dice it was noted from three days to a week before the appearance of the jaundice.

In some cases of pulmonary tuberculosis a bad taste comes on about noon and lasts the rest of the day, and in acute rheumatic fever a disordered taste, either acid or bitter, appears to be present in about 60 per cent of the cases.

In two cases of pernicious anemia a persistent bitter taste was found to have preceded the other clinical symptoms by six and eight months, respectively. Patients with arteriosclerosis sometimes complained of an inversion taste, salty things tasting sweet, for instance. Anomalies of taste were also occasionally noted in disease of the central nervous system, and were believed to be often due to syphilis of the brain or cord.

Among other conditions in which Reilly has found a complaint of bad taste are diabetes, hysteria, neurasthenia, pregnancy, gastric and duodenal ulcer, and cancer of the stomach and uterus.

As the result of a year's close questioning of hundreds of patients, he concludes that persistent bad taste in the mouth is a symptom of much importance, that it is for the most part an expression of a serious toxemia, and that it may be of very great service in the early diagnosis of disease. In the two affections, interstitial nephritis and gall-bladder disease, when the sign is present it sometimes affords valuable information. As to the significance of its presence in other diseases, time will disclose, he says, whether or not it has any practical value.

Doc

THE NEW DISINFECTION. Editorially the Dietetic and Hygienic Gazette declares that the newer disinfection-the killing off or rendering impotent the germs of a given disease in homes which it has invaded-has come about through newer knowledge gained in the last half century as to how infectious diseases (yellow fever, typhoid, malaria, measles, tuberculosis and so on) are transmitted to humankind. tors still well in middle life will recall when a saucer containing a solution of carbolic acid placed in the sick room was considered a potent preventive of such infections as diphtheria, scarlet fever and measles. When epidemics of yellow jack threatened our ports a great deal of property and merchandise was confiscated by quarantine authorities, on the erroneous theory that fabrics (fomites) contained and conveyed the germ of that dreadful disease. And comic relief was afforded in the situation by an official kiting through railway cars that had come up from our Southland with something burning in his hand under the obsession that the car would thus be rendered free of the yellow fever virus. Yet everybody

knows that yellow fever is transmitted only and solely by a special kind of mosquito; malaria only by another kind of mosquito, and n.ver in any other way-certainly not by bad air (malaria); the body louse transmits typhus fever: such diseases are not directly from one person to another but by such intermediaries as these. Cholera and typhoid fever are not contracted through atmospheric effluvia but solely by swallowing their essential germs in impregnated food and drink. Diphtheria is probably communicable through the air; but only by direct contact with the sick, as in kissing; or by contact of the mouth and nasal surfaces with the diphtheria germ. One need apprehend nothing from the air of a diphtheria patient's sick room, but only from substances contaminated with his expectorations. Hospital physicians and nurses careful in their ablutions are in constant attendance on sufferers from diphtheria, scarlet fever or measles for months, without contracting these diseases or being in any fear of doing so. The safest place in the world against diphtheria is the properly conducted ward of a diphtheria hospital. The surest place not to contract tuberculosis is a well managed sanatorium. What germiphobia, what ignoble public hysteria, what discomfort would be obviated by a general knowledge of such facts. Here as elsewhere fear vanishes immediately it is comprehended.

Nor are scarlet fever and measles transmitted through the peeling from the skin in these diseases; nor is the "peeling" stage, as was formerly supposed, that when transmission is most likely to take place. And measles is infectious anyway only during the first several days of the disease. Such facts, then, have led to more rational public health measures. London, for instance, maintains hospital accommodations for some ten thousand infection sufferers and treats nine-tenths of its infectious cases in its hospitals; yet it gives hardly any attention to measles, which is not even notifiable to the authorities. Why not? Because by the time the report is received and the case placed under surveillance the damage has been done. For the same reason disinfection is not now done after measles cases. The only cases of this disease the authorities consider are those occurring in schools and which are at once removed. Dr. Charles V. Chapin, the able health officer of Providence, R. I., has for years abandoned the disinfection of the homes of diphtheria, scarlet fever and measles patients, with no increase in the number of secondary patients (such as would have contracted the disease from their sick relatives and friends). Any way the number of secondary cases of scarlet fever occurring in private families directly exposed is surprisingly small-less than

four per cent of those who come directly in contact with the disease, states the superb August Bulletin (on which these observations are based) of the Department of Health of the City of New York.

Certainly disinfection will destroy germs or render them innocuous; but most germs cannot in any event retain their vitality and their capacity for mischief for any length of time after leaving the patient's body; and, as a matter of fact, the best disinfectants ever invented are pure air and sunshine; a sick room thus ventilated after the termination of the case, and the bedding, carpets, rugs and so on exposed to the blessed sunshine, with plenty of soap and water for scrubbing up will, for most infections, be all the disinfection necessary. Thus, in accordance with the modern conception of the spread of infections, and following a report of Dr. Herman M. Biggs, its general medical officer, the Metropolitan Board of Health last year abandoned fumigation (the burning of disinfecting gases) after the diphtheria case but removed the bedding to its disinfecting station. But when the patient died or was removed to a hospital during the height of the disease, fumigation was done, it being considered possible that fresh discharges containing living germs might be present in the sick room. Measles was similarly handled except that the household goods were not removed for disinfection after death or recovery. In scarlet fever fumigation was done after recovery, death or removal; and the infected bedding was sterilized. In June last, however, the Department discontinued, by reason of the practical absence of danger from the patient's bedding, its disinfection after cases of diphtheria, scarlet fever, measles, cerebral spinal meningitis and poliomyelitis.

HOW MANY WILL BE KILLED AND WOUNDED IN THE PRESENT WAR? Last month we ventured some guesses at the number of soldiers likely to be killed and wounded in the world war now in progress. We based our predictions upon the number of casualties during the Franco-Prussian war. Dr. Octave Laurent, of Brussels, has also been speculating upon this subject, and in a volume recently published upon the surgical aspects of the recent Balkan wars, using these as a basis for comparison with present conditions, arrives at the following conclusions:

"Bulgaria put into the field during the two wars more than 500,000 soldiers, drawn from a population of about 4,300,000. In the first war 30,000 men were killed and about 53,000 were wounded. In the second war the killed numbered 16,000, and the wounded about 62,000. The totals for the two

wars were: Killed, 46,000; wounded, 115,000. The total of killed and wounded, 161,000, represented one-third of the effective force of the whole army, or three per cent of the entire population of the country. The deaths were one in twelve of the whole army, one in four of the wounded, and one in a hundred of the population. During the month of July, 1913, 150,000 men were killed or wounded on both sides; and more than half of these, at least 80,000, fell on the banks of the Bregalnitsa during the six days from June 30 to July 5.

"If you put a zero behind each of these numbers you will have some idea of the effective strength of the armies and the losses that must be presumed to take place in any war which would tomorrow set the armed forces of any two firstclass powers of Europe on the fighting line before each other. There would be not less than 1,500,000 dead and wounded in the course of the first month.'

"The high proportion of the killed to the wounded during the Balkan War is a modern feature that would be likely to be repeated. Artillery fire, meaning by that the use of explosive shrapnel, was responsible for more than half of the deaths, but for less than one-fifth of the wounded. Rifle fire was therefore relatively ineffective by its failure to produce those massive destructive effects which follow so swiftly on the skilful use of artillery. It is precisely the reliance on the large use of artillery fire which would mark the operations of the great European, armies, and from that one has little excuse for forecasting any but high figures for the killed.

"Under modern conditions, many of those wounded by the small calibre, high velocity bullets now used would stand good chances of recovery with probable small permanent disablement. One of the surprising features of the wounds in the Balkan War was the great number of perforations by bullets which did comparatively little permanent damage. In some of these seemingly serious cases of wounds, healing was rapid and uneventful. Even bones were sometimes neatly pierced with small holes, without fracture, or other serious consequences. This was not the rule in bone injuries, however, for there were many complicated fractures of the larger bones, these constituting a special surgical problem. Flesh wounds from direct rifle fire were often absolutely harmless; and in many cases the wounded were back on the firing line in two or three weeks after wounds that in the older wars would have meant absolute disablement. The mortality was distributed among fiftyfive per cent wounds of the head; thirty-five to forty per cent wounds of the trunk; and five per cent wounds of the limbs. Amputations were done

in less than one per cent of all the cases treated in the hospitals.

"In modern warfare, where the soldier fires under cover as much as possible, lying prone in a trench, bullets from the enemy either hit him on the head or catch his hands. The right hand is protected by the rifle, so that it is the left that gets hurt.

"Laurent suggests the use of a metallic shield, sufficiently light, yet resistant, to protect the head, another fixed to the left hand or on the rifle itself, and a third to protect the region of the heart. Many soldiers have had their lives saved by the chance presence of a pocket-book filled with papers, or even of a metallic cigarette-case, in the left breast-pocket of their tunic. Superposed sheets of paper have always constituted, even in ancient wars, an excellent shield.

"Laurent's statistics show from 82 to 84 per cent of bullet wounds, from 15 to 17 per cent of shrapnel wounds, and 1 per cent of wounds by cold steel. Infection by the projectile was observed in 40 per cent of cases by shrapnel and from 10 to 28 per cent of bullet wounds.

"The number of wounds cured without any complication was 75 per cent. Shrapnel bullets have a much less penetrative force than rifle bullets, at any rate when the shrapnel does not burst close to the soldier."

FOREIGN

XXX

BIRTH-RATES AND THE
EUROPEAN WAR.

The Paris correspondent of the Journal of the American Medical Association has recently communicated the following additional data about the constantly diminishing birth-rate, and other impor

tant vital statistics of France:

"There were 745,539 living infants born in France in 1913 as contrasted with 750,651 in 1912. No lower total has ever been registered, with the exception of the year 1911. In recalling the steady fall in the French birth-rate, it will be enough to mention that the annual average of living births was 945,000 during the period from 1872 to 1875; that, since 1907, the number of births dropped below 800,000, and since 1911, below 750,000. This means that in less than forty years the French births have diminished by more than 200,000 a year. The proportion of living children to every ten thousand inhabitants was 188 in 1913, instead of 190 in 1912, 187 in 1911, 196 in 1910, and 205 in 1906. The decrease, therefore, is accentuated each year. It is true that the birth-rate is falling in all the large countries of Europe, but the proportion is much less than in France; and, moreover, the excess of births over deaths is proportionately five or six times greater. Thus, for the

year 1912, the excess of births over deaths for each ten thousand inhabitants was only 15 in France; in the same year it was 158 in Holland, 140 in Italy, 130 in Hungary, 127 in Germany, 107 in Austria, and 105 in England. Last year showed an excess of 41,901 births over deaths, or only 10 for each ten thousand. The excess in 1912 was 57,911, or 15 per ten thousand. This diminution is due to a deficit of 5,112 births and an increase of 10,989 deaths. The departments in which the birth-rate exceeds the death-rate are those of the north, Pas-de-Calais, Brittany, the frontier regions of the northeast, Limousin and Corsica. On the other hand, the valley of the Garonne, Normandy, the plateau region of Langres and Dauphiny continue to lose ground. The number of deaths (703,638) is greater by 11,000 than that of 1912, which was lower than any recorded number since the opening of the nineteenth century. The proportion of deaths to the population is 178:10,000, as against 172 in 1912, 196 in 1911, and 179 in 1910. The mortality has increased in 64 departments, and particularly in Bouches-du-Rhône, Dordogne, Var, Haute-Savoie, Corsica, Somme, Haute-Vienne, l'Aveyron and Tarn-et-Garonne. In 1913, 298,760 marriages were recorded, or 13,169 less than in the preceding year. The proportion of the newly married for each ten thousand has dropped from 158 in 1912 to 151 in 1913. The number of divorces has increased by about 500; 15,706 were recorded in place of 14,579 in 1912. The increase has therefore continued; in 1900 there were but 7,157 divorces; in thirteen years the number has more than doubled."

"These statistics, always of interest for speculation, acquire new significance in the light of the great European war now in progress," remarks the Boston Medical and Surgical Journal. "If it be true that this war is at bottom racial, another step in the great medieval barbaric invasion of South European civilization by hordes of superior vitality from the north, then the outcome of the conflict, whichever way it may befall, should go far toward solving the question whether decreasing race fertility is or is not an accurate index of declining race vigor."

On Aug. 7 the Berlin correspondent of the Boston Transcript communicated still further data of interest in connection with the German birth-rate and population:

"The imperial statistical department gives the population of the German Empire, for the middle of the year 1914 as 67,812,000. In the middle of last year it amounted to 67,000,000 in round numbers, and it is assumed that in the meantime it has increased to the amount of 800,000. Of course this is merely an estimate. But the statistical de

partment is extremely careful in such calculations, so that the figures may be regarded as likely to be extremely accurate. As the population of France has increased by only 42,000 persons in the course of the last year, the natural increase of population in Germany would amount in the same period to nearly twenty times that of France.

"At the same time, it must be borne in mind that there has also been a falling off in the birthrate of Germany of late years. For whereas in the year 1906, 2,085,000 children were born in Germany, in the year 1910 the total amounted to only 1,983,000, that is to say, to over 100,000 less, and in the year 1912, the total amounted to only 1,926,000, that is to say nearly 80,000 less. This decrease in the births is, however, almost equalized by a nearly equal decrease in the death-rate. In the year 1905, 1,256,000 persons died in Germany, whereas in the year 1912 the total deaths amounted to 1,086,000; so that the falling off in the deathrate amounts to 170,000, the result being that this falling off is only 10,000 less than the decrease of births since 1908.

"Then we have the fact that there has been no falling off in the number of marriages in Germany during the last few years. The number recorded for the year 1909 was 494,000, and that for 1912 523,000. We see, therefore, that the number of marriages has increased by nearly 30,000, whereas in France the number has lessened almost to the same extent. This all points to the fact that, in contradiction to France, there is not likely to be any material falling off in the German birth-rate in the immediate future. Furthermore, the continued hygienic improvements being introduced into Germany, more especially all that is being done to fight against infant mortality, render it extremely unlikely that any increase of the deathrate should take place, of course, barring all unexpected events, such as epidemics or a war.

"It is extremely difficult to reconcile this steady fall in the French birth-rate with the continued increase of the peace strength of the army. An eminent authority, the French General Pédeya, has expressed his opinion that the reintroduction of a period of three years' military service will place an unnatural strain on the resources of the country. He points out that Austria-Hungary, with a population of ten million more, possesses a much smaller standing army. Another authority, Troussant, the inspecting medical officer of the French army, states that the health of the French troops is in a very unsatisfactory condition. An appalling percentage of the young men serving with the colors are tuberculous. It will readily be believed that the great physical strain to which the modern soldier is subjected, even in times of peace, is

hardly likely to have a beneficial effect on such men. It is obvious that a country having a population of forty million inhabitants and increasing at the rate of only 40,000 annually, can keep the same number of men with the colors as a country of sixty-eight million inhabitants, and with an annual increase of more than 800,000, only provided that it is prepared to accept a far lower physical standard for its recruits, that is to say, such a country must take the recruits as they come, and be prepared to see a large percentage of them physically ruined by the strain thus imposed."

"It is probably true that the Germans have already, especially in the larger cities, begun to feel and show the debilitating and deteriorative effects of modern civilization," says our Boston colleague. "The question therefore remains whether this effect is yet sufficient to make them unable to cope, on the one hand, with highly civilized nations with a low birth-rate, like France and England, and on the other with the perhaps still sturdier and more prolific stock of the more barbaric Muscovite and other Slavic peoples of Russia and the Balkan countries."

THE SURGERY OF WAR.

A timely paper upon "War Surgery" appears in the August number of the Annals of Surgery. It is all the more significant because it is written by a Belgian, being the presidential address of Prof. Antoine De Page, of Brussels, at the meeting of the International Society of Surgery, recently held in New York. It was, of course, delivered before there was any thought of war in Belgium, which was, as Professor De Page remarked, "covered by Europe herself with the shield of peace and liberty."

Professor De Page had served as a volunteer surgeon with the Turkish army in the Balkan war. Speaking of the surgery of the battlefield the author said: The fate of the wounded depends more than all on the aid which is given in the front of the battle, for as long as the engagement lasts, the exposed ground is inaccessible for the ambulance men, of whom more than one has sacrificed his life in spite of all precautions taken; thus hours pass, during which the men remain without help.

Schaefer has drawn a heart-rending picture of this deplorable state of things. Haga acknowledges that it is no longer possible for the ambulance men to circulate on the battlefield, exposed to the hail of the shrapnels. What is to be done? The following is without doubt the solution: each of the combatants must carry with him, side by side with his cartridges, the objects necessary for a first dressing. This solution has already been

accepted and taken into use in different countries; at the most an improvement on this idea could be realized, by adopting a model of uniform packet for first aid; but the experience of the late wars has only proved too clearly that, before all, the sanitary education of the soldier must be improved.

He must fully realize the dangers of infection, by earth, dust and water; of what use is a disinfected compress, if it is soaked in polluted water?

A soldier must also possess knowledge of certain simple facts, for example, he should be aware, that in case of a wound in the abdomen, it is better to rest motionless, even if for hours, than to walk as far as a station.

The military instruction of a soldier in future will not be complete unless it comprises an acquaintance with the necessary measures to take for his personal safety, and especially the elementary rules of asepsis and antisepsis. The making general these instructions will result in a great saving of human life, I think.

Do not let us even leave the bringing of first aid to the wounded for the ambulance men, as thus, it may often arrive too late.

May I be allowed again to call your attention to a certain point?

If it is true that immediate help is the most efficacious on the battlefield, it must be considered that this help should be limited by precautionary measures, the stations at the front, those temporary erections which change place as the troops change, and cannot be provided with the necessary implements as hospitals, are only stopping places, where the sick and wounded are sorted out. Unfortunately they are not always made use of in this way: during the Balkan War the Turkish army doctors and others tried to extract the bullets and amputated in the ambulance at the front, and we were able to certify that on the arrival of the wounded at the hospitals of the town, the greater part of these interventions had produced deep-seated suppuration.

In the hospitals of the second line, which never change place whatever happens, the operations could be performed that were judged indispensable.

There experienced surgeons should be placed, who would have to decide the serious questions, and the most pressing and grave interventions would be decided on and carried out in these hospitals of the second line, where the wounded could be taken whose condition did not permit of a long transport.

Civil consulting surgeons should also be attached on regular duty; from every point of view this addition seems to be desirable, the presence

of these civil surgeons at the hospitals would give them a neutral character, which they have not at present. The capability of these consulting surgeons would assure the utmost caution being used at the critical moment, when the fate of the wounded is in the balance; in short, these tried surgeons would oppose the performance of all operations, of which they did not clearly see the urgency.

We all know that a man surprised by a traumatism can oppose less resistance to a general shock, than another who has had the time to prepare and arm his organism.

The wounded leave the battle-field discouraged, worn out, and join in general the number of "bad cases"; therefore still more reason to be careful.

Respect for human life should be our only guide. The finest operation is not always the most well directed, neither the battlefield nor the surgical clinic allow of experiments on human beings.

The discharge stations should keep up their character, therefore the addition of experienced civil surgeons appears advisable. During the last wars, a fact which filled all the surgeons with astonishment, is the comparative harmlessness of the modern gun; of it has been said that it is a "humane weapon," as if these two words would not swear at finding themselves together. But for a fact, I have seen, and others have also seen, bullets which had pierced the arm or the leg sometimes throughout their whole length, and others the abdomen or the breast or even the back of the brain without producing infection or any serious consequences.

The fact was so generally remarked upon, that the military authorities took up the matter; it is not uninteresting to notice this, just at a time when the effects of the cannon have become more deadly than ever.

Surely we surgeons will not reproach the modern gun for not killing his man with every shot, what we do desire is to reduce the so-called "efficacy of the shrapnels," it is too horrible.

At a meeting of the Imperial Surgical Society at Constantinople, December, 1912, just at the time when we could hear the thunder of the cannons of Tchatalja every day, we expressed the fervent wish, that the use of the shrapnels might be abolished on the same grounds as the explosive bullets.

To military men this wish may appear naive, I do not deny it, but at the same time let me tell you, that I am not in any way ashamed of it.

It seems to me that here, so far away from the lands divided by a deadly animosity, you wil