kind of bacterins to use, we have sometime ago noted with much pleasure and satisfaction that The Abbott Laboratories have undertaken the manufacture of this class of remedies, and we know that they are worthy companions to the old established Abbott remedies, being of Abbott quality which means that they are right. There is a full line available for the various infectious diseases.

XXX

PREVENTION OF BRONCHIAL AND
PULMONARY INFECTIONS

The value of cod liver oil as a means of guarding against bronchial and pulmonary infections by raising the index of resistance of the concerned tissues, is well appreciated by the profession, and many physicians advise the systematic use of Cord. Ext. Ol. Morrhuae Comp. (Hagee) for this purpose. It would appear that cod liver oil has a definite predilection for the tissues of the lungs and bronchi and adds materially to their powers of resistance against germ invasion. That this increase of resisting power means a diminution of susceptibility to colds and their consequences is very evident, and points

plainly to the need for a cod liver oil preparation, such as Cord. Ext. Ol. Morrhuae Comp. (Hagee) in those persons with the slightest susceptibility to bronchial and pulmonary infections. The superior feature of Cord. Ext. Ol. Morrhuae Comp. (Hagee) is its palatability which in no wise impairs its therapeutic efficacy.

SPECIAL NOTICE TO PHYSICIANS, DENTISTS, NURSES AND HOSPITALS Beginning with January 1st, 1917, the CamphoPhenique Company, by special request is placing on the market a 25-cent package of Campho-Phenique Powder. A liberal package put up in neat sifter top can, for physicians, dentists, nurses and hospitals. Your valued order invited.

Campho-Phenique Powder, 25-cent size, sifter top can, at $2.00 per dozen.

Campho-Phenique Powder, 75 cents net-1-oz. sifter top can, at $6.00 per dozen.

Campho-Phenique Powder, 1-pound can, hospital size, net $5.50.

ECTHOL AND INFECTIONS

It has been shown that Ecthol (Battle) has a distinctive value in infections, and with many physicians its employment in both local and systemic infections is a routine practice. While this clinical fact is easily determined, the actual modus operandi of this agent within the tissues is not so easily understood, but it seems logical to assume that it increases the phagocytic power of the blood stream, thereby enabling the system to overcome the assault of the infectious organ

THE MAKING OF AMPOULES

An illuminating article on the manufacture of glaseptic ampoules of sterilized solutions, as conducted in the laboratories of Parke, Davis & Co., appears in a recent issue of Therapeutic Notes. It is noteworthy because of the emphasis placed upon the careful methods which are essential in the production of both solution and container.

"First of all," says the Notes, "the greatest care is taken in the selection of the glass from which the ampoules are made. It is of the first quality, and must be free from alkali in order to obviate any possibility of contamination or chemical action on the solution. This is vital, for it is imperative that the purity and stability of the contents of the ampoule be assured.

"The medicaments used in preparing solutions are treated with the most suitable solvents-e. g.,

oils, distilled water, or physiologic salt solution -and the solutions are invariably adjusted to a fixed standard of strength; that is, each contains a specific amount of medicament to a given volume, thus insuring accuracy of dose. The solutions are subjected to the process of sterilization, either by heat applied in an autoclave, at intervals, for four or five days, or by passage through a Berkefeld or Pasteur procelain filter. They are then passed into sterilized bottles, and samples are submitted to the biological department for a series of sterility tests that extend over a period of five days.

"The ampoule containers, cleansed and sterilized, are filled with the sterilized and tested solutions by machinery. The neck of each ampoule is hermetically sealed in a gas flame, and ampoules and contents are again subjected to the sterilization process, this time by the careful application of heat, care being taken to adjust the temperature of the apparatus to such a degree that the medicament will not suffer injury. The hermetically sealed container effectually protects the solution from bacterial contamination and oxidation, while the actinic effect of light is prevented by enclosure of each ampoule in an impervious cardboard carton."

As indicative of the trend in hypodermatic medication it may be noted that more than sixty sterilized solutions are now supplied by Parke, Davis & Co. in glaseptic ampoules. Convenience, asepsis, stability, accuracy of dose-solutions in ampoules appeal to modern practitioners on these grounds.

The Typhoidin Test.-The Journal of Laboratory and Clinical Medicine thinks there is little reason further to doubt that the skin sensitiveness to preparations of the typhoid bacillus (typhoidin) described by Gay and Force in typhoid vaccinated individuals and in typhoid recoveries is, to a large extent specific. Question, however, may still exist as to the techmic of the test itself and as to the interpretation of the results obtained, and this communication deals with a group of 154 nurses and physicians studied from these standpoints. The technic used was that introduced by Force and Stevens, which is briefly as follows: First, the use of a polyvalent preparation from several chosen strains of typhoid bacilli to allow for the probable varieties and corresponding antigenic differences in typhoid bacilli; second, the employment of a carefully determined minimal effective dose of the dried polyvalent typhoidin (0.00002 gm. in 0.05 c.cm. of 0.5 per cent carbolated saline); third, the injection of thise dose intradermically; and, finally, the reading of the reaction in fortyeight instead of twenty-hour hours This latter period tends to eliminate the nonspecific irritative reaction which may occur in normal individuals from the protein of the culture medium or the phenol employed as a diluent The criterion of a positive reaction consists in the presence after forty-eight hours of a definite indurated papule plus a reddish areola of at least 5 millimeters.

A survey of the percentage of positive results shows that 75 per cent of those individuals that had recovered from typhoid gave a positive reaction. From 75 per cent to 40 per cent of those that had been vaccinated against typhoid also reacted positively, and in general in decreasing correspondence with the lapse of time since immunization. Something over 14 per cent of presumably normal individuals also gave a positive reaction-whether this is due to some peculiar nonspecific susceptibility of the skin, or whether they have at some time undergone an unsuspected typhoid infection, or, indeed, whether they are unrecognized typhoid carriers. In the author's opinion a positive reaction indicates that the individual is more or less perfectly protected against typhoid fever. He points out, in the first place, that no individual in whom a positive reaction has been obtained has acquired typhoid fever. In the second place, individuals who react positively, when reinoculated with typhoid vaccine, react much more violently than do individuals who give a negative typhoidin test. And, finally, individuals who have been vaccinated against typhoid and who react negatively become

positive in most instances on further immunization.

Septic Parotitis.-Blair, in Medicine and Surgery (Philip Skrainka's new journal) discovers acute septic infection of the salivary glands, most commonly seen in the parotid. This is often referred to as a secondary or metastatic parotid abscess. Formerly it was rather generally accepted that the acute septic infections of these glands were metastatic; later considerable evidence accumulated to show that most, if not nearly all, were ascending infections of the excretory ducts; and the fact that the stomata of both the submaxillary and the parotid ducts are at the apices of mucous papillae suggest that an effort has been made to protect them from contamination caused by foreign bodies or fluids entering from the mouth. The later work of Rosenow on infection of the bile-ducts must, however, make us hesitate before entirely condemning the metastatic idea. Neither theory has ever been demonstrated beyond dispute. Be this as it may, during the acute stage of some infectious fever, toward the period of subsidence, or a few days after some operation, supposedly more common after operation on the ovaries, a swelling may appear in one or both parotids; less commonly in one of the other salivary glands. In the parotid the swelling is usually first marked. in front of the lobe of the ear, where the capsule is less tense, but subsequently the swelling is evident over the whole gland. In fulminating cases the swelling may come up very rapidly, and the involvement of the parotid be obscured by the edema of the cheek and neck. The appearance of the swelling is accompanied by fever and the other ordinary symptoms of septic infection; occasionally by discoloration of the skin, and often there are severe pain and tenderness, most marked over the parotid. These patients frequently present evidence of being extremely ill. Within the mouth there is usually some swelling of the parotid papilla, and at its apex may usually be seen a minute dark red spot, which the author has interpreted as being a visible part of the swollen mucous lining of the duct. The flow of saliva from the duct may be entirely suppressed, or pus may be squeezed out. In milder cases the symptoms may subside in a few days or go onto localized suppuration. The infection is often of a severe grade, however, causing diffuse phlegmon of the gland, which may spread to the surrounding tissues. Even these severe cases can usually be spared by prompt treatment, if the infection is confined to the parotid; but fulminating, septic parotitis is frequently but one expression of a

Volume XL. Number 4.

APRIL 1917

THE GENERAL PRACTITIONER AS A

SURGEON

Just how much surgery shall the general practitioner attempt to do? As to the proper answer to this question, there wide divergence of opinion. Some hold that the average general practitioner can train him to do almost any kind of surgical work that arises in emergency practice, and a large share of the routine operative work which is now being turned over to the general surgeon. Others believe that operative surgery, requiring, as it does, special skill and training and a certain degree of natural adaptability, should be reserved, as much as possible for the men who practice surgery exclusively.

Personally, we are disposed to take a middle place between these two extreme views. The competent internal medicine man of today is the equal in skill and standing of any surgeon and deserves equal praise and honor for the work he is doing. Nor do all of these men live in the cities. There are thousands of conscientious physicians in the country and the smaller towns, and even at the crossroads, doing scientific work which is not appreciated at half its full worth by the communities in which they live. Some day, we hope, the people will wake up to a realization of their obligation to the country doctor. But when we are told that he is competent to operate in 95 per cent of all surgical cases that, we fear, is going a little too far. The very character of the greater part of the general practitioner's work, its arduous and irregular nature, precludes expertness in this special work. On the other hand, of course, there is a large amount of minor surgery which any ordinarily competent man should do.

"Of even more importance," says an eminent surgeon, writing on the subject, "is the question of surgical diagnosis. Today thousands of bellies are being opened by inexperienced and incompetent 'county seat surgeons' for purely Imaginary conditions. The number of healthy ovaries removed because the women have Glenard's disease, neuralgia of the ileohypogastric

nerve, sexual neurasthenia, or what not, is appalling. The number of theoretically diseased appendices extirpated is something astounding. On the other hand, the high mortality from unrecognized appendical abscess, or appendicitis diagnosed too late; the large number of fatalities from gall bladder and tubal infections; the infinite amount of suffering from chronic irritations which might be relieved by proper surgical treatment all these things are truly heart rending to the man who sees.''

The point we should like to make is this: No practitioner should attempt to do surgical work for which he is unqualified. But if he has the requisite skill to perform an appendectomy, or repair a perineum, or if he has the aptitude for this kind of work, and, through study, hospital training, or otherwise, can acquire such skill, there is no reason in the world why he should not learn to operate himself, instead of sending big cases away to the nearest city, where the expense to the pataient is much larger and the benefit not necessarily a whit more. One must learn to walk before he can run; and a physician should KNOW surgery before he takes the lives of patients in his hands in the operating room. Where he is not qualified, it is criminal for him to attempt to do surgical work. On the other hand, it is true that as he learns more, and acquires a larger degree of skill, he can do a constantly increasing percentage of the operative work developing in his community.

Why should he not? The conscientious physician is seeking, every day of his life, the knowledge and practice which will make him more skilled and successful in the management of pneumonia, typhoid fever, scarlatina, or tuberculosis. Is it not just as much his right and duty to enlarge his surgical knowledge and to perfect. his technical operative skill? Who knows but that, as he mounts the ladder, step by step-and that is the way our Fengers and our Senns got to the top-he is preparing himself to enter the class of the adepts and the masters?

The more difficult cases, those involving unusual technical skill and judgment, will continue

to flow toward the exclusive surgeons of unusual ability; and no class of men will send them to the expert more readily than the men who have enlarged their surgical knowledge, and in so doing have both acquired strength and learned their limitations.

IS MEDICINE A BUSINESS? One of our contemporaries, in discussing the decision of a judge prohibiting the conduct of a physician's office in a district wherein the pursuit of business was forbidden, on the ground that the practice of medicine is a business, approves the decision, and endorses the general conception which it involves of the practice of medicine, bluntly asserting that "we practice medicine primarily to feed and clothe our families."

With the obverse of this position-namely, that the practice of medicine is solely and altogether an altruistic service for which the practitioner can not consistently apply any of the rules governing the conduct of business-we have ourselves more than once taken issue, and agree with our contemporary not only that the supposed altruistic character of the profession has been taken advantage of by too large a proportion of the laity, but that such conception of the vocation is neither a sane nor an honest one for the physician himself. But we confess that we are equally unable to bring ourselves to subscribe to the sweeping and unqualified assertion that medicine is a business.

The truth is, almost all sweeping and unqualified characterizations are beside the mark There is nothing in human institutions that is altogether one thing or altogether the other. Whatever may be true of the ideal attitude of medicine to the lay world, as soon as one begins to attempt to make contact with the objects of medical service one instantly comes into the sphere of the latter's attitude, which is that of a composite member of society, and a kind of compromise has to be made between the two attitudes. This is very true of every department of industry and service that ministers to the civilized world. But it is also true that the prime essence and motive of medicine is the ministration, in an especial way, to the suffering and misfortune of mankind, and no legitimate compromise with the economic factors of civilization can justify the commercial exploitation of a service of this kind to the extent that one may be permitted to exploit a calling that ministers to the world's ambition and material progress.

We do not believe it can rightfully be said that "we practice medicine primarily to feed and clothe our families. For back of the purpose

to feed and clothe a family is the inspiration which moves one to choose the life-work by which he will support it, and it will require more than a mere assertion to persuade most of us that the economic consideration determines the choice of medicine as a vocation. We question indeed, whether as a general thing it enters into the choice of any occupation; there are, of course, individual exceptions. But just now we are discussing the vocation of medicine. It certainly cannot be seriously maintained that a man chooses the practice of medicine as being the life-work by which he can best feed and clothe his family; and if this were his prime motive he would certainly select the course by which it could be best attained.

Having determined, from some other motives, that he desires to undertake the vocation of medicine, then it may be granted that he takes into consideration, if he is a sensible man, those economic compromises that he knows must be made with the conditions of modern society, and not only excusably, as we think, but laudably sets himself to make those conditions, to the extent that they demand his compromise, minister to the best possible advantage to his own and his family's social condition.

To this extent, indeed, he is a business man, or he ought to be. This is the aspect of his calling in which he ought to be "as wise as a serpent." He is not individually responsible for social conditions, nor has he any business to rail against them. He has chosen to live in them, he is expected to accept them and to live in accordance with them as a member of society, and if he disregards or neglects them to his own economic disaster, he will not be regarded as a martyr but as a fool. This rule is, of course, like all rules, subject to exceptions, and especially to the great exception, human emergency, wherein all economic laws are suspended.

But, withal, the practice of medicine is not in itself a business, nor can its business features be rightfully pushed beyond legitimate, necessary compromise with society's economic institutions. No physician has any right to buy his skill in the lowest market and sell it in the highest; yet that is a canon of good business. No physician may create a demand for his services; but that is a legitimate and praiseworthy function in business. A man of business, so he be commonly honest, may engage in any and every commercial enterprise for the avowed purpose of enriching himself. But if there be any man in the practice of medicine for the prime purpose of making money, they know better than to say so, for the very declaration of such an intention would be sufficient to defeat its attainment.