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the rectum, and give rise to considerable irritation until gotten rid of. They are sometimes introduced from without, usually by patients themselves, or they pass down from above in the form of some indigestible ingesta. The first case of this

kind that I ever saw came to me from a family physician in Dakota, fully fifteen years ago. He sent to me a specimen in a small bottle, with the reqeest that I examine it microscopically and report my findings to him. It looked like a rolledup membranous cast from the gut. It had been passt by an aged lady, after several weeks of rectal irritation, and then was taken with forceps by the doctor who had sent it to me. Upon unrolling it I found it to be the stroma of an orange. Further inquiry, thru her attendant, elicited the fact that some time before her trouble began she had eaten an orange, sucking out the juice first, and then chewing and swallowing the entire pulp.

Other bodies that may pass from the rectum are gall-stones and gut-stones or enteroliths. Gall-stones are readily enough recognized. If they are from the gall bladder they are usually faceted; when from the hepatic ducts, they are not faceted. When there is but a single stone in the gall bladder, it is not, of course, faceted. I have seen, post mortem, many such instances, when death was due to other causes.

Sometimes food concretions form a compact mass in the gut, and this eventually becomes spherical from rolling about in the lumen of the intestine. They grow larger from fecal accretions being continually deposited upon them. They may become so large as to make their passage by the rectum impossible without frightful suffering and severe damage.

Worms are found, especially in children, with comparative frequency, but by no means so often as one would suppose by listening to the wise (?) remarks of the know-it-all old women one meets in so many cases. The only positive sign of worms is to see the parasite in the stools. They have no other significance than that the patient is beset with an enteric parasite.

The Circulatory Apparatus.

As in the consideration of the diseases of the digestive organs, it was advisable to take up the general function of the entire digestive tract, so it is also now best to go into the mechanism of the circulation 1 order that the points to be made under

this heading will be the more easy of comprehension and the more readily remembered.

The circulatory apparatus is composed of what might be called four sections, the heart, arteries, capillaries and veins. The heart forces the blood through the arteries towards the capillaries, and is assisted by the elasticity of the larger arteries and by the muscular coats of the smaller ones. Added to this, is the so-called vis-a-fonte, or the force ahead, in the capillaries that tends to draw the blood on thru the arteries, and th s force is known as capillary attraction. From the capillaries the blood passes into the veins, which are thin, larger than necessary to hold the blood volume, and of such limited contractile power as to be unable, unassisted, to propel the blood they receive onward to the heart without extraneous assistance. This aid they get in several ways. First of all, they have valves, so that when a column of blood has been forced up to a certain point, no force is required below the valve to hold it up. When, however, the pressure within the veins is so great as to sufficiently distend them to separate the valve segments, there is regurgitation of some of the blood to parts of the vein below the valve. Soon the process is extended to the valve next below, and thus on from one to another till they are all separated, and are of no further practical use in holding up the blood current. Then the veins become still more distended and tortuous, and are said to be varicose. If they are not supported by some outside means, such as an elastic bandage, for instance; they are apt to rupture, causing extravasations of blood under or thru the skin. They also are likely to so interfere with the local nutrition as to set up ulcerations, and these are known as varicose ulcers. These, as is so well known, require for treatment, support and stimulation before they can be made to heal.

Besides the valves the venous circulation is aided by gravitation in favorable situations, as in the legs when a person is up. Another help is the alternate contraction and relaxation of the muscles of the body and limbs. This squeezes the blood current onward, both within and between the muscles.

From all this it follows that the circulation of the blood may be hampered in a variety of ways. In the heart itself there may be trouble with the valvular mechanism, or in its muscle substance. Of this I

shall say more in detail when I discuss the heart itself. In the arteries there may be loss of elasticity, as in atheroma, or of contractility, as in vaso-motor disturbances. Vaso-motor troubles may also interfere with capillary attraction, thus lessening or destroying the vis-a-frontis. There are other conditions of the circulation that cause trouble, but they will appear as each part is taken up in detail.

The Pulse.

The pulse is the beat of an artery. It is not confined to the wrist, as so many of the public suppose, and, I am sorry to say, as so many physicians would seem to think, judging from the way they persist in getting the information from the radial pulse, when it can more readily be obtained elsewhere, say, for instance, from the temporal artery.

I shall not try to define a normal pulse, because I believe it impossible to describe so indefinite a thing in a way to mean the same thing to all men. I shall assume that I am addressing practitioners of experience enuf to have satisfied themselves upon this score. The learning of what constitutes a normal pulse can only be done by continued attempts at it under the supervision of a master. Once this knowledge has been gained, the deviations of which I shall treat are readily detectable and are mostly variations from a personal standard. In consultations one often notices the discrepancy in the interpretation of pulse qualities by the different consultants. One calls it normal, another a little hard, and yet another a trifle soft. Now these are all personal differences that correspond to the personal equation of the observer. One man sees quicker than another, or one registers an impression in shorter or longer time than another. These differences are carefully noted in all individuals making observations in astronomic observatories, and are called personal equations. To whatever extent they vary from an accpted standard they are recorded and either added to or subtracted from the findings of the observer, for otherwise the greatest errors in computation would ensue, because the difference of a small fraction of a second might mean a difference of millions of miles in estimated distance. So that when one reads of a pulse that is a little hard or a little some other way, it must be taken with some allowance. So much for the personal equation of the doctor, and it applies in all matters of judg

ment as well as in the determination of the pulse-quality.

Among the many things to be noticed about the pulse-quality are its rhythm, force, tension or compressibility, consistence of the vessel wall, shape of the artery (whether straight or torturous), its size or volume, and its frequency. All these qualities indicate either a condition of the heart or of the artery itself, and it often tells, especially in connection with other symptoms, that the heart derangement is due to some defect or irritation of the nervous system. All of these things it is necessary to know in order to make a true diagnosis, without which it is impossible to successfully treat serious cases that are not likely to get well without careful medication and hygiene.

Frequency of the Pulse.

A good deal is said about the normal pulsebeat, as though there was such a thing. What is meant is the average pulse-beat, and that is something very different. The frequency of the pulse of a new-born child is given at near 140, from which point it gradually falls to about 125 at one year, 105 at two years, 97 at four years, dropping to 90 at ten years and 78 at fifteen. During adult life, from twenty to forty-five, it averages about 70, after which it again gradually rises to 80 at eighty years of age.

Exercise and change of position alter the frequency of the pulse. It is slowest during sleep and quickest during active physical exercise. And it must not be forgotten that active mental work also increases the number of pulsations in a given time. The change from sleeping to waking causes an increase of several beats; it is still quicker while sitting, more so standing, and still greater in walking. It is increased by excitement of all kinds. In examinations for life insurance it is specially important, notable in excitable individuals to allow as much as ten beats for deduction, in consequence of this fact. It is also important to avoid an examination of the pulse as soon as the patient walks into the office. They should first be given time to rest and recover from the increased pulse-beat due to the exercise of walking and possible excitement. It is also well to bear in mind that the weaker the patient, the greater the variations in the pulse-beat from any of the causes that have been named. The contrary is also true, that the stronger the individual the less is the variation in pulse

frequency from all causes. I have repeatedly examined the noted George Littlewood. of six-day-go-as-you-please-race fame, after he had run 30 miles in three hours on a quarter-mile track, always finding his pulse either unchanged or beating possibly two beats more than when he started, which was usualiy 70 to the minute. It is also a fact that the pulse will rise in frequency shortly after exercise is begun in the strong, only to gradually slow down again, perhaps to the usual frequency and remain there during the entire exercise unless the work is increased.

The pulse may be either fast or slow in disease as compared with the average in health. A pulse that is too fast when associated with fever or other tangible causes, is what might be called normal for that condition, but when it is not due to other than a nervous influence it is called tachycardia. A pulse-beat below sixty a minute is called bradycardia.

A fast pulse is found in all febrile conditions unless associated with certain brain affections that cause slowing of the pulse. It is unusually fast, all other things being equal, in proportion to the height of the fever. In prolonged illness, the pulse beats faster in proportion as it grows weaker. In acute sthenic diseases, as in some cases of pneumonitis, it may beat fast, strong and furious. It is then

that aconite or veratrum viride are indicated, or some other heart sedative. All heart complications in febrile affections, cause increase frequency of the pulse. This is simply because the weakened condition of the heart, with its resulting lower force, has to be made up by increased frequency of beat. From this it follows that the relative frequency of the pulse-beat is a fair index of heart strength, so that the general rule may be laid down that the weaker the heart the quicker the pulsebeat, and vice versa.

Vierordt claims that an adult pulse above 120 requires special consideration, and that one of 140 is grave. To this I may add that a patient with pulmonary tuberculosis and a pulse that remains at or above 100, despite efforts to pull it down, is doomed. I have watched this for a long time, and in many cases, and have yet to see it fail. There may be exceptions, but I have not seen or heard of them.

Anemia has a fast pulse, for the simple reason that the heart is weak and the blood is so poor in oxygen that much more

has to be pumped through the lungs to insure proper aeration than would be necesssry if the proper amount of red corpuscles existed in it.

Valvular disease of the heart is characterized by a fast pulse for similar evident reasons, except in aortic stenosis, and this is an exception, for the reason that the work is too great to be done quickly.

A fast pulse may be due to peripheral paralysis or central paralysis of the pneumogastric nerve. It is present in all nervous conditions and is a part of the general manifestations of general excitability. And it is faster in all instances of excitement, anxiety or pain.

Finally, there are some individuals, in fact, there are entire families, in whom a high pulse rate is a constant manifnstation. I have seen a pulse of over 90 while sitting as an unvarying condition of some people, and in one I noticed that it fell ten points by exercise. In this case I attributed the fall to the tonic effect of exercise upon the heart. During quiescence, the heart beats were weak and quick, while after active exercise it was stronger and slower.

A. H. LEUF, M. D.


[This series of articles will be continued in subsequent issues of THE WORLD. Comments are invited by the author.-ED.]

Vicissitudes of Medical Life.

Editor MEDICAL WORLD:-I have been in active medical practice since 1846 and am now seventy-six years old. Had I not tried to increase my capital after ten years' practice, I would not now be almost a pauper. I was induced to take stock in a silver mine in Colorado, and came out of it with a clean loss of $2,000. Next, I brought stock in the oil wells of Pennsylvania, putting several thousand in them. I came out with a lot of stock certificates, but made another loss of over $3,000. My next venture was in California. It was a grand gold mine, but I came out of that venture holding 30,000 certificates that the press assured me would pay. Last year I was bankrupt and sold out. Nothing in it. My next venture was building a streetcar line in this city. This company has been so managed that it will be sold out in a few months, another clean loss of my stock of $18,000. And lastly, I put about $3,500 in a brick plant. That failed over

a year ago and the stock had to double up. That, with over $12,000 I paid by going bail to help my friends, constituted my losses. So, altho I made all this ill-spent money in the practice of medicine, now, at my age, I am penniless. Should you find it proper, give this article a place in THE WORLD as a warning to all my medical brethren to never give their hard earned money into any company as I have done or it thus may go as mine has. J. M. H., M. D.

Nasal Catarrh-Chloroform in Labor-Fetich

ism-Use of Stimulants.

Editor MEDICAL WORLD:-In treating nasal catarrh, acute or chronic, I find it very necessary to have the nasal cavity cleansed frequently with disinfectant solutions, and I find soda biborate most excellent for the purpose. This cleansing should precede the various local sprays, etc., which are to-day in use. Did it ever occur to you how negligent the human family is with regard to the nasal cavity? With clysters, lavage, Turkish and other baths, we would think man pretty well washed within and without, but this neglected cavity goes with an occasional "shoveling out."

Catarrh, acute or sub-acute, of the nose, ears or eyes, is quickly relieved by insufflation of boracic acid to the nasal cavity and eyes. The ears can be packed with the powder.

Chloroform in labor is a most humane procedure. Our present civilization demands it. Physicians need have no fear in its administration. It never did nor never can do other than relieve the intense suffering of child-birth. The only precaution needed is to procure the confidence of your patients and dispel any fear they may have. With most patients the mere mention of chloroform, or the first inhalation of it, arouses fear, frequently intensely so. We all know the depressing power of this emotion, how it lowers and unsteadies the action of the heart. The objectors to the use of chloroform in labor are found principally amongst two classes of persons-doctors who are unwilling to take the pains to become experts in its use, or who underestimate the importance of their patient's suffering, and the majority who, now exempt from the pains of child-bearing by age, can see no good reason why the younger women should be saved from what they once suffered.

Superstition, faith curers, etc., are rife in this section. I will briefly give an experience I had only yesterday. I took a meal in the country, and it is well for physicians to do this occasionally amongst patrons who are so constantly sick. It often leads to the discovery of the secret of their ill health. This particular man has a son, 18 years of age, who has been an invalid from childhood. I was given his history and treatment. Among the latter he told me he had used the "pumpkin cure." From his crude explanation I learned the theory was the latent development in the pumpkin would be transmitted to the child by the eating of this vegetable. This not succeeding, he bored a hole in a hickory tree, placed a lock of the child's hair in it, drove in a pin and left the child, till finally in its agony it would tear loose. This failing, he happened to see an advertisement of a rheumatic cure, and thinking that was what ailed the boy, sent for the cure. He called my attention to it, and asked for an opinion, at the same time passing his fingers thru the sawdust packing and uncovering a small package. In his surprise he said: "Why I have been feeding him with that sawdust for the past week!"' I blush when I say this is only one of many such instances occurring right here in "old Mother Cumberland county, Pa."

I would ask your family of readers to what extent they prescribe and find use in practise for whisky and other alcoholic beverages. I will instance a few cases wherein I have prescribed spiritus frumenti, a few times uncombined, generally tho in combination with nox vomica strychnia, aromatic spirits of ammonia, or capsicum. I have gotten most excellent results in elderly people in chronic bronchitis or purely functional cough from the use of whisky. In cases of dipsomania I have cared for patients thro the entire night, administering frequent doses of whisky combined with ammonia strychnia, etc., to keep up action of the heart. have tried other means to relieve these unfortunates, but find the above the only sure relief, often enabling them to return to work the following day. A very bright man of this town would take charge of his classes in the high school the next day after an attack if treated thus. A former patient of mine from an adjoining town called early one Sunday morning. His appearance indicated distress of body and mind. He held out a trembling hand and

pleaded for a little stimulant to help him get home. His pulse was extremely feeble. I prescribed a bottle of medicine containing tr. capsicum, nox vomica and whisky. During my past two years of practice I have seen indications for this

or similar treatment in about ten or fifteen cases, and these constitute about one in ten of those who have applied to me for whisky, the rest being refused, as I did not think it indicated or needed, or thought that fraud was back of it.

I would like to know if this practise is regular and if I have violated any law covering the dispensing of alchoholic liquors. From malice I have been arrested and bound over to answer at court for doing what I believed conscientiously to be my duty. I only fear the laity will not appreciate the trying ordeals which we as physicians have to face. Are we as physicians to reject means which we have learned from experience will relieve suffering the quickest and safest?

I myself am a "teetotaler," but we find many perverted appetites and constitutions which tax the physician's resources. M. R. PETERS, M. D. Boiling Springs, Pa.

[We do not know of any law to which you would have become amenable under the circumstances you relate. A physician's prescription is especially exempted in all laws we can recall concerning the sale and dispensing of liquors. You seem to be having pretty hard lines, but there should be no doubt of your speedy triumphing over your difficulties.-ED.]

A Peculiar Case of Recurrent, Localized Erythema.

Editor MEDICAL WORLD:-I have lately met with a case peculiar and interesting to me, and I submit it for publication, if you think it may be of interest to others.

The invalid is a male, American, single, a farm or mill laborer, as work offers, aged 42, of good family, and of good deportment and habits. So far as I can learn, he does not use wine, beer or other alcoholic drink.

He has been afflicted at intervals, for the past twenty-two years, with a dermatitis of the right hand, extending often nearly to the elbow. The attacks recur at intervals of from two or three weeks to four or five months. He has a greedy appetite for two or three days preceding the attack, and after a hearty meal is soon hungry again.

It begins with a chill, often severe, and a burning and itching of the skin of the right hand, which soon becomes red and greatly swollen. There are no vesicles, pustules or bullae on the skin, but it looks like an erysipelas. The inflammation subsides in about three days and the epidermis peels off. During the attack he loses entirely his desire for food, takes nothing but cold water, and is inclined to heavy and prolonged sleep. I have not learned that any one has taken his temperature at such time.

The joints of the hand are almost entirely free from soreness, but I learned by careful questioning that he had a little soreness of the thumb and wrist joints preceding the last attack, which may have come from the strain of husking corn.

Laboring men here are usually liberal, though not luxurious, feeders. I do not know as to his habits of eating meat. I have not learned that any examination has been made of the urine. He has not asked me for treatment. Says that the doctors do not help him. Capopolis, Mich. T. W. ANDERSON. [The case seems one of angio-neurotic edema.-ED.]

Fracture of Neck of Femur-Placenta Previa.


MEDICAL WORLD:-In 1882 I was called in consultation to examine a school boy who, with other boys, was playing by jumping on each other's backs. This boy was well grown and about twelve years old. He was crushed down and his legs spread wide apart. He did not complain of any particular pain, except near the knee. He could not walk or use his left leg to step, except to greatly increase the pain. I told the doctor in charge that he had a fracture of the cap of the femur, tho only a very slight crepitation could be discovered and only a shortening of about one-fourth of an inch. I advised that the foot and leg should be well supported to natural position and that he should prevent eversion by use of sand bags on each side.

This was neglected and the boy recovered, and to-day the toe points outward and it is with difficulty that he can walk over rough ground, or at a good speed.

Mrs. C., aged 40, mother of five or six children, very poor, called me for severe flooding. On examination I found she was in the fifth month of pregnancy and

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