OUR OPEN FORUM.

This department of THE MEDICAL COUNCIL is open to free exchange of proper opinion, criticism and matters of professional interest. Space precludes printing all letters in full, but so much of those received as will interest or instruct our readers will find place here.

The editor often regrets the late appearance of letters relating to previously printed articles. We hold open our pages as long as we can, especially for this department; but we would urge every physician who writes regarding something we have printed, that he do so as promptly as time will permit, so that the original matter and the comment thereon follow each other without break.

Threatened Abortion.

EDITOR MEDICAL COUNCIL :

Anent your article on "Pessimism in Threatened Abortion," I will agree with you entirely if necessary to resort to the course mentioned.

However, in an experience covering fourteen years, since I first received my introduction to viburnum prunifolium in dosage of 30 min. to 3j, hourly for three doses, after which extending the time to three times a day, I have in nearly sixty cases which have come under my care in that time, had no single failure where membranes were not ruptured, though the majority were produced attempts. Just two failures that I recall. I am simply suggesting this as an addition to treatment mentioned.

San Diego, Cal.

C. L. THUDICHUM, M.D.

An Unusual Case.

EDITOR MEDICAL COUNCIL:

I desire to report an unusual case of neurasthenia that baffled a number of physicians. The patient, a lady aged 42 years, had suffered for a long time with various ailments and all diag nosed as caused by a general nervous breakdown. A torn cervix was repaired a year or more before. She had had a severe pain in the region of the left kidney, the pain radiating toward the left iliac region. There had been no definite diagnosis made by the physicians, but her family physician had given her a powder that relieved her instantly. This relief was so sudden that I could account for it either of two ways, viz., that the powder was given for the mental effect or that it contained morphia. I made a diagnosis of stone in the left kidney, but she was not sent to me, on account of this pain. She was sent to me on account of a severe pain in the rectum. I examined the anus and rectum carefully and found a fissure which I deemed amply sufficient to cause the severe pain and to have undermined her nervous system. As she suffered from these two diseases, and as I did not think that if I cured the anal fissure that she would be cured of all her pain, I advised her to go to Philadelphia to have an X-ray examination made to confirm my diagnosis and have both operations at one time. She accordingly went to see one of the best surgeons in Philadelphia. The surgeon's assistant examined her without an X-ray, diagnosed the pain in the left side as stone in the pelvis of the

kidney and prepared the patient for an operation and sent me a telegram asking me to be present. By mistake, I did not receive the word in time, so I telephoned and asked for a postponement of the operation. It was agreed to have the X-ray examination in the meantime to confirm the diagnosis. To their surprise, both kidneys were normal and no pathalogical condition could be found that called for an operation. But on the day set for the operation everything was ready to cut down into left kidney and explore.

I positively refused to have the exploration made but advised operating for the anal fissure, which they had overlooked entirely.

It was done and the patient left the hospital in a week and has been entirely free from any pain in left side or at the rectum for more than a year.

This shows how we may be mistaken in our diagnosis, for this pain in the left side was merely a transferred pain caused by the anal fissure. C. M. RICKERT, M.D.

Millersburg, Pa.

The Cause and Treatment of Pellagra.. EDITOR MEDICAL COUNCIL:

The following are the conclusions of Alessandri and Scala, of Rome

1. Pellagra is a chronic intoxication caused by the presence of colloidal silica in drinking water. 2. Pellagra is a disease strictly localized and contracted in districts where the water supply is in contact with an argillaceous terrene.

3. Colloidal silica makes irreversible and insoluble compounds with the proteid substance of the tissue cells.

4. This combination abstracts water from the tissues, the resulting drying giving rise to the cutaneous manifestations, the digestive and nervous disturbances, the classical triad of pellagra.

5. The acid intoxication is concentrated by evaporation, hence the cutaneous manifestations in the face, neck and hands.

6. Pellagra is not affected by maize alimentation.

7. Pellagra is not due to filaridæ.

8. Pellagra is not communicated by the simulium fly.

9. Pellagra is not a parasitic disease. Prevention and Treatment.

1. Pellagra is prevented by treating water supplies and reservoirs with broken limestone.

"First of all, don't make a vaginal examination unless absolutely demanded, and it is really seldom necessary. Any such examination simply reduces the chances for staving off the trouble."

It would be interesting to know why this is the advice most often given and generally followed by the practitioner in dealing with this class of cases. I wonder how many of those who advise against local examination and treatment in cases of threatened abortion have ever really treated any such cases excepting on the "expectant" plan; or are they following some supposed long-established precedent in giving and following such advice?

My experience with this class of cases is that nine out of every ten cases of threatened abortion (not considering the induced ones) are due to developmental defects and displacements of the uterus. I shall here have reference to only this class, and their troubles may be more or less readily overcome by a proper line of treatment, both local and general. Why does the young woman so often abort at from six weeks to three months of her first pregnancy? Study this out, and the reason will be apparent. These defects produce a more or less fixed state of the uterus, which in the gradually developing, pregnant organ becomes more marked, so that even an apparently slight deviation from the normal may thus become decidedly pathological, owing to the pressure upon and by adjacent organs, and interference with the functions of all. Physiological activity of the uterus brings about engorgement and congestion of all parts, and on account of the crowded condition induced by these factors and its increased size, there may be considerable interference with the return flow of blood; it must find an outlet; so, naturally, in following lines of least resistance, a hemorrhage takes place, which may be slight and of short duration, intermittent, or continuous and prolonged. Oftentimes this slight blood-letting may really prove more beneficial than otherwise, as local congestion is thereby relieved, and if the uterus is not too firmly held down by displacement, deformities or contractures, it may yet be able to balloon up and overcome obstructions and hemorrhage cease, provided patient is kept off her feet for a reasonable time, and proper hygienic measures instituted. Little or no other treatment may be needed. Thus we use "expectant" treatment, and trust to luck; but, on the other hand, if Nature's efforts are unavailing, and the uterus cannot release itself from its pelvic environments, but continuing to expand in all directions, and failing in its efforts to rise, it becomes impacted within the pelvis; then, nothing short of main force from without will overcome the condition if it is not already too late to avail. Nature, worn out with useless effort, still following lines of least resistance, opens up her flood gates, and casts off the offender, and our patient does what we expected, aborts.

If one should see a man pinned to earth by a log or fall of rock, the first impulse of any bystander would be to remove the obstruction-lift the load! The next thought would be to administer restoratives. What would you think of one who would calmly sit down and load up a hypodermic and fire a shot at the poor fellow, and then walk off and leave him? And yet, this is the way the majority of women are being treated for threatened abortions-dumbly, blindly, without any idea of causative factors. This let-Nature-take-hercourse plan is too often followed; and Nature

works, naturally; and Nature naturally destroys sometimes! Still, they tell us don't examine; don't find out the cause!

After having examined and treated locally hundreds of pregnant cases, at all the various stages, from the first signs up to term, without harm but only good resulting from such examination and treatment, I would say: First of all, diagnose your case by making a very careful but thorough bimanual examination, noting particularly position of the uterus, whether markedly anteverted or retrodisplaced; next, any distortion or contracture, producing a fixed condition, whether or not it is freely movable in all directions (about 100 per cent. of threatened abortion cases present some such abnormality); and third, by careful and intelligent manipulation, aided by proper posture and deep breathing on the part of the patient, correct displacement or deformity, and place the organ at rest by a proper supportive packing. (It should be understood that common-sense, surgical cleanliness and care should be freely used in handling all these cases, and nothing but good can result from a thorough examination and understanding of every one of them.) In a former paper published in the COUNCIL on "Abnormalities of the Gravid Uterus and Their Treatment," I outlined fully methods of treatment for various conditions encountered, and also manner of packing for support. I have used these measures for a number of years, and am still examining and treating for these abnormalities, more confidently every day, and until some one can prove to me that I am committing a crime in thus saving the race, I expect to continue in my efforts at saving it. I want to be given some very good reasons why I should cease treating these cases and return to the so-called "expectant" plan, where Nature, overcome by ignorance and neglect, kills, instead of saves, nine out of ten. (Just over the border from Missouri-and must be shown.)

You, from the standpoint of the general practitioner, where eight out of ten threatened abortions to which he is called have been induced, might lay down rules for such-rules which are good and safe. I, perhaps, from the standpoint of the specialist treating pelvic distortions and displacements principally, find that nine out of ten of my cases of threatened abortion are the result of such distortion or displacement. Why? Because the correction of the abnormal conditions overcomes the impending abortion, and I get results. Consequently, any hard and fast rules I might lay down from my particular cases, or that you might make from your experience, would probably result in a hopeless muddle if we were to exchange work without changing our rules. It would be hardly wise or safe to advise every practitioner when confronted by a case of suspected pregnancy or threatened abortion, to examine, manipulate and tampon indiscriminately; not any more safe nor wise than it would be to advise all to immediately open the abdomen and fish about for a suspected "appendicitis." The operation might be a success, but the patient would probably die.

Pittsburg, Kans.

FRANCES A. HARPER, M.D.

The last paragraph accurately states the case. Our rules are dictated by our individual experiences. Personally, after trying out both plans, we have had better results under the hands-off policy. Let us hear from others.-EDITOR.

Nurses and Anesthesia. EDITOR MEDICAL COUNCIL:

In the November issue of THE COUNCIL, among others, I notice an article by Dr. A. F. Myers, on "Should Trained Nurses Administer Anesthetics?" I do not invite nor shall I engage in controversy on the subject, but it seems to me that the doctor is a little too sweeping in his criticism, and manifesly unfair in his apparent assumption that a trained nurse cannot be competent, and that a medical diploma per se is sufficient evidence of qualification as an anesthetist.

The physician or surgeon in charge must be held responsible for the care and management of his cases, and, it goes without saying, that it is in his interest to have the best assistance he can get. It is for him always to determine whether the case in hand requires an anesthetic, which one to use if choice is to be made, and the elements of danger if any are found to exist. Now, if the doctor had said that considering all these things the person best qualified to meet the requirements should be chosen as administrator, there would be no occasion to dissent. He very properly regards medical knowledge as essential. The safety of the patient who is about to be put into a condition of deep sleep with the possibility, however remote, of passing over the line, certainly requires on the part of the person administering an anesthetic a knowledge of the nature, functions and relations of the parts involved, and the properties and effects, usual and exceptional, of the agents used in anesthesia; but I should hardly deem skillfulness as a surgeon to be a part of it. This knowledge can be had from the text-books in general use, and I can not conceive of a trained nurse who has not this knowledge in fair degree.

Another qualification, not mentioned by the doctor, is experience. In no branch of our art is it of more importance that practice should supplement theory than in the use of anesthetics. There are some things here that can be learned only by practice—experience.

There is still another qualification, not the product of education, nor the result of experience, without which the anesthetist or surgeon will never be more than ordinary; that is, aptness, special fitness, which can not be acquired nor described, but belongs to the individual. I have time and again seen graduates in medicine, well educated and successful practitioners, who were awkward and inefficient as anesthetists; and I have seen a trained nurse safely and efficiently conduct the anesthesia through the most delicate and tedious operations. This should not strike us as so very strange, for it is generally conceded that women (in speaking of trained nurses I refer to women nurses) have a more delicate touch, a keener, quicker perception of sudden change in a patient's condition, a more subtle, intuitive premonition of threatened danger than is usually accorded to men. This, with adequate knowledge and experience, in my opinion makes the best possible combination for an expert anesthetist.

The statement that nurses are selected for this work by hospital management as time-savers for the operator or interne I do not fully understand. In upwards of fifteen years' hospital experience I have never known a case in which the well-being of the patient was not the first consideration. Finally, in answer to the personal application of the doctor's contention, I have,

The European War.

EDITOR MEDICAL COUNCIL:

No vocation, perhaps, has so many international relations as the medical profession. A year ago the great International Medical Congress met in London and the next meeting was to take place in Germany. Meanwhile numerous international societies had also made preparations to meet at different European cities. Now an iron fist has frustrated all plans. From Berlin we learn that besides those who make surgery their specialty there have gone in the field about 20,000 general practitioners. These suddenly placed in the position to do surgical work assume great responsibility. Their number is constantly increasing, and special courses have been arranged that they may prepare themselves. In the Lanzenbeck house Professor Walberger lectures on topographic anatomy with special description of gunshot wounds. On August 8th there was a meeting held of Berlin physicians to regulate the conditions of medical practice while so many physicians were absent. This matter has been satisfactorily arranged for Berlin, but great difficulties are met in regard to village and country-town practice, and Berlin physicians are requested to act as substitutes in country places deprived of sufficient medical help. By order of the government the export of surgical dressing material, instruments, and apparatus is interdicted. Among the articles which can not be exported are carbolic acid, mercurial preparations, iodine, iodide of potassium and sodium, iodoform, chloroform, pyrazolonum, phenylmethylicum and its preparations like pyramidon; further opium, morphin, quinin, codein, salvarsan, instruments used by physicians and dentists, material for bacteriological preparations, and sera.

Accidents to Epileptics. EDITOR MEDICAL COUNCIL:

I am preparing a paper on "Accidents Due to Epileptics Being Unsuitably Employed," or being in unsuitable places at the time of seizure; to be illustrated by photographs of patients showing resultant mutilations.

Will you kindly put me in touch through the pages of THE MEDICAL COUNCIL with physicians having had such patients, who would be willing to send photographs showing result of such accidents. The physicians would get full credit, names of patients would not be mentioned, and photographs would be returned.

I feel the importance of such a paper of warning on account of the number of crippled epileptics, often preventable cases too, who frequent my consulting rooms. MATTHEW WOODS, M.D. 1402 Spruce St., Philadelphia, Pa.

Only by prompt renewals can we afford such a journal at the price. It is to your interest, Doctor, to renew at once.

While we, as physicians, desire to be scientific students and practitioners of medicine, and that is the primary purpose for which this Journal is published;

Medical

MORE THAN two thousand years before the Christian era, Nimrod founded the city of Bab-il, gate of I1, or gate of God. After the confusion of tongues, the name was connected by the Hebrews with the root balal, to confound, and the city was called Babel. The Greek mode of spelling it is Babylon, meaning

confusion.

Confusion is the culminating evil of medicine in America. The medical profession was founded as a secular branch of the priesthood, the Bab-il, or gate of God to the heart of man, reaching him through the ministration to the ills of his body, even as the priesthood was the gate of God, reaching men through ministrations to the ills of his soul.

But, even as the tower of Babel was an ambitious project to reach by stepping stones of man's own creation to Heaven, so physicians forgot their sacred prerogatives, their priesthood of the body, seeking to reach to the divine by materialism, and, like the ambitious builders of the ancient tower, there was a confusion of tongues, and ever since "To him who in the love of Nature holds communion with her visible forms, she speaks a various language."

As Il meant the All-Good, or God, so ill came to stand for evil, and Homer's Iliad, a poem on the destruction of Ilium, the ancient Troy, was an ilias malorum, an iliad of woes or disasters. God did not necessarily mean good to the Greeks, as there were good and bad gods, hence Il for good or bad. The later Latin dramatic poets

added an 1 and made the word ill, a word transferred to English with no comparative or superlative, and used as an adjective, a noun and an adverb. Trace out the words meaning sickness or illness and their ancient forms in many languages go back to roots meaning god or devil. Sickness and medicine were acclesiastical in popular connection.

At base, that sort of thing had its advantages; it prevented confusing medici e with

Babylon.

vel, for the welfare of our dependent ones and our standing in the community, we must secure a fair compensation for the services we render our fellowmen.

secular learning at a time when such learning was mystical, superstitious and confused. Probably it was that tendency that prevented actual degeneration in medicine, really the only science we have surviving that goes back thirty centuries and is still going on intact along much the same general lines as it did in ancient Egypt.

A strange recrudescence of the old in medicine is the modern conception of the laws of God and the laws of Nature being one and the same. Natural law is being applied in the spiritual world and spiritual law in the natural world. The dividing line between the natural and the supernatural is being pushed on and on in our demonstration of molecular energy in modern chemistry, in our use of invisible forces like electricity, and in our application of Xrays and N-rays and radio-activity. So we really do not longer recognize any difference between the natural and the so-called supernatural. We are putting the thought of God in science.

But we are doing it slowly-doing it by taking mysticism out of medicine and putting Nature in; doing it with the ultramicroscope; doing it with our imponderable radium; doing it in spectrum analysis; writing it in exact chemical equation; applying it in opsonic indices, Wassermann reactions and attenuated vaccines. whole progress of modern preventive medicine is in seeking to obey the laws of Nature, the laws of God.

The

But the mysticism born of materialism

dies hard, especially in America, where commercialism is rampant and medicine is too narrowly a business, not a career, or has been such.

For some months past we have been printing articles upon medicine as we have seen it in the various sections of the Union. Having completed this survey, it is now the purpose to draw some general conclusions and suggest some remedies for the evils that beset us. This article has to do with confusion as a factor in medicine of the present day in America.

Confusion in Medicine.

The word Babylon stands for wickedness in popular esteem, while Jerusalem stands for righteousness. We are not so applying the thought here, believing that there are no elect or condemned classes in medicine. And, after all, evil is evil only by comparison with the good. It is by knowing the good that we recognize evil. Hence, until the good appears, we are unaware of many evils. We are becoming aware of

medical evils because of the advance of medical goodness. Yes, medical goodness has arrived, the medical Jerusalem, if you please. Jerusalem is the city of light, and the medical Jerusalem is the beacon of science now flooding with answers the medical interrogation marks of the past, and the reason we have confusion in medicine is because we are, medically, in a transition period.

Medical Transitions.

Not many decades ago medicine was frankly materialistic. Homeopathy was a protest against this tendency, crude though it was compared to what a clever reformer of this advanced day would have made of Homeopathy were he now first promulgating it. Most of the other new isms and pathies, except Christian Science, are densely materialistic. Modern medicine is heading away from materialism, except in so far as materialism is the basis in fact for a far-reaching theory.

Scientific Correlation.

is

Some doctors think that medicine has simply advanced, whereas the truth is medicine has been reconstructed during the last thirty years. Medicine used to consist of a group of isolated sciences; but modern methods have correlated them. In doing so new sciences have been embraced in the group and the inter-relationship and interdependence of these sciences have been demonstrated. The man of modern medical training recognized empiric medicine simply as a past phase indicative of defective or partial information. The modern medical scientist refuses point blank to dogmatize. Recognizing the errancy of mere intellectual processes, he wants a fairly complete array of facts before attempting to deduce a theory. If he lacks the facts, he puts off attempts at deduction until after he gets the missing facts, and meanwhile he says "I do not know."

It needs but to recall the status of medical colleges thirty years ago—a few bare lecture halls, possibly one or two miscroscopes in

the whole institution, a reeking dissecting room, a few chemical demonstrations, dogmatics galore in the class rooms and wild pranks among the students-and then to visit the up-to-date institutions now teaching medicine, to prove to one's satisfaction that the medicine of thirty years ago and that of today are two vastly different things. If we do not recognize it, the public does. Mr. Average Citizen prefers a modern Osteopath to the medical graduate who practices in the way of thirty years ago. Country Confusion.

After looking the matter up in twentyfive States, it has been brought home to us that, in every one of them, there are many small communities very poorly served medically. Dr. Brown has been the sole doctor in the district for forty years. True, once in so often a young competitor has appeared, soon to leave with a broken heart and an accumulation of debts. But old Doctor Brown goes on in the same old way he has for years, working all the time, casually reading a little, studying not at all, complacently chewing the same old medical cud, and pleasing his neighbors who are moving along in the same old rut that their fathers. did before; and when Old Doctor Brown dies, there will be $45,000 on his books.

We can't find it in our hearts to condemn with unkind words poor Old Doctor Brown; he is a product of his environment, but he has not even a hazy idea of modern medicine. But we can't help comparing him with his neighbor in the next township, a man also forty years in practice. Dr. Jones, Sr., whose young son is rapidly rising to credit in medical circles, has stubbornly decided he is not going to let the boy beat him at his own game. So the elder Dr. Jones leaves Jack in charge while he goes to the postgraduate college to brush up. Does he succeed? Assuredly he does. The old gentleman has an immense experience behind him, and he sees through the modern teaching, a wealth of detail in almost forgotten cases that he never saw and never could be expected to see on the old basis of empiricism. Dr. Jones is born again, medically speaking, and he and Jack get along together famously, each learning from the other. Dr. Jones, Sr., begins to weed out his library and buy new books, to take medical journals that print medicine instead of chit-chat and secret proprietary medicine boosts, to be active in the medical societies, to smile complacently over busted theories he used to lose his temper over in defend