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passed, about 3 quarts in 24 hours. At present and for past year he has been sore all over, especially along spinal column and radiating to the front. Weak in the legs. Short of breath on exertion. A heart murmur. Rests fairly at night, but can scarcely turn over in bed for the intense soreness. Patient very much discouraged, and so am I. He has spent lots of money in trying to get better, but keeps about the same all the time. I trust you may be able, from the symptoms given, to suggest something in the way of treatment that will help him. Winslow, Ill.

E. A. REED.

[Your description of the case is not complete enuf to admit of any positiv diagnosis. Have you made repeated examinations of the urin? Often grave alterations escape detection at a single examination. The fact of his voiding "three quarts" of urin strongly indicates some error in kidney function; certain cases of nephritis originate in this way. The heart murmur would not cause either the extreme weakness nor the muscular soreness. We suggest a short tepid bath, followed by thoro inunction with any bland oil such as oliv, just before retiring. At his age, a careful examination of the prostate would be good practise: His case may be one of simple diabetes insipidus, and the symptoms would be most simply explained on this hypothesis. See any book on treatment for the therapy of this affection.-ED.]

After-pains.

Editor MEDICAL WORLD:-Will some one please give a specific for after-pains, if there is such a thing as a specific for them? Something that will not lower the vitality of the patient nor cause other detrimental disturbances. Come along with your old and tried known remedy and no guess work; from any medical man whether regular, homeopath, eclectic or what. I am very anxious to find some good remedy, but do not say opium in any form, as it is not a desirable one. F. M. SHIRK, M.D.

Lost Springs, Kansas.

[Doctor why are you so positiv in your statements regarding the undesirability of the opium preparations in treatment of after pains? We have used the various preparations with perfect satisfaction. Only a very moderate dose is required. The theoretical objections of checking peristalsis, etc., do not hold valid in practise. We quote you Edgar, "Practise of Obstetrics," Blakiston's, just out:

After-pains are caused by irregular and painful uterin contractions, and are often due to clots in the uterus. The use of the fluid extract of ergot, in dram doses, every three hours, is usually beneficial in cases of retained blood clot; or, should the sleep be much disturbed, codein in moderate doses, one quarter grain every two hours, for two or three doses, may be used as less likely to produce unpleasant after effects than other preparations of opium. Depressants should be avoided. When pain is moderate, and not due to blood clots, phenacetin, five grains every three hours for two or three doses, will be found useful. I have found antipyrin, five grains, with a teaspoonful of aromatic spirits of ammonia every hour for two or three doses, efficient. When the pain is severe and not due to retained clots, the following will answer well: Tincture opium deodorized, I dram; chloral hydrate, 40 grains; elixir aromatic, enuf to make an ounce. Direct teaspoonful in water not oftener than every four hours."

Hirst, in "A Text-book of Obstetrics," publisht by W. B. Saunders & Co., says:

The appropriate treatment of after-pains is suggested plainly by their cause and nature. It is the administration of ergot to stimulate the vigorous contraction and firm retraction of the uterin muscle, and of opium to diminish the pain of its contraction. A mixture of fluid extract of ergot and paregoric is a useful prescription, tho, in cases of extreme pain, ergot by the mouth and morphin hypodermically give a better and quicker result.

"The Practise of Obstetrics by American Authors," Jewett, publisht by Lea Brothers & Co., says '

In primipara the after-pains are rarely severe enuf to demand interference, in multipara they may be very annoying and may seriously discommode the patient, interfering with sleep and rendering her miserable. Under such circumstances some treatment must be instituted. The physician should never consider any discomfort of the patient as too trivial for his serious attention, and tho at times he may not think it wise to have recourse to drugs for her relief, he will not hesitate to employ them whenever the situation demands ic. Opium, or its alkaloid, morphin, relieves pains more effectually than any other drug in the Pharmacopeia, but it is not always well tolerated. Chloral, alone, even in comparativly large doses of 15 or 30 grains, is not very efficacious in relieving pain, altho its effect is quieting. Some such combination as the following generally acts very well: Morphin sulfate, % to 4 grain; chloral hydrate, 10 to 20 grains. Bromids are practically worthless against acute pain; they act slowly and very feebly. Antipyrin, antifebrin, acetanilid, and phenacetin have considerable analgesic action and are occasionally of service. Their use, should, however, in no case be prolonged, as they are all depressants and are said to interfere with involution. Should opium be given, it is necessary to keep its constipating action in mind and be governed accordingly.

Opium is generally required in only small doses, and if some of the milder forms be employed, the constipating effect is practically. nil. See also our Editorial on Early Involution and After pains in this issue.-ED.]

Liquor Habit Cure.

Editor MEDICAL WORLD:-About three months ago an agent for the Willis Liquor Habit Cure of Indianapolis came to our town giving free samples and taking orders. There are today to my own knowledge eight men here who claim that it has cured them. It failed on one, but did him no harm. He says he didn't care for the liquor, but merely drank it to see if he could. I secured a few sample five day treatment powders and inclose two of them. Kindly let us know thru THE MEDICAL WORLD the composition of these so we may all have a chance to benefit our patients. FRANK POLLARD, M.D.

Albion, Cal.

[We are not able to tell exactly what the powders contain, but they are probably ccmposed of bitter tonics, as gentian, columbo, crude nux vomica, etc., and some saline eliminant, or possibly a bromid. We are reasonably certain that those eight men could have abandoned their bibulous habits without the powders. The benefits derived from such nostrums as this are due largely to the power of suggestion, plus the will power of the man. All such preparations are "fakes," yet we

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[It is not possible to give any schedule of fees which will suit all sections of the country. There is a growing tendency thruout many sections to gradually raise the ridiculously low fees so prevalent in many country districts. This tendency is manifested by both veterans and by young practicians, and certainly when the old men are willing, the young ones should not be bashful. A community values a physician's services in accordance with the value he puts upon such services. Therefore, it is well to charge fairly good fees from the start. We have known young men build up a practise in a community where the older men had accepted shamefully low fees all their lives, mainly by charging what some term "fancy prices." Do not be exorbitant or unreasonable, but consider what it has cost you to learn how to do it, and what it is worth to the patient, before you name your price. Many

practicians get good fees out of simple fracture cases by charging $5 to $15 for reducing the fracture, and enuf at subsequent dressings to make a fair amount in the end; where, had they named the total amount at the first dressing, it would have certainly been disputed. We should say any country practician who properly attends his fractures, and who has his patients come to him instead of taking up his time by going to them-such cases as are going about, we mean-could easily get the following fees: Clavicle, $10 to $20; humerus, $15 to $25; Colle's, $15 to $25; femur, $35 to $75; Pott's, $20 to $30. This includes reducing and subsequent dressings. Some doctors, you know, dress a Colle's fracture and never see it again till the splint is removed; such treatment is not worth as much to the patient, even if results are equally as good, as if the doctor redresses it every three or four days. It all depends on how you do it. Let us have discussion on this subject. Possibly some may think the above too moderate. Remember, we have the average rural community in mind. In some rural communities, ready money is usually scarce, and $5 or $10 seems a large amount; other rural communities not seem more than $5 or $10 in the former. are very prosperous, in which $50 or $100 would We are sorry to say, however, that these communities are exceptional. The practician must use his judgment. We, in these pages, can only suggest extremes and approximate averages. Some years ago we publisht schedules of fees from various parts of the country. Perhaps it is time to do this again. If your local society has adopted a schedule of fees, including fees for medical and obstetrical attendance, as well as surgical, please send it in, and we will publish samples of such schedules from different parts of the country for comparison. This request is extended to all our readers-and that means that this request will reach every part of this great country, including Canada.-ED.]

Myelitis.

Editor MEDICAL WORLD:-I am just a little late for sketch, as I am very anxious to receive help on the folthis month, but hope you will make space for this lowing case:

Three months ago I was called to see a patient living in Georgia, who had been sick from November 1902. The history of the case was such as to lead me to believe he was suffering from myelitis. He had had all the characteristic symptoms of that disease: Chill, fever, and general malaise; hands swollen and a peculiar tingling sensation, etc. He was treated for his liver by two other physicians before I saw him. At the time I saw him he was much better, having passed thru the initial stage of the disease, tho complaining of pain in the back, with a band or constriction around the body. Percussion developt soreness of the spine and muscular soreness of the limbs, tingling, formication, and left leg swollen to the knee; the pupils some

what contracted; threatened at times with slight dyspnea pulse frequent and irregular, heart's action weak; constipation. Also there was perfect anesthesia of the soles of the feet, and a disagreeable sensation or feeling of "fidgets." At this stage he was only taking liquid phosphate of sodium in teaspoonful doses three times a day for his liver. I let him continue the same as he exprest himself pleased with its effect, but advised him to take a dose or two of blue mass every second week, which he says relieves his peculiar feelings about the bowels. I then ordered mercury bichlorid one grain, potassium iodid 150 grains, comp. syr. sarsaparilla 12 fl. drams, water to make four ounces. Teaspoonful, increast to dessertspoonful after meals, in water.

While I knew no syphilitic trouble existed, I believed the iodid of potassium to be a good eliminator of effete matter. I ordered glyco-heroin four ounces, tinct. digitalis two drams to control dyspnea and heart's action. Teaspoonful every two or four hours when symptoms occurred. I ordered strychnin sulfate one grain, arsenious acid one grain, dried iron sulfate forty grains, euquinin forty grains, made into forty pills. One after meals. This was prescribed as a general tonic, but was never filled, not being able to get it at his drug store.

His kidneys were not acting well, altho urin seemed to be normal in amount, etc., and had previously been examined and found in good condition by other doctors. I ordered lithiated hydrangea (Lambert's) eight ounces, bromid of potassium one ounce, tincture of hyoscyamus two drams. Teaspoonful three times a day.

I saw no more of him till yesterday, when he came up to see me. I found him much better, and he tells me when he takes a dose of the hydrangea preparation the numbness, tingling and plantar anesthesia, and coldness (in spots about over the top of thighs, etc.) are relieved, and it warms him up in a few minutes.

I might add that his appetite remains good, but digestion somewhat sluggish. The pulse is a little below normal and has a double beat. The mind is clear, and while cold tingling sensations are mostly confined to certain spots, the tingling sensations are felt all over the body. He is continually rubbing his hands, arms, legs, feet, and face, and even his head, nose, etc., and smacks his mouth frequently as if trying to taste something.

I hope I have made this case plain, but if anything else is lacking, would be pleased to explain more fully. I might add that he is 60 years of age, and has been a very activ, energetic man. Has been merchandizing ever since 1866, and believes his disease to have started from a rheumatic background.

I would like the Editor to tell me what to do, and the brotherhood by letter and thru THE WORLD.

What do you think of giving iodid of potassium in full doses? Am I right in my diagnosis? The tingling sensation now is the most annoying symptom to deal with; the pains have all ceast, but the soreness in the muscles is felt to some extent. The swelling and pitting in the legs are about relieved, while the palms of the hands and soles of the feet have a hot sensation, and the toes at times pain considerably. When he attempts to walk there is a feeling as if a cushion were placed between the feet and floor, but this has been greatly relieved, but a considerable feeling yet exists. He is able to be up now about half his time. Some days he feels very well, and other days much worse. secretions are good, tongue clean, eyes normal, and the peculiar feeling of sensation is more of a numbness than tingling at present. He describes it being more like being shockt by a battery than any thing else. Chattanooga, Tenn. L. CASE, M.D.

The

[You were late for last month. Every query must be in before the 12th, to get a reply in the issue dated the month following.

We think you were right in your diagnosis. We believe we would have given larger doses of potassium iodid, as he became accustomed to the drug, stopping short of iodism, of

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Editor MEDICAL WORLD:-Will you please explain salivation? Do fruits, such as oranges, lemons, etc., play any part in salivation, if eaten when a patient has taken calomel? If so, how do they act? Please give best treatment for salivation. C. E. CALHOUN, M.Ď. Talihina, I. T.

[Ptyalism is a better term than salivation. It refers to a well known symptom of mercury poisoning. Mercury is eliminated from the body in the form of albuminate of mercury, and all the secretions contain it-tears, sweat, urin, feces, milk, and saliva. After a single dose the elimination begins within two hours and is completed within twenty-four hours, but when repeated doses are given it accumulates faster than the body can eliminate it, and hence poisoning occurs if the doses have been excessiv, or if they have been too long continued. The juice of fruits have no influence in producing ptyalism after ingestion of mercury in any of its forms. Ordinary cases are amenable to frequent rinsing of the mouth with a saturated solution of chlorate of potassium; severer cases may require painting with a saturated solution of iodoform in ether. The excessiv secretion of saliva may be checkt by to grain of atropin given once or twice a day. Morphin may be required to relieve pain and secure sleep.—ED.]

Rectal Ulcer.

Editor MEDICAL WORLD-I very much admire your concise and practical answers to queries in THE WORLD. I am troubled with a rectal ulcer of four years' duration. Rather extensiv, but superficial. I am 34 years old, and spend a good portion of my time in the saddle doing a country practise. I have treated it by rectal irrigation and ointments, used in pile pipe, but perhaps have not been thoro enuf. If you will kindly give me a few suggestions as to best method of treating it, also name and publisher of reliable work on rectal trouble of 200 to 300 pages, I will be under many obligations. Is the trouble likely to be difficult to cure? H. S. W.

Alabama.

[You will not be able to effect a cure by injections or by ointments used thru a pile pipe. Rectal ulcers are difficult to cure with the very

best of attention; so much so that nearly all writers omit mention of any local application, and universally advise operation. Our experience has been that they can generally be cured by proper local measures, if long enuf continued, and at proper intervals. You may not be able to attend your own case, since the first requisit in treatment is thoro and absolute cleansing of the ulcer, and this is only possible with the aid of a good speculum and a skilled or intelligent assistant. The only speculum worth the general practician's money is one made after the Kelly model. The proper size would be 5 inch for your case. It can be bought from Frank S. Betz Company, Chicago, for $1.20 postpaid, or you may get it more conveniently from your local dealer. If you have a friendly practician within reach. every day or every alternate day, you would better enlist him.

If you are too far from any friend in medicin, you may instruct wife or friend as to the proper method of introducing the speculum, manner of locating the ulcer, and method of treatment. Any one who can locate the ulcer can treat it for you, and if you are far away from help, you might take some one with you to some good physician's office and let him see the ulcer exposed thru the speculum; he could then treat it after your return home. The insertion of the speculum is painless if it is lubricated, and the patient "bears down" gently while the speculum is slowly pusht to position. The ulcer is then located, and the plug withdrawn. The ulcer is then thoroly cleansed by repeated swabbings with pledgets of cotton on an applicator which has been wet with water, hydrogen peroxid, or bichlorid of mercury solution in the strength of 1 to 2000. Powdered iodoform, full strength, is then dusted into the ulcer, and the speculum withdrawn. This treatment is given daily at first, every other day a little later, and once a week as the ulcer heals.

Systemic treatment includes tonics such as iron, quinin, and strychnin in maximum. dosage. The bowels must be kept moving at least once a day by some laxativ which is not irritating to the lower bowel. All irritating foods, and those which leave a large undigestible residue, are to be tabooed. Condiments must be excluded.

Saddle riding will not have any influence in the case. Proper cleansing and medication will heal this ulcer (any possible specific and tubercular history of your ancestors excluded) if it is above the grasp of the sphincter, and the proper local applications are made. Vol. II., Diseases of the Intestins, Hemmeter, pub lisht by P. Blakiston's Son and Co., is an excellent work on diseases of the lower bowel. -ED.].

A Cry For Help.

Editor MEDICAL WORLD-A year ago last fall, after riding a bicycle, I experienced a markt sense of discomfort in the perineal and supra-pubic regions, and a frequent desire to urinate. Did not consult a colleag until this had abated somewhat, under selfmedication; he told me that I had probably had a prostatitis. Above symptoms yielded somewhat to internal administration of benzoic acid, but have never been entirely absent since. Examination per rectum revealed a slight enlargement of the middle lobe of the prostate, but not large enuf to account for trouble. Repeated urinalyses proved kidneys to be normal, and microscopical examination of the blood gave no noteworthy results. Administration of salol excluded both renal disease and rheumatism. About six months ago a dull pain developt in region of sacrum, and on awakening at night or in morning I found my penis in state of erection. Coition the evening before made no difference in this respect. Fearing a spinal complication, I consulted our two best authorities on diseases of the nervous system in my nativ city, who assured me that there was no lesion in either the spinal cord or brain. Sensation in sacrum is more that of soreness than pain. I have tried saw palmetto and santal preparations in vain, and have experimented with hyoscin, hyoscyamin, ergot and nux vomica, etc. Hot sitz-baths and nocturnal administration of monobromate of camphor produced no appreciable effects. Large doses of the bromids prevented the priapism for a while, but not permanently. Small doses of Dover's powder had a similar effect. But now nothing seems to produce favorable results, and soreness in back is present every day and erections every night. Urination is difficult at times, fluid coming away in driblets; but when bladder is full I experience no difficulty in passing my water. Stone in bladder excluded by examination with sound. Am 43 years of age, married and father of two healthy children. Never had venereal disease. Am frequently afflicted with neuralgia, particularly supra-orbital, and stomach easily gets out of order. Urethroscopic examination in my case revealed normal urethra. Father died of carbuncle at age of 65, and mother of osteo-sarcoma at age of 62. Diagnosis in my case still obscure. What might it be? Will colleag having had experience in similar case kindly outline proper treatment and oblige a suffering fellow practician who signs himself H. E.

[Doctor, we must compliment you upon the succinctness of your report, and congratulate you upon the excellent treatment you have received. We believe in addition to a prostatitis, that you have been suffering with subacute cystitis, and that this accounts for the persistent and frequent erections. This, as you know, is a difficult affection to treat, and especially for one who is much on his feet, or traveling. Any good modern text-book will give you the latest approved methods for combating this trouble. In addition to their recommendations, we add the following hints: epsom salt is the best laxativ when such a drug is needed in the course of treatment, the salt having a selectiv action on the vesical mucous membrane. The old fashioned, and now little used, mucilaginous drinks are valuable aids to other medication and measures; we refer to infusion of true slippery elm bark made from the fresh bark, and to infusion of flaxseed. We would not consider strychnin indicated in your case; other tonics, like the simple bitters would be preferable. Diet will

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have considerable influence in your case. Strong meats and spices should be avoided, and no liquor of any kind should be taken. You should accustom yourself to drink large quantities of water every day, and coffee or tea, if taken, should be in moderation. The fact of your suffering with neuralgia shows that you have a tendency to the lithemic diathesis, and you must remember that after repeated examinations, it is quite possible for rheumatism to exist without furnishing evidence which our best tests can reveal; neuralgia and rheumatism are at least "first cousins," anyway. Make sure that your daily excretion of urin is fully up to the normal. We hope that these suggestions may lead you to a plan of treatment which will result in a cure.-ED.].

Gastro-Intestinal Trouble.

Quiz Dept., MEDICAL WORLD:-I would like help in the following puzzling case: Married man, aged 30 last March, after eating a little cold wienerwurst sausage at dinner, which had been left over from dinner two days before, was taken with vomiting, which continued all night, with severe pains. The next morning he was treated with all the known remedies, such as bismuth, ice, antiseptics, antispasmodics, etc., and was finally quieted with a large dose of morphin hypodermically, only to break out again on getting over the effect of the morphin. He was treated by several good physicians but the pain still was very bad nearly every day, but almost entirely confined to his back, not always in one place, but generally all over, from shoulder blades to sacrum; relieved best by 1st, rubbing and pinching up the skin so hard that it hurts as soon as the pain is gone; 2nd, Faradic battery; 3rd, and most peculiar, he will lie on his back with knees over his head or high up against a wall, squirming and twisting until relief comes. He almost never has it after 10 at night, but it comes on at 4 or 5 in the morning. He is sometimes nearly free from pain for a day or two and sometimes suffers nearly all day, getting relief only to have another attack. In July he went to a sanatorium and was confined to bed and to a milk diet for three weeks. He was very much reduced in flesh. I have had charge of the case since then and have obtained the best results from occasional doses of calomel and soda and large doses of oliv oil with bismuth. He has for a year past had feelings of faintness when his bowels moved. He still suffers with his back, but when the pain leaves there is a good deal of rumbling in his bowels. He does not vomit any more, has a good appetite, has regained what flesh he had lost. He vomited a few streaks of blood two or three times. No kind of food makes him feel worse excepting mush, which feels heavy. Oysters with lots of red pepper make him feel good. For several months his pulse was near 100 and temperature about 99°. It does not hurt him to lift. Excitement seems to relieve sometimes, at others it does not. Yesterday he had a bad spell in an exciting chase after a bear, alone with his dogs. The day before it commenced suddenly while milking, and he had to take his inverted position on his head and shoulders and squirm and strain hard and twist for ten minutes, then finisht milking, altho suffering pain; has occasional pains on lower left of abdomen, then it will change to lower right or to left shoulder, but always the worst is in his back. What is the trouble and what will cure him quickly and finally. He has taken glycozone, bismuth, charcoal, hot water and hosts of other things. Please do not publish name or address, as this is a noted case for miles around. MEDICUS.

[You have, of course, a case of chronic gastro-intestinal indigestion, secondary to the

acute gastritis caused by the tainted meat. When the food ferments in the stomach or bowel, the gas collects in some of the ramifications of the intestin, and by pressure on the inflamed gut causes the pain. Such pain may be, and often is, referred to the back. In such a case, the pain is felt at a point distant from the site of irritation, just as the pain of hip joint disease is constantly referred to knee or foot instead of the hip. The vomiting of blood streaked mucus is not uncommon in such cases.

As to what will "cure him quickly and finally," that is quite a different proposition. Your calomel and soda helpt him because it hastened the passage of the intestinal contents and helpt to check the fermentation; the oliv oil likewise acted as a simple mechanical lubricant to the inflamed and congested mucosa, while at the same time acting as a laxativ.

The problem is to check the fermentation, relieve the state of chronic congestion of the gastro-intestinal mucosa, and keep the bowels free enuf that no toxic or irritating substances may remain long enuf to cause irritation sufficient to provoke an attack. The condition will be allayed, therefore, by appropriate food and mastication, by artificial digestants for a time, by mechanical lubricants or "intestinal antiseptics," and by keeping up a rather free bowel excretion without deranging the digestion by administration of strong cathartics. Study of your therapeutics and experimentation will enable you to find the agents of choice for his particular case. Our first suggestion would be silver nitrate in solution, and also in pills so coated that they will only be soluble when they reach the intestin; in this way you will reach both the stomach and the intestin with your drug. Better begin with

gr. doses, and increase as toleration is establisht; an excessiv dose at the outset, in solution, will provoke nausea and vomiting. Remember the 50 grain therapeutical limitation. The faintness on evacuation of the bowels is not an unusual feature of such cases, and is best met by having the stool semisolid; occasionally cases do better by using the syringe and warm water when sensation of pending evacuation is felt, so as to dissolve the stool and prevent too great irritation of the lower bowel as the stool is passed. Non-alcoholic fluid extract of hydrastis in generous dosage will help him. Bismuth relieves nearly all such cases, but its action is purely mechanical, and it is problematical whether any permanent benefit accrues from the use of the drug.

Now you have the problem and its solution, with some of the equation workt out, but it can not be completed on paper.—ED.].

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