' "Illustrative Case. — Boy, aged 10 months, presented above symptoms; no history of acute illness. Fed from birth upon laboratory-milk, modified in composition as age advanced, until the following strength was reached: — Fat 4.00 No. of feedings . . 5. Sugar 6.00 Quantity 8 ounces. Albuminoids 2.50 Alkalinity 5 per cent. Heat 167° F. "Improvement began soon and continued steadily under a domestic mixture of: — Calculated Percentage. Cream, 10 per cent 1 tablespoonful. Fat 3.75 Milk 11 tablespoonfuls. Proteids 2.97 Milk-sugar 1 teaspoonful. Sugar 4.94 Water 4 tablespoonfuls. "For each feeding, every three hours, five meals daily. LABORATOEY MILK. 237 *'The acute disorders occurring in the third class are: "First. — Acute gastro-intestinal catarrh, indicated by pyrexia^ vomiting, and diarrhoea with the expulsion of curds and greenish mucus or large quantities of greenish serum. "Illustrative Case. — Girl, aged 2 V. months Avhen seen in con- sultation. She had been fed from birth on laboratory-milk: — First and Second Weeks. Fat 2.00 Alkalinity 5 per cent. Sugar 5.00 Heat 167° F. Albuminoids 0.75 "Bowels occasionally disturbed, stools curdled and greenish. No gain in Aveigbt. Third to Slrth Week. Fat 4.00 Alkalinity 5 per cent. Sugar 6.00 Heat 167° F. Albuminoids 1.00 "Bowel movements never quite normal, always too frequent and greenish, and often "very green, with isolated hard curds and a quantity of mucus; infant restless, sleeps badly, colicky, and gain- ing weight very slowly. Sixth to Eighth Week. Fat 4.00 Alkalinity 5 per cent. Sugar 6.00 Heat 167° F. Albuminoids 0.75 "No change in intestinal symptoms; no gain in weight; infant growing feeble. Ninth Week. "Same food, predigested six minutes with Fairchild's pepto- genic milk-powder. "Xo improvement, except that curds passed are smaller and softer. (Predigestion performed at laboratory?) "In the tenth week the infant suddenly became very ill; high fever; vomiting; frequent, large, green, watery evacuations, with mucus and curds; rapid and extreme prostration. Milk-food was stopped for twenty-four hours. Fed on barley-water and raw beef- 238 INFANT-FEEDING. juice. Intestines disinfected with small doses of calomel^ and cleansed by high rectal injections of normal saline solution. "On succeeding day fed upon: — Calculated Percentage. Creanij 16 per cent 1 tablespoonful. Fat 2.67 Milk 2 tablespoonfuls. Albuminoids ... 1.29 Milk-sugar 1 teaspoonful. Sugar 4.24 Salt 1 pinch. Water 6 tablespoonfuls. "For each feeding, every 2 V2 hours. "This was gradually increased in strength as the improve- ment, which was continuous, allowed, until at the end of a week the following was being taken: — Calculated Percentage. Creamj 16 per cent 1 tablespoonful. Fat 3.55 Milk 4 tablespoonfuls. Albuminoids . . .2.18 Milk-sugar 1 teaspoonful. Sugar 5.24 Salt 1 pinch. Water 4 tablespoonfuls. "For each feeding, every 2 V2 hours. "There was no further trouble after the above domestic mixt- ures were employed; the evacuations became normal, and strength and weight improved rapidly, the food being increased in strength and quantity as increasing age demanded. "Second. Infantile Scurvy. — This condition is an ex- ceptional result of laboratory-feeding, but the possibility of its occurrence is of importance. "The following notes^ were kindly furnished by Dr. W. F. Teller, in whose practice the case occurred: — "Boy, born January 28, 1897; weight seven pounds. It being impossible for the mother to feed the child from the breast^ he was placed upon laboratory-milk in the following proportions: — Fat 1.00 Sugar 5.00 Proteids 0.75 "This was gradually increased in strength until by the middle of April (aged 2 Va months) he was taking: — LABOKATORY MILK. 239 Fat 4.00 Sugar 7.00 Proteids 1.50 "Intestinal disturbance Avith green, mucoid evacuations con- taining curds ensuing, the food was changed to: — Fat 3.50 Sugar 6.50 Proteids 1.50 "Eight feedings of 4 V2 ounces each. "On June 15th (aged 5 V2 months) the weight was twelve pounds. The intestinal indigestion continuing, a further change was made: — Fat 3.50 Sugar 6.50 Proteids 1.00 "Seven feedings of 5 ounces each. "About one week later the child began to evince pain on mov- ing or handling the legs, which were drawn up toward the abdomen and rigid; there were no fusiform swellings, and no petechial spots. Four incisor teeth were cut, and the gums about these were purple, swollen, spongy, and bleeding. There was diari'hoea, with green, curdled, and fermented evacuations; no fever. "Orange-juice and raw beef-juice were ordered, with a simple treatment directed to the intestinal disturbance, and the scurvy symptoms gradually improved and soon disappeared entirely. "After this until October (aged 7 months) he had: — Fat 3.50 Sugar 6.00 Albuminoids 1.00 "Six feedings of 6 V2 ounces each. Together with half an ounce of raw beef-juice once daily, given 'because it was necessary to keep the albuminoid percentage so low in the laboratory-milk mixture.' "In October, as the child, though not ill, did not thrive, the beef-juice and laboratory-milk were discontinued, and a home- modified milk-food substituted^ with the most satisfactory results. "The question now naturally arises; Why should a 240 INFANT-FEEDING. food capable of being prescribed to a23proach so nearly breast-milk in chemical composition^ so uniform in its make-iip, so sterile, and so easily and accurately varied to meet digestive emergencies, fail when put to a clinical test? "My answer is that in its composition all the fat is removed by a separator, and the food as prepared for the infant is a recombination of this fat and an alkaline so- lution of the proteids and sugar. In a word, the natural emulsion is destroyed. This, I think, in some way lessens the digestibility of the proteids and leads to conditions either of malnutrition or to an irritative diarrhoea with the expulsion of the undigested proteids in the form of compact curds — and this, too, despite changes in the pro- portion of the proteids; for the partially-starved chil- dren are attacked with vomiting or diarrhoea with fever if the percentage of proteids be increased (say, to 2.00 per cent, at ten months), and those having irritative diarrhoea are not benefited until the percentage is cut down to a starvation-point (0.75 per cent, in a child of three months still showed numerous curds in the evacuations). What a contrast to normal breast-milk, an emulsion hav- ing over 2 per cent, of proteids (Leeds)! "I have never seen an infant from tw^o to ten months able to stand a laboratory-mixture of stronger proteid per- centage than 1.50, and have often seen cases of two months and more unable to digest a percentage of 0.50. "On the other hand, how does it stand with the cream, milk, sugar of milk, and water mixture made at home by capable heads and careful hands? These mixt- ures are still modified-milk mixtures; but their basis is unseparated milk, a natural emulsion, containing fat, pro- teids, sugar, and salts. Under this physical condition the proteids are much more easily digested; so that a badly nourished child of ten months, in whom laboratory-milk percentage cannot be forced higher than 1.50 proteids, LABORATORY MILK. 241 will easily digest and grow strong upon a domestic mixture of:— Calculated Percentage. Cream, 16 per cent Sss. Fat 3.75 Milk ^vss. Sugar 4.94 Milk-sugar 3j. Proteids 2.97 Water Bij- ''And an infant of two months having an irritative diarrhoea on a starvation-diet of 0.50 per cent, proteids will begin to improve and soon grow strong and well on: Calculated Percentage. Cream, 16 per cent §ss. Fat 4.00 Milk 3x. Sugar 6.22 Milk-sugar 3j. Proteids 2.09 Water Siss. "In domestic modification^ of course, the same care must be taken to secure clean, pure milk and cream from healthy, well-kept cows. This is quite possible now in Philadelphia, and is becoming easier each year, as more attention is being given to infant-feeding and greater demand is being made for a pure milk-supply. Pasteurization is as readily done in the nursery as in the laboratory. Accurate measurement of quantities and cleanliness of vessels and feeding-bottles is equally pos- sible and, in my experience, quite as certain at home as in the shop. "The milk and cream from a dairy may vary slightly in chemical composition from day to day, but this varia- tion seems to me to be a minor detail, and of questionable importance when compared with the separator's destruc- tion of the physical properties of the basal milk. One certainly would not sacrifice everything to chemical ac- curacy." Clinical experience has demonstrated the fact that some children will thrive on condensed milk in spite of faulty hygiene, while others will not thrive in the best 242 INFANT-FEEDING. environment with the best form of feeding; again^ some children will thrive on modified milk^ others will not. The majority of the cases seen by the writer suffered with intense constipation, having clay-colored stools. In one instance, in which two children in one family were constantly fed on modified milk of varying propor- tions, the formulae were changed at least a half-dozen times with the usual increase of fat and sugar and lower- ing of the proteids, and in spite of this fact, after re- peated trials, and no benefit, this feeding-method was abandoned. A child recently seen by the author did not gain one ounce in four months. This was one of the reasons that prompted the family to change both the physician and the food. The child, about two years old, was very pale,' restless at night, quite peevish during the day,, and decidedly backward in development. It could neither speak nor walk, although the teeth were well developed. From the time the modified milk was discontinued, and a nitrogenous diet given, the infant improved, and from last reports is quite well developed. The records of the laboratory will probably show that, at the time the writer first used modified milk, he had at least a dozen at one time using the same, but his results were identical with those quoted by Dr. Louis Starr, of Philadelphia, and hence home-modification of milk has been used to the exclusion of laboratory-modification. Do not let us blindfold ourselves with the belief that an infant is thriving unless our baby shows a regularity in the increase of weight, sleeps well at night, for at least from six to nine hours continuously, and, above all, as- similates its food, as evidenced by regular, unaided move- ments of the bowels; such movements should be once or twice in twenty-four hours, have a yellowish-white color, and a mustard-like consistency. If the stool is hard or lumpy or pasty, like putty, then it is certainly abnormal, and shows improper food. The same is also true if the LABOEATORY MILK, 243 stool contains white particles of cheesy curds, showing a casein indigestion. In one infant, which had taken modi- fied milk continuously for seven months, an obstinate con- stipation was only relieved after full doses of codliver-oil and extract of malt were given for several weeks — aided by massage, besides changing the diet. PALLOR OF THE SKIK. An unusual pallor of the skin, and also of the con- junctival mucous membrane, has frequently been noticed in modified-milk babies. In one instance an extreme leu- cocytosis was noticed for the treatment of which iron was given. An examination of a drop of blood showed a diminution of the red blood-corpuscles and an excess of the white blood-corpuscles. A decided h^emic murmur was noticeable in the vessels of the neck, in a child, two years old, which had been fed continually on modified milk. Craniotabes, softening of the cranial bones, as well as very late closing of the anterior fontanelle has also been observed in some children fed with this form of food. A boy, 4 years old, a typical Walker-Gordon baby, who was fed exclusively on modified milk, now shows typical knock-knees, besides having been under the treatment of his physician for a general furunculosis of the scalp. The furuncles were of such size that they required incision several times; others opened spontaneously. I have previously reported^^ ^^three distinct cases of rickets in laboratory-fed babies, and if we compare the ordinary infants that we see brought to our dispensary from tenement-houses, children that are fed on condensed milk and water, they are much the same class of rickets at less expense." Thus, I fully agree with Louis Starr, of Philadelphia, who, in his paper,^^ says: "^^I must not be Pediatrics, July 15, 1896, page 68. Archives of Pediatrics, page 7, January, 1900. 244 INFANT-FEEDING. understood as condemning laboratory-milk absolutely; if its introduction has done nothing else, it has greatly ad- vanced substitute infant-feeding, by fixing the attention of the profession upon the importance of cleanliness and ac- curacy in the quantity and chemical composition of cows' milk foods and by placing the whole question upon a higher scientific plane than it has ever reached before." More recently the author has tried raw milk and cream modified at the laboratory, and has noted a great difference in the assimilation of such modified milk. Thus, while all experience herein reported has been bad, it is possible that a good part of the fault is due to overheating the milk. Changing the character of the proteid and alter- ing the chemical relationship of the various ingredients must change its assimilability, and hence the author would urge those who use the laboratory to insist upon having formulae compounded by using raw milk and fresh cream. CHAPTER XXXII. Forced Feeding. This is commonly known as gavage. This consists in forcing a small feeding-tnbe, a Xo. 7 rubber catheter^ through the mouth and pushing it forcibly toward the pharynx and directly into the stomach. This feeding- tube consists of a black hard-rubber or glass funnel to which is attached a piece of rubber tubing about ten inches long; then a small glass tube (a connecting tube) over which is drawn the rubber Xo. 7 catheter. In case of emergency, nothing is handier as a connector than the glass portion of the ordinary medicine-dropper, the smaller end will serve to connect with the rubber catheter mentioned above, and over the larger portion of the medi- cine-dropper we draw the rubber tubing connected wath the funnel. This little apparatus has been very neatly combined for the author's use by Messrs. Ueorge Tiemann & Co. (See Fig. 38.) Having pushed this small catheter into the stomach, we pour the food, usually several ounces of peptonized milk, or dextrinized barley and milk, or albumin-water, or the white of a raw egg mixed with half of a teacup of cof- fee and milk; or, if desired, a good concentrated soup, or bouillon, or broth, can be used. The same interval govern- ing ordinary meals should be more strictly adhered to while this process of feeding is used. It is self-understood that all instruments, utensils, and food must be strictly clean and sterile. Place the child flat on its back, and, first, pin either a heavy blanket or a stout sheet securely behind the body so that the hands are pinned down; have the assistant hold the child's elbows securely on each side; then force (245) 346 INFANT-FEEDING. the mouth open and quickly pass the catheter, pour the food into the funnel, and when the funnel is empty with- draw the catheter as quickly as possible. If this forced feeding is done very slowly or clumsily, then nausea and sometimes vomiting will be produced thereby. Hence, Fig. 38. — Author's Apparatus for Irrigating Rectum and well Adapted for Stomach- washing (Lavage) and also for Forced Feeding (So-Called Gavage). Also Useful in Nasal Feeding. the technique should be carried out as completely as pos- sible. NASAL FEEDING. Nasal feeding has long been in use where diseases of the mouth or spasm of the jaw or intubation in diphtheria rendered swallowing attached to a long difficult. A thin rubber catheter is rubber tube ending in a funnel; FORCED FEEDING. 247 this is the same apparatus that has been described on page 345. Modus Operandi. — Lay the child fiat on its back and have a large sheet pinned over the body, so that the hands are firmly held; have the feeding-mixtnre all prepared, so that no time will be lost. A soft-rubber catheter, lubri- cated with vaselin or glycerin, is gently pushed into the nostril and glided through the pharynx into the oesopha- gus and stomach. When the tube is in the stomach, pour the required amount of food into the funnel so that it flows in the stomach. When the proper amount has been "used, withdraw the catheter from the nose, and boil it in warm water to properly sterilize it for the next feeding. Quantity of Food. — The quantity of food used in nasal feeding should be somewhat less than is ordinarily used in health. It is understood that only liquid foods — like peptonized milk, sterilized milk, soups, broths, or bouillon — can be used for feeding in this manner. A thin emulsion of egg can also be used. Owing to the fre- quency of both nausea and vomiting, which may be in- duced by irritation of the fauces, while the tube is gliding through the pharynx into the oesophagus, a much larger interval must be given between the feedings. It is de- sirable to introduce the tube rapidly and remove it rapidly if it is at all possible. Accidents will result in nasal feeding if a large quantity of liquid food is regurgi- tated through the oesophagus into the mouth and aspirated through the larynx into the trachea. In some instances it is easier to pass a soft, flexible catheter through the right or left nostril into the oesopha- gus, and forcibly push the same into the stomach. This is a very simple process, and I have never yet been able to pass the tube into the larynx while gliding it toward the oesophagus. All food should be given warm — prefer- ably between 98° and 100° F. Small quantities of milk, strained gruel, broth, or albumin-water will be far better 248 INFANT-rEEDING. digested than heavier food. In some instances, where milk is not well borne, the ordinary unsweetened cream, in the proportion of 1 teaspoonful of cream to 3 ounces of water, will serve quite well. In other cases I have used very successfully several teaspoonfuls of Mellin's food diluted with an ounce of raw milk, to which 1 ounce of boiling water was added. This latter mixture is highly nutritious, and scalds the milk, and does not require either pasteurization or sterilization. Meat-juice and expressed steak-juice or roast-beef juice should not be forgotten. CHAPTER XXXIII. Feeding in Diphtheria-Intubation Cases. "When an infant lias a foreign body — tlie intubation- tube — in its throat, swallowing is more difficult, because the epiglottis cannot close entirely. Frequently, while swallowing there is coughing, gagging, and regurgita- tion, caused by fluids (food) trickling into the trachea. In this manner, it is claimed, Schluck-pneumonia has fre- quently been caused. If the child's head is turned to one side — either side — and swallowing is provoked in this manner, then we can sometimes avoid this trickling into the trachea. Another method is to lay the child flat on ifs back and allow the head to hang lower than its body, and to feed slowly with a spoon. This is really known as the Casselberry method of diphtheritic feeding. If this method is not satisfactory, and if we find that we cannot get enough food into our patient, then we can resort to rectal feeding. RECTAL FEEDING IN DIPHTHERIA. Bear in mind that the rectum absorbs, and does not digest. Hence, all food must be peptonized. The method is very simple. First: Always cleanse the rectum. This is done by washing the rectum with an enema of a pint of soap-water made by dissolving ordinary Castile soap or glycerin soap in warm water. The temperature of the soap-water should be 100° to 110° F. Quantity, from 1 to 2 pints. After the rectum is cleaned, and the faecal move- ments all passed, it is advisable to wait about five minutes to give the rectum a chance to rest. Then we proceed to inject the rectum with a suitable quantity of peptonized (249) 250 INFANT-FEEDING. egg. Small quantities are better borne than large quanti- ties; hence, no more than 1 to 2 ounces should be thrown in at one time. The following formula will give an idea of the way in which food is to be prepared for rectal injection: — Take 2 teaspoonfuls of ordinary starch and rub the same up with an ounce of lukewarm water. This makes a very milky mixture. To this mixture we add the yolk of 1 egg, and one-half of an ordinary Fairchild peptoniz- ing tube. This is to be slowly, but forcibly, injected into the rectum. Various methods of injecting can be used, the simplest being with the aid of a bulb rectal syringe, known as the infant's rectal syringe. (See Fig. 40.) Another method consists in pouring this emulsion of starch-water and peptonized egg into a funnel ending in a rectal tube, a so-called rectal feeding-tube made by Tie- mann, of New York City. (See Fig. 38.) The secret of success is undoubtedly the amount of food brought into a child's body during its illness, and, the more food absorbed, the greater resistance will the child have. It is advisable not to overtax the rectum; hence, my method of feeding is to use the peptonized yolk of egg with starch-water as mentioned above, and follow it — three hours later — by substituting an ounce of pep- tonized milk instead of the yolk of egg. With this ounce of milk an ounce of starch-water should be combined. If there is looseness of the bowels, and the food will not remain in the rectum, then 1 or 2 drops of the ordinary tincture of opium added to each enema will soon quiet the irritation of the rectum, and thus aid in retaining the nutrient enema. CHAPTER XXXIV. Geneeal Eules for Eectal Feeding. In another chapter entitled "Rectal Feeding in Diph- theria" attention has already been given to the method Fig. 39.— Author s Double-Current Rectal Tube for Flushing the Colon and Rectum and Used for Rectal Feeding. Fig. 40.^Rectal Syringe. of cleansing the rectum, and also to the injection of foods. The same rules are applicable when there is excessive (251) 252 INFANT-FEEDING. irritability of the stomach with constant vomiting and where it is desirable to give the stomach absolute rest. Fig. 41. — Rectal Syringe. Small quantities properly injected will be retained and absorbed much easier than large quantities of food, which will merely serve as irritants and be expelled. CHAPTER XXXV. Infant-stools. Stool of a Nursling. — The stool of a nursling or a baby on an exclusive milk diet should be yellowish in color, smeary or pasty-like in consistency, and have an acid reaction. The smell should be faintly acid, but not disagreeable. The color is due to bilirubin, and the re- action depends on the presence of lactic acid, the source of which is the milk-sugar. The only gases present are H and COg. According to Escherich, HgS and CH4, to which the odor of adult stools is due, are not present. There are no peculiar albuminoids. Those existing in mothers' milk seem to be entirely absorbed. Peptone ex- ists in trifling amount. Sugar is not present. Pancreatic ferment is absent, and sometimes traces of pepsin have been found. Mucus is always present in considerable quantity; also columnar intestinal epithelium. In the stools of nurslings large quantities of lactate of lime can be found; so also we frequently find oxalate of lime, depending on the quantity of oxalate of lime in- gested. Uffelmann has noted the presence of bilirubin crystals in the stools of nurslings, in perfectly-healthy children. Miller, who carefully studied the various micro-or- ganisms in the mouth, found that most of them could again be found in the intestinal canal. He further found that certain germs possessed diastasic properties and were capable of producing lactic-acid fermentation. In the milk-faeces of nurslings Escherich found two germs; the one he called bacterium lactis aerogenes (or bac- terium aceticum, Baginsky) and the other the bacterium (253) 254 INFANT-FEEDING. coli commune. In the meconium he found proteus vul- garis, streptococcus coli gracilis, and bacillus subtilis. The number of stools during the first two weeks is from 3 to 6 daily. After the first month the average is 2 stools daily; many infants have 1, others 3 stools daily. This latter is due largely to the excessive quantities of water given to infants. As soon as the exclusive milk diet is changed to the mixed diet we then lose the characteristic infantile stool, and it resembles more that of an adult, though remain- ing softer and thinner throughout infancy. The stools Fig. 42. — Sclieriiig's Formalin Disinfecting-lamp. Well Adapted as a Deodorizer in the Nursery. become darker in color, assume the adult odor, and have more varieties of bacteria than those previously men- tioned as found in the stool of a milk diet. Eeadion of Stools. — Eeaction of stools in diarrhoeal disease and in health is chiefly acid or, next in frequency, neutral. Alkaline stools are rare. Green-grass stools, usually acid, are seen in the early stage of dyspeptic diar- rhoea, the color from a pale greenish yellow to grass- green, owing to improper food. Wegscheider has shown that the green color is the result of preformed biliverdin. The condition in the in- INFANT-STOOLS. 255 testine, upon whicli tlie transformation of bilirubin into biliverdin depends^ has been generally regarded as one of acid fermentation. Experiments. — Pfeiffer^s experiments^- show this for- mer opinion to be wrong. He found that none of the acids formed in such fermentation — lactic, acetic, butyric, propionic, etc. — added to yellow stools outside the body, turned them green, but that they made them deeper yellow. But dilute alkaline solutions added to fresh yellow stools turned them green after an exposure of thirty to sixty minutes, and strong solutions turned them, first, broAvn; later, after exposure to air, intense green. Typical Green Stools. — Typical green stools can be produced by giving an infant 2 or 3 grains of bicarbonate of soda. This I have tried dozens of times; the soda must be given for a few days. This explains Pfeiifer's alkaline theory. Typical green stools can also be produced by giving small or even large doses of calomel. If, after having given bicarbonate of soda and produced green stools, we give diluted hydrochloric acid in 5- to 10-drop doses, the yellow color will reappear in a few days. Rhubarb will also produce a yellow stool. Stools. — Stools which are pale yellow when dis- charged, and which afterward become green, are often seen in disease. They may be themselves neutral or alka- line in reaction; this latter may, however, depend on the admixture of urine. An excess of bile may often cause very green stools. Broivn Stools. — Brown stools may be due to changed biliary pigment and to drugs: e.g., bismuth causes the well-known dark stool. So also tannic acid and all iron salts give the dark stool, which varies from a deep brown to a black color. 82 "Verdauung im Sauglings-alter bei Krankhaften Ziistan- deii," "Jahrbuch fiir Kinderheilkunde," B. 28, page 164. 256 INFANT-FEEDING. Blood in Stools. — Blood from the stomach or small intestine frequently gives the stool a black color resem- bling tar. Thus, a practical point in Boas's "Diagnostik der Magen- imd Darmkrankheiten'' is that, the brighter the color of the blood, the lower down near the rectum and anus must the pathological lesion be looked for; the darker the blood, the higher up must the cause be found: e.g., the diseased conditions exist in the stomach, duode- num, jejunum, etc., if the stool contain black blood. If the corpuscular elements of the blood are wanting, then the presence of blood can only be positively diagnosti- cated by either a microchemical examination or by means of the spectroscope. The presence of red blood-corpuscles must always be regarded as a pathological factor. Brown Stools; Muddy Stools. — A brown stool in an infant is frequently caused by a diet of animal food or by a diet principally of broth. These stools have no distinct consistency nor reaction. In dyspeptic diarrhoea or in some forms of enterocolitis we have very offensive stools, and they resemble muddy water; with the latter there is considerable flatus during each movement. White or Light-Gray Stools. — White or light-gray stools usually are of a putty-like consistency, sometimes like dry balls on a diaper; sometimes they appear like ashes. Usually they are very offensive, consisting prin- cipally of fat. In the latter there is scarcely a trace of bile, or the latter may be absent altogether. Mucus. — Mucus is always present in all healthy stools, and is so well mixed with the stool that it does not appear as mucus to the naked eye. Any appearance, therefore, of mucus easily visible should be regarded as abnormal. Mucus is present in every form of intestinal disease: very abundant in inflammatory conditions af- fecting the large intestine, more so than in those affec- tions of the small intestine, and especially so in inflam- matory conditions of the colon, both acute and chronic. IXFAXT-STOOLS. 257 Jelly-Iilx 2Iasses. — Jelly-like masses of shreds of mucus, and cases where the stool consists chiefly of mucus, show that the affection is confined to the lower portion of the colon or that it is located in the rectum. Long Shreds of Mucus. — Long shreds of mucus, fre- quently resembling false membrane, are often found in catarrh of the large intestine. If the shreds of mucus are intimately mixed with the stool, then we must look for the lesion quite high up, and if it comes from the small intestine it is usually stained from bile. If the lesion is low down the mucus is not intimately mingled with the stool. Dyspeptic Stool. — The first change noticed in the dyspeptic stool is the increase of fat. Often the stool is quite green and contains small pieces, of yellowish-white color, Y\'hich vary in size from that of a pin-head to the size of an ordinary pea. Hitherto, from their color, they were supposed to be casein lumps. Wegscheider has taught us that they consist principally of fat. Baginsky has shown that large colonies of bacteria are contained in these lumps of fat. Frequently they are so numerous that it looks as though the stool were composed only of these cheesy lumps. They can be easily differentiated from real casein lumj^s by their solubility in alcohol and ether. Fat Diarrlicea. — Biedert and Demme have devoted considerable attention to this subject. ^^ In some children the fffices showed 50 to GO per cent, of fat, whereas the normal percentage in ordinary faeces varied from 13.9 per cent, (^^'hich is the normal quantity), according to Ufl^el- mann. Casein is not nearly as common an ingredient of f^ces as is commonly supposed. Casein lumps can be seen ""^ See Biedert : "Fett-Diarrhea/' in "Jahrbucli fiir Kinderlieil- kunde," 1878. 17 258 INFANT-FEEDING. in abTinclance in the conrse of a diarrhoea during an ex- clusive diet of milk. Quantity of Fceces. — The quantity of faeces varies, but it has been found that 100 grammes of milk-food will produce about 3 grammes of faeces, according to Baginsky. This is a vital point, but I have found it very difficult to determine, for in most cases the napkins of the infants are soiled with urine plus the faeces, thus adding to the gross weight. Proteids. — The proteids of milk are so thoroughly absorbed that only small traces of them can be found in the fseces. Normal milk-f^ces contain large quantities of bacteria, but chiefly two kinds, previously mentioned, viz.: bacterium lactis aerogenes (Escherich) and bacterium coli commune. Other germs, especially those of the proteo- lytic type {i.e., those that render gelatin fluid), are not found under normal conditions. Albuminous decomposition and its products — tyro- sin, indol, phenol, and skatol — are not found in milk- fasces. But lactic acid, acetic acid, formic acid, and other fatty acids are present, causing the acid reaction. Saccliarin Ferment. — Von Jaksch found a saccharin ferment in the fgeces of children. Peptonizing Ferment. — Baginsky foimd a peptoniziug ferment also in infantile fgeces. Escherich^* says: "If albuminous decomposition with very foul offensive stools exists, these articles should be withheld from the diet and carbohydrates given, dextrin foods, sugars, and milk. If acid fermentation is present, with sour, but not offensive, stools, carbohydrates are to be withheld and albuminous foods given, such as animal broths, bouillon, peptones, etc. In the decomposition of °*"Jahrbuch fiir Kindorheilkimde/' "Beitrilge ziir Antisep- n Behandl Siiuglmgsalters,' tichen Behandlungs-metliode der Magen-Darmkranklieiten des IXFANT-STOOLS. 259 milk, the sugar of milk, and not the casein, is usually broken up/^ Holt^^ says: "Eegarding the exact indications ac- cording to Avhich fat, sugar, and proteids of milk are to be varied, much remains to be learned." Sugar is Too Low. — If the sugar is too low, the gain in weight is apt to be slower than when furnished in proper amount. Sugar in Excess. — Symptoms indicating an excess of sugar: Colic or thin, green, very acid stools, sometimes causing irritation of the buttocks; sometimes there is re- gurgitation of food and eructations of gas. Excess 'of Fat. — Excess of fat is indicated by the fre- quent regurgitation of food in small quantities, usually one or two hours after feeding. Sometimes an excess of fat causes very frequent passages very nearly normal in appearance. In some cases the stools contain small round lumps somewhat resembling casein, but really masses of fat. This has already been mentioned in speaking of the differentiation of true casein curds and small fat lumps by the solubility of the latter in alcohol or ether. Dry, Pasty Stools. — When too little fat is given, it is indicated by hard, dry, pasty stools, and usually constipa- tion. This can be easily remedied by the addition of cream three-fifths of which is fat. Holt speaks against increasing the fat above 4.5 per cent, in infants under six months old, and believes we should not go above 4 per cent. ^"Artificial Feeding," page 179. CHAPTER XXXYI. Nathan Straus Milk-laboeatories and Similar Charities. Since 1894^ through the generosity of the Hon. Nathan Straus, pasteurized, modified, and natural milk has been supplied from laboratories and milk-depots scat- tered throughout New York City. Some of these are found in the different parks of the crowded portions of our city. Hundreds of thousands of bottles are dispensed annually in New York and in neighboring cities. Thus, in a report of the Board of Health of Brooklyn for the year 1895, we find that in Brooklyn 42,739 bottles were used. The i'nfant-mortality has certainly been lessened dur- ing the last few years in these cities; a great deal of it is due to the education of the poorer classes living in tene- ment-houses, by means of these laboratories, to the neces- sity of using boiled food, or call it sterilized milk, and boiled water. There are other factors which have less- ened the great infant-mortality in New York City. Let us not forget the difference in the cleanliness of the streets of this metropolis due to the energetic work of the late Colonel Waring. The weeding out of blocks of tenement-houses, and the substitution of small parks in the heart of the tenement-district must certainly be healthful. Whoever studies the development of rickets will find that it is not only the feeding which is the prime factor, but it is the environment, the faulty dwelling, with its foul air and general unsanitary condition, that con- tribute to the poisoning of the air breathed by the infant; this poisoning is as distinct a toxcemic condition as it would (260) MILK-LABORATORIES. 261 be if a poison were injected directly into the body. Faulty food, be it breast-milk or cows' milk, is the prime factor. Having been on continuous duty in the children's service of one of the largest clinics in this city for over ten years, the author has noted many, many changes. In recent years the large number of excursions, notably the St. John's Guild, which gives an excursion every day dur- ing the hot summer months to the poor destitute children of our city, has certainly added to the health of many little ones. There are also numerous sectarian excur- sions; so, for example, there is a Hebrew Sanitarium giv- ing excursions to Eockaway every day during the summer. Then there are numerous church excursions and chari- table funds, notably the New York Herald Ice Fund, all of which have a tendency to invigorate the lives of these poor infants, and in this manner they can withstand the terrible heat of the summer months, and survive it. The sanitary vigilance of the Board of Health of New York City has certainly improved the sewage and drainage, looked after the water-supply, and certainly benefited the city. These factors must be taken into account in studying the mortality and the population. The blessing for New York City will consist in giving it a pure, clean, and rich milk in which the stable, and cow, and milker's hands and all utensils are absolutely sterile. I cannot emphasize too strongly that the ideal milk of the future will not be ster- ilized milk, not pasteurized milk, but will be pure, raw milk. Nature supplies her infants in the human breast with raw milk at body-temperature; why must we feed our infants with boiled or steamed milk, especially so, when chemists have taught us that chemical changes take place in boiled as well as in sterilized milk, rendering the milk more indi- gestible than it was in its raw state? A vital point to remember is that the milk, when drawn from the cow, must be quicUy cooled and must not be allowed to reach a temperature above 50° F. until used. 262 INFANT-FEEDING. Such milk will not permit the development of bac- teria — dangerous to health. Eapid cooling, then, — to repeat again, — is as important as the absolutest assurance of cleanliness and sterility of every utensil brought in contact with milking, — so neces- sary to avoid introduction of filth or bacteria. CHAPTEK XXXYII. Colic. Colic is one of the most frequent causes of crying in children. They not only cry loudly, but will suddenly shriek, and when put to sleep will awaken with a sudden start, and cry loudly. The legs are usually flexed or they will move their legs back and forth, or up and down. They will seem to bend the body on itself. These attacks are usually associated with constipation; hence, it is a good plan, when the child is restless and utters a painful cry, to see if the bowels have moved. It is w^ell known that this colic may be as well associated with diarrhoea. The origin of all colic is certainly the stomach. When dys- peptic conditions, arising from undigested particles of food in the stomach, exist, then fermentation, resulting in gas- formation, is the result. Colic is frequently known by the terms of "meteorismus or tympanites,^^ but in the latter conditions the abdomen is greatly distended, and there is a permanent enlargement of it. Borborygmus can usually be made out, if the ear is applied to the abdomen. The vast majority of cases of colic have their seat in the intestine, and can be relieved very quickly. Worms (ascarides) have been known to cause colic. Besides, when there is a general loss of tone on the part of the muscular layers in the walls of the intestine, colic will frequently result. Jacobi believes that colic can be caused by chronic peritonitis resulting in adhesions or such local changes in the walls of the intestine that will produce local contractions or dilatations. The treatment of colic is simple when the cause is known. The quickest method of relieving colic is to give an enema of soap and water or of warm chamomile-tea. I usually take an ounce of German chamomile-flowers and (263) 264 INFANT-FEEDING. steep it in a quart of boiling water for from ten to fifteen minutes, and then strain. The injection is to be given in the same manner as will be described in detail in the chapter on constipation. My method is to allow 1 or 2 pints of chamomile-tea at a temperature of 100° to 110° (no hotter) to flow slowly into the rectum, and by all means the colon. When the colon is thoroughly flushed with this warm tea, and emptied of its faeces, it is usual for the attack of colic to cease. In addition to washing the colon^ it is a good plan to apply a small bag of either chamomile-flowers or slippery-elm bark, or ground flaxseedmeal. To do this, I make a bag of cheese- cloth, capable of holding from 1 to 2 ounces, and then fill it with one of the above-mentioned ingredients; sew the bag shut when filled, and heat it before applying to the abdomen. Several of these bags can be made and kept in readiness, so that they can be applied quickly. It is a good plan to have one heating on the stove, while another is on the abdomen. These little bags are very grateful, and we are frequently rewarded by having the infant not only expel wind shortly after they are applied, but also frequently fall asleep. MASSAGE. During an attack of colic gentle massage with warm sweet oil or melted vaselin or lard will certainly be very comforting to the child. My plan is to take a bottle of oil, warm it by placing it in a kettle of warm water, and then to pour it on the abdomen. The distended abdomen should then be thoroughly kneaded, and the gas expelled. Then the warm applications mentioned above can be applied. DRUG TREATMENT. If the colic originated from a fermentative dyspepsia, then treatment must be directed to the stomach. For COLIC. 265 this purpose antifermentatives, like tlie mistura rhei et sodse, should be given in doses of ^/o to 1 teaspoonful, di- luted with water, every two or three hours until there is a thorough evacuation. Very good results will be found, after the bowel has been cleaned with the quart of cham- omile-tea previously mentioned, by administering from 5 to 10 grains of bismuth; I prefer to use betanaphthol or the subnitrate; ^/2-grain doses of resorein will also be found useful. Paregoric in doses of 15 drops to ^/o tea- spoonful should be administered with great caution to children of six months or older. It is self-understood that no physician will forget the danger of giving repeated doses of paregoric or permitting the same to be admin- istered by incompetent people not aware of the dangers of the drug habit. The author has not only seen distinct opium poisoning follow the use of paregoric, but has also had occasion to see the distinct opium habit in very young children. This was reported by the author in a paper read before the New York County Medical Society, January 22, 18 91-, which was published in extenso in the Med- ical Record of February 17, 1891:. For an infant during the first few months, it is hardly safe to give more than 5 drops of paregoric repeated in an hour, if there is no relief. Another drug that has served the author very well is Hoffmann's anodyne in doses of from 1 to 5 drops, repeated in an hour if necessary. For an infant up to two months 1 drop per dose; from two to four months, 2 drops per dose; four to six months, 3 drops; six to nine months and until one year of age, 4 drops; children from one to two years, 5 drops. This is to be given in a tea- spoonful of sterilized water. Another valuable drug, and one that is to be given cautiously, and in the same doses as Hoffmann's anodyne, is spirit of chloroform; never should more than from 1 to 4 drops be given to a child up to one year of age, and younger children less in pro- portion. I cannot favor the administration of nauseating 266 INFANT-FEEDING. or foul-smelling drugs, such as asafoetida. We must try to cater to an infant's taste, especially so when in pain. THE USE OF SUGAR. When colic is caused by an excess of sugar, there will be quite some eructations of gas, and, frequently, small quantities of food will be regurgitated. The stools, when an excess of sugar is given, are thin and greenish, smell very acid, and usually produce a red- dened excoriation of the buttocks around the anus. When children show a tendency to the development of gas and have constant recurring colic, my plan is to discontinue the use of sugar, until such time when this fermentation is absent. To sweeten the food I use small, saccharin tablets, 1 tablet being ample to sweeten 1 pint of food. When there is a tendency to constipation, it is possible not only to sweeten the food, but also to modify this constipation by adding 1 teaspoonful of pure glycerin to each bottle of food prepared. EXCESS OF PROTEIDS. A careful observation of the stools would easily show whether the albuminoids are in excess, for they are usually present in the form of curds. This condition is usually associated with constipation, and the indication would be to cut down the quantity of curd administered. CHAPTEE XXXYIII. Constipation^. To CONSIDER the cause of constipation during the nursing period let ns first look into the mechanical cause. Concetti/® in a very elaborate article, gives the various anatomical reasons for constipation. He states that Huguier, in the Bulletin de I'Academie de Medecine, had reported this same pathological condition several years prior to Jacobi, of Xew York. Thus, Huguier advises, as a practical point, that when a colotomy was to be per- formed in an infant it would be wiser to perform the same on the right side rather than on the left. He stated that it was much easier, owing to the greater number of flexures, to reach the same by operating on the right side in cases of atresia of the anus. Concetti further states that Jacobi, in 1868, reported in the American Journal of Obstetrics an elaborate article, which has since appeared in the "Therapeutics of Infancy and Childhood^^ (A. Jacobi, 1887), giving the anatomical reasons in detail. They are well worth noting: — The embryonic intestine is formed in separate di- visions. There is no ascending colon up to the fourth or fifth month of foetal life. It is very short in the mature newborn. Despite this, the large intestine of the mature foetus is longer in proportion than that of the adult. It is three times as long as the body of the foetus, while it is only twice as long in the adult. There is the same disproportion with regard to the ^^Archiv fiir Kinderheilkundej vol. xxvii, 1899. (267) 268 INFANT-FEEDING. length of the small intestine. The small intestine of the foetus in the ninth month is twelve times as long as its body. The small intestine of the adult is only eight times as long as the body. The colon ascendens being very short, the surplus of length, particularly as the transverse colon also is not long, belongs to the descending colon, and especially to the sigmoid flexure. Drandt found it between 8 and 24 centimetres in length, averaging from 14 to 20. I have seen a case in which it was 30 centimetres long. As the pelvis is very narrow, the great length of the lower part of the large intestine is the cause of multiple flexures, instead of the single sigmoid flexure of the adult. Thus it is that, now and then, two or even three flexures are found, and to such an extent that one of them may be found to extend as far as the right side of the pelvis. Cruveilhier and Sappey speak of this position of the lower part of the intestine in the right side of the pelvis as an anomaly. Huguier finds it on the right side of the body in the majority of cases. Others only occasionally, al- though they admit the great length of the sigmoid flexure. In common with Huguier, who even proposes to operate for artificial anus in the right side, I have found one of the flexures on the right side many times. The great length of the large intestine and the multi- plicity of its flexures are of great functional importance. At all events, they retard the movement of the intestinal contents, facilitate the absorption of fluids, and thus the faeces are rendered solid. When this length is developed to an unusual extent, constipation is the natural result. In the American Jourmal of Obstetrics, August, 1869, I have described two cases in which the descending colon was so long that the diagnosis of imperforate rectum was made. In one of them the operation for artificial anus was performed. Such cases and such errors are certainly very rare; still they are those in which normal anatomical COXSTIPATIOX. 269 conditions will lead to incidents of great pathological im- portance. Other cases of constipation in the infant may be classed nnder four heads: — First. — The intestinal mncus is deficient or too Ads- cid. Such is the case in febrile conditions^ now and then in chronic intestinal catarrh, and also when there is too much perspiration and secretion of urine. Second. — Improper condition of food. A super- abundance of casein^ particularly cows' casein; of starch; the absence of sugar, and the administration of astrin- gents and iron. Third. — Incomplete peristalsis, such as exists in the rachitic debility of the muscular layer, in the muscular debility dependent upon sedentary habits ard peritonitis, intestinal atrophy, and hydrocephalus. Fourth. — Mechanical obstruction. Cystic tumors in the intestine. There is, further, intussusception and twist- ing of the intestine, incarcerated hernia, even umbilical hernia, hardened fseces, and imperf orations. In all these cases the diagnosis should not be made without manual examination. In most of the cases the abdomen is inflated, though it be painless. The faeces come away in small, hard lumps or in large masses. The liyer and spleen are disj)laced. The liver may be so turned that a part of its posterior surface comes forward. The abdominal veins are enlarged to such an extent that they form circles around the umbilicus, similar to what is seen in hepatic cirrhosis. These children lose their appetite, sometimes vomit, and the irritation pro- duced by the hardened masses in the intestinal canal may be such as to finally result in diarrhoea, which, however, is not always sufficient to empty the tract. There is, besides, an apparent constipation, which should not be mistaken for any of the above varieties. Now and then a child will appear to be constipated, have 270 INFANT-FEEDING. a movement every two or three days, and at the same time the amount of faeces discharged is very small. This apparent constipation is seen in very young infants rather than in those of more advanced age. Such children are emaciated, sometimes atrophic. They appear to be con- stipated because of lack of food, and not infrequently this apparent constipation is soon relieved by a sufficient amount of nourishment. Constipation resulting from a superabundance of starch in the food is easily cured by the withdrawal of the latter. Constipation produced by too much casein in the food will be relieved by diminishing its quantity. The proportion of casein in the food of infants should never be more than 1 per cent. Besides, this amount of casein ought to be copiously mixed with a glutinous decoction. Infants that have been fed on starchy food or even such cereals as barley, should have oatmeal substituted for the barley. Constipation depending on lack of sugar is very often speedily relieved by increasing the quantity of sugar in the food. This is the case, not only in artificial feeding, but also when the children are fed normally on breast- milk. Such mothers' milk as is white and dense, and con- tains a large amount of casein, is made more digestible, and will produce better evacuations, when a piece of loaf- sugar dissolved in tepid water is given immediately before nursing. As there is frequently a large excess of acid in the intestine, magnesia with or without rhubarb will fre- quently relieve the acidity and cause a movement of the bowels. In a previous section on "Cream" I have already spoken of the deficiency of fat, which is one of the most frequent causes of constipation. Hence, in an infant nursing at the breast it is wise to give the child a tea- COXSTIPATIOX. 271 spoonful of raw cream immediately before taking the breast to correct the constipation. Cream consists of so mnch fat that in this manner we add fat directly to our food. This is the secret of success attained by some authors when they advise giving codliver-oil, butter, olive-oil, or fried bacon to very young children. Each one desires to remedy the deficiency of fat in his own particu- lar manner. A DRINK OF WATER. From infancy, when the child is but a few days old, we should make it a rule to give it a drink of water; thus a very small infant during its first week can be given two to three teaspoonfuls of boiled water during the day. A safe plan is to give this drink of water when it is not time for feeding, and if the child appears restless. It is understood that we must first satisfy ourselves that the child has not had a stool, is not lying in a soiled napkin, and that other conditions — such as colic — do not cause uneasiness in the baby. When a child is several months old, the quantity of water can be increased from teaspoon- fuls to as many wineglassfuls. Frequently have I noted the disappearance of a continued constipation after giving an infant its '^drink of water'' regularly. IMMEDIATE RELIEF OF CONSTIPATION". A rule that I have always follov/ed, and one that I lay stress upon, is never to allow a child to retire at night without having had a movement of the bowels during the day. The reason for this is plain; not only will the ac- cumulated fasces and gas cause flatulence, colic, and un- easiness, but this constant distension of the bowels will dilate the intestines to such a degree that frequently a permanent pendulous belly remains. 272 INFANT-FEEDING. My plan is to order an injection of a half-tumbler of ordinary glycerin mixed with a pint of warm water, — temperature, 100°, — and to allow this quantity to flow into the rectum by using a fountain-syringe., the end of which has the smallest infants' rectal nozzle. In this manner we have a rapid emptying of the rectum and colon, and can be assured of temporary and possibly permanent relief. It is not absolutely vital to use glycerin and water, for a similar result can be obtained if we make soap-water by rubbing up a piece of Castile soap with a pint of warm w^ater, or using glycerin soap with the equal quantity of water, if the latter soap can be procured. Continued Use of Enema. — In obstinate cases it is well to slip a soft-rubber rectal tube over the nozzle, and, having anointed the rubber tube with vaselin or glycerin, the same can be pushed slowly into the rectum, then allow about half a pint of water to flow into the rectum, which will distend it gradually, and, by simply pushing the tube farther into the colon, we can allow the balance of 1 pint or more to flow directly into the colon. The continued use (daily) of these enemas is not fraught with danger; on the contrary, these rectal injections can be used for months. In safe hands, if the mother or nurse is intelli- gent, there should be not only no injury, but positive good, from its continued use. EEMOVAL OF SCYBALA. Hardened round balls or fragments of faeces will fre- quently be caused when the stool remains very long in the colon, or when the sigmoid flexure has an unusual length; in such instances the injection of either y^ pi^^ of lukewarm sweet oil or glycerin will soften these scybala and aid in their expulsion. At times these balls wdll be as hard as marbles, and may require the aid of a small scoop (a very small teaspoon will do) to aid in their removal. CONSTIPATION. 273 DRUG T-EEATMENT. A great many drugs are indicated and counter-indi- cated in the treatment of constipation. The intelligent practitioner does not desire merely one movement of the bowels, brought about by drugs, but seeks rather to use such therapeutic measures which will give a permanent cure. My choice of drugs is the following: — IJ Ext. cascara sagrada fl., Bj. Glycerin, 5j. Mix. Twenty drops of the above mixture in a teaspoonful of water three times a day, for children about three months old. At the age of six months, double the dose, or 20 drops three times a day. At the age of one year a teaspoonful three times a day. My plan is to give the first dose in the morning be- fore the feeding, and note the result. If the bowels move by noon-time then I discontinue the dose at noon, and give a second dose in the evening. If, however, there is no effect by noon-time, then I continue my second dose, and follow with my third dose in the evening. Thus, it will be apparent that, if one dose answers for the day, then we should discontinue the medicine for that day, but com- mence again on the following day, and keep up this form of drug treatment until it is apparent that the bowels are not as sluggish in their action as before. Another drug which has been one of my stand-bys for many years is nux vomica- thus, I give 1 drop of the tincture of nux vomica in a teaspoonful of sterile water three times a day, for an infant up to one year of age. Children of two years I give 2 drops three times a day. From three to six years, 3 drops three times a day. Six to ten years, 4 drops three times a day. Ten to fifteen years of age, 5 drops three times a day. Nux vomica is always to be adminis- tered on an empty stomach; in other words, before feed- ing. Another valuable drug is rhubarb in the form of the aromatic syrup of rhubarb. From ^f^ to 1 teaspoonful 274 INFANT-FEEDING. once or twice a day^ repeated every two days^ will fre- quently afford relief. Powdered rhubarb and magnesia^ given in teaspoon- ful doses to very young children^ is one of the best laxa- tives and antifermentatives that we possess. It is espe- cially indicated for the relief of colic. Citrate of magnesia^ given in wineglassful doses to children over one year of age once or twice a day, can also be recommended. In atonic conditions of the bowels depending on gen- eral weakness, strychnine, given in ^/goo grain twice a day, will be found useful. This may or may not be combined with iron. The infusion of senna-leaves is made by boiling a heaping teaspoonful of ordinary senna in a teacupful of boiling water for fifteen minutes, straining, and when cool adding 1 tablespoon of glycerin to 5 tablespoons of this infusion of senna. This quantity to be administered in three doses at intervals of four or five hours. In some in- stances the addition of syrup of manna will be found ad- vantageous in sweetening the infusion of senna. Certain drugs should not be given. Of these castor- oil may serve as a type. The constipating effect following the use of castor-oil is so well known that this drug is in- dicated when we wish to cleanse the stomach and bowels and remove stagnant food, as, for example: in fermenta- tive dyspepsia accompanied by diarrhoea. Thus, we not only have an effective movement, but a constipating effect following the same. The use of drastic cathartics — such as scammony, elaterin, or podophyllin — should not be thought of in the treatment of infants and children. Very rarely do I use aloes, owing to its offensive taste. • It is understood that calomel is only to be given when we wish to cleanse and produce an antiseptic effect in the intestine, but, for the treatment of constipation per sc, calomel is entirely out of place. COXSTIPATIOX. • prcpai'cil wiili •?() (li'op.s more of llic ncid. Tliis was a(l(l('(l |() tlic |)rc\ ioii,- 1 v-l)(tilr(l milk and arid, -liiTcd Ihoroii-Idv, and a-ain hi'on-lit lo \\\r hodiii- p^ini . 'I'li^ ]'('sidt thus olilaincd \\;is n i lidroiii;!! 1_\ p.ilal a hie nidk, willi no taslc ()[' lia\inu' hcfii liodi'd. and uaxc no indicalion of iVcr hydrochloric acid wilh (inn/hcru's rcai^'cnt. I(udis(di> jihan is simihii" lo tlic hillci'. Ti'otcids in excess ai-e indicaled hy Ihe presence of curds in llu' siool.-. This is the nio.-i rrcipuuit eau>c of colic in infants. Sonielinio thei'e is diaiThoM. more ol'len constipation when the proteid> are in excess. The excess of proteids fi'iMpU'iit l_v causes vonntiii'^ and >o (h>es an (Wcess of hotli J'at oi' suuai'. If, therefore, after nMhieini;' the percentage of proieids. lat, ov sui^ar, xomitinu' still persists, then we must feed the hahv witli >maller (pianli- lies. Thus, we may iia\<' to ,L:i\e a l-oiinee i)ottle where a (]-ounce OI' a o-ouiice feiMJiiiL;- causes vomiting'. Cei'tain rules can he laid down: if an infant does not 1 hrive, -that is, does not ,L:ain in weight without -howin^ any siuns of indigestion,— -t hen the pi'oport ions- -/.r., ])erc(Mitages of all ingredi(Mits — should he gradually iiiereased; cliielJv ihe proteids, ho\\cv(U", for the latter is the most impoiiant elenuuit in an infant's food. An infant soon after hii'th was put on modiljed nnik, conlriining: — fat 2.00 Milk-su;L^ar :^.0U Albuminoids 0.7.") JiiiiH'-walor '/,.. I ol'diU'ed eight feefjings, 'j oUUecS ill each. .\o the (diild was constipaled. soon after we imreased (he foi-- mula lo the following pcrcenlages: — Fat 2.50 I\Iilk-sngar G.OO Albuminoids 1 .00 Lime-water Vi,-, 303 INFANT-FEEDING. As the stools did not change^ the fat was increased to 3 per cent., other ingredients the same. The child gained but 3 ounces in weight in five weeks; had greenish, curded stools, and had distinct evidence of intestinal indi- gestion. It also vomited curds. The general condition of the child was one of extreme irritability, with very little sleep. Hand-feeding was stopped. The child's aliment- ary tract was thoroughly cleaned, and a wet-nurse secured. This happened when the baby was six weeks old; the child nursed well, gained 6 ounces the first week, 8 ounces the second, and weighed 14 pounds when it was four and a half months old. The child improved until it was seven months old, when suddenly the weight remained station- ary. A specimen of breast-milk was sent to John S. Adri- ance, the chemist of the Nursery and Child's Hospital, who found the following percentages: — Fat 2.000 Sugar 7.431 Proteids 0.882 Ash 0.162 Specific gravity, 1031; reaction, alkaline. It is very evident that the deficiency in albuminoids or proteids is accountable for the stationary weight. The child did not gain an ounce in one month. We discharged the wet-nurse, and resorted to hand-feeding, when the child's general condition changed, and she is bright and well to-day. In another instance, a child had been nursed by its own mother for three months, and had gained in weight regularly at the rate of 6 and 7 ounces per week; the stools were normal in quantity and quality, when sud- denly the child appeared to be colicky, was restless at night, had green stools, and did not appear to thrive. For two consecutive weeks the child did not gain in weight, and a specimen of breast-milk was sent to the Pediatrics ATHREPSIA INFANTUM. 303 Laboratory. Mr. E. W. Bailey, the chemist, examined th€ specimen, with the following result: — Fat 2.43 Proteids 1.25 Sugar 6.51 Ash 0.20 Total solids 10.39 Specific gravity, 1027; reaction, slightly alkaline. The percentage of fat and proteids is so low that it was very plain to me why this child did not increase in weight. On putting the child on an oatmeal and top-milk mixture, the digestion improved, the child's sleep was better, and the weight increased. Another case was that of a nursling, brought to me with a history of excessive crying, greenish stools, cheesy curd in the stools, vomiting, restlessness, and a general condition of malassimilation; I asked for a specimen of breast-milk, which Mr. Bailey kindly examined, with the following result: — Fat 4.32 Sugar 6.22 Proteids 1.80 Ash 0.19 Total solids 12.53 Reaction, neutral. The general history of the case showed that the child was fed every time it cried, and thus it was evident that overfeeding was the real cause of the trouble in this case, for I learned that the child frequently nursed for hours at the breast, and was also allowed to go to sleep with the nipple in its mouth. Whenever the child cried it was fed, frequently as often as every half -hour, so that in this case, while the quality of the breast-milk was absolutely nor- 304 INFANT-FEEDING. mal, as demonstrated by the chemical examination, it re- quired only the judicious interval for feeding to give the child's stomach proper time for the assimilation of its food. CHAPTEK XLIII. Infant-fkeding in Summer Complaint. The successful management of a case of summer complaint affecting the stomach and bowels depends largely on the feeding. We know that when food is given which is improper in quality or quantity. — in other words, when dietetic errors have been committed, — then the child will suffer with gastro-intestinal or gastric disorders. The nursing baby, fed exclusively from the breast, is usually exempt from summer complaint, unless it is fed irregu- larly or if the milk is of an improper quality. Thus we know that, when breast-milk contains large quantities of colostrum-corpuscles, such milk has a decided laxative effect. "\\Tiat has already been said in regard to the proper supervision of breast-milk, in the chapters on "Breast-feeding" and "Wet-nursing," must be emphasized when it is desired to feed an infant during the summer months. The depressing effect of extreme heat in midsummer naturally tends to lower the vitality of the infant. We must not, therefore, be surprised to find that an appetite, which has been unusually good heretofore, suddenly di- minishes. When the infant shows loss of appetite, noth- ing will tone up the stomach and bowels more quickly than a sudden cliange of air from the city to the sea-shore. If, in spite of the change of air to the sea-shore, the infant still continues to vomit or to have loose, greenish, or "muddy" stools (the latter are usually found in that most frequent form of summer complaint known as "colitis"), then the breast-feeding should be stopped and the stom- ach given complete rest for twenty-four or forty-eight 20 (305) 306 INFANT-FEEDING. hours. Substitute food such as barley-water^ rice-water, albumin- water, or weakened mixed tea to which the white of a raw egg has been added; these can be given in tea- spoonful doses. Steak-juice can also be advantageously given at regular intervals of every three to four hours. In this manner we remove milk from our dietary, for the time being, and give the above liquid nourishment, which is easily absorbed. It is a good plan to dextrinize all the cereals, if the child shows a tendency toward vomit- ing after the milk has been withdrawn. When sever-e vomiting persists, in spite of the withdrawal of milk and the substitution of the cereals and the white of egg above mentioned, then absolute rest of the stomach must be insisted upon and rectal feeding substituted therefor. EECTAL ALIMENTATION. Always cleanse the rectum by using an enema of soap-water or glycerin and water, in the proportion of 4 ounces of glycerin to a pint of warm water, at a tempera- ture of 100° F. Following this rectal cleansing, pepto- nized milk "thoroughly peptonized,'' or yolk of an egg with starch-water, or beef-blood and starch-water, should be slowly injected. More than 2 ounces should not be used for one feeding enema. This method of feeding has already been described in the chapter on the "Feeding of Diphtheria-Intubation Cases." DIETETIC MANAGEMENT OF A BOTTLE-FED BABY. Discontinue all kinds of food which were given at the beginning of the summer complaint. For example, if milk has been given, it must be discontinued, and in its place a food which is more easily assimilated must be supplied. Such foods are barley-water, rice-water, farina- water, sago-water or arrowroot-water. These are very easily made by adding a tablespoonful of either one of INFANT-FEEDING IN SUMMER COMPLAINT. 307 the above mentioned cereals to a pint of water and boil- ing the same for about one-half honr; strain through a cheese-cloth, and then add enough water to make 1 pint. This proportion will keep as a stock solution for days, if put into a refrigerator. In feeding we use 3 to 6 ounces, to which a pinch of salt and some sugar have been added, and warm the same to body-heat immediately before feeding. In making rice- water a much longer time is required to boil the same. For further particulars we refer to the dietary. The quan- tity to be fed depends on the age of the child; thus, if the child has received 6 ounces of milk at one feeding, prior to its attack of summer complaint, then a good plan is to substitute 6 ounces of barley-water, rice-water, or sago-water for the 6 ounces of milk. It is also a good plan to allow a larger feeding interval during an attack of summer complaint, and to give the stomach and bowels less work. Hence my plan has been to feed every four hours, if the interval prior to the attack has been every three hours. Thirst requires careful management. If the child is very thirsty it is a good plan to give plain boiled water, or to add the white of a raw Qgg (^^albumin-water"). If the child is over one year old, a few drops of expressed meat-juice, made by broiling a steak over a fire and ex- pressing the juice in a lemon-squeezer or meat-press, is advantageous. When the infant's condition is normal and its digestive power is strengthened, then we can gradually return to Nature's remedy, namely: milk- feeding. Every physician knows how difficult it is to keep milk fresh and pure during the hot weather, and, therefore, in summer it is advisable to pasteurize or sterilize the milk for about fifteen minutes, as soon as it is received from the dairy, and then to keep it in the refrigerator until it is time for feeding. Thus we prevent not only the for- 308 INFANT-FEEDING. mation of the germs, but also the development of toxins, which are so death-dealing in midsummer. The most vital point to be considered in the man- agement of summer complaint, next to the diet, is fresh air, and hence, unless children can be given the benefit of daily excursions to the sea-shore or to the mountains, and can be removed from unsanitary and improper hygienic surroundings, we must not look for permanent results. NUESING INFANT. If a nursing infant has summer complaint, then it is advisable to stop nursing. Frequently giving the stom- ach absolute rest for one-half or one whole day will work wonders. The breast-milk should be drawn with the aid of a breast-pump at regular intervals, as though the baby were nursing, and the milk should be thrown away. The same rule applies to the nursing baby as applies to the bottle-fed baby. Thus milk must be temporarily with- drawn and other feedinsr substituted. DIETARY. Almond-milk. Take 2 ounces of sweet almonds, scald them with boiling water; after a few moments express them from the hulls; then pour the hot water away. Put the blanched almonds into a mortar and pound them thor- oughly, and add either 2 ounces of milk or 2 ounces of plain water. After this is thoroughly mixed, it is to be strained through cheese-cloth, and the strained liquid will be the almond-milk. Keller's Malt-soup. Take of wheat-flour 50.0 (about 2 ounces). To this and 11 ounces of milk. Soak the wheat-flour thoroughly, and rub it through a sieve or strainer. Put into a second dish 20 ounces of water, to which add 3 ounces of malt-extract; dissolve the above at a tem- perature of about 120° F., and then add 10 cubic centi- metres (about 2 Vo drachms) of 11-per-cent. potassium carbonate solution. Finally mix all of the above ingredi- ents, and boil. This gives a food containing: — Albuminoids 2.0 per cent. Fat 1.2 per cent. Carbohydrates 12.1 per cent. There are in this mixture: — Vegetable proteids 0.9 per cent. The wheat-flour is necessary, as otherwise the malt- soup would have a diarrhoeal tendency. The alkali is added to neutralize the large amount of acid generated in (309) 310 INFANT-FEEDING. sick children. Biedert empliasizes the importance of giv- ing fat, rather than reducing its quantity, in poorly nourished children, and cites the assimilability of his cream-mixture or of breast-milk in under-fed children as proof of his assertions. The author has used this malt- soup most successfully in the treatment of athrepsia (marasmus) cases in which the children were simply starved. Junket of Milk and Egg. Beat 1 egg to a froth and sweeten with 2 teaspoonfuls of white sugar. Add this to ^/^ pint of warm milk; then add 1 teaspoonful of essence of pepsin (Fairchild); let it stand till it is curdled. The above is useful in typhoid and similar wasting diseases. Plain Junket. — This is sometimes called ^"^curds and whey.^^ Take '^/^ pint of fresh, raw milk, and heat it luke- warm. Then add a teaspoonful of Fairchild's essence of pepsin, and stir the mixture thoroughly. Pour into cus- tard cups, and let it stand until firmly curdled. The flavor can be improved by adding some essence of lemon or cinnamon or grated nutmeg. When the essence of pepsin (Fairchild's) cannot be had, or for convenience in traveling, the author has used Hansen's junket tablets, which will give similar results as the liquid essence of pepsin. Peptogenic Milk-powder. The pancreas ferment trypsin is known to have a re- markable affinity toward milk, digesting its casein with great rapidity without altering its other elements, and without rendering the milk repulsive. When milk is so treated it is known as peptonized milk. Through the ex- pert investigation of the well-known chemist. Dr. Albert Leeds, the peptogenic milk-powder was found to yield a milk which was similar to a humanized milk. The author DIETARY. 311 has had some experience in the modification of cows^ milk by the addition of peptogenic milk-powder, and can safely say that it is one of the most yahiable additions to our infant-feeding that we possess. There are three steps necessary for the preparation of "humanized milk'' in using the peptogenic milk- powder: — 1. To prepare — with peptogenic powder, cows' milk, water, and cream — a mixture which has the quantitative composition of average human normal milk. 2. To subject this mixture to the action of the di- gestive principle by which the albuminoids (casein, etc.) are converted into such form as to become identical with those of human milk. 3. To then destroy tlie digestive ferment by simply raising the temperature of the milk to the boiling-point. This heat also destroys the bacteria, and renders the milk practically sterile during the time required for its use: twenty-four hours. DIEECTIOXS FOR '^HU^ilAXIZED MILK." No. 1. — For the daily food of a healthy infant: Put into a clean graniteware or porcelain-lined saucepan one measure (which accompanies each bottle) of peptogenic powder; add to this V2 pint of cold water, V^ pint of cold, fresh milk, and 4 tablespoonfuls of cream. Place the saucepan on a hot range or gas-stove, and heat, with constant stirring, until the mixture boils. The heat should he so applied as to make the milk loil in ten minutes. Keep in a clean, well-corked bottle, in a cool place. When needed, shake the bottle, and pour out the desired por- tion, and warm the same before feeding. No. 2. — Specially designed for children with feeble digestion, or when the stomach and bowels are disordered, as in catarrhal conditions. Put into a clean bottle 1 meas- ure of the peptogenic powder, V2 pint of cold water, '^/^ 312 INFANT-FEEDING. pint of cold, fresh milk, and 4 tablespoonfuls of cream. Shake well, place the bottle in a pail or tin kettle of water, holding a gallon, as hot as can be borne by the hand (115° F.), and keep the bottle there for thirty minutes. Then pour all into a saucepan, and quickly heat to boiling- point, with constant stirring. The bottles of the peptog- enic milk-powder made by Fairchild Brothers & Foster have a metal screw-cap, which is the measure above al- luded to. If the infant's digestive powers are still weaker, or if, after feeding the last-named formulae, vomiting takes place, then it is safer to use: — One measure of peptogenic milk-powder. One-third pint of raw milk. Two-thirds pint of water. Mix, heat, and boil, as described above, and it is ad- visable to feed at longer intervals; for example, every three or four hours, if the infant has previously been fed every two or three hours. Never use the balance left over in a feeding-bottle, after the infant has sucked, but al- ways give a fresh quantity of food for each meal, and whatever the baby leaves should be invariably thrown away. The weight and the stools are important factors in judging when to increase the quantity of milk and cream, or vice versa. Peptonized Milk. Into a clean, quart bottle put the powder contained in one of the Fairchild peptonizing tubes, and a teacupful (gill) of cold water; shake, then add a pint of fresh, cold milk, and shake the mixture again. Place the bottle in water so hot that the whole hand can be held in it without discomfort. (About 115° F.) Keep the bottle there five or ten minutes as directed. At the end of that time put the bottle on ice at once DIETAEY. 313 to check further digestion and keep the milk from spoil- ing. Place the bottle directly in contact with the ice. The degree of digestion is very simply regulated by the length of time in which the milk is kept warm. PARTIALLY PEPTOXIZED MILK. Put into a clean agateware or porcelain-lined sauce- pan the powder contained in one of the Pairchild pep- tonizing tubes^ and a teacupful (gill) of cold water; stir well; then add a pint of cold, fresh milk. Heat with con- stant stirring until the mixture boils. The heat should be so applied that the milk will come to a boil in ten min- utes. When cool, strain into a clean bottle, cork well, and keep in a cold place. When needed, shake the bottle, pour out the required portion, and serve cold or hot, as directed by the physician in charge. Milk so prepared will not become bitter. niMEDIATE PEOCESS. Put 2 tablespoonfuls (1 ounce) of cold water in a gob- let or glass; dissolve in this one-quarter the contents of a peptonizing tube; add 8 tablespoonfuls (-i ounces) of warm milk; drink immediately, sipping slowly. If half a pint of milk is required, double the propor- tions of water, peptonizing powder, and milk. COLD PEOCESS. Into a clean, quart bottle put the powder contained in 1 of the Fairchild peptonizing tubes, and a teacupful (gill) of cold water; shake, then add a pint of fresh, cold milk; shake the mixture again and immediately place the bottle on ice, without subjecting it to the water-bath or any heat. Place the bottle directly in contact with the ice. 314 INFANT-FEEDING. When needed^ shake the bottle, pour out the required portion, and use in the same manner as ordinary milk. Peptonized Milk-gruel. Thick, well-boiled, hot gruel V, pint. Milk, fresh, cold V2 pint. Mix and strain into a small pitcher or jar, and im- mediately add the contents of 1 Fairchild peptonizing tube: mix well. Let it stand in the hot water-bath, or warm place, for five minutes, then put in a clean bottle and place on ice. Serve hot or cold. Gruel made from arrowroot, flour, barley, oatmeal, etc., will serve for the purpose. In each instance the fari- naceous material should be boiled with water until the starch-granules have been thoroughly swollen, broken up, and incorporated with the water. Junket (Cueds and Whey). Junket. — Take '^/^ pint of fresh milk, heated luke- warm — not warmer than can be agreeably borne by the mouth (about 115° F.); add 1 teaspoonful of Fairchild's essence of pepsin, and stir just enough to mix. Pour into custard-cups; let it stand until firmly curdled; may be served plain or with sugar and grated nutmeg. An Qgg beaten to a froth and sweetened with 2 tea- spoonfuls of sugar may previously be added to the half- pint of milk, forming a highly nutritious and smooth jelly. The essence will curdle milk with egg as readily as plain milk. Whey. — Curdle warm milk with the essence of pepsin as above directed; then beat up with a fork until the curd is finely divided; now strain, and the whey is ready for use. Whey is a highly-nutritious fluid food peculiarly use- ful in many ailments and always valuable as a means of DIETARY. 315 variety in diet for the sick. It is frequently resorted to as a food for infants to tide over periods of indigestion, sum- mer complaints, etc. Guie-Aeabic Water. Dissolve 1 onnce of gnm arable in a pint of boiling water; add 2 tablespoonfiils of sugar, a wineglassful of sherry, and the jnice of a large lemon. Cool and add ice. LniE-VATER. Ponr 2 quarts of water over fresh unslaked lime the size of a walnut; stir until slaked, and let stand until clear; then bottle. Lime-water is often ordered with milk to neutralize acidity of the stomach. Ta^IAEIXD- WATER. A very refreshing drink may be made by adding 1 pint of hot water to 1 tablespoonful of preserved tama- rinds, and setting aside to cool. LE^rOXADE. Squeeze the juice from 1 lemon. Add 2 tablespoon- fuls of sugar and 1 cup of water. Strain and serve. Milk axd Albu^iix. Put into a clean quart bottle 1 pint of milk, the whites of 2 eggs, and a small pinch of salt. Cork and shake hard for five minutes. MiLK-PrX'CH. Take ^/o pint of fresh, cold milk and add 2 teaspoon- fuls of sugar, and stir well until dissolved; then add 1 ounce of either brandy or sherry-wine. 316 infant-feeding. Orangeade. Substitute orange-juice for that of lemon in the recipe for "Lemonade.'^ Tea. Scald out the teapot and put in the tea, using 1 tea- spoonful for 1 cupful. Pour on toiling water, and let tea- pot stand four or five minutes. If allowed to stand too long, the tannin in the tea is developed, which not only darkens the tea, but also renders it hurtful. Albumin- water. Stir the whites of 2 eggs into ^/.^ pint of ice-water, without beating; add enough salt or sugar to make it palatable. Apple-water. Slice into a pitcher ^/^ dozen juicy sour applies; add 1 tablespoonful of sugar, and pour over them 1 quart of boiling water. Cover closely until cold; then strain. Barley-water. Wash 2 ounces (wineglassful) of pearl barley with cold water. Boil it five minutes in fresh water; throw both waters away. Pour on 2 quarts of boiling water; boil down to 1 quart. Flavor with thinly-cut lemon-rind; add sugar to taste. Do not strain unless at the patient's request. Cocoa. Allow 1 teaspoonful of cocoa for each cup; add suffi- cient hot water to form a paste; pour on boiling milk (or milk and water) and sweeten to taste; five minutes' boil- ing will improve the cocoa. Coffee (French). Some persons prefer filtered to boiled coffee. Fil- tered coffee is best made in a French biggin, consisting DIETAKY. 317 of two tin vessels^ one fitting into the other, the upper one being supplied with strainers. The coffee, being very finely ground, is placed in this utensil, and the boiling water allowed to slowly percolate through it. The pot should be set where it will keep hot, but not boil, until the water has gone through. Pouring it through the cof- fee a second time will make it stronger, but it loses in flavor. Cafe iioir is always made in this way. !N"uTEiTious Coffee. Dissolve a little isinglass or gelatin (Ivnox) in water; put ^/o ounce of freshly-ground coffee into a saucepan with 1 pint of new milk, which should be nearly boiling before the cofi^ee is added; boil both together for three minutes; clear it by pouring some of it into a cup and dashing it back again; add the isinglass, and leave the coffee on the back part of the range for a few minutes to settle. Beat up 1 ^^g in a breakfastcup, and upon it pour the coffee; if preferred, drink without the Qgg. EgCtNOG. Scald some milk by putting it, contained in a jug, into a saucepan of boiling water, tut do not alloiv tlie mill: to boil. When cold, beat up a fresh egg with a fork in a tumbler with some sugar; beat to a froth, add a dessert- spoonful of brandy, and fill up tumbler with the scalded milk. Soft Custaed. Take of corn-starch 2 tablespoonfuls to 1 quart of milk; mix the corn-starch with a small quantity of the milk, and flavor; beat up 2 eggs. Heat the remainder of the milk to near boiling; then add the mixed corn, the eggs, 4 tablespoonfuls of sugar, a little butter, and salt. Boil the custard two minutes, stirring briskly. 318 infant-feeding. Calf's-Foot Jelly. Thoroughly clean 2 feet of a calf, cut into pieces, and stew in 2 quarts of water until reduced to 1 quart; when cold, take off the fat and separate the jelly from the sedi- ment. Then put the jelly into a saucepan, with white wine and brandy and flavoring to taste, with the shells and w^hites of 4 eggs well mixed together; boil for a quarter of an hour, cover it, and let it stand for a short time, and strain while hot through a flannel bag into a mold. Tapioca-cream. Take 1 pint of milk, 2 tablespoonfuls of tapioca, 2 tablespoonfuls of sugar, 1 saltspoonful of salt, and 2 eggs. Wash the tapioca. Add enough water to cover it, and let it stand in a warm place until the tapioca has absorbed the water. Then add the milk and cook in a double boiler, stirring often until the tapioca is clear and transparent. Beat the yolks of the eggs. Add the sugar and salt and the hot milk. Cook until it thickens. Remove from the fire. Add the whites of the eggs, beaten stiff. When cold, add 1 teaspoonful of vanilla. Chocolate. Take 2 squares of vanilla chocolate to each coffeecup- ful of milk. Grate the chocolate and wet it with cold milk and stir into the milk when it boils. Whip a tablespoon- ful of cream, and beat it into the chocolate just as it is taken from the fire. This makes one cup of rich, de- licious chocolate. Do not let it boil, as it becomes oily and loses its fine, fresh flavor. Toasted Bread (Toast Dry). Cut thin slices of bread into strips, toast carefully and evenly without breaking, slightly butter, and serve immediately on a hot plate. DIETAKY. 319 Cream-toast. Take 1 cupful of cream, 1 saltspoonful of salt, 2 slices of dry toast, or make the same as milk-toast, using cream in place of the milk. If preferred, the slices of toast may be first dipped in hot, salted water. Egg-toast. Take 1 egg, 1 saltspoonful of salt, 1 cupful of milk, 6 slices of bread. Beat the egg lightly; add the salt and milk. Soak slices of bread in this until soft. Butter a hot griddle, put on the bread; when one side is brown, put a bit of butter on each slice, then turn and brown the other side. Serve with sugar and cinnamon. Milk-toast. Take 1 cupful of milk, ^/^ tablespoonful of corn- starch, ^/^ tablespoonful of butter, 2 slices of dry toast, 1 saltspoonful of salt. Scald the milk. Melt the butter in a saucepan; when hot and bubbling, add the corn-starch. Pour in the hot milk slowly, beating all the time until smooth. Let it boil up once. Then add the salt. Toast 2 slices of bread. Pour the thickened milk over the slices. Let it stand five minutes. Serve. Baked Apples. Core and pare 2 tart apples; fill the core-holes with sugar; grate over the apples a little nutmeg; add a little water to baking-pan and put in oven and bake until the apples are soft. Serve with rich milk or cream. Sprinkle with icing sugar, if not sweet enough. MUTTON'-SOUP. Cut up fine 2 pounds of lean mutton, without fat or skin. Add 1 tablespoonful of barley, 1 quart of cold water, and a teaspoonful of salt. Let it boil slowly for 320 INFANT-FEEDING. two hours. If rice is used in place of barley, it will not need be put in until half an hour before the soup is done. White-Celery Soup. Take V^ pint of strong beef-tea; add an equal quan- tity of boiled milk, slightly and evenly thickened with flour. Flavor with celery-seeds or pieces of celery, which are to be strained out before serving. Salt to taste. Scrambled Eggs. Take 4 eggs, ^/^ teaspoonful of salt, 1 saltspoonful of pepper, V^ cup of milk, and 1 tablespoonful of butter. Beat the eggs lightly; add the salt, pepper, and milk. Put the butter into a saucepan; when melted and hot, add the eggs. Stir over hot water until of a soft, creamy con- sistency. Serve on buttered toast. Soft-Boiled Eggs. Drop 2 eggs into enough boiling water to cover them. Let them stand on the back of stove, where the water will keep hot, but not boil, for eight minutes. An ^^^g to be properly cooked should never be boiled in boiling water, as the white hardens unevenly before the yolk is cooked. The yolk and white should be of a jelly-like consistency. Infantas Food. About 1 teaspoonful of gelatin should be dissolved by boiling in ^/^ pint of water. Toward the end of the boiling 1 gill of cows' milk and 1 teaspoonful of arrowroot (made into a paste with cold water) are to be stirred into the solution, and 1 to 2 tablespoonfuls of cream added just at the termination of the cooking. It is then to be moderately sweetened with white sugar, when it is ready for use. The whole preparation should occupy about fifteen minutes. DIETARY. 321 Custard Pudding. Break 1 egg into a teacup, and mix thoroughly with sugar to taste; then add milk to nearly fill the cup, mix again, and tie over the cup a small piece of linen; place the cup in a shallow saucepan half-full of water and boil for ten minutes. If it is desired to make a light batter pudding, a tea- spoonful of flour should be mixed in with the milk before tying up the cup. CoRx-FLOUR Pudding. Take 1 pint of milk, and mix with it 2 tablespoonfuls of flour; flavor to taste; then boil the whole eight min- utes; allow it to cool in a mold, and serve up with or without jam. EiCE Pudding. Take 1 teacupful of rice; wash, and pour over it boil- ing water, and let stand five minutes; then drain off the water and add a cupful of sugar to the rice, a little nut- meg, 2 quarts of milk, and 1 egg. Bake slowly about two hours, stirring occasionally until the last half-hour, then brown. Sago Pudding. Same as above recipe, sago being substituted for rice. Snow Pudding. Dissolve Vo box of gelatin in 1 pint of cold water; when soft, add 1 pint of boiling water, the grated rind and juice of 2 lemons, and 2 V^ cupfuls of sugar. Let the gelatinized water stand until cold and beginning to stiffen. Then beat in the well-beaten whites of 5 eggs. Pour into a mold and set on ice. Serve with custard sauce: 1 quart of rich milk, the yolks of 5 eggs, and 2 extra eggs added, and V2 cupful of sugar. Flavor with vanilla. 322 infant-feeding. Peptonized Oystees. Mince 6 large or 12 small oysters; add to them^ in their own liquor^ 5 grains of extract of pancreas with 15 grains of sodium bicarbonate (or 1 Fairchild peptonizing tube). This mixture is then brought to blood-heat (98° F.), and maintained, with occasional stirring, at that tem- perature thirty minutes, when 1 pint of milk is added and the temperature kept up from ten to twenty minutes. Finally, the mass is brought to the boiling-point, strained, and served. Gelatin may be added, and the mixture served cold as a jelly. Cooked tomato, onion, celery, or other flavoring suited to individual taste may be added at beginning of the artificial digestion. Oyster-stew. Take 1 pint of oysters, 1 pint of milk, 1 teaspoonful of salt, ^/^ cupful of water, 1 tablespoonful of butter, and 1 saltspoonful of pepper. Scald the milk. Wash the oysters by adding the water, and remove all shells. Drain, saving the liquor. Put the liquor into a stewpan and heat slowly. Skim carefully. AVhen clear, add the oysters and cook slowly until the edges curl and they are plump. Add the hot milk, butter, salt, and pepper, and serve. Do not let the oysters boil, as that toughens them and renders them indigestible. Oyster-broth. Cut into small pieces 1 pint of small oysters; put them into V2 pint of cold water, and let them simmer gently for ten minutes over a slow fire. Skim, strain, and add salt and pepper. Arrov^root Pudding. Add the yolks of 2 eggs to the plain arrowroot recipe (following), with 1 teaspoonful of powdered white sugar; DIETAKY. 323 mix well and bake in a liglitly-biittered dish for ten or fifteen minutes. Arrowroot. Mix 1 teaspoonfnl of Bermuda arrowroot with 4 tea- spoonfuls of cold milk. Stir it slowly into ^/^ pint of boiling milk, and let it simmer for five minutes. It must be stirred all the time, to prevent lumps and to keep it from burning. Add '^/^ teaspoonful of sugar and a pinch of salt, and, if desired, 1 of cinnamon. In place of the cinnamon '^/ ^ teaspoonful of brandy may be used or a dozen large raisins may be boiled in the milk. If the raisins are preferred, they should be stoned and the sugar may be omitted. Oatmeal-gruel. Pound V2 cup of coarse oatmeal until it is mealy. Put it in a tumbler, and fill the tumbler with cold water. Stir well; let it settle; then pour off the mealy water into a saucepan. Fill again and pour off the water, and again repeat this, being careful each time not to disturb the sediment in the bottom of the tumbler. Boil the water twenty minutes. Season with salt. Thin with a little cream or milk. Strain and serve hot. Chicken-broth. Skin and chop up a small chicken or half a large fowl; put, bones and all, — with a blade of mace, a sprig of parsley, 1 tablespoonful of rice, and a crust of bread, — in a quart of water and boil for an hour, skimming it from time to time. Strain through a coarse colander. Clam-broth. Wash thoroughly 6 large clams in the shell; put them into a kettle with 1 cupful of water; bring to boil, and keep it boiling one minute; the shells open, the water 334 INFANT-FEEDING. takes up the proper quantity of juice, and the broth is ready to pour off and serve hot. Add a teaspoonful of finely-pulverized cracker-crumbs, a little butter, and salt to taste. ElCE-WATER. One ounce of well-washed Carolina rice. Macerate for three hours at a gentle heat in a quart of water, and then boil slowly for an hour and strain. It may be sweet- ened and flavored with a little lemon-peel. Useful in diarrhoea, etc., when the flavoring is best dispensed with, and a little old cognac added. Barley-water. Take a tablespoonful of pearl barley, grind it in a coffee-grinder, or pound it in an ordinary mortar; add 1 pint of cold water, and allow it to simmer slowly for about an hour. Strain and add enough water to make 1 pint. Oatmeal- V7ATER. Take a tablespoonful of ordinary oatmeal, and add 1 pint of water. Allow it to simmer slowly for one hour and strain. Add enough water to make 1 pint. The same directions apply to making a household mixture of farina- water, rice-water, and sago-water, using the same propor- tions as above. ArROV7ROOT-V7ATER. Add 2 tablespoonfuls of arrowroot to 1 pint of water; allow it to simmer for half an hour, stirring it constantly. Egg-water. This is made by mixing thoroughly the white of 1 egg with 6 ounces of water and adding a little salt. The addition of a few grains of sugar will make the child take it better, and adds also a food-element. DIETARY. 325 Such a mixture is one of the best foods we have for temporarily feeding an infant with digestive disturbances when we wish, for a time, to stop temporarily all milk- food. Artificial Milk. One ounce of suet cut up very finely, and tied loosely in a muslin bag. Boil slowly for an hour in thin barley- water, with V4 ounce of isinglass and a little sugar of milk, adding a little water occasionally as it boils away. Pound up 12 sweet almonds, pour the fluid slowly on them, and incorporate well. Strain before using. Milk Thickened. A great deal of nourishment can be given in milk by thickening it with either wheat-flour, rice-flour, isin- glass, or gum arable. The method of doing so is this: with Wheat-flour. — Eub a large spoonful of flour quite smooth, in a few spoonfuls of cold milk. Then add more milk by degrees till you have V2 pint. Sweeten and flavor with a little cinnamon, and then boil up the milk, stirring it all the time to prevent its getting lumpy. Rice-flour is done in exactly the same way. To thicken milk with isinglass, boil V2 ounce of it in a pint of new milk, after sweetening and flavoring it. When boiling, strain it off. A little less isinglass will do, unless the milk is desired very thick. For thickening with gum arable the proportions will vary according as the milk is wanted more or less thick. If powdered gum arable is used, it is done in the same way as flour; but if lumps, drop them into hot milk, until it is of the desired thickness, and then boil. There is much nourishment in this hot, and it is very soothing where either chest or stomach are in an irritable state. 326 INFANT-FEEDING. ElCE-MILK. Three tablespoonfuls of rice, 1 quart of milk; wash the rice and put into a saucepan with the milk; simmer until the rice is tender, stirring now and then, and sweeten. Tapioca, semolina, vermicelli, and macaroni may be similarly treated. Humanized Milk. A pint of milk is set aside until the cream rises, and this cream is skimmed off and kept. To the milk remain- ing is added enough rennet to curdle it. The whey is strained off the curd and added with the previously- separated cream to a pint of fresh cows' milk. This is known as humanized milk. In some infants it will be well borne during the first three months, and to this can be added farinaceous liquid for dilution if required. Pasteurized Milk. This is really partially sterilized milk, and consists of sterilization at a temperature of 167° F. instead of 212° F. This sterilization to be continued for from twenty minutes to half an hour. Pasteurized milk should only be used during the twenty-four hours following this process. A good apparatus for this purpose is the one known as Dr. Freeman's pasteurizing apparatus. Peptonized Milk. This is milk in which the proteids are changed to peptones, or, in other words, digested, by the addition and action of pancreatic ferment. This process may be stopped when partially performed, giving a product of which the taste is not objectionable; or may be carried on to complete peptonization, when the product has a very bitter, disagreeable taste. DIETARY. 327 Method. — To peptonize milk partially, add to 1 pint of fresh cows' milk and 4 ounces of water 5 grains of pan- creatic extract and 15 grains of bicarbonate of soda. Allow this to stand at a temperature of 105° to 115° F. for five to twenty minutes, then bring to a boil to kill the ferment, or stand on ice to prevent its further action. If the milk is to be used at once, neither of these latter is necessary. To peptonize the milk completely, allow the process to continue for one to two hours. After this time the ad- dition of acid produces no coagulation. In infant-feeding it is better to peptonize a modified than a whole milk. Peptonized milk is frequently very useful in feeding an infant with feeble digestive powers; but it is unwise to continue its use over too long a period, as then the infant's stomach, being called on to do no work, becomes enfeebled from disuse, and gradually un- able to perform its proper function. Whey. — By coagulating 1 pint of fresh milk by add- ing a teaspoonful of essence of pepsin, and allowing this to stand, a solid curd is formed swimming in a liquid (whey). This has the following composition: Proteids, 0.86 per cent.; fat, 0.33 per cent.; sugar, 4.79 per cent.; salts, 0.65 per cent.; water, 93.38 per cent. This at times makes a very valuable food for infants in cases of gastric or intestinal disorder, where the use of milk must for a time be interdicted. Babies like it, it is very easy of digestion, and does not irritate the stomach. A little wine may be added if desired. Scraped Beef. This is another valuable and easily digested food. It is prepared by scraping with a dull knife some raw or rarely-done lean beef. A tablespoonful of this salted is the amount usually given at a feeding. 328 infant-feeding. Beef-tea in Haste. Scrape 1 pound of lean beef into fibres on a board. Place the scraped meat in a delicately-clean white-lined saucepan and pour ^/^ pint of boiling water upon it. Cover closely and set by the side of the fire for ten min- utes; strain into a teacup, place the teacup in a basin of ice-cold water; then remove all fat from the surface, pour into a warm cup, warm this gently with hot water or otherwise, and serve. This can be ready in fifteen min- utes, and double the quantity of meat can be used if necessary. Bread and blotting-paper are ineffectual to remove all the fat. A tomato makes excellent flavoring, and other flavors can be added if desired. For children, however, the simpler aliments are the better. Beef-and-Chicken Broth. One pound of good lean beef and a chicken boned should be pounded together in a mortar, and a little salt added, and the whole placed in a saucepan with nearly 3 pints of cold water. Stir over the fire until it boils, then boil half an hour, strain through a coarse sieve, and serve. Liebig's Extract of Beef Thickened. A teaspoonful of Liebig's extract may be added to a pint of boiling barley-water, with a little salt, or to this may be again added a teacupful of milk, or, instead of the milk, the white of 2 eggs beaten up with 2 tablespoon- fuls of milk may be stirred into the Liebig beef-tea and barley-water when cool enough to be taken. Too great heat will coagulate the albumin. Chicken-, Veal-, and Mutton- broths. The fleshy part of the knuckle of veal; a chicken, bones and all chopped up; or 2 pounds of the scrag end of neck of mutton, added to 2 pints of water, with a little DIETARY. 329 pepper and salt^ and boiled two hours and strained, all make excellent broths. Pearl barley, rice, or vermicelli, boiled separately till quite soft, may be added when either of the broths is heated for use. All fat must always be carefully removed by skimming when cold. Beef-juice. Expressed beef-juice is obtained by slightly broiling a piece of lean beef, and then squeezing the juice from it by a lemon-squeezer. One pound of steak yields 2 or 3 ounces of juice. This is flavored with salt and given cold or warm. Do not heat enough to coagulate the albumin. This is very nutritious and usually well taken. It may be given at the rate of a tablespoonful three times a day. Good, Nutritious Beef-tea. Mince 1 pound of good beef (from which all skin, fat, etc., has been carefully removed) and pour upon it in an earthen jar 1 pint of cold water. Stir, and let it stand for one hour. Then place the jar in a moderate oven for one hour, or stand the jar in a saucepan of water and allow the water to boil gently for an hour. To be exact, the heat to which the beef-tea is raised should not exceed 180° F. Strain through a coarse sieve and allow it to grow cold. When wanted, remove every particle of fat from the top; warm up as much as may be required, add- ing a little salt. Beef-tea should, except in the hottest weather, be made a day before it is wanted. Essence of Beef (with Heat). One pound of gravy-beef free from skin and fat, chop as fine as mincemeat, pound in a mortar with 3 table- spoonfuls of soft water, and soak for two hours. Then put in a covered earthen jar with a little salt, cement the edges of the cover with pudding paste, and tie a piece of 330 INFANT-FEEDING. cloth over the top. Place the jar in a pot half-full of hoiling water, and keep the pot on the fire for four hours, simmering. Strain off the liquid essence through a coarse sieve; it will be about 5 or 6 ounces in quantity. One tea- spoonful frequently, with or without wine or brandy, as may be ordered. A teaspoonful of cream may occasionally be added with advantage to 4 ounces of the essence, or it may be thickened with flour, arrowroot, or sago. Essence of Beef (another Way Without Heat). Half a pound of fresh beef cut up as finely as pos- sible; to this add V2 pint of pure, soft, cold water (rain- water is excellent, filtered, if necessary, from the nature of the vessels in which collected, as iron tanks, etc.); an eggspoonful of salt, and 5 drops of pure hydrochloric acid (spirit of salt). Mix and stir well, and after an hour filter through a conical sieve without pressure. The fluid must be returned into the sieve until it runs through clear. Next, another '^/^ pint of cold, pure, soft water is to be poured on the meat in the sieve, and this is also to run through without pressure. The result will be about ^/^ pint of a red solution of meat containing most of the al- bumin, coloring and flavoring matters, salts, and other soluble materials. Half a wineglassful of this may be taken cold for a child twelve years old; a teaspoonful to a dessert or tablespoonful for younger children. Or it may be slightly warmed by standing in a jar immersed in hot — not boiling — water. It may be colored with burned sugar, if desirable. This is a veritable meat-essence, and is of use in extreme prostration, notably after burns, in continued fever, in some cases of dyspepsia, and in the diarrhoea of infants, as alluded to elsewhere. Fresh Pabula. These contain essentially the so-called antiscorbutic element, and may be given, not only to provide this un- DIETARY. 331 known, but necessary, constituent of food, but also as additional nutrient agents. The chief articles are: — RaiD Meat-juice. — To prepare this take 2 ounces of gravy-beef, free from fat, and chop into small pieces; add to 2 ounces (4 tablespoonfuls) of water in a cup, and stand in a warm place for half an hour; then squeeze through muslin to express the juice. The temperature of the meat-juice must never be above lukewarm, or the soluble albuminoids will be coagulated and its value destroyed. Eaw meat-juice will not keep for more than 10 or 12 hours, and should be made fresh whenever wanted. Bananas. — Fresh ripe bananas, either grated or sieved, afford a valuable fruit-food. It has been found that these with milk will constitute a useful nourishing food for infants. Egg-albumin. — Egg-albumin is prepared for use by stirring up the white of 1 new-laid egg with 4 ounces of water. Prepared thus and sweetened, it may take the place, for a time, of the ordinary milk diet in infantile diarrhoea, after appropriate treatment with repeated small doses of calomel. Egg-albumin can hardly be considered as a substitute for raw meat- juice, which contains only about 3 per cent, of albumin (myosin), but which is a powerful digestive stimulant, owing to the presence of extractives (creatin, etc.). LIST OF BOOKS CONSULTED. Baginsky: "Diseases of Children/' 1899. Henoch: "Diseases of Children." Biedert: "Infant-feeding." Monti: "Infant-feeding and Dietetics." Jacobi: "Intestinal Diseases of Infancy and Childhood." Jacobi : "Therapeutics of Infancy and Childhood." Article by T. M. Rotchj in Jacobi "Festschrift." Hammersten : "Text-book of Physiological Chemistry." Hammersten : Eichhorst^ "Clinical Pathology." Archiv fiir Kinderheilkunde (editor, Professor Baginsky). Wing: "Milk and its Products." Ellis: "Diseases of Children." Tuttle Gallaudet: "Diseases of Children." Keating : "Eneyclopsedia." H. Neumann, Berlin: "Ernahrungsweise und Infectionskrankheiten im Sauglingsalter." W. Knoepfelmacher, Vienna: "Verdauungsrueksyande bei der Ernahrung Mit Kuhmilch." Sternberg: "Manual of Bacteriology." Hueppe: "Principles of Bacteriology." Pfeiffer: "Analysis of Milk," Wiesbaden, 1887. Heubner: "Sauglingseraaehrung und Saeuglings-spitaeler," Berlin, 1897. Holt: "Diseases of Children." R. Schroter: "Jahrbuch fiir Kinderheilkunde," 1887. A. Wroblewski: "Beitrage zur Kenntnis des Frauencaseins, etc. Mittheilungen aus den Kliniken und medicinischen Instituten der Schweiz/' 1894. J. Lehmann: "Milchuntersuchungen," Pfliiger's Archiv, 1894. Fr. Soldner: "Die Salze der Milch," etc. Inauguration dissertation, Langensalza, 1888. Th. Escherich: "Jahrbuch fiir Kinderheilkunde," 1891. E. Salkowski and M. Hahn: Pfliiger's Archiv, 1895. H. Wegacheider: "Ueber die normale Verdauung bei Sauglingen," Berlin, 1875. 0. Heubner: Berliner klinische Wochenschrift, 1894. (332) LIST OF BOOKS CONSULTED. 333 J. Uffelmann: Pfluger's Archiv, 1882. Biedert: "Jalirbuch fiir Kindeiheilkunde," 1881. Th. Esclierich: Miinchener medicinische Wochenschrift, 1889. F. Soxhlet: Miinchener medicinische Wochenschrift, 1893. Th. Escherich: "Verhandlungen der XI Versammlung der Gesell- schaft fiir Kinderheilkunde/' 1894. Gartner: Ibidem, 1894. A. Jacobi: in Gerhardt's "Handbuch der Kinderheilkunde." INDEX. PAGE Absorption 21 of carbohydrates 14 of fat 16 Acidj hydrochloric^ the addition of, to food 71 lactic, quantity of, in infant's stomach 3 Acids in the infant's stomach 2 After-weaning diet 83, 86 Albuminoids, deficient 31 Albuminous, or proteid, substances 29 Albumin-water 316 Almond-milk 309 Amylopsin 11 Apples, baked 319 Apple-water 316 Arrowroot 323 Arrowroot-water . . .' 324 Athrepsia 98, 290 causes of 292 stages of 290 treatment of 292 Bacillus acidi lactici 113 b, summary of 54 d of Booker 44 e of Booker 45 f of Booker 47 g of Booker 49 h of Booker 49 k of Booker 50 n of Booker 51 Backhaus's milk 223 Bacteria of the intestine 39 bacterium coli commune 39 biological characters of 41 morphology of 40 pathogenesis of 43 varieties of 44 bacterium lactis aerogenes 51 biological characters of 52 morphology of 52 pathogenesis of 53 Bananas 331 Barley-water 316, 324 Barlow's disease from improper feeding 167 Beef, scraped 327 Beef-and-chicken broth 328 (335) 336 INDEX. PAGE Beef-juice 329 -tea 329 in haste 328 Biedert's cream^ directions for making 139 -mixtures 138 Bile in nurslings 18 Bottle-brush 172 -feeding 137 amount of milk to be given in 137 Breast-feeding 66 rules for 66 suggestions for 67 time for 66 Breast-milk 60 composition of 61 immunity by 56 specimen ofj for chemical examination 63 Breast-pump 89, 90 Brooder 181 Buttermilk 229 composition of 229 Calf's-foot jelly 318 Carbohydrates 26 and their formulae 21 Cellulose 22 Cereal milk 195 compositions of;, when prepared 195 Chicken-broth 323 veal-, and mutton- broths 328 Chocolate 318 Clam-broth 323 Cocoa 230, 316 Coffee (French) 316 nutritious 317 Colic 263 causes of 263 drug treatment of 264 massage in 264 treatment of 263 Colostrum 55 Condensed milk or condensed cream 226 quantity of sugar in 227 Constipation 267 causes of 267 dietetic treatment of 276 drug treatment of 273 electricity in 275 exercise in 276 hygienic treatment of 277 immediate relief of 271 massage in 275 INDEX. 337 PAGE Couveuse 181 Cow, age of 121 peculiarities of the 125 the breed of 120 Cows' food 110 milk, albuminoids in 122 analysis of 107 average percentage of fat in 110 composition, variation^, and production 107 raw 97 solutions used for rendering alkaline 133 yellowish 113 Cows, tuberculin reaction in Ill Cream " 127 eight per cent 128 for home-modification 127 mode of pasteurizing the 129 ordinary 127 toast 319 twelve per cent 128 uses of 127 Custard, soft 317 Cyanosis in premature infants 182 Dairy, the ideal 126 Decimal cream 141 Dentition 286 Dextrose 11 alcoholic fermentation of 12 Diarrhoea, fat 257 Diastasic action of succus entericus 12 Diet, after-weaning 83, 86 Dietary 309 Dried-milk foods 190 Drugs taken by a nursing woman, influence of, on baby 68 Egg-albumin 331 -toast 319 -water 324 Eggnog 317 Eggs, scrambled 320 soft-boiled 320 Enzymes 22 Epithelium and the glands, secretory and absorbing power of . . 16 Eskay's albumenized food 198 composition of, when prepared 199 Essence of beef 329, 330 Faeces, peptonizing ferment in 258 proteids in 258 quantity of 258 saccharin ferment in 258 22 338 INDEX. PAGE Farinaceous dried-milk foods 190 Fat in milk 25 Fats 26 Fats and carbohydrates, value of 27 Feeding, forced 245 in diphtheria-intubation cases 249 in incubators 178 dangers of 180 nasal 246 modus operandi 247 quantity of food to be used in 247 rectal, general rules for 251 in diphtheria 249 time of 83 Feeding-bottles 173 Fermentation 20 lactic 12 of glucose 12 of sugars 13 Ferments, organized 20 unorganized, and their action 18 Flour-ball feeding 70 Foods, additional, during the nursing period 70 Freeman's pasteurizer 163 Gastric juice, influence of, on pathogenic germs 4 of infantile stomach 2 power of transforming albumin 15 Gavage 179, 245 Glandular system of infants, development of 16 Green stools, typical 255 Gruel, oatmeal 323 Gruels, dextrinized 175 method of dextrinizing 175 Gum-arabic water 315 Hand-feeding 137 Horlick's malted milk 193 composition of^ when prepared 193 Humanized milk 326 composition of, when prepared 201 directions for 311 Hydrocarbons 26 Hydrochloric acid in the infant's stomach 2 Hydrolysis 22 Hydrolytic agents 20 Ice-cream 230 Imperial granum 197 composition of, when prepared 197 Incubator treatment of premature infants, results of 183 Incubator-feeding 178 Incubators, method of feeding in 178 INDEX. 339 PAGE Infant-feeding 102 in summer complaint 305 Infant-foods 190 as adjuncts to fresh cows' milk 190 Infants' food 320 general rules for feeding 104 premature 181 saliva 2 weight 91 Intestinal muscles, action of 16 Intestine, infantile, formation of gas in 15 relative length of 15 Junket (curds and whey) 314 of milk and egg 310 Keller's malt-soup 309 Koumiss 114 Laboratory milk-food, results of using 235 Laboratory-milk 105 Lactic acid in the infant's stomach 2 Lahmann's vegetable-milk 225 Lemonade 315 Liebig's extract of beef, thickened 328 Lime-salts in cows' milk 33 Lime-water 315 and milk 34 Liver in nurslings 18 Malt-diastase, action of 23 Malted dried-milk foods 191 Maltose 11 Mammary glands, the two 56 Marasmus, or atrophy 290 Materna home-modifier 149 Meat, raw, beneficial effect of 101 Meat-juice, raw 101, 331 Mellin's food 85, 199 composition of, when prepared 199 formulse and analyses for preparing 200 Men suckling children 59 Milk, addition of sugar to 132 aeration of 188 albuminoids of 62 and albumin . 315 artificial 325 bacteria in 117 burettes 31 certified 188 changes in, caused by sterilization 148 chemical and physiological changes in, caused by boiling. . 155 contra-indieations to the use of sugar in "^ 133 3-10 INDEX. PAGE Milk, cows', properties of 96 curdling and diluents of 121 decimal method for home-modification of 141 detection and addition of preservatives to 114 directions for pasteurizing 163 effect of alkalies on 121 effect of heating 146 experiments with bacteria in 119 formaldehyde as an addition to 114 fresh raw 99 frozen 113 general ingredients of 107 gruel, peptonized 314 home-modification of 141 human, excretion of drugs in 124 properties of 95 sterility of 69 humanized 326 modification of 130 laboratory 231 modified raw, and cream 244 nutritive value of sugar in 125 of infants' breasts 57 composition of 57 of men's breasts 59 of nursing women, microbes in 69 origin of bacteria in 118 partially peptonized 313 pasteurization of 156 pasteurized 161, 326 peptonized 326 phosphorus in 63 punch 315 raw, assimilation of 99 salicylic acid as a preservative of 117 salts contained in 123 salty 119 sour 113 Soxhlet method of sterilizing 158 sterilized 153, 157 sugar 35 bacteria in 38 impurities in 37 process of making 35 solutions 132 -teeth 286 test for salicylic acid in 117 tests for formaldehyde in 115 thickened 325 toast 319 use of glycerin in 133 woman's, fat-globules in 70 methods of chaneino' the ingredients in 77 INDEX. 341 TAGE Milkine •. 194 composition of, when prepared 194 Milking, precautions necessary in 119 time and stage of 120 Mixed feeding 68 ^Modified raw milk and cream 244 Muscle-juice, raw, antitoxic properties of 101 Mutton-soup 319 Nathan Straus milk-laboratories 260 Xestle's food 85, 192 composition of, when prepared 192 Xipples, artificial 169 mode of cleansing 169 management of 88 before the baby is born 88 odor of 172 recommended 171 tender 89 Xipple-shield 88 -sterilizer 172 the choice of a 171 ventilated 171 Nursing centre 2 mother^ the diet of 72 Oatmeal-water 324 Orangeade 316 Oyster-broth 322 Oysters, peptonized 322 Oyster-stew 322 Pepsin and hydrochloric acid, functions of, in infants" stomach. 3 Peptogenic milk-powder 201, 310 Phosphorus 29 Professor Gaertner mother-milk 203 Proteids, deficient, of breast-milk 31 method for estimation of, in breast-milk 31 Ptyalin 11 Pudding, arrowroot 322 corn-flour 321 custard 321 rice 321 sago 321 snow 321 Putrefaction 20 Rachitis 280 causes of 281 diet required in 283 external treatment of 283 internal treatment of 284 prevention of 280 343 INDEX. PAGE Rachitis, prognosis of 283 use of table-salt in 280 Raw-milk assimilation 99 Rectal feeding 180, 249, 251 in summer complaint 305 Rice-milk 326 Rice-water 324 Rickets 280 Saccharated skimmed milk 142 Saliva, bactericidal action of 4 of infants 2 Salts 28 and water 29 Schedule for feeding healthy infant 147 Schizomycetes, intestinal, diastasic action of 12 Scorbutic hsematuria 100 Scurvy, avoidance of 104 -rickets 100 value of milk in 100 Scybala, removal of 272 Self-weaning 83 Sick children, the feeding of 71 Siphon, mode of cleaning the 130 Soda, bicarbonate of^ in milk 34 Standard sugar solution 142 Starch, soluble 22 Statistics of births and deaths 278 Stomach, infantile 1 absorbent power of 15 acids in the 2 capacity of 6 gastric juice of 2 mucous membrane of the 1 muscular fibres of 1 ptyalin in 11 quantity of lactic acid in 3 relative acidity of 2 Stool, dyspeptic 257 of a nursling 253 Stools, blood in 256 brown 255 casein in 257 dry, pasty 259 green 255 infantile, reaction of 254 jelly-like masses in 257 mucus in 257 muddy 256 white or light gray 256 Succus entericus, diastasic action of 12 Sucking act " 2 Sucking centre 2 INDEX. 343 PAGE Sugar in milk 25 Sugars, groups of 22 Sulphur 29 Summer complaint, infant-feeding in 305 dietetic management of a bottle-fed baby 306 nursing infant 307 rectal alimentation in 306 Tamarind-water 315 Tapioca-cream 318 Tea 316 Teething 286 Toasted bread (dry) 318 Top-milk 128 Tubercular diseases in children, causes of 112 Tyndallization 167 Walker-Gordon laboratory-milk 231 Wampole's milk-food 196 composition of, when prepared 196 Wasting disease 290 Water in the feeding of infants 135 quantity of, to be given to infants 135 Water-ices 230 AVeaning . 75 and feeding from one year to fifteen months 81 Weighing to determine the quantity of milk an infant has taken 92 Wet-nurse 75 diet of 76 manner of living of 76 Wet-nursing 78 AMiite-celerv soup 320 Witch's miik 57 i SEr 39 ijii