stipation for more than twenty-five years, interspersed with violent attacks of pain in the epigastric region, accompanied with the most obstinate vomiting for days and weeks at a time; the only relief she obtained was by the use of morphin hypodermically. Pre An operation was performed eight years ago by a surgeon of good repute, for gallstones, as he supposed, but, contrary to expectations, no stones were found, and after closing the incision a second incision was made in the region of appendix, and it was removed at the same sitting. ceding, during and after the operation serious heart symptoms manifested themselves which seemed to grow worse as time progrest, and at the end of six weeks the friends were advised to remove her from the hospital, as it would only be a short time until death would close the scene. Operation. In January, 1914, this lady was placed in my hands for treatment while she was suffering with one of the above violent attacks, and after spending several weeks in a futil effort to relieve the pain and vomiting, I advised an exploratory incision. Calling to my aid counsel specially verst in stomach and bowel troubles, a diagnosis was arrived at of obstruction to the common duct (?), possibly stone, with a question mark, as you will note, owing to the history accompanying the patient of no stone being found at the previous operation mentioned above. It is worthy of notice here which may throw some light upon the case that while the vomiting was very persistent and obstinate, there was but little bile ejected and the stools were usually light, the urin laden with bile and the skin moderately discolored. The x-ray threw but little light on the subject. All else having failed, an operation was determined upon, and all being in readiness, the usual right rectus marginal incision was made sufficiently large to pass in the hand and thoroly explore the parts. Owing to the weakened condition of the patient, 2 quarts of saline solution by hypodermoclysis was given during the operation. The gall bladder was of small size, flattened out, pasted up against the liver, with its margin adherent to the diaphragm at its attachment to the ribs. The bowels and abdominal cavity were walled off by sponges and the bladder and duct brought into view, the gall bladder incised for at least three centimeters, the contents removed, which were of dark-almost tarry— consistence. No stones or concretions were found. On further exploration of the duct it gave one the impression of a rope with knots at intervals of one centimeter. The first impression was of malignancy or possible tubercular glands, but on closer examination I wedged my finger underneath the duct, breaking up adhesions and liberating it from the underlying structures and straightening out the kinks. Not being satisfied as to the patulency of the duct I made an incision longitudinally thru all its coats about one centimeter long and then passed a probe down into the duodenum from the point of entrance, with some difficulty. difficulty. Still not feeling quite safe in trusting this duct to act as the future conductor for the bile, I dissected up the gall bladder from the margin of the liver and diaphragm, bringing it down and formed a direct anastomosis with the duodenum, which in the event of the common duct failing to carry the bile this would supplant or it. The formation of this emergency duct may not have been necessary, but owing to the distorted duct, which on close examination plainly showed several narrow strictured areas, I deemed it a wise precautionary measure. The usual drainage was adopted for 10 days, the wound healed quickly, and the recovery was unevent ful. The Heart Symptoms The heart symptoms were a feature in this case which stood out prominently for years, and as above stated, bid fair to cause the death of the patient; hence a few words of explanation will be in place. The intimate connection of the bile trouble with the heart symptoms is quite significant, and in my judgment were the result of sympathy; or, in other words, due to sympathetic irritation, which was responsible for the grave heart symptoms. It is well for us to know there is no like area in the body in which reflexes are so pronounced as in this locality. When I first saw this patient her heart was running away and intermitting every third beat. She gave me the impression of an exophthalmic goiter patient, and, in fact, I was not quite sure but there was a thyroid element in the case, as there was a nodulated condition of the right thyroid lobe. It is quite pertinent to note that the heart symptoms cleared up after the operation, which were, no doubt, dependent upon the impinged nerve filaments liberated at the time. It is appropriate at this time to think and look well into reflexes which frequently produce a train of symptoms foreign to the real cause of the malady. Symptoms are misleading and are not what they seem to be; hence, diagnosis built upon symptomatology should be well guarded against; otherwise, one may fall into an error which one would gladly retreat from if it were not for the embarrassing position it places one in. The surgeon is probably the one who hedges most in giving an opinion on internal diseases, because he has frequently found that his ante-operativ opinion is not confirmed by his post-operativ findings. Résumé. Résumé of the salient points that naturally attract attention of the reader: The length of the time the patient had been a sufferer. The diagnosis and findings at the first operation. The removal of the appendix; no doubt as a diurnary resort. The prominent heart symptoms. The finding at the second operation. The repair of the common duct with possible complete restoration. The formation of an emergency duct by anastomosis of the gall bladder with the duodenum. The frequent violent attacks lasting for several weeks. The use of the hypodermoclysis during the operation to sustain the exhausted patient. The impinged sympathetic filaments. The relief of the heart symptoms after the operation. DR. M. J. BUCK. Pittsburgh, Pa. In the Journal of the American Medical Association, for June 8, 1912, Dr. George Parker reports three cases of tetanus treated by subcutaneous injections of 25% solution of Epsom salt, 4 to 10 drams being employed, and the injections repeated when found advisable. He claims no specific action for the remedy, but calls attention to the fact that his patients relaxt promptly after the injections, and that this effect permits the taking of rest and nourishment. The body will elaborate its own antitoxin if such conditions can be secured. The drug is not expensiv, and is everywhere obtainable. The percentage is easily estimated even without any apparatus, and hence the treatment should receive recognition and remembrance at the hands of every practician. Treatment of Boils, Carbuncles and EDITOR MEDICAL WORLD:-"The treatment of boils, carbuncles and abscesses in general goes a long way to make up the everyday business of the general practician."-Dr. M. J. Buck. Yes. And few physicians realize in its fulness that these conditions are due to an overburdened and a poisoned blood stream. Either the intake of foods is too little or too much, or there are improper combinations of foods, or the output of waste matters, from the wear and repair of the body, is imperfect, insufficient and hence cumulativ, whereby the blood stream is contaminated by the chemical changes, in foods and waste matters, thereby laying the foundation for the growth of various kinds of micro-organisms that could not live in a relativly pure blood stream. Emergency treatment must be activ, as indicated by Dr. B. But there is much more to be done, by taking the patient under one's daily care for perhaps several weeks, and teaching him how and what to eat and drink, and what he should not eat and drink. He should further be taught how to care for the skin, so that the two and one-half million sweat glands, with their from eight to ten miles of tubing, daily eliminate there from two to four pints of liquid poisonous matter that should be thrown out, usually as insensible perspiration. When the skin will permit, one of the most valuable aids I use is to have the patient thoroly rub the entire naked body with his hands for from three to ten minutes each evening and morning, to wake up and invigorate the lazy, dormant skin. Physical exercise of the entire body. properly regulated, is absolutely essential to a pure blood stream and perfect health. The upper surface of the liver can be thoroly massaged by a system of deep breathing exercises, thereby aiding in purifying the blood stream. The drinking of large quantities of hot water must be insisted upon to flush the system of other impurities. But better than all other means is fasting for several days. No food whatever except hot water for from five to fifteen days, the patient to be seen and carefully directed every day. Unload the system daily, for fasting without daily purgation is toxemia. This method of treatment is absolutely essential to insure a pure blood stream so essential to perfect health. I have only given a few of the methods or means I employ, because I fear space will not permit at this time an extended paper. To the thinking physician, a poisoned blood stream is the prime cause of a very large percentage of all the diseases we meet in general practise. I am aware that germophobia has taken possession of most physicians, and they cannot see that germs are not primary, but secondary. Germs cannot live and do harm in a relativly pure blood stream and a normal body. When physicians shall know their physiology and psychology better, and apply their knowledge in a practical manner, get away from their commercialism, treat the patient, and not alone the disease, or the end products, teach the people how to live the life in conformity to the great universal law, that obedience to nature's law is the condition of well-being, then will the physician be what he should be, and will in the future be a teacher of the gospel of health for the saving of half a million of lives every year in these United States of America. Then will he cease to be a mercenary giver of drugs, whose activities he does not thoroly understand, and the use of which, except in emergencies, could be very largely abandoned, to the improved health, happiness and efficacy of the people everywhere. DR. L. A. MERRIAM. 409 Bee Building, Omaha, Neb. Systemic Poisoning from the Vaginal Use of Antiseptic Tablets. EDITOR MEDICAL WORLD:-There have been several articles and warnings in the medical journals the past year setting forth the danger of using the bichlorid tablets for the especial purpose of preventing conception. I desire to add several cases to the already long list of persons so poisoned. A short time ago I was talking with a doctor from a nearby town, when he mentioned a case he had just had. A lady was in the habit of using these tablets as above indicated. She suddenly developt a very sore throat, lookt like diphtheria; suppression of urin, and intense pain in her vagina. The doctor was a day or two learning what the real trouble was. Her vagina slufft badly, urin supprest until she died from acute uremia. The next case was here in the city. This lady introduced the entire tablet into her vagina, as her syringe was packed ready to move. Her husband, being more of a brute than anything else, insisted on his marital rights, even tho the syringe was not available. This patient rapidly developt similar symptoms as the above. Her throat was covered with a diphtheritic-appearing membrane; vagina very painful, greatly swollen, finally sluffing, suppression of urin. This patient died after great suffering in ten days. The husband likewise suffered as a result of his meanness, as enuf of the tablet came in contact with his penis to result in a very sore organ for some time. In fact, I guess he came near losing part of his appendage. This case was under other doctors' care. a My case is just a little the strangest I ever had in this line. On September 21st, I was called early to see Mrs. McD., young married lady with a child in arms. Her husband gave me a fairy story over the 'phone. When I arrived at the bedside, in order to get at the facts of the case, I kept him busy getting hot water, soap, towels, etc., while I was getting the real history of the case. About midnight she awakened with severe pain in the labia and outlet of vagina. Parts were greatly swollen. She was in great agony and did not know what to do. Finally her husband told her that he had placed a small-size bichlorid tablet just inside her vagina while she was asleep. Askt by his wife why he had done such a thing, he replied that she was very restless. That is all I can learn. I believe the lady tells the truth. I am satisfied her husband is something of a pervert. They had not had intercourse for a month. I confined the little lady when child was born, and from several conversations with her husband, I am satisfied he is very coarse, to say the least. As they had no telefone, and could not say over a neighbor's 'phone much about such a case, she partially drest and went to a doctor's residence nearby for help. The doctor was away, but his wife very properly gave her some zinc ointment to apply freely, and advised a salt-water douche. This relieved the great pain, in a measure. I found the parts greatly swollen and ordered the ointment continued liberally. The next day had a little fever and throat very painful, with several white spots. Ordered hot carbolic gargle. The urin was scanty, but no blood or albumin. Ordered liquid diet, eggnog and plenty of water, salines for bowels, and hydrangea compound. In a couple of days kidneys were doing fine, throat better, right labial mucous membrane necrotic, and resembled diph Hurried Diagnosis.-Neuritis.-Pellagra. EDITOR MEDICAL WORLD:-One chief difficulty in our hurried manner of prescribing and treating people is, of course, in making an accurate diagnosis. Being able, by a few moments' questioning and a casual looking over, to grasp enuf of the essential points to enable one to formulate a diagnosis upon which he is justifiable in basing a treatment of any worth is sometimes perplexing-and then to have to hurry thru and fix up your own medicins and at the same time maybe half a dozen impatient persons trying to hurry you up and talk to you about other things is, to say the least, annoying. In just such a state of affairs this morning did your little, but valuable, paper stand me in good stead. I had read the articles on neuritis in the December number, and then followed them up somewhat in "Musser & Kelly," which led me to form that diagnosis in the case whose symptoms I will relate briefly as they were given to me: A lady of 50, weight 165, six or eight children, fine physique and general health. No signs of menopause until about a year ago, and then only began to skip sometimes several periods, and when she did miss a period the skin would form in what she termed "whelps"; spots as large as a dollar rise up red, itch and burn, but would vanish in five to ten days. About a week ago, following a menstrual period, she began to complain of pain and tenderness about brachial and deltoid region of left arm and shoulder. This did not demand any serious thought until about three days ago she bathed her body all over, changed garments and also did two weeks' washing for the family-standing on damp ground and in the cold most of the day. That night this pain extended over entire arm and on to shoulder and grew to be an intense burning pain. The skin at once was so sensitiv that even the very slightest touch would cause pain of the most excruciating type. Motion of the limb was out of the question-I judge from the pain it caused. No swelling nor enlargement of joints, no discolored skin except from liniment, which had been applied from outset. This lady is in a most painful condition, and no efforts which they adopted gave any relief. I know of no rheumatic or other conditions which could have caused such, and unless the exposure and perhaps strenuous exercise brought on an attack of neuritis or an inflamed condition of the peripheral nerve endings, I do not know what to call her condition. I gave her calomel, 10 grains, in repeated small doses; aspirin, 5 grains; quinin, 3 grains, and left morphia to use at night if required. Also [We think your diagnosis correct. Have no criticisms to make on the treatment, tho we seldom give morphin in such cases, uncruciating pain which cannot be relieved by less absolutely necessary on account of exheat or any other measure. See Dr. Seryoss' article in this issue for substitutes for morphin. We shall be glad to have reports on your cases of pellagra when you are in position to give them. "Pellagra," Niles, publisht by W. B. Saunders Company, Philadelphia, Pa., containing 239 pages of text, and selling at $3, net, will give you much information.-ED.] Pituitrin to Resuscitate Newborn. EDITOR MEDICAL WORLD:-In your issue of January I notice Dr. Arnold's report of the death of an infant as a possible cause of administering pituitrin to the mother (pages 36 and 37). In this connection I would like to give the following brief experience with pituitrin as a means of resuscitating an asphyxiated infant. On the 15th of December last I had the following case: Woman, aged 40 years, mother of seven living children. At last birth, about two years ago, child died after three days; never breathed well and blood never seemed well aerated. This last labor was normal, reasonably prompt, and there was no occasion to use pituitrin or any other uterin stimulant. When the child was born it was "black and blue," limp and lifeless, and I thought I had a stillbirth on my hands. No sign of respiration and I think heart action must have been about 6, 8 or 10 to the minute. No pulsation in the cord, so I tied and cut the cord and did the usual stunts to establish natural breathing. After five or ten minutes of persistent efforts with apparently no results, out of sheer desperation I gave hypodermically 10 drops of P. D. & Co.'s pituitrin. Gradually following this and by aid of continued artificial respiration, application of hot and cold water alternately, etc., the child began to show a little sign of life, and after about one hour seemed to be breathing fairly well. I do not know whether it lived as a result of the pituitrin or in spite of it. I would certainly try it again under similar conditions. J. A. RUCKER. Bedford City, Va. The Quality of Contract Practise Among EDITOR MEDICAL WORLD:-Since receipt of the January, 1915, WORLD I have been much interested in an article over the signature of J. E. McDonald, entitled "Iniquitous Contract Practise" in McDowell, Mingo and Logan Counties, W. Va., a part of the state, be it remembered, which has always furnisht more than its share of sensational, not to mention tragic, newspaper material. And, lest some of our WORLD readers get the impression that contract practise is much the same everywhere, I desire to say that up here, in the Fairmont, W. Va., coal region, no such conditions prevail. Physicians do not "farm out" their contracts. I am personally acquainted with practically every mine physician in this coal region, about twenty in all, and I can recall only one of them who does not do all his own practise. This physician is not a very strong man, physically, and he has eight or nine small mines, distributed over so much territory that it is simply impossible for one physician to do all the work. He has an assistant, a young man, who is not only a physician, but also a pharmacist, with well-recognized ability in each direction. I have been engaged in contract practise for the past eighteen years. I was with the Hutchinson Coal Company six years, with the Consolidation Coal Company nine years, and three years ago I left this company to go with the Four States Coal and Coke Company, and in all these years of experience in this class of practise, and my association with the owners of these different mines, I do not know of a single operator who would stand for a state of affairs such as Dr. McDonald describes, either on account of politics, relationship, or for any other reason; but, on the contrary, I know of four physicians who lost their contracts for the following reasons, viz., two for drunkenness, one for neglect and the fourth for neglect of duty and discourtesy to the miners, and I am confident that nothing would avail to hold a contract except efficiency and close attention to duty. Difficult to Get Instructions Obeyed. Anyone who knows anything about domestic life among the foreign population of a mining town knows that there are many conditions tending toward a much higher mortality among infants and small children than would obtain in a community of English-speaking people of greater intelligence, and I dare say that, no matter if Dr. McDonald were in charge of one of these "iniquitous contracts," there would be very_little change in the infant mortuary statistics. Many foreigners cannot speak English any better than we English physicians can speak their languages, and this makes it difficult to have any treatment carried out no matter how clearly indicated, and the indifference which many of them manifest, when it comes to the question of buying infant food, is, to say the least, criminal. Still, I do not believe that the infant mortality rate is much higher at our mining towns here than it is in the larger commercial centers about us. Of late years the mine operators here in the "Fairmont" region have been making a specialty in sanitary and quarantine regulations, and this has borne fruit a hundred fold. Typhoid has been almost stampt out of existence, and to my certain knowledge there has been no epidemic of any contagious disease in a dozen years. Scientific Supervision. My "contract" has a normal population of approximately 1,500 people, and since beginning of development in April, 1910, there has been but four cases of typhoid fever. But notwithstanding this, last fall we went over the water situation in what we thought the most scientific way possible, and a month afterward submitted samples from each extremity of the system to our state bacteriologist at Morgantown, W. Va., for examination, and he reported the same entirely free from acid-forming bacteria, and nearly free of nonpathogenic germs. Of contagious diseases, we had but one case of smallpox and one case of scarlatina during the year 1914, and of death, from all causes, among infants and children, 3 died of chronic ileocolitis, 1 of capillary bronchitis, 1 died of burns and 1 chokt to death with a chestnut in the larynx. We had 3 deaths by accident in the mine and no adult deaths from natural causes. From this it may be seen at a glance how high our mortality went in 1914. The Consolidation Coal Company requires every physician in its employ to make a monthly report as to the number of cases of illness and accident treated, together with detailed report on cases of contagious diseases, including syphilis and gonorrhea, and furnishes antitoxin with which to treat every case of diphtheria. It places absolute quarantine over every case of contagious disease, and of its own accord, and at its own expense, keeps a force constantly at work cleaning up and abating nuisances generally, and while the Four States Coal and Coke Company does not require a monthly report from its physicians, its resident managers certainly do vie with its physicians in prevention and suppression of disease. It is held by many physicians that the very principle of the medical contract plan is unjust to the profession at large, and ever and anon one can read outbursts of indignation against it, similar to this one in question, which sounds very much as if the writer himself had, at some time or other, been unsuccessful in competing for one of these "iniquitous contracts" and was merely airing his soreness at having lost out. I trust that Dr. McDonald will pardon me for this presumption, if I am incorrect, but that is how his letter sounds to me. |