tinctly potent as a blood builder and general tonic and reconstructive.

SOMETHING NEW-CHLORAZENE SURGICAL POWDER

A valuable addition to the list of antiseptics is a new Chlorazene preparation just placed upon the market by The Abbott Laboratories, Chlorazene Surgical Powder. It contains 1 per cent of Chlorazene in a base of zinc stearate and sodium stearate. It is a fine, impalpable powder, free from grit and irritant substances, and powerfully antiseptic.

Chlorazene Surgical Powder may be dusted freely over denuded or abrased areas, cuts, wounds and skin eruptions, and used as an antiseptic dusting powder of general utility following surgical operations. It relieves itching and subdues infection. It is applied, with happy results, to the sensitive skins of young children.

This antiseptic powder promises to be another big success-a worthy associate of Chlorazene tablets, powder and Chlorazene Surgical Cream.

PERSISTENT COUGHS AND COLDS Colds that linger invariably owe their persistence to inability of the body to exert sufficient resistance to overcome germ activity. Recovery, in consequence, is always largely a question of raising the general vitality and increasing bodily resisting power. To accomplish this, no remedy at the command of the profession is so promptly effective as Gray's Glycerine Tonic Comp. Under the use of this dependable restorative and reconstructive, the appetite is increased, the digestion improved, the nutritional balance restored, and the vital resistance so raised that the body can control infectious processes and establish a safe and satisfactory convalescence.

In the treatment of colds, therefore, "Gray's" can be relied upon to raise the defensive forces of the organism and fortify it against germ attack.

济济济

TYPHOID FEVER

Attention is directed to a timely announcement which appears elsewhere in this journal over the signature of Parke, Davis & Co. and bears the caption, "Typhoid Fever." Prophylaxis, diagnosis and treatment, in logical sequence, are briefly and comprehensively considered in this advertisement.

Typhoid Vaccine, Prophlactic, is suggested as a suitable immunizing agent. This product is a twenty-four-hour culture of the typhoid bacillus, grown on inclined agar and suspended in physiologic salt solution to which has been added 0.2

We offer an excellent opportunity to enter a pleasant and profitable business to a limited number of ambitious wide-awake men.

We desire one or more representatives in every state and every large city in the Union. To such we can offer an exceptional chance to make money, by acting as representatives for our popular books for physicians and druggists and for our periodicals.

This work is not "canvassing" in the common acceptance of the term; our salesmen are not "book agents," and are not expected to make collections or deliveries. They simply solicit business. The pay is good and a capable man will find that he can make more money at this than any other similar work, and he will have an excellent chance to see the country.

We have the most salable line of medical books published. They are all new, written by the highest medical authorities and up-to-date.

Naturally we prefer men who know something about medicine. It is just the work for medical students during vacation and we want a representative in every medical college. Physicians who know any person or persons who would be likely to undertake such work will confer a favor upon them and upon us by calling their attention to this opportunity.

G. P. ENGELHARD & COMPANY, Subscription Department,

CHICAGO.

per cent trikresol as a preservative. It is accurately standardized. That this vaccine confers immunity from typhoid fever has been shown by an abundance of clinical evidence.

In the diagnosis of typhoid fever the Typhoid Agglutometer has undoubtedly done much to popularize the Widal test and to extend the usefulness of that valuable diagnostic aid. Parke, Davis & Co. supply two forms of the agglutometer, designated as No. 1 and No. 2. Directions for use accompany each outfit.

Ror the treatment of typhoid fever Typhoid Phylacogen is an agent of established value. A marked effect of its use in all favorable cases is an early subsidence of the fever and a prompt establishment of convalescence. The technique of dosage and other particulars of the treatment are covered in Parke, Davis & Co.'s literature on Typhoid Phylacogen.

Relation of Teeth to Enlarged Glands-Hartzell, in the N. Y. Medical Journal, points out that mouth infections should be regarded as a result of the organisms which were habitually found in the mouth and which had the power to invade the tissues. This reduced the field of intensive study to a comparatively small number -the fusiform bacillus, the mouth spirochete, Leptothrix buccalis, and the streptococcus. Research showed that of these the streptococcus was the primary cause of the various dental infections. The staphylococcus was one of the active factors in acute alveolar abscess, but was regarded as unimportant in the chronic alveolar abscess. Staphylococcus was not an important factor in cervical lymph adenitis. Streptococcus salivarius was absolutely constant in the mouth. Streptococcus viridans was found to have the power of penetrating tissues and of causing metastatic lesions in all parts of the body. Unquestionably it produced a toxin, and the speaker believed that it was the organism mainly responsible for most of the important dental lesions, including inflammation of the dental pulp. It was certainly the chief cause of pyorrhea. It could and did invade the lymphatics and swollen lymph nodes were often observed in direct continuity with the lymphatic drainage from the gums and peridental tissues which had receded rapidly, due to stamping out of the growth of this organism in the tissues contigous to the teeth. This organism gave rise to a nonsuppurative lesion in the beginning, which might become suppurative as the destruction of the peridental tissues progressed. The suppurative character of the pyorrheal process, however, was grafted upon the initial lesion produced by the streptococcus and was secondary to the streptococcal invasion. The chronic dental

abscess, or so-called granuloma, was more important than the pyorrheal pocket as a focus of infection to the lymphatics and blood stream. Clinically, the invasion of the cervical lymphatics by Streptococcus viridans presented a fairly constant picture of low grade infection involving swelling of the lymph nodes and slight tenderness to pressure with or without slight variations of temperature. On account of the narrow range of temperature Streptococcus viridans lymphadenitis was often mistaken for incipient tuberculosis. A careful examination of the mouth and jaws was of greatest value in children. A decided increase in weight and vigor was often observed to follow the removal of dead pulps of teeth and the curettement of abscesses. In these cases the extraction of the deciduous teeth was safer than attempted sterilization. Sublingual gland infections from pyorrhea pockets and deep gingival crevices which were exceedingly common and frequently pass unrecognized might give rise to metastatic infections of heart, kidney, and joints. Patients should be taught to report such conditions, thereby enabling the physician to eradicate these foci of infections. Heart disease, according to the statistics of the United States Government from the registration area, was a greater menace to life than tuberculosis. Heart disease, which was ninety per cent. streptococcal in its origin, was to a large extent preventable. When teeth had to be extracted they should be taken at intervals of five to seven days; the speaker had seen in the last two years four deaths resulting from wholesale extraction of teeth. These deaths were due to the circulation reaching a point of saturation with the toxins of the infecting organism; the granulating walls around the areas of inflammation were broken down and the patient was overwhelmed by a mass of living organisms thrown into the circulation at one time. The same was true of pyorrheal infection. He advocated the same caution in the removal of the tonsils. It was vastly better to remove one at a time if the patient was near the point of saturation with streptococcal toxins.

SPECIALISMS AND THE PUBLIC

The medical situation in the past ten or twenty years may be regarded as somewhat parallel to that of the commercial world, namely, tending toward large central co-operative monopolies of specialism, similar to the "trusts" and department stores, by which the general practitioner, like the smaller merchants, lose caste and business and the whole profession comes to be viewed by the public upon a commercial, competitive basis. It is the fashion of the time to regard every commodity and service as a matter of quid pro quo, a phase of the division of the world's labor, to which the doctor, by reason of long centuries of sentimental standards of reverence and tradition, has not adapted himself.

The doctor is, in fact, face to face with the self-same problems which confront the small local merchant. The public demands its "money's worth," and if they find that the specialist, like the trust, gives a better money's worth than the local practitioner, then the latter must, like the local tradesman, find some way in which he can give the people a better relative money's worth than the specialist. It is not a time or a place for false pride, or a traditional delicacy, but for true pride, which meets and vanquishes the new situation and gives all that is asked.

We believe the general practitioner will admit that he has himself been too neglectful of his own interests in relation to specialism. Without any intention of belittling specialism or the specialist, we do not hesitate to declare that the general practitioner has been altogether too ready to surrender his influence and to yield up his business to their demand. He has allowed himself to become a mere feeder for the specialist. We do not insinuate any more discredit or dishonor to him that he has done so. His course has undoubtedly been inspired by a praiseworthy desire to do the best for his patient, but the specialist has taken advantage of the position to use every kind of influence to divert this kind of practice to himself.

There is nothing in specialism, per se, to degrade medicine or to lessen people's faith in it;

quite the contrary. It is, as we have said, one of the natural tendencies of the times. But the utter subjection of the general practitioner to the specialist is both debasing and unwarranted and tends to discredit practitioner and specialist alike in the public mind. It is time that the general practitioner reassert himself, and show a sturdy determination to square himself with the spirit of the times, by giving the public what it demands by "delivering the goods." Such a step will go far toward reinstating the family physician in his former enviable position, and toward getting a fresh hold upon the popular esteem and confidence which is felt to be slipping away from him. 济济济

THE PSYCHIC FACTOR IN SURGERY Whatever may be the ultimate significance of Crile's anoci-association doctrine in its relation to surgical shock, it has at least served one excellent purpose; it has called widespread attention to the esthetic and suggestive element in our dealings with our patients, especially in the realm of surgery. For years we have inexcusably neglected this factor. Not only are no particular pains taken to shield the patient from the sight and sound of all the dreadful paraphernalia pertaining to the preparation for a serious operation, but, on the contrary, there seems to be a special conspiracy to parade it all before the victim's shrinking eyes and ears.

There is no excuse, in these days, for such a brutal neglect of all the psychological demands of the case. All the healing cults-Christian Science, mental healing, New Thought, and the like-have learned the lesson and put it into practice. Perhaps they have overdone it a little. Regular medicine alone remains heedless. Possibly its attitude has been one of thoughtlessness, rather than of deliberate disregard. It has been disposed to look upon this aspect of the matter as trivial and unimportant.

There is a limit to such psychology, of course. Extremes are always irrational. No one wishes the attitude and behavior of the surgeon and his corps of accessories, before and after the fact, to be one of irresponsible and frivolous

trifling, as though there were nothing serious afoot at all. Such a course would be just as hysterical and irritating to the patient's overwrought sensibilities as the opposite course is morbid and depressing. Everybody knows how trying, under some severe mental stress, is the light-hearted, unfeeling prattle of an acquaintance who knows nothing of the strain we are under. To imitate that sort of attitude would be foolish and futile.

What gives strength and composure in such times of stress is the ministration of a friend who knows, but who thoughtfully and tactfully relieves the situation of all its morbid, sombre entourage, and sheds an air of calm confidence in the out

come.

This should be the ideal at which our preand post-operative treatment of surgical patients should strive. "It is not death that men fear," said some ancient philosopher (Bacon, we believe), "but the paraphernalia of death." The same is largely true of a surgical operation; and it should be the aim of our modern system to shield the patient from its horrible paraphernalia, both psychic and material.

We emphasize the importance of this matter in surgery, because it is there that we doctors are guilty of the greatest neglect; and there, perhaps, that patients suffer most from our neglect. But the lesson applies in every department of medicine-in the arrangement and decoration and conduct of the doctor's office, in the matter of prognosis (many a sensitive patient has been psychologically, if not actually, killed by the abrupt announcement of his death-sentence, either verbally or in the expression of the doctor's face), in the management of the sick-room, and, in short, in every relation between the physician and the patient.

Whatever we may think, and whatever may prove to be the case, concerning the direct effect of anoci-association upon actual surgical shock, nobody can gainsay the influence of emotions and sensibilities upon vital function and resistance during the consciousness of the individual; and it is certainly an important part of the physician's business to reckon with and utilize this psychic element.,

PURE MILK VS. PASTEURIZATION We do not forget that the problem of the milk supply of a large city is a serious and difficult one, both from its scientific, and also from its administrative, standpoint-a problem which has taxed the intelligence and resourcefulness of great minds since public hygiene became a systematic function of civic government. Nor do we overlook the incalculable debt incurred by milk hygiene to the advances of modern medical

science, especially to that branch of it which deals with bology and micro-organisms. Indeed, almost all the illumination which has been shed upon the nature and origin and general behavior of milk impurities, and therefore upon the best means of avoiding them, has come from the laboratory of the bacteriologist and the bacteriological chemist. But the laboratory, invaluable as it is in its advisory function, is not the proper place from which to administer public hygiene, and he who attempts to govern the practical regulation of a vast public utility by the rule of thumb that applies to laboratory regime is exceedingly likely to bring about some ridiculous, if not disastrous, situation.

The bacteriologist has revealed to us what are the chief elements of danger in impure milk, and shown us how to detect their presence. Herein his service has been invaluable, for it has enabled us to differentiate dangerous milk from innocent. He has further taught us whence these elements originate a still more valuable service, since it points the way to their avoidance and prevention. It may be gravely questioned whether it would not have been better for the practical aspects of public hygiene at large if bacteriology had stopped there. For its third step, the demonstration of artificial means for destroying nocuous germs, carries with it a subtle temptation to modify the stern, uncompromising demands imposed upon public hygiene by the first two.

We do not say that this germicidal contribution of science to the milk problem is an unmixed evil, but, unless it be very carefully and judiciously applied, it is decidedly a mixed good. And, above all, we assert that it ought not to form the basic principle of civic hygiene. If bacteriology has put it within our power (as it has) to determine, qualitatively and quantitatively, the presence of nocuous elements in milk; and if it has further demonstrated to us (as it has) the nature and habitat of these germs, and how they may be avoided, then public health and safety demand that the milk supplied for consumption be kept free from such harmful elements by the application of the prophylactic measures prescribed by science, and certified to be free by the tests furnished by the same science; and no less rigid or exacting requirements should for a moment be permitted to obtain. Certainly, no official provision should be made, by ordinance or otherwise, for condoning and legalizing low standards of milk by the application of scientific germicidal methods.

Thanks to the application of this prophylactic principle the milk supply of the country is unquestionably of a far higher character than formerly. It has resulted in a salutary competi

tion among producers in the matter of cleanliness and care. It is, in our opinion, a serious step backward to substitute a dead level standard of pasteurization. Such a plan must inevitably discount and discourage the clean production of the conscientious dairyman, and put a premium on impure milk. If all milk is to be pasteurized, and pasteurization gives all milk a legal status, what shall it profit the dairyman to spend time and money in the production of naturally clean milk?

For one thing, pasteurization is utterly inadequate to the destruction of several of the more dangerous micro-organisms, notably the tuberculosis bacillus, and is therefore unfit to serve as the standardizer of milk. In the second place, it is a process very difficult to carry out properly and uniformly, and, in municipal systems one knows how carelessly such things are done. And, further (and most important of all), the demand of the child is for LIVE milk, and no civic government has a right to cheat the babies of a city out of this right by establishing a standard of cooked milk, for the sake of playing to an overstrained science. If it were necessary to cook the milk, in order to make it safe, that would be another matter, but it is not. Natural mlk can be, and should be, pure. Impurities are in themselves unnatural and unnecessary, and are not be met by still further denaturizing, but by rigid prophylaxis.

慌慌慌

CO-OPERATIVE DIAGNOSIS

These are days of co-operative effort, and the principle of co-operation has already been applied successfully to various phases of medicine, to surgery, and specialism, and the like. The general practitioner frequently finds himself unable, by himself, to carry out an adequate form of treatment, so that he is obliged to remove his patient to a hospital, often in some distant city, and call in the services of a surgeon, and an anesthetist, and a corps of trained nurses, and impose upon the patient the necessity of laying up in the hospital for several days.

There is no reason why the same system should. not be followed in making a diagnosis. Indeed, so far as we can see, it must be followed if the doctor wishes to avail himself and his patient of the limit of modern diagnostics. All that is needed is that the physician should boldly institute such a system of dealing with his patients, to which, we are confident, he will encounter no general opposition, but, on the contrary, will find that it is met half-way by the spirit of the times.

It is no longer necessary to the doctor's prestige and influence that he should pretend to be all-sufficient in himself and by himself. Nobody in these days expects him to be so; rather, peo

ple look askance at the doctor who does so pretend. But they do expect him to be an alert, conscientious, well-informed agent of his science, who will procure for them, where he himself is quite justifiably unable to render it, the best service that modern medical science can furnish.

In many instances the making of a correct diagnosis, is a matter of several days, and demands expert skill and conditions of control, such as can only be attained by having the patient under continuous observation in a hospital, and the co-operative work of two or three investigators working together on the case. In such instances the doctor should not hesitate to impress this upon his patient, and get his co-operation in bringing it about, just as he does in the event of a surgical operation. As stated, he will find the ground ready for this kind of thing; it is just what people expect and demand. Nor will he find any serious obstacle in the financial aspect of such a system. In the main, patients are ready and willing to pay, and pay well, for thorough, painstaking diagnosis, if they are once assured that they are getting the goods.

We do not mean, of course, that this kind of co-operative routine should be followed with every patient. In many cases, doubtless, the majority of cases, the doctor is perfectly capable of carrying out his own diagnostic procedures. Most of the cases he is called upon to treat, happily, are mild and simple, easily diagnosed and readily cured. But in the exceptional and obstinate cases of diagnosis, just as in the rare and difficult cases of treatment, it is both his privilege and his duty. to avail himself and his patient of the co-operative facilities furnished by the present-day centres of medicine. Nor does this variably involve the removal of the patient to a hospital for observation and control, as suggested above. There are many more instances in which this co-operative assistance can be invoked by proxy. A urinalysis, a little more thorough than the physician himself can make; a blood-count; the identification of a suspected tissue; an examination of the sputum; will many times give the clue to an obscure and unmanageable case, and turn defeat into victory. And these can be obtained in these days by the simple, but all-too-little-exercised, expedient of mailing the specimen in question to a trustworthy clinical laboratory.