irreducible for several years. There was a peculiar condition of the sac in this case. It had been split close to the internal ring, and a slender prolongation of omentum had projected through it for about two inches, which had become adherent outside of the sac. Was operated on by the lap-joint method with excellent results. Was discharged August

Case 40.-July 13, 1897. V. R.; aged 32 years; a native of Finland. Left oblique' inguinal hernia, scrotal, of ten years' standing. It was retained by a truss with great difficulty. Was operated on by the lapjoint method, using cable-twist silk for sutures. Unfortunately one of the deep sutures was drawn too tight and caused a sloughing of the aponeurotic layer inclosed within the grasp of the suture, thus necessitating its removal and delaying union for several weeks. Discharged September 11. The scar remained very firm when last seen.

Case 41.-September 15, 1897. A. S. L.; aged 49 years; a native of the United States. Right oblique inguinal hernia, scrotal, of seventeen years' standing. During the past few years it had become very painful, thus greatly interfering with his work as a marine engineer. Was operated on by the Andrew's lap-joint method, with kangaroo tendon sutures. Primary union. Was discharged October 5. Scar remains very firm and he is free from pain and discomfort.

Case 42.-September 20, 1897. C. F. J.; aged 36 years; a native of Norway. Left oblique inguinal hernia. Was operated on by the lapjoint method. Discharged October 20. Has not been seen since. Case 43.-September 27, 1897. E. E.; aged 31 years; a native of England. Left oblique inguinal hernia of four months' standing. Was caused by jumping. Operated on by the lap-joint method, with kangaroo tendon sutures. Primary union. Discharged October 15, and

has not been seen since:

Case 44.-September 27, 1897. J. D.; aged 45 years; a native of the United States. Right oblique inguinal hernia of three months' standing. Was caused by lighting heavily on his feet from a fall. Was operated on by the Andrew's lap-joint method, with kangaroo tendon sutures. Union by first intention. Discharged from hospital October 17. Patient has not been under observation since.

Case 45.-December 21, 1897. M. H.; aged 33 years; a native of Norway. Right oblique inguinal hernia, which had been caused by a fall six months before. Was operated on by the lap-joint method, with kangaroo tendon sutures. There was a slight suppuration in the wound. Was discharged January 28, 1898.

Case 46.-February 5, 1898. J. L.; aged 37 years; a native of the United States. Right oblique inguinal hernia, which occurred eighteen months before from a slip of the foot while carrying a heavy load. Was operated on by the lap-joint method, with kangaroo tendon sutures. The union was considerably delayed by a suppuration of the wound, but a firm scar was the final result. He was discharged March 16.

Case 47.-February 23, 1898. F. T.; aged 49 years; a native of Ger

many. Right oblique inguinal hernia. Was caused by a fall. Was operated on by the imbrication method, with chromicised catgut sutures. Owing to the too frequent occurrence of suppuration when the Marcy kangaroo tendon was used, I abandoned it for the chromicised catgut, sterilized by boiling in absolute alcohol under pressure and preserved in hermetically sealed tubes. Primary union. Was discharged March 15. Case 48.-March 11, 1898. C. H. D.; aged 50 years; a native of the United States. A very large right oblique hernia, scrotal, of eleven years' standing. Was caused by lifting a barrel. A variety of trusses had been worn, but without comfort or success in retaining the hernia. Was operated on by the lap-joint method, with chromicised catgut sutures, and was followed by primary union. Was discharged March 31 and reports that scar is very firm.

Case 49.-March 16, 1898. J. C.; aged 35 years; a native of the United States. Left oblique inguinal hernia, which had occurred one year before. Operated on by the lap-joint method, with chromicised catgut sutures. Primary union. Was discharged April 4, and has

not been seen since.

Case 50.-March 17, 1898. F. L.; aged 31 years; a native of Russia. A left oblique inguinal hernia, which had occurred one month before while pulling on a rope. Lap joint method, with chromicised gut sutures. Primary union. Discharged April 4.

Case 51.-March 18, 1898. G. H.; aged 46 years; a native of the United States. A large right oblique inguinal hernia, scrotal and irreducible, on account of adhesion of the omentum to the sac. It was of seven years' duration. Imbrication method, with chromicised gut sutures. Primary union. Was discharged April 6, and is now serving in the United States Volunteer Army.

Case 52.-March 19, 1898. N. D.; aged 35 years; a native of Finland. Right oblique inguinal hernia of two years' standing. Was operated on by the imbrication method, with chromicised gut sutures. Primary union. Discharged April 7.

Case 53.—March 25, 1898. C. H.; aged 53 years; a native of Denmark. Right oblique inguinal hernia, which was operated on by the imbrication method and followed by primary union. Discharged April 23.

Case 54.-April 9, 1898. P. M.; aged 37 years; a native of the United States. Left oblique inguinal hernia of three years' standing. Was caused by lifting the end of a spar. Was operated on by the imbrication method, with chromicised gut sutures. Primary union. Was discharged April 28.

Case 55.-April 14, 1898. T. B.; aged 30 years; a native of Australia. Left oblique inguinal hernia of two years' standing. The testicle, which was high in the canal and atrophied, was removed with the sac. The canal was then closed by the lap-joint method. Primary union. Discharged May 4.

Case 56.-April 16, 1898. J. W.; aged 33 years; a native of England. Double oblique inguinal hernia. Both were operate on at the same time by the lap-joint method, with chromicised catgut sutures. Primary union. Discharged May 5. Result excellent when last seen.

Case 57-June 10, 1898. Dr. C. B. Ford, operator. J. D.; aged 46 years; a native of the United States. Right oblique inguinal hernia. Was operated on by the lap-joint method, with chromicised gut sutures. Primary union. Was discharged June 26.

REPORTS ON TUBERCULOSIS IN RIO AND ON THE ETIOLOGY OF

BERIBERI.

By Sanitary Inspector W. HAVELBURG.

PREVALENCE OF TUBERCULOSIS.

Among the diseases which constantly prevail in Rio de Janeiro tuberculosis occupies the first place. It causes the greatest number of deaths, and, therefore, it may be proper to report particularly thereon.

In order to prove the great mortality from tuberculosis I present the following table:

If we consider that the city of Rio de Janeiro is of large extent, that the people for the most part live in one or two story houses, and spend a great deal of time in the open air on account of the climate; that manufactories here are not yet so much advanced as in many other large cities, so that the air is not so much contaminated by them, in short, that in many respects the natural hygienic conditions of Rio de Janeiro are more favorable than those of other large cities, then the importance of the foregoing figures assumes much greater proportions.

The people of north and central Brazil are in general of low stature and very thin, with tender bones, so that they are inclined to what is called a predisposition to consumptive habits. The constitution of Brazilian women in general is still another cause for suspecting in them a disposition to consumption. The vital resistance is, speaking in general terms, considerably reduced. The damp, warm climate is, as is known, very favorable to the propagation of tuberculosis. Therefore all the circumstances are highly conducive to the development and

increase of the tuberculosis germ, which already exists here and is so widely prevalent.

No precautions whatever for preventing its propagation are used. The sputum is carelessly expectorated by the patients; its danger is not generally known. Even if it is expectorated into a spittoon it is not properly disinfected, and the possibility of the particles being carried by the breeze after drying is not generally realized.

In view of the great number of consumptive patients, it is evident that Koch's bacillus of tuberculosis exists to a great extent in the habitations of the people, and we know from scientific investigations how this germ is preserved on the walls and tapestry and in the dust, etc.

Climatic treatment, which is much used in Europe, is impractiable here. There are, indeed, some localities (Campos do Jardao, Barbacena, etc.) which are well known for their immunity from consump tion. I do not know whether their reputation is well founded. However, patients who repair to those places are unfortunately obliged to deprive themselves of the greater part of the requisites for the proper treatment of the disease, therefore the result of the treatment is very doubtful. In my own medical experience I have seen no real success. The treatment of patients and the means adopted for the extinction of tuberculosis consists merely in administering medicine. But we know how impotent are purely medicinal measures from an etiological point of view. . In regard to the symptoms of consumption we can certainly do something; in regard to the etiological cause nothing. In this country the modern scientific and practical efforts for constructing special sanitary establishments have received hardly any attention.

Precautions for protecting children against infection are entirely insufficient. Many children are directly infected from hereditary causes or from close and constant contact with their parents.

Another source of infection, principally for children, is the cow's milk with which they are fed. In this country tuberculosis prevails to a great extent among cattle. There is no inspection of the animals by the authorities.

In the city and its suburbs it is usual to milk the cows in the presence of the buyer, which is useful for the latter's protection against adulteration. The milking is done in the open streets. No care is taken to insure the cleanliness of the udders or of the hands of the milker. Thus suspicious particles of foreign matter may enter the milk.

Other important measures for combating the disposition to tubercu losis, such as hardening the body in different ways, as for instance by gymnastic exercises, which contribute to physical development, and by a strict attention to methodical alimentation, are taken by the public here into little account.

I regret to say that, in my opinion, there is little probability of any change in the hygienic conditions relating to tuberculosis. By the