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they can. sleeps." The average physician is easily led into the prescribing of proprietaries by the arguments of the manufacturer, because he has much of the inherent human trait of believing what he sees in print, and accepting as truth what is told him concerning the proper. ties of medicines. This fundamental weakness of all civilized people-cultivated as well as ignorant-medical men share equally with the lay public.

Literally "they work while he

This innate tendency on the part of physicians could be materially controlled if they had a better knowledge of legitimate materia medica; if they thoroughly understood the physiological action of the important known drugs and chemicals, and if they had a reasonable comprehension of pharmaceutical compatibility and the allied subject prescription writing.

We find that the physician is not trained with the view of being able to withstand a negative pressure from within and the positive force from without; negative within, because of his consciousness of the fact that he is unable to combine prescriptions with therapeutic and pharmaceutic accuracy and positive force without by reason of his inability to resist the arguments of the trained manufacturer when he points out the claimed advantages of his particular nostrum.

Now, we we are getting to the primary source of the difficulty.

The medical college does not give its graduate a sufficient working knowledge of prescription writing. When the young doctor leaves school to enter active practice he is at a loss as how to write, at the spur of the moment, and in the presence of a suspicions patient, an order for the medicines that he may have in mind as meeting the indications. In the hazy whirl of his excited brain there stands out in the midst of a conglomerate of remedies the name of the most recently exploited proprietary, which he remembers the agent assured him was the best thing in the therapeutic universe for just such a case. And down goes the name on the prescription blank with a sigh of relief that will hardly be echoed by the patient.

This experience, repeated daily, leads him into the habit-easily acquired, but difficult to shake off-of writing for ready-made mixtures and newly launched remedies.

In defence of the medical college it may be argued that the demands of modern medical education are so severe that there is not sufficient time to devote to the acquirement of the technique of prescription writing.

And it might be further claimed that this ability must be gained in actual practice

that it is not in the province of a medical school to make its students adepts prior to graduation.

True enough, but the young physician has a right to expect a foundation of instruction in that direction that is a little more practical than is generally the case. And he also ought to be fortified by a consistent example on the part of his teachers-a deficiency that is glaring only too often.

In the last year at school more time ought to be devoted to the teaching of this important practical subject. And the instructors should inform themselves more thoroughly in the matter of prescription writing so that they may be better able to instruct their pupils. Our medical teachers in many instances show an inexcusable ignorance of the United States Pharmacopeia, and as to the National Formulary that work may as well be a volume in Sanskrit so far as their familiarity with its contents is concerned.

What can be expected of a medical graduate whose instructors do not know the difference between the United States Pharmacopeia and the United States Dispensatory, and are unable to comprehend the points of dissimilarity between an authoritative pharmacopeia and commenting dispensatory?

I will venture to say that one-half of the professors and other instructors in the medical colleges of the United States today could not intelligently describe the subject matter of either of the above mentioned works. And it is a self-evident fact that without a clear conception of what these books are and contain, no one can comprehend or teach ethical and legitimate prescription writing.

In view of the known fact that we cannot prevent the commercial instinct of the manufacturing pharmacist from attempting, with all his resources, to accumulate wealth, and to accomplish this purpose in a manner that experience has shown him to be most successful, that is, through the medium of the medical prescriber, what can we do to minimize this admitted evil?

In answer I should say: teach the teachers, that they in turn may train the coming generation of prescribers. The older nostrum prescribers are firmly fixed in their habits and will in most instances have to be allowed to dose their patients with proprietaries to their mutual graves. But with the younger and coming physicians something can be accomplished in the way of guiding their steps in a correct line, and we must plan for them.

At every possible opportunity (for instance occasions like this evening's meeting) let us remind the medical teachers of the duty they owe to their pupils, the profession-and ul

timately to the general public-in that they should so familiarize themselves with the legitimate materials of medicine that they may, by force of example, always lead their followers in the proper direction.

Every lecturer in a medical school should own a copy of the last revision of the United States Pharmacopeia and a copy of the National Formulary, ought to thoroughly acquaint himself with the important features of each of these books, and then frequently refer to them in the course of his lectures. By these oft-repeated reminders the young doctors will be lead into the habit of looking to these two very desirable sources for prescriptions, and this routine practice inculcated early in their professional lives will leave lasting and valuable impressions.

Thus they will be in a position to meet the nostrum vendors' specious arguments with some degree of self-confidence.

We must not let those physicians who having no medical college affiliations think they can hide themselves in their obscurity and go on prescribing in their own reckless way without censure. They also have a duty to perform and owe it to their profession that they do not by word or example render the way of the reform now under progress any more difficult. They should look to themselves carefully, and see if they cannot prescribe rationally, as becomes scientific men, who recognizing a definite pathological lesion, meet the condition with a definite and known therapeutic measure; a remedy whose composition they know.

If then they obtain favorable results they have a scientific basis on which to plan subsequent treatment in similar conditions. The physician who is constantly vacillating from one nostrum to another, knowing nothing of their composition, having no data bearing upon their physiological action, and being in the dark as to their therapeutic value is illy adapted for a pattern for the young practitioner who should have placed before him ideals of a profession whose modern aim and goal is exact scientific methods.

In closing, let me summarize my suggestions: Let all physicians, especially medical teachers, familiarize themselves with the United States Pharmacopeia and the National Formulary, and restrict their prescribing as near as practicable to the preparations embodied in those two books.

2701 Stoddard street.

THE appearance of pus in the breast of a woman who is not, or has not recently been nursing, is suspicious of some unusual form of infection, e. g., tuberculosis.

THE MEDICAL FORTNIGHTLY

Issued Tenth and Twenty-Fifth of Every Month.

THOMAS A. HOPKINS,
Managing Editor.

Editorial Staff:

O. E. LADEMANN, Internal Medicine.
JOHN MCHALE DEAN, Surgery.

F. P. NORBURY, Nervous and Mental Diseases.
R. B. H. GRADWOHL. Pathology and Bacteriology.
W. H. VOGT, Obstetrics and Gynecology.
WALDEMAR FISCHER, Ophthalmology.

A. LEVY, Pediatrics.

W. T. HIRSCHI, Therapeutics.

A. F. KOETTER, Otology.

HERMAN STOLTE, Laryngology and Rhinology.
T. A. HOPKINS, Genito-Urinary Diseases.
ROBERT H. DAVIS, Dermatology.

Editorial Rooms, Suite 319-321 Century Building, St. Louis.

EDITORIAL

The Season's

Greetings.

be

If you

IT is a happy custom that makes the year's end and beginning a season of greetings and expressions of good wishes; in the intimacy of the family, between friends, and even tween strangers, the exchange of felicitations result in a comfortable uplift. It is a form of giving which surely blesses both him that gives and him that receives. As has been our custom for years past we most heartily wish our readers each and all a Merry Christmas and a Happy New Year. May your new year be the best year, just as every year should be. will look for it with a sufficient degree of earnestness, happiness and prosperity in all your goings to and fro will be a matter of daily experience. You may not have noticed it but people find pretty much what they are bent on finding in this world, and he who enters 1907 with "a chip on his shoulder," and bitterness in his heart, will surely find a lot of unpleasant people and many unhappy The real experiences before the year ends. lesson of the life of Christ, whose birthday the world celebrates at this time, has inseparably woven into it a deal of cheerfulness, helpfulness and good will; these are features of the real Christian life; we have no purpose to deliver a sermon, but we can wish for the readers of our journal no better things for 1907 than a full realization of the spifit of Christmas throughout the year.

THE FORTNIGHTLY INDEX.-A glance at the annual index inclosed with this issue will give our readers a fair conception of our work during the past twelve months.

Retrospect and Prospect.

THE time for stock-taking has come again and a careful inventory may quite as advantageously be taken by the man of medicine as by the man who follows a mercantile calling; even a medical journal may find future advantage in checking up and coming to a realization of how fully it is fulfilling its mission. The year has been one remarkable for general prosperity throughout the country, as is shown in all lines of commercial activity, and there are few of us who have no reason to appreciate it from its effect on some one or another phase of our lives. THE MEDICAL FORTNIGHTLY has experienced its share of good things of the good times, and has enjoyed a satisfied sense of a very considerable degree of usefulness. At the same time we must confess to some disappointment that we have not achieved a considerably greater degree of use. fulness, having that healthy lack of complete satisfaction which leads to continued effort toward better things.

Our readers will have noticed some change in the editorial management recently made, Dr. Norbury remaining with us only as editor of his department, Neurology, and in an advisory way. While we have deeply regretted his being compelled, on account of increasing professional duties, to withdraw from the active editorial management, we believe that the change has been effected without loss to our readers. Some further changes and additions to our editorial staff will be made early in the future, it being our definite purpose to give a considerable increase in the amount of translations and department work during 1907. THE MEDICAL FORTNIGHTLY Continues the official journal of the Medical Society of City Hospital Alumni, and we hope to present considerably more original matter from this source than during 1906. The society is one of the strongest in the city, it is doing splendid work, has a most pleasing outlook, and our readers, other than members of the society, will have the benefit of this through the FORTNIGHTLY.

It is our purpose to resume our course of Post-Graduate lectures in an early issue. Among our readers we are so fortunate as to include a large number of physicians who are residents of smaller towns and of the country tributary to St. Louis who are compelled by the circumstance of their location to do some little of the lesser work of each and all of the specialties; for this class of readers. and as a matter of general interest, it has been our custom to conduct what we have called our post-graduate course, and which has been

made up of concise, practical papers, from men of eminence, dealing with such points as their experience has shown them are liable to be overlooked or misapplied by the general practitioner. It is our purpose that the course for 1907 shall be, above all, practical, the papers already promised indicate that we will have those to address us who can command an audience anywhere.

The managing editor feels his indebtedness to all those who have by their contributions and otherwise, assisted him in making 1906 one of the better years of the FORTNIGHTLy's existence, at the same time we would thank our readers for the encouragement we have found in their appreciation of what we have had to offer; such an audience is indeed an incentive to enthusiasm. It is also meet that we acknowledge our obligations to the advertising patrons; without their hearty co-operation in this work, our plans for enlarging and improving could scarcely be consummated.

THE development of the Sunday paper is one of the marvels of recent days; the influ

The "Funny", Paper.

ence of the Sunday paper is still an undetermined factor in the weal of the community. We have expressed ourselves freely in the matter of certain advertisements which appear in these papers, and we had purposed giving some attention to the so-called "Funny Side," it appearing that the fun is largely so frightfully overdrawn as to be no longer humorous, making the sheet as a whole pernicious in its effects. The editor of the Alienist and Neurologist may well be quoted on the subject. He says that the morbid imagination of the "Sunday newspaper illustrators suggest the lunatic asylums. The antics of Maud, Little Nemo, Panhandle Pete, Foxy Grandpa and the Kids, Jimmy, Buster Brown and others of that ilk can be duplicated in any well supplied asylum for the insane and indicate a ready vocation for lunatics. The fun of Buster Brown appears the most rational and is indicative of a higher grade of reasoning insanity than the others. It is a sort of humorous paranoia that ought to soon end in silent terminal dementia. The antics of a few lunatics at large, if faithfully delineated would duplicate the entire performances of the entire funny picture progeny of our public press. The psychic influ ence of Foxy Grandpa series is especially bad on children, who are disposed to take many of the pictured portrayals too seriously, gen erating in their minds irreverence and disre spect of age."

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MEDICINE AND PHARMACY.

An analysis of the New Pharmacopeia, Mr. J. M. Good. Discussion by Dr. J. L. Boehm.

The Mission of the National Formulary with Exhibit of Selected Preparations, Prof. Francis Hemm. Discussion by Dr. Justin Steer.

The Ethics of Prescription Writing, Dr. A. E. Taussig. Discussion by Mr. A. A. Kleinschmidt.

The Ethics of Prescription Compounding, Mr. Emil A. Sennawald. Discussion by Dr. O. A. Wall.

This meeting is gotten up by the St. Louis Medical Society, which has invited the Alumni Association of the City Hospital, the Cinchona Club, the St. Louis Retail Drug

gists Association, the St. Louis Drug Clerk Association and the Alumni Association of the St. Louis College of Pharmacy to participate. This joint consideration of a live topic follows up an excellent program recently carried out by the Society of City Hospital Alumui, a report of which will be found in this issue.

HOSPITAL SATURDAY AND SUNDAY COLLECTIONS. The annual collection for charitable work in the various city hospitals took place the first Saturday and Sunday of December, the amount collected has not yet been announced definitely, but returns have come in sufficient to indicate that the figure will be about $40,000.

A RARE FORM OF INTESTINAL STENOSIS.— Gayanes (Rev. de Med. y Cir. Pract., July,) publishes a remarkable and hitherto unrecorded case of ileus. The obstruction resulted from two constricting circular bands of proliferated mesenterial fat about the small intestines (ileus lipomatosa anularis). Death followed a perforation of the rectum as the result of a careless inflation with a carbon dioxide enema a day preceding the contemplated operation.

A PLAN FOR SAVING INFANT LIFE.-When Alderman Broadbent, a brother of Sir Wm. Broadbent, the King's physician, took office as mayor of Huddersfield, on November 9, 1904, he devised a novel scheme to reduce infant mortality. He offered to give parents living in a specified district of the city a guinea for every child born during his twelve months in office and living at the end of twelve months. The result of the experiment was announced recently, on the second anniversary of its inauguration. The rate of infant mortality in the Longwood district of Huddersfield, which is the experimental area, had averaged 122 per thousand for the preceding ten years. The period of the tests proved somewhat unfortunate. There were sericus epidemics of whooping cough and measles, while the summer of 1906 was one of the deadliest recorded. The first baby to earn the gift was born on November 10, 1904, and the last on November 8, 1905. The mothers notified the managing committee of the births of these babies. No fewer than 107 received the gift. Four died and one did not claim the gift and its fate cannot be learned. If, however, it is reckoned as dead the average mortality works out 44 per thousand as compared with the previous 122 per thousand, certainly an astounding reduction. Med. Record.

REPORTS ON PROGRESS

Comprising the Regular Contributions of the Fortnightly Department Staff.

SURGERY.

JOHN MCHALE DEAN, M. D.

Excision of Neck Cancer.-Crile (Jour. A. M. A., Vol.. XLVII, No. 22) in a well illustrated article treats the subject of cancer of the neck from an operative standpoint. The author maintains that all cancers naturally have an operative stage, and that when taken in time the results as far as cure are concerned, are better than in other not superficially located areas. Cancer at this site seldom shows metastasis or are the deep tissues often involved. The chance of prema nent cure is accordingly greater. He advocates the block dissection of the neck, removing all glands, and if necessary, the internal and external jugular veins can be removed. Temporary closure of the carotids make clean dissection more easily accomplished. This is done by a pneumatic rubber tube. Infection of the wound and lungs is guarded against by previously packing the fauces with gauze after passing a rubber tube through each nares in such a way that the external ends can be adjusted to the anesthetic inhaler the internal ends passing well into the laryngeal space. In this way the anesthetic can be administered conveniently, at the same time lessening the danger of infection, and absorbing the mucus and blood that may be present. The author reports 132 cases operated on, and in the above number the lips, lymph glands and face were the most frequent sites. Of twelve cases operated on according to the block dissection, nine are living three years after without a recurrence is a strong argument in favor of this method of treating these cases. The author makes no mention of deformity following these dissection neck operations. In some extensive operations of this type the deformity is appalling.

Surgical Treatment of Goiter, Based upon Three Hundred Observations.-(Abstract of a paper read before the Southern Surgical Association, Dec. 11, 1906, by C. H. Mayo, Rochester, Minn).-The medical profession of America is taking a progressive position in recommending operation as the cure for goiter, including, also, that serious affection, exophthalmic goiter. The simple goiters in girls at puberty are not included in this rule. Excepting operation for malignancy and Grave's disease, the great majority of operations are those of expediency and not of necessity. Therefore, a low operative risk

is imperative. In uncomplicated cases, the mortality following operation is almost an accidental one. There were 110 cases of Grave's disease with nine deaths, and but two of these were in the last 64 operations. In two sarcomas and six carcinomas there was one operative death, which occurred on the third day. Aside from these recorded there was one death from pneumonia on the eighth day. Pathologically, there is a change in the gland which is essential to Grave's disease or hyperthyroidism. This is in the greater number, size and shape of the cells and in the lack of normal colloid.

Preparation.-Patients are prepared as to lung complications, and the rhythm and tension of the pulse, which should be carefully investigated, as they are the danger signals. Anesthetic. Very rarely is local anesthesia employed, the preference being for the open drop method of giving ether. The patients receive from 1-120 to 1-150 grs. of atropine and 1-6 gr. of morphine 20 to 30 minutes before the giving of the anesthetic.

Operation. The position of the patient is head up (reverse Trendelenberg with a roll of gauze under the neck to elevate small tumors.) A transverse collar incision is made through the skin and platysma muscle, the sternohyoid muscles separated at the mid-lines. In exophthalmic goitre and complicated cases, the anterior muscles on one side at least are severed as high as possible over the thryoid to preserve the nerve supply and break the scar effect. Cysts and encapsulated growths are enucleated; other goiters are extirpated, care being exercised in preserving the parathyroids to prevent tetany and in protecting the recurrent laryngeal nerves. In this we are aided by leaving the posterior capsule of the gland in the extirpation. Sufficient gland substance should be preserved to prevent myxedema, and, as it depends upon the character of the gland, no definite rule can be given as to what constitutes the proper amount.

GENITO-URINARY.

T. A. HOPKINS, M. D.

Syphilis of the Testicle.-In a consideration of syphilitic testicle (Am. Jour. of Surg., Dec., 1906) Muren discusses the two forms: 1st. An epididymitis usually occurring during the second period, sometimes of sufficient extent to attract the patient's attention, but frequently existing as a small nodule not noticed, and in either case responding readily to anti-syphilitic treatment. 2d. An orchitis, or epididymo-orchitis, appearing as

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