Reply to Dr. Cooper.

Editor MEDICAL WORLD:-Pardon me for so soon again using my pen. It is an unavoidable effect, and Dr. Cooper's article, in the March issue, page 105, is the innocent cause. Dr. Cooper, to be consistent, would surely not complain of my attacking the cause. I agree with Dr. Cooper, that we should seek the cause, but not to the exclusion of everything else. Dr. Cooper is a clever writer and has the courage of his convictions, but his arguments sometimes proceed from false premises, and at other times lack logic.

A fever patient may be compared to a burning house; every conflagration, even the socalled spontaneous combustion, has its cause. According to Dr. Cooper's logic, when the fire department is called to a fire it should seek the incendiary, or the cause of the fire, and not extinguish the fire. But does it? It puts out the fire first and seeks the cause afterward. This may not be in the exact order of scientific methods, but scientific methods are not necesarily the most practical !!

Now, as to his "dogmas." First. "Never give a purgativ or laxativ at the beginning of pneumonia. How can one tell, on the first call, whether it is pneumonia ? I often rely on a calomel purge for a diagnosis, to wit: On February 22, 1904, I was called to a girl, 19 years old and an attendant of the State University. The complaint was fever, diffuse pain in abdomen and a slight cough. Her face was flusht, but did not evince any signs of pain, and her intellect was unimpaired. Her temperature was 103.4°, pulse 110, and respiration normal; her tongue was covered with a white fur, except tip and edges. quiry developt that she was constipated, but had diarrhea a few days previous. That she suffered from severe headache the past four days, and that two days before the headache she attended "a party." That there were numerous typhoid cases in the university town, due to the water.

In

Examination of abdomen showed no distention; there was tenderness, especially at McBurney's point, but no rigidity of the recti muscles. There was no tympanites, but a dull, diffuse pain. Examination of the fauces showed no congestion whatever, yet there was a dry, hacking cough; examination of the chest was negativ.

I had to differentiate between toxemia, typhoid and appendicitis, and possibly bronchitis or pneumonia. I did so by means of calomel. Ordered calomel gr. 4 and sod. bicarb. gr. j every hour to effect, with instructions to preserve the stools.

Next morning, instead of the characteristic calomel stools, found characteristic typhoid

The

stools, both as to appearance and odor. temperature was 103°, pulse 110 and gurgling in right iliac fossa. On the fifth day got a pronounced diazo reaction, and on the seventh day there was epistaxis. It was typhoid fever.

Second. "Never whip the tired heart, etc., etc." What! Shall we allow the patient to die of adynamia, while we wait on nature? What is a doctor for, if he cannot hasten a natural cure? Has the Doctor never seen a heavily laden truck caught in a rut or excavation which could be extracted only by lashing the horses and pushing behind? The extraordinary exertions overcame the obstructions and the horses were not injured by their severe

treatment.

Third. "Never use a drug antipyretic-use sponging." Often parents will object to hydrotherapy in children with high fever. Again, water alone may not be sufficient. The exalted condition which calls for the antipyretic will neutralize its depressing effects.

Fourth. This proposition is too weak for argument. If no stimulant ever saved a life, then surely no doctor ever saved a life, and so doctors are only an expensiv luxury.

Fifth. Emollients relieve by the warmth and moisture they produce; clay poultices by osmosis.

Sixth. Counter-irritants do not act on spaces; they act on the blood vessels, causing them to deliver blood from the congested part to the surface.

Seventh, "Do not deplete in any way; the patient is below par." The patient may be above par, by reason of the arterial or venous circulation being above par, and the treatment is directed to the circulation.

Eighth. "Use only one medicin, as only one medicin reaches the cause." Does the Doctor not believe in the electiv power of drugs, or their synergic power. Evidently

not.

two inches protruded beyond the vulva; also profuse hemorrhage. On examination found child so high up that it could not be felt easily with the finger. When she would have a pain the pneumonia pain would cut off her breath, and, all in all, it was a bad case; pulse 140 and wiry, temperature 1042°. She was spitting up large quantities of brick-dust sputum. Now, gentlemen, what shall we do? Shall we work quickly?

Treatment

. Hypo. of ergotin, 2 grs. 2. Quinin and Norwood's veratrum, 3. Gelsemium, acetanilid and caffein. 4. Chloroform freely.

5. Labor set in in good shape. Tried all the plans for keeping back the cord, but in vain. Delivery in about one hour.

6. Gave I gr. ergotin by hypo.

7. Delivered placenta and stopt bleeding. 8. Covered the entire lung with a 1/4-inch coat of antiphlogistine.

9. Ordered castor oil to open bowels, put her on Norwood's tr. veratrum, Dover's, ammonium chlor., strychnin and aconitin. Stript the bed, also patient, washt her with wet towels, using carbolic acid, put good diaper on her and came home. Child dead. Mother doing well. G. A. BUNDREN.

Remmel, Ark.

Had

Reply to Dr. Cooper on Pneumonia. DEAR DR. TAYLOR-I will stake my reputation as to success during thirty-seven years of activ practise, with Dr. Cooper or Dr. anybody else, in the treatment of pneumonia. nine cases this winter with no deaths--and can't recall when I had a death-and I use a cathartic in beginning of case, use strychnin thruout case, use an antipyretic when fever goes over 102°, use stimulants in all cases when needed, use turpentine stupes and blister often. Now this is my treatment--the reverse of Dr. Cooper's--and success as great.

I would like to have the Editor's opinion about a mistake that was made in a prescription for an old gentleman who had been sick for sometime with la grippe, probably three months. There was considerable dropsical effusion in the lower limbs. The following prescription was intended: blue mass, powd. squills and digitalis in pill form, and instead of the blue mass, cerate of cantharides was substituted accidently (as you know they look very much alike), and the prescription was used several days before the mistake was discovered. What would be the effect of this combination, on the stomach as well as on the disease? I feared that the irritating consequences that naturally belong to fly-plaster, would be manifested on the mucous membrane of the sensitiv stomach at once; but instead of that there was no complaint made in that direction whatever, and the effect on the disease for which it was administered was very gratifying indeed, as the effusion disappeared more rapidly, I believe, than I expected it would under the original formula, and the patient has been recruiting slowly ever since. Now Mr. Editor, would it be wise to substitute that med. again, under like conditions, purposely, instead of the blue mass? judging from the happy effect it had on this case. Or was it merely a lucky chance that it turned out so well? The patient was over 80 years old. Hoping to get your opinion, even if it is a severe criticism, in April number, I remain, yours fraternally, K. TAYLOR, M.D.

Possible Vicarious Menstruation.

Editor MEDICAL WORLD:-Mrs. D., age about 32, mother of four children, all living; family history good, menstruated after birth of first three in about eight or nine months. After birth of fourth child had not menstruated, tho child was near thirteen months old. After enjoying, as she stated, unusual good health thru the summer, and while still in good health, while churning in the month of September was seized with (as described to me) a rather profuse pulmonary hemorrhage. I was called in eight days afterwards on account of

persistent daily recurrent hemorrhages. Found temperature 102°, pulse 120, respirations 42, with entire left lung consolidated, and all the ear marks of typhoid. Did not treat the case, but death resulted. Was this a vicarious hemorrhage? or the usual hemorrhagic diathesis causing nose bleed in incipient typhoid, or both combined?

Dr. Rawls, in February WORLD, speaks of tr. iodin in puerperal septicemia. I have always found Lugol's solution in half strength, or less, to be all desired.

Sneedville, Tenn. J. B. MITCHELL, M.D.

[It looks much more like pneumonia than typhoid, according to the symptoms mentioned. Doubtless the lack of menstrual flow had something to do with the bleeding, but just how much no one can, at this time and distance, estimate.-ED.]

After-Pains.

Editor MEDICAL WORLD:-I notice with considerable interest the short opinions of the contributors to your journal on the treatment of after-pains. One thing particularly strikes me as being rather singular, viz., to see one contributor recommending ergot while another will recommend nitroglycerin. As is well known, these two drugs have an entirely opposit effect on both the blood vessels and all unstriped muscular fibers, still they are recommended for the same thing where both the blood vessels and unstriped muscular fibers are most concerned. As to the use of ergot for after-pains I will say that I can not see where there is to be anything to be gained beyond causing the uterus to empty itself of any blood clots that it may contain; beyond this I think it perfectly useless, for as is well known it will cause pain in the unimpregnated uterus. As for the use of glonoin for after-pains, I will say that from a theoretical standpoint it certainly would be contraindicated, from the fact that it causes a dilatation of the blood vessels and a relaxing of unstriped muscular fibers, thus favoring hemorrhage. It may be claimed by those who advocate the use of it that it decreases the blood pressure, hence there is ro danger of hemorrhage from its use; but so does hemorrhage do this, but it does not overcome its tendency to produce death. I have nothing against the opium treatment of this condition, but think there are other remedies that are just as good and without any of the dangers of opium in any form. I note what Dr. Fretz has to say in regard to the use of quinin in the treatment of after-pains, and can thoroly endorse him in his views on this remedy. I have used nothing else for the past ten years, and have the first time to see it fail to be effectiv. I will say to him that the next time

that he has a case that will not tolerate the ordinary forms of quinin that he give some of the tasteless preparations a trial. In my practise I use no other form of quinin than one of the tasteless preparations, preferably saloquinin or euquinin. I give them to promote pain and hasten labor, also to prevent or check afterpains. They are nonirritating, and can be borne by the most delicate stomach, producing none of the unpleasant symptoms that follow the use of the ordinary forms of quinin. Give them a trial (not particularly these preparations but any reliable tasteless quinin) and you will never use any other. S. E. LUCKETT. Campbellsburg, Ind.

Diagnosis.-Croup.-After-Pains.

Editor MEDICAL WORLD:-It is funny how few of the doctors who report their successful treatment of the most prevalent diseases of the country, can diagnose their cases. I admit I am not a first-class diagnostician, but I try to find out what the trouble is during the course of the disease, and some how or other my cases get well, whether it's thru my knowing what's the matter with them or not. I have been a medical student for twenty-eight years. my degree in March, 1880. I expect to be a student as long as I have the faculty to learn.

Got

For croup, the best thing I have found is iodized lime, 3 gr. to 1 gr. every 15 minutes to 30 minutes until better; then every hour or two. Empty stomach and bowels as soon as you can.

We have had an epidemic of measles this winter, and in cases where the larynx was much affected, and the voice and cough hoarse and croupy, the iodized lime gave relief and stopt the trouble in twenty-four hours.

The brother who is looking for a cure for after-pains, can prevent them by giving strychnin. My plan is this: Shortly before the child is born, give from gr. to s gr. of strychnin arsenate, either by mouth or hypodermically, according to the severity of labor. This counteracts the shock and prevents hemorrhage. In one or two hours after birth of child, begin with gr. strychnin, and give it every three hours during the day. At the end of twentyfour hours give a cathartic-enuf to move bowels a couple of times. Have bowels move once every twenty-four hours afterwards. Give 10 gr. of the triple sulfocarbolates every three hours, to keep down fermentation in bowels. After the bowels move, feed liberally of nourishing, digestible food. If there is nothing serious to prevent, let mother sit on vessel for bladder and bowel movements. Keep patient in bed for twelve or fourteen days. No douching, unless something comes up that makes it

The Retained Placenta. Editor MEDICAL WORLD:-I read with considerable interest your editorial (February issue) on the above subject. The first case of this kind with which (the after-treatment) I had to do was attended by an old country doctor. He said the patient was delivered by means of the instruments, and that he had to insert his hand and "scratch" the placenta loose. (Do you think there are such adhesions?) Infection appeared promptly and the patient died, without curetment.

Recently I had a retained placenta case in my own practise. On the birth of the child I could scarcely get cord enuf out to "get at it" to tie, and on making slight tension I found there was no "slack;" the thing was fast. The "placenta not appearing promptly and Credé's method failing to speedily dislodge it," the husband saying, "growed fast like the growed fast like the other one?" I inserted my hand, "the tips of my fingers shaped like a cone" (?) and scooped it out. I did not "scratch." The cord was sixteen inches long. The skin at the umbilicus extended out "to meet the cord" nearly an inch. The placenta was examined carefully in a "basin of clean water" and found to be whole and intact.

Everything went along nicely; no temperature, no hemorrhage. The fifth day I dismist the case.

Two days later I was called because the wife had two chills; temperature 101°, bleeding for twenty-four hours; bowels blockt for three days; subinvolution. I detected no odor, but irrigated the womb with formaldehyde. For two days more the fever went up; the bowels would not move; the irrigations continuing twice and thrice daily. The milk was not affected. Ninth day after confinement, tem

After the third capsule she began perspiring. About the same time I called. Without an anesthetic I cureted, using a sharp instrument. Besides fresh coagulum I got out probably a teaspoonful of debris. I told the nurse there was nothing there, meaning, I did not find enuf to produce the disturbance we were having.

Immediately the temperature went down and she made a nice recovery. What was it that did it? The quinin, the cleaning out of so small an amount of secundines, the "irritation" or medicin contracting the womb, or all, or what?

May I comment a little on your editorial? I do not see how you can leave a placenta longer than fifteen minutes. I did leave one once an hour-my freshman year-because I did not know where it was! But I find if the placenta does not appear soon the blood does, and that's time enuf for me.

The

Again, I do not see how you can grasp and twist a placenta in the vulvar opening! placenta is an awkward, slippery thing, and to make enuf turns to form a cord of the trailing parts seems to me not practicable.

I believe in asepsis and sterilization in obstetrics; but after you wash the pubes and external genitalia don't forget to dry them, especially the mons veneris, because it is always poorly washt and the water easily runs over the top, the wrong way, and by your neglect this soapy and dirty water may drain down afterward into the vagina. H. N. JENNETT.

Kansas City, Mo.

["Do we think there are such adhesions?" well, rather. We have been forced to pinch the placenta from the uterin wall and to separate bands which were fibrous in character, by cutting thru them with the nails of the thumb and the index finger, the woman bleeding meanwhile. We never had to do it but twice, but the memory of both occasions will never fade. In neither case did we have a curet with us, and in both cases we had time only to give the exploring hand a hasty washing and a quick dip in bichlorid solution of the usual strength. We expected infection in both cases; one made an uninterrupted convalescence, and the other had a mild purulent endometritis of a few weeks

duration, but not of sufficient severity to keep her in bed beyond the usual time. When we could have produced the curet at the bedside, we doubted the wisdom of using it. The curet is not a universal panacea, by any means, and we believe some women die because the curet has been used, who might have gotten well if left alone. Some authorities worthy of credence believe cureting, under certain conditions of infection, increases the chances of virulency of the infection.

66

The longer you practise, Doctor, the fewer times you will pull on the cord." We never do it. If traction is made on the cord, one is almost certain to bring it down in improper presentation for expulsion. There are many socalled "growed fast" cases, where the placenta is merely retained, and is not adherent. The placenta may lie in the vagina or in the lower part of the uterus. The retained placenta is best removed by inserting the aseptic hand, working the placenta into the palm, and gently withdrawing it during expulsiv effort; the truly adherent placenta is only removed by the pinching process.

We cannot think the quinin gave the results. It is quite likely the removal of the detritus did. Very small quantities of retained secundines will make serious trouble oftentimes.

We have observed cases where the placenta was retained many hours (no physician being in attendance) without hemorrhage.

If you

grasp the placenta firmly so that the nails will be imbedded in the "awkward slippery thing," you will be able to twist it sufficiently to form a rope of the following membranes, provided your motions are sufficiently gentle and delib

erate.

Your suggestions as to drying after washing are good; you might have added, "let the towel be steril." Every case of obstetrics should have a liberal supply of old cloths which have been sterilized by baking for a time just short of the scorching point, and then wrapt in a large cloth similarly sterilized, to await demand. ED.]

Duration that the Dead Fetus can Remain in the Uterus.

Editor MEDICAL WORLD:— -In your February WORLD, page 72, under "Quiz" column, G. Huston Chapman asks: "How long can a dead child remain in the uterus?" Allow me to cite a case: Twenty years ago Rachel Scales, colored-ginger cake color-the mother of three or four children, the youngest 7 years old, a stout, healthy woman, sent for her physician to attend her in confinement. Foy, her physician, attended. She had pains as other women; she was in labor about eight hours, when all pain stopt, and yet the mouth

of the uterus had never dilated at all. He left her in one or two hours after all pains stopt, and told her to let him know when pains returned. Three months after that she told the doctor that for the last month, quite a lot of something like flesh was passing from her, and she said, "I brought a quantity with me thinking you would like to see it; and also to tell you that for the last day or so it smells bad." The mass consisted of decomposed remnants of the child, and in the mass was some of the bones of the feet and hands. For two weeks after that time she passed all of the smaller bones of the child; all except the thigh bone (femur), tibia and fibula, and the bones of arm and fore arm and skull. This is what Dr. Foy told me.

Five years after her illness I examined her and could easily (thru the walls of the abdomen) feel the skull and leg bones and possibly arm bones. Ten years after, and five from the last examination, my brother, a physician, and I examined her again; all the bones I have before mentioned were still present. Since that time I lost sight of her, and heard today that she died last summer upwards of 65 years old. She did not have any septic trouble at all, and kept at work all the time, even when she was discharging the fetus. I will also state that I made a vaginal examination each time, and found the mouth and neck of uterus normal, altho the body of uterus showed quite large.

Since writing the above I have heard from a trustworthy source that at her death the bones were plainly felt in the uterus. The above case was a colored woman belonging (formerly) to my uncle. After the "surrender," as the negroes all say, she went to Madison (this State), seven miles from her old home, and engaged her services to Dr. Ben. Foy, and was with him when all of this that I have written was happening. After Dr. Foy's death she moved to a small house in the village and did washing for several of the towns people. Stoneville, N. C. J. R. SMITH, M.D.

Editor MEDICAL WORLD:-In answer to the question, "How long can a dead child remain in the uterus?" (MEDICAL WORLD of February, 1904, page 72), I will give one of my late experiences. December 1, 1903, I attended Mrs. Z., primipara, whose labor had begun several hours previous to my arrival. In the course of two hours a healthy boy was born. Shortly after this, I applied my hand to the abdomen to deliver the placenta by Credé's method, when, to my surprise, there came forth another bag of water, much smaller in size than the first one, and which contained a dead fetus of about five months' gestation, the