DISCUSSION.

DR. S. S. GLASSCOCK: I have come in contact with many railway employes. Local surgeons are too often political selections. This method of selection will never produce medical efficiency. I doubt the local surgeon is any more prone to drug habituation than other physicians. The large per cent of physicians using narcotics is deplorable and alarming; their unfitness for any medical position, the handling of the sick or injured, needs no comment other than to protest against their employment at all, the habit prohibits their further usefulness as medical men. I question the possibility of a sufficiently early diagnosis in incipient paresis to anticipate accidents; I think sufficient disease progress would have been made, causing them to make judgment errors, resulting in accidents, before the diseased condition was suspected or could be accurately diagnosed. It is an easy matter for the employe to hide epileptoid, or, even true epilepsy in some forms, from the physician, especially the local physician unaccustomed to diagnosing such; the employe and friends usually argue the necessity of retaining his position. Dr. Burnett's histories date back to 1890, a period of 23 years. I would like to think that the dangers to the public are not as great as the figures would indicate.

DR. PAUL V. WOOLLEY: The important suggestion of Dr. Burnett's paper is that the corporation owes protection to the traveling public. This would be increased proportionately to the efficiency of the medical service. In their railway hospital service, he said, they had no experience in meeting up with drug using local surgeons.

DR. T. J. BEATTIE: Do employes undergo an ex'amination when employed?

DR. WOOLLEY: Yes; but the examination is only of a general character and might not be sufficient to detect technicalities brought out in the paper.

DR. BEATTIE: That's what I thought; those initial examinations are like many insurance examinations, being of no exact value. An examiner recently questioned me about an old patient of mine and said he thought he would pass him anyway. I told the examiner that the patient had tabes and if properly observed the inco-ordinated walk could be seen a block away. That's about in line with the exactness of the local surgeon's examination of the average railway employe.

DR. D. E. CLOPPER: I will see about 1000 railway employes a year. The company allows $1.00 for an examination. The absurdity of such a fee covering the expense of a technical examination is apparent. It is impossible for the examining physician to give the time and expense entering into the requisite of a recorded, scientific examination in all its detail for the little paid. The company always gets a dollar's worth, but many examiners are not inclined to give more than they received. And this is where the fault lies, the company won't pay for more than a perfunctory examination, and that is what they usually get.

DR. JOSEPH S. LICHTENBERG: Dr. Burnett has pointed out through his paper the various palsies of eye muscles, indicating the seriousness of the condidition causing them. The eye symptoms are common and valuable aids in detecting brain disorders. Is the local surgeon's examination liable to note them?

DR. W. K. TRIMBLE: The Wassermann is valuable in detecting specific infection. Syphilis is the underlying danger to be detected, but some of the

employes are smart enough to have the local physician give them treatment for a time before coming to have a Wassermann made, and the result is a negative Wassermann in specific cases, masking the proper diagnosis.

DR. BURNETT (closing): In many instances the selection of the local surgeon is a joke; the local physician sending in the most private cases to headquarters is the loyal and deserving man. Dr. Glasscock calls it a "political selection," a nice way of putting it. If a local surgeon is a keen, up-to-date medical man he is apt to do his own work, therefore, not valuable to the department-privately. I once overlooked centralizing my value, being too much inclined to delve into matters scientifically rather than diplomatically. I then traveled on a pass; by the time I saw the point I was passing on a walk while my reciprocal competitor passed by in a Pullman. So much for the local surgeon's selection.

Dr. Glasscock is correct in stating that the local surgeon is not more addicted to morphine than other physicians. As near as can be obtained, statistics show that about 10 per cent of physicians in general are drug users. I do not agree with the statement that incipient paresis is too difficult to admit of a correct or a reasonably accurate diagnosis in many cases. Neither does Dr. Glasscock believe it excepting as the diagnosis may be left to the technically untrained local or general surgeon. Men can be found who can make the diagnosis if the hospital department will raise the $1.00 ante and forego "kissing by favors. The array of mental symptoms, varying from the slightest degree of depression and momentary or prolonged amnesia, leading up to the more pronounced symptoms, with some of the many physical signs always present; and last, but not least, about 89 per cent of positive blood Wassermanns and a positive spinal fluid Wassermann in the doubtful blood. Wassermanns, all collectively studied, leave no reasonable doubt in making a diagnosis. Even in old cases of paresis and tabes, long classed as paraspecifics, recent spinal fluid cultures have been made and this culture reinfection gave initial and secondary lesions, showing we are still dealing with the spirochete. Therefore we must diagnose the presence of syphilis or its sequel or both. I admit that varied forms of epilepsy may be difficult to uncover because of the deception of the patient, his family, a co-worker, as in the case of the fireman cited, and when backed up by a union. The least attack of vertigo in any phase should subject the employe to rigid and prolonged medical observation. Such a man might carry a train load of people to their deaths and the cause remain unknown. Dr. Glasscock's hope that the matter may not prove as bad as it looks would not be brightened had I been able to add my fifteen years records lost in the fire.

Dr. Beattie's criticism of the similarity of the method of railway medical examinations to some insurance examinations of these particular cases was illustrated in my paper, "Syphilis versus Accident and Life Insurance" (read before the Academy, April 8th, 1911, and published in the Medical Fortnightly, June, 1911). Six years studies of my private cases tabulated in that paper show that inefficient examinations cost the insurance companies approximately One-half million dollars. While the insurance companies can pay these blunders in cash the railway medical deficiency is paid in a heavy toll of human life; 3,633 employes killed last year; one death every seven hours and fifteen minutes; a man injured every nine minutes. Add the large death and injury list of passengers to this and ask is it worth while to lessen the list by preventing preventable accidents?

An expert internist, a scientifically trained neurol

ogist, not a neurologist made over night, a competent oculist, and accessible laboratory facilities, would be able to check up any technicalities left in doubt by a competent surgical department. It is just a question of a systematized organization of superior medical talent with money enough to run it without non-medical dictation.

EXPERIENCE.

GEO. F. BUTLER, A. M., M. D., Kramer, Ind.

Medical Director, Mudlavia.

There is a comforting proverb which tells us that if a man never has been a fool, he never will be wise. This does not mean that we should do foolish things in order to learn wisdom. What it does mean is that we should improve the future by means of our past experience. We should profit by our blunders and mistakes, and the broader the range of our digested experience, the sounder will be our judgment. Medical knowledge is not all acquired in a medical college, but is made up of little bits of information, little observations picked up in the course of daily bedside experience; the proper sources of knowledge are not books, but life, experience, personal thinking, feeling, and acting. It is not the quantity of knowledge a doctor acquires from books, but the useful lessons learned from past failures and successes-from a rich experience-that is of consequence.

The experience gained from books, though of immense value is but of the nature of learning; whereas the experience gained from practice, is of the nature of wisdom and a store of clinical experience is worth more than a stock of theory.

Practical wisdom is only to be learned in the school of experience. The doctor made wise by experience is better able to judge correctly of the things which come under his observation. One's knowledge, in fact, cannot go beyond his experience, and the treatment of disease may be taken for knowledge-the opinion of the laboratory pharmacologist-man to the contrary notwithstanding."

We progress only through experience by bringing forward from yesterday the good of yesterday, and adding it to the store of the good of today. True progress is improvement, not movement, merely. Its measure is not the ground passed over, but what has been gained from our own experience and from our association with persons wiser, better and more experienced than ourselves.

The act of seizing every bit of knowledge, every scrap of information, no matter how insignificant it may seem at the time,

the laying hold of every opportunity and every occasion, and grinding them all up into experience, cannot be overestimated. A wide experience will do this for you; it will teach you to be forbearant toward those who differ from you, provided they observe patiently, think honestly, and utter their convictions freely and truthfully.

So get experience every time an opportunity presents itself.

The results of experience are, of course, only to be achieved by living; and living is a question of time.

ROENTGEN THERAPY OF UTERINE
FIBROIDS AND MYOMAS.

E. H. SKINNER, M. D., Kansas City, Mo. The Roentgen-ray treatment of uterine fibroids and myomas consists in the application of intensive roentgen exposures to both the lower abdomen and sacral regions, with penetrating rays carefully measured and filtered through aluminum.

This method of attacking fibroids and myomas is suitable where there is no evidence of extensive degeneration; where the patient is over 40 years of age; where the hemoglobin is not below 50 per cent; where .. the pressure symptoms are not so severe but that they could be borne until the shrinkage of the tumor occurs in the course of the treatment. Intra-uterine or polypoid fibroids are not treated but operated.

Kroenig and Gauss of Frieburg, Germany, do not consider any objections to roentgen therapy at all, excepting the expense to the patient. Therefore they only operate upon the poor and clinical patients.

The method of intensive therapy as pursued by the Frieburg school (Kroenig and Guass) consists in the blocking off into two inch squares of the abdomen, below the transverse umbilical line and the symphysis and the sacral area likewise, and then apply two erythema doses to each segment successively, paying careful__attention_to protection and filtration. The protection consists in surrounding the segment under exposure with thick lead and filtering the rays from a protected tube_through three millimeters of aluminum. The hardness of the roentgen ray registers ten Benoist, and in order to prevent the rapid heating of the tube it is necessary to use water cooled tubes with a continuous flow and an additional interrupter or flash apparatus upon the primary circuit. exposures are made as rapidly as possible for each series of treatments so that the entire lower abdomen and sacral area receives

The

the two erythema doses within three to four days or quicker, and then the patient rests until after the succeeding menstrual period when the series of exposures is repeated under exactly similar conditions. It usually requires from three to five series before the menses cease, but the relief from hemorrhage and pain is secured quickly.

The beauty of the treatment is the absolute absence of any mortality and its uniform success when courageously and diligently applied. The treatment is expensive, and it requires from three to five months to secure a cure, but the clean mortality record is beyond argument.

The extensive use of roentgen therapy in uterine conditions by European roentgenologists and the splendid results after careful analysis will surely provoke the increased use of such a benign therapeutic agent in America. Unfortunately the method requires excellent apparatus, and especially hard tubes with every attention to protection and filtration if results are to be secured.

1020 Rialto Building.

MEDICO-LEGAL PROBLEMS.*
LAWRENCE H. HEDRICK, Hot Springs. S. D.

States Attorney for Fall River County.

The subject of medico-legal problems is no doubt embraced within the subject of medical jurisprudence. However, the former is not so broad and does not cover as a large field as the latter. I take it that the subject of medico-legal problems is identical with medical jurisprudence as known to the lawyer but is much more restricted in the objects embraced and subjects treated than the term medical jurisprudence as understood by the physician and surgeon. To the lawyer medical jurisprudence is that science which applies the principles and practice of the different branches of medicine to the elucidation of doubtful questions in courts of justice. It is sometimes spoken of as forensic medicine-that is to say the medicine of the forum or public place. Now as I understand it the word medicine as

used in this definition does not necessarily mean drugs, but rather remedial substance and the practice of medicine as originally and popularly understood as having relation to the art of prevention, curing or alleviating disease or pain. In short I

medicine consists in the discovery of the cause and nature of disease and the administration of remedies or the prescription of treatment therefor. It follows then that the term medical jurisprudence as known to the lawyer includes not only the school. of medicine to which you gentlemen are allied, but as well includes the other two leading schools besides the many schools which have sprung up in recent years among which I may mention-osteopathy christian science, botanical medicine, chiropracty, and all other known schools of supposed prevention, relief or cure of disease or ailment of the physical body.

In dealing with this subject tonight it will be necessary to merely skim the edges, for the reason that it is a subject so farreaching and upon which so much can be said, that one would be imposing upon his hearers to attempt to cover it in an evening's address. I will therefore divide it into two parts, which division, as I view it, will enable me to touch upon the subject as a whole. The division which I have chosen is: first, malpractice; second, expert witnesses. In one we consider that portion of medical jurisprudence with which every physician should be most familiar in order to protect himself from pecuniary loss and from criminal prosecution. In the other we find the medium by which the entire remainder of forensic medicine is communicated to the lawyer, court and jury.

Malpractice, as you no doubt already know, is divided into different branches, viz., ethical malpractice, which is peculiar to and wholly confined within the medical profession, and which is that kind of malpractice in which persons, claiming to be medical men, bring suits against physicians or medical societies for alleged insults to their professional dignity. This is a branch which is little understood in the outside world, and to which none of you who stay on your job and attend strictly to your own business need pay any attention or in which you need any instruction.

known as criminal malpractice, and which The next branch of malpractice is that is governed entirely by the statutes of the different states of the Union and of the United States. In this branch, the real

An address delivered before the Black Hills Medical Sociery at a meeting held in Hot Springs, S. D., in September, 19.3.

statute.

a degree as to involve criminal liability is a question for the jury. The liability is

by malpractice, I desire to say at the start, that the physician or surgeon is not an insurer, unless by express contract. He merely, by offering his services to the public, impliedly contracts that he possesses and will use, in the treatment of his patients, a reasonable degree of skill and learning, and that he will exercise reasonable care and exert his best judgment to bring about a good result. The physician cannot, in the very nature of things, be absolutely sure himself of accomplishing what he sets out to do. As said by a Pennsylvania judge, "He deals not with insensate matter, like the stone-mason or the bricklayer, who can choose their materials and adjust them along mathematical lines, but he has a suffering human being to treat, a nervous system to tranquilize and a will to regulate and control;" and further the physician often is battling against that grim reaper who knows no defeat and the best that any of you can do is merely postpone his victory to a later day. In a Minnesota case, the court say, "The white head stones and monuments that glisten in the sun shine within the sacred precincts devoted to the repose of the dead in the suburbs of every city in the land, testifies with unerring certainty that man is mortal, and the most effective efforts of the healing art are incapable of resisting the conqueror of all." If I might here be allowed to venture a suggestion to the medical profession, it would be, that you should not place your sole reliance in drugs or the knife, as so many physicians and surgeons are so prone to do, but give that greatest of all physicians, Nature, an absolutely fair chance, unhampered by doses of dope, shots of opiates, or rips and rents of the knife. If you will but do this, I say without fear of successful contradiction, that many patients' lives will be saved, and a vast amount of sickness, pain and sorrow escaped. Yes, you wonder why I have the audacity to make such a statement. I'll tell you why, common sense tells me that it is true, and way deep down in your hearts you know that I am right, if you will but heed that best of all teachers, your own common sense. Human life is too valuable to be the subject of experiment, but far too often we must submit to experiment. If you are not absolutely sure what to do, you'd better let Nature alone. But I am digressing.

The great and governing question in a suit of this nature is whether or not the physician has used the care and skill above referred to, and it is in this question that, in my opinion, exists one of the greatest

And

inconsistencies in the law of liability. The general rule of law provides that "physicians are bound by what is universally established in the profession," but, "the reckless disregard of a new discovery, and the adhesion to a once approved, but exploded or abandoned practice, resulting in injury to the patient will give a cause of action." I have wondered, gentlemen, by what superior intelligence, for superior intelligence it must be, you are able to determine the precise moment this explosion or abandonment occurs and just how you all manage to explode or abandon at the same time, so that none are caught in the recoil. again it seems to be the law that no medical man is bound to resort to any practice or remedy that has not had the test of experience to recommend it, and the physician or surgeon who does so with injurious consequences would be more liable to attack than one following in the old rut. In other words, while experiment is the father or mother of progress, and without it medical science or any other science would be an obsolete farce, still one who has the ability and ambition to progress must do so at his own peril; and that's precisely why so many physicians are still giving calomel and quinine, they're afraid to quit. is not a question of how much skill a physician or surgeon may have, but he must use such skill in the established mode or practice in the particular case. This is the law, but it doesn't necessarily follow that I approve it, for I don't.

It