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diff --git a/old/53827-0.txt b/old/53827-0.txt deleted file mode 100644 index 41ca40a..0000000 --- a/old/53827-0.txt +++ /dev/null @@ -1,2060 +0,0 @@ -The Project Gutenberg EBook of The Hospital Bulletin, Vol. V, No. 2, April -15, 1909, by Various - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: The Hospital Bulletin, Vol. V, No. 2, April 15, 1909 - -Author: Various - -Release Date: December 29, 2016 [EBook #53827] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK HOSPITAL BULLETIN, APRIL 15, 1909 *** - - - - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - - - - - - ------------------------------------------------------------------------- - - - - - THE HOSPITAL BULLETIN - - - Published Monthly in the Interest of the Medical Department - of the University of Maryland - - PRICE $1.00 PER YEAR - - Contributions invited from the Alumni of the University. - Business Address, Baltimore, Md. - - Entered at the Baltimore Post-office - as Second Class Matter. - - VOL. V BALTIMORE, Md., APRIL 15, 1909 No. 2 - ------------------------------------------------------------------------- - - - - - THE ETHICS OF THE GENERAL PRACTITIONER. - - _An Address delivered Before the University of - Maryland Medical Association, - March 16, 1909_, - - BY GUY STEELE, M. D. - Of Cambridge, Md. - - -A celebrated divine once said that the most difficult part of a sermon -was the selection of a proper text. I must thank the President of this -society for saving me this trouble. When, however, Webster's is -consulted for a proper definition of the word "Ethics," and it is found -to mean "The science of human duty," it would seem that he has chosen a -text almost too comprehensive for the limits of a short paper, even when -restricted to the "ethics of the medical profession." It may not be out -of place to thank him for the honor he has conferred upon me by deeming -one whose student days are scarce twelve years behind him worthy of -presenting this subject to you, for a paper on this topic is almost of -itself a sermon, and we naturally look up to those, whose many years of -experience and works have brought them prominence, for instruction in -morals and duty. Still, I take it, whether young or old, all of us like -to preach on fitting occasions, and not the least part of the -inspiration to effort is the character of the audience. My invitation -was to read a paper before the Clinical Society, and incidentally I was -told that some of the students had expressed a desire to be present. -Little, however, did I anticipate such a flattering attendance from them -when examination time so nearly approached, and it is evidence of a most -commendable spirit when they can bring themselves to take even an hour -of their most valuable time from study to devote to a consideration of -the moral duties and responsibilities which shall be theirs when they -shall have passed through the April ordeal. Much that I have to say -tonight will be directed especially to them, and if they or their elders -in the profession may in the years to come look back upon this night -with the recollection that I have more forcibly brought to mind some of -the old and half-forgotten maxims and axioms that make for a better and -purer professional life, I will have been more than repaid for the time -I have expended in the preparation of this paper. - -In discussing the ethics of the general practitioner towards his -patient, I would have you remember that your first and most important -duty is to give to those who trust you the very best that is in you. - -To you young men, full of enthusiasm for your new profession, and imbued -with Utopian ideas of the mission which you have undertaken for the good -of mankind, it would seem almost foolish for me to mention this as the -first advice I would offer you. But I think I can see a smile of -understanding flit across the faces of those who have for some years -fought the battle of life, and who have had the wire edge of early -ambitions and determinations blunted by contact with unappreciative -patients and unworthy professional competition and the daily incidents -of a busy life. They know that it is very easy to feel too tired, or be -too busy, or have some other engrossing affair in mind which prevents -that entire devotion to duty which all admit is essential to success in -medicine. Half of success in life or in any undertaking is due to a -successful start; therefore, let me ask you to firmly determine on one -or two fixed principles, and to stick to those principles through thick -and thin. Be fully assured that no halfway devotion to your profession -will ever bring you prominence or success. The time-worn phrase that -"Medicine is a jealous mistress" loses none of its truth by frequent -repetition. Recently I saw in a prominent medical journal the advice -given that doctors should take a prominent part in politics and bring -themselves forward in other ways, and that thereby in some way unknown -to me the glory of the profession would be enhanced, and much benefit -result to the community. Far be it from me to discourage a proper civic -spirit and a proper interest in public affairs, or to advise an -avoidance of any duty which good citizenship imposes upon every honest, -patriotic man, whatever his business or profession. But I take it that -no more baneful, no more dangerous advice can be given to our young -professional man than this. You cannot be successful in both politics -and medicine, and while we can point to one member of our profession in -the United States Senate, and to some notable exceptions in our own -State, where men of our profession have, for a time, abandoned medicine -and returned to it to win success, you can rest assured that the medical -politician possesses little beyond a musty diploma to remind the world -that he was once of our cult. So don't be a halfway politician and -halfway doctor. Success in either field will take all of your best -effort and all of your time. - -What I have said of politics will apply, though not quite so forcibly, -to any other engrossing business or pleasure. Time forbids me to -elaborate this idea, and in concluding it let me say that you cannot be -a successful politician, merchant, sport or what not and carry medicine -as a side line. - -It may seem useless to remind you that, in order to give the best that -is in you, you must keep abreast with what is new and best in -professional literature and scientific progress. You all have determined -to be students, and even those who pride themselves on having passed -through the University without having opened a book have a half-formed -desire to really know something beyond spotting a possible examination -question, and when once examinations are over, and they have reluctantly -withdrawn themselves from the delights of the city by gaslight for the -pine woods and mountain trail, they will burn the midnight oil and -browse diligently through their musty tomes. May I tell you that nothing -is harder than to find time for study. Many of us, even though city men, -with the best and latest literature at our elbows, are ashamed to think -how thoroughly we abhor the sight of a medical book or magazine, and how -easily we can persuade ourselves that we are too tired and stale, and so -engrossed during the day with scenes of sickness and suffering that we -must have our brief hours of release from duty for recreation. We do -need our hours of relaxation and rest and our too infrequent holidays, -and they are absolutely essential to good health and good work. Don't, -however, confuse the words rest and relaxation with sloth and idleness, -and don't think your professional work completed when your round of -daily visits is done. Indeed, if you would know medicine you must woo -your mistress in the small hours of the night, and in many of the -leisure moments that the day may bring you. - -Much has been spoken of the man who practices by common sense, and whose -school has been that of observation and hard experience. A most worthy -brother he is at times, and many are his friends and wonderful his -success. But if the science of medicine is to advance, more is required -for progress than mere common sense, and observation untrained and -experience undirected and unguided by the observation and experience of -others will rarely discover a new bacillus or elaborate a side chain -theory. So, to be truly ethical in the duty you owe to give the best -that is in you, you should be reading men. Take one or more of the -medical journals. Buy for reference the latest and best text-books. Make -the opportunity to read the daily papers and something of current -literature. A well-rounded man can afford to do nothing less. Besides -the information you obtain, it pays in the respect of the community to -have the reputation of being posted in your profession. Often the -country man simply hasn't time at home to read. A busy life, with its -miles upon miles of dusty roads to travel, precludes all chance for the -easy chair. Then cultivate the habit of reading while driving. Many are -the useful and happy hours I have spent in my carriage with my journals -and magazines. I am frank to say that, but for this habit, I never could -have found time for one-half of the reading I have done. Last year I was -somewhat amused when a most worthy, well-educated and well-posted man -summed up his opinion of another by saying that he was one of those who -read magazines in his carriage. If I mistake not, this indictment was -brought against the late Dr. Miltenberger, who as a young and busy man -was forced to form this habit, and I could but think that, could I die -with half the honor and respect and love that were his, I could plead -guilty to even this mark of devotion to my profession and desire to -advance in it. - -Would you be ethical in giving the best that is in you to your patients, -you must give ungrudgingly of your time. This may again seem a useless -piece of advice, and yet almost all of us are familiar with the man -whose motto is "Veni, Vidi, Vici"--"I came, I saw, I conquered." This -intuitive diagnostician is by no means a myth. The man who comes in a -rush and goes in a rush, and who, with pencil in one hand and -prescription pad in the other, feels the pulse while the thermometer is -under the tongue; who sees at a glance, without necessity of personal or -family history or of physical examination, just what is the matter, and -who, giving four or five prescriptions, rushes out, trusting that -something in his shotgun therapy may hit the enemy. Perhaps the next day -he prescribes four or five more remedies or combination of remedies, and -should the patient begin to improve, prides himself that he has made and -confirmed a diagnosis by his experimental therapy. Is it necessary for -me to say that no ethical man with any regard for the rights of his -patients and his obligation to his profession can really practice -medicine in this manner? The plea that you are too busy to give the -proper time to your cases is no justification for your neglect. Anything -less than a careful inquiry into family and personal history, followed -by a painstaking and thorough physical examination, is unjust to your -patient and unjust to yourself. No ethical man can give the best that is -in him by doing less than this. If you haven't the time to do your work -thoroughly, make a clean breast of the matter and take fewer cases. But -you will say that a man, even in large practice, cannot afford to give -any of it up. He needs every dollar that honestly comes his way, and to -say that he hasn't time for his work is only another way of throwing -practice into the hands of a rival. This is, indeed, a proposition hard -to solve, as most of us do need every dollar that honestly comes our -way; but if our work is only half done, if we have neglected some -important point in diagnosis, and thereby omitted some equally important -measure in treatment, have our dollars been honestly earned? Let us -start out with and carry in mind this axiom of a truly ethical life, -that success in medicine cannot be measured by commercial success; that, -while no sensible man can neglect the business side of his vocation, or -refuse to demand and collect just compensation for his service, such -compensation cannot be measured in dollars and cents alone; that a good -conscience and whole-souled devotion to duty, giving ungrudgingly of the -very best that is in you to those that have confided in you, will be -your very best asset when the final account is made up. - -May I impress the fact upon you that an ethical man, with a just -appreciation of his duty to his patients, can never be a vendor of -patent or unofficial medicines. Indeed, I would be lacking in my duty -if, with the opportunity this paper offers me, I did not, from the -standpoint of experience, impress upon you with all of the force at my -command the necessity of being wary of the detail man and the alluring -advertising literature with which your mail will be flooded. You will -scarcely have opened your office, and be waiting with what patience you -can command that rush of the halt, the lame and the blind to which you -feel that your talents entitle you, before the suave detail man, having -heard of the new field, puts in his appearance. What you lack in -therapeutic experience he can supply you by drawing liberally on the -experience of others who have worked little less than miracles in an -adjoining town by the use of his pills and potions, his elixirs and -tinctures. You will find him smooth and oily, placid and plausible. He -knows his story well, and even by his much speaking can almost persuade -you that what you knew, or thought you knew, or what you had recently -been taught, were all out of date; that by some stroke of genius the -chemist of his house had discovered some way by which compatibles would -combine with incompatibles into the formation of a new and staple -mixture, possessing all of the virtues and none of the defects of its -original constituents, rendering chloral as soothing as the strings of a -lute and as harmless as the cooing of a dove, extracting from cod-liver -oil every disagreeable feature and leaving nothing but its supposed -virtues behind. He will show you the short road to fortune and success. -Treat him kindly; the ethical man should not be rude, and brusqueness is -not a sign of Roman honesty or virtue. Be assured he feels his position -keenly, and is dreading the catechism which will sooner or later display -his ignorance of everything but the story that has been drilled into him -like a parrot. - -There has been no greater shame in our profession than the influence -these men and their houses have exercised, and incidentally the -indorsements and recommendations that thoughtless men have furnished -them. The blame is all ours, and we cannot shun it. We pride ourselves -on our scientific attainments; that we take nothing for granted; and, -now that the age of empiricism has passed, we accept nothing that does -not bear the stamp of scientific approval. And yet, before the campaign -of the American Medical Association and the revelations of Collier's and -the Ladies' Home Journal, we accepted our treatment from the hands of -the manufacturing houses, and dosed our patients with nostrums about -which we knew nothing except the statements of those whose sole purpose -it was to sell. There are few of us who have been many years in practice -to whom a blush of shame does not come at the recollection of our -gullibility and our guilty innocence. Can any man deem it ethical to -give even to a good dog something about which he was totally ignorant? -And yet this is just what we were doing. A short time ago a particularly -shrewd detail man was discussing this very point with me, and claiming -that, as the formula was now required by law to be printed in each -bottle and package, this most formidable objection could not now hold -good. Handing me a bottle of his patent cure-all, he glibly called my -attention to the six or seven ingredients, with the amount of each -contained in the fluid ounce. Among other potent quantities I can recall -1-48 gr. of morphia and 1-240 gr. of strychnia. The dose was a -teaspoonful three times a day. Any man can imagine the more than -homeopathic effect of 1-48 gr. of morphia divided into eight doses. -These well-known and well-tried drugs were not, however, the life of the -nostrum, and presently we came to the twenty minims to the fluid ounce -of the fluid extract of the drug from which the remedy derived its name. -Something I had never heard of. Something unlisted in the U. S. P. -Something discovered and owned and controlled by this house alone. As my -ignorance became more apparent his eloquence increased, and I have no -doubt that a few years ago, before my moral conscience had become -aroused to the therapeutic sin of prescribing something whose botanical -family, whose chemical formula, and even whose physiological effects -were totally unknown to me, I would gladly have accepted a sample and -would have tried it on some poor soul too poor to pay for a -prescription. It is nothing short of a shame to think of what we have -done in this line. The sin has been one of carelessness and laziness -rather than of ignorance. Here we had ready to hand some remedy, -beautiful to the eye, palatable to the tongue; then why take the time -and trouble to bother about constructing a formula of our own when -someone else of equal experience had constructed one for us? I am ready -to thank God that most of these nostrums are as harmless as they are -beautiful, and, while I may not have done good, I rarely did harm by -their use. I am not discussing the opium and cocaine laden classes. I -wish to emphasize incalculable harm that must result to the physician -himself who allows someone to do his thinking for him. I am also -referring to the attitude of the ethical man to his patient, and beg to -ask if we are doing even part of our duty when we are doing no harm. -Allow me to conclude this topic by asking you to spend an hour some day -in casually glancing over (a deep study would fully repay you) the pages -of the U. S. P., or a list of the remedies that have in one year -received the sanction of the Council on Pharmacy of American Medical -Association. If you don't find enough drugs and combinations to meet -every case and every conceivable situation, you had better desert -practice and exploit some wonderful cure-all as a detail man. - -If we, as physicians, had nothing but our duty to our patients to -consider, and incidentally our own profit and glory, the practice of -medicine would soon degenerate into a mere trade. I may even say that, -had we nothing but the promptings of our consciences to keep us in the -straight and narrow path, if we had nothing but the knowledge of work -well done, and if the desire and determination to give the best that is -in us were our only incentives to an ethical life, the profession would -be so beset by the temptations of commercialism, and the notoriety and -prominence which commercial success brings, that the halls of Esculapius -would soon need a scouring and purging greater than Hercules gave the -Augean stables. Despite the high incentive to all that is best and -purest in life which our noblest of callings should beget in us, -physicians are only human, and human weakness, like disease, is no -respecter of persons or of callings. It may have been that the medical -fathers, with a knowledge of the temptations to which they were -subjected, and a desire to save others from the pitfalls which beset -their paths, were imbued with a determination to place their profession -on a higher plane than others; or it may have been the natural evolution -which inevitably resulted from and followed the promptings of man to -help his fellow-man, to devote himself to the relief of pain and -sickness, to sacrifice his comfort and ease and almost every pleasure in -order that others might have ease of body and peace of mind and soul, -which from the earliest days have placed medicine as a profession apart, -and have imposed upon those who have entered its ranks certain standards -of conduct and insisted on certain ethical relations which have lifted -it above mere questions of gain and the vain acquisition of renown. We -have been taught that Hippocrates himself was great not only as a -physician, but greater still as an ethical teacher who has left with us -certain maxims and proverbs which, though handed down through the ages, -have lost none of their truth and none of their spotless morality. Even -in the Middle Ages, when learning, not to say science, had sunk into -such an abyss of ignorance that the ability to write one's name lifted -one into the ranks of the educated, when human ills were relieved more -often with the sword than with the scalpel, the leech was a man apart. -His education, his scientific investigations, and even his supposed -communion and partnership with the evil one, placed his on a pedestal -above other professional callings. Then, as now, though men might scoff -at our profession of superior knowledge and skill, when "pallida mors" -stalked abroad or knocked at the hovels of the poor or palaces of the -rich, all arose to call us blessed. It has been often said that, could a -medical man live up to the ethical standards of his profession, his -chances without creed or priest would not be small at the last great -day. But with all of our high ideals we are only mortal, and we know and -have sorrowed at the fact that many of our ethical standards are not -lived up to, and that the Hippocratic law is frequently more honored in -the breach than in the observance. - -We have in every community where one or two are gathered together in the -name of medicine the man who is everything to your face and everything -else behind your back; who damns by faint praise; who sympathizes with -you in your sorrows and trials, who visits the family of the patient you -have lost to assure them of your skill and to insist that everything was -done that could have been done, "but"----and that one harmless little -conjunction, meaning nothing in itself, is more eloquent than a thousand -terrible adjectives or burning, blistering adverbs or participles. So -many things can be said by the pious uplifting of the eyes, the -sanctimonious upturning of the palms. He would not for the world leave a -doubt in the minds of your people, and, no matter what in his inmost -heart he thinks of your mistakes (from his standpoint), it is not his -place to injure a brother, but, alas! he is not responsible for the -unguarded tongues of his friends, and he usually sees that they do his -work well for him. Often it is "if I could only have reached him -earlier," which, being interpreted, means a miracle would have been -wrought. Almost every community has its miracle worker, its medical -resurrectionist. His cases are always a little worse than others, his -victories a little more wonderful. Where you have a bronchitis, he has a -desperate pneumonia, your transitory albuminuria is with him acute -Bright's, and hopeless cases follow him to undo him, only to meet defeat -at his skillful hands. You hear that Mr. A. is desperately ill with -pneumonia on Monday, and on Friday you meet him on the street, looking -hale and hearty, firmly believing that, had Dr. X. been one hour later -in reaching him, he would ere this have been gathered to his fathers. -Should you mildly suggest that some error in diagnosis might have been -made, that even the best of us at times go wrong, and that resolution in -true pneumonia could hardly be expected in four days, you will find that -he has been prepared for you, feeling that Dr. X. has used some potent -remedy as yet unknown to you and his less skillful brethren, and firmly -convinced that your suspicions of his case are based upon your ignorance -or your jealousy of poor Dr. X., who was not there to defend himself, -who had always spoken so kindly of you, and had uttered nothing worse -than the harmless little conjunction "but"---- - -A little bragging is not a sin, and indeed is usually harmless, and in -the long run reacts on the miracle worker. But the ethical man does -frequently suffer from it, and it is a fact, absurd as it may seem, that -the average man or woman would much prefer to be considered at death's -door about three-fifths of the time--indeed, almost a walking -Lazarus--than to be deemed the picture and personification of vigorous -health. Dr. X. knows this, and plays upon the credulity of his patients. -He frightens them to death's door, works a miracle, and has tied them to -himself forever. We all have suffered from this, and will continue to do -so until the little grain of truth has grown from the tiny mustard seed -to the vigorous bush. Dr. X., with his faults, has his virtues. He -aspires to be the busiest man, the richest man, the most popular man in -his community. All of these ambitions, if properly guided, are laudable, -and, indeed, while enhancing his power and prestige, may be redounding -to the good of his people, for a man to be the busiest and most popular -man in his profession must usually be the best posted, the most highly -educated, the hardest working man, not only for himself, but for those -he serves. So, while we may smile at Dr. X. and his big ways, we may -love him for his virtues and forgive his small faults. - -But for the man who deliberately goes to work to undermine another; who -takes advantage of some temporary absence of the regular physician to -ingratiate himself; who, appreciating the fact that people worried -nearly to death by the illness of a loved one, will forget every -obligation and desert every old friend in the hope that the new one may -offer some encouragement or extend some hope, is ready for these -emergencies. He carries satchels full of hope for all cases and -occasions. He prescribes it liberally, diluted, however, to the point of -despair because he was called in an hour too late, or because the case -had already been damaged beyond his power of repair. This gentleman -advances not only by his own deceit, but uses the power of church, of -politics, of family influence and social opportunity, to lift himself -along. Verily he has his reward, but it is not in peace of mind, not in -the honor and respect of his community, but the contempt of every honest -man, be he of the profession or laity. Not the least of the perplexing -questions which beset the man who is trying to lead an ethical life is -his duty in his relation as consultant. Indeed, there is scarcely a -situation in professional life that at times presents more embarrassing -possibilities, or calls for the exercise of more tact. It is a pleasure -to be able to bear witness to the ability of the man who has called you -to his aid, to assure the family that everything has been done that care -in diagnosis and skill in treatment could demand. But what of the cases -where gross carelessness or blind ignorance have hastened what might -easily have been delayed or averted? There is only one way here, only -one duty. Treat the man as his carelessness or his ignorance deserves. -Again, you are called in consultation with a thoroughly good man who has -given ungrudgingly of the best that is in him. Perhaps your superior -skill in certain lines, perhaps your superior opportunity to observe a -certain line of cases, have taught you something that he has not had the -chance to learn. As before it was your duty to expose the careless -ignorance of one, now it is your place to so give your opinion and -explain your position that no possible reflection can be cast upon the -other. Don't approach a consultation with the manner of a priest of -Delphi. Don't pose as the fountain of all wisdom and of all experience. -Indeed, in this work you will be surprised how often you will learn from -him you are called upon to assist. He has seen the case for days, where -you can spend but minutes with it. It is his part to bear the blame, -yours to share his fame should success crown your combined efforts. - -Frequently you will be called upon when a resort to surgery is -demanded--not so much to perform the operation as to give your opinion -as to the advisability of a certain line of procedure. Having determined -what is to be done, don't assume the place of prominence. You have -little by way of reputation to gain by performing an operation that you -were known to be competent to perform or you would never have been -called. Let him do the work with your assistance and advice. In this way -you will have gained a fast friend for future consultations, and you -will have enshrined him in the esteem and confidence of his people. -Therefore, help him and uplift and bear witness to his worth, and don't -humiliate him by your airs and assumed superiority. - -As a last word, don't consult with an unworthy man, for be assured that -your reputation is worth more to you than any consultation fee, however -badly you may think you need it. - -The question of fees is one that must be considered. We hate to think of -the combination of medicine and money, and our patients abhor it even -more. The days once were when only the sons of the rich sought the -liberal professions. It was thought unworthy in the days of the dim ages -for a pupil of Esculapius to charge for his services. Any remuneration -that came to him was an offering of gratitude--indeed an honorarium -which might be tendered or withheld at the will of the patient. A truly -noble conception this, that the good we offered was beyond a mere -question of price. Equally comforting was the belief that the ill which -resulted despite our best efforts was no reflection on our skill, but an -evidence of the wrath of the Gods. Would that we were as near Olympus -now as then, and that the Gods walked with men to reward the worthy and -punish the unjust. Would also that the manners and costumes and climate -of Ancient Greece were still with us, so that man need take little heed -of raiment beyond a robe and sandals; that he required no expensive -outlay for instruments, no intricate electric outfit, and no automobile. -What a life ours would be if now as then our grateful patients sought -us, and we passed our many hours of leisure in eloquent discussion or in -lazy lounging amid the leafy groves or shaded porticos of the temples! -But the times have changed, and we have changed with them, and abhor as -we will the combination of medicine and money, we are forced to take -thought of the morrow and to spend many, many anxious moments in this -thought and in trying to evolve ways and means by which a balance can be -maintained between the honoraria of patients, both grateful and -ungrateful, and the claims of persistent creditors. Perhaps it is best -thus, as the average man needs some incentive to good work beyond the -acquisition of honor and glory. An axiom in the question of fees is -this, that in order to be respected we must respect ourselves, and no -one can respect himself unless he holds his calling above a trade and -bases his charges upon this feeling of respect for himself and his -profession. This axiom should be held in mind in arranging any fee -table, and should be insisted upon in our settlements with those who -think a doctor's bill should be discounted from one-quarter to one-half. -I have often wondered how this right to a discount in a doctor's bill -ever got such a firm hold in the public mind. Perhaps the city man -cannot appreciate this fact like his country brother. The poor, honest -old farmer, part of the bone and sinew of the land, expects the highest -cash price for everything that he sells. If anybody has ever heard of -one who when ten barrels of corn at $3.50 per barrel comes to $35, -offering to take $25 for his bill, he should corral and cage this rara -avis. But hundreds of us from the rural districts have been deemed mean -and close-fisted and extortionate because we gently insist that $35 -worth of professional services rendered are worth $35 and not $25. - -This is largely our own fault, for so many of us present a bill in one -hand and an apology in the other. We collect our bills not as if they -were our just dues, but with a half-hearted insistence, inducing our -debtor to believe that we have scruples ourselves as to the value of our -services, and that a liberal discount from the face of the bill will -about bring us to a fair settlement. It will be better for all--for -patient as well as physician--to realize that the "science of human -duty" implies a duty to oneself as well as a duty to the public, and -that a small proportion of the charity of our profession should begin at -home. To the young men I would especially give this advice: Having -settled on a fair and honest fee for your services, do not depart from -this fee. With us, as a rule, prosperity in the form of a numerous -clientage comes sooner than to the other professions. You will not long -have opened your office before you will be surprised at the number who -demand your services. There will be no doubt of the demand, for those -who pay the least invariably demand the most. Don't turn them away, for -if you properly employ your time, you will gain in experience and -occasionally a dollar or two. You will soon be enlightened as to your -popularity, for the first pay day will send most of them to another and -it is presumed easier man. Many of those who stick will tell you that -Dr. ---- never charged but 50 cents a visit, when the regular fee is -$1.00. Dr. ---- will vigorously deny this and produce his books to prove -his truth. Here is everything plain before you. Every visit is listed at -the established figure. You will rarely see his cash book, for then the -whole transaction would be plain, and you would discover the simple -manner by which in every community some supposedly ethical man is -supplanting his truly ethical brother by charging full fees and settling -for half. - -Dr. ---- will cut 50 cents or a dollar from the established fees for -out-of-town work, and immensely increase his practice by it. For be it -understood the bone and sinew of the land dearly love the wholes and -halves, and will flock to sell in the dearest and pay in the cheapest -market. Don't envy this man his prosperity and, above all, don't follow -in his footsteps. Bide your time with the assurance that the man who -charges $1.00 for $2.00 worth of service rarely gives more than a -dollar's value, and that when a real emergency arises and a capable, -honest man is demanded, one who respects himself and his calling, if you -have prepared yourself and are known to give the best that is in you, -the cheap man will go to the wall and your merit will receive its -reward. If by chance any of you have not seen Dr. McCormick's paper on -this question of fees and collections, let him by all means find the -proper A. M. A. Journal and read it. It is a classic worth any man's -time and attention. In concluding this subject, let me endorse what he -says about the cheap man, the price-cutter. Whatever his charge may be, -he is usually getting full value for his services. Realizing his lack of -education or ability or temperament, or whatever it is that puts him -below his professional competitor, he cuts his fees in order to live. It -is not our place to meet his competition, but to pity him, to extend to -him the helping hand, to endeavor to elevate him to our standard, and -never to lower ourselves to his. - -I have only a few words to say on the subject of professional -confidences. So sacred is the relation between the physician and patient -regarded that the courts will not compel a physician, while on the -witness stand and under oath, to tell the truth, and not only the truth, -but the whole truth, to reveal what is imparted to him in confidence by -his patient. - -If in this exalted function of doing justice between man and man the -courts will not compel the recital of some important piece of evidence, -how carefully should we regard our professional relation, and see to it -that neither in strict confidence or in idle gossip do we betray the -secrets that suffering man has confided in us. - -It may be somewhat out of place in a paper dealing with "The Ethics of -the General Practitioner" to speak of the tendency, or perhaps better, -the half-formed determination of the majority of every class to be -specialists. I must confine myself to the predilection of the average -medical student for surgery. It was so in my day, and I suppose it is so -now, that almost 75 per cent. of the graduating classes are thoroughly -satisfied that the end and aim of medicine is surgery; that practice and -the less spectacular branches are parts of the profession essential to -it as a whole, and fitted for those who intend to lead the plodding -life, but too slow and too prosaic for the man bursting with the -knowledge of his own brilliancy and his own special fitness. There is no -question but that this tendency has done much to lower the average -fitness of many classes. Men become listless and careless, neglecting -everything but their hobby, and while the surgical amphitheatre is -crowded, the medical clinics will be shunned, even deserted were it not -that the sections are such that the absentees can be spotted and warned. -There is no question also but that indifference to everything but -surgery is responsible for many of the failures before the State -Examining Boards. We must have surgeons, and they must begin their -training in medical schools, and it is not my purpose to discourage -earnest work and honest effort to this end. I wish, however, to say that -every ethical specialist needs a thorough grounding in the general -branches of medicine, and he should not in his student days neglect the -other essentials to a well-rounded man. Most heartily do I wish to -condemn the careless, happy-go-lucky manner in which so many men totally -unprepared and totally unsuited by temperament for this branch "rush in -where angels fear to tread." I wish especially to draw your attention to -the fact that there is a vast difference between the operator and the -surgeon. Almost any young man with a disregard of the sight of blood, -with nerves unaffected by human suffering and a heart untouched by a -knowledge of his power to do harm, can in six months' practice on the -cadaver learn to cut, to sew and to ligate with neatness and despatch. -Indeed, there may be many before me of the student body whose young and -nimble fingers could teach dexterity to the best surgeons of the city. -Very many with no pretense to this dexterity, and no equipment but a -superabundance of assurance, graduate as surgeons and assume and aspire -to a position of prominence that it has taken the true surgeon years of -the hardest, closest, most untiring study, observation and work to -reach. We are told as an excuse for this remarkable evolution from the -student to the surgeon that the young man of today is taught so much -more than the old men were; that the very manner of teaching, the -equipment of the schools and the superior requirements for matriculation -cannot but turn out better posted and more competent men. There is much -truth in this. There is much truth also in the fact that while more is -taught, more, infinitely more, is demanded of the student, and the -knowledge that would have secured him a diploma fifty years ago will now -scarcely carry him through his freshman year. - -We also hear that "I want to be a surgeon, because surgery accomplished -positive results." This is very true also, and it is evident that if you -amputate a leg your patient will be minus a member. Don't lose sight of -another fact, however, that if without being competent to meet any -unforeseen emergency that may arise, you lightly open the abdominal -cavity, you will have a positive result in the shape of your own little -private graveyard. The newly graduated surgeon is not as dangerous as -the man who left medical school years ago, before the students received -one-third of the surgical training that they do now. Many of these men -have not taken a post-graduate course, have never been associated with a -hospital, nor have they had even an opportunity for moderate surgical -observation; and yet they are attempting to do the work that only a -skilled specialist should undertake. I am not speaking of emergency -surgery for which any man should try to prepare himself, and be brave -enough to undertake when human life is at stake. I am referring to -operations of election when the services of a competent man can be -secured. The point is just this, gentlemen, that medicine as a science -is the result of evolution and not the creation of some brilliant brain; -that what has been done in it has been accomplished not so much by -inspiration as by close plodding work, exhaustive experiment and -continual observation; that surgery as one of its branches cannot be -mastered in the four years of student life, but that to be surgeons you -must be workers and observers. It will not do to settle the matter by -saying that a man must make a start. This truth is too self-evident to -be smart, nor is it entirely convincing. An answer equally true will be -that you will not allow the embryo surgeon to start on you, and before -you put yourself or your wife or your mother in his hands you will -demand that he possess some other qualification for his specialty -besides his conceit, his gall and his need of the fee. There may be some -exceptions where the man is born and not made, but I beg to assure you -that the surgeon rarely springs full-fledged and fully fitted from the -brain of Minerva. - -Our profession is nothing if not altruistic. It demands daily and hourly -more of self-sacrifice, more of self-devotion, than any secular calling. -Indeed, the comparison is often drawn between the nobility and necessity -of the duties which we perform and those of him who by divine -inspiration and laying on of hands has been called to succor the -diseased soul. It is not my place nor is it my purpose to enter into a -discussion of this point, and I mention it only to show that we are -marked men in every community; that we are placed on a higher plane and -that more is expected of us than of our brethren of the other liberal -professions. This, indeed, is right, for no man, the priest possibly -excepted, enters into such intimate relations with his people. He is -ever present with them to share their sorrows and their joys, and in his -position of family friend and family confessor it is his place to bind -and salve wounds more deadly than those made by the hand of man. It is a -popular impression that this close relationship between the physician -and his people is one evolved by the brain of the novelist or one -possessed by that most beloved, but now extinct, old family physician. -Let us get this impression from our minds and let us realize that our -duties, our responsibilities and our relationship to those we serve are -just the same, are just as close, and are just as engrossing as they -were when that dear old patriarch of the profession made his rounds, -scolding some, chiding others and advising all to better, purer and -nobler lives. Changed as our relationship to the community may be in -some respects by the translation of many of the brightest and best of -our cult into the ranks of the specialist, it is still and always will -be the general practitioner who is looked up to as "the physician," and -by his work in professional and private life our profession will be -judged. - -In the beginning of my paper I stated I could do little more than -rehearse to you some of the old axioms and maxims that have been handed -down to us for generations. I am aware that I have taught you nothing -new tonight, and that I have not tapped that fountain of inspiration -from which genius gushes in poetic or oratorical streams. I trust I may -have convinced you that it is not amiss for us at times to hold close -communion with our souls, and to take stock of our moral and -professional assets. The further I have advanced the more fully I have -realized how impossible it is to evolve new ideas or elaborate new -creeds to supersede those by which the fathers lived and died and earned -honor for themselves and our profession. - -So we face today, gentlemen, just about the same propositions that have -always been ours to meet, and what was ethical one hundred years ago is -ethical now. - -The science of human duty simply demands that you be honest to -yourselves, honest to those you serve; that you may look every man -squarely in the face and not as if you feared he had heard something you -had said behind his back. May I quote to you the words of the Earl of -St. Vincent to the immortal Nelson: "It is given to us all to deserve -success; mortals cannot command it." - - - - - THE STUDY OF RECTAL SURGERY IN - NEW YORK CITY. - - BY J. DAWSON REEDER, M. D., - _Lecturer on Osteology, University of Maryland, - Baltimore, Md._ - - -Having decided to take a course in Rectal Surgery, I arrived in New York -and matriculated at the New York Polyclinic Hospital on October 1st for -a course of instructions under Prof. James P. Tuttle, and desire to -herewith describe briefly my reception: - -Professor Tuttle is a finished surgeon of the old school of gentlemen, a -master of his art, and, under all conditions and circumstances, adheres -strictly to the ethics of the profession. I was not only most cordially -received by him socially, but was most fortunate in being honored by -requesting me to assist him, or be present, on operations upon his -private patients at an uptown hospital. This unexpected and friendly -honor gave me an opportunity to observe closely the work of this great -surgeon in detail, and I had the pleasure of witnessing every case under -his care during my three months' visit. As to his colossal work on -cancer of the rectum and sigmoid, his results are too well known for me -to dwell upon at this time, and he has an enviable record which makes -him the authority of this distressing malady which is so prevalent in -the cases referred to the Rectal surgeon, and have so long been -unrecognized by the general profession. I had the pleasure of witnessing -him extirpate the rectum by his bone-flap and perineal route, and in -some of these cases was honored by being his assistant. As to the method -and technique in each of the above mentioned, I will endeavor to give -later. Another very important point gained by association with this -surgeon was, that my own theory as to the merits of the Whitehead -operation were simply an endorsement of his teachings, namely, that this -particular operation, while classical, was only justifiable in selected -cases of hemorrhoids, while the Clamp and Cautery or the Ligature method -had no restrictions as to variety or location of the pile mass. - -Another important subject was the question of treatment of Tubercular -fistula. For a number of years Dr. Tuttle said he was most discouraged -in his results and had almost abandoned any attempt to cure this class -of infections, but of late he had obtained most excellent results by -introducing his soft flexible probe and following this tract with a -grooved director; opening this throughout its entire extent, and then -completely cauterizing at dull red heat with the actual cautery. This is -then packed with iodoform gauze, and since using the cautery, his -results have been decidedly better. Under the direction of his -assistant, Dr. J. M. Lynch, a class of three was formed, with regular -work and instructions in the dispensary of St. Bartholomew's Clinic, -where we were given cases to diagnose and treat. This course consisted -in introduction of proctoscope and sigmoidscope diagnosis of ulcerations -specific and benign, and local treatment through this instrument. To the -inexperienced the results and probabilities gained through the use of -this pneumatic instrument of Tuttle's, which is a modification of the -Laws proctoscope, are surprising. By the electric illumination with -which it is equipped one is able to introduce the instrument with -absolute safety to the patient for a distance of 10 to 14 inches, -exploring the entire circumference from the anus up through the sigmoid. - -My next course of instructions was under the direction of Prof. Samuel -Gant at the New York Post-Graduate Medical School. Dr. Gant likewise was -most cordial in his reception, and on several occasions honored me by -entertainments, including letters of membership to his club, and at his -home with his family. Dr. Gant, also a master of his art, has made a -reputation of renown, and is a most successful operator. While of an -entirely different character from that of Dr. Tuttle he is equally -attractive. Dr. Gant argues that the majority of cases of cancer when -seen by the specialist are too far advanced to offer any hope by radical -operation, and generally limits his attempts at relief to a colostomy. -As to the merits of this procedure, I am not sufficiently versed to -offer criticism further than to say that the results of Dr. Tuttle are -certainly encouraging to the surgeon who will undertake this ordeal of -extirpation in hopes of eradicating the disease, while Dr. Gant's -operation of colostomy, of course, is only palliative, he making no -claims of a cure, except when the growth is seen very early and is -freely movable; then he will extirpate. - -As to the operation for hemorrhoids, Dr. Gant uses ligature and sterile -water anesthesia in nearly every case, and the patient is thereby cured -without the administration of a general anesthetic. The difference in -the time of recovery is a question to be always considered, in my own -judgment, and is as follows: Dr. Tuttle uses the clamp and cautery -almost universally, and the patient is discharged within the period of -one week, while the ligature method requires local treatments to the -ulcerations produced by the sluffing of the linen threads, and takes -from 10 days to three weeks. - -Constipation and Obstipation are treated surgically by both of these -gentlemen by the operation of Sigmoidopexy or Colopexy, which consists -in anchoring the gut to the abdominal parietes after having first -stripped back the peritoneum over the area covered by their sutures. - -Chronic diarrheas and Amœbic Dysentery are likewise treated by -Appendicostomy and Caecostomy. The difference in this operation being -that the former consists in delivering the appendix upon the abdomen and -fixing the same with catgut sutures until the peritoneal cavity is -walled off by adhesions, and then amputating later, so that the stump -may be dilated to permit of regular colonic irrigations. - -Dr. Gant performs a similar operation, to which he has applied the name -of Caecostomy, and having devised an ingenious director consisting of -one metal rod within a tube of slightly larger calibre, he is able to -pass the obturator through the ileo-caecal valve, and then, by -withdrawing the rod or obturator, is able to pass a rubber catheter into -the small intestine. The metal tube is then withdrawn and a shorter -catheter is placed parallel with the long one, which necessarily is in -the caput, and after placing clips upon each tube to prevent leakage, he -is able to flush out both large and small bowel at desired intervals. - -As to the irrigations through these newly-made openings, it is a matter -of choice with different operators, those in greatest favor, I think, -being Ice Water, Aq. Ext Krameria and Quinine Solution. - -A very interesting case brought before us by Dr. Tuttle was one of -Specific Stricture of the Rectum, and the treatment anticipated is as -follows: He performed a Maydl-Reclus Colostomy in the transverse colon, -in order first to treat the ulcerations and infected area locally, and, -secondly, so that he would have sufficient gut above the stricture to do -a Perineal extirpation later and bring down new healthy intestine from -the upper Sigmoid for a new permanent anus; then later he would close -the artificial anus in the transverse colon, and his patient should have -a perfect result. The period required for these three operations would -cover a period of not less than nine months; and if after this there is -not perfect Sphincteric action, Dr. Tuttle does a plastic operation to -repair his sphincter. - -Before continuing with a brief description of the technique of -Extirpation as above referred to, I wish to herewith express my sincere -gratitude and appreciation of the many honors and courtesies extended to -me by these gentlemen, and am quite sure that the same was not all -personal, but honor to the University of Maryland's Faculty of Physic, -who have aided so materially this younger specialty by such men as -Hemmeter, Pennington and Earle, who are constantly quoted by all -intestinal and rectal surgeons. - - -EXTIRPATION OF RECTUM. - -The operation of removing the rectum is now almost two centuries old. -Faget performed it in 1739, but Listfrane first successfully extirpated -the rectum for cancer in 1826. The results of the operation in nine -cases were embodied in a thesis by one of his students (Penault, Thesis, -Paris, 1829), and in 1833 the great surgeon himself gave to the world a -complete account of his operation and method, thus establishing the -procedure as a surgical measure. The results in these cases were not -calculated to create any great enthusiasm, for the mortality was high -owing to the lack of aseptic technique. The methods described in older -books give us five varieties of operation for extirpation--the perineal, -the sacral, the vaginal, the abdominal and the combined. In this paper I -shall only endeavor to describe briefly the two methods used by Dr. -Tuttle. Before describing these methods in detail it may be well to -consider the preparation of the patient, which is practically the same -in each. In order to obtain the best results, it is necessary to -increase the patient's strength as far as possible by forced feeding for -a time, to empty the intestinal tract of all hard and putrifying faecal -masses, to establish as far as we may intestinal antisepsis and to -check, in a measure, the purulent secretion from the growth. It requires -from 7 to 10 days, or longer, to properly prepare a patient for this -operation. The diet best calculated to obtain a proper condition of the -intestinal tract is generally conceded to be a nitrogenous one. The -absolute milk diet is not so satisfactory as a mixed diet composed of -meat, strong broth, milk and a small quantity of bread and refined -cereals. The patient should be fed at frequent intervals, and as much as -he can digest. Along with this forced feeding one should administer -daily a saline laxative which will produce two or three thin movements, -and to disinfect the intestinal canal one should give through the -stomach three or four times a day sulpho-carbolate of zinc, grs. iiss., -in form of an enteric pill. On the day previous to the operation the -perinaeum, sacral region and pubis should be shaved, dressed with a soap -poultice for two hours, then washed and dressed with bichloride -dressing, which should be retained until patient is anesthetized. -Notwithstanding all of these preparations, it is impossible to obtain -absolute asepsis of the affected area, and so many fatalities occur from -infection that it is deemed wise by many surgeons to make an artificial -inguinal anus as a preliminary procedure in all extirpations of the -rectum. - - -PERINEAL METHOD. - -Under this method may be included certain operations for small -epitheliomas low down in the rectum done through the anus. The patient -having been properly prepared, the sphincter is thoroughly dilated; a -circular incision through the entire wall of the gut is made, and the -segment is caught with traction forceps and dragged by an assistant -while the operator frees, by scissors and blunt dissection, to a point -at least one-half inch above the cancer. The free end of the gut is then -tied with strong tape, as the temptation is very great to put your -finger in the bowel as a guide, and thereby invite infection. A deep -dorsal incision is then made, going down to the right of the coccyx -through the post-rectal tissue. The hand is then placed in the sacral -fossa and the structures lifted out into the pelvis, after which this -space is thoroughly packed with gauze to control the bleeding and hold -the structures out of the fossa. The edges of the wound, including each -half of the sphincter which has been cut posteriorly, are held by flat -retractors, while the operator proceeds to dissect the anterior portion -of the rectum loose from its attachments. A sound should be held in the -urethra in men and an assistant's finger in the vagina in women to -prevent wounding these organs. After the gut has been dissected out well -above the tumor, it is caught by clamps and cut off below these. -Bleeding is controlled by ligatures and equal parts of hot water and -alcohol. This newly-exposed gut is then sterilized by pure carbolic acid -and alcohol, or may be seared with cautery. Sometimes the peritoneum can -be stripped off from the rectum and its cavity need not be opened; it is -better, however, to open the cavity at once when the growth extends -above this point. The peritoneum is incised, cut loose from its -attachments close to the rectum, back to the mesorectum, which should be -cut close to the sacrum, in order to avoid the inferior mesenteric -artery. When the gut has been loosened sufficiently above the tumor, it -may be still fastened by two lateral peritoneal reflections, which are -the lateral rectal ligaments, and should be cut at once. The gut is then -brought down and sutured to the anus, and the operator should proceed to -close the peritoneum and restore the planes of the pelvic floor down to -the levator ani by fine catgut sutures. After this has been -accomplished, the anus, which is now well outside the operative field, -should be reopened, the gauze removed, and the gut flushed with a -solution of bichloride or peroxide of hydrogen. Quenu advises that in -amputating each layer should be cut separately, in order to avoid -hemorrhage, but there appears to be no advantage in this; in fact, we -are more likely to meet with deficient blood supply, causing subsequent -sloughing of the gut, than with hemorrhage. The posterior and anterior -portions of the perineal wound are packed with gauze and left open to -assure drainage, and the parts are covered with aseptic pads, held in -position by a well-fitting "T" bandage. A large drainage tube is passed -well up into the rectum, its lower end extending outside of the -dressings, in order to convey the discharges and gases beyond the -operative wound. - - -TUTTLE'S BONE FLAP OPERATION. - -"The Kraske Operation" is applied to various methods in which access to -the rectum is obtained by removing the coccyx or cutting off certain -portions of the lower end of the sacrum. They are all modifications of -Kraske's original method, with which we are all familiar. Dr. Tuttle has -modified this plan, as it furnishes a rapid and adequate approach to the -rectum; it facilitates the control of hemorrhage and restores the bony -floor of pelvis and attachment of the anal muscles, and involves injury -of the sacral nerves and lateral sacral arteries on one side only. The -technique which he employs is as follows: - -The patient is previously prepared as heretofore described, and an -artificial anus established or not, as the conditions indicate; before -the final scrubbing the sphincter should be dilated and the rectum -irrigated with bichloride 1-2000 or hydrogen peroxide. It should then be -packed with absorbent gauze, so that the finger cannot be introduced. -The patient is then placed in the prone position on the left side, with -the hips elevated on a hard pillow or sandbag; an oblique incision is -made from the level of the third foramen on right side of sacrum down to -the tip of the coccyx, and extending half-way between this point and the -posterior margin of the anus. - -This incision should be made boldly with one stroke through the skin, -muscles and ligaments into the cellular tissue posterior to the rectum; -the rectum is then rapidly separated by the fingers from the sacrum, and -the space thus formed and the wound should be firmly packed with sterile -gauze. A transverse incision down to the bone is then made at a level of -the 4th sacral foramen, the bone is rapidly chiseled off in this line, -and the triangular flap is pulled down to the left side and held by -retractor. At this point it is usually necessary to catch and tie the -right lateral and middle sacral arteries. Frequently these are the only -vessels that need to be tied during the entire operation, although if -one cuts too far away from the sacrum, the right sciatic may be severed. -The first step in the actual extirpation of the rectum consists in -isolating the organ below the level of the resected sacrum, so that a -ligature can be thrown around it, or a long clamp applied to control any -bleeding from its walls. If the neoplasm extends above this level and it -is necessary to open the peritoneal cavity to extirpate it, one should -do this at once, as it will be found much easier to dissect the rectum -out by following the course of the peritoneal folds. By opening the -peritoneum and incising its lateral folds close to the rectum, the -danger of wounding the ureters is greatly decreased and the gut is much -more easily dragged down. - -When the posterior peritoneal folds or meso-rectum is reached, the -incision should be carried as far away from the rectum, or, rather, as -close to the sacrum, as possible in order to avoid wounding the superior -hemorrhoids artery, and to remove all the sacral glands. The gut should -be loosened and dragged down until its healthy portion easily reaches -the anus or healthy segment below the growth. A strong clamp should then -be placed upon the intestine about one inch above the neoplasm, but -should never be placed in the area involved by it; for in so doing the -friable walls may rupture and the contents of the intestine be poured -out into the wound. As soon as the gut has been sufficiently liberated -and dragged down, the peritoneal cavity should be cleansed by wiping -with dry sterilized gauze and closed by sutures which attach the -membrane to the gut. By this procedure the entire intraperitoneal part -of the operation is completed and this cavity closed before the -intestine is incised. After this is done the gut should be cut across -between two clamps or ligatures above the tumor, the ends being -cauterized with carbolic acid and covered with rubber protective tissue. -The lower segment containing the neoplasm may then be dissected from -above downward in an almost bloodless manner until the lowest portion is -reached. It is much more easily removed in this direction than from -below upward, and there is less danger of wounding the other pelvic -organs. If the neoplasm extends within one inch of the anus, it will be -necessary to remove the entire lower portion of the rectum. If, however, -more than one inch of perfectly healthy tissue remains below, this -should always be preserved. Having removed the neoplasm, if one inch or -more of healthy gut remains above anus, one should unite the proximal -and distal ends either by Murphy button or end-to-end suture. - -All oozing is checked by hot compresses, and the concavity of the sacrum -is packed with a large mass of sterilized gauze, the end of which -protrudes from the lower angle of the wound. This serves to check the -oozing, and also furnishes a support to the bone-flap after it has been -restored to position. Finally the flap is fastened in its original -position by silk-worm gut sutures, which pass deeply through the skin -and periosternum on each side of the transverse incision. Suturing the -bone itself is not necessary. The lateral portion of the wound is closed -by similar sutures down to the level of the sacro-coccygeal -articulation; below this it is left open for drainage (Tuttle, Diseases -of Rectum, Page 829-1903). - - - - - REPORT OF A CASE OF GANGRENOUS - APPENDICITIS, FROM THE SERVICE - OF PROF. R. WINSLOW. - - BY C. C. SMINK, '09, - _Senior Medical Student_. - - -In selecting a case I have not taken one that is a surgical curiosity, -or at all an unusual one, but I have taken this because it is just in -these cases that a doubt sometimes exists as to the treatment when -diagnosed, and often the condition of the appendix and surrounding -peritoneum is in doubt, even if a diagnosis of trouble originating in -the appendix is made. - -_History of Case_--Patient, a boy, L. W., age 9 years, schoolboy; -admitted December 26, 1908, with a diagnosis of appendicitis. - -_Family History_--Parents well; one brother died in infancy, cause -unknown; two brothers living and well; only history of any family -disease is tuberculosis in one uncle; no rheumatism, syphilis, gout, -haemophilia or other disease bearing on the case. - -_Past History_--Measles at 5 years, with uneventful recovery; -whooping-cough at 6, no complications; badly burned two years ago; has -had "indigestion" (?) since he was 3 years old; pain but no tenderness -during these attacks; treated by different physicians and got better for -a time; no history of scarlet fever, influenza, pneumonia, typhoid or -other disease of childhood. - -_Habits_--A normal child. - -_Present Illness_--On 20th of December, 1908, patient came home from -church complaining of pains in the right side. This was Sunday. Next day -he complained of severe pain all over abdomen, but on Tuesday these -became localized in the right lower quadrant of the abdomen. Had some -fever. Bowels constipated. No nausea or vomiting. There was a localized -tenderness in the right lower quadrant from the start. Pains got better -on Friday, but temperature and pulse still stayed up, and patient came -into hospital on Saturday, December 26. The unusual feature was that -there was no nausea or vomiting. It is also to be noted that the pain -subsided suddenly on the 24th. The child entered hospital on the 26th, -and on entrance the whole right side was rigid, while the left side was -comparatively soft. A lump could be felt in the appendical region, the -centre of which was above McBurney's point. Temperature was 99 and pulse -78. The leucocyte count, however, was 30,200; urine negative. - -Child was put to bed; an ice cap placed on the abdomen. Liquid diet. The -next day, December 27th, leucocytes stood at 35,200. Temperature -unchanged, but the pulse had risen to 110 beats. A hypodermic of -morphine and atropine was given, and patient taken to the operating -room, anesthetized, and abdomen cleaned for an aseptic (if possible) -operation. - -Prof. Winslow made an incision in the abdominal wall, well out toward -the crest of the ilium, using the gridiron incision. The caecum was -found and pulled over toward the middle line, and in looking for the -appendix, which was supposed to be behind the caecum, a great quantity -of pus was found. This nasty smelling, grayish pus welled up into the -wound and was sponged away. Several pieces of mucous membrane and -presumably the tip of the appendix were found in the pus. Also several -faecal secretions. The pus was sponged away and carefully a search was -made for the appendix, or rather what remained of it. It was found tied -down by adhesions and dissected loose. It broke away in pieces, and it -was unnecessary to ligate any of the arteries of the meso appendix. The -stump of the appendix close to the caecum was crushed, cauterized and -ligated. No attempt was made to invert it, as the tissues would not -stand it. The pus cavity was found to extend up behind the caecum and -over toward the median line for some distance. The puncture, which I -will refer to later, was then made in the right lumbar region, and two -cigarette drains were introduced extending clear back into the bottom of -the abscess cavity. Then a gauze drain was introduced into the anterior -wound, and this sutured up. The wound was then dressed and the patient -taken to the ward. Recovery from anesthetic without ill effects. - -The next morning the patient was unable to pass his water, and had to be -catheterized. Aside from this no ill effects were seen, and his -temperature and pulse remained practically at the same place. At the end -of 48 hours the drains and dressings were changed and the patient was -doing well and the wound draining profusely. At no time was the bed -elevated and at no time was a stimulant administered, with the exception -of a hot normal salt enema on the day following the operation. Several -times during his stay a dose of castor oil was given, but no other -medication was necessary. As the dressings were reapplied and drains -introduced daily the wounds were found to be granulating up, and -gradually these closed, first the one in the lumbar region and then the -one in the abdomen. By the tenth day a normal temperature was present, -and he sat up on the twelfth. - -The child went on to an uneventful recovery, and went home on January -21st fully cured. - -This was undoubtedly one of those cases of gangrenous appendicitis -where, owing either to the intensity of the infection or to a thrombosis -of the vessels supplying the appendix, the vitality of the tissues is -lost and gangrene results. Now, "even in this, the gravest form of -appendicitis, the general peritoneal cavity is often protected against -infection by walling off the pus, and the appendix, detached in the form -of a slough, is often found on opening the localized abscess." But "in -other cases there is from the beginning the symptoms of peritoneal -sepsis and peritonitis." - -Now, it seems to me that a great deal depends on the kind of -infection--or, rather, the kind of organism infecting--and often the -difference between a localized abscess and a general peritonitis is -really the difference between a colon and a streptococcus infection. -Again, should a general peritonitis develop, I have noticed from a -number of cases in the wards that the prognosis practically depends on -the organism, although we all know that a general peritonitis is a -mighty grave condition, no matter what it is due to. - -Another point in favor of the child was the fact that the gangrenous -process seemed to start in the tip of the appendix, and it seems that -when it starts there, there is greater likelihood of localization, and -when it starts in the base a greater likelihood of general peritonitis. - -I said that there was often doubt as to the condition in the abdomen in -these cases. Now, there can be no doubt that the two main points in the -diagnosis of a localized abscess are tumor and an aggravation of the -symptoms present. But this case exemplified the fact that there may be -cases where there is no aggravation of symptoms, and in a great many -cases it may be impossible to feel the tumor until it has become very -large, owing to its situation, viz., post caecal. Even in this case, -from which a great quantity of pus was evacuated, there was no absolute -certainty of finding pus on opening the abdomen, although it was -suspected strongly. - -I have seen a patient walk into the hospital on Sunday with a -temperature of 100 and a pulse of 99, and when the abdomen was opened on -Monday morning a most virulent form of general streptococcus peritonitis -was found, from which the patient died the next day. It is said that it -is much better to depend on the pulse and its variations than on the -temperature. - -I would like to call attention to several points in the treatment of -this case also. - -First, the place of incision was, as I said, well up towards the iliac -crest, and not in the time-honored McBurney point. The wisdom of this is -self-evident. - -Second, the care used in not breaking up the wall of the abscess formed -by the peritoneum. - -Also, the fact that the appendix was carefully dissected up and tied off -and allowed to heal by itself, obviating, as much as possible, the -danger of a faecal fistula. The older books advised evacuating the -abscess and leaving the appendix to slough off, and, while I have seen -seven cases where this method was used and not a single faecal fistula, -yet it seems to me the more rational treatment to remove the offender, -as I have also assisted in three operations where the appendix was -removed at the second operation. That is, an operation supposedly an -appendectomy was done, and later, at a subsequent period, the diseased -appendix was found still causing the same old trouble. - -Again, the use of the lumbar puncture, so as to drain the abscess cavity -from its very bottom. I wonder this is not done oftener, as it appeals -to me as being a most sensible thing. - -Then the abscess cavity was sponged out with gauze, and not washed out -with the antiseptic fluid that books advise, thus spreading bacteria all -over the peritoneal cavity, and really doing no good. Nature was allowed -to throw off such things as she deemed necessary, an avenue of escape -having been provided. - -And, lastly, the omentum was found and brought down, covering in the -cavity as much as possible, and thus aiding in the walling off process. - - - - - DIRECT LARYNGOSCOPY. - - BY RICHARD H. JOHNSTON, M. D. - - _Read Before the Baltimore City Medical Society, - Section on Medicine and Surgery, - February, 1909._ - - -Direct laryngoscopy, as the name implies, is the inspection of the -larynx through a hollow tube without the use of a mirror. The -examination is made with the patient in the sitting position, under -local anesthesia, or in the prone position, under general anesthesia. To -examine the larynx in the sitting position it is practically always -necessary to give a hypodermic injection of morphia and atropia a half -hour beforehand, to relax the muscles and to prevent excessive -secretion. The patient is seated upon a low stool with the head extended -and supported by an assistant. With curved forceps 20% cocaine or 25% -alypin solution is quickly passed into the throat, anesthetizing -pharynx, tongue and epiglottis. Jackson's slide speculum is then -introduced and the base of the tongue, with the epiglottis, gently -pulled forward. At this point it is usually necessary to use more -cocaine directly in the larynx, which is introduced by means of special -cotton carriers. In a few minutes anesthetization is complete, and the -examination can be made at leisure. It will be found easier to inspect -the different parts of the larynx if the head is held about halfway -between the erect position and complete extension. In some patients with -short, thick necks and large middle incisor teeth the slide will have to -be removed from the speculum to enable one to see well. The examination -in the prone position under general anesthesia is made with the -patient's head over the end of the table supported by an assistant. The -speculum is introduced and the base of the tongue and the epiglottis -pulled upward forcibly. In this position direct laryngoscopy, even in -children, is unsatisfactory, and operative procedures are well-nigh -impossible on account of the muscular rigidity. The force required to -lift the tissues is so great and the position of the arm is so cramped -that it is difficult to get a clear view of the field. The difficulty -has impressed all who have worked in this particular line. It remained -for Dr. H. P. Mosher, of Boston, to discover a method of direct -laryngoscopy which makes it as simple under ether anesthesia as in the -sitting position. In April, 1908, he described in the _Boston Medical -and Surgical Journal_ the "left lateral position" for examining the -larynx and the upper end of the esophagus. He designed certain -instruments which I believe are too cumbersome to meet with popular -favor. In Mosher's position the patient lies on the table with the head -turned toward the left until the cheek almost rests on the table; the -chin is flexed on the chest. In our work at the Presbyterian Hospital we -have found a modified Mosher's position and Jackson's child speculum the -ideal combination for the examination in the prone patient. In children -the procedure is carried out with or without anesthesia. Without -anesthesia the head, hands and feet are held, the chin is flexed on the -chest in a normal position by placing a pillow under the head, the -speculum is introduced and the larynx inspected. In adults under -anesthesia the same procedure is used, and will be found much simpler -than the extended position. In adults, after the speculum is in -position, if the anterior part of the larynx is not seen, gentle -pressure on the thyroid cartilage will bring the anterior commissure -into view. Operations can be done through the tube satisfactorily. With -the different methods of direct laryngoscopy it is possible to remove -any growth from the larynx. - -919 N. Charles Street. - - - - - ITEMS. - - -The Board of Trustees of the Permanent Endowment Fund of the University -held its annual meeting on January 11. Judge Stockbridge was re-elected -president and Mr. J. Harry Tregoe secretary-treasurer, and, with Dr. -Samuel C. Chew and Judge Sams, constitute the executive committee for -the year 1909. The funds and securities in hand total the gross sum of -$18,635.74. - - ------- - -A special meeting of the Washington Branch of the General Alumni -Association was held at the office of the president, Dr. Monte Griffith, -March 11, 1909, to consider the advisability of petitioning the Board of -Regents to establish a Board of Alumni Counsellors, a paid president and -a Board of Trustees, independent of the teaching faculties. Resolutions -in favor of these measures were adopted. - - ------- - -Dr. Louis W. Knight, class of 1866, of Baltimore, has presented to -Loyola College a valuable collection of papal medals. - - ------- - -Drs. H. O. and J. N. Reik have removed their offices to 506 Cathedral -street. - - ------- - -Drs. W. D. Scott and W. E. Wiegand attended the banquet of the Virginia -Military Institute Alumni Association of Baltimore, held at the New -Howard House, March 2, 1909. Dr. W. D. Scott responded to the toast "The -Younger Generation and the Splendid Work of the Virginia Military -Institute Today." - - ------- - -Major William F. Lewis, class of 1893, U. S. A. Medical Corps, has been -relieved from duty at Fort Thomas and ordered to sail on June 5, 1909, -for the Philippine Islands, via San Francisco, for duty. - - ------- - -Dr. Hugh A. Maughlin, class of 1864, of 121 North Broadway, an official -in the United States Custom Service, who was assistant surgeon in the -Sixth Maryland Regiment during the Civil War, is dangerously ill of -pleurisy at his home. Dr. Maughlin is a member of Wilson Post, G. A. R. - - ------- - -Dr. James A. Nydegger, class of 1892, past assistant surgeon, United -States Public Health and Marine Hospital Service, has been promoted to -the rank of surgeon. - - ------- - -Dr. Eugene H. Mullan, class of 1903, assistant surgeon, United States -Public Health and Marine Hospital Service, has been commissioned a past -assistant surgeon, to rank as such from February 2, 1909. - - ------- - -Dr. Samuel T. Earle, Jr., of Baltimore, Md., records the case of Mrs. F. -H. D., who, the latter part of August, 1907, while eating ham, swallowed -a plate with two false teeth. Ten days later she had a violent attack of -pain in the abdomen, followed by a chill and fever. There was no -recurrence of this for one and a half months. Since then they have -recurred from time to time, but not as severe, nor have they been -attended with chill and fever. A diagram taken of the lower abdominal -and pelvic regions showed the plate in the sigmoid flexure of the colon, -on a level with the promontory of the sacrum. Examination through the -sigmoidoscope brought it into view at the point shown by the X-ray. -There was considerable tenesmus, and the passage of a good deal of -mucous, also a tendency to constipation. Under the influence of two -hypodermics of morphine, gr. 1-4, hyoscine hydrobromate, gr. gr. L-100, -and cactina, which produced satisfactory anesthesia, Dr. Earle was able -to grasp the plate through the sigmoidoscope with a pair of long -alligator forceps, and withdraw it immediately behind the sigmoidoscope. - - ------- - -At the Conference on Medical Legislation, held in Washington, D. C., -January 18-20, 1909, resolutions were adopted providing for a committee -composed of one member each from the medical departments of the Army and -the Navy, one from the Public Health and Marine Hospital Service, one -member from the District of Columbia and one member from the Council on -Medical Legislation, to present to the medical profession the conditions -under which the widow of Major James Carroll is now placed, and to -devise such plans as might seem advisable for her relief. The following -committee was appointed: Major M. W. Ireland, U. S. A.; Surgeon W. H. -Bell. U. S. N.; Dr. John F. Anderson, U. S. Public Health and Marine -Hospital Service; Dr. John D. Thomas, Washington, D. C., and Dr. A. S. -Von Mansfelde, of Ashland, Nebraska. - -Mrs. Carroll has been granted a pension of $125 a month on which to -support herself, seven young children and the aged mother of her -husband. The house, which Major Carroll had partly paid for, is -mortgaged for $5,000. Since the conference adjourned the medical -officers of the Army have raised enough to pay the taxes on the house, -one monthly note of $50 and the overdue interest on the first mortgage, -amounting to $125. Believing that the members of the medical profession -will wish to contribute toward a fund for the purpose of paying the -balance due on the house, the committee requests contributions of any -amount. They may be sent to Major M. W. Ireland, United States Army, -Washington, D. C. The editors of THE BULLETIN sincerely hope our alumni -will honor the memory of our most distinguished alumnus by contributing -liberally to this most worthy cause. - - ------- - -At the last regular meeting of the University of Maryland Medical -Association, held in the amphitheatre of the University Hospital, -Tuesday, March 16, 1909, the program was as follows: 1, "The General -Practitioner: His Relation to His Patients, to His Fellow Practitioners -and to the Community in Which He Lives," Dr. Guy Steele, Cambridge, Md.; -2, "Medical Ethics," Dr. Samuel C. Chew. Dr. A. M. Shipley, the -president, was in the chair, and called the meeting to order promptly at -8.30 P. M. The attendance was large and appreciative, and listened to -two remarkably able addresses. Those who had the privilege and pleasure -of listening to the words of wisdom and advice both of Dr. Chew and Dr. -Steele went away with a clearer conception of their duties to their -professional brethren and the public. - -Immediately after the adjournment of the Medical Association the Adjunct -Faculty, with its president, Dr. Joseph W. Holland, in the chair, held a -very important meeting, the gist of which is as follows: Resolved by the -Adjunct Faculty of the Medical Department of the University of Maryland -that the Board of Regents be implored to effect such changes in the -charter as to make possible the election of a president with a fixed -salary, and with the duties usually associated with that office in -standard universities, and a Board of Administrators independent of -teaching faculties. The Adjunct Faculty also endorsed tentative plans -looking towards the formation of an advisory board of alumni -counsellors. - - ------- - -At the meeting of the Section on Ophthalmology and Otology, Thursday, -March 11, 1909, at the Faculty Hall, the following of our alumni read -papers: "Rodent Ulcer of the Cornea (Ulcus Rodens Mooren), with -Exhibition of the Case," Dr. R. L. Randolph; "Purulent Otitis Media of -Infancy and Childhood," Dr. H. O. Reik. - - ------- - -At the meeting of the Section on Neurology and Psychiatry, Friday, March -12, 1909, the following participated: - -"History and Forms of Chorea," Dr. N. M. Owensby; - -"Etiology of Chorea, Dr. H. D. McCarty; - -"Treatment of Chorea," Dr. W. S. Carswell. - - ------- - -The Baltimore _Star_ of March 27th, 1909, has this to say concerning -Prof. Randolph Winslow: "Prof. Randolph Winslow, head of the Department -of Surgery of the University of Maryland, is one of the best-known -lecturers and demonstrators in the East. He is a close student, and has -the faculty of impressing the young men of the University with the force -of and practicability of his knowledge. Professor Winslow stands high in -medical and surgical circles of the country, and ranks with the best -surgeons." Under the caption of the leading men of Maryland _The Star_ -also included a photograph of Professor Winslow. By honoring Dr. Winslow -_The Star_ also honors the University of Maryland, whose authorities -feel a natural pride in the eminent position held by its professors. - -Dr. Fitz Randolph Winslow, class of 1906, a former resident physician in -the University Hospital, and a resident of Baltimore, has located at -Hinton, Virginia. - - ------- - -The Phi Sigma Kappa Fraternity had an at-home Saturday, March 27, 1909. - - ------- - -About sixty members of the Theta Nu Epsilon Fraternity, University of -Maryland, attended a banquet at the Belvedere recently. It was served in -the main hall, and the tables, which formed a semicircle, were -beautifully decorated with trailing asparagus and cut flowers. During -the meal a string orchestra rendered popular selections. Dr. Arthur M. -Shipley, toastmaster, introduced Mr. Frederick W. Rankin, who made the -address of welcome. Mr. Rankin was followed by Dr. C. H. Richards, who -responded to the toast "Past and Present;" Dr. W. D. Scott had as his -subject "The Fraternity Man;" Dr. R. Dorsey Coale, "The Undergraduate;" -Dr. Randolph Winslow, "The Near Doctor;" Dr. John C. Hemmeter, "Our -University," and Mr. C. B. Mathews, "The Ladies." The reception -committee in charge of the arrangements was as follows: Frederick W. -Rankin, chairman; Ross S. McElwee; John W. Robertson, John S. Mandigo, -Arthur L. Fehsenfeld, J. F. Anderson. - - ------- - - - - - DEATHS. - - -Dr. Joseph R. Owens, class of 1859, mayor of Hyattsville, Md., and -treasurer of the Maryland Agricultural College, died at his home, in -Hyattsville, March 15, 1909, after a lingering illness of six months. -Death came peacefully, and at the bedside were his wife, who was Miss -Gertrude E. Councilman, of Worthington Valley, Baltimore county, Md.; -his daughter, Mrs. Geo. B. Luckey, and his son, Charles C. Owens, of New -York. Besides these he is survived by his mother, Mrs. Percilla Owens, -90 years of age; a son, Mr. L. Owens, of New York, and a daughter, Mrs. -A. A. Turbeyne, of England. - -Dr. Owens was born in Baltimore, February 20, 1839, and was 70 years -old. His parents removed to West River when he was seven years of age. -When he was ten years old he entered Newton Academy, Baltimore, and in -1859 was graduated from the Medical Department of the University of -Maryland. Immediately after leaving the University he was appointed -resident physician at the Baltimore City Almshouse, and served in this -capacity to 1861, when he returned to Anne Arundel county and began -farming on West River. In 1885 he removed to Hyattsville and accepted -the position of clerk of the Claims Division of the Treasury Department, -Washington. He held this office until 1890, when he was named as -treasurer of the Maryland Agricultural College, which position he filled -until death. For several years Dr. Owens was collector of taxes in Anne -Arundel county. When the municipal government of Hyattsville was changed -from a board of commissioners to a mayor and common council, Dr. Owens -was elected councilman from the Third ward, and served with marked -ability until May, 1906, when he was elected mayor. - -He was elected for three consecutive terms without opposition, and was -foremost in every move tending to the advancement of the town. As -treasurer of the Maryland Agricultural College he became acquainted with -many of the leading men of the State, by whom he was held in the highest -esteem. He was secretary of the Vansville Farmers' Club for many years, -a director of the First National Bank of Hyattsville. Interment was in -the cemetery adjoining Old St. James' Protestant Episcopal Church, near -West River, Anne Arundel county. The coffin was borne from his late -residence, Hill Top Lodge, by seven cadets of the Agricultural -College--Cadet-Major Mayor, Captains Burrough and Jassell, Lieutenant -Jarrell and Sergeants Freere, Saunders and Cole. A squad of 25 cadets, -five from each class of the College, under command of Captain Gorsuch, -escorted the body to Pinkey Memorial Church, where the Episcopal burial -service was read by Rev. Henry Thomas, rector of St. Matthew's Parish, -of which Dr. Owens had been registrar and a member of the vestry for -several years. The body, preceded by the college cadets, was taken to -the Chesapeake Beach Railway Station and shipped to Lyons Creek, and -thence to St. James' Church. Rev. Henry Thomas officiated at the grave. -The pall-bearers were: Messrs. Wirt Harrison, Harry W. Dorsey, E. B. -Owens, O. H. Carr, T. Sellman Hall and E. A. Fuller. A special meeting -of the Mayor and Common Council was held in Heptasophs' Hall March 22, -1909, to take action upon the death of Dr. Joseph R. Owens, late Mayor -of Hyattsville. Acting Mayor John Fainter Jr., was chairman and Town -Clerk G. H. Carr was secretary. Former Mayor Dr. C. A. Wells eulogized -the late Mayor, both as a public official and a private citizen. Dr. -Joseph A. Mudd, W. P. Magruder, R. E. White, J. W. Aman and Edward -Devlin, all members of the Council who served with Dr. Owens, and R. W. -Wells, M. J. Smith and S. J. Kelly, the last named as members of the -present Council, also made appropriate addresses. It was resolved that -in the passing away of Dr. Joseph R. Owens, Mayor of Hyattsville, we -have lost a conscientious official, a valued associate and a personal -friend, and the citizens of Hyattsville at large, as well as his -official associates, have experienced a bereavement, the effects of -which they will ever feel. - - ------- - -Dr. Asa S. Linthicum, class of 1852, a former member of the Board of -County Commissioners of Anne Arundel county, died at his home, in -Jessup, Md., Sunday, March 28, 1909, from apoplexy, aged 78. About 25 -years ago Dr. Linthicum retired from the active practice of medicine to -engage in iron ore mining. - -Dr. Linthicum's wife, who died about five years ago, was Miss Nettie -Crane, of Clifton Springs, N. J. Interment was in Loudon Park Cemetery, -Baltimore. - - ------- - -Dr. John Bailey Mullins, class of 1887, of Washington, D. C., a member -of the American Medical Association and the American Society of -Laryngology and Otology, formerly of Norfolk, Va., died at his home, in -Washington, D. C., from cerebral hemorrhage, February 11, 1909, aged 42. - -Resolutions on the death of Dr. John Bailey Mullins: - -WHEREAS, It has been God's purpose to suddenly call hence one of our -most useful and beloved members; be it - -_Resolved_, By the Washington Branch of the General Alumni Association -of the University of Maryland, that we are deeply grieved by the -premature death of our honored associate. By his death the public, -especially those worthy of charity, whom he was ever ready to serve, -have lost a most useful citizen, the medical profession a skilled and -painstaking physician and surgeon, and the University of Maryland an -able and active worker. And be it further - -_Resolved_, That the sympathy of this Association be extended to his -daughter, whom he loved before all else on earth, and to whom he was -ever a dutiful father. And be it further - -_Resolved_, That these resolutions be spread upon the minutes of our -Association and a copy of the same be sent to the parent Alumni -Association in Baltimore. - -Committee--I. S. Stone, William L. Robbins, Harry Hurtt, Monte Griffith, -president; W. M. Simpkins, secretary. - - ------- - -Dr. Samuel Groome Fisher, class of 1854, of Port Deposit, Md., died at -the home of his son, in Port Deposit, February 22, 1909, aged 77. For -more than 50 years Dr. Fisher was a practitioner of Chestertown, Md. - - ------- - -Dr. Charles Brewer, class of 1855, of Vineland, N. J., died at his home, -in Vineland, March 3, 1909, aged 76. From 1858 to the outbreak of the -Civil War he was a member of the Medical Corps of the Army, and during -the war a surgeon in the Confederate States service. Under President -Cleveland he was postmaster at Vineland, N. J., and resident physician -at the State Prison, Trenton, from 1891 to 1896. - - ------- - -Dr. William F. Chenault, class of 1888, of Cleveland, N. C., a member of -the Medical Society of the State of North Carolina, died at his home, in -Cleveland, N. C., February 24, 1909, from cerebral hemorrhage, aged 46. - - ------- - -Dr. James B. R. Purnell, class of 1850, of Snow Hill, Maryland, died at -his home, in Snow Hill, March 7, 1909, from senile debility, aged 80. He -was vice-president of the Medical and Chirurgical Faculty of Maryland in -1900-1901, formerly physician to the county almshouse and health officer -of Worcester county. - - ------- - -Dr. Benjamin Franklin Laughlin, class of 1904, of Kingwood, West -Virginia, died at the home of his father, in Deer Park, Md., from -paralysis, March 9, 1909, aged 31. - - -=IN PNEUMONIA= the inspired air should be rich in oxygen and -comparatively cool, while the surface of the body, especially the -thorax, should be kept warm, lest, becoming chilled, the action of the -phagocytes in their battle with the pneumococci be inhibited. - - _Antiphlogistine_ - - (_Inflammation's Antidote_) - -applied to the chest wall, front, sides and back, hot and thick, -stimulates the action of the phagocytes and often turns the scale in -favor of recovery. - -=Croup.=--Instead of depending on an emetic for quick action in croup, -the physician will do well to apply Antiphlogistine hot and thick from -ear to ear and down over the interclavicular space. The results of such -treatment are usually prompt and gratifying. - -Antiphlogistine hot and thick is also indicated in Bronchitis and -Pleurisy - - * * * * * - - - =The Denver Chemical Mfg. Co. New York= - - * * * * * - -Certain as it is that a single acting cause can bring about any one of -the several anomalies of menstruation, just so certain is it that a -single remedial agent--if properly administered--can effect the relief -of any one of those anomalies. - -¶ The singular efficacy of Ergoapiol (Smith) in the various menstrual -irregularities is manifestly due to its prompt and direct analgesic, -antispasmodic and tonic action upon the entire female reproductive -system. - -¶ Ergoapiol (Smith) is of special, indeed extraordinary, value in such -menstrual irregularities as _amenorrhea_, _dysmenorrhea_, _menorrhagia_ -and _metrorrhagia_. - -¶ The creators of the preparation, the Martin H. Smith Company, of New -York, will send samples and exhaustive literature, post paid, to any -member of the medical profession. - ------------------------------------------------------------------------- - - - - - Transcriber's Note - -The original spelling and punctuation has been retained, accept for -confirmed typos. - -Variations in hyphenation and compound words have been preserved. - -Italicized words and phrases in the text version are presented by -surrounding the text with underscores(_). - -Bold words and phrases in the text version are presented by surrounding -the text with equals sign (=). - - - - - -End of the Project Gutenberg EBook of The Hospital Bulletin, Vol. V, No. 2, -April 15, 1909, by Various - -*** END OF THIS PROJECT GUTENBERG EBOOK HOSPITAL BULLETIN, APRIL 15, 1909 *** - -***** This file should be named 53827-0.txt or 53827-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/3/8/2/53827/ - -Produced by The Online Distributed Proofreading Team at -http://www.pgdp.net (This file was produced from images -generously made available by The Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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