contaminated food supply from a single case that will spread the disease over a whole community.

A few years ago I investigated a local epidemic in one of the boroughs of New York, where it was found that a milkman was dispensing milk in bottles that had been taken unsterilized from the room of a typhoid patient, refilled with milk and passed on to another house, there to become the source of infection for another case. It should ever be in the minds of attendants having the care of typhoid patients that certain of our foods, especially milk, furnish the best possible medium for the growth of the typhoid bacillus and that where one organism transferred by the fingers to the mouth would succumb to the protective substances always present in the body, a single organism passing from the finger to a milk bottle and left there for a few hours in a warm atmosphere multiplies, until when the milk is ingested it represents thousands of bacilli and there are not enough protective substances in the body to keep back a general infection with the resultant typhoid fever.

6. Dysentery.-Dysentery due to the bacillus of that name is quite a common disease, and it is not unusual to find outbreaks of it in large institutions. In every instance it can be traced to contaminated water or food supply and the same care exercised in dealing with it that should be used with typhoid fever will prevent its spread.

T

I remember an epidemic of this disease among prisoners on Riker's Island, N. Y., a few years ago. found that whenever a man was ill he was sent to help in the kitchen. The water supply was not polluted. and a gang of contractor's men working on the same island and near the afflicted prisoners, but with a separate mess, were not afflicted. Here, then, was a good illustration of how easy it is to control an acutely infectious disease even if in this instance it was to spread it among the controlled.

7. Cerebro-Spinal Meningitis.-This disease is found. in epidemics from time to time in every large city. There is no question as to the infecting organism. Here

as in the other well-known infections diseases we are not justified in carelessly exposing other ill persons to it.

But with a knowledge of the general insusceptibility to infection with the meningococcus the control of this disease even in a general ward is not difficult. In the epidemic of 1905 it was found that while there were a good many recurring cases in houses it did not spread rapidly from case to case. This does not mean, however, that persons afflicted with this disease are to be mixed indiscriminately with others. The question of susceptibility being an unknown factor, all persons should be considered susceptible and the disease properly isolated.

8. Erysipelas.-Erysipelas must be isolated in hospitals that have a surgical service. When we consider the possibility of the dried living streptococcus being carried by draughts in the dust-laden air of the hospital and deposited in the open wound either at operation or on the dressing table, then we know that not to isolate these cases is unpardonable.

Right here I would like to call your attention to a question of virulence in infectious organisms; the common way of increasing virulence is by passing the organism through susceptible animals. It must not be forgotten that as one case of infection follows another in human beings the virulence is probably being raised and that the infecting organism is losing its combining power with the lysins of the body, so that a few of these very virulent organisms may be sufficient to cause an infection, where in the first cases large amounts of infectious material were necessary.

9.

Gonorrhoeal Vaginitis.-This infection is the scourge of many institutions, and many institutions refuse to admit cases until after vaginal smears have been made and the case pronounced free from the intracellular diplococcus that causes the disease.

In the Department of Health Hospitals we must admit the cases whether we wish to or not. Furthermore, the exanthemata seem to make children particularly susceptible to this infection. It is therefore essential to use every care to keep this disease from spread

ing through the wards. All new cases should be held in a special room until the laboratory reports show the condition of the vaginal secretion. The presence of the intracellular diplococcus means that the patient is kept in isolation until discharged from the hospital.

Even with most careful guard against the cases being admitted one will slip in and the whole ward become exposed. Here is where a knowledge of the character of the organism, its virulence, and the danger attendant upon infection is necessary in the nurse in charge of the ward. A careless and ignorant staff of doctors and nurses in wards where vaginitis is prevalent are responsible for more distress and expense than can be overcome by any other good qualities they may have.

The control of all these infectious diseases is dependent upon the observance of the same general rules. First, they must be isolated. Second, the attendants taking care of them must not have the care of other patients or if they are assigned to others they are to cleanse themselves and change their wearing apparel. Third, foods and medicines must not be carried from the infected area to other parts of the hospital, there to be used again. Fourth, instruments, linen, goods and utensils must be sterilized before being used in other parts of the hospital, after having been in the infected area. Fifth, in addition to the precautions of isolation and quarantine used to prevent spread of infection from the infected area, all persons liable to exposure must be immunized, if such procedure is possible. Sixth, after the case is terminated the entire infected area must be thoroughly cleaned and disinfected before other persons are allowed to enter into it.

Having specifically mentioned the foregoing infections as types that are justly within the jurisdiction of general hospitals, where they can be taken care of by the application of first principles in medicine that should be the common knowledge of all of us, I wish to say just a word about the contagious diseases and the possibility of their care by general hospitals.

I can see no reason why contagious diseases should not be cared for by general hospitals, if a proper provision is made for them. The buildings in which they are housed should be separate and a reasonable distance apart from those in which non-contagious diseases are kept. The residence staff, both nurses and doctors, when on duty in contagious disease wards should not be allowed to enter the general wards of the hospital. All means now used to prevent mixed infection in the contagious disease hospital should be observed by the staff. In small cities there would not be anything gained from a financial standpoint, perhaps, by such arrangements, but in large cities, where the amount of territory covered by one hospital is very great, frequently necessitating a patient being transferred for miles, it seems to me that if there were separate buildings attached to general hospitals, for contagious diseases, it probably would be the proper way to care for them.

THE HYGIENE OF INFECTIOUS DISEASES IN MEDICAL WARDS.*

D. L. EDSALL, M. D.,

Professor of Therapeutics and Pharmacology in the University of Pennsylvania.

(By Invitation.)

Since I have recently described at some length my views regarding the hygienic management of infectious diseases in the wards of general hospitals, and the various observations that have led me to these views, the present paper must necessarily consist chiefly of a more direct and condensed statement of the points that seem to me of most importance.

Everyone who has followed the work done in the last two decades in regard to the methods of propagation and spread of infections has been impressed with the already enormous and constantly increasing mass of evidence that the sick man is the great source of infection with almost all these diseases, if not all; and that direct or almost direct contact with the sick now has undoubtedly the position of sovereign importance among the means of transmission, while only a few years ago it had a subsidiary position in all except the highly contagious diseases.

The weighty importance of these facts in relation. to hospitals cannot be overlooked, for in these institutions there are always, in the nature of things, an overwhelmingly large proportion of those whose resistance to infections is low, and at the same time a considerable proportion of the inmates are always carriers of infections of various sorts.

*Read by Dr. W. E. Rowley, St. John, N. B.