foot, leg, thigh and pelvis, and a Buck's exten- plate in suspected fractures near the shoulder sion should be used. Don't forget the danger to the popliteal artery from traction and extension in a transverse fracture of the femur above the condyle; an almost right-angle fracture box or splint is the best fixation dressing. Don't place recent fractures in plaster of paris without due regard to swelling; either place a wire saw underneath the circular plaster of paris bandage, or cut it through from end-to-end when first applied, so it can be removed or readjusted when the swelling subsides; or what I like better in a great many fractures, apply moulded splints which can be made any shape desired while wet and can be removed much more easily than the circular type. Don't forget that should severe pain develop within a few hours after a splint has been applied, the splint is either too tight from swelling, or the fracture has not been properly reduced-excepting in cases where a severe sprain complicates the fracture; if pain is caused by swelling and the splint be not removed, within a few hours degenerative changes are likely to occur in the musclecells which may induce ischemic myositis or (in the forearm) Volkmann's contracture. I have seen four or five such cases. Don't forget to suspect degenerative changes due to syphilis, central sarcoma or other pathologic process producing friability of the bone, when fracture is produced by stepping upon a pebble or other slight violence. Don't forget that in such instances there is usually a certain degree of anesthesia of the soft structures of the involved limb, and it may be difficult to prevent the patient walking too soon if a leg is fractured; and if the fracture is near a joint the condition may resemble a Charcot joint. Don't fail to have an X-ray plate made in all fractures where perfect reduction seems doubtful, and this means nearly all of them; it is a valuable means of confirmation, and may be of great benefit to the surgeon should the result be unfavorable. Don't attempt to plate a recent compound fracture, otherwise amputation will most likely be the inevitable result. Don't use a plate in any recent fracture (week or ten days) until all means at hand have been exhausted in attempted reduction. Don't forget that in plating or inlay work the strictest asceptic technic must be used, not even the gloved hand should come in contact with the wound or the wound-touching portion of the instruments. Don't place too much reliance upon the X-ray joint, and in fractures at the angle of the lower jaw, as good pictures of these localities are difficult to obtain. Don't forget that painful passive motion is always harmful where fracture involves a joint. Don't forget in placing any kind of a splint around or to the outer side of the knee, to pad well over the head of the fibula, as pressure is likely to injure the peroneal nerve, producing paralysis of the muscles supplied by it. Don't forget to pad liberally under the heel of any splint that envelopes the foot, as pressure necrosis sometimes occurs. I have seen one such case in consultation following fracture of the patella, and healing was delayed for several months. Don't forget to pad well over all bony prominences where splints have to be adjusted over them. Don't forget that a burning sensation in the heel or other parts underneath a splint signifies that too much pressure is exerted; the splint should be immediately removed. Don't forget that unless a fracture is complicated by a sprain, or severe contusion, when properly reduced and splinted pain should cease. MEDICAL REFORMS AND THE REFORMER A correspondent of Clinical Medicine says: Many excellent men do I know in the medical profession; Many of grand character and sterling principles; Men who cure the sick and relieve human misery; Men who labor for the public good and try to prevent disease. These men say little for publication; They never play for the grand-stand; They do not pretend to have made good discoveries; They never lend their medical journals to the lay reader; Nor do they advertise their knowledge by teaching their patrons how to pronounce such words as phytolacca, belladonna, and hexamethylenamine; They aim to be up with the times and their profession; They interest themselves in their patients, their journals, and their books; Most of their patients get well. Such doctors have their share of the business. They help the public by attending to their busi ness. But there are a few who hurt the honest members of this great life-saving brigade by their love of the limelight. This small minority are fascinated by the glamor of publicity; and they lack the wit to see that, instead of making bright and shining stars of themselves, they are misrepresenting the noble profession in the ranks of which they are permitted to stand. When I hear a man addressing a lay audience to the discredit of the many honest and capable physicians of America, I know that I am listening to a man who has an axe to grind or who is unable to build up a practice. And now we are facing the result of such folly. It has been folly to grant such men space in which to prejudice our patients against us. If what these men say were true, it would be very mortifying. But it is not true. They diagnose no more cases correctly than does the average country doctor. They sign more death-certificates than do some of their modest brothers. They do no more prevent the spread of contagious and infectious diseases than do the regular everyday doctors. They have been telling the "dear public" that there should be more state supervision of medicine; and they, being the fathers of the bills proposed, think that they ought to be made the heads of a lot of commissions at about $10,000 per. animals and in plants to cancer in man, so far as the acquirement of the disease by man is concerned, is purely an academic question, an hypothesis so far from verification that even the "whisper" of it should not reach the public. (4) That those members of the public in charge of or in contact with sufferers from cancer with external manifestations, or discharges of any kind, need at most take the same precautionary measures as would be adopted in the care of any ulcer or open septic wound. (5) That in the care of patients with cancer there is much less danger to the attendant from any possible acquirement of cancer than there is of septic infection, or blood poisoning from pus organisms. Of all the theoretic ghosts that stalk through the realm of cancer, however, the veritable Banquo's Ghost, refusing to be downed, is the ancient Constitutional Theory of the origin of this disease. It followed close upon the Evil Eye, the Curse, and other primitive ideas of the cause of disease, and it looms more or less vividly upon the horizon, its vestments varying with the times or with the "spotlight" cast upon it. Hand in hand with this ghost goes another, just now Possibly the public cannot see through the deal. Heredity, an unintentional ally. A six weeks' health course will provide a fat place for the lazy son or the shiftless nephew. The doctors will be favored according to their political pull. Merit in curing diseases will not be recognized. Neither the people nor the physician will have any appeal. The socialists suggest a better system, and it is free from graft. Considering the fact that nine-tenths of the health reforms of the past twenty years have been suggested by the physicians of America, is it wise to turn the public welfare over to a group of lay politicians? It is time for the physicians to call in some of their self-appointed publicity agents. CANCER Bainbridge, in the American Journal of Surgery, reaches the following conclusions: (1) That the contagiousness or infectiousness of cancer is far from proved, the evidence to support this theory being so incomplete and inconclusive that the public need have no concern regarding it. (2) That the communication of cancer from man to man is so rare, if it really occurs at all, that it may be practically disregarded. (3) That any relationship between cancer in The combination is not an easy one to combat in the campaign of education, for a bewildering array of facts, figures and fiction have been collected by the supporters thereof. To be sure, the facts are not fundamental ones, the figures may be impugned as may all statistics, and the fiction is as interesting as any other fiction concerning this homely subject; the serious import thereof, however, has a bearing upon the treatment of the disease, as we shall see, and hence upon the campaign of education as applied to the layman. It is important, therefore, that a rational stand be taken concerning these theories of the origin of malignant growths by those who are earnestly endeavoring, without preconceived and biased views, to instruct the public in the matter of the eradication of this scourge. Is it not enough then, to teach, in effect: (1) That the hereditary and congenital acquirement of cancer are subjects which require much more study before any definite conclusions can be formed concerning them, and that, in the light of our present knowledge, they hold no special element of alarm. (2) That in cancer, as in all other disease, attention to diet, exercise, and proper hygienic. surroundings, is of distinct value, aside from any consideration of the essential cause of the disease. (3) That suggestions which are put forward from time to time regarding the eugenic, dietetic and other means of limiting cancer, should not be accepted by the public until definitely endorsed by the consensus of expert opinion. Such consensus does not exist at present. 济济济 CO-OPERATION BETWEEN DOCTOR AND DENTIST T. J. Tuder, in the Virginia Medical SemiMonthly, thinks that in the robust and healthy a small amount of infection, or oral sepsis, may, by the natural resistive forces of the body, be held in check, but there is a potential danger, which must be reckoned with, and it would seem a matter of plain common sense to apply the same reasoning to the matter of treatment of oral sepsis that we would to the treatment of sepsis elsewhere, for instance, if involving the gall bladder, the appendix, or the tonsil, and that is remove it absolutely-by treatment of the teeth and gums, if possible, and if that is not effective, by extraction. The physical condition of the host should always be considered, and just as the physician should refer the patient to the dentist for adequate oral treatment, the dentist, when treating a patient, whose natural defenses need building up, should send that patient to the physician for this. purpose. Capped, loose, dead, or teeth containing large fillings, or connected with bridges, should be watched closely for evidences of infection. Just as we have learned that a tonsil may appear normal and yet be septic, so even the expert may be deceived as to a septic tooth. Of course, we know that the removal of a septic tooth will not always clear up; for instance, a septic arthritis, even when the septic tooth actually produced the arthritis, as the damage is often already done, and the joints in question are regular nests of infection, but amelioration of the symptoms, and often a cure, follows the removal of the septic foci, whose continued presence would be a menace to other joints and structures of the body. A word about children's teeth: We know the value of the conservation of these teeth only too well; we have learned the sad lesson of the danger of caries of the deciduous teeth, but so few dentists will do any considerable work on the teeth of the little fellows. Many of them tell the parents that the children will soon lose the temporary teeth, and that it is hardly worth while to spend their money to have them kept in repair. Of course, the dentist realizes that if they are not saved the permanent teeth may be crooked, but they might be so any way, and so it goes. When the dentist really does any work on children's teeth, he usually puts in a few small fillings and tells the mother that the others do not need filling, as they have not ached. I realize that such work requires a great deal of tact and patience and that the remuneration is often inadequate, but the need is certainly most urgent. Another problem is the teeth of those who cannot pay for their repair, and this class is a huge one. We treat these systemic diseases as best we can, and when we trace them back to a septic focus in the mouth, "we have the coon up the tree," but no way to get to him. From statistics it would seem, however, that in this case "God tempers the wind to the shorn lamb," for it certainly seems to be true that systemic disease results very much less frequently from oral sepsis in the very poor than in the well-to-do and the rich, and the reason doubtless is that when the teeth of the very poor ache they know only one remedy and that is extraction, which they usually have done soon after the onset of pain, and also the rougher, coarser class of their food tends to keep the teeth and gums in a more healthful condition. The negro, with his appalling death rate, almost everywhere twice that of the white' rate, and in some sections even exceeding the birth rate, is causing no little anxiety to health boards, medical societies, etc. What about his teeth? Here is a virgin field for capable dentists. About all the work they get on their teeth, aside from that done by quacks, usually of their own race, is extraction, and, aside from the two great enemies of that race, syphilis and tuberculosis, which are practically decimating it in this country, their dental needs are most urgent. I believe that the day has come for a great awakening of the people of this country as to the importance of their teeth, and I hope that some of the great research agencies may furnish the men and the money for an intensive study of the subject of dental caries, pyorrhea alveolaris, and allied diseases, and that the day may soon come when the supply of dentists will be adequate for the work, and the people educated to the importance of having the necessary treatment, and some provision made to enable those who cannot afford it to have the necessary attention. lifting the diastolic pressure 15 millimetres will save life, as a rule. I have elsewhere insisted on the importance of the inclined position. In shock, the sufferer bleeds into his own abdominal veins. They take the blood from the heart and brain. The inclined position feeds the heart and brain by gravity. But gravity is slow and death draws swiftly on. How may the wounded wait and still be safe? Time may be gained by adrenalin and by injecting normal saline into the veins. Both tend to fill the heart; one by narrowing the arterial outlets, the other by adding to the volume of the blood. Neither is a logical remedy, for neither brings back the blood from the congested veins into the arteries and thus into the feeding capillaries. The veins store but do not feed. We should pump the blood from these fatal wells into the heart. Such is the logical ideal. I propose a remedy which satisfies this ideal. I propose the thoracic pump. When the diaphragm descends in inspiration, the cavity of the thorax is enlarged. It is as if a squeezed rubber bulb were expanded under water; the surrounding fluid enters the sucking ball. So do surrounding fluids enter the chest. The air is sucked in through the trachea and blood is sucked in through the veins. In man, this suction may balance a column of mercury 30 millimetres high, equal to a column of blood 15 inches high-a value one-third the total normal diastolic arterial pressure. Without this respiratory suction, a weak arterially-toned man would faint every time he stood up. It is this potent force I propose as a life-saver in traumatic shock. If the normal contractions of the diaphragm so aid the circulation, its powerful contraction will aid still more. Powerful and frequent contractions are within our command. We have but to increase the carbon dioxide in the inspired air to call forth deep and rapid respiration. The necessary amount of carbon dioxide is not injurious. To an animal it can be given from a gas tank discharging through a Wolff bottle into a T tube, the short limb of which is attached to the tracheal cannula. In man, rebreathing may be employed. The patient may breathe in and out of a rubber bathing cap, previously inflated with Davidson syringe. When oxygen hunger approaches, the cap is removed. In a moment or two the experiment may be repeated. In the course of the past two months, March and April, I have with carbon dioxide produced deep and rapid respiration in many animals in whom surgical shock had been brought on by injecting oil into the external jugular vein. The THE SALVARSAN ISSUE The Medical Sentinel informs us that during the last few months there has been another shortage of salvarsan, and the profession is facing a situation that existed a year ago when this needful and necessary drug was practically off the market, and the little that remained was held by speculators at an almost prohibitive price. In view of the fact that the little that remains will soon be gone, a demand is being voiced by many members of the profession that the patent on this German-made drug be abrogated. This demand is taking the form of resolutions passed by various medical societies and is being sent to their respective congressmen, inasmuch as a special act of congress is necessary to cancel any existing patent law. There are several facts that strongly support the justice of this contention. The supply of the drug is in the hands of one agent who practically says who shall and who shall not receive the drug, and who sends just as little or as much as he sees fit to each customer. Thus one physician known to the writer who uses quite a considerable quantity of the drug ordered twenty ampoules and received but six; another who wished to lay some away for a rainy day ordered ten and received ten. The price of the preparation likewise is exhorbitant, an ampoule selling for $4.50, so that the patient or physician is forced to pay a premium or royalty to the manufacturer of almost treble of what it is worth. Some time ago when the drug was unobtainable, Dr. Schamberg, of Philadelphia, succeeded in manufacturing it and announced that he would. be prepared to furnish any quantity for $1.00 per ampoule. Reports from physicians using this American-made product declared it to be superior to the imported article. Unfortunately, however, as long as the agent of the imported 606 has any on hand the law forbids the sale of any of domestic manufacture. Further than this, the United States is now at war with the country making this product, and it seems a deplorable situation if we cannot find a way to avoid paying further tribute to the German manufacturers or its agents. Enough inflated profits have already flowed into the coffers of the manufacturers of this drug, and it is about time to end this and any other condition that hampers the profession in obtaining needful, supplies or forces them to pay exorbitant prices for them. It is up to our local societies to adopt similar resolutions and to forward them to our congressmen for immediate action. A copy of the resolutions adopted by one Eastern medical society is as follows: Whereas, salvarsan is a drug which is of vital importance to the protection of health and to the saving of life, and Whereas, the patent rights conferred on salvarsan and its congeners, have created a monopoly which has permitted a price to be placed on the drug which makes it unavailable to tens of thousands of indigent sick in this country, and Whereas, the drug has hitherto been supplied to this country from foreign shores and the supply during the war has been uncertain and insufficient, and Whereas, the patents have prevented the preparation and distribution of the drug in this country by American laboratories, and Whereas, the patents conferred are operated against the health interests and the public welfare of this country. Therefore, be it Resolved by the Medical THE ADRENALS IN NEURASTHENIA The Medical Review of Reviews thinks there is much reason to believe that adrenal dysfunction is a factor which deserves a good deal more responsibility placed upon it for the causation of neurasthenia than as yet has been given to it. In a recent article in my series, "The Diagnosis of the Internal Secretory Disorders" (Western Medical Times, Sept., 1916) you will find an outline of some facts connecting the adrenals with neurasthenia. I will quote a few paragraphs here: "Minor functional hypoadrenia is more common than some have appreciated, and the fact that there is a psychic origin as well as other physiologic causes already considered, allies it to the fashionable 'neurasthenia' of today. In fact some have stated that what is improperly called 'neurasthenia' is not a disease per se, but really a symptom complex of ductless glandu lar origin, and that the adrenals are probably the most important factors in its causation. Campbell Smith, Osborne, Tom Williams and others, including the writer, have directed the attention of the profession to the importance of the adrenal origin of neurasthenia (tho a pluriglandular dyscrasia is practically always discoverable), but SO far this is not understood as well as its frequency and importance warrant. "The subject is too large to receive exhaustive consideration here, but a few quotations from recent literature will firmly establish the importance of this angle from which to study this common and annoying symptom complex. Quoting first from the Journal A. M. A. (Dec. 18, 1915, .p. 2166): 'The typical neurotic generally has, if not always, disturbance of the thyroid gland. The typical neurasthenic probably generally has disturbance of the suprarenal glands on the side of insufficiency. The blood pressure in these neurasthenic patients is almost always low for the individuals, and their circulation is poor. A vasomotor paralysis, often present, allows chillings, flushings, cold or burning hands and feet, drowsiness when the patient is up, wakefulness on lying down and hence insomnia. There may be more or less tingling or numbness of the extremities.' "Again Kinnear Wilson, of London, in his monograph on 'The Clinical Importance of the Sympathetic Nervous System' makes the following pertinent remarks: 'Many of the common symptoms of neurasthenia and hysteria are patently of sympathetic origin. Who of us has not seen the typical irregular blotches appear on the skin of the neck and face as the neurasthenic subject 'works himself up into a state'? The clammy hand, flushed or pallid features, dilated pupils, the innumerable paresthesias, the unwonted sensations in head or body, are surely of sympathetic parentage. In not a few cases of neurasthenia symptoms of this class are the chief or only manifestations of the disease. Here, then, is a condition of defective sympathetico-tonus; may it not have much to do with impairment of function of the chromophil system? . There does not appear to be any tenable distinction between the asthenia of Addison's disease and the asthenia of neurasthenia. Cases of the former are not infrequently diagnosed as ordinary neurasthenia at first. It is difficult to avoid the conclusion that defect of glandular function is responsible for much of the clinical picture of neurasthenia." Be prepared to look for the adrenal element in gynecology or in neurasthenia and it will surprise you how common it really is. Kinnear Wilson, in the same address from which the |