ures had been carried out. Only .14 per cent of those who were similarly away from home during the period since compulsory disinfection was abandoned, contracted the disease. With regard to scarlet fever during the six years previous to 1909, the rate of recurrence with terminal disinfection, was 1.48 per cent, while in the four years which followed its abandonment the rate of recurrence was 1.61 per cent. The health officer of Providence during this period was Dr. C. C. Chapin, and it is thought that these results may mean a great saving in municipal funds. Anderson and Goldberger have shown that infectivity of measles depends upon the particles of tissue thrown off during sneezing and coughing and not upon general desquamation. Such discharges dry rapidly and drying favors loss of virulence, hence safeguards should be provided during the incipient stage of measles, rather than by terminal disinfection.

Disinfection after a communicable disease is of diminished importance if quarantine and isolation have been enforced during the course of the disease. The danger from carriers is therefore greater than from fomites. Personal contact with communicable disease should be diminished. Personal hygiene with disinfection of the nose and throat is more rational than house disinfection as at present carried out. Still we hope there are not many health officers who are as courageous as the one in Providence and who will take the chances which he seems to have taken. We are not convinced by his figures. Perhaps he will also tell us that rooms in tenement houses which have been occupied by the tuberculous are also innocuous and do not require disinfec

tion.

Effect of Present Prevention on the Spread of Consumption.1- Mays thinks that inasmuch as very active measures for the eradication of pulmonary consumption have been in force for ten or fifteen years we ought to begin to see some positive results in the diminished number of cases.

We must not forget, however, that improved sanitary measures alone, resulting from wise legislation have been a potent factor in reducing the death rate from 1Medical Record, November 30, 1912.

this disease, irrespective of any specific preventive measures. The rational means of preventing consumption consist practically in inculcation of the fundamental principles of hygiene. Such principles will include the use of wholesome and properly prepared food, avoidance of damp, il ventilated, overcrowded dwellings, suitable clothing, and personal and domestic cleanliness. They will include furthermore the avoidance of overwork and strain. Trades, agricultural and mechanical occupations should be taught to boys and domestic economy, cooking, sewing and the proper care of a home should be taught to girls.

The hygiene of the home, workshop and factory includes ventilation, temperature and general cleanliness, and all these things must be carefully inculcated. Care must

be taken when there are colds and coughs which are apparently trivial, and accidents and all other physical mishaps must receive efficient medical attention, nursing and medication.

Insurance against sickness and accident is recommended and a sufficient number of sanitary tenement houses should be erected for the poor, the profits from which should be applied to the erection of other buildings of a similar nature.

Elimination.1- The editor mentions the different organs of elimination and their way of performing their function.

In respiration he states that the explanation of the current movement of CO2 and O is found in the difference in their volume and pressure. They form true chemical compounds when their pressure is high and the compounds are broken up when the pressure is lowered. The O and CO, being in loose combination with hemoglobin are easily affected by the carrying pressure to which the blood is subjected. The pressure CO, in the blood in the lungs is higher than in the air sacs and it is therefore forced into the air sacs, while in the body the pressure of CO, in the tissues is higher than in the blood and hence it is forced into the blood vessels.

The daily elimination work of the kidneys is of water 50 ounces, urea 500 grains, and uric acid 7 grains.

1 American Practitioner, December, 1912.

The quantity of water is in direct relation with the pressure of the blood in the renal arteries and the glomeruli.

The epithelium also exerts positive and negative influence, positive in secreting some of the salts of the urine, and negative in preventing the serum albumin of the blood from passing through. Urea is formed through metabolism of the tissues, an adult man secreting enough of this material in two days to cause death from uremia.

Secretion of sweat is not only filtration but is dependent on the action of nerves on the gland cells. It supplements the kidneys and carries off medicines and poisonous vapors.

Feces contain deleterious substances formed within the body in addition to undigested food substances. Menstruation eliminates useless blood, the unusued ovum, epithelium and mucus from uterine glands and prepares the way for new blood, a fresh ovum, and a new endometrium. The lochial discharge consists of clots, membrane and dead epithelium. The eliminants are the expectorants, diuretics, diaphoretics, and purgatives. Examples of the first are ammonium chloride, apomorphine and creasote. Diuretics are caffein, digitalis and squill. Pilocarpin is the most important of the diaphoretics. Calomel, cascara, castor oil, senna and the hydragogins are wellknown purgatives.

Elimination may also be effected by massage, hot air, and hot baths.

TREATMENT.

The Friedmann Treatment of Tuberculosis.' -This matter was discussed at a meeting of the Berlin Medical Society. Hr. Friedmann on the occasion added somewhat to his previous pronouncement. He repeated that he had not said what his curative material consisted in. Whether he will act up to the traditions of the noblest of professions, or as a quack-keep his secret and sell it to the highest bidder, and so make a fortune for himself out of it, still remains to be seen. "I have thoroughly tested many and many a kind of avirulent cultures, also such as were obtained from the human subject, that had been rendered avirulent by various methods, but I have quite given them up."

In fact, he had made use of the most varied nonvirulent kinds-those from warm-blooded 'Med. Press and Circular, Dec. 18, 1912.

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animals that had been made avirulent, others from the most diverse cold-blooded ones. In 1903 he had published results of investigations into tortoise tubercle. In 1904 he made a further communication on a second tortoise strain. If the first strain was only slightly virulent, it set up nodules in the guinea-pig that never led to tuberculosis; still the nodules could be felt year after year. A third strain was discovered, a natural one that showed avirulence in a high degree, and concerning this he had never published anything. Even in its natural state it was perfectly harmless for guinea-pigs, it caused scarcely any nodules, and in a short time it lost the last trace of virulence. He then used the preparation more extensively, and on the human subject. His preparation was, therefore, perfectly harmless for guinea-pigs. Animals that had been injected two and three years were perfectly sound and free from nodules. He might also state that he had experimented with other cold-blooded animals, fish, salamanders, blind worms, snakes, also with other tortoises, but, without exception, with results that were not good.

Hr. Erich Müller said they had just heard from Hr. Friedmann that his form of bacillus was not from the human subject or from cattle, but from some cold-blooded animal, the bacilli from which were quite avirulent for man. The recoveries he had seen were such as were not possible by any other known means. He believed also that children injected would be safe from infection. A child shown by Friedmann was very remarkable. Like many similar cases, it showed the harmlessness of the injection, and spoke strongly in favor of the protecting power of the preparation in that in the midst of a tuberculous milieu it had remained free from the infection. The protective inoculation had been then made about a year. For the future the immediate future, at any ratethey would limit their injections to children that were ill.

Hr. Kausch would ask them to restrain their enthusiasm for the present, and bear in mind Koch's first pronouncement and salvarsan in syphilis.

Hr. Piorskowski related some details of the work he had done for and with Friedmann, and concluded that the culture, some of which he had brought with him to show, looked exactly like human tubercle, and behaved exactly like it in the incubation oven. For that reason he believed that the tubercle from the great tortoise of the Berlin aquarium was of human origin, and was to be reckoned as of the typus humanus.

Hr. Aronsohn would like to know the dose given by Friedmann-i. e., the number of bacilli he injected. He could only understand by the simultaneous method that a smaller dose than usual was given in each, and that the absence of abscess formation was due to the smaller quantity injected.

Hr. Wolff-Eisner said that no proof had been brought forward that the injections were harmless. In that short time it was impossible to say that they were harmless. It was also pos

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sible that some of the cases recorded as cured were not really cases of active tuberculosis.

Hr. F. Meyer would like to know whether Friedmann had submitted his cases of cure to the tuberculin test. The cases that had been shown would have got better by tuberculin treatment. He could not take it that Friedmann had said that they were cured. He would raise an energetic protest against protective injections, both on ethical and scientific grounds. Hr. Bier had seen a number of Friedmann's cases. He must confess that he had received the impression that there was a decided curative action, but he had not so far seen any decisive proof.

Hr. Schwenk said that he could not altogether agree with what Friedmann had said. There was one case which his colleague (Hr. Friedmann) had described as cured. He (Hr. Schwenk) had seen the case the day before. There was no question whatever of a cure, nor even of improvement. The patient was sent to Friedmann in 1911. She had about six injections. In August of last year she was again under treatment, and had two injections. She reacted with a universal urticaria, which lasted for several days. She was no better.

Hr. Katzenstein said that in surgical cases of moderate degree we had in tuberculin such an excellent remedy that we had no occasion to have recourse to an unknown remedy.

The Technique of the Operation for Lacerated Cervix.-The desirability of repairing cervical lacerations as a prophylactic measure against cancer needs no comment. As it is an operation every practicing physician may be called upon to perform the following description of the technique is exceedingly interesting:

An anesthetist and one assistant are necessary; two assistants are better. Lithotomy position. If two assistants besides anesthetist, no leg-holders for patient need be used; if one assistant, use leg-holders. Chief assistant is on operator's right, holding patient's left thigh.

Instruments: Two tenacula, one double tenaculum, uterine sound, uterine curette, Wylie uterine dilator, irrigating bag, tube and nozzle with control, bistoury with narrow blade, long-handled uterine scissors curved on the flat; medium sized, full curved, stout needles; needle holder, silk worm gut (a double carrying thread of linen a foot long, should be fitted to each needle), one dozen hemostatic forceps.

1. By means of the tenacula seize the lips of the cervix, and by folding together, try to reconstruct the cervix as it was before laceration. Find the situation of the uterine canal with the sound and by observing the arbor vitæ of the cervical mucous membrane.

2. Fix the double tenaculum in the center of the anterior lip, i. e., in the mucous membrane of the canal-and hand it to the assistant to hold.

1W. L. Burrage, M. D., Boston, Mass., Med. Council, Nov., 1912.

3. Pass the blades of the dilators into the uterine cavity. If it is very tight, Hank's dilators must be passed before the blades of the Wylie dilator will pass. Dilate gradually, occupying at least ten minutes. Stretch the tissues and wait for the uterine muscle to become tired; then stretch a little more.

4. Curette the uterine cavity, remembering that it is a flattened isosceles triangle in shape, and that it has only anterior and posterior walls. Go over both walls and the regions of the uterine horns. Rinse out uterine cavity with irrigating tube. If there is much oozing, use very hot water in irrigating bag.

5. Mark out with scalpel the lines of incisions to be made in both lips of cervix, leaving along the line of the arbor vitæ a strip of mucous membrane one centimeter wide, with which to line the canal of the cervix.

6. Seize the tip of one strip of tissue to be removed on the crown of the posterior lip with a tenaculum, and cut out the tissue up to the angle between the anterior and posterior lips with the uterine scissors. Repeat with the anterior strip.

7. Cut out a wedge-shaped piece of hard tissue in each angle after seizing it with the tenaculum. Irrigate. (Excessive oozing may be checked by seizing the bleeding point with a hemostatic forceps, or by passing and tying a suture).

8. Take needle in needle forceps, steady cervix by burying tenaculum in denuded surface, and pass needle from outside into mucous membrane of canal, well above angle in vagina, on right side until its point emerges just in edge of mucous membrane of anterior lip in the canal. Seize and pull through. Re-insert in the canal in lower edge of mucous membrane of lower lip, and pass through tissues of cervix until it comes out in a corresponding spot above and posterior to the angle of vagina. This stitch should be passed deeply so as to include space left by the removal of the wedge of tissue.

9. Put strand of worm-gut in loop of carrying thread, and pull through; make both ends even; catch in a hemostatic forceps; lock forceps, and hand to assistant to hold.

10. Repeat procedure, placing stitches about one centimeter apart until the crown of the cervix is reached.

11. Do the same on left side, placing both ends of each strand of worm-gut in a separate pair of hemostatic forceps as soon as placed. From three to five sutures, depending on the length of the lacerations, are generally needed on each side in the case of bilateral tears.

12. Separate both lips by tenacula and irrigate among the sutures.

13. Separate the topmost suture in the left side from the others by means of a tenaculum. Hand all the rest of the forceps holding sutures to the assistant to hold. Take off forceps from topmost suture, and bring lips of wound together and tie suture, not too tightly. Reapply forceps and hand to assistant.

14. Repeat with remaining sutures on left side, working from above towards crown of cervix.

The Treatment of Acute Suppurative Tenosynovitis of the Finger.-Kanavel, in discussing the treatment of acute tenosynovitis of the finger states that very commonly, when a finger is infected, it is some days before the tendon sheath becomes involved; again, it may be early, and when it is invaded the symptoms develop rapidly because, as was mentioned above, there is so little resistance that the infection spreads throughout the sheath in a short time. However, during the preliminary stage, much may be done to prevent a spread into the sheath. The best sort of application is undoubtedly some form of moist, hot dressing. Boric acid solution in saturated strength is most commonly used, but any of the other solutions in common use are probably just as efficient. Carbolic acid dressing in any form should be avoided because of the danger of gangrene. Local painting with ichthyol. iodine, and such irritating solutions is absolutely useless. German surgeons speak highly of 95 per cent. alcohol dressings left on twentyfour hours. They probably are no more efficient than the hot boric solution, and are always a source of some anxiety, owing to the possible danger of their catching fire, as the author has personal knowledge of in one case. Probably the next most essential procedure is to keep the part at rest; this, of course, is indicated in any infection, since the muscular action tends to disseminate the germs, thus extending the area to be walled off by the leukocytes carried in by the dilatation of the vessels incident to the hot dressings. Elevation of the part is recommended by many, but personally I could never see any advantage in it except to make the arm comfortable, and it is true the elevation of the hand is sometimes necessary for this. If the infection is severe, put the patient in bed. An ice bag in the axilla may help some. Keep the bowels open and the kidneys active. Preserve the nutrition of the patient. The methods of Bier and Klapp are discussed above.

Indicanuria.-The cure for indicanuria, says Morgan, must come through measures preventing the formation of toxins and the elimination of those already formed. In the treatment it is necessary first to eliminate if possible the primary cause of the excessive putrefaction and to prescribe treatment for any disorder of the gastro-intestinal canal whether causative or associated with the production of indican. Fur

'From Infections of the Hand, published by Lea and Febiger, Phila.

"Wm. Gerry Morgan, M. D., Am. Jour. of Med. Sciences, Nov., 1912.

ther consideration will not be paid to this, as it includes the treatment of nearly all of the gastro-intestinal disorders. In a not inconsiderable number of the cases the excessive production of indican ceased without direct measures being instituted for its treatment when the mental strain was removed; other cases have taxed our ability to the utmost before they have responded to treatment.

Measures directed toward the putrefaction and indicanuria itself consist of general hygienic directions, diet, exercise, irrigation, and occasional medication. Purgatives not only do not cause a diminution of the indican, but may even be followed by increased excretion. Irrigations are nearly always found necessary when direct treatment for the indicanuria is needed. Different solutions have been used to meet varying conditions in my series. Salt solution, soda, argyrol, and ichthyol have all given admirable results. Ichthyol solutions often seem effective when others have failed.

In arranging the diet we have greatly reduced the proteid food, thereby removing much of the material available for the putrefaction. Frequent changes in diet have been tried, with the idea of producing unfavorable conditions for the growth of the putrefactive bacteria. Although buttermilk has been given to many, the writer's experience with it, and the artificial preparations of the lactic acid bacilli has not been such as to cause any reliance to be placed in these preparations per se.

No one point has been found to be of more importance in those many cases where overwork is a factor than a restoration of nerve tone, as by a vacation spent under ideal conditions in the mountains. Morgan states that some of his patients have indicanuria which recurs with some degree of regularity in the spring, and disappears after a thorough bodily and mental rest.

HYGIENE AND DIETETICS.

Modified Cow's Milk as a Substitute Food in Infant Feeding. The author emphasizes the necessity of using pure cow's milk, not milk that has been pasteurized or sterilized, but fresh, wholesome milk from a healthy herd. It is a recognized fact that the milk offered for sale in the large cities is not as pure as it should be, but under the active work of the Boards of Health and the medical profession, it is rapidly improving in quality. When procurable, certified milk should always be used. Dr. Fitch points out the fact that the modification of cow's milk with a cereal is a mechan ical one due to the gelatinized starch, which changes the hard curdling cow's milk into a soft curdling milk like human milk. The casein of cow's milk clots in hard lumpy masses in the infant stomach, the digestive enzymes cannot get at it, and any means whereby we can break up the clot and make it more floccu'Dr. E. W. Fitch, Pediatrics, Oct., 1912.