THE DIETETIC GAZETTE.

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As a

the malformations which are often traceable to it-man- | other nutritional diseases. other nutritional diseases. We have said that in the ¿fold as it is in its expressions and far more numeri- relation of sequelæ to this group of maladies, stand cally important than the statistics tell-the profession the members of the last class of death-causes. of medicine can do naught but to educate the people matter of course this is not always the case, but it is up to a sense of their progenital responsibilities and very commonly true. Meningitis may appear even in to favor those ethical and legal restrictions which will infancy, as a primary disease, but its occurrence as put some check upon the transmission of this social such is rare. This and the term cerebral congestion plague. are used somewhat doubtfully, as respects their true pathology, to describe those conditions of brain exhaustion which are so commonly the final act in the tragedy of an infant life wasted by cholera-infantum, gastro-enteritis or so-called marasmus. Especially true is it that convulsions, invariably the reflex result of some primary disease, is usually a late or sudden consequence of gastric or intestinal irritation. Making allowance for their occasional primary existence or their relationship to other disorders, these nervous maladies, added in due proportion, to the nutritional diseases we have grouped together, constitute the means of the causation of at least 35 per cent. of the entire fatality of infancy.

There remains to discuss the most important classes of death-causes in infant-life, most important alike in the order of their numerical frequency and in the possibilities of their prevention—the nutritional diseases and the nervous diseases, which, in infancy, are the common sequale of gastrio-enteric disorders. Let us review the several members of these two groups. Cholera-infantum-a term made to do duty for almost every form of infantile diarrhoeaic disease is in its true character, the consequence, in all probability, of a germ which finds a favorable habitat in the disordered alimentary tract of the infant. In the sum total of deaths laid at the door of this complaint are often included, under various statistical tables, gastro-enteritis and its attendant symptom, diarrhoea. In other instances, a line is drawn between the two maladies.

sive one.

The next term-gastro-enterocolitis is a comprehenAs the writer took occasion to show, in the essay already referred to, many authorities on children's diseases separate arbitrarily the several conditions grouped under this head describing diarrhoea, gastro-intestinal catarrh, gastritis, enteritis and colitis in detail. Such a disseverance of conditions-which are closely related to each other and differ only in the degree of their intensity and in the particular portion of a practically continuous food-passage which is attacked, is, to say the least, unfortunate. It is confusing alike to the student, the statistician and the practitioner.

In the same group with these gastro-enteric diseases is included marasmus-a name covering all those death-causes to which this term and such unscientific phrases as inanition, infantile debility and malnutrition are ordinarily applied. It is intended to be descriptive of conditions which involve any sub-acute or chronic malady of infancy, in which indigestion, alternating constipation and diarrhoea, vomiting and nonabsorption or non-assimilation of food, are the noticeable symptoms which variegate the progressively downward course of the suffering infant, who is simply ill-nourished and ill-fed, and who finally falls a victim to gastro-enteric disease and its attendant nervous sequel; conditions which are related to each by their most common characteristics, a disturbance of the digestive organs and an invariable impairment of nutrition, which results therefrom, and which are further unified by the similarity of those errors in hygiene which underlie them all. As such, and so understood, marasmus finds its proper place with

One and all, the members of these two classes should be included, to a very great degree, among preventable diseases. They are truly death-causesbut causes which, in their turn, are the effects of a primary, an ultimate and an almost universal cause of a neglect of the hygiene of infancy. Perhaps the writer would be pardoned if he laid down, very briefly, the principles of their prevention in his own very recently published words.

This prevention lies in the education of the people up to a simple understanding of those sanitary laws which, almost intuitively, we apply to adult life. For why is it that gastro-enteric disease kills so commonly in infancy and so rarely in later years? That cholera infantum is fatal and that cholera-morbus tends to speedy recovery? Why is it that so soon as the child emerges from infancy and adopts the gastronomic habits of his elders, his tendency to gastro-intestinal disease diminishes, and its fatality is practically at an end? It is simply because we have not learned the lesson that the human baby is built upon the same plan as the child of larger growth; because we imagine still that the "mewling and puking" infant of Shakesperian renown is the type of healthy infancy; because we blindly neglect provisions for the wellbeing of the baby which we count indispensable for the adult, and permit abuses in the cradle that would ruin the health of a robust man.

How long would the best of us of mature years withstand the terrors of marasmus if we should be confined in one or two close, stove-warmed or furnaceheated rooms for an entire winter, without an excuse for ventilation, or a whiff of fresh out-door air; if we were strangers, born and bred, to the taste of pure water or of any water, in fact, pure or impure; if we were compelled to be perpetually "hungry" in order to get anything to drink; if we revelled in ten or

twelve square meals a day and lunched at pleasure, from the breast or bottle, through the live-long night; if the food we ate were placed in the kitchen sink or in the damp cellar to keep cool," prepared in bottles lined with the milk of yesterday, and drawn through rubber tubes, especially fitted for the culture of the tyrotoxicon of Vaughan? And yet this is no And yet this is no parody upon the lives of infants in the majority of our families in the humbler walks of life, and traces of these infantile habits persist even among the more educated classes. To a child unprejudiced by a syphilitic or tuberculous heredity, who enjoys pure air, pure water and pure food, suitably prepared and eats it at reasonable intervals-to such a child cholera infantum has no fatality, teething has no terrors, diarrhoea is as innocent as it is to an adult, and marasmus is a myth.

It devolves upon the medical profession, in the face of the prevailing ignorance, to educate the public in the principles of infant hygiene.

And, first, the choice of infant food is an important and a very difficult task. It goes without saying that the breast milk of the healthy mother is the ideal diet of infancy. But it is equally true that the nursing power of our American mothers is not good; that there are, indeed, mothers whose milk not only fails in quantity, but is prejudicial in quality. The pernicious character of the mother's milk is, I am convinced, a common cause of sickness in infancy. As a substitute, I do not favor the wet-nurse. I regard the chances of physical and moral contamination by this means as something more than fanciful. The choice, moreover, in Western cities is extremely limited, and an infant at the mercy of a capricious nurse for its food-supply may awake at any time to find itself in a deplorably hungry plight.

Cow's milk is, par excellence, the best artificial food, but it demands careful selection and intelligent preparation. In cities a good mixed milk will vary in quality less within a given time than will the milk of a single cow. In the matter of milk used for infant food, however, there is greater need of vigilant food inspection than in the line of any other item of human consumption. The rapid extraction of the animal heat from the milk immediately after milking and before it is carried far or used, is an essential, particularly in warm weather. Milk intended for infantfood, that has to be kept for twenty-four hours, should' be bottled and then placed on ice.

quality which they possess in common with these gruels, though in varying degree, of separating into fine particies the casein curds of the cow's milk with which they are usually combined. Dilution with water will not contribute to this result and involves only the necessity for the separation from the curd, in the child's stomach, of an even larger quantity of water than the milk normally contains.

Of all manufactured articles of infant diet, Carnrick's Foods are the best. They have a larger quantity of proteids than some others, their starchy constituents are mainly converted into the intermediate digestive product of dextrin and their fats are in a stable form. Those "foods" which approximate the Liebig formula are objectionable because of the conversion of their starchy elements into the ultimate digestive products of maltose and dextrose, which are liable to fermentation in the child's stomach. Condensed milk is difficult of digestion on account of the large quantity of cane-sugar it contains and is frequently the cause of gastro-intestinal disturbance. The "Peptogenic Milk Powder," of Fairchild, has been found useful in many cases of indigestion, and it contributes to the same fine subdivision of the casein-curd of the cow's milk, to which we have already referred.

It is hardly necessary to say that the mother's milk digests with greater rapidity than will any form of artificial food. It follows that infants may be safely fed more often from the natural sources of food supply than with any substitute therefor. The duration of the digestion of any food may vary slightly with different individuals, but the average period may easily be determined.

It is an absolute essential to the present and future health of the infant that the digestive organs shall enjoy a due interval of rest between each meal and its successor. It should be remembered, in this connection, that digestion is not completed when the food leaves the stomach, but has to be carried to its conclusion in the duodeum. Time must be allowed for the completion of the entire act and for a succeeding and sufficient interval of rest before a second meal is ingested.

Moreover, it should be observed that the contents of the stomach increase in acidity progressively during the digestive act, and that to introduce new food into that viscus when it contains old materials, at a maximum degree of acidity, is to prejudice the digestion of the former.

The too frequent feeding of infants is a vice almost universally prevalent and quite generally countenanced or actually encouraged by the profession. It is grounded in custom as hoary, perhaps, and certainly as absurd as the encasement of the Chinese infants* feet in permanent baby shoes. It is entrenched be

The casein of cow's milk has been shown to differ from that of human milk in the matter of its curding in the child's stomach. To secure, in the digestion of cow's milk, the preliminary formation of the soft flaky curds which characterizes the mother's milk, it should be carefully blended with oatmeal or barleygruel, gelatine, or other mucilaginous preparation.hind that most dangerous of all arguments-the arguMany of the infant foods, whether home-made or the product of manufacture, owe their measure of success less to their intrinsic nutritional value than to the

ment from experience-among the ignorant, while it is condemned by every careful observation of the lower orders of animal life and by every physiological

THE DIETETIC GAZETTE.

ing to Galenus, become affected to such an extent, that they resemble a sieve. An increased flow of water can therefore be easily understood.

The period of the middle ages may be ignored; here as in almost all other domains, it shows stagnation going back to superstitions. Miraculous cures took the place of the natural Hippocratic medicine which was only revived in modern times.

We may quickly pass over the first few hundred years of modern times, Theophrastus Paracelsus Syłvius and Giordano Bruno may here be mentioned; to neither, however, can be credited any noteworthy progress. It was left to Thomas Willis to re-discover the presence of sugar in the urine by its remarkably sweet taste in diabetes. It was therefore reserved for the 17th, century, after more than two thousand years, to again get into the right track, and bring before the

eyes of an astonished world a diabetes mellitus (Thomas Willis 1674), Dobson, Poot and Cowley, Home, as also Rollo, were worthy successors of Willis. Rollo inaugurated the use of opium and animal diet, Rollo inaugurated the use of opium and animal diet, and made some noteworthy chemical experiments

that are of value even to this day.

A new era in the investigation of diabetes began

with the 19th, century. The distinguished London specialist in diabetes, Prout, also Bouchardat, Mialhe, and Piorry already gave intimation of the same. Chemistry here already made some triumphant dis

coveries. Mialhe was the first to recommend alkalies. Piorry endeavored by the ingestion of sugar to replace the loss of the same through the kidneys.

New fields of experimentation, not known to ancient times; have been opened by modern chemistry. This is, compared to the utter want of such knowledge in olden times, an immense advantage. It is to chemistry that we owe knowledge of the most important changes in tissue-metabolism caused by Glycohæmia. The foundation of the future researches in diabetes lie in the studies of bio-chemistry.

CLINICO-PHYSIOLOGICAL DIVISION.

Traces of dextrose, glycose, and glucose or diabetic sugar have been found normally in the blood, chyle, muscles, liver, and urine.

It has also been found in the intestinal tract owing to the action of diastatic ferments on the carbo-hydrates during digestion.

Glycogen is found chiefly in the liver, hence it is called liver-starch. It is also found in muscles, em

bryonal tissues, in normal and pathological epithelium. In minute traces it is also found in the testicle, lun, skings, pus, inflammatory niduses in the spleen, lun, skings, pus, inflammatory niduses in the spleen, kidneys, etc. Concerning the chemical properties, composition and physiological significance for the organism, so much has already been written that

we will only briefly mention that which may be considered as well established.

The most important points concerning the relation existing between glycogen and sugar may be found in every text book on Physiology. Much however is still subject to controversy. There is not even unanimity as to the place where sugar is mainly produced; also little is known about the combustion of

subject. He says it is very evident that our knowledge of diabetes can go no farther than our under

standing of the origin and destruction of sugar in

the human economy:

"The first source from which the blood derives its

sugar, is the digestion, which furnishes the sugar in large quantity, and in a proper form for absorption, by causing the starch etc., of vegetable food to undergo the saccharine fermentation."

Outvying in brilliancy all these, his predecessors, is Claude Bernard. His Leçons de la Physiologie Ex-sugar. Let us see what Frerichs has to say on the périmentale, as also the Leçons sur la Diabète et la Glycogénese Animale are immortal and mark an epoch. His "Puncture," the experiments with curare, lastly the investigations of glycogen and the formation of sugar in the liver, were the first steps as to the determination of any cause for diabetes. It may be asserted that giant strides have been made as a re. sult of his labors, not only in our knowledge of diabetes, but in experimental pathology as well. His brilliant pupil and opponent, Pavy, could not deny the main points of the "Puncture," he could only assert that the formation of sugar in the liver as observed by Claude Bernard was post mortem. The rest, Schiff, Voit and Pettenkofer, Cantani, Epstein, Frerichs and Seegen already belong to the present time. We observe in this, as in other domains of medical research that ancient views, which are correct in the main, reappear and after centuries gain for themselves full recognition. Then suddenly discovery follows discovery, until again stagnation sets in. Susruta, as stated, knew of the saccharine character of the urine; after two thousand years of oblivion it was again discovered by Willis. Now the track was clear and for the ninteenth century was reserved the colossal wrench of the "Puncture," and whatever has since followed this experiment.

Concerning what follows, there is much less known, it has not yet been determined if in diabetes there is increased production or decreased destruction. The statements concerning the percentage of sugar in the several parts of the circulatory system, the derivation of sugar from the albuminoid, and its relation to glycogen have not yet by any means been proven.

The importance of these transactions

in tissue metamorphosis is so great, and it reaches so far in all developmental processes, that it would be well to have a care not to come to a hasty conclusion one way or the other.

It is however apparent that the change and destruction of glycogen is under the influence of the nervous system. It is also certain that regulatory processes go forward in the cells of the liver and muscles, the nature of which is little understood.

THE DIETETIC GAZETTE.

As little is known concerning the primal cause and the real nature of diabetes. In more recent time, the conviction is gaining ground that the self-same pictures may symbolise other causal momenta.

Without mentioning diabetes, insipidus and aiabetes inositns, cases of diabetes phosphaticus, diabetes oxalicus have been observed (Führbringer). On the other hand it cannot be gainsaid that the sugar stands in a certain relation to the symptoms presented by the disease. This impression is corroborated by the cases of diabetes intermittens. Of course cases have been observed in which the intermissions were characterized by inosuria, phosphaturia and oxaluria and the symptoms therefore remain very nearly unchanged.

It is a very simple matter to determine the presence of dextrose in the urine, we have methods as simple as they are sure.

I. Determination by means of polarization. Dextrose is dextrogyrate, hence its name; this process is however useless for the practising physician, on account of the fact that every physician does not possess the necessary apparatus, furthermore that small quantities cannot be positively demonstrated by it.

II. Moore's test. Caustic potash or soda hydroxide is added to the urine in the proportion of one of the former to three of the urine and heated. If sugar is present the urine becomes yellow, brown, changing into black. By the addition of nitric acid this color is again removed. This method is simple but somewhat uncertain, and hence cannot be relied upon.

III. Trommer's test. This is by far the most positive test and also one of the oldest, if not the oldest. It is based upon the property which sugar possesses of reducing copper oxide in alkaline solution. It is performed as follows:

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the use of this diagnostically important test, that there are other substances that will act in a like reducing manner upon boiling, hence it is never well to boil too long. Albumen when present, must first be removed by acetic acid. This test is of no use in decomposed amoniacal urine.

IV. Boettger's test. To the urine is first added potassa and then a small portion of basic nitrate of bismuth-Magisterium Bismuthi. The smaller the quantity of sugar suspected, the less must be used, as a small quantity of sugar will only reduce a small quantity of oxide of bismuth, the excess will hide the characteristic dark coloration. Upon boiling, the liquid becomes smoky; after standing a while it clears, and a black powder, metallic bismuth, settles at the bottom. Occasionally the powder is not black but gray. This is the case with a small quantity of sugar, which is only able to reduce the oxide of bismuth to the suboxide, and not to the metallic form. In this test, a counter-test is made to determine whether or not the precipitate be due to sulphate of bismuth. For this purpose, a new specimen of urine is taken; potassa, and finely powdered litharge is added thereto and boiled. In the presence of sulphur, a black precipitate of sulphate of lead will be formed.

Phenylhydrazin test. Jaksch describes this test as follows: Place in a test-tube, two pen-knife points. full of phenylhydrazin hydrochlorate, and three penknife pointsfull of acetate of sodium; the test-tube is then filled one-half full of water slightly heated, then a like quantity of urine is added. The mixture in the test-tube is placed in boiling water, and after the lapse of a quarter of an hour, it is placed in a beaker glass filled with cold water. Should the urine contain sugar, a yellow crystalline precipitate will at once be formed, which under the microscope will be seen to consist of yellow needles, disposed singly or in cirThis test is of the greatest importance because it demonstrates the smallest traces of sugar and is the only test which demonstrates the sugar as such; crystals of phenylglucosazon being formed by the action of the glucose on the phenylhydrazin.

cles.

QUANTITATIVE ANALYSIS OF SUGAR.

I. Moore's test may be used to approximately determine the quantity of sugar present, by noting the different shades of color. A slight darkening in color during the boiling will demonstrate a small quantity of sugar and vice versa.

After the addition of one-third solution of potash, the same as in Moore's test, a very dilute solution of sulphate of copper is added and well agitated. A small quantity of the hydrated oxide of copper is formed, showing itself in a cloudiness of the liquid, this is however, speedily re-dissolved on shaking, giving to the fluid a beautiful deep, blue, color. This is especially the case in urine containing sugar. After a while, a small quantity remains undisolved. The test tube is then heated, preferable above, as the changes in color can there be best observed. If sugar be present, then the yellow sub-oxide of copper will be precipitated at the place where the heat is applied. The contrast between this and the beautiful blue color of the rest of the liquid is very striking. When only a change of color and no precipitation of suboxide is noticed, the faintest traces of sub-oxide may be demonstrated by carefully placing a layer of dilute hydrochloric acid in the test tube upon the cooled liquid. The upper part of the liquid is thereby somewhat supersaturated, and at the juncture of the two liquids, a very delicate precipitate of a yellow or red-glass over the same. The fermentation will be comdish color will be observed, which gradually sinks to the bottom. It is however, necessary to observe in

II. Fermentation test. Taphenier recommends the following: The specific gravity of the urine is determined by means of a urinometer in the usual way. To the urine is then added ordinary compressed yeast 150 C.C., say, a piece as large as a nut. Disseminate the same by agitation, cover the vessel with filter paper to prevent evaporation, and then invert a beaker

pleted, at the ordinary temperature of a living room,in 24-28 hours. This may be recognized by the fact