into closer relationship with one another, sometimes act in the opposite direction. The St. Paul Medical Journal (November) puts the matter succinctly, when speaking of charges of misconduct made by a member of the Ramsey County (Minn.) Medical Society against the society's president:

"Medical societies bring physicians nearer to each other, promote personal and professional friendships and unite individual physicians in a fraternal relation. Discord, envy and bitterness are hostile to the well being of a society, and anything that tends to stir un strife among the members should be avoided. Charges of unethical conduct are serious things, as they involve the good name of the accused physician, and they should not be brought heedlessly or wantonly. Every effort should be made to find the truth before accusing one of misconduct."

"Rheumatism."

The Journal of Advanced Therapeutics is sometimes a misnomer. Its claims for electricity as a panacea for human ills remind one too much of the enthusiastic promises of claimants of the past-promises that outran the performance. But here is something on "rheumatism,” so-called, that is really advanced. Paste it in your text-book on theory and practice:

"The old notion of the uric acid diathesis and the systemic accumulation of the products of poor metabolism as a causative factor of socalled articular rheumatism, is becoming obsolete during recent years in the advanced professional mind. The lay opinion, and, too often, the professional assertion, that this or that inflammatory condition involving a joint is rheumatism, is open to criticism. Far too many physicians without careful investigation are treating for rheumatism, employing the usual remedies, such conditions as neuritis, synovitis, rheumatoid arthritis, and flat-foot. The differential diagnosis of these conditions from infectious arthritis is not difficult. Any physician who fails to differentiate these conditions and submits his patient to a large dose of the salicylates, thereby producing an irritation of the gastric mucous membrane without any possibility of benefiting the condition, is incompetent to treat these cases. The fact that infectious arthritis yields to such remedies, may too often lead the medical man to prescribe without further investigation for other joint or muscular inflammations, as though it were "rheumatism," as the neurologist too often prescribes mercurials and iodide of potash for tabes and other cord affections, as though they were only of syphilitic origin. The only excuse that can be forrd for this carelessness in treatment is in the fact that for such conditions there is a drug remedy; whereas for many other chronic processes under the old regime and even the present, with those who do not know the physical methods, there is nothing to be derived from drug medication.

Man's Inhumanity to Man.

Mawkish sentimentality over the unfortunate pauper in the abstract sometimes goes with the

grossest injustice to the indigent in the concrete. It is much like the emotionalism which women display when they deluge a criminal with flowers and tears, yet would consign the fallen members of their sex to still greater depths of despair and iniquity if possible. Physicians who in an official capacity have the inmates of eleemosynary institutions in their charge, are frequently lacking in humane feelings toward these, and yet prate about "reform," and its urgent necessity. However, nature is not always human. Vestiges of the brute creation cling to it still. But, pardon the digression. Here is what the Therapeutic Record (November) says on the subject of "Crimes Against Paupers":

"All inattention and neglect and cruelty to those who have to depend upon charity is criminal. The physician who allows himself to give less attention to these than he would to his private patients is dishonest. He deceives the public and draws a salary to which he is not entitled, and he deserves exposure and punish

ment.

"This is the twentieth century, and its civilization should be divested of barbaric usages that for centuries have clung to the treatment of unfortunates who are confined in eleemosynary institutions.

"We do not for a moment think that the medical profession in general are in sympathy with the crimes that are perpetrated on paupers, or the criminal neglect to which they are subjected, yet many physicians do fail to perform their duty, and others tacity approve cruelty and neglect.

"We urge the profession everywhere to use every effort to bring about reforms in the treatment of the indigent, and to do their duty when they have to serve them in the capacity of medical attendants."

"The future generation of civilized beings tends fair to be more prone to mental disorders than the preceding, as its members will have inherited various nervous traits in an exaggerated form."

This must be true, coming from such a source. "Mental aberration is enormously on the increase in all civilized countries," is indeed a fact. So is neurasthenia and all that the vague term implies. Folia Therapeutica (October) has an interesting article on "The Treatment of. the Neurasthenic Patient," by J. Snowman. Let him speak for himself:

"The fundamental origin of neurasthenia must, in most instances, be sought for in psychical and not in physical causes. The most violent physical disturbances are, as a rule, impotent to arouse by themselves the profuse

symptom-complex of neurasthenia. A railway accident or an epidemic of influenza may produce a crop of neurasthenic sequelæ; but we shall find on investigation that each individual patient has been the subject of antecedent circumstances which only required the collision or the illness to determine the onset of neurasthenia. We shall find that worry, anxiety or nervous overstrain had been taxing the cerebral faculties of the sufferers for some time past. Some cases will stand cross-examination on this point without revealing any evident predisposition of this kind; there are patients whose path of life has never swerved from pleasant courses, but in these it will probably be found that the influence of a bad heredity is responsible for some definite cerebral instability.

"It is of the utmost importance, from the point of view of treatment, to differentiate between the neurotic and neurasthenic states. The former really amounts to a diathesis-it is an integral characteristic of the nervous organization of the individual. It has physical aspects, because a neurosis is apt to fasten itself on one organ, or even on a whole anatomical system. The neurotic state is, moreover, one which offers a determined resistance to therapeutics. On the other hand, neurasthenia is merely an incidental phase in a constitution on which there may lie no suspicion of a neurosis. It is a disease which is quite amenable to correct and adequate treatment. But the guiding post to success indicates the path only to those who pursue it with the conviction that there is definitive recovery at the goal. In the pursuit of this goal the sympathetic and intellectual co-operation of the patient is indispensable.

"The acquisition of this essential point is one of the difficulties of treatemnt. If the practitioner has once betrayed himself into suggesting a physical origin for the complaints of his neurasthenic patient, it becomes almost impossible to satisfy him subsequently that the true diagnosis lies in the regions of mental pathology or psychology. But this is a faux pas which it is not easy to avoid in the earlier interviews with the patient. The experience of the writer has been that the neurasthenic comes at first with a very plausible story, which throws the family attendant off his guard. There is an absence of those woebestricken tones and the passionate excitable periods which proclaim the neurotic disposition. The neurasthenic, on the contrary, recites his complaint in measured phrases, without hyperbole or evident exaggeration. In the initial stages of the disease this complaint is often limited to some definite symptom, and the error is almost inevitable that this symptom will be corelated to some organic cause.

"It is seldom given to the general practitioner to diagnose neurasthenia at a first examination. The symptoms develop under his observation, and therefore the diagnosis really grows upon him. The consultant, however, is usually confronted with a well-filled-in clinical picture, easy of identification. This confers a considerable advantage upon the consultant, because it admits of his presenting a clear scheme of treatment with confidence and authority, directed to the general condition and not to the detailed symptoms which form the burden of the patient's complaint.

"A great amount of vagueness surrounds the conception of neurasthenia. Perhaps this is not to be wondered at in view of its comparative

infancy as a recognized disease. In the opinion of Dr. James Mackenzie, of Burnley, there is so much obscurity about it that he prefers to call it the r disease. Notwithstanding this, there are very definite indications for treatment, and these may be easily understood."

Dental Caries.

Mucus clings tenaciously to the surfaces with which it comes in contact, and thus, besides facilitating deglutition, it coats the teeth where they are not subjected to friction, and being of an albuminous nature it does not induce the acid-forming bacteria to proliferate, while if the food is acid it becomes insoluble and forms a more or less impassable barrier for the acid. After the meal, however, the alkaline salivain which it is soluble-tends to clear it away, together with adherent food particles. Akin, no doubt to this mucous coating are the gelatinous plaques under which caries starts. I am inclined to believe that caries occurs not on account of the plaques, but in spite of them.— J. SIM WALLACE.

Too Much Work.

The average doctor tries to do much work. Every doctor wants everybody to patronize him. He likes to be going night and day, rain or shine, Sunday or week day; hot or cold. This is a business mistake. It wears a doctor to a frazzle. It gives him no time for bill-collecting and business matters; no time for patients who naturally feel neglected and are slow pay as a consequence. A doctor can do better work, more good, and build up a more enviable reputation if he coolly takes his time and is careful and painstaking in his examinations.-Dr. J. E. DILDY, Lampasas, Tex., in Texas Medical News.

THERE is little doubt that an open-air life and healthy surroundings encourage the formation of sound teeth in a sound body; but I cannot but think that the principal cause of caries must be looked for in the food. Structural defects, due to inherited weakness or imperfect nutrition during the development of the teeth, combined with the use of soft cooked food, which is long retained in contact with them, and is of a nature eminently suitable for fermentation give us the principal factors of decay of teeth amongst civilized races.-Nature.

The Louisville voters last Tuesday defeated the proposition that $1,000,000 in bonds be voted for a new city hospital decisively, the issue not getting 10,000 votes, when 25,000 were required.

THE principal organic products that impair the clearness of urine are pus and muco pus, blood, oil globules, various organisms.

WHEN the urine is glycosuric there is generally, though not invariably, a rise in the specific gravity above the normal.

FIFTY-TWO Countries have been infected with the plague since the primary outbreak in China in 1894.

URINE containing blood is always albuminous.

VOLUME C, ΝΟ. 20.

I most heartily endorse the prevailing custom of prescribing an annual address by the President of the association, in that it presents so rare an opportunity to scold without being scolded in return. That all men are benefited by an occasional exploitation of the truth has been exemplified in every household since Adam first entered into conjugal relations unto the present day, and probably will be until the farthermost reach of time.

It is my purpose to consider the new obligations which were thrust upon the medical profession in the surgical awakening covering the past quarter-century in the smaller cities, and in some instances in towns and villages-some of the conditions which made it a necessity, and the many abuses which are now being engrafted thereon by reason of the present riot of sporadic surgery by amateur surgeons. In this connection it is well to state that criticism does not apply to life-saving procedures, at which time it is often difficult to secure an experienced operator, but that it does apply to operations of choice. Let us consider this question together, and see whether we can find the root of the evil, and whether or not it is possible to limit its ravages. For this purpose it is required that we begin at the beginning. Our medical schools and their handmaidens, the post-graduate schools, are all familiar with the student's transition. No matter what his inclinations and ideals may have been when he matriculated, by the time he graduates he is imbued with the idea that surgery is the only department of medicine worth considering. This position is accentuated if perchance he has served a short period in some hospital as an interne. To this end every endeavor is directed to the exclusion of much that is essential for general practice. When the latter subject is broached he becomes

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listless, deems interest an element of weakness; but mention a gastro-enterostomy, and note the heightened color, the flashing eye, the nervous interest. Thus the heroic appeals alike in medicine and war, and each has its background of blood and carnage.

If you require further confirmation, come with me to his newly furnished offices. Note the profusion of works on surgery, the surgical appliances, the wealth of instruments. We shall also find a work on practice, new, clean, seemingly untouched, or at least to have been so lightly handled as to leave but a fingering impression.

Suppose we go a step farther the postgraduate school. Here the matter of surgeon making is taken up supposedly where the medical college left off. In truth, it is at a period remote, when much that is indispensable for intelligent operative work is forgotten. Notwithstanding this, a finished product warranted not to shrink or fade is guaranteed in a six weeks' course of instruction irrespective of fundamental attainments, practical experience, anatomical or pathological knowledge; and this finished product is manufactured largely by watching some expert operator working at a distance.

None will deny that a diploma from an accredited medical school to-day means much more than it did twenty years ago. Preliminary requirements, a longer course of study, more thorough instruction, better clinical facilities and more capable teachers, presume in the abstract a degree of efficiency equal to all emergencies. How we waited, we who have maintained an interest in medicine and its uplifting influences. How sad our disappointment in some cases; how much our surprise in others.

We have seen the young man fresh from

the inspiration of a worthy alma mater, with hospital experience which equipped him for the practical application of the knowledge gained by years of close, enthusiastic study, begin his journey across life's sea. We saw him bend to his oars, we noted the firm, even stroke, we saw the boat shoot forward, and waited that we might be the first to grasp his hand and lead the applause. Alas, the disappointment! The stroke lagged, then stopped, and our young man of promise reclining at his ease, became an unmarked addition to life's flotsam and jetsam.

In marked contrast we see the young man whose aspirations, judging from opportunities and preliminary advantages, seemed pathetic, struggling against the disadvantages of a medical education obtained at an institution whose only claim to confidence was the name it filched; whose commercialized faculty, inflated with ignorance and egotism, cast its blighting shadow upon all progress. Even with this heritage of association and environment, we have seen him grow in strength and wisdom until, standing erect in full confidence of merited recognition, he commanded the highest estimate of human appreciation, the verdict, "This is a man.”

As individuals, jealousies may cloud the judgment; collectively, the support given to a man by his collaborators when once the honesty of his purpose is proved, is given ungrudgingly. It is not the man who is striving to reach a higher plane at whom we are wont to hurl the javelins of our disapproval, but it is the one who without proper preparation or effort essays to achieve the finished product of master minds, notwithstanding that what they have done was done only after years of patient study, work and sacrifice. To our shame, this latter type predominates. There exist in many communities men whose intellects have not been quickened, nor their consciences cleansed, by the advent of Listerism. On the contrary, in spite of this antiseptic age, the commercial microbe, sown in the agar of an exaggerated ego, has multiplied. To placate his conscience the amateur excuses his debut into the field of surgery by referring to some who with seemingly less equipment have reached a position of assured proficiency. In further defense he maintains that he must begin some time and learn as they learned in the hard school of experience.

These conclusions would be justified had

former conditions remained the same. Twenty years ago surgery was a chaotic mass of unformulated and indefinite theories. Men were barely freed from the shackles of custom and prejudice, the heritage of past centuries. The pioneers were blazing the way. Large clinics and postgraduate schools were hopes but not facts. Surgeons, now of national and international repute, were still in embryo. Few men in general practice outside of the large cities could embrace the opportunities, few though they were, for thorough equipment as surgeons. The exigencies of the situation compelled some to do the best they could. It was hard work. The foundation, which had disintegrated through lapse of time, must be relaid, that the new superstructure might be erected, but every presenting opportunity was fully developed. Let there be no apology. They did much good, some harm, and from their ranks there has emerged a large number of creditable operators and surgeons whose work will compare favorably with the best.

Coincident with the evolution in surgery comes the changed code. Things which were permissible, or even commendable, under past conditions, are at present high crimes or misdemeanors. With the opportunities now available in morgues and clinics to see and study living and dead pathology, there exists no excuse for a repetition of our former mistakes. We know that it takes more than the ability to cut and sew to make a surgeon. We know that a recent graduate, except in rare instances, is not competent even to operate. We recognize the wide distinction between the words "operator" and "surgeon." We know that skill, confidence and judgment in any vocation come from constant repetition. We know that we as individuals would not select the occasional operator for ourselves or our families in any matter of serious import. We are capable of protecting ourselves; are not the public entitled to like protection? Balloon pilots before being qualified must make seven ascensions, some under the guidance of a master and some under conditions that will demonstrate their fitness in the presence of difficulties incident to their calling. The law permits a licentiate in medicine to rummage around in the abdomen indiscriminately, although his previous surgical experiences were limited to the opening of an abscess. It is true that conditions are gradually re

adjusting themselves, but that there should be a common understanding or basis as to the qualifications of the one who elects to limit his practice, it might be well to give this question some thought.

In Germany and Austria the ministry of education, noting the widespread misuse of the title "specialist," has submitted the following rules for discussion and subsequent adoption by the profession, as to who may legally adopt that title. "First, only those who have followed the study of their special branch for not less than three years in a special hospital or under a recognized specialist, may qualify as a specialist in that particular branch; and second, no one can specialize in more than one branch at the same time."

In this country at the present time it is hardly possible to adopt these conditions. as our standard, neither is it advisable that surgeons be merely moulded or machinemade. A period of general practice will later develop better surgical judgment and a higher sense of responsibility than is possible in the devitalizing moral atmosphere too frequently found in our large hospitals. A man deciding to specialize in surgery should file notice of his intention with the State Board, and he should be furnished by them with a list of accredited post-graduate schools. His course of study should not be less than one year, conducted along lines that would establish a practical as well as a theoretical basis. No one should be permitted to announce himself a surgeon or practice surgery unless specially licensed.

One of the benefits hoped for is, that these restrictions would limit the supply, for no matter how perfect the training, unless there be reasonable opportunity for practice the hand soon loses its cunning and the judgment errs. It is reasonable to suppose that a creditable equipment could be maintained by a surgeon drawing from a population of from fifty to sixty thousand.

Supposing all legal requirement be enforced, and that these requirements are in the main sufficient, has the profession and the public further interest? We maintain that they have. There are many things connected with surgical operations which render the result vicious, passable or perfect, judged by our present standards. No one person, no matter how well equipped nor now resourceful he may be, can give proper attention to every detail; and that his work approach perfection, he owes it

to himself, the patient and the consulting physician, that he provide a trained assistant and an experienced anesthetizer. These should be as much a part of his armamentarium as his instruments and his knowledge. They should share equally his responsibilities in their individual departments. Nothing too severe can be said in condemnation of the vicious habit, almost a law, of the operator drafting his assistants from those present.

The surgeon is consulted presumably on account of his attainments, his experience, and, let it be hoped, his honesty. It is a compliment which no man can ignore; under these conditions one who does not give the best of all he has, is unworthy. He owes it to himself, his consultant, and most of all his defenseless patient, that every avenue of possible danger be safeguarded. The assistant unacquainted with individual methods not only does not assist, but in many instances interferes with the operator, often inadvertently courting complications by some simple act of omission or commission. When the question is one of health or illness, life or death, sentiment should not o'ertop our duty. Our object, once understood, will be appreciated, and no earnest physician will withhold co-operation in attaining the best results for his patient. It may be urged in objection that trained assistants are rare outside of our large hospitals or under exceptional conditions, that one doing a restricted amount of work is unable to maintain such assistants; yet the writer has personal knowledge of at least a score. of men in smaller cities who have perfected an organization composed of a few men, who while engaged in general practice have found it possible to attain a high degree of proficiency as assistants. These men have found this association indispensable. The degree of efficiency may not be as high as that observed in the larger clinics, but it is worthy of commendation.

The most valuable asset in any community is the educated, capable and honest family physician. His position is assured. He should not, neither will he be displaced by the specialist, no matter how gifted. The welfare of the community is in his keeping; it is his family. Try as he may, he cannot escape the moral obligations that rest upon him. He is the first consulted; and, deeming a disease amenable only to surgical procedure, his opinion is sought as to whom may be safely trusted. At times he may err, but there is small