there that which was only absolutely neces. was frequent, and he had seen the entire leg sary). Finally, the great toe, the second toe affeoted progressively. and their metatarsi were removed. The espe. Dr. M. J. Lippe, referring to the second cial point of interest was the infected foot in case, said that the stone had evidently been a marked diabetic of at least eighteen months' in the gall bladder a very long time. This standing without important local or general woman had complained of a train of symp. changes. Another point of interest was that toms of one kind and another for a very this gentleman, though abnormally sensitive, long time, and she had seen a number of had been anesthetized twice, with perfect re. doctors and had been allowed to go on to sult with the scopalanine, morphine and an age when operation was more dangerous ethyl chloride-ether combination. He came than if undertaken earlier in life. Eleven out from under this anesthesia with a nice years ago Dr. Lippe had seen a patient who full pulse and no nausea.

complained of a pain in her stomach. She

would bave this pain and again get better. Dr. Soper, referring to the removal of the Dr. Lippe had concluded after two or three infected toe, thought that the surgery was to years that this patient must have gall stone be commended. He had seen a similar case disease. For eleven years he bad observed in wbiob there was pus in the joint and it had this patient, but there was no set of sympgone to the bad for lack of thorough opera. toms that would allow him to make a positive tive procedure.

diagnosis of stone in the gall bladder. Some Dr. Deutsch said that it was not a question

two months ago this patient was taken with any longer as to the results following surgical Seve

severe pain. He could palpate the distended interference in cases of diabetes mellitus. A

gall bladder. There was also a rise in temcontinuous gangrene was to be expected, but

perature. When he had exposed the gall the doctor's premises in amputating this toe

bladder he had found it was large as the fist because the sepsis were correct, for the sepsis

and bad gotten out a lot of muco pus, but was more likely to kill the patient than the

could find no stone. Down in the cystio diabetes. It was always bad surgery to am

duct was a stone as large as the end of his putate if conservative surgery and watching

thumb. It was embedded in the duct and the condition would take its place, for ampu

only by considerable pressure was be en. tations in diabetics were followed by poor re.

abled to milk it back into the gall bladder. sults..

He used the Mayo method, and within two

weeks the gall bladder ceased draining and Dr. W. C. G. Kirchner, speaking of the the woman made a perfeot recorery. If first specimen presented, said that it illus- there was any set of symptoms by which the trated that class of cases often too long ne- diagnosis could be made, these patients glected. Those having hospital experience would not have to go on suffering for so many saw such cases persistently. They always years. The diagnosis of stones in the gall came to the surgeon at the rery last stage. bladder was not easy; impaction in the duots These patients were given morphine and were of course is not so difficult. often practically hopeless cases when first

Dr. William S. Deutsch thought these re. seen by the surgeon. There was no discoloration of the abdominal wall and this led the

marks belittled both medical and surgical patient, his friends and the doctor astray.

men. He was sure that Dr. Rush and Dr. There might be no external indications of

Taussig would bear him out in the statetrauma of the abdominal wall, yet with rup

ment that these gall bladder cases did give a ture of the spleen, liver or kidney. He had

train of symptoms that would permit a diag. recently seen such a case at the hospital. A

nosis of the disease. It was true they might man entered the hospital with no sign of in.

not be able to decide just how many stones jury to the abdominal wall, yet a ruptured

was any uld be malfering for the gall

here might friends and wall and no dis

there were, or exactly in every case where spleen was removed, the bleeding continued,

they were until the abdomen was opened, but and the next morning it was found that

it was certainly possible to diagnose these there was an extensive rupture of the liver. That patient died of hemorrhage. Such Dr. Lippe replied that if the previous cases should all be explored as soon as pos. speaker could diagnose stones in the gall sible. The second case is interesting because bladder so readily he should tell the profesthose large stones would sometimes perforate sion how he does it. Impacted stones with the gall bladder and enter the intestinal colic or jaundice, which occur years after tract. In one case that had come to his at the formation of stones in the gall bladder tention the stone was of sufficient size to ob- is easily diagnosed. Dr. Lippe replied that struct the bowel and peritonitis followed. statistics showed that fully 50 per cent of Gangrene following slight injury in diabetes the people past middle life had gall stones,


yet many of these certainly did not manifest was felt indicated that there were no stones symptoms of the disease, at least not sufficient in the gall bladder, for in such cases the for a diagnosis. Sabli could not make this gall bladder was usually shrunken. diagnosis in many cases, Da Costa could not Dr. Deutsch stated that his object in mak. do it and many other good men were unable ing the remarks he had was to bring out a to do it. Ten per cent of the people present little discussion on the subject. He had had stones in the gall bladder and did not noticed that the Eastern societies devoted but know it. The presence of stones was a very little time to the set papers, but they had difficult matter to diagnosticate.

these discuusions, which were most helpful. Dr. Shattinger considered Dr. Lippe's re

In regard to Dr. Lippe's remarks, while it marks exceedingly to the point. He had

was not always possible to diagnose the num. said something Dr. Shattinger had often

ber and size of the stones, yet it was possible wanted to say himself. For many years on

to diagnose trouble in the gall bladder the floor of the wedical society, they bad been

region. The works of Moynihan and Mayo told that they must bring these cases to the

gave a train of the symptoms found in such operating-table early, and, often had their

cases, and Dr. Deutsch believed these men eyes regaled with bead-strings of gall stones.

were competent and positive in their state.

ments. Many bad been the admonitions that the general practitioner should not allow his pa. : tients to suffer untold agonies for untold ages, but to get them operated upon. But

INTESTINAL OBSTRUCTION.-G. P. La Ro. these gentlemen had failed to tell the gen. que, Richmond, Va. (Jour. A. M. A., April eral practitioner iust how to make the diag. 7), gives in rather full detail the diagnostic nosis. After a patient had had all sorts of points and symptoms of simple dynamic ileus diagnoses made, after all sorts of treatment and of mechanical obstruction of the bowels bad been tried for years, and after an im- in its various forms. He gives a table for mense amount of data had been collected differentiating strangulation from occlusion then, when this patient came to the surgeon

and a study of individual symptoms. The and told him the story. wben this surgeon differential diagnosis between meohanical had the benefit of everybody's mistakes and

ileus and all forms of acute dynamio ileus, was driven by exclusion to make a diagnosis particularly those due to pain, from aoute that was something more than a shrewd pancreatitis, appendicitis, eto., are noted. guess, be operated and pulled out the gall The article is instructive in its details. stones and then criticised all his predecess.

THE FORMATION OF URIC ACID.-L. B. ors. It was a fact, as Dr. Lippe had stated,

Mendel, New Haven, Conn. (Jour. A. M. A., that in very many cases one did not get March 24), discusses the formation of uric symptoms clear enough to make the neces. acid in the body, reviewing the later physio. sity for operation apparent.

logic investigations on the subject. The Dr. A. E. Taussig came to the defense of probable endogenous and exogenous anteced. the internist and expressed his belief that in ents are considered, and the probable chemi. a great number of obscure cases the diagnosis cal reactions involved in the formation of could be made. Each case must be consid. uric acid from other purin bodies are given. ered upon its merits. If it were possible to He calls attention to the peculiar role of enstate a few symptoms by means of which zymes in both the formation and destruction the diagnosis could be made in the great of uric acid. The organs and tissues concerned majority of cases, nothing would be easier in these processes and the factors modifying than the recognition of gall stones. It was these metabolic changes are all considered necessary to examine the liver, the urine, to and treated of in detail with full references to know the history of pain, etc., in fact the pa. the leading literature on the subject. There tient must be examined from the ground up, are many admittingly missing links, especially there must be a careful study of the gastrio as regards the origin and significance of en. function; then if the physician could not dogenous uric acid. The questions yet reconceive of any adequate explanation of the main to be solved as to the cause of the mod. symptome except the existence of gall stones, ifications in physiologic conditions, the vari. the diagnosis was sufficiently certain to jus. ations of the endogenous output, the tolertify turning the patient over to the surgeon, ance of the organism, the chemical regulaIf the case had been studied with sufficient tions of the balance between formation and care, when turned over to the surgeon the gall destruction, the differences in different stones would be found. Of course, many species as regards purin metabolism, and cases gave no symptoms. In the case de still many other unmentioned questions yet scribed, the very fact that a large gall bladder remain for investigation.


THE crusade against quacks and medical men and midwives doing illegitimate work which

was inaugurated by the Issued Tenth and Twenty-Fifth of Every Month.

St. Louis Medical So.

The Crusade
Under the Editorial Direction of

ciety some months since

Against illegal

has borne fruit. In two THOS. A. HOPKINS,


lower courts judgments CARL E. BLACK. With the following staff of Department Editors

have been gained in the 0. E. LADEMANN, Internal Medicine.

test case in the matter of indecent and obscene JOHN MCHALE DEAN, Surgery. R. B. H. GRADWOHL, Pathology and Bacteriology.

advertisers, and the prospect is that this deW. H. VOGT, Obstetrics and Gynecology.

cision will be confirmed by the higher courts WALDEMAR FISCHER, Ophthalmology. A. LEVY, Pediatrics.

to which the case is being taken. A test case W. T. HIRSCHI, Therapeutics. A. F. KOETTER, Otology.

against one of the papers carrying such ad. HERMAN STOLTE, Laryngology and Rhinology. vertisements is at present in the courts, and F. P. NORBURY, Nervous and Mental Diseases. T. A. HOPKINS, Genito-Urinary Diseases.

if tbe explicit wording of the law stands there ROBERT H. DAVIS, Dermatology.

can be but one result in face of the facts.

The matter of abortion has been taken up,

and as a result of the evidence brought to the EDITORIAL

State Board of Health the certificates of two

midwives and one physician have been reThe annual meeting of the Illinois State Medical Society will be held in Springfield. The St. Louis Medical Society has raised a

May 22 to 24, and prom. fund to follow up this good work and cleanse

ises to be one of great our city of these evils. The undertaking is Illinois State Medical Society. location being being interest and profit. The tremendous and merits the moral and finan.

cial assistance of every lover of decenoy and central, will attract å order. Its success depends on a continuance large attendance, and then Springfield has of endeavor for months, and until the desired always opened its doors on such occasions,

end be accomplished. A spasmodio effort and as a result the meetings held there have with slight result and then relaxation is worse been uniformly successful. The preliminary than making an attempt. The oampaign must program has not yet been announced, but be vigorously pushed, and those active in it a full One is assured, as the number of should be assisted by the profession and by Danera allotted to each section were sun. the public that our cleaning may be thorough plied early in March. Since tbe reorgan. and permanently effective. ization of this society some few years ago it has been gradually growing in numbers, un. til now it is among the foremost in num. bers in the United States. The spirit of or.

Much is being written in the medical press ganization is growing, and largely tbrough

about the soientific side of medicine, and but the missionary influence of Dr. McCormack,

little upon the business who in his journey through Illinois bas The Fee of the

side. And yet tbe soi. preached the spirit of fraternity and the use. Physician.

cientifio side cannot be fulness of medicine to every community, en

fully developed unless couraging Jaymen as well as physicians to

the business interests of see the true light in organization and per

the physician are likewise looked after. There fected service.

is a disposition at the present time "to out. The Illinois State Medical Society is de rat

rates' in meeting the presence of more com. cidedly in line with this wave of organiza.

petition than has existed in the history of tion, and is more and more becoming of

medicine. In place of this petty commercial greater service to its members in all that per.

spirit, there should be a fair increase in tains to a united brotherhood and honorable,

rates. There are many reasons for such an scientifio profession which seeks the oppor.

increase. In the first place at best medical tunity for greater service.


skill and attention is probably the most poorly paid of any of the professions. The doctor as compared to the lawyer, for in

stance, receives paltry fees. This has been DR. PALMER FINDLEY, of Chicago, will so since time immemorial. The education of remove to Omaha on May 1st, where he will the physician is probably more expensive in future reside. He was recently elected to than that of the lawyer. The expense of do. tbe chair of gynecology in the College of ing business is as a rule more for the doctor Medicine of the University of Nebraska. than for the lawyer. The nature of the doc

tor's calling and work is indeed more enob. In this place, it is but fitting to speak of ·ling, self-sacrificing and with a bigher end the niggardly practice of physicians encour. result than that of the lawyer. While the aging the various insurance companies who lawyer struggles over the mere dollars and pay for the first aid treatment for injuries of cents in dispute, the doctor struggles for the employes of corporations to out their rates to life of his patient, besides which the posses. the absurd state so largely exposed in the sion of wealth fades into insignificance. Journal of the American Medical Associa

The practice of medicine at the present tion. In the issue of Maroh 31, 1906, there time requires a liberal preliminary and pro. is interesting reading concerning the rebuke fessional education. It requires residence given by the editor of the Journal to the presin hospitals without pay, it requires time for ident of the Maryland Casualty Company for post-graduate work. It requires money for the ridiculously low scale adopted by that expensive equipment, instruments of preci. company for payment of physicians employed sion and skill. Improvements in these in. by them. The president of that company struments leads to their disuse and the nec. denies the right of the medical press to proessity of buying new paraphenalia from time test against these low rates for service. He to time. And again, after a time of hard work says it is no man's business to protest against in practice, the up-to-date physician needs a them as long as physicians are content to rest, a change of scene and a relaxation from take the work and take the pay offered by labor. At the same time, after a while he them for such work. We contend with Dr. needs to visit medical centers of learning, Simmons that it is the province of the medical there to refresh himself by attendance with press to protest. We contend that the physi. the masters so as to avail himself of all the cian should refuse to give their services for new methods and advances since the time of niggardly fees. These accident and casualty bis last post-graduate study. All this requires companies derive a large part of their revenue money. This money must be made by a from the practicing medical profession. judicious taxation of his patients, according They have at their disposal at all times the to their means. Mistakes are made by phy. honest advice and honest opinions of the sician as a rule in estimating the size of his medical men who are treating accident cases patient's pooket-books with a loss on the all over the country. They should be willing side of the physician. The layman is too to encourage the medical profession in the prone to take advantage of the physician in high oharacter of its work by lifting it out finance. The laity know how we estimate a of the commercial field in which they are tryfee by the means of the patient and some of ing to put it by elevating rather than by dethem know how to accordingly underestimate preciating their fee lists. They do not real. their financial standing with physicians. ize that such a depreciation long-continued More care should be exercised by the physi. will work great havoc to their own interests. cian in this regard.

Suppose for a moment, that a doctor could At the same time, the practice of some be bought" and sold” for the highest bid. physicians of remarking that such and such der; suppose bis opinion instead of being å specialist's fees are "too large," or this or candid and honest and straightforward, that surgeon's fee list "too high" should be whether it be good for the patient's pooket. depreciated. Instead there sbould be a laud. book or for the company's, was always de. able effort made to make the practitioner's pendent upon the amount of money offered clientele understand that the physician must to him, what state of affairs would follow be well paid if he is to give the best that is in with these accident and casualty companies ? him in the saving of human life. This de- Many and many a damage suit is averted, preciation of another pbysician by one pbysi. many and many a damage suit is settled out cian is most pernicious, and only serves to of court through the honest offices of the at. make the rates worse than they are now. tending physician, and always with an ad. When patients are brought to the surgeon vantage for the company; many and many a for operation, the practitioner should not fix case in court ends with a judgment ma. the fee for the surgeon. Let the surgeon at. terially reduced by virtue of the attending tend to that. If he gets a fee of the proper doctor's honest expression of opinion consize from the patient, the practitioner who cerning his patient's injury. What would bas sent him the patient should not com- bappen to the accident and casualty com. miserate with the patient afterwards, agree- paines if by their antagonism, their cheap ing with him that the fee was “exorbitant," methods, their commercializing tenedencies as is often done. Let him defend the higher they so brought it about that medical prostandard and let him also elevate his own fessional opinions could thus be bartered ? standard. In no other way can this matter There is no reason to fear that this could be put in its proper place.

ever happen, yet these companies should be reminded at this time of their injustice and their narrowness in viewing the matter of payment for medical attention.

R. B. H. G.

tunities for improvement go by and then bemoan bis fate, when according to tbe law of natural events, this ebb of work is really an opportunity to be ready for the flow when it comes.

“Let us then be up and doing.
With a heart for any fate,
Still achieving, still pursuing,
Learn to labor and to wait.'

Health ispitisnode into

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The past winter has been one of those remarkable seasons when a wave of universal

F. P. N. good health bas swept

over the entire country, A Lesson

and especially here, in from the Wave the Mississippi Valley, The City of St. Louis and the profession of Universal where climatic condi. have recently suffered great loss in the death Health tions bave been suob as

of Dr. C. A. Snodgras, to insure no epidemics,

Health Commissioner and to prevent even the Dr. Charles A. of this city. Dr. ordinary diseases of winter in their usual Snodgras, Health. Charles A. Snodgras frequency. As a result of this rather unpre. Commissioner was born forty-two cedented state of good health, physicians of St. Louis. years ago on a farm in have had comparatively little to do. To the

Jackson county, Mo. public, upon whose woes the prosperity of

His father, William A. the physician depends, this has been a bless. Snodgras, and mother are living at an ading, but to many physicians it has been a vanced age and reside with his sister, Mrs. great hardship and trial. The young pbysi. Emily B. Mays, at Independence, Mo. cian, just entering practice, has felt keenly Dr. Snodgrass gained bis collegiate educathe idleness which while expected, has been tion at the Missouri State University; after rather beyond the expectations of the most leaving this institution he taught for some sanguine, while to many thoughtful physi. years and spent his summers in post-graduate cians of established practice it has proven an study at the University of Chicago, where unmixed blessing, because it has created an he perfected himself in the branob of learnopportunity to avail themselves of the post- ing which was to be his life work. graduate school privileges, now so thorougbly In 1898, Dr. Snodgras came to St. Louis presented in our many excellent schools in and was attached to the Department of Apatthis country. The physicians supply dealers, omy of Washington University. His indonpharmaceutical houses and physicians' speo. itable will and close application to the study ialty dealers have not had a very prosperous of medioine while teaching in Washington winter, due to the lack of demand for their University enabled him to take the degree of goods. Now, reviewing conditions as they Dootor of Medicine at that university in the are all in all, it has been a good season, and year 1900. physicians should not complain, for after all As a bacteriologist he did some very valuathe public upon whom patopage depends, has ble work in the recent suit of the City of St. been blessed and profited, and after all the Louis regarding the Chicago drainage canal, public gives due consideration to medicine, his investigations being complete and conwhen the demand exists, and will always be vincing to men of science. a friend to progressive medicine.

In 1903 Dr. Snodgras was appointed city We quite agree with John Burroughs in bacteriologist by the Mayor of St. Louis, in believing that to share the common lot is which position he worked unremittingly un. good enough for any one, and that “unlucky til his promotion to the position, first, of is the man who is born with great expecta acting health commissioner, and finally-on tions,” especially in medicine. Such trying the removal of the former incumbent-health times as this past season give many a physi. commisisoner, of the city St. Louis. .. cian an opportunity to take account of stock Dr. Snodgras, while employed in teaching and see what he really has to offer as services in Marshall, Mo., became acquainted with to a willing public when the opportunity Miss Anna Gamble, a colaborer along edueventually comes. He should clean up his cational lines in this school, and the acstock, brush the cobwebs and dust off some quaintance led to their marriage. Two child. of his old ideas, put in new thoughts by ren, Alvin, aged five years, and Dorothy aged reading and study and visiting clinics, and three years, together with his wife, remain to thus make conditions really declare dividends mourn his untimely death, which nocurred by being better prepared for work when it as a result of double pneumonia on Friday, does come. We bave little sympathy witb April 6th, 2:30 p.m., at the City Hospital of the man who is contented to let such oppor St. Louis, notwithstanding the ungrudging

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