himself, but imposes upon his family, his neighbors and his community, he is in a position very similar to the insane or the criminal. The sooner he is forcibly removed from the circumstances which promote his weaknesses and add to his burdens and those of his family, the, better it will be for all concerned.

In this country we could with much advantage emulate the example of the Austrian authorities; and while we would immediately hear from those who are strong on "personal liberty," there is no doubt that the habitual drunkard and those affected by his pernicious habit, would be the better of earlier action on the part of the authorities than is at present the rule.

Pain.-Nothing is more distressing or disastrous to the human being than pain. It assumes many forms, which require individual and antipodal treatment. Narcotics, particularly opium or its alkaloids, are considered panaceas, and therefore all too often resorted to, notwithstanding the many objections to their use. Heat and cold, either one or alternated, will often serve as most excellent analgesics; a change of posture, if the pain is in a limb, will sometimes suffice to relieve; or when pain results from exposed nerve terminals, such as often follow burns, wounds, etc., the application of fomentations will many times relieve. To treat pain, however, is usually but to afford a temporary measure of relief, for pain is but a symptom. The cause should always be carefully sought for, and when found, it should be removed or corrected as promptly and effectively as possible, with minimum disturbance of bodily functions. Gastric and intestinal disturbances frequently give rise to pain which can often be relieved by lavage or laxatives. The pain of rheumatism, and sometimes that of gout may be surprisingly lessened by restricted diet, elimination and immobilization; neuralgias by isolation, rest, embrocations or counterirritants.

It should constantly be remembered that pain is but a danger signal, an evidence of disordered function and whenever possible treatment should be instituted accordingly.

WHAT THEY ARE SAYING

Surgical Immunity.-Discussing the problem of surgical immunity (New York Med. Jour., Dec. 9, 1916) W. Wayne Babcock says that for the successful treatment of many surgical conditions the production of an artificial immunity is much less important than the maintenance of the normal bodily resistance. Too frequently we forget that vaccines and serums can never replace such timeworn aids to immunity as rest, support, noninterference, protection, and other important measures that have been reiterated and forgotten many times. It has been well said that surgery should be retaught every seven years, so that the useful things of the past are not forgotten and thrust aside by the innovations of the present. It is my intention briefly to review a number of conditions in which attempts to produce artificial immunity are of secondary importance in the treatment of the affection. As surgeons no longer believe that disease is an evil to be scourged from the body by fire and other drastic measures, inflamed tissues are handled with greater gentleness, not because the handling is painful, but because we realize that traumatism may destroy the local immunity, or may diffuse infection beyond imperfectly erected tissue barriers. It has long been recognized that absolute, general, and local rest, frequently determines whether a contused. wound leads to disorganizing infection, or a simple aseptic wound healing. A crushed hand treated by aseptization, and a careful dressing, but put back at once to work, is frequently followed by a disorganizing phlegmon that spreads up the arm. same injury treated with a simple wet dressing, support, elevation, and complete local and general rest, may heal without inflammatory reaction. Against the handicap imposed by the first plan of treatment, no vaccine or other measure for the production of artificial immunity will avail. Again, many of us have seen a crushed and lacerated hand treated by painstaking aseptiza

The

tion, and the most accurate suture of the divided deep and superficial tissue, swell, become necrotic and disorganized from tension, infection, and secondary inflammatory processes. The same injury treated without suture of the divided tissues, especially the overlying skin, but by the free division of any skin that may cause constricting tension when the secondary swelling occurs, may heal with no sign of infection. No method of artificial immunity has been devised that will take the place of absence of local tension, or local or general rest in the treatment of certain wounds.

Therapeutic Results.-"All along the therapeutist may test the efficiency of his personal work by comparison with the results of general practice," states Konkle (New York Med. Jour., Jan. 13, 1917). "This he should conscientiously and assiduously do. Pausing thus to check, to orient himself, to take his bearings, not only absolutely but also relatively, if he finds that his average success is equal to the average success recorded as the outcome of enlightened effort in the field at large, then he should be satisfied; if his surpasses the common ratio, he may congratulate himself. Having proved that he is abreast or in advance of the professional body in attainment and accomplishment, he need not apologize for measures or methods. With his mortality rates speaking for him, he will not have to plead his own case. Gauging with such a standard his operations and endeavors, he will dare to be independent and original-to ignore fashion-to defy the toils of the bête noire. He will not be 'tossed to and fro, and carried about with every wind of doctrine.' He will not heedlessly follow the thoughtless throng to the worship of false gods of healing-impotent, ephemeral gods, which in number and variety outclass the gods of old Rome. But he will be a good, true, strong doctor. His work may not be dramatic nor spectacular; finer, nobler still, it will be the expression of power and virtue. And he will be content, knowing that worth is better than show, and feeling that rather than a mere refined and cultured counterpart of the

African fetish doctor or the Indian medicine man, he would prefer to be forever a Telemachos exploring earth and sea under the aegis of Pallas Athene, or a Numa in devoted discipleship sitting at the feet of divine Egeria within her grotto at the base of the Cælian Hill."

Large Business and Medical Supervision. "The time is not far distant," says W. J. Stone (Jour. of the Mississippi Valley Med. Assn., Jan., 1917) "when all corporations employing large numbers of industrial workers will recognize the efficiency value which follows medical selection. This will involve regular medical examinations, the control of intemperance, as well as social service in the homes. The contentions of the American Association for Labor legislation, which may be taken as the best organized work for the improvement of workers along the line of health insurance, are deserving of commendation. The legislation proposed in the various states not only attempts to secure compensation for the worker after he has become ill, but aims to prevent disease by proper regulation of devices and methods which are inimical to health.

What is needed to make such legislation effective is emphasis upon the phases which have to do with preventive medi

incipiency, is worthy of every encouragement and help from the laity as well as the profession. The movement is bound to grow and its sphere of usefulness is unlimited."

Milk Borne Infections.-From his statistical study, altho it is incomplete in several respects, E. R. Kellogg draws several very interesting and suggestive deductions.

Continuing (Jour. A. M. A., Dec. 30, 1916) he says "Analysis of Massachusetts investigations does not corroborate the the statements to be found in various places in recent literature, alleging that milk is a very important channel of infection in a quantitative sense in this group of diseases.

Massachusetts experience would seem to indicate that even in raw milk supplies, with widely varying conditions of supervision, diphtheria transmission thru milk is so rare an occurrence as to be negligible.

The transmission of scarlet fever thru milk, while much more common than diphtheria, is of very small percentage signifi

cance.

Typhoid fever in this large series, extending over a period of years, was reasonably attributed to milk infection in a much larger number of cases than diphtheria or scarlet fever, but these amounted in all to only 5 per cent. of the total cases of typhoid reported, a very different story from the statements of from 10 to 25 per cent. frequency of typhoid infection by milk that can be found in various places in recent public health literature.

Septic sore throat is par excellence the milk-borne disease, but its occurrence is fortunately relatively rare. When it does occur, it is nearly always in epidemic form. and is of more serious consequences.

In all probability, the menace of tuberculosis is the best justification that we have as practical sanitarians for the amount of propaganda that has been carried on and the money that has been expended by health authorities for the supervision and control of milk supplies, so far as such supervision aims at the suppression of communicable diseases."

The Determination of Gastric Ulcer."Simple gastric ulcer" says Harris Weinstein (New York Med. Jour., Jan. 6) "cannot be demonstrated by any known method short of actual inspection. The history, clinical or laboratory evidence, and radiographic findings are alike disappointing. Assuming the existence of a simple gastric or duodenal ulcer without complications, we cannot but admit the efficacy of proper medical treatment. Recrudescence of the ulcer occurs where the prescribed regimen is grossly abused, or where the etiological factor is operative and cannot be removed. Healing of an ulcer depends upon sparing of the mucosa, neutralization of hyperacid contents when present, improvement of the general nutrition and of cell resistance, and removal, if possible, of the focus of bacterial invasion. Even in the presence of multiple ulcers which constitute about twenty per cent. of the cases, these desirable results can be attained by proper management. The arguments advanced in favor of surgical interference cannot be lightly set aside. The occurrence of a possible hemorrhage, of chronic oozing, and resulting anemia and debility, of chronic induration and subsequent obstruction or hourglass contraction, of acute, subacute, or chronic perforation, and of probable malignant degeneration, cannot wholly be prevented by medical means. Radical surgery, which alone can be relied upon to prevent the dangerous complications above enumerated, suffers from a rather bad reputation in point of mortality. To make resection still more undesirable, gastric ulcers are frequently inaccessible, as they occur in about eighty per cent. of the cases on the posterior wall of the stomach; are often imbedded in a mass of adhesions, and are just as frequently not found at all."

Dr. Jelliffe Joins Staff of New York Medical Journal.-As we go to press we learn that Dr. Smith Ely Jelliffe has joined the editorial staff of the New York Medical Journal. This is welcome news to the many friends of all concerned.

TUBERCULOSIS IN GREAT BRITAIN AT WAR.

BY

HALLIDAY G. SUTHERLAND, M. D., (Edin). Temporary Surgeon, Royal Navy; Consulting Tuberculosis Officer for North Marylebone, and Medical Officer to the St. Marylebone Tuberculosis Dispensary, London, Eng.

The number of men discharged from the combatant services of Great Britain on account of tuberculosis since the beginning of war has drawn the attention of the medical and lay press of that country to one aspect of a very complex problem. Tuberculosis not only renders men unfit for active service, afloat or ashore, but also carries in its wake low wages, unemployment, and poverty, and by these circumstances it is associated with many of the difficulties of our present and future national existence. On these grounds an attempt should be made to solve the problem before our great armies return, for if apathy and indifference have their way it may be that the whole question will be submerged for a time amid those vast social and political changes which wise men see in the immediate future.

The control, treatment, and eradication. of tuberculosis can only be achieved by a policy based on knowledge and foresight. As a disease, tuberculosis is one of the many realities of national life against which neither sentimentality nor political expedi

ency can prevail. Three aspects of this question stand out clearly and demand a settlement, each on its own merits. Firstly, there is the amount of a pension, for with the purchasing power of a sovereign reduced to eleven shillings, it is obvious that a sum of money which might have constituted an adequate pension during the Napoleonic Wars, can only now be regarded as an inadequate pittance. Secondly, there are the men to whom pensions should be granted on account of tuberculosis, and lastly there is the provision for treatment on national lines which will apply to every aspect of the disease.

In order to state a definite policy the tuberculous patients discharged from the services may be classified in four large groups.

1. There are the men, free of tuberculous infection at the time of attestation, who became infected and developed active disease in the services. They are entitled to a full pension for life since their disability is wholly due to the conditions of service.

2. Some of the men invalided out of the services never suffered from active tuberculosis in civil life but nevertheless had the seeds of latent infection which developed under the strain and stress of active service into declared aggressive disease. It would be idle and uncharitable casuistry to speculate as to whether a man might not have broken down had he remained in the easier and less exacting circumstances of civil life. Such a man had earned and won the benefit of the doubt, and ought to be pensioned on the ground

that his infirmity was aggravated by the conditions of active service.

3. Another group consists of those who were treated prior to the war at tuberculosis dispensaries, at sanatoriums, at hospitals, or at farm colonies, and who regarded themselves as cured inasmuch as they were able to earn their livelihood in civil life. In the belief that they were able to serve the Empire they joined the services when the call first came. Many have withstood the strain of war, and in so doing have shown how much scientific treatment is able to achieve for individual patients. In other cases the disease returned, the men broke down, and have been discharged as unfit for further service. When they joined they signed the attestation certificate in perfect good faith "I hereby certify that to the best of my belief I have never suffered from *** any other disease likely to render me unfit for His Majesty's service." They were allowed to serve after having undergone a medical examination. for physical fitness and for the purpose of excluding active disease. Lastly there is the patriotism which led them to join, and that it is well to remember in the middle

of war.

and at the end no less than at the opening On these grounds such men have a right to claim that their relapse was aggravated by the conditions of active service.

4. In this group there are consumptives, whose disease had rendered them unfit for employment in civil life but who nevertheless succeeded in joining the services. An instance of this has been recorded by me in the Lancet of 3rd June, 1916. "One such recruit joined one branch of the services three times in eighteen months and when seen by me had been twice discharged. For two years before the war he had done no regular work, and at the time of attestation his name was on the waiting list for admission to a sanatorium in the north of England. During his time in the service he only appeared for duty on three occasions and went 'sick' each time. The remainder of his service was spent in hospitals. When I asked him why he had joined again after having been discharged he replied with engaging frankness, 'It's easier than working at the docks.' One Wild Goose does not make a Michaelmas, but further evidence is at hand. In civil life it has been noted that there is a falling

off in the attendances of male patients at tuberculosis dispensaries, and in many parts of the country the waiting lists for sanatorium treatment for civilians is much reduced, so that it is not improbable that a certain number of these lost patients has entered the military services.

It may be asked how did these patients pass the doctors, but the lay critic, tempted to wholesale critism of doctors, should remember that at the beginning of war the total supply of men was relatively small in proportion to the numbers required, and, consciously or unconsciously, many a doctor, believing himself to be acting in the national interest, must have had at the back of his mind the idea "How many men can I possibly pass," rather than "How many can I possibly exclude." Again the number to be examined was relatively large in proportion to the number of doctors and to the time available for examination. These circumstances did not allow for the searching clinical examination which even by the hands of an expert may be required to detect the less obvious forms of disease of the lung.

It

If pensions are granted for disability "directly and wholly caused by military service," it is clear that those who became infected and developed the disease after joining the services, and those in whom latent infection was lit up under conditions of strain, are entitled to a pension. would be entirely against public interest to grant pensions to those who were suffering from active disease at the time they joined the services. The very practical point now arises of devising some method of distinguishing the deserving from the undeserving.

The Local Government Board of England has recently called upon medical officers of health to forward to the Army Council the names of men of military age