be given opportunity without being given opportunity to help or to injure the patient. We ought to teach each interne everything that can be taught without injury to the patient. I call an appendectomy a simple thing, which the interne can be taught to do without injury to the patient. Even more difficult operations can be safely done by the interne. Every interne can be taught to make the incision into a joint or the abdomen and can be given opportunity to sew up such wounds. He has the opportunity to learn these without jeopardizing the patient and not to allow him to do these things does jeopardize future patients when he is in practice. In the hospital, the interne learns many things besides technique. He will copy our example, even if it is bad.

A couple of generations ago there were practically no hospitals; a generation ago, patients were sent to the hospital to die, because there was no other place for them. We now keep the patients who are going to die at their own homes, rather the reverse of the custom of previous generations. Now patients are sent to hospitals as an efficiency procedure, to get them well. We look upon the hospital as the place where the interne is taught to do what is necessary to cure the patient, and not to attempt to until he has learned the proper method.

I feel that every interne, medical or surgical, should learn to do many simple things necessary in modern practice, such as to take the blood for the Wassermann test, how to set a Colles' fracture, how to draw the spinal fluid, etc., but he should not be given the opportunity to set the Colles' fracture, tap the vein or put a needle in the spinal canal, until he has learned how, with some one standing over him to see that it is done rightly. We must teach him to take responsibility, but not unwarranted responsibility.

I would suggest a sort of card for the interne, on which various similar procedures are listed and which he should know, and which we should know that he knows, before we let him graduate from our hospital.

DR. E. A. WELLS: Dr. Patterson's subject interests me much. It is very aptly chosen. Our responsibility in this matter has not been felt by some as much as it should be. My sense of responsibility to the interne has been growing on me in the last few years. I have frequently had occasion to say that the first duty of the hospital is to its patients, and its second is to its internes. The interne comes second in our organization; I put myself third and my assistants last. (Many of them do not like that.)

The hospital is not only a place for the sick, it is also a teaching institution, and the interne should have that teaching. We do not want so much to teach them technique as habits of thought, and of these the first is proper records. No hospital can be said to do good work that does not keep good records. The habit of putting things down in black and white makes

a man's thinking concrete. Encourage them to keep a personal record for themselves of the cases of unusual interest, just as they would in private practice. I did that during my interneship in the New York Hospital and started a card record system that become the nucleus of my present clinical records. They go back for twenty years, and I can to-day turn back to my old hospital cases, for they are filed and indexed with my other records. I tell my internes that they will never regret it if they begin to keep records right away of the cases that interest them. Later on they can file them with their other records and they will be very glad to have them.

One practice common in hospital work I believe to be vicious. That is the excessive tendency to the establishment of routine treatment. This is the root of a great deal of evil. As a general rule the more routine the less brains, and the less routine the more brains will be used. Of course, certain things have to be done according to a routine, but when it comes to a cathartic for every patient on the third post operative day, say, or the same routine method of preparing the abdomen and the face, these are bad. I tell my internes that I have no routines except such as are understood between them and me. Orders to nurses should be specific for the specific case, and for a specific reason. These are some of the things that I would suggest.

Some internes are pig-headed and you cannot tell them anything; they are born that way, but others are susceptible to suggestion and I tell them one of the important things to learn in a hospital is a proper attitude towards the friends of the patients. When everything is serene and smooth it is easy. Anyone can talk to these, but when you have a lot of critical friends who are pestering you, it is exasperating to a degree. It is the simplest thing in the world to tell them to go to the warm place and get out, but if you want to do the big thing, set yourself the problem of meeting the unreasonable friend, the man or woman that is mad and doesn't like the way a patient is being treated. If you can make that one that comes in hot go out smiling and succeed in turning him from being a critical, unreasonable person into one who goes away thinking that that hospital is the best place in the world, you have accomplished something and you have schooled yourself. If you can do that with fixed intention, you have learned something.

DR. PATTERSON (closing): We have an obligation to fulfill to the internes which is an important part of our work, only second to the care of the patient. They have to be taken in hand and trained. They cannot be left too much to themselves. Some you will find can be directed or led into a proper appreciation of their opportunities for work, others will require considerable driving.

Endocrinology in Gynecology.

A Review of Reviews.

KATE C. MEAD, M.D., Middletown.

To endocrine enthusiasts in these days the beginning and end of all pathology, through the seven ages of man, is based on the effects of ductless glands on nerves and viscera. All the mutations of physiology and psychology are to them the work of a few peculiar cells gathered together for one great purpose near the largest nerve and blood centers.

To one writer there are no more males and females but "sexless majorities." Another likens the ductless glands to an orchestra playing life's tune to all eternity. Another, in the hectic rhetoric of an advertisement, says, "In the endocrine solar system of a woman the ovary is the sun around which revolve the spheres of physical well-being and mental health, separate, yet united within her complex body." And yet another blossoms out with this gem: "There is a pituitary stream coursing through the brain of a sweet young girl, and fountains of adrenalin bathing the nervous system of the woman in her prime, to control their activities and beautify their being, while the sad lack of ovarian juice turns women of middle age into men, like the pea-hens who strut in male plumage after their life-work of egg laying is finished."

This is merely a hint of the propaganda put forth by chemists and meat-packers in the not vain attempt to sell their goods by flamboyant advertisements. Doubtless many of us are influenced by the pseudo-experiments and polysyllabic words. Even the term endocrine is so new that it is not found in any dictionary, and we wonder if it means inner lilies, or internal cockle shells, or some kind of worms, all of which are translations of similar Greek or Latin words, or must it mean ingrowing hairs? The learned. editor of the A. M. A. Journal answers that it means "to separate within," and for this ambiguity we have to blame Shafer, of London, who, in 1916, found the word "complacencious" to himself.

But although the word is new we find old Hippocrates teaching the connection between the gonads, and cupping the breasts to cure amenorrhea, though it was nearly two thousand years before Meckel described the various ductless glands and attributed to them a function. Now, at last, theories of their function are accumulating at such an alarming rate that we tremble for the future of medical experimentation along these lines.

In his popular work on Endocrinology in Gynecology, Bandler1 appeals to the neurologist, alienist and criminologist to cease speculating on the nerves and to study the ductless glands. He finds in the little pituitary glands of the female all the tenderness and sympathy which differentiates her from mere man, whose pituitary is of the brutal kind, although happily, something in his thyroid gives him greater memory and nobler instincts with which to combat his unfortunate pituitary secretion. For this reason Bandler would prescribe anterior pituitary gland to man to cure his pugnacity, and to woman thyroid treatment if she were too soft and clinging. But it is chiefly in women that he finds the greatest lack of endocrines in general, upon which to base his system of endocrinology. He admits that an insufficient diet, infectious diseases, a poor neuro-circulatory system, and weak ancestry cause hypo- or hyper-functioning of the endocrines, but from a long study of cause and effect he deduces a gland therapy with which to reclaim all women from ill health and set young and old to jazzing together. He considers fibroids and myomata of the uterus as expressions of excessive pituitary dysfunction, vomiting of pregnancy as a sign of persistent corpus luteum, while abnormal menstruation he believes is caused by dysfunction of the mammary glands or ovarian stroma, sterility and the phobias of the menopause by defective corpus luteum, the uterus being but an offshoot of the thymico-lymphatic system.

Over-enthusiasm is as dangerous as apathy, and to the disciples of glandular activity there is only one cause and one remedy for all diseases. They discover that a patient lacks lateral incisor teeth, that she has moles on her skin, is short of stature and has thin hair, and they at once declare that her Fallopian tubes are

1Bandler, S. W. The Endocrines. W. B. Saunders Co., Phila. 1920.

twisted, her ovaries imperfect, and they prescribe for her pluriglandular treatment.

To the more moderate enthusiast, however, we may turn for a safe middle plane upon which to base our review. Novak, of Baltimore, for example, says: "There is no field in which the study of endocrinology is of so much importance as gynecology. The highly volitional functions of the body are under the control of a rapidly acting nerve mechanism, but the primitive vegetative functions are under the sympathetics, which are activated by the hormones of certain endocrine glands, such as the ovary which seems to have three separate hormones, the corpus luteum, which influence menstruation, the follicles which determine sex characters, and the stroma which concerns bodily functions." For example, amenorrhea in obese women may be caused by overaction of the ovarian stroma, in thin women it may be due to lack of corpus luteum, while dysmenorrhea and menorrhagia in young girls comes from hypoplasia of the uterus or hyperplasia of the endometrium and is due to defective ovarian follicles. But the rock bottom reason for these defects must be sought in heredity, which, as Bandler says, "shapes our ends, while endocrinity runs parallel with our lives." Whatever this may mean we know that heredity which gives us our glands gives us also our nerves and bones and muscles and the wherewithal to react properly to our environment, and in this respect, pound for pound, women have more endurance and can stand more work, worry and suffering than men, although when women do succumb to the strain of menstruation, pregnancies and the menopause, they never after react normally or with their former promptness.

Hypotheses are always interesting; if, for instance, a pineal tumor was found in a little girl to whom theories of the immortality of the soul were not bewildering, pineal tumors might be said to cause precocity, but for a working therapy of endocrines we must have more than mere hypothesis. We must prove, for instance, whether certain symptoms from which patients suffer

2 Emil Novak, Endocrinology, Sept., 1920, p. 411.

Emil Novak, The Role of the Endocrine Glands in Certain Menstrual Disorders, J. H. Bul. 1916, A. M. A. Journ. 1920.