"In the endeavour to attain these ends I have designed two models. The better of these, perhaps, is the aluminum flask constructed like Dettweiler's, but without the extra opening at the bottom.

"It is lighter, less bulky, and unbreakable. It is easy to disinfect as it can be boiled without injury. It possesses every advantage except that of cheapness. The other is a strong glass flask modelled like the aluminum flask just described. The funnel is of vulcanised rubber and the cover of white metal. The cleaning and disinfection are simple, and its cost is only about one-third of that of the aluminum flask. . . . All of these flasks are so constructed that the contents cannot be spilled when tipped over, even when the cover is open. The patient should have two pocket flasks, so as never to be without while one is being cleaned."

The reporting of cases of pulmonary tuberculosis, by their attending physicians, to the health authorities, should be required, not with a view to isolation of the patient, as is demanded in the case of acute infectious. diseases, but in order that the patient and his friends may receive reliable information with reference to the danger of the transmission of the disease and the method of preventing it. In New York City, which has taken the lead in this country in preventive measures, the method of procedure is stated by Dr. Hermann M. Biggs, Medical Officer of the Health Department, as follows:

"With certain exceptions, such as patients under the care of private physicians, all reported cases, living or dead, are assigned to the medical inspectors of tuberculosis for the district

from which the cases are reported. The inspector visits the ad dress given, and, if the patient is living, leaves a circular of information and gives verbal instruction to the friends about the danger of infection and the care of the sputum. If the address is that of a dead patient, or if the patient, though living, has moved, the inspector examines the premises and makes such recommendations as seem to him necessary to render the habitation free from danger of infection. These recommendations, made out on a prescribed form, usually advise the following routine treatment of apartments: Kalsomined or whitewashed walls or ceilings are washed with a solution of washing soda (onehalf pound to three gallons of hot water), and then kalsomined or whitewashed again; papered walls or ceilings are similarly washed and repapered; the woodwork is scrubbed with the soda solution and repainted. The inspector's recommendations are forwarded to the board, and on them as a basis a ten-day order is issued on the landlord requiring him to carry out the specified renovation. The execution of the order is then (as with all others of the board) placed under the supervision of the sanitary police. The premises are reinspected, and if, at the expiration of ten days, the owner has not complied with the order, it is referred to the attorney of the board for enforcement. This procedure was determined on because of the difficulty of disinfection of apartments in which cases of tuberculosis have been, and the greater efficiency attained by the system of renovation. The method is easy of enforcement, as is shown by the fact that compliance with the order has not been refused in a single case. The chief point of interest in this plan is that renovation rather than disinfection is called for. Disinfection involves the use of materials and methods which are not universally familiar. The method of renovation required is understood by all, and is more efficient than any method of disinfection which could be employed."

Prior to this renovation the room with its contents may be disinfected with formaldehyd gas, or

articles of clothing and bedding which cannot be sent to the laundry may be disinfected by the Health Department, at its disinfecting station, either by steam or formaldehyd.

The danger of contracting tuberculosis through the medium of milk from tuberculous cows is to be guarded against by the killing of animals recognised as tuberculous and by the sterilisation of milk when it comes from a source not known to be free from suspicion.

That the tubercle bacillus is frequently, if not usually, present in the milk of tuberculous cows, has been demonstrated by numerous independent investigators.

We regard the danger of contracting the disease by eating the flesh of tuberculous animals as extremely remote. This should be condemned if the animal is found to have the lesions of pulmonary tuberculosis; but if these are not discovered, the facts that the bacilli are not located in the muscles, and that the meat is cooked before it is eaten, probably reduce the danger to an imaginary one.

It has been shown by experiment that tubercle bacilli may retain their vitality and infecting power in desiccated sputum for several months. Infected houses are therefore dangerous for a considerable time after they have been vacated by a consumptive

person. The bacillus may also retain its vitality for one hundred days or more in putrefying material. This bacillus has also greater resistance to heat and various germicidal agents than most other pathogenic bacteria. But it is quickly killed by exposure to the temperature of boiling water; by a five-per-cent. solution of carbolic acid; by a two-per-cent. solution of chloride of lime; by milk of lime, solution of caustic potash (lye), or the mineral acids — a one-per-cent. solution of sulphuric or hydrochloric acid. Wood vinegar, or pyroligneous acid may also be used if at least six hours' time is allowed for disinfection.

What has been said with reference to predisposing causes will indicate the measures which should be taken to increase the resistance of individuals to infection—especially of those who have an inherited or acquired feebleness of constitution. An out-door life, systematic exercise, and a nutritious diet will be the main factors in establishing a relative immunity to the disease. Children with narrow chests and insufficient lung capacity should be required to take breathing exercises as prescribed by Dr. Knopf, of New York.

"The patient is taught to stand properly-that is to say, straight, chest out, and head erect-and to breathe always through the nose. He takes a deep inspiration slowly, beginning with the abdominal muscles, and then expanding the chest to its fullest

capacity. During this inspiration he raises his arms from his sides to a horizontal position. He holds the breath for a moment and then lowers the arms during the act of expiration, which should be somewhat more rapid.

"The second exercise is like the first, except that the upward movement of the arms is continued until the hands meet over the head.

"In the third exercise the patient stretches his arms out as in the position of swimming, the backs of the hands touching each other. During the inspiration the arms are moved outwards and finally meet behind the back. They are brought forward again during the expiration. This exercise can be greatly facilitated and made more effective by the patient rising on his toes during the act of inspiration and descending during the act of expiration. Each respiratory act should be followed immediately by a secondary forced expiratory effort."

Exercises of this kind should not be taken soon after eating or when greatly fatigued. Abundant ventilation of sleeping- and living-rooms and sun-baths will do much to invigorate the system. When practicable, delicate children and individuals already infected by the tubercle bacillus should have the advantage of a favourable climate, such as that of portions of Colorado, New Mexico, or Arizona, where one may be out-of-doors nearly every day in the year, and where the continued sunshine and pure invigorating air often work wonders in the way of re-establishing the health of such persons.

To further enforce the statements made in this chapter, I take the liberty of quoting from a recently