productive period. Each year more deaths than from yellow fever in 115 years, and each year three times the deaths from battle on both sides in our civil war, an expense to our nation of over $1,000,000,000 annually.

The cause is the bacillus found by Dr. Koch only thirty years ago.

Contact and not heredity gives one the bacillus; yet not the casual contact, as in many diseases, but where it continues for a time and then only when the patient is careless of the sputum or other infected excretion.

To quarantine is not needed, nor is there danger unless the patient refuses control. In our sanatoria there are no secondary cases. The organism in quantity is dangerous as with children fed upon infected milk. In the body it may lie dormant for years, so may not be traced to its origin.

To prevent tuberculosis then destroy all infected sputum, segregate the uncontrollable or indigent patients.

In organizing a local society small units are more efficient.
In education exhibits are most valuable.

They show the extent of the disease, the how and the why.
Literature and illustrated lectures, perhaps to groups by

trades.

The press is a valuable agent and a willing one.

Addresses to assemblies of all sorts.

Sale of the Red Cross seals.

The local organization should employ the visiting nurse; she can search out not only the advanced but the incipient case and aid in securing to each the actual condition sought.

This burden of tuberculosis is upon society a problem to be met either in the worst or the very best way-a great social problem.

Institutions should be accessible, and if well conducted all fears from them cease.

Expensive construction is uncalled for. Wind, snow and rain are of course to be kept out of shack or lean-to.

Treatment consists in life out-of-doors, selected diet, regulated exercise, medication for improved nutrition.

But the experienced physician is needed to apply any treatment, for even the sanatorium cannot cure. With his guidance it is far safer than the home, which often tempts the patient to indiscretions he cannot control.

Climate is not an essential factor. That cures are effected in or out of sanatoria in so many varieties of climate proves this. A recent writer found 20,000 sufferers in the arid southwest of whom 12,000 die in the first twelve month. Yet physicians who ought to know better allow this to go on.

They should all teach better.

Dr. Arthur Ransome, an eminent English authority; Dr. Arthur Latham, another eminent English authority; Dr. A. P. Francine, director of the Pennsylvania Society for the Prevention of Tuberculosis, and Dr. Detweiler of the celebrated sanatorium at Falkenstein concur. "There is no specific climate for consumptives."

Cure in the home climate is more permanent. Cold is better than warm weather.

The sanatorium should hold all classes of cases. The personal efforts of the patient, so essential, are more diligent if he is familiar with the failures and success of his fellows.

Time is needed. Tuberculosis is not curable in a few weeks. Two years is often required. This that results may be permanent.

"A few weeks to learn the treatment" is not to be considered.

A patient should be frankly told his condition. To withhold the truth is a mistake. He can then and then only be led to meet the issue squarely. The average patient is more of a problem than is his disease.

We also have his friends and associates to consider. Sacrifices have to be made. Here, as elsewhere, strong character succeeds where the optimist fails. The regime of the sanatorium has to be submitted to. Home rule is too easy.

The esprit du corps, the example of others, the rivalry, all are found at the sanatorium.

Its educational value is great.

It is more economical than the home, weeks do what requires months at home.

Recovery is the sole business at the sanatorium.

Early diagnosis is very essential, since 90 per cent are then curable.

A cure means far more than recovery from active symptoms; this is often but the beginning.

A sanatorium is a benefit to a community, first financially and then educationally, teaching how to avoid contagion among themselves and how to improve health in general.

The social life keeps the mind so agreeably employed at the sanatorium as to surprise an outsider by its atmosphere.

Local sanatoria are needed. Simple structures to aid both incipient and other cases; not that a cure is always to be expected.

The suggestion for local campaign and a short discussion. followed. S. R. TOWNE, Omaha.

A Diuretic Mixture.

Rowntree and Geraghty, in Archives of Internal Medicine for March, 1912, mention the following mixture as being in constant use for diuretic purposes at the Johns Hopkins Hospital:

M. Sig. One dessertspoonful three times a day.

"Mary had a little Lamb,

Likewise an Oyster Stew,
Salad, Cake, a piece of Pie,
And a bottle of Pale Brew.
Then a few hours later

She had a Doctor, too."

ORIGINAL ARTICLES.

Pelvic Inflammatory Disease.

*By M. J. FORD, M. D., Omaha.

I use this term as the title of my paper, as I think it will convey my subject to you more clearly than the older term, "pelvic abscess," which included all forms of pelvic inflammation and would lead one to believe that all the inflammation was located in the cellular tissue between the rectum and the uterus, where in reality minute observations made by some of the leading gynecologists of the country have clearly proven that the seat of the abscess is usually on the uterine tube or the ovary and rarely in the cellular tissue. Dr. Howard Kelly cites fourteen different places where he has found accumulated pus, among the most common locations being one or both tubes, ovary, combination of tube and ovary, the cornua uteri, floor of the pelvis, anterior to the tubes in the cellular tissue at the base of the broad ligament.

Cause of Suppuration may be any of the pus producing organisms, chief among these being the gonococci and streptococci; staphyloccus is rarely found to be the cause. I in gonorrheal infection the inflammation is usually found to be local, the inflammatory process being confined to the pelvic organs. The organism finds its way through the vagina into the uterus and then to the tube which usually becomes sealed at its extremity and thereby protects the general peritoneal cavity. This, however, is not always the rule, as we may have the escape of the gonococci into the pelvis setting up a pelvic peritonitis; gonococci have been found in ovarian abscesses and have been known to penetrate the submucous connective tissue and enter the circulation. H. Cushing reports two cases of acute gonococcal peritonitis in the Johns Hopkins Bulletin.

Streptococcus Infection differs from gonorrheal both in its clinical manifestations and its mode of invasion. The course of this infection is usually following abortion, a break in the technique during the puerperium, introduction of dirty instruments, sore on the hand of the examining doctor or carelessness in making internal uterine applications. The germs invade the muscular walls of the uterus, so we may have an endometritis, metritis, parametritis, or an invasion of the cellular tissue

*Read before the Elkhorn Valley Medical Society at Norfolk, January 11, 1911.

without any involvement of the tubes or ovaries. In fact, cases are cited in literature where an accumulation of pus has been found in the cul-de-sac of Douglas with the wall of the uterus involved and the tubes and ovaries lying on top of the abscess intact.

Symptoms. In the gonorrheal type, the pelvic symptoms are usually preceded by an inflammation of the urethra, vulva and vagina, which is followed by pelvic pains. The pelvic inflammation may occur months after the primary infection. In this form of inflammation the pulse is good and the patient is generally in pretty good condition, which is not true of streptococcus infection, which almost always follows closely upon labor, abortion, or local treatment. The onset is rapid, may be preceded by a chill, the temperature is high, the pulse quick and the abdomen may become distended. The patient has a depressed anxious appearance due to a septic absorption and is usually confined to her bed. The pain is severe, there is a marked tenderness over the lower abdomen. In fact, we have a picture of a rapid general infection. Then the symptoms may abate, only to appear again in a few days, and this may continue until we have a well defined abscess in Douglas' cul-de-sac.

Diagnosis of Pelvic Inflammation, as a rule, is easy. You can usually get a history of gonorrhea. If not recent, you may get a history of pelvic discomfort after marriage with an irritating leucorrheal discharge which has been worse at times or the patient may date the beginning of her illness back to a labor, miscarriage or local treatments. Upon examination it will be found that the uterus has lost its mobility and you may find a mass on either side or posterior to it; the vault of the vagina has that characteristic stony feel to the examining finger. Prognosis depends upon the virulence of the microorganism.

Gonorrhea as a rule does not extend beyond the tubes and ovaries but may become chronic with acute exacerbations.

Streptococcus is rapid, often producing general peritonitis or septicemia and a great number of the cases die; those that do recover are usually more or less crippled by the great number of adhesions in the pelvis.

Case No. 1, Mrs. T., age 28, married.

Family and early history negative, periods always regular, no pain, no clots, no leucorrhea. At twenty-five aborted, was taken to the hospital, curetted and kept in bed for one week. She did not conceive again for three years, when she was de