now rarely called for. It may be that in the future even the medical examiner's services will be only exceptionally called for. Feilchenfeld concludes that the present method of having the medical examiner perform the uranalysis is quite acceptable. The services of a specialist should be required only if the results obtained by the examiner require control in any particular and difficult case.

Advanced Extra-Uterine Pregnancy.-Wagner, in Zentralbl. f. Gynak., reports the case of a patient who came to his clinic in a pregnant condition complaining of almost constant pain in the abdomen. When pregnant about six months the fetal movements ceased, and the abdominal pain grew very much less. On examination, the abdominal tumor extended two fingers beneath the tip of the sternum. The head of a full term fetus could be palpated in the abdomen, and the pelvic tissues showed signs of pregnancy. The placenta could be made out as a comparatively soft mass attached to the uterus by a pedicle. Operation was performed under lumbar anesthesia and the tumor was covered by the omentum which was adherent to the pelvic brim. After this was loosened the fetus was found in a grayish-white capsule. The tumor, which was supposed to be the placenta, was a hydrosalpinx as large as an orange. On the right side the tube terminated in a grayish-white hard tumor as large as two fists, which was attached to the sac containing the fetus. This tumor was adherent to the surrounding tissues. The appendix was adherent to a smaller tumor. The ovaries were normal, and the uterus and left ovary were left. The hydrosalpinx, fetus, and placenta were removed. On examination, it was found that the fetus had now become a lithopedion. The placenta showed calcareous changes, and was contained in a sac composed of the tube. The fetal sae was connective tissue developed in a plastic peritonitis, and the sac was so adherent to the fetus that some of the hair from the scalp was firmly fixed in the sac. There was no amniotic liquid. The left foot of the fetus was much bent, but otherwise the skeleton was normal. There had been no symptoms of intraperitoneal hemorrhage or acute peritonitis.

Bath-Bed. Shut, in the Interstate Medical Journal, remarks that water and ice applications are the best and most convenient mediums for reducing high temperatures. Bath-tubs are not always obtainable and are usually against a wall. It is very convenient to be able to work with

the patient from both sides. It has been found that an ordinary bed can be arranged to take the place of a bath-tub, and may afford some advantages. Two or three boards should be placed across the bed under the mattress to prevent sagging. If the bed has a woven wire mattress, the top mattress may be removed. Two firm rolls, six to eight inches thick, are made quickly by rolling blankets, carpets or other material, and then placed lengthwise about two feet apart on the bed. Short rolls of pillows or other material is used for the ends. The corners are pinned to prevent spreading. If a full-length rubber-sheet is obtainable, it is placed over the rolls and the improvised tub is ready for use. If such a sheet is not obtainable, two pieces of oilcloth may be joined. An impermeable joint is thus formed. The edges of the sheet may be tucked under the rolls.

A bed so arranged has several advantages. It can be made up on short notice and may be placed so that attendants may work from all sides. Three to five gallons of water are sufficient. Ice may be used to advantage, but it is not entirely necessary. A thin cloth is placed over the patient and is kept constantly moist. Constant fanning produces rapid evaporation and the temperature is quickly reduced. When the temperature starts down, the water may be let out at corner of the bed and dry blankets and warmth applied. This plan has been used in very severe cases, and it has been found unnecessary to move the patient during the treatment.

one

"Please, sir," said the office boy, "me gran' mudder's dead, an' I want de afternoon off."

"Johnny," exclaimed his employer severely, "do you know where little boys go who tell lies?"

"Yes, sir, to de ball game," replied Johnny, unblushingly. 慌慌慌

Mr. Slimson-Willie, didn't you go to the trunk maker's yesterday and tell him to send 'round the trunk I ordered?'' Willie "Yes, pa."

Mr. Slimson-Well, here is the trunk. but no strap."

Willie "Yes, pa; but I told him I thought you hadn't better have any strap."

The Care of the Baby.-A Manual for Mothers and Nurses, containing Practical Directions for the Management of Infancy and Childhood in Health and Disease. By J. P. Crozer Griffith, M.D., Clinical Professor of Diseases of Children in the Hospital of the University of Pennsylvania; Physician to the Children's Hospital; Consulting Physician to St. Christopher's Hospital for Children. Fifth Edition, Thoroughly Revised. Philadelphia: W. B. Saunders Company. 1911.

We are not surprised to see the fourth edition Dr. Griffith's little book, which. if we remember ber rightly, only appeared last November, so quickly followed by a fifth. Indeed, if our mem

ory serves us correctly, we predicted at that time that the publishers would be kept busy distributing that issue and that the author had best occupy himself with the necessary preparation for a new one. In short. Dr. Griffith's book deserves every bit of succetss and popularity that it has achieved. His experience in all that pertains to the medical and hygienic care of the baby has made him a standard authority on this popular subject, and his happy way of imparting what he knows makes him a peculiary apt and pleasant teacher. Mothers and nurses who possess and read this book are well equipped for their nursery and sick room experiences, and it should be the business of every family doctor to see to it that the book is in every home which he can influence.

Manual of Diseases of the Ear Nose and Throat.By John Johnson Kyle, B.S., M.D., Professor of Otology and Laryngology, Indiana University School of Medicine; Otologist, Rhinologist and Laryngologist to City Hospital, St. Vincent's Hospital, and City Dispensary, Indianapolis, etc. Third Edition Revised and Enlarged. With 176 Illustrations. Philadelphia: P. Blakiston's Son & Company. 1911.

We used to think that books dealing with dis

eases of the ear, nose and throat, were compara

tively few and far between, but we are beginning

to change our mind. There are, to our present knowledge, more than a score of excellent and standard text books on this subject, and we are wondering how they all find a sufficient sale to warrant their continued publication. Dr. Kyle's book, so far as we can see, is as good as any

other one in its class, which is that of a manual. It contains about all that the general praetitioner needs for his work in the ear, nose and throat. It is hardly broad or extensive enough to be of much use to the specialist. So far as the physical appearances of the book are concerned no complaint can be made, but we do not think that from any point of view it calls for any special notice.

1000 Surgical Suggestions.-Practical Brevities. in Diagnosis and Treatment. By Walter M. Brickner, B.S., M.D., New York, Adjunct Surgeon, Mount Sinai Hospital. With the Collaboration of Eli Moschcowitz, James Warbasse, Harold Hays and Harold Heugof. Fourth American Edition. New York: Surgery Publishing Company, 92 William Street.

It seems to be the ambition of the author of this little book to increase the size of each edition by an arithmetical progression. When we reviewed the first edition in 1906, it was called simply "Surgical Suggestions," and at that time practically contained some three hundred items. The second edition contained and was entitled "Five Hundred Surgical Suggestions"; the third edition, seven hundred; and now we observe that the fourth edition boasts one thousand.

Happily we are also able to say that this increase does not take place by any process of dilution. Each fresh contribution to the book is just that much good and substantial value added to it; so that the present edition is really and truly about four times as valuable in every way as the first. Among these thousand therapeutic hints and diagnostic wrinkles, it is certain that every reader will find some which are new to him and a great deal more that are useful.

"Charlie's perfectly wild over his new motorcar," remarked a man to a friend.

"Wild over it!" responded the latter. "You should see and hear him when he's under it!"

"Do you tell your wife everything you do while she is away?"

"No; the neighbors attend to that."

VOLUME XXXIV.

SPECIALISM AND THE PUBLIC.

The medical situation in the past ten or twenty years may be regarded as somewhat parallel to that of the commercial world, namely, tending toward large central co-operative monopolies of specialism, similar to the "trusts" and department stores, by which the general practitioner, like the smaller merchants, lose caste and business, and the whole profession comes to be viewed by the public upon a commercial, competitive basis. It is the fashion of the time to regard every commodity and service as a matter of quid pro quo, a phase of the division of the world's labor, to which the doctor, by reason of long centuries of sentimental standards of reverence and tradition, has not adapted himself.

The doctor is, in fact, face to face with the self-same problems which confront the small local merchant. The public demands its "money's worth," and if they find that the specialist, like the trust, gives a better money's worth than the local practitioner, then the latter must, like the local tradesman, find some way in which he can give the people a better relative money's worth than the specialist. It is not a time or a place for false pride, or a traditional delicacy, but for true pride, which meets and vanquishes the new situation, and gives all that is asked.

We believe the general practitioner will admit that he has himself been too neglectful of his own interests in relation to specialism. Without any intention of belittling specialism or the specialist, we do not hesitate to declare that the general practitioner has been altogether too ready to surrender his influence and to yield up his business to their demand. He has allowed himself to become a mere feeder for the specialist. We do not insinuate any moral discredit or dishonor to him that he has done so. His course has undoubtedly been inspired by a praiseworthy desire to do the best for his patient, but the specialist has taken advantage of the position to use every kind of influence to divert this kind of practice to himself.

There is nothing in specialism, per se, to degrade medicine or to lessen people's faith in it; quite the contrary. It is, as we have said, one of the natural tendencies of the times. But the utter

NUMBER 9

subjection of the general practitioner to the specialist is both debasing and unwarranted and tends to discredit practitioner and specialist alike in the public mind.

It is time that the general practitioner reasserted himself, and showed a sturdy determination to square himself with the spirit of the times by giving the public what it demands-by "delivering the goods." Such a step will go far toward reinstating the family physician in his former enviable position, and toward getting a fresh hold upon the popular esteem and confidence which is felt to be slipping away from him.

TRAINING IN THE CORONER'S OFFICE.

To the average student and practitioner of medicine the significance of medical jurisprudence is confined to the identification of dead bodies, the detection of poisons and signs of rape, the giving of expert court testimony, and similar functions dwelt on at great length in the current text-books and by lecturers on the subject. But the man who has actually done work in or connected with the offices of coroner knows that these exceptional duties form but a small and not particularly instructive part of his experience, and that medical jurisprudence of the real, practical type is a most interesting and instructive phase of medicine, well worth cultivating for many reasons.

The most striking thing, as it is the most fundamental, about the medico-legal practitioner's experience is that it obliges him to constantly get around on the public side of a case, and to view everything connected with it that has to do with medical science from the standpoint of the man in the street; and this is of itself most excellent trainnig for any medical man. No man who has ever gone through it ever again regards his practice in quite the same way. He never again loses that peculiar viewpoint of medical science and practice

call it public, or legal, or vulgate, whatever you will-which if of inestimable value to a broad estimate and proportionment of professional work. We recommend that every medical man who has the opportunity to serve in the office of coroner of his county embrace the opportunity with avidity. He will very shortly discover the crudeness of his education in this aspect of medicine, and will

awake, by means of his experience, to undreamedof relations of his profession, the acquiring of which he will never regret.

THE PHYSICIAN AND THE MICROSCOPE. We can hardly conceive how a practitioner of medicine in these days can manage to get along without a microscope. We are not, and never have been, as our readers well know, sticklers for all the paraphernalia and technique of the laboratory in the general practice of medicine. We do not believe it is necessary for physicians to possess all the apparatus and appointments of the medical and biological and chemical and pathological departments of a great university in order to be a successful practitioner of medicine. We do not even believe it is essential for him to have a working knowledge of all these branches of medical science and if this be heresy, make the most of it. But in the present state of medical knowledge and with our present views of infectious disease, it is hard to see how diagnosis can be adequately performed, even by the general practitioner, without a microscope.

The usefulness of this instrument is by no means confined to rare and obscure diseases. There is hardly an infectious condition with which the doctor may come in contact but owes its positive diagnosis to the miscroscope, and almost all of the metabolic diseases may have invaluable light shed upon them through the glass of an objective. To make mention of no others, surely the recognition and positive detection of such old friends (or enemies, rather) as tuberculosis and diphtheria are of themselves sufficient to warrant the expense, and if need be the sacrifice, of equipping oneself with a microscope. And it may be safely asserted that he who once possesses himself of one of these usful instruments will speedily find the range of its usefulness increasing every day and week and month and year.

It is usually accepted as a foregone premise that the country practitioner is more or less exempt from the necessity of equipping himself with such ultra-scientific armamentaria. Nothing, however, is further from the truth. If anyone is justified in leaving such things out of his equipment, it is the city man, where there are so many facilities for having this kind of work done for him by specially established laboratories, or by the hospitals with which he may be affiliated. The country practitioner on the other hand, has no such facilities. Either he must do his own laboratory work, or it will go undone. And while, as we have intimated, there is doubtless a great deal of the ultra-refinement of laboratory work which is not really essential to the general prac

tice of medicine, the microscope has unquestionably aligned itself, in these days, with the thermometer and stethescope as a necessity of practice rather than as a luxury of technical science.

There is really no economic reason why any practitioner should not now avail himself of the service of the miscroscope. To be sure, to the rural practitioner its purchase usually means something of a financial effort, but a good microscope does not cost nearly as much nowadays as it used to, and we repeat that the sacrifice-if it entail a sacrifice-will amply repay itself in the wonderful addition it will make to the physician's diagnostic, and therefore to his therapeutic, efficiency.

THE ETIOLOGY OF CLIMATE.

We are a little surprised-or we would be, if we did not know in how many other directions the excursions of medical research were beating the air-that so little attention has been paid to the etiological influence of so very obvious and immanent a factor in human environment as the climate. We refer, not so much to the conditions of temperature as to those of the barometer. Three glaring facts stand patent to us all: First, that the effects of climate are common to all, rich and poor, high and low, male and female, young and old-none escape them; second, that the conditions of climate, even within a given circumscribed area, are probably the most changeable and changeful influences to which any human being is constantly subjected during the course of his natural life; and, third, that these conditions do exercise a very real and considerable influence upon the functional activities of the human body, and probably also of the human mind. Yet, in spite of these truths which stare us in the face, we have never, as a science of a profession at large, given any worth-while consideration to the question of climate as an etiological agent. It is true that there have been one or two individual efforts in this direction, which we would scrupulously except from our sweeping criticism. Our own Guy Hinsdale, it will be remembered, has but recently issued a book on the subject. But in general our criticism stands.

The most we ever do is to order some poor consumptive (who usually cannot afford it) to another "climate," by which we mean a place where the sun shines at an even temperature all day, so that he can be continually in the open air; or to recommend the victim of hay fever to get away on the hills out of reach of the pollen during seeding time; or to send a malarial patient out of the saturated marshes to get the malaria out of his system. All of which is good enough, as far as it goes. But so far as we are aware, no systematic

study or experimentation has ever been made of the precise effects of the various climatic conditions upon the physiological and pathological processes common to mankind. There is, in short, no science of medical climatology except the limited contributions of a few men, whose utterances on the subject have not been given any very serious or extensive consideration.

Of all the features of climatic environment, the question of temperature has undoubtedly been. given the greatest attention. Yet it seems to us that the barometical element is one which calls for far more serious and careful sudy, and that for two reasons: first, because it is an element in the climate which commonly escapes observation and calculation, and second, because it is an influence against which the mechanism of human physiology has not as great a range of defense and adjustment as against temperature. Within reasonable limits (and quite extensive limits, at that) the body is perfectly well able to adjust itself to any kind of change in temperature. Its twin functions of radiation and evaporation will amply take care of extremes of temperature. But under the stress of an unfavorable barometic pressure, not only is evaporation itself seriously compromised, but many other activities of the body are gravely embarrassed, including respiration, circulation, and elimination.

We are not belittling the other fields of medical research which claim so much attention at the present day. We are not silly enough to imply that in the conditions of the climate are to be found the fons et origo of all the ills that flesh is heir to, or even to insinuate that any of the diseases which are being attributed to micor-organisms and palladia and ferments are really due to barometric influences. Why should the suggestion of one source of danger imply the belittlement of another? We have over and over again asserted in these pages the wide range of etiological influences as wide as human associations themselves. But we do assert that here, in the climate, is a very real and well-recognized element of environment, literally pressing upon the very gateways of our bodies, to which every man Jack of the human family is directly subject, which is itself the subject of sudden and villainous changes, and against whose embarrassing influences, at least in some of their aspects, the human body is practically powerless to defend or adjust itselfhere, we repeat, is a powerful, omni-present, everchanging element of environment, whose influence as an etiological agent has never been given the least systematic scientific consideration. Isn't it about time there was a Section on Climatology in the American Medical Association? If organ

ized medicine is so anxious to affiliate itself with governmental departments, here is a really promising field for their joint efforts; and we venture the opinion that more practical benefit to public health will come of an alliance between medicine and the Department of Meteorology than of the questionable alliances that now exist between medicine and some other departments and bureaus we could name.

斑斑斑

TRUST THAT DESERVES ENCOURAGEMENT The Journal of the American Medical Association quotes, with a good deal of smug complacency, the uttearnce of Senator Owen, in his argument in favor of a National Department of Health, in which he refers to the declaration made in certain quarters that the American Medical Association is a medical trust. Said Senator Owen:

"In point of fact, if the American Medical Association forms a trust and if they are concerned in establishing a Department of Health with a view to prevent sickness, which would be the purpose of the Department of Health, they would be engaged in tearing down their own business; they would be engaged in depriving themselves of their patients from whom they make their living. It would be the only trust in existence which is concerned in diminishing its own revenues and destroying its own financial foundation. Such a trust as that is a very noble trust and one that deserves encouragement."

We have more than once paid our respects to this kind of sentimental slush concerning a profession that is in no need of whitewashing. No medical man with any sense is engaged in such quixotic business as "diminishing his own revenues or destroying his own financial foundations," and it is not particularly complimentary to his sanity to suggest that he is. The ordinary medical man is quietly and conesientiously doing his duty, as he sees it, and in so far as it is consistent with his honor, is increasing his revenues and strengthening his financial foundations as much as he can and he would be an impossible fool if he did not 'do so. To be sure, he is continually weakening the hold of disease, and abolishing suffering, and promoting health and sanitation. But so is the lawyer-the good lawyer-constantly lessening litigation and preventing lawsuits, and promoting harmony and law-abiding agreement. And so is every high-grade workman, in every branch of industry, as a matter of fact, and in a general way, working to bring about a state of affairs which would seem to restrict his own scope of profitable employment.

Yet everyone with a grain of sense or an inch of vision beyond his own nose, understands perfectly well that neither are any of these workers