mittee composed of the Conference of State Boards and of the American Public Health Association and the American Medical Association which are looking over the various forms of reports of the states and cities.

In this work the United States Census Bureau has co-operated and has collected samples of the various forms at present in use in nearly all of the registration offices of this country, for the purpose of analysis and study by the above mentioned committee. It is a difficult task to study all these forms and to formulate a report of the absolute essential tables that are to be recommended for uniform use in this country. The Committee so far have only been able to perfect an international classification of the cause of death, but hope soon to report on the other questions relating to uniformity of Vital Statistics, and also the extention of adequate registration laws.

Massachusetts and the other New England States, also New York and a few other states are leading in collecting vital statistics. Pennsylvania does not seem to be up to the standard and Luzerne County is below the Pennsylvania state standard, while Wilkes-Barre, the county seat of a quarter million people, is more deficient and lax in recording vital statistics than any other city of its size in the state. In fact, most cities of ten thousand inhabitants can show a better record than we can. We report in a very rudimentary way our losses, but take no account of our gains. A child born in Wilkes-Barre might well say, like "Topsy," that she was not born any place-she just grew. For if a notice does not appear in the columns of our daily papers or the Record Almanac, then there is no record of the child's existence. Pittston, Nanticoke and Plymouth all report births. In response to my letter written to Dr. Benj. Lee, Secretary of Pennsylvania State Board of Health, he wrote me "I know of no city of a population anywhere near approaching that of Wilkes--Barre in which births are not registered." On the other hand, there are many small boroughs, of a population of from six hundred to fifteen hundred, which do maintain a system of registration of births and report the same to the State Board of Health.

With such a deplorable condition of reporting births is it any wonder that babies cry when they are born in Wilkes-Barre?

Before starting this paper, I asked the city clerk how many children were born in Wilkes-Barre last year, of course, he was unable to tell, but since then I notice an ordinance has been introduced requiring physicians and mid-wives to record births, That brings us to another phase of the question. No doubt the physician or attendant in an obstetrical case is the proper officer, to report births, but in doing so he is acting as a public officer, collecting data for the good of the Commonwealth and there should be a small fee, not to exceed twenty-five cents, attached to reporting births. Perhaps in some cases it may be all the fee the physician will receive, beside some promises and expressions of gratitude. I advocate this method, together with other matters, in order to use every incentive to obtain complete reports. We should secure the registration of births by the payment of fees, by every appeal to private interest and public necessity. All physicians, all mid-wives and persons attending confinements should be made to report and there should be a penalty for not doing so. Then we could find out how many persons are illegally conducting obstetrical cases.

In regard to reporting marriages, that duty falls on the clergymen and can easily be collected on account of the contracting parties being obliged to procure a license.

In reporting deaths, we are all aware our blanks are very unsatisfactory. There is no place to report occupation of deceased and they are very incomplete when compared with the uniform international blanks. I have a sample of this kind of blank as in use in Scranton. I think Plymouth uses a similiar

one.

But if

We do report contagious diseases in Wilkes-Barre. We are to report them within six hours after seeing the case. we send in a report on Saturday the Health Officer does not attend to it until the following Monday, notwithstanding that Sunday is a great day for visiting the sick. Our report of contagious diseases is of only local value, as we do not report to the State Board of Health.

Thus it is apparent that vital statistics as they are reported in Wilkes-Barre, are of no value to the state or national health boards and of less local value than if they were carried on by a better system. The fault in Wilkes-Barre lies in our Sanitary Committee which stands in the way of a Board of Health in Wilkes-Barre.

Dr. Benj. Lee, in reply to my questions, "How many municipalities have sanitary committees ?" says "The only other city in this state in which the out-of-date, ineffective and slip-shod method of controlling sanitary affairs by a sanitary committee of Councils except Wilkes-Barre is Harrisburg."

We have only to go to our neighboring city of Scranton and see the admirable monthly reports of vital statistics and see their laboratory for examining tubercular sputum, etc., to compare the efficiency of the two methods.

In 1898, Dr. Walter Davis responded to a toast to WilkesBarre's Board of Health and favored such a board at that time. Our Sanitary Committee never attend the Conference of State Boards, they often know little about preventative medicine, and are not as progressive as boards that are composed of physicians.

At the present time our city needs a municipal laboratory, where water and milk can be examined, where physicians can send suspected diphtheria sputum and have them examined by a bacteriologist, also where blood from a suspected case of typhoid fever can be examined by the "Widal test."

All these things has Philadelphia, Pittsburg, Alleghany, and Scranton, and with our population we need this laboratory as much as the other mentioned cities. At present, we pay a physician six hundred dollars per annum for examining the water and milk, but he must furnish his own laboratory for examining the same. Now in Scranton, for one thousand dollars, per annum, they have a bacteriologist who examines milk and water, tubercular sputum, diphtheria and Widal test, together with free vaccination to those who wish it. Then at a cost of between seven and eight hundred dollars, the city has a well equipped laboratory.

Hence, it would not entail a much greater cost for WilkesBarre to maintain and equip a city laboratory and its usefulness would more than repay the extra outlay. Now I do think that if this necessity were made clear to the members of our city councils that they would not be adverse to enact laws creating and maintaining a city laboratory.

In closing, I would state that as vital statistics are reported in Wilkes-Barre they are of little value locally and of no value to the state, for Wilkes-Barre has not reported to the State Board of Health since 1896.

I would recommend:

(1st.) A system that would make monthly reports to the city and state.

(2d.) That births should be reported.

(3rd.) That we adopt the uniform classification of death certification as recommended by the National Committee on Vital Statistics.

(4th.) That a committee be appointed to confer with the Sanitary Committee and if possible to procure a city laboratory.

CASES REPORTED

BY DR. A. TRAPOLD, WILKES-BARRE, PA.

READ DECEMBER 16, 1903.

The two cases I desire to report are chiefly of interest on account of the obscure conditions present, which made it practically impossible to make a correct diagnosis.

CASE I. Sister A., aged 33, occupation general housework. This patient was referred to me by her dentist, to whom she went on account of the soreness of her teeth. The dentist being unable to find anything wrong told her the soreness was due to uric acid in her system and sent her to me for treatment. On questioning her I found that she also complained of frequent and painful urination, the pain being sometimes so great

that she was fairly doubled up.

Bowels were somewhat con

stipated, menses regular and appetite fairly good.

Examination of urine:-Sp. G. 1022, reaction acid, no albumen or sugar. Under the microscope numerous uric acid crystals.

For a time she improved somewhat under treatment and her urinations were less frequent and less painful. After I had treated her for about six months, with more or less success, she began to complain of severe pain around the umbilicus, the pain being constant but more severe at times, she also had attacks of bilious vomiting and headaches. These attacks generally occurred at or near the time of her menstrual periods.

Having tried almost everything by this time without giving the patient much relief, I advised a careful examination under Ether to which she readily consented. We found the bladder and generative organs normal but on examining the abdomen discovered a small umbilical hernia.

Thinking there might be some omental adhesions to the hernial sack and that these adhesions might cause reflex irritation we advised operation to which the patient agreed.

We made an incision over the hernial sack, there were absolutely no adhesions but on exploring the abdomen I found the gall-bladder completely filled by a large stone. I made, therefore, a second incision over the gall-bladder, stitched it to the wound, incised it and removed the stone which I here show you.

The patient made a rapid recovery, there was practically no discharge of bile after the operation and the wound was completely healed within five weeks. The pain in the umbilical region, the bilious vomiting and the frequent and painful urination disappeared at once and to-day, about two years after the operation, she is perfectly well.

Now in this case there was absolutely nothing which would lead one to make a diagnosis of gall-stones; there never was any jaundice, no pain over the region of the liver, the only pain she complained of was over the umbilical hernia. The patient also had bilious vomiting but this always occurred around her menstrual period and rather pointed to some trouble of the