ularly obnoxious in all acute digestive disturbances, and may provoke a definite and often severe train of symptoms due to acidosis; that a deficiency in proteids is a common cause of mal-nutrition, rickets, scurvy, anemia, feeble circulatory, digestive and assimilative powers and constipation; that normal or increasing weight may occur with deficient proteids, and, with constipation, is frequently an early sign of rickets; that when these symptoms occur, the proteids should be increased, often with diminution of the fat, especially if there is constipation, or if there is diarrhea with fatty curds; that when increased amount of proteids are indicated, but apparently not tolerated, even though the fat be reduced, resort should be had to peptonization and digestive tonics,-although it will repeatedly be found that perseverance in the increased proteids will frequently cause the apparent evidences of their injurious influence to disappear; that buttermilk is a convenient medium for exhibiting the proteids; when they are otherwise not well tolerated; that the stools may be practically disregarded, so long as the infant is gaining regularly and developing naturally; and, finally, as will have been observed by those who have grasped the full significance of these remarks, that simple dilutions of whole milk with cereal decoctions, and the addition of sugar, are sufficient, in very many cases, for the successful nourishment of infants.

GONORRHEA IN WOMEN.

J. L. Peck, in the Hahnemanian Monthly, admonishes that instrumentation should not be resorted to for fear of carrying the infection higher up into the cervix, endometrium and tubes, and producing serious extension of the disease into these and other parts. Coitus should be prohibited, and the patient instructed as to the manner of preventing the conveyance of the disease to other parts and persons. Such internal medi

cation as required to relieve the pain and irritation of the parts affected should be prescribed. The external parts should be bathed two or three times daily with a boracic acid solution, or other mild antiseptic, and clean pads applied frequently.

In sub-acute and chronic cases the most effective treatment is the local application of silver nitrate, ten per cent. solution. Great care should be taken to see that all the folds and crevices of the vagina are thoroughly treated, and if the cervical canal has been infected, applications of silver nitrate should be made within the canal. Following this treatment the vagina should be well smeared with vaseline and packed with cotton or gauze, or a tampon medicated with ichthyol and vaseline, or ichthyol and glycerine, ten per cent, is placed in the vagina. The packing or tampon is removed in forty-eight hours and douches of permanganate of potassium one to five hundred, or creolin, or bichloride of mercury one to four thousand. The local treatments should be applied two or three times a week with the daily use of antiseptic douches when the tampons are not in use. targol ten per cent, or argyrol twentyfive per cent may be substituted for the silver nitrate, but the latter are not as effective in destroying the bacteria. Where the urethra is involved a Kelly's urethrascope should be introduced to within a short distance of the bladder and application of solution of silver salts applied the entire length of the urethral canal. It may be advisable to use ten per cent applications of cocaine in the urethra in painful cases prior to these applications. The ducts of Skeenes or para urethral ducts, and Bartholinian ducts, if involved, are treated by pressing out the purulent discharge and using injections of silver salts with the aid of a blunt pointed syringe. In obstinate cases these ducts should be incised freely under local anaesthesia and thoroughly cauterized.

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"DONT'S" IN THE USE OF 606.

The Journal of the A. M. A. offers the following advice in the use of salvarsan:

The most recent advice from authoritative sources as well as our own experience, favors, in general, the employment of salvarsan by intravenous injection.

1. Don't use salvarsan in myocarditis, in advanced cases of tabes dorsalis and general paresis, in nerve syphilis affecting vital centers, in grave kidney disease, in cachectic and debilitated persons (unless the condition is due to syphilis), in aneurysm, in optic neuritis, and in persons with lesion (such as gastric ulcer) in whom increased blood-pressure may produce hemorrhage.

2. Don't use intravenous injections of salvarsan until you have fully qualified yourself and possess a detailed knowledge of the technic. Deaths have occurred and more will occur from unskilful administration.

3. In the preparation of the drug for intravenous use, don't use a solution made with common salt or undistilled water (such as is often supplied in hospitals), but use a specially prepared sterile physiologic salt solution made. with chemically pure sodium chlorid; otherwise you may find it impossible to obtain a clear solution.

4. Don't under any circumstances inject into the veins a solution which is not perfectly clear; a flocculent or cloudy liquid may produce alarming symptoms of collapse or even death.

5. Don't use a solution any more alkaline than is absolutely necessary to secure a clear solution.

6. Don't inject the salvarsan into the veins without previously running in physiologic salt solution; if the needle is not in the vein you will infiltrate the surrounding tissue with the salvarsan solution and cause subsequent inflammation and unnecessary pain.

7. Don't infuse the solution into the vein too rapidly; it is best to have a needle of such a caliber as will require eight minutes to introduce 200 c. c. of fluid. With the gravity apparatus, the rapidity of inflow can also be governed by the heights of the receptacle.

8. Don't infuse a cold solution; the liquid should be about the temperature of the blood.

9. Don't use "glass pearls" in the mixing jar, as is often recommended; we have found that minute particles of glass chip off, which might cause embolism.

10. Don't use a routine dosage of the drug; the dose should be gauged according to the weight of the patient and the character of the condition to be treated.

11. Don't employ intravenous injections in your office or in a dispensary. The patient should be treated in a hospital and put to bed and carefully observed for a period of not less than three days. 12. Don't persist in the intravenous injection if the patient should show signs of collapse during the administration, but stop at once.

ELIMINATING THE ANESTHETIC.

Blain, in the International Journal of Surgery, cannot understand why patients should not be allowed fluids after operation. It is merely one of the traditions which have been so long handed down. Yet we see nurses busily watching patients to see that they do not steal water from a hot-water bottle or bag, under the supposition that this would be very detrimental. When we consider that the mode of elimination of the anesthetic is to no small extent by way of the gastric mucous membrane, it is quite easy to understand that any means which aid in its removal will be of benefit. This end is accomplished by lukewarm water or a glass of water contain

ing ten grains of sodium bicarbonate, or a cup of black coffee administered shortly after the patient comes out of the anesthetic. As a rule, nausea and vomiting, which would ordinarily continue from twenty-four hours to two or three days, can be entirely done away with.

Some have advocated the washing out of the stomach at the completion of the operation by means of the lavage tube. This method is open to two objections: First, the danger in passing the tube with the patient anesthetized (the author has known of one death by this method), and, second, because it is best that a patient should be fairly out of the anesthetic at the completion of the operation. However, it is often necessary, in order to relax the jaws sufficient to permit the passage of the tube, to administer more ether.

In most cases where the pulse is weak, the best results are to be obtained by saline solution given by one of the several routes-subcutaneous, rectal or intravenous. This, coupled with heat externally and other mechanical means, will eventually supplant the giving of whisky, strychnine, nitroglycerine, etc., under the guise of stimulating the heart. Saline solution is at present the best means at our command to replace the lost blood, combat shock and aid in diluting toxins and eliminating the waste products from the body. Its employment by the drop method is also advantageous after a large percentage of operations-even though shock is not extreme, and aside from its well-known use in peritonitis-to relieve the thirst and aid in restoring the patient.

QUANTITY OF FOOD FOR INFANTS. Copeland, in the Virginia Medical Semi-Monthly, sums up this question as follows:

A determination of the total amount of food required in a given case is of great importance, for the reason that in

depending upon clinical observation, the harm is oftentimes done before the error in diet is fully appreciated. Such a determination has been satisfactorily worked out for man, and owing to the balance between the protein intake and nitrogen excretion is not difficult. With the infant such work has been especially difficult, from the fact that the rapidly growing organism requires a supply of protein far above what is shown by its nitrogen excretion. Forty calories per pound of body weight for each twentyfour hours is the average need. Now, having prepared a food acceptable to the infant, with a proper nutritive ratio, the estimation of its caloric value is not troublesome. A comparison of such value with the infant's requirements is important in determining a minimum energy value, below which we may not safely continue for any length of time.

Having satisfied ourselves as to the amount of food required in twenty-four hours, it must then be determined what quantity is to be used at a feeding and what interval there must be between feedings. Conclusions must be based upon the character of the food, the age of the infant and the capacity and muscular tone of the stomach. The infant's stomach empties much more quickly after a feeding of human milk than after any other possible nourishment. The acidity of the gastric juice is largely dependent upon age, and the influence of acid in retaining food for gastric digestion has been pointed out. Stomachs deficient in motile power as the result of faulty feeding or disease require time. to evacuate their contents.

Fortunately, the healthy infant, like all other healthy young animals, adapts itself readily to altered environment, including food, if due time is given; otherwise, our efforts could never meet with success. We must bear in mind that any artificial food, no matter how scientifically worked out, is essentially foreign and may give trouble. Finally, we must

remember that what meets indications in one child will fail with another under apparently the same conditions, so that in so far as it is possible we must arm ourselves with such knowledge as will enable us to interpret alike the causes of success and failure.

AN IMPROVED TONSIL SNARE.

William D. Black publishes a device of his in the Journal of the A. M. A., and the instrument and its various parts are so well shown in the illustrations that no further description is necessary. It is a more powerful instrument than

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the ordinary tonsil snare and does not get out of order like many others. It is simple in application, can be used a number of times without requiring a new wire, and, if properly adjusted, the wire cannot slip. It should be manipulated by a sort of forearm and wrist movement, instead of by the fingers, in closing it, so that the barrel will not be thrown out of line. It is made of solid brass with a heavy nickel coating. Number 7 or 8 piano wire should be used.

THERAPEUTIC POINTERS.

The Clinical Reporter gives the following miscellaneous hints which may prove useful to many practitioners:

A full dose of ergot, administered as soon as the uterus is empty, will do more in the way of preventing puerperal sepsis than all the antiseptics that can be applied to the parturient tract.

Exposure lowered the bodily resistance and the pneumococcus invaded the system, overcame the organism and caused the patient's death. Is this any different in meaning or result than the old-fashioned statement, "He caught cold, took pneumonia and died?"

Eryngium Aquaticum in doses of onehalf grain administered three times daily has repeatedly cured cases of spermatorrhea after all other remedies and measures failed to give permanent relief.

Don't load your "grippe" patients up on "coal-tar" products, depressants and massive doses of quinine, if you would have fewer sequela of pneumonia, middle ear diseases and protracted conval

escence.

Aconite is the first aid to the injured; whether this injury be done by the surgeon's knife or a railway wreck, or exposure to the elements. Sometimes it is the only one needed, but to be of any value it must be used early.

Apocynum Cannabinum, the "vegetable trocar," is one of the best remedies at hand in cases of anasarca due to heart or kidney lesions. It is of little value, however, in dropsy due to obstruction of the portal circulation.

The neurasthenic whose condition is due to "wild oats," of which he is reaping a bountiful crop, will be immeasurably benefited by the use of Avena Sativa. It is one of the few remedies that is best given in hot water and is also of great value after the excessive use of morphine.

IMPORTANCE OF NASAL BREATHING. Schmitt, in the New York Medical Journal, points out that the volume of air passing through the nasal fossæ from infancy onward exerts marked pressure on all the structures within the nose, pushing the lateral wall outward and the floor downward sufficiently to give the space required for the growing capacity of the lungs. The low floor corresponds to the properly flattened roof of the mouth, the wide alveolar process allowing the teeth to develop without crowding. The air normally conducted through the nose and nasopharynx will produce sufficient pressure to support the vessels in the adenoid tissue normally present in the nasopharynx and hence keeps its growth within bounds. The nasopharynx is commodious, gives the palate a wider range of motion, and adds to its mobility.

To overcome the resistance offered by the comparatively small entrance which the anterior nares present for the large quantity of air to fill the lungs, the muscles of respiration are brought into play for the uniform expansion of the entire chest and lungs. A great quantity of blood is thereby drawn into the chest which bathes the lung tissue, thereby tending to preserve its healthfulness and also to increase the exchange of gases, and hence establish better metabolism throughout the body.

Against all this let us compare mouth breathing. The neglected nostrils are collapsed from disuse. The absence of air pressure within the nose has permitted the fosse to remain narrow. If they are sufficiently roomy the mucous membrane covering the turbinals is swollen from nonsupport. From the same lack of pressure the floor of the nose has not been depressed, resulting in the high vaulted palate, the contracted alveolar process, and irregularity in the position of the teeth. The upper jaw and lip are pushed forward and the lower lip droops and is thickened.

At this point the author takes exception to the accepted theory of Lombroso that the vaulted palate is a distinctive mark of degeneracy and substitute the above explanation as the true cause of that deformity.

In those in whom there is an abundance of adenoid tissue lining the nasopharyngeal wall, the vessels of this tissue being unsupported are continually in a congested state. Added to this is the negative pressure or suction resulting from the air sweeping through the mouth down the pharynx, constituting a second factor in the production of hyperæmia of the adenoid tissue, both factors resulting in the true cause for the superabundant growth of that tissue. The adenoid tissue which occludes the postnasal space interferes with the proper aeration of the middle ear through the Eustachian tube producing defective hearing and interferes with the proper function of the soft palate which so often is manifest in young children and frequently is the only cause for their defective speech. With the disturbed circulation in the nose and nasopharynx the circulation at the base of the brain is affected, influencing the mentality of the mouth breather who frequently is put down as a dullard at school.

The dust laden and infected air passes through the mouth, producing dryness, infecting, and inflaming the tonsils and pharnyx, eventually permanently enlarging the tonsils through repeated insult and increasing liability to circumtonsilar infections. On account of the large

opening which the mouth presents, no extra effort is required during inspira-tion, as is the case when the resistance of the smaller aperture of the interior nares must be overcome; hence the muscles of the chest are not brought into play as in the former instance, the chest remains contracted, and the lungs incompletely expanded and aerated especially at the apices. The increased amount of blood which should normally