Now, despite many unfavorable reports upon morphin and hyoscin in labor-the journals were full of it a few years ago there are many physicians using these drugs and claiming good results. They must have a reason for it, just as others have a reason against it. But merely giving morphin and hyoscin is not practicing the "twilight sleep" method; no, not even approximating it!

The fact is that racial differences should modify our obstetric practice, as women of different races present differing problems. No hard and fast rules can be laid down. Some women of neurotic tendencies -pampered, petted, unaccustomed to the hardnesses of life-will welcome the German technic of "twilight sleep." One can readily understand that the method has a legitimate application among a certain class. Also these women should be confined in a special institution, where they can safely have the balm of "twilight sleep." And one can understand readily enough that the hard-headed country physician sometimes has cases in which morphin and hyoscin will serve him and his patient. True, if he uses these potent drugs, he should remain a longer time with the patient-charging for his time-so as to be on the safe side, and he should not overdo the dosage. But he should not bluff. Giving a dose or two of morphin and hyoscin is not "twilight sleep," any more than the common but unscientific custom of giving a hypodermatic dose of morphin before anesthesia is "anoci association."

And the blunt fact remains that neither "twilight sleep" nor the administration of morphin and hyoscin in labor is good practice as a routine procedure. Most women need neither one of them. The obstetrical authorities who are opposing these methods are not doing so from mere crankiness.

Surgery and Anesthesia.

There is a popular demand upon the doctor to "stop this pain!" After all, most of the doses of narcotics we give are given, not because we think the patient needs the narcotic, but because he will promptly go to another doctor if we refuse. This editor may preen himself upon his virtue because he point-blank refuses a narcotic nine times out of ten it is asked for, and loses practice by the many refusals; but the Scotch are good refusers, and it may be bluntness more than virtue. But whatever it is, it saves many a man and woman from themselves. And that is part of a doctor's job.

The surgeons are responsible for much

of this craze for pain-stopping. Incising a boil for a dollar has given way to the tendollar, local-anesthesia surgical operation. "Painless dentists" have the call. Blisters are out of date, principally because they hurt. The man who invents "painless vaccination" will have the anti-vaccinationists on the run in short order. Women who have hair removed from their faces by the electric-needle method are now demanding that cocaine first be applied. It is the pain and annoyance that keeps many women from nursing their babies. Ear rings have gone out principally because it hurts to pierce the ears. Men are not a bit better. Every headache must be "stopped" by a dose of poison and we must soothe our nerves with several cigars a day. Fie on us! We are becoming soft. And modern surgery is helping along in the craze for "stopping" pain.

So, is it to be wondered at that women are asking why it is that normal labor is being made a matter of elaborate surgical technic and without any form of anesthesia, whereas in other surgical work she is fully anesthetized? Years ago, before a labor was regarded as a surgical crisis, ether was given, and we are being asked why its use was nearly abandoned in the lying-in room.

But physicians know the danger of semianesthesia. Maybe we have exaggerated these dangers. Certainly we have devised no way to overcome them. And yet it would seem that, in the supreme crisis of a woman's life, there should be a way. Let us try to find it. "Twilight sleep" may be a beginning. So, instead of denouncing it, let us try to find out its weakness. Personally disappointed in all methods of anesthesia or semi-anesthesia we have employed in labor, and not at all inclined to view hyoscin favorably, yet we feel that a way should be found, even if it is simply some modification of or improvement upon present methods. Meanwhile, let us be charitable to the physicians who advocate "twilight sleep" and hyoscin. If we discover some better way, then our condemnation will come with better grace.

Pain and Eugenics.

But a few general considerations must not be forgotten. If we are to retain our regard for the well-being of the race at large, we will not allow ourselves to be swept off our feet by the ultra-modern fear of pain and the craze for narcotics. Sex consideration is admirable in its way; but child-bearing is not a matter of ordinary

sex consideration, because the race, not merely the female sex, is most vitally involved in it.

Of course, it is a trial for women to face child-bearing and its pains. Every proper effort should be made to mitigate. these trials. But if eugenics means anything vital to the modern woman, she will not act the coward and menace the safe conduct of the important function of childbearing. She will seek for a remedy, but

she will also face the issue whether a remedy is found or not.

With the war craze sweeping the earth and the consequent destruction of the best manhood of several races, we should encourage a sex patriotism in women. Historically women have shown themselves eminently capable of such a patriotism, and the women of Europe are signally manifesting it now.

And as regards the men: is it not time that we suppressed the narcotism of alcohol and tobacco in excess? Why does our civilization cry out for these harmful things? As regards the unavoidable pains and discomforts of life, medicine and surgery will be but poorly employed if it devotes too much of its energies to softening moral fiber, inducing fear of ordinary pain, taking moral heroism from the people, destroying stoicism and engendering the feeling that our primary animal functions are something the race have outgrown and their normal pains something that must be "stopped" with drugs.

Therapeutic Notes.

Keep the urine acid in old prostatics. Try pilocarpin to increase vagus tone in angina pectoris.

Opium and belladonna suppositories, per rectum, are useful in acute prostatitis.

Alternating hot and cold anal and perineal douches relieves the rectal irritation and

constipation of neurasthenics.

In pruritus try this: Salicylic acid, 1 part; zinc oxid, 12 parts; starch, 12 parts; lanolin, 24 parts. Apply to affected parts night. and morning.

Crapper, in Amer. Jour. Surg., recommends, in pruritus ani, the application of tr. iodine; but claims that tr. benzoin comp. is better for continued application.

Anders recommends, in bronchial asthma, the following: Tr. lobelia, 1 drachm; spirit of nitroglycerin, 16 minims; sodium bromid, 5 drachms; wine of ipecac, 5 drachms; ext. hyoscyamus, 7 grains; simple elixir, to make 4 ounces. Teaspoonful doses.

Phys. Drug News gives this formula for "white liniment": Mix 14 ounces soft (green) soap with two ounces water; dissolve 6 drachms camphor in 104 ounces oil of turpentine; gradually add latter solution to former, emulsifying them; lastly add distilled water to make 16 ounces.

When a new proprietary is submitted to you, carefully study the formula, noting the proportion of alcohol therein; then study the solubilities of these drugs and work out the formula yourself. Some of the fraudulent products give "formula" which look well, but they positively won't work out. Judge for yourself.

One reason why the German synthetics are condemned by many physicians is because they know of instances where they did harm. Most of these are instances of self-medication by the patient. Most synthetic analgesics are valuable but potent drugs, and they have perfectly proper indications. The safe plan is to carry them in stock and dispense them as needed. If you don't dispense, note on the prescription not to repeat.

The following papers are contributed exclusively to this journal. Repulication is permitted if credited as follows: MEDICAL

COUNCIL,Philadelphia.

We are not responsible for the views expressed by contributors: but every effort is made to eliminate errors by careful editing, thus helping the reader.

IRWIN, PA.

A live subject before the profession is that of mixed vaccines and the phylacogens. Much of the literature upon the subject is very one-sided. We have been seeking some keen and analytical author to present the whole subject in a disinterested and wholly non-commercial manner. In Dr. Marchand we believe we have found the man for whom we have sought.

In, probably, three papers, of which this is the first, a very broad and enlightening discussion will be had of vital interest to the profession. In no sense of the word will these papers be either exploitation or condemnaiton of the mixed vaccines or the phylacogens; but they will be purely scientific and clinical discussions of the infectious processes and the use of vaccines therein, the phylacogens and certain mixed vaccines being merely incidents in a broad argument for and against vaccines in general.

Doctor, we urge your careful attention to this valuable and interesting series.— EDITOR.

First Paper.

Recognizing the impossibility for those not closely following the research work on immunity to keep in touch with all the communications made at different times.

concerning ideas and theories that have been constantly changing; indeed, the difficulty even for some of those actually engaged in this work so to do; but above everything else, the extreme unlikelihood of the many "to find a sure footing," to quote Abderhalden, "amongst the somewhat pleonastic nomenclature and terminology employed"-to separate the wheat from the chaff, so to speak-and to recognize among these many theories those few which much corroborative work by different investigators has raised above the status of even tenable theories, and has fixed as fundamental laws, the writer is here attempting a rational exposition of the

infectious process, and the production of immunity, based upon these laws, and expressed in a language as plain, containing as few "coined" words of doubtful meaning or questionable applicableness, as the necessity of touching upon the mass of unwarranted, ambiguous and contradictory statements upon immunity and its kindred subjects, will allow.

If the writer makes use of the first person singular to an extent that may seem unwarranted, look upon this rather as the convenient expression of his interpretation of the views of others, who speak with greater authority, than as of his own; or of his clinical corroboration of the laboratory work of others, rather than anything new discovered by himself.

The subject, especially as touching the bastard terminology now in vogue, will be handled in a straight forward manner; and as no rancor is felt, no particular person or persons are aimed at; but the remarks, such as they are, are meant to apply generally to a profession among whose ranks the writer is an humble and equally guilty co-worker.

The majority of cases from the observation of which these conclusions were drawn, and from which the conclusions of others were either verified or not, were advanced ones, principally tuberculosis; the first fifty of these were chosen haphazard for the working out of the cutaneous tuberculin reaction, and of the effects upon its showings of the concomitant infections of the tuberculous process. These fifty cases were treated for the most part with mixed and straight phylacogens, other straight and mixed vaccines, as well as with autogenous phylacogens.*

These cases, as well as with others since, a total now of several hundred, were all treated for periods varying from six months to two years, and have been followed with a minutia of detail that has been absorbingly interesting, but arduous work. But what applies to advanced cases, applies also, if in less degree, to any other class; and what applies to the tuberculous process, applies to other infectious processes as well, if, also, in less degree; although it is not by analogy alone that what may be said of the tuberculous process of an earlier evolution has been arrived at, nor, equally so, of some of the other infectious processes.

Mixed Vaccines.

As these "experiments," if you will, might be said to have been entered upon with the view of seeking an explanation of the many happy results of a mixed vaccine treatment, as well as of some results not so happy; and, as the mixed phylacogens had already appealed to me as being good sensitizers, so that these mixed preparations, as well as special ones, both straight and autogenous, constituted, for the greater part, the vaccine therapy employed, it is only just, but especially, as I shall avoid further confusion by so doing, that I continue the same designation of these preparations, as was adopted in my case notes, and that I give my interpretations and conclusions as they really areresults which would have undoubtedly followed, to a greater or less extent, the use of any other similar vaccines, but which are here, nevertheless, phenomena characteristic of the modified vaccines of Schafer, or phylacogens; even if by so doing I may appear, to the superficial reader, a not altogether disinterested seeker after knowledge.

Vaccine Iconoclasm.

A careful study of much of the current literature on the infectious process, including so many articles on the "scientific" indications for the employment of vaccines, makes me content to be considered an iconoclast in regard to the accepted teachings on immunity. The history of, as well as my experience with, the antitoxins; the recent articles on the employment of the socalled toxin-antitoxin "vaccine" for the establishment of the so-called immunity against diphtheria, after the ideas of Theobold Smith, or the employment of salvarsan in the treatment of syphilis, intravenously, or by the method of Swift and

Ellis, in no way, to my mind, influence the fact that vaccine, either auto-vaccine or the prepared product, is the sine qua non in the establishment of an acquired immunity; nor have the many adverse criticisms, aimed mostly at the phylacogens, presumably as mixed products, changed my ideas of these vaccines as sensitizers, nor of the justifica. tion for mixed products, under certain well defined conditions.

It matters not what the so-called scientific criticisms say of the dangers, which can be applied mostly to ignorance or carelessness, or of the "scientific unjustifiableness" of the employment of stock vaccines, and more especially of mixed stock vaccines; the same arguments could be used against any one of a number of therapeutic agents other than biologic products, which have very much less scientific justification than even stock vaccines, and which are now being used widely, and without criticism, carefully and carelessly, with results to correspond, just as are the vaccines.

Facts are stubborn things to down, and very many of the results from vaccines are facts noted by too many capable men to be ignored; men capable of thinking for themselves, of making unbiased interpretations of animal experiments and of correlating these with others of the same, or of a like, nature, or with clinical conditions, and even of forming tenable theories of their own, if reasonable grounds for such exist.

Theory vs. Findings.

But the time has passed when any theory can be longer formulated in utter disregard of findings which much corroborative work has fixed as a fundamental law, in whatever terminology it may be expressed; or, when these laws can be conveniently ignored to aid in the explanation of some new and startling discovery, which, in so many instances, upon proper interpretation, proves to be further and perhaps strong proof of the soundness of that law it only apparently weakens or refutes.

Terminology.

The groundwork of the final understanding of the infections has been laid; but that this is not generally recognized is due to the fact that there is only a subconscious recognition of, or purely a secondary importance attributed to, the vital function of the infecting microbe, in its broader sense; that is, its ability to grow and multiplyincrease in amount, of foreign protein; while every stress is laid upon a purely sup

positious secondary property-its ability, really its inability, to secrete poisonous sub

stances.

This seems strange when it is considered that increase of kind constitutes the first law of existence, and that everything else is subordinate thereto.

The full recognition of the overwhelming importance of the life of the pathogenic bacterium, and of the fact of the constant presence in every living thing, animal, vegetable or bacterial, of one essential matter, protein, which, although of many kinds, yet contains, as first demonstrated in the laboratories of Vaughan, at the University of Michigan, the same constant substance of a poisonous nature-these two things especially, tend to make for simplicity, ease in understanding the infectious process. Not one of the least important factors tending against this very desirable condition of understanding is the continuance of the employment of a language coined off-hand for the explanation of pure suppositions, hastily drawn conclusions, or misconceptions of phenomena, since proven to be wrong; or, of the use of a terminology, still correctly applicable only in certain restricted senses, for the explanation of phenomena of purely secondary importance to the infectious process as a whole, but which was, at first, assumed to apply to the closely related subjects of protein sensitization and immunity.

Mental Gymnastics

If the confusion ended here, chaotic as it is, it would not be so bad; but it does not. The mental gymnastics necessary in attempting to follow the, as politely expressed by Abderhalden, "pleonastic terminology," tinctures many of the writings on the infections, and on many kindred subjects, and in ways having little to do with terminology.

Why, for instance, should one have any great confidence in the unbiased judgment and profundity of an editorial writer who says, in a review of certain experiments, when speaking of toxin (exotoxin) producing bacteria: "It is easy to understand how bacteria whose metabolism produces demonstrable toxic substances give rise to toxic smyptoms in the organism which acts as host," when the experiments, as set forth, not only plainly show, but the context of the authors which inspired the favorable comment, plainly states that "there is no reason to believe that such a

substance as a primarily toxic exotoxin exists."

Again, what weight should the comments of another editorial writer carry who, in favorable mention of an article giving the "scientific" indications for vaccines, in very unscientific language, however, makes use of the following highly illuminating absurdity: self limited diseases characterized by general dissemination and systemic infection?"

66

That such crass superficiality can be perpetrated, and that such jargon is read with sobriety, and passed without comment, but shows to what depths of complacency we have fallen. And these are only two fair examples from many which are appearing daily in our best scientific journals. The truth of the matter is that we are so accustomed to hiding our ignorance under an ambiguous phraseology that nobody expects anything else; and if we can make use of a high-sounding word at the same time, and the meaning of the word seems to be of the least importance, why, so much the better. We are fooling the laity, perhaps; which does the laity no particular harm, unless, at the same time, we are fooling ourselves.

Getting Down to Cases.

To gain weight with the thinking element, reasons for, or against, any .certain therapy must be clearly expressed, and backed by other than bald assertions of benefit derived, or of harm done; and more especially if these reasons are couched in a language as incorrect as to application, or ambiguous as to meaning, as it is sonorous in terminology, or perfect in grammatical construction.

A knowledge of the fundamental principles of sensitization, preferably as advanced by Vaughan, is essential to any person even attempting the safe employment of vaccines therapeutically. I say "preferably" Vaughan, for this distinguished worker is one of the few who did not handicap his epoch-making research work, as well as his wholly tenable theories, by a sonorous and confusing nomenclature. Abderholden also helps to form this exclusive class, and there is practically no difference in the fundamentals of the theory of protein sensitization, of the former, and those of the theory of the protective fer ments, of the latter, even in the terminology employed; but as the former deals more particularly with the application of the