the greater frequency of hemorrhages, neuritis and phlebitis in those cases treated by the Brand bath. When, however, we realise the lower death rate obtained by this method, it is not surprising that there should be an increase in the complications and sequelæ. A number of observations by different investigators have shown almost invariably a rise of blood pressure in case of perforation with peritonitis, coincident with, and sometimes preceding, the pain, and always before the symptoms of collapse. Further observations are, however, necessary before formulating a positive rule.

Nothing new has been added to our knowledge of pneumonia and pleurisy, diagnostically or therapeutically, except that there has been a decided increase in the number of reported cases ushered in or accompanied by severe abdominal pain.

In diphtheria the profession generally is learning to recognise the value of the early bacteriological diagnosis and prompt administration of large doses of antitoxin. Perhaps the most noteworthy advances in relation to diphtheria, have been in the recognition of the value of the administration of the prophylactic dose to all other members of a household in which a case of diphtheria occurs. My own experience in the use of diphtheria antitoxin is that since beginning its use I have not lost a case in private practice; and in hospital practice only those cases that have come in too late for anything to be of any avail. Moreover, in private practice, by the prompt use of the prophylactic dose, I have prevented the development of any new case in a family where a case has been discovered. This is the experience of all who use this remedy sufficiently early and in sufficiently large dose. If I were so situated that I could not avail myself of bacterial diagnosis, to every doubtful case I should give antitoxin. I have given enormous doses,-10,000 units at a single dose, and as much as 20,000 units in 24 hours, and have never seen any evil results beyond an evanescent urticaria, or a few joint pains, which readily yielded to a purge, alkalies, and occasionally small doses of sodium salicylate or aspirin. A. Caillé proposes the regular immunisation of school children two or three times a year during the school year, by the injection of the prophylactic dose, 200 to 500 units, as a means of preventing diphtheria and the diphtheritic complication of scarlet fever and measles, and gives statistics showing the value of such procedure.

Of other sera used for therapeutic purposes, the only one that is of proven value is the antitetanus serum, though evidence is accumulating that seems to give some reason for hope that before long we will have a reliable serum with which to control the streptococcus. Antiplague, anticholera and antidysentery sera

are apparently more useful as immunising than as therapeutic agents.

Cerebrospinal meningitis has of late attracted great attention, on account of the severe epidemics raging in different parts of the world, which give the disease almost a pandemic character. The cause is now accepted as the diplococcus intracellularis of Weichselbaum; but therapeutically the only advance that has been made is the practice of lumbar puncture and withdrawal of the cerebrospinal fluid. In several instances this procedure has apparently been the means of saving life, but it is by no means the cure-all that some zealous advocates would have us believe. Continuous drainage of the cerebrospinal canal by this means, under thorough asepsis, is advocated, but has not been given sufficient trial.

The role of protozoa as producers of disease is prominently before the profession, especially through the work of Councilman and Calkins in regard to smallpox, and inferentially of the whole class of the exanthemata; and through the work of Plimmer, Clewes, Gaylord and Calkins in relation to the etiology of The conclusions of all these observers are still subjudice,

awaiting confirmation.

In the etiology of arteriosclerosis, through the conscientious work of Cabot and others, alcohol has almost been ruled out as a factor of any great importance; and through the observations of Thayer and others the acute infections, especially typhoid, malaria and influenza, are assuming greater importance.

The importance of autointoxication from the mouth and from the colon, and the necessity of thorough cleansing of both ends of the digestive tract, are becoming more generally recognised.

To Stockton, clinically, and to Charlton, of Montreal, experimentally, we owe the knowledge that infection by the colon bacillus of low virulence will produce an anemia which is almost the counterpart of severe pernicious anemia, and unquestionably some cases in the past of anemia, tabulated as pernicious, must have been due to such colon bacillus infection.

The importance of chronic nephritis as an etiological factor in many disturbances of the metabolism, especially such as are often classed under the heading of asthenia or of neurasthenia, is being more generally recognised, and necessity for frequent examination of the total twenty-four hours excretion of urine in all such cases is paramount. In the majority of such cases, the microscope gives us the most important information of any one procedure in the examination.

In the treatment of nephritis, Bendix has demonstrated clearly that it is possible for the skin to take up vicariously the action.

of kidneys, thus proving the scientific value of the well recognised clinical procedure of induced sweating.

Widal and Javal have proven the value of salt starvation in the reduction of the dropsies of nephritis, and that a patient with chronic parenchymatous nephritis may be allowed a fairly free diet, including bread, meat, sugar, potato, butter, and the like, provided that the foods are not salted.

THE TUBERCULOSIS PROBLEM.

It is impracticable for me to undertake to review the advances in surgery, gynecology, obstetrics and the minor specialties, so I shall proceed immediately to a brief discussion of the tuberculosis problem as it now presents itself to us.

As to the prime etiological factor, the profession is now practically unanimous in giving that rôle to Koch's bacillus; and the existence of tuberculosis in an ancestor, unless the patient has been more or less constantly associated with that ancestor, is no longer considered of any etiological significance. Therefore, the study of the environment of the patient, especially the presence of other tubercular cases in the home, or the school, or the factory, or other place of work or residence, assumes the greater etiological importance.

The role of bovine tuberculosis as an etiological factor of the greatest importance, is still insisted upon by von Behring, who maintains that human pulmonary consumption is the end-stage of an infection acquired in infancy. Most observers do not agree with Behring, the concensus of opinion being that bovine tuberculosis is a factor in the etiology of human tuberculosis, but a relatively small one; that, nevertheless, all efforts should be maintained to suppress it. Of interest in this connection are the observations of Naegeli in the postmortem room at Zurich. He found practically everyone above 30 to be tuberculous, between 18 and 30, about 96 per cent. had traces of the disease; 50 per cent. of those between 14 and 18; 33 per cent. of those between 5 and 14; and 17 per cent. between 1 and 5, had tuberculous foci. Infants less than 12 months old were usually found uninfected.

Franz, of Budapest, tried the tuberculin reaction in soldiers, in doses of 1 to 5 mgm. In the first year, 61 per cent. were tuberculous; in the second year, 68 per cent. reacted positively; when 10 mgm. were used, 96 per cent. reacted. Of 96 infants in whom Behrend employed the same dose, all gave a negative result.

The observations of Harbitz, reported in the Journal of Infectious Diseases, for March 1, 1905, go far to support the conten

tion of Behring that tuberculosis is primarily a lymphnode infection by way of the throat or intestinal tract, and that the pulmonary disease is a later manifestation of the disease.

From the observations of most investigators, the largest number of cases of tuberculosis in children occur during the second and third year; and this is readily explained in two ways—namely, infection through food, including milk, and infection from the floors, walls and furniture of infected surroundings,-children of this age crawling about on the floors and putting their hands and any article they may pick up into their mouths.

Whether the route of infection is most commonly by the digestive or the respiratory tract, is of secondary importance, in my opinion, to the well established fact that the chief, if not the only, source of infection is the sputum of the subjects of pulmonary tuberculosis. The discharge from other tubercular lesions is relatively slight, and is almost invariably carefully destroyed. It is possible that people dead of tuberculosis and buried, may infect the soil. Tubercle bacilli have been found in earth worms.

Patients with advanced consumption throw off in the expectoration countless millions of the bacilli daily. Some idea of the extraordinary number may be gained from the studies of Nuttall. From a patient with moderately advanced disease, the amount of whose expectoration was from 70 to 130 cc. daily (a quarter to half a tumblerful), he estimated that there were in sixteen counts, between January 10 and March 1, from 11⁄2 to 43 billions of bacilli thrown off in the 24 hours. The observations made by Cornet under Koch's supervision, are, in this connection, most instructive. He collected dust from the walls and bedsteads of various localities, and determined its virulence or innocuousness by inoculation with susceptible animals.

Of 118 dust samples from hospital wards or the rooms of consumptive patients, 40 were infectious and produced tuberculosis. In a room in which a tuberculous woman had lived, the dust from the wall in the neighborhood of the bed was infective six weeks after her death.

In the Paris General Hospitals, tuberculosis decimates the attendants. On the other hand, the statistics of the Brompton Consumption Hospital, of Detweiler's Sanatorium at Falkenstein, and all thoroughly equipped and carefully regulated hospitals devoted to the care of consumptives, in which the sputum is collected and destroyed, nurses and attendants are rarely attacked.

It is interesting to know that by exposure to the direct rays of the sun, the tubercle bacilli is killed in a few hours, and, exposed to diffused sunlight, it is killed in one to six days. but moisture, darkness and bad air can keep them alive for weeks. In dark places there is the greatest danger of

infection, and narrow alleys, courts and dwellings shut off from light always have been rightly regarded as the special breedingplaces of consumption.1

The careful compilation of statistics for a great many years, in many places, shows that tuberculosis causes one-seventh of all deaths, and that tuberculosis of the lungs-consumptioncauses one-tenth of all deaths: that it works its greatest havoc in early middle life: according to the statistics of Lillian Brandt, of the New York C. O. S., it causes one-third of all the deaths that occur between the ages of fifteen and forty-four.

The following most valuable contribution to the economics of tuberculosis is made by Cornet in his exhaustive treatise on the subject of Tuberculosis, in Nothnagel's Encyclopedia :

Averaging the mortality reports for the years 1876 to 1891, in Prussia, the annual mortality from tuberculosis in the class of breadwinners, including the ages of fifteen to seventy, was 71,895, or a third of the entire number of deaths. Consumption runs a number of years before it proves fatal; but, if we reckon the invalidism due to it at only one year and the average loss of wage (or unemployed labor) at a value of two marks per day, then the loss of earnings for each person per year, 300 working days to the year, amount to 600 marks; so, for the total number of those who have died in the breadwinning period, 71,895 persons, the annual loss of earnings amount to 43,137,000 marks annually.

If we add to this figure, the money for doctors and medicine, for food and care (counting that the sick pay out 2.19 marks per day), for burial, and furthermore, the expenditure for invalids not included among breadwinners, we may estimate at least twice as much as the previous figure, or 86 million marks as the yearly cost of tuberculosis to the Prussian state.

A similar estimation of the cost to the state has been made by Dr. Herman M. Biggs, of New York, giving as a total annual loss to the city from tubercular diseases of at least 23 million dollars, and to the United States of more than 330 million dollars. By looking a little more closely at our subject, we find that in certain occupations the disease is more prevalent and more fatal than in others. Among those who are especially prone to the disease are stone cutters; cigar makers and other workers in tobacco; plasterers; compositors, printers and pressmen; servants; hat and cap makers; bookkeepers, clerks and copyists; nonagricultural laborers; workers in tin; cabinet makers and upholsterers; musicians; glass blowers; barbers; coal miners,

1. Osler's Practice.