While on No. 4 the patient must take from 12 to 24 fluidounces of pure water, barley-water, or white-of-egg- (albumin-) water each twenty-four hours. These must be given in small doses at short intervals. For some time past I have almost abandoned the use of raw-beef juice, as it is very difficult to obtain fresh beef from which to express it, and the juice from cold storage beef has been the apparent cause of a number of cases of ptomain poisoning that have come under my observation. Substitutes that can be recommended are Wyeth's Beef Juice and Panopepton, both sterile preparations; of the former twenty to thirty drops and of the latter half a teaspoonful about correspond to the dose of raw-beef juice already directed; either one should be diluted with one or two teaspoonfuls of cool water.

All the above foods are only to be used temporarily until the tendency to disturbance within the alimentary canal ceases; then milk may be gradu-ally and cautiously resumed.

While the onset of acute gastric or intestinal disorders, and the fact that the infant does not thrive indicate radical changes in the food, there are other minor alterations that may be made to meet certain symptoms which are troublesome without being serious. Thus, loss of appetite is often due to overfeeding or to the presence of too much fat in the food mixture, and is to be met by weakening the food generally but especially reducing the proportion of cream, by giving water freely and by increasing the intervals between feedings, but never by coaxing or forcing the child to take food. Eructation of small quantities of food immediately after feeding, results from the taking of too large quantities or the too rapid emptying of the bottle, or it may depend upon too tight clothing or upon so handling the baby, directly after feeding, as to make undue pressure upon its stomach. Habitual vomiting, or often repeated regurgitation between feedings, may be relieved by reducing the fat and increasing the lime-water in the food, by substituting milk sugar for cane or malt sugar, and by feeding at longer intervals. Habitual flatulence and colic demand a decrease of the sugar and proteids in the food, and the removal of any tendency to constipation that may exist.

Chronic constipation requires an increase of the fat, though care must be taken not to carry this so far that other abnormal conditions result; the milk sugar should be replaced by some "infant food" containing maltose, as Mellin's Food, for example, and after the eighth month orange juice may be given once daily for its laxative effect.

When infants who have passed the first year become affected with indigestion, it is often sufficient to reduce the strength of the food to a point compatible with digestive powers. For instance, at fourteen months the food may be reduced to that proper for a healthy child of eight months, or even less. At this more advanced age, too, predigestion of the food is very serviceable.

If a few grains of extractum pancreatis be added to a goblet of thick, well-boiled starch-gruel, at a temperature of 100° F., the gelatinous mucilage quickly grows thinner and is soon transformed into a fluid, the starch having been rendered soluble by the action of the pancreatin; by still longer contact, the hydrated starch is converted into dextrin and sugar. Advantage may be taken of this property to render the foods containing starch assimilable. Thus, to a mixture of barley-jelly and milk, e. g.:

Barley-jelly.............

Milk sugar..............

Warm milk.............

2 teaspoonfuls. 1 teaspoonful. 16 tablespoonfuls (fld. oz. 8).

Add three grains of extractum pancreatis, and five grains of bicarbonate of sodium, and keep warm for half an hour before administering.

The same process may be employed with food containing oatmeal, arrowroot or wheat flour, with a view of converting the starchy ingredients into digestible elements without materially altering the taste.

When the infant has arrived at an age to take meat broths, these too, when digestion is enfeebled, may be readily peptonized.* d. Success in hand feeding depends upon proper administration as well as careful preparation of the food.

From birth up to such time as broth, bread, and eggs are added to the diet, all the food should be taken from a bottle. Even after this, as the bottle is a comfort and insures slow feeding, it may be allowed for milk preparations until the child is fourteen or fifteen months old, then, if he has not given it up of his own accord, he must be weaned from it and taught to drink from a cup. If persevered in much longer there is great risk of the "bottle habit" being formed, the child refusing to take food except from a bottle, and when finally deprived of it, will not drink milk during the remainder of childhood, both unfortunate conditions. If formed, the habit must be broken by withdrawing the bottle suddenly and completely, and allowing no food but milk, given from a cup, until the child takes it with relish. Several days starvation will overcome the difficulty, and no harmful result need be feared. During the months of bottle feeding only simple bottles and tips are to be admitted to the nursery.

* See Chapter IX (Dietary).

All complicated arrangements of rubber and glass tubing are not only an abomination, but a fruitful source of sickness and death. Rather than use them, it is far better to feed the infant with a spoon.

Fig. 19. - Graduated Nursing Bottle.

The graduated nursing bottle (Fig. 19), first suggested by myself, is a useful implement. Its interior surface is so shaped as to present no angles for the collection of milk; it is easily cleaned, and the graduated scale is convenient for nursery use. It is made of transparent flint glass, so that the slightest foulness can be detected at a glance, and varies in capacity from six to twelve fluidounces. The modern cylindrical, graduated bottle is even more readily kept clean, and is to be recommended. The number of bottles in use should exceed by one or two the number of daily feedings, the extra ones being on hand in case of accident. Immediately after a meal, the bottle, if not drained by the infant, is emptied of whatever quantity of food it contains, thoroughly washed out with cold water, filled with a solution of bicarbonate of sodium - one teaspoonful to a pint of water - and placed out of the way in some convenient place; in the morning, before filling, all the bottles are carefully washed with hot soap suds and a bottle brush, and finally sterilized by immersion in boiling water for twenty minutes.