kind, it has been repeatedly held, are not competent evidence to establish a decedent's estate, and it is time that the physicians of this city found this fact out. Where both parties are alive the case is different, as the physician can then be a witness in his own behalf; but where the mouth of one party is closed in death the law closes that of the other also." Under all the light which the testimony threw upon this claim, Judge Ferguson awarded to Dr. Brooks $400, adding that if any injustice were done Dr. Brooks by that award he could only blame himself for not having his books in such a shape that they could be admitted in evidence. -Philadelphia Ledger. [This is only one of the many instances, occurring almost daily, of the losses entailed by the use of visiting lists which indicate services by the use of signs. In this single account Dr. Brooks lost nearly $3,000; enough to furnish him with first-class visiting lists all his life and buy a good home besides. What is the use of devoting one's time to the practice of medicine if he is to lose the reward of his labors? counts are just as strong before the law in the doctor's memory as in books of this kind. Ac Had THE MEDICAL WORLD VISITING LIST been used, this snug little sum would have been saved to Dr. Brooks. Besides its legal character in allowing space for describing services, it is more compact than any other, being but little larger than a card-case. It can be begun at any time and continued until the space is all used, while the old-fashioned ones must be used within the dates from January to Janauary, and any unused space therefter must be thrown away for a new book. It is vastly cheaper, as the blank sections only must be renewed, not the leather cover. Those who have used it say that it is the best money-saver they have found. -ED.] DISEASES OF THE RECTUM. Editor MEDICAL WORLD: Piles is the people's name for any ailment of the rectum. There are, however, twenty three or twenty-four well-defined diseases of the rectum. So, when we speak of piles in this paper we mean piles, and not fistula, fissure, condyloma or any other rectal disease. The causes of piles are extremely numerous. Among them are constipation, costiveness, diarrhea, dysentery, congestion and other diseases of the liver, straining at stool, excessive use of purgative medicines, want of cleanliness, accumulation of fecal matter left for hours or days in the rectum, tumors of any of the organs of the abdomen, excessive sexual intercourse, alcoholic drinks, smoking, too high living, tight lacing, child-birth, dyspepsia; these and like causes produce rupture or permanent enlargement or distension of the smaller bloodvessels of that part of the lining membrane of the rectum situated within the sphincter muscles, and piles are formed. External piles are always caused by a rupture of a blood-vessel just under the skin at the verge of the anus, appearing as a hard, very sensitive and painful boil-like lump or clot. Internal piles are an enlargement (rarely a rupture) of the bloodvessels of the mucous lining of the lower onethird of the rectum. In arterial variety. Internal piles are veinous, External piles are probably always of the arterial or capillary. Either or all of the varieties may be present in the same case. ternal piles possess an erectile power, and when first observed they "come on "in "attacks of piles" which, after a few days, seemingly disappear or "get well." After a number of attacks, they are present all the time but not with the same degree of severity. The diagnosis and examination of a case of piles, as in other serious ailments, is an important part of the management of the case. As was stated in the "introductory paper" in October WORLD, it is necessary to have a personal interview with, and make an examination of, each case. The earlier attacks of piles are characterized by either heat, fullness, pain, burning, aching, itching, or bearing down sensation of the rectum; also, constipation or diarrhea, back| ache, weakness across the loins, dizziness, headache, drowsines, fever, slight chill, or fretfulness, wakefulness, melancholia, lassitude, general mental depression, loss of appetite, desire to sit long at stool, almost constant desire to go to stool, slight protrusion of small tumors at the rectum that will "draw up" when the straining ceases, attended by a special mental distress and anxiety undefinable and indescribable. As the case or the disease progresses the attacks are characterized by the above symptoms greatly intensified. The piletumors may protrude very much more and seem very much larger, and after repeated attacks will not "draw up" of themselves; but have to be replaced by the hand, and a little later the sphincters loose their tone, the piletumors loose much of their erectile power, and will protrude on the slightest provocation, and eventually remain down all the time. In other cases the piles never protrude, but the distressing symptoms and the systemic disturbances are equally great, or even more severe. Now, the examination. 'Ah, that's the rub." Patients, either men or women, have a great aversion to an examination of the rectum. It is, however, necessary to make the examination. It is like shooting at a flock of birds in the dark to undertake to treat the case without knowing just what the case is. As every physician has observed, in similar instances, the more educated and intelligent the patient the less foolish will he be and the less resistance will he offer. The examination, if skillfully managed, is not very painful, nor is it very disagreeable in any respect. You have been told by the patient that he has piles, but you must be prepared to find any of the other rectal ailments as well. To conduct an ordinary examination, one needs To conduct an ordinary examination, one needs an operating office chair, a lounge or a common table from two to three feet wide by four feet in length. The table is by far the best. Adjust the patient's clothes and place him on his left side, with the thighs well flexed, and so he will be in a comfortable position. It is convenient to have an assistant, but not necessary. The right hand of the patient can be utilized to hold the rates apart. The instruments and appurtenances necessary are the educated index finger, a medium sized bivalve speculum, a silver probe from your pocket case, or, better, one eight inches long, a box of cosmoline or a cake of soap, an office towel and good light, either from the sun or any good artificial light. Observe the exterior appearances first. Look for external pile tumors, for protruding internal piles, for any bloody or pus discharge; examine any condylomata or excrescent growths of any kind, any excoriation, any little wart-like growth close to or more remote from the verge of the anus. Lubricate the index finger well and insert it into the rectum and note what you see. Lubricate the speculum, hold it in the left hand and insert it carefully; gently dilate the speculum after it is fully inserted, and keep up an even and constant pressure with the left hand to retain the speculum in place and note what you observe. Rotate the speculum, if you can without pain to the patient; otherwise, withdraw the speculum gently and slowly, and do not allow the valves to close entirely, so as not to pinch a pile tumor or the lining of the rectum. Insert the speculum again, and rotate to any angle desired before opening the valves. Repeat the insertions as often as may be required. Should there be a discharge of matter at any point, examine with the straight, curved or bent silver probe thoroughly. The examination completed, tell the patient promptly and clearly what is necessary to be done, arrange with him as to whether you are to treat him just this once, for a little relief possibly, or if you are to take the case in hand and attend it to a cure. It is best to speak of the expense of treatment, for you cannot afford to operate on him for piles or other rectal disease at $2.00 a sitting, and your patient will be disappointed when you render your bill. The fee should be from fifty to one hundred and fifty dollars. These preliminaries arranged, we will suppose you have a case of external piles, an ordithe well-defined tumors. nary case. You can operate at once on all of Do not inject any kind of a stpytic. You do not need an anesthetic; "brace the patient up" with some encouraging words, and grasp an external tumor between the thumb and index finger of the left hand, or, better, between the jaws of a pair of forceps; get well below the tumor, so as to press it well up, and make the skin very tense over it. The tumor when squeezed up thus will appear "blue black." Slit the skin over the tumor with a sharp knife or sharppointed scissors, and divide the integuments down to the sack of the clot, and generally you will unsheathe and shell the tumor out entire. If you rupture the sack by the pressure or cut it in making the incision, you will press out a mass of thick clotted blood, and if you rid the cavity of the clot-sack and all you will entirely cure that tumor. So operate on each one of the tumors, making as small an incision as possible to let the clots out. The simplest dressing of ointment and cotton held in place with a T bandage will be all that is required. These external tumors are liable to occur at any time, and are more likely to recur after treatment than are the internal piles. The patient should return to your office next day for observation, and you should redress the case and clip off any little ragged pieces you may have left by awkwardness in making the incisions. The treatment will be satisfactory from the first, as the patient will be less sore than before operation, taking it for granted, of course, that you are pretty skillful and deft at a minor surgical operation, even though you never did it before. The above is for an ordinary case. If you are called to a case in its "bad" form you will not be able to make the examination, perhaps, without an anesthetic. In its worst form a case of either external or internal piles so affects the patient, and so debilitates him from pain and shock, that he cannot bear any handling at all without profound anesthesia. In a case of external piles the worse the stage of the disease the more definitely is prompt treatment indicated. In a case of protruding internal piles or a case of non-protruding piles in a state of erectile irritability or inflammation it is best to select a proper time to treat or operate on them. Supposing we are called to see a patient with protruding piles. On examination we find them strangulated by the firm grasp of the sphincter muscles; the patient in great agony, exhausted with several hours of the most intense pain, physically irritable and nervous, and mentally impatient and unreasonable. If it is at all practical, the best thing to do is to get an assistant and a bottle of chloroform at once and operate on the case. The operation in this special condition will generally consist in the ligation of the strangulated piles, using strong silk, and excising the bulk of the tumor outside of the ligature, the patient having been first profoundly anesthetized. In order to make a clean job and a complete cure treat all of the internal non-protruding piles by the injection of a styptic. Insert some suitable anodyne ointment with a hard rubber pilepipe, and press the stumps of the ligated tumors and the prolapsed bowel well up in the rectum, within the grasp of the sphincters, and keep the patient quiet in bed for some days. There are several ways of applying a ligature to a pile tumor. If small at the base in proportion to the body of the tumor it is safe to pass the ligature around the pile, not too close to the inner lining, and tie it all in one ligation. If a large pile and conical in shape pass a needle, armed with the ligating silk, through the middle of the tumor, near the base, and ligate each half, and then throw the last coil around both parts and tie them in this way in halves, and then both halves together. The patient does not suffer any more pain, and generally not so much after ligating two or three pile tumors, such as we have supposed in this case, as he does during their erectile, inflamed strangulation. We The above is a case demanding prompt treatment, and one affording an opportunity to make a complete and permanent cure. are supposing that the ligatures were properly applied and the proper styptic in just sufficient quantity was skillfully injected. If a portion of the submucous tissue is included within the grasp of the ligature we are likely to have greater pain and systemic disturbance, and marked contraction of the sphincter muscles. Now, if in addition to this contraction from the ligation of the protruding piles we have a deep, sloughing ulcer at the inner canthus of the internal sphincter as a result of the injection of a styptic not indicated in the case, or as the result of the proper styptic unskillfully applied, we have a case on our hands in which the last state of that man is worse than the first. We literally have a case wholly changed. and different from the one with which we began, and one requiring special surgical treatment for its relief. The introduction of a styptic into hemorrhoidal tumors is a subject of very special importance. Not any more from the actual danger to life than from the serious complications that are very likely to arise. It is, perhaps, impossible to give in writing the indications with sufficient explicit ness to enable one to treat successfully the variety and diversity of cases that will be presented in a score of patients. The failures resultant either from ignorance, awkwardness, or unskillfulness, are not sufficient cause to condemn an operation. The treatment of piles by the injection of a styptic is a crowning success. It will effect a cure safely, easily and quickly in ninety-five per cent. of all uncomplicated cases of veinous, arterial or capillary hemorrhoids. It is not expected that every surgeon can at the first effort operate successfully in lithotomy, ovariotomy, iridectomy or nephrotomy, and the writer speaks from experience to say that it requires skill and dexterity to operate on complicated cases of rectal diseases not second to any of these. The modern "manufactured rectal specialist" treats, but very seldom cures, a case. It is the desire of the writer to make the subject clear to the reader-so clear as to be of practical use to him. Knowledge of the kind the great Froude had in his mind when he penned the lines that stand at the head of the editorial page of THE MEDICAL WORLD. Treatment in next paper. E. H. DORLAND. 4329 Lake avenue, Chicago. Preparation for Railroad Disasters. Answer to Dr. John A. Elliott's Inquiry. Editor MEDICAL WORLD: The first thing necessary to answer this inquiry is to consider the peculiarities of injuries of this kind. Railway injuries vary considerably from the ordinary ones that we meet with, not only in their character, but the symptoms they present. The number of accidents in railroad travel being directly in proportion to the increase in the number of railroads. We have in an accident of this kind cases varying from the slightest bruise to the most grave injury and probably death if we consider the speed at which the train is moving, and what must occur in the collision or other accident. We have the cars violently thrust one upon another, things are crushed and torn to pieces, subjecting the inmates to all accidents directly as the condition. One may be violently crushed, another may be torn limb from limb, another suffering from concussion, and so on to death, and if to this is added injury by fire, then truly is this complicated. Concussion is frequently the only symptom shown. The whole economy is violently disturbed by the opposing forces, and the sufferer shows all that condition peculiar to it. The accident is always as the speed. The injuries may be entirely confined to the soft parts. The tissue crushed, bruised or torn, more or less violently. The abdomen or chest may have been pierced by fragments of timber or the debris. We may have the osseous tissue injured with or without injury of the soft parts; special organs, as the heart, brain, lungs, etc., may have sustained injury, which, if not directly fatal, may cause serious if not fatal symptoms. Now this variety of accidents is distinguished by the preponderance of shock and concussion to the nervous system, and the comparatively slight hemorrhage. The concussion may have been so severe that fatal results may have taken place immediately; or, if not, be so severe that in every case the most skilful aid is necessary. In fatal cases no injury may be visible, yet capillary rupture and minute extravasation may be noticed. Concussion, like shock, may be complicated by profuse hemorrhage, when the large arteries are lacerated and torn or considerable quantities of blood may have been thrown out into some internal cavity, thus greatly complicating the other injuries. Shock is not always in proportion to the amount of injury. Special organs maybe injured with the most profound shock and no other complication. Extensive internal lacerations and crushes may have occurred, and then a case may present the most typical symptoms of shock, and yet show very little injury. The injuries are varied as we see, from a mere scratch to the most horribly mangled limb. This rapid summary bears out our inquirer in his description of his feelings at such times. What are the indications in an accident of this kind? The first that calls our immediate attention is that of hemorrhage and shock. Yet we have seen that hemorrhage is not excessive as a rule. The peculiarity of injury, the laceration and contusion of the wound prevents free hemorrhage. But shock is marked and calls for prompt attention. Now to consider the medical attendant. What is requsite for him to take when an emergency like this arises? Ist, a proper outfit. 2d, a cool head. It begets judgment. In considering the first I will take my case to illustrate : I have made it a rule to be so fitted up that no matter what emergency may arise I can always be equal to the occasion. I will describe my operating outfit that I always keep ready for the house to do almost every operation required action, so that on five minutes notice I can leave in an emergency, from a finger amputation to an ovariotomy. this I have an operating case that will do for I have a telescopic bag of moderate size. In both major and minor work: Hemostatic forceps, 11⁄2 dozen. Needle holders, large and small, 3. Antiseptic gauze, I can. Absorbent cotton, I can. Antiseptic tablets (Hydrarg. Bichlor.), I bottle. Fluo silicate of soda, 6 vials, āā gr. vij. 3 quart irrigator. Rubber apron and cloth for patient. Rubber tubing for controlling circulation. Finger brush. Roll of silk worm gut. Antiseptic sponges, half dozen. Iodoform duster. Whiskey, half pint. Dishes for ligatures and needles, 3 This bag is always ready; if anything is taken out it is replaced immediately so that the contents are never absent. With a case of this kind any operation may be done. It is not cumbersome and is easily carried. 2d. The call has reached him; he has gathered his instruments and started with what is requisite. The most important is a cool head. This is a necessity, for without this there is no expedition. Then experience. From experience comes coolness in trying situations. Experience is not always possible in the case, then judg ment makes up greatly for its absence. He has now reached the field of action. We have seen that the two important things are hemorrhage and shock. Now as in making the diagnosis of a case, the field must be scanned over. Thus he obtains the history of the case. This is a necessity, for without the history of a case treatment is not definite. By 'this hurried examination he knows the character of the injuries, their probable gravity, and what means are required, not only in the attention as far as wounds are concerned, but what means may be taken to extricate those who are not at liberty. This does not take any unnecessary time, as a surgeon should be able to grasp a situation like this at a glance. He must see that a certain amount of order and unity of action is preserved. The carrying of the wounded to a definite place; the rescuing of those who are fastened in the wreck should also be attended to, or means devised to relive suffering until extrication is accomplished. These items can be attended to while getting his instruments in order. Then hemorrhage must be looked after, arteries taken up and tied, or hemostatic forceps can be applied temporarily, or compressors and bandages applied. These can be dressed, and the case finished at one sitting; but, if help is urgent, they can be left and dressed later. Shock is the next, and almost as urgent. This is met by position, removal of all constriction, control of hemorrhage, if any. Then stimulants by the mouth, or hypodermically. Whiskey is given for effect; of course, care must be excercised in its administration; yet as force is easier controlled than created, I believe in giving whiskey for effect. Concussion must be handled carefully; treatment must not be too active. Modify all existing conditions that are apparent; but bear in mind that its treatment must not be too active. Make the patient comfortable by position, covering as the atmosphere and the system needs. Stimulants mildly. This is a condition similar in character to shock, but varying in its force, results, and the tolerance of treatment. Injuries of special organs must be met as they arise; no rules can be given for such accidents. Opium for pain, restlessness and shock. Broken bones can be put in comfortable positions and left until more urgent work is over. Splints can be made from anything; this calls into play the mechanical ingenuity of the physician. The nervous must be reassured; confidence and presence of mind in the doctor begets confidence in the surroundings. Wounds are to be dressed. This may be more or less thorough, though sure and comfortable enough, until the sufferer can be removed to more comfortable surroundings. No special methods can be given how to dress injuries of this kind; only place the parts in a condition as near nature as possible, then you will not be far wrong. Minor injuries can be finished on the field; arteries ligated. Lacerated tissues are to be removed and trimmed; the parts thoroughly cleansed and coapted. The antiseptic dressings to be applied by all manner of means. The major operation can be made comfortable and supported for transportation. Large operations are not apt to be done on the spot; for the country would have to be very desolate indeed where no habitations could be reached in a reasonable time. If this is not possible, and the case urgent, do the operation to the best of your ability and surroundings. There is one thing that is as important as any other, and that is allow no meddling interference from bystanders. Either be the doctor or nobody in the case. This will pay to consider. I know full well the annoyance from too ready wiseacres. appropriate means. Meet these characters by It may be said that I have not discussed any I have not done so, for special medical means. none are needed. Stimulants and opiates will fill all the needs called for. Several applications are met by the antiseptic dressings. Burns, if no other resources are present, can be dressed with the cotton and gauze. The cases are acute cases, and pain is the predominant symptom, and but one thing is indicated, and BENJ. T. SHIMWELL, M. D. 1253 S. 17th St., Phila., Pa. that is comfort. Pneumonia. Editor MEDICAL WORLD: The treatment of acute pneumonia in a previously healthy person.-In the first part of the first stage, that is before exudation has occurred, bleeding will cut short the inflammatory action at once. When pneumonia really exists, that is, where exudation has occurred, the use of tartrate of antimony in doses of of a grain, with the same quantity of one of the salts of morphia every two hours for a day or two, and afterwards every three or four hours, will cause the symptoms to ameliorate. The object of adding morphia is to cause a free action of the skin, and to prevent the antimony from purging. My experience has been, that in a case where free purgation has taken place the case has been a prolonged one; consequently, I have attempted to prevent any free action of the bowels; in |