Medicine. IN CHARGE OF J. J. CASSIDY, M.D., W. J. WILSON, M.D., MILK AND INFANT FEEDING. THE Hygienic Laboratory of the Public Health and Marine Hospital Service of the United States have issued a bulletin (No. 41), of 750 pages, on "Milk and its Relation to the Public Health." This must be considered the most authoritative work to-day on the conveyance of disease through milk, on the chemistry and bacteriology of milk and ice cream, their contaminations, the question of sanitary inspection and pasteurization, while the subject of infant feeding presents much which does not appear in our text-books. The various and often complicated methods of modifying cow's milk for infant feeding have meant so much in time and trouble that we read with much relief the statement," Undiluted cow's milk can be given from the beginning of the first month on, provided its content of fat does not exceed 3 to 3.5 per cent., nor the daily quantity greater than 150 c.c. per kilogram of body weight." Maternal nursing is fully considered, but the article on artificial feeding is most interesting, leading up gradually to the above statement. The great objection to cow's milk has been the belief that the proteids are very difficult of digestion, and to overcome this supposed difficulty, the various modifications have been suggested, the addition of alkalies and diluents, split-proteids, and other methods to lessen the percentage of proteids. The work of Heubner, Keller and Czerny, which has been confirmed, shows that cow's milk proteid is almost as easily digestible per se by infants as are the proteids of woman's milk. On the other hand, these workers have shown that the element in cow's milk which causes digestive disturbance is the fat and not the proteid, for they state that the apparent curds found in the stools following gastro-intestinal disturbances in bottle-fed infants, and which have been taken for curds without further investigation, are for the most part saponified fat, neutral fat, and fatty acids, interspersed in severe cases with clumps of bacteria. If infants are fed on fat free milk, although the milk be undiluted and containing 3.50 per cent. of bovine proteid (woman's, 1.50), no trace of casein appears microscopically in the stools. It has been found that an energy quotient of 70 is the minimum on which a child of less than one year of age could maintain its weight, while a quotient of 100 calories per kilo of body weight marks the upper limit which can only be temporarily surpassed without inducing disastrous nutritive and gastro-intestinal disturbances. One gram of fat produces 9.3 calories, and one gram of proteid and one gram of carbohydrate have each a caloric value of 4.1. Thus it is impossible by inadvertence with carbohydrate or proteid alone to get an energy quotient of a dangerous height without producing a food which either, from its state of concentration, or by reason of its bulk, would be manifestly impossible to feed to any infant. On the other hand, slight increases of 1 or 2 per cent. in the fat content of a food containing normally 3.00 to 4.00 per cent. may have the effect of raising its caloric value to a dangerous extent. An excess of fatty food is not absorbed but remains in the intestine and is there saponified. In this way an excessive. abstraction of the alkaline bases of the body takes place, causing nutritional disturbances. It would seem that a milk which contains 4 per cent. butter fat were too rich and that a fat content of 3 to 3.5 per cent. would be better for infant feeding. Dairymen tell us that calves do best on this. Rich milk, i.e., rich in fat, for with increase of fat there is no corresponding increase in salts present, is a result of careful breeding and not a condition original to the milk of the cow. A second effect of excessive fat lies in its behavior, that, when casein is curded in the stomach by rennet, a large per cent. of the butter fat present is carried down with the casein. This action of fat in making curds large and indigestible by reason of their excessive fat content, has long been known to dairymen, as they are well aware of the fact that Jersey cows often can not nurse their calves by reason of the excessive richness of their milk. In the case of the human infant, if the milk be too rich it is vomited. If is just rich enough to produce a curd with a fat content larger than it should have, peristalsis is checked and the stomach discharges its contents slowly to permit the gastric juices to act. The next meal finds the stomach with a residue from the one previons, this vicious cycle keeping up, fermentative changes take place, with resultant troubles. There is a full consideration of the percentage system of feeding and a discussion of some well known tables, but this system is found to be based upon conclusions that are incomplete. The whole question of artificial feeding of infants may be reduced from a condition of extreme complexity to a relatively simple and scientific basis. To settle any doubt as to the digestibility of whole cow's milk in the stomach of infants, reference is made to the observations of a number of continental clinicians, who have fed infants from the earliest days of life on whole cow's milk, in proportion to their needs, without observing anything but the happiest results. In feeding cow's milk undiluted, our practice must be controlled by this circumstance; abroad, owing to different methods of feeding and different grades of cattle, milk containing over 3.75 per cent. of butter fat is rarely found, and the average is probably not over 3 to 3.50 per cent. in most cases. Here, a milk is poor in butter fat which does not average 4 per cent., while selected milk and certified grades are often nearer 4.50 or 4.75 per cent. Consequently, though undiluted cow's milk may be used satisfactorily in France and Germany, it cannot be advised in this country unless its fat content is known to be below 3.50 per cent. This condition can be secured either by using milk from Holstein cattle, which is normally no richer than this, or by removing appropriate amounts of top milk from bottled milk after the cream has risen and thoroughly mixing the remainder. GENERAL DIRECTIONS FOR THE ARTIFICIAL FEEDING OF INFANTS. For children one month old or over. First, weigh the child; allow a daily quantity of cow's milk of one-seventh body weight for infants up to three months of age, one-eighth the body weight from 3 to 6 months, and after that from one-ninth to one-tenth. Quality of milk to be used.-Use nothing but clean, fresh bottled milk, "certified," if possible, or from a high-grade dairy, making sure that fat content is not over 3.50 per cent. If it is greater than this it must be reduced by dipping the cream from top of bottle as per this table. Table showing quantities of top milk that must be removed from top of quart bottles of milk in order to reduce the percentage of fat to 3.50 per cent: Mix the milk thoroughly by pouring into another vessel and measure out the amount of the daily supply requisite, as indicated by the age and weight of the child; e.g., for child one month. old, weight, 9 lbs., 1-7 body weight=19 oz., daily quantity of milk 19 ounces. Divide the quantity so obtained equally into nursing bottles, corresponding in number to the number of daily feedings. Sterilization of all milk is advocated for infants under three months, after that pasteurization until the eighth or ninth month, when raw milk may be used, provided weather be cool and milk reliable. There have been two objections to the use of sterilized milk. First, on account of supposedly greater difficulty in digestion, and second, because of danger of producing infantile scurvy. Careful investigations of the digestive absorption of the constituents of heated milk have shown evidence of a considerably greater degree of completeness in such absorption than is the case in unheated milk. And, too, the French clinicians bring forth almost conclusive evidence of the superiority of both sterilized and pasteurized milk over raw cow's milk in this respect. The second objection, that of causing infantile scurvy, appears to reside in qualities inherent in the milk used, and is not attributable to the sterilization. This scurvy also occurs in breastfed infants. Should a prophylactic be desired, all danger may be averted by the administration two to three times a day of onehalf to one ounce of orange juice one hour before feeding. For infants under one month of age. In the early period of lactation woman's milk shows more proteid and less sugar and fat than at subsequent times. We can, therefore, more easily imitate the provisions of nature by feeding skimmed milk to infants during the first month of life. Walls has found that sterilized undiluted skimmed milk is entirely digestible even by premature infants. Skimmed milk is obtained either as centrifugally skimmed milk from the dairy, or by siphoning off the under half of a quart bottle whose cream has risen. After the end of the first week, one-third whole milk and two-thirds skimmed milk can be given; after the end of the second, one-half whole milk and one-half skimmed milk; at end of the third week, three-quarters whole milk and one-quarter skimmed milk, passing to whole milk at end of fourth. Feeding of older infants.-The seventh month marks the time when it is desirable to supplement exclusive milk feeding by some other food. This should take the form of some cereal broth, such as oatmeal jelly, barley water, or dextrinized gruel, and should be added to the milk in proportion of one-third broth to twothirds milk. While, as a rule, it may be postulated that no infant is born with a digestion congenitally weak, still, as the result of inadequate feeding, either maternal or artificial, we do encounter infants whose digestive processes are a law unto themselves. Such cases must be attacked along individual lines. Fat-free buttermilk, or equal parts of buttermilk and malted cereal broths, are in many instances digestible with apparent satisfaction by such infants. Skimmed milk, closely resembling buttermilk in composition, is also recommended. When tolerance for cows milk in this form is established, it must be supplanted by a gradual return to whole cow's milk, as both buttermilk and skimmed milk are too poor innutritive elements to furnish the basis for any long-continued scheme of artificial feeding. Atrophic infants, of course, require a greater energy quotient than the normal child of the same weight. In such cases the food given may be increased above the normal, both in quantity and caloric value, taking care that in providing such excess the digestion be not embarrassed. It is important in artificial feeding to remember that cow's milk, when compared with human milk, is essentially an alien food, its fats and proteids are different in composition from those of human milk, and must of necessity be regarded as substances foreign to the human infantile digestive tract. As a consequence, greater energy is required for its digestion and assimilation, hence we should spare the infant metabolism any further strain which might be due to the conversion of a milk impaired by fermentative charges due to its improper preparation and preservation as a food. While we can never hope to vie with maternal nursing, a careful study and application of the principles expounded in this bulletin should go far toward eliminating the excessive complexity and uncertainty which have hitherto characterized the whole subject of infant feeding and, in the main, be productive of better results than we can obtain by other methods. ACCIDENTS IN THORACENTESIS. DR. W. F. HAMILTON, in the Montreal Medical Journal, November 1907, relates four cases of accidents in thoracentesis. In the first, after the withdrawal of fifty ounces of fluid, cyanosis and troublesome cough set in, with expectoration of albuminous fluid. Under stimulation he recovered. In the other three, exploratory puncture was made for diagnosis, serous or purulent effusion being suspected. In one pneumothorax developed from puncture of lung. Good recovery. In another exploratory puncture was made in eighth interspace in the posterior axillary line. Alarming dyspnea and collapse followed, with spitting of blood, face ashen, involuntary urine and feces, pulse 147 and weak. The right lung, hitherto clear, filled with moist rales. Using stimulants (heat, brandy, etc.), patient recovered, and right lung cleared in four hours. In the last, puncture was made in anterior axillary line, between fourth and fifth ribs, the needle pointing upwards. On withdrawal, the head was drawn back, and all the body became rigid, splinietus of bladder relaxed, face cyanosed, skin elsewhere mottled, pulse absent, respiration suspended. Artificial respiration was adopted and strychnia given; rigidity persisted twenty minutes, when some clonic spasms appeared, skin gradually became dusky and pallid; consciousness returned in one hour. There was some vomiting later. |