THE ARTIFICIAL FEEDING OF INFANTS. 
BY T. M. ROTCH, M.D., 
VISITING PHYSICIAN TO THE BOSTON CITY HOSPITAL; INSTRUCTOR IN DISEASES 
OF CHILDREN IN THE HARVARD MEDICAL SCHOOL. 
READ BEFORE THE OBSTETRICAL SOCIETY OF BOSTON, MAY 28, 1887. 
Reprinted from the Archives of Pediatrics, August, 1887. THE ARTIFICIAL FEEDING OF INFANTS.* 
BY T. M. ROTCH, M.D., 
Visiting Physician to the Boston City Hospital; Instructor in Diseases of Children 
in the Harvard Medical School. 
While recognizing the importance of feeding infants dur- 
ing the early months of life by means of human milk, we 
must allow that in civilized communities the necessity of sup- 
plying the infant with food not directly from the human 
breast must often arise, and will in all probability be a de- 
mand which will increase rather than decrease as our civiliza- 
tion advances; and when in addition to this we consider the 
great proportionate mortality of the artificially-fed over the 
breast-fed, and the difficulties which are so frequently met 
with in adapting the food to the individual case, it manifestly 
becomes a duty to carefully investigate the different methods 
of artificial feeding, and adopt some more uniform plan for 
starting human beings in life than is met with among phy- 
sicians as a class and the laity as a whole, for diversity and not 
uniformity is the rule. 
With the exception of the very small proportionate per 
cent, of inherited diseases which occur at birth, this diversity 
of method in feeding is the most prolific source of disease in 
early infancy. The group of symptoms which for want of a 
better name is represented by dyspepsia, difficult digestion, 
occurs most frequently in the three periods when the infant's 
digestion is likely to be tampered with,-namely, in the early 
weeks of life, when experiments are being made to determine 
what food will be best to start with ; next, when in addition 
to the irritation arising from the beginning of dentition new 
articles of diet are added to the original food; and, thirdly, at 
* Read before the Obstetrical Society of Boston, May 28, 1887. 2 
The Artificial Feeding of Infants. 
the time of weaning, when there is often a sudden and entire 
change in the charactei' of the food. 
The proper management of the first of these periods is of 
the greatest comparative importance, because it is the time 
when the function of digestion is being established and is in 
a state of unstable equilibrium, and therefore, following the 
rule of functional establishment, the stomach is in its most 
active period of growth, and hence the most careful regulation 
of the bulk of the food given is needed to correspond to this 
activity in order that we should not weaken the digestive 
function by overtaxing its capacity and yet provide the proper 
materials for nutrition, thus avoiding by prophylaxis the dys- 
pepsia of the later periods of infancy and childhood, the seeds 
of which are continually being sown in this early transitional 
period. 
We therefore, have the question not only of infantile digestion 
but infantile development to deal with, and we should at once 
recognize the fact that the problem of artificial feeding is not a 
simple factor,-namely, which food shall we give to the infant, 
-but is a combination of factors, of which the kind of food is 
only one, and all these factors, from which we deduce the gen- 
eral problem for the average infant and the especial problem 
for the individual, must approach as closely as possible to the 
analogous factors which nature freely presents to us for inves- 
tigation,-that is, we must follow nature as closely as possible. 
Our scientific knowledge and ingenuity have not yet enabled 
us to follow nature exactly, and we therefore have not yet ob- 
tained an ideal method of artificial feeding; but we must, never- 
theless, go as far as the present state of our knowledge will 
allow, thus gaining a little ground every year; and we must 
be especially careful not to be led astray by the fictitiously 
brilliant results which are reported from time to time in favor 
of certain foods, instances continually occurring where one 
food will fail and another when substituted for it succeed; 
and yet these successes are merely temporary, and the mor- 
tality always remains far above that of human breast-milk. 
It is certainly wiser and more economical not to spare ex- 
pense and trouble in arranging the infant's diet, for, as has 
been explained above, the period of active growth of an organ The Artificial Feeding of Infants. 
3 
is the time when its function is readily weakened, and when 
once weakened the digestive function is a prolific source of 
annoyance and expense in childhood and adolescence. Cheap 
foods and cheap methods of feeding, unless they are the best 
that can be procured, should no more be tolerated, and in fact 
not nearly so much so, in the early feeding of infants than in 
adult life: we often, however, see a food recommended for a 
young infant because it is cheap and easily prepared, and yet 
where its well-known lack of nutritive ingredients would with 
adults at once stamp it as unfit for use. 
What are the general factors of the problem which consti- 
tutes nature's method of feeding? We have first a receptacle, 
the human breast, which mechanically provides a fresh supply 
of food at proper intervals, absolutely prevents fermentation 
of the food before it enters the infant's mouth, forms the 
mouth by the process of sucking, incites to action the neces- 
sary digestive fluids, avoids a vacuum by collapsing as it is 
gradually emptied, thus allowing the food to flow continuously, 
and finally is practically self-regulating as to the amount of 
daily food according to the infant's age. Second, the food 
itself adapted to the infant's digestive function and for its 
development, by its temperature, 98° to 100° F., its alkaline 
reaction, and its chemical constituents. Given these factors, 
how nearly can we approach them artificially? Human in- 
genuity has not yet been able to devise anything which ap- 
proaches the perfection of nature's receptacle, and the best 
that we can do to offset this complex mechanism is to adopt 
that which is exactly the reverse,-namely, a receptacle of 
absolute simplicity,-and thus combat the tendency to fermen- 
tation by, through perfect cleanliness, preventing the receptacle 
from becoming a source of fermentation. To meet this de- 
mand I have had made what are practically enlarged test-tubes, 
which not having any angles are readily cleaned. 
The receptacle, however, has to receive a food which usually 
is non-sterilized, and hence, where the factor of fermentation 
appears to be prominent in disturbing the infant's digestion, 
the food should be sterilized before it is given to the infant. 
The process of sterilization is most simply accomplished by 
placing the food in one of the above spoken of feeding-tubes, 4 
The Artificial Feeding of Infants. 
adjusting the rubber nipple as on any nursing-bottle, then 
drawing tightly over the nipple and well down on to the tube 
a strong rubber cot, which, not being perforated, completely 
excludes the air. The tube is then exposed to steam confined 
in any vessel for twenty minutes, which is sufficient to render 
it sterile, in the sense of destroying the developed bacteria and 
thus making it correspond to human milk; at the same time, 
so far as my investigations on this subject have gone, the 
steam, while it sterilizes, does not apparently alter the chemi- 
cal attributes of the food, as is essentially the case where the 
sterilization is accomplished by boiling; then again, in the 
steaming process the receptacle is sterilized as well as the food, 
so that when the rubber cot is removed we have the food 
enter the infant's mouth as free from bacteria as has been 
shown to be the case with human milk by Esherich,* who 
experimented with the milk of twenty-five healthy women, 
and found, by keeping it in sterilized tubes, that it remained 
sterile for some weeks, while, on the contrary, in women whose 
temperature was raised from fissures and excoriations of the 
nipple and by general puerperal infection, bacteria were found 
in abundance. It is thus seen that this factor of sterilization 
is likely to be found of considerable importance in the future, 
and should certainly be called to our aid in those cases where 
the other factors of our problem are as nearly correct as we 
can make them, and, if for no other reason, because nature 
plainly tells us that a perfect food should be sterile, and, in fact, 
our practical clinical experience for years has taught us to 
withdraw the infant from the breast in exactly that class of 
diseases where we now know bacteria to occur in the milk. 
Reference has been made above to the developed bacteria; if 
it is desired to prepare the food so that it shall remain sterile 
for some time, it is necessary to sterilize for several days in 
succession, for the first sterilization, according to Dr. Harold 
Ernst, Demonstrator of Bacteriology in the Harvard Medical 
School, only destroys these developed bacteria, while the spores 
are left to develop later. Dr. Ernst also kindly placed one of 
my tubes in which there was a mixture of cream, milk, lime- 
* Baumgarten's Jahresbericht. Erster Jahrgang, 1885, p. 34. The Artificial Feeding of Infants. 
5 
water, and milk sugar in his sterilizer for twenty minutes 
and then in his incubator for twenty-four hours, and at the 
end of this time no change could be detected in the mix- 
ture, either in color, odor, or taste, all of which appeared to 
exactly correspond to a freshly prepared mixture of the same 
kind. 
I have devised a simple apparatus for household use, which 
can be made at any tinsmith's at small expense, and answers 
for the purpose of sterilization very well. 
'It is a round tin pail, eight inches in diameter and fourteen 
inches deep, raised on three legs, sufficiently high to allow an 
alcohol lamp to stand under it; four inches from the bottom 
of the pail on the inside is a perforated tin diaphragm on 
which the feeding-tubes stand while being sterilized. 
The pail has a cover and handle. Water is placed in the 
bottom of the pail, and when heated by the lamp the tubes 
are soon enveloped in steam. 
The process of sucking is accomplished by the rubber nipple 
as by the breast, and a small hole near the end of the feeding- 
tube prevents a vacuum being formed and regulates the rapidity 
of the flow, while it allows it to be continuous; this is done by 
rolling up the edge of the rubber nipple from the hole with the 
finger, or letting it cover the hole according to the demand 
shown by the infant when feeding. 
The artificial receptacle is not self-regulating, and hence we 
must first determine anatomically the amount of food in bulk 
which nature provides for the average infant at different ages, 
and from these average figures deduce the proper amount for 
the especial infant, having also the feeding-tubes graduated 
for the more important periods of growth, for the purpose of 
continually impressing, upon the mother and nurse, what the 
physician only has the opportunity of telling them at the be- 
ginning of the nursing period,-namely, that the error is in 
giving too much food rather than too little, an error also 
which naturally results when, as is commonly the case, the 
usual eight-ounce nursing-bottle is provided as the receptacle 
at the very beginning of infantile life. 
Diagram I. represents the stomach of an infant five days 
old, in life-size. 6 
The Artificial Feeding of Infants. 
The specimen was prepared by Dr. C. W. Townsend, and 
was found to hold twenty-five cubic centimetres. 
Diagram I. 
Diagram II. 
Diagram II. represents the size of the tube, which is 
sufficiently large for each feeding during the first week; and 
when we consider the space which would be needed to repre- 
sent the full-sized nursing-bottle, these two diagrams express 
better than can be explained by words the disproportion be- 
tween the size of the infant's stomach and the amount which 
the mother supposes it should hold to keep her child from 
being starved. 
Frolowsky's* investigations show that the activity of 
growth in the stomach's capacity can be represented by the 
ratio of one for the first week, to two and one-half for the 
fourth week, and three and one-fifth for the eighth week, 
while it is only three and one-third for the twelfth week, 
three and four-sevenths for the sixteenth week, and three 
and three-fifths for the twentieth week. 
We thus see that there is a very rapid increase in capacity 
in the first two months of life, while in the third, fourth, and 
* Inauguraldiss., St. Petersburg, 1876. The Artificial Feeding of Infants. 
7 
fifth months the increase is slight. Guided by these data, 
which we find correspond closely with the results of clinical 
investigations bearing on this point, we should rapidly increase 
the quantity of the food in the first six or eight weeks, and 
then give the same quantity up to the fifth or sixth month, 
unless the infant's appetite evidently demands more, when of 
course a gradual increase should be made. A considerable 
increase in the quantity needed, also, usually takes place be- 
tween the sixth and tenth month. 
Ssnitkin, after a series of careful investigations in the 
Children's Hospital at St. Petersburg to determine the amount 
which should be given in the first thirty days of life, finds 
that the greater the weight the greater is the gastric capacity. 
His general results also show that one one-hundredth of the 
initial weight should be taken as the starting figure, and to 
this should be added one gramme to each day of life. This, 
for example, gives the following amounts for each feeding, 
which closely correspond to the average figures which I have 
computed and introduced in Table I. on the basis of three 
thousand grammes as the initial weight. Thus, one one- 
hundredth of three thousand would be thirty grammes for 
the early days, and at thirty days the amount given would be 
30 + 30 = 60 grammes, about two ounces. 
The younger the infant the greater the metabolic activity, 
and hence the greater need for frequent feeding, for nutriment 
is required not only for the excess of waste but also for the 
rapid proportionate growth; this makes the intervals of feed- 
ing a factor of considerable importance in the management 
of the infant's diet. 
The figures in Table I. are merely approximate average 
computations taken from the results of a number of Russian, 
German, and American observers and from my own experi- 
ence during the past ten years, and are only intended to be a 
guide for the physician in his management of cases of difficult 
digestion, for of course some infants will have a greater ap- 
petite and a greater power for digestion than others of the 
same age and weight. 8 
The Artificial Feeding of Infants. 
Table I. 
The average initial weight of infants is 3000-4000 grammes = about 6-8 pounds. 
The average normal gain per day in the first 5 months is 20-30 grammes = about 1 ounce. 
General Rules for Feeding. 
Age. 
Intervals of 
Feeding. 
Number of Feedings 
in 24 Hours. 
Average Amount at 
each Feeding. 
Average Amount in 
24 Hours. 
let week 
2 hours. 
10 
1 ounce. 
10 ounces. 
1-6 weeks . 
m hours. 
8 
1% to 2 ounces. 
12 to 16 ounces. 
6-12 weeks, 
and possibly 
to 6th or 6th 
month . . 
3 hours. 
6 
3 to 4 ounces. 
18 to 24 ounces. 
At 6 mos. . 
3 hours. 
6 
6 ounces. 
36 ounces. 
At 10 mos. . 
3 hours. 
5 
8 ounces. 
40 ounces. 
The weight, as well as the age, is necessary to determine the amount for each feeding in the 
individual infant, the rule being rJ5 of the initial weight 4- 1 gramme for each day during 
the first month. 
Illustrations of above rule to serve as guides for especially difficult cases. 
Each Feeding. 
1 
1 
Initial Weight. 
Early Days. 
I 
At 15 Days. 
1 
At 30 Days. 
3000 grammes. 
30 grammes (about 31). 
30 4-15 = 45 grammes 
(about 31%). 
30 4- 30 = 60 grammes 
(about 32). 
4500 grammes. 
45 grammes (about 31%). 
45 4-15 = 60 grammes 
(about J2). 
45 4- 30 - 75 grammes 
(about 32%). 
6000 grammes. 
60 grammes (about 32). 
60 4- 15 = 75 grammes 
(about 32%). 
60 4- 30 = 90 grammes 
(about S3). 
I have experimented with the glass-blower in having tubes 
of different sizes made, and finally out of a large number of 
samples the following have been chosen as the most practical 
and the easiest to handle. For convenience I have had these 
tubes fitted to a box, which also contains directions for their The Artificial Feeding of Infants. 
9 
use. The tubes as seen in Diagrams III. and IV. are merely- 
enlarged test-tubes blown into a glass standard, and having a 
small hole at the mouth for the entrance of air. 
Diagram III. 
Diagram IV. 
A measuring-glass graduated to hold two ounces, and shaped 
like the larger tubes, is also in the box, and is used as a feed- 
ing-tube during the first six weeks, and later as a measure for 
the larger tubes. The smaller tube, Diagram IV., holds four 
ounces, has a calibre of one and five-eighths inches, and a 
height of six inches; it is to be used from the sixth week to 
the fifth or sixth month, and is intended to correspond to the 
above-described rapid growth of the stomach in the first two 
months, and its insignificant further increase in size up to the 
fifth or sixth month; it is represented in the diagram with 
the nipple adjusted for use. The large tube, Diagram III., 
has a calibre of one and six-eighths inches, a height of eight 
and three-fourths inches, and corresponds to the common half- 
pint nursing-bottle; it is represented in the diagram without 
the nipple, and shows the air-hole. 
The box, besides the rubber nipple, contains a rubber cot 10 
The Artificial Feeding of Infants. 
for sterilization, test-paper for ascertaining the reaction of the 
food, and a bottle of soda for keeping the tubes pure during 
the intervals of nursing. 
A medium-sized tube, which does not come with the box, 
but can be haa separately, has a calibre of one and six-eighths 
inches, a height of seven and three-fourths inches, and holds 
six ounces. It of course is not a necessity, but is intended to 
be used between the sixth and tenth month, merely to enun- 
ciate the importance of careful supervision of quantity through- 
out the first year, as where a food qualitatively correct is being 
used, the error, as a rule, is in giving too great an amount 
quantitatively than too little, and a food which otherwise 
would be digested perfectly well often fails if it is given in 
too large an amount or at improper intervals; we may, how- 
ever, here notice that while in breast-feeding frequent feeding 
is contraindicated from its altering the character of the food, 
in fact, condensing it, this trouble does not of course arise in 
artificial feeding, the food remaining the same, and we thus 
have a little more latitude given us in our management than 
we can have in regulating the breast-feeding. 
The question of the food itself in artificial feeding is prac- 
tically reduced to some modification of cow's milk or to cow's 
milk itself, for in most civilized communities cow's milk is 
far more easily obtained than other milks; and although the 
milk of other animals may approach more nearly the per cents, 
of the ingredients of human milk, they must all be modified, 
and if we modify at all, it is as easy to deal with cow's milk 
as with these other milks. Then, again, the various foods, 
patent or not, all depend for their basis on milk, and without 
this addition of milk would show but an insignificant percent- 
age of many of the most important ingredients of the food, so 
that logically we should speak not of the various foods as such, 
but merely as adjuvants to cow's milk, for if this is thoroughly 
understood it will, in many minds, do away with much mis- 
apprehension regarding the apparently successful results of 
innumerable foods which, in reality, when given to the infant, 
are merely a means of modifying the almost universal repre- 
sentative of the artificial foods, cow's milk. Cow's milk, 
therefore, should be carefully compared with the standard The Artificial Feeding of Infants. 
11 
human milk in order that we should know how nearly it re- 
sembles it, and Table II. is a comparison of the two foods, the 
figures representing the later and more reliable analyses. In 
considering the preparation of the various foods with reference 
to making them correspond in their analyses as'nearly as pos- 
sible to human milk, the problem is somewhat simplified if we 
recognize the fact that although the per cents, of the ingre- 
dients of human milk vary under certain circumstances, yet so 
far as the age is concerned, in the early months there is so 
little variation that a variation is as likely to occur between 
different milks of the same age as the same milk at different 
ages, so that we probably are doing wisely not to change the 
per cent, of the ingredients, but as the infant grows older give 
a food qualitatively uniform but of varying quantity. 
From the comparison, we at once see that cow's milk itself 
differs so markedly from human milk that it evidently should 
be modified before being used as a food. 
It may be modified by water, or by the patent foods, or by 
any adjuvant, such as barley-water, lime-water, or its own 
cream. 
There is a very large number of patent foods, but they all 
claim about the same advantages, and closely resemble each 
other in their constituents, and in their honest endeavor to make 
cow's milk easily digestible, and also to make their resulting 
analysis agree as closely as possible with human milk. There 
are, however, certain differences by which we can divide them 
into classes, and we can speak of individual foods as represent- 
ing their class. 
Human Milk. 
87-88 
13-12 
Water 
Total solids 
Cow's Milk. 
86-87 
14-13 
4. 
Fat 
4. 
1. 
Albuminoids.. 
4. 
7. 
Sugar 
4.5 
0.2 
Ash 
0.7 
Alkaline. 
Reaction 
.. Acid. 
Small proportionately 
Coagulable albuminoids 
..Large proportionately. 
• Marked in test-tube: 
greatest with pure 
Scarcely perceptible in 1 
test-tube. ) 
Coagulation by acids . 
milk; least when 
mixed with lime- 
water or barley- 
water. 
Not present. 
Bacteria 
... Present. 
Table II. 12 
The Artificial Feeding of Infants. 
My own opinion in regard to patent foods as a whole is that 
they must necessarily be unreliable; they are thrown on the 
market in such numbers that the competition is extreme, and 
when once they have made a reputation I cannot but feel that 
irregularities and changes, slight, perhaps, in the eyes of the 
makers, may unintentionally creep in and carry their analysis 
still further from that of the standard human milk than it 
was in the beginning. 
Analyses show that there is a lack of uniformity from year 
to year, and that original claims are apparently forgotten or 
allowed to give way to cheaper production. A striking ex- 
ample of the truth of this statement is the world-wide repu- 
tation of Mellin's Food, with its printed analysis, by Dr. 
Leeds, showing that it contains no starch, its starch having 
been converted into sugar; and yet careful analyses made later 
by Dr. Charles Harrington, of the Harvard Medical School, 
show conclusively that all the starch has not been converted 
into sugar, and that it is present in very appreciable quantity,- 
perhaps, as it may be argued, not in sufficient quantity to do 
any harm, but, as it is claimed not to be present at all, it gives 
rise to an element of uncertainty. If we wish to be exact in 
the preparation of our food, and if we wish to introduce 
starch into the food, we should prefer to use a food where 
starch is acknowledged to exist, and can be reduced to the 
amount which we may deem necessary for the especial case; 
and yet just as the makers of Mellin's Food in good faith 
state that it contains no starch, while the unquestioned reputa- 
tion of Dr. Harrington as a chemist proves that in certain 
cases at least they are mistaken, so in the patent foods which 
claim to contain starch in a certain percentage, that percentage 
may vary so much as to make any combination which we may 
wish to make an uncertain rather than an exact one. Besides 
the objections just given to these foods as a whole, it will be 
seen by referring to the representatives of each class as shown 
in Table HI. (page 14), that, even taking the analysis as 
given by Dr. Leeds and also the percentage of the ingredients 
when mixed, according to the maker's direction, with cow's 
milk, there is a striking similarity in all of them, in that they 
all show a marked variation from the standard human milk. The Artificial Feeding of Infants. 
13 
The patent foods can practically be divided into those which 
are manufactured from cereals and those which are not. The 
first class contains the starch of the cereal unchanged or con- 
verted into sugar. 
We have then, I. A cereal food with its starch unchanged, 
represented by Imperial Granum. II. A cereal food with its 
starch claimed to be converted into sugar, represented by 
Mellin's Food. III. A cereal mixed with condensed milk, its 
starch unchanged, and represented by Nestle's Food. IV. Con- 
densed milk. V. The so-called humanized or peptonized milk. 
I have prepared Table III. not only to show the ingredients 
of the representative foods (the analyses of the patent foods in 
Table III. were made by Prof. Leeds, and were published in 
the Medical News of July 21, 1883), but the ingredients of 
the food as it is usually given to the infant, mixed with cow's 
milk, and reference to this table and to the analysis of human 
milk on the upper line will not only show the errors of nu- 
trition, which are made when we use them in this way, but 
enables us, by a simple process of calculation, to make any of 
them correspond more closely to the standard, for all of these 
foods are at times useful, provided that we use them intelli- 
gently for the especial case; but, of the foods represented in 
the table, we should avoid the patent foods for general use on 
account of the objection referred to above regarding their 
manufacture as a class; they are also the most difficult class 
of foods to make correspond to human milk. 
An examination of Table III. will at once explain how 
difficult it is to make the artificial foods correspond to human 
milk by the methods which are usually employed, and also the 
errors in percentage which result from these methods; it is, in 
fact, a series of figures which represent the element of nutri- 
tion rather than digestion, and the merits of every food should 
be determined in this way before submitting it to the test of 
clinical experience, for our common sense must certainly be 
better satisfied if we know that the infant is not only digesting 
the food, but that the food itself is similar (or as nearly so as 
we can make it) in its proportions, ingredients, and reaction 
to the standard which, in its results, shows the lowest rate of 
mortality. 14 
The Artificial Feeding of Infants. 
Human milk 
Reaction. 
Starch. 
Water. 
Total Solids. 
Fat. 
Albuminoids. 
Sugar. 
Ash. 
Alkaline. 
0 
88 
12 
3-4 
'-2 . 
7 
0.1-2 
Cow's milk 
Acid. 
0 
87 
13 
4 
4 
M 
0.7 
Cow's milk 1 
Water 2 
3 
Acid. 
.0 
95.61 
4.39 
1.33 
1.33 
1.5 
0.23 
Cow's milk 1 
Water 1 
5 ~2 
Acid. 
0 
93.4 
6.6 
2 
2 
2.25 
0.35 
Condensed milk 
0 
28 
72 
10 
10 
50 
2 
Condensed milk 1 
Water 9 
10 
Neutral. 
0 
92.8 
7.2 
1 
1 
5- 
0.2 
Condensed milk 1 
Water 6 
7 
Neutral. 
0 
89.66 
10.34 
1.45 
1.45 
7.14 
0.3 
Comparison of Human Milk with Cow's Milk and Cow's Milk Modified. 
(The figures are approximate and represent general averages.) 
Table III. The Artificial Feeding of Infants. 
15 
Imperial Granum. 
Fat 1.01 
Albuminoids 10.51 
Sugar trace. 
Ash 1.16 
Starch 78.93 
Milk 
Water 
3 
32 
64 
99 
Add. 
2.36 
92.88 
7.12 
1.33 
.03 
1.36 
1.33 
.31 
1.64 
1.5 
trace. 
1.5 
0.23 
0.03 
0.26 
Mellin's Food. 
Fat 0.15 
Albuminoids 5.95 
Sugar 48.2 
Ash 1.89 
Starch present. 
Milk 
Water 
■ T 
. 48 
. 48 
99 
Acid. 
Present. 
91.74 
8.26 
to | K) 
8 8° 
1 4- 
2.0 
.17 
2.17 
2.25 
1.44 
3.69 
0.35 
0 05 
0.4 
Nestle's Food. 
Fat 1.91 
Albuminoids 8.23 
Sugar 38.92 
Ash 1.59 
Starch 40.1 
Water 
• 1 
. 10 
11 
T 
.. 2 
3 
- 
Neutral. 
3.63 
91.69 
8.31 
0.17 
0.74 
3 63 
0.14 
Barley-Waler. 
As usually made with 
Robinson's barley con- 
tains starch 1.4. 
Milk 
Faintly acid. 
0.47 
90.75 
9.25 
2.66 
2.66 
1.11 
3.0 
0.46 
* Cream 
Milk 
Lime-water 
f Sugar-wator 
...2 
... 1 
... 3 
8 
Alkaline. 
0 
88.42 
11.58 
4.0 
6 26 
0.21 
f The sugar-water consists of milk-sugar 317%; water 01. 
* The cream must contain from 14-16 per cent. fat. 16 
The Artificial Feeding of Infants. 
It will at once be seen that no matter how cow's milk is 
diluted with water it cannot be made to correspond to human 
milk. It is well, however, to remember that clinical experi- 
ence has shown that infants seem, even in the early days of life, 
to digest the casein well enough, provided that it is sufficiently 
diluted,-that is, about four times, which reduces it to one per 
cent., and this will be of significance when we come to prepare 
a food which will correspond to human milk. If, however, we 
reduce cow's milk so that the percentage of albuminoids is one 
per cent., the fat and sugar fall so far below the standard that, 
although the ash has the proper percentage, yet we have an 
acid food markedly deficient in its nutritive quality. 
Condensed milk is one of the most interesting foods which 
we are called upon to deal with, and represents in its produc- 
tion, its chemistry, and its clinical results an almost perfect 
illustration of all that has been so far said on the subject of 
artificial foods: it has strong advocates and strong opponents, 
but a simple consideration of its vital properties will easily 
explain the causes of its successes and of its failures. 
The process of manufacture of condensed milk sterilizes it 
to a certain degree, and we thus have a very important factor 
in its favor which does not exist in cow's milk : it is also supe- 
rior to cow's milk in that when mixed with water it is, although 
not alkaline, still not acid, and its large percentage of cane 
sugar helps to avoid the occurrence of fermentation, which so 
readily occurs in cow's milk. In Table III. the percentage of 
the ingredients of condensed milk-when diluted, as it com- 
monly is, ten times-is given, and we at once see why it is 
easily digested but non-nutritious, for two of its ingredients, 
notably the fat, are found to have fallen below the standard as 
represented in the upper line of the table, the ash and casein 
only attaining the proper percentage. The nearest approach 
to the standard is obtained by diluting it with six parts of 
water, which, as shown in the table, results in giving the proper 
per cent, for the albuminoids, sugar, and ash, but the fat is still 
much reduced, and, unless supplied in some way, we should 
suppose that the nutrition would suffer, and this supposition 
appears.to be supported by clinical results. That is, clinically, 
condensed milk represents a food easily digested but not suffi- The Artificial Feeding of Infants. 
17 
ciently nutritious: the former explained by its low percentage 
of albuminoids and ash, its neutral reaction, its anti-ferment 
properties, and its proper per cent, of sugar; the latter by its 
great lack of fat. Among the poorer classes and in infant 
asylums it is a favorite food for the physician to prescribe, be- 
cause the infants digest it so easily, but the testimony of those 
clinical observers who look beyond the temporary digestion to 
the subsequent nutrition of the child supports the view that 
condensed milk, even if we set aside the objections which, in 
general, arise from its being a patent food, must be modified 
by more than the addition of water before it can safely be 
given as a continuous food to the average infant. For prepar- 
ing the way for other more nutritious foods in cases of difficult 
digestion, for convenience in travelling, and where for any 
reason the intelligence or the proper desire to take trouble about 
the food is lacking in the parents, condensed milk, from 
its simplicity in preparation as well as from its other attributes 
mentioned above, is a valuable addition to other more rational 
methods of artificial feeding. The commonly accepted opinion 
that condensed milk contains too much sugar is an error, for by 
referring to the table it Adil be seen that, as usually given, the 
sugar in the mixture is below the proper percentage, but if it is 
diluted six times, as recommended above, we then have merely 
the fat to deal with, and the reaction, which should be made 
alkaline. We must, then, modify this condensed-milk mixture; 
and not only is the fat an important factor in this modification, 
but the proper amount of fat: for although it is admitted that 
a large per cent, of surplus fat is frequently found in the nap- 
kins of infants whose digestion and nutrition are normal, and 
whose food is breast-milk, yet we have no right to conclude 
from this that a small per cent, of fat is sufficient for nutrition 
or that a large per cent, will be taken care of by this outlet; 
in fact, it is far more probable that nature introduces a certain 
per cent, of fat in human milk with a purpose which can only 
be accomplished by that per cent., and that it is an error to 
vary this per cent, beyond the variation which commonly 
occurs in average human milk. From what has been said 
above we would naturally expect that unless the standard per 
cent, was attained, or at least a near approach to it, trouble 18 
The Artificial Feeding of Infants. 
would be likely to arise, and this corresponds to my individual 
experience in the cases where the especial ingredient which was 
disturbing the success of the food was the fat: for I have found 
clinically that under the proper per cent, of fat the nutrition 
suffers, and that where the fat percentage was decidedly above 
the standard both nutrition and digestion were affected unfa- 
vorably. Unless, then, it is impossible to be more exact in 
arranging the percentage of fat in condensed milk, as is often 
the case among the poorer classes, where cod-liver oil is used 
as a cheap expedient for rectifying this source of error, the 
addition of indefinite amounts of fat to a food is to be depre- 
cated, just as it is unwise to add indefinite amounts of sugar, 
and we should seek for a better combination than is offered to 
us in condensed milk. 
Any food which introduces an element foreign to the ingre- 
dients of human milk is to be looked upon with suspicion, as 
it is not likely that we can improve on nature's method of 
adapting the food to the infant's digestive functions; we 
should therefore consider carefully before recommending the 
various classes of food which contain starch, which by refer- 
ring to Table III. will be seen to *be the foreign element 
which enters into the representative patent foods, Imperial 
Granum, Mellin's Food, and Nestle's Food. 
It of course is not merely necessary to know the percent- 
age of the different ingredients as they exist in the food itself, 
for what concerns us is the percentage as given to the infant, 
and the table therefore shows the sum totals of the milk per- 
centages and the food percentages, and a glance at these figures 
tells us whether we have an easily digestible and nutritious 
food to deal with. 
For instance, the success of Imperial Granum is evidently 
in its correct percentage of albuminoids and ash making it 
easily digestible, but its failures are readily explained by its 
reaction, its foreign ingredient, and its very low percentage of 
fat and sugar. 
Reference has been made above to the capability shown by 
even very young infants to digest the casein of cow's milk 
when it is reduced to one or two per cent., and this is a factor 
which probably enters to a greater degree than is usually The Artificial Feeding of Infants. 
19 
recognized in the easy digestion of these foods, and possibly 
too much credit has been given to the starch as a means of 
making the casein more digestible. 
This was suggested by Dr. Arthur V. Meigs some years ago, 
and is worth considering, as it certainly is more rational not 
to introduce a foreign ingredient like starch into the food if 
we can make it digestible in some other way. Examining this 
question of casein percentage in the three large classes of patent 
foods represented in Table III., we find Imperial Granum 
1.64, Mellin's Food 2.17, and Nestle's Food .74. Now all 
these correspond very closely to the casein percentage of human 
milk, that of Mellin's Food perhaps being rather high, and 
all these foods are found to be easily digestible; so also where 
barley-water is mixed in the usual way with milk, one to two, 
the casein of the resulting mixture is notably diminished in 
amount and naturally is more easily digested than when it 
stands at a higher per cent., as it does in cow's milk undiluted. 
The fat and sugar also are very notably diminished in all these 
mixtures. We therefore find from the table that there is a 
decided failure to fulfil the factor of nutrition when cow's 
milk is modified with these foods, and that all of them need 
still further modifications, some in one ingredient and some in 
another, that they all contain a foreign ingredient, and all, 
when mixed and prepared for use, fail in that important requi- 
site for at least the early months of life, an alkaline reaction. 
There are, of course, many other foods which might be 
spoken of, but they all come under one or the other classifica- 
tions above referred to. It may be well, however, to say a 
few words about peptonized milk. This is cow's milk with 
its casein partially or entirely predigested by means of the ex- 
tract of pancreas and soda. Now there is no doubt but that the 
casein of cow's milk has been a source of trouble to the in- 
fant's digestive apparatus, and under certain circumstances can, 
with great benefit to the infant's digestion, be treated by pre- 
digesting it for a time and thus allowing a stomach, which 
otherwise digests well, to rest and recover itself. It is of use, 
also, where a decided idiosyncrasy of the individual precludes 
the digestion of this especial ingredient of the milk; but be- 
sides the probability that the indigestion is often attributed to 20 
The Artificial Feeding of Infants. 
the lack of power to digest casein at all, while in fact the 
stomach is simply rebelling against an amount of casein above 
the standard per cent, or against some of the many other 
factors of the problem, it would seem that for the average 
infant digestion this predigesting of the casein or any other 
constituent of the milk is contrary to nature's teaching. There 
are certain natural functions which should be allowed to act 
as they do on human milk, and it seems irrational and con- 
trary to the laws of physiology not to encourage all the func- 
tions to act naturally, each in its own province, instead of 
forestalling their action and allowing them to fall into disuse 
and thus be weakened. The baby's stomach is intended to 
digest casein, and not to have the casein digested for it. Clini- 
cally, also, the use of peptonized milk supports this view, for, 
so far as I know, no very brilliant results have been obtained 
from its use. Peptonized milk, then, is a food consisting of 
too large an amount of digested casein, too little sugar, and a 
very large over-proportion of ash. 
The question next arises as to whether cow's milk can be 
modified without the use of patent foods or foreign ingredients 
and made to correspond to the percentages given in the upper 
line of Table III. This has been accomplished, with more 
or less success, by the addition of fat in the form of cream 
and by alkalies. It seems to me, however, that unqualified 
credit should be given to Dr. Arthur V. Meigs, of Philadel- 
phia, not merely for devising the mixture which will be spoken 
of presently, for any good mathematician and chemist could 
have done that, but for carrying out the principle which it 
has been one of the chief objects of this paper to inculcate,- 
namely, to prepare the food free from foreign ingredients and, 
by chemically altering the constituents of cow's milk and 
especially reducing the casein to one per cent., to clinically 
adapt the food to the average infant's digestion. Common 
herd cow's milk can be diluted until the casein is reduced to 
one per cent., the reduced fat is then raised again to the 
standard by the addition of cream of a known per cent., and 
the sugar is also brought up to the per cent, found in human 
milk by means of sugar of milk. The ash is reduced to the 
proper per cent, at the same time that the casein is, for if we The Artificial Feeding of Infants. 
21 
divide the average per cent, of albuminoids and of ash in 
cow's milk by four, we obtain the per cents, of albuminoids 
and ash as they are found in average human breast-milk. 
It will be noticed that the figures in Table III. give the 
per cent, of the ash as a whole, although we know that a 
number of different ingredients make up the analysis of this 
portion of the milk. In the future, chemistry will in all prob- 
ability give us exact data regarding this analysis of the ash, 
and we can then by computation make a corresponding com- 
bination in the artificial food. At present, however, we are 
forced from want of sufficiently accurate knowledge on this 
point to compute the ash as a whole. Empirically, Dr. Meigs 
has shown that by combining two parts of cream containing 
from fourteen to sixteen per cent, of fat, one part average milk, 
two parts lime-water, and three parts sugar-water, the latter 
consisting of seventeen and three-fourths drachms of milk- 
sugar dissolved in one pint of water, we have an alkaline 
mixture with the percentage of its ingredients closely cor- 
responding to that of human milk. 
The figures in Table III. are the result of an analysis made 
by Dr. Charles Harrington of a mixture made as directed 
above, and the similarity to the figures in the upper line of 
the table representing the analysis of human milk is very 
striking. A number of analyses have been made for me by 
Dr. Harrington at different times and with different creams, 
and they have all corresponded closely to this one, provided 
that an analysis of the cream was first made in order that the 
proper per cent, of fat should be added to the mixture. 
To avoid the necessity of having the cream analyzed, cream 
made by the centrifugal process can be used, for this has a per 
cent, which varies very little from thirty-two, so that by di- 
luting this cream with water one-half we have a cream with 
a per cent, of about sixteen, which is what is usually needed 
for the average infant digestion. 
It is possible, then, in artificial feeding, to approach the 
standard human breast-milk much more nearly than is usually 
attempted, and there is no reason why clinical results should 
not be much improved if physicians will only take additional 
time and trouble to follow more uniformly nature's teaching. 22 
The Artificial Feeding of Infants. 
In all classes of life a much greater amount of time, expense, 
and thought is given proportionately to the preparation of food 
for the adults of the family than for the infants, and this is a 
mistake both from a humanitarian and an economical point of 
view, for the infant is much more susceptible to irregularities 
of diet, with their resulting suffering, than the adult, and 
when once the train of symptoms usually called dyspeptic is 
established, infinitely more trouble and expense is entailed 
than if more exact methods of feeding were adopted before 
the digestion has been tampered with. In the early weeks 
of lactation, after the mammary function has been fully estab- 
lished, it is well to have a number of analyses made of the 
mother's milk, and to keep the results as a control record 
to act as a guide for the preparation of an artificial food in 
case, as so frequently happens, something should occur to end 
the nursing at an early period, for it is highly probable that 
the digestive function of the individual infant may have cer- 
tain idiosyncrasies which correspond to some idiosyncrasy in 
the percentages of its mother's milk, and in cases of difficult 
digestion where the artificial food, which has been made to 
correspond to the analysis of average woman's milk, fails to 
agree, reference to this control record may accomplish the 
solution of the problem sooner than if we had to ascertain 
experimentally, by changing in turn the percentages of the 
different ingredients, in which ingredient the idiosyncrasy of 
this especial infant was to be found. The assistance of the 
skilled chemist is too little sought after in determining these 
questions of infantile digestion and nutrition, and in the future 
must necessarily be made use of if there is to be any advance 
for the better in this subject of artificial feeding. 
Many instructive cases could be cited, and must occur in the 
practice of every physician, illustrating the importance of not 
omitting the careful regulation of every factor of the problem, 
when we attempt to substitute an artificial food for the natural 
method of feeding, and proving that no one factor can be 
given undue prominence at the expense of the others, without 
in some way causing disturbance to the digestion and general 
nutrition. Making the food alkaline will at times rectify an The Artificial Feeding of Infants. 
23 
otherwise intractable digestion: again, as in a case of Dr. 
Ernst's, sterilization was the only change that was needed. 
I have a number of cases showing the importance of a pre- 
cise regulation of the fat percentage, and also of the sugar and 
the casein, while, many times, the food, although chemically 
correct, has proved a failure because it was given in improper 
quantity or at irregular intervals. 
Where an infant, then, is to be fed with artificial food, give 
precise directions as to the times of feeding, the amount at 
each feeding, and the feeding apparatus which is to be used. 
See that the analysis of the food corresponds as closely as pos- 
sible to that of human milk; give instructions as to the 
proper temperature of the food ; see that the reaction is alka- 
line, and then if there is any difficulty with the digestion, 
sterilize the food. If this is not successful, refer to the con- 
trol record and adapt the food to any maternal idiosyncrasy 
shown by this record. If no control record has been kept, 
experimentally try to discover the especial idiosyncrasy of 
the individual infant by changing the per cent, of the fat, 
sugar, casein, or ash.