that large families in such cases should be avoided. Furthermore, they should be advised to prevent, as far as possible, the marriage of their children to people suffering from direct hereditary blindness. They should be warned that sisters of men suffering from hereditary optic nerve atrophy, although they may be nor mal themselves, will transmit the disease to between one-half and three-fourths of their children, and should advise their sons to seek wives elsewhere. And finally they should be told that the misfortunes of the fathers are sometimes visited upon the children to the third and fourth generation, and that though the one who desires to marry into their family may have normal eyes, and the parents may have normal eyes, if any ancestor has had an hereditary eye disease, there is a latent taint which may appear at any time. Therefore it is their duty as parents, who desire the welfare of their children, to investigate not only the financial and moral status of the one who. is to enter into their family circle, but the physical status as well, and to refuse consent where hereditary disease exists.

DEVELOPMENT

PHYSICAL, MENTAL, MORAL.

BY H. C. FAIRBROTHER, M. D. Lecturer on Medical Economics, Medical Department, St. Louis University.

1. Physical Development.

To the physician good health is his greatest boon and his best recommendation. The doctor has no right to be sick. In most other vocations men may step aside for a few days' illness, but not so with the doctor. "Physician, heal thyself," is the immediate cry. It is expected of him that he so understand the laws of health and disease that he be able to avoid sickness. But, if he should ever be so unfortunate as to have an ailment, he must not expect sympathy by relating it to his patients, as they have troubles of their own. Also the emer gency character of medical and surgical and obstetric practice is such as to make ill-health practically a barrier to his success. Therefore, a very proper part of the preparation for practice in the medical profession is, like that of the athlete, a preparation of the physical condition. One of the best means to this end is the proper study and practice of physical development.

That a well-developed body is a better home for good health than a poor one there can be no doubt. That the body is susceptible to development is witnessed in the ordinary illustration of the blacksmith's arm. Muscle and tendon and joint and bone and voice may all be developed by exercise. Deep inhalation in

*First Lecture in Course on Medical Economies.

creases chest expansion and lung power. Even the special senses, as sight, hearing, smell and touch are made more acute by training. Fat can be reduced by severe exercise and the reduction of food. No better illustration of the effect of physical culture can be found than in the horse-jockey and the prize-fighter who reduce their weight and increase their muscular strength at will. There is scarcely any limit to physical development under systematic and regular practice. In the classics we read of the man lifting the ox by beginning the lifting of it when a calf. With these facts before us how strange it is that so little attention is paid to physical development. To the great majority of mankind it is an unknown quantity. Very many toil along through a weary life full of deformities and weaknesses and ailments, and never learn their remedy. In Pilgrims Progress, the pilgrim dug continually in the niuck and never looked up to see the crown above his head. By the giving of only a little time systematically every day to physical development, to chest expansion, voice exercise and the usual forms of physical culture, how great could be made the improvement of the human race, and how many ailments could be banished. Hence the approval of athletic sports, such as football and baseball by the higher institutions of learning.

2 Mental Development.

"Sana mens in sano corpore."

How great the desideratum! A sound mind in a sound body. The brain is an organ and thought is its function. A sound mind is nothing more than the normal function of a sound brain. All we know of the mind is that it is thought, and thought is brain action. We cannot conceive of mind as an entity. Therefore when we speak of mental development we mean increased power of action on the part of the brain. All normal brains are capable of improvement by systematic and properly directed exercise, hence we have schools for education. Education consists of two forms, one, the exer cise or gymnastics of the brain, the other, the acquiring of knowledge. The common and academic schools are devoted to the former, medical colleges to the latter. But they are all made up of mental processes, that is, brain action. Brain development is a slower process than muscular development, the one requiring generations, the other only a few years. But even a good hereditary brain, if left uncultured, will remain dormant. On the other hand, many hereditarially weak brains, by systematic train ing, may develop great powers. The size of the brain bears very little relation to its capacity, idiots sometimes having large brains. But, as the biceps muscle in the blacksmith's arm is developed by action, so, certainly, is the brain developed by properly directed exercise. This

is important. We can state, without doubt, that the mind is susceptible to improvement. That by daily exercises along certain lines, it will attain greater power. We may acquire the art of high thinking by practice just as we may acquire the art of football or music, by practice. We may increase our mental capital at will. In increasing our financial wealth we may fail, but in increasing the wealth of the mind there need be no failure. The mind is supreme. Time, and place, and happiness, and misery, and circumstance, and pain and disease, to a certain extent, are all subservient to the mind. When Milton's satan was thrown into the lowest pit, glaring back, he said:

"The mind is its own place, and in itself Can make a heaven of hell, a hell of heaven." But in what vocation or calling is the highclass mind in such demand as in the medical profession? The physician holds in his hands the delicate threads of human life. He decides upon the course of action when death and life are in the balance. Upon his opinion hangs the hopes and fears of the household. His advice is asked not only on the subjects of health and medicine, but upon the various questions that arise in the families of his patients. A well balanced mind in the doctor is of the greatest importance. The weak-minded vascillating, hesitating man should choose some other calling. The doctor must be decided and positive. "He lacks presence of mind," should never be said of the physician. Neither should it be said that he is wanting in tact, discretion or wisdom. These are all faculties of the mind, or the mind acting in different directions, and all capable of development.

3. Moral Development.

In the armementarium of the physician, mor. al character is of the first importance. In the life of the physician and the clergyman, vice should receive equal condemnation. In the economy of the world, there may be vocations where the moral character of the individual plays but a minor part, but it is not so in the medical profession. The physician enters the household, he passes the portals of the sacred chambers, he sits by the bedside of the dying, he presides at the dawning of life, he is entrusted with the secrets of the family; his advice is asked upon a thousand things pertain ing to the health, and happiness, and moral conduct of his patients and their families, and his example is always before them. In view of all this, how important then it is for him to possess a high moral character. There may be differences of opinion, in some particular instance, as to what constitutes moral quality, but on the broad subject of morality there is a pretty general agreement among enlightened people. What is right and what is wrong is pretty well understood. And the life of the physician

is so open to public view that no wrong-doing can long be hidden, nor escape condemnation. On the other hand an honorable character is never overlooked or allowed to go unrewarded. A few years ago in this city there passed from the ranks of the medical profession, a character especially conspicuous for its nobility. At the memorial exercises following his death, there were gathered here professional friends from every part of the city and state. And one thing was especially noted in the remarks of the various speakers upon that occasion: while the deceased received high encomiums for his skill as a surgeon and his faithfulness as a lecturer, the greatest of all praise was accorded to him for his high moral character as a man. Dr. Gregory so lived in a perpetual atmosphere of exalted life that all who met him felt its influence. And at the end of that long and honorable and successful career-after fifty years as a lecturer and sixty years in practice, it was he who said "There is no dark side of life."

Some attain this desirable end through the teachings of religion, others through philosophy or ethical culture, while some are naturally good. The only truly noble character is in

the life where all action is in accordance with the dictates of will and an enlightened conscience and not governed by feeling or desire or passion. Others I have known who were successful in their professions and successful in a business way but whose moral conduct placed a blot upon their careers that could never be effaced. In view of the infinite value of high moral character in the physician may it not be well to ask, What is moral character? Upon what does it depend, and what are its modes of development? Self-control, self-sacrifice, selfabnegation lie at the foundation of all high

moral character.

It is not that men do not know the right that they do not do it. "Video, meliora proboque; Deteriora sequor." (I see and approve of the better, yet follow the worse), is a phrase of the ancients.

When, however, the moral quality of an action is in doubt there are certain rules that are often helpful. The Golden Rule, "Do unto others as you would that others should do unto you," will often relieve the doubt. Another rule, especially applicable to college life and professional conduct: What all may not do, one should not do. If, for example, it would not be well for all to come fifteen minutes late to lecture, then it would not be well for one. If it would not be well for all physicians to advertise in the newspapers, then it would not be right for one to do this. If it would be bad for society for all men to be liars then one should not lie. If it would be wrong for this entire class to go over to the corner and take a

drink, then it is wrong for one to do this. By the application of this rule, many a vexed question as to conduct may be settled. Also the question, Is it right? will decide many a doubtful point. If the conscience decides that it is not right, and still the act is committed there can be no moral development until the will power is improved. All progress in moral education depends upon the cultivation of the conscience. This is the moral sense that determines the moral quality of the action. This sense may be so cultivated as to be a perpetual guard against wrong-doing, or, by refusing to obey its admonitions, it may become so blunted as to offer no further resistance. Good thoughts, good books, high ideals and good associates are the greatest aids in the development of moral character.

The temptations to wrong-doing most open to physicians will be considered under the head of Medical Ethics.

Special Abstracts

Under this heading we present from time to time abstracts of papers that seem especially worthy of note, on account of the intrinsic value of their subject matter, their topical character, or the official or other preeminence of their authors.

BURSITIS SUBACROMIAL, OR PERIARTHRITIS OF THE SHOULDER JOINT.

Dr. Codman in an interesting and instructive article (Boston Medical and Surgical Journal, Vol. CLIX, Nos. 17, 18, 19, 20, 21, 22, 25), has taken up the subject of "sub-deltoid Bursitis” or, as he prefers to call it, "Bursitis Subacromialis, or Periarthritis of the shoulder joint." This condition, which is much more common than was formerly supposed, is treated in an exhaustive manner. Conditons described are by far the most common lesions of the shoulder joint, including tuberculosis and fractures. Where this is not the case the condition has probably not been recognized.

In going into the anatomy of the shoulder Dr. Codman points out that the sub-deltoid and subacromial bursae are the same, and thinks that subacromial is the best name; for in abduction the whole bursa is subacromial. The sub-deltoid is the portion which in abducrion lies beyond the edge of the acromion under the fibres of the deltoid. The relative size of the two varies with the position of the arm, for the tuberosity moves in and out carrying the floor of the bursa with it. The base of the bursa is firmly attached to the top of the tu berosity and the tendinous expansion of the supraspinatus, and the roof is firmly attached to the under side of the acromion ligament. The loose periphery of the bursa is movable and

rolling on itself allows the roof to slide on the base. The bursa is about the size of the palm of the hand.

Dr. Codman explains the motions of the shoulder and points out in adduction of the arm the greater tuberosity actually passes beneath the acromion and coraco-acromial ligament. He also emphasizes the function of the supraspinatus in abduction and elevation of the

arm.

He says that the deltoid, when acting alone, tends to press the head of the humerus up under the acromion process, and only acts as an abductor when accompanied in its action by adductor when accompanied in its action by ultaneously, the power applied by the supraspinatus furnishes a fulcrum for the power of the deltoid. As the lines of force of the two muscles approach one another the deltoid is able to obtain a fulcrum on the glenoid. In normal action the glenoid bears all the weight and the power of the supraspinatus keeps the tuberosity from seeking as a fulcrum on the acromion and coraco-acromial ligament. The function of the bursa is to avoid friction at this point. Soreness in the bursa or of the tendinous insertion of the supraspinatus throws the latter out of action, and the deltoid alone cannot perform adduction. An important anatomical fact is that the ligamentous capsule of the joint is a muscular one.

For the pathology, Dr. Codman refers to an earlier paper and confines himself to pointing out that the spot on the greater tuberosity where the tendon of the supraspinatus is, is usually found damaged in that point which acts as a fulcrum on the acromion when the supraspinatus is not doing its work.

In speaking of the symptoms Dr. Codman treats the condition as a definite lesion, and divides inflamation of the bursa into the following three types: (1) acute or spasmodic type; (2) sub-acute or adherent type; (3) chronic or unadherent type.

In type (1) there is localized tenderness; in those cases where there are no adhesions, the point of tenderness on the base of the bursa disappears under the acromion when the arm is adducted (Dawborn sign). This is almost pathognomonic when adduction and external rotation are attempted, the scaputa, after a certain point, is locked and moves with the humerus. In mild cases, the spasm is momentary. About 10 per cent of motion can always be obtained. In mild cases patient may not be able to raise arm unaided on account of pain in tendon of supraspinatus. Pain may be referred to attachment of deltoid, down outer side of arm even in the hand, and is worse at night. There is occasional effusion into bursa. In type (2) the symptoms are those of adhesions with mechanical limitation of adduc

tion and external rotation. Localized tenderness may or may not be present. The Dawborn sign is absent. Beyond an arc of 10 degrees the scapula accompanies the humerus in all its motions, both active and passive. Pain is the same as in type (1). In some seven cases we find inability to completely extend elbow.

In type (3) the essential characteristic is painful motion, but the full are of motion prevails. Localized tenderness may or may not be present; if present, Dawborn sign is present. Adduction and external rotation are little, if any, limited, but there is acute pain at some point of motion, as tender point passes in and out under acromion. The motions are jerky. There may be considerable pain, especially after sleep.

The differentiation between tuberculosis and sub-acromial bursitis is difficult. The x-ray appearance of tuberculosis is typical in tubercuiosis also the 10 per cent motion which is always free in sub-deltoid bursitis may be lost. The x-ray is a means of positive diagnosis in fractures of tuberosity and of the anatomical and surgical neck. A small deep axillary ab scess has been confused with sub-deltoid bursitis. Chronic rheumatic conditions may effect the bursa and simulate bursitis. Osteophytes may penetrate the bursa. Acromioclavicular arthritis may simulate bursitis, but a careful examination shows a localized tenderness at the acromio-clavicular articulation. Before careful diagnosis was made, cases of subdeltoid bursitis were diagnosed as circumflex paralysis.

Possibly some of the sub-acute cases may be the result of inflamation of the sheath of the biceps tendon. Brachial neuritis is very dif ficult to differentiate and Dr. Codman "is not sure but that the fairest way is to say that sub-deltoid bursitis, is the most common cause of brachial neuritis," but he does not think this neuritis typical. He likens the condition to a cinder in the eye. "An irritation on the surface of the sub-deltoid bursa is similar in its effects to a cinder in the eye, and starts a train of reflexes which fix the joint and cause pain through the whole arm."

The prognosis of all these types is fairly good. Where properly treated, the duration is considerably shortened, but even when untreated the disability rarely lasts more than two years, even in the cases with adhesions.

The second portion of the paper is devoted to treatment and this portion is illustrated by a number of cases. The main indications in the treatment of type (1) are the patient's comfort and the avoidance of adhesions. For comfort, drugs may be used. Rest is obtained by adduetion either in bed, on a splint, or resting arm on a table. This relaxes the muscles and allows the tender point on the base of the bursa to

avoid contact with the tip of the acromion. A sling should be used with caution and the arm removed from it at intervals. A velpeau should never be used for more than a day or two. Counter irritants are of doubtful value. Massage is of value if applied to surrounding tissues but not to the region of the bursa itself. The treatment, then, consists in rest until the soreness has disappeared, then gentle exercise and massage.

In type (2) the same treatment as in type (1) applies when the adhesions are more or less plastic. Later, when these become firm, three. methods may be employed. (A) Gradual stretching, i. e., leaving improvement to natural use. Massage, manipulation without anesthetic; Zander exercises; baking, electric light, baths, etc.

(B) Rupture under an anesthetic; manipulation under anesthetic without incision; manipulation followed by fixation in abduetion. (C) Division. Incision into bursa and direct division of adhesions; excision of subdeltoid portion of bursa.

In Group A, selected cases must be treated, patients who can intelligently carry out the treatment. The exercises should be carefully graded, and not so frequent as to irritate the condition. The results would probably be the same if untreated, except that by treatment a few months could be gained.

Rupture by manipulation under an anesthetic has been advised by many authors as hastening the recovery. Dr. Codman thinks that in some cases the convalescence may be shortened by many months, but he also thinks that there are two main objections to this treatment. It may tear the normal joint structures more easily than the dense adhesions. The other objec tions is that in those cases where the adhesions alone are ruptured, there is a tendency for them to re-form again, since the soreness incident to the operation causes a muscular spasm and leaves the raw surfaces in contact. To obviate this latter a splint was devised holding the arm in adduction. This was unsatisfactory, as it required much care and attention. At present the patient is kept in bed for several days with the arm fastened in a position of adduction. Painter and Baer do not think this is necessary. Codman says "In considering the methods of treatment under Group B., we may say, that as a whole they deminish the period of pain and convalescence, but are far from satisfactory, as being painful to the patient and requiring a disproportionate effort on the part of the surgeon and attendants."

Dr. Codman thinks that in some cases incision into the bursa and division of the adhesions offers a safer method than blind rup ture under an anesthetic. In his cases the patients suffered less and obtained functional use

sooner than in Group B, though complete recov ery took about the same time. Cases reported by Painter and Baer recovered sooner, which was possibly due to the fact that the arm was held in adduction. In summing up the treatment of Type 2, as a whole, Dr. Codman says: "I feel that it is largely a matter for the patient to make a choice between his dread of a comparatively simple and harmless operation and the prospect of pain and incapacity for several nonths. Where the pain is great, operation will be a great relief; but where there is no pain and the disability does not interfere with the patient's occupations the cure may be left to time, and assisted by massage, exercises, and manipulations by the physicians.”

The cases in type (3) are very variable. Many people have marked crepitus in the shoulder, due to chronically thickened folds in the bursa. In some, these give pains; in others there is none. Thickened folds, fringes, small osteophytes, and calcarious deposits may be found in the base of the bursa. If there is severe pain these may be removed by operation. Codman says that in cases of this sort, many do not have an operation even if advised, because he always gives a good prognosis without operation. Much relief is experienced from knowing that the conditon is not serious. Except operation, massage is the most effective treatment.

Dr. Codman thinks that, though it may seem meddlesome to operate in cases in which the prognosis is good without operation, still, the relief obtained justifies it. He thinks that with improved knowledge and technic, the confidence in the efficacy of the operation will become more general, and that surgeons will urge the operation rather than simply consent to it.

In summing up results of his experience he says: "(1) The subacromial bursa and the supraspinatus muscle are of essential value in abduction of the arm. (2) Lesions of the subacrominal bursa and of the tendon of the supraspinatus are the common causes of stiff and painful shoulders. (3) Many cases which pass under the diagnosis of contusion of the shoulder, neuritis, periarthritis, circumflex paraly sis and muscular rheumatism are in reality due to lesions of these structures. (4) The final prognosis of these cases if good, but when pain is severe, or disability is great, relief may be obtained by a simple operation of little danger." ARCHER O'REILLY, M. D.

Letters to the Editors

UNIVERSAL ESPERANTO ASSOCIATION FOR PHYSICIANS.

To the Editors, ST. LOUIS MEDICAL REVIEW. Sirs:-I noted sometime ago a very trenchant letter from Dr. Ivy Kellerman on the value

of Esperanto as an international language. I do not wish to reopen that subject in the abstract, but I do wish to say that at the last Esperanto Congress at Dresden, in August, 1908, an association of physicians interested in Esperanto, whether proficients or not, was formed, with the following officers: President, Prof. Dor, of Lyons, France; Vice-presidents, Drs. Myles, of Altona, and Whitaker, of Liverpool; Secretary, Dr. W. Robin, Warsaw, Russia; Treasurer, Dr. Roblot, of Charenton, Seine, France. Consuls were appointed for France, Russia, Austria, Germany, Poland, England, Sweden, Spain, Canada and the United States. As the Association grows, the number of Consuls will be multiplied according to the requirements of large cities and medical centers in each country. The chief aim of the Association is to bring into relationship physicians of different countries, affording them, in a language that all can understand, an organ for the discussion of matters of professional interest-questions mainly that effect the wellbeing of the profession and its members, though the scientific aspect may receive attention as well. It will also prove in some measure an aid to traveling physicians by enabling them to get into touch as a matter of right with someone in any country in the world, of whom they can seek information on local professional matters. Every member will receive gratis the Vocho de Kuracistoj (Voice of the Physicians"), the monthly organ of the Association, which is now in its second year. and which any physician of moderate training can learn to read with little casual study in the cars, in a few weeks. For myself, I learned the language sufficiently well in three weeks to write an article in it several columns in length. on the "Professional Secret in the United States." It was published in the November issue. I did not take Esperanto up from fanev, for I have always been prejudiced against it. But my experience with it when I was called on to deal with it in the way of duty, has led me to regret that I allowed so long a time to elapse after first hearing it advocated, before I began seriously to study it. It has brought me into personal, friendly relations with many physicians of many lands.

Should this note prompt any physician to take an interest in it, I shall be glad to answer as far as I can any specific questions, and as Consul for U. S. A. I shall be particularly glad to receive and transmit the application for membership of any physician in the Tutmonda Esperanto Kuracista Asocio (T. E. K. A.). The subscription is $1.00 per annum. Checks should add the exchange if any is necessaryabout 15 cents.

KENNETH W. MILLICAN, 103 Dearborn Ave., Chicago.