Each includes anatomy and chemistry, 14 include physiology, 9 embryology, 7 pharmacology, 1 pathology, 2 bacteriology, 1 physics, 1 hygiene, 1 medical terminology, 1 surgery, 1 biology, 1 prescription writing, 1 physiological chemistry.

The elementary branches are anatomy, chemistry and physiology, and these three-meaning by anatomy osteology, syndesmology, histology and embryology-suggest themselves as the proper studies for the freshman year. Bacteriology, materia medica, pharmacology, pathology, hygiene or surgery, certainly have no place in the first year's work. Physics and biology might with some propriety be assigned to this year.

Methods of Instruction. To my mind there is no question but that the laboratory method is far more interesting and infinitely more instructive than the didactic. In a measure, we are slaves to the traditional methods of the earlier teachers, who were deficient in material and equipment, and were compelled to give didactic instruction. At the present day there is no such excuse. The laboratory is the workshop wherein the student must learn by actual work, using all his special senses to acquire

common sense.

In the teaching of anatomy I believe much better results can be obtained by having the class work in small rooms-that is, a separate room for each body undergoing dissection-these rooms opening into one of sufficient dimensions to accommodate all for general conference or recitation. The large dissecting-room, like the large amphitheater, should give way to the small laboratory. For some unaccountable reason, students industrious and well-behaved in other departments of their work, once in the dissecting-room, seem to become imbued with the idea that it is a place for ribaldry. They seem to think that to act otherwise would make them appear effeminate in the presence of the dead. Discipline is not so easily maintained in the large dissecting-room, as there are nearly always some students who are continually trying to appear smart, thereby distracting the attention of the seriousminded. In the dissecting-room each student should be compelled to work his part thoroughly under supervision and given to understand that only such work would be credited. Satisfactory work, and not time spent in the dissecting-room, should be the criterion by which the student should be graded. The dissecting-room is the place to learn anatomy, and the student should be most emphatically given to understand that he must work, otherwise he fails in his anatomy.

Truth, honesty and purity of character are as essential to the physician as are the sciences, and I endeavor to inoculate them with the fact that these cardinal virtues are as important as anatomy, chemistry or physiology.

We owe a paternal duty to the freshmen entrusted

to our care.

DR. W. F. MERCER: I believe that in the first place the students should have a pretty thorough knowledge of the general sciences, especially physics, chemistry and general physiology. Four years of medical school above the high school is not enough. Students ought to have a good, thorough

scientific knowledge before entering the medical school. We, the people, are interested considerably in the pure science side of it, not the technical side. This general science should be required for entrance. Inorganic chemistry, for example, should be ground in before entering the medical college; then when the students enter the medical schools they are ready for the practical or technical side of the science. I believe these subjects should be left out of the first year of medicine, and be required for entrance. These sciences can be just as well done outside of the medical schools, which will give them all of the four years for pure technical training. No one will doubt for a minute that any medical school that is equipped to do high-grade medical work needs every minute of the four years for pure medical training. I think that we can hardly expect a thoroughly trained physician in these days, when our modern sciences are so well developed, without first having a thorough science course before entering the medical school. But it seems we cannot make the jump from allowing the high school graduate to enter the first-year medical course, to requiring a college graduate for entrance with special courses in science. It may be possible, however, to require the fundamental sciences equivalent to one or two years of college work above the high school. It will be seen that I am not in favor of reducing the number of years; rather I am in favor of requiring more years, because I believe the medical profession best and most highly trained men in this profession, one of the great professions. We want the very for they are dealing with human lives that cannot afford to be practiced upon. We have to practice enough upon them anyway. We are training teachers for different kinds of work, in special schools for that purpose. It is no more than proper that we should train the physician thoroughly before he is allowed to practice on people. Taking, as an illustration of what is being done outside of the medical colleges, our class in human anatomy. This work is done in the dissecting-room, the instructor being present all of the time. A quiz is given in the dissecting-room, at least once a week, on the part that the student has worked out himself. This is the method we are using all along the line. We think we have it pretty fairly worked out. In physiology we give a strong course-not a technical, but a general one. Histology, embryology and bacteriology follow the same general method. In bacteriology the student gets the technique of preparing media, and follows out the methods of handling bacteria with special reference to hygiene and sanitation.

I do not expect time credit in the best medical schools. The students that expect to be the best trained for their profession should have the full four years for professional work. My students get credit in this State and elsewhere for work done in the more technical branches. I prefer they should pass them off, as they have done in many of the leading institutions of the country, which will give them all the more time for special work.

We can readily see that every school must have some standard for admission, the higher the better. The only thing I contend for is a good, thorough grounding in the general sciences before admission is allowed to the professional schools.

DR. MEDBURY (closing): There is very little I want to say, and that refers to the matter of entrance examinations, or, I should say, requirements for entrance, whether it should be a high school diploma or one year in college, to get this brain power looked for in the future doctor. After taking these students, in our freshman year we ourselves must sift them out. So far as Ohio schools are concerned, what do we get? In many cases we get students who have been in high school four, and sometimes six or seven years, to whom their teachers have given their diplomas simply to get rid of them. All these diplomas look alike when they come to us, but if they were more careful in turning out their students, the proposition would be different.

Now, as to college training. I have had all kinds. of students-one-year, two-years, and those who have received the A.B. degree. I have had miserable failures of high school graduates, and failures almost as bad of students with the A.B. degree, but not one failure of a student who was compelled to take and pass an examination under Professor Albright before entering.

I fully agree with Dr. Lewis about dissectingrooms, and have often wished for several rooms for dissecting purposes, but not on account of difficulty in keeping order. That can be done with a hundred students as easily as with a dozen, if the right man is at the head of the department.

Cincinnati Covington Cleveland

Indianapolis

325,902 42,938 5.323 381,768 124,631 169,164 17,122

58,961

14.498

4.4

1.6 15,963 9.44 204,731 21,427 39,141 19.1 125,560 12,328 8,225 321,616 84,878 9,579 United States |76,303,387)

Louisville Columbus Pittsburg

1,580 191.8 113.0 1,880 208.4 164.1 6.55 1,600 208.8 124.1 2.98 2,070 137.9 215.3 11.0 |1,660 195.0|134.9

The topography of Cincinnati, which until recently has been a great factor in concentrating factories and residences in a small area, has no doubt been an important element in fostering the spread of tuberculosis. Its position has also sheltered it from the influences of the winds, which are supposed to be so important in conserving the health of the dwellers in the cities on the lakes.

The topography of the site of Cincinnati presents a variable aspect. We first have a comparatively level tract, roughly circular in outline, of an average diameter of three miles, bordered on the east and north by a so-called belt of hills and on the west by another; between the two is an extensive valley, formerly the channel of the Ohio River. On the south we have the Ohio River. The latter at low water mark is 431.70 feet above sea level. From the river the ground rises until the level of Fourth Street is reached. The entrance of the Sinton Hotel on this street is 113.76 feet above high water mark. Above Fourth Street there is only a slight rise until the foot of the hills is reached. All of this bottom tract is covered by gravel, the result of river drift. The hills rise rather abruptly

from the bottom tract to a height of between 400 and 450 feet above low water mark.

Geologically the region belongs to the Lower Silunian era, the strata of the Utica and Lorraine groups being exposed. They consist of clayey or marly shale alternating with thin layers of blue lime stone. As the proportion of stone is only 10 per cent., conditions are favorable for the retention of moisture by the shale.

Because of the sloping ground living rooms are frequently seen on a line with the cellar; this condition may explain the high mortality shown later on. Manufacturing at first was largely done in the territory along the river. Recently many plants have been erected on the high and open ground north of the city. Business firms have likewise removed from their proximity to the river. Many of the houses left vacant have been transformed into

tenements.

The average annual death-rate from tuberculosis in Cincinnati is 230 per 100,000. When the relative mortality of different portions of the city is compared it is seen it varies as greatly as different portions of the country.

The tenements are located almost exclusively in the basin of the city. The houses on the hill sides. are small and occupied by one or two families. The larger and finer residences are on the hills.

The highest death-rate, 525 per 100,000, is found in the territory along the river front between Eggleston Avenue and John Street, extending up to Fifth Street. This is the oldest portion of the city; the tenements are large, illy ventilated, damp, dirty and poorly lighted. Negroes and the poorer white people live here. The two regions adjoining show the next highest rates, 443 and 429 respectively. The first is occupied largely by Hungarians, Italians and Jews and the other by negroes.

Adjoining the first division on the west the rate is 308; this territory is occupied by emigrants from Kentucky, Irish, Jews and negroes. The region to the east, along the river, with a rate of 352, is largely occupied by a native population. The houses are small, but old, damp and dilapidated. The remainder of the bottom region is largely occupied by natives and Germans; the character of the houses is indicated by the mortality rates. The portion in the northeast, with a rate of 292, is the thickly built up German settlement.

On the hill tops the rates are low, with the exception of Mt. Adams and Price Hill. The houses on the former are old and the ground very irregular. The reputation of Price Hill for pure air and its consequent selection as a place for consumptives no doubt contributed to its apparent unenviable record. The marked plurality of deaths along the hill sides when compared with those in the territory at the top must indicate they are not desirable sites for residences. The hill sides bounding Clifton Heights and Mt. Auburn have much higher rates than are found on the summits. The rate of

Total number of dwellings, census 1900, 40,634. 6,936 deaths reported in 5,984 (14.75) dwellings. Single deaths reported in 5,285 dwellings. Multiple deaths in 699 (11.75 of infected houses), with 23.85 of deaths. The distribution was as follows: 2 deaths in 561 houses; 3 in 97; 4 in 28; 5 in 6; 6 in 1; 9 in 1; 10 in 2; 11 in 1, 22 in 1; 28 in 1.

A glance at the above table shows us that 144,777 persons, or 44.3 per cent. of the population, live in houses accommodating over ten people. The 11.75 per cent. of infected houses, with 23.85 per cent. of the deaths from tuberculosis, is also significant.

The mortality and morbidity of a city from tuberculosis is in inverse ratio to the average income of its people. The prevalence of tuberculosis varies almost arithmetically with housing conditions; the denser the population the greater is the number of deaths from tuberculosis.

From statistics obtained from 662 cities in France it was shown that in cities of 5,000 population the rate was 1.81 per 1,000; 10,000, 2.16; 20,000, 2.71; 30,000, 2.88; 100,000, 3.05; 450,000, 3.63; Paris, with upward of 3,000,000 populaaitn, 4.90. The ratio of phthisis increases with the overcrowding in buildings.

In Dundee, Scotland, taking the ratio of dwellings of four rooms and upwards as 10, it was found that the other ratios were: For three rooms, 17; for two rooms, 20; and for one room, 23.

In London, in districts with under 10 per cent. of overcrowding (overcrowding being taken to mean when more than two persons occupy a room in tenements of less than five rooms), the death rate per 1,000 living from tuberculosis is 1.10; in districts with under 15 per cent. overcrowding it is 1.43; under 20, 1.61; under 25, 1.80; under 30, 2.07; under 35, 2.42; over 35, 2.63. In London, where the average number of inhabitants to a dwelling is 8, the rate is 17 per 10,000; while in Paris, where 35 live in a dwelling, the rate is 47. In the Champs Elysees the rate is 11, in the more crowded blocks 125, in the worst districts as high as 426 per 10,000 inhabitants.

These facts are fundamental, and teach that if you give the people proper rooms and dwellings

P = population; T= total number of deaths from tuberculosis; the bottom figures give the annual death rate per100,000 from tuberculosis.

and workshops, where the sun can enter freely, where air is admitted and cleanliness is observed, the spread of tuberculosis is prevented to a large degree.

Were one to attempt to epitomize the cause of tuberculosis, "poverty" would be sufficient, for in its train follow-at times precede-ignorance, alcoholism, indifference or misfortune. In Hamburg tuberculosis is in inverse proportion to the income of the family. It is 60 per 10,000 where the income. is $225; 39 where it is between $225 and $300, and only 10 when the income is over $900. The mortality from tuberculosis is an expression of the social and economical position of the family.

In the production of poverty alcohol is the mightiest agent. Lindblom, the poor-law inspector of Stockholm, states that alcohol is the cause of the poverty of 90 per cent. of those in the workhouse (poorhouse), and in more than 50 per cent. of those seeking out-of-door relief. The financial condition of the tuberculous in Sweden showed 8.3 per cent. were prosperous; 37 per cent. well-to-do, and 54.7 per cent. poor. Henschen found among the tuberculous 5.6 per cent. prosperous; 34.1 per cent. wellto-do, and 60.2 per cent. poor. The relation of alcohol as a direct etiological factor in the production of tuberculosis is hard to prove. Its indirect influence is evident through its effect on character, making the individual careless of himself and others, leading to lack of proper personal necessities, choice of vicious and detrimental surroundings, and, worse than all, dragging those dependent on him into the same environments, with the same penalties.

Koch has shown that alcoholized rabbits evidence the effect of inoculations earlier than the non-alcoholized. This was true of large as well as of small doses. Experiments have also shown that alcohol causes a considerable increase in the susceptibility or disposition of the body to artificial infection. Statistics of alcohol consumption in the various departments of France show the increase of tuberculosis is in proportion to the amounts of alcohol used.

[The fourth paper of this series or articles by Dr. Lyle will appear in an early issue of the LANCET-CLINIC.-ED.]

The Unsanitary Soda Water Fountain.

With the advent of spring the food inspectors are again reporting the old troubles with soda water fountains and equipments. It might be well for patrons of the soda water counters to take one of the beverage straws usually found on the counter and poke it into the steady stream attachment of the draft arm. This is usually the worst source of contamination. It accumulates the washings from the filling of soda water glass with the various syrups until the flow of the water is actually stopped and it is only then that the attendants think of cleaning out this part of their expensive equipment, seldom before. If the draft arm contains dirt it will fill the end of the beverage straw when the latter is inserted. It would also be well to look at the glasses used to serve you, before they are filled. Some attendants think it sufficient to wash these once a day, though using them repeatedly from morning until night.-Chicago Health Department Bulletin.

Book Reviews.

EMERGENCY SURGERY FOR THE GENERAL PRACTITIONER. BY JOHN W. SLUSS, A.M., M.D. Second edition, revised and enlarged. With 605 illustrations, some of which are printed in colors. Price, $3.50 net. P. Blakiston's Son & Co., Philadelphia.

This big little book serves well the purpose for which it was written; the first edition was exhausted within the short space of a year, and we bespeak the same generous welcome for the second edition which lies before us.

Certain alterations, omissions and additions in the primary text have greatly enhanced the volume, and the author gracefully acknowledges his debt of gratitude to the scribblers who review the works of master minds and assist in making or marring prog

ress.

A new chapter on laparotomy has been added in which advice is very properly given to observe the patient for two or three days in order to familiarize yourself with the temperament, laboratory findings and the preliminary preparation of the patient. This sound teaching comes awkwardly in dealing with emergency surgery! The most we can say in fairness to the author, reviewer and prospective purchaser is that the man who has not acquired more knowledge at the great surgical clinics of our country than is contained in this chapter would serve humanity and the art of surgery better by utilizing the two or three days of preliminary preparation in getting some competent surgeon to do the operation. A faux pas in the chapter on hernia says. "avoid cutting blindly when possible," we would move to amend by saying, "when not possible, don't cut."

In draining the pleural cavity the author seemingly agrees with Carstens, who says too many ribs are being resected in this operation, and rests with simple incision; it has been abundantly demonstrated that any opening in the pleura which does not readily admit of the free entrance and exit of air predisposes to pneumothorax, a condition which may prove more disastrous to the patient than the condition for which operation was instituted.

The words "wipped out" should be wipped out of the directions given for making the peritoneal toilet after operation.

The foregoing thoughts came while hastily sketching the book and count as nothing when compared with the many pages and chapters of sound advice, born of broad experience and correct thinking. which the book contains.

The illustrations, taken largely from French textbooks, are painstakingly reproduced and serve as valuable guides to illume the text.

The author of this book, while readily conceding the many advantages of X-ray confirmation in the diagnosis and treatment of fractures, is old-fash