Book Reviews.

PAIN AND ITS INDICATIONS. An Analytical Outline of Diagnosis and Treatment. By EDWARD C. HILL, M.S., M.D., Medical Analyst and Microscopist: Professor of Chemistry in the Medical and Dental Departments of the University of Denver; Attending Physician to St. Anthony's Hospital, Denver; Author of "A Text Book of Medical Chemistry." Chicago: G. P. Engelhard & Company, 1904.

THE Consideration of pain according to the region of the body in which it is found, is rather an unusual method of treatment, but it is none the less interesting. The writer in his preface calls attention to the varieties of regional pains and the consequent difficulty of differentiation and of rational causal treatment. The text deals with all sorts of pains, which are arranged systematically for comparison. In the introduction, the writer differentiates local inflammatory pain, general pain, local noninflammatory pain, referred or reflex pains, neuralgic pain, hysterical pain, traumatic pain, pressure pain. The first chapter deals with headache of various kinds and from various causes, with suggestions concerning treatment. Chest pain, backache, abdominal, pelvic and genitourinary pain are the topics of various chapters. The book is full of suggestions and will fill a valuable niche on the reference shelf.

AN ESSAY UPON THE GENERAL PRINCIPLES OF PREVENTIVE MEDICINE. By W. WAYNE BABCOCK, M.D, Lecturer on Pathology and Bacteriology, MedicoChirurgical College, Philadelphia; Pathologist, Kensington Hospital; Assistant Pathologist, Philadelphia Hospital, etc. Awarded the first prize of one thousand dollars in the competition instituted by The Maltine Company Reprinted from the Brooklyn Medical Journal, January-August, 1903.

AN ESSAY UPON THE MEDICAL INSPECTION OF SCHOOLS: A Problem in Preventive Medicine. By LEWIS S. SOMERS, M.D. Awarded the second prize of five hundred dollars in the competition instituted by the Maltine Company. Reprinted from The Medical News, January 17 and 24, 1903.

MUCH interest was taken in the outcome of this plan for competitive essays on preventive medicine, and the results have not been disappointing. The paper on the general principles of preventive medicine, considers the subject under three heads: the factors of disease; the diffusion of the parasites of diseases; and the inhibition of the factors in disease. The essay on the medical inspec tion of schools is much shorter and is not subdivided. Both monographs embody the latest researches in the subjects treated.

ELETTRICITÀ MEDICA, ELETTROTERAPIA-RAGGI RÖNTGEN -RADIOTERAPIA - FOTOTERAPIA OZONO - ELETTRODIAGNOSTICA. Pel Dr. A. D. BOCCIARDO, Assistente ordinairo all' Instituto di Clinica Medica della R. Università di Pisa. Con 54 incisioni e 9 Tavole. Milano: Ulrico Hoepli. 1904.

THIS little hand-book deals in a clear and simple manner with the various problems of electricity as applied in medicine and discusses the subjects of electrotherapy, the x-ray, radiotherapy, phototherapy, ozone, and electrodiagnosis. It is a convenient guide in the practice of electrotherapy. The author has written from a fund of experience, which he has acquired during the practice of many years. The text is embellished with fifty-four cuts, many of them representing the machines in use at the present day. There are also tables with illustrations showing the position of the various muscles and nerves. LA RACHITIDE E LE DEFORMITÀ DA ESSA PRODOTTE, CON 110 Figure intercalate nel Testo. Pel Dr. PAOLO MANCINI Milano: Ulrico Hoepli, 1004. THE subjects discussed by the author cannot fail to be of value to physicians in general. So much is included in their consideration that they are of almost universal interest. The etiology and pathogenesis are first discussed with the various theories that have been advanced. The pathological anatomy, chemical alterations in the bones, and anatomical changes in the organs which have been noted in this disease, follow in order. The writer then devotes considerable space to the deformities incident to this malady. The chapter on diagnosis deals mostly with differential diagnoses. After touching on the prognosis of rachitis, the author deals in the last part of his work with the treatment of the various manifestations of this malady. One hundred and sixteen cuts are scattered throughout the text. An elaborate bibliography is appended. The book, though so compact in form, will prove of much value to physicians.

NOUTBAL FORMULAIRE MAGISTRAL. Par A. BOUCHARDAT. Professeur d'Hygiène à la Faculté de Medecine de Paris. Membre de l'Academie de Medecine, President d'honneur de la Societe de Medecine publique et

d'Hygiène professionnelle; G. BOUCHARDAT, Membre de l'Académie de Médecine, Professeur à l'Ecole Supérieure de Pharmacie de Paris, Agrégé de la Faculté de Médecine de Paris. Trente-troisième édition. Paris: Félix Alcan, 1904.

THE thirty-third edition of this compact little manual has been brought completely up to date. Many additions have been made. A table giving the principal ones is placed after the preface. The section treating of diet in various diseases is full of valuable suggestions. The indexes both of author's and of contents make the volume a most convenient one for reference. Technique du MASSAGE. Par le Professeur J. ZABLUDOWSKI, Directeur de l'Institut de Massage de l'Université Royale de Berlin. Traduit sur la deuxième edition allemande par A. Zaguelmann. Avec un atlas de 80 figures. Paris: G. Steinheil, 1904. THIS Volume of 146 pages is divided into three sections: (1) General Technique of Massage; (2) Methods of Massage with Apparatus; (3) Massage of Organs. Appended to the text is a series of 80 illustrations which show the author's methods of work as no description could possibly do. These begin with a cut illustrating the massage of flatfoot. There is a full and clear description below every cut. The various parts of the body are taken up one after the other for discussion. Such practical points as the suitable ointment for massage, the proper temperature for the operating room, position of the physician in relation to the patient, precautions necessary for the avoidance of pain, the duration of the entire treatment, hour of the day for massage and massage of pregnant women are all carefully discussed. The book is most attractive and is a decided addition to the literature on this subject. LA MÉDICATION SURRÉNALE. Par les Docteurs R. OPPENHEIM and M. LOEPER, Anciens Internes des Hôpitaux de Paris. Paris: J. B. Baillière et Fils, 1904. THE authors first consider the preparation of the supra. renal extracts used in experimental medicine, their toxicity and physiological effects. The dosage of the different praparations is then discussed. The latter half of the work is devoted to the consideration of the therapeutics of these extracts. Their value as a cardiotonic, hæmostatic, antiphlogistic, and anæsthetic. The concluding chapter deals with suprarenal medication in Addison's disease.

PRÉCIS D'ANATOMIE DENTAIRE. Par J. CHOQUET Chirur gien-Dentiste, D.E.D.P. de la Faculté de Paris Professeur suppléant à l'Ecole dentaire de Paris. Paris: F. R. de Rudeval, 1903.

THE writer in his preface states that his object in presenting this book has not been to offer an absolutely exhaustive treatise on this subject, but rather a volume which will prove useful to the student of dentistry or of medicine, or even to the general practitioner by giving a sufficiently detailed review of this subject. The value of the work is greatly enhanced by the cuts with which it is embellished. These have been made from original drawings, photographs, and photo-micrographs. The volume teems with original work and well fulfils the purpose for which it was written. FATIGUE. BY A. Mosso, Professor of Physiology in the University of Turin. Translated by MARGARET DRUMMOND, M.A., and W. B. DRUMMOND, M.B., C.M., F.R.C. P.E., Extra Physician, Royal Hospital for Sick Children, Edinburgh; author of "The Child, His Nature and Nurture.' New York: G. P. Putnam's Sons; London: Swan Sonnenschein & Co., Ltd., 1904. THE name of the author of this volume is a sufficient guarantee of its value and interest, and the reader is not disappointed in perusing the pages. In the chapter on "Lectures and Examinations" there is a convincing series of experiments demonstrating the relation between cerebral and muscular fatigue. This work is most important in relation to school curricula. An obvious practical conclusion is that games, or any form of athletic exercise should not be forced upon students during any time of special intellectual strain. The writer shows the impor tance of a quiet situation for schools; he proves experi mentally that the time of perception is lengthened by noise. Again the author demonstrates that the best results are obtained by alternating short periods of work with play. Of the many instruments which of recent years have been invented to record and measure the vital and mental processes one of the most important is Mosso's Ergograph or Fatigue Recorder. Most of the writer's conclusions are based upon experiments which he has performed with this apparatus. Among the subjects touched on are The History of the Study of the Movements of Animals. The Origin of the Energy of the Muscles and of the Brain, The General and Special Characteristics of Fatigue, The Law of Exhaustion. Attention and Its Physical Conditions. The Method of Intellectual Work and Overpressure. This volume is a most interesting and valuable addition to educational works

LES ACTUALITÉS MÉDICALES. TRAITEMENT CHIRURGICAL DES NÉPHRITES MÉDICALes. Par le Dr. A. POUSSON, Professeur agrégé à la Faculté de Médecine de Bordeaux, Chirurgien des Hôpitaux de Bordeaux. Avec 7 figures dans le texte. Paris: J. B. Baillière et Fils, 1904. THE writer has compiled this little volume, believing that it will be of value to those interested in this subject. The question of the surgical treatment of Nephritis has been so warmly discussed of late years by both its advocates and its opponents that the present work is most timely, as it presents a general résumé of the whole subject.

LES ACTUALITÉS MÉDICALES. DIAGNOSTIC DE L'APPENDI. CITE.

Par le Dr. MAURICE AUVRAY, Professeur agrégé á la Faculté de Médecine de Paris, Chirurgien des Hôpitaux de Paris. Paris: J B. Baillière et Fils, 1904. THE writer calls attention to the paramount importance attaching to the diagnosis of appendicitis. Much interest has been taken in late years in the treatment of this disease, but the author believes that if more knowledge were possessed by physicians in regard to the diagnosis there would not be so many avoidable errors made by clinicians of the best standing. The book is well written

and of much value.

A SYSTEM OF PRACTICAL SURGERY. By Profs. v. BERGMANN, V. BRUNS, and v. MIKULICZ. Translated and edited by Drs. W. T. BULL and WALTON MARTIN. Vol. I, The Surgery of the Head. New York and Philadelphia: Lea Brothers & Co., 1904.

THIS monumental work, conceived and executed by three of the greatest surgeons in Germany has attained the distinction of a second edition in its own land and of a contemplated translation into several other languages. It is in the form of a manual and is intended to occupy a position among German writings on surgery intermediate between the well-known collection of monographs published as the "Deutsche Chirurgie" and the more or less elaborated textbooks. It is intended to serve the general practitioner as well as the surgical specialist with a means of reference which shall be applicable at the bedside and in the study. The herculanean task of bringing out this work in the English language has been entrusted to Dr. Wm. T. Bull, Professor of Surgery at the College of Physicians and Surgeons, New York, and associated with him in the translation of the first volume is Dr. Walton Martin. This volume takes up the surgery of the head, and its various chapters have been written by specialists in their fields-v. Bergmann, Krause, Krönlein, Kummel, Kuttner, Lexer, Schlatter, and Wiesmann-men of acknowledged authority and large clinical experien e In each subdivision the pathological data, the symptomatology and treatment are very fully considered, and the details of original research and statistics presented by individual authors in connection with the subject assigned to them, give to many of the chapters the character of authoritative monographs. Personal opinions are not insisted upon and the polemical discussions so frequently met with in German books, are wisely omitted, so that the work remains as a practical manual of reference which affords to the reader a trustworthy guide to the best and most recent methods of surgical practice.

The translation is free and literal, but too often the German idiomatic constructions are, unfortunately, very faithfully followed, to the detriment of brevity and clearness. The book is well printed and supplemented by a complete and satisfactory index. The illustrations are numerous and the greater proportion well executed, but many have seen previous service to such an extent that they might well have been retired when this book was printed. The bibliographies which constituted a valuable and important feature of the original German edition, are unfortunately omitted from the American translation. Foreign works are often considered of doubtful value when introduced into this country. This may be true in many instances, but in this case it may well be said that if the remaining volumes round out the promises held forth by this one, the work will occupy a high position as surgical manual and will form a most valuable addition to the armamentarium of the practising physician.

LECTURES, CHIEFLY CLINICAL AND PRACTICAL, ON DISEASES OF THE LUNGS AND THE HEART. BY JAMES ALEXANDER LINDSAY, M.D., F.R.C.P. (London), M.A., Professor of Medicine Queen's College, Belfast, Physician to the Royal Victoria Hospital, Belfast, etc. New York: William Wood & Company, 1904. THE series of twenty-one lectures contained in this volume deal with most of the phases of intrathoracic disease that come under the observation of the physician. The various subjects are not taken up in a systematic manner, but they are discussed in a practical fashion from the clinical standpoint. The actual consideration of the diseases in question is preceded by a brief descrip

tion of diagnostic methods, a discussion of the interpretation of the history in relation to disease and also a recital of methods of physical examination and of the results yielded thereby. Ten lectures are devoted to diseases of the lungs and pleura, and five of these deal with the subject of pulmonary phthisis alone. An additional lecture takes up the causes and management of hæmoptysis. The various disorders of the heart are discussed in seven lectures, an additional lecture dealing with the physical examination of the blood-vessels. The text is supplemented by an index of authors and a general index. We have here presented a considerable mass of The facts in an interesting and instructive manner. type is large, the paper heavy, and the binding neat. LESSONS ON MASSAGE. BY MARGARET D. PALMER, Masseuse and Manager of the Massage Department of the London Hospital; Instructor of Massage to the Nursing Staff of the London Hospital; Member of the Council of the Incorporated Society of Trained Masseuses. Second edition. New York: William Wood & Company, 1904.

THE author of this valuable work pays special attention to the anatomy of the parts, for after the opening chapter, in which she considers the history of massage, the preparation of the bed and patient, lubricants, and the definition and classification of movements, she makes a study of the human body in its various aspects, beginning with the skeleton. Massage of the various regions of the body is described, one chapter being devoted to the treatment of affections of special parts, such as stiff joints, lawn-tennis arm, writer's cramp, flat-foot, sciatica, varicose veins, etc. The author touches on spinal curvature. Massage of children is considered by itself, including the consideration of infantile paralysis, greenstick fractures, separation of epiphysis, talipes and intussusception. In this new edition a few alterations and additions have been made, besides the chapters on the Nauheim treatment, and bandaging. Some of the old photographs have been replaced by new ones, while two colored plates and other illustrations have been added. The writer has had many years of experience both in teaching and in practical work. L'ENTERO-COLITE MUCO-MEMBRANEUSE.

FROUSSARD. Paris: A. Maloine, 1904.

Par le Dr.

IN the present monograph Froussard describes the symptom complex of membranous enteritis and its treatment. The writer does not believe that this malady is especially apt to be complicatied with appendicitis. The latter is occasionally met with here, but is not caused by the membranous enteritis, and exists independent of the other disease. As a therapeutic measure of great value, Froussard considers the olive oil enemas of Kussmaul and Fleiner. The small volume will be read with interest by the practitioner.

INFECTION AND IMMUNITY, with Special Reference to the Prevention of Infectious Diseases. By GEORGE M. STERNBERG, M.D., LL.D., Surgeon-General U. S. Army (retired), Ex-President of the American Medical Association, and of the American Public Health Association; Honorary Member of the Epidemiological Society of London, of the Société Française d'Hygiène, of the New York: Royal Academy of Medicine of Rome, etc.

G. P. Putnam's Sons. London: The Knickerbocker Press, 1903.

THE importance of this work can hardly be overestimated. The name of the author is a guarantee of its excellence and scientific accuracy. The leading part that preventive medicine is playing of recent years makes any knowledge The writer has stated on this subject of great interest. the main facts as far as they are now known in reference to infection and immunity in order the more clearly to point out the measures necessary for the prevention of infectious diseases. The book is intended for non-medical readers, and with this purpose in view the use of technical terms is avoided as far as practicable. When these terms have to be used, they are explained. A discussion of the theories of immunity and the results of recent work in relation to the "antitoxins," 'agglutinins, "precipitins,' "bacteriolysins" and so forth, have not been incorporated in the text, as such discussions involve the use of many new technical terms. The writer in his preface expresses the hope that this book may serve, at least to a certain extent, as a textbook in high schools and colleges. The volume is divided into two parts. In the first are arranged the general subjects of Infection, Channels of Infection, Disinfection, Sunlight as a Disinfectant, Natural Immunity, Acquired Immunity, and Antitoxins. The second part is devoted to the consideration of the most important infectious diseases and the manner of their propagation, their importance as a factor in mortality statistics, and the best methods of restricting their dissemination. The book is written in a charming style, and is sure to prove of great value to all interested in the subject of sanitation.

Society Reports.

THE PRACTITIONERS' SOCIETY OF

NEW YORK.

Dr. FRANCIS P. KINNICUTT said he was inclined to agree with much that Dr. Peabody had said in his interesting analysis of the statistics of the Health Department. At the Presbyterian Hospital it was the

May 6, 1904.

Dr. CHARLES STEDMAN BULL, PRESIDENT, IN THE CHAIR. A Case of Giant-celled Sarcoma of the Lower Jaw Treated by Radium.-By Dr. ROBERT ABBE. This patient had already been shown at the March meeting of the society, and a preliminary report of the case was published in the MEDICAL RECORD, April 30, 1904, page 715. The growth, which was an extensive giant-celled sarcoma of the lower jaw, was first noticed by the patient six months ago. It extended from the middle toward the left, bulging inward under the tongue and outward under the skinthe inner part comprising one-third of the mass, and the outer two-thirds. The diagnosis of pure giant-celled sarcoma was confirmed pathologically.

As the case, surgically treated, called for resection of the jaw, with hopeless mutilation and inevitable recurrence, Dr. Abbe decided to try the effect of radium. A small glass tube of 10 cgm. of the 300,000 x-Curie radium was applied over the growth within the teeth for one-half to one hour daily, a lead shield protecting the tongue. Under this treatment, the entire bulk of the projecting internal tumor was considerably reduced. Subsequently the tube was inserted directly into the mass of the tumor and allowed to remain imbedded for two or three hours at a time. By this treatment the growth of the tumor had not only been arrested, but there was an appreciable shrinkage in its bulk during the first two months.

A week after the above preliminary report was made, Dr. Abbe said a small slough appeared on the inner surface of the neoplasm. This, he thought, was the result of overradiumization. The treatment was discontinued,

and within a few days a severe dermatitis of the skin and subcutaneous tissue developed over the site of the tumor. This was rather unexpected, as the view was generally held that the skin was never affected when the radium was buried in the tissues or applied internally. This dermatitis persisted for over three weeks, and then, under the use of soothing applications, it gradually subsided. No applications of the radium had since been made, but the improvement in the malignant condition had steadily continued. There was apparent arrest of development of the growth, and a marked shrinkage in its bulk.

Dr. Abbe said that at a subsequent meeting he would report the final outcome of the case.

Dr. GEORGE L. PEABODY said the appearance of the case had certainly improved since it was first shown, two months ago. The tumor was smaller, and its bony walls, which were then very thin, had apparently grown firmer. The development of the new bony tissue, as well as the shrinkage in the size of the growth, could only have taken place at the expense of the tissue of the tumor itself, unless, perhaps, it was due to the subsidence of an accompanying inflammation.

Some Thoughts Suggested by the Statistics of the Health Department, Especially Concerning Typhoid Fever and Smallpox.--Dr GEORGE L. PEABODY read this paper. (See page 9050

Dr. Asss said that many of the deaths attributed to malaria were possibly cases of præmia in which the source of the infection had not been recognized. In certain cases of appendicitis, mastoid disease or empyæmia, the condition was often difficult to recognize, and the symptoms-repeated chills, daily elevation of temperature, etc.—were strikingly like those of malaria. The large number of deaths from strangulated hernia was not surprising on account of the delay that so often occurred before these patients were brought to the surgon. Many general practitioners failed to appreciate the danger of allowing a strangulated hernia to go over Twenty-four hours

typhoid fever as to the possible source of infection, and in the great majority of cases it was found that the drinking water was the only common factor. It was interesting to note that a large proportion of the patients used neither raw milk nor oysters. The speaker said that accepting the Health Department's statistics as correct. viz., that there was a constant greater prevalence of typhoid fever in the Borough of New York than in Brooklyn, he thought Dr. Peabody's suggestion that this was due to the fact that New York was largely supplied by surface water, while the Brooklyn supply found an efficient natural filter in the sandy soil of Long Island, was a reasonable explanation. Dr. Kinnicutt said be was disposed to agree with Dr. Abbe that many deaths from so-called malaria were really cases of pyæmia. In regard to the removal and segregation of smallpox patients, the speaker inquired whether, under exceptional circumstances, such cases were not allowed to remain in their own homes under the supervision of the Health Department.

Dr. HERMANN M. BIGGS said the figures quoted by Dr. Peabody furnished another illustration of the fact that one was often misled by unexplained statistics. According to the figures, Brooklyn had a higher death rate from typhoid fever than the Borough of Manhattan, although the number of cases of the disease in Brooklyn, according to the population, was less than in New York. This was due to the fact that many of the cases in Brooklyn had not been reported to the Board of Health. The same difficulty in getting cases of typhoid fever properly reported was formerly encountered in Manhattan; less than ten years ago not one-half and probably not even one-quarter of the cases of typhoid fever in this city were reported. Two years ago the Health Department began following up the hospitals in this connection, and it was found that only one hospital, the Presbyterian, was making fairly accurate reports of its cases of typhoid fever. In the others, both large and small, hardly more than one-half the cases were reported. Vigorous steps were at once taken to remedy this. The superintendents of several of the hospitals were summoned before the Board of Health, and since then the proper reports have been forthcoming. The previous defects were due to negligence, as the internes in these institutions are frequently changed, and no one felt himself particularly charged with the duty of making the reports to the Health Department. The same fault was found with general practitioners, and many of the cases treated in private practice were only discovered by the death returns. In such a case, the physician was com municated with, and informed that his neglect to report the case was a violation of the sanitary code. To such a communication, usually, a prompt reply is received, stating that the neglect to report it had been due to an oversight, or that the report had been sent and evidently miscarried, or some other excuse was given, which, if it was plausible and the offence was not repeated, was accepted by the department and the matter was allowed to drop. If no response was received to the first communication, however, a second one was sent, and perhaps a third. Then the matter was referred to the secretary of the board, and a further communication sent to the delinquent. If no response was received to this the matter was turned over to the Corporation Counsel for prosecution. This was the usual routine followed by the Board of Health in the cases of failure to report typhoid fever, tuberculosis and the various other contagions or communicable diseases. Dur ing the past three months, forty or fifty physicians who had been negligent in this respect had been brought before the Board. On account of this activity, the number of cases of typhoid fever reported Manhattan had largely increased during the past few years, especially since the

establishment of the bacteriological department in connection with the Board of Health. An attempt was being made to bring the department up to the same standard of efficiency in the Borough of Brooklyn, but thus far with only partial success. Not only were the returns of contagious diseases from that Borough much more incomplete than those from Manhattan, but all attempts to introduce improved sanitary procedures there had met with a great deal of obstruction. For example, in the adoption and general use of antitoxin in diphtheria it took a much longer time to accomplish in Brooklyn what had been done in two years in Manhattan. The same was true in regard to the prevention and treatment of diarrhoeal diseases in children. On account of the comparatively few tenement houses in Brooklyn and the lack of overcrowding and excessive poverty, the mortality of diarrhoeal diseases in children in that city should be much lower than in Manhattan,while, as a matter of fact, it had been continuously from 30 to 35 per cent. higher. These figures showed that either Brooklyn people did not boil their milk in summer, or else the children were brought up largely on artificial food or condensed milk.

Dr. Biggs said that during the past five or six years the Health Department had investigated all the cases of typhoid ever occurring outside of the hospitals, and many of them n the hospitals, in order to determine, if possible, the source of infection. In the majority of instances it was of course only possible to learn the probable source of inection, while in isolated cases the true source of infection could often only be conjectured. In every instance, the family or physician of the patient, or both, was visited by the inspector, and special inquiry was made as to whether the patient had been outside of New York during the month previous to the onset of his illness; if so, where he had been, and for how long a time. Inquiry was also made is to whether he was a milk drinker habitually, and whether he had been in contact with any other case of yphoid fever. Also, whether he was accustomed to parake largely of shell-fish, or had recently bathed in either he East or North River. The Department had a regular ɔlank prepared on which these questions were asked, and 1 tabulation of the information obtained showed in a general way that in about 25 per cent. of all the cases occurring in the Borough of Manhattan, the source of the nfection was almost certainly outside of the city, while in 3 considerably larger per cent. there was a possibility that the disease was acquired outside of the city. About 6 or 7 per cent. were certainly instances of contact infection, while in a considerable number of cases the infection was traced to milk. One group of forty-nine cases was due to milk infection and traced to the same milk supply. This was one of the most difficult sources of infection to trace, as the milk of New York came from a radius of 500 miles and was collected in the creameries from so many different farms that its identity was lost. A certain family, for example, might receive milk one day from a certain group of farms, and the next day from a different group, so that the difficulties of tracing the milk supply of a given family became almost insuperable.

The total number of cases of typhoid fever comprised in small groups was considerable. In a group of ten cases seen at St. Vincent's Hospital, the patients were all employed as stewards on the steamship New York. A careful inquiry was instituted as to the source of the infection in these cases, but nothing could be learned until a number of the patients were about to be discharged, when one of the men, who had been desperately ill and almost constantly delirious up to that time made the statement that previous to their illness, the steamship New York had been ordered to the Cramp's ship-yards, in Philadelphia, for repairs, and that while there they had been dependent on the Schuylkill River for their water supply. Orders were issued by the chief steward to see that all the drinking water was boiled, but this order was disregarded in the second cabin, and ten cases of typhoid fever resulted.

Similar groups of cases had been treated in other hospitals in the city.

Dr. Biggs said he had no doubt personally that a percentage of cases of typhoid fever in New York City, apart from those contracted outside of the city, was the result of milk infection. In from 40 to 50 per cent. of those who apparently contracted the disease in the city, the patients were habitual milk drinkers, which was a very large percentage, compared to the number of habitual

milk drinkers as a whole.

Speaking of the water supply of New York, Dr. Biggs said he did not think the facts justified Dr. Peabody's interpretations. The Croton Watershed covered an enormous area, and was very sparsely populated. With the exception of one or two small reservations, the city had acquired title to the land adjoining all the reservoirs and along the banks of the principal streams, and had cleared these of all kinds of habitations and nuisances. There were still a few localities where considerable contamination of the water might take place, but the danger had been reduced to a minimum. Last summer one of the assistant bacteriologists of the Health Department had been in constant communication with the physicians practising on the Croton Watershed, some forty in number, and he was kept informed of all cases of typhoid fever and diarrhoeal troubles that came under their observation.

Typhoid fever was comparatively rare in that locality, not more than six or eight cases being recorded during the entire summer. Diarrhoeal troubles, however, were exceedingly prevalent in some seasons. Not a single instance was found in which by any possibility the water supply could have become contaminated by the evacuations of these patients. Even admitting the possibility of an occasional pollution from a single case, the quantity of the water was so great that the enormous dilution rendered the danger of infection in the city very slight.

Shell-fish, as a possible source of infection in typhoid fever, had received considerable attention from the Health Department, but in these cases the infection was even more difficult to trace than with milk. There were many cases, however, in which the presumption was very strong that the infection was due to shell-fish, and investigation had shown that many oyster-beds were located where the Some the water could not fail to be polluted by sewage. of the oysters were placed in brackish water near the outlet of small streams along the Staten Island, New Jersey, and Connecticut shores, and these streams served as sewagecarriers from the surrounding houses and villages. Dr. Biggs said he had seen a number of cases of typhoid fever in which he thought there could be no question that the infection was due to oysters. Experiments had shown that the typhoid bacilli might be present in the oyster for perhaps twenty-four to thirty-six hours after its removal from an infected water, and that in oysters which were not absolutely healthy the typhoid bacilli were often present in enormous numbers and remained for several days. The Board of Health had at present under consideration certain measures for the regulation of the oyster traffic. In the course of their investigations, one oysterbed was found at the Erie Basin, the water of which was nothing more than dilute sewage. While the New York Croton water supply was often muddy and had a disagreeable odor, the speaker said he did not think it was a factor of any importance in the production of typhoid fever in New York City. In Brooklyn, however, the drinking water was not above suspicion. Originally, Brooklyn had an excellent water supply, but at the present time, possible sources of pollution had been discovered in Ridgewood and all the way down the South shore. There were a large number of definite sources of possible infection, which had been located, but which the Board of Health was not yet empowered to remove.

Dr. Kinnicutt said that in the purification of drinking water, sedimentation was quite as important as dilution,

if not more so. While the water supply of New York City had the benefit of the latter, it did not have proportionately the benefit of sedimentation. The sedimentation noted in a glass of drinking water or bath indicated how largely the Croton water was a surface water. It was a well-known fact that in a running stream the typhoid bacilli were capable of doing harm after being carried for a long distance in great dilution. Outbreaks of typhoid fever had been reported from the use of water many miles away from the source of infection. As a possible example of this the question was now being agitated in St. Louis, whether the water supply of that city was not being contaminated by the drainage of Chicago. If that be so, the infection must travel through the Chicago Canal and the Illinois River into the Mississippi River.

Dr. Kinnicutt said that all the sources of infection in New York other than the water supply mentioned by Dr. Biggs should necessarily also apply to Brooklyn.

Dr. Biggs said that in the New York City water supply the dilution was on a vast scale, and there was also a certain degree of sedimentation in the several reservoirs connected with the system. Nearly 300,000,000 gallons of water were used daily, and the only possible infection could come from some individual case which might escape detection.

In regard to malarial fever, Dr. Biggs said he quite agreed with Dr. Peabody that the deaths reported from that cause were far in excess of the actual number. The reports in that respect, however, were far more accurate now than they were five years ago, the number of reported deaths from malaria having fallen to one-third or onequarter of what they were at that time. During the past three years, every death attributed to malaria, coming under the notice of the speaker, had been investigated by a medical inspector of the Health Department, and in every instance in which the facts justified action, the death certificate was changed. In this way, the number of deaths had been cut down to twenty-seven per annum in Manhattan, whereas not many years ago over 300 deaths here ascribed to typhomalarial fever and intermittent fever. In a certain number of these cases, the true cause of death could not be ascertained. A certain number of them were n young infants, with high temperature and sudden death, and the attending physician, without further justification, pronounced the cases malarial fever. A few deaths from malaria had undoubtedly occurred in the Borough of the Bronx, usually in young children.

Dr. Biggs said that the high death rate from diphtheria was largely due to the fact that it was almost impossible to get the tenement-house population to realize the importance of early diagnosis and treatment in this disease. While the death rate from diphtheria in the city, as a whole, was 11 per cent., that among the cases treated by the Health Department inspectors was only 6 per cent. The reason for this was that the physicians in the tenement-house districts did not resort to the use of antitoxin early enough in the course of the disease.

The decrease in the smallpox mortality was undoubtedly due to the very extensive vaccination that had been carried out during the past few years. During 1902 more than 800,000 vaccinations were made by the Health Department, and in 1903 nearly 600,000. As a result of this, smallpox had practically been stamped out. In the few cases that were seen, the infection as a rule occurred outside of the city. No exception was made to the rule that smallpox patients must be removed to the Smallpox Pavilion on North Brother Island, but plans were being made to provide special accommodation for patients who wished to be accompanied by their private physician or

nurse.

In reply to a question as to whether there was a law under which smallpox patients could be forcibly removed from their homes, Dr. Biggs replied that the Health Department had absolute power to establish any rule with

regard to the protection of the public health, and it was under that provision that the power of removal was exercised. A year ago a smallpox patient in Queens County refused to go to the hospital on North Brother Island. He was forcibly removed and his friends took the matter to the courts. A habeas corpus was issued, but no one could be induced to serve it.

Dr. EDWARD G. JANEWAY said that while the city water was sometimes so muddy that it was unfit even for bathing purposes, he did not think it could be held responsible to any extent for typhoid fever. Otherwise, that disease would be of more frequent occurrence in the city than was the case. The city was supplied from two sourcesone, a high pressure service, which came direct from the Croton Water-shed, and the other through the reservoir in Central Park. In the high pressure service there was no sedimentation, whereas in the reservoirs, which supplied, the lower part of the city, there was more or less sedimentation. The speaker said he favored a filtration plant, such as Philadelphia was now using for the Schuyl kill River water.

As another possible source of infection in typhoid fever, Dr. Janeway mentioned the green vegetables that were eaten raw, especially watercress which was usually grown in marshy lands and along the banks of brooks. He had seen a certain number of cases in which this was the only source of infection he could find. Raw fruit was another possible source of infection. He also recalled a case of typhoid fever in a pedler, who had been sick for ten days, traveling from house to house and using the water-closets promiscuously many times daily. He was strongly convinced that raw oysters were the source of infection in certain cases, while among the poorer classes milk was probably a very potent factor.

In regard to the forcible removal of smallpox patients, Dr. Janeway said that was rather a difficult question to handle. If some patients were left at home, while others were removed, it might be regarded as class legislation and the public might object against such discrimination, yet this existed in the dealing with diphtheria and with scarlet fever. The rules in this respect were more stringent than was formerly the case.

Dr. BEVERLEY ROBINSON said that as long as the Health Department exercised its arbitrary right to remove smallpox patients, every citizen should also exercise his authority and refuse to harbor any person in his house who was not willing to be vaccinated; or, better still, that a compulsory vaccination law should be passed.

Dr. Janeway said he was afraid that a compulsory vaccination law would only have the effect of exciting greater opposition to vaccination than now existed. That had been the result of such a law in England.

Dr. Biggs said that while vaccination was not compulsory in New York, it was practically universal, especially among the lower classes. So far as the public schools were concerned, it was compulsory, and in the large department stores, hotels, and factories it was practically So. At certain periods, or when there was any danger of smallpox, the proprietors of these establishments were communicated with, and informed that the Board of Health would like to vaccinate their employes. Usually, they readily consented. If they refused, they were informed that in case smallpox appeared among their employees, their establishment would be quarantined for such a length of time as the Health Department thought necessary. Such a letter usually brought a satisfactory response. Many of the large department stores refused to engage unvaccinated help. A new difficulty that the Board of Health had to contend with in this connection had recently come to light. Certain physicians and dispensaries on the lower East side of the city had been found issuing certificates of vaccination, which read as follows: "Certificate of Vaccination. Within five years of date, children presenting these certificates are entitled