not trouble you with details; it will be sufficient to give you briefly the conclusion to which I came. It was that in Maryland towns where the population. had a considerable negro element the death rate was above 40 to the 1000 living inhabitants. This is enormous

and I hope in the near future to again call your atttention to the subject with the hope that this Society may consider it advisable to form a permanent committee on village mortality. It is a very unpopular subject for public discussion but it cries aloud for remedy.

THAT water is often a carrier of disease is a well established fact. Typhoid fever is frequently disseminated by this. means. Epidemics of typhoid fever in several American and European cities have been demonstrated to be due to the specific pollution of public water supplies (notably in Lowell, Lawrence and Newburyport in Massachusetts, and Chicago, due to the pollution of the lake water with the sewage of the city).

No matter what the active factor in the production of typhoid fever, be it the presence of pathogenic bacteria, of algae and other vegetable organisms, of animal forms of life or of other suspended matters, there can be no doubt that the infection of sewage thrown into water supplies is known to produce a condition of the system with all the clinical symptoms and pathological conditions of the intestinal tract which cannot be distinguished from typhoid fever and in which the bacillus of typhoid fever cannot be found. Bacteria in large numbers can be found and the decomposition of organic matter produces ptomaines or poisonous products which cause the same lesions as the typhoid bacillus, especially when the intestinal tract has been devitalized by the constant presence of decomposition of decayed animal and vegetable matter or by the constant retention of fecal matter.

Open wells, as is well known, draw towards themselves the ground water from considerable distances and when in the vicinity of cesspools become a receptacle for their surface and sub-surface drainage. This is in evidence in country places, or towns and villages where the water supply is drawn from wells.

In an examination of 104 outbreaks of typhoid fever in Michigan, reported to the State Board of Health, 52 per cent. were given as directly due to "infected and impure water" and in 13 per cent. as supposed to be due to "impure water," leaving but 35 per cent. as due to unknown causes. This evidence can be multiplied.

Of surface water the best comes from rivers whose waters, by flowing over and through uneven beds of silicious sand and gravel of considerable slope, and being brought continually in contact with the air, are freed from organic matter by sedimentation and oxidation. Yet notwithstanding these supposedly advantageous methods of purification, epidemics' have developed from the use of river waters that have undergone the above mentioned processes.

Dr. S. W. Abbott of Massachusetts (March, 1879) makes the following statement, showing the relation of the water supply to the prevalence of typhoid fever in the cities of Lowell and Lawrence, Massachusetts. During the four years ending with 1889, the cities of Lowell and Lawrence have had a constantly high death rate from typhoid fever amounting to 10.3 per 10,000 annually of the population for Lawrence and 9.5 per 10,000 for Lowell, as compared with a death rate of only 4 from the same cause in Boston, and 4.5 as the average of the principal large cities of the State. The cause of this increased prevalence in Lowell and Lawrence is undoubtedly to be found in the peculiarity of their water supply, which is taken from the Merrimac River. Upon this river and its tributaries above Lawrence

and Lowell are situated the cities of Nashua, Concord, Manchester, Fitchburg, and other towns, having a total population of 230,000, a considerable part of which is connected directly with the river by means of sewers.

That favorable conditions are thus presented for the propagation and transmission of typhoid or enteric fever, from the excreta of the sick into the river and thence to the water supply of Lowell, and thence to the population of that city, can scarcely admit of a doubt. Nor can there be any doubt that the sewage of Lowell, carrying typhoid excreta from its population, infects the water supply of Lawrence, nine miles farther down the river. Eight miles below Lawrence is Haverhill, in which the mortality rate from the same cause was less than 5, but Haverhill does not take its water supply from the river.

In this connection, the theory that the bacteria of running streams disappear gradually in the course of the stream, the city of Newburyport at the mouth of the river, 17 miles below Lawrence, and 26 miles below Lowell, suffered from the same cause (in 1894). For the past ten years this city was comparatively free from typhoid fever (its death rate from this cause being but little more than 2 per 10,000 annually). In conse

quence of a scarcity of water, the Water Company began pumping a portion of its water from the river and distributing it to the inhabitants after having been warned in November against the danger of such a course by the State Board of Health. In January, 1893, the cases of typhoid fever, following closely after a similar prevalence in Lowell, suddenly rose from an average of less than 1 per month to 34 in January, with 4 deaths.

In Berlin, 1889, during an epidemic of typhoid fever, which was due to the impure water from the river Spree, whilst the portion supplied with water from the Tegeler Lake was spared.

The sanitary value of a source of water supply depends not only on its present condition, but also on the possibility of future pollution. The restriction of pollution by sanitary inspection is useful and is undoubtedly beneficial. But it is desirable to avoid fallible agencies wherever possible and to adopt the infallible when such can be secured by careful study and at a reasonable expense, and it should be apparent that the securing of unpolluted supplies and their maintenance as such, rather than the classification of those already polluted, will attain the surest results in the protection of the public health against diseases disseminated by polluted water.

TREATMENT OF CHOLELITHIASIS.Blum (British Medical Journal) draws attention to the value of large olive oil injections in the treatment of biliary colic. These rectal injections can be substituted for the large doses of olive oil given by the mouth to which patients often object and which may disturb the functions of the stomach. In addition to the probable cholagogue action of these injections, olive oil has a slight laxative action. The author follows Fleiner's directions in giving these large enemata; 400 to 500 c.c. of pure warm oil are introduced, at first daily and subsequently at longer intervals. author gives details of five cases treated with benefit in this way.

The

FOREIGN BODIES IN THE BRONCHI.S. Kobler (British Medical Journal) investigated the anatomical position of the bronchi to explain the undoubted greater frequency of foreign bodies in the right than in the left bronchus. In conjunction with v. Hovorka he made experiments on bodies hardened by chromic acid and found that the right bronchus, contrary to the old teaching, always runs more in a line with the trachea than the left, thus confirming the previous work of Aslay and Kocher. Another factor, which decides which bronchus the foreign body enters, he considers to be the position of the individual at the moment when the aspiration takes place.

SOCIETY REPORTS.

MEDICAL AND CHIRURGICAL FACULTY OF THE STATE OF MARYLAND.

NINETY SEVENTH ANNUAL SESSION, HELD AT THE HALL OF THE FACULTY, APRIL 23 to 27, 1895.

TUESDAY, APRIL 23, FIRST DAY. Dr. Robert W. Johnson, President, in the chair; Drs. Joseph T. Smith and Robert T. Wilson, Secretaries.

The ninety-seventh annual session of the Medical and Chirurgical Faculty of the State of Maryland was called to order at the Hall of the Faculty, corner St. Paul and Saratoga Streets, April 23, at 12.30 P. M. After the reading of the minutes of the last meeting by the Secretary,

Dr. Robert W. Johnson delivered the President's Address on the subject of Pernicious Delay in Surgical Cases. He referred to the contrast between the local nature of many surgical troubles and the constitutional nature of medical diseases. It is very important to eradicate lesions before the local trouble becomes a constitutional trouble, as in chancres, cancers, etc. Pernicious delay has caused fatal results in fracture of the skull and in wound treatment. The thermometer is a surgical compass and will guide us in the work. Formerly in the treatment of gangrene it was the custom to wait until a line of demarcation had formed; now this is considered pernicious delay and an operation is done at once. Our advance in surgical technique has brought about a substitution of the certainty of exploratory incisions for the guess work of pre-aseptic times. There is too often pernicious delay in completing an operation. There is great danger of delay in operation on such cases as appendicitis, strangulated hernia, etc.

Dr. Edward M. Schaeffer then read a paper on Certain Sanitary Needs of our City and its Public Schools.

Dr. George A. Fleming read a paper entitled A Plea for the Sight of our Little Folks.

Dr. Edward M. Schaeffer was glad to hear papers on such educational value

and thought the subject of child life one that was less understood than any other department of medicine. Professor Stanley Hall had pointed out the fact that much too minute work is expected of children's muscles. It is unphysiological to teach writing, for example, before the larger muscles are developed and forces a premature activity of the brain centers. Certainly the eyes are no exception to this rule and much needlethreading or delicate pattern work in kindergarten methods is to be deprecated as injurious to the eyesight.

Dr. E. J. Bernstein then read a paper on Subconjunctival Infections in Profound Ocular Inflammation.

Dr. George Thomas read a paper on the Surgery of the Septum.

NIGHT SESSION.

The subject for General Discussion, Typhoid Fever in Country Districts, was then opened and occupied the whole evening. After the remarks of Drs. William Osler, Charles M. Ellis of Elkton, and James F. McShane (see page 55 and following),

Dr. C. Birnie of Taneytown said he could speak of this subject more especially for Carroll County, where he lived and practiced. In 1885 there was a general epidemic in that district and there had been two or three smaller ones later. The mortality had been about five per cent. It probably came from the water supply. The purification of

the water supply is a complex subject. It depends on the channels of water supply, the flow of the ground water, the trend of the rock, etc. He thought that these factors were as important if not more so than the mere presence of the germ. A sudden outbreak may occur from a thaw after a hard freeze, flushing all streams and wells. A similar condition may exist for years without an outbreak and then suddenly with no apparent change in the conditions a violent outbreak occurs. Such an outbreak is hard to explain. Bored wells in his opinion. are the safest. The general impression is that springs are the safest source of water supply in the country, but in his opinion they are the most dangerous

kind of water supply. The surface drainage and even that below the surface washes into the springs, which are usually at a low level and so often below the cesspool and privy pit. What is needed is sanitary laws properly enforced for country districts. As a rule the county health officer has no pay, little authority, and unless he has an unusual amount of tact he is always going against his fellow practitioners or his neighbors, and altogether he has a thankless task. In the country dependence must be put on the attending physician.

Dr. I. E. Atkinson thought we should bear in mind the great difference between hospital statistics and those in private practice. In hospital the very ill and the pronounced cases are seen, but outside some cases are so atypical that they do not come under the physician's care at all. The ambulatory cases of typhoid fever may never be recognized at all unless sudden death from bowel rupture reveals the true cause. When all these are properly diagnosed and taken into the account the mortality rates are much lower. The public is trained to deny the presence of the disease as affecting that neighborhood and may call it typho-malarial, gastric or bilious fever. If an untrained nurse fails in cleanliness she may carry or contract the disease. The ice supply is a source of typhoid when it is taken from a sheet of water from the watershed of an inhabited district. The milk supply causes the disease more often than is supposed because it is so hard to trace it. The dairyman may be honest in looking for the disease, as in series of cases which he had seen in an institution, but as most dairymen gathered milk from many farms it is almost impossible to trace the disease. The cesspools in Baltimore are a factor in the causation of this disease; the autumnal prevalence of it may be due to infection. at summer resorts.

Dr. George H. Rohé said that we should bear in mind that many cases of acute miliary tuberculosis were mistaken for typhoid fever and only the autopsy revealed the true state of affairs. thought that much harm was done in

He

using what was supposed to be a germicide when it was not. Many so-called germ destroyers came put up in beautiful bottles and with strong recommendations from men who liked to see their names in print. Such stuff was not only worthless, but it allowed infectious matter to be thrown out as inert. Too many of these so-called germicides were of no use. Hot water at a temperature of 160° to 170°, as Dr. Sternberg had shown, was an efficient and easily obtained germicide.

Dr. William H. Welch said it was difficult to trace the origin of typhoid fever, especially in a given case or group of cases. We are inclined to be too adherent to the exclusive source. It may come from water, from milk, the soil and even the dust. We have no proof of this, but it cannot be disproved. Even the theory of spontaneous origin cannot be disproved, but it cannot be proved. Rubner says that the typhoid bacillus may be considered with our present knowledge a saprophyte. All investigations lead to one point and that is thorough prophylaxis. Use good water, pure milk, disinfect the dejecta in doubtful cases and keep the surrroundings clean, and do all we can to improve the sanitary arrangements in all directions. The special problem is typhoid fever in country districts. There is a great reluctance to recognize the disease in places; perhaps it is due to local patriotism. It is an index of the sanitary condition of that district and it is considered a reproach to have the disease to any extent. We should have definite information of the number of cases in any district, not for curiosity, but for sanitary reasons. He heartily endorses Dr. Osler's remarks to stir up the physicians generally to learn more about this disease and take prompt action for the benefit of all to keep it away or to restrict it. A city should be protected beyond its boundaries. There should be co-operation between city, State and county boards of health. One reason why we are so backward is because we have no national board of health. disease does not respect artificial boundaries. The national need not inter

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fere with the State board of health, but only act as a co-ordinating agent. He agrees with Dr. Atkinson about central filtration. Self purification is a delusion and a snare. The detection of the bacillus is very difficult, that is in water; so difficult that it has no practical value. The typhoid bacillus lives in water from 6 to 8 to 20 days and in soil it lives indefinitely, three months at least. The incubation period is from 20 to 22 days. We should guard against contamination of the soil and should not be hasty to blame water or milk. The determination is difficult. Few houses will stand a thorough investigation without finding some sanitary flaw and, this found, the physician is satisfied when this may not be the cause and the real cause goes on unnoticed. Usually the physician is too easily satisfied. A thorough cleaning up on all sides reduces the chances of spreading the disease and removes the

cause.

Dr. B. B. Browne asked how it was possible to have such hot water as Dr. Rohé suggested always on hand, especially in the country.

Dr. Rohé said it was very simple to heat water anywhere and even if it was boiling, by the time it was mixed with the typhoid dejecta it would be about at the right temperature and should stand for an hour or more.

Dr. James A. Steuart deplored the absence of vital statistics in Maryland. He had sent out a large number of cards to physicians throughout the State asking questions and a return card addressed was enclosed and the questions required short answers, and yet he received but few answers. The trouble was the great apathy of the physicians of the State.

Dr. Thomas S. Latimer said that if the doctrine of spontaneous origin were true then there would be a general unsanitary condition. The great difficulty in the way of boards of health was defective legislation. Every physician should carefully disinfect the stools at the time they are passed. This would be little trouble and this plan would be simple.

Dr. John R. Uhler said that the disease was spread by the large amounts of

manure that was spread over the watersheds that supplied Baltimore with drinking water. The use of service reservoirs for boating and skating where the ladies' dresses swept the ice could affect the drinking water.

Dr. William Osler, in closing the discussion, said he thought that he was voicing the sentiment of the Society when he moved that the authorities of the cities and counties throughout the State be urged to adopt means for the compulsory notification of cases of typhoid fever in their respective boards of health. This was carried unanimously.

WEDNESDAY, APRIL 24, SECOND DAY.

Dr. Julius Friedenwald read a paper entitled The Quantitative Determination of the Rennet Zymogen; its Diagnostic Value in Certain Diseases of the Stomach.

Dr. Charles O'Donovan related A Case of Syphilitic Endocarditis causing Mitral Insufficiency.

Dr. Simon Flexner then reported A Case of Peritonitis Caused by the Invasion of the Micrococcus Lanceolatus from the Intestines. This was discussed by Dr. P. C. Williams, who related his own experience when he had peritonitis.

Dr. John W. Chambers then reported some Notes on Sarcoma with Cases.

Dr. L. McLane Tiffany then spoke of Bullet Wounds of the Liver and Stomach with Closure by Tampon. His case was a German, male, aged 37, who received a pistol wound in the abdomen. The ball was fired at short range. The wound was to the right of the median line, two inches below the xiphoid cartilage. There was a stellate wound in the liver and two in the stomach. He cleaned off the parts, stopped the hemorrhage, sewed up the wounds in the stomach. There were no bad symptoms. He gave the man a purge and the bullet passed by the rectum. He put a tampon over the liver wound and this he took off on the seventh day. There was some phlebitis, from which he recovered. The man at the time of the report was doing well. Immediate treatment was important. It is not so hard to see to operate in the lower abdomen where the con