In feeding healthy babies our constant aim is to keep them free from these disturbances. It is for this reason that long intervals between feedings and caloric and volumetric control are so urgently recommended. Improperly balanced food mixtures, such as many of the

"baby foods," should be avoided. The appearance of any stage of a food disorder should be recognized at the earliest possible moment and a more serious condition avoided by proper dietetic measures.

Curative

In the earliest stage it is simply necessary to cut down the amount of food to a proper one, or for a time below that amount. If either fat or carbohydrate is excessive, it should be reduced and a more properly balanced mixture given. Caloric control is here of value as a measure of the maximum amount of food to be permitted.

In the dyspeptic stage it is commonly well, except in the mildest cases, to give a starvation diet of water, or tea, or barley water, for twenty-four hours. The return to a proper amount of an appropriately modified milk mixture must be gradual and under the necessary clinical control. In severe cases it is best, after a day of hunger diet, to begin with a skimmed, or even fat-free, milk and cereal-water mixture; then add sugar, and finally add whole milk or gradually leave in more and more cream. Human milk is here, as in the preceding condition, the specific remedy.

In the stage of decomposition human milk is often indispensable and always the ideal food. It must be used, however, with caution, at first, in severe cases, because it may lead to a severe paradoxical reaction or to an intoxication. We have repeatedly seen one or the other alarming result when a weak marantic baby, with low vitality and subnormal temperature, was suddenly put freely to a generous breast. In the worst cases only two or three ounces a day can be safely tolerated at first, and for this the milk is best drawn by hand or pump. These cases die without human milk. To meet this important indication, Dr. Walls introduced the employment of one or more wet-nurses at our ambulatory clinic at Northwestern University Medical School, and we are able to save many of these cases that would otherwise be hopeless. The amount is gradually increased to what is necessary, or cow's milk is gradually substituted. In less severe cases the human milk can be given freely. The breast milk acts in these cases apparently not only as a food, but has, furthermore, some specific curative property, and only a few ounces a day in the twenty-four-hour food mixture seems to be of decided benefit. One wet-nurse can thus be of extensive usefulness even in an out clinic. If human milk is not obtainable, we enter upon the unequal struggle with milk mixtures from which the fat has been wholly or partly removed with the addition, at first, of only a small amount of sugar, preferably malt sugar, and the addition in older infants of cereal waters, or dextrinized or baked flours, broths, etc., and slowly progress to a better-balanced food. In the latter part of the first year children of this type will often do better when additional food that is appropriate for a baby of that age is given than if kept too rigidly on a milk mixture. These cases must not be started off with a day of starvation unless there is a complicating intoxication, because this additional insult may diminish the vitality of the disintegrating child to the extinguishing point. With the slightest dietetic error, and often apparently without evident cause, these babies will gradually sink into an alarming state of low vitality from which it is only too often utterly impossible to rescue them.

Treatment Of Intoxication

We have here to deal with an intoxication by food, and the first step is to withdraw all food for at least twenty-four hours, no matter what the condition of the baby. The customary cathartic can usually well be dispensed with, except in those severe cases where obstinate constipation exists at first. The bowels are rapidly emptying themselves as it is, and there is reason to believe that calomel and castor oil are not entirely harmless. The former is distinctly irritating, and several clinical observations have led us to believe that the use of a teaspoonful or two of castor oil, a fat equivalent to that of three to six ounces of milk, may seriously aggravate conditions. Colonic flushes, too, would seem of little use. The absence of intestinal lesions and the prompt effect of the withdrawal of food alone leave little use for drugs. In place of food, then, we give water, or a weak infusion of tea, or, if desirable for the mother's sake, a weak cereal water, or albumin water. Sugar, of course, must not be added to these. If water is not taken freely without sweetening, as is very frequently the case, then a grain of saccharin is best added to the quart of fluid. The child must have water at any cost. It can commonly live many days without food, but very few without water. If too sick to take it from a bottle, it must be given from a spoon, or by rectum, or, better still, the stomach may be washed out with a catheter and funnel, and a large amount left at one time, and repeated p. r. n. If vomiting and diarrhea are prominent symptoms, normal salt solution may be given under the skin in repeated small amounts. This is especially true of cholera infantum where these conditions are present, and where the loss of water from the bowels is the alarming symptom. It is in these conditions, where an insufficient amount of water is retained, that scleremic conditions and marked apathy occur. If the pulse is very weak, and especially if it becomes slow and only one sound of the heart is heard at the apex, hypodermic stimulation with camphorated oil, digitalis, adrenalin, etc., is indicated.

The change from an alarming condition to one of undoubted convalescence within twelve to twenty-four hours reminds one strikingly of such changes as the crisis in pneumonia or the result of opening an abscess, and is one of the quickest and most decisive therapeutic results in medicine. A child with heavy, fixed eyes, and in stupor, with a temperature of 105° F., is often on the following day found to have a normal temperature, with eyes bright and with no trace of intoxication. If this disintoxication has taken place at the end of twenty-four hours, we can proceed with the feeding. If not, and the child is only partly convalescent, we can safely wait another day or even two, if the child was previously fat and strong. One must never wait for the usual yellow bowel movements before proceeding. The normal water-diet bowel movement is soft, semi-transparent, or slimy, and of a dark greenish-brown color, and continues in spite of the withdrawal of food.

From what has been said before, we would expect to be able to give the different food elements in the following order: Proteid and gruels, starches in older babies, sugar, and, lastly, fat. If we could easily separate the casein and obtain it in a serviceable form we would not hesitate to use it in considerable amount from the start. We have several times given the pure washed casein of twelve to sixteen ounces of milk to the severest cases of intoxication with only the happiest and most unexpected results in view of the still prevalent teaching of difficult proteid digestion. Practically the simplest procedure is to begin on the first day of convalescence with a small amount of boiled fat-free milk, say ten to sixteen ounces of separated milk, less if skimmed or siphoned, with an equal amount of barley water with saccharin, if necessary. This is gradually increased till the baby gets perhaps two ounces of fat-free milk to the pound of body weight. Sugar is then cautiously added, or, in older children, starches and partially dextrinized flours, till an ounce to an ounce and a half is given in the daily food. After this is well tolerated, whole milk is gradually substituted for the fat-free milk, and an appropriate diet for a healthy infant of that age and weight is approached as rapidly as its condition will permit. The greatest danger is from too rapid giving of fat and sugar. At the beginning, the sugar of the fat-free milk even may be injurious and may necessitate slower progress. The signal that fat and sugar tolerance have been reached is the reappearance of fever and the other symptoms of intoxication. Such a relapse is simply another intoxication, and requires a repetition of the treatment given in the original one. The necessity for taking the temperature and otherwise watching the child is evident. Only when we know the infant's immediately present condition do we know what to give next. The same food that today may be ideal, may to-morrow, under altered conditions, act as a toxin.

When the stage of intoxication is reached, the tolerance for human milk, too, is lost. The child must be taken from the breast at least twenty-four, often forty-eight, hours, or even longer. The breasts must be emptied as thoroughly as possible several times daily, to keep up the secretion, by hand or by breast pump, but much more effectively by another baby. Nursing is cautiously resumed after disintoxication has taken place, with long intervals and very short nursings. In the severest cases, even after several days of starvation, the milk, with its large fat and sugar content, will again bring on an intoxication. We have here repeatedly seen the startling phenomenon that an infant will tolerate, perfectly, separated fat-free cow's milk in considerable quantities, while human milk is toxic in minimum amounts. The significance of this fact in the pathogenesis of this food disorder cannot escape one.