region of the parotid gland was swelling and finally became a large mass on the left side of the face and was extremely painful. He was at first told by some of his friends that the growing tumor came from a rotten tooth, and inasmuch as all of his teeth were very rotten, he was easily led to believe the statement, and when he was told to poultice the tumor he did so persistently. Under this treatment the tumor grew faster than ever and became dark blue in color, fluctuated under deep pressure, a facial paralysis developed slowly and finally his left cheek became freed from lines of expression, and when he attempted to whistle he drew his mouth toward the right and he was unable to close his left eye completely. There was no irritation of the conjunctiva and the tears passed away in the usual channel, but the tumor had on admission to the hospital assumed large proportions, and he was not able to masticate food on the left side of the jaw. He could, however, swallow liquids, and except for the pain in his face could undertake ordinary manual labor. I explained to him that the tumor had progressed so far that the nerves of the left side of the face had become involved and that he could not expect to have the tumor removed without having the whole side of the face paralyzed, and that, of course, a large scar would result. Understanding these conditions fully, he desired to have the operation performed and it was done on the date mentioned above, and the house staff assisted me. The branches of the common carotid that are of major importance in considering operations upon the neck are the external carotid and the internal carotid, each of which have several branches that supply the inside and the outside of the bones of the head and the muscles that are attached. The external carotid supplies the temporal that passes through the substance of the parotid gland, and it was evident that any blood vessel passing through such a distorted and swollen gland as presented that day, would be found so much distorted that it would have bled at practically every manipulation made with the knife. Furthermore, as the tumor had developed there had appeared a large gland in the left side of the man's neck, and, as it was necessary to remove that as well, I decided to remove the gland and tie the common carotid in the triangle of election through the same opening which I did tying the common carotid with twenty-day chromocised catgut in two places about one-half an inch apart without cutting the artery. The wound in the neck was immediately closed with catgut sutures and covered with a piece of dressing, and the removal of the tumor on the side of the face was begun. An incision commencing at the apex, or rather above the apex of the tumor, and carried well around all the involved tissue and well back of the angle of the jaw to the external auditory meatus, and well below the angle of the jaw down to a point one inch below the horizontal ramus, and then the tumor was cut away down to the fibrous covering of the temporal bone and the zygomatic process, and then dissecting the tissue away down to the last vestige of the apparent tumor and scraping the last remnant so far as it could be secured from behind the angle of the jaw, then the skin edges were as closely approximated with silk-worm gut sutures and the wound was dressed with powder and allowed to granulate, and then on December 8, skin grafting was performed and the balance of the wound was covered with skin from the man's leg. Before the operation there was inability to fully close the left eye, and after the operation the man could not close the eye at all, but that was to have been expected, and the man was amply repaid for the inconvenience resulting on account of the comfort he now enjoys as compared to the fearfully painful time he suffered before the operation. In operations upon the parotid gland it is particularly difficult to satisfy oneself that the last remnant of the parotid from behind the angle of the jaw has been removed and so to assure the patient that there will be no return, but it is much more easy to operate upon the parotid or upon any part of the side of the gland or face if the carotid has been tied in the first place. Operations on carcinomatous tissue where the original supply of blood was of ample quantity, when that tissue is changed and the tissue becomes engorged and swollen, and all the immediate blood supply distorted, then every time. one attempts to hurry the matter at all, the flow of blood makes the field difficult in which to work with safety and accuracy, and when the gravity of the tumor or of the operative procedure is of such magnitude that one feels justified in going deep, and tying the common carotid, then the operation is comparatively dry, and can be prosecuted with vigor and satisfaction as the hemorrhage is very little more than venous. The man suffered no inconvenience in the way of brain symptoms and has been up and around the wards since the fourth day after the operation. May I review the points spoken of in the first part of the paper? First-One certain and two suspected cases of pernicious anemia in one family. Second-No tourniquet need be used in senile gangrene, the hemorrhage is easily controlled by light pressure. Third-Abdominal symptoms may be so marked that an apparently nodular tumor may seem to be in the abdomen and yet prove to be a tubercular kidney. the pylorus, before the tumor can be felt, mak- president of which was most courteous and gave ing the operation easy. Fifth-Tie the common carotid before operating on the parotid. Sixth-Expect facial palsy. MUNICIPAL SEWAGE.1 BY DOUGLAS C. MORIARTA, M.D., Mr. Chairman and Gentlemen of the Conference: IT T is not my purpose in treating this subject at this time, to take up the scientific side of the problem; nor to consider the rights of riparian owners, or what constitutes a pollution of the waters of the State, or the liability to personal infection therefrom, but rather to consider it from the practical side as we have at Saratoga, and I hope I may be able to show you that some changes in the present methods of our State Health Commission would be of value to a municipality, and so indirectly to the State, when they are forced to consider such a problem. Recent enactments of our Legislature clearly demonstrate that in the near future the Health Commissioner of the State will have remedied the pollution of our waterways, by the enforcement of our sanitary laws, and this of necessity means that sewage disposal plants must be constructed. At Saratoga, we were permanently enjoined from using the streams of the State as a terminal for our sewage and were given one year by the courts in which to build a sewage disposal plant and remove our sewage from Kayaderosseras Creek. Special legislation gave the power for a sewer commission and provided the necessary funds. The commission was appointed with power and funds to install a sewage disposal plant, a time limit of one year being the only condition. This commission organized at once and endeavored to learn where the successful sewage disposal plants were located, and their character; also, if as a whole or in part, any of them were adaptable to our purpose. The commission interviewed several men, who were eminent as sanitary engineers; and it was apparent, after being advised by these learned gentlemen, that the sewage disposal problem was not only in its infancy, but decidedly unsettled. To dispose of the sludge seems to be the difficult part of the problem. We learned that New York State had done nothing in the way of sewage disposal, except to enact legislation intended to prevent the pollution of its streams. Other States have done but little more, with the exception of Massachusetts, which is practically the pioneer in this study. She had a State experimental station, and more sewage disposal plants in operation than any other State in the Union. Our commissioners visited Boston and met the officers of the Massachusetts State Board of Health, the Read at the Fourth Annual Conference of Sanitary Officers of the State of New York, Albany, N. Y., December 16, 1904. us the freedom of their experimental station at Lawrence, arranged for us to meet several sanitary engineers, who were prominent in this work in their State, and to visit the several intermittent filtration plants which were in operation. The experimental station at Lawrence, while small has been established for a number of years, and is under the observation of the State chemist, who plans all the experiments and determines their value. The conclusion from these studies is that the septic tank is uncertain in its action and that intermittent filtration will be the scheme of the future. The latter was the view of all those whom we met who were familiar with the construction or maintenance of these various intermittent filtration beds. We also visited New York and saw there some chemical precipitation plants in operation, and observed the construction and details of maintenance. We found the original cost of construction of these plants very large and their cost of maintenance prohibitive for our village, due to the fact that the sludge had to be handled, when wet, whether burned or composted. After a year's observation, we reached the following conclusions concerning the solution of our problem: 1. That our sewage was out of all proportion to the population of our village, due to seipage, surface, storm and waste tap waters, being in amount about 400 gallons per capita per diem instead of 40 gallons per capita per diem. 2. Our sewage must be reduced to a normal quantity. 3. That we would not consider broad irrigation. 4. That contact beds were yet in the experimental stage. 5. That chemical precipitation was an unsatisfactory and extravagant method. 6. That there were several intermittent filtration plants in Massachusetts being successfully operated. 7. That the disposition of the sludge was the one feature that the sanitary engineers had been trying to solve and so far had been unsuccessful. At this time we were obliged to decide upon some method of sewage disposal for our village, and so, basing our conclusions on our practical observation, and such theoretical knowledge as was available, we decided to accept that of intermittent filtration and employ Mr. F. A. Barbour, a sanitary engineer, of Boston, to come to Saratoga and ascertain if the local conditions were adapted to the intermittent filtration proposition, and if possible, find an area of land that would answer our purpose. Mr. Barbour's report was particularly favorable. We then directed a second report embodying plans and specifications, which if acceptable to us, would be submitted to the State Commission of Health for its approval. The second report made necessary the meter ing of our water supply, the construction of many miles of water carriers, a mile or more of trunk sewer, a pumping station and twenty-one filter beds; it also advised the construction of three retaining tanks and an aerator. groomed one or more times a week and the crust, or deposit, removed, otherwise the bed would become slow or clogged. I am informed that over 3,600 tons of this material have been removed from the surface of the beds at the Brockton plant during the past year. The quantity of sewage at Brockton is about the same as at Saratoga, but is a much heavier sewage. Below the surface of the beds, anaerobic bacteria thrive; these bacteria act particularly on the fats which are contained in the sewage and which are most difficult to dispose of. Thus two classes of bacteria which are present in filtration beds have to do with the results of the problem, though the results must depend upon the period of contact of the sewage with the bacteria, which in filter beds is brief, as the sewage soon leeches away. That this, Nature's method, might be increased to its greatest usefulness and so dispose of the sludge, was the ambition of our engineer, and he accordingly suggested to us the adoption of the retaining tanks and aerator, that the full bacterial action might be possible. The anaerobic bacteria will act on the sediment at the bottom of the tanks, while the aerobic bacteria will be most active in the scum on the surface of the sewage. 1. Bird's-eye view of sewer beds, showing surface of some of the beds furrowed as they are during the winter months. An intermittent filtration plant consists of a number of beds, each bed having an area of about an acre, under the surface of which tiles are arranged to collect the effluent and conduct it to a common center. The beds are bounded by an embankment, in which the pipes and gates are located to control the distribution of the sewage. The surface of the beds is level, in summer, unless crops are grown; for winter it is plowed in furrows, and where ice forms it is permanent and the sewage flows under the ice in these channels. The sewage is allowed to flow on the beds in definite quantities and at fixed intervals. The quantity of sewage for each bed is governed by the area of the bed, the character of the soil and the interval between the doses, and by the condition of the surface and activity of the bed; the object of the interval is to allow oxygen to gain access to the soil, which is essential if the best result is to be obtained in caring for the sludge, which is deposited on the surface of the beds or in the first inch of the soil, which is laden with scavenger bacteria. The organic compounds present constitute the insoluble portion of the sewage, and are mostly nitrogenous in character. The chemical changes which occur are principally those of oxidation and nitrification-ammonia compounds, nitrites and nitrates of the alkaline bases are the principal compounds formed. While we have studied the sewage and effluent and estimated the chemical changes weekly, since the inception of our plant, as stated, I do not propose taking this study up at this time. The surface of the beds where there are no retaining tanks has to be The sewage passes out of the tanks to an aerator, where it flows in a thin sheet over rough surface of metal, not unlike an open umbrella in appearance, which breaks it up, allowing the sewage to more readily take oxygen from the atmosphere, to give activity to the aerobic bacteria while the sewage is passing through the filter beds. By actual tests we know that the sewage takes up 90 per cent. of oxygen while passing over our aerator. As you know, the activity of all bacteria depends upon the temperature of the medium in which it exists. This was forcibly illustrated last winter-as the temperature of the sewage became lower, the sludge in our tanks increased. In the spring as the temperature of the sewage became higher there was an increased bacterial activity and the accumulated sludge of the winter months commenced to disappear, illustrating most forcibly the necessity of keeping all surface and storm waters from the sewers, as these would materially lower the temperature of normal sewage. The activity of the bacteria is also modified by antiseptics which are present in the sewage from municipalities where manufactories are present, if they use chemicals which are discharged into the sewer. After two years of continuous observation and study the commission accepted Mr. Barbour's final report. It was approved by the State Commissioner of Health and we were ready to commence our practical work. We first reduced the quantity of sewage which was due to our original system being a mixed one, i. e., carrying sewage, seipage, surface and storm waters, and a very large quantity of waste water from our taps; the latter was due to defects in plumbing, and also to its use to protect plumbing in cold weather. In almost every home there was one or more taps that were allowed to run so that the water would circulate and not freeze; the poorer the construction of the house, the more freely water would be allowed to run. This complication was overcome by metering the entire water supply of our village, and charging a fixed rate for each 1,000 gallons of water consumed. The construction of many miles of water carriers, the converting of certain parts of our smaller sewers, where the seipage was great, as well as a mile or more of our trunk sewer, into water carriers, did the rest. The abandoning of our old trunk sewer necessitated the construction of a new one, of a mile or more, which carries the sewage to our pumping station by gravity. Here we established three centrifugal pumps, run by electricity, working automatically and independently or together as required to raise the sewage nineteen feet, through a mile and one-half of pipe into the retaining tanks at the filter beds, here it remains until the bacterial action is accomplished. We have four of these tanks, each having the capacity of 500,000 gallons. We use one or all of these tanks as required to allow the sewage to undergo bacterial action. The exact time it should remain in the tanks is a matter of continuous observation, as conditions of sewage and temperature must always be considered. From these tanks the sewage flows over the aerator, then into a tank called the dosing tank, which holds 50,000 gallons, the quantity usually emptied on one bed at a time. This tank has an automatic apparatus which will distribute the sewage on any one of four beds in rotation that may be selected by the caretaker. We have in all 21 beds, 19 of which are intended for the usual sewage as it leaves the tanks, while two are arranged for sludge beds, when we shall have occasion to empty the retaining tanks. As yet these beds have not been used. By measurements made twice weekly the deposit in the bottom of the tanks and the amount of scum on top of the tanks is the same in amount as a year ago. (I am speaking of the period from November 1, 1903, to November 1, 1904, when the tanks had only been used five months.) Because of the bacterial action in the tanks there has not been the slightest nuisance from the beds or aerator. As a matter of fact, these sewage beds are an added attraction to our village, and many of our guests visit them and find them not only free from annoyance, but speak of them as picturesque. At the Brockton (Mass.) plant they do not have retaining tanks, and they have had to remove 3,000 tons of compost from the surface of their beds during the past year, while we have not removed any during the whole experience of a year and a half. This fact with the automatic pumping station and dosing tank reduces our maintenance to an unprecedentedly small figure, our maintenance costing about $3,000 per year for 1,500,000 gallons per diem. I will ask your indulgence while I itemize our maintenance for the past year from November 1, 1903, to November 1, 1904, as the maintenance of our plant is of very great moment to those contemplating the establishing of a sewage disposal plant. One man at pumping station (half time).. $300 One man in charge of filter bed. Extra labor at beds.. 750 660 200 1,500 $3,410 This includes preparation of beds for winter, leveling and extra care in the spring and the removal of the snow from the sewage runways in each bed. Another year I believe the cost of extra labor will be reduced to $1,000, and now that our pumps are adjusted our bills for power will be as they have been for the last three months-about $50 per month, making a saving in the year's power at the pumps of $250. So I believe the system can be maintained for materially less than $3,000 annually. In closing I trust the review of the experience 2. Bird's-eye view of the beds, showing the run-way in which the sewage flows to reach the surface of the beds. of the commission compelled to install a sewage disposal plant at Saratoga warrants making the following conclusions: First. That the sewage disposal plan at Saratoga is an ideal one for sewage not contami nated with germicides; the beds did perfect work last winter with a temperature that would average zero and for days was from 20 to 30 degrees below that point; there is no local nuisance of any kind at or near the beds. The maintenance is low and the effluent potable, the latter meeting the State's requirements. 3. The aerator as it appears in the winter time. Second. That the State Department of Health should be in a position to advise a municipality, it is compelling to establish a sewage disposal plant, concerning the proper course to pursue. In other words, the State Department of Health should not only be competent to, but it should be the duty of the department to determine the best and most practical method for the village to adopt, thus obviating the anxiety, delay, uncertainty and expense that our commission had to experience for two years while determining the most practical method of sewage disposal for our village. The whole undertaking necessary to divert our sewage necessitated an expenditure of $200,000, with no assurance of the plant being of service to the village, other than our own conclusions. This is too much to ask of citizens unfamiliar with the technical knowledge involved. Third. The State Department of Health should provide means either by establishing a small sewage plant, where all the essential features, both theoretical and practical, could be determined, or else make a temporary experimental station at any of the sewage disposal plants in the State, moving from one to another when all the features of a particular plant are acquired. This would naturally stimulate the head of the department to gain a knowledge concerning all sewage disposal plants in the United States and Europe. The knowledge accumulated in this way with a chemical and practical examination of the sewage from any municipality and an examination of the local soil should enable the State to determine and inform the city or village that which is best and most practical at a very small cost. The local engineer could then prepare plans and specifications for such construction as was required. This would save thousands of dollars to the city or village, and, to my mind, insure the installation of sewage disposal plants of a very high efficiency. Fourth. I would emphasize the above statements and the urgent need of a State sanitary department to take up the study of sewage disposal by reading the discussion of Professor Landreth's paper presented to us in 1901. At this time our Commissioner of Health, Dr. Lewis, said: "Are there any gentlemen present who wish to discuss this paper? You know dinner doesn't come until 8 o'clock to-night. If there is to be no discussion, and I can understand why you do not wish to discuss this paper-it is because you don't know how to discuss it. is the way I feel about this question of sewage disposal. I have spent considerable time in studying the question. I went with a number of others to England a few years ago with the express purpose of studying their plants and found that the same uncertainty exists there as here as to what is the best and most feasible method of disposing of sewage." That EARLY DIAGNOSIS AND TREATMENT OF PULMONARY TUBERCULOSIS.1 TH BY JAMES J. WALSH, M.D., Ph.D. HERE is no doubt left now in the minds of medical men that tuberculosis, even in the form of tubercular consumption, can be cured if taken in time and properly treated. Long ago Dr. Holmes said that he could cure anything if it only came to him in time. He added, however, that most of the diseases that came under his care to be successfully treated should have come in the persons of the grandparents, or perhaps the great-grandparents of his present patients. Without harking back as far as this, consumption is absolutely curable. Over 70 per cent. of the bodies of patients who have not died from tuberculosis that come to autopsy at the Vienna general hospital present healed tuberculous lesions. Not only are there pleuritic adhesions, but there are puckerings at the apices and occasionally even calcified nodules to show the former existence of a tubercu |