time before making a trial again, perhaps in some most exceptional ones not until childhood; and one cannot dismiss this subject of feeding in difficult milk cases without recording the fact that in giving these substitute foods mentioned, a stranger can often accomplish better results with those little patients than can their parents.

A subject of which more will undoubtedly be written in the future is that of the feeding of surgical cases. Here is a class of patients which, with the progress of surgery, is rapidly increasing in size each year. Now, while infants under any condition are a problem to successfully nourish, how much more so is this when surgical procedures may have been necessary for their betterment. The feeding of those infants who are deformed, as in the case of cleft palate or hare lip, until they can be saved by operation, and afterwards, the avoiding of intestinal disturbances in abdominal work, and the building up of the little convalescent whose condition may have required a major operation, are but a few of the many instances in this field.

But time will not permit of further elaboration. It has been the aim of this paper to recall, from the bedside standpoint, some of the substitute articles of food used in feeding sick infants, and to suggest that as commonly employed, their food value is much too low. Furthermore, to note in the temporary, and in very rare instances the more lasting cases of milk intolerance, certain symptoms of considerable aid in their early recognition, and that by proper feeding, these infants may be successfully tided over this period, when a suitable milk régime can be resumed; and lastly, to allude to the increasing importance of the subject of feeding of surgical cases.

DISCUSSION.

DR. HENRY M. STEELE (New Haven): In complimenting Dr. Goodrich on the excellence of his paper, I wish to thank him particularly for so well calling attention to the fact that so many sick babies are insufficiently nourished.

In a recent paper on the subject of infant nutrition, the opening remark comes to my memory: "A state of nutrition which maintains the weight of the organism of an adult is desirable, but it cannot be endured with

impunity for any length of time by an infant." Remembering that a baby in its first year must treble its birth-weight or, in other words, gain from 12 to 14 pounds, it is self evident a "nitrogenous-balance" is not our aim. None of the cereal waters as commonly used anywhere near come up to the requirements of a baby's caloric needs.

Time and again, after a few years ago, when this was called to my attention, I have fed summer-diarrhoea cases with well-cooked cereals, nearly as thick as the ordinary breakfast foods, and I believe with much better results than when using the weak cereal waters. As Dr. Goodrich says, it is probably the water that sustains. A teaspoonful of barley flour twice a day cannot!

If one must needs starve for twenty-four or forty-eight hours (and starving really means flushing the digestive track), I believe water alone the treatment; attention being paid the salts. Of course the parent responds to a little cereal added; and often one is driven to it, because otherwise the parents add food (and particularly milk) on their own

account.

It seems in a sense trivial to lay such stress on this point of the nonnutritive value of cereal waters; but in every work on diseases of the nature that calls for such feeding, we so constantly read that the baby's diet was barley water, etc., that we subconsciously think the baby was thus fed—and, naturally, sufficiently. In consequence, we are often led to continue such abusive treatment far beyond the time that the organism (and particularly a baby's) can stand such malnutrition, and I am sure that I have witnessed such cases, and have had cases of my own in which the continued fever was due to starvation and nothing else. They were absolutely cases of inanition fever.

I agree most emphatically with Dr. Goodrich in his recommendation of milk sugar as a food for tiding over acute cases. It is, however, as he states, a hard food to prescribe; for, in the lay mind, it is so closely connected with the idea of fermentation that it is almost impossible to convince people that it does not, and that it is really a food, and not a condiment.

Before leaving this question of milk-sugar, however, I feel it necessary to call to your attention the fact that just at present a good many investigators would probably seriously disagree with my statements and those of Dr. Goodrich.

Finkelstein of Germany has for some time contended that one of the chief causes of gastro-intestinal disorders is the sugar in the food. Also that fat is particularly dangerous in the presence of high percentages of sugar, being relatively harmless in low proportions.

This "casein milk" recommended by him is prepared by coagulating the milk with rennet, and then straining off the whey. The coagulum remaining contains the casein and the fat, while the whey consists of

the soluble albumins with the sugar and salts. The casein curd is then rubbed through a sieve and mixed with buttermilk. The result is a food containing a high proteid percentage and a fairly good fat percentage. The fat is allowed to remain, on the theory that it is digestible, if the sugar has been removed.

My experience with casein milk is limited, and agrees with that of Dr. Griffith, of Philadelphia, as reported in a recent communication. I have tried it in bad cases only, and with no good result; but the test is, of course, not a fair one. Some in this country have tried it with moderately good results, but have by no means obtained the success claimed for it by its originator.

In rectal feeding dextrin in solution probably furnishes more absorbable material than any other food at our command. Recent observations and experiments corroborate this statement.

Regarding the use of whey, as recommended by Dr. Goodrich, although he speaks of the point that I would make, I wish to emphasize it, and that is, that whey be given undiluted, or if at all very slightly, otherwise most of the nutritional value is lost.

Remembering that whey contains but 0.32 per cent. fat and 0.86 proteid, it is evident that it cannot be ordered, as milk and cream mixtures are, highly diluted, without reducing these ingredients to starvation quantities. As to the addition of milk sugar to whey, as suggested by Dr. Goodrich, one must go carefully; for whey itself contains over 4 per cent. sugar, as compared with 6 per cent. in whole milk. In consequence, one might easily overstep the limit of tolerance of this ingredient unthinkingly.

I am glad that Dr. Goodrich brings out the point and fact that undue stress is often laid upon the character of the stools in the convalescent cases of summer diarrhoea.

It has been my common experience to find an infant still confined to a cereal and animal broth diet, long after the fever has ceased and long after all toxic symptoms have passed, simply because its three or four semi-fluid movements contain mucus and undigested food.

Here there is absolutely no contra-indication to beginning milk feeding; in fact, these little patients need it, and it is remarkable how quickly they respond in gain in weight, when it is given, and how soon the stools regain their normal character. It is my habit to begin their milk feeding by the use of skimmed milk partially peptonized, with the addition of cream following. Some recent observations would indicate that small doses of olive oil aid materially in the assimilation of the fat. Olive oil in itself is not the laxative that domestic medicine would lead us to believe.

Regarding the cases Dr. Goodrich speaks of as having intolerance for milk in both health and disease, and his system of overcoming it and getting back to a milk diet, I would suggest a trial with buttermilk.

Two such cases of this rare condition in healthy children, where there seemed to be some inherent peculiarity that forbade sweet milk, responded quickly to the course of buttermilk feeding. I have always been sorry that I did not study the stools in these cases bacteriologically.

Buttermilk has also a distinct and valuable place in those cases of summer diarrhoea in which toxic symptoms are not a prominent symptom, despite high temperatures, and in which, although the frequency of the stools is far past normal, they are not the watery, serous, bloody stools of real enteritis.

Infants take buttermilk well, apparently utterly disregarding its peculiar

taste.

In the feeding of sick children, as well a healthy, it is essential that we do not forget the value of the salts of food. In a recent conversation with Professor Underhill, of the Sheffield Scientific School, he strongly emphasized this point of the need of salts, and particularly calcium salt. In many diet lists, this essential, salt, is reduced to a minimum by ignorance of the foods that do and do not contain it.

On the contrary, in cases of rickets, calcium is often abused and digestion upset; as constipation and its attending evils.

The old theory that a high fat intake caused a corresponding low salt assimilation has probably been refuted in the light of recent investigation. In consequence, those of us who feared that the giving of even moderate amounts of fat in rickets and malnutrition would deprive the bony tissue of their needed salt, may now, in security, give the fat which is so badly needed in these conditions.

In closing, I would speak a word against the totally unscientific use of such substances, loudly vaunted and thrust upon us, as Panopeptone, Bovonine, beef extracts, etc., in the feeding of sick infants.

Years ago, the physiological chemists taught us the absolutely nonnutritive value of domestic beef-tea and the like. Why, then, does one so often see by the bedside of a half-starved baby a glass of water containing a teaspoonful of these abominations with directions to give one teaspoonful, i. e., one sixty-fourth of this mixture, which, in its dose, contains about another sixty-fourth of this so-called highly-concentrated food?-in other words, a drop or so every two hours, say!

Likewise, a baby suffering from an inability to digest and assimilate milk for the time being is suddenly fed Eskay's Food, for instance, being thus fed a condensed-milk, dried albumen and carbohydrates.

In the beef extracts and its imitators there also comes in the dosage of alcohol, which in some of them is no mean proportion of the whole. Beyond the absolute lack of correct nutritive value for sick infants, comes their cost; and to me, at least, it is a lasting and burning shame to see these preparations on the medicine table of a working man. I believe our duty poorly done to those who so trust and lean on us in the time of their affliction, if we allow this useless expenditure.

DR. WALTER G. MURPHY (East Hartford): In discussing Dr. Goodrich's excellent paper I wish to speak particularly of barley water. For years barley water has been employed in the modification of cow's milk. Dr. Jacobi has always been an ardent advocate of barley water, as a diluent, and through the various changes in the theory of infant feeding, has held fast to this procedure. Used empirically, it has been found, that children after the age of four months often do better on a mixture containing milk and barley water than on milk and water or any other diluent.

Lately the food value of barley water has been considered and this opens the question which has been presented by Dr. Goodrich. When shall we employ barley water, and how long is this to be continued? The food value of barley water is so low that if too long continued, the patient may actually suffer from a lack of sufficient nourishment.

In the use of barley water, as in the use of any remedy, definite indications should be observed and the individual patient carefully considered. This is particularly important in children.

If we divide the cases for treatment in:o four general classes, we may formulate certain principles of treatment.

Class I-Acute irritative diarrhoea. In this class are babies, either artificially or breast fed, who are overfed. There is a decided reaction present with vomiting of the undigested contents of the stomach, some mucus and a diarrhoea accompanied by masses of undigested food. In this condition the indications are to get rid of all irritating substances in the intestinal tract and to withhold all food until vomiting ceases. In this class food values are unimportant and plain water would do quite as well as barley water, probably better.

Class II-Toxic cases in which babies with pneumonia or some other general infection are temporarily disturbed and there is vomiting or an evidence of intestinal toxæmia from constipation or the presence of undigested food. High temperature and prostration are usually present and there is an intestinal toxæmia in addition to the toxæmia of the disease. In these cases, which are usually acute, drainage and rest are indicated until the symptoms subside and food values are not important.

Class III-Acute fermentation diarrhoea. This may appear in children who have been previously healthy and the infection is accidental as the result of fermented or contaminated food. Vomiting and diarrhoea are present and prostration often extreme. In these cases the indications are rest and drainage.

Babies suffering from any of these conditions are better without food than with it, during the active stage of the process. Babies who have always been well, who are well nourished and with good resistance to disease, who have high temperature and a rapid pulse, with a level or bulging fontanelle and the abdomen not depressed below the level of the ensiform