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Eureka Springs, in the northwest corner of Arkansas, has a wide reputation on account of the purity of its waters. They are quite free from solids, and are cold, carrying more oxygen than the waters of Hot Springs. The purity of its air, and the very rugged, broken character of the country in which they are located, commands attention. There are more than forty springs inside the town, and one can get his fill of the solvent diluent at almost every corner. In the treatment of rheumatism and nephritis, these waters are quite unsurpassed. The man with the torpid, sluggish liver, renal insufficiency, and a feeble heart, will, if he drinks these waters and climbs these hills under the direction of a skilled physician, commonly find the obstruction to his circulation soon disappear, his respiration grows less frequent, his sleep become less fitful and restless, and his general condition vastly improved; but even here I found, in conversation with physicians, that a high degree of skill is necessary to achieve results in the treatment of rheumatism, nephritis, eczema, or the distressing pruritus, often found as symptoms of impaired nutrition of the central nervous system. Nor is Eureka Springs a surgical town; there is not a hospital or sanitarium in the town. All the surgery is the homemade sort, and is performed wherever the need of it is manifest. People with tumors do not come here, although I believe not a few cases might be found in which the solvent action of the water in cases of chronic empyema of the gall-bladder, and the agglutination of the ducts might be supplemented by a surgical operation for drainage of the gall-bladder. Bathhouses are plentiful, fine hotels are numerous, good food is abundant, and pure air is universal at Eureka Springs. In a talk with Doctor Russell G. Floyd, who has a wide reputation in the treatment of nephritis, I was pleased to learn that he advised stripping the kidney in many of the cases of water-log nephritis, that he gave the patient plenty of the pure waters of the springs to drink, that he prescribed digitalis, and that he subjected them to vapor baths, massage, and cold douches with the most gratifying results. Doctor Floyd invariably treats the eczemas and prurities with copious dilutions of the fluids of the body, by having the patient drink daily one or two gallons of the pure spring water, and bathe in warm spring water, whitened with bags containing four or five pounds of bran to each twenty gallons of water. Exercise on the hills, climbing the mountain paths, or following the bridle trails on horseback are valuable accessories of his treatment. The country here is free from mosquitoes, and no stagnant water is found anywhere. The whole region around about is underlaid with caverns, and into these the waters filter through the flinty soil, to appear finally in the beautiful strong flowing White river which rises in and drains this region of the Ozarks.
I learned of a fever not altogether rare, which the doctors told me is neither typhoid nor malaria, but may be appendicial. It seizes the patient in the form of a high temperature, lasts from three to four weeks, and commonly ends in recovery if treated with hot sponge
bathing. It lacks the stepladder rise of temperature in typhoid, as wel! as the intermission and the remission of the malarial fevers. Nor is it in the least influenced by quinine. It occurs at almost any season of the year and is found in any part of the Ozark mountains. The local doctors call it mountain fever, slow fever. It is never epidemic, nor is it mosquito-born, for it prevails in localities where mosquitos are never seen. There is tenderness in the region of the appendix in most of the cases, quite suggestive of appendicitis. May it not be a type of ulceration of the appendix mucosa, allied to the ulceration of Pyer's patches, a characteristic of typhoid? Near the Basin Park Hotel is a large spring and a little park, where, during the better part of the two hundred odd bright days of the year, may be seen numbers of people. who come here to drink the water, and increase their stock of health. The pallid face, the puffy eyelids, and the hurried respiration of the nephritic patient is frequently seen among them, and in almost every instance these people are improved, not a few being absolutely cured by the waters of the springs and surgical stripping of the kidney.
Fort Smith, Arkansas, is a city of twenty odd thousand people on the border of Indian Territory. It is in Sebastian county on the Arkansas river at the head of steamboat navigation. The Sebastian County Medical Society has a membership of forty-two, but there are about one hundred seventy-five doctors in the city, and they are all either irregulars, eclectics, or homeopaths. The mass of practice is in the hands of the irregulars. The profession lives in reasonable harmony. There are several very good surgeons, who operate at the City Hospital and at the Saint Vincent, a Catholic hospital. There is, however, no great amount of surgery done. Some of the operators having met with disaster in their abdominal work have caused the people generally to be averse to surgical procedures. They prefer to trust to powdered roots, fluid extracts, and divers teas for the relief of their ills. Some of the doctors, however, have large practice, visit a great many patients, and put up or dispense bushels of medicine. Malarial fevers are not uncommon. Quinine and other alkaloids of Peruvian bark are in constant use. Calomel and epsom salt seem to be effective in most of the abdominal cases. The positive obstructions are either operated upon, with more or less reluctance, or go surely to the bad. I could not learn that there was much surgical enthusiasm in Fort Smith. It is a fine growing city, full of splendid homes, in the midst of a fertile country, maintains two ambulances owned by undertakers, who are a thrifty class. There is an opportunity in Fort Smith for an apostle of surgery, but he must cure the people whom he operates upon.
My medical jaunt to Arkansas would not be complete without some account of Little Rock, the capital of the state, where are located the medical department of the Arkansas Industrial University, Saint Vincent's Hospital, and the Logan H. Root Hospital. Mr. Root endowed the hospital with $100,000, but only $10.000 of that sum was found
available by his executors for the uses of the institution. The clinics of the medical college are in part held there, and as good courses in clinical medicine and surgery are given in Little Rock as in any city of its size in the United States. The Medical College was founded about twenty years ago and it numbers among its alumni many of the ablest physicians of the state. Little Rock has about fifty thousand people and is growing. It has Saint Vincent's Hospital, a church institution; a Railroad Hospital under the care of Doctor Joseph P. Runyon, who is generally recognized as one of the leading surgeons of the city; and a City Hospital, in charge of Doctor Watkins, the city physician. At the County Hospital and Poor House, a short distance. from the city, senior medical students act as internes, and get a part of their course in clinical obstetrics. Little Rock has a School for the Blind-both white and colored, a School for the Deaf-both white and colored, the State Penitentiary, and the Asylum for the Insane, which contains more than one thousand patients. All of these institutions furnish more or less medical and surgical work, which is available for the instruction of industrious and enterprising medical men. In the Asylum for the Insane the custodial features of the work is paramount, but not a little attention, probably fully as much as in asylums generally, is given to the internal medication of the patients. Gastrointestinal work is done tentatively, but every patient is given a careful physical examination, which supplements the perfunctory examination carried out under the direction of the county judge. There is, however, no reason to contrast the medical and surgical care of the insane of Arkansas, outside of the Poor House in Garland county, with the care that is given those people in other states. At Fort Smith they have a fine Poor House under the care of able physicians, and the most conscientious and discriminating treatment is given to the patients. The same may be said of that institution at Little Rock and of the asylums generally. The blot on the escutcheon of Arkansas in Garland county, near Little Rock, a prominent physician in Little Rock told me, is the fact that Hot Springs is the mecca for countless thousands of people, mostly poor, who suffer from constitutional diseases and pour into Hot Springs in great numbers. If the municipality built a city hospital they would swamp it. If they kept a decent Poor House they would swamp it. Most of the inmates of the County Poor House were from other counties and states, who had come to Hot Springs with the hope that the hot waters would heal them, and had no means to get away. He further said that it was the policy of the municipality of Hot Springs to discourage the coming of poor people to that place, by withholding all the usual eleemosynary institutions from their use. Even the jail, I found overcrowded and a relic of antiquity. It was built in the early days of the county and ought to discourage every evilminded person who looks at it, much less stays in it.
The expectation of finding any considerable amount of up-to-date surgery and surgical institutions in Arkansas were not fruitless; and
there is good reason to believe that the small band of vigorous, aggressive, well-equipped practitioners of the chirurgic art will meet with better reward in the near future. The wealth of Arkansas forests, her mines of coal and metal, her cattle, sheep and hogs, her grain and cotton cannot help but bring a population which will want more and better schools, ask more and better care of their minds and bodies, and consequently give employment liberal and ample to those who stand today for the advancement of medicine along the most progressive lines.
THE VALUE OF TIME AND NATURAL UTERINE EFFORTS IN PARTURITION.*
BY ALVAH N. COLLINS, M. D, DETROIT.
IF the signs of the times indicate anything to the more mature medical student, they indicate a closer study of the natural processes in the care and cure of those seeking our advice and assistance. This is true as well of surgery as it is in so-called general medicine and obstetrics. In general medicine we cannot fail to note a falling off in complex drugging and active interference. Given a complex prescription containing a half dozen different ingredients, the ultimate action of which, given separately, we know little enough, when combined, we know less. We had a specific that was good for this symptom and that symptom, while at the same time it might be hammering the life out of some other vital part of our machinery, unnoticed, in our mad pursuit of the particular symptom. How the multitudinous remedies have dwindled in this renaissance of more accurate observation. Just now in all branches of medicine the pendulum of all active interference without a very plain indication is swinging back toward a reasonable letting alone of all the natural processes unless we have a plain indication for interfering, either mechanically or medicinally, with am organization in which countless generations have developed recuperative and curative properties and which, in many cases, now interfered with were much better left alone. The man who always has his monkey-wrench in his automobile will do considarable walking. The doctor who cannot keep his fingers out of the delicate processes of the animal machinery will often do irreparable damage to the nicely adjusted and wonderfully complex machinery of the living organism. Nevertheless, there are times when the monkey-wrench will help the machine and there are unquestionably times when the careful physician will assist in benefiting the laboring organism. I simply plead for more care and judgment when to, and when not to, interfere. If a labor is going along reasonably well, if there are no apparent reasons why a natural labor may not be consummated, in the name of all that is sacred let it alone.
*Read at the Ann Arbor meeting of the FIRST COUNCILOR DISTRICT MEDICAL SOCIETY, December 22, 1905.
The subject of obstetrics is a broad one, and I will confine myself to one phase the value of time and natural uterine efforts in parturition-drawing my conclusion very largely from mistakes that I have made myself, and from mistakes that I have seen, and known of others making. In an experience extending over a period of twenty years it was my misfortune to have a very large obstetric practice. I cannot compete with some figures I have heard as to number of cases so will give no figures, but conclusions drawn not so much from books as from the bedside. We need to have a fairly definite knowledge of what is the average time necessary for normal labor. We must take into consideration that this is so modified by individual peculiarifies that one patient may need hours for certain changes that are necessary for safe delivery to take place while another will only need minutes. Each patient has a normal period of time distinctly her own. Yet from the study of a large number of cases we estimate a fairly definite period during which the process is completed. This period, as you have all observed, often varies greatly in the same patient, differing presentations, differing size of child, differing physical conditions, et cetera, all modifying the time needed for the most conservative and safe completion of this truly awful phenomenon, parturition.
Hirst states that the average duration of all labors is from twelve to fifteen hours: in primaparæ from twelve to twenty-four hours; in multiparæ from six to twelve hours.
In Spiegelberg's five hundred and six cases, commonly quoted, the three stages for primiparæ are, stage of dilatation, fifteen hours; expulsion, two hours; third stage, one-half hour. Multiparæ-dilatation, eight hours; expulsion, one hour; and placental, one-half hour. A proper conception of the long time necessary to bring about a condition of the parts for a safe delivery, a delivery as free from injury to the structure of the parturient canal and with as little offense to those organs as is possible, is the sine qua non of obstetrical practice.
My observation and experience at the bedside have shown me conclusively that more damage is needlessly done from a failure to remember that the normal period of the stage of dilatation in primiparæ is fifteen hours and may be thirty-six hours or more and still be normal for that case, than from any other one cause. I am satisfied that many a woman in her first labor is unnecessarily injured and made a semiinvalid, forever after to be a supplicant at the shrine of the gynecologist, from this failure on the part of the attendant to properly realize the necessity and value of time for the physiological changes to be brought about for safe delivery. I am not discussing abnormal conditions. Abnormal conditions may imperatively demand violent treatment of these organs as a lesser of two evils. Whenever we forget the value of time in parturition, and with our anesthesia and our forceps force these delicate structures to dilate and stretch to their utmost and beyond before they have been prepared for the ordeal by