8. Add massage to the hyperemia resource for as long a time as appears to be desirable. 9. Do not swear in a court of law that this is the best treatment for Colles' fracture. State that it is first rate routine for the average case.

Is Atropine a Neglected Remedy?-A great many medical articles are written extolling the virtues of atropine, says an editorial writer in the Med. World. As a matter of fact, however, we believe this alkaloid has no wide spread use. We know that it generally tags along with hypodermic morphine tablets, altho we never could see any earthly reason for combining two agents that hate each other so badly. Then occasionally some one reports good results from atropine in hemorrhagic conditions. The general practitioner may occasionally employ this remedy to check enuresis, allay spasm or check excessive secretions. Atropine seems to find the greatest favor, however, in hemorrhages. All exceptions are in the case of hemorrhages so severe and sudden that death has occurred before atropine has had time to act.

All other cases of hemorrhage of every description have been remedied by a full dose of atropine, sufficient to dilate the cutaneous capillaries and thereby flush the face.

Atropine is highly serviceable in dissipating spasm. Pertussis, chordee, asthma-there is scarcely a spasmodic malady in the category which does not acknowledge the domination of atropine, altho it sometimes fails.

So many forms of pain are really spasmodic in their nature that one is tempted to term this alkaloid the kind of pain, dethroning the less effective morphine. Atropine does not lock toxins in the system or establish the drug habit; its effects are powerful and lasting. Colics give way to its influence, and the spasm of the circular fibers of the bowel that is present as a factor in many forms of obstruction relaxesso that many a clinician looks first to atropine in his cases of strangulated hernia, and only resorts to the knife when the lesion is not alone spasmodic. Many hernias can be reduced after a hypodermic of 1/50 of atropine sulphate. As a rule atropine should be given alone. The action however is quickened by the addition of nitroglycerine, and deepened and prolonged by that of strychnia-both in very small doses. If all of this is true, the inevitable conclusion must be that atropine is a neglected remedy.

The Operative Treatment of Goiter. The operation for the relief of goiter, according to H. B. Epstein (Am. Jour. of Surgery, Jan., 1917) calls for the following important considerations, the observance of which has largely contributed to the success attained in the modern operation for thyroidectomy:

First: The collar incision should be of sufficient length to permit a free dissection, the ample space giving the surgeon better exposure and making the procedure safer.

Second: The choice of alert assistants, for

rapid hemostasis is essential. This together with speed saves the patient from unnecessarily long anesthesia, too much handling and shock.

Third: After separating the fibers of the sternothyroid muscle keep close to the gland thruout the separation. If necessary, the sternocleido mastoid muscle may be cut across to give better exposure to the parts, the ends being sutured after the gland is removed. Care should be exercised to avoid the spinal accessory nerve.

Fourth: Careful dissection of the posterior and lateral borders in order to avoid injury to the carotid sheath or the inferior laryngeal nerves.

Fifth: Be sure to expose, freely, the upper pole of the gland so that a safe ligation may be performed with a generous pedicle. If necessary, cut the transverse layer of the deep cervical fascia. This is an important factor in reaching the superior thyroid artery and veins.

It is necessary to leave a small portion of the gland behind and also to avoid injury to the parathyroids in the dissection. The body being already over-saturated with thyroid secretion, it is advisable, in order to avoid additional strain, to handle the glands as little as possible. Vessels should not be ligated until the dissection is completed. If the temperature rises to a considerable height within twenty-four hours and the pulse is accelerated to over 120, with a suffusion of the face and eyes, I administer hypodermatically atropine sulphate, gr. 1/80, every two hours until reaction occurs.

The Use and Abuse of Pituitrin.-Skeel (Ohio State Journal of Medicine, December, 1916) concludes that pituitrin has three distinct fields of usefulness in obstetrics: 1. To terminate the second stage of labor in cases where no reason exists for delay except insufficient uterine activity and provided the head has reached the pelvic floor. This includes the delivery of the second child in twin labors. 2. Laceration of the cervix when used before complete dilataton. 3. To limit the bleeding in cases of marginal placenta previa, and in Cesarean section. Its possibilities for harm may be summarized as follows: 1. Rupture of the uterus if obstruction of any nature exists. 2. Laceration of the cervix when used before complete dilatation. 3. Laceration of the perineum when precipitate labor is caused by a full dose. 4. Occasionally its use results in tetanic uterine contractions somewhat resembling that produced by ergot, with consequent asphyxiation of the child. Before pituitrin should be used the following conditions should be fulfilled: 1. Complete cervical dilatation. 2. The membranes must be ruptured. 3. The presentation must be longitudinal. 4. There should be no malpresentation. 5. There must be no disproportion. 6. The presenting part must be completely engaged. It is a good plan to use pituitrin in fractional doses, 0.33 to 0.5 c.c., and repeat when the effect wears off. This reduces the risk of uncontrollable action. If pituitrin causes excessive pain either chloroform or ether should be

administered. It has been used as a galactagogue and as a substitute for the catheter in post partum urinary retention.

The Eskimo Medicine Man.-From the earliest times, says an Alaska correspondent in the Medical Record, (June 10, 1916) the subject of abnormal states of health and their treatment has been shrouded in mysticism with the Eskimo. They do not believe in healing through the medium of herbs or any form of medicine and they have the greatest horror of any form of surgical interference, but believe that certain persons are born with the gift of calling into play certain invisible powers by means of which the disease is driven out of the patient's body. These certain persons are the Medicine Men and the invisible powers are believed to be and are called Spirits by the Eskimo.

There are three distinct classes of natives inhabiting Alaska; the Indian of southeastern Alaska, the Aleut of western Alaska (in the region of the Aleutian Islands), and the Eskimo of northwestern Alaska. All three classes have about the same belief in regard to the medicine men but differ somewhat in their method of carrying out their line of treatment. They have a profound belief in the actions of good and evil spirits in the prevention, cause, and alleviation of disease.

The present letter is based on observations among the Eskimos, and the medicine man is described as seen today in this portion of Alaska.

There are about 18,000 Eskimos (Innuits) in Alaska and they inhabit principally the coast, so it is not surprising that their food and habits are associated with the sea. The natives are gathered in small settlements called "villages," each village having a chief and one or more medicine men. There is also in each village a council house called the "Kashim" or "Kasga," which is open to every one alike for work or play. It is the common meeting place where the natives gather for their dances and "powwows" and is also the place where the medicine men treat the sick.

As above stated the medicine men are born and not made. They usually descend from families long known in this vocation, altho occasionally a medicine man develops from other sources. In this same connection it may be of interest to note that there are a few medicine women.

Shamans, conjurers (tungaks) and medicine men are looked upon as mediators with the invisible world. They claim to be able to call the spirits into their environment, to see them, and to converse with them. They also claim that there are several kinds of spirits and that

each spirit has a separate and distinct power of its own. The medicine man here tells me that there are five and that each one has the power to heal a certain kind of a disease (he recognizes five diseases); that when he calls the spirits and the wrong one comes, he must drive this one away and continue calling until the right spirit comes and that this may take as long as ten hours or as short a time as ten minutes. The writer thinks that the prosperity of the sick one is in direct proportion to the length of time required to call the certain spirit.

No two medicine men are alike because they associate with different spirits, however there is always rivalry in a village where there is more than one medicine man. One tries to get rid of the other and this results in ill feeling. As soon as the ill feeling becomes manifest, the Eskimo stamps the one with the most manifest malice as a fraud and the then preferred medicine man attempts to shorten the life of the "fraud" so, as a rule, we find but one active in a village, but the sick will often go from one village to another seeking treatment.

The sick may be treated at home or in the kashim, the latter being much preferred by all and believed to be more effective. In order to understand thoroly this procedure it is necessary to know the plan of the kashim. It is a building constructed in the side of a bank if one can be found, about 20x20 feet, with a 10-foot ceiling. The sides and top are built of logs and are covered with dirt. In the center of the flat top there is a hole about 2 feet square and covered with a seal-gut covering. This is the only opening thru which air and light can enter. The seal-gut window or covering is translucent and, as it is usually fastened down tight, there is little or no ventilation. All around the interior, about 4 feet from the floor, there is a shelf upon which the men sit (the women sit on the floor under the shelf). The floor is of dirt or boards; the center boards can be removed, exposing a hole 18 inches square. This hole is about 5 feet deep and is the inner opening of a tunnel, which tunnel leads to another vertical hole, which in turn leads to the storm entrance through which all persons must pass on coming into and passing out from the kashim. Some of the modern kashims have a door from the storm entrance, thus avoiding the underground passage, but the older natives and those far away from civilization believe that the crooked passageway will keep out evil spirits, therefore they will not allow the ground level door. The walls are as black as tar from smoke. This smoke comes from the seal oil lamps the Eskimos use and from the fire that they build in the inner vertical hole after all persons have entered.

When the Eskimo is taken sick and desires the services of the medicine man, the medicine man is notified. He in turn notifies the whole village, stating the hour, day, and place for the performance. At night, just after dark and in the hashim, is preferred. The natives collect in the council house and seat themselves, the men on the shelf and the women on the floor. The spectators are made up principally of men; however, all ages and

sexes are at times present. The medicine man makes his entrance through the underground passage. He is nude with the exception of a rain parka and a pair of short reindeer muclucs. A parka is a one-piece garment with hood and sleeves and slips over the head and falls to the knees. A rain parka is a parka made of seal gut. When finished it is translucent and will turn rain. This garment rustles like paper and is used by the medicine men on account of this property. Reindeer muclucs are short boots made of reindeer skins with the hair on them. After the medicine man enters the kashim he calls for the patient. The patient is brought in, usually lowered through the opening in the roof, and placed in the center of the room. Selected men then sing (accompanied by the tomtom of improvised drums) the medicine songs of this particular medicine man. The medicine man begins his dance, shaking the rain parka violently. From time to time he rapidly shakes his head from side to side, making a peculiar noise with his lips-"bluba luba luba lub-a!" The dance consists of standing in one place, leaning first on one leg and then on the other, throwing the arms around violently in a manner to show off the muscles and making various gruesome facial expressions. There is nothing artistic or pretty about the dance. The rustling of the parka and the songs are to call the spirits. From time to time the medicine man will stop and converse with a spirit. If this is the wrong spirit he will tell it to go away and the performance will begin all over again. This is kept up until the right spirit arrives. He then tells the audience and patient that he sees and is conversing with the invisible spirit. He will ask what is the matter with the patient and after a pause will state that the spirit says that this sick person did so and so, describing something that happened possibly many years ago, such as killing a female reindeer just before calving, or slapping a certain child (usually mentioning some act of which the medicine man knows). He will then ask the patient, "Is that so?" The patient will say "Yes," and the audience is then spellbound. The medicine man again converses with the spirit and asks what will heal the patient. After a few moments' pause he will turn to the sick man and tell him what to do to be healed. This treatment consists in prohibiting a certain kind or kinds of food, as, for example, the eating of seal oil, whale blubber, or dried fish; it may also forbid "the use of the knife." By this expression is meant that he must not chop any wood and at times this applies to the whole family. Sometimes the medicine man will hold a piece of fish or something else to eat, in his hand and ask the spirit to give this piece of food the power to heal the sick and will then make the patient eat it.

After the medicine man has finished his instructions there is much singing and rejoicing and the sick man is taken out of the kashim thru the opening by which he was brought in. This ceremony may last from a few minutes to an all-night performance, regardless of how sick the patient is.

The medicine man usually states that the sick person will rise from the bed at a certain time.

If the patient gets worse or cannot get up at that time the medicine man claims that his instructions have not been carried out and will at times become very much enraged about it or he may administer another treatment. The fees of these native doctors vary a great deal. Some few will not charge as they claim that in charging for their treatment they anger the spirits. However, this is not the rule as they get all they can. They may charge ten pounds of fish, so many gallons of seal oil, a dog, sleigh, furs, or anything. They get as much as they can and many of them do not work at all. The medicine man, next to the chief, is the most important and most respected Eskimo in the village. He is sometimes a "sleight-of-hand" performer and if successful is always one of the brightest of a settlement. This is necessary in order to gain the native confidence, as they look upon him as supernatural. The natives consult him and pay him for other things than treatment. For example, they consult the medicine man about the coming fishing, whaling, and sealing seasons and will often pay him so many furs to ask the spirits for a good catch. also presides over the "Feast of the Dead," which will be described in a subsequent letter.

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Alcohol Not an Antidote for Carbolic Acid.— In a recent number of the Johns Hopkins Hospital Bulletin, Dr. David I. Macht published the results of a series of experimental investigations relative to phenol poisoning and the antidotes ordinarily used in cases of this kind. It seems that we shall have to revise our ideas relative to the value of the various antidotes for carbolic acid. Ever since 1899, when Powell introduced alcohol as a preventive for phenol poisoning, this substance has been used probably more than any other for this purpose. It will be remembered that Powell used to demonstrate its value as an antidote by washing his hands in pure carbolic acid and then in alcohol, even by filling his mouth with the acid and then rinsing it out with 95 per cent alcohol.

However, the studies of Macht seem to show that not only is the alcohol useless, but actually increases the danger, because it hastens absorption. His studies also show that lavage with alcohol was followed by death more often than by recovery. When large doses of phenol had been given by mouth, washing the stomach with alcohol was followed almost invariably by death, in the experiments which he made upon cats.

The remedy which proved most effective as an antidote, in Macht's, was a solution of sodium sulphate. Dogs, he declares, withstand carbolic acid better than do cats, and he found it possible to save these animals by means of immediate lavage, irrespective of the remedy employed. After large doses of phenol, washing with sodium sulphate or plain water sometimes saved life. In late lavage, that is if the stomach was washed about fifteen minutes after the ingestion of carbolic acid, sodium sulphate gave the best results, plain water the next best, while as already stated, the use of alcohol was almost invariably followed by death.