The Hospital Bulletin, Vol. V, No. 2, April 15, 1909
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Title: The Hospital Bulletin, Vol. V, No. 2, April 15, 1909

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*** START OF THE PROJECT GUTENBERG EBOOK THE HOSPITAL BULLETIN, VOL. V, NO. 2, APRIL 15, 1909 ***

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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.

*** END OF THE PROJECT GUTENBERG EBOOK THE HOSPITAL BULLETIN, VOL. V, NO. 2, APRIL 15, 1909 ***

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Table of Contents

- THE HOSPITAL BULLETIN

- THE ETHICS OF THE GENERAL PRACTITIONER.

- THE STUDY OF RECTAL SURGERY IN NEW YORK CITY.

- REPORT OF A CASE OF GANGRENOUS APPENDICITIS, FROM THE SERVICE OF PROF. R. WINSLOW.

- DIRECT LARYNGOSCOPY.

- ITEMS.

- DEATHS.

- Transcriber's Note

- THE FULL PROJECT GUTENBERG™ LICENSE