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J. A. (Joel Asaph) Allen.

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Patient has always enjoyed good health, but stated that drinking
on an empty stomach, overeating, or slight injuries, would bring on
attacks of swelling, which usually appeared on extremities and eyelids,
and that he had been troubled with this ever since he was four years
old.

In conclusion, I will state that the following day the edema of face
and neck had subsided, but at the same time his right foot and ankle
began to swell, whereupon an examination of his urine was made, and
it was found that he passed 900 cc. of urine in twenty-four hours ;
specific gravity, 1022. acid reaction, containing 28.8 grams of urea;
no albumin ; no sugar. Microscopical examination showed uric acid
crystals and amorphous urates ; no casts.

The treatment consisted of hot fomentations and rest. On May
22, 1893, after all signs of edema had disappeared, patient was dis-
charged.



gefeofionx&.

THE EVILS OF SUBSTITUTION.

Bt CYRUS EDSON, M. D..

Commissioner of Health of New York City and State; President of the Board of Pharmacy
of the City and County of New York.

Thk term " substitution," in its commercial sense, is the perpetra-
tion of a fraud by the seller upon the buyer, the former selling the
latter something different from the article demanded, under the
same name. This fraud is really bat another phase of commercial
adalteration, and in the practice of pharmacy its evils are as
insidious and harmful as those of any crime committed by man.
These evils are both direct and remote in their effects. They
in j are, first, the patient ; second, the physician ; third, the manu-
facturer. From the standpoint of the patient, the evil affects him
directly and indirectly. The dishonest pharmacist has, of course,
palmed off on his unsuspecting customer a cheaper preparation
than that ordered by the prescriber, because the motive for the
orime is, in ninety-nine cases out of a hundred, a mercenary one^
The result to the patient from the inhibition of the substituted
article may be one of the following : first, no therapeutic action ;
second, therapeutic action of less potency ; third, therapeutic



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288 SELECTIONS.

action of greater potency ; fourth, therapeutic action of different
character than aimed at by the prescriber. It needs no argument
to prove that any of these four results would, under certain condi-
tions, be likely to be disastrous to the patient.

The pharmacist is the responsible and trusted dispenser of the
physician's order, and when he acts differently than ordered by
the' doctor, he snips at the threads of fate, possibly without the
slightest idea of what will result from the snipping. Then, he is
no better than a man who fires a bullet among a crowd of people*
The result in either case may be manslaughter. Let us take a less
extreme view of the crime from the patient's standpoint. The
latter fails to get benefit from his medicine, and, as a result, loses
time and money. He was cheated when he bought the prepara-
tion. Now, indirectly, he has lost the fee he paid the physician,
and, last but not least, he has lost confidence in his doctor.

From the standpoint of the physician, the evils of substitution
have a wider range in their effect than on the individual patient.
Medicine has been said to be an inexact science. The reason of
this is because it is very difficult to ascribe a given effect to a
certain cause. In other words, so many causes operate to produce
a given effect in the human economy that it is difficult to ascertain
and fix upon a definite cause. Modern therapeutics is the outcome
of the physician's observations and experience of the effect of
drugs upon the human system. It is a science to which every
physician contributes his mite or his much, according to his
ability and his opportunity.

The pharmacist who substitutes leads physicians astray. By
presenting false premises to the latter, the former causes him to
make erroneous deductions. The entire medical profession may
thus feel the result of a single instance of substitution, and
numerous other invalids suffer on account of the errors following
faulty experience in the case of the physician treating a single
patient who is the victim of the fraud in question.

I have already spoken of the loss of confidence in his physi-
cian on the part of the victimized patient. This has not only a
direct effect upon the invalid, because confidence in his doctor's
efforts are, to a great extent, essential to the latter's success in the
treatment of the case, but it may also cause the dismissal of the
physician, and his loss of what, perhaps, would have been a lucra-
tive practice. In this country, physicians have the reputation of
being practical. They are the best practitioners in the world.



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THB EVILS OF SUBSTITUTION. 289

In Other countries, medical men are deeper students and better
theorists, but here we pride ourselves on the results we obtain in
curing disease. The reason for this is because we strive less for
honor and glory than we do for the almighty dollar. We must
give our patients the worth of their money, and we know we will
not be tolerated unless we do. Our patients are quick to discover
mistakes, and they are laid at the door of the physician rather
than at that of the pharmacist. If this was not the case, the
subject of substitution would not be worth consideration, for it
would be a rarely committed crime.

The question of injury to the manufacturer is a very important
phase of the matter, for, rather singularly, the remedy for the
great evil must spring mainly from this source. This is not so
strange after all when we come to think of it, for here we find the
effects of the evils of substitution so direct and so distinctly felt
that interest is natural. Nothing causes men more concern than
pecuniary loss. Cause and effect are here so closely associated
that a hue and cry at once follows. The manufacturer invests
large sums in producing a reliable preparation ; he spends more
in bringing it before the medical profession. The latter find it
worthy of use and patronize it until the weeds of substitution
check its growth. The way these weeds act, after what I have
said, is obvious. For example, some pharmacist substitutes an
inferior mixture or drug in the preparation of the physician's
prescription ; the effect of the medicine on his patient is nil. The
disappointed doctor heralds the fact to his brethern. Such news
travels faster than any favorable comments, and undoes in a short
time that which the manufacturer has taken months, or perhaps
years, to accomplish. « Great injury is in consequence done to a
deserving business.

Then again, the evil is a widespread one, and the same substi-
tution in a good preparation is very large, and directly affects its sale.
I know of no other crime that tends so much to destroy one's faith
in man's goodness as substitution. For the sake of insignificant
profit, the dishonest pharmacist deliberately cheats and perhaps
destroys his fellow-man. I can only account for the practice by
assuming that the perpetrator in some way persuades himself that
he is doing no harm, that he is selling something << just as good,'^
that he holds the judgment and knowledge of the physician in
small repute, and that he feels perfectly competent to act in the
premises. It is a curious psychological fact, that it is the easiest



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^90 SKLBCTIONS.

thing in the world for a man engaged in a nefarioas trade to
|)er8aade himself that he is doing no harm so long as he is making
money by his acts.

To correct the practice of substitution does not seem to me a
•difficult matter. A few years ago, the adulteration of food
products was a very serious fraud. Confectionery, for example,
was greatly adulterated at that time. The exposure of the practice
by the Health Department of New York City so injured the
<^onfectionery business, that the reputable manufacturers banded
together in an Anti-Adulteration League. Not only did the
Health Department cause the formation of the league in the way
I have described, but the unfair competition, engendered by
adulteration, also had its effect in forcing honest manufacturers to
protect themselves. This league made it its business to run down
and punish all persons who adulterated their wares. The result
was that in a short time adulteration ceased, and today it is
impossible to find any adulterated candy offered for sale. Another
instance of manufacturers banding together for mutual protection
is offered by the Jewelers' Protective Association. This body
pursues like an avenging Nemesis any one who robs or cheats its
members. Let the manufacturers of pharmaceutical preparations
who suffer from the evils of substitution, form a like union, and
charge its agents with the duty of bringing to justice the perpe-
trators of the fraud of substitution. The Penal Code and the
Pharmacy Act both afford excellent laws for the punishment of
these criminals. The Board of Pharmacy is not sufficiently
equipped to enforce the provisions of the law to this end, and the
Health Department is too busily engaged fighting disease to cope
with the evil. The formation of such a union as I have indicated,
however, and the punishment of a few offenders would soon stop
the practice. The mere publication of a few instances of fraud,
giving the names and addresses of the dishonest pharmacists,
would go far towards suppressing substitution, for the public is
quick to discover and shun the druggist who is considered
unreliable and unscrupulous. — The Doctor of Hygiene,



The Indications forTrional. — Therecenttestsoftrional point to
its special value in moderate or severe conditions of melancholic or
hypochondriacal depression, in which case Brie and others state
that it is always successful in doses of one to two grams. Some-
times a dose of two grams, given in the beginning, controls



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TBBATMBNT OF UBINABY INCONTINENCE IN THE WOMAN. 291

the condition so well that the following doses need not exceed one
gram. That group of patients usually spoken of as having
" melancholia with agitation " are also especially amenable to the
trional treatment, even in cases which had proved refractory to
treatment by opium, morphine, paraldehyde, and amyl hydrate.
In maniacal excitement, inclusive of paralytic mania, doses of two
and even three grams were sometimes required, especially when
the restlessness was very marked. In hallucinatory dementia and
paranoia, from one to three grams of trional gave satisfactory
results. It is indicated in simple agrypnia (one to two gram
doses), and in insomnia, with restlessness and excitement, as often
observed in persons suffering from organic disorders. Ti'ional
causes no nausea, vertigo, or gastric disturbance of any kind, and,
in suitable doses, causes no more than a transient drowsiness,
which passes off after eating. — Ex.



SUBGICAL TbEATMENT OP UbINABY INCONTINENCE IN THE WoMAN,

— Gersuny and Zuckerkandl (Internat. Klin, Mundachau^ No. 19,
1893). Incontinence of the urine in many women is by no means
rare. As it is known, the slightest increase of abdominal pressure
produced by coughing, laughing, or any other effort, causes the
urine to escape. Therapeutic attempts have been made to remedy
the weakness of the sphincter and the shortness of the urethra by
cauterization of the external orifice of the canal. Three years ago,
Oersuny proposed to twist the canal, and this operation has just
been successfully performed by Zuckerkandl. The patient was a
woman, fifty-four years of age. Examination showed the bladder
to be in normal condition. She was afiiicted, however, with the
variety of incontinence just described, and had been submitted to
various modes of treatment without favorable result. Zucker-
kandl made an oval incision around the urethral orifice, and
separated the walls of the canal up to the bladder. By then twist-
ing the urethra in the direction of the hands of a clock, he
obtained a rotation of 360°. The external orifice was then fixed
in this new position with a row of stitches, a sound was left in
place for two days, and after fourteen days' rest the cure was com-
plete, and the patient could easily retain her urine. It is well to
remember that the first patient operated on by Gersuny in this
way, three years ago, has never again been troubled by incontin-
ence, but has, on the contrary, to make an effort to pass water. —
New York Therapeutic Jieview.



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292 EDITORIAL.

BUFFALO MEDICAL AND SURGICAL JOURNAL

A MONTHLY REVIEW OF MEDICINE AND SURGERY.

EDITORS:
THOMAS LOTHROP, M. D. - - WM. WARKEN POTTER, M. D,

All oommunications, whether of * literary or business character, should be addressed
to the managing editor: 281 Framklim Stbxxt. Butfalo, X. Y.

Vol. XXXIII. DECEMBER, 1893. No. 5.

THE SOUTHERN SURGICAL AND GYNECOLOGICAL
ASSOCIATION.

Thb sixth annual meeting of this association was held in New
Orleans, on November 14, 15, and 16, 1803, and it may be justly
characterized as one of the best medical meetings of the yean
This association is noted for its good work, but it seems to
have fairly outdone itself during its late annual gathering. Dr,
Bedford Brown, the President, is a representative Southern sur-
geon, and an experienced man in the conduct of medical socie-
ties. It was fortunate for the association that Dr. Brown's term
of service occurred during the year that the meeting was held
in New Orleans. In his response to the address of welcome^
among other things, he said :

'< I am sincerely glad that I came to New Orleans. I am glad to
know the gentlemen of the profession of this city. I have long
heard of the high character, the great skill, and high order of
intelligence of the medical men here, and I congratulate the
association that we have met in this grand, old, historic city,
and that we are permitted to associate with them on common
grounds and on terms of friendship and unity. Gentlemen, I thank
you."

His speech was greeted with prolonged applause, and the asso^
ciation then fairly got down to its work. The first paper was an
address on the Life and Character of Ephraim McDowell, of Ken-
tucky, by Dr. L. S. McMurtry, of Louisville. Dr. McMurtry is sin-
gularly adapted to the task which he assumed by vote of the asso-
ciation on this occasion, for he himself is a native of the city of
Danville, where McDowell first introduced to the world abdominal
surgery by the performance of an ovariotomy. Dr. McMurtry is
thoroughly familiar with the subject on which he discoursed,



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SOUTHBRy SUBGICAL AND GYNECOLOGICAL A880CLA.TI0N. 293

having been secretary of the McDowell Association, and one of
the prime movers in erecting the monument to the memory of the
great surgeon, which stands in the center of the plot set apart
therefor in the city of Danville. We shall anxiously await a fall
report of Dr. McMurtry's address.

The association was the guest of the Boston Club and the Pickwick
Club during its stay in New Orleans, and a special entertainment
Was given by the French Opera Company for their enjoyment, the
opera of "Faust" having been selected for the evening. On
Wednesday evening, November 15th, the association was enter*
tained at a reception at the St. Charles Hotel, given by the medi-
tsal profession of New Orleans.

Dr. Joseph Price was especially invited to operate in the
amphitheatre of the Charity Hospital on Wednesday morning, at
B.30 o'clock, when a large audience assembled to witness the tech*
nique of this expert and successful abdominal surgeon. The attend-
ance upon this annual meeting was uncommonly large, the scientific
work done was enormous, the debates were spirited and instmc*
live, and the work of the stenographer. Dr. Whitford, was especi-
ally heavy. The next volume of transactions will be an interesting
one, and deserves to be in the hands of every Southern physiciani
AS well as those who may be unfortunate enough to reside on the
north side of Mason and Dixon's line.

Dr. Brown was especially felicitous in his annual address^
which secured the attention and the approbation of his auditors as
testified by generous plaudits. He gave the history of the organ-
ization of the association, ^nd traced its eventful career down to
the present tiipe. He said, inter aliay that the origin of the
Southern Surgical and Gynecological Association was based on
the necessity of the times. Its object was the promotion of the
practice of scientific surgery and gynecology in the South, and its
aim was the development of the surgical talent and learning of
the Southern profession. Forming, he said, an opinion on his own
individual experience and by that of others, he was persuaded that
no member who had followed the progress of the association
olosely, and who had taken assiduous part in the proceedings, had
failed in having his knowledge of the science of surgery and gy ne«
oology expanded, or his ideas enlarged by the able papers and dis-
cussions that have characterized the transactions. He defended
the association from the charge of sectionalism in the following
^ords :



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294 BDITORIAL.

In conclusion, I desire to make some passing allusion to the alleged
sectional character of our title and purpose, • * The Southern Surgical and
Gynecological Association/^ Those who founded this association
never entertained the remotest idea or intention of organizing it, or^
using it, for sectional purposes. They believed that the necessities of
the medical profession of the South demanded and required such an
institution, based upon broad, liberal, and democratic principles, open
to merit, talent, and character for the encouragement of medical
progress in that section.

No, we are of all people the least sectional. We are a band of
workers linked together, working with one mind, with the single
put*pose, the noble object alone of promoting the sciences of surgery
and gynecology. We know no politics, no political distinctions. Wa
do not even know the political opinions entertained by each other. We
are composed of ardent workers in search of scientific knowledge from
the far North, the distant West, the East, and the South, that mingle
together on perfect terms of equality, in social pleasure, and in a spirit
of kindliness and mutual confidence. There are those here mingling^
together in friendly intercourse who took part in the great struggle
and who stood arrayed against each other in bloody array, now united
in friendship and engaged in the humane office of devising means for
alleviating human suffering and prolonging human life. The scene, aa
it presents itself to my mind, of men with one single and grand and
glorious object, working together harmoniously, congenially, trustingly,
forgetting all differences of opinion, political and social, each ready to
make sacrifices for the other and for the good of the cause, presents a.
eight truly noble and worthy of the greatest admiration. To those
illustrious and distinguished men who have, at our invitation, come
from the great cities of the north — Boston, New York, Philadelphia,
Buffalo, Chicago, Cincinnati, and St. Loui^ — and united their destiniea
with ours, and are sharing with us our toils and responsibilities, I
have only words of admiration, commendation, and kindliness.

The conclnding sentences of bis splendid address were words
of caution towards faithfully guarding the honor of the as80«
elation, maintaining its high standard of parity, and its great
strength of character. When the erudite and venerable President
had concluded his address, the plaudits that rang in his ears must
have nearly deafened him. After the usual complimentary vote
of thanks, a resolution was offered by Dr. Kollock, of South Caro^
Una, instracting that 500 copies of the President's address be
struck off for distribution among the members. We believe the
careful perusal of this valuable paper will be of great service ta
this and similar associations.



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SOUTHERN SUBGICIX AND GYNECOLOGICAL ASSOCIATION. 295

A long list of new Fellows were read, and it was unanimoasly
TOted to hold the next meeting at Charleston, S. C. The follow-
ing-named officers were elected for the ensuing year : President^
Cornelius KoUock, M. D., of Cheraw, S. C; Vice-president, A. B.
Miles, M. D., New Orleans ; Secretary, W. E. B. Davis, M. D.,
Birmingham, Ala.; Treasurer, J. B. S. Holmes, RTome, Ga.; to fill
vacancy in Council, Bedford Brown, M. D., of Alexandria, Va.

Dr. L. S. McMurtry, of Louisville, then took the floor, and pre-
sented resolutions expressing the thanks of the association for the
courtesies and hospitalities so gracefully and generously extended
by the Committee of Arrangements, and from the members of the
profession in New Orleans ; to the ladies who graced with their
presence the reception on Wednesday night ; to the daily press
for its very complete report ; to the Boston Club and the Pick-
wick Club for courtesies and hospitalities enjoyed. Dr. McMur-
try supported his resolutions with the following remarks :

Mr. President — The scientific work provided for the sixth annual
meeting of the Southern Surgical and Gynecological Association has
been completed. Within a few hours the trains will be carrying our
Fellows to their distant homes and their respective fields of labor. The
valuable papers, discussions, and demonstrations, which have made this
meeting a conspicuous one in its history, will be presented to the
profession in the annual volume of transactions. Before the gavel falls
we would express our appreciation of the hospitality and courtesies we
have received from our confreres in this Crescent City of the South, a
hospitality so cordial and generous, a courtesy so spontaneous and
graceful, as never to be surpassed or forgotten. The bright sunshine
of this genial clime, where the air bears abroad the fragrance of the
magnolia and orange blossom, has seemed only a natural and harmoni-
ous element in these three days of pleasing labor and delightful
recreation. It is all beautiful, and will remain a happy memory.

It is most appropriate that this organization, to advance and diffuse
surgical science in the South, should convene in this Southern metropolis,
where was founded, in the century^ s early decades, one of Americans
most famous schools of medicine. To conduct our deliberations in this
beautiful Temple of Medicine, fresh from the bands of the builder, and
so recently dedicated to science, has been an inspiration. Here, within
a square of us, was the home of Warren Stone and the site of his
private hospital, the first ever founded in America by individual enter-
prise. The surgical career of Stone is one of the glories of this univer-
sity. A great teacher, an original and courageous operator, he made
a lasting impression on Southern surgery. If the elder Gross has the
place in our surgical annals occupied in the history of European



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296 BDITOBIAL.

surgery by Sir Astley Cooper, then was Stone our Velpeau. To Stone,
more than any other, is due the gratitude of the profession for the
splendid educational privileges we have witnessed in the Charity Hospi-
tal. There, in those wards, taught for years the scholarly and sagacious
clinician, whom many now present knew and loved, Samuel M. Bemiss.
Who that ever heard the gifted Hawthorn, cut down by the reaper in
his prime, can forget the clinical lessons ? If in Stone we found here
the prototype of the blacksmith surgeon of the French school of
surgery, surely in Hawthorn we had the American Trosseau. These
halls have so forcibly and constantly reminded us of the life and labors
of Richardson and Logan, so recently gone over to the silent majority,
that we can scarcely realize that these two eminent Southern surgeons
are no longer here. These eminent teachers are at rest, the lot
universally meted out to mankind, but their great work goes on. We
know that the standards they bore are safe in the hands of our con-
freres, and will be borne ever onward in the front ranks of advaDciDg
science.

These thoughts, Mr. President, have, been suggested by the
occasion, and it is our wish that our confreres be assured of our keen
appreciation of their courtesy. We hope that our visit here may
strengthen the professional ties among our members, and cement those
ties by the stronger bonds of personal friendship and mutual esteem.

The speech was received with prolonged applause, and the



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 30 of 78)