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who entered the mouth of the hungry P. G. school, passed immediately through its short, angleworm-like primae viae and promptly tumbled down the back steps with a special course certificate in their hands, have not seldom outheroded Herod-which means that where the haughty professor of the special P. G. course hath slain his dozens, some of hi shalf-baked special students have slain their scores, aye, hundreds.

The independent medical journal meets the demand of the everyday practitioner who wants to know "what to do." The self-styled high-class medical journal-and there is really only one "high-class" journal, you know, which is climbing so high that its head looks from below very like that of a pin-often gives him a stone when he asks for bread. He seeks for light on the treatment of disease, and on looking over the menu card presented by the "most high" he finds such things as "My Last Thousand Cases of Excision of the Calamus Scriptorius," "My New Postural Method of Catheterizing the Iter a tertio ad quartum ventriculum," The Opsonic Index in the Care of the Second Bicuspid," etc., and editorials in which the mantle of dignity conceals vast intellectual abysses. In despair he turns. to that cemetery in which so many fond therapeutic hopes lie blasted and buried under tons and tons of therapeutic nihilism, Osler's Practice-and still he finds no balm in Gilead. And then he turns to the independent journal and is consoled-which is a blessing, e'en though he be sometimes cajoled into belief in things unsubstantial. And the proof of the pudding is that thousands upon thousands of doctors buy and read the very journals. upon which the "lily whites" of medical journalism frown so blackly.

The ultra-scientific one who does not overmuch believe in treatment and recognizes naught but the scalpel and hemostatic forceps sometimes marvels that any one could condescend to read, much less contribute to our independ

ent journalistic media of medical expression. "Nothing in drugs," he wails; "send 'em to me and I'll cut 'em." He forgets that modern science has not yet conquered the lay aversion to the knife, nor the honest practitioner's belief that, after all, the knife is often a confession of our limitations and weakness. And there is much in the training of the experienced practitioner which inspires him with therapeutic hope in a vast number of ills of the flesh. By drugs he can produce anesthesia, local or general, relieve pain, produce sleep, stimulate or depress the circulation, allay nervous irritability, aid digestion, relieve constipation and hepatic torpor, produce emesis, diaphosesis and diuresis, antidote malaria. and cure syphilis. What wonder that he has confidence in drugs per se while rather skeptical of our knowledge of them? "There must be a remedy. If I only knew"-is a brow-contracting reflection familiar to the conscientious practician. And so long as there are sick ones to heal so long will he search for remedies-and so long will he read and believe in the literature that offers therapeutic hope.

Apropos of the snobbish question, "Why do you write for X's journal?" I myself have something of an eye to the "medium of expression" end of medical writing. If I have anything of value to say, I fancy that it does the greatest good to the greatest number in the journal that reaches the largest number of average practitioners. Moreover, there's where it does me the most good-and be it remarked, I am not one of those who profess to be writing "for the good of humanity' first, last and all the time. I believe that the product of my pen which does the profession and humanity the most good, is the stuff that is most likely to do me good, and vice versa. The hypocrisy and conceit of the medico-literary snob with a heaven-born “message" make me seasick. The pinheaded egotist wasting midnight oil in compiling ideas-or "facts," rather, for an idea would addle his composition

from other men's work for his message to an eagerly expectant scientific world is a spectacle for gods and men! And what shall we say of the toiling brother, primarily infertile of brain and who, dreading the pains of even the mechanical operation of literary parturition, merely affixes his name and manifold unearned titles to a compilation prepared by some poor devil of a medico-literary hack? I once heard vociferous and earnest applause at an overflowing meeting of a great medical society rendered a paper which had but one original line in it-the name of the author-and that was composed by his parents and written by his typewriter. Alas! poor literary Adam. And this is the sort of stuff that fills some of our ultra "high-class" journals to overflowing.


A special feature of the independent medical journal which commends itself to me is the possibility of individual expression in its editorial pages. Vigorous independent thought trenchantly expressed is what the medical man most needs. And the thought expressed should not always be medical dry bones. Medicine is broad. should embrace things literary, political and sociologic. Take the editorial columns of the independent medical journals away from him, and the overworked practitioner will be in a bad way for intellectual pabulum. The editor of an official "society organ" who should venture to express himself in terms stronger than a literary milkshake couldn't hold his job for twentyfour hours. Take away editorial independence and what would the organizers of a professional monopoly or a medico-political trust have to fear? What check would there be on their system? Why, they would not meet even criticism of any degree of potency.

The leaven of consolidation, unification and trustification is working most potently. By and by the firmament of American medical literature will contain naught but a central literary sun and his satellites, the "State" journals.

The independent journal that has been the representative at court and the great educator of the medical rank and . file, will be no more--and the rank and file will die of intellectual inanition. starved to death on the mental breakfast foods prepared by the great medical trust whose bat-like wings are already casting baleful shadows over the profession. The average practitioner will hunger and thirst for intellectual pabulum and he will get the shavings and gelatine broths dispensed by the hierarchy.

The struggle of the medical babies. to keep their erythematous rear elevations covered with the ethical garments inherited from our medical daddies is agitating to one's sense of humor. No use; our professional daddies didn't employ wool soap! Still less did they use good horse senseif they had, they would have realized that the medical man is a creature of his environment and must adapt himself to it or be a social anachronism and a political nonentity.

Moral-Don't be a clam merely because the paleozoic senilescents of a dead and gone medical age were contentedly stuck in the fossiliferous mud on the shores of the ocean of progress. Let the dead past bury its dead-and bury it deep, and let us not often open the doors of our ethical mu


It has occurred to me that the ambition of the doctor to own and operate a medical journal is conducive to the best interests of the profession. The medical editor has in general stood for what is best in medicine. He has often gone astray, it is true, and has sometimes pandered to the proprietors. of worthless or doubtful drug preparations, but on the whole the profession has benefited by the influence of the independent medical editor. He has been our watch dog in a way, and while by no means perfect-he is human, you know-has been a pretty creditable part of the body professionWhere he has made a living out of his journal he has been useful by


demonstrating a bread and butter outlet for the energies of medical men, and we have, alas! only too few such resources for physicians.

Had I ever wavered in my opinions. as to the ethics of contributing to independent medical journals my faith and courage would have been restored by something I saw a few short weeks ago in a journal which the ethical ultras regard so unfavorably that they throw an autotoxic fit and roll up their eyes like a dying jack rabbit whenever they hear it mentioned. It was an article by "Saint George," of Philadelphia. And, mirabile dictu, it was headed by his picture! Think of it-the peerless St. George, the erstwhile arbiter elegans of medical literature, slayer of ethical dragons and mastodonic hypocrites and humbugs, peerless knight of the medical ink pot, had an article and picture in a journal owned and controlled by a manufacturer of pills and "sich!" And-oh; joy! I had an article-with picture-in the same issue of that proscribed magazine.


An Autobiography by Clifford Whittingham Beers.


This book is a narrative of compelling interest, a wise and for the most part a kindly criticism of existing meth ods in some of the insane hospitals of the country and an outline of means for their betterment.

The author has himself passed through the Valley of the Shadow, having suffered an alternating insanity, evidently maniac depression in type if one may classify from his description. The book is of great value if for no other reason than that it contains a rare account of the subjective side of a

certain class of cases which is nearly or quite inaccessible to examination. For who engaged in the study of mental disease has not spent many hours in nearly futile speculation as to what is going on behind the mask of mutism and katatonia? It is only upon long and careful observation of these cases that one may perhaps obtain the key to the mental process and avoid the very mistakes in their conduct that are referred to by Mr. Beers.

During his period of exaltation and mental hurry, the author conceived his plan of asylum reform, the details of which have been tempered and readjusted by his return to sound judgment and by his willingness to seek the best advice, a plan the author has adhered to with remarkable tenacity. In fact so zealously did he endeavor to carry out his mission that overwork at so early a period was no doubt responsible for a partial relapse. Only by a rare insight into his mental resistence and by an unusually early development of that experience in detecting danger signals, not uncommonly found in those who have recovered from mental illness, did he save himself from recurring attacks with their almost certain resulting deterioration.

A tremendous amount of hard work and investigation has been done in his studies; indeed as the author says it was even necessary for him to learn how to write a book, a task that he has accomplished successfully. His work is excellent in composition and consecutive interest, remarkably temperate and as dispassionate as can be expected. However, his information is better in regard to hospital administration than it is in the classification and pathology of mental diseases. For example, he says: "A violent ward is not a place where insane patients violently attack their keepers and fellow patients except in the rarest instances and then as a rule only after they have been goaded into a revengeful madness by unremitting cruelty." Here he evidently largely fails to take into account the

crises of paresis, epilepsy and mania, to say nothing of deliberate outbreaks of paranoics and those patients acting under delusions of persecution and selfaggrandisement. Such outbreaks do at times occur even under excellent conditions of classification, the abolition of violent wards with careful redistribution of patients and the most gentle individual supervision.

No doubt it is quite natural in view of Mr. Beers' experience and opportunity for observation that he should exhibit a certain finality in the expression of his views as to the best method of hospital reform. But this problem is being attacked along slightly different. lines by others, chief among whom are certain eminent physicians. Within a few weeks a Chicago daily paper has published at length an address by Dr. Frank Billings recounting the past two years work by the Illinois Board of State Charities, of which Dr. Billings is a member. In Illinois, as everywhere, the fundamental difficulty has arisen from adverse or niggardly legislation by an uninformed or politically interested legislature. Notwithstanding legislative negligence and neglect, great advance has been made and it has been shown that physicians of intensely active professional lives are willing. to sacrifice time and income to this great work. It is among those finely trained in hospital organization and whose probity and unselfishness need no scrutiny must be found the men to carry on this work.

We strongly advise that the developing of better psychiatric equipment be left in the hands of the medical profession to be organized and directed through the State Society, as each state is the unit in hospital administration. For further organization the American Medical Association is best equipped to carry on this work since in perfection of organization, in number and personnel of membership and in facilities for publication no other body in this country may be compared. This method is most logical since an im

portant part of the new era of psychiatry must be the utilization of insane wards for thorough clinical teaching in every medical college.

The "National Committee" as proposed by the author would be without other than advisory functions and would of necessity consist in considerable part of well meaning but totally. untrained and largely ornamental "representative citizens." And, since every great asylum is a community in itself the superintendent must, so long as he holds office, be in absolute authority. There will then be more perfect understanding, less lost motion. and more prompt and uniform results if the advisory board or state committee be composed of thoroughly trained. and experienced physicians who require a minimum of groping to obtain. information.

We would, if our pen had sufficient power, add emphasis to Mr. Beers' plea for the great principle of "Non-restraint" and for the non-employment of ignorant and unsympathetic attendants through whom the great majority of instances of abuses and neglect must have been admitted. These evils will disappear entirely when enlightened legislative bodies supply as rapidly as possible sufficient funds for reconstruction of asylums which must have as a unit the small pavilion with perfect modern equipment, and then place in the hands of superintendents ample means for administration as hospitals rather than as asylums. This of course, implies the maintenance of a training school for nurses and a sufficient medical staff.

Every general hospital in a town or city of considerable size should have a detention or psychiatrical department which should also admit acute mental cases from adjoining counties which can not support such wards and the State should aid in support to that extent. Admission to this department should be upon voluntary application or by a simplified short term commitment so that admission may be prompt

and without publicity. This class of borderland and acute cases is also the most valuable for clinical instruction.

It is perhaps not untimely here to sound a note with reference to the many luridly illustrated though otherwise excellent articles on almost every medical subject that are appearing in the popular periodicals. Their number and variety of subject matter has increased insidiously since a few years ago when the fashion was set by the perfectly proper campaign of publicity regarding tuberculosis and other contagious diseases. However, that was a matter vastly different from the content of some of the articles which are now encouraging an already neurotic. public to further introspection. It is likely that a fuller measure of good would have resulted in the instance of this particular book if some kindly philanthropist had enabled its author to place a limited edition in the hands of the legislators and physicians of the country rather than to have placed it for popular sale upon the book stalls.

With all kindness and appreciation of Mr. Beers' work it is to be hoped that in a future edition he will entirely eliminate the chapter detailing his suicidal mental process and attempt at self-destruction. Longmans-Green & Co., New York, $3.00.


fitted wit ha stylet like a trocar, but in this case the needle is sharp and the stylet blunt. The needle is marked in centimeters. With the stylet withdrawn the needle is pushed through skin and subcutaneous tissue; the stylet is then pushed down to make the instrument blunt and needle is inserted to proper depth. A separate route is taken for each division. The ophthalmic division is reached by inserting the needle at the external markin of the orbit and passing it along the external wall to a depth of 3.5 to 4 cm. The author has made this injection only once. For the middle branch the needle is inserted at the lower border of the zygoma 0.5 cm. behind a vertical line drawn from the posterior border of the zygoma 0.5 cm. behind a vertical line drawn from the posterior border of the orbital process of the malar bone. At a depth of 5 cm. the nerve is reached at its emergence from the foramen rotumdum into the pterygo-maxillary fossa. The inferior maxillary division is reached at a depth of 4 cm. from a point at the lower border of the zygoma. The solution used is 75 per cent. alcohol to which a little chloroform and cocaine are added; at subsequent injections 85 or 90 per cent, alcohol is used.

Uncertainties and Dangers:..On account of variation in the conformity of the bones, particularly in the zygoma and coronoid process, one never is certain of striking the nerve at any given time. The author thinks he has missed oftener than he has struck it. This un

BY HUGH T. PATRICK, M. D., CLINICAL certainty is the only difficulty in the


Doctor Patrick in this article relates his experience with the use of deep alcohol injections by the external route in trifacial neuralgia as devised by as devised by Levy and Baudouin of Paris. The instrument employed is a straight needle 1.5 mm. in diameter an d10 cm. long,

method, and the known dangers are few. Infection has never occurred. A few times transient abducens paralysis has been produced, and once the solution went into the orbit causing great edema of the eyelids, but no injury to the eye. No anesthetic is required. When the nerve has been reached the patient feels pain in the area of its distribution, and immediately after the injection this area has a swollen, stiff feeling and is relatively analgesic.

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