to the right bronchial tubes. It is also for the same reason that this souffle may be heard over the interscapular space, in the superspinous, and even in some instances in the supra-clavicular fossa.

Less frequently, another physical sign is remarked, namely, a marked decrease in the respiratory murmur at the base of the right lung, due to a compression of the right bronchial tube by enlarged glands of the mediastinum.

The cervical adenites of scrofulous children are often accompanied by a tumefaction of the pharyngeal chain of glands. This condition has recently been considered as distinctly tubercular, but Neumann of Berlin, who has given this subject much attention, does not admit it.

A hyperplasia of the pharyngeal lymphatic chain which is generally met with in about one-third of cases of scrofulosis, and particularly in half of the cases of cervical adenitis is a distant symptom of scrofulosis, but which has its importance on account of its consequences.

Hypertrophy of the pharyngeal tonsil often exercises an unfavorable influence on the physical development, as well as the intellectual, of the child, and among other things produces an hypertrophic rhinitis, otitis, as well as malformations of the upper jaw and teeth. A very frequent anomaly of the teeth, which is quite frequent in scrofulosis, is a circular caries seated near the gum, occurring even in the first dentition. The same may be said of a greenish and very adherent deposit which is seen to appear on the permanent teeth.

As to the various cutaneous affections of an eczematous type, so frequent in children, and which is too often attributed to scrofulosis, it should be remembered that many of them are due either to parasites or to etiological factors having nothing in common with tuberculosis, as for example a seborrhoeic eczema, lichen ruber, eczema of the face, etc. On the other hand, there are other cutaneous lesions whose scrofulous nature cannot be denied, such as lupus, scrofulous lichen, tuberculous ulcers, etc.

Neumann distinguishes three periods in the evolution of scrofulosis. The first, which extends to the age of from three to four years, is especially characterized by the presence of scrofula dermies. During this period, Pott's disease, spina ventosa, tubercular meningitis and visceral tuberculosis occur.

In the second period, which covers the ages of from four to eight years, we have the florid scrofulosis and eczematous affections. In the third period, up to the age of fourteen, the gradual disappearance of the eczematous eruptions takes place.

The general symptoms of scrofulosis are weakness, loss of color, a continual little dry cough and headache. An equally important sign is fever, to which enough attention has not been given by most writers. According to Leichtenstern it is only met with when there is retention of pus or when there are serious lesions in the bone.

Now Neumann has been able to convince himself by observation that fever is generally present in simple scrofulous glands with hypertrophy of the tonsils and in such cases the temperature varies between 37°.8 and 38°.5 C.

When an examination of a patient does not reveal enough evidence to make a diagnosis of scrofulosis the latter may be sought for and be confirmed by the hereditary antecedents of the patient.

DEPARTMENT OF PEDIATRY.

CONDUCTED BY ROBERT W. HASTINGS, A.M., M.D.

ORIGINAL COMMUNICATIONS.

THE HYGIENE OF MILK AND ITS RELATION TO INFANT FEEDING.*

W. C. BENNETT, B.S., M.D.

It is my purpose in treating this subject to apply such general rules to a special subject as our knowledge of biochemistry will permit. Such treatment is partly speculative, it is true, but this is unavoidable.

The Composition of Human Milk.-One of the most striking peculiarities of human milk is the variability in the relative quantity of its constituents. It varies greatly in different women, and also in the same women at different times and under changing conditions. The amount of fat, at any rate, varies greatly, according as the milk is that which first flows from the breast or is from the nearly exhausted breast. The milk in the first instance will contain perhaps only 2.0 per cent of fat, while that in the latter case may contain 7.0 per cent or 8.0 per cent of fat. Consequently it makes the greatest difference from what part of the breast the milk is obtained, not only when taking a sample for analysis, but also to the child, because unless the breast is nursed entirely dry the child will not get that milk which is richest in fat. Moreover, the frequent complete emptying of the breast tends to produce milk richer in fat. So, if a woman produces a large amount of milk, poor in fat, the child may be deprived of sufficient fat, even when there is plenty of fat for it. Under the circumstances it

*Read before the Wisconsin State Medical Society, May, 1898.

would seem to be the proper thing to diminish the amount of fluids taken by the mother. This would diminish the actual amount of milk so that the child could get the final richer portion, and it would also increase the actual amount of fat. The converse also holds true, though probably not many nursing children receive an inordinate amount of fat.

The proteid matter of human milk amounts to about 2.0 per cent, and differs from the milk of other mammals (except that of the ass) in its methods of coagulation. The casein coagulates in fine flakes, whereas the casein of other animals coagulates in large chunks, and is therefore less easily digested.

In the delicate stomachs of some infants this fact must play an important part.

The lactose amounts to 5.0 or 6.0 per cent, and possesses no peculiarities in human milk.

The analysis of the ash shows calcium, potassium and phos phorus to be present in greater amount than the other elements. It contains a small amount of iron. Under most circumstances human milk is sterile.

Cows' Milk.-Cows' milk contains about the same amount of fat, nearly twice as much proteid and less lactose than human milk. The ash shows a higher percentage of calcium and phos phorus. The proteid coagulates in large chunks ordinarily, and as received and used is never sterile. Its reaction, as well as that of woman's milk is slightly alkaline. Milk from cows fed on distillery slops may contain alcohol. Cows' milk is said to contain resorcin, which acts as a natural germicide.

Milk of other Animals.-The milk of other animals varies greatly, but all (with the exception of asses milk) possess casein, which coagulates in large chunks.

The milk of no other animal possesses any quality which gives it any advantage over cow's milk in infant feeding.

This

Milk as a Food for Infants.-Water, constituting as it does so large a proportion of the body, forms a large part of the milk, and amounts in woman's milk to 700 or 800 c.c. a day. amount, however, is usually insufficient for the needs of the child, and therefore additional water should be given to it.

Proteid. The proteid of milk is of two kinds, (1) caseinogen, a nucleo-albumen, and (2) lact-albumen. The first constitutes nearly the whole of the proteid content of human and cow's milk,

and is of great importance. The action of the rennet ferment converts caseinogen into casein, a coagulated proteid, and this is acted on by the pepsin and hydrochloric acid in the stomach and converted into peptone, the diffusable proteid.

Caseinogen, being a nucleo-albumen, contains a large amount of phosphorus. The importance of this fact will be seen when we remember that bone and teeth consist mainly of phosphates, and that in infants the bone-forming process is most active. The absolute necessity for the presence of phosphorus is emphasized by the fact that eggs, the food of all vertebrates except the mammalia also contain a large amount of phosphorus. It is probable that though phosphorus may be assimilated as an inorganic salt, it is more easily handled, and nature evidently intended that by the young it should be handled, in organic combination.

Fat.-The fat in milk is one of the most variable constituents and serves the same purpose that fat usually serves as food. Being a natural emulsion, it is probably in the condition in which it is most easily absorbed. Milk fat also contains a small amount of lecithin, a phosphorized fat. In the egg, lecithin constitutes the chief source of phosphorus. Excess of fat may produce diarrhoea and too small an amount of fat, of course, partial starvation.

Lactose or milk sugar represents the sole carbohydrate in milk. Cane sugar or starch are not present.

The function of the fat and lactose is to prevent waste of proteid. Their oxidation produces the heat requisite to maintain the body temperature. It goes without saying that a good supply of fresh air is essential. It must not be forgotten that oxygen is a proximate principle, without which food would be useless.

Foremost among the salts in milk is calcium phosphate; foremost in quantity and in importance. It is an absolute essential in new tissues, since growth cannot take place without it. It seems to have an effect similar to the catalytic effect of enzymes. Its presence is necessary to the instituting of growth. Moreover its important rôle in the formation of the skeleton of the child makes its presence in food imperative. When it is withheld, or under certain abnormal conditions of metabolism, calcium phosphate is not deposited in the bones and teeth, rickets is produced. Normal bone contains from 50 to 60 per cent of calcium phosphate, while a rickety bone may contain only 30 per cent.

A condition somewhat similar to rickets is infantile scurvy,