ditions found in the given case, and not treat the "chronic enteritis" or the "acute nephritis"; in short, do not treat the disease by fixt rules or ready-made medicin, but treat the pathological conditions present in each individual case. This cannot be done by Dr. Parker's method. Each prescription should be prepared and directed to fit the case for which it is prepared. Printed labels are not scientific, as they do not afford opportunity for variation in directions to suit each case. The plan of making merchandise out of the remedies we have for scientific use is a poor example to place before the profession, and much less the laity.

By buying patent medicin, or standard pills by the 1000,"Dr. Hooper's female pills," for instance, and selling them under our own printed labels, at a certain price, to whomever makes a diagnosis for themselves of female derangements and even prescribe for themselves, and we furnish the dope at a fixt price of 25 cts., 50 cts., or $1, we would then be making of ourselves pill-sellers rather than physicians. Nor shall we ever suffer the profession to surrender its dignity and sink to such a level!

Last winter I had under treatment a mother and daughter. After coming to the office regularly for some time they were so improved that regular treatment was suspended. Then they occasionally would send up to the office for medicin as they felt they needed it. This continued for several months. Recently the daughter came back and wanted a dime's worth of the headache powders for herself and a dime's worth of the heart tablets for her mother. Then I balked. It had been several months since the heart-tonic tablets had been prescribed. I referred to my ledger, then to my R file, and found five months prior I had examined the mother and prescribed a general tonic and the heart tablets, with special directions, also directions as to hygiene, diet, exercise, etc. I told the daughter I was not sure that was the treatment her mother needed; ask her to please come to the office and I would see what she needed. She did so, and I diagnosed anemia with neurasthenia and prescribed accordingly, and now it is Doctor, not just common Doc! Let us guard the dignity of our profession. Holliday, Kan. W. H. FINLEY, M.D.

Dividing the Fee.

Editor MEDICAL WORLD:-Dr. A. D. Hard's article on "Dividing Fees," publisht in Sept. WORLD (pages 350 and 351), brings forward a question that has been discust by the medical press from one side only, and that the surgeon's side. As Dr. Hard has broken the ice for a discussion, I would like to hear from more of the general practicians on this subject. I believe Dr. Hard's views are right, and that he voiced the sentiments of the majority of the profession.

I do not believe in dividing the fee to get an extra amount from the patient; neither does Dr. Hard nor any other honest, conscientious doctor; but I do believe the local doctor should have something to say about what the operation is going to cost the patient. And if the patient is to pay the regular fee for the operation, which should be governed by the particular operation and the patient's ability to pay, let the patient know that you are to get your pay from this amount without his being burdened with any more expense than he would have been had he first fallen into the hands of the surgeon (railroad fare excepted). For the time, knowledge, responsibility, and skill required, I believe the country doctor should receive one-third and the surgeon two-thirds of the fee.

Speak up, doctors; what do you think? De Smet, S. Dak. H. DENMAN, M.D.

Consultations?

Editor MEDICAL WORLD:-A consultation of two or more physicians in a case of illness or injury is supposed to be a joining of their skill and ability in order that the patient may receive the very best possible service. I have practised medicin only one-fourth of a century, and within that time I have not seen a single consultation of physicians that met fully these supposed requirements. I think that I am justified in stating that consultations, as a rule, are more detrimental to the patient's interests than advantageous. I never knew of a case of consultation in which one or both consultants did not carry a knife up his sleeve to rip his brother consultant up the back at the slightest opportunity. Professional jealousy is so common and so fierce that very few physicians hesitate to sacrifice even the patient's interests in their strenuous efforts to supersede and displace a brother physician by fair means or foul. It seems to be a game so desperate that each strives to elevate himself by placing his foot on his brother's neck, and sometimes the other foot upon the patient, in order to win supremacy.

I will relate two incidents which are only typical of what is common, as you must admit. A physician was attending a case of recurrent appendicitis in a little boy of seven years. It was the third attack, and was quite severe, yet no general peritonitis had occurred. When the symptoms had been nearly subdued and the attack almost over, the physician told the parents that it was absolutely necessary, in order to safeguard the boy's life, that he be operated upon in the near future. The parents were surprised and could not see why an operation was needed when the boy was now almost well again. The matter was fully explained to them, but an old aunt advised against the physician, and the parents requested a consultation in order to see if the aunt or the

DECEMBER, 1906] physician should be followed. The consultant was an up-to-date physician, yet he advised that a medicin which he was in the habit of using be given the boy as a preventiv of future attacks, and that no operation be done. Six months afterward the boy had the fourth attack, followed by extensiv peritonitis, and when he recovered from the acute symptoms he was a mass of intestinal adhesions. Then the parents askt the physician to take the boy away for an operation, as he had first advised. The boy died two hours after the operation. The consultation resulted in the boy's death.

The same physician had a case of encephalitis due to extension of inflammation from a blind and injured eyeball. He decided to enucleate the injured eye ball, but delayed the operation a few days while getting the patient in better condition for the operation. The patient got anxious and requested that another physician be called to see if the two coincided in their opinions. The consultant decided that if he had the case he could give relief without the operation. The man died one week afterward. The consultation resulted in the man's death.

There are five physicians in the town in which I practise, including myself, and under the circumstances I feel like "knifing" all of them, and I have no doubt but that they feel just that way toward me; at least they act as tho they felt that way. disgusted with consultations, and after this I shall not permit any in my practise unless I want the patient to die.

I am

Marshall, Minn. A. D. HARD, M.D. [Either Dr. Hard is entirely wrong, or the profession is in a deplorable condition in his community. We commend to the doctors in his community, and in all other communities in which what he says is true, the first article on page 387 of October WORLD. We know that in communities where the profession is what it should be, consultations are helpful to the attending physician and beneficial to the patient. Within the past year there was a case in the Editor's own family in which this was preeminently true, particularly as to the benefit to the patient. There were two consultants and the attending physician, and all workt with a total absence of selfishness for the good of the patient; and the patient, with every advantage that science and unselfish devotees of science could offer, made a notable and unexpected recovery. ED.]

Medical Law Not Executed.

Editor MEDICAL WORLD:-I notice that you publish the examination questions used in various states. In my home state, Georgia, a physician must hold a license and a diploma before he can practise. He can keep his own drugs, but he cannot run a drug store unless he also holds a pharmacy license and diploma.

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But down in this neck of the woods, anybody can practise medicin and run a drug store. I passed the Florida State Board in Tallahassee in 1904; also in Georgia in 1903; but there are doctors and drug men in Florida that have never seen a diploma or license, and are allowed to practise. What protection are state boards to a doctor and to the people? What does a license amount to? Anybody can practise here. Get a Texas horse and sulky, an old hand bag, and a fifty-cent thermometer, tell them your name is Dr. So-andSo, and you will do well. Sopchoppy, Fla. I. H. HUNTER, M.D. [Have you no officers whose duty it is to see that the law is executed? No prosecuting attorneys? Why don't your state and local societies look after this?-ED.]

Was It Cerebro Spinal Meningitis, or Autointoxication?

Editor MEDICAL WORLD:-On Oct. 4, '06, I was called to see Opal D., a girl of 4 years. Previous health had been good until the preceding evening, when she complained of pain in epigastrium, was restless all night, tost about in bed, moaned, and showed decided nervous symptoms until 7 a.m., when I was called. Upon arriving I found child in a dull, heavy stupor; eyes turned back in head, pupils unevenly dilated, temperature 97°, pulse 120, respirations 20. History of one movement of bowels previous day, which smelled very bad; bowels somewhat tympanitic, kidneys o. k. I diagnosed auto-intoxication, left aromatic spts. ammonia 10 drops to be taken every half hour for four doses, then every hour or two until patient rallied and got stronger, when she was to be put on calomel gr., soda gr. every half hour for five doses, to be followed by Epsom salts two teaspoonfuls every two hours until bad odor left stools. I was to return next day.

me.

At 3 p.m. same day I was sent for post haste; also Dr. G. of this town to come with Upon arriving we found child's nervous symptoms had assumed the convulsiv type, tossing, rolling about, head drawn back, eyes rolled back, nervous twitching, etc.; temperature 102°, pulse 120; bowels had not moved. Dr. G. thought it cerebro-spinal meningitis, while I hung to my original diagnosis. He suggested bromid of soda for nervous condition, and we agreed to give 'good round doses" of castor oil until effect. Upon returning next morning I found conditions but little changed; continued physic with enema; good results. Next day child much better. I then put it on the triple sulpho-carbolates, 2 grs. every 4 hours with 1 grs. salol in hot water half way between. Child improved rapidly. Fed on broths, bovinine, etc., gradually assuming regular diet. Exhibited pepsin, hydrochloric acid, and pancreatin on the fourth day of illness, to

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be taken after nourishment. Dismissed case October 10, after illness of 6 days.

Now who was right? and was line of treatment according to your idea of good judgment and common horse sense? I would beg to say in conclusion that I have found it a rational course in the majority of cases to inaugurate treatment with a course of calomel and soda, followed by salts or oil. Full many a time have I seen the brain cleared up by it, as well as the bowels. I am forced to the conclusion that most of the ills to which human flesh is heir are dependent, directly or indirectly, upon some abnormality of the gastro-enteron. Dr. F. M. THURMON. Pearl, Ill.

[The rapid recovery would invalidate the diagnosis of cerebro-spinal meningitis.ED.]

The water should be used hot or boiling; let it steep an hour or so, or over night; then strain thru a linen cloth or cheese cloth.

This infusion can be given to an adult in teaspoonful doses every four hours; when administered in cold tea, sweetened, it is not in the least objectionable. I think the country practician will find that he will get better results from the infusion of digitalis than from any other preparation that is made. The infusion does not keep long, even when prepared by a druggist; this is easily prepared, and can be made fresh every time it is needed by the country doctor. Oroville, Cal. S. P. JOHNS, M.D.

M. Sig.-Teaspoonful in hot water every 2 to 6 hours.

When there is tenderness over bladder I add gtts. x sp. med. eleterium to above. F. G. THOMASON, M.D.

Austin, Texas.

Scalp Massage for Dandruf.

Editor MEDICAL WORLD:-On page 452 of Nov. WORLD, I have just read Dr. W. R. Fowler's plea for help for a case of dandruf. Having been a sufferer of this kind, I wish to give the doctor the treatment which cured me. My case could not be better described than in the doctor's language describing his own case, only that it is more troublesome than the doctor's language would indicate. I tried every sort of formula, the one mentioned being used, and finally my wife cured me by simple means. She would rub the scalp briskly for 5 or 10 minutes each day, and gently lift off the scales with her finger nails. This was continued for 2 months, and my dandruff all disappeared, to return no

more.

Try this, doctor, but be persistent, and I am sure you will find relief. In rubbing the scalp, just use the ends of the fingers. Wash the scalp no oftener than necessary for cleanness, and then with non-irritating soap. CHARLES S. SKAGGS, M.D.

East St. Louis, Ill.

[It is the Editor's habit to rub the scalp with the tips of the fingers, a part of the time making sufficiently firm pressure to move the scalp, a little while before retiring at night, and sometimes also in the morning; also sometimes using coco-nut oil. If he did not do this he would be bothered with dandruf, as he was before adopting this custom.]

Obstetrical Observations.

Editor MEDICAL WORLD:-In "An Obstetric Case," by Dr. Parker, page 445, is related how not to do it. Here is one physician who believes in "resting on his oars" while Nature does the work. "Meddlesome midwifery" is bad, of course, but sometimes it is advisable to interfere when one meets

with a case such as this one cited by Dr. Parker, absolutely demanding assistance. To wait six hours, and again six, and again eight hours and do nothing in all that time that nature couldn't do as well, is not up-to-date obstetrics. That is the practise of the midwife; a physician is supposed to know therapeutics, and knowing, to apply remedies to relieve suffering that in even the easy cases is sufficiently great to arouse all our sympathies. I cannot understand how a physician finds it possible to lie down for hours and permit his patient to suffer when relief is so easy. Possibly there will be no trouble in this case, but I should expect to find a lacerated cervix after delivering by forceps thru a partly dilated os.

As to remedies for rigid os, there are several that are almost specific when given according to their indications. Gelsemium is indicated in rigid os with sharp thin edge; give one granule, gr. T, every fifteen minutes in hot water. Lobelin is best for thick, doughy os, gr., one granule every ten to fifteen minutes. Caulophyllin, gr., in hot solution may be combined with either of the above or given by itself. It relieves rapidly. Six granules may be given at one dose, and the rigidity of the os vanishes as if by magic. Sometimes a hypodermic of morphin and atropin causes rapid relaxation. Timely use of chloroform is also efficient. Local applications of atropin or cocain has helpt in my hands, the os being first dried carefully.

In Dr. Blakeley's case reported under "Death in Confinement," page 440, it is extremely likely that the midwife had been in attendance much longer than twelve hours, as the Editor suggests. The indication was for immediate delivery, giving attention to the uterus as soon as the child was born. Severe hemorrhage in the patient's exhausted condition, as evidenced by the pulse and respiration, was sufficient cause for death, without rupture. The proper procedure would have been to insert the hand well into the uterus, kneading thru the abdomen at the same time. Cold water poured on the abdomen from a height of three or four feet, or slapping with a towel wet in cold water, or vinegar, very hot water, applied to the interior, are remedies always at hand.

Certainly this midwife, a relic of the barbarous dark ages, should be made to suffer for her cruelty. If there is no law at present in Michigan to reach such a monstrous case, there is work for county and state organizations. They should bring sufficient pressure on the legislativ bodies to force a strict law thru. It is a public necessity in every state. Not alone in Michigan is such a condition of affairs possible, but every year sees one or more states adopting legal requirements for the practise of midwifery.

Reply from Dr. Blakeley Concerning His Case of Death in Confinement.

Editor MEDICAL WORLD:-Replying to your criticism of my report of death in confinement in November WORLD, page 440: You say you cannot see by what basis of reasoning I could justify a wait of one hour when my patient was already in collapse. To my mind the indications were as plain for a wait of one hour as they appear to you for immediate instrumental delivery. Had I not a reason to expect that under strych., min. ij digitalis, one dram of ergot, and normal salt solution by rectum, that my patient would be in a better condition to stand an anesthetic and shock of instrumental delivery at the end of one hour? What more chance, doctor, do you think my patient would have had for her life had I delivered as you suggest? How much short of one hour, doctor, have you ever properly prepared instruments and patient for delivery, say nothing of the time it takes in nine homes out of ten to overcome the objection to the use of instruments?

I take no exception to your criticism of my aftertreatment, as I forgot to state in reporting the case that the uterus as well as vagina was packt.

It is true that I should have been able to determin whether the uterus was ruptured or not when I was removing the tampons, but with a husband and nine grief-stricken children in a two-room house, I admit I spent very little time in looking for the rupture, which I was perfectly satisfied existed in her uterus.

You were right in your suggestion as to the length of time my patient had been in labor. I have learned since reporting the case that she had sent for her husband to return from lodge twenty-four hours before I was called, and askt him to send for a doctor, as she feared all was not right with her.

Sanford, Mich.

E. A. BLAKELEY, M.D. [Our criticisms, doctor, are intended to be justthey are not by any means to be interpreted as condemnations; they are given in the hope that they will prove of help and service, not only to the inquirer, but also to all the rest of the family. You appear, in the main, to have taken us as kindly as we meant; but we think you have failed to understand us completely.

The woman's condition, when you first saw her, could only indicate one of three things. (1) Exhaustion from severe or prolonged labor. (2) A threatening rupture of the uterus due to severe or prolonged labor. (3) Concealed hemorrhage, either from a ruptured uterus or a prematurely detacht placenta.

Assuming that none of the three possible conditions could be definitly separated from the other, immediate delivery was indicated. We would not deem the possible benefits following the ingestion of the medicin as a sufficient warranty for delay. Tho you might get a certain effect from such medication, the cause of the trouble would be still constantly acting, and therefore the patient would be in better condition if delivery were performed at once rather than by waiting. The added shock of delay would be greater, in other words, than the shock of instrumental delivery.

It is not necessary in cases of such grave emergency to palaver with the unknowing laity. It is our custom to go straight ahead as speedily as we can; then, if objections are raised, we simply make rapid preparations to retire from the case and advise them to get a doctor who will follow their directions; this settles it, and we are allowed to do as we please without molestation. We have prepared (we will not say properly) everything for instrumental delivery in less than three minutes, in emergencies. In emergencies, especially obstetric ones, one must suspend many of the laws which under other circumstances one would wish to obey implicitly. Many times, in delivery, emergencies arise, which, properly handled, would result in the saving of two lives; but which, if parleyed over for even a few moments, would result in the death

of one or of both patients. Many times one must do things which may expose the parturient woman to infection; if infection arises, he must take the chances and combat it; often it does not occur. We always have our forceps reasonably clean; in dire emergencies we do not hesitate to use them, even without warming, and with no further preparation than wiping on a towel and anointing with carbolized vaselin. If you always intend following explicitly the teachings of antisepsis, you will allow many patients to die while you are "getting ready to succor them."

We cannot say, of course, how we would have proceeded after we had extracted the child. But we would then have been in position to take measures to check the hemorrhage-something not possible before delivery. It is possible that you had no rupture of the uterus at all, but that your patient died of hemorrhage following premature detachment of the placenta, and that the blood that followed for "ten or fifteen minutes" merely flowed from the uterus after the obstruction to its outpour was removed. Supposing that the uterus was ruptured, and that you would not attempt an abdominal section, or that the patient's condition did not admit of it, or that no competent surgeon could be obtained, then you should have endeavored to pack the tear with gauze from the inside to prevent further infection from the uterus.

Had you delivered at once, as would have been easy according to your experience an hour later, she would have stood a much better chance for her life (providing you had made the indicated investigation during the postpartum hemorrhage). In passing the hand to the fundus to clean out clots you would have been most likely to have found the tear if it existed, and then it would have occurred to you to pack the tear. Moreover, if the concealed hemorrhage followed a prematurely detacht placenta, the hour's delay was amply sufficient in which to allow her to bleed to death. Had delivery been performed immediately, it is possible that much of this hemorrhage might have been prevented, and contraction secured and maintained.ED.]

DEAR DOCTOR TAYLOR:-I herewith inclose $3 to pay my subscription for three years. Let me say that I regret that loss of a dollar to you by the failure of Dr. Parker to renew his subscription, as given on page 458, November WORLD. I also regret that the medical profession has, still lingering, a pessimist who would fain boast of his forty years' practise in which he has never sterilized or otherwise disinfected his obstetrical instruments. I hope that all delinquent subscribers will promptly send in their subscriptions, and others will pay in advance, to make good this loss. Baltimore, Md. L. B. EVANS, M.D.

Directions Concerning Diet.

In a general way, the following suggestions on diet should be made to every patient who is being treated for chronic stomachic or gastro-intestinal trouble: I. Let the food be simple. Do not combine a large num ber of different varieties of food in the one meal. If variety is craved, let such assortment be made at separate meals. A mixt diet imposes a greater tax on digestion than does a meal made up of but one or two articles. 2. Let every meal be markt by frugality. Most people eat too much. After trying this plan for a time the patient will be convinced that he is not in danger of starvation. 3. Masticate all food thoroly. Insist upon the importance of this provision until the patient appreciates what it means. The mere direction to chew thoroly will not be appreciated nor obeyed by the average patient. It is well to direct that they chew each particle a given number of times before swallowing, say twenty five times; when they have obeyed this rule implicitly for a few meals, they will confess that never in their lives have they masticated their food properly. 4. If fluids are taken at meal times, order that they be taken before beginning the meal, or not until after the meal is completed. This is not only a rational direction, but its observance adds to the improbability of the food being "bolted."

QUIZ

New books as they appear, are sent to our Assistant Editor, Dr. A. L. Russell, of Midway, Washington Co., Pa., for review. As the Doctor thus has all the late books for reference, and is made familiar with them by reviewing each one carefully as it reaches him, he is unusually equipt for answering queries. Therefore it has been our custom for a long time to send queries to him for reply. In fact, the Doctor made a special request that this be done, as he enjoys this work. It now occurs to us that time will be saved if you will send directly to Dr. Russell matter intended for the Quiz Department, which has grown so much under his vigorous "treatment." Please notice that our query department is not used to "boost" proprietary remedies, almanac fashion. THe Medical WORLD has no interests other than to give to the medical profession the greatest amount of honest service possible. It has absolutely no interests in any proprietary preparation nor any medical supply house. Other medical editors bave become, and are becoming, wealthy, by using their pages to increase the sale of preparations that they are interested in; but we prefer to render service to our subscribers that is above suspicion of personal pecuniary interest. How can a man interested in the sale of certain preparations render the best service? He is always trying to push one of his preparations in. That is commercial journalism. We prefer ethical journalism-and so does the profession, for THE MEDICAL WORLD is growing in popularity faster than ever before-and our subscribers are paying ones. They must be, for we have no medicins to "boost," nothing to sell, nothing to depend on but pure journalism; but doctors that wart honest, straight journalism are willing to pay for it-they are glad of the opportunity.

Only such queries will be publisht as are likely to interest and instruct many others, as well as the one asking help. No charge has ever been made, nor will any charge be made, for this service to our subscribers. However, those who wish an immediate and personal reply by mail may obtain the same by inclosing two dollars to Dr. Russell. This is really a consultation in the interest of the patient, and should be charged to the patient-two dollars being a very moderate consultation fee. The Doctor agrees to give full, careful and immediate attention to such consultations. We reserve the right to publish in this department any such consultations that may be interesting and helpful to our readers. Name and address will be withheld if requested; but anonymous com munications will receive no attention. Come freely for help, but read up as fully as you can before coming to us.

We have tried to make it plain that it is a physical impossibility to act as corresponding consultant for the profession in general, and attempt to do anything else. We are running a medical magazine, and must have a chance to do the work which that involves. To provide for those who wish private and immediate consultations, we have had a notice standing at the head of this department for years, but it seems impossible to induce some people to read it-yet we put it there to be read. But on account of the urgency of the above letter, we askt Dr. Russell to make an exception, and the following letter was sent : MIDWAY, PA., Oct. 31, 1906. Dr. W. C. Kimbro, Tyro, Ark.

DEAR DOCTOR :-If you will read the standing notice at the head of the quiz column, you will note that we cannot undertake to give personal replies to our subscribers. It is only in the hope of affording some aid to the unfortunate patient that impels us, in this instance, to write you direct.

First, establish beyond doubt that you have made no error in diagnosis. This can only