rare in children and when it does occur it is usually after the ninth year. The Bier method of producing hyperemia sometimes favorably influences an inflamed area, and, when it proves successful, does so rapidly. It certainly lessens pain and the results in some cases of joint tuberculosis warrant its extended trial. The operative treatment involves several principles and the chief ones are thoroughly to empty and remove all tuberculous foci and to complete the destruction of any bacteria that are present. Unless the operative prooperative procedure can be radical and complete, it should be deferred, for partial operations or those which are not sufficiently radical nearly always result in a widespread diffusion of the process, with its attendant dangers to the activities and life of the patient. There may be times when it is good surgery simply to open and drain, but these instances are so rare that the decision to do so must come only after the most careful deliberation and a consideration of all of the factors involved. An incomplete operation, that is, with the removal of some of the tissue, is much more dangerous than incision and drainage, because partial removal of tissue opens up new avenues of infection avenues which were closed before by white blood corpuscles or fibrous tissue. In considering any operative procedure upon a focus of tuberculous infection, we must be mindful of the fact that just as long as the focus is circumscribed in the depths of the tissues, without contact with the external air, the tubercle bacilli are the ones that are present in pure culture, but, once the focus is exposed to the air, the staphylococci and streptococci are added and bring another danger to the tissues and the patient, favoring further local degeneration and devitalizing the child. At one time it was presumed that a radical operation meant only amputation or resection. Amputation fortunately is practically a relic of the past. Resections are open to the very serious objection that they are usually followed by persistent sinuses, and continuous suppuration and destruction of the joint do not bring with them any certainty of a cure because of the involvement of adjacent adjacent structures. There is always a very considerable shortening and often a useless limb. Resections should therefore be avoided whenever possible because of the mentioned dangers and the fact that simpler operations are just as certain in their results. It is always better to take the chances offered by nonoperative local treatment rather than to do a hasty resection. In the operative treatment of cold abscesses, the usual unsatisfactory results are largely due to faulty technique. That is, no good results can be expected from puncture and subsequent injection (as of iodoform and ether) unless the right time is chosen for the procedure. If the skin is already reddened above the abscess, we are certain to find that a fistulous tract has already been formed and puncture is apt to bring about just the condition that we are trying to avoid-to wit, septic complications. But, upon the other hand, if we open by puncture too early (that is, before fluctuation) the procedure is not successful. In performing puncture, the very strictest attention must be paid to every detail as far as the most rigid asepsis is concerned. As much of the content of the abscess cavity as possible should be removed and then it should be washed out with a saturated solution of boric acid until the return is quite clear, after which the iodo form and ether may be immediately injected. The amount of iodoform used is that which is within safe limits for the particular child. As ordinarily used, iodoform should be mixed with ether in the strength of one to ten. With a mixture of this strength the penetration of the deeper structures is great, the expansion of the ether, as it vaporizes, carrying the iodoform with it. We might add the precaution that in withdrawing the canula from the trocar sufficient time should elapse to allow the ether to vaporize sufficiently to distend the cavity of the abscess and then its escape should be slow. After such a procedure it is very important that the part subjected to the operation be immobilized, preferably with a plaster apparatus. The procedure may have to be repeated two, three or even four times, but, not infrequently, one operation is all that is required. The interval between punctures should be close to three or four weeks. Even when not curative, puncture, when repeated, gives us a good clue as to the course of the disease thru the character of the liquid that is subsequently withdrawn. Occasionally, despite all precautions, a sinus will form and the contents of the sac be forced thru the opening made by the trocar, but the protective influence of the iodo form seems to prevent any septic complications. When puncture fails, it is usually because the cavity is filled with a caseous material which cannot be completely removed by this method. In such instances free incision and cleansing, with subsequent phenol swabbing, is efficient. The phenol is liquified with glycerine and the whole cavity swabbed so that the solution is in contact with the surfaces for one to three minutes, and then the excess is washed off and neutralized with alcohol. Cutting operations should not usually be undertaken as primary measures, but should be reserved for such cases as offer little or no chance for improvement under the less radical methods of rest, posture and general hygiene. We must never lose sight of the fact that the child's constitution is such that conservative measures and particularly nutritional conservation, are more succesful than in later life. The child's tissues tend to heal unless the process is an old one, and, altho the less radical methods take time, they ultimately offer the best chance for a cure, and there is but little danger of the process spreading while the primary focus is under conservative treat ment. The disease as it affects the bony structures shows a decided predilection for the epiphyses, and, in this particular, we observe that it is quite the opposite to osteomyelitis, which usually invades the diaphyses. Of course, we must not be unmindful of that peculiar localization which localization which is almost exclu sively confined to the period of infancy, in which the diaphyses of the smaller long bones of the hand and foot are affected. It is the spongy portion of the bone that bears the brunt of the primary invasion, as a rule. The interior of the bone is not uncommonly the site of original infection and in that case we observe a tuberculous osteomyelitis. A cold abscess may result, but more often we encounter a caseous focus in the thickness of which there may be a sequestrum which differs materially from that of an ordinary osteomyelitis in that it is not so hard, much more friable, and has all of the characteristics of a caries. When occurring in the superficial structure of the bone there is commonly a quite strictly localized lesion of the bone, with subsequent extension of pus, thru and finally over the periosteum; yet when such an abscess is incised we frequently observe that the periosteum is more intact than one would expect to find it. It is a common experience that tuberculosis beginning in bone may heal spontaneously, and this is particularly so if a joint is not involved. And, even in the latter case, resolution sometimes takes place. But the tendency is toward extension and progression and therefore every case must be treated as radically as the circumstances demand. And no matter how carefully the surgeon may be in his removal of all seemingly diseased tissue, it is often impossible to be sure that some small area has not been left untouched. In infancy and childhood the onset is usually not that of an acute arthritis, but it occurs as a slow and painless condition. Despite the marked tendency toward progression and extension, we cannot too strongly state that tuberculosis of the bones and joints is amenable to treatment, and the results are remarkably good, considering the destructive changes. The use of tuberculin should perhaps be more general, because, if properly administered, its effects are often most beneficial. If it causes marked reaction, its use is contraindicated, or the dose should be markedly reduced. Practical Points in Infant Feeding. BY HENRY WINANS BURNETT, M.D., PROVIDENCE, R. I. Physician, Department of Children's Diseases, Rhode Island Hospital (o.p.d.). There is one royal road in infant feeding and that road is straight altho ruts and stones may now and then be encountered. The other road, the artificial one, is rarely straight, often rough and usually hilly. If a baby must be fed artificially it should be fed scientifically, and only those who have followed difficult feeding cases closely and therefore well can appreciate what a scientific and fascinating pursuit it is. The careful adjustment of the various percentages of fat, carbohydrate and proteid so that the caloric and other needs shall be measurably satisfied in the individual case, of whatever age and weight, is fascinating or tedious and tiresome, according to the abundance of enthusiasm or the lack of it in him who has this sort of work to do. To know just where one is at in any particular case and to know when to change and what to change to is of course the important thing, but how to do it and what not to do is quite as important. The purpose of this paper is, therefore, to call attention to a number of things, gained largely from experience and found necessary in practice to insure success. It is a perfectly easy thing to write a prescription for the needed ingredients of a food mixture, send it to a milk laboratory and have it delivered each day immersed in cracked ice at thirty or forty cents a quart and often plus express charges, but what proportion of families in one's practice can afford this expensive arrangement. It is quite another thing and not nearly so easy to instruct mother, aunt or nurs ery maid in the making of mixtures which will represent approximately the percentages required. And is it not after all better that the poorer classes should, by making their mixtures at home, get a clearer idea of the importance of the proportions and the proportions and of the method and so appreciate that a milk modification for a baby is after all a big something based upon careful observation and scientific truth? One cannot expect that the home modification of cow's milk for infant food will exactly represent the percentages required, but home modifications may be made in such a manner as to be safe and successful in practice. In the elaboration of the percentage method by different authorities we have top-milks alone, creams of different fat strengths, middle milks and bottom-milks, alone or in combination; together with whey and whey and cream mixtures, not forgetting the more recent albumen (eiweiss) milk, advised in all kinds of combinations and dilutions. Some writers give a long series of formulas seemingly with out regard to percentages, calories or proteid values, while others consider the calories as the important element without much regard as to how they are obtained. If to the observer "every little movement has a meaning all its own," the particular method with which to continue the improvement or to combat an adverse condition matters little. The stools are the indicators, and the percentages, which must ever be kept before one, are the guides to successful infant feeding. To get along without percentages and calories in this matter is like getting along without amperes and volts in electrictiy or without horse-power and supporting-surface in aviation. THE APPARATUS The newer cylindrical bottle, often termed a sterilizing or pasteurizing bottle, is by far the best to use. It may be had in 4 and 8 oz. sizes. Three of the 8 oz. size have often been advertised for ten cents. They are less often broken by heat than other kinds, because better annealed and of thinner glass, and are easy for the baby to handle. Simple nipples with bulging ends are preferred, the hole or holes being made with a hot needle just after the redness has subsided, the eye-end of which is inserted in a cork as a handle. A very red or white hot needle will leave a border of soft rubber around the hole. The size and number of holes are determined by experiment and experience, so that the baby may get its total amount of food in a reasonably correct period of time. Nipples which cannot be easily turned inside out should not be used. There is no special nipple or special shape except that a long nipple such as is used on the Continent is to be condemned, long nipples often causing ulcers of the palate. Rubber will not stand a temperature of over 175° F. without being made permanently viscid. cid. Rubber nipples should always be wrapped in several thicknesses of cloth before immersion in hot water to prevent their coming in contact with the hotter sides of the vessel. They should be kept in cold sterile water or boric acid solution until used and the solution or water should be changed daily. A level tablespoonful of lactose in powder weighs two and a half drams. To insure accuracy always order level tablespoons ful- the average person will not make two rounded or two heaping spoonfuls alike, and the same spoon is to be used throughout. DILUENTS Except water, barley flour gruel is the commonest form of diluent. This is best in one per cent. strength or three level teaspoonfuls to a pint of water. Oatmeal flour may be substituted in the same strength or a little stronger (1.5%) because of its laxative effect if needed. Arrowroot, cornstarch and rice have been used. Never forget to consider the starch content and to add it in to obtain the total carbohydrate strength. Make the cereal gruel twice as strong as needed and dilute for use with an equal part of water in which while boiling hot (to make a sterile solution) has been dissolved, and later filtered through absorbent cotton, the required amount of milk sugar. All proprietary foods contain from seventy to ninety per cent. carbohydrates and act, if the carbohydrate is not mainly sugar, as any other cereal diluent. Lime water is to be used in definite proportions to the milk or milk and cream, not over 50%, usually from 25% to 50%, in order to retard or cut out gastric digestion when indicated. The following is a valuable table to have on hand: |