notion that things are the worst ever. If you must go skunk hunting in order to relieve your pent-up indignation, which may not be wholly unrighteous, concentrate your fire; don't carry such a wide-range scattergun.

By the way, Doctor Taylor, I have a case under observation that may be of interest to some of your readers. About three years ago I began to treat a woman, aet. about 37 years, who presented all the symptoms of diabetes. She was passing about one gallon of urin in the 24 hours, acid reaction, specific gravity 1035 to 1040, containing a large percent. of glucose, as frequently demonstrated by the copper and picric acid tests; also diacetic acid (red reaction with iron chlorid). Besides she had excessiv thirst, was losing flesh, while eating excessivly. She also had a sluf gangrene, of right shin. For a year I treated her with various and sundry drugs and static electricity. Of course, most decided results were obtained from a strict dietary; but the only agent that had any apparent effect on the ulcer was high tension, glass electrode, applications from the static machine. During the past three years she has had sundry sorrows incident to the diabetes. About two months ago she performed a surgical operation on herself— removed a corn with an old pair of scissors. The "operation" was rather too radical. The toe and foot began to swell, and finally became so painful that she wanted some help. In short, gangrene resulted from this corn trimming, as she had frequently been warned might happen from any break in the skin. The corn is cured and the sluf is filling in. She seems destined to recover from the gangrene, which involved about four square inches of area, down to the tendons (extensor), the sheath of the extensor longus apparently having been the conduit for the passage of the microbes to the tissues of the dorsum of the foot. It is perhaps worth while to mention that she was given echinacea from the time she came under observation (a dark spot was then forming) until the sluf was nearly all separated from the healthy tissue. She also took arsenic, and a few doses of atropin, for an intercurrent congestion of the lungs. At first the foot was drest with a kaolin preparation. Later a wet dressing was deemed better and acetozone was used. But it was difficult to keep the foot warm, and a dry dressing was substituted. Thymol iodid (aristol) is sprinkled on thickly, twice a day. Twice each day it is irrigated with hot, steril water; four to six quarts are used, from a fountain syringe, elevated about two feet. Dioxygen is used in a small cavity in the toe, 'to disintegrate the pus and detritus, otherwise inaccessible. Clifton, Kan. H. E. POTTER.

[In a private letter not for publication, the -doctor says: "Some of the fellows deny

your statement that antikamnia is advertised to the laity. Last winter my hostler received their samples and plenty of advertising matter. A county surveyor and others outside the medical profession have received these vest-pocket necessities."-ED.]

A Case of Fecal Impaction with Dilatation of the Colon; Death.

Editor MEDICAL WORLD:-In reporting this extreme case of fecal retention, I do not intend to enter into the etiology or pathology, but will confine my efforts to the symptoms and treatment of the conditions as I saw them.

My patient was a young lady of 16 years. She consulted me for the relief of constipation, stating that a movement of the bowels occurred only at intervals of six to fifteen days. It was found that constipation had existed for a period covering the greater part of the patient's life, and that an evacuation was produced only with difficulty. She was well nourisht, had a good color, and only complained of loss of appetite and a constant headache. Melancholia existed in a markt degree, and intentions of suicide had been hinted at.

Prior to this time she had nurst a sister thru a long illness, and from anxiety and overwork had so neglected this all-important function, defecation, that the resulting paresis was very markt. The patient had an aversion to telling or making known her condition, and seldom revealed this to her mother, which disposition only tended to aggravate the trouble, a fact to be noted later.

Treatment was directed along the line of catharsis, tonics, dietetics, and massage; beginning with the milder remedies, cathartics were given until almost the entire materia medica had been gone over, yet without result. I might mention here that very little effect, either physiologic or therapeutic, was ever manifested from full doses of any remedy. This was explained as being due to an idiosyncrasy, and to a personal indifference or antagonism to all forms of treatment. Her plea was that she wanted to die.

Having failed to empty the bowel by enemata or drugs so far, I decided to try some drastic measures, and accordingly gave about four ounces of oleum ricini with two minims of oleum tigli. This was followed in about four hours by two fecal discharges.

Strychnin, the hypophosphites, massage, outdoor exercise, and small enemata were then ordered. The case ran along for four months, during which time I was led to believe that the trouble had been, in a measure, overcome. By close investigation it was found that the enemata had not been rejected at all, altho the quantity of water had been increast (against my orders) up to one and a half gallons. Digital examination per rectum disclosed large scybala so hard and dry as to

resist the dissolving action of hot water. The next step taken in the way of treatment was the administration, by high enema, of one-half pint of kerosene to soften the fecal mass. By means of a long rectal speculum and external manipulation, the rectum was emptied. This operation was repeated every day for five days, with the exception that the kerosene was used only two or three times in all. The colon was again flusht with hot water, and the patient instructed to watch the condition, and report any failure on the part of the bowels to perform their function.

The case was lost sight of for about three months, when it again came under my observation. After persuasiv measures the patient was induced to go to a hospital for treatment, where she remained two weeks. I have her own statement that during her stay at the hospital enemata were resorted to but no fecal matter was discharged, and not to exceed three times was the water returned. The next time I saw the young woman was three and a half months later. During this time she had not been under any kind of treatment. At this time examination showed the colon full and hard, a decided tumor at the sigmoid flexure, and much pain and tenderness.

The same procedure to empty the bowel as before was tried, but only proved futil. There was an entire absence of peristalsis. Any fluid injected into the bowel could not be gotten out. I suggested consultation, hospital treatment, and surgical intervention, but all these were met by ruling opposition from the patient and family. Treatment from this on was entirely symptomatic. Gastric ulcers developt with pronounced hematemesis; suppression of urin; uremic convulsions and stercoraceous vomiting. These conditions continued the same for about four weeks, with the exception of a slight abatement of the convulsions and vomiting. Pain referred to left anterior lumbar region increast each day, and finally became almost uncontrolable. Multiple abscesses developt upon the face and neck, beside a large circumscribed collection of pus in the abdominal cavity. Very little nourishment was taken during the last month of illness; the condition of the rectum made nutrient enemata impossible. The patient lapsed into unconsciousness and died from exhaustion.

In retrospect, we find that the colon had been gradually dilated from early life; first, by the accumulation of feces; second, by the increast quantities of water used in the enemata. We also find a paresis of the motor and secretory apparatus of the intestinal tract, due to over-stimulation of these centers by continued catharsis. Had it not been for the co-existing melancholia and constant aversion to treatment, I believe that much could have been done toward effecting

Injection Treatment of Piles. Editor MEDICAL WORLD:-I would reply to Dr. E. B. Graham (page 354 of the Sept. WORLD) that I have for years used the injection method of treating piles to the exclusion of almost every other method, and that I do not remember a solitary case, when this treatment was used, that was not cured. Furthermore, eight or ten years ago I was treated by this method for a very aggravated, painful, internal pile. I think I was in bed part of one day, suffered scarcely any pain, and have never had a symptom of hemorrhoids since. Surely that honestly can be termed a cure. L. Y. KETCHAM.

Ensenada, B. C. Mexico.

P. S.-If the doctor is interested, I would suggest a small work, "Rectal Diseases," by Dr. W. P. Agnew, of San Francisco. It is the only place I have ever seen the subject treated understandingly or scientifically. L. Y. K.

Was This a Case of Perinephritic Abscess? Editor MEDICAL WORLD:-Will you report the following case for discussion and diagnosis by the family?

B., a minister of the Gospel, aged 68 years, 6 feet tall and weighing 150 pounds, sallow complexion. Had coated tongue, with red edges. Pulse full, soft, and regular, 68 to the minute. Temperature normal. Physical examination showed normally acting lungs. Was constipated, and the abdomen was tympanitic and tender over entire area. Urinary examination was negativ, tho patient complained of frequent urination, voiding urin eight times during a night. No pain on urination, but he is not able to check the stream voluntarily. The sympton causing greatest complaint was a "severe aching" thru the region of the left kidney. He had anorexia, headache, and general weakness. Over the left kidney I found a spot the size of a silver dollar, which was extremely tender. The muscles about the spot seemed normal. Patient has suffered from rheumatism in mild degree, at times. No tubercular history in the family. His father died of nephritic abscess.

Thinking the trouble might be rheumatic, I prescribed semi-solid diet, free ingestion of water, hot and dry packs to painful area. Also 10 grains salicylic acid three times a day; half a dram cascara on retiring; and half a grain acetanilid every three hours. I reacht the physiological effect of the salicylic acid without alleviation of the symptoms,

Wring flannels out of mixture, and apply cloths over the hepatic area at night.

Same diet, with half dram cascara on retiring. Under this treatment the hectic flush disappeared, and patient has gained steadily. Pain is gone, patient walking about house, and bowels move normally without aid of cathartic.

One of the best skilled surgeons in the state saw the case with me and diagnosed tubercular involvement of the kidney and intestin. Personally I believed it to be a small abscess, and ascribe the sudden improvement to evacuation of abscess thru bowels. DR. A. C. STROUT.

Garland, Me.

[The Editors do not think that it was a case of perinephritic abscess. Absence of pronounced fever and rigor would not indicate such affection. One would expect a more rapid advancement in the tumor (up to time of rupture of the abscess), and more markt local trouble, had it been perinephritic. On such a hypothesis, how do you account for improvement under acid medication (previous to rupture)? However, we will not express ourselves too positivly, for we are not able to hazard a guess as to what the actual condition might have been. Perhaps others of the family may present something more definit.]

He Seems Discouraged.

Editor MEDICAL WORD:-So many things are occurring in this locality to make the life of a physician unbearable, that I don't know what better to do than write to you for advice. I am led to believe that while the whole country is similarly affected, we are having a double portion here. For a number of years all schemes which could be advertised as "patent medicins," appliances, Christian science, viavi, etc., have been exceedingly popular, and regular, legitimate medicin has been almost lookt down upon. If people have no money to invest in some of these they will run to a physician; but under few other conditions. I have learned

that when I wish a tonic taken, if I can get hold of an old bottle with printed matter advertising the contents that they can read and believe it, I can get it taken; but generally in no other way. A farmer of above average intelligence, said in my office: "I know doctors do not favor patent medicins; but I believe all really well-informed doctors recommend them." I tried to explain, as I always do, but I have no faith that he believed me; he needed printed matter he could read and not see the author; then he would have understood and believed. Is it possible that anything could be done in this line? D. R. EMMONS.

North Lewisburg, Ohio.

[Decidedly there is something that can be done. See notice of "The Great American Fraud on page 461, November WORLD, and send for a supply (they don't cost much), and distribute them to the leading citizens in your community. In order to be sure that the and-so, ask him how he liked it; and ask pamphlet is read, whenever you see Mr. Sohim to pass it among the neighbors, particularly get it going among the ladies of every section of your community. It will do wonderful work for you. When they see a picture of the tomb of Lydia Pinkham, in the pamphlet above mentioned, they will know that she can't be answering the letters of "suffering women." This will shake the confidence that your people seem to have in nostrums; then you must do all you can to inspire confidence in the medical profession. -ED.]

Are Negroes Immune from Gall-stone
Disease?

Editor MEDICAL WORLD:-I have seen many white persons suffering from gallstones, but have not diagnosed a single case as such among negroes. Does this race enjoy some degree of immunity from this trouble? or is my experience exceptional? Louvale, Ga.

W. W. PEEK, M.D. [Don't know. Never thought of this before. What is the knowledge and experience of the brethren upon this subject?-ED.]

A Remarkable Case of Ascites.

Editor MEDICAL WORLD:-On the 9th of Dec., 1906, I was called to see a woman who is about 23 years old; unmarried, but is the mother of one child, which is about 3 years of age. She was supposed to be in confinement. I got up quickly, prepared my obstetrical case, which also contained a few of my surgical instruments, and hurried to the scene. On my arrival I found the house crowded; they were watching to see the last breath of this woman, who suffered with one continual pain in abdomen and back. There was no intermission of these pains, as in labor. The abdomen was very much dis

tended; more so than it would have been in a case of labor. On pressure I felt no hardness; on palpation I failed to get any movements; the abdomen was very tender. I then proceeded to make a vaginal examination. I found the uterus in its normal position. The os was not dilated. The patient stated that her "flowers" were regular, and that she detected this trouble coming on about eighteen months ago. I inserted my hypo. needle into the abdomen and drew out a few drops of a dark, dirty fluid, tinged with blood. Then taking my trocar and cannula, I inserted it in the median line of abdomen half way between the pubic bone and umbilicus. In a few moments a stream of the above described fluid rusht out. I secured a vessel and allowed it to run for more than au hour. As the patient had been suffering so long, I gave a hypo. injection of morphin sulf. gr., strych. sulf. gr., and atropin sulf. gr. 1.

When I had drawn about three gallons I had her turn on stomach and used pressure, so as to have all of this fluid escape. The last that came was a thin, bloody fluid. My patient was very soon relieved of all pains. The abdomen became flat and flabby. I measured the fluid and found that I had drawn three and one-half gallons. The second day she was allowed to sit up for four hours. The third, she said she was feeling fine. I restricted her diet and gave her saline cathartics. Now, members of THE WORLD family, will you suggest a line of treatment for this patient that will prevent an accumulation of this fluid? Is it possible to render a permanent cure? Beaufort, S. C.

G. W. SINGLETON.

Clean Mouth in Typhoid. Editor MEDICAL WORLD:-The December WORLD, first page, advises the care of the mouth in typhoid fever. This is a most worthy suggestion and one which no physician should neglect if he wants the fullest measure of success. To appreciate the good and wholesome sensation of a clean mouth, let it be tried on himself. For more than ten years it has been one of the essentials of minor detail with me in the case of any patient with a prolonged illness. An alkalin solution of sodium bicarbonate and borate and peppermint oil in glycerin and water makes a most delightful and efficient means to this end. I instruct the patient to take a teaspoonful in the mouth and scrape his tongue on his teeth, if he has enuf, or a proper stick, removing by this process all detritus imbedded between the papillae, then to scrub his teeth, and finally to rinse the mouth, churning it thru the teeth. This is always followed by a most refreshing sensation, removing the pasty, sticky feeling, correcting fermentation, preventing decomposition, and removing or limiting infection. Food and water are then

readily taken, and they agree; likewise medicin. Try it.

St. Louis, Mo. HENRY L. FIELD, M.D.

Dandruf-Uses for Epsom Salt. Editor MEDICAL WORLD:-Replying to Dr. W. R. Fowler's plea for help (Nov. WORLD, page 452), will say that I was a sufferer from dandruf for a long while. I tried various remedies, also used medicated soaps, without benefit. I finally quit all applications and soaps, and simply washt my head with yolks of eggs, using two at a time. It has cured me. My hair is soft and glossy, is growing fast, and thickening rapidly. Rub the egg on the scalp, using the tips of the fingers; follow with warm water and soft cloth, just sufficient to wet the scalp; rub gently but briskly for ten minutes. Then rinse thoroly in warm water, and wipe as dry as possible; then give a good brushing. It leaves the scalp beautifully clean, and relieves all itching. I repeat as often as necessary for cleanliness.

I desire to add a word of praise for Dr. Burgess' little book, The New Field (see Nov. WORLD, pages 449 and 450). I have read it with profit. His formulas for Laxativ Syrup and Epsom water solution have benefited me wonderfully; my catarrh, also, is greatly relieved. The recipes are easily prepared, pleasant to use, and cheap in money value, but high in merit. I used his Epsom solution in an attack of bronchitis with happiest results. It is fine in throat troubles of children. Success to THE MEDICAL WORLD.

A TEXAS DOCTOR'S WIFE.

How to Enforce Medical Laws. Editor MEDICAL WORLD:-I see in Dec. WORLD, page 495, that Dr. Hunter refers to the non-execution of the medical law in Florida, and he refers to the law in Georgia. He is correct on the law, but I practise in Whitfield county, where to my certain knowledge as many as six are practising without license; besides some others are manufacturing medicin and practising with it. Now you say, have we no prosecuting officers? Yes, but to my certain knowledge this has been reported to them, and has been in the courts three different times and nothing has been done. This being the case, how are we to get rid of this violation of the law, and how are we to protect the profession and the people? H. J. AULT, M.D.

Rocky Face, Ga.

[Your county society or your state society should employ a lawyer to prosecute violators of the medical law. If your county society thinks itself too poor, and if the state society won't move in the matter, several of the county societies in your section of the state should join in employing a lawyer to push prosecutions. That is the way to do it. At

your next meeting empower your president, or secretary, or both, or appoint a special committee, to confer with the societies of adjoining counties to join with you in employing a medical prosecuting attorney. Perhaps you would first better appropriate a sum from the treasury of your society for the purpose of employing a medical prosecuting attorney, and ask adjoining societies to join you in this movement.-ED.]

Reciprocity Conditions.

Editor MEDICAL WORLD:-I herewith inclose check for three dollars, which pays for four years' subscription to your journal in advance. Can't you sometime, at your convenience, give a list of states whose medical examination boards reciprocate with other states unconditionally? I notice states which allege to reciprocate with others hamper the applicants for reciprocation with so many ifs and ands and buts that it would be hard to find an applicant who can comply with all the requirements. You stated in your Dec. number, page 504, that New York reciprocates with New Jersey. Does it do so unconditionally? or must you have passed the New Jersey Board on or after a certain date and submit a college diploma or a high school certificate in addition to your medical diploma? It would be interesting for one to know just what value is placed on one's certificate by the medical boards of neighboring states. The State Board Journal's report is misleading, inasmuch as many doctors may think the reciprocation is unconditional, while on the contrary the conditions required are numerous and in some cases insurmountable for some.

The above questions are askt in the interest of doctors who passed the New Jersey Board prior to the present increast requirements, which I think went into effect in 1903. L. C. CORBIN, M.D.

Passaic, N. J.

[This reply can only be general. There are in practically all the states some "left overs," who were never required to qualify except as to the number of years in practice; it has been the policy, in making state laws, not to disturb those who have been in honorable practise a certain number of years in the state. These would never be disturbed in their own states, but it can hardly be expected, in this age of progress and definit requirements, that they would be received in other states on the same terms. Their years of practise should be placed decidedly to their credit by any board before which they appear (the Illinois board has made a beginning in this direction), but some showing of competency in the fundamentals, and of up-to-dateness in practise, must be required. Then the man who shows a certificate from some board, issued a long time ago: has he

gotten rusty in the meantime? or has he kept himself bright and up-to-date? board to which he might apply would be justified in not being satisfied with the old certificate alone. You see, reciprocation must necessarily be subject to many conditions. The best way to learn the conditions at any particular time is to write to the board of any particular state and submit just what you want answered.-Ed.]

Home Surgery and the Divided Fee. MR. EDITOR:-I wish to invade the columns of THE WORLD, which I read every month, for the purpose of supplementing your remarks on a divided surgical fee. I do not believe in discussing such things too much, either in societies or journals, as every man has to decide for himself about a thing of this character. You have hit the nail on the head as I look at the matter. For years I have been doing the most severe surgical operations in the home with as good results as can be shown in any hospital or sanitarium. In fact I do not see how doctors get rid of doing them. My patients beg of me to operate at home, and many of them are too sick to be moved; and what is to be done with them? Are we to let them die when surgical help will give them a chance to live? Your article seems to imply that there is a question in the minds of some doctors as to whether a room can be made surgically clean in an ordinary house. I have operated dozens of times in the home, sometimes when we were short of room and in houses not the best. I have never seen any trouble in making them surgically clean. I never attempt it without a trained nurse. Get the nurse first. You will often be surprised to see what a fine operating room one of these girls will make in a home where there is not much to do with, and a house that you would not pick out for a hospital. My cases of appendicitis are pus cases before I see them at all, many times; they are miles away from any doctor, miles away from the rail road or a hospital. Too sick to be carried on rough roads, and I wonder what other doctors do with these cases? I get a trained nurse, and watch the case; if they will recover without operation I let them; but some won't. Are we justified in letting them die because they cannot be taken to a hospital?

I say it takes brains to be able to know that your patient must be operated on, and not to do the operating. You make the diagnosis, appreciate the gravity of the situation, and say operate. Your ability equals the surgeon, who uses the knife. You help in the operation and thus get familiar with surgical technic, and then take care of your patient, with the help of the nurse. You say the surgeon will bring his own trained nurse and leave her with the case after the opera