IS STARCH A SUITABLE FOOD FOR INFANTS?

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’,(angina) are seized while they are walking, and more parti-cularly when they walk soon after eating." James Mackenzie, who has given much attention to the nature of the paroxysm, mentions the frequent association of flatui with the pain symptom, and suggests that air is swallowed by the patient in the initiatory stages and eructated in the

poured freely from the chest. After gastric lavage has been practised I have known patients walk many miles without pain, although for weeks before insignificant efforts had usually resulted in seizares, and when large doses of iodide of potassium are administered, which maintain an atmosphere of iodine in the stomach and intestines and thus

later. He writes : "Another symptom is very common in these prevent fermentation and voluminous accumulation of gas,16 cases-namely, the belching of air."In another place : "The attacks of pain may cease altogether. When exercise is taken by the healthy subject upon a full chief feature is the noisy expulsion of air from the stomach ";* and again:IThe case may end by expulsion of air from the stomach, by the flatulent dyspeptic, or by the subject of chest." Douglas Powell observes: "Eructation gives relief."6 angina, certain symptoms common to all occur. A sensation ’’ The patient vomits and becomes easier."7 I I Flatulent of fulness is felt in the epigastrium and a desire to eructate distensi on of the stomach is frequently an exciting cause." 8 flatus is experienced. According to Hertz precisely similar 41 Flatulent distension is a frequent concomitant of anginal symptoms are felt when intra-gastric pressure is raised by ’Paroxysms."8 I I Dyspepsia is a frequent exciting cause. "10 the induction of hypertonus of gastric muscle,17 consequently R. Quain has noticed this symptom : "An oppressive meal it may be inferred that muscular effort induces hypertonus of of indigestible food brought on a first and distressing anginal gastric muscle, and that hypertonus is the cause of the attack followed by others."11 It passes off with the escape gastric symptoms which m:l.ke their appearance in the of flatulent air from the stomach.]2 Stomach often affected, anginal subject when he walks soon after eating. That a giving rise to eructations and vomiting]13 Exciting cause, full stomach predisposes to hypertonus is abundantly demonoverloading the stomach.14Attack may terminate with strated by Hertz,18 and bypertonus, whether excited by vomiting or with eructations.15 This phase of the subject walking, by mental excitement, by sensory impressions, or has also received attention in the works of Russell and by intra-gastric stimuli, may be regarded as inducing the Gibson. gastric symptoms contained in the anginal syndrome. The effects of hypertonus of gastro-cesophageal muscle A patient under my own care, namely, Dr..X, on setting out for a walk seldom covers a distance of 80 yards without upon the central and peripheral circulatory systems are feeling thoracic pain and eructating flatus. If eructations illustrated in cases of gastrismus and œsophagismus.19 The .are copious Dr. X is able to continue walking for miles cardiac and circulatory symptoms associated with the without suffering any further attacks, but sometimes several prodromal stage of the simple vomiting attack demonstrate the profound impression produced by hypertonus of gastric recurrences of pain associated with expulsions of gas take a of is attained. muscle upon the heart and vessels through the central before period immunity - place In the case of three patients, eructations of flatus do nervous system, and the progressive weakening of the connot occur, but if the stethoscope be applied to the left tractile function of the myocardium by a prolonged season hypochondrium in the neighbourhood of the duodeno- of paroxysms of oesophagismus is a matter to which refer,’j ’3i unal flexure at the moment when the seizure is under- ences have been made and may be found sparingly in the going subsidence borborygmal sounds are usually heard, and literature of medicine .20 The effect of gastro-cesophageal sometimes the sound of rushing, gas continues for several hypertonus upon the circulatory system is illustrated in a minutes afterwards. In the case of another patient, after case described by Dr. William Rassell, Royal Infirmary, the administration of nitro-glycerine, the same phenomenon Edinburgh, referring to which the following sentences I have verified this sequence of events on occur :was noticed. In one case, no very definiteflatulent occasions. The sensations which now more ordinarily precede an [anginal] many were a sense of discomfort and distension in the stomach and symptom was noticed, but heart-burn, nausea, and an attack attacks were often associated with definite flitulent distension, the uncomfortable sense of fulness were frequent accompani- escape of gas being followed by, relief. The medical attendant noted ments of the seizure.From these remarks it is observed that when the abdominal discomfort supervened the pulse-rate increased that gastric symptoms occupy an important and probably and there was distinct hypertonus, as the attack passed the vessel wall relaxed and the rate returned to normal. a constant place in the anginal syndrome. In the same case it was noted " that any digestive upset Fulness of the stomach, whether occasioned by the at once threatened to produce an increased number of of an excess or seems to of have fluids, solids, presence gases, 2i mo effect by itself in exciting a seizure. Dr..X, in a series attacks. In short, in accordance with the preceding argument the of experimental observations made just after a full meal, noticed that although sometimes the waistcoat had to be anginal habit, whether of the abdominal or thoracic type, unbuttoned on account of distension of the abdomen, no results from a state of increased irritability of certain paroxysm is excited symptoms occurred while he yet sat at table, but imme medullary and spinal centres, and the from these centres gastro-oesophageal
Diseases of the Heart. 5 Ibid. Ibid. 6 Allbutt’s vol. vi. System, 8 9 Ibid. 10 Ibid. 7 Ibid. Ibid. 11 Dictionary of Medicine, p. 53. 12 Handbook of Medical Science, Buck, p. 227. 13 Ibid. 14 Medical Diagnosis, Stevens, p. 705. 15 Ibid. 4

16

During a course of treatment when Dr. X was taking 40 grains daily he lost 5 inches in abdominal girth. potassium 17

of iodide of

Hertz: Goulstonian Lectures. 18 Ibid. Gastrismus, Twentieth Cent. Med., vol. x., pp. 539-540. T. M. Tibbetts, Practitioner, August, 1911, p. 237. Œsophagismus, 21 Arterial Hypertonus, Russell, p. 141. 19

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Babies," which I summarised and criticised in a paper on not think it amiss for the Research Defence Society to put the facts of the case before the public in the most. subject in THE LANCET of Nov. 6th, 1909. Undoubtedly the natural food of the young infant is the conspicuous way that is possible. I am, Sir, yours faithfully, maternal milk. In former days, and even at the present this

date in certain countries and occasionally in this country, has been continued for two or three years. Yet we are not justified in assuming that such a practice is indicative of the unsuitability of starch during the first two In many, but not in all, instances of or three years of life. prolonged lactation the milk-supply has been supplemented by other food, usually of a starchy nature. At what date such supplementary food can be safely commenced depends on various factors, but chiefly on giving very small quantities. It is purely theoretical to take the eruption of teeth as a guide. Some infants cut their teeth late, others early, and in rare instances have teeth at birth. When the natural food is not available an artificial substitute is given. This is generally some modification of cow’s milk. Yet no matter how cow’s milk is modified, it remains different from human milk and is certainly not " the natural food for the quite young child." Identity in chemical analysis, according to present-day methods of analysis, may be obtained, but the two fluids are not identical in biochemical characters. The infant’s stomach has to be trained in the digestion of modified cow’s milk. Similarly, if a starchy diluent is used as a component part of the food, the stomach has to be trained in the digestion of starch. Admirable results have been, and still are, obtained by feeding babies on milk and barley water, often from the early days of life. The late Dr. Jacobi, an eminent American authority who reached an advanced age, always advocated the use of barley or oatmeal water as a diluent of milk. It is of almost universal use. On the grounds of physiological chemistry there is much recent evidence justifying the gradual addition of starch to the diet. It is true that "the saliva given out by a young child is nothing like that of a grown-up person." No one would assert that it is. On the other hand, there is proof that a diastasic ferment is secreted by the salivary glands and pancreas of the newborn, and even by the foetus. Admitting that its amount and activity are slight at first, these glands can be trained to secrete an increased quantity of the amylolytic ferment. And I am unable to suggest any cogent reason why such a process of training should not be begun gradually in the early weeks of life, if the child has to be artificially fed, instead of waiting until some fixed date such as six months of age or the eruption of a tooth. Fundamentally it seems to me to be a question of quantity. Mixtures of milk and barley-water commonly contain 0’5 to 1 per cent. of starch. In giving starch to an infant it is essential to begin with a very weak solution, increasing the strength slowly according to results. If the stools become very acid or give a distinct starch reaction, reduce the strength of the starchy diluent. Conclusions based on the percentage of raw starch in the various " foods for infants " are of no value. What is of importance is the percentage of unchanged starch in the mixture of which such a food is a part. In most cases the starch is partly digested by the heat and moisture in the process of preparation. My own conclusion is that starchy foods can be used with advantage, though not invariably so, and that the evil effects of the starch in the diet are due to (1) excess ; (2) its administration as a more or less insoluble emulsion instead of chiefly as soluble starch ; and, mainly, (3) the substitution of starch for the necessary fat, protein, and salts. Evil results from artificial feeding are quite as often due to a deficiency of the proximate principles of diet as they are to the starch present therein. I am, Sir, yours faithfully, EDMUND CAUTLEY. Park-street, W., May 29th, 1912.

breast-feeding

RESEARCH DEFENCE SOCIETY. To the Editor of THE LANCET. SIR,—This society has taken temporary premises in Oxfordstreet, between Bond-street and Oxford-circus, next to a very lurid anti-vivisection shop. I hope that the members and associates of the society will approve of this action. If any should be inclined to think it undignified or vulgar, I hope that they will look into the windows of the anti-vivisection shop. I feel sure that when they have done that they will

STEPHEN PAGET, Society.. Honorary Secretary, Research Defence Society. Ladbroke-square, London, W., May 29th, 1912:

THE HEIGHT OF BEDROOM WINDOWS. To the Editor of THE LANCET. to draw attention to the fact that the Local. Government Board is prepared to sanction by-laws which }an only be described as retrograde under Section 23 of the Public Health Acts Amendment Act with respect to the weight of rooms-intended to be used for human habitation. rhe Board’s Model By-laws allow the walls of bedrooms tooe only 5 feet high in part, if the height from the floor to theceiling, over not less than two-thirds of the area of the floor; be not less than 8 feet. When it is remembered that it is, bhe outside (or window) wall that would probably be 5 feet high, internal measurement, while the outside height owing to the sloping roof, would be little more than 4 feet, it will be seen that it is almost impossible to have the top of the window, unless dormer windows are constructed, more than 3’feet above the bedroom floor. Thus a man could not look out straight through his bedroom window without goings on his knees and then bending his back. The difficulties of ventilation also with such low windows would be insuperable. It is not likely that dormer windows would be constructed.. because the idea of this loose by-law is to cheapen construction, while the cost of a large dormer window would b& almost equal to the amount saved over a bedroom of satisfactory height throughout. If houses constructed under this by-law become numerous the public health movement and, the conquest of tuberculosis would be retarded at least 25 years. I am, Sir, yours faithfully, THOS. E. FRANCIS, Medical Officer of Health, Health. Llanelly, June 3rd, 1912.

SIR,—I beg

THE TREATMENT OF ANAPHYLACTIC SHOCK. To the Editor of THE LANCET.

SIR,—The pathology of anaphylactic shock has recently been described by Schulz and Jordan as due to spasm of the muscle fibres in the large bronchi resulting, in fatal cases, in asphyxia from complete occlusion of their lumina by folding of the mucous membrane. There is also a marked fall in the blood pressure in the systemic blood-vessels, probably due toa similar spasmodic contraction of the walls of the larger arteries. The following case, we think, will be of some interest. Mrs. -, aged 43, is suffering from typical exophthalmic goitre of two years’ standing. Some weeks ago treatment with small doses of thyroidectin was commenced, and it. was found that while the thyroid gland had markedly decreased in size, and tremor and exophthalmos were improved, a far more alarming train of symptoms had developed. Dyspnœa became marked, the patient complained of acute pain in the epigastrium, and jaundice, diarrhoea, and vomiting followed. The pulse was markedly increased-16per minute-the tension being very low. There was marked dilatation of the right side of the heart shown by jugular pulsation in the neck and extension to the right of the cardiac dulness. There was intense lividity of the skin and signs of cardiac failure. The patient was in a most critical condition and death seemed imminent from cardiac failure. In view of a recent annotation in THE LANCET on anaphylactic shock, we considered that this case fell under that heading, and that it might prove useful to your readers if we We described our treatment of this serious condition. stopped treatment by thyroidectin. The marked increase in the agglutinative power of the serum in typhoid patients. exhibiting small haemorrhages, either natural or artificially induced, pointed out by other observers, led us to hope that by venesection the power of the toxic proteins in the blood would be reduced, and we strongly recommended venesection. Six ounces of blood were drawn from the median 1

THE

LANCET, May 25th, 1912, p. 1419.