is generally used in cities contains as many million bacteria per cubic centi meter. Physicians and sanitarians have long recognized the necessity for the introduction of systematic inspection of milk and other dairy products. Unfortunately, this necessity has been met in too few localities. The Philadelphia Pediatric Society has appointed a committee, consisting of a bacteriologist, veterinarian and physician, whose duty it is to note all the conditions which affect the milk traffic of that city. Certificates are issued to the different dairies when their products are up to the standard fixed by the society. In New York a somewhat similar restriction is placed upon the milk traffic. These methods cannot be commended too highly for universal adoption. The remarkable strides made in the preparation of palatable and digestible foods, placing the art of cooking on a scientific basis, has been one of the characteristics of nineteenth century progress. There is still a great need for the advance of this work, especially among the poor classes. The establishment of cooking schools and the relation existing between pure food and health are signs that indicate better things. The chemistry of food is an important branch of science and should be understood by the housewife. article of food has been subjected to adulteration by unscrupulous merchants. The addition of water to milk has been one of the most universal instances of this practice. It has, without doubt, been the cause of thousands of deaths from typhoid fever and other water-born diseases. The results achieved by health officers in Chicago, Buffalo and Washington, in the reduction of infantile mortality one-half is convincing proof of the efficacy of food legislation. The question of food is indissolubly linked with that of exercise; especially is this true in the later years of life. In childhood the system readily accustoms itself to the demands made upon it, but later on there is not such adaptability. Neglect of exercise brings on certain results. At the same time another unfortunate thing happens in that this same person who neglects to take the proper amount of exercise eats too heartily. This practice is more. prevalent in the cities, and more common among the well-to-do than among the poorer classes. The former contract sedentary habits, confining themselves to their offices during the day, taking a very small amount of exercise and living upon the richest kind of food. The result of such habits soon becomes evident. A mild sort of intoxication is set up and metabolism is disturbed. Excretory organs fail to Already a great degree of perfection perform their functions. The kidneys, has been attained in the manufacture of foods similar to mother's milk in their constituency, which may properly be used when, for any reason, suspension of breast feeding is desired. The first movement toward securing legislation against the adulteration of foods was made in 1879. National legislation is necessary in order to effect the greatest good. Almost every liver and circulatory organs become. impaired and inactive, and there results a storing up in the system of poisons. which effect a slow disintegration of the tissues. School Hygiene and Sanitation. Statistics show that there are over fifteen million children enrolled in the common schools of the United States. Important as its existence is, nevertheless it was not until forty years ago that modern school hygiene and sanitation had its birth. Since then there has been considerable attention paid to the environments which are a part of school life. School buildings are built with regard to sanitary laws. Cleanliaess is more rigidly observed. Sewage drainage is more thorough. Drinking water facilities are much improved, and altogether the general conditions are more favorable to hygienic living. Not wishing to under estimate the great importance which should be attached to those conditions which underlie and to which are due many nervous and chronic affections, it is, nevertheless, to infectious diseases that we owe our most concern. When it is considered that children up to the age of six or seven years are allowed to run and play and are sub ject to no restraints, and at this time without a period of transition they are. plunged into a life with new environments, being obliged to remain in a sometimes unsanitary school room, it is not to be wondered at that there exist these so-called school diseases. Statistics show that there is a decided increase in infectious diseases during the school year. This is due, unquestionably, to the mingling together of children from many localities, thus establishing many routes and possibilities for infection. In the school room there is a continual interchange of slates, pencils and books. In kindergartens their caresses bring them in close contact with each other. In both instances these habits invite infection. Children are more susceptible to infectious diseases than adults, and these habits are sufficient to prepare a means of communication. ex uary, 1896, 16,790 children were amined in the schools of Boston. Of this number, 6,053 were found to be not well; 10,000 ill, and 2,041 sick enough to be sent home. Of the number examined, 453 had contagious diseases; that number were sitting alongside of well ones, thus exposing them. When a number of sick children are allowed to remain in school it is obvious that the number of exposures will be very great. In 1899, in this same city, there were 468 specific infectious disease cases; oral and respiratory, 2,738; ear, 144; eye, 434; skin, 3.252, and miscellaneous 10,413, making a total of 17,499. Most of these were in a condition to communicate the disease. From a consideration of this subject and the facts which are involved, it becomes plain that there is a need of an organized corps of inspectors to afford an adequate school supervision. The duty of the school inspectors should be to visit schools, examine pupils and give such directions as will reduce the danger of spreading contagious diseases to a minimum. They should also make regular inspections of the school buildings and recommend any measures which they might deem advisable for the well-being of the pupils and teachers. Such measures are in vogue in many of the large cities, and are proved to be very effective. Tuberculosis: a Preventable Disease. When Robert Koch pointed out that the tubercle bacillus was the etiological. factor in tuberculosis, it no longer could be regarded as a stigmata of social depression and as an inevitable evil, but immediately became known as a preventable disease. The recent discussion regarding the communicability of bovine tuberculosis For fourteen months, ending in Jan- by means of infected meats and milk was not productive of definite results. While it is generally conceded that cattle and their products should still continue to receive inspection at the hands of authorities, it is nevertheless agreed that human infection from this source is comparatively small. The question involves most decidedly infection from man to man, and consequently has a wide social aspect as well as a medical one. The crowding together of the poor in cities; the unhygienic surroundings; the use of unwholesome food and deficient clothing, are factors upon which the latency and spread of tuberculosis depend. Persistent and powerful efforts are needed to correct this state of affairs. Legal action, in connection with the education of the masses, regarding the nature of this disease, will do much to limit its ravages. Whatever is done to accomplish the best results must be secured by means of systematic and rigid efforts at the hands of enthusiastic and capable workers. The desirability of sanitary life, especially as it exists in a number of the larger sanitariums, is questionable. Here, often, tuberculous patients are found huddled together in rooms in which the walls, curtains and furniture have not been disinfected since the removal of the last patients. Then, too, there is a disastrous intermingling of towels, linen and clothing. A social communication exists between the sick and the well. The natives in these parts where tuberculous patients are. brought together suffer infection through the same means. Influenza often becomes rampant and furnishes a means of communication of infection through the instrumentality of towels. and other effects of the sick. In the general hospitals a somewhat similar condition prevails, wherein the rooms occupied by persons suffering from the disease are insufficiently disinfected, and the fact that they have been occupied by patients suffering from tuberculosis is guarded as a professional secret. A complaint which is generally laid at the door of these institutions is that they habitually underfeed tubercular patients; also that they refuse to admit patients in the last stages of the disease, and persist in sending them to their homes when they become hopeless, with the statement that their death in the hospital seriously affects the welfare of other patients. while in truth these things are practiced to keep down the mortality records. Of course, if these institutions were in the hands of the state, these objections might be eliminated. Efforts directed toward the prevention of tuberculosis should aim to correct the various predispositions, those depending upon heredity as well as those which originate post natal. The part legislation can finally play in the demand of a physical and mental standard to be obtained by those contracting matrimony is an unsettled question. In this regard the United States is advanced beyond the other nations. Already the state of Michigan requires that all lunatics, epileptics and criminals three times convicted shall be castrated before leaving the hospital. And in other states (Indiana, etc.), tuberculous individuals are forbidden to marry. What class shall we include when we decide to take legal steps in the way of the prevention of this disease? If at every numbness of the apices, with stertorous or bronchial breathing, or expectoration of tubercle bacilli, a teacher or clerk is deemed a dangerous associate and isolation enforced, then there would be crowded sanitariums and families deprived of bread-winners. It must be readily conceded that the vital factor in this question of tubercular infection concerns not so much the fact of the presence of the Koch cells as it does the readiness with which they find a nidus favorable to their growth and multiplication. Hence it becomes. apparent why we should attempt to strengthen the individual resistance by means of an untainted heredity and strict post natal hygienic influences, the former calling for more rigid rules. governing matrimony, and the latter attention to food, clothing, sanitation and exercise. In order to obviate the difficulty presented in the over-crowded dwellings, it will be necessary both for the wellbeing of the patient and the public at large to remove the tubercular patient to a suitable hospital. Whether this is to be done by compulsion or by whatsoever means remains a question. As the general hospitals at present feel a reluctance in accepting a tubercular patient well advanced in the disease, it is very probable that state and municipal authorities only can provide. means for the establishment of suitable retreats. But until this is brought about very much can be done by the establishment of special wards in the existing hospitals, where the tubercular patients could be housed with a minimum amount of danger to the other inmates and with a great good to themselves. Pecuniary facilities might be introduced, and in this way the patients might be induced to remain for a longer period in such institutions. The great effect of such a project would be the obvious diminution of infection and consequently a reduction in the sum total of tuberculosis could not fail to be secured. The execution of these plans provides a wide field for the action of philanthropists, state and municipal authorities, and. is a certain way to successfully combat a disease. that is responsible for one-fifth the mortality in the human family. At present there is no single measure alone adapted to combat tuberculosis. It is the union of the several hereafter referred to that can produce a successful issue. Among the measures necessary for a well understanding of the nature and progress of the disease, obligatory notification is especially valuable. It is the only sure means of keeping in touch with the state of dissemination and the increase or decrease of the disease. It will point out a way for help, a place for instruction and material for disinfection. It would, of course, be unnecessary to notify all cases of tuberculosis, but only those which owing to domestic conditions, are elements of danger to the people about them. Norway has such an instance of limited notification, instituted by special law. In Saxony, the condition prevails by order of a religious decree. In New York, and in several American towns which have followed its example, a similar practice is in Vogue. Stress can not too often be laid upon the importance of thorough disinfection in connection with tubercular cases. Besides strict, thorough disinfection of sputum and the bodily excreta, the dwellings, beds and clothing should come in for their full quota of attention. (Continued Next Issue.) Hoped He Might Improve. Husband (vituperatively)-I was an idiot when I married you, Mary. Wife (quietly)-Yes, Tim. I knew you were. But what could I do? You seemed my only chance, and I thought then that you might improve a little with time.— Washington Times. Medical Miscellany Hamline University Clinic. St. Mary's Hospital, Nov. 28.-A case of gonorrhea arthritis, patient 25 years old. The left knee was swollen; inflammation lasting five months, with the result of anchylosis. The knee was bent at an angle of 160 degrees. The patient was anasthetized and the adhesion partially broken up by A forcible flexion followed by extension. posterior splint was applied to further extension of knee after treatment consisted of ice bags for twenty-four hours, followed by passive motion. Another similar operation was performed later. The patient is now about with a moveable knee joint. L. LIMA. St. Mary's Hospital, Nov. 28th. SYMPOSIUM ON TYPHOID FEVER. Hemorrhage. Dr. R. G. Curtin read a paper entitled "Hemorrhage in Typhoid Fever." The etiology is hard to explain. He thinks that the more profound the toxemia and the greater the blood changes the deeper will be the sloughing. He had never seen hemorrhage in a patient under 6 years; it is rare in children and when it occurs is rarely fatal. It should be remembered that a patient may die without external signs of hemorrhage. The amount of blood loss may be estimated by the fall of temperature and depression. Those with most severe symptoms sometimes recover. The associated conditions most serious are renal disease, organic heart disease, hemophilia, tympanitice condition of the abdomen, obstinate diarrhea and vomiting. Treatment is believed to be usually more or less valuable. Following are some of the remedies advised: Ergot, turpentine externally and internally; oil of erigeron when the stomach will bear; mineral and vegetable astringents; ice externally and in the bowel, employed continuously; suprarenal extract the author has used with good effect; elevation of the foot of the bed; ligatures about the limbs. The speaker, in 1893, reported 17 cases with a mortality of 5. More recently he reported a series of 43 cases with a mortality of 23. The recent increase in mortality is ascribed to the cold water treatment. It is believed that the number of cases has also been increased. The effect of the sudden chilling is believed to congest the internal organs and thus increase the liability to hemorrhage. The speaker cited several cases in which he believed the cold bath or sponge to have been the immediate cause of hemorrhage. Pain in Typhoid. Pain Dr. H. B. Allyn presented a paper: "Significance of Pain in Typhoid Fever." was classified as extra-abdominal, due to hyperesthesia and hysteria, and as abdominal, due to intestinal colic, entero-colitis, chloecystitis and peritonitis either with or without perforation. The speaker dwelt on cholecystitis as a common complication, and believes that recrudescences often ascribed to indigestible food are really not infrequently due to this complication. Clinical cases were cited. Pain indicating perforation of the bowel is most serious. Tenderness and muscular rigidity are usual symptoms of this condition, but pain, often in the right lower quadrant of the abdomen, is the only constant symptom. Confidence was expressed in the value of the frequent skilful blood-counts regarding leucocytosis, especially as helping to diagnose complications. Pain and tenderness are not necessary accompaniments of typhoid fever, but should be regarded as danger signals. Operation in Typhoid Perforation. Dr. R. G. Le Conte advocated prompt operation following diagnosis of perforation. The peritonitis of typhoid perforation is much more rapid and widespread than that of appendicular perforation. Fatal result from operation may usually be attributed to one of two causes, namely, delay in operating, or surgical errors of judgment or technic. To prevent delay in operation, three things are essential; first, Osler's advice must be followed and all our past cases of perforation carefully studied, that light may be thrown on the early diagnosis of this condition; second, in a hospital, consent for operation should habitually be obtained for |