The Medical Herald

Incorporating the

Kansas City Medical Inder-Lancet

Under the Editorial Direction of

Chas. Wood Fassett and S. Grover Burnett

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(Entered at the St. Joseph P. O. as second class matter.)

For Sale.-Second hand nebulizer and physician's chair. Write or call for price. Bender's Pharmacy, 11th and rederick avenue, St. Joseph, Mo.

For Sale.-Instruments, books, and office equip ment. Address "Retired," care of Medical Herald, St. Joseph, Mo.

When confronted by stubborn, unruly, cutaneous conditions, the physician will do well to make his prescription read elixir iodo-bromide of calcium comp. (Tilden's) either with or without mercury bichloride, as conditions require.

CAUTION! Whenever the true merit of

a preparation is authoritatively established, imitation is sure to make its pernicious appearance. To counteract the injurious results of another of these fraudulent proceedings-in this instance affecting firm name and reputation-Sander & Sons have been compelled to appeal to law, and in the action tried before the Supreme Court of Victoria, the testimony of a sworn witness revealed the fact that this witness suffered intense irritation from the application to an ulcer of the defendant's product, which was palmed off as "just as good as Sander's Eucalyptol." Sander & Sons had the satisfaction to obtain a verdict with costs against this imitator, who is perpetually restrained from continuing his malpractice. Dr. Owen, in a report to the Medical Society of Victoria, and Dr. J. Benjamin, in the Lancet, London, both denounced, as others did before, on the strength of negative results, the application of unspecified eucalyptus products.

This forms convincing proof that only, an authoritatively sanctioned article can be relied on.

SANDER & SONS' EUCALYPTOL (Ecalypti Extract)

1. Has stood the test of Government in vestigation.

2. It was proved at the Supreme Court of Victoria by experts to be an absolutely pure and scientifically standardized prep

aration.

3. It is honored by royal patronage. 4. It always produces definite therapeutic results.

Therefore, to safegaurd the physicians' interest and to protect their patients, we earnestly request you to specify "Sander's Eucalyptol" when prescribing eucalyptus.

The Meyer Bros. Drug Co., St. Louis, Mo., agents, will forward one original package (1 oz.) on receipt on One Dollar.

Fine Opening for a Physician.-Owing to the recent death of a physician in a central Missouri town, there is an excellent opening for an energetic, well-qualified doctor in a town of 1000, with splendid surrounding territory. A good physician with a little cash to buy half interest in a paying drug store, will find this a chance of a lifetime. Write at once, stating your age, qualifications, and experience. Address, "H.L.B." care Medical Herald, St. Joseph, Mo.

ENGRAVING

TEACHENOR-BARTBERGER

ENGRAVING COMPANY DESIGNERS, PHOTO-ENGRAVERS. KANSAS CITY, MISSOURI

Vol. XXXII

By the errors and accidents of surgery we are taught quite as surely as by our successes. This is an old observation. But the remarkable case to be here recorded illustrates how even when we are on the watch for a particular source of inaccuracy and when we have taken all reasonable precautions against it there may appear nevertheless, complications so unexpected that the most careful and scrupulous will be led astray.

Miss Mary M., about 33 years of age had had typhoid fever two years before her present illness. For more than two months she had suffered with pain in the nephroureteral regions, most marked on the right side, and at first accompanied by high fever. At this time she was in a distant city, but as soon as the constitutional symptoms had somewhat subsided she came to New York and entered the private pavilion of Mt. Sinai Hospital. There was then frequency of urination and what she called a "pricking feeling" most noticeable on the right side. The temperature varied between normal and 102 degrees. The acid urine contained a large quantity of pus and some red cells. Cystoscopy demonstrated a mild cystitis, both ureteral orifies being free and admitting the large catheters which withdrew clear urine from both kidneys.

A radiographic plate by Dr. Jaches showed a dense shadow of oval form just above the spine of the right ischium its long axis directly in the course of the

ureter.

It appeared to be the shadow of a stone about one centimeter long and four or five millimeters in its shortest diameter.

In order to promote diuresis and with the idea of flushing the urinary tract so as to dislodge the calculus Miss M. was told to

No. 4

take large draughts of water between meais. Also, I injected sterile olive oil behind the "calculus" so as to force it downward if possible. Another X-ray taken after some weeks of this treatment showed the shadow unchanged so I determined to operate.

In order to be absolutely sure that the object was indeed a stone and not a calcified lymph-node or a phlebolith I passed a socalled X-ray catheter into the right ureter an hour before the time set for operation and another radiogram was made. This showed the catheter very nicely, passing directly by and apparently touching the "stone." The roentgenologist, a man of great experience, gave it as his opinion that the shadow was indeed that of an object within the ureter. With the catheter still in place to act as guide, I made an incision in the inguinal region through all the structures except the peritoneum and easily palpated the "calulus" within the ureter. The soft parts covering the object were grasped with toothed forceps and drawn up toward the surface, the "stone" coming along and to my surprise coming away from the ureter, which I could easily prove by palpating the catheter. So certain was I still, however, that I explained this phenomenon by assuming that the "stone" must be in a diverticulum of the ureter.

Carefully dividing the soft tissues I extracted a smooth, glistening object the size and shape of the shadow, but evidently not a ureteral calculus; nor did it look at all like a calcified node. Dr. Eli Moschcowitz, the patient's physician and an experienced pathologist, made a section of the little body and from its peculiar laminated appearance was inclined to believe that it was of osseous histology. He later made a laboratory examination and reported that

after all we had been dealing with a phlebolith.

To make sure that the ureter had not been incised I injected air through the catheter, still in place within the viscus, and filled the wound with water. There was no bubbling.

During the manipulations the peritoneum had been opened at one point and I fortunately took advantage of this to explore the right iliac fossa. To my surprise a rather smartly inflamed appendix was delivered and it was ablated in the usual manner. Its walls were much congested, thickened and extremely tense. The peritoneal opening was now sutured and the entire wound closed without drainage. Healing was satisfactory and Miss M. went home in good health three weeks after the operation.

Reviewing the unusual points in this puzzling case it will be interesting to consider how perhaps we might have avoided the diagnostic error.

The fact that clear urine was drawn from each ureter might at first sight suggest the impossibility of kidney infection; and in the presence of pus in the mixed urine might have made us think of cystitis or even so rare a condition as triple kidney or multiple kidney-pelvis with an infection in one chamber.

On careful search of the bladder, however, there was nothing which looked like a third ureter, and also the radiographic picture showed us two clearly outlined kidneys of normal size.

Cystitis we knew was present, but this, too, is a not infrequent accompaniment of renal infection.

I have on one occasion at least, observed intermittent limpidity in the urine drawn from a distinctly pyogenic kidney, and I have at operation removed this kidney and carefully inspected its interior without discovering any explanation for the phe

nomenon.

In the case of Miss M. we had a perfectly oval shadow apparently in line with the ureter itself. And this shadow was on the side where the subjective symptoms were most pronounced, though in the light of subsequent events, including the relief afforded by appendicectomy, it is clear that these symptoms were those of a chronic appendicitis. It is well known that many

an innocent appendix has been removed for the cure of right sided pain due to a calculus of the ureter. Here the position has for once been reversed and an operative exploration for ureter stone has been undertaken in a case of appendicitis complicated as it was with the pyuria of an acid cystitis.

It is possible that the error might have been avoided had we employed stereoscopic radiography. But even with this refinement it must not be forgotten that the phlebolith was so close to the ureter and that it lay in such lax areolar tissue that perhaps nothing thicker than the wall of the normal ureter lay bewteen the "stone" and the opaque catheter. And this argument would hold also, had we distended the ureter with a solution not transparent to the Roentgen ray.

In a similar situation, however, I should employ stereoscopic methods.

This patient is now quite well. The distressing right abdominal sensations are gone and the cystitis has yielded to medical treatment. Since her discharge from the hospital she has kindly consented to a final radiography which failed to show any ab normal shadow.

In spite of the difficulties of this trying case with its error in diagnosis it is gratifying to report a "cure" instead of merely an unnecessary, operation.

48 East Seventy-fourth.

A

car.

C. S. PETTUS, M. D., Little Rock, Ark.

I have taken the liberty to change the title of my paper from fallacy in surgery to the subject just announced.

Possibly I should title it a hybrid, that of dogmatic fallacy in the work of the untrained surgeon, as I shall deal with his peremptory opinion displayed in surgery, as well as the sophistic reasoning he many times demonstrates, which is evidently done for the sake of an impression, or through the lack of knowledge, or to swell his fee. The profession has much to say of the quack who advertises himself as a cure-all with drugs, but nothing is said derogatory of quackery in surgery which is practiced all over our country. Surgery offers the better field for the quasi doctor to impose upon the public than medicine by retaining a certain degree of prestige with organized medicine, having its protection while he continues to slaughter and deface.

Unfortunately the spectacular attraction of surgery has more to do in influencing many to enter surgery than the scientific aspect of the work, on account of the captious reasoning that courage is the only requisite to success in surgery. They overlook completely the necessity of surgical knowledge, knowing there will be a silence among the profession, which by their failure to condemn, is rather an endorsement. Then the credulous public's willingness to give them the distinction of being surgeons because they incise, remove and suture, has its effect to lead many astray, causing them to attempt matters of surgery of which they know nothing.

The idea the public has of surgery is a stimulus to many that beckons them on, and causes them to conclude they have some surgical ability. For instance a curet

The following papers were read before the Medical Association of the Southwest at Hot Springs, Ark., Oct. 8-10,

1912.

tement is by them considered an operation; to do that they are under the impression it demands as much surgical skill as to do an anastomosis.

Such an idea of surgery is entertained by many doctors. This is the opinion of a certain physician who never did an operation and whose clinical experience extended to a school that graduated in three years. He lamenting the fact he had no infirmary to take surgical patients, as so many of his clientele wanted him to operate.

The amount of surgery done thoughout the country by those unprepared is surprising. I know an undergraduate who has done several laparotomies and assures the public he is thoroughly capable to do all kinds of surgery.

The fact that in many instances they get through some way and the patient survives warrants them to pursue surgery boldly.

The number of curettements done by those who are unable to do scientific surgery, and knowing an operation is needed, resort to such, are as numerous as the sands on the sea-shore.

I want to pause just here to say that if it was against the law to do a curettement, the women of America especially of the South would be much better off.

The idea is prevalent that to use the knife is all that is essential to become a surgeon, and the elimination of such unscientific practices can go through but one channel, namely, educating the public and impressing on the profession the necessity at all times to consider the welfare of the patient as well as the dignity of the profession, and the necessity of the surgeon carefully ascertaining and properly estimating the values of the facts relating to his cases. that the outcome of his advice and procedure will not needlessly inflict the patient, nor cast opprobrium on himself or the profession.

It is to be regretted that the greatest thing in surgery is so often thought of the least a knowledge of pathology and the