A system of practical medicine. By American authors. Vol. 2

by Unknown

It is a common error to expect too much of a new remedy which has a real value, and we must not expect that all patients not in an utterly hopeless state will begin to improve as soon as peptonized milk is prepared for them, or that it is a full and exact substitute for human milk, so that wet-nurses may be dispensed with. Healthy human milk is the best of all food for infants under the age of twelve months, and should always be preferred when it can be obtained, but we claim that peptonized milk is a most useful addition to the dietetic preparations for infants, probably surpassing in value the best of those in the shops. We employ it in the belief that it affords important aid in curing the dyspeptic and diarrhoeal maladies of infancy. Who first formulated and recommended the process of peptonizing milk I am not able to state, but I am informed that Roberts of Great Britain called attention to it as a means of improving milk at a time antedating the German conference.

Milk from healthy, properly-fed cows may be prepared without peptonizing, so as to agree with many infants except in the warmest weather, but is obviously less easily digested than peptonized milk. It should be diluted as follows with water boiled so as to free it from germs: In the first week after birth one-fourth milk with the addition of a little sugar. The milk should be gradually increased, so that it is one-third by the end of the fourth week, one-half by the end of the third month, and two-thirds to three-fourths by the end of the sixth month. After the sixth month it is still proper to add one-fourth water, but pure milk may be given. Water increases the urination.

Before peptonizing—which, as we have seen, digests the casein to a great extent, and changes that which is not digested so that it coagulates in flakes in the stomach like breast-milk—was resorted to, it was customary to use a thin barley- or oat-water in place of the water used for diluting the milk. One heaped teaspoonful of barley flour to two tablespoonfuls of water make a gruel of proper consistence. A little farinaceous substance added to the milk by mechanically separating the particles of casein tends to prevent their coagulation in large and firm masses. This was the theory which explained the beneficial action of the admixture. If for any reason peptonized milk be not employed, milk prepared in the way I have mentioned, by admixture with a farinaceous substance, is probably the next best substitute for human milk.

It is very important to determine when and how farinaceous foods shall be given in this disease. It is well known that infants under the age of three months digest starch with difficulty and only in small quantity, since the salivary and pancreatic glands which secrete the ferments which digest starch are almost rudimentary at that age. The artificial digestion of starch is, however, easily accomplished. Among the last labors of the renowned chemist Baron Liebig was the preparation of a food for infants in which the starch is digested and transformed into grape-sugar, and thus infants at any age who are fed with it are relieved of the burden of digesting it. The baron led the way which has been so successfully followed since in the artificial digestion of foods. A considerable part of the starch in wheat flour is converted into grape-sugar by the prolonged action of heat. I frequently recommend that from three to five pounds of wheat flour be packed dry in a firm muslin bag, so as to form a ball, and be placed in water sufficient to cover it constantly and the bag kept over the fire three or four days. During the nights the fire may go out for a few hours. At the expiration of this time the external part, which is wet, being peeled off, the remainder resembles a lump of yellowish chalk. The flour grated from it gives a decided reaction of sugar by Fehling's test. Starch is also quickly transformed into glucose by the action of the diastase of malt, which indeed Liebig employed. If to a gruel of barley flour, oatmeal, or other farinaceous substance, when hot, a little of a good preparation of extract of malt, such as that prepared by Trommer & Co. at Fremont, Ohio, which acts promptly, or by Reed & Carnrick, be added, it becomes thinner. It is claimed that the starch is thus quickly converted into glucose; which seems doubtful. It is, however, so modified that it is apparently more readily digested and assimilated. Farinaceous substances thus prepared may be employed with peptonized or other milk. Infants frequently do better with this admixture than when either the milk or gruel is used separately.

Of the foods contained in the shops which have been most prescribed, and which have apparently been useful in certain cases, I may mention those which have been prepared according to Liebig's formula, of which there are several, the analyses of which I have given, and Nestle's farina. In the use of those foods which contain no milk, as Ridge's food, Imperial granum, etc., it is recommended that milk be added, while for such as contain condensed milk, as Nestle's and the Anglo-Swiss food, only water should be employed. The Anglo-Swiss food contains about 60 per cent. condensed milk and about 20 per cent. each of oatmeal and Russian wheat flour. It gives an acid reaction, unlike Nestle's, which is alkaline. When Biedert's cream conserve was announced great expectations were awakened from the fact that the inventor is an authority in pædiatrics, but, unfortunately, they have not been realized in this country. Much of Biedert's conserve when it reaches us is spoiled, and the directions for its use are too complicated for ordinary family use, since a different mixture is required for each month of the infant's age. I have employed this food, but, with Henoch, "could not convince myself that it is more efficacious than cow's milk." I am informed that the sale of it in this country has ceased.

Condensed milk is largely used in the feeding of infants. The milk is condensed in vacuo to one-third or one-fifth its volume, heated to 100° C. (212° F.) to kill any fungus which it contains, and 38 to 40 per cent. of cane-sugar is added to preserve it. In the first month one part of milk should be added to sixteen of water, and the proportion of water should be gradually reduced as the infant becomes older. The large amount of sugar which condensed milk, preserved in cans, contains renders it unsuitable in the dietetic rôle of the summer diarrhoea of infants. The sugar is apt to produce acid fermentation and diarrhoea in hot weather. Borden's condensed milk, freshly prepared, as dispensed from the wagons, contains, I am informed by the agent, no cane-sugar or other foreign substance, and on this account is to be preferred to that in the cans. It is cow's milk of good quality, from which 75 to 79 per cent. of the water has been removed under vacuum. The sole advantage which it possesses—and it is an important one—is that it resists fermentation longer than the ordinary milk.

To select the best food for the infant from this considerable number of dietetic preparations is one of the most important duties of the physician. If called to an infant unfortunately deprived of wholesome breast-milk, and suffering in consequence from indigestion and diarrhoea, what diet shall we recommend? My recommendation would be as follows: Use cow's milk of the best possible quality and peptonized in the manner stated above, and peptonized in small quantity at a time, such as a pint, or, better, half a pint. This may be the sole food till the age of five or six months. Unfortunately, in the cities the milk that is delivered in the morning is the milking of the preceding evening, mixed with that of the preceding morning, brought often many miles from the farms where it is produced. Milk twelve and twenty-four hours old, notwithstanding the use of ice around the milk-cans, is apt to undergo some fermentative change before it reaches the nursery. This prevents the preparation of the best quality of peptonized milk, so that in some instances during the heated term I have found that the peptonized milk did not agree as well as the condensed milks, like Borden's or Nestle's food. Not a few infants suffering from diarrhoeal maladies seem to do better if some farinaceous food properly prepared be added to the peptonized milk than when the milk is used alone. It is better, I think, that the starch, or a considerable part of the starch, be converted into glucose before the admixture. This can be done if a few pounds of wheat flour be pressed dry in a bag, so as to form a ball, and boiled three or four days, as I have elsewhere recommended. The flour grated from the mass gives a decided sugar reaction to Fehling's test. For infants under the age of six months one tablespoonful of the flour thus prepared should be mixed with twelve tablespoonfuls of water and boiled. When it has been removed from the fire and become tepid, a small quantity of a good extract of malt, as Trommer's or Reed & Carnrick's, may advantageously be added to the gruel to increase the transformation of starch and render it more digestible. To avoid the time and trouble of preparing the food in this manner, one of the foods contained in the shops, in which the starch has been transformed into glucose by the employment of Baron Liebig's formula, may be used, as Mellin's or Horlick's, instead of the wheat flour prepared by long boiling. The older the child, the thicker should be the gruel.

Beef-, mutton-, or chicken-tea should not be employed, at least as it is ordinarily made, since it is too laxative. Occasionally, for the older infants, we may allow the expressed juice of beef, raw scraped beef, or beef-tea prepared by adding half a pound of lean beef, finely minced, to one pint of cold water, and after allowing it to stand for half an hour warming it to a temperature not exceeding 110° for another half hour. By this process the albumen is preserved. Salt should be added to it, and I am in the habit of adding to it also about seven drops of dilute muriatic acid to facilitate its digestion. It is chiefly for infants over the age of ten months that the meat-juices are proper. A concentrated nutriment, prepared, it is stated, from beef, mutton, and fruits, has lately been introduced in the shops under the name Murdoch's Liquid Food. Young infants with dyspeptic and diarrhoeal symptoms can take it, and it appears to be readily assimilated, as the quantity given at each feeding is small. It has its advocates, and it appears to be of some service in cases of weak and irritable stomach.

But since one of the two important factors in producing the summer diarrhoea of infants is foul air, it is obvious that measures should be employed to render the atmosphere in which the infant lives as free as possible from noxious effluvia. Cleanliness of the person, of the bedding, and of the house in which the patient resides, the prompt removal of all refuse animal or vegetable matter, whether within or around the premises, and allowing the infant to remain a considerable part of the day in shaded localities where the air is pure, as in the parks or suburbs of the city, are important measures. In New York great benefit has resulted from the floating hospital which every second day during the heated term carries a thousand sick children from the stifling air of the tenement-houses down the bay and out to the fresh air of the ocean.

But it is difficult to obtain an atmosphere that is entirely pure in a large city with its many sources of insalubrity; and all physicians of experience agree in the propriety of sending infants affected with the summer diarrhoea to localities in the country which are free from malaria and sparsely inhabited, in order that they may obtain the benefits of a purer air. Many are the instances each summer in New York City of infants removed to the country with intestinal inflammation, with features haggard and shrunken, with limbs shrivelled and the skin lying in folds, too weak to raise, or at least hold, their heads from the pillow, vomiting nearly all the nutriment taken, stools frequent and thin, resulting in great part from molecular disintegration of the tissues—presenting, indeed, an appearance seldom observed in any other disease except in the last stages of phthisis—and returning in late autumn with the cheerfulness, vigor, and rotundity of health. The localities usually preferred by the physicians of this city are the elevated portions of New Jersey and Northern Pennsylvania, the Highlands of the Hudson, the central and northern parts of New York State, and Northern New England. Taken to a salubrious locality and properly fed, the infant soon begins to improve if the disease be still recent, unless it be exceptionally severe. If the disease have continued several weeks at the time of the removal, little benefit may be observed from the country residence until two or more weeks have elapsed.