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pills were composed of Barbadoes aloes, sulphate of iron, powder of myrrh,
soap, and oleum pulegii. A reference to the analytical portion of the report
of The Lancet inquiry under the heading *' Quacks and Abortion — A Criti-
cal and Analytical Inquiry," will show that in the majority of the pills
examined, exactly these substances were found. It is interesting to note the
druggist's statement that he understood that the pills were harmless, and
the clause in the verdict that death was accelerated by an overdose of some
medicine of a corrosive character; and the matter, in spite of these irrec-
oncilable statements, was apparently allowed to drop. — Lancet,

Modern Surgical Treatment of Hemorrhoids. — Since a hem-
orrhoidal tumor is but the result of an inflammatory process, he believes
that germ infection must be the main etiologic factor. A locus minoris resisten-
tict is produced by certain mechanical influences, which, however, in the
light of modern pathology, can be considered only as predisposing causes.
In this class belong straining during defecation, obstruction of the portal
vessels from liver disease and abdominal tumors, pressure produced by the
gravid uterus, pressure on the veins from impacted feces, etc. That germs
are primary factors in the production of hemorrhoids the author is satisfied
from observations in his practice.

As to the treatment, he said that in the earlier years of his professional
career he was in the habit of removing internal and external hemorrhoids
with the ecraseur. His objection at present to this method is that the wire
of the instrument is very apt to break, leaving the operator in a dilemma,
especially when the operation is half completed. Secondly, the cut surface
is not accurate, nor can it be regulated. No matter how close the wires
are kept down to the base of the pile, the ecraseur cuts as it pleases and
not as the surgeon desires it. Thirdly, it frequently happens that after the
operation is finished complete separation of the tissues does not take
place, and if the screw is tightened some tissue is drawn into the stem, and,
if continued, the stem is apt to bore itself into the rectal wall. He does
not favor the Whitehead operation. His method of operating for internal
hemorrhoids diff^ers but little from that of most surgeons. If he has to
remove but one tumor of large size, he simply throws around its base a
temporary ligature, cuts off" the entire tumor, and then sews the wound
with interrupted sutures in the direction of the axis of the rectum.— Z>r. G.
M, Blechy in Medical News,

Chamber Disinfection after Death from Phthisis.— Dr. Edward
O. Otis (Boston Medical and Surgical Journal, September 21st) says that
the importance of disinfection or renovation after a case of phthisis is in
his experience not generally appreciated. No tenement, apartment, or



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The American Practitioner and News. 399

room should be again occupied or let until satisfactory evidence of thor-
ough disinfection or renovation has been furnished. A case narrated to
him by a physician of Boston will illustrate the importance of this. The
daughter of the landlady of a well-to-do boarding-house died of consump-
tion. Some time afterward a young woman from the West took up her
residence in the boarding-house and occupied the daughter's room. In the
course of time she exhibited evidences of tuberculosis, and her physician,
suspecting the source of infection, had her removed. Such experiences
were probably familiar to many. According to the author's knowledge the
disinfection of premises which have been occupied by consumptive patients
and vacated, either by death or removal, before they can be occupied, is
compulsory only in New York City, Italy, and Spain. — New York Medical
Journal,

The Ocular Causes op Headache. — Dr. S. D. Risley (Journal of the
American Medical Association, September 23d) thus concludes a paper
read before the Section on Neurology of the American Medical Association
at Columbus : The following conclusions may be regarded as established
by clinical experience : (i) Abnormities of the ocular apparatus are in a
large group of patients the sole and sufficient cause of headache. (2) These
abnormities of vision may be the unsuspected cause, and therefore the
absence of symptoms obviously referable to the eyes does not exclude them
as an etiologic factor in headache, insomnia, vertigo, petit chorea in
children, and certain stomach derangements. (3) The recent or sudden
development of symptoms, after attacks of severe illness, as typhoid fever,
the exanthemata, etc., or in association with more or less acute exacerbations
of some general dyscrasia, is not sufficient evidence against ocular participa-
tion in causing the symptoms. (4) The participation of the eyes as an
etiologic factor in headache can be positively excluded only in the absence
of ocular disease or after the most painstaking correction of any existing
error of refraction or abnormity of binocular balance. (5) For the relief
of reflex symptoms accurate corrections are essential, and these can be
secured only by the more or less prolonged use of a strong cycloplegic. (6)
Immediate relief by these corrections in a large group of patients is not to be
expected, since the pain is frequently due to associated pathological condi-
tions of the fundus oculi, which require time for cure. — Ibid,

Intestinal Obstruction from Biliary Calculi. — Dr. J. Wesley
Bov^e, of Washington, D. C, read a paper at the meeting of the Mississippi
Valley Medical Association with this title. He stated that intestinal
obstruction from biliary calculi is not very common. Brinton found in 500
cases of intestinal obstruction but twenty-four cases due to gall-stones, and
Leichtenstern found but forty-one in 1,544 cases of bowel occlusion. In
the Manchester Royal Infirmary but one case in 50,000 patients treated for
all troubles was found. As it is a condition practically limited to late life,



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400 The American Practitioner and News.

its rarity is to be expected. The author then dwelt upon the varieties of
obstruction, the location, causes, symptoms, and prognosis.

In considering the treatment, he stated that Hippocrates, and later
others, recommended the injection of air into the bowel. Tobacco smoke
and infusion and diflferent gases have been thus employed. Purgatives are
positively harmful. Morphin and belladonna are the two best drugs in this
condition. Of course the use of electricity has not been omitted. With
medical treatment nearly half the patients recover, but is that a sufficient-
ly large proportion? In 1662 Barbette recommended laparotomy for acute
intestinal obstruction, and as abdominal surgery is now practiced, its use in
acute obstruction of the bowel from biliary calculi should give brilliant
results. Medicinal treatment may be employed for a short time, and, fail-
ing, should be superseded by laparotomy, with a careful exploration of the
abdominal and pelvic contents. The seat of obstruction being found, the
condition of the patient and the degree of mobility of the stone in the
bowel will guide the operator in the subsequent steps. The plan of Tait,
of passing a strong needle obliquely through the bowel wall into the stone
to break it up, may first be tried, the puncture wound being closed by a
Lambert stitch. This failing, the stone should, if possible, be pushed higher
in the bowel and a longitudinal enterotomy performed with extraction of
the stone. Gangrenous bowel, perforation, or localized peritonitis, with or
without pus, should be treated secundum artem. It is always well to look
for a second obstruction, as this has caused death in some cases. The
deaths following laparotomy for this condition are nearly always from
shock or sepsis, a strong argument for early operation. It would not seem
improbable that early laparotomy in these cases should have a mortality of
less than 10 per cent. — Medical News,



F. E. Harrison, M. D., Abbeville, S. C, says : I have used Celerina in appropriate
cases, and can heartily recommend it to all who wish an elegant preparation, com-
bined with undiminished therapeutic activity. It is peculiarly fitted to such cases as
delirium tremens, headache from debauch or excessive mental or physical exertion.

Rbndbr unto Ci^SAR THE THINGS WHICH ARK C^Sar's. — It gives me pleasure
at all times to render unto Csesar the things which are Caesar*s. Although I am
ojpposed to giving certificates relative to proprietary medicines, in this case I overlook
my objections, as I consider Sanmetto one of the greatest vitalizers of the reproduc-
tive organs now in use. P. C. JONBS, M. D.

Kansas City, Mo.

Indigestion. — As lonj? as people will be unwise in matters of diet, just so long
will physicians be called upon to treat all forms of indigestion. It therefore is well
to consider a remedy which is suitably adapted to this condition^ We desire to call
attention to Ingluvin for treatment of all forms of dyspepsia. It is a bland prepara-
tion of the ventriculus callosus gallinaceous. It has a property of soothing the
irritated gastric mucous membranes and re-establishing a norms^ secretion of the
digestive fluids. It has time and again proven itself superior to pepsin. Its prescrip-
tion is attended with more certain results than pepsin. Whenever pepsin is indicated,
try Ingluvin. It will give you more satisfaction. Messrs. Wm. R. Warner & Co.,
Philadelphia, the manufacturers, will send you sample upon request.



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THE



American Practitioner and News.



'NEC TENUI PENNA."



Vol. XXVIII. Louisville, Ky., December i, 1899. No. n.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the
ftwest possible words, or his reader is sure to skip them ; and in the plainest possible words, or hi^
leader will certainly misunderstand them. Generally, also, a downright fact maybe told in a plain
way ; and we want downright facts at present more than any thing else.— Ruskin.



©riginal Clrticles.



THE DOCTOR'S PAY.*

BY JOHN G. CECIL, B. S., M. D.
Professor Practice of Medicine, Louisville Medical College, Louisville^ Ky.

For fear this paper may chance to meet the eye of some good fel-
low, I wish to say right in the beginning that " there are many except
tions to the rule," By a good fellow I mean a person who wants the
doctor often, who never grumbles at the size of his bill, but sends a
check by return mail. May his like be greatly multiplied !

That which is to foljow applies particularly to general practitioners
of medicine, and not to surgeons and specialists. These latter have
learned many things well worthy of emulation.

The necessity for a readjustment of the financial aflFairs of the doctor
becomes more apparent year by year. The multiplication of doctors,
the difficulties in making a competence, not to mention the desirability
of putting aside something for old age ; the growing tendency of people
to postpone payment for services rendered, all suggest the importance
of serious consideration of this subject. The effisct that inattention to
the monetary aspects of our profession which I shall endeavor to show
has upon our standing among other professions is one of no mean
importance.

In the race for ascendency the commercial spirit of the age should
prompt us to put aside old ways and customs, no matter how much
honored by long-time observance, which are dragging us down day by

* Read before the Louisville Medico-Chirurgical Society, October so. 1899. For discussion see p. 417.

81



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402 The American Practitioner and News.

day, and adapt ourselves to later-day methods, which will not onljr
improve the material aspects of our business, but which elevate and
ennoble our profession. This is a matter that will demand unanimity
of action in the whole profession. It means a hard fight and a long
fight. The tendency is for things to grow worse rather than better^
and there is no more favorable time than the present to meet the issue
at hand. I feel safe in the assertion that whatever evils exist are
largely of the doctor's own making. It therefore behooves him to set
about the correction of them. Nothing is more certain than that if we
wait for some one else to correct them, we will wait in vain.

It is with no little diffidence that I undertake to suggest some of
these evils which are generally conceded to exist, and the remedies for
them. Should this effort succeed in starting the agitation of this
matter, then its object will, in part, be attained.

It is customary for commencement orators to indulge in beautiful
platitudes to the young graduate about the grandeur of the noble pro-
fession, the self-sacrificing life of the doctor, the admiration, love, and
esteem of the laity, the gratitude and devotion of his clientele. Con-
trast this with the first five or ten years of the real professional life of
the hopeful but misguided young doctor, recall the beggarly, niggardly
remuneration for his services — fifty cents for a call with medicines
furnished, five dollars on long time for obstetric cases — with a few
complimentary post-partum visits thrown in for good count. It is
quite true that these figures may represent the full value of the services
of some doctors, but it is not true of all. The public does not always
exercise a very fine discriminating judgment in the selection of a
doctor, otherwise the hands of the members of this Society would be
covered with callosities from the excessive use of the scissors in
clipping coupons, even at the above-quoted figures.

Likewise the popular-address man delivers himself of a lot of
tommy-rot and fol-de-rol to the beloved public about the nobility
of the medical profession; how the doctor spends his life fighting
disease, the dread enemy of mankind ; how, with matchless skill, he
snatches the wan and wasted sufferer from the very jaws of death ;
how, in sickness or in health, he is ever ready to answer the call of the
sick ; how he plods his weary way through rain or shine, heat or cold^
night or day, to alleviate pain and suffering, and sorrow, and distress;
how he gives up home and family and friends, and throws himself
with reckless abandon in the breach to check the invasion of some



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The American Practitioner and News. 403

^Kre epideaiic, heedless of exposure to himself^ little recking he of fame
or fortune to follow. That same beloved public applaiids the addfess,^
professes great admiration for the noble profession, says ***I>Dc''is a
mighty &ie fellow," but ** he winks his other eye '* and forthwith pro-
ceeds to stand '*Doc "off for eighteen months; then, with an awful tale
of woe, and with cold, steelly glittering nerve, asks him to cut his bill
half ia two. In fact, as individual members of the professiott wt also
applaud the noble sentiment of these addresses, but we commune witb
oiixselves. in thought on other and different lines.

Ftom the above or the reference to the commercial spirit of the age^
Ijje inference must not be drawn that I am advocating in the practice
of medicine a sole and overweaning desire for the " loaves and fishes,'*
but I wish in passing to intimate that sentiment will not keep* the
"Indian" from your door nor satisfy the clamors of the. butcher,, the
baker, and the candlestick-maker.

There are other phases of this subject to which I ask yottu especial
attention. What is the real standing of the doctor as a professional
man ;, how does his profession rank with other professions^ and uponj
what basis should he be remunerated for his service? I ami con-
strained to believe that in the mind of the public onr profession* is not
classed with the other professions; it is not accorded a place on: the
same high planfe. Ours is sort of a brother-in-law to the othier profes-
sionis. Many will call it a profession, but think of it as really a trade.
This is because some doctors make a trade of it. In part, at least, this
misconception of the standing of the profession and the value of med-
ical service has arisen through the doctor's own fault, from the unpro-*
fessional value he has placed on his service, and from the unprofessional
method he has adopted of fixing th« value of that service, is it not a
feet that most people estimate the value of medical service by the
anmber of visits made, the length of time engaged, the number of
miles traveled, or the amount of medicine prescribed, paying little or
no heed to skill ? And is it not a fact that doctors have accepted this
wiay of estimating the value of their services ; and is not the absurdity^
a£ it glaringly apparent? Upon skill, and skill alone, should rest the
ipay to make a charge for professional service. A large part of the
imlilic look upon doctors as skilled mechanics ; the only difference they
see is in the doctor's dress and ordinary mode of locomotiouk They
tiiink because he rides in a buggy, therefore he ought to charge lew for
hiti work. Until we can get away from the $2.00^ oc %j/so pes visit



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404 The American Practitioner and News.

plan, I very much fear our profession will always be ranked on a low
plane.

To change the present prevailing method of charging does not nec-
essarily mean to increase it. It is the method that I insist is wrong.
For a service requiring little skill, then a small fee ; but for a service-
requiring great skill, then by all means a fee that is commensurate. It
is ridiculous to estimate the value of a doctor's service in the manage-
ment of a case of pneumonia or typhoid fever by the number of visits
made, at so much per visit. Why, some people keep a count of the.
number of visits made, and in making out the bill a little mistake of
adding on a few dollars to round it out to an even number is very
promptly called down.

Many a man will cheerfully pay $500 for an ovariotomy, or $200 for
an amputation, that will kick like a mule over a bill of $150 for a case*
of pneumonia, because the doctor only made about sixty visits. I mean
no disparagement to the surgeon; he earns every dollar he collects,
but so does the doctor. I rather glory in the surgeon's nerve, and I
believe he would stand by the doctor if he would cultivate the grace
of charging well. The custom of charging fees by sprgeons and spe^
cialists has elevated these branches of the profession, and among other
reasons is our explanation of why so many young men are attracted to
these fields. The doctor, in the meanwhile, has plodded along in the
way his great-grandfather trod, ofttimes fearing even to present his
long-over-due-$2.oo-a- visit bill lest he offend his patron.

Still another aspect to this subject is the direct loss to the doctor
by bad debts, slow pay, etc. No class of men, professional, mechanic,
merchant or farmer, loses so great a proportion of his earnings. The
practically compulsory credit system has done us incalculable injury.
A man that can't get credit for ten pounds of sugar or ten yards of
calico thinks nothing of standing his doctor off for a ten-dollar consul-
tation for which the doctor has probably only charged him one dollar.
He would be grievously offended if asked for spot cash. People tell it
as a joke that the doctor's bill is the last one settled. They even tell
the doctor himself that if they have any thing left after paying the
milliner, the florist, the jeweler, the confectioner, and all the other
luxury dealers, that they will pay him off, with never a thought of the
jar that it gives his nerves. Who is to blame?

Another idol that should be broken is the custom of rendering bills'
yearly or half yearly. This custom has made the doctor not only poor,^



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The American Practitioner and News. 405

but a poor business man. To affirm that prompt presentation of bills
compromises the dignity of the J)rofession is isilly and absurd. What is
the custom of our step-brother, the lawyer? He compromises his dignity
and your bank account by collecting your money, pocketing his fee —
simply to save you the trouble of writing a check — and sometimes he
hands you the little balance. Verily, every young man ought to have
a business education before beginning the study of medicine.

Before closing I wish wish to propound a conundrum, and to sug-
gest the answer to it. Why is it that people will pay a quack more
than a regular doctor for the same service? Is it not because the
quack magnifies the ill and never forgets to magnify his own skill?
Do not for a moment accuse me of wishing to imitate the method of
the quack or charlatan. I know that I am on rather thin ice along
here, but if a patient magnifies his own ills, or magnifies our service in
telifeving him, where is the harm, though scant is the probability
of allowing him to magnify the bill? Is it incumbent on the doctor to
disabuse his patient's mind or to underrate his own service? Remem-
ber, I am not talking to recent graduates nor making a popular address.
Is it not, worth more to relieve one man of a colic than another, espe-
cially if number one thinks his colic the worst that human ever
endured ? Should we insist that one price must prevail for all ? Is it
very wrong to turn a penny, an honest penny ? Who, in your experi-
ence, values your service more, the man who asks you a year after the
bill is due to knock off fifty per cent, or the man who pays promptly
full value for services rendered? Which do you retain as your friend?
I truly believe the worst enemies that I have made in a professional
way are patients to whom I have made nominal charges for valuable
jtervices. I am trying to break myself of that habit.

People usually take a doctor at his own price, and no man's stand-
ing is improved by charging two dollars for ten dollars' worth of skill.
A doctor, either young or old, makes a great mistake and debases his
profession in underbidding his competitors in order to get business. It
will return to plague him long after he intends to abandon the custom.
Did time permit, I would sum up and draw some conclusions, but lest
I overtax your patience I will let you draw your own.

Louisville, Ky.



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4o6 TjIt Amerzcun Practitioner and News.

MQTnVLENB BLUB AS A LOCAL APPLICATION IN DISEASES OP

THE MUCOUS MEMBRANE : WITH REPORT

OF THREE CASES.

BT CHARLES MOIR, A. B., M. D.

MathHM io •fkr Chair of Physiology and Clinicai Instructor in Diseases of the Eye^ Bar, Nfse, auM
Throat, Kentucky School of Medicine^ Louisviile, Ky.

Cass I. Mamie D.^ age sixteen, presented herself at the college
cUntc August 7, 1899, with the following history : Menstruated at the
age of twelve years; health not good. After she attained her fifteenth
year she noticed that at each menstrual period her tonsils would become
very much enlarged, and sometimes a profuse hemorrhage would take
place (vicarious menstruation); following this condition the tonsib
would usually suppurate for a week or ten days.

The day she presented herself at the clinic I found both tonsils
covered with a thick muco-purulent, adhesive material of a greenish
color, offensive odor. I cleaned the tonsils with peroxide hydrogem
full strength, and by its effervescent action separated the adhesive
exudate, leaving the tonsils clean. I then applied methylene blue, three
grains to one ounce of aqua dist., freely over the entire surface of boA
tonsils, and gave her a solution of the methylene blue, and told her to
apply it to the tonsils three times a day, and ordered a general tonic
oontatntng iron, and told her to report back the next morning.

I did not see her again for nine weeks, when she told me that she
had 00 further trouble with her tonsils, but had made frequent appltr
Cations of the blue solution, had gained three pounds, and menstrua-
ttoo was about normal.

Case 2. Jas. W., age thirty-eight years ; occupation, laborer. Pre-
sented himself at the college clinic August 25, 1899, with the following
history : Has had recurring attacks of tonsillitis for several years, fol-
lowed by attacks of muscular rheumatism ; no history or evidence of
syphilis ; health usually good, excepting slight attacks of headache.

Examination showed both tonsils and pharynx covered witti
tenacious muoo-purulent exudate, very foul odor, tongue furred txA
covered with yellowish-gray coat, uvula elongated, constant attempts
to clear the throat, deglutition very painful, and bowels constipated.

Treatment, Used spray peroxide hydrogen full strength, which



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 100 of 109)