cow's milk.

Therefore the "milk question" becomes of primary importance in the artificial feeding of babies. For cow's milk to be wholesome, it must come from a healthy and properly fed cow; its nutritive qualities should not be diminished by adulteration, whether with harmless substances or not; and it should be free from contamination by decomposing animal matter or by bacteria. This makes it almost as important a subject as the question of water supply, and certainly a more difficult and complicated one to solve. When we refer to cow's milk in the following notes we mean only wholesome cow's milk, which is fresh, free from adulterants and bacteria, and is obtained from healthy cows, which are properly fed on hay or grass, kept in clean stables, and given clean and fresh bedding. At milking every precaution is taken to prevent contamination of the milk by dirty hands, udders, and vessels.

directs: "One quart of good ordinary milk is placed in a high pitcher or other vessel, and allowed to stand poured off from this, care being taken that the vessel in a cool place for three hours; then one pint is slowly is not agitated, the object being to obtain the upper layer of fluid, rich in fat, and leave the lower, com

paratively poor, portion behind." This upper half

can be drawn off much more easily by having a stop-cock in the side of the vessel, half-way between the top and bottom.

MEIGS makes his food by adding three tablespoonfuls of this weak cream to the same quantity of sugar water, made by dissolving 18 dr. of sugar of milk in one pint of water; and to this is added two tablespoonfuls of limewater. If a larger quantity is needed, the same proportions are kept.

However, it seems to me that ROTCH's plan is better, as it is simpler and allows more accuracy and variety in modification. He lets a quart of good milk stand in ice-water for six hours, and siphons off from the bottom 24 oz. of milk, leaving 8 oz. of cream on the top, which will, on the average, contain 10 per cent. of fat.

Now it becomes a comparatively simple matter to

if good human milk in sufficient quantity can be obtained. When cow's milk is used, it must be modified to resemble as closely as possible human milk. Cow's milk contains somewhat less fat than woman's

milk, but the former contains 3.76 per cent. of albuminoids, while the latter only contains 1.94 per cent., or about one-half, and of the albuminoids, the casein in cow's milk is five times, while the albumin is only one-half, as great as in human milk. If we remember that cow's milk contains more proteids and less fat and sugar, that it is distinctly acid, while the other is slightly alkaline, we have a basis upon which to prepare the food.

The general principle underlying all methods of artificial infant-feeding is to modify cow's milk so that it will resemble as closely as possible human milk; and this is done by diluting with water to reduce the percentage of albuminoids to the proper amount, and adding enough cream and sugar of milk to raise their percentage to that in normal human milk, not forgetting to compensate for the loss brought about by the first dilution with water.

The average milk for a baby will contain 4 per cent. of fat, 7 per cent. of sugar, and 1 to 2 per cent. of proteids, which proportion can be approximately obtained by mixing cream, milk, sugar of milk, and water in proper quantities, and adding

enough bicarbonate of soda or saccharated solution of lime to make the mixture slightly alkaline.

Good centrifugal cream contains about 20 per cent. of fat, but even where people have their own cow the cream is liable to be exposed to contamination by being kept too long. Therefore, it is wiser to use a cream obtained by either Meigs's or Rotch's method, although it is weaker in fat. MEIGS thus

* Read before the Hospital Graduates' Club.

to get any percentage of fat, proteids, and sugar. The average milk-namely, 4 per cent. fat, 7 per cent. sugar, 1 per cent. proteids-will be obtained by mixing 8 oz. cream, 1 oz. lime water, 11 oz. water, "4-7-2" milk and 84 dr. of milk-sugar (no milk); will be obtained by mixing 8 oz. cream, 2 oz. milk, 1 oz. limewater, 8 oz. water, and 7 oz. milk-sugar, etc. By increasing the cream, the percentage of fat and proteids will be increased in a 20oz. mixture by about 0.5 per cent. of the former and o. 18 per cent. of the latter for each ounce; the percentage of proteids will be increased 0.18 per cent. for each ounce of the skimmed milk., etc.

Even more accurate than the home modification of the food is the process of the Walker-Gordon Laboratory, and this undoubtedly marks an era in the use of infant-foods. The objections to it are those which apply to all patented processes, and its expense. My own experience has been that the best results are obtained by the home modification of a cow's milk which is wholesome and properly handled; and when such a milk can be obtained, the infant thrives on a raw milk much better than on a

pasteurized or sterilized one. And again, I usually ble with rennet or dilute hydrochloric acid, and subremove as much of the casein of the milk as possistitute in its place the albumen from an egg.

This

gives better results, as we would expect when we re

member that the proteids of cow's milk, as compared to human milk, is for casein, as 3.01 is to o 63, while for albumen it is as 0.75 is to 1.31. In other words, cow's milk contains five times as much casein and only one-half as much albumin as human milk.

There is no doubt that some children with weak digestion require certain additions to the foregoing combinations; and the question of adding cereals, Liebig foods, milk foods, meat juice, or of sterilizing,

pasteurizing, or peptonizing the food presents problems that would require more time to discuss than can be devoted to it in this short paper.

The farinaceous foods and the so-called milk-foods are, in my experience, rarely or never indicated, and are usually harmful. The Liebig foods are often of value in children with poor digestive powers; but it must be remembered that they never can and do not claim to be a substitute for milk, but are only to be used as a valuable addition in certain cases to properly handled and properly modified cow's milk.

THE ACTION OF STRYCHNINE IN PULMONARY CONSUMPTION IN RELATION TO THE NEUROTIC ORIGIN OF THIS DISEASE *

By THOMAS J. MAYS, A.M., M.D. Professor of Diseases of the Chest in the Philadelphia Polyclinic, and Visiting Physician to the Rush Hospital for Consumption in Philadelphia

F

REEDOM of thought is the foundation of all progress; and while this law develops a diversity of opinion in practical therapeutics so great as to give rise to the belief that no two physicians treat the same disease in the same way, it is nevertheless true that in the struggle to relieve and cure diseases we consciously or unconsciously seek and follow methods which finally lead to the adoption of the same principles, if not of the same details of treatment. This unanimity in practice is sometimes reached through certain etiological and pathological convictions which we hold of disease; or, as is most often the case, we are driven to it by the power which comes from witnessing the successful effects of well-directed medication, either in the hands of others or in our own, and in spite of any theory we may possess in regard to the origin or the

mechanism of disease.

For a number of years I have said and written a good deal in favor of the neurotic origin of pulmonary consumption; and while this theory may not be perfect in all its details, I believe that it gives us a more rational explanation of the causes and of the nature of this disease than any other. Not only do I feel convinced of this, but my experience assures me that the therapeutic measures which are directly addressed to the nervous system are the most effective in the relief and cure of this disease. Led by

these considerations I have employed in the treatment of this disease a number of neurotic agents, the principal one of which is strychnine, and to which I shall now devote a few remarks.

Of all the drugs in the materia medica, there is none that compares favorably with the action of strychnine in the treatment of pulmonary consumption. As is well known this agent has an elective affinity for the whole nervous system, but over and above this it possesses a special influence on the nerves which preside over the function of respiration. Its action is reputed to be wholly devoted to

Read before the Section on Neurology and Medical Jurisprudence of American Medical Association, May, 1896.

the motor nervous system; but there is some reason for believing that it also affects the peripheral sensory nerves. In small doses it stimulates, in medium doses it tetanizes, and in large doses it paralyzes the nervous system. paralyzes the nervous system. Thus, for example, a small dose invigorates the normal movements of a frog, a medium dose throws him into a stiff tetanus, while a large dose produces no appreciable stimulant or tetanic action, but brings on as marked a degree of general paralysis as if he had received a large dose of curare, or of morphine. The dose is a relative or movable quantity, however, for that which produces tetanus or paralysis at one time may act as a stimulus at another.

The action of strychnine may be compared to the shape of a cone; one side of which, from the base to the apex, represents the stimulant side of its action, the apex its tetanic action, while the opposite side, from the apex to the base, represents its paralyzing action.

How then does strychnine act in pulmonary consumption? It is taken for granted, of course, that the lung disease is merely a superficial manifestation of disorder of the pulmonary nerve supply. Therefore, the strychnine primarily raises the tone of the nervous system as a whole, and of the respiratory nerves in particular. In this way it not only increases the resistance of the lung to disease, but it aids digestion, assimilation, and blood-building. Let us say, for example, that the tone of the nervous system is depressed so far that it is located near the

next week give dose to about

base of the cone, and that we wish to raise it from this point to as high a level as is consistent with health. By employing strychnine we can do this, but we must be careful to avoid the apex danger-point, yet at the same time this point must be hugged as closely as is consistent with the safety of the patient. The best way to bring about this object is to begin. with a moderately small dose of the drug, say 3 grn. four times a day; give this for one week, then increase it to grn. for another week; during the grn.; the following week raise the grn., and so on, making a slight increase every week until you observe nervousness, restlessness, or twitching-the signs of the beginning of strychnine intoxication. In most cases these symptoms do not develop untilorgrn., or even It must be understood a larger dose, is reached. that the drug is to be given in these doses four or five times a day. The aim is to impress the nervous system with the full stimulant effect of this drug. The sooner this end is attained the better it will be for the patient. For this reason you begin with small doses and work upward as rapidly as you can with safety. After the desired point has been reached, the question arises whether it is better to go on with the largest dose, or to go back and start with the original dose. I think it is best not to wander far away from this line during the remainder of the treatment, for you do not want to lose the grip on what you have so far accomplished. Keep the strychnine-tone up to the highest level, but shun the

point where the strychnine-stimulus goes over into the region of tetanus and of paralysis It is good policy, however, to reduce the dose at this point somewhat. If, for example, it is found that grn. is a maximum dose, go back to grn.; gradually increase the dose again until grn. is reached, and then return to or grn. After you have gone over the same ground several times in this see-saw fashion, you will probably find that grn. no longer produces any danger symptoms, and that you now can give as much as grn. When administered in this way the drug may be given for an indefinite period in the great majority of phthisical patients.

The remedial effects of the drug show themselves in various directions. The nervousness and sleeplessness and pain in the chest will be ameliorated, and perhaps will entirely disappear; the cough, expectoration, and the dyspnea will diminish; vomiting will abate; the appetite improve; the patient gain in flesh and in color; the weak and frequently acting heart will become quieter and stronger, the red corpuscles increase in number, and the whole outlook of the patient will become more hopeful and brighter..

Of all the drugs in our possession, strychnine makes the most profound impression on the nervous system, and, in my opinion, it, too, yields a larger measure of benefit in the treatment of pulmonary consumption than can be derived from any other single agent. In connection with it I employ wellregulated rest, good food, quinine, phenacetin, hypophosphites, electricity, cod-liver oil, etc.

In conclusion, I will not weary you by relating any examples from my experience in confirmation of what I have said', but will take the liberty of quoting in part a most interesting "case of phthisis apparently cured," which is reported by Dr. WILLIAM PEPPER in the December (1895) number of The University Medical Magazine. The patient, female, aged 21, with a decided phthisical family history, began to emaciate rapidly in March, 1893, and in less than a month she was bedridden and only weighed 100 pounds. She had high fever, night sweats, anorexia, vomiting, copious expectoration, and all the physical signs of pulmonary disintegration. She received an egg-albumen diet, and the medicinal treatment consisted of grn. of strychnine nitrate with Too grn. of atropine sulphate every two hours hypodermatically, and grn. of strychnine nitrate with grn. of the double chloride of gold and sodium, and grn. of a vegetable digestive every two hours by the mouth. After a few days the amount of gold and sodium was increased to grn. every two hours. At first she showed signs of strychnine-intoxication, and the dose was reduced; but she soon resumed the original dose, and after the first two weeks she bore the drug well, although always just inside the border-line of its toxic action. During April she improved decidedly, and during May the improvement

1 "The Strychnine-treatment of Pulmonary Consumption," A. M.-S. BULLETIN, May 15, 1894.

was very rapid. By the latter part of this month she weighed 125 lbs. The abnormal physical signs and the tubercle bacilli disappeared, and in September she weighed 132 lbs. and was in perfect. health. In August, 1895, she had a slight attack of pneumonia, after which all the symptoms she had had two years previously recurred, and her weight fell to 114 lbs. She was placed on her former treatment and she made a rapid recovery. On November she again weighed 124 lbs., her cough and expectoration had almost disappeared. No tubercle bacilli were found since previous October.

Dr. PEPPER, in summing up the case, says that among its noteworthy points are the absence from the treatment of all cough medication and antiseptics, and the large doses of strychnine, and the double chloride of gold and sodium with which the system was kept literally saturated.

There can be no doubt that this was a most desperate and an apparently hopeless case of phthisis from its very outset, and great credit attaches to the distinguished prescriber for guiding it to such a successful termination. The question arises as to which of the agents played the most prominent rôle in bringing about this issue. From my own experience with the drugs which were employed, I believe that the strychnine is chiefly responsible for this, although in forming a correct estimate we must not lose sight of the value of the nutritious food which she received, and of the physical rest to which she was, in all probability, subjected.

Now, when we take into consideration that insanity, idiocy, hysteria, chorea, epilepsy, asthma, and all forms of nervous disorder are excessively prone to develop into pulmonary phthisis; that the former diseases are frequently converted into the latter through heredity; that all poisons like those of alcohol, syphilis, lead, mercury, influenza, whoopingcough, etc., have a power of engendering nervous disease and pulmonary consumption, and, as a matter of fact, the former are followed by the latter disease; and that the markedly beneficial action of strychnine in this disease comes exclusively through the nervous system, it does not require a very great stretch of the imagination to perceive that the neurotic element plays a leading part in the etiology of pulmonary consumption.

Philadelphia; 1829 Spruce street.

being jammed between two railroad cars four years before. The mid-dorsal region of his back and one arm had been badly bruised. He had been comatose for four days and confined to his bed for two months. At the end of this period he seemed to have received no permanent bodily injury and was not paralyzed.

His health, however, although gradually improving, remained very poor, never entirely recovering from the effects of the accident, and he gradually developed a number of nervous symptoms which puzzled the local physicians.

During the first year after his accident, despite his shattered nervous condition, he was able to do a little work.

In September, 1894, three years after the accident, he complained that his stomach troubled him, and he vomited occasionally. In January, 1895, his

anemic and weak, suffering from spastic paraplegia and only able to walk with assistance; he presented marked ataxia, much increased knee-jerks, and ankle-clonus on both sides. Blindness and deafness were complete, yet he was mentally bright, and answered promptly all questions put to him by means of the deaf and dumb finger-sign language. The memory was unimpaired. He was in a very fretful, nervous condition, complaining bitterly of pain in his head, especially in the vertex and occipital region, and of indefinite pains equally severe in various parts of his body. There was, moreover, a recent hematoma in the occipital region, caused by a fall. A sudden jar of any part of his body seemed to make him complain, as if in pain.

The skin seemed anesthetic to the touch in most places; but after a number of seconds of delayed

yesight began to fail. In February he began to hold his head upon one side and his eyes were worse. One day, in March, his right eye suddenly became totally blind. He became somewhat deaf. His face was paralyzed on the left side, his right arm felt "dead," but not "stiff." His legs were both His legs were both "paralyzed" and "stiff."

Within 24 hours, however, he again, rather suddenly, recovered the use of his arms and legs, but in the course of two weeks he became absolutely deaf in both ears and had been deaf and blind ever since. The history since that time had been one of increasing feebleness and nervousness but with no change in the condition of the arms and legs. The nervous symptoms were said by the family to have varied from day to day.

When the patient was first seen by the writer, December, 1895, he was a man of large frame,

sensation to a pin-prick, he would begin to feel it and would cry with pain.

The buttocks and lumbar region (just below where he had been jammed by the cars) were almost hyperesthetic, with no delay of sensation. He was extremely sensitive to cold objects, much less so to warm. Extreme ataxia of the legs was present and an irregular jerky ataxia of the arms which was practically an exaggerated intention tremor. He was in a condition of very unstable equilibrium so that when pushed with a moderate degree of force he fell over sideways toward his right. The voice. was monotonous and "scanning," and he stumbled very noticeably over long words. The hands were weak and registered twenty-five pounds with a dy

namometer.

There was no paralysis of the external eye muscles, no reaction of the pupils to light, although they were

dilated. There was a constant twitching of the eyes. Ophthalmoscopic examination, although unsatisfactory on account of the intense nervous condition of the patient and the deficiency of the light, gave evidence of a very pale optic disk, and suggested probable optic atrophy. His face was not paralyzed, but showed very little expression. The tongue moved normally. He complained of a constriction or lump in his throat, which he said made it difficult for him to swallow anything. The heart, lungs, and arteries were normal. There was no anesthesia

of the cornea or pharynx. The control of the sphincters was normal.

On

The first impression derived from this case was that it was some form of traumatic hysteria or railroad spine," following his railroad accident, and that his various symptoms were purely functional. This view was rejected because of the long period of negative symptoms, the sudden apoplectiform attack a year before, with its blindness, deafness, and paralysisall of which indicated some real organic lesion. account of the difficulty of explaining by one local lesion the combination of symptoms referable to the brain, spinal cord, and peripheral and cranial nerves, some lesion disseminated over various parts of the nervous system seemed probable. His spastic gait, ankle-clonus, jerky intention tremor, peculiar "scanning" or monotonous voice, and irregular indefinite sensory symptoms made the diagnosis of a disseminated or multiple sclerosis reasonable and adequate to properly explain the entire combination of symptoms.

Further study of the case, absolutely laying aside all the indefinite nervous symptoms, and noting the fairly clear history of vomiting, blindness, vertigo, intense headache, localized, and tenderness on touching the head, together with the well-marked cachexia, made the diagnosis of brain tumor seem more probable.

He was sent soon after this to the Methodist Episcopal Hospital with a request for further eye examination to settle the diagnosis. He there developed difficulty of deglutition, rapid pulse, opisthotonos and marked respiratory symptoms, dying suddenly a few days after admission. No attempt to examine his eyes had been made.

The autopsy was performed by Dr. WM. BELCHER. The thoracic and abdominal viscera were normal. Under the scalp posteriorly was a recent hematoma, partly absorbed. The calvarium was very thin in spots.

The dura externally was normal. On removal of the brain the tentorium cerebelli was found adherent, and on its upper surface was a tumor which grew in both directions, but chiefly upward, forward, and inward. It presented internally toward the left cuneus and precuneus, but did not affect the falx cerebri. It took the place of the entire occipital lobe, and extended 20 ctm. laterally to the external limit of the hemisphere, and was in contact with the calvarium, which was thinned in the parts adjacent to the tumor. It measured 6 ctm. antero-posteriorly and vertically, fitting against the remnants of the

It

occipital and posterior parietal and temporal convolutions. Its general form was kidney-shaped, and was placed with its long diameter laterally. weighed 300 gme., and was extremely hard, containing ovoid nodules. The rest of the brain was large and edematous, with flattened convolutions, and contained no other tumor. The right hemisphere was broader and shorter than the left, to make room for the mass. The right occipital lobe, the cuneus, precuneus, and the fourth and fifth temporal convolutions of the right side were all wanting, or were compressed into an indistinguishable mass. The spinal cord was absolutely normal.

The tumor was thought by Dr. BELCHER to be an endothelioma, springing from the tissues of the dura. Its exact nature was obscure, and it seemed to several who studied it to be sarcomatous, but more careful study of sections demonstrated that the diagnosis of endothelioma was correct.

The most interesting points in this case are: First, the history of the railroad accident with the resulting shock to the nervous system; second, the indefinite and largely functional nervous symptoms of the first two or three years; third, the acute and apoplectiform nature of the symptoms in February and March, 1895; fourth, the marked spinal character of most of the symptoms of the last year; and, fifth, the enormous size of the tumor found in the occipital region after death.

There are frequently histories of malignant tumors recorded which seem to have followed traumatism. The following two cases of cerebral tumors show a certain amount of connection between a previous traumatic cause and the subsequent production of a brain tumor: KEEN (Amer. Jour. Med. Sc., Oct., 1888) describes a man who fell from a window when a child, striking his head against a brick. Epilepsy developed when he was 23 years old. A brain tumor was removed three years later. KNAPP and BRADFORD (Bost. Med. and Surg. Jour., April 4, 1890) give the history of a man who received a blow on the head in 1868, followed on the next day by convulsions. From 1886 to 1888 he developed various symptoms of a brain tumor, which was diagnosed and localized. A large tubercular tumor was successfully removed.

Tumors arising from traumatism are more frequently sarcomatous than of any other variety. SENN says, in reference to such a connection: "Sarcoma may be developed, in consequence of an injury, from the embryonic tissue which was arrested in the course of its development into mature tissue by unknown local or general influences. We must therefore admit that the transformation of a benign growth and of a matrix of embryonic cells of post-natal origin into a malignant tumor is not only possible but probable, when the embryonic cells, under the influence of local or general causes, assume active tissue-proliferation, and their migration is permitted by a diminished physiological resistance. on the part of adjacent tissues." This relation between a severe traumatism and a malignant growth