vision and by the advice of a physician. The indiscriminate and long-continued use of strong applications can do very little good, and may be the means of doing a great deal of harm. Such use really defeats the end at which it aims by producing a leathery thickening and hardening of the vaginal mucosa. On the other hand, the use of mild solutions has a softening and relaxing effect upon the vaginal tract, producing a marked action upon the deeper tissues generally, increasing and improving the circulation of all the surrounding parts, thus maintaining the nutrition of the whole generative system.

The Deep Action of the Douche.

To my mind, this deeper effect of the vaginal douche is the most important one of all; the one least considered, least understood. I desire to emphasize the great efficiency of the depleting douche for a few special conditions: In congestive endometritis, probably one of the most discouraging conditions to be combated, where, in spite of local and systemic treatment given, the uterus still remains chronically engorged and easy to bleed, I have obtained the best results from the use of the depleting douche. The patient is advised to secure a good smell rubber hose attachment for the bathtub-the simple little shower bath device is excellent, removing shower attachment from end. If desired, a nozzle point may be inserted, or the soft rubber tube end may be used, which gives a free, flushing flow of water.

With rubber tube attached securely to bathtub faucet, the hot and cold water may be turned on until the temperature is right, and the douche continued until the hot water supply is exhausted, which may be twenty minutes or half an hour, following up with a quart or two of some mildly antiseptic solution from the douche can or fountain syringe. Owing to its generally relaxing effect, such a douche is best taken just before retiring at night. N. B.-The general effects of the prolonged, depleting douche should be noted, and if any marked feeling of exhaustion is experienced, it may be of shorter duration, and the intervals between may be lengthened out.

This method of using the vaginal douche is especially applicable when treating old pelvic infiltrations, uterine distortions and displacements with fibrosis, as the application of heat improves the circulation and acts wonderfully in softening up the tissues and securing good drainage, the great desideratum in all these complicating abnormalities. Thus are the tissues placed in the most receptive state for the application of other remedial measures.

An Illustrative Case.

Illustrative: A recent case, a young married woman, who had spent several years previous to marriage as clerk in a drygoods store; dysmenorrhea always had been marked. Wondering why she

had never become pregnant, she had been examined and advised that surgical intervention would be necessary to overcome the existing retroversioflexion, the "shortening-of-the-round-ligament” operation being described as the preferred one. She drifted under my observation. The uterus was very pale and anæmic, retrodisplaced and flexed, with marked fibrosis at site of flexure, the entire organ being hard and gristle-like. She complained of an abnormal dryness of the vaginal mucosa, little secretion and no discharge being observable.

It took three or four treatments, with continued supportive packing, to effect a good reposition, after which a soft rubber spiral spring pessary or supporter was adjusted, which served as an effective "crutch," and patient was instructed to continue her special postural exercises several times each day, and to take a prolonged douche in bathtub each night before retiring, and to report for treatment in about three days.

At the expiration of the stated time she returned, and upon being asked how she had been getting along, replied, "Just fine; but it sure kept me busy heating water and taking those douches three times a day!"

Upon examining and noting conditions, I want to say that I have never observed such marked improvement in so short a time in any case ever treated. The uterus seemed soft and velvety, having lost much of its fibroid feel, was in splendid position, resting easily within its encircling "crutch," and the color was a deep, healthy pink, showing a wonderfully improved circulation. I never have advised such a douche to be taken oftenter than once a day, but certainly this case was a revelation to me. It would almost seem that one might, in certain cases, safely prescribe such a mode of procedure to be followed out "before meals and at bedtime."

The Action of Heat.

It is a well-known and easily demonstrable fact that the primary effect of heat is to relax and bring the blood to the parts, producing congestion. Continued to its secondary effect, it drives the blood from the parts, producing a comparative anemia. A common example of the effects of hot water may be seen in the hands of the washerwoman. First, red, swollen and congested; second, pale, wrinkled and shrunken-anemic.

The taking of a vaginal douche seems a simple procedure, too simple to merit anything more than: "And you might take a douche occasionally." Not so simple nor so unnecessary as might appear at first sight! The various methods of using, and their effects, should be thoroughly studied and understood; and the manner of using to obtain the desired results, and meet indications in a given case, should be intelligently followed out by both physician and patient.

Antiseptics in the Douche.

Antiseptics. It will not be necessary to mention in detail the many good antiseptics in such common use, as each one of us have a few tested and tried favorites which we are in the habit of using in our routine practice, while the various new ones brought to our attention from time to time give us ample opportunity for testing their greater or lesser efficiency and merit.

Vaginal Suppositories.-The numerous suppositories put out by the various firms meet special indications and needs, and are often a very convenient and beneficial form of medication to place in the hands of the patient for home use during the intervals between office treatments. Especially are these advised where the mucous membranes are

greatly irritated or eroded, and conditions seem to call for continuous specific medication.

In closing, I desire to say that all remedial measurcs serve a good purpose if intelligently and properly applied when specifically indicated, and discontinued when the need for their aid no longer exists. It is so with the vaginal douche, as it is with the curet, the pessary, tamponade and the various other uterine supports and medicaments; when properly used the results are good; when improperly applied, indifferent or bad results may accrue. Their indications or contra-indications in any given case must be determined by careful examination, thoughtful experimentation and practical experience. But discriminate, discriminate, DISCRIMINATE!

By B. W. STEARNS, M. D.,
UNADILLA, N. Y.

The operating surgeon specialist deals largely with incised wounds made by his scalpel; the general practitioner deals more commonly with industrial injuries producing lacerated and contused wounds. First aid is commonly rendered at the factory, and the physician summoned has first, by careful examination, to determine the extent of injury and the requirements to be met. In my experience, these requirements are commonly met with few appliances-warm bichloride solution in one bowl, sterile water in another, cotton pledgets, suture material, facilities for sterilizing instruments, one or two dressing forceps, knife, two scissors, several artery forceps, needle holder, phenol, etc.

The importance of removing gross contamination should be emphasized, and the use exclusively of sterile material in applying disinfectants and giving other care to the wound. And it is important also, after arresting hemorrhage, to remove minor contaminating agents, debris, blood clots, etc., not attempting to save material in so doing. The mistake is often made of neglecting thoroughly to explore the wound with the sterile finger at the first dressing of the wound; the finger may detect what the eye may not. The care and thoroughness with which the first dressing is made measures the whole after progress of the case.

Severed Tendons.

At the first dressing, while the wound is open, severed tendons should be looked for and sutured in apposition, for they show little tendency to heal later on. I have seen an insignificant cut on the back of the thumb sever the tendon of the extensor, allowing the distal phalynx to remain permanently flexed. I have seen the result of

such neglect by good surgeons, and have later operated for the relief of the condition, succeeding in securing union of the severed ends of tendons after six days' neglect. Don't forget, in doing such work, that the distal end of the tendon is readily found, but the proximal end retracts back up the sheath.

Severed tendons are encountered in the most unexpected places from insignificant wounds, usually from sharp instruments, such as butchers' knives, scythes, etc. The patient often objects strongly to the surgeon making the necessary incision to secure the proximal end of the severed tendon; so insistence is necessary.

Sutures.

Fascia and the sheaths of muscles must be separately sutured, as must also the skin. In emergency work too often sutures are introduced through the tissues in a way as to cause an unsightly puckering of the overlying skin after the wound has healed. The function of the skin is to cover, and it is intended to be freely movable over the underlying structures. Nicety in introducing and tying sutures does much to favor union by first intention. Because a wound is in an unexposed part does not excuse us from making the utmost effort to be accurate in suture work.

Scars on the face may often be avoided by inserting a subcutaneous linear suture, starting at one end of the cut or wound and zigzagging from side to side, just on the under edge of the skin, and then bringing the suture up out of the skin at the opposite end of the wound; then applying just enough tension on the opposite ends of the suture to bring the edges of wound into apposition. The ends of the suture may be fastened by sealing them down to the skin with collodion.

Antiseptic Dressings.

After a wound has been thoroughly cleansed and closed, there is no better dressing than plain powdered boric acid, applied liberally and covered with absorbent cotton. It is non-irritating and odorless, and easily crumbles loose from the wound in re-dressing. Aseptic wounds treated as herein described should heal by first intention, and should not be disturbed, under ordinary conditions, for eight days, at which time the sutures may usually be removed. Small wounds about the face or scalp should be covered with collodion, instead of bandage or plaster.

In the case of severe lacerated and contused wounds, with more or less destruction of tissue and integument, where the process of granulation must be looked for, the same care in the primary cleansing is necessary, but a different dressing will be found more effective, viz., the use of zinc oxide, two parts; powdered boric acid, one part. Apply liberally over the granulating surface. Wounds of this nature require dressing every forty-eight hours, using the bichloride solution (1 3,000) to dampen the absorbent cotton used in cleansing the wound at each dressing, being careful not to cause bleeding by roughly removing the powder applied at the previous dressing. After applying the powder, a thin layer of absorbent cotton, dampened in the bichloride solution, should be placed over the powder and cotton; then all covered with a good layer of dry cotton, retained in place by bandage or adhesive plaster, according to the location of the wound. In case of a wound with considerable contusion of the tissues, which will produce quite a profuse discharge between dressings, it is well to apply a ring about the edges of the wound of some mild salve or ointment, like the oxide of zinc softened up with a little petrolatum, to prevent the drying on of the dressings, thus saving unnecessary pain in removing the old dressings at your next visit. Use Simple Dressings.

I hope you have noticed that all the agents I have mentioned in this paper are simple chemical preparations, readily secured by every one. I can sum up the arguments in their favor in two words, efficiency and economy, which is more than may be said of many of the proprietary preparations so extensively urged on the profession at the present time. Another very important consideration in favor of these agents is their being entirely odorless, so that the odor of the dressings will not mask any undesirable condition of the wound that might light up between the times of dressing by the surgeon. Personally, I always feel that the use of some odorous dressing is being used to mask some undesirable condition present, and consequently have always avoided the use of all such preparations, carbolic

acid with the rest of them, except for the immersion of metallic instruments while in use.

Amputation.

1

In case of an injury so extensive as to necessitate the amputation of an extremity, all the principles of asepsis are required. Most text-books give the main points on which the decision for amputation shall be made, unless it be the point of severence and the pattern of flap for covering the stump, keeping in mind the utility of the limb after recovery as the most important consideration to the patient.

Many times an extra inch of bone may be removed in order to provide the best form of flap, viz., the single flap cut from one side of the limb or arm, the end of the flap being rounded to fit the round contour of the opposite side of the limb or arm. The side of the extremity from which the flap shall be cut will depend on the location at which the amputation is made. For instance, in an amputation at any point between the ankle and knee the flap should be cut along the inner side of the leg, and brought over the stump to form a line of union a little short of half the circumference of the leg on the outer side, where it will not be exposed to pressure or chafing. An amputation at any point in the fore-arm should provide for cutting the flap on the under side, as the hand would lay prone on a table, while above the elbow the flap should be cut on the inner side, leaving the line of union on the outer side. The removal of an extra inch of bone, to avoid over-tension on the flap, is nothing compared to the comfort and utility of the stump to the patient in the years to follow. Bad Flaps.

In giving an anesthetic, before now, I have witnessed the integument on the inner side of the arm deliberately cut off to form a common coatsleeve flap, with the line of union over the middle of the stump, where it would always be exposed to pressure and chafing, which I shall never do without at least suggesting the proper cutting of a flap for the particular amputation at hand. For the case I have in mind has experienced no end of trouble with the stump ever since it was done, something over six years ago. Another important point in the way of providing a useful stump following an amputation is to make provision for a flap of facial tissue, to be brought down and sutured over the end of the bone before bringing the skin flap over the stump. The shape in which the fascia flap is cut is immaterial, so long as it comes over the end of the bone.

By carrying out the points herein mentioned, I have had patients able to get about comfortably on an artificial limb inside of three months from the time of the amputation.

OUR OPEN FORUM

The Necessity for Mydriatics in Refracting. I read the article "Medical vs. Non-Medical Optometry" by Dr. Claud Walcott, of Texas. With all due respect to the doctor's viewpoint, I must differ with him. His method of refracting without the use of a mydriatic is unreliable, not trustworthy; it is misleading from beginning to end. In a word, we have nothing more than the patient's side of the story.

Refracting is by some regarded as a simple procedure, which any one with a test case can master in a short time. My experience of more than forty years does not substantiate these views. Oculists in this country and Europe use mydriatics in proper cases. You must know how, when and where to use them. The fact remains that there is no accuracy without the use of mydriatics. Of course you resort to the retiniscope, the ophthalmoscope the sine-qua-non, with the regular oculist. Men have labored for years on problems of refracting, and have not yet solved them. Correct diagnosis in retracting frequently requires all the anatomical, neurological, medical and special knowledge we can muster to get results. One-half of my work in refracting comes from patients that have been refracted by non-medical men. I have made over 60.000 examinations in my practice. My experience has not verified the statement made in the doctor's closing paragraph in which he states: To those who expect to continue in this work it must be evident that a change is being made to the noncycloplegics practice. G. T. Fox, M.D.

Bethlehem, Pa.

The Point of View of the "Therapeutic Nihilist." Under the caption "The Death of Therapeutics Promises a Funeral for Medical Business," appearing in your November issue, and which I take to be an editorial, several statements are made that I believe need light on the other side in order to make them take their proper place; and craving a little space I wish to say a few words as a so-called therapeutic nihilist.

When the writer speaks of the death of therapeutics we must all realize that there is not and never will be such a condition; but if he had said "drug therapeutics" we could view such a calamity with considerable equanimity, for truly drug therapeutics is gradually finding its own level, and will some time come to occupy the niche intended for it, simply as a reliever of annoying symptoms.

Why will we persist in deluding people, and actually trying to delude ourselves as well, with the idea that drugs are curative; that they actually make permanent changes in the system; that they remove the causes of diseased conditions, when aside from the possible exception of sulphur in the itch and the well-known syphilitic specifics, quinine in malaria, thymol in hook worm and a precious few others, there is no such thing as cure, in its broadest sense, from the exhibition of a drug?

Now, we are not speaking for publication among the laity, but among ourselves, and why, I ask, cannot we be honest with ourselves and admit this very evident fact and so get down to a better understanding of just what we can and cannot do with drugs?

We know when we knock off a fingernail that 'a new one replaces the one lost, but we cannot do this artificially with a magic remedy-when we lose epidermis it is replaced naturally and without thought on our part; our hair grows again if cut, and we give every evidence externally of growth, of rehabilitation, and can we deny to the unseen parts of the body, the internal organs, the same growth? Is the liver we have this year the liver we were born with, or even the one we had seven years ago, say?

Has it not been replaced cell by cell with new tissue till in a few years every old cell is dead and gone and a new cell is occupying its place and continuing the function for which it was created? Is there any magic dope that will recreate these dying cells?

Is it not a fact that all we can do to assist in re-establishing normal conditions is to remove the known, causes and keep them removed?

Do you blame the average case of progressive pernicious anæmia, say, for becoming discouraged when he goes from one to the other and finds all willing to wait on him, all prescribing medicines for him, and, if honest, at the same time assuring him that even if he is stimulated into a better condition temporarily his disease will ultimately get him?

Does the case of spasmodic asthma get any encouragement from the use of drugs?

Does the diabetic, the hyper-thyroidia sufferer, the neurasthenic, the arthritic, the nephritic, the case of perverted nutrition, whether he be a skeleton or obese; and, coming right down to cases, what remedies, aside from the few specifics named, are of such general usefulness as to command anything like a general use among the rank and file or the more select ranks of the specialists?

Not Sore on Drugs.

I am not sore on drugs, but I have asked myself these questions, and after seventeen years of painstaking effort to keep up with the procession of newer remedies turned out by the very prolific and active synthetic chemists, I was compelled to admit to myself nine years ago that drug therapeutics was a broken reed, so far as the cure of disease was concerned.

Now do not get the idea that we should throw away drugs because they are not specifically curative, for they are most useful; but let us be honest with ourselves and our patients and realize that all that is curative of wrong conditions is the removal of the causes, often very obvious, of the annoying conditions for which relief is generally sought.

Let us so impress our patients, that they will understand that the real cure lies in undoing the causes that led up to the diseased condition, and when this lies in an increasing toxemia, as it generally does, that the only real cure lies in cutting out of

the diet all those things that leave behind the encumbering waste, and that whatever drugs may do for the condition is not curative in any sense, but palliative of the distressing symptoms, intended for relief, not cure, and that so far as real cure is concerned that is specifically a matter for the body itself to adjust; that when the resistance of the body rises high enough the invasion, or accumulation, or infection, or whatever, will be thrown off, and that the part of drugs is merely to make this more agreeable or less painful; and let us cease to allow our patients to regard drugs as in themselves specifically curative, and teach them that to be well is not a matter of taking the right kind of dope, but merely living within our capabilities, digestive, assimilative and excretory, and observing that moderation in everything that will safeguard us from an overdone function.

If we would do our patients the most good we would impress on them the necessity of a frequent blood-pressure reading, a urinary examination, a general looking over by the regular medical attendant, whether that be us or some one else, and that the time to cure disease is before it has begun, by avoiding those causes that interfere with function of all kinds, and we will not be made to feel that we are taking money under false pretenses or aiding and abetting a steal of any kind.

Such therapeutics need no apology, will never die, and no man need be ashamed to call himself a physician if he practices along such lines; but to foster the idea of the ignorant that there is for each diseased condition a drug specific, if one were smart enough to find it, is not honest or apt to reflect credit on the profession which we all hope to see honored, and the death of such therapeutics is not to be greatly deplored.

The Profit Side.

I want to say that since I have felt this way and have had the courage to tell my patients what I think, I have enjoyed the best years of my life, making more money, feeling more like a man, and actually doing a great deal more good-good that becomes permanent, and that reaches out to others that come in contact with the patients who have been made to understand that health is something within the reach of all, if we observe the very plainest of indications, and that to be sick is to be in disgrace, and indicates either gross ignorance of the simplest of hygienic laws, or an abandon to pleasures that kill, regardless of results. Youngsville, Pa.

W. H. HAY, M.D.

Regular Feeding of the Infant.

I wish to take exception to Dr. J. G. B. Bulloch, in the November issue of the CQUNCIL, in the paragraph on "Management of Infant," when he states that it is of utmost follly to try to feed an infant at regular intervals. I believe, or thought, that regular feeding of infants was a distinct advance in infant management advocated by all progressive practitioners, and practiced by all except those too indolent to accept it with the rest of our marked improvements-sterile gowns, rubber gloves, etc.

The statement is accepted, that for the first few months there is no marked development of the infant's mind or reasoning power-special reason why his judgment of the feeding hours should not be trusted. Habit and regular feeding is a part of our daily system, and should be cultivated early in the life of an infant. I do not believe it can be too early.

If the infant is fed at certain intervals, its stomach will learn to receive a certain amount of food at regular intervals, and to digest this amount, giving it stated intervals of rest between feedings. And it is not under-fed at one feeding, and overfed, with regurgitation or improper digestion of the next feeding. Also Chapin and other authors have proven by breast analyses that when the breast is emptied at irregular intervals the percentages of the milk differ, and when emptied at regular intervals the percentages are regular.

It is a habit the infant takes with it in childhood and adult life, and no doubt the movements of the bowels are more regular with the interval feeding, and continues so with the advance life of the infant.

The history of most infants is that it is not necessary to awaken them for feeding at night, as they awaken themselves. If they are to feed at night, why not at stated times?

How does an infant express his desire for food? By crying. Crying is the newborn infant's mode of exercise, and if you feed him every time he wants exercise, you will have an overfed and sickly child. In feeding an infant at stated intervals-and the infant cries between these intervals-he certainly is not crying from hunger.

I would like to know what harm the Doctor means could befall the child from regular feeding.

The thoughts expressed in my letter can be found in any or all modern books on Infant Feeding, and I mention them here only that I believe the Doctor's statements to be conducive of much harm if accepted as facts, and practiced by fellow practitioners.

The greatest argument for the regular feeding of infants at stated intervals is the excellent results thereby procured in his infant and subsequent life. I do not consider it a modern obsession, but a marked advance in infant management and the prevention of infantile diseases, with the building up of a robust child.