When prostration is extreme, which it often is because of intoxication by the poisons of the malady, the maintenance of strength is a prime indication for treatment. It is an indication oftentimes difficult to meet, especially in children, because of vomiting, nausea, and pain in deglutition. Adults and older children endeavor to take food whenever it is possible in spite of these difficulties, but the amount eaten is always small. Because of the desirability of eliminating the toxins of the disease as rapidly as possible water or liquids should be given freely. When toxins are thus diluted, they are less liable to produce nephritis. Albuminuria is common. When present, the patient's diet must consist exclusively of milk, or at least, must not include other protein foods.

If the case is a mild one, a normal diet is frequently continued or modified only by diminishing the amount eaten. In the severe cases, when there is not only disgust for food but great pain if it is swallowed, little children will not take it. Forced feeding by the nasal or esophageal tube has been advised under these circumstances. However, the danger of wounding the mucous membranes of the nose and esophagus is so great, and the danger of spreading the malady or making new gateways for the absorption of poisons is therefore so much increased, that the practice is one of questionable advantage. It is better to give what can be given through the mouth by a spoon or medicine dropper and supplement such feeding for the time by nutritive enemata. When swallowing is painful, ice-cream can often be taken more easily than other things, because it melts slowly in the mouth and trickles down the throat. Food must be liquid. If general symptoms, such as fever, feebleness, or dilirium, are especially noticeable, even though albuminuria does not exist, milk and gruels are the safest foods to use. When albumin is present in the urine, they must be used exclusively. Under other circumstances broths, meat-juices, custards, egg-nog, and similar preparations are also useful. Whenever feeding is difficult because of anorexia rather than of dysphagia, food should be varied as much as possible and offered as temptingly as possible. In all those cases in which water and food are taken in small amounts or not at all, I unhesitatingly urge the use of enemata, with hypodermic administration of therapeutic saline solution, to dilute the poisons in the blood and to favor their elimination by the kidneys.

Semisolids, such as farinaceous foods, rice, arrow-root, Mel-lin's food, malted milk, milk and cream toast, or soft-cooked eggs, should be given whenever the patient can take them. During convalescence, food may be given generously and in greater variety.

Pineapple-juice, which is capable of digesting proteins, has been given in this disease to dissolve the membrane in the pharynx. It is doubtful if, when swallowed, it stays long enough upon the mucous membrane of the pharynx to produce results.

When the disease is recognized early and antitoxin is given at once, every case becomes a mild one and few problems of feeding are developed. Antitoxin should be given as early as possible. It has taken from the disease most of the difficult problems of feeding and prevents the dangerous complications which have in the past made feeding a problem of great importance.

Intubation, which sometimes forms a part of successful treatment, necessitates care in feeding. The epiglottis does not always close the tube perfectly, and sometimes the larynx is not so easily lifted with the tube in it as it should be. Semisolids have been found less likely to enter the tube than liquids. When liquids are given, they should be swallowed rapidly; afterward coughing will force out any fluid that may have entered the larynx and the intubation tube. Mush or thick gruels, junket, eggs, and ice-cream are articles that may be administered with safety. A nursing infant succeeds best if it is so held on the mother's lap that its head hangs low and is tilted backward.

To prevent the entrance of food into the trachea through the tube, an occasional mischance after intubation, the method of feeding first suggested by W. E. Casselberry has proved the best. He advises keeping the patient upon his back with head and shoulders lower than the body. Liquid food can then be taken from a nursing bottle, or through a tube or from an invalid's drinking cup. It is important that the position of the body shall not be changed after drinking until several efforts to swallow have been made and time enough has elapsed for any liquid that may have gotten into the tube to gravitate back into the naso-pharynx and be swallowed or expectorated. Children can be held best in this position across a nurse's lap with the head and shoulders unsupported by the knees. It is not difficult for them to swallow and food will not enter the trachea.

Usually the relief that intubation affords to dyspnea makes swallowing easier rather than more difficult. When a tube has been worn for a few days, the patient becomes accustomed to it and swallowing also is less troublesome. In some cases when dyspnea is not great, the tube may be removed for a few minutes while the child is fed. This, however, necessitates the very frequent attendance of the physician.

Postdiphtheric paralysis, which involves the pharynx and sometimes the esophagus, makes feeding very difficult. In rare instances a stomach-tube or catheter must be employed in order to conduct food into the stomach. Much more frequently enough food to maintain life can be swallowed, if it is taken in very small amounts and with sufficient slowness, although flesh and strength may wane. In the prolonged and most severe cases, nutritive enemata may be used as adjuvants to such food as can be given through the mouth.