beyond the reach of the hypochlorite solution; or the germicide may not be applied according to the prescribed technique. Be the reason what it may, the charts constitute unmistakable warnings. Not only that, but each graph is, after a fashion, a check on the other.

Doctor Dehelly, who has now joined the instructional staff of the War Demonstration Hospital, spent some months in Rumania, arriving there just when typhus fever was rampant. Well-nigh all of the patients that came under his observation were sadly debilitated by lack of proper nourishment, and because of their rundown condition most of them developed abscesses, which added just that much more to the acuteness of their suffering and the aggravation of their condition. In treating typhus it is the practice to give hypodermic injections of camphor. Almost invariably the tiny wound of the needle became in a short while an abscess, simply because the prick brought to a focus, by secondary infection, the streptococcus bacteria present. This localized the septic state of the fever-stricken patient. Doctor Dehelly found that these suppurating sores were readily responsive to the Carrel-Dakin treatment; and by this cleansing process convalescence was speeded up.

In cases of mastoiditis, one of the most painful of inflammatory diseases recovery is often retarded by rather prolonged suppuration, and the peril of a serious relapse is thus encouraged. However, it has lately been established that final healing and a return to normal can be greatly hastened by sterilizing the surgical wound with hypochlorite of soda applied agreeably to the Carrel method. Again, there is the malady of empyema, as suppuration of the pleural cavity incasing the lungs is called. The usual treatment consists in providing an artificial drain for the pus, but because of the lingering nature of the infection the relieving wound more often than otherwise becomes a rather persistent fistula. This is very apt to invite serious consequences. The Carrel system of sterilization works wonderfully well in combating empyema. It not only efIt not only effectually sterilizes the infected pleura,

but it makes it possible to close the point of drainage at the desired moment without fear of a distressing aftermath of any sort.

In many instances of appendicitis the problem is complicated by pustulent abscesses which may provoke peritonitis or lead to other septic and inflammatory conditions. These are ordinarily very hard to combat and may enforce long periods of pain, if nothing worse. Adaptations of the Carrel-Dakin method of dealing with infected wounds, in conjunction with surgery, have wrought astonishing cures in cases of this character. The measure of suffering that can thus be prevented is inestimable.

The ever-menacing bacilli streptococci, which add to the gravity of scarlet fever and diphtheria, are certainly contributive to the seriousness of puerperal sepsis, all too common in maternity cases. Infection, once established, is ordinarily an insidious foe which the physician finds difficult to fight successfully. The odds, however, are now in his favor, thanks to the means of attack put in his hands by Carrel and those who have worked valiantly with him. Thus are tempered the hazards of the women that go down into the very Valley of the Shadow of Death that the race may live on. Such is one of the paradoxical reflexes of the battle-fields where millions of men have died.

66

Years ago Pasteur classed microorganisms in two general divisions: those living in the presence of air he called 'aërobic," and those living remote from such contact he named 'anaërobic.' The bacillus of tuberculosis is of the aërobic variety and flourishes best when exposed to an abundant supply of oxygen. What is technically termed surgical tuberculosis is that permitting the curative use of the knife, such, for instance, as of the joints, bones, glands, etc. In surgical tuberculosis the parts of the body affected are generally excluded from the air; oxygen reaches them only through the circulation of the blood. By keeping a tubercular knee, for example, in a plaster cast and quiet for months, a cure may be accomplished without recourse to the scalpel, if the general physical state be improved the while.

But this measure of inaction is not always practicable, and the tubercular affection may work out to the surface and become a suppurating sore. This last stage is commonly complicated by secondary infection-i. e., by the implanting of other septic microbes. In a large majority of tubercular joints, etc., the malady reaches the distressing climax just described, and it is nearly hopeless to deal with the tubercular condition, per se, so long as the open wound is otherwise infected. Doctors who have specialized in this field of surgery have frankly admitted that, no matter how painstaking their efforts, it was only rarely they succeeded in completely closing the wound after treatment. The practice of some of them, in order to prevent reinfection through stitching, has been to use grafts of healthy tissue laid in the excised areas and bound down or held in place by bandages or adhesive plaster until union was effected.

However, while union has been brought about in this way to a degree, nearly perfect in numerous instances, secondary infection has balked ultimate success. Sooner or later abscesses appeared, and all because the surgeon, by his unaided eye, could not make sure that he had removed every trace of the troublesome microbial colony. At the War Demonstration Hospital, cases of tuberculosis of the hip and the knee have responded to the treatment practised there after other efforts to deal with them have failed. The abscesses or sores are opened so that the sterilizing hypochlorite of soda can do its cleansing work and search out the intrenched microbes. In this manner the secondary infection is dealt a death blow and disposed of, and the wound thereafter is reduced to a condition which allows the surgeon to treat unhampered the tubercular area. Again, the microscope and the bacterial smears guide him in determining the sterility of the wound. With this established, it is practicable to proceed to close the opening entirely.

Doctor Dehelly, who has charge of cases of this nature, is very hopeful of the ultimate benefits of this new treatment and its probable widespread application. Just the same, he recognizes

that surgical tuberculosis indicates a general tubercular condition of the patient, and that the affected part is merely a focus of the disease. Accordingly it is not logical to expect systematic relief or cure by the amelioration of a purely local manifestation of the bodily prevalence of the malady. However, this application of Carrel's revival of antisepsis is a long stride forward, because it obviates piecemeal surgery which, sooner or later, involves amputation of the whole or better part of the affected limb. Not only that, but by reducing the septic and debilitating results of suppuration, it makes it possible to bring into play curative agencies which may finally restore the sufferer to health and strength.

These benefits should not appear speculative, because we know now what the Carrel method has achieved in dealing with injuries of extreme gravity among the battle-stricken in Europe. It has made cures possible despite the fact that the virulence of infection during the present conflict has surpassed anything recorded of previous wars. Why, then, should we be skeptical of the results when applied to the problems of the civil and industrial surgeon? It has been reported by Doctor Tuffier, as a result of wide experience with war wounded, that something like 70 per cent. of the operations demanded were required because of the inroads of infection and not because of the anatomical damage done by battle agencies! In the earlier stages of the conflict, when the antiseptic method as devised by Carrel was not employed, fractures of the hip were closed successfully in only 14 per cent. of the cases the other 86 per cent. remained suppurating. To-day, so it seems, thanks to the genius of this man who has contributed in many ways to the wonders of modern surgery, 94 per cent. of the hip fractures heal perfectly, and only a modest 6 per cent. are obstinate and continue open!

The layman is prone to judge by results only, quite forgetting that the circumstances leading up to such a climax are anything but unimportant to the sufferer lying abed. It is said authoritatively that, "There is a profound difference between the facial appearance

of a patient whose wounds are in a fair way for sterilization, even if he still has some fever, and the 'look' of a man whose wounds, treated aseptically, are still suppurating." The latter does not sleep; his appetite is gone; he is apt to be agitated and depressed; and his state is aggravated by pain. Sterilization effects a transformation: pain vanishes; the appetite is lively; and hopefulness is the dominant mood. No wonder, then, that cheerfulness prevails in the wards of the War Demonstration Hospital in New York city. This is a happy augury of what we may find commonly in the future when antiseptic surgery comes into its own.

Knowing, as we do, that micro-organisms multiply rapidly, and after half a day of neglect may seriously infect an injury, the question may be reasonably asked, What can be done to deal with these germs, particularly in wounds of moderate extent, in the absence of an apparatus for the application of hypochlorite of soda? Syringes have been devised to take the place temporarily of the more elaborate equipment already described; and in one of our great industrial plants it is the practice to spray the "walking cases" with Dakin's solution and supplement this by a bottle of the antiseptic which the patient applies himself before returning to the company's physician for the next dressing. As a precautionary measure, all injuries, involving breaking of the skin, are considered infected wounds at the start. By thus anticipating septic developments, a great deal of pain and suffering is prevented; and it seems that new injuries when treated promptly with the solution heal by first intention, while others, manifestly infected at the start, clear up in an astonishing manner under the influence of the germicide. To be more specific, instances are mentioned, at the plant in question, of lacerated fingers and of compound fractures of the bone, in which, by the use of Dakin's solution, the partly severed members, held only by the slightest piece of integument, have been saved!

As an evolution of the hypochlorite of

soda we have another germicidal agent in chloramine paste. For fresh surface wounds this sterilizing medium is admirable, and its bactericidal potency is of a high order. It can be packed in collapsible tubes just like vaseline and other pharmaceutical preparations, and as part of any first-aid kit is far more desirable than caustic iodine which has figured so commonly in the soldier's outfit in the past three years. Chloramine paste is benign in its action upon raw and living tissues, and therefore differs radically from iodine, carbolic acid, and bichloride of mercury. Accordingly, it lends itself to general use and to the services of those not familiar with the limitations and the drawbacks of the other germicides mentioned. Here is another helpful heritage of the present conflict.

He

Doctor Carrel started out to save the lives of stricken soldiers and likewise to preserve, as far as his skill permitted, the bodily integrity of his patients. In other words, his object was twofold— vital and physical conservation. knew how important to France was the maintenance of her man power fit for the battle-lines and, falling short of this standard, to return the wounded back to civil life in a condition that would enable them to be self-supporting in one way or another and not public charges or burdens upon their loved ones.

What he has done in behalf of the fighting forces becomes equally applicable to industrial armies-not to mention the vast civil populace in its multiple walks of life. Infection is not discriminatory; it is not balked by social conditions; and those best qualified to know admit its omnipresence and its ceaseless menace. Doctor Carrel has shown what science, the microscope, and common sense, in collaboration, may bring forth; and of this triad he personally lays a great deal of stress upon the last. By reason of Carrel's amazing successes the pioneer work of Lister shines in a brighter light; and, as the Psalmist of old sang, "The stone which the builders refused is become the head stone of the corner."

"Don't look like much of a carpenter. "Where'd he go?" Guess he'd had sup

"Did he have his tools?" "I dunno."

"Well, he can't be much worse than Louisiana.'

And

The kid felt sick, deathly sick. There were so many things the matter. now he was afraid- afraid of those men. If he could only sleep! Then he'd forget.

In the stable below, the men were passing coarse jokes. And he was a sissy, a contemptible, milk-and-water-sissy! He knew it. He'd fought against it, but it was no use. He couldn't harden to the raillery of such as they, couldn't stomach their dissipations, couldn't brave their horse-play.

He finished spreading his blanket on the bare haymow floor and moved over to the open window. He was here; he must make the best of it. Perhaps, after all-But what hopes were there? His father had said he could come with

him or go to the devil. A sudden fury possessed him. "Damn him!" he whispered, his nails clawing the palms of his hands. "He thought I'd starve. He thought I'd be back begging for mercy. But I won't. I won't. I won't! I'll make a man of myself, or-or

The men were coming up. Most

seemed not to notice the kid. He watched them as intently as the rapidly darkening shadows of the long summer day permitted. At length one addressed as "Dad" turned to the boy.

"Well, kid, where'd yah come from?" "North Dakota."

"North Dakota? Whew! You're a long ways from home." "Yes."

"Come out tah take up land?"
"I may when I'm old enough."
"Well, well; ain't you eighteen?"
"No-not quite."

"Where'd yah put your bed?"
"Over there.'

"Got many blankets?" "One." "Only one? Best come in with me, then. I hain't got but two, and it gets mighty cold 'long toward morning.'

Summer in northern Alberta outdoes herself. Nature seems never to sleep. Almost before the last rays of twilight have disappeared from the west, the brightening east betokens another day. Yet, even so, the same sun awakes a world entirely refreshed, a world surging, teeming, exulting with life. But nature's parasites are a slothful lot. Already the day had lost its freshness, had grown dry and stale, when the hired man sat up with a start, dug under his coat for his "watch," muttered a curse, and reached for his shoes.

The kid, sleeping near, awoke, and for a long time after lay still and stiff, hardly daring to undertake the task of relating himself to his surroundings. Surely, surely it must be a dream. All this last

month was nothing but a dream. He might awake any minute and laugh at the impossible things that now seemed actualities. He just couldn't be here; it was too too unthinkable. But the boy was unused to such early hours; his eyes closed, and he fell back again into his troubled dreams.

In one vivid dream it seemed that the old bearded man was angry; he was telling him to go. It didn't bother him, though; he'd never liked to herd sheep. He'd much rather lie under a tree and watch the squirrels, the birds, the grass, the flowers. But the old man was very angry; he must get away. He grew afraid. He must run, run, run, as fast as he could; so he ran, ran, ran, until he was so tired he'd lost all sense of direction, of distance, of speed-there was such a roaring in his ears and burning under his tongue. Finally he felt himself falling. He resisted it for a long time, still trying to run. At last he had to give in. But-yes-some one had caught him! Some one was holding him! His head was close, close against a warm, pulsing breast. It was she; somehow he recognized her; he knew her. It was all right, then; he could sleep now. He snuggled his head closer and she began to sing. Every weary, tense muscle relaxed to bathe in the lulling flood of that song. It was the song the flowers sang, the grasses breathed, the wind sighed; only until now his mind, not his ears, could appre

ciate it.

"Come on, you North-Dakota-ite! What dah yah think this is? Rest-cure for invalids? Kick him, Ole."

It was a terrible wrench to wake thus. And even then the boy could hardly rouse himself. He saw the men-most of them were waiting turn at the ladder, though a few were still clustered, grinning, around him; but the song that was what confused him-the song still re-echoed in his ears.

"Guess you'll have to hunt your baby his bottle, Dad. He don't seem tah have the strength tah rise, so kinda fagged, don't yah know."

The kid shuddered and rose. "Gee! I guess I—I must have been pretty tired. I- What time is it?"

But no one, now he had awakened, gave him any more attention.

The boy hurried and was able to climb down the ladder just behind Dad. Outside, but one man was left at the pump. "I guess we're kinda late, kid. Better wash after breakfast," Dad advised.

But the kid hastened to the pump. He wanted to plunge his head into the cold water. Perhaps then that song which was still ringing in his ears would stop.

The cold water fully awoke him. He straightened. He was alone now; all the others were inside. But the singing —yes, the singing was real! Some one was actually singing! The realization thrilled him. He felt the uprush of new life. It was morning; it was summer; and he was young—and decidedly hun

gry.

The kid's tools had already given him away. He had got them in Calgary, on lower eight, leaving in return a halfdozen scarf-pins and a cheap watch. The square was rusty and bent. The saw-even Louisiana shivered when he sighted down it. Only the hammer was good-for tacks.

"Hey, kid, we want to top-plate that sill. Start there." The foreman winked to the others.

The kid, his face coloring, walked to the place evidently designated and looked hopelessly around. What-where was the sill? He looked at the other men; they were presumably all busy. The man nearest him was nailing pieces of "two-by-four" to of "two-by-four" to a heavy plank. The kid watched a moment and then tried clumsily to imitate. The men, all the while, seemed to pay him no heed. A number, though, coughed considerably. After he had pounded and banged away for what seemed hours, trying to nail a "two-by-four" to the plank, he was suddenly conscious that the foreman had come up from behind and was watching him. It made him even more nervous. Still, it was some time before the foreman spoke; he must have been enjoying it.

"Say, yah little fool, what yah doin' with that studdin'? Can't yah obey orders?"

"Did-didn't you tell me to do this?"