You, Doctor

Your work, Doctor, is exceedingly important. The productive capacity of a people is directly dependent upon the scientific care taken of their health.

A certain proportion of Physicians are needed for army work. Those whose situation best qualifies them— age, dependents, special skill, etc.-should go first. If they don't go voluntarily when the government needs them it will take them. The profession, however, is setting a splendid example of patriotism and such a course is not probable.

For that proportion of the profession that is their readjustment-army work.

But only a proportion of the profession will be needed for army work. What about the far larger proportion who are not needed for army work? What is their readjustment?

To take the profession of medicine and your everyday

the world we will benefit equally with those who have "borne the heat of the day.'

Doctor, it should make us very humble in spirit. Let us remember the millions for whom the readjustment is giving up life itself. Let us remember that this final readjustment is ahead of thousands of our own.

We should feel it a tenfold duty to make our work count to the utmost.

And as we work let us thank God from the bottom of our hearts that a man like Woodrow Wilson is President of these United States to see to it that this world agony shall not be perverted for the selfish purposes (hypocritically camouflaged under high-sounding protestations) of any self-centered class of any nation, but that out of it shall be born a fairer, better world for all peoples. C. C. TAYLOR, Bus. Mgr.

life before no matter how earnestly, how seriously you have always taken it.

Avail yourself of every opportunity to develop your scientific efficiency-to increase your skill. Read, study more earnestly than ever before. I say that in spite of the fact that our work is to supply you with some of your reading matter and so it helps to grind our own ax; I say it because it is the enlightened common sense of the case.

Avail yourself of every aid-every scientific advance (and practical medical progress is quickened in war times) that you can possibly afford, if it will help you to get better results in your everyday work. But don't buy anything or cause your patients to buy anything that won't stand that test.

You, Doctor, in almost certain probability are going to make money. Unprecedented demand for both labor and farm products (always the basis of a ready circulation of money) with scientific medical service of more importance to both the individual and the nation and a smaller number of physicians to do the work.

There are two ways in which you can use it that will most practically serve your country, help to win the war and justify your having it-use it to increase your scientific efficiency in your everyday work in every possible way and buy Liberty Bonds.

What is MEDICAL COUNCIL'S readjustment?

If MEDICAL COUNCIL is to be worth its salt in this epoch-making time, it must have this same practical common-sense point of view.

MEDICAL COUNCIL can be of the most practical help to our country and the cause by giving you the most practically helpful medical journal we have ever published.

Our Duty

Frankly, Doctor, readjustment for most physicians and for MEDICAL COUNCIL will not be hard.

Unfortunately the burdens of war can not be distributed equally.

The people of Belgium have suffered all, their readjustment has been a cross almost too heavy for humans to bear.

The people of France (except the invaded portion, of course) have suffered greatly, but not as the Belgians have suffered.

The English people have suffered but not as the French have suffered.

And we Americans, we suffer least of all; our readjustment is far, far the easiest to make. Why in comparison with even the English (let alone the Belgians) our readjustment is for the majority of us nothing more than a certain amount of inconvenience.

Yet in the new day of freedom that is breaking over

Helpful War Conservation

A certain Roman, whose name has slipped from my memory, when writing to a friend apologized for writing a long letter and excused it because he didn't have time to write a short letter.

"Sentences like sunbeams burn deepest when most condensed" has been a MEDICAL COUNCIL motto from the first issue printed.

The value of a journal is not determined by the number of pages but by the number of practical, usable thoughts per page. The less chaff mixed with the wheat the more usable the wheat.

One of the most unpatriotic things we can do at this time is to use materials of any kind unnecessarily.

Any journal, whether medical journal, daily newspaper or whatever kind of paper that at this time fills space just to make a "showy" journal and uses paper and printing unnecessarily, that journal doesn't know the meaning of practical patriotism. Use to good purpose but don't waste anything must be our slogan in the use of all materials if we want to help and not hinder the winning of the war.

Medical practitioners will be busier in the months ahead than ever before. As a matter of practical patriotism every physician should make the fullest possible use of everything that will increase professional efficiency and help to get better results in every-day work. The right kind of medical journals are more important to the progressive physician in the months to come than ever before.

The right kind of medical journal will realize the heavily increased demands on the physician's time and while real conciseness requires the hardest kind of editorial work to attain, the right kind of medical journal will emphasize conciseness-the number of practical usable thoughts per page and not the number of pages matter can be spread out to fill-more than ever before. Intensive service, not extensive service, is the mark of a journal's value particularly in the coming months. While intensive service has always been MEDICAL COUNCIL'S idea as is natural with a journal that concentrates on the one aim of service that is really of practical help in the problems of everyday work, this coming year we shall strive to give MEDICAL COUNCIL a greater conciseness than it has ever had before.

By doing this we will serve our country and the cause in two most practical ways-we will help in the needed conservation of labor and materials-and we will give you the kind of journal that will be of the greatest practical usefulness to you in your everyday work.

Surgical Scissors

As Wielded by Douglas H. Stewart, M.D., F.A.C.S.

The Heating Cell.

Feuillade and Blechmann, in Paris Medical.— The heating cell or warning chamber is a room for warming wounded men. It is hardly necessary to devote much space to the great advantages that such an apparatus would possess, nor how much it would make for the success of operative measures if the patient is brought to the table well warmed rather than chilled, miserable and so wretched that his fear seems to be that perhaps he will not die. The authors report one case that after two days of warming manifested a resurrection.

While such a warming room may be an adjunct of any hospital building, yet a portable chamber could be easily constructed whether of doublewalled canvas in tent form or of metal or wood and mounted upon wheels. The working out of an appropriate plan is a mere matter of detail and experience. But whether hut, house, wagon or tent, whether used in connection with hot-water bags, blankets or other similar expedients, or however it is applied, heat has an undisputed value when a wounded soldier is about to undergo a more or less severe operation. An ideal temperature is 97 degrees F. Manifestly, then, a body that has only so much vital force to draw upon is very greatly aided by the artificial elevation of the temperature of its atmospheric envelope; rather than the depressing waste of vitality necessitated by the act of the maintenance of normal body heat, in an environment that presents from 20 degrees to 60 de; grees of temperature to be overcome by a handicapped economy.

Hemorrhoids and Health Balance.

Wm. M. Beach, A.M., M.D., F.A.C.S., Pittsburgh, in N. Y. Med. Journal.-Hemorrhiods disturb the health balance by their deleterious effect upon the patient's mind, by their increase of his irritability and by making him anxious and morose. Many reflexes accompany ulcerated hemorrhoids, the latter have an evil influence upon the vegetative functions and have also an intimate association with diseases of the heart, lung, liver and kidney. A refractory relationship in many cases of constipation and a tendency toward sepsis, anemia or cancer are not unusual.

Inasmuch as hemorrhoidal disease is not a constant factor in the causation of constipation, but

rather a coincidence to hepatic congestion, it offers & mechanical obstruction to passage of feces and thereby aggravates colon stasis. Hemorrhoids should be removed; but at the same time caution should be exercised in making promises to cure constipation by the procedure.

Hemorrhoids respect neither age nor sex; they incapacitate for work, prevent buoyancy of spirit, counteract efficiency and add weight to years.

Traumatic Streptococcus Meningitis.

C. N. Chipman, M.D., Washington, D. C.; Summary-Partial Autopsy, Oscar B. Hunter, M.D., Virginia Med. Semi-Monthly.-As the result of an automobile accident the patient was bruised from head to foot. Two days later the prognosis seemed good, his wounds were re-dressed and two sharp clean cuts over right and left temporal regions were noted. The last had been sewed up and looked to be in good condition. Mental condition and urine normal. Date of injury June 12, 1916. On June 16, meningitis symptoms appeared. Spinal fluid on blood agar showed streptococcus hemolyticus. Cuts over temporal regions were opened, washed out with tinct. iodine, but no fracture was found. Temperature went to 106.2 and on June 18, the patient died. Streptococcus infection is usually of the wildfire type with short duration. Autopsy revealed a skull fracture from which the patient might have recovered. The fracture was one-half inch medial to the skin wound, so that probing revealed no fracture. The case shows the danger of tight sewing of a dirty wound for infection was traced from the right temporal cut through thrombosed parietal An occipital perforation was found, but that region. was free of infection with no evidence of purulent exudate. With removal of dura mater a frank purulent lepto-meningitis was exposed in the unfractured parietal region. A sub-pial purulent exudate extending from parietal emissary regions anteriorly over frontal lobe and downwards in temporal regions.

Possibly in connection with this case it might not be without interest to mention a similar one as an example of the wonderful contrast that the item of body resistance to infection affords. Everyday Scissors is more and more impressed with the idea that the multiple small infections of wild animals and of workmen have a tendency to produce immunity to their environment. An old man, whose mental confusion prevented history taking, presented all the signs of fracture of skull and had a tightly sewed infected wound of scalp. The wound was opened, carefully cleansed, and the patient was

turned over to Dr. Claude A. Frink. About a week later Dr. Frink remarked "That fracture case was a bad actor and I put him to bed." This was so utterly at variance with Scissors' idea of the conditions that he went to that patient's bedside and found the man stowing away a rather large dinner. The house-surgeon volunteered the information that the patient had been awfully bad, but they had watched him constantly and he had come out all right. No operation was performed, but measures directed against infection were carefully observed, together with appropriate treatment. The patient did come out "all right," but there was no doubt a month after the accident that he had been a very sick man and was then far from "all right," even though he eventually regained his usual health. As an operative risk, alcohol and exposure with other things made him bad indeed, but he had many scars here and there. [Permit personal emphasis on the valuable point here made, viz., never to close tightly wounds of the scalp, especially if the pericranium has been cut.-EDITOR.]

Corpus Luteum Extract.

H. E. Happel, M.D., St. Louis, in Interstate Medical Journal. The doctor considers that three grains of the desiccated gland dissolved in water and administered intramuscularly by syringe is the best method of employment. Such injections are usually given twice a week, though this dosage may be increased to three times a week if such increase is advisable. Menstrual irregularity with nervous symptoms appears to be the indication for this remedy, and this no matter whether the condition is post-operative, climacteric or other, or whether accompanied by sterility, by sexual anesthesia, by frigidity or by the vomiting of a pregnant woman.

The value to the surgeon lies in its employment in post-operative treatment, especially when an artificial but undesirable climacteric seems about to be established. A summary of the matter would seem to be that the aqueous solution of corpus luteum may best be administered hypodermically. Furthermore, the statement of many years ago, that the characteristics of ovarian substance are produced therapeutically by a principle contained in the corpus luteum, is every day verified.

Amputations.\

Wm. Arthur Clark, A.M., M.D., Chicago, in Surg., Gyn. and Obstets., October, 1917. Very early in the progress of the war it was found that the shaping of a classical flap in doing a primary amputation was a waste of time and tissue. The infection which invariably followed resulted in sloughing of the flaps which demanded a secondary operation and in some cases a reamputation. It was found more expedient to perform a rapid amputation of all tissues, skin, muscle and bone, at the same level, what the French

call coup de hache. Aside from ligature of vessels nothing is done but the straight-across cut, severing the part as it might be done by laying it on a block and clipping it off with a headsman's axe. In the wide-open wound thus formed, the infection can be easily controlled and cleared up. In the meantime the soft parts, of course, have a tendency to contract away from the bone and in the thigh cases this is sometimes serious, as the surgeon seeks to conserve as much tisue as possible. To overcome this contraction, it is necessary to apply wide adhesive straps at four points around the stump and attach a weight of from five to ten pounds which will hang over a pulley, at the foot of the bed and maintain a constant traction against this retraction of the skin and muscle.

When the granulations begin to form and the pus is all gone, the plastic repair of the stump is done, including reamputation of the bone and of the nerves and the shaping and suture of the flaps.

At the Ambulance de l'Océan at La Panne before the adoption of the coup de hache technique, the mortality from amputations of the thigh was 60 per cent. After this technique was introduced the mortality fell to 30 per cent. This reduction, it must be admitted, was not due entirely to the technique, as there has been a general decrease from the rather high mortality percentages of the early part of the war, but this is one of the important factors which have brought about the decrease.

Conservatism in Surgery.

Samuel J. Mixter, M.D., Boston, in Annals of Surgery, September, 1917. Working by any fixed. set of rules is sure to be followed by disaster. There is no surgical rule that should not occasionally be broken. It is better to open the trachea with a dirty knife and unclean fingers than to have a person choke to death. It is better to leave an occasional septic appendix or gall-bladder to drain, even if we believe in their routine removal. This is where that something called "surgical judgment" come in. Many a brilliant operator is a poor surgeon and a man should never let deft fingers tempt him to useless or unnecessary work.

X-rays were a valuable remedial agent, but their non-conservative use was such that cases of beginning cancer of the breast were X-rayed to death. So far as they were used for the cure of malignant disease, more lives were lost than would have been the case had X-rays never been discovered. [A true statement that needs emphasis today.-ED.] Let us hope that this statement may not be made of radium and of serum therapy.

The true surgeon is never fearless. He fears for his patients, for his own short-comings, his own mistakes; but he never fears for himself or for his professional reputation. His fear makes him a better man.

A Dangerous Misunderstanding. To make a long story short: the Carrell-Dakin solution is not intended for intravenous use and it is not Fralick's istonic sodium hypochlorite solution. The whole matter would occupy too much time and space to abstract here. A renewed interest in the subject was given at the N. Y. meeting of the A. M. A. Some of the doctors, at least, have an idea that the Carrell-Dakin solution might be used intravenously. The patient mentioned had a bacteremia with strepto. viridans. All that is possible to say in this place is that Carrell's solution is made from chloride of lime and washing soda. Fralick's solution is derived from permangante of potash. Ample literature in the way of reprints may be obtained from Wilfred G. Fralick, M.D., 33 East Sixtieth street, New York City. These reprints go over the ground of experimentation, observation, preparation and many other matters of value to any one who is employing hypochlorites.

The plea entered here is: before adopting intravenous methods of treatment, for goodness sake try and find out just what the consequences are liable to be. There is no appeal from an error in judgment when intravenous methods are in question. A bad result is apt to be very positive.

Circumcision.

F. D. Austin, M.D., Charlotte, N. C.; P. G. Sharpe, M.D., Greenville, S. C., in N. Y. Medical Journal. Without illustrations it is difficult to make this new method clear, yet it should be both an ingenious and a valuable method of procedure. Perhaps if one took a candle as a schema and marked the various points upon it, that would be a help. The foreskin must be retractable until the glans may be uncovered; if phimosis is present, a small dorsal incision should be made to free that. Measure foreskin from corona to margin. Go back on penis shaft, say, one-fourth inch behind corona; make a circular mark around that shaft. On the urethral side make a mark as much behind the previously drawn circle as the corona-margin measurement shows (say, one-half inch); upon the top of the shaft make a similar mark twice as far behind aforesaid line (or 1 inch). Draw a circle (ellipsis) touching both guiding marks. Cut out the skin between the circle and the ellipse and stitch the two margins together with interrupted suture. This unfolds and straightens out the skin and mucous membrane folds so that the foreskin as such disappears; but it is transplanted to fill the gap.

For the Lord's sake, cheer up! "A merry heart maketh a cheerful countenance, but by sorrow of the heart the spirit is broken." If the spirit of this Nation is broken, then its head will be. It's our job to get pep, not pip, and let Germany do the worrying.

Practical Therapeutics

Antitoxin for Gaseous Gangrene.

Carroll G. Bull, M.D., New York Medical Journal. Since the description of the gas bacillus in 1891, many conceptions of its pathogenic action have arisen. There are twenty-nine strains and each strain secretes a toxin which may be neutralized by an antitoxic serum obtained from immunized animals. The toxins were alike in quality but were unlike in potency, hence it is probable that the members of the Bacillus Welchii group possess a common toxin. A series of guinea pigs was given a subcutaneous prophylactic dose of antitoxin. Two days later thirty-two acutely lethal doses that were injected into the circulation proved harmless; this immunity gradually diminished and ceased after the expiration of fourteen days. A passive immunity of two weeks' duration can be conferred upon man. This will suffice, since the greatest number of cases occur forty-eight hours after exposure. The antitoxin is being prepared on a large scale and potent serums are obtained from horses. A few cases in man have been treated, and the efficacy of the antitoxin was unmistakeable.

This antitoxin should be administered intravenously, and locally around and about the wound.

Quinine Intramuscularly and Intravenously. An editorial writer in Southern Medical Journal says:

Never inject quinin in any form or dilution into the tissues superficial to the deep fascia. Never inject it anywhere stronger than 10 per cent., and in this strength not more than 10 grains in one place. If the patient is able to stand up, he can be made to stiffen the gluteal muscles so they can be felt. Pick out the belly of one muscle, insert the needle (not less than 1/2 inches long) vertically into it and then require the patient to relax ("balance on the other leg") and inject slowly. Strict asepsis is understood. If in bed, order the patient to brace his heel hard against the hand of an attendant. This also detracts attention from the puncture. Superficial cellular and fatty tissue almost always dies from the chemical effect of the quinin. Ampules of the dihydrochlorid (so-called) with or without urea containing 5 per cent. and 6.5 per cent. are marketed. Ten cc. makes a convenient dose. Some criticism has been offered for putting up quinin, 10 grains in 10 cc., on the ground that it is mixing systems. The fact is, most doctors think in grains and they buy syringes of 10 cc. capacity.

The writer has used quinin intramuscularly in this strength for several hundred consecutive injec

tions without getting anything worse than indurations.

Intravenous Method.-Experience, beginning with that of Bacelli, has shown that quinin can be safely injected in 5 per cent. solution. The writer prefers large dilutions, 1-200, especially in pernicious forms where massing in capillary areas is the rule -in the hope of flushing these out. Von Ezdorf preferred 1 per cent. solutions. If the 10 cc. ampules containing 10 grains are used, a small needle must be employed and the injection made as slowly as possible so as to get ample initial dilution. As a rule, the intravenous method belongs to hospital practice where facilities for diluting this solution with six-tenths per cent. salt solution are at hand. Only one salt is to be considered, the dihydrochlorid without urea. Dilution must always be with six-tenths per cent. salt solution and never with water, Ringer's or other mixtures.

Rational Treatment of Dysmenorrhea. Walter William Chipman, Montreal; Canada, in N. Y. State Jour. of Med., Oct., 1917, after describing a case in the young and unmarried woman, and deprecating the routine vaginal examination and the ordinary findings therefrom, but urging a systematic general examination, goes on to say:

The treatment is determined naturally by the findings. If there be no organic disease, there remains always the faulty metabolism. You will correct this by hygienic reform of her daily life. Elimination is the missing word in her vocabulary. Encourage the intake of water and compel the bowels to one complete evacuation after breakfast. Make this by education, exercise and diet, as the sun rises, an invariable rule. Control the indulgence in sweets, cane-sugar aggravates all dysmenorrheas. Give for a time a mild chalybeate saline, and for months ovarian extract. You may exhibit iron or arsenic. Prescribe a holiday with change of barometric pressure. In my experience a low reading, for example, the seaside, gives the best result.

So in these ways you improve the general health, ballast the crank nervous system, and promote muscular growth in the small, fibrous uterus.

Now for the treatment of the pain itself: The secret of success is to anticipate the pain, create a state of general preparedness. These are the orders: Six hours before the onset of the severe pain, remove the corsets and lie down, preferably in bed. Keep warmly covered and place a hot water-bottle at each foot, so bleeding yourself into your feet. Take enough castor oil to make the bowels move twice. All this is six hours before onset of the pain. If pain still supervenes, take a teaspoonful of salvolatile, or of viburnum compound in hot water every hour for three doses; or in like fashion, five grains of aspirin or phenacetin. Alcohol or morphia you take never. You will find, gentlemen, that

such treatment answers in the ordinary cases, and these are the greatest number. In only a few instances am I compelled to resort to cervical dilation with or without the use of the stem. Surgical procedure here is always to be regretted, for while the relief is usually transient, it magnifies, in the mind. of the patient, the sense of sexual disability. We must never forget that the sensorium is above the neck.

In the rare cases with the migraine-syndrome of headache, nausea and vomiting, nothing succeeds so well as cauterization of the genital tubercles of the nose, according to the method lately discussed by Brettauer of New York.

Syphilitic Brain Conditions.

G. H. Williams, Columbus, Ohio, in The Ohio State Med. Jour., Oct., 1917, deplores the increase of paresis, which he views hopefully since physicians are diagnosing and treating syphilis better than formerly. He stresses the treatment of tertiary syphilis, favoring the deep muscular injection of the salicylate of mercury. Sodium cacodylate has failed in his hands. Full doses of iodides are commended. Fournier's dogma, "Strike hard, quick and often," is the secret of success in preventing syphilitic diseases of the nervous system.

Calcium Sulphide in Poisoning by Mercuric Chloride.

Charles C. Haskell and R. H. Courtney, Richmond, Va., in The Jour. of Lab. and Clin. Med., Nov., 1917, consider, more especially, the intravenous use of calcium sulphide. Basing their findings on carefully conducted animal experimentation, they conclude:

1. The value of intravenous injections of solutions of calcium sulphide in the treatment of poisoning by mercuric chloride depends chiefly or entirely on the fluid which is introduced, and results fully as good can be secured by the intravenous injection of physiologic salt solution.

2. The intravenous injection of calcium sulphide is a procedure fraught with actual danger and it is possible that cases of mercurial poisoning may have the lethal exitus hastened rather than retarded by this administration of calcium sulphide.

3. In the present state of our knowledge, it would be unfortunate if we neglected to avail ourselves of every one of the measures that are of proved value in the treatment of bichloride poisoning; such as gastric lavage, colonic irrigation, hot packs, and the free exhibition of fluids, intravenously, subcutaneously, by rectum, and by mouth.

Here is another warning against the dangers of intravenous medication. A most useful resource under proper circumstances, yet the intravenous administration of a host of drugs now so much in vogue is dangerous and unwarranted.-EDITOR.