The extreme form of malnutrition from gastro-intestinal catarrh is known as marasmus. Some infants are born with very low vitality and with an alimentary tract which is apparently incapable of dealing with any form of food, but such cases are rare. In the great majority of marasmic patients the underlying cause is improper food and feeding. The vital powers of the infant may be at the lowest before advice is sought, and a diagnosis of tabes mesenterica is often erroneously made. The methods of feeding, as already described, may fail. In such cases a wet nurse is the best line of treatment. If the infant is too weak to take the breast, the milk may be drawn off and given with a spoon. Failing to obtain a wet nurse one has to depend for a time on brandy and meat juice. A drachm each of brandy and fresh meat juice may be mixed with 6 oz. of water. Of this mixture 1 oz. may be given every hour for an infant of three months, eighteen feeds being given in the twenty-four hours. In place of the meat juice one may use weak chicken or veal soup. After a few days' trial of this some whey or peptonized milk may be given occasionally, and an attempt made to establish toleration of milk food. Another mixture which may be tried in these cases is composed of white of egg, 2 drachms, brandy and malt extract, of each 1 draohm, and water to 6 oz. This may be given in the same quantities as the meat juice mixture. White-wine whey may also prove serviceable in these cases, as used by Myers and Still. Ten ounces of milk are brought to the boil and 2 1/2 oz. of cooking sherry are added. The mixture is again boiled, removed from the fire, and allowed to stand for three minutes. The curd is then strained off and the whey is ready for use. Analysis of this whey shows the following composition : protein (almost entirely lactalbumin) 0.45 per cent; fat, 0.95 per cent, and sugar, 5.00 per cent. The amount of alcohol in 1 oz. corresponds to that in twenty-five drops of brandy. Myers and Still give one tablespoonful of the whey every half-hour or three-quarters of an hour to an infant of six weeks, and gradually alter the amount and times until 2 oz. are taken every two hours. The maximum at a feed is 2 1/2 oz. The acidity (tartaric and acetic acids), the nature of the protein, the carminative ethers of the sherry, and the stimulating effect of the alcohol render this whey suited to the weak digestion and exhausted vital powers of a marasmic infant. It should not be given as the sole food for more than a week or ten days. The effect of the alcohol in the mixture must be carefully watched, as it is intended to act as a stimulant and not as an intoxicant. When, as often happens, the mucous membrane of the alimentary tract has become atrophied and functionless, the results of treatment are very disappointing.

II. After Infancy

In the case of chronic gastro-intestinal indigestion in children beyond the age of infancy, one must also recognize that probably the same factors are at work, namely, overfeeding and improper food. The course of events is often as follows : A child with a healthy appetite is allowed too full a diet, with an excess of farinaceous foods and sugar. This excess of carbo-hydrate material is often given in such fluid form that the teeth are not used, the food is swallowed rapidly, and goes down so easily that much larger quantities are consumed than if thorough mastication had been necessary. By and by symptoms of intestinal indigestion appear. The child looks pale, and begins to lose flesh. A course of feeding-up is begun, and beef juices, patent foods, cream, etc., are added to the already over-full dietary. Finally there comes a complete breakdown of the entire digestive system. The course of treatment to be adopted is to give the overtaxed intestine as much rest as possible. Peptonized milk, or whey, and freshly-made mutton, veal or chicken soup are to be given in small quantities every few hours. A word of warning must be given to the cook that she is not to make the soup as "strong" as possible, but of the strength of ordinary dinner soup. When the intestinal rest has led to the recovery of appetite, solids may be begun in the form of fish, chicken, or mutton, plainly cooked, with a little bread crumb or bread sauce. After toleration for these has been established, some carbo-hydrates may be added to the dietary, toast, milk pudding, and plain biscuit. Last of all the stage of fatty foods is reached - butter, yolk of eggs, cream, and cod-liver oil - and the building-up process will then go on rapidly. The length of time taken to secure complete recovery will depend on the time during which the improper feeding has lasted.

To prevent a recurrence of the condition one must arrange for the future a dietary which contains (1) a sufficient amount of hard food which requires chewing, and (2) a limited amount of farinaceous foods and sugar. For the former purpose beef or mutton or chicken should not be given to children in a minced or pounded form, but plainly cooked. Toast, rusks, biscuits, raw apples entail an amount of chewing which is good for the digestion and the teeth. Further, the child's appetite will be satisfied more readily after chewing food thoroughly, and there will not be the same tendency to swallow down large quantities of food as in the case of fluid milk puddings. When a child has had a sufficient amount at a meal and still complains of hunger, a raw apple or a hard biscuit will be better than another helping of sweet pudding. The excessive use of carbo-hydrates is very marked in the present day. Many children are allowed to consume far too much bread and butter and sweets. These must be strictly limited. Finally, the coaxing of a child to eat more food must be absolutely forbidden. No child should ever be coaxed to eat, and much harm is often done by this line of treatment on the part of over-anxious parents and nurses.