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, 1913

, Vol. VIII

ten to twenty small tubercles, some of them in the liver and some in the spleen. The examination of the tubercles did not reveal the presence of Koch's bacillus, but, instead, it showed the presence of numerous fibres of young connective tissue. In the bodies of the other three guinea pigs, those which had been treated with garlic up to the end of September, I could find no tubercular formations, though the most minute examination was made.

If these results should be confirmed by further research, it would be proved that garlic prevents, at least guinea pigs, from contracting tuberculosis diseases through breathing the germs. As this seems to be the commonest way of contracting phthisis, it may mean the discovery of a method for preventing consumption."

Dr. E. Blake Knox, Captain Royal Army Medical Corps, in a letter to the London Lancet, 1904, (13) after referring to the articles of Dr. Cavazzini, and Dr. Minchin, says: "For some years past, as opportunity presented, I have been working out the influence exerted by garlic on such different forms of tuberculosis as have been presented for treatment in the military hospitals to which I have been attached. have used garlic as a poultice applied to tubercular ulcers with most beneficial re

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sults. It has a most powerful germicidal action, and when mixed with powdered charcoal it has the power of cleansing and healing the most fetid ulcer."

Dr. Knox then cites the case of a relative infected with tuberculosis of the lungs, whose sputum swarmed with Koch's bacillus, and who had a cavity in the lung as large as a walnut, and also several consolidated patched in lower lobe. He was under continuous garlic treatment for

three years. The disease has been arrested, as proved by repeated physical and bacteriological examinations. He followed Dr. Minchin's method of treatment in the army, and met with unqualified success in arresting the disease. In his cases of tuberculosis of the lungs he found the best results by using the expressed juice mixed with water in one or two drachm doses at bed time and first thing in the morning, and in bad cases has used the juice alone. in an inhaler. In no case was the digestion affected.

Whether Dr. Cavazzini has pursued his researches on this subject beyond the point recited in his preliminary note, I have been unable to learn from any later publication. But may we not safely ask the question if the subject opened up by him is not of sufficient importance to warrant investigation by American bacteriologists in order to determine definitely the value of garlic. and the onion as a prophylactic or remedy for pneumonia and tuberculosis, etc.?

In conclusion, if, as shown above, garlic is used extensively and successfully in the treatment of anthrax in cattle, and it has been proved to destroy tubercles in guinea pigs, may I not be justified in suggesting the possibility that the depriving of milch and dairy cows of garlic in the spring and summer months to prevent them supplying garlicky milk, may account for so much tuberculosis in dairy cattle? Would it not

be well for the Bureau of Animal Industry of the Agricultural Department to make some experiments along these lines, and ascertain whether cows which are given free access to garlic are as subject to tuberculosis as those deprived of it, and also what effect the free feeding of garlic to cows already affected with the disease would have in arresting it?

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WARD BRYANT HOAG, M. D., Adjunct Professor Pediatrics, N. Y. Polyclinic; Attending Physician, Out-Patient Department, St. Mary's Free Hospital for Children.

While we are to consider the artificial feeding of infants, it is the earnest wish of the writer to emphasize in the most positive manner the necessity of taking advantage of breast feeding in whole or part, where it is in any way possible. No matter how confident we may feel of our ability to offer a substitute food, only dire necessity should make us bold enough to suggest depriving a young baby of its mother's breast. Even one or two breast nursings a day are of very great assistance to enable a baby to properly digest his artificial food.

Read before the meeting of the Bellevue Hospital Alumni Association, Nov. 6, 1912.

Before referring to the different methods of supplying artificial nutrition, let us consider certain general principles relating to infant feeding.

First, each infant is a separate proposition, and his assimilative possibilities can be known only as we begin at a minimum amount of nutrition and increase to a reasonable maximum, as the baby shows ability to assimilate. If these statements are correct, they set at naught the desirability or propriety of following prescribed formulae for the different months of age or pounds of weight of the infant.

Published formulae in connection with proprietary foods have done a great deal to confuse the general practitioner in feeding infants. They tend to establish feeding according to a rule, and negative the personal equation that must be solved for each individual. Every practitioner among infants should have some definite, easily solved method by which he knows the amount of fat, proteid and sugar he is giving his patient; this, in order to safeguard against giving an unreasonable amount, particularly of fat or sugar.

It is by no means a rare experience to find babies getting five or six-even seven per cent fat mixtures, and again seven, eight or nine per cent sugar. True they may take this amount of nutrition for a time and show phenomenal growth; but in giving these excessive percentages we are violating all precedents established by nature, and are almost sure to develop trouble.

Percentage modification of infant foods will be an incentive to try and increase one or all the elements of nutrition, when we realize we are giving less than nature intended the babe should have. Of course here our efforts should be most carefully

, 1913

, Vol. VIII

supervised, and should be entirely subject to the possibilities of the infant's assimilation. Nothing is ever gained by giving food in excess of a child's ability to make use of it. Rather feed a child on a food on which he develops indifferently, than attempt to push him beyond his possibilities of assimilation, and make him sick or very uncomfortable.

While we appreciate there is much latitude in the selection of a food which will agree with and nourish properly the infant with weak digestive possibilities, there is one factor in our experience which has more to do with causing and perpetuating trouble than any other. This is too frequent feeding.

In the past it was the rule, and is very largely at present, to feed infants every two hours; this means to put one mess of food into the stomach before the previous one has been digested. The stomach has no interval of rest, and the most appropriate nutrition sooner or later disagrees. If there be any question regarding this fact, pass a tube into the stomach two hours after a feeding, and wash out the contents.

Seven feedings in twenty-four hours should be the maximum number from birth; every three hours from six A. M. to six P. M., and four hour intervals from six P. M. to six A. M.; one night feeding about two A. M.; this till the child is about four months of age. Then the night feeding should be discontinued. More than a majority of infants fed every three hours during the day, and at ten P. M.mother's bed time, will not require the night feeding.

If an infant shows a certain amount of digestive disturbance fed as above, make the interval of feeding three and a half or

four hours, and give an ounce of boiled water, with a few grains of sugar added, a half hour before the milk feeding. This means a clean stomach for the reception of the food. If the ounce of water as a drink is not effective, once or twice a day, before feeding, pass a stomach tube, and wash out the stomach with plain boiled water, or use water with a little bicarbonate of soda or salt added. Too much emphasis cannot be placed on the value of the above expedients to enable an infant to assimilate an increased amount of nutrition.

Next in point of value to the character of the food and the intervals of feeding, is the amount of food given at a feeding. The normal capacity of infants' stomachs has been very definitely ascertained by Holt and others; a safe rule is seldom to allow more than one ounce more of food than the number that represents the number of months of age: two months, three ounces; four months, five ounces, etc.

A greedy baby will frequently, if allowed, over distend his stomach. This disposes to discomfort, vomiting and finally a dilated stomach. Nothing is gained by having a three months' infant take six ounces of food, and then have him vomit four or five ounces of it.

During the past five years there has been a great change in our conception of the relative frequency of trouble from proteids, fats and sugar, and undoubtedly this change has been productive of good results.

Until recently the proteids of cows' milk were considered the most difficult for infant digestion, while sugar (lactose) up to six or seven per cent was practically never considered to have any pathological significance. There is now shown an entire reversal of opinion from the old con

ception. As a matter of fact, it is now believed that sugar, particularly lactose, is the primary cause of intestinal fermentation, and in cases of this trouble, the sugar should be reduced to a minimum; that fat should either be very much reduced or cut out entirely; and that the previously much abused proteids may be materially increased.

Again, the experience of very recent years has shown that while lactose is a most frequent cause of trouble in infant feeding, and ought not to be given in diarrheal conditions, that cane sugar is less liable to cause or perpetuate fermentation, and that malt-sugar, or malto-dextrin, is still less a cause of trouble. The discovery of this latter fact has enabled us to facilitate the nutrition of a large class of infants susceptible to lactose fermentation, or infants having been subject to an acute attack of diarrheal disorder.

In the successful artificial feeding of infants, proper consideration must be given to climatic conditions, regardless of social status or character of food. Prolonged high temperature always has the effect of decreasing an infant's possibilities of food assimilation, and increasing his chance of acute infections. During very hot weather we should reduce the amount of nutrition given an infant by one-quarter to one-half, thus protecting the child in a large degree from acute attacks of indigestion. While the nutrition is to be decreased, the bulk of the feeding is maintained by addition of water.

Social conditions, as influenced by either lack of money or mental conceptions of responsibilities, frequently make it necessary that we advise during hot weather a food of very much reduced nutritive value, but with increased protective qualities,

temporarily, for the child's subsistence. Given a mother who cannot afford to buy a safe quality of milk, and who has no ice, we might better advise condensed milk, or one of the proprietary foods that is fixed without fresh milk. Again the same expedient is advisable when no amount of cautioning will convince the mother of the necessity of care as to cleanliness and regularity of feeding. It is remarkable how little nutrition will maintain life during protracted intervals, and it is infinitely preferable to have a live baby rachitic, than a dead one.

For practical reasons we will consider our feeding propositions: first, in connection with normal or ordinary babies; second, sick babies; third, babies with idiosyncrasies or difficult feeders.

Normal or Ordinary Babies:-Our only means of ascertaining a baby's digestive possibilities is by trial. The feeding of normal or ordinary babies should constitute the large part of our work. No baby should be fed on the "try this" or "try that" theory, for only too frequently with this plan. will we upset the baby's digestion and make him sick.

We should have a definite idea as to what is safest and most appropriate, and with this we should begin. Let us first consider the demands of the new born babe, for until the third or fourth day, or later, we never know to what extent we shall be obliged to furnish artificial nutrition; and in furnishing this nutrition we are to be particularly careful to keep the babe, as he comes in a great majority of cases, a normal one.

During the first two or three days the baby never gets sufficient drink from the mother's breast. The question of nutrition need not positively be considered for

this short period, but it is often well to include with the water three per cent cane waste. The sugar to prevent tissue writer, during the first two days or until the breasts fill with milk, has the baby put to the breast every four hours for say five minutes, then one ounce of a sugar solution, one rounded tablespoon of cane sugar to one pint of water may be given. After the second day, if there is no breast milk for the baby, a certain amount of cow's milk is added to the sugar solution, and the baby is placed at the breast, and afterward fed every three hours.

The three hour interval of feeding during the day, breast or bottle, is continued indefinitely.

Now as to how much milk we shall add, and of what nature. Cream is more often offensive than proteids, and the only way we can ascertain the baby's capacity is by trial. Consequently we will first use skimmed milk, adding usually as little as four ounces to twelve ounces of the three per cent sugar water. This gives us a one per cent proteid. After two or three days, the skimmed milk can be gradually increased to one and a half per cent, six ounces to ten of sugar water, and one and a half ounces be given each feeding. Now the baby needs cream also in its food, and can usually take it up to two or two and a half per cent; we will ascertain his tolerance by beginning with as little as onehalf of one per cent, (one-half ounce of gravity cream, 16 per cent, to the pint of food). At two or three day intervals, if the food agrees, the cream is increased one-quarter to one-half per cent each time, until we are giving two or possibly two and a half per cent.

While developing the baby's diet, if the bowels do not move properly, a quarter

to a half teaspoon of calcined magnesia, or preferably milk magnesia is added to one or more bottle feedings each day.

The bowel functions can usually be regulated by the diet without resource to medicine.

After the baby has been taking the artificial food a week, possibly ten days, and remaining comfortable, the cane sugar should be increased from three per cent to four. This, with the one and a half or two per cent lactose, brings our carbohydrates to reasonable proportions.

Having now demonstrated the baby's ability to take fat, proteids and sugar in reasonable proportions, it is only necessary as the age of the baby increases to increase the amount of food, being particularly careful to keep the percentage of sugar and fat within the bounds indicated by nature in mother's milk.

Malt Soup. "Malt Soup," in the estimation of many if not most men giving special attention to infant feeding, represents the most valuable artificial feeding product we have for infants. "Where 'malt soup' fails, the wet nurse is practically the only resource available." This is a very common statement among pediatrists. At the same time, malt soup is only too frequently given as a last resort, or when everything else has failed.

One very noted pediatrist objects to malt soup because infants fed on it can get scurvy; at the same time this authority. says he has never had a case of scurvy on malt soup, because he always gives orange juice. The giving of orange juice is a simple expedient, and reduces the objection to nought. Again, in the "malt soup" preparation, if we have a safe supply of milk, or if it is not hot weather, we need not boil the milk with the malt flour and water.

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