On the Mortality of Infants in Foundling Institutions, and Generally, as Influenced by the Absence of Breast-Milk

C. H. F. Routh
1858 BMJ (Clinical Research Edition)  
Physician to the Samaritan Free Hospital. for Women and Children ; late Physician to the St. Pancras Royal Dispensary; etc. PART III. [Coueluded fron page 311.] C)-reart as a Substitute. I have before said (p. 145) that there are some cases in which no wet nurse can be, found to suit a child and in these cases, moreover, milk in its several forms may be tried, but the efforts to bring up that child upon milk will fail altogether. In many of these cases, it is observed that there is a great
more » ... ere is a great quantity of acid produced upon the stomach of the child, and the same effect results when that child takes saccharine matters. It is in such instances that the mixture of one part of cream to three of water proves often very beneficial. I have known a child reduced almost to a state of complete atrophy, gradually recover its good looks and strength on this change of diet. Cream in composition contains pretty nearly the same ingredients as milk, except that the casein is diminished, and the fatty matters considerably increased. In this manner, the absence of sugar is compensated for by the excess of fatty matters; and thus the fluid produced is sufficiently rich both as a nutritive and as a calorifient aliment. Tile addition of water diminishes the density, and makes the mixture more digestible. If to every half-pint of this half an ounce of lime-water be added, the tendency to the formation of acid is removed, the solubility of the casein and the emulsion of the fatty matters are insured, and both these last become more assimilable. What has been said will suffice on the use of the various kinds of milk in their natural condition. But here I must take up two other points-1. The correction of infetior milks, so as to adapt them for infant purposes; 2. The preparation from strong and rich milk of a compound resembling human milk. 1. Correction of Inferior Kinds of Milk. Here I am especially indebted to Dr. Merei of Manchester for the information he has given me, which I have in this paper in great measure inicor)orated. If we take a tube nine inches long by half an inch wide, graduated in sixteenth parts of an inch, and put into it about two ounces of milk and the same quantity of water, and expose it to a temperature of 50°to t0' Fahr. for about eighteen or twenty-four hours, the cream will be found to have separated, and will be observed as a whiter, more opaque substance, floating on the surface of the milk. If this stratum above the milk amount to seven or eight of the graduated degrees, that milk is essentially good and rich, and contains about six and a half to seven and a half of butter. Medium milk will contain only five or six degrees; the worst kinds, only three degrees; and the inferior qualities supplied to the poor (skim milk), only two degrees. Here, then, is a ready means of measuring quality. Now, experience has shown that such poor milk causes more gastric disorders than rich milk: nay more, that, to obviate this result, it requires a greater dilution than rich milk, notwithstanding its poverty. Dr. Merei attributes this to the preponderance of casein, which is one of the chief causes of gastric disorder. This casein, it is observed, is both harder and coarser in cows' than in human milk. This is, no doubt, ote cause; but there is another which, I think, applies, and which is mainly due to the dishonesty of milk-dealers. The cowkeeper has already watered his milk, to separate a certain amount of creami from it. The retail milk-keeper has done the same very frequently. The butter has thus been already taken out. Lactic acid has formed, and what butter remains in the milk is scarcely now contained in perfect combination as an emulsion, but is disintegrated, or, as it were, in imperfect mechanical suspension only. The casein is perhaps in the same state. Dr. Merei's experience in the method he adopts to improve inferior milks seems to point also to this view of the case. In case of feeble children, with bowels previously deranged, he recommends that, instead of diluting the milk with water, we should add a decoction of arrowroot, made with one teaspoonful of this substance to three-quarters of a pint of water, this quantity to serve for the admixture of the whole day's supply. In mole severe cases, the arrowroot may be increased to two teaspoonfuls. This arrowroot is not given as an ali-ment, but as a softish substance to soothe by its mechanical pressure the irritation of the intestinal muicous membrane. Langenbeck, indeed, believes that, in such cases, the. granules of starch intersperse themselves between the particles of casein, and thus in great measure prevent the formation of hard indigestible curds. The mixture Dr. Merei gives consists of three or four pints of this thin decoction of arrowroot to one part of new milk slightly boiled, and in the twenty-four hours amount of food thus prepared lhe adds about one to two tablespoonfuls of cream. Children will digest well from a pint to a pint and a half of this mixture in twenty-four hours, according to age. As they grow older, he increases the proportion of milk, but not of the cream. If an infant be tolerably strong and regular in his bowels, and has to be bottle-fed, under four months of age, a mixture of first rate quality of milk simply with water, in equal proportions, or, after three to four months, one part of water to two of milk, agrees well, if given at a temperature of 900. For children liable to diarrhcea, a very thin and weak infusion of aniseed tea, instead of water, may be substituted. Where the gripings and diarrhcea are severe, it is well to combine a teaspoonful, three or four times a day, of dill or peppermint water and water in equal parts, with lime water anti a trace of opium to allay the irritation. (Extract of private letter.) The above has been very generally the plan upon which I have acted in these cases, with two exceptions. The ease now-a-days of giving cod-liver oil to infants, anti its cheapness as compared with cream, have led me usually to prefer the former, which doubtless acts in the same way as cream in supplying an oily but highly assimilable combustive aliment. Also, I have usually combined sugar, because existing in cows' milk in smaller quantity than in human milk. 2. Preparation front Rich or Strong Milk of a Compound resembling Human Mrilk. MAy attention has been called to this especially by Mr. Harry W. Lobb, a gentleman who for some time past has closely studied the subject. In page 133 in his little work on Hygiene, he gives us the following method of preparing Professor Falkland's milk for infants. I subjoin it here in full. One-third of a pint of new milk is allowed to stand until the cream has settled; the latter is removed, and to the blue milk thus obtained about a square inch of rennet is to be added, and the milk vessel placed in wat-m water. In about five minutes, the curd will have separated; and the rennet, which may again be repeatedly used, being removed, the whey is carefully poured off, and immediately heated to boiling, to prevent its becoming sour. A further quantity of curd separates, and must be removed by straining through calico. In onequarter of a, pint of this hot whey is to be dissolved threeeighths of an ounce of milk sugar; and this solution, along with the cream removed from the one-thitd of a pint of milk, must be added to half a pint of new milk. This will constitute the food for an infant of from five to eight months old for twelve hours or, more correctly speaking, it will be onehalf of the quantity required for twenty-four hours. It is absolutely necessary that a fresh quantity should be prepared every twelve hours; and it is scarcely necessary to add, that tho strictest cleanliness in all the vessels used is indispensable. The above is a very ingenious process, but it is open to objection in one or two particulars. a. Messrs. Parmentier and Deyeux have shown that there is a disadvantage in boiling milk. When eight pounds of milk obtained from cows fed on grass, cabbage, potatoes, and maize, respectively, were distilled, eight ounces of a colourless ifuid were obtained. That from those fed on grass was aromatic; on cabbage, offensive; on maize and potatoes, quite inodorous. Hence they infer that, if this volatile principle constitutes in any way one of milk's constituent parts, it must be wrong to deprive milk of it, or to expose it to those circumstances which favour its separation. Experience with infants has also shown me, that boiled milk is seldom so well borne as milk simply warmed by the addition of hot water. b. The objection has been made by Mr. Lobb, that in Dr. Falkland's process scarcely enough casein is removed. That gentleman has another method of preparing this artificial human milk, which he calls miflcasea, which I here subjoin. " Half a pint of new milk is set aside for the cream to separate, which latter is removed; and to the blue milk half a teaspoonful of prepared rennet is added; this is placed over the fire, and heated until the curd has separated, when it is broken up with a spoon, and the whey poured off. In winter, three drachms of powdered sugar of milk is added to this warm whey; and the whole is mixed uaith half a pint of new milk. In sum. 332 [APRIL 9,4, -1858. BRITISH ME,DICAL JOURNAL.]
doi:10.1136/bmj.s4-1.58.103 fatcat:tfs27sq4evhqhi3f2fsxlmqd2y