Some Modern Meddlesome Midwifery.

to pay heavy damages. All such hardware promptly went out of style there and the and-sane way.

who enjoys quite an extensive obstetrical practice became a believer in the follow-up methods of intensive pregnancy, so he had cards printed supplying some admirable advice for women who engaged his services somewhat in advance. Unfortunately, he included a list of symptoms presumably indicative of trouble. He forgot how the patent medicine almanac worked the symptom list game, and became quite irritable when his several patients with the cards became a nuisance with their continual running in to ask about a multitude of trifling symptoms. Some of these women, who before his obsession took little account of a pregnancy, became hypersensitive invalids with all manner of cranky ideas, some of them leaving his care and entering city hospitals weeks before their expected confinements. The idea spread to women under the care of other physicians in the town, the upshot of it all being that more of the pathology of pregnancy occurred in that little town in one year than had been noted in the decade before, and young wives became so fearful of pregnancy that small families became the rule where no such thought had been entertained before.

Pelvimetry became the fad of a physician who had read about the bounden duty of external and internal measurements being made in every case early in the pregnancy. He practiced in a little town where narrow minds were common but narrow hips were unknown. There had never been but one

or two cases of dystocia in the history of the place and the sturdy women there seldom remained in bed more than two or three days after confinement. But this doctor procured a formidable array of pelvimeters, forceps of complicated design, Smellie's scissors, cranioclasts, cephalotribes, basiotribes, basilysts and other hardware, and he kept them on display in his chamber of horrors. The good news soon spread, and he was a wonderful doctor. All the impatient women who had "pains" for a few hours had him called in consultation if, indeed, he were not first called, which he usually was. And in five years more obstetric operations were done in that little town than had been known there for the fifty years preceding. The upshot of it all was two suits for malpractice, in one of which the wonderful doctor was compelled

We started into practice with a young man as a medical neighbor who was a natural-born surgeon but who amounted to nothing as a diagnostician and therapeutist. Finally he became an assistant professor of obstetrics. Happening to be in town where he lectured we went to see him, and in due time he returned our call just in the nick of time to go with us to a difficult obstetriHe cal case requiring podalic version. favored immediate removal to a hospital for a Cæsarean section, and he was frankly and outspokenly shocked at the "crude" way we managed the case. Nevertheless the woman and child did well. Some time after we had a great wrangle over obstetrical technic, and he "proved" the validity of his contentions by exhibiting his case records, all most elaborately kept, but showing what shocked usone-third of the cases operated upon in some way or other and four times the maternal mortality we have had in twice as many cases. Both his and our own records were those of private practice, so the comparison is fair, a comparison of eight to one in mortality: Now this man, now no longer a professor, was an extreme instance of the surgical craze in obstetrics; but there is no doubt that such methods are often over

done.

We could go on noting man after man and instance after instance illustrating modern meddlesome midwifery. So could you, Doctor, if you took time to think over your experiences. It is far from the present purpose to discredit advanced methods in obstetrics; but we do believe they lead to meddlesome midwifery just as frequently as did the old methods, and vastly more dangerous meddling at that. There is an idea abroad that meddlesome midwifery is a thing of the past. Is it?

Sunshine and Disease,

One of the most transparent businesstainted theories of the day is the Northern tuberculosis specialist's contention that the actinic rays of the sun are detrimental to the tuberculous. Were there no Southwestern tuberculosis sanatoria bidding for business, the theory would never have been advanced.

The fact is that reflected or radiated

second-hand sunshine from an environment of asphalt paving and tin roofs, causing hot and dead air, is what does the harm.

It's perfectly true that pellagra, and some of the dermatoses, are aggravated by actinic rays from direct sunshine, but that tuberculosis is in this class has never been proven. The evidence is the other way.

Winter is the time to start sunshine treatment. Exposing the patient when the sun is weak in actinic power prepares him to endure summer sunshine with impunity.

Involved Rulings on the Anti-Narcotic Law.

In our March editorial, pages 27, 28 and 29, opinions were expressed as based upon "Treasury Decisions" for January 21, 1915. Since this was in print we have received a bulletin from the American Association of Pharmaceutical Chemists, a portion of which reads as follows:

"Our original interpretation of the words 'personally attend' (which we still believe to be correct) was that the record must be kept only when the physician has not personally seen the patient, diagnosed the ailment, and duly begun the treatment. In the first issue of the regulations the Bureau of Internal Revenue followed the statute exactly and did not explain the official interpretation of 'personally attend.' In the second edition of these regulations the words 'personally attend' are held to mean 'personally visit.' We are even informed that the Bureau rules that office dispensing must be recorded. That is to say we understand that the present position of the Federal authorities is that no record need be made only when the medical practitioner goes out and personally visits and treats the patient at his residence, etc. In other words, that the physician 'attends to his patient in his office and 'attends upon' the patient at his home. This fallacious and absurd attitude is like the distinction between 'tweedledum' and 'tweedledee.' The cardinal rule for interpreting a law is to so interpret it as to carry out its intended meaning. The history of these provisions clearly and unquestionably indicate that the intent was to force a record when the physician is not personally treating the patient in the usual practice, and after the customary manner, with the personal diagnosis followed by the personal treatment (the physician not always being present). Even a severe and close construction might be acceptable which would require a record in all cases when the physician does not personally see the patient. But to hold that the record must be made in the case of office dis

pensing and not in the case of outside personal dispensing is not only directly contrary to the obvious and historical intent of these provisions, but creates an unwarranted discrimination. The dentist, for example, practically never goes outside of his office to treat his patients. Thus these record exemption provisions would have no meaning at all in his case. The treatment in hos

pitals by resident physicians would have to be recorded, while it is presumed that the treatment of the same patient by a visiting physician would not have to be recorded. The same professional and personal treatment is subject to two different rules. The distinction is absurd and we believe entirely unwarranted. But the fact remains, until this ruling is changed, that the Federal authorities construe 'personally attend' to mean 'personally visit.' We do not believe that any physician who fails to make a record when he 'personally sees' the patient will incur legal liability."

It impresses us that, until after this ruling is withdrawn, adversely reported upon by the Department of Justice, or decided against by a Federal Court, physicians can be compelled to live up to it. And now comes even later rulings, noted below.

"For purposes of checking up the quantity of drugs, coming within the scope of the Harrison Anti-Narcotic Law, received and dispensed, this office deems it necessary for a record to be kept of all such drugs so dispensed or distributed in the office of the physician, dentist, or veterinary surgeon. A record must be kept also of these drugs left with a patient to be taken in the absence of a physician, dentist or veterinary surgeon. Only such drugs as are administered directly to the patient by the physician in person, when away from his office, are exempt from record."

Dentists and physician specialists, such as oculists and aurists-not general practitioners-who administer minute quantities of interdicted drugs in the form of stock solutions kept in their offices, need not keep a record of the names and addresses of patients to whom they administer these minute quantities; but they must keep a dated record when the stock solution is made and of what it contains, and a further record of the date when such stock solution is exhausted. This concession does not apply to general practitioners.

Nurses are not allowed to register under this law; and they may have narcotic drugs in their possession only under the direction of a registered physician and while nursing a patient under the professional care of such a physician. Nurses may obtain such drugs only on prescription, the same as any other lay person.

Exemption of medicines for external use does not apply to liniments, etc., except those which could not be taken internally, or, in other words, are denatured.

All of which still further involves the situation. Without knowing exactly the reasons of the Governemnt for this rigid interpretation of the law, which differs radically from what the profession was led to expect, we prefer to await events before expressing any personal views, since we desire to be fair to all. But, if physicians in general believe these regulations to be needlessly oppressive, let them say so. Time will probably correct any defects in the law, or in its interpretation.

B

Batting It Up to the
"Regulars.

IG BROTHER always comes handy, especially when the big stick needs to be wielded; and then Big Brother gets the reputation of being a bully.

A few years ago, comparatively speaking, the colleges of the three schools in medicine were becoming as inefficient and back-number as the theological seminaries of the several religious denominations. Europe was forging ahead in medicine, while this country was stagnating. The national medical societies were weak and inefficient. State boards of health were a joke. Hospitals were poorly equipped and more poorly managed. The leading physicians had few conveniences in their offices, tearing up old sheets for bandages and generally employing primitive appliances, while many of the rank and file of doctors did business in offices which now would be shunned by any person who values his health. Of course, things were rather peaceful; but they were medically dead and desperately inefficient.

Then it became the style to go to Europe to study, and the returning students brought back new ideas-ideas we sorely needed. A new era dawned in medicine in America. Why, it was only about 1888 that the first bacteriological laboratory supplies and appliances reached this country; and it took years after for the medical colleges generally to establish such courses here. Original research was almost unknown in American medical colleges as recently as 1880.

Much-traveled and widely-read doctors. acutely realized the state of affairs and that drastic remedies were needed to correct them. These were applied, largely through the supervision exercised by a rejuvenated American Medical Association, which has even stirred up pharmacy, especially in its medical relationships.

Medicine generally, quite aside from the membership of the American Medical Association, which comprises about 42,000 out of a total number of about 150,000 doctors in the Union, has vastly profited by the uplift now in process. We are developing creditable medical ideals-ideals not for a few but for the whole profession.

But practically all of this has been batted up to the "Regulars." And many of them have been obstructionists. It is perfectly

true that some harsh things have been done, some of them unwisely; but it is equally true that the good has vastly outweighed the evil. Modern medicine can't stop; it must go ahead.

Viewing medicine in its world-wide aspects, it is the "Regulars" who have developed the fundamental sciences, who have reconstructed pathology, who have popularized preventive medicine, who have created modern surgery, and who are now trying to place the difficult branch of therapeutics upon a scientific basis.

This last task is a tremendous one, and modern pharmacology has a big program on its hands, a program which should not all be batted up to the "Regulars." Pharmait is to be expected that its text-books concology is a comparatively new science, and tain many erroneous conclusions. But on the other hand, they contain many which are not erroneous; enough of them, in fact, to render it certain that the coming pharmacology will be just as universally accepted as is the present surgery.

All physicians "Regular," Homeopathic and Eclectic-should recognize the present trend in medicine and proceed to "play ball." Physicians who stand aloof from the trend of the times simply become bitter and

fail to "arrive."

We wish that:

Every physician would purchase a modpeutics based upon pharmacology, and ern work upon materia medica and therawould read it;

Every "Regular" would make an intelligent survey of the so-called "sectarian" writings upon materia medica and therapeutics;

Every physicain would join a County Medical Society, and, by contact with his fellows, orient his own views;

The profession in general would stop starting so many one-sided things, all tending to accentuate some one form of drug administration or other form of therapy;

The American Medical Association would be a little more patient with the views of gentlemen who have not followed the path of attempted advance along the same road;

Talk about trusts and all other obstructionists tactics would cease, because we were all rolling up our sleeves to work out the problems of the profession at large;

And that kindly expression and “an eye single to the truth" would animate all. Next month we will be "Batting it up to the Eclectics and Homeopaths."

The following papers are contributed exclusively to this journal. Repulication is permitted if credited as follows: MEDICAL

COUNCIL,Philadelphia.

We are not responsible for the views expressed by contributors: but every effort is made to eliminate errors by careful editing, thus helping the reader.

Patient, male, aged 50 years; single, farmer; sent to me August 30, 1913, on account of attacks of lower abdominal pain.

In January, 1912, the patient was seized with an attack of cramp-like pain in the lower abdomen. The attack lasted about three days, disappearing, and returned in three weeks. During the interval between the attacks he felt perfectly well. The attacks, which have recurred at intervals of several weeks to a month since that time, lasted from three or four days to a week up to about one month before he consulted me, when the attack lasted nine days. During the nine days he did not have a movement of the bowels. The attacks have been getting worse. During each attack the bowels have been constipated but regular at other times. The attacks have been getting more severe and for over a month he has been weak and unable to work. He is short of breath and tires easily. His appetite is lost and there is some thirst. There

is constant abdominal fullness and distress, which is worse after eating, and considerable belching. Regurgitation of sour liquid, at times frothy in character, occurs frequently about half an hour after eating, particularly in the morning after breakfast. He vomits everything he takes during an attack. The vomitus is usually of a greenish watery character and at times contains mucus, and food, if any has been taken into the stomach. The quantity of the vomitus varies, but is usually of small amount and

the vomiting disappears after the attack has subsided. The vomitus did not contain any blood at any time. His attacks began by nausea first, then vomiting followed by abdominal pain, usually across the lower abdomen or in the region of the umbilicus. Occasionally the pain was most severe in the right lower abdomen. Pyrosis was present, and a heavy feeling as if a "stone" were in the lower abdomen was complained of. Sleep was sound, except during attack. There was a loss of weight from 154 pounds, his normal weight, to 139 pounds. No blood has been noticed in his bowel movements. There was palpitation of the heart; no headache. He was obliged to urinate from one to three times during the night.

Family History.

Father died at 83 and mother lived to be 76 years of age.

Previous History.

Patient had typhoid fever eighteen years ago, and pneumonia ten years ago. Habits were good; took liquors seldom; used tobacco moderately.

Physical Examination.

This showed a man who appeared to be anemic with a greenish lemon color of skin. No emaciation; tongue coated white; chest long and flat. He had some cough; lungs negative; heart increased in size with a systolic murmur at the apex. Heart sounds irregular and intermittent, radial pulse, which was soft and weak. Tenderness was present in the right upper abdomen, which in my opinion was not significant. The cecum was distended and a mass was palpable which was probably feces. Sigmoid flexure of the colon was also palpable.

This man had two sets of symptoms, one involving the gastro-intestinal tract with attacks of nausea, vomiting and pain in the lower abdomen, during which time the bowels were locked, and which at other times were regular, moving once a day. These symptoms pointed to an intermittent

obstruction probably low down and indicating that the stomach symptoms were reflex. Therefore, I made the diagnosis of recurrent volvulus of the sigmoid flexure of the colon. The other group of symptoms pointed toward the heart and vascular system, as indicated in the shortness of breath, weakness, palpitation, increase in size of heart, systolic murmur, and soft weak pulse. The sense of weight in the lower abdomen was probably due to an overloaded sigmoid flexure which, when it became filled, fell over into the pelvis, producing obstruction. Rectal examination was negative. Blood pressure was 110 systolic and 80 diastolic.

Examination of Stomach.

Contents aspirated forty minutes after an Ewald test breakfast showed good motility and digestion, with a total acidity of 32 and a free hydrochloric acid of 10. The secretion of the stomach was not exactly normal, but that was satisfactory and did not show that organ to be organically diseased. I did not have in mind that it was diseased, for I made a tentative diagnosis before making laboratory tests, and this was shown to be

correct.

Urinalysis.

Urine pale, amber color; reaction, acid; sp. gr. 1010; no glucose; no albumen, indican moderately increased. Microscopy, phosphates; no casts; no blood, feces did not show presence of occult blood. Blood Examination.

4,800,000; w. b. c., 8,400. Hemaglobin, 75 per cent.; erythrocytes,

The recurrent volvulus would have called

for surgical interference, but I did not regard him as a good operative risk, and furthermore, he needed medical treatment. It has been my object to treat every case on its own merits, not regarding all cases surgical, or all medical. I treat each case, cure him medically, if I can; surgically, if I must. I took the patient to the Medico-Chirurgical Hospital, had the gastro-intestinal tract radiographed and studied with the fluoroscope by Dr. George E. Pfahler.

Fig. 1 shows the sigmoid flexure coiled upon itself, extending over almost to the cecum. There is also ptosis of the transverse colon.

Fig. 2. This is also an illustration of the size and position of the sigmoid flexure of