J. FINLEY BELL, M. D.,

East Hampton, L. I.

In no branch of medicine or surgery has there been expended more patient laboratory work, research, and clinical observation than in Pediatrics; and in Pediatrics, no subject has been productive of a greater effort or a more voluminous literature during late years than the study of nutrition and its disorders. This has been rendered imperative by the constantly increasing number of infants nourished by artificial means. On the one hand we have the results of patient laboratory work from a purely scientific standpoint; on the other, the almost limitless array of proprietary foods in which commercialism holds more or less complete sway.

This is not surprising when we consider the immense importance of a proper artificial diet, the dire consequences of an improper one, and the complexity which is involved in the production of a proper food as adapted to individual cases. It must be noted that this work has been done by the comparatively few, by far the larger quota of the profession standing by, showing scarcely interest enough to be regarded as awaiting results. The reasons for this attitude on the part of the majority are manifold; but the chief ones are, first, the inaptitude of many otherwise thorough and competent men for Pediatric practice; and second, the ever-ready refuge offered by proprietary foods and canned milks, to which they rush, first trying one and then another, until by good fortune a suitable dilution or a partial adjustment of the elements has been unconsciously found on which the child can live and perhaps thrive. Very frequently this good fortune does not obtain. While one food rapidly replaces another in the most aimless and empirical way the child perishes; whereas, a competent observance of the cause of the malnutrition by an inquiring and painstaking investigation, together with a thorough knowledge of the methods of modification in its pres*Read before the Associated Physicians of Long Island, at Southport, June 16, 1900.

ent state of perfection, would save valuable time and thereby many lives.

In order to be successful in the artificial feeding of infants it is necessary to be thoroughly acquainted with the anatomy and physiology of the infantile digestive system under normal conditions-the capacity of the stomach, the length of time required for digestion, the manner in which the various elements of the food are disposed of all are necessary to a complete understanding of infantile dietetics. We must have a thorough chemical and physical knowledge of the substitute food, the amount and character of the different elements, and a rational method of arranging and combining them, so that the natural food will be approximated. This constitutes the modern modification of milk and marks the first real advance in infantile dietetics.

The first modified milk mixtures were those of Meigs, whose modification was based approximately on analysis of mother's milk, viz.: Fat 4.00 per cent. Sugar 7.00 per cent. Proteid 1.5 per cent.

Ash .15 per cent. (analysis by Leeds). This was recommended to be diluted in case it disagreed with the child. But this was faulty, in that the individual digestive powers of the infant were not considered, or the variability of the different constituents of cow's milk taken into consideration. The proprietary foods hold out the inducement that they are already modified to suit the needs of the infant. No doubt they are carefully prepared and are the result of much well-directed study. However, almost all of them contain starch or carbo-hydrates in excess, and as the saliva and pancreatic juice cannot digest starches before the fifth or sixth month, their continued administration will eventually cause intestinal fermentation. Some of these foods serve a useful purpose in making mixtures of partially dextrinized starch and modified milk, which, under certain conditions, are admissible and even advisable. The dextrinized foods intended to be used without milk, in the hands of the writer, have always been disappointing. Some of them claim an analysis closely approximating mother's milk, such for instance as Eskay's Albuminized Food, the formula of which is said to be:

Total Solids 11.33 per cent.

They succeeded for a time in a limited number of cases, but if continued for several months, malnutrition more or less severe will almost certainly ensue.

Condensed milk is perhaps the most universally popular article of substitute food, and is by all odds the most pernicious. It is responsible for more malnutrition, gastro-enteritis, rhachitis and infantile anæmia than all other articles combined. Holt states that after six years of critical observation he has yet to see an infant, fed solely on canned or condensed milk, who did not exhibit the signs of rhachitis to a greater or less degree. They may on casual examination seem like healthy infants, for they are frequently fat. However, a careful inspection will disclose a rhachitic rosary, delayed and irregular dentition, frontal prominences, lustreless hair, dry skin; and in one case, a very fat baby which came under the writer's notice, craniotabes was present to a marked degree. It should be noted that infants fatted on foods rich in carbo-hydrates, lose their fat rapidly and have little resistance during acute illnesses.

The analysis of condensed milk, containing sugar (by Leeds) gives:

12.10 per cent.

Albumenoids 16.7 per cent.

Fat

a total solid of 8.7 per cent., water 91.31 per cent. As compared with mother's milk as analyzed by the same chemist (Leeds), the above will show a deficiency of fat of 2.49 per cent., an excess of proteid of .51 per cent., and a deficiency of sugar of 2.14 per cent. If less water is used, the proteids, which are high with this dilution of one to eight, will be further increased, and the result is the passage of stools containing lumps of undigested casein. The Anglo-Swiss and the American-Swiss brands. of canned milks, preserved without sugar, and with any rational dilution, will give deficient fats, excessive proteids, and deficient sugar.

Therefore, condensed milk, let it be ever so pure and carefully prepared, is not a suitable substitute for infant feeding. To meet the in

dications rationally, we must select some substitute which contains all the elements of mother's milk and is susceptible of such modification as will suit the needs and digestibility of the infant, taking human-breast milk as a standard. It has been found that cow's milk furnishes the elements in a form available for such modification as is required.

To properly modify milk for infant feeding, it is well to bear in mind that these elements differ, not only in their proportions as compared with mother's milk, but the elements themselves differ both chemically and physically. The reaction of cow's milk is either neutral or faintly acid, and mother's milk always alkaline. The degree of acidity of the cow's milk varies with the kind of food which she is receiving, some of the grasses producing a neutral or even an alkaline milk, notably the blue grass of Kentucky, the grasses indigenous to the islands of the St. Lawrence River and Lake Ontario, and most of the clovers. The fat of cow's milk is in larger globules and more difficult of digestion and has a higher refractive index. The proteids differ in coagulability and digestibility as well as chemically. This chemical difference is not well understood, but Siegfried and Wilmaack have found a diminution of neuclein in cow'smilk; human milk containing 1 to 1.3 per cent.. grams to the liter, while cow's milk contains only .6 per cent. grams to the liter.

If the composition of mother's milk is to be a guide in artificial feeding, a grave error has been committed in the administration of proteids. The Adriances, in an examination of two hundred specimens of human breast milk, show that the proteids constantly diminish during lactation, diminishing very rapidly during the first two days, not so rapidly during the next twenty days, and then very slowly to the end of lactation. The rule has been to begin with low proteids, say .75 per cent. during the first week, and increase gradually to about 2.25 per cent. at the sixth month. It is very probable that infants during the course of their lactation would assimilate more of the proteids from cow's milk with a closer observance of the diminution of proteids as noted in human lactation. This condition was noted by Pheiffer, Konig, Klemm and others. Holt mentions it on the authority of Konig, but ignores it in his modifications of cow's milk to infant feeding. This point has been plainly noted by Zahorsky in his article "A Critical Study of Infant Feeding Based on Recent Analyses of Human Milk," published in Pediat

rics, Volume V., 1898. He quotes Schlossman in support of this view, that babies, from four to eight months on high proteids, show an increased mortality. This is at a period in the child's life when, according to the "gradually increasing method," the lines cross, the proteids becoming excessive at a time when they should be diminishing.

During last season the writer had occasion. to test this theory clinically in two cases, and found that they rapidly improved after cutting the proteid from 1.5 per cent. to .75 per cent., then gradually working up to 1 per cent. and finally to 1.25 per cent., when the return of casein curds in the stools necessitated a reduction to I per cent., on which they thrived until weaning. The fact is, that after a serious gastro-intestinal lesion, perhaps caused by an excess of proteid, it will be months before the same amount of proteid can be tolerated, as if the lesion had not occurred. When proteids are not well borne by the infant and it becomes necessary to reduce the percentage very low, they will sometimes thrive on whey mixtures. Whey has the composition, according to Konig:

Proteid .86 per cent.

Fat Sugar

.32 per cent. 5.00 per cent.

Salts .65 per cent.

the proteids consisting largely of lacto-globulin and lactalbumin.

Now the carbo-hydrates also differ chemically and physically. In human milk there are probably two sugars, a crystalline and an amorphous. Zahorsky notes that sugar from human milk crystallizes in rhomboid plates and sugar in cow's milk in wedge-shaped plates. In human milk the carbo-hydrates constantly increase during lactation, and this should be noted in modification of cow's milk.

The above are some of the inherent difficulties found in the adaptation of cow's milk to infant feeding, which are in part compensated by proper modification, so much so, that every infant free from congenital weakness or disease, can be made to thrive, if the indications governing the modification are complied with. From observation it seems that the proprietary foods are used as extensively or even more extensively in the country districts than in the cities, and condensed milk of various brands is very popular with the laity and receives considerable support from the profession. This is a condition which, in the light of the results obtained by our city brethren in modification of cow's milk, shows a decided lack of

interest on the part of the country practitioner; and these results too obtained under all the adverse conditions consequent on a lack of supervision in the production and transportation, during which time it is liable to contamination from various sources. The city doctor has given us data and methods for modification, and it now behooves the country doctor to use his influence and advantage toward the reversal of the more or less filthy methods employed in most dairies at the present time.

Holt and Rotch in their text-books give excellent methods for modification, but recently exact formulæ have been derived, giving more accurate results.

There have been a number of formulæ published for the modification of milk for infant feeding. Westcott's formulæ I believe first appeared, then Coit's Decimal System, then Baner's formulæ, and later Taylor's. Of these formulæ, Baner's is the simplest and most popular. It is founded on two propositions: first, the proteids and fat are practically equal in whole milk, being about 4 per cent. of each; and second, the cream must be thought of as a whole milk plus a certain percentage of fat. According to Baner's formulæ, to estimate the quantity of cream required in a certain mixture: divide the total quantity by the extra fat and multiply by the difference between the desired percentage of fat and the desired percentage of proteids. To estimate the quantity of milk: multiply the total quantity by the desired percentage of proteids and divide by the percentage of fats. To estimate the quantity of water: subtract from the total quantity the sum of the cream and milk.

Coit's decimal method is simpler arithmetic, but requires a number of standard cream mixtures, which will be difficult to obtain, besides the metric system is not well understood by the laity. Taylor's Formulæ were suggested to meet a short-coming in Baner's method. Given a milk over-rich in fat, for instance, 8 per cent., the modification by Baner's formulæ would give far too much fat. However, milk over-rich in fat will not be suitable to infant feeding, because, not being a well-balanced milk, it will probably have other inherent shortcomings.

The most serious problem confronting the pediatrist to-day is the universal difficulty of securing a pure cow's milk for suitable modification. Even before it leaves the milk duct of the cow it is liable to contamination, and this liability increases with every manipulation until it is prepared and fed to the infant.

This brings us to a consideration of certified milk, which is the second part of the paper. The first efforts in this direction were made in the city of Newark seven years ago, and were the result of an agitation begun in 1889 by Dr. Coit, a leading pediatrist of that city. He brought the matter to the attention of the Practitioners' Club of Newark, and it resulted in the appointment of a committee to secure a better milk supply. After considerable effort a dairyman of superior intelligence was found who was willing to attempt the experiment. A veterinarian, a chemist, and a bacteriologist were appointed, and, after certain exactions were satisfied, the milk received the certificate of this committee. Several producers, as soon as the experiment promised success, attempted to imitate the methods of this dairy, but their results fell far short of the standard, thus exemplifying the necessity for intelligent and trained supervision.

Soon after, a committee of physicians in the city of Buffalo, following closely the methods of Dr. Coit, furnished a certified milk. They had entire supervision of the dairy, including the feeding and caring of the herd, the straining, aerating, cooling and bottling of the milk. The committee required a percentage of fats of 4.5 per cent., and the number of bacteria to be below ten thousand per cubic centimeter. In the milk ordinarily supplied to the city there were from 125,600 to 1,000,000 bacteria per cubic centimeter. The next city to adopt a method for certified milk was Rochester, which was done under the supervision of the Board of Health. This Board contracted with one of the most reliable dairymen to furnish them a milk for the season of a certain standard of fat and a bacteria limit. The product soon became unsatisfactory, when an inspection of the dairy revealed an almost absolute return to the careless methods obtaining in most dairies. A contract was then made with another dairyman, noted for his intelligence and honor; but this too proved a failure. They finally concluded that the only sure method to obtain a good milk for infant feeding was to rent the cows, barn and pasture for the season, and produce their own milk.

It is obvious, therefore, that there is something radically wrong in the methods heretofore pursued for the production of a suitable milk for infant feeding. A reform of this kind. should begin, first with the cow, then the dairy man, and next the distributor. It should be determined that the cows are healthy, preferably the native Holstein breeds; they should

be well fed on nutritive grasses in the summer with a grain ration of at least ten pounds per day, and in the winter on good hay, meal and sugar beets. The writer finds that milk from cows fed on green corn during the autumn almost universally produces a diarrhea in infants, and that the cows themselves while on this food have diarrhea, and after feeding for several weeks they expel large quantities of mucus, the bacterial flora of which will prove a wonder to the examiner. In order to determine the changes produced in milk from cows on this diet, I communicated with Professor Vaughan of Ann Arbor, who replied that he was not aware of any such condition of the milk produced by this food, that he could readily see how the bacterial flora of the intestinal canal of the animal might be changed, and he believed that the diarrheas were produced by the excrement of the cow getting into the milk. Dr. A. W. Kratzsch, in an article on "Infant Feeding," in Pediatrics, Volume VII., 1899, has had the same experience as the writer.

The cows should be tested for tuberculosis at least twice a year, and those responding to the test should be destroyed at once. Ninetyeight per cent. of cows responding to this test will present post mortem evidences of tuberculosis. The other two per cent. may be cases of such recent infection that post mortem evidences are not perceptible. Even if this small percentage were not infected, it would be obviously unwise to attempt to save any of the number responding to the test. Dr. Jacobi believes that two out of every hundred cows will be found tuberculous. This percentage on Long Island, where the breeds of cows susceptible to this disease predominate (viz.: Jersey and Guernsey), is evidently too high. They should be examined daily for excoriations of the teats and udder, and also for suppurative conditions in the udder. Garget is much more prevalent than is generally supposed. It is frequently overlooked by the milker or its importance not recognized. Woodward, of Philadelphia, reports a case of a woman who became very ill after drinking milk which was supplied by her dairyman. An examination of this milk showed that pus and streptococci were present in large numbers. Up to the present time no streptococcus toxine has been found; however, the very alarming symptoms produced by their ingestion would indicate the existence of one.

Garget is frequently caused by abrasion of the teats, the infectious matter finding its way