Source:  Snow, John. Lancet, July 4, 1857, pp. 4-5.

On the adulteration of bread as a cause of rickets

By John Snow, M.D.

On commencing, in the year 1839, to see a considerable amount of practice amongst the poor of London, chiefly the out-patients of a public hospital, I was very much struck with the great number of cases of rickets. The complaint was shown more particularly in the bones of the leg, causing an outward curvature of the tibia and fibula; in children in their second and third year, it seemed almost the rule, and might be observed in the streets and the parks, as well as amongst children brought for advice. The complaint, moreover, was not by any means confined to the poor, but affected the children of the middle class to a considerable extent.

The usual causes to which rickets are attributed are of a somewhat general nature, such as vitiated air, want of exercise and nourishing food, and a scrofulous taint. These explanations, however, did not satisfy me, as I had previously seen a good deal of practice in some of the towns in the north of England, where the over-crowding and the other evils above mentioned were as great as in London, whilst the distortion of the legs in young children was hardly present; moreover, I noticed that the most healthy-looking and best-nourished children often suffered most from curvature of the bones of the legs, owing to their greater weight; and I afterwards found that this complaint was quite common in the villages around London as well as in the metropolis itself.

The bones owe their hardness to phosphate of lime, which exists ready formed in many articles of food, and only requires to be assimilated, whilst in rickets the phosphate of lime in the bones is known to be deficient; and therefore it seemed extremely probable that the want of this earthy salt in the food of the infants of this metropolis was the chief cause of the soft state of the bones. My attention was naturally directed to milk, which contains one chief supply of phosphate of lime, and which is somewhat scarce and dear, and not of the best quality in London; but I immediately recollected that in some of the mining and manufacturing districts in the northern counties of England milk was scarcely used at all in the families of the operatives, and yet I had hardly seen a case of curvature of the legs from rickets. On reflecting on the subject of bread, however, there seemed to be something which might explain the prevalence of this complaint in London. In the northern counties, where coals are cheap, it was the universal custom for every family to bake their own bread, and I believe still remains so; whilst in the south of England it is as much the custom to buy bread from the baker. Now, the bakers, so far as I have examined, all put alum in their bread, whilst this is never done in domestic practice, and the flour dealers rarely adulterate the flour with this substance. They are liable to a heavy penalty for adulterating flour, but the law is never enforced against the bakers. I have never examined a specimen of flour which contained alum, or a specimen of baker's bread which did not contain it.

When my attention was first turned to the subject of rickets, I thought it likely that the sulphuric acid of the alum would decompose the phosphate of lime of the wheat, and form sulphate of lime, which would not be available as nourishment for the bones; and I formed an intention to investigate the question both chemically and statistically; but this intention was long postponed, on account of other engagements and inquires. In the meantime, and without any regard to the question of rickets, Liebig has inquired into the action of alum in bread, and his investigation will justly have more weight with the reader than any inquiry of mine. He says, "Since phosphoric acid forms with alumina a compound hardly decomposable by alkalies or acids, this may perhaps explain the indigestibility of the London bakers' bread, which strikes all foreigners."* (*Letters on Chemistry, third edition, p. 443.)

It is evident from the above passage that Liebig has ascertained that alum decomposes the phosphate of lime of wheat, and it is not likely that the bones would be able to nourish themselves with this salt out of phosphate of alumina and sulphate of lime; and where the baker's bread forms the chief and almost the only article of food, as it does amongst the children of the working classes in London and many other towns, one might expect the bones to be ill nourished, as regards their earthy and hardening materials. This appears to be the actual fact, as far as I have been able to extend my inquiries. The subject is capable of being decided by an exact numerical investigation, but I have thought it better to publish my inquiry in its present imperfect state, than to wait till I should be able to make such a complete research as I could wish, more especially as, by directing the attention of the profession to the question, it may be earlier decided. I expected to be able to contrast some of the large institutions containing young children in this metropolis with each other; but, so far as I have inquired, they are all supplied alike with bakers' bread containing alum. So far as I have been able to learn rickets are not common at present in the towns in the north and west, [4/5] where home-made bread is chiefly used; and I was lately told, that in one town in Cornwall, where the people make their own bread, this complaint is almost absent; whilst in town a few miles off, where bakers' bread is consumed, the complaint is extremely common; but as my inquires have been only of a colloquial nature, I hesitate to mention places and persons. If it could be obtained, perhaps a return of the number of cases of rickets in the children under four years, as compared with the whole number, which are brought to the dispensaries, in towns where respectively the people buy chiefly flour or ready-made bread, would best help to decide the question.

It does not follow, if my conclusions are correct, that every child eating bread adulterated with alum ought to have rickets, or that every child fed with good bread ought to be free from the complaint; for, on the one hand, the other articles of food may often supply sufficient phosphate of lime without that of the bread, and, on the other hand, derangement of the digestive and urinary functions may prevent the phosphate of lime being assimilated when present. What we might expect, however, would be precisely what we observe--that rickets would be much more common in the children of the working classes fed almost entirely on bread than in those who have a greater variety of food. It can also be explained how the bones ultimately become hard from the gradual accumulation of the scanty supply of phosphate of lime derived from milk, potatoes, and other articles of food, whilst that which ought to be supplied in the bread is still withheld.

If the deformity in the bones of the legs does not proceed too far, it has a great tendency to diminish, and even disappear, as the children grow up; and the artificial support which is afforded by iron instruments and splints, both in the various hospitals for deformities, and under the advice of private medical men in London, diminishes very much the amount of permanent deformity which would otherwise be met with.

In my examinations of bakers' bread I have been much struck with the apparent universality of the practice of using alum, and with the large quantity employed--a quantity between twenty and thirty times as great as that usually stated by authors. I have met with alum, not only in the ordinary bread sold by bakers, but also in captains' biscuits, and in the so-called farm-house bread; and I was somewhat surprised to find that the high-priced bread, sold in the fashionable neighbourhood to the west of Regent-street contained more alum than the cheap bread sold in many of the poorer districts. I found that the bread supplied to me last autumn contained 10.13 grains of alum in 500 grains--i.e., 561 grains, or more than ounce and a quarter in the 4lb. loaf; whilst some bread obtained from a very noted baker contained 11.37 grains in the 500 grains, or nearly an ounce and a half in the 4 lb. loaf. The following is a brief account of the analysis of the latter bread:--500 grains, being carefully dried at the temperature of 100 Fahr., lost 128 grains of water, or more than one-fourth. Being carefully incinerated in a crucible, the ashes weighed 5.85 grains. The ashes yielded alumina, which, being washed, dried and ignited, weighed 1.2 grain, representing 11.37 grains of crystallized alum; with chloride of barium, they yielded 1.4 grains of sulphate of baryta, and with the nitrate of silver, 6.7 grains of chloride of that metal, representing 2.8 grains of common salt.

Dr. Hassall and some other authors have very properly pointed out that the only safe way to seek for alum is to incinerate the bread, and examine the ashes; but many writers go on repeating the statement that alum may be found by digesting the bread in distilled water, filtering, and applying tests to the water. In this way seldom more than a trace of alumina can be detected, even when the bread contains a large quantity; but it is probable that many persons take this short and easy method of examining it, and it is probably in a great measure owing to this circumstance that the bakers continue to use alum with so much impunity. An instance came under my notice not many months ago where a baker expected, with the utmost confidence, to have a satisfactory certificate to lay before the committee of a club-house respecting his bread, although it contained a great quantity of alum.

A probable way to break through what seems the universal practice of bakers to adulterate bread, would be for the committees of the public hospitals and the guardians of the poor to oblige the bakers who contract to supply their respective institutions to furnish an unadulterated article. No one pretends that alum is either nutritious or wholesome; and if the loaves without alum should cost a little more, owing to their carrying less water, no one can doubt that as much nutriment would be obtained for a given sum as under the present system.

Sackville-street, June, 1857.

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