cated by means to which everyone is liable and to which the occasional visitor, especially if of small means, is especially liable by virtue of his inability to take precautions within the power of the humblest intelligent resident and, in the case of typhoid, by the lack of previous immunization.

A good many northern cities are practically free from malaria, there being less than one death a year per hundred thousand population, such cases as do occur being almost always easily traced to travel. On the other hand, Washington, D. C., had an average of over 8 for the period 1901-5; the Borough of the Bronx, noted for its zoological park, the same; New Haven and St. Louis about 10; New Orleans 27; Memphis 125; Sacramento and San Diego, Cal., Annapolis, Md., Saratoga Springs., N. Y., Charleston, S. C., Nashville, Tenn., Norfolk, Petersburg and Richmond, Va., all have considerable malaria, ranging from 10 to 40 or more deaths per hundred thousand. Savannah, Jacksonville, and Wilmington, N. C., have, from 1902 to 1906, shown mortalities well above the hundred mark, in one instance corresponding to about one death in every ten from all causes. A great many small New England towns, which no one who had not consulted these particular statistics would imagine to be points of danger, report from 10 to 30 deaths from malaria per hundred thousand population. While not in the ordinary sense places of resort, most of these towns are historic; they are intimately connected with the family history of about 1/3 of the inhabitants of the northern and western states and are more and more sought by travellers as interest in genealogy increases.

A few hours' study of statistics will convince every thinking person of the very practical danger of malaria along almost all ordinary routes of travel for either pleasure or business, even in parts of the country well to the north and by no means of low altitude or swampy, according to the conceptions of the physical geographer. Nor is it necessary for the traveller to leave

his train to incur the risk of a bite by an infected anopheles.

With regard to typhoid fever, there has been, within a comparatively few years, a reversal of the relative dangers of European and of American travel, the dense population of Europe having compelled special care as to water supply of practically every large city and of most small towns liable to be visited by the American traveller. Meantime, in America, we have reached a point at which typhoid is becoming important as an incentive to sanitary engineering but at which the incidence is either not sufficiently great or has not been sufficiently appreciated to compel the filtration or protection of the water supply.

Sacramento, Pueblo, Jacksonville, Key West, Savannah, Wichita, Annapolis, Sault Ste. Marie, Duluth, Niagara Falls, Wilmington, Charleston, Nashville, San Antonio, Salt Lake City, Norfolk, Richmond, Petersburg, Spokane, Tacoma, show typhoid mortality rates three to twenty times what may be regarded the practical normal for cities with fairly good unfiltered water supplies-15 deaths per hundred thousand population. It is only fair to state that conditions are rapidly improving so that there may already have been, or is likely to be at any time, a drop from a rate of 100200 to 20 or lower in the typhoid death

rates.

Niagara Falls is a particularly striking example of the danger of a resort to the whole country. Here is a small city of some 25,000 inhabitants, taking its water about 20 miles, or by current not much over 8 hours below the sewers of Buffalo, a city of over 400,000 inhabitants and with additional discharges of 25,000 to 30,000 inhabitants, still nearer. Inclusive of excrement from the lower animals, it has been estimated that the Niagara Falls water contains about I part of actual excrement per 100,000 and this estimate was made nearly ten years ago when the population above Niagara Falls was not much more than half its present size.

There is probably no place in the world

outside of a few very large commercial and social centers, which draws so large a transient population and from such great distances. And, to a large degree, the visitors are of the trolley and coach-excursion class, who patronize restaurants which make not even the pretense of supplying pure water, who consume large quantities of candy, peanuts, popcorn and other thirstproducing foods, who carry luggage, go on foot and perspire freely. To how large a degree Niagara Falls is responsible for typhoid fever, it is impossible to say, but it is significant that its typhoid mortality ranged from 127 to 181 per hundred thousand in the years 1902-6, when there was no notable prevalence of the disease in Buffalo and that there is scarcely a community in the United States that has not had at least one and often many visitors to the Falls in that period. Previously to 1902, typhoid was still more prevalent both in Buffalo and, a fortiori, in Niagara Falls. Hence it is reasonable to conclude that a very considerable proportion of the population has been immunized by a previous attack and the ratio of typhoid deaths, enormous as it is, in the resident population, falls far short of representing the mortality which would at once develop in a community, drinking the same water, but having a previous average incidence of the disease. Moreover, we cannot overlook the danger of healthy bacillus-carriers, both supplying a continual infection to the drinking water from the up-stream communities, and accidentally communicating infection through food and otherwise, in Niagara Falls itself.

A JUSTIFICATION OF PHTHISIO

PHOBIA.

FOR several years past, most authoritative utterances on the hygienic regulation of consumption, have insisted that the conscientious consumptive is not a source of danger, does not require segregation as a sanitary precaution and that the phthisiophobia which desires his exclusion is both cruel and foolish.

We need not repeat the prophylactic details whose performance marks the conscientious consumptive. It may, however, be well to preface our remarks by a statement of certain data bearing in a general way on the decision for or against the segregation of the tuberculous.

1. So far as human beings are concerned, tuberculosis means the infection with one of two closely related varieties of bacillus, human and bovine.

2. With exceedingly few exceptions, tuberculosis in human adults is due to the former type, that is, it arises from a preceding human case or accident and not very frequent involvement of a lower animal, especially a domestic pet, which, in turn, owes its infection by at most a few moves, to a human source.

3. The majority of cases of tuberculosis in children are also essentially human, as just explained, but a considerable minority of non-pulmonary cases are due to the bovine variety, probably communicated mainly by milk.

4. About 85 per cent. of all tuberculous infections are pulmonary and 90-95 per cent. have a distinct avenue of discharge, as in sputum from the air passages and lungs, the skin, bowel, kidney or an abscess or empyema (using the term empyema in the general sense of an involvement of a previously existing cavity).

5. Rosenberger's claim that practically all cases of tuberculosis involve a marked degree of circulation of bacilli in the blood and, hence, their elimination in considerable quantities, in the aggregate, by the fæces and urine, has not been substantiated, but still cannot be considered as absolutely disproved.

6. However, for the present, we may consider closed foci of tuberculosis as safe and may limit our attention to the question of danger from discharges, notably sputum.

7. While, in an academic sense, most human beings in civilized life have at some time received tubercle bacilli, which have multiplied to some degree locally, practical infection with tuberculosis depends in large

degree upon susceptibility and, unless the lesion is essentially local or unless early and systematic treatment, mainly hygienic, is instituted a diagnosticable tuberculosis usually ends fatally.

8. From the practical, as well as the theoretic standpoint, both the susceptibility of the individual and the availability of the germ must be considered. The theory that tuberculosis depends upon a definite diathesis which will some time, somehow, inevitably encounter a source of infection, cannot be accepted. Still less tenable is the theory that tuberculosis is a scavenger which removes only the unfit. Experience shows that almost any kind of temporary depression may be sufficient to lessen the resistance to tuberculosis and, occasionally, we encounter cases far enough advanced to be diagnosticable physically and bacteriologically, in persons otherwise of robust physique.

9. Thus the prophylaxis of tuberculosis must depend largely on the destruction of fomites. Nor can we excuse neglect of this measure by the plea that the bacilli are too freely scattered to make our efforts of avail. The tubercle bacillus is essentially a parasite, not a free-living plant. It is readily killed by sunlight and other natural vicissitudes, and it rarely persists for any great length of time outside the body, except in dry, dark accumulations of dust, indoors, whence it could easily have been excluded by ordinary care of a human case. Even if we neglect the bovine bacillus entirely, the removal of human sources of contamination will reduce tuberculosis in man to a small fraction, probably 1/5 to 1/10 of its present incidence, and the cases will be, on the whole, more controllable, at least in the prophylactic sense.

10. Only confusion results from quibbling as to whether tuberculosis is contagious or infectious. The important point is that 90-95 per cent. of all cases in man, so far as present knowledge of the distinction of the two types is concerned, are due to antecedent human cases. The fact that we cannot usually trace the exact source and that brief proximity to a consumptive

practically never results in infection, have nothing to do with the consideration.

The fact that most human tuberculosis results from antecedent human cases ought to justify some degree of phthisophobia. The word fear, in English, Greek or, so far as the writer's limited knowledge of five Aryan and one Semitic language goes, in any other language, has several shades of meaning. For instance, in agorophobia, the phobos or fear is an obsession which brings us pretty close to actual insanity. Undoubtedly, phthisiophobia may have this significance in individual cases, just as an individual may go through life with a morbid horror of death by cancer, fire, drowning, apoplexy, etc. The fear may also be an exaggerated selfish dread of something that may happen to the individual himself. Certain phobias, paradoxically enough, represent a fear entirely disconnected from danger as necrophobia and ophiophobia, although they probably originated, early in the history of the race, with actual experience as to danger from corpses and serpents. Shelley, with a layman's ignorance of pathology, covered tuberculosis with a glamor of superficial beauty. On the other hand, with a better understanding of pathology and a closer analysis of symptoms, many persons dread tuberculosis, not so much because of the suffering of anticipation of death, but because of its disgusting nature.

Quite apart from these types of phobia, there is the very practical and altruistic realization that an infectious process whose germs are capable of reproducing the disease without a specific predisposition, or peculiar method of implantation-as in malaria, yellow fever, venereal diseases, etc.and without undergoing such life cycles in the outer world or in mediate hosts as modifies the infectivity of certain protozoa and vermes, is dangerous. In this sense, we freely confess to being phthisiophobic, nor do we believe that a sharp, reliable line of demarcation can be drawn between careless and conscientious consumptives nor that the utmost intelligence and sense of duty can entirely remove the danger.

We believe also, as a general principle, that the only absolutely efficient method of preventing any infection, except perhaps those requiring very special methods of implantation, as by an insect, is isolation. Eminent authorities characterize this view, applied to consumptives, as cruel. We fail to see why it is any more cruel to isolate a consumptive than a leper, or indeed, except for the greater duration of the quarantine, than a scarlet fever patient. Even if segregation ignored entirely the welfare of the victim, the sacrifice of a part for the interests of the whole of humanity, future as well as present, cannot be considered cruel. But segregation of advanced cases of tuberculosis is no more essentially ruel than that of incipient cases. It involves, relatively to the higher mortality rate as the disease progresses, a greater increase of the remaining chance for recovery than in incipient cases and segregation if practiced as a routine, would also enable the poor consumptive to enjoy better nursing and greater comfort than he could have either at home or in a hospital not especially adapted to his needs.

MEDICAL EDUCATION.

IN no department of education has there been such rapid advancement toward higher requirements of scholarship as has come about in our schools of medicine. Up to 1900 only one institution required more. than a four-years' high-school course for entrance upon regular medical work. In 1908 ten schools required two or more years of college training. During 1909 seventeen schools required this preparation. This year eleven more will be added to the list, while twenty others will require one year of preparation in addition to four years of high-school study.

There is now a total of one hundred and sixty-two medical colleges, so that at the beginning of the second decade of the century more than one-third of them will have a standard of preliminary training of at least one year in addition to the four years of high-school, and nearly one-fourth will require two years.

Improvement in the teaching force and in

other equipment has come about through the merging of schools which has taken place in the past few years. Some schools have otherwise dropped out of existence and, although more than a score of new ones have sprung up, the total number has been diminished by twenty-two within the last five years.

As shown by the statistics compiled by the Journal of the American Medical Association, the total number of students matriculated the past year showed a decrease of four hundred and fifty-seven below that of 1908, and the lowest number since 1900.

While the new requirements are a sign of advancement, the standard of scholarship within many medical schools is still none too high, even among those requiring this longer preliminary training. Expenses of maintaining such a course are so great that it is a temptation to keep all the pupils they possibly can, while numbers also give apparent prestige. Such defects can hardly be corrected save by making the school independent of outside support.

Probably the decrease in students is due partly to the more or less apparent lack of demand for physicians. While there is no immediate prospect that disease is to be done away with, so rapid has been the increase in hygienic measures that the amount of sickness has decreased markedly. Certain forms of disease, as typhoid and diphtheria, have been greatly reduced, and tuberculosis is not only diminishing, but its treatment has to a considerable extent been transferred from the individual practitioner to state and other sanitariums. Various educational movements in prophylaxis are helping to increase the general health, while the physician himself is directing and pushing forward this campaign in which he himself is the loser in everything except the reward of a good conscience.

Since the field of lucrative practice is diminishing, it is well that, at the same time, the requirements in education are in themselves tending to reduce the number of those who seek to enter the profession. We have thus a double means of regulating against an oversupply in this field of work.

I. PHYSIOLOGY AND PATHOLOGY OF GAS

TRIC DIGESTION.

MANY of the older authors, beginning with the American physiologist, Wm. Beaumont, believe that the mechanical irritation of the foods cause the gastric secretion, but the experiments in Pawlow's laboratory, in the institute for experimental medicine, St. Petersburg, have proved the fallacy of this view. In the first place, if the secretion were due to simple mechanical irritation, there is no reason why irritation with the point of a glass rod, with a feather, or with sand placed in an animal's stomach, should not cause the secretion also. The mistake of the older experimenters, according to Pawlow, grew out of the fact that they ignored the so-called psychic secretion-a secretion which can be set up by the mere sight or smell of food, or even a very intense feeling of hunger. If the esophagus of a dog is cut, and its end sered to the edges of the abdominal wound, or allowed to open above the serum in the neck, and at the same time a gastric fistula is established, pieces of meat which are fed to the dog after recovery from these operations will not reach the stomach, but fall out of the upper end of the fistula leading into the esophagus. Nevertheless, in five or six minutes after swallowing the food, which never reaches the stomach, gastric juice begins to be secreted, running from the gastric canula first in drops and afterwards in a continuous stream. If the dog be offered meat without receiving it, the gastric secretion will also appear, though not so plentifully as when the dog was actually allowed to eat the meat. A further interesting phenomena observed in these dogs was that no secretion followed the swallowing of indigestible substances like small stones. These experiments furthermore elicited the

astounding fact that for every kind of food a definite gastric secretion is formed of specific composition. Therefore we can say that the stomach provides a certain chemical composition of gastric juice to meet each case. We must therefore conclude that the mucous membrane of the stomach is capable of distinguishing between the varieties. and classes of food that come in contact with it, much as the skin recognizes mechanical, chemical, thermic and electrical stimulation. The question might be asked, "What is the object of this psychic secretion?" for Pawlow has clearly established the existence of two kinds of gastric secretion, the chemic and the psychic. This question applied to the human physiology would be the same as inquiring, "What is the object of appetite?" The answer is that under the influence of the psychic secretion a gastric juice is furnished which is much more effective than that which is secreted under purely chemical stimulations of the food, i.e., when food is taken without any special appetite. Furthermore under the influence of psychic secretion, foods which otherwise would not stimulate the gastric mucosa to secretion become converted by the already present psychic secretion into something else which constitutes a further stimulant to the secretion of gastric juice. For instance, if a solution of albumin be introduced into the stomach of a dog, upon which a Pawlow operation has been performed, i.e., splitting off part of the stomach with all the vessels and nerves intact, and making this second smaller stomach communicate with the external abdominal wall, but not with the general cavity of the large stomach from which it is dissected. (see International Clinics, XII, p. 276), there will be no secretion. But if the psychic secretion is set up by some other means, before the albumin is placed in the