Special caution should be observed in returning to milk. The prompt administration of breast-milk is often enhanced when given ad libitum if the tolerance to relative fat and sugar amount has not been established. The condition frequently recurs, especially in eases which have been starved, and there is sudden death. Therefore human milk should be used in small quantities at first and should be increased slowly after no reaction occurs. It must be assured that this resource does not fail. Salge, Finkelstein and others recommend the usu of centrifuged human milk.
Where breast milk cannot be procured, skim milk (0.2 per cent. fat) which has been carefully prepared may be given, and as the ease improves flour may be added. Whey has no advantage, as the albumin content is not influenced and the child takes skim milk well. In returning to the previous ways of feeding, the diet should be small with a low atnount of fat and sugar. Mixtures rich in sugar, as buttermilk, malt soup, etc., are out of place, as well as preparations rich in fat. Cow's milk with small amount of fat, and easily digested flour soups should be chosen.
Itt cases of alimentary intoxication certain conditions are met with which, aside from dichotic measures, require energetic therapeutic treatment.
When the vomiting is severe the administration of liquids by the mouth is impossible and the danger from the loss of water must be com bated by other ways. Rectal injections (physiological salt solution, Luton's and Hayem's solutions) are, because of the intestinal irritation, either not possible or give but slight satisfactory results. There is then the subcutaneous method, and from this effective results are usually obtained. Strictly antiseptic injections are made once or twice daily or even oftener. They are made under the skin in the upper arms, breasts, and abdomen; 100-200 cns. of physiological salt solution at body temperature are injected. This is rapidly absorbed, exercising beneficial results on the general condition, stimulating the skin, warming the extremities, slowing, the pulse, etc. The fontanel is less depressed and the expression becomes better. (The effect of subcutaneous injec tions of isotonic salt and sugar solutions in raising the fever has been mentioned recently by- Schaps, Meyer, Rietschel, Tixier and others. In these cases' with such a severe loss of water the injeetions do not have such an effect and therefore should not diseredit the influence of this most effective manner of treatment.) Ether or spirits of camphor may be used to stimulate the action of the heart,. Hot water bottles and hot mustard baths may be used to eounteraet the lowered temperature of the skin.
Immunity being at its minimum, special care should be taken of the skin and against infection.
4. Decomposition.—Finkelstein has brought nearer a practical expla nation of those conditions of atrophy which have been the horror of physicians for years, and for which there has been a very unsatisfactory method of treatment. He speaks of its being an alimentary decomposition. The condition in a certain form is aggravated by nourishment, increases rapidly:to a decomposition of the body, and reaches a stage at which there is no way possible to save the patient. At this stage it is impossible to nourish the infant, and es-en the small part of the foodstuff is not used by the body and as a consequence disastrous results follow.
First, we were dealing with disorders of balance and dyspepsia, causing local damage but which could be remedied by regulating the diet. Next we were dealing with alimentary intoxication in which the poison ous effects of undigested foodstuffs in the bowel can be eliminated by properly getting rid of the trouble makers. We are now confronted by a failing of digestion which affects more and more the resources of the organism until finally it breaks down.
Our knowledge of this severe sickness and its efficacious treatment was made clear by certain accurate observations. This condition follows dyspepsia and disorders of balance (without such conditions it never occurs) and the administration of intoxicating sugars, even though they be low, cow's milk and preparations rich in fat. The weight curve, instead of increasing, falls with the progress of the disease. The daily losses at first are from 30 to 50 Gni., later 100 Cm. The general state of the child undergoes a radical change. He is nervous, the sleep is unsound, he cries for hours, and can be quieted only by the bottle which he takes with great eagerness. During the interval between feedings Ile appears hungry and thirsty. If possible he places the fingers in his mouth, or sucks the whole hand with evident hunger. At first the loss of flesh is less noticeable—later is becomes marked. This is especially' so about the arms and legs, where the skin hangs, dry and withered, loosely about the bones. The appearance of such a patient, with large hollow eyes, wide mouth, and bluish waxy color of the skin, has been likened to that of an ape. Two photographs of such children show their pitiful condi tion better than it can be described. (Pages 131 and 132.) The evacuations show different characteristics. They may be nearly normal, with usual odor, or somewhat frequent like those of dyspepsia. They may be slimy, loose and offensive. They may show the eharacter isties of fat stools, being hard, dry, pale yellow, and putrid, due to soaps, or the fatty, dull, pungent, loose stools of fat iliarrhcea.