this in mind, many cases recovering from illness, in place of being emaciated convalescents, may be restored to their former body weight at an earlier period in their treatment. In this connection it must not be forgotten that to suddenly provide this kind of food for infants who have never been given cereal flours, and also for many under three months of age, may invite further digestive disorders.

Albumen water is another favorite substitute in the feeding of acutely ill infants. As commonly made in the strength of the white of one egg to one-half or one pint of water, there are many in which this has been the only article of diet that could apparently be retained. On the other hand, the same thought applies to this food as to the foregoing cereal waters, namely, as to its real food value. When one stops to think that the white of an egg represents only about the same number of calories as half an ounce of milk, and realizes how much water an infant has to take in order to obtain any reasonable degree of nourishment, the question naturally arises as to whether in the cases in which the above-mentioned strengths were employed, the water intaken was not the real beneficial agent rather than the egg. It must also be remembered that proteid food, besides being a poor kind of running fuel, may invite putrefication, and what is of even more importance, the fact that in health many infants cannot readily digest egg albumen without gradually having their digestive apparatus prepared to care for it. Still there are infants who seem to be able to assimilate this food readily in illness and in these it is most desirable that its food value be borne in mind in prescribing, for as a matter of fact, a number of infants will show an ability to digest this substance after stomach tolerance has become reëstablished in much stronger proportions than are ordinarily provided for them.

A solution of milk sugar is not used as frequently as are the cereal waters or albumen water in acute illness, but all things considered, this food is probably of more real use in the beginning of some of the digestive or febrile disorders than is generally recognized. Some of the reasons for its limited employment are the popular idea that it will produce fermentation or that it is of

but little real strength as a food. Practically, however, it does not produce fermentation as a rule, and the fact that an ounce of a good grade of milk sugar represents approximately as many heat values as do five ounces of milk, besides its being so easily digested in five per cent. solution or even stronger, makes it a food worthy of trial or at least one that will enable the machine temporarily to run and thus indirectly save tissue waste. This food is also readily taken, easily prepared, and is a suitable diluent for other foods when improved health allows of their use. It is in addition a pleasant way of giving water which in these disorders is so much needed; but in prescribing this, regular intervals of feeding with the proper time elapsed is essential. In many of the acute enteric infections as well as in the febrile states of infancy, a solution of milk sugar makes an excellent form of nourishment at the onset. The same, on the other hand, cannot be said of cane sugar solutions.

Whey as a temporary food for sick infants produces in many cases most satisfactory results, but it is obvious that the refinements of making materially influence its nutritive value. Unlike the foregoing articles, in which their strengths are increased as occasion requires or tolerance allows, in using whey the essential point is to give it the limit of capacity, and this, of course, has to be ascertained by trial. When once the full amount that an infant can ingest has been determined, it is most gratifying to see in many cases the rapid increase in weight that follows its use for short periods. Thus, in an infant suffering from malnutrition, which is taken acutely ill, it is evident that to attempt to give a milk mixture which will supply its bodily needs is out of the question at the beginning, and to spend the time necessary to gradually increase the strength of a weak mixture may prove disastrous. In these cases, by the use of whey, and that in full amounts, not only may a temporary halt be called on tissue waste, but what is especially desirable, some increase in weight may be obtained, and then a suitable milk mixture be provided or the milk gradually added to the whey feedings. It will be found, on the other hand, that certain infants have intestinal distension when given whey, and in these, by pasteurizing the feedings for

five minutes and decreasing the time one-half minute a day, this disturbance may be avoided. Others will vomit this food, but may retain it when lime water is added; and then there are those who will not take sufficient amounts for their daily need. In these latter, the addition of milk sugar may be of benefit.

Besides the various individual advantages of the different substitute articles of food so far mentioned, there are, of course, greater possibilities in their successful combinations, and to obtain results, even more thought must be given to the details of the subject than is spent in carrying out milk feeding, for while the question of artificial feeding in health presents many problems, these are much increased in illness.

So far, certain substitutes for milk in illness have been considered and special emphasis laid on their real nutritional values. It is an understood and generally accepted fact that every attempt should be made to continue milk feeding in sickness, if possible, or, if not, to reëstablish milk feeding at the earliest opportunity; for it is agreed that next to breast milk, all things considered, cows' milk is the most suitable and available food for infants, sick or well. Unfortunately, however, owing to the nature of the illness, or on account of an idiosyncrasy in the infant under treatment, it is not always possible to continue milk feeding, or for that matter to rapidly return to the normal rations during convalescence, and in some rare cases milk has to be withheld altogether. So there is yet a more intricate problem connected with the subject under discussion than has been taken up, and that is milk intolerance.

Milk intolerance, for convenience of description, may be divided into that occurring in disease, and, secondly, where certain peculiarities in the infants are present. Again, this latter kind may be temporary, or, in rare cases, present for a long time. This intolerance, in either instance, is an abnormal condition and one that profoundly influences the feeding problem.

As an example of the first class, that is, where milk intolerance occurs in disease, may be mentioned particularly those acute enteric infections commonly spoken of as summer diarrhoea. Here it is not the milk itself that causes trouble so much as that

being a suitable medium, it favors the further growth of microorganisms. Hence, in these affections, the necessity for withholding all milk for variable periods. There are two points deserving of mention in these cases. First, and unfortunately, there is not a clear understanding in the popular mind of this need of withholding all milk, for it is not uncommon to find infants who are progressing badly in which small amounts of milk have been added to their food under the mistaken idea that a little could not hurt; and, secondly, there is often undue stress laid upon the character of the stools in convalescent cases of summer diarrhoea. These, contrary to general belief, frequently become normal on gradually resuming the milk diet.

In infants belonging to the second class, that is, where there is some inherent peculiarity present, the questions relating to this intolerance of milk are even more complex, particularly as this is a rather uncommon condition. There are in these infants certain symptoms that especially aid in the diagnosis, but, inasmuch as they do not always attract attention, being common in other conditions, it may be well to recall them here, for to successfully feed these cases they must be recognized early.

The most important symptoms occurring in this condition are a peculiar dullness or apathy, loss of appetite, vomiting and malnutrition. There may at times also be others of more rarity, as, for instance, oedema of the subcutaneous tissues or even of the lungs, all of which disappear, or remain absent, after having occurred, on stopping the milk. This dullness or apathy is a very peculiar phenomenon. These cases lie listless in their cribs or others resemble in a way the mental habitude of the cretin; but the most interesting thing about it all is the sudden mental brightening which takes place on withholding the milk. Concerning the loss of appetite, where an infant has had a careful feeding schedule, and in the absence of disease shows at no time a special desire for food, a suspicion of this intolerance is warranted. The vomiting alluded to seems to come on at intervals say of a week or two, and, what is more to the point, right after this occurs an infant may desire, and take without apparent discomfort,

a

second feeding. As regards the malnutrition, this also in the absence of other demonstrable causes is a symptom of significance in milk feeding.

These infants having a milk intolerance, whether in apparent health or disease, make some of our most difficult feeding cases. Not only must their nutritional needs be considered from a fuel standpoint, but in choosing their foods the selective values of these in reference to building the different tissues of the body must also be considered.

It is here that the cereal gruels find their use, either plain or dextrinized, those made from the flour of barley, wheat and oats, and in later infancy, the pea and bean. With these gruels, as with the cereal waters, the amount of flour consumed in the twenty-four hours is the main point. In using these substitutes for the milk, the danger of scorbutus supervening must always be kept in mind, so some raw food, as beef juice or the fruit juices, is necessary, and if a philanthropic friend is available who is willing to let the patient have a few ounces of surplus breast milk a day, so much the better. In older infants the cooked cereals add to the efficiency of this dietary and especially desirable is the soy bean flour to supply the nitrogenous elements lacking. This can be cooked in beef, chicken or mutton broth. In the cases of milk intolerance referred to, no matter of what kind or degree, there is regularly reëstablished with but very rare exceptions, sooner or later, a tolerance for milk, and it is most important that this period be ascertained as early as possible, so that the case may be put back on a suitable milk régime, and this must be done by trial. To accomplish this resumption, the plan of very gradually adding pasteurized milk to the cereal waters or gruels, and in some mild cases using pasteurized whey at first, is the one generally followed. The milk or whey is then heated less each day until the raw product is tolerated, or in older infants, junket, or raw milk on their cereals makes a good beginning, and as soon as it is proven that milk can again be taken, the former diet is gradually resumed. In these rare exceptions, however, where this plan causes a return of the symptoms, one is justified in waiting a much longer K*