If malt soup is so valuable when we are having trouble, it is even more valuable as an every day food for the normal baby, making gastro-intestinal trouble less frequent or possible. The time is not far distant when "malt soup" as an artificial baby diet is going to be increasingly popular. To repeat, when we have a safe supply of milk, or the weather is cool, add the fresh milk to the boiled mixture when cooled; if we boil the milk, give two to four teaspoons of orange juice each day. "Malt soup" is particularly valuable after the baby is four or five months of age. This is the time, too, when the mother's supply is most apt to diminish or fail, and artificial food be demanded. Preparation of "Malt Soup" Any malt extract is available provided about fifteen grains of carbonate of potash be added to each ounce of the malt, to neutralize the acidity. "Malt soup" must be used with care, as too much tends to loosen the stools. For a baby three months or younger, begin with one teaspoon of the malt extract for the day's supply; and increase very gradually, if the condition of the stools permit, to tablespoon. Of flour, begin with two teaspoons and increase to a tablespoon and then two tablespoons. The writer usually uses prepared flour, flour that has been thoroughly baked or roasted. Ordinary wheat flour can be used, especially after the child is four or five months of age. Of milk, skimmed at first, take eight ounces. Gradually add cream after a few days. Use sufficient water to bring the quantity of food up to the day's requirements. A three months' baby may have seven feedings of four ounces each, twenty-eight ounces for the day. We have now: , 1913 , Vol. VIII tacle, and the malt and water in a second; then put these two together in a double boiler; boil slowly thirty minutes. Cool, and put on ice. Feed as directed. There will be no occasion to strain the mixture if the flour is carefully rubbed with the milk. Let me repeat what was said before: if we have a safe supply of milk, and particularly if it is cool weather, we will boil the malt flour and water, and then add the milk when the boiled mixture is partially cooled. While much more could be said regarding the feeding of normal babies, we will dismiss the topic with a few words regarding the amount of milk we would like to have a baby consume. What he can take, though, must be our rule. With the carbohydrate addition, a three months' baby can seldom be expected to take more than twelve to fourteen ounces of cow's milk; six months, twenty to twenty-four ounces; and eight to ten months, one quart. We must bear in mind that many babies fail to gain because they get more food than they assimilate. Sick Babies:-In the feeding of sick babies, a distinction should be made in general between those sick with acute gastro-intestinal infections, and other conditions, though the initial advice should practically be the same for all. Regardless of the nature of an illness in an infant, we can seldom go astray if we advise a laxative at once; and for the first day at least let the diet be reduced to a gruel, or a two or three per cent sugar water. The condition of an infant's digestive organs is of supreme importance, particularly when sick; and by taking the above caution, we avoid complicating a pneumonia, a pleurisy, a severe bronchitis, a tonsillitis, or any one of a dozen other conditions with a gastro-intestinal factor. General sick diet: After the laxative and a short period of rest to the gastrointestinal tract, we can usually with safety put the child on one-half strength of his usual food, If the sickness is an acute intestinal, or gastro-intestinal attack, while our initial advice is as outlined above, we can not after a day or so, by any means with safety to the patient, return to a fairly liberal proportion of his original diet. In these cases, haste practically always means waste. We should make the mistake of withholding Gastro-intestinal sickness: milk too long rather than not long enough. What we first give the infant in the shape of milk, after an acute gastro-intestinal attack, has much to do with the length of time necessary for his convalescence. Our early assertions regarding milk sugar particularly, also fat, are here to be recalled; whatever scheme of return feeding we attempt, there is absolutely no question regarding the necessity of avoiding fats as completely as possible, and of keeping fairly low with the sugar, using either maltose or cane sugar in preference. to lactose. This means we get the best results if we use maltose only with the water or gruel at first; and afterwards add fat free milk in the preparation of the food. The simplest scheme will be to work up from a few ounces of skimmed milk, to which is added water or gruel, and two or three per cent sugar. We are to be very guarded in our attempts to add cream. Take a six months' baby having had diarrhea; he has been cleaned out with castor oil; his diet has been a weak carbohydrate mixture for some two, three or more days; the stools are not offensive; the mucus has largely disappeared; the color and consistence of the stools are better. What addition shall we make to his diet, and how go about it? First day, add as little as three ounces of skimmed milk to thirty-three ounces of gruel or water; to this add two tablespoons, rounded, of malto-dextrin, and feed six ounces six times in the day. If the stools remain good, the next day increase the skimmed milk one or two ounces, decreasing the gruel by the same amount, and leaving the sugar stationary. After two or three days, making these small increases in the skimmed milk, we may make the increase a little more rapidly, until we are giving of skimmed milk twenty-possibly twenty-four ounces, the rest of the bulk of the food being the carbohydrate mixture. Now we may begin the addition of a very little cream-onehalf ounce, or even less, to the day's food. Especially if the weather be hot, should we be very guarded about the increase of the fat. Do not mind the stationary weight. The child that is taking a fair amount of proteids will be substantial, even though he may not be fat. "Malt Soup."-"Malt soup" made with skimmed milk, and beginning with a small amount of malt extract, particularly with infants over four or five months of age, meets our requirements more often than any other scheme of return feeding. Here we may usually safely begin with six or eight ounces of skimmed milk for the day's feeding, and work up gradually, being satisfied for quite a period with fat free milk. The caution, observed above, regarding the amount of malt extract to be used, is particularly applicable when beginning "malt soup" as a food following an attack of diarrhea. Begin with the little and increase gradually to reasonable proportions, if the condition of the stools will warrant it. "Eiweiss Milch."-"Eiweiss Milch" was first suggested by Finkelstein to meet the requirements of infants and children suffering with fermentative trouble, where sugar-theoretically at least, has been the causative factor. Fat, as we have said, has to be reckoned with in advising a food for an infant recovering from diarrhea, so that now when "Eiweiss Milch" is used under these conditions, it is most appropriately made from skimmed milk at first, afterwards adding more and more cream. "Eiweiss Milch" being a sour milk preparation, it is frequently impossible to get an infant to take it. When it is used, its place seems to be as the first departure from the gruel diet, which has been given. during the acute symptoms. Its use is seldom indicated for more than one or two weeks; for infants to whom it is given seldom thrive. In place of the "Eiweiss Milch," after this first short period of use, we may appropriately substitute either "malt soup," modified fresh milk, or condensed milk, either sweetened or unsweetened. Finkelstein's formula for "Eiweiss Milch."-Heat a quart of whole milk to 100 deg. F. Add four teaspoonfuls of essence of pepsin and stir. Leave the mixture at 100 deg. F. until the curd has formed. Pour the mass into a linen cloth and strain off the whey. Remove the curd from the cloth, and press it through a rather fine sieve two or three times by means of a wooden mallet or spoon. During this process, add one pint of water to the curd. The precipitate should now be very finely divided, and the mixture have the appearance of milk. To this mixture add one pint of buttermilk. Note that this formula is made from whole milk, and contains 2.5 per cent fat, 1.5 per cent sugar, and 3.00 per cent proteids. With our present conception, we can most appropriately use fat free milk, when first using Eiweiss as a return diet, following diarrhea. In using Eiweiss Milch, we can very appropriately begin with a small amount, one or two ounces to water sufficient to make up the feeding, and gradually increase as the stools approach the normal. We may also, as soon as conditions are favorable, add increasing amounts of maltose, also cream when we make it from skimmed milk. This not only increases the nutrition, but improves the taste, and the possibilities of the child's taking it. Condensed Milk.-Remarkably good results are frequently observed by using condensed milk, diluted with water or gruel. This is particularly true where we are able to obtain the fresh or unsweetened variety. This is easily prepared and requires little or no ice for keeping purposes. It must be obtained fresh each day though. We may begin by using one-half or one teaspoon to each or every other feeding, and gradually increase the amount to one or two tablespoons to each feeding. When we consider it prudent, we may also add increasing amounts of cream, also malt sugar. The unsweetened condensed milk diluted one part to six of water, gives us approximately one and a half per cent each , 1913 , Vol. VIII DIAGNOSES BY B. G. R. WILLIAMS, M. D., of fat, proteid and sugar. If we put one MUST OUR The canned, or sweetened condensed milk has a large addition of cane sugar. A one in six dilution contains nearly nine per cent sugar, so that we are unable to give enough proteid and fat for a legitimate, long continued diet, without giving too much sugar. For the beginning return diet, though, after a sickness, we frequently get surprisingly good results. Deficient as it is in nutrition, it is safer than a poor quality of milk without ice; and among the poor we frequently are obliged to use it for long periods. When possible and prudent, we can easily add cream. Difficult Feeders:- By "difficult feeders," we refer to that class of infants that show an idiosyncrasy to one or more of the three elements of nutrition-fat, proteids or sugar. On account of the already too great length of this paper, we will omit going into details; and simply say we must ascertain the incompetence of the babe by beginning with one element, and discarding it for another, if this proves offensive. Much ingenuity is many times necessary to enable one to give enough nutrition to cause an infant to thrive, and at the same time keep him well and comfortable. 126 West 81st Street. BE AC "He does his best; angels can do no more." So great is the difference between the impotent speculator and the sober physician, that many hours must be set aside by the latter to correct the errors and abuses of the former, that our great science may not perish thereby. Through diagnosis, we are introduced to our patients; and through diagnosis, therefore, do they obtain their first and most lasting impression of our present and future fitness. Time was when the family physician (and he makes up fully ninety percent of our profession) lagged somewhat behind, giving his chief attention to therapeutics. But watch him now slowly elbowing his way to the front. Let us see. Several centuries ago, our medical forefathers delighted and astonished us with their vivid and accurate descriptions of symptom complexes. Behold the face in peritonitis, according to Hippocrates-the pinched expression, the dusky suffusion and the forehead bathed in clammy sweat. Behold the skin of smallpox according to Rhazes-macules associated with fever, appearing first on the forehead and anterior surfaces of the wrists, then slowly spreading to other portions of the body; in turn, a gradual fall in temperature, followed by a rise with the formation of vesicles and finally pustules. Behold the manifestations of scarlet fever according to Sydenham-a sudden onset, an intense fever, a marked angina, a diffuse and scarlet rash and swollen lingual papillae. But yet we failed to correlate into systematic outlines and commit to memory these descriptions in such a manner that with but a glance at any sufferer, we could at once pronounce a final diagnosis. Because of various factors better understood to-day, a given disease failed to exhibit exactly the same visible phenomena in two different individuals. Then despairing but still struggling gamely, we attempted to select out certain symptoms here and there-rose spots of typhoid, buccal spots of measles, spleen cake of malaria-of pathognomonic significance, but in vain. At length the wonderful Rene Laennec gave us the physical aids to diagnosis. And what could we not diagnosticate then? By percussion and auscultation, we were at last in a position apparently to make accurate conclusions in every instance. But valuable though these aids have proven, our disappointment was keen when we realized that while we might ascertain the nature of the structural alteration, we could not by accoustics alone, determine etiology. For to treat a disease, we must know something of its cause. Ah, here at last was the true path; and so we had Virchow and Pasteur whose researches enabled them to bring under the domain of scientific laws, phenomena of disease and lay the foundations of modern pathology. No longer could we say with our medical predecessors: "We must be on our guard against the fancied excellence of accurate diagnosis; remember that it is our business to treat disease, not to be supremely wise," but must use these new truths along with the older ones that we might in the end treat best the disease. Pathology being still in its infancy, we have no right to predict whether it will or will not lead us to precise diagnoses in all diseases. We can only say that in many conditions, the laboratory information, though not the entire arch is certainly the keystone for the arch upon which we must build our treatment. Despise it and tear it out and a fall is inevitable. In this connection, I could give many illustrations; and I might add that in a communication of this kind the urine, blood, sputum, pus, gastric and bacterioological examinations are usually cited by the writer to prove his case. But it seems to me that one of the most beautiful fields of accurate diagnosis is that which has been developed chiefly by Carl Ruge, following the induction by Olshausen of abrasio mucosae as a gynecologic operation-the diagnosis of uterine diseases by an examination of the curettings. Here with practically no danger and with the greatest of ease, our most positive diagnoses are realized and the most rational therapy instituted. Then there are the cytological examinations of the puncture fluids and indeed many other exact procedures which have been placed in the hand of the diagnostician. If the selection of my subject warranted, I could continue to enlarge upon other fields in which pathology has put diagnosis upon a scientific basis. While we must ever be conservative, we cannot (as we often do in therapeutics) diagnosticate the patient rather than the disease. Now this applies chiefly to those morbid conditions due to extrinsic factors rather than those of intrinsic etiology, or inherent in germ protoplasm. In other words, while syphilis may respond only to different treatments in two individuals, yet the finding of the treponema pallidum gives us the final diagnosis irrespective of any |