illness of his father, who subsequently died, and he asked that his patient go to another physician, whom he named, which physician was left to care for the other patients of the doctor who first treated the finger. The woman did not go to the other physician, but subsequently went elsewhere, and on March 2d it was necessary to amputate the finger, and she sought to hold the doctor who first treated her liable by reason of his failure to give treatment after February 22d. In this case (84 Maryland 363) the court held that where a physician, instead of going to the home of his patients, maintained an office to which his patients were in the habit of calling, the same duty devolved upon the doctor to be at his office for subsequent treatment as devolved upon the general practitioner to make subsequent visits. But under the facts stated in the Maryland case the physician was absolved from any liability by reason of the due notice of his departure, which he had given, together with the ample provision which he had made for the subsequent treatment of his patient, but which advice the patient in question neglected to follow. A somewhat similar case was decided by Judge Taft (now of national reputation) when on the United States Circuit Court bench, for the Southern District of Ohio. In this case Mrs. E. had employed Dr. G., an oculist and surgeon, to treat her eye. He made an operation and continued his treatment until he was called out of the city. He gave notice of his intention to go, and left word with his patients that another reputable physician would look after his patients while he was away. There was some conflict in the discussion as to whether or not the patient went to this other physician, but Judge Taft held that the absence of Dr. G. under the circumstances, he having given notice and provided for the necessary treatment of his patients, absolved him from all liability, and the case was taken from the jury and a judgment entered in favor of the physician. The same duty of continuous treatment exists even though the treatment be gratuitous. This rule is peculiar to such employments where a peculiar knowledge or skill in the employed is a part of the service contracted for. Ordinarily an agent who acts without compensation is only liable for gross neglect or wilful and malicious fraud, but a physician, although he may know that he will never be paid for any service he may render in a case, if he has once undertaken it is under obligation to see it through, unless he terminates the relationship of physician and patient by one of the two methods above given. As well said by Justice Pryor in Becker vs. Janiski, 27 Abb. N. C. 45: "It appears that the plaintiff was a charity patient; that the defendant was treating her gratuitously. But I charge you that this fact in no way qualifies the liability of the defendant. Whether the patient be a pauper or a millionaire, whether he be treated gratuitously or for reward, the physician owes him precisely the same measure of duty and the same degree of skill and care. He may decline to respond to the call of a patient unable to compensate him; but if he undertake the treatment of such a patient he can not defeat a suit for malpractice nor mitigate a recovery against him upon the principle that the skill and care required of a physician are proportioned to his expectation of pecuniary recompense. Such a rule would be of the most mischievous consequence, would make the health and life of the indigent the sport of reckless experiment and cruel indifference." The physician first treating a case who recommends another physician for subsequent treatment is not liable for any lack of care and skill on the part of a physician recommended, if such physician is practicing medicine independent from the physician recommending him. If the physician recommended is a partner, or if he is actually employed by the other physician as a mere clerk or assistant, a different rule applies, and the act of the agent or lack of skill on the part of the agent will be imputed to the principal, who will be responsible therefor. The duty of determining what continuous treatment is necessary, and of rendering that continuous treatment, has been held to be a duty which the law imposes on the physician incident to his contract of employment, and is not itself a part of the implied contract, but a necessary incident thereto. The patient may discharge the physician at any time, and such discharge terminates the physician's liability for subsequent injurious consequences; but of course does not relieve him from any liability which may have been incurred prior to such discharge. Many practical reasons may suggest themselves why a physician who undertakes a case should continue the treatment thereof for his own benefit, as well as to prevent the opportunity of malpractice of others being laid, or attempted to be laid, at the door of the first physician, but the design of this paper is to make known those legal phases which the practitioner is bound to know, for "ignorance of the law will excuse no one." QUININE TANNATE IN MALARIA. Quinine tannate is coming into favor with Italian physicians as a very efficient remedy against malaria, especially in children. Since the bitter taste of the usual quinine preparations makes their administration to children difficult, the nearly tasteless tannate is unquestionably to be preferred. It must, of course, be given in larger doses than the other salts in order that the quantity of actual alkaloid administered may be the same. It is best given with chocolate, preferably in the form of tablets or powders.-Pharm. Centralh. THE GILLIAM OPERATION FOR DEVIATIONS OF THE UTERUS. BY D. TOD GILLIAM, M. D., Columbus, Ohio. [Written for the MEDICAL BRIEF.] This, the original round ligament ventro-suspension of the uterus, in which the ligaments are left intact and in their natural relations, has steadily grown in favor and is now being used by many of the best gynecologists in this and some foreign countries. Its chief recommendations are its simplicity and ease of execution; its non-interference with the cardinal functions of the uterus, pregnancy and parturition; its freedom from unpleasant sequelæ; its applicablity to all forms of displacement, and its adaptability to combined operations where time and the minimum of interference are matters to be considered. Operation. (1) An abdominal incision three or four inches in length is made in the median line at the usual site between the umbilicus and pubes. (2) The adhesions are broken up and the fundus brought forward. (3) By lifting up the broad ligament on one side on the tip of a finger applied to the posterior surface, the round ligament is brought into view and is picked up with a bullet forceps. (4) Selecting a point an inch and a half from the uterus, a thread is passed under the round ligament, and the ends of the thread are brought out of the opening and secured in the bite of a clamp forceps, which is laid on the surface of the abdomen. (5) The other ligament is sought for and secured in the same manner. (6) At a point about an inch and a half above the pubes, the peritoneum, muscle and fascia are caught up by a volsella and pinned together, being careful that the edges of these layers are in line. (7) Traction is now made, and with a claw retractor the skin and superficial fat are drawn in the opposite direction, and by a sweep of the knife the face of the fascia is laid bare. (8) With a narrow-bladed knife, or better, with a Cleveland ligature carrier, or some similar instrument, a stab wound is made from the surface of the fascia into the peritoneal cavity one inch from the edge. of the abdominal incision. If the ligature carrier is used, the jaws are separated, and by an outward movement of the handle brought into plain view at the large opening. The thread which loops the round ligament is now placed in the jaws, the clamp forceps removed, and the ligature carrier withdrawn, bringing with it the thread and the ligament. If a knife has been used to make the perforation, it is withdrawn and a slender forceps introduced, with which the thread is caught up and the ligament drawn into place. (9) Now, while the ligament is held taut with the loop end just above the surface of the fascia, a catgut suture is passed through it, including the tissues on either side, and back again, where it is tied. This is cut loose to the knot, the suspending thread cut on one side close to the ligament and withdrawn and the volsella and retractor removed. (10) The other side is dealt with in like manner and the abdominal incision closed. 50 N. Fourth Street. INTERCOSTAL NEURALGIA. BY DAVID N. KINSMAN, A. M., M. D. Professor of Clinical Medicine in the College of Medicine of Ohio Medical University, Columbus, O. [Written for the MEDICAL BRIEF.] Intercostal neuralgia is, briefly, pain in the chest, of a short, sharp, stabbing character, which immediately arrests respiration. It is located in the upper part of the chest, mostly above the seventh rib. It may extend to all of the intercostal nerves below, and, instead of being limited in the chest, may be felt over the abdomen. There are two forms, one due to neuritis and the other evidently depending upon simple functional disturbance. The former is associated ordinarily with herpes. It may be due also to tabes, caries of the spine, and to meningitis. Formerly, we had many cases of intercostal neuralgia due to malarial intoxication, though this latter causation no longer exists in Central Ohio, for the mosquito that transmits it has gone, and for twenty years there have been no cases of malarial intoxication in Ohio which were not imported. It may be confused with myalgia, pleurisy, or peritonitis. It is diagnosticated from the first by grasping the muscle in the hand and squeezing. If due to myalgia the pain is thus excited. This has no influence upon intercostal neuralgia. It is diagnosticated from pleurisy by the presence. of friction sounds upon auscultation, in addition to other signs of intercostal neuralgia, as the presence of pressure points looked upon as diagnostic ever since pointed out by Valleix. Treatment.-Treatment is rest in bed, reinforced by the application of broad adhesive strips from the spinal column behind, to the middle of the sternum in front. This compresses the chest and limits the motion of the intercostal muscles and the ribs which provokes this stabbing pain. The same treatment is equally valuable in cases of dry pleurisy. Recently it has been proposed to rub into the course of the affected nerve an ointment composed of one part of suprarenal extract to one thousand parts of lard. Internally, arsenic, quinine, cod liver oil or other fats in the diet are of value. Cups over origin of nerve of no value, I think. 603 American Savings Bank Building, High and Town Streets. DIAGNOSTIC SIGNS IN NERVOUS DISEASES. BY LEO M. CRAFTS, B. L., M. D., Professor of Nervous and Mental Diseases in the Medical Department of Hamline University; Visiting Neurologist to the City, Asbury, St. Barnabas and Swedish Hospitals, Etc., Minneapolis, Minn. [Written for the MEDICAL BRIEF.] Convulsions in infants are always important; they indicate at once nervous instability in the child. They may be due to any source of irritation like simple gastro-intestinal disturbance, intestinal parasites, cutting the teeth, and the like. While the individual spasm may not be serious, in the outlook is always the danger of merging into actual epilepsy, and the most painstaking attention to determining and removing the cause is essential. Similar seizures in youth or adult, whether mild or profound, are always indicative of either epilepsy, eclampsia, or due to gross cerebral lesions; more frequently the epileptic type, idiopathic or symptomatic. History ordinarily is important. Repeated attacks of partial blanks of consciousness with giddiness should receive early recognition, as petit mal, where vigorous treatment may save bursting into the major state. If the seizure, with tonic and clonic elements retains consciousness, showing the symptomatic Jacksonian type, the indication points strongly to gross brain lesion. The recurrence in any case of attacks of vertigo alone, which can not be traced to gastro-intestinal or aural conditions, is, as a single symptom, always suspicious of brain tumor. Unremitting cephalalgia, projectile vomiting, inequality of pupils and monoplegias point equally in the same direction. Also at times hemiplegias, mental irritability, disturbances of memory, vision and hearing in varying combinations. Various reflex reactions as a part of the sensori-motor mechanism possess signal importance; loss of patellar reflex usually indicates interference with the sensory side of the arc, becomes more significant when accompanied by reflex immobility of the pupil, and inequality in size should be noted; these being present without incertitude or lancinating pains may be sufficient for early diagnosis of locomotor ataxia. Increase in patellar reflex or variability, often accompanied by the same condition. of other tendon reflexes with or without irritability, is a common condition in simple functional nervous states of the neurasthenic order. In these also quite sharp attacks of vertigo are present, and not infrequently a moderate degree of ataxia purely of functional nature. Marked exaggeration of the patellar or other tendon reflexes, especially if clonic reaction is present in any part, more often the ankle, the conclusion must be of organic inroad upon the motor tracts. |