be from the twentieth to the thirty-fourth week, but as before stated, no hard or fast rule can be formulated, and each case must be studied and managed by itself. Ordinarily it is the albuminoids that make trouble and some infants will not digest as much as two percent of albuminoids until they are nearly a year old. If curds are noticed in the stools the albuminoids are in too large percentage and should be reduced, sometimes even to leaving them out as much as possible for a time and then increasing gradually. If the fats are too low the infant is apt to be constipated. It is not, however, possible to cure every case of constipation by increasing the fat, and it should not be increased above 4 or 4.5 percent for an infant under six months of If this percentage does not remedy the constipation other means should be resorted to. The sugar is the least liable to cause trouble with the infant's digestion of any of the constituents of the milk and it is seldom necessary to reduce the percentage below 4 percent. If the sugar is too low the gain in weight will be slow; if in excess the most reliable symptoms are colic and green acid stools and perhaps gaseous eructations.

If the fat is in excess the infant is liable to eructations of food one or two hours after feeding and perhaps frequent stools, which, however, may be normal in appearance. Rarely lumps of fat are found in the stools which somewhat resemble casein. The infant should be weighed at least every week, and if the gain in weight is not sufficient the milk should be varied to meet the conditions present. It will thus be seen that to attain success in feeding infants from the laboratory as well as by any other method of feeding them care must be exercised and careful attention given each case by the physician himself; but the results that are obtained certainly repay for the

attention.

I will add a few prescriptions that have been given to some of the babies that I have fed from the laboratory, which show how the food has been changed from time to time in each special case. The first one was put upon the laboratory when seven weeks old. This was a second child; the first was fed artificially, the mother being unable to nurse it. This child was born seven weeks before the laboratory in this city was opened and was put to the breast for that time but did not do well. The first two weeks the fats in the mother's milk were in excess, causing a very high fever and very frequent green stools, and later the albuminoids became excessive, becoming at one time nearly six percent, being the cause on one occasion of a convulsion in this infant, and for the most of the time undigested, curdy stools. At seven weeks of age and weighing eight pounds, it was put upon the following prescription: Fat 3.50, sugars 6.50, albuminoids 1.50. This was September 16, 1897. Six tubes of four ounces each were ordered for the twenty-four hours, and the child was nursed two or three times for the first few days. On this prescription there were

Sep

some curds in the stools and some symptoms of overfeeding as well. tember 18 the albuminoids were reduced to one percent and the fat to 2.50 and the amount to three ounces. This was well digested, but the baby was not satisfied, being unable to go to sleep after feeding and showing that she was hungry. She was now taken entirely from the breast. On September 20 she was given eight feedings of four ounces each of the following: Fat 2.50, sugars 6.00, albuminoids 1.00. This did not seem to be sufficient nourishment, and on September 23 the percentages were changed to fat 3.00, sugars 6.50, albuminoids 1.00. September 27, the child was still hungry and was given fat 3.50, sugars 6.50, albuminoids 100. The amount and number of feedings remained the same. October 4, the amount at each feeding was increased to five ounces and on October 26 the little one was given six ounces of the following: Fat 4.00, sugars 7.00, albuminoids 2.00 I should say that in all these prescriptions the alkalinity was made five percent. Up to this time the infant had gained 12 ounces per week, weighing at 4 months, 14 pounds. By December 26, the amount of each feeding was increased to seven ounces. On December 29 it was necessary for the parents to go east for the winter and the infant was fed from the New York Laboratory, returning in April, '98, still taking the same prescription I had given in December, but taking only six feedings. On April 26 it was changed to fat 4.00, sugars 6.50, albuminoids 2.25 and on May 13 it was put upon whole milk. The child has thrived from the beginning of the laboratory feeding, has good digestion, good muscles and has gotten its teeth at the normal time, the first coming just before seven months of age. The little one always slept well and was in every way a perfectly healthy, happy baby from the time the modified milk was commenced.

Another baby was fed from the laboratory from birth. On the second day, December 27, 1897, the prescription was as follows: For an infant two days old and weighing 7 pounds; fat 2.00, sugars 5.00, albuminoids 0.75, two feedings, one ounce each. On January 1, the amount was increased one ounce. As the patient did not seem satisfied, on January 3 the prescription was fat 2.50, sugars 6.00, albuminoids 1.00. On January 10: Fat 3.00, sugars 6.00, albuminoids 1.00, the amount remaining the same. On January 10 the amount was increased to three ounces. On January 27 four ounces of the following: Fat 3.50, sugars 6.50, albuminoids 1.00 were given. By February 2 the baby had of its own accord dropped two feedings in twenty-four hours, so eight feedings were ordered of five ounces each with the percentages as before. On February 22 the baby had dropped two more feedings in the twenty-four hours, so six feedings were ordered of six ounces each of the following: Fat 4.00, sugars 7.00, albuminoids 1.50. This was continued till April 18 when the following was given: Fat 4.00, sugars 7.00, albuminoids 2.00, six feedings of six ounces each. On June 9 the amount

was increased to eight ounces, otherwise the same, and this prescription has been continued until the present time and the little one is in perfect health and condition. It sleeps all night and is a thoroughly happy looking baby, weighing 16 pounds.

The following case was taken from the breast and put upon the laboratory because the mother's milk was too rich in albuminoids in consequence of which the baby was irritable. It could not sleep and was constipated and evidently suffered from severe indigestion although perfectly well nourished and weighing 15 pounds at 3 months of age. The breast milk analysis showed nearly 5 percent of albuminoids. At 3 months of age this infant was given the following: Fat 2.50, sugar 6.00, albuminoids 0.75. This was on November 15, 1897. This mixture agreed perfectly and on November 17 the percentages were changed to fat 3.00, sugar 6.00, albuminoids 0.75, eight feedings of six ounces each being given. On November 29 the baby was given fat 3.50, sugars 7.00, albuminoids 1.00. Immediately this little one dropped off two feedings in the twenty-four hours. On December 6 it was given fat 4.00, sugars 7.00, albuminoids 1.00 and on January 3 fat 4.00, sugar 7.00, albuminoids 2.00. On February 12 as the baby did not seem satisfied the amount was increased to seven ounces and on May 27 to eight ounces and by June 14 to nine ounces of the following: Fat 4.00, sugars 6.00, albuminoids 2.50, and from the time the baby was fed from the laboratory it had no more sleepless nights nor any symptoms of indigestion.

The following case is one in which the infant did not digest albuminoids well during the first few weeks and was put upon the laboratory. On December 30, when 18 days old, the prescription as follows: Fat 2.50, sugars 6.00, albuminoids 1.00 with ten feedings of two ounces each. This did not satisfy the baby and the percentages were increased as follows: Fat 3.00, sugars 6.00, albuminoids 1.00. After the child began taking this curds appeared in the stools and on January 6 the following was given: Fat 3.50, sugars 6.50, albuminoids 0.75. The baby was given eight feedings of three ounces each. The baby still seemed hungry and on January 13 the following prescription was given: Fat 3.50, sugars 7.00, albuminoids 1.00. Of this prescription eight feedings were given of four ounces each. Curds reappeared in the stools and the albuminoids were cut down to 0.75. On February 14 the baby was digesting well but seemed hungry and was given the following: Fat 4.00, sugars 7.00, albuminoids 1.00. On February 19, as the baby was still hungry, the amount was increased to five ounces at each feeding, the percentages being the same as before. On March 7 the baby had dropped off one feeding in twenty-four hours and was ordered seven feedings of six ounces each, the percentages being the same as before. On March 31 another feeding was dropped off and six feedings of six ounces each of the following was ordered: Fat 4.00, sugars 7.00, albuminoids 1.50 and on April

1

18, when the baby was four months old, the following prescription was given: Fat 4.00, sugars 7.00 and albuminoids 2.00 in six feedings of six ounces each. On May 17 the amount was increased to seven ounces, the percentages remaining the same and on this the child is still living and thriving, weighing at 7 months 21 pounds and having two teeth.

These four cases are sufficient to show how necessary it is for the physician to keep watch of the little patients and what perfect results can be obtained by this system of infant feeding. The infants have only to be seen to convince anyone that they have been perfectly nourished and have good digestions. A letter received today from the father of the baby that was taken from the breast and fed from the laboratory because of indigestion, reads as follows:

"The baby has done well on the Walker-Gordon Milk, notwithstanding it is sent 200 miles and the little fellow has not had a single stomach disturbance in all the time he has been taking it."

I could give numbers of other cases of which the same could be said and, this of itself speaks volumes for this system of infant feeding. There is no doubt that the laboratory rightly and intelligently used is a great help to the physician in caring for those infants that must be artificially fed; but like any other means in our employ it must be used intelligently and under careful supervision.

73 Tilden Avenue

INTUBATION OF THE LARYNX

BY WM. E. LOWER, M. D., CLEVELAND

EFORE the advent of the serum treatment for laryngeal diphtheria,

BR

the mortality of intubation was about 75%. Since the use of antitoxin the mortality has been reduced to about 25%, showing a reduction of 50% in the death rate by the use of the serum treatment. Of the 25% mortality following intubation a certain number die from the accidents in the operation of intubating and extubating. It is to these accidents that I wish to call attention, especially to the effect of manipulation of the larynx. This I believe to be more or less new and is a resume of an experimental research by Dr. Geo. W. Crile of Cleveland, in which I was engaged with him.

Manipulation of the base of the epiglottis, of the rima glottidis, and the mucosa of the larynx to a point below the vocal cords of the anterior wall of that portion of the esophagus lying opposite the "vocal" area in the larynx, may produce reflex inhibition of the heart and of the respiration. External pressure upon the larynx produced like results.

The course of the reflex impulse is through the superior laryngeal

Presented at the Ohio State Pediatric Society, Columbus, May 2, 1898

nerves, for in the experiments in which these nerves were severed in advance no such reflex inhibition could be induced.

It was proved that the local application of cocain also prevented the reflex inhibition upon both the heart and the respiration, and that the administration of a physiologic dose of atropin prevented the reflex inhibition. upon the heart but not upon the respiration.

The experiments by which these propositions were established will be elsewhere published in detail. In the operation of intubation or of extubation

there is a manipulation of a part, usually a considerable part, of the "reflex inhibition" areas above described, and in most cases there is a temporary respiratory arrest, and occasionally a permanent arrest. The heart is not so readily affected, but when affected, the result is very striking; there is a sudden collapse and death.