^ ^!»^^.. IMAGE EVALUATION TEST TARGET (MT-3) ^ ^ 1.0 V^ lii ■tt Itt 12.2 I.I u lUteu llig Ui^ U4 V'^. c>^ FhotograiM; Sdmces CarpoiHtiQn 19 WIST MAIN STMIT WIMTIR.N.V. I4IM (7U)I71-4I09 ^ ^ ^-t. 'W^' ^P> ^ ^ CIHM/ICMH Microfiche Series. CIHM/ICIViH Collection de microfiches. Canadian Inttituta for Historical IMicroraproductiona / inatitut Canadian da microraproduetiona hiatoriquas Tachnieal and Biblio9r«phie NotM/Notas tachniquM at bibltographiquaa Tha Inttituta haa attamptad to obtain tha baat original copy availabia for filming. Faaturaa of thia copy which may ba bibliographieaily uniqua. which may altar any of tha imagaa in tha raproduction, or which may significantly changa tha uauai mathod of filming, ara ehaekad balow. HColourad covara/ Couvartura da eoulaur rn Covara damagad/ D Couvartura andommagAa Covara rastorad and/or laminatad/ Couvartura raatauria at/ou pailiculAa r~n Covar titia miaaing/ La titra da couvartura manqua □ Colourad mapa/ Cartaa gAographiquaa mn eoulaur D D D D D Colourad inic (i.a. othar than blua or black)/ Encra da eoulaur (i.a. autra qua Maua ou noirai I — I Colourad plataa and/or illuatrationa/ PIcnchaa at/ou illuatrationa •r eoulaur Bound with othar matarial/ RalM avae d'autraa doeumanta Tight binding may cauaa ahadowa or diatortion along intarlor margin/ Laraliura sarria paut cauaar da I'ombra ou da la dlatoraion w long do w margo intarwufa Blank laavaa addad during raatoration may appaar within tha tast. Whanavar poaaibia, thaaa hava baan omittad from filming/ II 80 paut qua oa talnaa pagaa blanchaa aloutAaa lora d'una raatauration apparaiaaant dana la tanta. mala, loraqua cala Atait poaalMa. eaa pagaa n'ont paa 4tA film4aa. Additional eommanta:/ Commantairaa tupplAmantairaa: L'Inatitut a microfilmi la maillaur axamplaira qu'il lui a AtA poaaibia da aa procurer. Las details da cat axamplaira qui sent paut-Atra uniques du point da vua bibliographlqua. qui peuvsnt modifier una image reproduite, ou qui peuvent exiger une modification dana la mAthoda normale de f ilmaga sent indiquAs d-deesous. D n Coloured pages/ Pagaa da eoulaur □ Pagaa damaged/ Pagae andommagAae □ Pagaa reatorad and/or laminated/ Pagaa reataurAae et/ou peiliculAes 0ftgee discoloured, stained or foxed/ Pages dAcolorAes, tachetAes ou piquAes □ Pagaa detached/ Pages dAtachAes Bhowthrough/ Transparence Quality of prir QuaiitA inAgaia da I'impreesion Includee supplementary matarii Comprend du matAriel supplAmentaira Only edition available/ Saula AdHion diaponibia Fyj Bhowthrough/ rn Quality of print varies/ r~1 Includee supplementary materiel/ rn Only edition available/ Pagaa wholly or partially obscured by arrets slips, tissuee, etc.. have been refilmed to enaura the best possible image/ Lee pegee totaiament ou partieilement obacurciaa par un feuiiiet d'errata, une pelure. etc., ont AtA fiimAea A nouveau da fa^on A obtanir la mailleure Image possible. This Item is filmed at tha reduction ratio ehaekad below/ Ce document est fllmA au taux da rAduetlon IndiquA el 10X MX lix nx MX 30X y 12X HM MX 2IX aax ■ils du difittr una laga Th« copy fllmad hmrm haa baan raproduead thanka to tha ganaroaity of: MMical Library McGill Univaraity Montrsal quality fagibiHty tha Tha imagaa appaaring hara ara tha poaaibia eonaidaring tha eondition of tho original copy and in icaaping fliming contract apadflcationa. Original copiaa in printad popar covara ara fllmad baglnning with tha front covar and anding on tha laat paga with a printad or illuatratad impraa- •Ion, or tho back covar whan appropriata. Ail othor original copiaa ara fllmad baglnning on tho firat paga wKh a printad or iiluatratad impraa- •ion. and anding on tho taMt paga with a printad or illuatratad impraaaion. L'ajcftmplaira fiimi f ut raproduit griea i la g«n4roalti da: MMlical Library MeQili Univarsity Laa imagaa aulvantaa ont 4ti raproduhaa avac la plua grand aoln, compto tanu da la condition at da la natiati da i'axamplalra fiimA, at an conf ormltA avac laa condMona du contrat da fUmaga. Laa ORamptalraa orlglnaux dont la couvartura an papiar aat Imprim4a aont fHmte an common^ant par ia pramiar plat at an tarminant aolt par la danMra paga qui comporto una ampralnta dimpraaalon ou dlHuatration, aolt par ia aacond plat, aalon la caa. Toua laa autraa axamplairaa orlglnaux aont fllm4a an commandant par la pramlAra paga qui comporto uno omprainta dimpraaalon ou dlHuatration at an tarminant par la damlAra paga qui comporto uno talla ampralnta. Tha laat rocordad frama on each microflcho •haU contain tho aymbd — ^ (moaning "CON- TiNUlO"). or tho aymbol ▼ (moaning "EIVD"), whichavar appliaa. Un daa aymboloa auhranta apparattra aur ia damMra Imaga da chaqua microflcha, aalon ia caa: ia aymbolo -^ algnlfto "A 8UIVRE". lo aymbolo ▼ aigniflo "FIN". IMapa. platoa, charta, ate., may ba fllmad at diffarant reduction ratioa. Thoaa too larga to ba antiraly inciudad in ono axpoaura ara filmed baglnning in tha upper left hand comer, left to right and top to bottom, aa many framea aa required. The foliowkig diagrama iiluatrate the method: Lea cartee. planchea. tabieeux. ate., peuvent tire fllm4e A dee taux do rMuctlon diffirenta. Loraque la document eet trop grand pour Aire reproduit en un aeul cllch4. ii eet fllmA A perdr do rangle aupArlaur gauche, do gauche A droHe. et do haut an bee. en prenem ie nombre d'Imagee nAceeaelre. Lee diagrammaa auhMinta INuatrent la mithoda. rrata o laiura, lA 3 nx 1 2 a 1 2 3 4 5 6 Vibv Jl'VtKJ-vy^ » il ^» ^ /. tions of physicians upon any basis of milk they maj' elect to us^ These laboratories have the oversight of the feeding and cai'e or fhe cows ; and the handling of the milk to insure its purity, cleanlijii^iS> 4 \ '-^l ^ ']} and freshness. They have trained men to carry out the preparation of tlie food called for by the prescriptions. At the present time there are about 30,000 infants being fed by these laboratories in the United States and Canada, and they are everywhere giving satisfaction. Rotch in a recent paper said : " The position which it seems fair for us to take is that the principle of the modification of milk is scienti- fic, is practical, is right, and that in the milk laboratory we have one more instrument of pi-ecision to aid us in our work." In infant feeding there are three important factors. (1) Quantity. (2) Quality. (3) Idiosyncrasy. It is impossible to give exact rules for modification, but in ordering milk for an infant not only its age, but its weight must be taken into account. A large healthy child for its age requires, not infrequently, the quantity and percentage of food advisecktior an average child of some weeks older. As a rme it is well to begin with a low percentage and work up till a percentage and quantity is reached which the infant will digest and gain an average amount in weight per week upon. It is absolutely necessary to insure success, that a close watch be kept of the infant's weight. It should be weighed at least once a week. The weekly gain in a healthy infant should be from three to eight ounces ; at four months an average infant should have doubled its hirt|i- weight and at one year have trebled it. Aa-tt* rule I think there is a, tendency to give an artificially fed infant too large a quantity of food. Amount of Feeding. — During the first month of life, an average infant requires about ten feedings of from one to two ounces daily. During the second and third months, from two to four ounces and so on. As the amount is increased the number of feedings must be reduced and the interval between each lengthened. An average formula for a healthy infant during the first week of life wouk' be ••Fat 2.00, sugar 6.00, proteid .60. The percentage may then be gradually increased to reach : Fat 3.00, sugar 6.00, proteid I.OO, by the end of the first month. By the third month a healthy infant thrives well on a fat 4.00. sugar 7 QQ, proteid 1.50 mixture. As a rule those of lai'gest experience nnd they get the best results from rather low percentage mixtures. ModijicationH called for by Particiilar Symptoms, — Proteids. — The modifications called for by particular symptoms are important. If the, pr»)teid8 are in excess they are passed as undigested curds in the motB)ns. These proteid curds are small and hard. It is proteid in(!ttgestion which gives rise to most of the colic of early infancy and ft rule a proper management of the proteids means success in infant feeding. Proteid indigestion may be shown by restlessness, sometime by diarrhoea, but more frequently by constipation ; the latter is prone to occur with a great excess of proteid. Vomiting of small proteid curds is not infrequently met with. Fat. — An excess of fat is usually shown by frequent motions of normal colour, containing large soft flocculi, which we call fat curds, Vomiting and regurgitation also occur from an excess of this element in the food. It is rare that fat indigestion is a cause of colic. Dry hard motions occur if the percentage of fat is too low. Sugar. — If the sugar percentage is too low the gain in weight is apt to be slow. Excess of sugar is shown by colic and thin acid motions, which cause irritation of the buttocks, and have a sour yeasty odour. Generally we have eructations of gas and a sour odour to the breath, with an excess of sugar in the food. Holt summarises the most important indications as follows : " If not 'gaining in weight without special signs of indigestion, increase the proportions of all the ingredients ; if habitual colic, diminish the profceids ; for frequent vomiting soon after feeding, reduce the quan- tity ; for the regurgitation of sour masses of food, reduce the fat, and sometimes also the proteids ; for obstinate constipation, increase both fat and 'proteids." Premature Infanta. — The signal value of the exact modification of cow's milk as carried out by the laboratories is shown in the feeding of premature infanta Here the gastro-enteric tract is undeveloped and unfit to digest even human milk. I have had experience of a few successful cases of this kind where at the start the infant could only digest a food containing fat 1.50, sugar 3.00, proteid .25, of which a drachm every hour was administered. It is most satisfactory to see cases of this kind improve, and finally take and digest easily the mother'sjmilk. I think that at the present time it is unwise to attempt any other form of feeding in the case of these premature infants. Unhealthy and Feeble Infants. — The proper feeding of unhealthy and feeble infants, is one of the most trying and difficult undertakings. One is not infrequently called upon to superintend the feeding of an infant of five or six months of age, weighing scarcely more than at birth, with a digestive tract that has been struggling to nourish its proprietor from all kinds of so-called infant foods, and has finally given up the attempt or refuses to retain anything committed to it. These are the most trying cases and require the greatest care and persevemnce to ensure success. No gain in weight can be looked for till the digestion has improved. In the modification for these cases, as a rule the sugar is not at fault and need not be reduced below 4-4.50 per cent. It is the proteid that gives the most trouble, then the fats. 6 It is well to start these cases on a formula of about : Fat 2.00, sugar 6.00, proteid .60, and then gradually increase aa the symptoms of indigestion pass away. In my experience, at first small quantities at short intervals, then larger quantities of the same formula at longer intervals, give the best results. It is extraordinary in these cases what severe symptoms will follow the slightest excess of the element of the food at fault, thus the increase in percentages must be made with the greatest care and precaution. Marasmus. — In the treatment of marasmus cases in children, of from 6 to 18 months, it is not infrequently the case that the fat must be kept low, while the proteid can be quite rapidly increased. Diarrh(£a. — In the treatment of summer diarrhcea the results of modified milk feeding are most satisfactory. In a series of 115 cases treated under Dr. Rotch's direction last summer, five died, one was not improved and one hundred and nine recovered. The average age of the infants was 6.42 months. The milk was pasteurized in all cases ; the average number of feedings was 7.0, with an average amount of 4.5 ounces. The average per- centages were : Fat, 2.6 ; sugar, 6.8 ; proteid, 1.2. The important point is to keep the percentage of fat as low as possible. The chief objection to modified milk, as prepared by the labora- tories, is the expense. But it is a rule of life that one cannot have a good thing without paying for it. The average expense is from $2.10 to $2.40 per week, which includes bottles and nipples, and cannot be considered excessive when the whole process is considered. For some years I have, in feeding infants, rarely made use of any- thing but modified milk, and the more experience I gather the stronger is my faith in this scientific and accurate method. Of course, in home modification one cannot hope to obtain any great degree of exactness, and, therefore, there is apt to be a greater proportion of failures. Home Modification. — Home modification is inaccurate because it is impossible to procure a standard milk and cream. Rotch recently had the cream from a reputable dairy tested on four successive days with the result of a variation in the samples of from 10.13 to 28.34 per cent. Then it is difficult to secure the care and attention to detail from the parents or nurse necessary to ensure success. A safe milk cannot be obtained under ordinary circumstances in large cities. This difficulty cannot be overcome until the public has been trained to recognize the advantages of a pure milk supply, and '^^- is willing to pay a sufficiently high price for it to ensure the conscien- tious care necessary on the part of the producer. The relationship between contaminated milk and the severe diar- rhoeas of infancy is too well known to be more than referred to. Provided the milk is fresh when delivered, fairly accurate results may be obtained, in healthy cases especially, from home modification . ' It has been my habit to depend upon a 12 per cent, and an 8 per cent, cream, diluted as required by a 6, 7 or 10 per cent, sugar of milk solution. With these, several of the most ordinary percentage food mixtures can be obtained. I usually order the cream of the percentage desired from the labora- tory, where it is pasteurized before delivery. A 12 per cent, cream may be obtained by taking two parts of gravity' or skimmed cream (16 per cent.) and diluting with one part of milk. 8 per cent, cream may be obtained by diluting one part of skimmed cream with two parts of milk. The sugar solutions are obtained by adding sugar of milk to boiling water in the following proportions ; A 10 per cent, solution by adding one ounce of sugar of milk to ten ounces of water. A 7 per cent, solution by adding one ounce of the sugar to fourteen ounces of water. A 6 per cent, solution by adding the same quantity of sugar to six- teen and a half ounces of water. The alkalinity is secured by adding lime water or bicarb, of soda to the food as required. Let us suppose, for example, that we wish to prescribe a food for a healthy infant of one month, of average weight. We would require ten feedings of two ounces each with the following percentages : Fat 3.00 ; sugar, 6.00 ; proteid, 1.00. This is prepared each morning by diluting live ounces of a 12 per cent, cream with fifteen ounces of a filtered 7 per cent, sugar solution. A half teaspoonful of soda bicarb, is added, and the food put on the ice and used as required. The dilution here is one part of the cream to three of sugar solution. By adding two and a half parts of sugar solution to one part of the cream, one would have a food containing : Fat, 3.60 ; sugar, 6.00 ; proteid, 1.20, and so on. If the physician is careful to give exact directions in writing any intelligent person can prepare the food. As to results. In private practice, with healthy infants, I have Seldom failed to obtain good results with home modification, where 8 those in charge of the infant were intelligent and careful in the pre- paration of the food. In the Montreal Foundling and Baby Hospital we have been using moditied milk for the past eighteen months, with the most satisfac- tory results. As we have become more familiar with the practical working of this method of feeding our results have improved. We have at present forty-four infants in the hospital, which is greatly over- crowded, and not one of them is the subject of marasmus. Our mortality during the first four months of this year is half of what it was during the same period of last year. The admissions so far this year were exactly double those of the same period last year. We attribute our success in a great measure to this system of feed- ing. Most of the modification of food is done in the hospital by the nurse girls in training. Recently, in order to test whother pasteurization of the food could be dispensed with, the infants were fed on unpasteurized milk. In a few days every infant so fed was suffering from indigestion and pass- ing green motions with undigested curds. These troublesome symp- toms disappeared entirely, without the use of drugs, on resuming the pasteurization. The Walker-Gordon Co. report having put up prescriptions for over two thousand physicians with a mortality of 2| per cent in healthy infants. In closing I may be permitted to quote the recent utterances of two of the most eminent authorities : Dr. Holt, of New York, says : " After two years' experience I have found the laboratory of great value in difficult cases of infant-feeding, and it soon becomes almost as much of a necessity to the physician practising among young children as does the apothecary shop to the general practitioner." Dr. Rotch, in a paper read before the New York Academy of Medi- cine on April 3rd last, stated us follows : " I have never yet seen an infant who was carefully fed on milk during the firat ten or twelve mouths of its life, by carefully changing the percentage of the milk constituents, and on nothing else, not enter on its second year with firm fiesh and an average development I have found the teeth to be sound, and to come at the usual age. I have found the functions of sitting, walking, standing, and the amyolytic functions all appear and develop nonually. I have followed these children into their third, fourtn and fifth years, and have found them strong, ruddy, with good bones and teeth, and with (ligcHtions which permit them to Im) fell on a general mixed diet of all the food elements. '