By making a large number of observations on healthy breast-fed children who were thriving in every way, Huebner found that in the first six months of life, infants consume daily an amount of milk equal to forty or forty-five calories per pound of body weight, and somewhat less than this in the last six months. Numerous observers have confirmed these results.

Its application to Finkelstein's methods is simple. One quart of "eiweiss" milk contains four hundred calories, one of buttermilk five hundred calories, and one of breast milk six hundred fifty calories. When, therefore, one has determined the number of calories an infant requires in twenty-four hours, it is simply a matter of adding to either of these enough carbohydrates to bring the total daily calories up to the amount required. The capacity of the stomach which serves as a guide for the maximum amount of liquid at each feeding is as follows for the first twelve months of life: 90, 100, 110, 125, 140, 160, 180, 200, 225, 250, 275, 290 cubic centimeters.

Healthy infants who are unable to get breastmilk are fed milk dilutions with the addition of a carbohydrate.

For the first month, the mixture is as follows: One-third liter cow's milk, two-thirds liter water, forty to fifty grams carbohydrate, five to ten grams of wheat flour. This gives a mixture containing four hundred fifty calories per liter.

In the second and third months: One-half liter of milk, one-half liter of water, forty grams of carbohydrate, twenty grams of meal. The meal and sugar are cooked in the water five minutes before adding the milk. One liter contains five hundred fifty to six hundred calories.

In the fourth month: two-thirds liter of cow's milk, one-third liter of water, forty grams of carbohydrate, twenty to thirty grams of flour; giving a mixture containing seven hundred calories to the liter.

In the later months of the first year, the food is prepared with three-fourths milk. No full milk is given until the end of the first year. There are three kinds of carbohydrates which may be used in infant feeding:

(1) Lactose or milk sugar.

(2) Cane sugar.

(3) Maltose.

Milk sugar is probably the most used and may be fed in relatively large quantities without producing diarrhea. It does, however, undergo bacterial decomposition in the alimentary canal more readily than the others.

Cane sugar is objectionable on account of its sweetness and because it easily produces diarrhea.

Inasmuch as maltose may be absorbed without further digestion. and may be assimilated in much larger amounts than other carbohydrates, it should be the most useful of all. Unfortunately, however, it easily produces diarrhea. It is also very expensive.

Dextrin, a solution of carbohydrate, is a transition between starch and maltose. It has the same food value as maltose and does not produce diarrhea. On the contrary, when given in large doses, it causes constipation. It also produces greater growth in equal quantities than

does milk sugar. Combined with maltose, in such a proportion that the laxative action of the maltose overcomes the constipating action of the dextrin, it is probably the best carbohydrate we can use.

Such a mixture containing fifty per cent maltose and thirty-eight per cent of dextrin is sold in this country in the form of a popular patent infant food which is obtainable in every drug store.

It must not be forgotten that "eiweiss" milk is for sick babies and is given by Finkelstein to healthy babies only under one condition. In a large institution such as his, there is always more or less infection about, and inasmuch as infants who are being fed on "eiweiss" milk are less subject to secondary dyspeptic disturbances than those taking any other form of artificial food, all infants entering his hospital who are not given breast milk are fed "eiweiss" milk until they have become acclimated. Speaking broadly, "eiweiss" milk is indicated in all diarrheal disturbances. It is made as follows: Coagulate a quart of fresh, full milk with essence of pepsin and let it stand a half hour in a bath of about 105. Then filter this through a linen sack, letting it hang over a clean dish for an hour, by which time the whey should have filtered out. The coagulated casein is then to be mixed with a pint of water and forced through a fine hair sieve. This is to be repeated two or three or more times until the coagulum is very finely divided and the mixture looks like milk. To this add one pint of fresh fat-free buttermilk. The water and buttermilk should be boiled before using. It is therefore, composed of the casein from one quart of milk and onehalf quart of buttermilk; the fat from one quart of milk and the sugar and salt from one quart of milk and one-half quart of buttermilk. A chemical analysis shows it to contain three per cent of albumin, two and one-half per cent of fat, one and one-half per cent of sugar and five per cent of ash. It is, therefore, weak in sugar, containing one-third the amount found in cow's milk, and is also somewhat below cow's milk in fat and ash. It contains about the same amount of proteid as cow's milk which Finkelstein thinks is an advantage as the alkaline albumin neutralizes the acid fermentation of the sugar and is, therefore, useful.

"Eiweiss" milk is rather difficult to make, but I am happy to say that the nurses of the D. A. Blodgett Home for Children have mastered the difficulties of its preparation and I think will be glad to supply it to anyone.

84 Monroe Street.

REPORT OF TWO CASES OF ACIDOSIS; ONE WITH AUTOPSY.*

WARD F. SEELEY, M. D.

ANN ARBOR, MICHIGAN.

Case 1.-Mrs. M., aged forty-eight, entered the Gynecologic clinic July 28, 1911. Family and personal histories are in all respects negative. She entered the hospital complaining of severe headache, diagnosed by Doctor Klingmann as migraine. There was also a tender *Read before the Clinical Society of the University of Michigan, October 11, 1911.

area in the left lower quadrant, which had been said by her physician to be due to an abscess. Her gynecologic examination showed an inflammatory mass in the left side of the pelvis, extending into the posterior culdesac. Her lungs were negative. There was a systolic murmur at the apex and in the pulmonary area. Her urine on entrance showed no albumin nor sugar but a few granular casts were seen. Her stomach on two occasions showed no free hydrochloric acid.

Patient was operated upon August 8, 1911, panhysterectomy being done. The operation was a difficult one, there being many adhesions and was accompanied by considerable hemorrhage and oozing. The pelvis was packed with gauze, drainage being left from below. The operation required two hours and forty-five minutes to complete. The pathologic report showed the uterus to be of the fibroid variety, appendages adherent and one ovary cystic.

On the third day after the operation the patient began having frequent stools, which rapidly developed into a very severe diarrhea, with twelve or fifteen movements daily. This condition persisted until the fifteenth day and was accompanied by nausea and vomiting, which gradually grew more severe, for which purpose the stomach was repeatedly washed. On the afternoon of the fifteenth day after operation, the patient went into a state of collapse, with cold, moist extremeties, violent hiccough, temperature of 102.2°, pulse of 120, and respiration of 34. Hypodermolysis was resorted to and the next day the patient was much improved. The nausea and vomiting, however, still persisted and gradually grew more and more severe. About the twentieth day the patient complained of difficulty in swallowing and upon examination of the throat a pseudodiphtheritic membrane was discovered. The patient at this time was unable to take nourishment by mouth on account of the excruciating pain accompanying the swallowing. Rectal feeding was then resorted to. At this time the abdominal wound having healed except for a small pocket at the lower extremity the patient was transferred to the Medical clinic. As the throat was practically clear the patient was tried on very small quantities of salt solution by mouth, but complained of intense pain in the lower thoracic region, and was consequently put again on rectal feeding. At this time the patient was nauseated and vomited at times, but the condition was apparently not so severe as previously. After four days of rectal feeding, nourishment by mouth was again tried and fairly well borne. The urine was very acid and showed both diacetic acid and acetone, which persisted in all subsequent examinations. Three or four days after this the vomitus began to show blood, the amount rapidly increasing. The stomach was washed with ice water and chloretone was given, with only temporary relief. There were suspicions of a pneumonic process but this could not be demonstrated clinically. The patient continued to grow weaker and the gastric hemorrhage more severe. Shortly before death the axillary temperature was 104°, pulse 160, respiration 72.

Autopsy findings:-Lungs; purulent metastatic pneumonia, congestion and edema, streptococcus infection. Heart; cloudy swelling, fatty degeneration and brown atrophy. Spleen; atrophy and chronic passive congestion. Kidneys; marked cloudy, swelling, numerous hyaline glomeruli, marked passive congestion and hyaline casts. Pancreas;

slight atrophy. Stomach; chronic catarrhal gastritis with cystic glands, Liver; extremely fatty degeneration and infiltration with simple necrosis; findings evidently due to some intense intoxication, either an infectious process or a combination of the same with chloroform or some other poisoning. Bladder; slight chronic cystitis.

Case II-Mrs. O., aged forty-eight, was admitted to the Gynecologic clinic August 8, 1911. She came to the hospital for excessive flowing during her menstrual periods and for an abdominal tumor. Her family and personal histories were practically negative except for occasional attacks of vomiting, without apparent cause, which began in December last. On entrance her blood was negative. The urine showed albumin and hyalin casts, but no sugar. Gynecologic examination showed a large fibroid uterus with adherent appendages. Examination of the heart showed the apex to be in the fifth intercostal space well beyond the middle clavicular line. There was a loud systolic murmur at the apex, transmitted to the axilla with accentuation of the pulmonic second. Examination of the lungs was negative. There was a slight Graeffe sign, a moderately enlarged thyroid, fine tremor of the fingers and heart rate of 114. A diagnosis of mitral insufficiency, chronic interstitial nephritis and hyperthyroidism was returned with advice that patient be transferred to the Medical clinic for treatment and further observation before operation. On entrance into the Medical clinic the patient was put on a course of digipuratum which was quite successful in reducing the heart rate. When sent back to the Gynecologic clinic for operation, the rate varied between 80 and 88. The urine was free from albumin but a few casts were found. No glucose was present at any examination.

The operation (panhysterectomy) was a severe one, the uterus being bound down by adhesions, so that it was impossible to elevate it and deliver it without the abdomen. After the operation, for a few days, the patient's condition was uneventful, when a paroxysmal irregularity of the heart, of the permanently irregular type, developed. This condition continued intermittently and is still noted at times. The pulse ran from 120 to 135, but the temperature was not elevated in proportion. On the eleventh day after the operation, the patient began to complain of nausea and vomited small amounts. The condition, however, did not become severe until the fifteenth day.

The patient at this time was having frequent stools, averaging seven daily and on the twentieth day nourishment by mouth was refused. Shortly after this patient was again transferred to the Medical clinic, the laparotomy wound having healed by first intention. On entrance. into the medical service the patient was extremely nauseated, vomited frequently and was put on rectal feeding and given gastric lavage with ice water. There was a sweetish odor to the breath and acetone was demonstrated in the urine, which was very highly acid. The pulse varied from 128 to 144, temperature about 99°, blood pressure 138. Vomitus showed no free hydrochloric acid. Sodium bicarbonate in doses of two drachms, twice daily, was given by rectum; and as soon as the nausea somewhat subsided, liquids containing considerable sugar were taken by mouth. Hypodermoclysis of ten ounces of a twoper-cent solution of sodium bicarbonate was given under each breast.

It was gratifying to note that on the third urinary examination, after entrance, tests for acetone were negative and the urine alkaline. The diarrhea, which had heretofore been rather severe, also diminished and at the present time the patient is having only one stool daily. Progress has been rapid since the acidosis has disappeared and unless there are further complications, recovery can be looked for.

In a discussion of acidosis, Edsall, in the British Medical Journal, states "that as a consequence of the use of ammonia to neutralize the acid, ammonia is excreted in abnormally large amounts in the urine, and the presence of ammonia in abnormal quantity, is therefore an index of the extent of acid intoxication." In the human body only one acid is known to occur in quantities large enough to be dangerous, the acid in question being beta-oxybutyric. Acetone and diacetic acid are oxidation products of the mother substance. Diabetes is of course the classic condition in which the acidosis is found; other conditions are starvation, various poisonings especially by some of the narcotics; severe digestive disturbances; cyclic vomiting of children; acute yellow atrophy; phosphorous poisoning; eclampsia; after anesthesia and in certain neurologic conditions.

The occurrence of a large amount of acid in acidosis is dependent upon two main factors, the inability to use carbohydrates and the coincident excessive use of fats. The same conditions obtain in starvation, where no carbohydrate is taken and large amounts of body fat are burned. Cases are seen, however, in which acidosis is clearly marked at the very beginning of the symptoms, when there has been no change of diet. There are, therefore, two types of acid intoxication. In the diabetic type there are no tissue lesions sufficient to explain the amount of intoxication. In the other type there are serious lesions, which evidently may of themselves be enough to produce violent symptoms.

The work of Reichter on the influence of narcotics upon the fat content of the blood, shows that such substances as chloroform mobilize large amounts of body fat. The oxidation process being probably reduced by the chloroform, the fats are not properly oxidized and their by-products in the form of acids accumulate in large amounts. That the acids do harm in these conditions is shown by the fact that in a fair proportion of cases, as Wallace and others have shown, carbohydrate and alkali treatment will go far toward preventing postanesthetic intoxication.

The older literature on the subject of acidosis lays much stress on chloroform poisoning. More recent work, however, shows that this condition occurs frequently after ether, as well. The length of anesthesia, while to some extent an index to the amount of intoxication, is not always reliable for diagnostic purposes as both acetone and diacetic acid are found after anesthetics of not unusual length. French authors lay considerable emphasis upon the acetonemic vomiting.

In regard to the autopsy findings in acidosis, those of Mrs. M. are quite typical. Acute degeneration of the liver with fatty degeneration and infiltration is the common finding. Fatty degeneration in other organs, as the heart, is also frequently found. It must be understood, however, that these findings are only typical in cases of the second type above described, there being no lesions in the clinical form of which diabetes and starvation are types.