First: The parts should be heated thoroly before any manipulation or electrical

treatment.

Second: In flexing movements there must also be traction. This is especially true when attempts are made to stretch the shortened capsule..

Third: Massage and passive, assistive, and resistive exercises are used in every

case.

Fourth: The vibrator should be used

for two reasons: (1) It enables a greater amount of flexion without pain; (2) it gives an active massage to the joint capsule when the capsule is under tension. It is in this class of cases that we would consider the chemical effect of the electric current. Salicylic or chlorine ionization with a current of 40 to 90 maximum for 30 to 45 minimum may be of value, especially where there is marked tenderness, or for its effect in softening tissues. A lesser amount of current strength or a shorter time would probably prove useless. To use such a current for so long a time requires a very perfect technic and apparatus in perfect condition.

The benefit from such a treatment would be derived in two ways:

First: From the salicylate or chlorine driven into the tissues.

Second: From the marked active hyperemia that is produced by such a current acting for such a length of time.

Treatment of the muscles above the injury by heat, massage and exercises and by faradism as advised by Bristow or by slow sinusoidal, do much to prevent atrophy and restore the muscle tone when it is lost. With normal muscles and a normal blood supply above the injury it is reasonable to suppose that metabolism and nutrition will be better in the affected part of the limb than in those cases where the muscles are allowed to atrophy and the blood supply to be reduced to a minimum.

A final point is in regard to early splinting of median and ulna cases. This perhaps more directly concerns the orthopedist than those of us interested in physiotherapy or nerve surgery. Certain ulna and median cases that recover have hyperextension at the metacarpophalangeal joints when at rest. It would seem that early splinting might shorten the after-treatment and make the final result better.

SUMMARY.

1. In treating fibrosis by physiotherapy we use three classes of electrical applications: (1) heat, (2) mechanical, (3) chemical.

2. The first aim is to improve the general condition of the part treated.

3. This is accomplished by means that promote circulation and nutrition.

4. The treatment of the local patho

logic conditions caused by fibrous infiltration and degeneration depends on the anatomy, physiology and pathology of the part affected.

5. In many cases both physiotherapeutic and orthopedic treatment are necessary for the best results.

Treatment of Tuberculous Abscess By Aspiration.-Given early diagnosis, treatment by aspiration will frequently arrest the course of a tuberculous abscess and effects a complete cure, so states Fernandez in the Lancet (Dec. 27, 1919). Delay in diagnosis and treatment by incision not infrequently ends in disaster. French authorities quoted by Gauvain maintain that 50 per cent. of patients with spinal abscesses treated by incision end in sinus formation, and that 70 per cent. of cases of sinus formation in spinal disease die. In cases treated by aspiration the result has been more satisfactory in a shorter period.

A

In all cases the general treatment has been carried under sanatorium conditions on conservative lines. In aspiration a stout needle with a good bore is essential; one also avoids inflamed area and prefers an oblique puncture. An attempt should be made to arrest an abscess without modifying fluid. In some of the cases simple aspiration has been found effective. great many diluents have been advocatedtrypsin, lactic acid, bipp, cinnamic acid, essential oils like garlic, cajuput. Personal experience of the nature of the abscess will be an asset in the choice. Saline, iodine, colloidal solutions have also been used. In certain types solution of ether, camphor, and thymol, first advocated by Menard, Koch and Risacher, and followed by Gauvain, has been found effective.

The conclusion reached from the consecutive cases was that sinus formation fre

quently follows incision, while it is an exception in the aspiration method. The mortality and the time factor in the former also do not compare favorably. In pulmonary cases avoiding anesthesia is an additional advantage. With early diagnosis and efficient continued aspiration tuberculous abscess is arrested sooner than by incision, and complication prevented. In the Lancet of December. 21, 1912, Openshaw and Roth in treatment of Pott's disease by conservative method preferred aspiration to incision. In certain cases they found arrest was secured by non-interference.

By-ways and High-ways

The Evolution of the Undertaker. There are few callings that have undergone such a radical and dramatic change as that of the undertaker in recent years. It must have impressed many observers that the old, conventional, sombre, almost lugubrious figure, garbed in unrelieved black, has given place to one that is gay, blithe, sociable, humorous, well-dressed, almost debonair. The undertaker of today is a man of the world, a dinner-guest, a companion, a hailfellow-well-met. He is given to postprandial speeches, to swapping a Roland for an Oliver, to taking tea (until recently he did not pause at stronger stuff) and to wearing his evening clothes with a style that would do justice to an advertising illustration. He has become prosperous, he has syndicated himself, he has even attained a considerable degree of popularity and he has succeeded in doing so because he has made his business more popular. He has taken the sting out of death, he has made it a gay, almost trivial thing. He has made jokes about it, smiled at it, and has taught people to make jokes and smile. He has become a social figure. Recently a Jersey undertaker, in a newspaper advertisement, invited the public to make more frequent use of his superb establishment. upon a time this would have been regarded as grim humor. Now it is taken in good part and it is more than likely that the pub

Once

lic will avail itself of the generous invitation. Another undertaker, finding himself overwhelmed with business, has seen fit to add a publicity manager to his staff. This publicity manager's duty is to make death more popular, and many regard him as a success. Certainly his employer does, for he is under contract at a generous salary. This man is a humorist, a writer of quality, a student of human nature, a scholar and a wit. At a recent dinner, his speech was considered the most humorous and successful of the evening. He spoke of his calling with the pride of an artist and he told of an incident in the pursuit of his trade which brought the house down. One day he received a call from a hotel and he immediately dispatched two men to attend to it. They found the man with a gas tube in his mouth. They opened the windows and applied a pulmotor, miraculously saving the man's life. Soon after they came back and reported. They were fired at once. "Thereafter," concluded the speaker, "I made it a point to send my men half an hour late · to every call." The mortals who heard the story applauded vigorously and enthusiastically. It is no mean achievement to make death such a light and humorous incident. The modern undertaker is a genius. Some day his genius will win the recognition it so amply merits.

Insanity and the War.-Dr. Britton D. Evans, medical director of the Morris. Plains State Hospital, in a report made public recently, gives an interesting explanation for the reduction in the number of patients admitted to the hospital in 1917 and 1918. At the same time he issues a warning regarding an imminent increase in the number of psychopathic cases that appear in the near future. Accounting for the reduction in cases in the last two years, Dr. Britton explains that many persons of constitutional psychopathic make-up, more sensitive than the average to the lure and excitement of war, were the first to volunteer under the stress of the emotional days of April, 1917, when war was declared. Others deliberately entered the service, aware of their defects and feeling that the discipline and rugged life of the army would help them. Among these Dr. Britton in

of

cludes the inebriates and drug addicts, who had long lost control of themselves and sought relief in this way. Further, many hysterical and neuresthenic types find an excellent outlet for their various neuroses in the intense emotions that the war aroused as well as the numerous activities, such as social service and community activities, which were made accessible. Now that the war is over, in the view of Dr. Britton, there will be an increase in the insanity figures thruout the country. The emotions The emotions of war having disappeared, and the other activities with them, these types will no longer have a legitimate outlet and will succumb once more to old practices. The strain of readjustment to normal conditions will prove trying to many. "Under this stress," concludes Dr. Britton, "and removed from the stimulus of war, a great many of the psychopathic individuals will probably again become morbid in their line thought. There is accordingly every reason to believe that the next twelve months will see a marked increase in mental diseases and in commitments to institutions, and some provisions should be made immediately for this extra burden of our already overcrowded state hospitals." Dr. Britton's warning is a timely one and his logic is convincing, but it is hardly likely that it will move those in authority to take measures to meet the situation. It is a tradition among the powers to act after the fact and not before, and it is only when they find themselves overwhelmed by a situation about which they have been properly warned that they will begin, and then only reluctantly, to adopt measures to combat them. This has always been the rule and it will be the rule in this instance, without doubt. The pity of it is that such neglect, culpable as it is and often disastrous in its consequences, is not regarded as a criminal of fense. Dr. Britton has fulfilled his duty in calling attention to the situation. It is now the duty of the various communities to see that their representatives take steps to meet it adequately.

Music and Insanity.-A conference of physicians, nurses and laymen was held recently in New York to promote and encourage the employment of music in the

treatment of nervous and "other bodily ailments." What the "other bodily ailments" are which can be helped by music were not specifically mentioned and it is rather difficult to imagine what they might be. But that music is a great help in nervous cases has long been a commonplace among the profession. In other respects, chiefly in convalescence, music has proved valuable chiefly as a diversion rather than a cure. Most insane asylums under the direction of the state have their orchestras, which give regular concerts for the inmates and these concerts are regarded as valuable aids in the treatment of cases. Musical entertainment has also proved of great value to sick and wounded soldiers at base hospitals. Dr. Siegfried Block, neurologic expert at Bellevue Hospital, told of instances within his own experience where music had been of inestimable value in allaying nervous disorders and "other diseases." That music has been useful in the treatment of "other diseases" there is as yet little evidence. The purpose of the conference was to encourage a study of the problem, collect data and arouse a keener interest in the medical profession. The subject is hardly a new one, but if data can be collected to prove that music is helpful in the treatment of the "other diseases" so vaguely referred to, no one would be more pleased to hear of it than the medical profession. Contrary to the belief expressed at the conference that doctors are slow to adopt innovations, it is safe to predict that, if the case for music is clearly established, every physician will add a victrola to his office equipment without hesitation.

Awakening of the Public to the Real Problem of Drug Addiction.-One of the gratifying signs of the times is the gradual but none the less certain awakening of intelligent and humane people to the fact that drug addiction is not merely a voluntary surrender to morbid desires or vicious tendencies, nor yet an evidence of mental degeneration, but that it is indeed a true physical disease with as definite a pathology as any other condition of disordered or perverted physiology. A good many crude and mistaken views still exist in respect to narcotic drug addiction, but every now and then some article will appear in a lay publica

tion which will show the extent to which the true situation is being recognized and its needs appreciated. A particularly noteworthy article of this character appeared in the November, 1919, issue of the Delineator. While written in more or less sensational language, as lay articles so often. are, the author, Miss Carolyn Van Blarcom, deserves great credit for her grasp of the problem and keen realization of its humanitarian phases. Some of Miss Van Blarcom's references to the medical profession are not pretty, and while unquestionably deserved in some instances, we strenuously protest at the stigmatization of the whole profession. Doctors are human and subject to the same influences that other people are. If medical men have been loath to give drug addiction the attention it should have had, this can be largely attributed to the attitude of the public-faddists, erstwhile reformers and propagandists in particular to the problem. People have refused to patronize a doctor who paid any attention to drug addicts. As a matter of self-preservation, in order to make a living, and to support their families, many medical men have had to avoid a class of patients that the people have declared taboo. Enlightened as Miss Van Blarcom has become, and as fine work as she is doing, we warrant she entertained entirely different views concerning drug addiction until some good, intelligent and humane doctor enabled her to see narcotic drug addiction in its proper light.

In all sincerity, therefore, we say that the great duty rests on the people. Let them learn the truth and realize that drug addiction is a true disease, a sad and serious affliction that calls for as sympathetic and kindly consideration as any other human ill, and there will be no reason to complain at the lack of professional interest.

In spite of her criticisms of the medical profession, Miss Van Blarcom's article is excellent and one that cannot help but do a world of good. It is to be hoped that with her comprehension of the fundamental details of the problem she will not stop here, but will continue to spread the truth not only in regard to the real nature of drug addiction, but also the urgent need for seeking its solution in a broad and sympathetic spirit, never forgetting that the drug addict is a victim of circumstances, a sufferer from a real bodily affliction, and not a panderer

to morbid desires or a vicious sensualism. We wish we could print Miss Van Blarcom's article in its entirety, but lack of space prevents us from doing so. The concluding portion is such a splendid exposition of the situation and sums up the need of the hour so sententiously that we feel it a duty to reproduce it. Miss Van Blarcom depicts the suffering drug addicts undergo, recites special instances of the innocent acquirement of the disease and shows how far afield most people are in their understanding of what narcotic drug addiction really is. In referring to the development of the disease in the individual she says:

"The existence of addiction in childhood may not be suspected, even by the individual himself, until an operation or painful illness later in life makes the use of an opiate necessary. This is the match that lights up the whole trouble. When its effect wears off the victim finds himself suffering the usual withdrawal symptoms.

Cases of this kind are frequently baffling to physicians who are unfamiliar with the withdrawal symptoms of addiction disease.

A distressing case of addiction begun in infancy is that of one of the most brilliantly successful surgeons in this country; in fact, an operator of international fame. He has been a secret addict thruout a long, useful life.

He says that he was made an addict by the paregoric his mother gave him when he was a baby. As a little boy at school he remembers that he was excessively nervous and that his mother quieted and steadied him by giving more paregoric.

She was like the doctor who did not know what else to do but keep on. And so it went. He could work only when he had his drug. He is not an isolated experience. There are many like him in all walks of life.

Another case is that of a nineteen-year-old boy who is the sole support of his widowed mother and her three grandchildren.

Made an addict in infancy, he is now so dependant upon heroin that he could not work without it. His weekly allotment of heroin costs him about seven dollars.

In order to make enough money to make both ends meet, he is compelled to work overtime steadily. By lengthening his working day to sixteen hours he is able to earn twenty-one dollars per week. And so he struggles, whipped on by his need of the drug and his dependents' need of food. He is on the verge of a nervous collapse but dares not stop.

There is no place open to him for treatment, such as he would have for any other disease.

Lack of medical help and the difficulty of getting opiate drugs thru legitimate channels is driving many decent addicts into the underworld for their supply, where they are charged exorbitant prices.

'What is to be done?' do you ask as you mentally hold your hands over your eyes.

The remedy is summed up in one master word: 'Education'.

Education of the entire public concerning the causes and results of drug addiction; and the danger of taking any sedatives frequently or over a prolonged period.

Education that will show young girls the peril of associating with those who use drugs, particularly heroin and cocain.

Education of the medical profession. This profession as a body has so far showed itself incapable of coping with the misery which has largely grown out of its own inefficiency.

Most of the special institutions for so-called 'drug cures' are utterly ineffective, for cures are rarely effected within them. Far too many of the 'cured' patients leave the institution with but one possession-drug addiction. Money and hope of relief are gone.

More scientific knowledge is needed; more human understanding and with these will come compassion.

Education then let us have, so widespread and far reaching, that there will be no longer an uninformed public to stigmatize innocent sufferers of drug addiction.

A complete rending of the black curtain of ignorance and misunderstanding! 'More Light! More Light!'"

AMONG THE BOOKS

Mental Hygiene. The growing interest in mental hygiene carries with it the necessity for a wider understanding of mental processes. This involves an appreciation of the psychologic processes involved in existence. Too frequently emphasis is laid upon intellectual developments with great consideration of the conditions constituting feeble mindedness.

The understanding of human conduct with an appreciation of motives and actions demands a practical viewpoint free from much of the worrisome symbolism that pervades recent texts. For this reason Psychology of the Normal and Subnormal, by Henry H. Goddard, (Dodd, Mead & Co.), is a book of unusual value that commends itself because of its recognition of the unity of the human mind. The discussions of the development of the nervous system and the beginnings of mind lead to a discussion of the higher mental processes. The affective phases of experience extend into a consideration of the primary and complex emotions as a preliminary to the consideration of the numerous elements entering into thought, involving perception, judgment and reasoning. Action, habits and temperament are discussed with reference to volition and social adaptation. The second part of the book is devoted to a

consideration of the application of the theories and the determination of levels of intelligence as well as the inter-relation between intelligence and emotion.

Thruout the volume there is evidenced a clear and single viewpoint which enables Dr. Goddard to present his subject matter with a most valuable degree of definiteness and conciseness. The merit of his book lies in its all pervading rational and non-fanatical psychologic unity.

Methods of Mental Examination. In the consideration of methods of testing mentality, it is necessary to possess a definite working plan. S. I. Franz in his Hand Book of Mental Examination Methods, (The Macmillan Company), offers a practical, systematic and scientific exposition of the methods of mental examinations which have proven of value in connection with service at the Government Hospital for the Insane. A large degree of the value of this book lies in its selective character, in that many methods have been omitted because of difficulties and complexities involving time and special apparatus. The gamut of methods is sufficiently large to permit of the study of sensation, movement, attention, perception, memory and association with a determination of general intelligence and a broad understanding of the complex physical, neurologic, mental and social characteristics of patients.

These two volumes referred to constitute a valuable contribution to a type of literature for which there is an increasing need and which should commend itself to physicians who desire to keep abreast of the developments in modern psychiatry, and of the fundamentals of the movement for improved mental hygiene.

Social Work. The tendencies of medicine to take on a larger measure of sociologic importance require a closer relation between the general practitioner and social workers. The frequency with which medico-social diagnoses are demanded indicates the growing importance of this phase of modern medicine. Cabot in Social Work, Essays on the Meeting-Ground and Social Worker, (Houghton Mifflin Company, Price $3.00), presents the substance of some lectures given by him at the Sorbonne during 1918, that serve as an excellent outline of the field of work, and the part it plays in the every-day investigation and treatment of the frailties and ailments of suffering humanity. The point of view which he has presented is what might be termed the human element in medicine. He deals with the physical status of individuals; but he looks beyond their individual existence to their conditions that have arisen as the result of interacting social and economic forces. He views the individual as a unit and as part of the family and community capable of having the current of his life deflected by forces not of his own selection, because of which, he cannot be held wholly responsible for them.