W

ITH few exceptions, the fingers that fashion powders to soothe human ills are not facile wielders of the pen. The noted men of that great army who practice the "healing art" usually aspire to deeds, not words; the rank and file seldom venture to launch a self-made craft upon the turbulent sea of literature, and so it happens that the Shaws and Hendricks appear in print and take up the doctor's burden. But a lack of the true inward spirit of an honest physician leads them to make erroneous assertions and form mistaken conclusions.

In their criticisms they adjust in the spotlight the conspicuous exceptions, and lead their readers to believe that the great whole is equal only to the selected examples. And, although probably not admitted, they waiver to the influences of interests, personal and extraneous, and fail to represent truly the inconspicuous, who constitute the great body of physicians toiling against unjust criticism as well as human suffering.

We should like to have a fair show. "Ethics" is a lofty word, commanding an upward look, but, sad to say, behind its etymological significance of proper human action there frequently crouch demons-Deception, Selfishness and Injustice and it was the discovery of these spirits of evil mien that led to the adoption of a supposed improvement upon the "Code of Medical Ethics," to help physicians toward a higher

human level.

But the original "Code" was no more a "collection of windy and self-praising platitudes" than is that portion of the Holy Bible that has been designated "The Sermon on the Mount." And to speak of the period of its birth as "the time of cutting, bleeding, shotgun doses, and sawbone surgery,' ," has no justification except as a very thin joke.

It may be true that "in mediaeval times the doctor dressed in a long robe and a black cap, conducted his conversation in Latin, and administered his mysterious and nauseous and utterly worthless nostrums according to fixed formulas that amounted almost to incantations."

But the term "the doctor," as thus applied, should not include those who were inspired by noble motives, no matter what mistaken and un

Reply to Burton J. Hendrick, in McClure's Magazine.

developed means of treatment were honestly pursued.

We do not object to condemnation of that which is wrong in the lives or methods of men, but it does not tend toward ambitious uplift to group the good with the bad and discard the whole lot.

"Old superstitious days" is an unfortunate term to use in this day, when the dignity of Justice quite uniformly selects Friday as the day for executions, and our great hotels abjure a room with the number "13" upon its door.

To term writing prescriptions in Latin as "monkish superstition," is an evidence of incomprehension of scientific knowledge. I should not be supposed to state that scientific terms, to be permanent in their form and significance, must be dressed in words of a dead and unchanging language. The time may come when the English language will assume all the advantages of these requirements, but at present it is not so considered.

To state that "as a matter of fact the remedies of most nonsurgical disorders today are diet, fresh air, exercise, nursing, and a clean mind and body," is to lean extremely toward those views of unsuccessful and disgruntled freaks in the ranks of medicine who are termed "medical nihilists,' ," and, yet, Mr. Hendrick speaks with enthusiastic admiration of "the days of serum-therapy, vaccines, and antiseptics."

To state that "professional secrecy" has "two purposes," is obviously incorrect. If that criticism is to be used at all, the word "professional" should be omitted. The courts of justice require secrecy among physicians in regard to disclosures made solely to enable the physician properly to diagnose and treat his patient. The extreme of protecting criminals, as a result, has been carefully weighed and determined as just and right by the highest authority in law. The protection of innocence is not detrimentally affected by this principle.

"Consultation" has ever been debatable ground. I wince under the stabs of Mr. Hendrick upon this subject, for I must admit that a consultation of physicians furnishes the most fruitful field for dishonest trickery in the whole realm of medicine. Very seldom does the absolute integrity of the ordinary physician withstand the inducement to derive selfish advantage from the opportunity offered in a consultation.

Very seldom, indeed, does a consultation conduce to the patient's advantage in any respect. As a rule, the attending physician's personal zeal and ambitious interest in the patient's welfare here reaches the turning-point, and the "soreness" which he feels quite largely destroys his future usefulness in the case.

The term "fee-splitting" is a derisive one, originating among a certain class of surgical hogs who sincerely wish that by so doing they may justify themselves in the estimation of good people in their custom of demanding that the ordinary country physician shall assume great personal responsibility, make difficult and important diagnoses, give extreme medical skill and knowledge, and then turn the case over to the surgeon with the entire fee for the complete work called for by the two physicians. They go so far as often to ask the country physician to attach an extra fee for himself upon the already often enormous financial burden which they heartlessly push upon those who are doubly unfortunate. And then they have the effrontery to claim the virtue of honesty! These are the men who are making

Does

the hue and cry against "fee-splitting." it not suggest that when you hear the cry of "thief" you will do well to watch the man who makes the noise?

Besides, dishonest fee-splitting is not a common occurrence in the profession. So far as I have been able to observe, no case has ever been brought to public attention by these self-righteous participants in the crime. For, if the fee is ever split, they are the ones to control the splitting. The most effective means of stopping dishonest fee-splitting would be to publish the names of the parties in the medical publications; but no such names have ever been published.

The remedy for any wrong is simply right. Do not give us any fixed "code" or "principles" in detail, but rather let us depend entirely upon that "platitude," "Do unto others as ye would be done by."

Let me close by calling to your attention the finest compliment to medicine that ever has been spoken. Mr. Hendrick says: "The great glory of modern medicine is, that it regards nothing as essential but the truth."

I

N the treatment of internal hemorrhages I rely upon but few drugs, as I have found only these few reliable in most cases. I have seen but few cases of hemophilia, and all of these prior to the introduction of normal serum for the treatment thereof, and so have had no experience with this agent in this connection. In the few cases coming under my observation I have employed the calcium salts, chloride and lactate, and gelatine, with satisfactory results as a rule. although there have been recurrences under such treatment. From my reading it seems to me that normal serum is the preferable remedy in all such cases.

Within the past few years, eight or more, I have not seen a single case of hemoptysis, owing to the fact that there are but few cases of phthisis in Nevada and those coming under my observation are getting well and without hemorrhages. I have, however, while located elsewhere, employed atropine in preference to all other agents, in emergencies, to bring a stop to the

bleeding, this being followed by the calcium salts, chloride, lactate and sulphide, to increase coagulation. Hydrastinine hydrochloride has given me some good results in bronchial cases. When there has been chilliness of the extremities or skin, showing an inequality of the circulation, I have employed aconitine with strychnine and digitalin, the Triad of Burggraeve, or strychnine arsenate with aconitine. Glonoin, followed by atropine, meets the indication nicely, in that the blood is forced to the periphery by both, the first acting quickly and the latter sustaining the effect. In these cases I endeavor to counteract occurrence of hemorrhage through doing everything to increase vitality of the patient. Since the suggestion of emetine in hemorrhages of this sort I have not seen a single case in which to exhibit the agent. In connection with atropine I sometimes have used morphine, especially in those cases where there has been much restlessness and coughing. I believe that codeine would be equally efficient. Atropine is my favorite, but it must be pushed to full effect if results of a satisfactory nature are to be obtained.

In the severe hemorrhages, following normal delivery or abortion, I pack the uterus and vagina with either iodoform or sterile gauze and administer atropine in full dose hypodermically. In some instances, with uterine inertia, a full dose of hypodermic ergot, given alone or in conjunction with atropine, acts as a synergist, through increasing the contractile powers of the uterine muscles. Hydrastinine hydrochloride given in conjunction with atropine, I have found very satisfactory. I have also found local applications of epinephrin solution effective. Here again, however, atropine is a very dependable remedy. It acts quickly and that is the desirable thing in cases of this sort. Glonoin might be exhibited prior to atropine with good results, the former paving the way for the latter.

In the oozing of blood from the uterus, in those cases where surgical interference seems unwarranted, I prefer the calcium salts, given until such time as the coagulability of the blood is sufficiently increased. To these I add a diet of gelatine, allowing this article of diet several times during the day and night. I have also found hydrastinine hydrochloride efficient in cases of this sort. Ergot will have an influence on these hemorrhages but its continued use is inadvisable for obvious reasons. In addition to these agents, the tonics, especially those carrying iron, are indicated. The patient should be built up to the highest possible point.

In the treatment of hemorrhages occurring during the course of typhoid fever (which rarely occur in my practice) I place great dependence in atropine and morphine, for the following reasons: The first throws the blood to the surfaces, thus equalizing the circulation, while the latter puts the bowel at rest and favors healing of the ulcer. In some cases I have applied cold to the abdomen in conjunction with these remedies, and with satisfaction. Following such a hemorrhage I add gelatine to the diet and in some instances give the calcium salts for a while. I have employed bismuth subgallate in a few cases with seeming good results.

Subsequent to all hemorrhages I exhibit the calcium salts until I am practically sure that there will not be recurrence, or until such time as the coagulation point is raised to a considerable extent. I also feed my patients liberally on gelatine. If there has been an excessive loss of blood, or if there are symptoms of anemia, I find hypodermies of iron cacodylate very effective in bringing about the normal. I have seen patients with a blood count of less than three million red corpuscles brought to normal or nearly so within a very short time. I had an experience within myself which emphasized the satisfactory points

of the above outlined post-hemorrhagic treatment. Following the erosion of a blood vessel of a duodenal ulcer with which I had been afflicted for some years I was left practically exsanguinated. A weak after the acute hemorrhage my blood count was about three and one-half million reds and between 40 and 50 per cent hemoglobin. To check the acute hemorrhage atropine and morphine were employed, with calcium chloride to prevent recurrence. Four days later the hypodermics of iron were begun and within less than two months my blood count was practically normal. Gelatine was given me several times a day for a period of more than six weeks. Both the hypodermics or iron and the gelatine seemed to have a stimulating effect, as I felt better after the injection of the meal than before. Iron employed in this manner has a decided advantage over all other forms of the metal. The gastric function is not interfered with and constipation does not follow. Under this treatment there were no recurrent hemorrhages. I have followed this plan in others and with as good results.

Epitomized, the treatment of all internal hemorrhages in my hands is as follows: During the acute stage atropine, either alone or preceded by glonoin, or given in association with hydrastinine hydrochloride. Subsequently the calcium salts with a diet of gelatine and with iron cacodylate, if there is any considerable anemia. The indicated drugs, in my mind, are but few, but these few should be given to full effect, and that effect maintained. In abdominal hemorrhages, especially those associated with pain, the ice bag seems to relieve the patient, whether it has any other effect or not. I frequently use it, but cannot truthfully say that the bleeding is influenced thereby.

Anaphylotoxin Reaction in Relation to Traumatic Inflammation. In experiments upon rabbits' eyes, it has been found by Dold and Rados, of Strassburg (Dent. Klin. Woch., 1913, No. 32), that, similar to autogenous and phylogenous tissue-fluids, a homologous serum containing anaphylotoxin is capable of inducing, within the short space of less than twenty minutes, an intense sterile inflammation.

Thus, the authors point out that, besides favoring coagulation and cachexia, the aqueous fluids derived from the animal organs (which are not so much intracellular substances as extracts of the pericellular tissue-fluids) possess the additional property of arousing an inflammatory process. And this, they think, suggests an explanation of the origin of certain noninfectious traumatic inflammations.

I

N Le Monde Médical for March 5, 1914, Robin discusses clinically dyspeptic albuminuria. One patient instanced was a woman 35 years of age who had been ailing three years and had quit work as a chambermaid a month before.

This woman's urine showed traces of albumin and sugar, but there were no symptoms of diabetes or of nephritis. However, her skin was of earthy hue, emaciation was pronounced, breath fetid, tongue saburral; her appetite was irregular, at times hunger being such that nothing could satisfy it, and at others there was insuperable anorexia. After eating she felt a disagreeable heaviness, an invincible somnolence, and three or four hours later, emerging from her torpor, she had colic and other abdominal distresses, followed by eructations. An hour or two after retiring she was awakened by a sense of warmth, palpitation, and colic, the attack terminating by gaseous or acid eructations. Her stomach was resonant, distended, the liver slightly enlarged, the conjunctiva slightly yellowish. She complained of spells of headache and vertigo, and after meals she had palpitation with intermitting pulse upon the least excitement.

The acidity was much augmented, as to free and combined hydrochloric acid and as to the acids of fermentation, especially lactic acid; traces of butyric; no acetic. Albumin digestion was normal, but feculents were badly digested. The urine from midnight to early breakfast showed neither albumin or sugar; when present these were solely derived from the food not completely digested.

Robin distinguishes three classes of gastrointestinal albuminuria: (1) The albumin is absent from the morning urine; often present in that of digestion, but not constantly; if present, it does not exceed 0.30 gram. (2) The albumin is always wanting in the morning urine, but constant in that of digestion, to the extent of from 0.25 to 1.0 gram. (3) Traces of albumin are found in the morning urine, while that of digestion constantly contains from 0.50 to 2.0 grams.

There are, really, three stages of the development of the malady. The kidneys do not, with impunity, continue indefinitely to pass albumin. Patients who have for a long time had 1 or 2 grams of albumin in the urine of digestion al

One of the most striking characters of these dyspeptic albuminurias is the facility with which they increase or disappear under the least influence. The role of repose is predominant, as often has been described, with apparent exaggeration, by all those who have described the "'orthostatic" albuminuria. Take a case in the early stages, put the patient in bed, and often the albuminuria will disappear.

Cloetta found that in these cases the albumin always was a serum, and that only when true nephritis developed did globulin appear.

Besides albumin, the earthy phosphates are almost always present in large quantities. When the urine is heated without acetic acid being added, the albumin and phosphates form a coagulum. Add the acid, and the phosphates disap

pear. Uric acid and the urates are habitually increased. Indoxyl and skatoxyl are found almost constantly. Glycosuria is present in 13 per cent of the cases. The microscope detects uratic sediments and crystals of calcium oxalate. A variable leukocyturia is present in 80 per cent, this proving the epithelial irritation from the uric acid. The respiratory exchanges are lessened. There is reason to believe that in these cases the catalytic action of the leukocytes has been greatly exaggerated.

The malady is frequent among the leisure classes, adolescents, and not rare in children, especially those of neuroarthritic parents, and whose diet during infancy was too rich in meats.

The precedents to therapeutic intervention, are, broadly, these factors: The influence of neuroarthritism and of over-feeding of meats; the presence in the stomach of undigested albumin; the intermittence of albuminuria; the absence of tube casts; the frequent association of glycosuria; the increase of nitrogenous excretion; the demineralization by loss of phosphates, especially of the earthy bases.