The matter of bacteria per c.c. is also important and while the rule enunciated by some to pasteurize (at 175° F. for half an hour) in this part of the world from June 10th to September 10th holds good this may even then be avoided if the bacterial count is relatively low. Milk advertised as pasteurized before sold with 90% of its bacteria alleged to be killed, is not to be depended upon always. With the pasteurizing plant out of commission such milk has been found on sale. Does not a pastuerized milk, whose bacteria have been permitted to come to the city to be killed, offer a false sense of security? The top ounce of cream has more bacteria per c.c. than the rest of the quart and the bottom two ounces may contain any heavier particles of foreign matter. Gravity Gravity cream is 16% butter-fat after the cream line has become well defined and this is usually after eight hours standing at ordinary temperature. There should be 5+, oz. of this strength of cream after 12 to 16 hours standing, on a quart. It can be readily seen that there must be 8 oz. of 16% cream in a quart of 4% milk, i.e., 8/32 of 16 equals 4. If 5 oz. is the amount usually removed there are two and onehalf ounces left in the remaining 26 oz., making a one and one-half fat per cent. milk. This is important to remember when, during a fat intolerance or for any other reason, it is desired to make the diet fat free. The following table is valuable in estimating percentages in mixtures made from top milks of different fat strengths:

Koumyss is best and easiest made as follows: Take two teaspoonfuls of cane sugar to one pint of milk into which has been stirred 1/6 of a cake of yeast dissolved in a little cold water. Divide into amounts sufficient for each feeding in beer bottles and place them where it is warm after closing down. the stoppers, so that for ten or twelve hours they shall be at about 100° F. (38° C). Then place on ice and use during the next 24 hours. It is well to turn them bottom up and vice versa two or three times to keep the cream mixed while fermenting. With a high bacterial count pasteurize the milk first. It is often advisable to remove a certain quantity of the cream from the milk, replacing that quantity with skim-milk, so that when a lower fat is indicated it may be had in the koumyss. Except in older infants a lower fat than that in whole milk is always indicated. It is just as important to know what percentages one is working with in koumyss as in any other food or mixture.

Whey made from carefully skimmed milk is practically 0.00% fat: 5.00% carb.; 0.90% proteid. As a matter of fact whey usually has at least 0.30% fat and often a little more. Now if it be desired to increase the calories, add cream, but first pasteurize the whey at 150° F. to destroy the ferment so that curds will not be produced in the mixture when warmed for use. Whey and cream mixtures are written with a fraction to indicate that milk proteid. has been added. For instance, 1.005.00-.22/.84, means that in a pint mixture one ounce is 16% cream and 15 oz. whey.

THE MIXTURES

Having decided just what percentages shall be used a mixture must be prescribed which will represent these

percentages. A table of mixtures cannot always be consulted and shouldn't be if it could. That weakens one's ability to construct formulas with facility and rapidity from the material available to fit the particular case. There is no such thing as one mixture representing certain percentages for one period of infancy and another for another period. Younger infants in general, however, take lower percentages.

The upper half of a quart of milk in a quart bottle after the cream has become definitely marked may be considered to represent a 7.00-4.50-3.50 milk. Pouring the upper 12 oz. from the same bottle or dipping the upper 8 oz.

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will give a 10% fat strength with the other elements unaffected. The writer has found that the most accurate mixtures are obtained by using gravity (16%) cream and skimmed milk. The latter may be considered, if from the bottom of the bottle as, 1/2 per cent. fat, and that fat being diluted as it usually is so many times in the mixture may be disregarded in practice.

The method which follows, of estimating the required amounts, has the advantage of preventing mistakes and of being very simple. For instance, a 2.50-6.00-1.50:5 oz. ev. 3° :7 F. (+1), is required (Plus one extra feeding to allow for loss by breaking a bottle or otherwise).

= 1.50

The writer, in a paper read before the Brooklyn Pathological Society, December 14, 1911, recommended that patients with typhoid fever be fed according to the following plan.

1. The diet in the average case. Give only fluid food from the first recognition or suspicion of the disease until five to seven days after defervescence, as follows:

At 6, 8, 10, A. M., and 2, 4, 6, 8, and 10, P. M., give seven and a half ounces of milk and barley gruel, in the proportion of two parts of the milk to one of the gruel, the gruel being made with one tablespoon of barley flour to eight ounces of water. At 12 M. give seven and a half ounces of plain beef broth. At I P. M. give the strained juice of one orange, with water to make seven and a half ounces, in which is dissolved one ounce of milk sugar. At some hour during the night give another glass of orangeade similarly made. Give the equivalent of three glasses of water in divided amounts at any time during the day or night.

The above serves as a standard diet, supplying 105 ounces of fluid daily, with a protein content of about 50 grams, and a fuel value of about 1,500 calories. It can be varied in quality and quantity to meet different conditions.

If the patient is of large frame, the feedings can be increased to eight ounces, and one or two extra feedings can be given during the night, or some of the predigested cereal foods can be added to the milk mixture.

If the patient complains of hunger and his di

gestion is good, the amount of food can be similarly increased. If he is emaciated the calorific value of the food can be increased by giving more milk sugar, either in the orangeade or in the milk and barley mixture; or cream can be added for the same purpose; but it is seldom necessary or advisable to add more than three extra ounces of milk sugar, nor more than six ounces of cream. The water can be increased ad libitum.

In place of any or all of the milk and barley feedings either of the following may be substituted: lactacidized milk, peptonized milk, milk and lime water. These substitutes, if given in the same amounts, increase the protein. and fuel ration, and if the patient shows intolerance of such increase the

quantity of each feeding may be cut down to six ounces. Advantage is usually gained by substituting lactacidized milk for four of the regular feedings.

In suitable cases milk diluted with one-third weak tea or coffee can be substituted for one or two of the regular feedings.

The following articles can be allowed occasionally in substitution for a regular feeding: junket with cream and milk sugar, oatmeal jelly, ice cream, in amounts not exceeding four ounces.

Grape juice can be substituted for, or given in addition to, the orange juice. Ginger ale can also be given as a drink.

Claret can be used to flavor and color the milk and barley mixture.

If anorexia is obstinate, and the patient cannot be induced to take the full ration, be contented with a less quantity for the time; but tempt his appetite with the various articles on the list. If there is gastric irritability substitute peptonized milk or lactacidized milk for the milk and barley mixture, or discontinue all milk temporarily and give barley gruel, or barley water, or the predigested cereal foods dissolved in water, or orangeade, or grape juice. If the stools show imperfect digestion of milk, give the milk peptonized or lactacidized, or temporarily discontinue it, and give the cereal preparations in its place.

If there is diarrhea stop all food except barley gruel or barley water, or greatly diminish the amount of milk

in the food.

If there is tympanites, which occurs but rarely in patients fed according to the directions here laid down, give only milk that has been lactacidized, or no milk at all for a time, but barley gruel and the cereal foods, and perhaps the fruit juices.

If there is intestinal hemorrhage, give only barley gruel or the fruit juices, or no food at all for a time.

If there is perforation stop all food. III. The diet in convalescence. On the fifth, sixth or seventh day after defervescence, according to the severity of the case, give oatmeal gruel in place of one or two of the regular feedings, and on the following day substitute for two of the regular feedings boiled rice and milk and milk toast. On the day next following, boiled wheat cereals may be added and macaroni, and on the tenth day a poached egg. On the eleventh or twelfth day a scraped beef sandwich may be given, and, if no rise in tem

Surgeon General Wyman, in a circular of information (U. S. Public Health Reports, May 19, 1911), says:

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Experience has shown that the use of anti-typhoid vaccine affords protection. against attacks of typhoid fever, and that the incidence of the disease, particularly among troops, is reduced by its use."

A. W. Hollis reported to the New York Academy of Medicine, May 16, 1911, 40 cases of typhoid fever treated by vaccines. The average duration of fever in these cases was 32 days; there were twelve per cent. of relapses; no hemorrhages; no perforations; one case of phlebitis; otherwise no complications. Two of the cases died, but these were neglected cases which came under treatment late in the disease. The method of administration of the vaccine was as follows: 50,000,000 dead bacteria were injected every other day until the fever began to decline, and then the dose was increased by 50,000,000 each time until 500,000,000 were given, when the treatment was stopped.

J. C. Allison (Medical Record, June 24, 1911) reports 24 cases of typhoid fever treated by himself with vaccines, and gives a summary of 325 collected