have a certain specific effect in a certain pathological condition. (Read this wording carefully before you dispute it.)

3. Small doses oft repeated to effect.

4. As a result of the above, it is possible to abort many diseases in the first stages, and to materially modify the course of others.

5. The "clean out, clean up, and keep clean" doctrin as applied to the alimentary canal.

The Editor will think this is already too long for a "brief, terse experience;" but some time I may write the matter up more fully, for this "newer treatment" has made my work very enjoyable, at least to myself.

Dr. Parker's article in the March WORLD (page 113) should cause us to forgive him for all the "mean things" he has ever written. Every few days I re-read it and laugh till my sides ache. It's simply "killing "; and a sure cure for the "blues." I would like to meet him personally. F. A. COGSWELL.

Swaledale, Iowa. [Every time you ride several miles east from your place and then stop, do you "abort" a trip to New York? Or, suppose John Smith lives five miles west of you, and he calls you, and you go, we think you would call it a trip to John Smith's, instead of saying that you aborted a trip to San Francisco. We only ask doctors to call things what they are. Do you see the point? Your treatment is good; and we congratulate you upon the improvement you have been able to make. It is every, doctor's duty to take hold vigorously along safe and rational lines as soon as he is called to a case; but he shouldn't use names that are unjustifiable in the case. We all know one or more blow-hards who are always being called "just in time to save his life." As soon as they begin to read a little in certain journals, they will change their expression, and say, "Yes, I was called just in time to abort death'!"—Ed.]

[Later: Upon reading the above article in proof, we notice that the doctor has wisely avoided the use of the word pneumonia. So some of our remarks do not apply; but they apply to many others.-ED.]

An Open Mind on the Subject of Pneumonia.

Editor MEDICAL WORLD:-I was very much interested in your editorial in the January WORLD) on the Treatment of Croupous or Lobar Pneumonia-so much so that I am going to ask the privilege of making a few suggestions, and one criticism.

First, as to your remarks concerning the application of ice to the chest. Your objections to ice and argument in favor of hot applications seemed to me sound, and I accepted your conclusions. But I notice that

Dr. J. E. Taylor in the February WORLD takes exception, and puts in a strong claim for ice as the best application. He is right in saying that this method has some good

advocates; and while like yourself, I have never had the courage to try it, and would not now dare to do so, yet I realize that there is much to be said in favor of it, and I feel that the question ought to be thresht out. and settled. This can be done in two ways: (1) Let the members of THE WORLD family who have used ice as a local application in pneumonia give in their testimony, and especially those who have used both hot and cold applications. Then those of us who have not tried ice can judge whether it is worth our while to try it. (2) Then let those of us who wish, make the experiment in our own practise, and we shall soon be able to decide, for ourselves at least, which is best.

In the same way I would like to have the companion question as to the superiority of cold or warm air thresht out. I note that some good men now claim great success from exposing the patient to what is practically out-door temperature in the winter. Most of us, on the other hand, have been in the habit of advising fresh air, but air from which the chill has been removed-say a temperature of about seventy degrees. While I am still in favor of this plan, yet I desire to keep an open mind until the evidence is all in.

One more point, and this time I am going to venture a criticism. You say, "If there is evidence of heart weakness, alcohol in judiciously divided doses, and strychnin in

grain doses are the agents of choice." Now this is a point which I have studied with a good deal of care, and it does seem to me that all the evidence is that strychnin and alcohol are antagonistic in almost the whole sphere of their action. To give alcohol with strychnin simply requires more strychnin to produce the strychnin effect. To give strychnin with alcohol only calls for more alcohol to get the alcohol effect. The best treatment of alcoholism with which I am acquainted is based upon this antagonism. In treating these cases, I have myself observed the balancing of the action of the two drugs, and seen how either one in excess has the power of overcoming the effects of the other. The keynote of strychnin is stimulation, that of alcohol is paralysis. There can, in my judgment, be no good excuse for the combined use of the two. J. M. FRENCH, M.D.

Milford, Mass.

[An open mind is a good thing, in other things as well as in pneumonia. The effect of alcohol is largely according to the dose. In small, repeated doses it is consumed in the system, as a food; in larger doses it is stimulant; in still larger doses it is sedativ. To help sustain the heart in pneumonia it should be given only in small doses.-ED.]

Oil of turpentine, 1 part to 3 parts of ether, is a remedy of service in biliary and flatulent colic.

Two Letters Concerning the Diagnosis of Pneumonia.

In connection with recent discussions on pneumonia, perhaps the following letters may be of interest:

Editor MEDICAL WORLD:-I have been reading your journal for a number of years, and have always appreciated it and all of its talks until lately. There is too much critcising going on. Your comments on the article written by the Va. doctor, as you term him, is only one-sided and uncalled for. I believe, like him, that pneumonia is aborted when treated correctly, and not a self-limited disease. I have not lost a patient by pneumonia in twelve years and none needing treatment more than five days.

Therefore, as you claim I am a year in arrears on THE WORLD, I inclose you that amount ($1), and ask you to discontinue same to my address.

Casey, Ill., 3-7-1907.

J. C. PAXSON, M.D. PHILADELPHIA, Mar. 12, 1907. DEAR DR. PAXSON:-After your name was crossed off, as per your request, your letter was referred to me. All I have to say is, that THE WORLD stands fearlessly for the highest and best truth, as I am able to see it. While I advocate prompt and efficient treatment in every case, I am convinced that there is too much looseness and carelessness abroad in the land in regard to the diagnosis of pneumonia. If, by prompt treatment, a case of pulmonary congestion is arrested and the patient cured, why call it a case of pneumonia?

As long as doctors send me such articles as the one on page 107 of March WORLD, just so long I will continue to criticise them and try to help their writers to something better. I ask you, in your own interest, to read the article again, with an open mind, and also my comments. Better first read Dr. Oldham's article. I do not favor a do-nothing policy, but I do urge that we all be honest with nature, our patients, and ourselves.

You can withhold your patronage if you want to. I am working for you just like you are supposed to work for a patient: with the good of the patient as the first consideration, the pay being secondary. You need THE WORLD, and you ought to know it. I can get along better without your dollar than you can without THE WORLD. Hoping that you will see it in this light, and that you will join us again for your good, I am Very sincerely yours, C. F. TAYLOR.

Pneumonia in S. D.-Also Small-Pox.-Rubber Gloves.-Kargon.

Editor MEDICAL WORLD:-I always read THE WORLD thru from cover to cover as soon as I have time to after receiving it; and there are usually some parts I read twice. In the March issue the piece that interested me most was Dr. Saylor's, of Cogswell, this state, and it made me wonder if the pneumonia we have here is as severe as in some other places; and if Dr. Saylor's good results were not due more to location than to medication. I have practised here five and one-half years; never treated pneumonia with a supposed specific; have given quinin in small doses in some cases; always give calomel and generally strychnin. That is to say, my treatment has been simply symptomatic, and I do not think or claim that it has been more than ordinarily effectiv. But still I have never lost a case of lobar pneumonia or of any kind of pneumonia in a person over four years of age during all that time, and have seen very few cases have a crisis. I expect my practise is very similar to Dr. Saylor's, as we are both in small prairie towns. I have lived in N. D. twenty-seven years, and cannot recall a death from lobar pneumonia; and I honestly believe that if the snow blockade here this winter that the eastern editors knew so much about had been so bad that Dr. Saylor could not have secured quinin, his results would have been equally as good.

What I have said concerning pneumonia seems to be true to some extent with other infectious diseases; for instance, small-pox. There have probably been

seventy-five cases of small-pox in my field during the last year with no deaths except one still-birth, the child being well covered with the rash. It had acquired the disease from the mother, who had it about a month before. None of these cases, so far as I can learn, had been vaccinated within twenty years. Only four houses among the many infected were fumigated, and as few were quarantined. There are still a few cases in the neighborhood. It is not customary here to call a doctor unless there is a question about diagnosis. I see the Minn. Board intends to do away with quarantine for small-pox after 1907. This, I think, is the proper thing to do. I might add that there is no vaccinating being done here, as people would rather have small-pox. I suppose if I had seen all these cases early and given 20 grs. of quinin to each, I might have discovered a specific for smallpox, too. I think the profession makes too many discoveries, and I expect the Abbott Lamphear anesthesia will soon be out of date, as the gravity of confinement cases usually does not warrant such heroic measures, and it certainly would necessitate the use of forceps more often, and there would be worse lacerations, which are not desirable, even if they are repaired at once.

There seems to be very little said about rubber gloves in obstetrics. I wonder how many are not using them. I think they are the most important part of the doctor's outfit, except possibly forceps; and if a large, light glove is used, it goes on and off quite easily and the wrinkles do no harm. They can be kept in a dish of hot water, and are always ready, making it unnecessary to soak one's hands in bichlorid solution or other antiseptic, which is disagreeable. When one is done, the assurance of not having toucht the woman is a great satisfaction; and if the hand has to be passed into the uterus it would be almost criminal to be without the gloves. It may seem a little superfluous to mention rubber gloves, but there are no doubt many doctors who are not using them. May this not be true long.

Dr. Adams asks about kargon. The great dailies out this way are advertising it with no company name attacht; so it goes as an editorial item. Many are getting the prescription filled. When I tell them about it they are disgusted and say they might as well buy any other patent. I wrote to the editor of the Minneapolis Journal about it, inclosing their ad and a circular sent to druggists, and told him I thought the Journal should be able to get along without stooping so low as to deceive its subscribers for merely their share of the $200,000 which the company claim to be spending the first six months of this year for advertising. I received no answer. Kargon tastes and smells almost exactly like fl. ex. buchu. The regular, old-fashioned patent medicin business seems to be failing fast in this state, mostly on account of our strict state laws concerning same, I think.

I, for one, would like to hear a discussion on medical honesty. Is there a living in general practise for a strictly honest man, one who would treat others same as he does his own family? G. F. DREW.

Crary, N. Dak.

After the above, let us take a rest on pneumonia until about next November. In the meantime, let us try to cultivate rational ideas concerning this disease.

Doctors Should Organize for Sociability and Business.

Editor MEDICAL WORLD:-It is a proverbial fact that physicians, as a rule, are poor business men; but as to why this should be has not been, as yet, satisfactorily proven. If any man on earth should have a competency to keep him in his declining years, when he can no longer perform the arduous duties of his calling, it should be the physician. Who is it that sacrifices more of his time-frequent

APRIL, 1907]

ly without remuneration-loses his rest and sleep, that was designed by nature for him, and spends more of his physical and mental force for the benefit of his patrons, than the physician? He is called upon at all hours of the day and night to administer to the wants of his patients and is expected to respond instantly, regardless of the weather, condition of the roads, the health of himself or family, or the financial responsibility of his employer.

The physician in general practise, especially the country practician, can have no regular office hours, but is expected to answer at any hour in the twenty-four that he might be called. The merchant has his regular hours for work as well as his rules of business, and the public generally expect him to live up to them. Should a customer come in who is of doubtful financial standing and want to purchase goods on credit, the merchant would not hesitate to tell him that it was against his rules to sell goods on time, and the people would commend him for it and say that he did just right. But should the same man call the doctor to see some member of his family and he would refuse to go, because he knew that he was a dead beat and would not pay, the same people who said that the merchant did right in refusing him credit, would say, "What a hard-hearted man the doctor was for not going to see the sick one," when by so doing he would not only lose the time it would take, but would stand a chance of losing other patients who were good while gone. If it is business for the merchant to not favor the dead beat, it is also business for the physician not to favor him; and if the physicians would stand together and educate the people as the business men do, we would not have so many dead beats.

If the doctor wishes to buy a horse he is expected to pay the cash for it or give a bankable note; but should he pull a patient thru a long and severe spell of sickness, he is not expected to ask for the money or a bankable note as soon as the patient is well. Why? Because he has not educated the people as they have him. See?

There is an old saying that "life is what we make it ;" and it is just so with business. The great trouble with the medical profession is lack of business methods and organization along the right lines. There is, I am sorry to say, a woeful lack of charity and sociable feeling among physicians. We, of all men, should be bound together by an indissoluble tie, as we represent the noblest profession of this world. There is no need of physicians being at "loggerheads" with each other, if every one will observe the Golden Rule, do his duty, and be a man. But jealousy, if not carefully watcht, will creep in; and, I am sorry to say, that there is such a thing as a medical hog abroad in the land. We sometimes meet with road hogs-men who

143

are not willing to give half of the road. And so we sometimes see the medical hog, who wants to do all the work of the neighborhood, regardless of fee, ethics, or anything else. How much more pleasant the practise of medicin would be if physicians would treat each other as they should, and work to their mutual interests and thereby educate the people to respect the profession as they should.

The physicians of this (Piatt) county met in convention at Monticello, Oct. 31st last, for the purpose of discussing the advisability of making a uniform rate of fees for the county, as our fees have been very low, considering the wealth of the people and the condition of the roads over which we have to travelespecially thru the winter season, and the rise in price of the commodities which has obtained in the last eight or ten years. According to Bradstreet and Dunn, the commodities of life as well as medicins and materials that we are compelled to use, have risen from 25 to 100 percent more than they were only a few years ago, and the result is that we have to increase our fees so as to bring us up to a level with the balance of mankind or else donate the difference to the publicand the Lord knows that the doctor always donates enuf anyway. We had a very enthusiastic meeting, ending with a banquet, and everybody was highly in favor of formulating a fee bill, raising the price something like 25 percent over the existing rate, which was done and signed by all the physicians of the county-twenty-eight in number. It was

decided to have the fee bill publisht in the various county papers, so that our patrons could see what was done, as we thought it best to acquaint them with the new scale before it was to go into effect, which was December 1, 1906. But when the papers came out such a storm you never did see! The people rose up in their wrath, held an indignation meeting (at this place), passed resolutions against us, circulated petitions with the intent of getting us to come back to the old fees, and threatened us with a boycott if we did not. But for some reason best known to them they did not present their petition. The storm has blown over and we are getting better fees, and I think their respect for us has moved up several notches. One brother being more weary than the rest deserted our ranks and advertised over his signature that he would come back to the old fees, but we were not surprised at that, as he has always exhibited symptoms of being closely akin to the animal described above. Why is it that men will stand in their own light? and why is it that they are not willing to do anything that will elevate the profession and cause the public to respect it as they should, and at the same time do themselves and families justice? I can see no other reason but that described above.

As stated at the outset, I believe the medical profession to be the most honorable of the earthly professions, and the man who will so demean himself as to be a disgrace to it should have his certificate revoked and be relegated to the place where he belongs. The good Book says that a man who will not provide for his household is worse than an infidel; and I think that applies to physicians as well as other people. The business man is respected by every one-even by the dead beat; and I think that the physician who is also a business man will have more respect shown him than if he conducts his business in a loose, slipshod manner, even tho he be one of the best of physicians.

Modern Obstetrics Once More. Editor MEDICAL WORLD:- As a companion piece to Dr. Excell's case in the February number (pages 59 and 60), of which he asks "who saved her life at the second ?" I will present a somewhat similar case of mine. I will, however, have to go to the chart, kept by one of those capable nurses of mine, for the case history.

Mrs. W. E. D., ivpara, aged 30, entered the Gaynor Hospital Dec. 6, 07, in premature labor, the patient being in the 34th week of her fourth pregnancy. Her cow, being in estrum, had jumpt on the patient ten days ago, throwing her down so that she struck on her abdomen. A free but untreated uterin hemorrhage followed, and fetal movements have been unobserved since the accident. Labor pains, occurring every half hour, set in two days ago and have been increasing in force but not in frequency for some hours. Tentativ diagnosis: premature labor.

The word "tentativ" was used to forestall the habit of snap diagnosis. The nurses were told that the uterus contracts every half hour or oftener, following a regular cycle, during the entire period of pregnancy. These contractions, subconscious, become conscious and often severe during the last six to the last two weeks of pregnancy. The point of interest was that in private practise the nurse and family physician are often scurried out of bed in the midnight hours by these false alarms. Three cases of regular and severe half-hourly contractions were cited in recent hospital work, the history of a previous pregnancy in one case being that nurse and doctor had been called out of bed on an average of once a week for six weeks before labor set in.

Getting back to the chart, the nurse goes on to say that she assisted in obtaining the following data and measurements: Last menstruation began April 16; quickened in

Abdominal palpation: Diastasis of recti; fundus at lower border of epigastric fossa; transverse diameter of uterus in right oblique diameter of pelvis. Fallopiah tubes palpable; placenta large and covering back wall of uterus from tubal openings to upper border of lower uterin segment. Fetal presentation, left occipito-transverse; fetal head, occipitofrontal diameter 10 cms.; fetal length, 42 cms.; estimated weight, 2.8 kgms. (6 lbs). Abdomen flaccid; amniotic fluid moderate; pains improving.

Stethoscopic ex.: Fetal heart rate 175 and very feeble; point of greatest intensity of heart-sounds, where a line from the umbilicus to left anterior superior spine of the ilium crosses the outer edge of left rectus. Presentation diagnosis: left occipito-transverse. Fetal indications: maternal hypodermic of strychnin, and rapid delivery. Fetal contraindications: prolonged labor, scopolamin-morphin, or morphin-hyoscin-cactin anesthesia. These anesthetics are also contraindicated because of the large placenta and the maternal history of postpartum hemorrhage.

Bi-manual ex. : Perineum dilatable; cervix effaced and dilatable; admits two fingers; membranes intact but detacht about internal os; sagittal suture in transverse of inlet. Presentation, 1. o. t. Sacral promontory normal; ilio-pectineal lines free from exostosis; ischial spines do not impinge on pelvic space. Pelvic capacity: natural delivery of a 4.5 kgm. (10 lbs.) fetus, or high forceps, (axis-traction) delivery of a 5.4 kgm. (12 lbs.) fetus. Patient catheterized: urinary ex. negativ.

It developed during examination that this patient has a history of almost fatal postpartum hemorrhage in her three previous labors, following both the birth of the child and the expression of the placenta. She was quite sure she would die this time on the principle that three times in jeopardy, the fourth would be fatal. She was quietly but very positivly assured that we would prepare in advance for any emergency suggested by the previous history, or indicated by the physical and pelvimetric findings.

The amusing thing about the history was that each physician had blamed the colleague that had waited on her in the previous labor for the hemorrhage following, and was cock

sure the accident would not happen in his own hands. This bit of history is characteristic of the profession. The nurses lookt forward as eagerly for the complication as I was for the opportunity for a clinicai lecture on postpartum hemorrhage. The case meant work, not worry-opportunity for class experience instead of stage-fright.

The patient was ordered prepared for labor, using the full hospital technic of surgical asepsis for operativ delivery. A description of this technic would take 1,500 words and must be passed over. We deliver all cases in an obstetric operating room, on an obstetric operating table, before a class of five graduate nurses taking the post-graduate course in obstetrics. These class women are alert and observant.

The patient prepared as carefully as for a vaginal hysterectomy and placed on the table, assistant nurses and obstetrician gowned, hands and arms sterilized as for abdominal section, first and second assistant and operator wearing steril rubber gloves, the very impressiveness of the aseptic precautions possesses an educational value that should stay with these women for life. Going out into the world, they force the laggard physician to cleaner methods by educating the community up to the best standards. The fittest survive, whether physician or nurse.

The history of the first and second stages of labor is but common hospital technic: rapid dilatation of the cervix and completion of the first stage at once by the Edgar-Bonnaire method followed by delivery of the fetus in 35 minutes. Two-thirds of the energy expended in labor is employed in dilating the cervix. During the wasted hours the doctor smokes, sleeps, or tells smutty stories, and the woman wears out. Because this is true, because the average physician learns but little from his material, a man with a record of 3,000 cases may know as little about the possibilities of being helpful obstetrically as the expert Dr. Wiley did about the pneumogastric. These possibilities cannot be gleaned from text-books, but may be learned from the private practises of text-book writers.

After the delivery of the fetus the patient was not given ergot, despite the expected hemorrhage. About the ordinary flow appeared till the first after-pain, which was announced by a gush in a large jet, large enuf to suggest immediate expression of the placenta if one had no conception of what might be really the cause. The uterus was contracting well, and after the pain passed off there was left but a vulvar trickle. second pain announced itself by a similar gush and subsidence after subsidence of pain. While we probably had a placenta succenturiate in addition to the serotinal placentathe stethoscopic findings justifying this belief -the placenta was evidently separating from the uterin wall according to the Duncan in

The

contradistinction to the usual Schultze mode. The flow was being collected so that the placenta might be exprest when the limit of normal amount of hemorrhage-250 to 360 c. c. (8 to 12 oz.) was reached. Between afterpains my nurses were told that separation of the fetal from the maternal placenta usually begins within the border and towards the center. Behind this separated portion a retroplacental hematoma forms, and being thus inclosed, but little hemorrhage appears at the vulva. The hematoma increases with each pain and increast area of separation, one effect of this posterior pressure being to turn the placenta and membranes fetal side out, in which way they are usually delivered, the membranes following and inclosing the seven to twelve-ounce hematoma. This is the Schultze mode of separation, and is the common one and least alarming.

Change the mode by having the placenta separate at the edge and come down edgeways as in the Duncan method, and the hemorrhage that in the other form was consealed now appears at the vulva and seems really alarming. The tyro rushes into the breach, expresses the placenta, and is rewarded by postpartum hemorrhage. In the Duncan mode, the placenta is born edgeways, maternal side out, with the membranes torn off the fetal surface of the serotinal placenta. We see about five such placental deliveries in every hundred cases, so that this one was not a new experience.

Our placenta was found in the vagina and lower uterin segment after the fourth pain, and was exprest at once. While one nurse gave ergotole hypodermically for educational purposes, the vulva was resterilized, the vagina freely opened with vaginal hysterectomy retractors, the uterin cervix drawn into plain sight, and an intrauterin irrigation of one gallon of 2 percent steril acetic acid solution at an irrigator temperature of 118° F. given. The nurse in charge of the fundus learned the lesson of how rapidly and firmly the uterus contracts under hot 2 percent acetic acid irrigation. The uterus was replaced, a box bandage put on, and the patient put to bed. The puerperium was normal.

We examin critically every placenta and membrane born in our service in or out of the hospital. Space forbids development beyond points of the present case. The placenta being found whole, the membranes around the placental border are examined, under irrigation, for large blood vessels leading from the serotinal placenta, out and onto the membranes. These vessels being found, are followed outward to the accompanying succenturiate placenta, which they supply. If the succenturiate placenta be missing, the uterin cavity is at once explored and the succenturiate placenta removed by the gloved hand. Introduction of the gloved