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IPECAC IN DYSENTERY
No two men are alike or anything nearly equal in mental gifts or capacities. There are innumerable stopping places along the mountain-sides, and each is tenanted by a single individual. It may be that each could have risen, but, certainly, he didn't. What is is, and has reason behind it. We can only reason safely from actualities; beyond lies the region of conjecture.
With many persons, their greatest fault is their inability to estimate values. The best wisdom is to know what is worth while and what is not.-Frank Crane.
SNOBS AND REAL PEOPLE
Always ride in a Pullman, do you? Just a bit proud of it? Like to plume yourself on being somebody, not one of the common class?
Coming east from the Pacific Coast once, I took a tourist sleeper; primarily because I felt I had more urgent use for the seven dollars than George M. Pullman had. You know what you get in the "standard" sleeper-a lot of folk who look as if they were afraid you were going to speak to them. You read, doze, look at scenery till it palls on you, play (or think) solitaire, look at your watch to see how long till next mealtime-not that you are hungry but as a welcome respite from the monotony or you go into the smoking department and listen to the drummers' stories, if you still retain any tolerance for that sort of thing.
In the tourist was another class of people: men who had established homes and were going back for wife and family, young folk coming east to school, returning soldiers from the Philippines, men who had been west to see and invest, and so on. These people were so neighborly! Meal time came, and the woman who makes coffee brings you a cup. Lunch-baskets replace the dining car, and the contents. are shared. Talk is animated, everybody seems to have something to say in which the others are interested, and you learn a whole lot at first hand that is not as the magazines tell.
This is the Real Thing, and these are the real people. How nice they are-and smart! Hard workers, shrewd planners,
with a world of good sense and energy. And others feel this, too. Before the trip is half over a dozen of the Pullman folks are spending the best part of the day with us-and when they thaw out they're not so bad either. They, too, turn out to be like the rest of us-just folks. Even the insufferable prig who corrected a stranger's pronunciation turned out better than one would have expected and made you realize that he might have been fairly human if he had been caught when he was young.
I left the train feeling that I had never enjoyed a trip so much, or found one as instructive. Probably this acknowledges the writer's origin and station-just hoi polloi—at least he hopes so.
But, my fastidious friend, before you assert that you "never travel except in a Pullman" ask yourself whether you do this because you really prefer the conditions there or because you feel it necessary to keep good your hold on "society"? And if you really plume yourself on associating with the possible social magnates as represented by the special Pullman crowd, do they feel as proud of you?
"A thing for laughter, fleers, and jeers, Is American gentility."
Same with doctors. Get hold of a good, solid old country practician who has been in the work twenty years and get him talking; and if you can learn, he'll teach you something worth while.
It is not the size of the dog in the fight that counts, but the fight in the dog that wins.-A. G. Lewis.
IPECAC IN DYSENTERY
In The Bulletin of the Manila Medical Society for March, 1911, Captain Vedder discusses the value of ipecac in the treatment of dysentery. Much contradiction has ensued over this remedy, Manson and others lauding it, and Shiga condemning it unreservedly. This discrepancy is common enough, of course, and explicable when the cruder drug preparations are under consideration.
Dr. Vedder's first experiments were with agar cultures impregnated with ipecac. With Shiga's, Flexner's, and Morgan's
No. 1 bacilli, also with bacillus typhosus and bacillus paratyphosus, the 2-percent ipecac agars showed less growth than did the corresponding controls. With staphylococcus aureus, the growth was the same as that of the control. Digitalis, hydrastis, and opium, in 2-percent strength, were substituted for the ipecac, and each one gave good results, the first-named inhibiting the Morgan and Shiga bacilli completely, as hydrastis did that of Shiga.
The results were more decided when bouillon was employed: the controls developed innumerable colonies, while the ipecac-tubes showed none, excepting one lone colony of staphylococcus and three of paratyphosus. In the case of the three other agents, similar results followed, except that the Flexner bacillus was not checked by the digitalis or the opium and showed one colony with hydrastis, and that the Morgan bacillus gave innumerable colonies with opium.
The conclusions were: that 2 percent of ipecac inhibits the growth of the dysentery bacilli; the action is not specific, since other drugs do the same; the Shiga bacillus is more susceptible than the Flexner strain. The ipecac treatment, therefore, is not recommended.
Experiments on the amebas showed that ipecac is much more effective, as these were killed by a fluid extract in a dilution of 1 in 50,000, and sometimes in one of 1 in 200,000. Another brand of extract failed, but was found to be deficient in alkaloidal content.
Emetine proved amebicide in dilutions of 1 in 100,000, which was double the effectiveness of that of the best fluid extract of ipecac. The effect was attributed to this alkaloid alone and none to cephaeline, since the total alkaloidal strength did not affect the results, as did the strength of emetine alone.
This fact explains why the Rio ipecac has given the best results in practice, for in it emetine predominates, cephaeline being the principal alkaloid in the Carthagena variety. The remaining elements of the root were left in the deemetized ipecac tested, and this failed; so these can not be credited with curative influence.
Quinine proved effective in the test tubes in a dilution of 1 in 20,000, but failed in higher dilution. Silver nitrate succeeded. in dilutions of 1 in 300,000, but this loses much strength when in contact with albuminous substances and with certain salts, leaving little of it to reach the upper colon.
Ipecac, given by the mouth, may reach all parts of the intestine. Emetine may also act after being absorbed and eliminated into the intestine, penetrating the deeper layers beyond the reach of local applications. While in the blood, emetine may even destroy amebas in the liver; which may explain Rogers' good results in treating hepatic abscesses with ipecac. One form of dysentery is caused by the balantidium coli. Ipecac killed a species of paramecium and a balantidium isolated from tap-water, as did emetine in a 1 in 100,000 dilution. Duncan reported a case of balantidium dysentery promptly cured by ipecac. Further trials of ipecac in this form are suggested.
Dr. Vedder concludes by recommending the treatment of ameboid dysenteries by ipecac, making sure that the due amount of emetine is present, and if this can not be proved by actual analysis, to insist upon the Rio ipecac. Whether we do get that is problematical, in view of the pharmacopeial authorization of the cheaper Carthagena variety.
An optimist is a fellow who will sit up at night to make lemonade out of the lemons handed him through the day.-W. E. Mason.
ARE WE "CALOMEL” DOCTORS?
A correspondent calls our attention to the frequency with which calomel is recommended in these pages, asserting that it has become a routine practice with us, and that we are getting to be calomel doctors. Are we, really?
That calomel was anciently abused nobody can doubt who reads the works on practice of a half century ago. Then physicians prescribed calomel until so many pints or quarts of saliva had been obtained as the measure of depletion. But since we have been in the profession, now more than forty years, we have never
A RATIONAL VIEW OF THE DISPENSING QUESTION
seen or known or heard of a death from mercury. Have you? We have witnessed, and even caused, some instances of salivation, but in not a solitary case has it proceeded to the loss of a tooth or any other mutilation or permanent injury. Do you know of any such harm having been worked by this potent drug? Fifty thousand doctors read this issue of CLINICAL MEDICINE. Let every one who knows of such a case tell of it, and we will give the dread statistics in a subsequent number.
This is a day of broad sunlight. Prejudice and bigotry have no place with us. We want the truth. If you charge calomel with crimes or misdemeanors, bring up your evidence and let the culprit be tried at the bar of reason and adjudged in accordance with the testimony.
Looking over our files, we find that our correspondent is right in that we are in the routine habit of commencing treatment with calomel or podophyllin, or both, followed by a laxative saline. "There's a reason." Most patients are carrying about in their bellies a load of rotten feces, absorbing its decomposition products, and rational treatment begins with getting rid of this poisonous truck. It is preposterous to try to stimulate the eliminative glands until this load has been removed; or to give disinfectants before cleaning out the stables. The presence of this fecal accumulation is so universal a condition that the remedy likewise must be universal. Personally we have employed the method thousands of times, and never have known harm to result, and only very rarely has good failed to follow.
This is the distinct and comprehensive reason for our use of calomel, and a totally different thing from its ancient use as an antiphlogistic. As to the latter, its value, when properly employed, has never been disproved; but we live in the present and have neither time nor inclination to squabble over a dead issue.
This use of calomel as a means of emptying the bowels is the routine application of a general principle. Of course there are other cholagogs, and if one prefers juglandin, jalapin, or any other cathartic, there are no reasons why he should not utilize
them. But the fact that nearly everybody prefers calomel is significant. It is not our precept, nor mere custom; if the drug did not give satisfaction some other would soon be substituted. Saline laxatives are not used to prevent calomel poisoning, but to complete the work of the mercury; to sweep out what the calomel has loosened. Wunderlich noted that his cases of typhoid fever, in which calomel had been administered at the beginning, did better than those in which no calomel had been given; and a similar experience, not consciously noted perhaps, has undoubtedly led to the preference for this drug as an initial measure in this disease and in many others.
What has been your experience, respected reader?
Life, my brethren, am mostly made up of prayin' for rain an' den wishin' 'twould cl'ar off.
A RATIONAL VIEW OF THE DISPENSING QUESTION
In pleasing contrast with the view taken by some other druggists' journals, that all doctors should be forbidden by law to dispense their own remedies, is the position of The Druggists Circular. In one of its recent issues it comments upon the letters of two gentlemen who are sure that the dispensing business is a menace to the public (and to them), and that doctors ought to quit selfdispensing or quit practising. In reply to the first communication on this subject the editor of The Circular says:
"Physicians can get along fairly well without the aid of pharmacists, and from all accounts some of them are doing so. If pharmacists think they can get along better without the physicians' trade and cooperation they should do what our friend, the writer of the above letter, is doing— abuse the doctors. If, on the other hand, pharmacists believe it would be to their advantage to keep on good terms with physicians, there is a way for them to do that, too, and a very simple way-prove worthy of the physicians' friendship and confidence."
Every word of that we can endorse. It's good sense and clean ethics. Even more pertinent is the editor's comment upon
the letter of the second writer, in which he says:
"In a recent issue of the New York Times appeared the following editorial note: 'Three thousand barbers have combined to demand the suppression of the safety razor by legislation. Do not laugh at them. They are following a long-established American precedent. They, too, have acquired the appetite for legislation. The safety razor hurts their trade, and the government must intervene."
If the advice given by the editor of The Circular could be taken earnestly to heart by pharmacists everywhere, they would not find it necessary to call for the aid of a law, essentially as absurd as the one the barbers want, to bolster up a waning business. Not only is it foolish to agitate for the passage of such measures, but it is poor business policy, as pushing the professions apart instead of drawing them closer together. We believe that the doctor should keep on good terms with the druggist, employing his services wherever he can advantageously do so; and we also believe that the druggist will find it to his financial betterment if he cultivates the physician and tries to serve him better along the lines of least resistance. That old saying about "driving a horse to water" is just as true today as it ever was.
LODGE PRACTICE IN BELGIUM
For many years physicians in Germany and other countries have made strenuous attempts to be relieved from the foolish and demoralizing obligations which they had entered into when the sick-benefit societies were first called into existence.
In our own country, we have, for years, had similar abuses to deal with. Sickbenefit societies, lodges, and similar organizations enter into a contract with their examining physicians to pay them a certain fee, say, a dollar per year for each member, for which the physician is obliged to attend to the members, in case they fall ill, free of charge. It stands to reason that such a remuneration is absurdly inadequate, and lodge-doctors are apt to give services far in excess of the fees received.
The only possible excuse for any physician to accept such a humiliating and lowering honorarium is that the money paid is reasonably safe and is, at least in the case of large lodges, a considerablé sum paid at a certain time. Unfortunately in only few instances can the general practician count on definite times when he shall receive money, since his patients are apt to forget conveniently that they owe their doctor, and if they do pay, try to impress him with their benevolence in paying him at all.
A correspondent of The British Medical Journal for April 15 describes the struggle of the Antwerp Medical Society (Cercle Médicale) against the exploitation of the clubs (lodges) which has resulted in great success against the most determined opposition.
One of the points insisted on by the Cercle Médicale has been payment per attendance according to a fixed scale of fees. This was resolutely opposed by the clubs and various workmen's organizations and sickness-insurance societies, but owing to the solidarity of the profession in Antwerp, several of these clubs have been unable to obtain any medical officer, and they are gradually beginning to see the fatality of opposing the profession which is united to defend its rights.
Chief among the laws adopted by the Cercle Médicale to bind its members together is a form of agreement which every medical man signs on joining the Society, and the success of the Antwerp union, which comprises almost the whole of the practicians of the district, has led the profession in other parts of Belgium to imitate this organization.
We fancy that the success of the Antwerp physicians was in a great measure made possible by the fact that they made themselves liable, over their signatures, to severe monetary penalties in case they should not live up to the agreement and to the rules of the Cercle Médicale. They obliged themselves, for instance, to enforce an increase of fees up to the tariff adopted. They agreed to pay an indemnity or fine of 500 francs if they accepted any vacant post in a sick-benefit society without the written permission of the union, and made
INFANCY, AND THE NEWER THERAPEUTICS
themselves liable to other penalties if they did not obey the decision of the majority of the members. While such a proceeding, although voluntarily assumed, may be irksome and may appear to interfere with the personal liberty of the individual, it was nevertheless unavoidable in order to enable the medical society as a whole to fight and to come out victorious in the struggle for existence.
The position of the medical profession in Antwerp today shows that physicians everywhere can improve their financial standing, which is absurdly low in our own country at the present time; and from such a proceeding it would inevitably follow that the medical profession would regain some of its lost prestige, lost through its own fault and carelessness. If, under this arrangement, some of the weaker members were to drop out because they could not stand the strain, that would simply be in the line of the survival of the fittest. It is not much use to talk about, it is necessary to act, and if associations of physicians will stick together and oblige other members to live up to the agreement and to the decisions of the society much good will result.
"The really correct practice is our practice. It is difficult to comprehend how the other doctors can be so blind as not to see this the way we do. Now, there is and can be but one way to treat appendicitis." "Certainly," breaks in the Surgeon, "the only remedy is the knife."
"But first test the accommodation," says the Eye-Man, "I could tell you of a most remarkable case
"Cut it out," roars the Gyn-Man, "all appendicites come from the pelvic viscera and are curable by a gyne
"Never mind that," cries the Nervy One, "as the brain presides over the whole body, and the appendix has a hole in it
"Go to," yells the Proctologist, "no sane man now dreams of any other treatment than dilating the sphincter."
"Nasal reflexes-" shouts Nosey"Inverted scabies" howls Skinny
"Pockets and papilla" shrieks the Rectal Chap
"Why not cure it?" mildly suggested the Internist. Whereupon they all turned on him and rent him asunder.
INFANCY, AND THE NEWER THERAPEUTICS
The future of medicine lies in the more careful and thorough study of physiologic phenomena. Every disease begins with a disorder of function, and as long as the difficulty is strictly functional, it is amenable to curative treatment in a way that is not possible when material lesions have been inflicted. Progress, therefore, lies in the ability to detect disorders at a still-earlier stage of their course and to apply the right remedy when there is yet a possibility of preventing material lesions.
This ability to detect disease early often has been so far above the capacity of the profession that there has been a disposition to sneer at studies of "simply functional maladies," as if these were unworthy of serious consideration. The term functional has been held as almost synonymous with hysterical. But that day, fortunately, is past. No longer is organic chemistry looked upon as a jungle into which no wise man will venture, such "wise men" rather choosing to follow the beaten paths of chemical knowledge, studying the definite metallic salts alone. As it is, we have made so many advances in physiology that they have rendered our former drug studies obsolete and reinvestigation of body processes on modern lines has become imperative.
One of the most fruitful fields for investigation is the study of the infant. Not one human being has an absolutely mathematically perfect eye, says the ophthalmologist. Not one of us was born exactly equilibrated and normal. Not one of us but has imperfections of frame, deficiencies of functional power, disequilibriums that mar the symmetry of our bodies and the harmonious workings of our organisms. These are most advantageously studied in early life, before they have been outgrown, or rather obscured, by complemental developments. Happy is he who has been