DR. O. BERGHAUSEN: I wish to speak of specific therapy in typhoid fever. Prophylactically, dead or attenuated bacteria are used to actively immunize soldiers before sending them to South African fields, or such as are infected with typhoid. The Germans use Pfeiffer's and Kolle's method of injecting subcutaneously 2 mg. of a twenty-four hour culture of the typhoid bac`llus. There follows a slight local reaction and a general reaction, consisting of fever, chills, nausea, and at times vomiting. These symptoms last at the most a week. The patient is thereby actively immunized and is prepared against any future exposure to the infection. This protection has been found to last only about a year, however, when it must be repeated if desired. The English use a sterile bouillon culture, or lately Wright's method of injecting 700 to 1,400 million of dead bacteria after an interval of ten days. Brilliant results have been obtained. Soldiers thus inoculated have at times been taken down with the disease, but the course of the disease, its morbidity and mortality were always diminished. For directly therapeutic results Chantemesse has prepared what he terms a pure antitoxic serum. Its use has shown that both the morbidity and the mortality of cases thus treated was remarkably reduced. In a series of cases treated in Paris, one-half with and the other half without the use of the serum, the advantage was decidedly in favor of those thus treated, the course being milder and the complications less frequent and severe.

In regard to the question of the early diagnosis of typhoid, blood cultures are of value when positive. Late investigations have shown, however, that in the opsonic index determinations we have a valuable aid in making a positive diagnosis during the first week of the disease, since the index is persistently low.

In regard to the question as to the use of alcohol in typhoid fever, in small quantities no bad effect will folow, but in large repeated doses it has been shown that even in healthy individuals the opsonic index has been found to remain subnormal. This probably explains why alcoholics are so subject to erysipelas and pneumonia. The immunizing powers of such individuals has been reduced, as can experimentally be shown by the opsoinc index determinations.

DR. W. E. KIELY: I can indorse nearly all the doctor has said regarding the treatment of typhoid fever, but I would not go so far as he in the condemnation of alcohol. While the vast majority of typhoid patients do not need it, now and then it is of benefit, especially if you resort to the antipyretics to reduce temperature, which is occasionally necessary.

I am convinced that the character of typhoid fever has undergone a change. Compare, if you will, the type of the disease twenty or thirty years ago, of which diarrhea played such an important rôle, and the meningeal type. Now constipation is the rule, and instead of a pulse of 120 to 130, it rarely exceeds 90.

I believe in absolute rest both of mind and body from the beginning. And the most important of all, and it will aid more than anything else to prevent intestinal complications, is a proper regulation of the diet. See to it that it is properly digested and that the intestines are not overloaded.

I have never tubbed a patient and never saw the need of it. My observation in the Cincinnati Hospital, while an interne there with a staff offi

cer who tubbed every case when the temperature went over 103°, was that the shock and lifting of the patient was decidedly injurious, and the mortality in such cases was higher than that of the doctor who had the service on the west side of E ward, who treated the cases with sponging, diet, etc., on the expectant plan. An ice cap on the head will be of great benefit and help to reduce temperature, which, after all, is not attended with any danger provided the heart is acting well and the patient gets a sufficient amount of sleep. Attention to details, aided by good nursing, is about all that is required. I have little faith in intestinal antiseptics.

DR. W. C. HERMAN: Why does Dr. Landis prefer acetanilid to other treatment? I have seen patients who have used acetanilid and who have shown the use of it by the pulse, circulation, etc. It is dangerous in the majority of cases, and especially so when the health is weakened by the typhoid bacillus. The only use of acetanilid is to make cheap headache cures and other nostrums, but even in this form it is a heart depressant, as the results of their use have shown. But the law now requires a label on these nostrums, stating their composition when acetanilid is present. I think we have had enough literature to show that acetanilid is a dangerous drug.

DR. LANDIS: Before attempting to answer, I desire to express my thanks to those who have discussed the paper.

I am unable to answer Dr. Greiwe's question as to why the palms are dry and yellow. That such is a fact can readily be demonstrated in any typhoid fever ward. They are most marked in the palm of one accustomed to working with the hands, but they are also present in the soft palms of women and children. When present in a case in which the diagnosis is in doubt, they point to typhoid.

Dr. Isham and Dr. Herman have questioned the wisdom of using acetanilid in these cases. The proper dose of any drug is the amount necessary to produce the desired effect. When a two-grain dose of acetanilid lowers the temperature and slows the pulse-rate, the evidence of having benefited the patient is positive. Individual idiosyncrasy must be watched for. Our dose should be made to fit the patient and not the patient to fit the dose. By starting with small doses we have been able to avoid symptoms of poisoning in all but one case. This patient became cyanotic and the drug was discontinued. Under the use of cold water injections into the bowel the temperature was controlled and the patient recovered.

Phenacetine was not objected to by Dr. Isham, yet the most marked drop in temperature that I have ever seen was caused by a five-grain dose of phenacetine given in a case of typhoid with a temperature of 105°. The temperature dropped to 97°, and sweating was so profuse that the clothing and bedding was saturated. Later it was found that a quarter of a grain would produce a fall of from two to three degrees in this

I believe that a moment's study of the effect of alcohol will show that it is positively contraindicated in hemorrhage. After an indefinite amount of blood has been lost the blood-pressure falls and the hole in the vessel wall is plugged by a protecting clot. The tendency of this clot is to contract. If alcohol is administered, for its alleged stimulating effect, paralysis of the vessel follows and its calibre becomes greater. In the center is a contracting clot; about it an expanding vessel; the result, detachment of the clot and more bleeding

In so far as it applies to typhoid fever, there can be no doubt of Solomon's wisdom when. centuries ago, he wrote: "Wine is a mocker; strong drink is raging, and whosoever is deceived thereby is not wise."

Needs of a University.

A recent issue of the St. Louis Medical Review, commenting editorially on the fact that Washington University, of St. Louis, graduated only twenty-two students, suggested certain reasons and remedies therefor. These suggestions apply with equal force in other localities. Among other things it says:

"How is the university to get more students? By getting in line with the universities with which it presumes to rank itself. How shall that be done? By getting a modern corps of professors, and at their head some man who commands public attention, like Hadley, or Jordan, or Schurman, or Wilson, or Wheeler. The university needs the advertising such an organization would give it. This it has not had. Nothing emanates from the place that shows its teachers are in vital touch with the times. The university has an appearance of dullness. Its teachers are not putting out the work that attracts the public-though one of them did reverse Judge Landis for his big fine against Standard Oil. All the material things to make a great university Washington has, but it lacks the big, broad, new, inquiring, reconstructive spirit. It is too much dominated by the business idea. There is a lack of the new democratic ethic and ideal in its organism. To be brutal about it, there's too much of our Big Cinch about Washington University, and it is run on about the same line of exalted ethical aspiration as was the World's Fair. The World's Fair was all right enough as such, but a World's Fair business ideal is not the proper informing spirit for a big university.

"What the Washington University needs is men. The St. Louis University School of Medicine was not known, not even upon the medical map, until the past three years when men were brought here from the University of Chicago, Rush Medical College and from Harvard. Now inside of three years St. Louis University School of Medicine has leaped into prominence. Why? The answer is very plain, because of the fact that they have well-known men. If Washington University hopes to keep pace and have the attendance that other universities have they must scour the country and no matter what it costs bring the high class men to their school. Then they will find that they will get the students. This is a commercial age and a progressive one, and for a school or university to succeed it must have the best men money can secure."

Dudley Sharpe Reynolds, M.D.

geon to the Western Dispensary (an incorporated charitable institution), 1869 to 1871 inclusive, when he resigned, abandoning the general practice for the specialty of ophthalmology and otology. He took post-graduate instruction at the University of Pennsylvania, the Wills' Eye Hospital at Philadelphia, at the New York Eye and Ear Infirmary, the Royal London Ophthalmic Hospital, the London Throat Hospital; he visited Profesors Donders and Snellen, at Utrecht; attended the clinical lectures of De Wecker, Sichel, Ed. Meyer, and Galezowsky, at Paris; Stellwag, Gruber, Pollitzer and Fuchs, at Vienna; Schwigger, Hirschberg and Von Bergmann, at Berlin.

He was one of the chief organizers of the faculty of the Hospital College of Medicine,

Medical Department of the Central University of Kentucky, in September, 1874. He was professor of ophthalmology and otology. In addition to the chair above named, he was professor of general pathology and hygiene, 1882 to 1892. In 1892 the chair of medical jurisprudence was established and occupied by Professor Reynolds until 1901, when he retired from teaching.

At Chicago, in June, 1877, a permanent organization of the medical colleges of the United States was entered into. Professor Reynolds took an active part in this work, and was chairman of the Judicial Council of the Confederation of American Medical Colleges, by which name the institution was known until it went out of existence in 1883. Subsequently a convention of medical teachers and governing boards assembled at Washington, D. C., May 2, 1881. As chief executive officer of the Association of American Medical Colleges, he enforced the laws to the letter, and in this way made it possible for the general adoption of a minimum standard of preliminary education required of all medical students, and a minimum standard of requirements for the degree of Doctor of Medicine, and the graded system of instruction of four courses of not less than six months each, in separate calendar years. Dr. Reynolds regards his services as chairman of the Judicial Council of the Association of American Medical Colleges as the most important and best of all his efforts to improve and advance medical education in the United States.

He served as chairman of the Section of Ophthalmology, Otology and Laryngology of the American Medical Association in 1880, which section was created in 1876 by the adoption of a resolution prepared by Dr. Reynolds, Prof. X. C. Scott, of Cleveland, nad Prof. J. M. Bodine, of Louisville. At Richmond, Va., Dr. Reynolds presided over the section, and was sent as delegate to the British Medical Association. At Ryde, Isle of Wight, August, 1881, Dr. Reynolds became a member of the British Medical Association.

He was elected President of the Mississippi Valley Medical Association in 1887, and presided at St. Louis, 1888, over the largest meeting this society has ever held. He was one of the organizers and constantly active members of this Association.

In 1892 he was elected President of the Mitchell District Medical Society.

When the property of the Public Library of Kentucky, as it was then known, was about to be sold by the sheriff to satisfy a judgment of the Louisville Chancery Court, he secured the co-operation of about fifty of the best citizens of Louisville, and reorganized the Polytechnic Society of Kentucky, which by act of the legis

lature had been authorized to take charge of the public library property. As chairman of the Library Committee, Dr. Reynolds, with his colleagues, labored unceasingly for the establishment of a great free library at Louisville.

He has been an active member of the local, county and district medcal societies, and of the State Medical Society of Kentucky, seldom missing a meeting for about thirty years, and contributing almost annually an original essay or clinical report. He has been a faithful, almost constant, attendant at the meetings of the American Medical Association for more than thirty-five years. He is a Fellow of the American Academy of Ophthalmology and Oto-Laryngology, and a frequent contributor to its annual Transactions. He is a member of the American Geographic Society, the American Association for the Advancement of Science, the British Society of Arts, and of an almost innumerable list of other medical and scientific bodies.

He was for many years editor of a medical monthly having a large circulation and a wide sphere of influence and usefulness. His clinical lectures and essays on medical subjects have appeared in nearly all the leading medical journals in the United States and Europe.

MORAL precepts, which to a superficial view appear arbitrary, and seem made to spoil our zest for life, have really but one object-to preserve us from the evil of having lived in vain. That is why they are constantly leading us back into the same paths; that is why they all have the same meaning: Do not waste your life, make it bear fruit; learn how to give it, in order that it may not consume itself! Herein is summed up the experience of humanity, and this experience, which each man must remake for himself, is more precious in proportion as it costs more dear. Illumined by its light, he makes a moral advance more and more sure. Now he has his means of orientation, his internal norm to which he may lead everything back, and from the vacillating, confused, and complex beginning that he was, he becomes simple. By the ceaseless influence of this same law, which expands within him, and is day by day verified in fact, his opinions and habits become transformed.-CHARLES WAGNER, "The Simple Life."

THE Pacific Pharmacist (July) laments the fact that only a fraction over 65 per cent. of North Dakota drug-stores investigated had a copy of the eighth revision of the U. S. P., and yet our druggist friends want us to be sure to always substitute in our prescriptions a U. S. P. or N. F. formula for a tried proprietary, no matter how ethical the preparation or elegant its composition!

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SATURDAY, AUGUST 15, 1908.

A DELICATE QUESTION IN ETHICS.

"It is incumbent on physicians to be temperate in all things, for the practice of medicine requires the unremitting exercise of a clear and vigorous understanding; and in emergencies — for which no physician should be unprepared a steady hand, an acute eye and an unclouded mind are essential to the welfare and even to the life of a human being."

Physicians who practice in sparsely settled districts and country practitioners in general should above all things be temperate. By temperate in the above section is meant abstemiousness in the matter of food and drink, but particularly is slight or non-use of alcoholics and other narcotics enjoined. City physicians and specialists are not so liable to be called upon to act alone in grave emergencies, but professional dignity should act as a deterrent to various excesses and abuses.

A physician is a public official privately paid (and very often underpaid) who is on duty twenty-four hours for three hundred and sixty-five days each year. As such it is incumbent upon him to be ready to respond to any call of duty at any hour. The more isolated his location from fellow-practitioners, the more imperative his moral obligation to be always ready to respond with a clear understanding.

Statistics on inebriety in the medical profession are not obtainable; it is, there

parisons. The great wave of temperance reform sweeping the world at present, in which physicians are taking a leading part, would leave the inference that alcoholic excesses are on the wane. A noticeable feature of medical banquets in recent years is the absence of all liquors. However, it is a common observation that in the sections where alcohol as a beverage is legally interdicted, other narcotic vices have sprung up. Especially is this true of opium and cocaine and their various derivatives.

That the profession owes a duty to the public in this matter is admitted. To have and to hold the confidence and respect of the public is an especial privilege of the medical profession. To merit its continuance should be sought by every member of this profession. The great moral regeneration apparent in all walks of life in this country will not pass the medical profession by. The mote is becoming more evident, while the beam is being temporarily overlooked. But a time is soon coming when the professions and trades which have cleaned their own doorsills will look askance upon the soiled domiciles of others.

State boards of health and boards of medical examination and registration have disciplinary powers to revoke the license to practice of physicians found guilty of gross immorality-powers rarely employed because of inability to secure indictment and evidence sufficient to convict. County medical societies have powers to fine or suspend or expel members guilty of great inebriety. inebriety. Here again action is rarely taken for similar reasons.

This brings up the delicate question in ethics. Who in the profesion as a class would be cognizant of the shortcomings of their felow-practitioners? Evidently, specialists in charge of sanitariums and others treating drug addictions. When a man becomes incapacitated from too free. indulgence in narcotics he turns to a specialist for aid. The specialist then hears

the whole revolting story-the story of unreliability, incapacity, degeneracy, misery and utter degradation of the victim, a story that invariably harks back many years. How often the unfortunate victim has failed in his full duty toward his patient, and of the resultant incapacity, pain and possibly death inflicted thereby upon the trusting innocents only the Good Book has any record.

It is true that the relations of the inebriate and his physician are professional, and therefore confidential and not to be divulged. The duty of the physician is always to his patient, and the utmost circumspection must be observed by the medical attendant. But is there not a larger duty toward the entire profession and the public? Are not other interests at stake besides the personal ones of the inebriate and the professional and business interests of the specialists? Is it fair to the entire profession and the public to let this matter rest only between the patient and his attendant?

How this matter can be adjusted and the best interests of all concerned safeguarded is a difficult proposition. The inebriate usually has more at stake than his own livelihood. A wife and children may be dependent upon his earnings. The family honor may be jeopardized by exposure, and even business associates injured by his moral downfall. If the victim had any sense of moral responsibility and obligation left, he would of his own accord retire from active practice. However, the blunting of the moral nature is one of the first effects of drug addiction. It is, therefore, unlikely that the inebriate will commit professional hari-kari.

The profession as a whole either cannot or will not take action, for reasons mentioned above. Some time in the future, when this matter will be brought home more forcibly to physicians, ways and means may be devised to expose and discipline members of medical societies, and revocation of license to practice will have a salutary effect.

The public in a measure is adjusting this evil. As education and refinement gradually permeate all classes, the demands upon the physician will be ever more exacting. A known alcoholic in the profession finds it more difficult every year to gain or hold a lucrative practice. The breath of alcohol on the medical attendant in the sick-room is gradually being considered a desecration by most people. Even liquor dealers themselves prefer abstemious medical attendants for their families. It is difficult, however, for the public to recognize the opium, cocaine or other drug habitués. It must depend upon the profession for their elimination.

This brings us to the specialist consulted by the inebriate. What course should he pursue? What are his duties in the premises? The first impulse is always to protect his patient. This is as it should be. If he owns or conducts a sanitarium, business reasons will unconsciously creep in. To make a profit on the investment is part of his duties. Not only will the medical inebriate be a source of income, but as "birds of a feather flock together" he will no doubt be in a position to send in boon companions. When the inebriate has been on the downgrade but a short time, and there is every assurance of making him again a useful member of the profession, every possible encouragement should be given. But when relapse after relapse occurs, and there is every evidence of the patient's inability to perform his professional duties, it would seem the specialist's duty toward himself, his patient, the profession and the public to attempt moral suasion looking toward the retirement from active practice of the inebriate. Failing in this, and the victim persisting in active practice, it would seem the absolute duty of the specialist to aid in a revocation of license to practice by presenting the facts to the proper officials. Anything short of this would be an irreparable injury. And Cain's reply, "Am I my brother's keeper?" is an evasion and stultification.

G. S.