JULY, 1903]

I dressing forceps.

I caustic holder.

2 flexible probes.

I needle holder.

2 artery forceps.

I grooved director.

I doz. assorted needles.

Silk for ligatures and suturing.

Catgut for sutures and ligatures, assorted sizes. Second. A general operating case containing:

1 Esmarch tourniquet.

I amputating knife, medium.

1 amputating saw.

1 trephine.

I elevator.

doz. hemostatic forceps.

1 hernia knife.

1 pair bone forceps.

1 metacarpal saw.

I pair retractors.

I pile clamp.

303

goes to a better equipt surgeon, and the new man orders an instrument. It is better to be prepared for all ordinary work from the first. While many instruments make an alluring display, a very few of each class will be sufficient for skilful work.

To meet emergencies away from the office, the general practician should always carry a pocket case containing a sharp point bistoury, small scalpel, dressing forceps, needleholder, combined catheter, scissors, two needles half curve, medium and small, a few sutures and ligatures. These are enuf for the pocket case, and with antiseptic tablets from the medicin case will enable him to handle an emergency case. If he should need more than these he will also need other articles for aseptic and antiseptic work, which will require a visit to the office.

In the general operating case he should have two scalpels, a probe point bistoury, dressing forceps with catch, two artery forceps with catch, bone forceps, six hemostatic forceps, scissors, amputating knife, amputating saw, metacarpal saw, trocar, probes, one dozen needles in metal case, instantaneous tourniquet, silk, catgut and horsehair sutures and ligatures.

In the obstetric bag he should have delivery forceps, placenta forceps, cephalotribe, perforator, uterin douche, inhaler (chloroform), fountain syringe, obstetric cushion.

For abortion cases a Knott or Auvard vaginal speculum, vulsellum forceps, sharp and blunt curets, McDade curet, iodoform gauze bandage width, gauze packer.

In the vest pocket he should have a thermometer, tongue depressor, hypodermic syringe, four inch pocket scissors for everything except surgery, and a fountain pen.

In the office will be required beside these a few assorted urethral sounds, rectal speculum, stethoscope, cotton applicators, catheters, dental forceps.

There are many other instruments that will be convenient, but except in the less frequent cases, not a necessity. A few of these enumerated could be omitted, but each will be profitable on account of its convenience. The same instruments may be used in either bag or office, to save duplicating.

It is universally recognized that the skin, bowels, lungs and kidneys are each complementary to the others. In most young people the skin is healthful and activ, and like our good mothers, always ready to take upon itself both its own work and the work of others. If the bowels are inactiv, the skin takes up the work of elimination which belongs to the bowels. Even when the bowels are regular and seemingly perfect in action, yet the skin

sometimes reaches out to help, and is actually carrying on part of the work belonging to the bowels. But the excretory ducts of the skin are too small to admit of perfectly free discharge of fecal matter, so it becomes lodged in the ducts. Irritation, inflammation and ulceration follow, and we have the well known pimples, blackheads and festers so common in youth, when the skin is most activ and the desire for food greatest. Skin treatment will fail to cure these cases; bowel treatment will succeed. The bowels must be kept free. If they are already free, they must be kept more free. They must do their own work and they must do it so quickly and thoroly that the skin can find none of it to do. A remedy that acts upon the entire length of the canal is best. Aloin, strychnin and belladonna pills are excellent. The bowels must be kept a little more loose than would be otherwise required, and so continued for a few weeks or in severe cases several months. As result you will soon see the face begin to clear up, the pimples disappear and the skin become smooth, except in chronic cases where there may have been produced hypertrophy of the glands, the hard nodule remaining long after the eruption is gone. A few of these may require removal surgically. J. W. COLLER, M.D. Wellsville, N. Y.,

I Found It to Be a Matter of Diet. Editor MEDICAL WORLD:-In the March WORLD, page 98, you state that the old method of treating rheumatism was not satisfactory, which is a fact. You also said it was now considered an acute infectious disease. I have been suffering with sciatica and lumbago since October, 1902. Had erythromelalgia all of 1902. Thought the latter owing to shoes and for a long time wore rubber and cloth shoes, and even went barefooted; but it did no good. Treated the sciatica and lumbago alopathically and by the eclectic method, but neither did any good. So I just quit treating rheumatism and commenced to cure dyspepsia and disinfect the digestiv tract. It has workt like a charm; I am nearly well. I think that 50 per cent of the inmates of mad houses are there from some form dyspepsia or malnutrition; the same of epileptics. Fifty years ago people only had one or two dishes on the table; now they have a dozen, and by the time they get thru eating they have made swill barrels of their stomachs. Rheumatism and neuralgia originate in the digestiv tract—at least it has been so with me. Please excuse my blundering manner. I can't tell even what I know well, much less write it.

Later: On pages 261 and 262, June WORLD, under the head of Neurasthenia," Dr.

Wildman describes my condition pretty well, as it has been. I thought the trouble was dyspepsia, and so wrote you a few days ago. When I quit eating I improved, and became clear of all neuralgia and rheumatism. Can plow all day or walk four miles an hour. I don't eat any meat—just milk and corn bread, vegetables and a little butter. I am 62 years old and I farm as well as practise. Yes, when I ate as formerly I was like a balloon, and urin was offensiv, and coated the chamber with a calcareous sediment and was high colored; sp. g. 1,015, acid reaction, albumin none, sugar none, tongue coated all over. Cathartics, salines, aperients, triturates, all did no good. My tongue, excretions, etc. just kept on being foul. The salicylates and colchicum did not faze that lumbago and sciatica. I used the sulfocarbolates and sulfite of soda to disinfect, yet the offensivness continued. Then I just quit eating, and took only three glasses of milk per day, commenced on glycerin, juglandin, colombo and quassia and I am just about well; my nerves are steady all the time, tongue clean, feces moulded and have lost their feter. Now I guess I have dyspepsia on the brain. I believe if we would eat right, we would hardly ever be sick. Dr. Wildman or I have hitcht the horse to the wrong end of the cart. I diagnosed my trouble as chronic or subacute gastritis. H. J. WARD. Coaling, Ala.

A Reasonable Request.

Editor MEDICAL WORLD:-I enjoy and benefit by THE WORLD of course, or else I wouldn't take it. I have no "gems" to offer, but when some one publishes a dogmatical letter which runs counter to the experience of the profession, won't he append his date of graduation? It might have weight, or the opposit, if we knew whether he had practised medicin a year and a half or thirty years like some of the rest of us. JOHN SABIN, M.D. Ceur d'Alene, Idaho.

Hints.

Editor MEDICAL WORLD:-Some of the most useful little things I have found in fifteen years of hard study and practise are the following:

1. A tablet of aloes, belladonna, podophyllin, and nux vomica, ãã 1 gr. (every manufacturer catalogs it), taken t. i. d., will cure and help more cases of constipation than anything else. When it acts too freely, tell the patient to take,, or of a tablet, but never skip. For infants, mix it up sweet with licorice and syrups, and give t. i. d., q. s.

2. In all fevers we should clean out the bowels with salines, oils, injections, and calomel, and then disinfect them with the sulfocarbolates.

3. In erysipelas we should use ichthyol externally and pilocarpin and strychnin internally.

4. It is imprudent to go to a distant call without a syringe. At the beginning of any fever a full rectal injection of soap, soda and water will do good.

5. Where there is jaundice or any suggestion of biliary disturbance, calomel, sodium phosfate, and nitrohydrochloric acid are the agents to use. When sodium phosfate proves unsatisfactory, the acid will usually do the work.

6. When I sew up a cut I apply a streak of ichthyol along the line of coaptation, cover with isinglass plaster, and keep it dry.

7. To an ulcer I apply a spray of H2O2 frequently.

8. I wrap a sprained or rheumatic limb in a cloth soakt in oil of gaultheria, then cover with guita percha bandage, and elevate the part.

9. For a sick stomach I give a cup full of hot capsicum solution, and even when there is pain I find that this, an injection and a saline laxativ, will frequently restore comfort without recourse to opiates or anodynes of any kind.

10. I have learned to regard the doctor who uses morphin and opiates with nearly all of his patients as very limited as to his resources.

11. When in gonorrhea gr. of calcium sulfid is taken every one or two hours, there will be no chordee or gonorrheal rheumatism.

12. Where hemorrhage is a symptom and it tends to slowly persist, give 10 grs. of calcium hypophosfite every two to four hours. Some patients can take 20 grs. at a dose, which is better.

13. In endocarditis, endarteritis, pneumonic sequelae, and tuberculosis, give cacium sulfide, gr. every two hours for months.

14. Remember that a single man, without fixt abode and who smokes cigarets, cannot one time in ten be safely trusted: charge cash.

15. A tablet of acetanilid compound, caffein, nitroglycerin, heroin, atropia, etc., will act much more rapidly if allowed to melt into solution upon the tongue than by being swallowed at once. C. E. BOYNTON.

Los Banos, Cal.

Fees and Partnerships. Editor MEDICAL WORLD:-I would appreciate it if you and the WORLD family would give your opinions and advice in the following:

Is it within the bounds of medical ethics for a physician, either alone or two or more as partners, to make two or more visits to the same patient in the same day for same charge as for one, or three visits as above for less than the ordinary charge for two visits? For instance, when the visit rate is say $2.00, make two visits for $3.00.

Also for partners, either two, three, or four, should they visit a patient for the same amount as that usually charged for by one? Is it not generally very unusual for such charges to be made? Also for three or four physicians to unite in a general practise as partners?

Now, suppose a certain physician locates in a place and charges about half what the ones charge with partners. Is this man justified in doing this under the circumstance, he, being alone, charging accordingly? If not, it seems that trusts have about entered our noble profession, and a physician in that town, if he has no partner, or doesn't desire one, will be compelled to move or stop practise. Any physician prospecting for a location in that town will, if he investigates first, be kept away unless he gets together the requisit forces-one or more physicians as partners-which may not suit him. JUSTICE.

[Two men practising as partners expect to make an income for two, and not for one. However, there may be some conveniences to the partners in a partnership, and also some advantages to the public, without any real injustice to competing practicians.-ED.]

A Medical "Merger."

There is in existence at Hastings, Minn., a condition of affairs calculated to cause many physicians to stare in amazement. Hastings is a city of some three thousand people, and harbors within its limits five physicians-four old-timers" and one who has settled there within the past few months. In such towns there usually are bickerings and jealousies, petty quarrels and rivalries between the medical brethren, and so common has this been the condition that the inhabitants get suspicious if there is no quarreling. And today some of the Hastings people are suspicious.

Some weeks ago one of Hastings' M.D.'s studied the local situation over and noted the following facts regarding the four "old-timers: "

1. They were of about the same age.

2. They were doing about the same amount of busi

ness.

3. They had all been in practise about the same length of time.

4. They were all graduates of reputable medical colleges, and licensed practicians.

5. They were all of good moral, social and business repute in the community.

It was evident that these four physicians were on an equal footing in the city, and the idea was at once promulgated of merging the business of the four into one common institution; of establishing a community of interests to supplant the existing antagonism. Several informal meetings were held; the matter was thoroly discust pro and con, and as a result the merger became an establisht fact, with the following result:

1. The business is centralized in one building. The second floor, eight rooms, of a prominent business block, was leased, remodeled, decorated and equipt for the purpose. Each doctor has his separate consulting-room, his own hours, and sees his own patients as of old. Should one of them be absent, his cares are attended to by one of the other physicians-just as would have happened before the merger, and the absent physician gets the fee-just as would not have happened before the merger. Patients understand this and are not so apt to suffer from delay in waiting the return of 66 their doctor.”

2. The merger has increast the equipment of the physician four-fold. Whereas in olden times four

copies of one book were necessary to supply four separate physicians, one copy now supplies the four mergers, and the money so saved is expended in purchasing additional books which previously none of the mergers felt individually able to afford. The same is true of instruments and appliances. Today, instead of the scanty office outfit of last summer, they have a complete electrical outfit, x-ray machines, Betz hot-air

apparatus for knee, limbs, and body, and fully equipt

laboratories and operating-rooms.

3. It is now possible for each member to indulge in post-graduate study. In fact it is made compulsory upon each physician to take a six weeks' course in post-graduate work every year. During his absence his business is attended to by the three remaining at home, and he gets his income just as tho he were at home. The expenses of the post-graduate work are paid out of the common funds of the merger. The specialties are divided so as not to conflict.

4. A decided help to each individual in the merger is his every day work without putting patients to unusual expense for consultations or exposing the physician to the insinuations of ignorance and incompetency.

Besides these palpable advantages there are many others in a business and professional way which are of undoubted benefit to the physicians, their patients and the community at large. In fact so commendable does the idea seem that to those situated similarly to our Hastings brethren we say: Go thou and do like

wise."

When we read the above (in the Medical Standard, quoted from the Minneapolis Homeopathic Magazine) we clipt it, went to our subscription books to see who were subscribers in Hastings, Minn., and sent the article to one of them, with a request for direct and more com. plete information for publication in WORLD. The following is his reply:

HASTINGS, Minn., June 1, 1903. C. F. TAYLOR, M.D. :-Yours bearing date of May 29 is at hand. The inclosed article is true in the main. On the 10th of this month we will have been in business one year. Upon the whole it has proven very satisfactory, and in many respects advantageous, to each one concerned. So far as I know our plan is re garded favorably by the public. I am one of the members of the so-called "merger." At the beginning of the new plan we were all the doctors there were in town. Very soon after we started a so-called "homeopathic" came, and about six months after a new young man, "regular," located here. During the year which is nearly past we each attended a postgraduate course, while the general business went on in the even tenor of its way. We have establisht in connection with our business a small but very convenient hospital, which has been a convenience to the public and a gratification to ourselves. I do not think I can state this matter more fairly by giving you a "write up" for THE WORLD, which now is my favorit journal. We have quite a number of medical journals, which are placed on the library shelves as common property which, as mentioned in the article referred to, is one of our advantages. J. C. FITCH. [Here the thing was done without the aid of

a Morgan and without the expense that the services of a Morgan would have involved. This combination possesses all the advantages of a trust without its disadvantages. The members are better and more conveniently prepared for work, have more personal freedom, more personal advantages, and are relieved of the strain and anxieties involved in competition. The public is better served, more promptly served, receives the advantages of many kinds of instruments and apparatus not available before, receives the services of men who take a post-graduate course at least once a year, and all this without additional expense! It is like the discovery of a new factor in economics, or the invention of a new machine.-ED.]

A Case of Fecal Impaction.*

Editor MEDICAL WORLD:-I was called on September 1, 1900, to attend a boarder from the West-Miss H., age 25. She gave the history of having the usual diseases of childhood, and had always been perfectly well except an occasional constipated condition, which yielded nicely to some light carthartic. First matured at 13, and had always been regular. Her present trouble dated back some two weeks previous to the time that I was called. She had returned home one afternoon after a short walk, when she felt a sharp pain in her abdomen, with a sense of fulness. That night she took a saline carthartic, had several movements of the bowels and felt much better for a few days, but pain, fulness, etc., returned. repeated the saline and had relief but for a short period, only to have a return of the above mentioned symptoms, with the addition of nausea, vomiting, and some temperature. This time she consulted a physician and was given a few compound carthartic pills and Tilden's antiseptic. The patient told me that on her right side a hardened mass could easily be felt at that time, and a tumor of the bowels was suspected.

She

Her condition did not improve, and as above stated I was called on September 1 and found her suffering great pain at pit of stomach and along right side of abdomen. Pulse, 106; temperature, 101°; she had been vomiting considerable bile and undigested food during the night and in the morning of the day I first saw her. Her bowels had moved freely, but with considerable pain and distress at each stool, which made her sick at her stomach. Her face

lookt pale and pincht, with quickened breathing.

On attempting to make a physical examination of the abdomen she said it hurt so much

*Read before the Medical Society of the County of Greene, New York State.

she could not stand it. The walls of her abdomen were tense and hard, but I could map out a hardened mass on her right side. I then gave

her a hypodermic injection of 4 gr. of morphin sulf. and 1/100 gr. atropin sulf. and left some 21⁄2 gr. tablets of Dover's powder to be given to control pain; also tablets of bismuth subnit. gr. ij, cerium oxalate gr. ij, and cocain hydrochlorate 1/12 gr. for nausea, and elix. maltopepsin (Tilden's) to control vomiting, and directed to withhold all solid food.

The next day when I saw her the pain was much diminisht, vomiting less frequent, and she had slept nicely during the night. The bowels moved twice with little pain, pulse 96, temperature 100.3°, and tongue badly coated. Made pressure along the course of the colon which occasioned considerable pain, particularly at McBurney's point and just above the navel. I could plainly outline a mass which extended from just above the ileo-cecal valve to the lower border of the liver, and along the transverse colon half way across the abdomen. Could not detect anything by rectal examination. Fecal vomiting was not present at any time, but moderate distention and tympanites. Her general health had evidently been impaired, as she lookt anemic and emaciated. I then made a diagnosis of fecal impaction and partial obstruction of the large intestin, and told the patient that she did not have a tumor of the bowels; and no matter if she did have a daily evacuation she could still be very costiv. My treatment then was: Calomel, 3 grs. every two hours until four powders were taken, followed four hours afterward with 12 ounce of olive oil, and three hours later a rectal injection of a gallon of soap suds. I ordered them to keep what passed after the injection for my inspection. My next call, on September 3, I found her resting more comfortably than she had on my former visits, and the result of the injection had been to relieve her of about thirty scybala. Her temperature was 99.2°, pulse 82. The mass could still be felt, but not so hard, less distention and tympanites, and practically no pain, but tender and sore. Her diet was still restricted to milk, peptoniods, albumin water, etc. I ordered two tablespoonsful of Epsom salts, to be followed by an ounce and a half of olive oil, and three hours afterward by another rectal injection. I saw her again on September 4; she had passed about twenty-five more scybala. These injections were again repeated until in all about one hundred scybala were removed, anywhere from the size of a pea on to that of a walnut, and some were so hard that it took considerable force to mash them. The patient made a rapid and uneventful recovery, the muscular walls of the abdomen returned to their normal condi

tion, and the hardened mass entirely disappeared.

No doubt you have all met cases similar in many particulars to the one I have just reported, but the object is to show that fecal impaction is possible whether the bowels move daily or not, and that it is far commoner than is supposed. It is my opinion that these impactions are responsible for many, if not all, the cases of appendicitis; the mechanical pressure causing a congestion, which results in peritonitis. Fecal impaction has, I think, largely to do also with many of the diseases of the uterus, bladder, urethra, ovaries, prostate gland, hemorrhoids, etc. L. B. HONEYFORD.

Cairo, N. Y.

The Comstock Collection Agency. Editor MEDICAL WORLD:-I, too, am a victim of the Comstock Collection Agency of Oswego, N. Y. I send you all papers and correspondence in regard to my case. I do not think that there is one man in a hundred who can avoid violating their contract; it was gotten up with that idea in view. Success to you and the best medical journal I know of, THE MEDICAL WORLD. I. E. GRAHAM.

Marseilles, Ohio.

P. S.-I paid the balance to get rid of them. We have gone over the papers which Dr. Graham sent, with interest and care, and wish we could spare space to publish them all. On October 19, 1901, he sent them a list of thirty names, with accounts amounting to $483.50. On November 7 he sent a duplicate of the same, evidently no payments having been made. November 26 another duplicate of the same list, evidently accompanying each name with two two-cent stamps at each sending, according to the demands of the contract. On December 14 he sends one name short-only twentynine names. Here is a break that the agency was evidently looking for. The list sent January 2 consisted of twenty-six names, but still the total of accounts was far above the stipulated $150. It seems that the names were omitted because part payments had been made, and arrangements made for satisfying claims in full. It would be foolish, under these circumstances, to continue sending these people dunning letters; but this seems to make no difference to the agency. It seems that they were looking and wishing for some little detail upon which to claim a technical violation of the terms of the contract, and here they found it. It also seems that the Doctor promptly sent to the agency all money realized from list. On December 18 he sent them $7.00 and on January 3, $11.90 besides money for double postage for each name, at each sending, as per demands of contract. But, nevertheless, he had committed the crime of sending twenty-nine names on the fourth list and twenty-six names on the fifth list instead of the thirty, which the "bond" called for, so the regular bombarding was commenced. Nine of these letters are before us; we will present two of these as samples: