much at the hands of pretentious, self-assertive, newspaper-seeking physicians. Our society has set its mark of disapproval on this, but here we need to be cautious and to be just. This is a day of newspapers and of publicity. It appears to be one of the consequences, or, if you choose, penalties, of a republican form of government, and the people demand to know what the individual has and does. Neither the physician nor his work can escape this demand. If you have done something noteworthy in medicine the people insist on knowing it. If your opinion on matters of public health, or the welfare of the community, is of value they insist on having it, and with right. The doctor ought to be heard in the newspapers.

Listen to the code: "As good citizens, it is the duty of physicians to be ever vigilant for the welfare of the community, and to bear their part in sustaining its institutions and burdens; they should also be ever ready to give counsel to the public in relation to matters especially appertaining to their profession." Again: "Medical men should be always ready, when called on by legally constituted authorities, to enlighten coroner's inquests and courts of justice on subjects strictly medical."

As it appears to me, many physicians are woefully ignorant as to the location of the boundary line between right and wrong in this field. We have had the rather amusing spectacle of a physician on the floor of this society quoting the evidence given in court by another physician who had been summoned by the state to assist it in prosecuting parties who were said to have sold poisoned food for the children of this community, quoting this testimony as an example of wrongdoing.

As I understand the matter there is no question of right and wrong if a physician chooses to inform the newspapers every time he goes out of town, writes an article, delivers an address, or does something a little out of the ordinary. It is a question of manners, not morals; he is lacking in modesty and self-respect. It is essentially the same thing as when Mrs. Smith requests the paper to announce every time she invites Mrs. Jones to tea. Simply vulgar, an attempt to gain prominence not voluntarily accredited to him. But when the physician through the public prints makes claims to exceptional skill, cites cases and operations wherein he succeeded after others failed, plainly bids for patronage, he becomes a charlatan and should be so characterized by our societies.

The newspaper is the principal means of communication between the quack and his victims and is unquestionably the most powerful enemy of the profession. They persistently defeat any attempt of congress or state legislature to regulate the sale of dangerous or worthless medicines. Their columns are usually open, for pay, to the quack, the procuress and the abortionist. But it will usually be found that newspaper editors and their assistants are aware of the harm of such and are at heart opposed to the policy of their business managers on this subject. This means that space is usually accorded the physician who has anything to say to the public. The proposal of a member of the American Academy of Medicine is worth considering. He says: "Would it not be preferable for the profession to come forward boldly and address the public through the public press regarding all sorts of ailments, thereby preventing their accepting the beguilements of charlatans?" I can picture immeasurable good that might come to this community from a series of carefully prepared newspaper articles on medicine, its limitations, uses and abuses, coming from one of our older physicians who is an authority in the com

340

ORIGINAL CONTRIBUTIONS.

munity. As said before, I believe it is our duty some way, somehow to assist the people in choosing their medical advisers. So, the medical society should be, either directly or through its appointed representatives, an advisory body for the community on medical matters.

In the profession at large, there is a feeling of unrest and dissatisfaction among the majority of physicians. Life has become more complicated, living more costly, while their income has not proportionately increased. No longer is there the dog-like confidence of the people in the physician. They dare question his advice and presume to ask what his pills and potions are expected to do.

According to the treasury statement, proprietary, stampable medicines paid during the last fiscal year four million dollars in revenue taxes, or, as the tax was two and one-half per cent. of the selling price, there were sold for the year one hundred and sixty million dollars of such medicines. A very small part of this amount was paid by patented medicinals, principally German synthetics. But I should say that at least one hundred and fifty-five million of this was medicine that was sold directly to the people. For the same time, one of the best informed pharmaceutic journals of the country estimated that the entire sales of strictly pharmaceutic preparations was ten million dollars. The one hundred and sixty million does not include the salts, pills, herbs and forty and one nontaxable medicines sold directly to the people. But making all allowances, I feel sure that I am well within bounds when I say not onetenth-probably not one-twentieth-of the medicine used in this country is prescribed by its physicians. What an awful, woeful lack of confidence. in us!

Several explanations may be offered for this state of affairs. It may be said that the people are usually mistaken as to the need for medicine; that the majority of the ailments for which they seek relief in drugs are self-cured. Then where did they get this idea that every ill of the body should be followed by drug taking? From us? As a body it is our custom to give them drugs for any and every complaint. We are to blame. Again, it may be said that the people would prefer to go to the physician, but that they cannot afford to pay his fees every time they have a slight ailment. Then it follows that our services are not worth to the world the price we ask for them in all these cases. Still again, it may be said, the people are mistaken. If they would go to the doctor every time they feel ill, take his prescription, pay his fees, they would be better off in every way. I hope it is not treason to doubt this. But suppose the statement to be true. What a commentary on our teaching and practice! Ours is an ancient art—the doctor antedates history. Yet after all these centuries of observation of our work the people are not yet convinced that in the average case we can do better for them than they for themselves.

Is not the correct explanation this? By our teaching and practice we have led the people to believe that in drugs we have remedies for almost all bodily ills; that our medicine is all we have to give? The patient comes to us, we attempt to look wise, ask a few questions and give him medicine. Does it appear to him that he has gotten anything but medicine? And is not the conclusion a very natural one, that this bottle of medicine, which he can get at the corner store for fifty cents, all duly labeled, with explicit directions, and accompanied by hundreds of testimonials of people who have been cured by it that this is as good or

1

1

better medicine than DOCTOR JONES'S? It must be good medicine, else so many people would not use it.

We are responsible for the medicine habit; on our heads belongs the blame that the people ask for drugs instead of a physician. One hundred and sixty million for secret nostrums; ten million or less for physicians' drugs! Ay, but the people are so ignorant in medical matters -we are and have been for centuries their teachers - and it is far from being the ignorant only who show a lack of confidence in our profession. The best educated people of the community are often found paying tribute to Christian science, osteopathy, Similia, and the like. Rulers and statesmen give testimonials to Peruna. The fact that intelligent people run after every medical fakir, Indian, herb, Chinese or Voodoo doctor is less of a reflection on them than on us. Why is it that the people have not confidence in us? My friends, looking the facts squarely in the face, there can be but one answer. We do not deserve it. By our attitude, if not our words, we practically promise, in every case we undertake, betterment, or at least amelioration, and we fail to deliver the goods. Too often it is a case of obtaining money under false pretenses. Blame the other fellow. Yes, his faults and failings are many but tonight we are considering our own. Would you trust the average doctor to treat you? Take his medicines without a question? Follow the life he prescribes? Submit to the operation he advocates? Would you? Then, why blame your neighbor, the merchant or harness-maker, if he shows a lack of confidence?

If I am right, the greatest mistake the profession is making is in its too implicit reliance on drugs and in leaving or leading the world to believe that drugs are all we have to give. One firm in this city is said to make more than five thousand different combinations of drugs. I believe it safe to say that more than ten thousand different mixtures and combinations of drugs are being used by the physicians of this country. Has not this passed into uttermost nonsense? Again, how many new preparations of drugs are called to your attention each year? Note the everchanging panorama in the advertising pages of our medical journals. It appears to me that an impartial jury, with these facts, might well return the verdict that "we know not what we do."

Relying so much as we do on drugs an outsider would certainly suppose that we were thoroughly conversant with all the ingredients and properties of those we use. Is it so? How many here have ever used antikamnia, potonuclein, listerine, cystogen, or any of the one hundred and one concealed formula preparations that are sold to the physician? Several years ago I attempted to poke fun at the representative of an eastern concern by asking how it was that he could sell such a worthless preparation. His rather contemptuous reply was: "Claim enough for it and you can sell anything to doctors." The sad part of it was that he told the truth.

Much is written nowadays on the overcrowding in the profession. We read of physicians in some countries receiving but fifteen cents for a call. But note again the enormous field which should be ours which we fail to occupy. More than one hundred and seventy million of medicines used; less than ten million supplied through physicians. Has it occurred to you to ask why, of the millions on millions given in recent years for the endowment of schools and colleges, only a pittance here and there has been given for medical education or research! It must be, either that our

work is unworthy, or that we need to be censured for not acquainting the world with its worth and needs. In either event the blame belongs with us.

Reviewing the conditions I have described, it seems to me that we must conclude that in many respects our profession is in a bad way. We fail to command the respect and confidence that ought to be ours. Notwithstanding all our claims of ability and skill, the world prefers to do by far the larger part of its own doctoring. It is humiliating to confess that after all these centuries of medical work a well-educated man of affairs having to choose between the best trained physician of his community and an illiterate, unkempt quack, the latter is often his choice. I am sanguine enough to believe that these troubles are not beyond relief. But we must recognize clearly that they are of our own making, or at least permitting, and are to be remedied, if at all, by ourselves and not by legislators.

We need to recognize clearly that we are relatively ignorant of disease, and woefully ignorant as to remedies. We need more students and fewer practitioners of medicine. Perhaps the greatest of our needs is to lessen the incompetents in our ranks and to frown down those who make a trade of the profession and bring the whole into disrepute. We must teach the world that there are doctors and doctors. They cannot choose wisely; we must aid them in their choice. The practice of medicine must stand on its merits in the full light of day. The day of authorities was. The time when the doctor could look wise, pour out some powders or pills, mutter a few polysyllabic words, and then be credited with all but supernatural wisdom, is passing. The man of affairs counts the cost and reckons the gain when he comes to us, pays a dollar for a prescription, and when he goes to the corner store and buys Stuart's Dyspepsia Tablets or Bromo-Laxative Quinine for a quarter. We must be able and willing to stand the comparison. The doctor must we worth all and more than he costs the community. May the Detroit Medical Society have a fair share in solving these and other problems of our profession.

MEMOIRS.

A SYMPOSIUM ON CERTAIN ABNORMALITIES OF GESTATION AND LABOR.

MALPOSITION.*

BY AUSTIN W. ALVORD, M. D., BATTLE CREEK, MICHIGAN.

(PUBLISHED IN The Physician and Surgeon EXCLUSIVELY]

AMONG the most pronounced causes of abnormal gestation and labor is malposition of the fetus. In the practice of physicians who have a large obstetric experience, only two or three cases of ectopic pregnancy may be met during a lifetime. A badly deformed pelvis is rarely observed, and only seldom a difficult nephritic complication of pregnancy, but some one of the varied malpositions of the fetus will be sure to often become an unwelcome factor in the problem the physician will be called upon to solve at the bedside.

The fetus can truthfully be said to be in malposition when the larger * Read before the MICHIGAN STATE MEDICAL SOCIETY at its Battle Creek meeting.

extremity of the ovid fails to present at the superior straits, for by only such condition can the vertex lead the way into the parturient canal; but even with this position of the ovid at the superior straits, the vertex may not present at the outlet. It may be the occiput, or one of the lateral portions of the head that presents. Should the lesser end of the ovid present at the upper strait, it will be a breech presentation, or a footling, or mayhap the knees will impinge on the border of the superior straits, and so prevent descent and rotation. If neither end of the ovid presents, but, rather, one of its sides, one of the gravest complications occurs, and valuable time must not be lost. Any of these abnormal positions prevents the proper mechanism of labor, and so jeopardizes the life of mother and child.

In discussing this subject it might be well to consider what conditions lead to fixation of the fetus before parturition. For a time after impregnation of the ovum by the spermatozoa of the male, it is tossed about, by any chance movement, in the cavity of the uterus, gaining nutrition by that wonderful life process, endosmosis, from the previously prepared lining membrane of the womb, and gradually developing as a whole, but chiefly at the head end of the fetus during the first few weeks of its new life. According to the natural law of attraction by gravitation, the head of the fetus is brought downward. Finally the placenta is developed and becomes attached to the uterine walls while the head of the fetus is directed downward. Such, at least, is the usual method of development to this time. As the amniotic fluid increases the fetus can and often does swing and float about in many positions, twisting the cord and performing evolutions which appear to be at the risk of its existence, to say nothing of various mutilations caused by bending and knotting of the cord. Fortunately, the impetus that drives this frail structure is derived from without and not from within, until fully half the period of fetal life is passed, by which time presumably half its growth within the womb is accomplished, or else its twistings and turnings would be greatly exaggerated, and the risk to its safety largely increased during the time. when the greatest freedom of movement was possible. While a change of position is often possible during the later months of pregnancy, the tendency is to a return to its former position, head downward. This tendency is increased not only by the greater weight and size of the head end of the fetus, which would become more readily dependent when floating about, but by the larger end of the ovid sac becoming fitted to the needs of the larger position of the fetus, because of early occupation of this part. Thus, as parturition approaches we usually find the head presenting, and in a large majority of cases, the vertex, but the frequent deviations from the normal course of affairs constitute the varied malpositions with which we are concerned.

It is most important that a complete diagnosis of any malposition be made early in the case, as by only this means can proper effort be directed toward its alleviation before it is too late to save precious lives. If a complete and true understanding of the case is deferred until the bag of waters has been evacuated and the uterus has contracted with force on its contents, version of any kind will often be impossible without most serious injury to the mother, while the child is sacrificed. Therefore, an early and correct diagnosis of the conditions is indispensable to the intelligent and successful management of any malposition. By external manipulation, it is not a difficult matter to differentiate