that the entire profession is committing an unpardonable sin-simply expressing a fear that the sin is on the increase. Knowing how well our competitors take an inventory of our happenings in daily work, I feel that we are all competent judges and are in a position to know. I have a knowledge of this and so have you, and the truth of my assumption is the subject of your honest verdict, and calls for a combined effort to check the unwise practice upon the part of healthy women to attempt to raise healthy babies away from the support of a healthy breast.

I can but feel that we are making mistakes-that we are culpablebut have no right to occupy your valuable time to discuss the matter at length. I simply express my regret that a gland which is the culmination of such anatomical beauty and excellence, and which is nature's purest legacy, should be the subject of such willful neglect, and express an earnest hope that intelligent, honest doctors will linger to practice medicine in accordance with methods which will yield the greatest returns to over-credulous humanity.

OWENSBORO, KY.

A FEW SCATTERING THOUGHTS.*

BY T. ATCHISON FRAZER.

The title of my paper does not indicate anything, yet it indicates most anything we may desire; it is rather impromptu, as I have had only six months for its preparation; it is liable to partially cover the field of medical science from the time of Hippocrates down to this good hour, and yet it is liable to scarcely touch either science or medicine for that matter; it will be mostly original, as I have not read more than one hundred volumes during its preparation, and I am satisfied you will think either the title fits the paper or the paper fits the title. There is no branch of our science that is more important to the general practitioner, and of yet more importance to the poor victim upon whom we are practicing, than diagnosis. It matters not how perfect our understanding of therapeutics, how skillfully we write our prescriptions, or how wise we look when we give the sorrowing loved ones our prognosis, favorable or unfavorable, if we have not yet made a correct diagnosis our opinion is worth but very little; and we should never be content until a diagnosis is made, for we have no right to an

*Read before the Ohio Valley Medical Association, Owensboro, Ky., May, 1902.

opinion unless that opinion is based upon facts; and a careful study of physical diagnosis will always pay us tenfold for our labor. Physical diagnosis studied by the bedside, studied while walking the streets, studied while in our office, and studied everywhere else, will always be useful to us.

Hippocrates gives us a nice example of physical diagnosis in his description of mumps, when he says "the disease is characterized by swelling of the glands at the angle of the jaw, and often, after exposure, the swelling retires to the testicles."

In order that we may make a careful examination of our patients we should know a few things about anatomy; we should remember that the spleen is in the left side and appendix in the right, and not make the mistake I once knew a doctor make in diagnosing appendicitis in the left side of the belly. We should also know whether or not a woman is pregnant before we curette the uterus, for if she is pregnant we might produce an abortion. When we are called to attend a woman in confinement we should know the presentation and the approximate diameter of the pelvis before we assure the good old women present that "everything is all right." We should never feel that we have done our duty until we have exhausted every means at our command to arrive at a correct conclusion. We should ever bear in mind that the history of many of our patients is only half told, and that that half is not always reliable. We should never be content after we have only counted the pulse and looked at the tongue, for the laity might suspect something and we might lower the dignity of our honorable profession. After any disease is diagnosed we should endeavor to make a reasonably correct prognosis, for the laity will often measure our skill by the accuracy of our prognosis; and many busybodies will delight in informing their neighbors that the doctor did not know, but if they had had Dr. A "he would have known as soon as he saw the patient."

Therapeutic measures should be applied with as much accuracy as possible, for after we have diagnosticated and prognosticated the patient we must begin to apply our therapeutic skill. First, we must select the remedies that are indicated in each particular case. We must study the indications and contraindications, also idiosyncrasies, and apply our therapeutic measures with all the accuracy possible; and before we prescribe a drug we should have a clear and concise idea of what to expect of each special drug. We must see that the dose is

correct; we must know that the nurse understands the directions properly, and we must impress upon the nurse the necessity of a strict compliance with our orders; and we must by our deportment impress all interested in the patient that we are masters of the situation. When our patients are in the most critical stages of disease we must be vigilant, and assert our authority in the most positive way possible. The more critical the condition of the patient, the more meddlesome the laity; the more suggestions they will make, and the more liable the family will be to do their bidding, and the more the physician's patience will be tried and his mind taxed.

Emergencies arise in every physician's practice, and no part of our memory is more vivid than that of emergency practice; times when our very souls are tried and our medical skill is taxed to its utmost; when a few moments mean the loss of a valuable life; when our patient is about to die from collapse, or about to bleed to death from a severed artery, or about to die from asthenia or post-partum hemorrhage, then it is that we must gather up all our reserve fund of knowledge and like valiant soldiers loosen the hold of the enemy on our patient. When the emergency has arisen we should use heroic remedies. When our patient is about to die of asthenia, we should not hesitate to give one-fifteenth grain of strychina and one-fiftieth grain of nitro-glycerine. We should not fail to repeat them in thirty minutes if we do not get the effect we desire; and oftentimes we will tide our patient over the crisis when otherwise we would have had a funeral.

When an artery is severed we should not hesitate to throw a ligature. around it and stop the bleeding. When we are confronted by postpartum hemorrhage we should not fail to act, and act promptly, for a moment's delay often means the loss of a valuable life. We should not fail to keep a record of all the births and deaths that occur in our practice, and make a report of same to the county court clerk on or before the 10th day of January in each year; for, if you do not, you are liable to indictment and the penalty of the law. Do not fail to collect every bill you can; and when you make a collection, be certain that the proper credit is entered on your books, for I meet many men that some cruel doctor has made pay his bill twice. But the trouble with us is in collecting our bills once. We should look diligently after the financial side of our professional life and endeavor to lay away something for a "rainy day."

How often do we see a physician who has worn his life away battling with disease, comforting the dying, consoling the bereaved, and ministering to the widow and orphan, and has reached the evening of his life without common comforts in his declining years!

We should always strive to bind the profession together by stronger ties, and we should endeavor to make all medical men one common brotherhood. We should avoid private piques and petty jealousies, and we should despise anything that tends to mar the unity of the profession.

Now, as I am about to close this paper, I am sure that the Association agrees with the assertion I made at the beginning, that the subject fits the paper and the paper fits the subject-if we were to apply a musician's term we would call it a medley.

MARION, KY.

ERRORS OF DIAGNOSIS OF CONTINUED FEVERS.*

BY HORACE T. RIVERS, M. D.

There is not a subject in the whole field of medicine that has been discussed more regularly in medical societies than that of continued fevers and their treatment. It is not my purpose to deal with this phase

of the subject, as there have been so many able opinions advanced and defined by very competent men that to review them in a paper of this character would be impracticable. I will confine my remarks to what I conceive to be the errors in diagnosis which we are liable to make in the atypical cases which we usually encounter in this decidedly malarial district.

Every physician present has seen cases like the following: May or may not have had an initial malarial paroxysm, with general malaise and slight afternoon rise of temperature, constipation, anorexia, and nausea; on examination you find large, flabby, heavily coated tongue, indented by the teeth; skin sallow; breath offensive; liver and spleen slightly enlarged and tender to pressure; perhaps some tympanites or gurgling in right iliac fossa, temperature one, two, or three degrees above normal. These cases have been variously called typhoid, typho-malarial, continued, and slow fevers.

Actuated by a desire to know the true diagnosis, last fall and winter I secured the blood and urine of thirty cases from the practice of several

Read before the Kentucky State Medical Society, Paducah, Ky., May 7-9, 1902.

physicians of Paducah and surrounding country, which were turned over to Dr. M. M. Cooley, who made the examinations for malaria and the Widall reaction of the blood; also the Diazo reaction of the urine. These specimens were from cases in all stages of the disease, and consequently the examinations for the malarial parasite were not as satisfactory as we could wish, as in the majority of the cases the patient had received heroic antimalarial treatment for some time before the specimen of blood was secured. The results of the examinations are as follows: Decided evidence of malaria was found in cases one, five, six, seven, and ten. The fever in these cases continued for eight, eight, thirteen, five, and sixteen days respectively. The Widall reaction of the blood in these cases gave negative results, as did the Diazo reaction of the urine. In none of the remaining twenty-five was the examination for malaria positive enough to cause us to think that the very few parasites present could be a factor in the disease, and especially so since in no instance did we find the æstivo-autumnal form, which is supposed to be the special one that causes the continued fevers. In this last class the Widall reaction of the blood was positive on the first trial in twenty instances; of the remaining, four were positive on the second and one on the third trial. The stage of the fever during which these specimens were secured was from the fourth to the thirty-fifth day. The results of the reaction became positive enough to recognize in from ten to forty minutes. In a majority of the cases the clumping would begin in fifteen minutes, especially if the blood was from a case during or after the second week. The Diazo reaction of the urine was positive in every case in which the Widall reaction of the blood gave positive results. In two instances in which the Widall reaction of the blood was negative on the first trial the Diazo gave positive reaction. In cases twelve, thirteen, fourteen, fifteen, sixteen, nine, three, two, and nineteen, during the course of the disease there developed all the symptoms that we would expect to find in a typical case of typhoid fever. Of the remaining sixteen cases a few developed some of the symptoms, but in not a case were the typhoid symptoms of enough prominence to warrant a positive diagnosis of typhoid fever that is, if we are to accept as gospel what we have been taught by medical authorities on the subject.

My conclusions are: First, that we often have typical cases of typhoid fever which are readily diagnosed as such. Second, that much more frequently they are atypical cases masked by malarial poisoning, and as such we have failed to properly diagnose them, but still typhoid fever just