the exact kind and degree of modifying influence at the best available point, we bring about a wholesome reaction on the part of the whole mechanism which remeIdies the trouble.

This is what we have ventured to call "dynamic therapeutics." It is a much more scientific and rational system than the old scheme of forcing what was loosely termed the "physiological" action of drugs, i. e., the crude primary result obtained by the chemical or physical action of the drug upon the tissue or organ to which it was applied, without any reaction on the part of the function. By the same token, it is a much more difficult system of therapeutics to practice, for it puts out of court all the clumsy, arbitrary labelling of diseases and their treatment as classified entities, and demands a thorough canvass of all the factors, etiological, pathological, and symptomalogical, which enter into each individual case, and the proper application of the therapeutic agent to call forth the necessary reaction in the patient.

And further, it opens out to the practitioner a much wider and more varied field of therapeusis than was possible under the old regime. For, if the therapeutics be understood to mean the awakening and the proper direction of a reaction in the patient, then any agent which, from its character and the nature of the case, may be reasonably calculated to bring about such a properly-directed reaction, belongs to the realm of rational therapeutics. It need not be a drug-although a drug is frequently indicated. It may be some form of electrical or physical stimulation; it may be some properly directed exercise on the part of the patient himself; it may even be some form of suggestion by the physician. Nor is it necessarily the same agent that is called for in every individual suffering from the same trouble. Different people react differently to the same agent. Scold some persons and they wilt, while others are spurred by sharp rebuke into healthy effort. So it is with the body. The crucial test is not the agent, but the patient's reaction to the agent.

One of the most notable features of this new therapeutics is the remarkable widening that has taken place in the number and variety of remedial agencies. Drugs themselves have taken on a new and more scientific aspect, and lend themselves to a far more accurate and rational application. And to drug therapeutics have been added a large group of curative agents which, properly understood and applied, call forth a health-restoring reaction in the mind and body of the patient such as drugs cannot accomplish. No physician who desires to be abreast of the modern rational medicine, and to do the best for his patients that twentieth century medical science makes possible, can afford to neglect these newer methods of therapeutics. It is the men who have come to distrust the old system of forced drug action, and who have not acquainted themselves with the new system of dynamic therapeutics and its available agencies-it is this class of men who constitute the "therapeutic nihilists" of the present day. It is against this paralyzing spirit of therapeutic nihilism that the influence of this journal is earnestly directed; and we combat its insidious negativism by a fair and rational presentation of all the armamentaria which latter-day skill and knowledge have placed, and are placing, at the disposal of the progressive, ambitious physician.

ويب

Rhinoplasty in Nose Destroyed by Cancer.

BY B. L. EASTMAN, M. D., Kansas City, Mo.

Surgeon and Gynecologist to the Missouri Hospital for Women, former Professor of Gynecology in the University Medical College, Kansas City.

T

HE report of this case is prompted by the desire to contribute modestly. to the current literature on Rhinoplasty, which is almost a minus quantity in English.

The barrenness of our literature as compared with that of the French, Italian, and German, is surprising when one starts to investigate it even in a small way, as the writer did prior to the beginning of this paper.

The chapter on Rhinoplasty in Binnie's Surgery is probably the best and clearest resume of the subject in any of our modern works. To this most excellent book this article owes the modicum of historic and scientific data that it may contain.

Rhinoplasty, the operative correction of deformities of the nose, is a branch of constructive surgery that has developed most in France and Italy, surgeons there reporting series of cases far in excess of any in England or America. The reason of its wider application there may lie in more virulent and neglected syphilis in the lower classes, and the, until recently, fashionable Code Duello among the gentility.

Nasal defects are roughly grouped in two large classes; the partial or sub-total, and total, loss of the nose. The latter is rare even in Europe, and is scarcely ever seen in this country. Sub-total defects include all the minor losses of substances, such as destruction of one ala, loss of the fleshy tip, loss of the whole end, defects in the skin and cartilage or septum or all, and saddle-back deformity with flattening of part or all the organ.

The causes of these partial defects are variable and may be anything from mules to mayhem, but in this country, cancer, accidental injury, freezing, and late syphilis, are the chief factors in about the order named.

Whatever the cause and however slight the defect, it is noticeable on the individual and a nuisance to him out of all proportion to its anatomic importance. With an extensive defect, the otherwise welcome person becomes repugnant almost beyond toleration.

The technic of nose repair broadly follows one of two methods; first, pedunculated living flaps swung down from the

forehead, or, second, living flaps attached to the hand, forearm, or elbow. The one is known as the Indian, the other as the Italian method.

The French school a generation ago tried to impress its individuality on the method of sliding flaps from the face and cheeks and would have it that this should be called the French method. The name, however, is not generally adopted.

Such a

As between the Italian and the Indian methods the choice is always with the latter; pedunculated flaps from the forehead are easier to plan, easier to handle and simpler in their mechanics. The Italian method shapes the flap from the living finger or arm, later attaching it to the defect in the face until it becomes vitalized in its new location. method is complex to say the least; it requires two or more operations to get the flap in place, and a complicated apparatus to hold the donating limb solidly. Patients who have the fortitude and toleration to stand such treatment will be hard to find in our restless and impatient Occidental civilization.

Photograph not retouched. Taken March, 1910, four months after first operation. Scar on forehead shows prominent and dense.

Mass at left side of base of nose prominent and spoils perfect vision. The edges of nose scar are still slightly uneven.