lower animals will enable us eventually to deal effectively with infectious diseases in man is one of great interest and importance.

It is quite possible that some methods of treatment, founded on the knowledge which has been gained by the influence of microorganisms and toxines, may not prove capable of practical application; if, however, this be the case, certain facts as to this influence are proved, and we have good grounds for hoping that further experiments made on the use of microorgan isms and their products will before long put in our hands new therapeutic agencies for the cure of infectious diseases in man.

Any reference to modern therapeutics would be incomplete without a passing glance at modern diseases. One cannot be unobservant of the vast proportionate increase during the past twenty years of diseases of the nervous system. The business and social conditions of daily life are vastly altered. We live at high pressure. Competition, rapidity of travel, ambition, the struggle for wealth, place and power, with all the anxieties, cares and worries involved therein, the exactions of social life, what is spoken of as "hurry," and a thousand and one other such things, have undoubt edly been productive of serious functional nerve disturbances previously unknown, whilst others involving coarse lesions have been rendered more common. Further, long-continued functional disturbances alone. may, and not infrequently does, bring about organic change, such change being the outcome of perverted and impaired nutrition.

In these conditions of physical strain and mental tension we have a state provocative of nerve changes both coarse and subtle, but all degenerative in type. With these, therapeutics has not, and cannot keep pace. The requirement of the sufferer is for speedy, nay, immediate relief; but the call is in vain. We now, no more than formerly, have the power to build up new and healthier tissue. The human machine refuses to acknowledge any law other than the law of nature, and there is no therapeutics outside the universality of her harmonies.

Despite therapeutic and pharmacologic advances; despite new remedies and new methods of cure, the tendency, in increasing measure, of modern thought and practice is toward the recognition and employment of preventive as distinguished from curative medicine. A larger and better understanding and observance of the laws of health, a more perfect knowledge of the causes and spread of disease, the attainment of a higher educational and intellectual standard, have in part contributed to this. May not also the thought of the inadequacy of curative medicine in grappling with disease constrain us to endeavor rather to anticipate those conditions which appear to underlie and give rise to morbid change?

Literary Notes.

Essentials of Diagnosis. Arranged in the form of Questions and Answers. Prepared especially for Students of Medicine. By Solomon Solis Cohen, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic, etc., and Augustus A. Eshner, M.D., Instructor in Clinical Medicine in Jefferson Medical College, etc. With 55 Illustrations. Philadelphia: W. B. Saunders. Cloth, 382 pp. Price,

$1.50 net.

The road to medical knowledge is rapidly becoming a much more easy, if not a royal one, when experienced and able men like the authors of this book devote time and energy to the construction of such books as this "Questions Compend."

The colored plate, furnishing an accurate view of the relations of the thoracic and abdominal viscera, and numerous other excellent illustrations, facilitate the comprehension of the text. Without entering into detailed citation, it may be said of this little book that it will accomplish the purposes of the authors in facilitating the true methods of study.

The book is not a mere cramming machine; its aim seems to be to lead the student to further observation and study.

A New Pronouncing Dictionary of Medicine. Being a Voluminous and Exhaustive Hand-book of Medical and Scientific Terminology, with Phonetic Pronunciation, Accentuation, Etymol. ogy, etc. By John M. Keating, M.D., LL.D., Fellow of the College of Physicians of Philadelphia, Editor Cyclopædia of the Diseases of Children, etc., and Henry Hamilton, author of "A New Translation of Virgil's Æneid into English Rhyme," etc. With an Appendix containing important tables of Bacilli, etc, Poisons, Weights and Measures, etc. 818 pp. Price, Cloth, $5.00; Sheep, $6.00 net. W. B. Saunders, Philadelphia.

It would seem incredible that another dictionary was needed by the profession, after the recent additions to this kind of literature; and yet this work is badly needed, because it settles for us the exact pronunciation of medical terms, besides presenting other interesting features, not the least of which is the elegant and clear type and paper.

We trust that the care and attention bestowed upon the book by many eminent living teachers may satisfy the profession that at last they have reached "hard pan "in this matter. This book is indispensable to the library of the physician.

THE GOSPEL OF CLEANLINESS.

In this era of common sense and practical trend it is refreshing to find the gospel of cleanliness so constantly and unremittingly preached. The text is not yet "Be clean and thou shalt be saved." But the day is coming when the medical profession will say more plainly, and therefore more effectively, that cleanliness saves life, cleanliness prevents and cures disease. That cleanliness in food and drink, in clothing and air, prevent disease is a well-known axiom in hygiene. But alas, how feeble is its practical application. In a recent issue we illustrated the neglect of cleanliness in food by referring to the manner in which fruit is bought from the street vender and eaten without cleansing. Does it often occur to the consumer, who swallows the luscious grapes or cherries that these fruits have probably been gathered by filthy hands? Does it often occur to the consumer that the meat he eats has been hanging for hours or days in front of a shop in a populous and dirty street; has the consumer ever thought of his milk being dipped out of a can and poured into his pitcher in the early morning hours while the street sweeper is "raising a dust" in front of his house? The contamination of water and milk is a commonly known evil. How many people protect themselves against this or the less well-known impurities above mentioned? And yet how simple it is to wash fruits carefully, to boil suspicious milk and water and meat,

pause before consuming food and drink and inquire into the source of supply, and into the manner of the transit from source to consumption.

And are our hands always clean when we eat? Decency demands that they should be. Decency demands that the body should be clean. Does the surgeon take it for granted even in the most respectable person on whom he is about to operate? He draws the line between cleanliness of decency and surgical cleanliness (asepsis.) So should the line be drawn in all things connected with eating and drinking, and special care be exercised on these occasions. In a recent able address on preventable diseases by that brilliant medical orator, Dr. T. Gaillard Thomas, he deplored the abolition of the Jewish custom of washing the hands before eating. And well he may deplore it, for if this were a religious duty, or a common custom, access of many impurities to the mouth would be prevented.

In another column of the present number a brief extract on the Jewish method of killing cattle for meat is offered, which demonstrates how in those primitive days cleanliness was truly a gospel, preached by the high priests of the nation, and made obligatory by religious observance. The entire Mosaic dietary law is but an exemplification of the gospel of cleanliFilth was an abomination in the eyes of the Lord in that day, and the observance of the laws amplifying that beneficient idea. has brought

ness.

forth a nation whose continued existence under the most unfavorable environment, and despite the most persistent efforts at extermination, is the best evidence of the growing qualities of the gospel of cleanliness.

Let it be preached, therefore, in season and out of season; let it be laid down line upon line and precept upon precept, that cleanliness is the one great and only road to health and vigor of body and mind.

In disease the importance of cleanliness as a prime factor in treatment is becoming daily more recognized. In a recent discussion in the New York Academy of Medicine, one of the speakers referred to the fact that the prevention and cure of summer diarrhoea of infants might be summed up by putting clean food into a clean stomach, and removing its detritus from a clean intestinal canal. These were characterized in a recent editorial of a prominent journal as "golden words." How to apply them is the problem. The sterilization of milk, for instance, is a great step in advance, and practically renders it clean before entering the stomach. But of what avail is sterilization, though correctly executed, if this milk is poured into a half clean, or perhaps dirty cup, before being fed to the child. And yet the writer has often known this to be done. Let the principle of

sterilization be taught clearly, let the mother understand that the chief aim is to keep the milk clean from dust or germ-laden air from the moment it is sterilized to the moment it enters the stomach. When this principle is once mastered by lay people (and we confess with sorrow by the profession also) safety in this matter will be assured.

In another direction cleanliness is asserting itself as the chief agent in preventing disease and death. Modern obstetricians are beginning to preach the gospel of cleanliness in the most emphatic manner. Here we have the same evolution from crude antiseptic methods to the more simple and scientific one of pure and unadulterated cleansing, that has made surgery triumph over unthought-of difficulties and dangers. The carbolized injections after normal labor of a decennium ago have given way to an absolute abstention from all interference with the vagina during and after labor.

Litzman, Leopold and others do not even permit vaginal examination for purposes of instruction. So little confidence have they in antiseptics that they insist upon the "nole me tangere " doctrine as the only safeguard to the puerpera. This principle will doubtless be applied in many other directions at an early day. It is easier to prevent dirt than to remove it, must sooner or later become an axiom, because it is sanctioned by common sense.

THE APPROACH OF CHOLERA. Vigilance is the price of safety. In the alertness of the public lies its safety from invasion of this arch enemy of mankind. The authorities, even if they be oversanguine, will be forced to vigilant and energetic action by the apprehensions of the populace. In benighted Russia the latter seeks expression in superstition and excesses that are horrible to contemplate. What else may we expect from a country which has exiled a whole race on account of its religion. It is not surprising among such a people to find murdering of physicians and nurses, whose self-sacrifice has led them to alleviate and prevent the spread of this distress. As a matter of moral hygiene, it would be best if the scourge would sweep this foul excrescence upon civilization from the face of the earth. The laws of nature brook no interference either in the physical or the moral world.

How different is the action of more enlightened countries. The German Government has issued from the office of the Minister of Spiritual Instruction and Medical Affairs, elaborate instruction about the nature of cholera, and the conduct to be observed in cholera times. The following are worthy of reproduction here:

1. The contagious material exists in the excretions

of the patient, and may by this means be conveyed to other persons and objects. Objects thus exposed, for example, clothing, food, water, milk, and other fluids, may communicate thedisease, even though nothing perceptible to the senses may be upon them.

2. The spread of the disease, therefore, is favored by contact with persons who are endeavoring to escape from infected districts. One is better able to protect himself at home than by running away to a strange place.

3. Persons are warned not to harbor people coming from places where cholera has even commenced.

4. Careful attention to the health is important. All disturbances of the digestive organs favor the disease; hence, extra care in eating and drinking is necessary. Especially should diarrhoea be guarded against, and treated at once by a physician.

5. No food coming from a house in which cholera exists should be taken. Fruit, vegetables, milk, butter, fresh cheese are specially dangerous.

6. All water which has been exposed to contamination by feces, urine, kitchen refuse, etc., must be absolutely avoided. Underground water in populous districts is suspicious. Care should be taken not to aid contamination of water, by throwing water after used for cleansing, upon the ground.

7. If water is at all suspicious it must be boiled. This is applicable to water used for washing utensils as well as for drinking.

9. It is better to send cholera patients to the hospital. At any rate they must be isolated at home. 10. Visits to cholera patients and places must be abandoned. Eating, drinking and smoking in rooms containing cholera patients is to be avoided.

12. Clothing soiled by evacuations should be burned or scientifically disinfected.

13. Special care should be taken that the evacuations from patients are not thrown out in the vicinity of wells and streams.

14. All articles that have been in contact with the patient must be disinfected by steam, or at least exposed to the sun and air for six days.

15. Persons having come in contact with the patient, his bed, clothing, etc., should disinfect and wash hands, especially before eating.

16. The corpse of a cholera patient should be removed as quickly as possible, and contact with it avoided in every way.

17. Persons receiving clothing or other property of cholera patients, should have them carefully disinfected in an institution.

18. There are no other means of protection against cholera than those mentioned. The resort to the advertised cholera remedies is urgently advised against.

Besides these excellent common-sense directions,

the government has issued "Directions for Disinfection," and "Advice to Practicing Physicians with regard to their co-operation in the Sanitary Measures against the extension of Cholera," which are an epitome of all that is known on these subjects.

In a recent interview, Dr. Edson, the Chief of the Sanitary Bureau of the city, has given the public an admirable resumé of the subject, which will surely result in the proper understanding and allay useless anxiety and apprehension. We are glad to learn from this source that our city authorities are wide-awake, and will meet the enemy with all the forces which modern sanitation furnishes. With vigilance at this important gateway the country has little to fear from the scourge. Especially in this city the spread of cholera is little to be dreaded. We have an excellent water supply not subject to contamination; we have an intelligent community, whose good practical sense will lead them to appreciate the sources of danger and then avoid them.

Annotations.

PULMONARY CONSUMPTION :-ITS DIETETIC AND REGEMINAL MANAGEMENT.

BY EDWARD F. WELLS, M.D., OF CHICAGO. Pulmonary consumption, the greatest enemy of mankind, is not an incurable disease. However, if the unfortunate subject of this disease is to be given an opportunity to escape the fate of the majority he must be surrounded by favorable conditions and must submit to certain necessary rules and regulations. I deem it an essential preliminary to success that there should be a happy combination of interests and hopes between patient and physician. The patient should be candidly informed of the nature of his malady; of its varied and tedious course; of its . leading symptoms and complications; of its dangerous character; of the possibility of a cure and of the necessity of his exercising to the utmost his powers of patience, hope and confidence. On the other hand the physician must have a wide, varied and exact knowledge of medicine in general and of phthisis in particular; he must know and believe that the disease is curable; he must be kind, considerate, resourceful, hopeful and enthusiastic and, above all other qualities, he must be able to transfer his convictions, enthusiasm, and hopefulness to his patient. That this mutual confidence may be obtained and retained, week after week, month after month and year after year, until at last the victory is won, or defeat has been suffered only after every point has been stubbornly contested, requires a most profound

knowledge of human nature and the highest qualities of the physician.

One of the most striking features of consumption is the progressive loss of body weight. In the presence of advancing local affection this is so constant that it affords a very accurate index of the progress of the case. Experience has abundantly proven that in a great many cases it is possible to stay the waste of tissues and even to cause the patient to gain in weight by giving careful attention to the diet, and that under these circumstances the pulmonary trouble is held in abeyance and the local lesions have a tendency to heal. This being the case it is evident that the subject of feeding our tuberculous patients is one of prime importance and worthy of the most careful consideration.

Anorexia and defective powers of assimilation are present in those cases in which the stomach and intestines, including their adnexia, are affected by organic disease. Loss of appetite is also a prominent feature in many cases during the height of a febrile attack, and in a certain proportion of patients without any obvious cause. However the rule is, especially in the earlier part of the attack, that the patient has either a good appetite, with moderate capabilities of assimilation, or he can receive, digest and assimilate liberal quantities of food, although he may have no desire for it-there being a state of apathy rather than one of disinclination. It is in this last and largest class that we are able to utilize our knowledge of dietetics to the greatest advantage, and that this paper may not be unduly extended my remarks are confined, in the main, to this class of cases.

Foods which contain nourishment in the most concentrated form should constitute the basis of our dietetic management. In order, however, that the best results may be attained these must be accom. panied by properly selected adjuvants, correctives and --padding. By the last term I mean certain bulky articles of food having but little nutritive value, but which are necessary for the greatest digestive and assimilative activity. For many years I have discussed this subject very freely with my patients, inquir ing into their preferences and sensations and obtaining their opinions and estimates, and the following diet table is the result of my experience. In practice it is suitably modified to meet the surroundings and other exigencies of the individual case for which it is prescribed :

To this list may be added such other foods and drinks that the appetite craves and are found to agree. Any article of diet which the experience of the patient has shown to be detrimental is to be omitted.

Food should be taken in as large quantity as possible. At each lunch from a half-pint to a pint of liquids should be taken, and at each of the three principal meals an equal quantity of milk, or of coffee, tea or cocoa, made of rich milk and cream, should be ingested. There is no objection to changing the dinner hour to 6:30 P. M., and taking a midday luncheon equivalent to the supper as prescribed. Meals should be never hurriedly taken and should be always accompanied by cheerful conversation. Eating should be made one of the principal objects of the patient's life.

The diet should be varied to meet special indications or the patient's desires. If there is little or no fever, and if starch, sugar and fats are well borne, foods containing these principles in abundance should be freely employed. If there is much fever, or if there is apathy or antipathy towards eating, the diet should be composed, mainly, of animal foods and very concentrated nourishment, with fresh fruits and vegetables.

If there is a tendency toward flatulent distention of the stomach or bowels after eating, bread and other farinaceous articles of food should be taken

sparingly. If the bowels become constipated, fruits, coarse vegetables, corn or graham bread should be largely eaten, and if diarrhoea supervenes avoid the kind of foods above mentioned.

At the very beginning of treatment the patient should be impressed with the great importance of certain bygienic and regimenal regulations. These should be fully discussed with him and he should be made to understand the reasonableness of the rules prescribed in order that his hearty and intelligent cooperation may be secured. The peculiarities of the patient must be fully weighed, but the following points I consider with every patient.

Consumptives are usually persons who have formed strong attachments for their home, family and friends and do not readily adapt themselves to changed surroundings. For this reason home is the best place for the majority of these patients. This does not apply to the comparatively small contingent of phthisical patients who are always in touch with their surroundings and who are natural travellers. With these travel, change of scene and climatic treatment may be considered, but a change of residence should not be undertaken without thoughtful consideration and special advice from the medical attendant.

The residence should be exposed to sunshine and sheltered from cold and raw winds. The rooms should be well ventilated, free from draughts and comfortably warmed and furnished. The home should be entertaining, pleasant and cheerful. The patient should sleep alone.

Pleasurable exercise, such as riding, boating, walking, traveling, games, etc., and non-exhausting employment which interests and does not expose to deleterious influences are beneficial.

At frequent intervals the patient should practice forced breathing, both inspiration and expiration. As a measure of the ærial capacity of the lungs he should count aloud as many as possible without taking breath.

The clothing should be light and comfortable. That next the skin should be of wool and of fine texture. In cold weather the clothing should be sufficient to prevent chilliness, and the chest should have extra protection.

Once or twice weekly the patient should have a hot sponge or tub bath. The surface should be quickly rubbed to a glow and enveloped in warm woolen garments. The bath-room should be comfortably heated.

Should night-sweating supervene, bathe the surface with very hot water or vinegar and, after drying, rub with flour, starch or other absorbent powder.

The cough should be restrained as much as possi