Skim milk may be reduced with either the natural or manufactured flours if especially heavy reduction of the fat content of the food be needed.
It is important to remember that when instituting feeding in these cases a very limited amount of food should be given in the beginning. Also begin with less than the amount necessary for maintenance about 70 Gm. per kilo.) and slowly increase, with the temperature and gain in weight as a control, until the tolerance for food is established. After a few weeks the carbohydrates may be partially substituted by fats. This is especially advisable in older children.
2. Dyspepsia.—This is the next grade of nourishment disorders which cow's milk and its preparations predispose to, and results from slisorders of balance. The duration of such disorders can be so short that the dyspeptic state may be thought to be primary, but such is not the fact. It differs from disorders of balance in that there is an abnormal weight curve and lowering of the temperature, marked symptoms of intestinal irritations. The evacuations are pathologically characteristic, being frequent, watery and containing much mucus. Eventually there is vomiting. There are efTects on the adjoining tissues, and. the high temperature associated with the local irritation of the intestines is injurious to the specific action of the epithelium and retards the conserva tion of the normal intestinal flora and the normal intestinal digestion.
It is clear without further discus.sion that each significant disturb ance weakens the defence and makes it easier for the barrier to be broken down, and then it is only a step to further intestinal and intermediary metabolic changes.
The symptoms observed in dyspepsia differ from the ordinary cases of disturbed nutrition in that there is associated vomiting and diarrhixa, more radical changes in the temperature, and the weight curve obsti nately reniains stationary or with little gain. There is as a rule no variation from the normal in the general condition, the heart action, respiration or in the action of the kidneys. In this condition the "paradox reaction" is even more marked. This is thought to be due to the more marked pathological condition of the intestines causing an abnormal disposition of the foodstuffs when the diet is increased.
The mild and severe cases are explained equally by the symptoms of intestinal irritation by the food supply. The early reactions of the sickness are caused by the food, and later ensue the changes which cause the diarrhcca, stationary weight, and variations in temperature.
Of the various foodstuffs concerned in the causation of this disorder, the fats play an important part, in many eases causing an abnormal fermentation in the bowels, which disappears after the fat is diminished or discontinued. Frequently the carbohydrates are at fault as well as the flours and especially the sugars. It has been observed that the pre digested flours are used more successfully than any other preparations. In regard to the sugars, the milk and beet sugars are tolerated less easily than maltose or dextrinized compounds. This is important therapeutic knowledge. It has also been observed that in these disturbances the casein in skim milk or buttermilk (without sugar or flour) acts bene ficially because the casein is of little importance as an etiological factor. The treatment therefore should be directed toward the food quantity and the right compound whieh will lessen the intestinal irritation, increase the weight, and regulate the temperature. This is done by eliminating the fats and sugars from the food (or replacing the sugar by one which is easily utilized) and substituting, one of the partially digested flours.
The quickest and surest result is obtained by returning to the breast milk, as this, even though containing fat and carbohydrate, does not fail to improve the condition of the bowels and aet favorably on the weight and temperature. The prognosis depends on the rapidity with which the return to normal is accomplished, the amount of food reduction which is necessary, and the frequency of the vomiting. It is most serious when from the administration of skim milk for a long time (over a week) there is no improvement in the general condition or bowel disturbance, and this sometimes makes it difficult to establish therapeutic measures.