caused 105,971 deaths; diarrheal diseases 46,907; typhoid fever 35,379; cholera infantum 25,576; influenza 16,645; diphtheria 16,475; croup 12,249; malarial fever 14,874; measles 12,866; whooping cough 9,958; septicemia 6,776; scarlet fever 6,333; cerebo-spinal meningitis 4,174. In order to appreciate the full significance of these figures we must consider not only the mortality, but also the number of cases treated. So, for example, the 35,379 deaths from typhoid fever in one year represent an annual prevalence of not less than 353,790 cases. The duration of a case of typhoid fever is not less than 30 days. If we calculate the average cost for care, treatment and loss of work to be $300, and the average value of a human life at $5,000, we have a total loss of $283,032,000 per annum from one of the so-called preventable diseases.

We know that many of these diseases are preventable, and can, at least, be checked, if not entirely stamped out. The decrease in the death rate from consumption, in the United States, since 1890, amounts to 54.9 per 100,000 of population. Diphtheria and croup, 52.5; cholera infantum, 31.9; diarrheal diseases, 19; typhoid fever, 12.5; malarial fever, 10.4; whooping cough, 3.1; scarlet fever, 2.7. Indeed, the average age at death in 1890 in the United States was 31.1; in 1900 it was 35.2 years.

"IF CERTAIN DISEASES ARE PREVENTABLE, WHY ARE THEY NOT

PREVENTED?"

This very pertinent question was asked some years ago by the Prince of Wales, now King Edward of England. Our answer is, while every scientific physician knows full well that if the methods of prevention recommended by sanatarians—including the prompt disinfection of the dejecta of typhoid fever patients, the expectoration and excretions of diphtheria, tuberculosis and pneumonia patients-were adopted, these diseases would be reduced to a minimum, and probably eradicated in the course of a few years. The facts are, these recommendations have not been generally adopted because the knowledge gained by experimental medicine is not sufficiently diffused. Nor is the medical profession responsible for the fact that so many States still permit every charlatan to practice one of the most difficult and responsible of all professions, without a rigid system of examination. So long as we recognize and employ irregular and incompetent practitioners, so long will infectious diseases be spread as the result of ignorance and neglect.

The public should be made familiar with the nature and causes of infectious diseases, and be taught that many are a source of darger against which it is entitled to be warned. The Health Department should have competent medical inspectors and a clinical laboratory for the

verification of the diagnosis. It should have the power, in certain of these diseases, to display warning signs, to enforce isolation and disinfection, and to take such other steps in the way of prevention as may be deemed necessary to limit their spread.

Isolation to be effective should extend to all persons who have come in intimate contact with the patient. This is rarely enforced, except in smallpox, in the case of the wage-earners of the family, but it is clearly their duty to take special precautions in the way of clothing and personal disinfection.

Since our knowledge of the nature of infectious diseases has been more and more defined, scientific methods for their prevention have been applied. We have learned, too, that in addition to the germ there must be a suitable soil for its proliferation and that sanitation should not only destroy the environment for its development without the body, but also place the system in the best possible condition to resist its poisonous. action. In the way of individual efforts, all measures which will improve the tone, nutrition and vital powers of the system, many of which have been alluded to in the preceding pages, can not fail to render us less susceptible to infection. Nor should we underrate the importance of preventive inoculations, for it must be remembered that smallpox, for example, would continue to carry off one tenth of the population and disfigure another tenth if it were not for the protective influence of vaccination.

The diseases which deserve special preventive efforts on account of their undue prevalence are consumption, pneumonia, scarlet fever, diphtheria, typhoid fever, diarrhea and dysentery. During the prevalence of the last three diseases, and especially when the water is regarded with suspicion, the safest plan is to boil the drinking water and bring the milk to the boiling point. While the general rules of hygiene are necessary at all times, they are especially indicated during the prevalence of epidemics. A simple life, hope and courage, avoidance of excesses, of overwork, fear and anxiety will serve to maintain a natural power of resistance to infection.

If in spite of all precautions, including, of course, avoidance of sources of infection, contagious diseases should gain a foothold in the family, the advisability of hospital treatment ought to be seriously considered. The advantages from every point of view are in favor of such a course, especially when we consider the danger of infection to other members. of the family.

SICK ROOM, CARE AND DISINFECTION.

If the patient is treated at home, a bright, quiet and cheerful room. should be chosen, and promptly stripped of carpets and unnecessary furniture. It is in just such instances, when the importance of simple furniture, oiled or waxed floors, avoidance of draperies, dust and germ traps gain special significance. It is needless to insist that the room must be kept properly ventilated.

In the light of our knowledge it is certainly our duty to tell the family, in typhoid cases, that the infectious matter is contained in the excreta, and must be destroyed for the protection of others. In like manner we should not hesitate to inform a consumptive and his friends that the germs of the disease are contained in the expectorations; how they may be conveyed to others in coughing, kissing and dried sputum, and how they should be destroyed. And so we might go through the list of infectious diseases.

Scientific disinfection had its inception with the labors of Koch and Sternberg in 1880. Although certain physical and chemical agents were used empirically for ages, now we know, from laboratory experiments, that they are effective, because they destroy the vitality of the germs. We also know that in most of the contagious diseases the infective matter is given off by the patient chiefly through the secretions and excretions, and it is evident that disinfection to be of value must be directed to these and all the media with which the patient has come in contact.

A small gas stove near the sick room, and a four-gallon wash-boiler in which napkins, soiled linen, or clothing can be boiled, and thus disinfected before being laundered, will protect other inmates. The use of separate eating and drinking utensils, which can be boiled in a weak soda solution, is also a necessary precaution.

The refuse of meals should be placed in a covered vessel containing a disinfectant solution: 11⁄2 tablespoonful of lysol to 1 quart of water. A similar solution may be used to wipe the floor, furniture and door knobs. Clinical thermometers, tongue depressors and other instruments should be kept in a disinfectant solution and rinsed off in warm water before using.

The stools, vomited matter, expectorations, urine, blood and pus of infectious patients, especially those suffering from typhoid fever, dysentery, cholera, tuberculosis, pneumonia, influenza, diphtheria and scarlet fever should be placed in a covered vessel containing the germicidal solution to be hereafter described, the whole to be thoroughly mixed and allowed to stand for one hour before throwing the contents into water closets or privy vaults. Disinfection is also indicated in diseases

like typhus fever, cerebro-spinal meningitis, smallpox, anthrax, glanders and yellow fever; in the latter disease chiefly for the destruction of mosquitoes. It would also be well to resort to disinfection in all the early cases of measles, whooping cough, doubtful cases of fever and diarrheal affections.

In diseases like smallpox and scarlet fever, in which the infectious agent is given off most likely from the surface of the body, occasional sponging with dilute chlorinated soda solution, 1 part to 9 of water, has been recommended, or the body may be anointed with some harmless antiseptic ointment; while during convalescence, i. e., just before the patient mingles with others, a corrosive sublimate bath, 3 drams to 30 gallons of water is indicated. Infectious corpses should not be washed, but enveloped at once in a sheet saturated with a 5 per cent solution of carbolic acid or a bichloride solution, 2 drachms to a gallon of water.

All worthless articles should be burned. Metallic bodies may be sterilized by exposure to red heat or boiling. A good solution for soiled body and bed clothing is made of carbolic acid 3 parts, common soft soap 2 parts and cold water 100 parts; they should soak for two hours, when they may be rinsed and sent to the laundry. Valuable clothing, mattresses, carpets and draperies should be subjected to disinfection in a special apparatus furnished by the Health Department, and in the absence of such facilities they should be hung up loosely in the room and subjected to the influence of formaldehyde gas, which has also been found the most effective agent for room and house disinfection after the recovery, death or removal of patients, and is usually conducted by agents of the Health Office. A cheerful compliance with the rules and regulations of this service can not fail to be a benefit to the family and public at large. If such a department does not exist, it becomes the duty of the Attending Physician to see that the premises are properly disinfected. For this purpose it is necessary to make the apartments as nearly air-tight as possible, and to generate either formaldehyde by the combustion of wood alcohol or liberate it from formalin. The room must be kept closed for six hours after fumigation and it should then be thoroughly aired and exposed, when practicable, to sunlight, which is in itself a very efficient germicide.

The Report of the Committee on Public Health of the Medical Society, District of Columbia ("Washington Medical Annals," January, 1908), shows that there has been a marked reduction in the mortality of diphtheria, measles and scarlet fever during the past ten years in the American cities, coincident with the establishment of municipal quarantine and

disinfection. The average reduction in the mortality from diphtheria in 10 cities amounted to 24.4 per cent. While in this disease the use of antitoxin has served to accomplish the result, the reduction of 44 per cent in the mortality from measles, and a reduction of 70.8 per cent in the mortality of scarlet fever must be largely attributed to preventive efforts, including, of course, higher standards of living.

In this connection the early use of diphtheria antitoxin should be emphasized. The average diphtheria mortality, where antitoxin was used, in Chicago, in 1902, was 6.48 per cent, and where not used it was 32.5 per cent; the mortality in children when used upon the first day was only 1.45 per cent, but when used later than the fourth day it rose. to 14.49 per cent.

Space will not permit a detailed statement of other triumphs in preventive medicine, but the fact that, according to Surgeon-General Wyman of the Public Health and Marine Hospital, there were during the last eight years 242,847 cases of smallpox with 6,067 deaths in the United States, prompts the suggestion that every death from smallpox is a disgraceful reflection upon the intelligence of the age. This disease is entirely preventable by vaccination and proper re-vaccination. The statistics of England show, that in the last half of the 18th century out of every 1,000 deaths from all causes 96, or nearly one tenth, perished from smallpox. On the 14th of May, 1796, Edward Jenner introduced vaccination. During the period of optional vaccination the death rate fell from 200 to 41.7 per 100,000 of population, and from 1850 to 1898, during a period of compulsory vaccination, it fell to 5.3. In August, 1898, the "conscientiously believes" clause was inserted in deference to the anti-vaccinationists; 230,147 persons were exempted by the operation of the law, and in 1902 the rate rose in Scotland to 7.5, and in the United Kingdom to 6.1 per 100,000. The statistics of Prussia show that with the enactment of the re-vaccination law in 1874 the mortality has fallen to less than one tenth per 100,000 of population, while the rate in the registration area in the United States is just 34 times greater. Indeed, it is claimed that Prussia would be entirely free from the disease were it not for the importations from Russia and Austria. President Thomas Jefferson was instrumental in introducing vaccination in 1801 in the South, and in 1806, according to Harrington, wrote the following letter to Dr. Jenner:

never

"You have erased from the calendar of human afflictions one of its greatest. Yours is the comfortable reflection that mankind can forget that you have lived. Future nations will know by history alone that the loathsome smallpox has existed and by you has been extirpated."