left out from this paper a consideration of the cystoscopic examination. of the bladder and the examination of the ureters, as it would render the paper too long, and he wishes to consider merely methods of examination not requiring a special equipment, and that anyone could make.

The writer himself wishes to acknowledge he has not been entirely free from mistakes in making diagnosis of the diseases of the female generative organs.

On one occasion he thought he had a typical case of appendicitis in a girl about fifteen years of age. The patient had tenderness over McBurney's point, marked rigidity of the right rectus, slight elevation of temperature, etc. A prominent abdominal surgeon and gynecologist agreed with the diagnosis, an operation was advised and consented to. What was our astonishment to find a pale normal appendix that had never been inflamed, but we did find the uterus and both tubes and ovaries studded all over with tubercular nodules, and this could have been correctly diagnosed before operation if we had been more thorough in our method of examination. That patient should have been anæsthetized, the cervix grasped with a tenaculum forceps, the uterine adnexa thereby pulled down and a bimanual examination made through rectum and abdominal wall, and I know those numerous tubercular nodules could have been palpated and correctly diagnosed and the patient given the chance of constitutional treatment, if her parents so desired. However, she recovered health and strength and was greatly improved following the operation.

The writer knows of a case where the physician could have saved himself much mortification if he had been in the habit of practicing thorough methods of diagnosis of the pelvic organs. It was simply a case of pseudo-cyesis, or false pregnancy. He even went to deliver her, and had the patient send for the nurse, only to find on consultation with a brother practitioner that his patient was not even pregnant.

The writer has seen, too, a large prolapsed fibrous ovary with a retroverted uterus, the posterior surface of the uterus pushing the ovary against the rectum, mistaken for a subperitoneal fibroid, whereas, if the uterus had been pulled down to vulva with a pair of forceps, the identity of the ovary as a separate organ from the uterus would have been established and the patient had a chance of relief without operation, as the uterus was not bound by adhesions, but could have been replaced. These are but a few of the frequent mistakes in diagnosis made in these regions.

The writer knows that the most expert often make mistakes after painstaking examinations, but the point he wishes to make is that so often mistakes are made through carelessness or a lack of thoroughness.

In closing this paper the writer wishes to again disclaim any special originality for this paper and to acknowledge indebtedness to recent authors on the subject, and to current literature.

DISCUSSION.

DR. SIMRALL ANDERSON: I have listened to Dr. Kelsall's paper with a great deal of pleasure. We all know that in intra-abdominal troubles we can never be certain what condition actually exists until the abdomen is opened.

I believe the position of the patient in making gynecological examinations is of great importance; have a table rather than a bed, then have the patient elevate her hips and at the same time relax her abdominal muscles. By elevating the hips we shorten the distance from the vulva to cervix which is a great help; the rectum and bladder must always be empty.

I do not believe pulling the uterus down is necessary. If there are adhesions it is not proper to attempt to do so, and if there are no adhesions, the hips of the patient beng elevated and the abdominal muscles lax, it is comparatively easy to push the uterus down from above sufficiently to detect any pathological condition in the pelvis. One of the most important things in making a gynecological examination is to determine whether there is any fixation of the uterus. If there is and the patient has pain in the back and lower part of the abdomen with some rectal and bladder symptoms, etc., it is nearly always safe to assume there is some pelvic trouble which requires abdominal operation. The bladder symptoms are also very important; in fact, I have known cases where the only symptoms of very extensive pelvic disease were those in connection with the bladder.

DR. KELLER: The paper was certainly an excellent composition and the doctor has covered the points very thoroughly.

I desire to agree with Dr. Anderson, however, about pulling down the uterus. I have always made it point to elevate the patient's hips and when this was done I have always been able to get around the cervix as far as was necessary. However, in a great many cases, notwithstanding expert examinations, we are unable to tell just what we are going to find until we open the abdomen.

I cannot add anything except to say that the paper is a very valuable one and I believe we have all been benefited by it.

DR. HENDON: Dr. Kelsall's paper is certainly a very valuable contribution to this particular subject and serves to impress upon us some very important and prac tical points that we are all prone to overlook for various reasons.

One thing that occurred to me while the doctor was reading his paper is that the physician himself should take some precautions to protect himself in making these examinations. We have all heard of cases of syphilitic infection having been transmitted in that manner and several members of the profession have suffered considerably on that account. As a general rule the doctor is more careless about himself than he is with the patient.

Another point is conducting gynecological examinations in the office. It has beenmy experience that such examinations are rather unsatisfactory owing to the fact that women generally come into the office dressed in their street clothes and on that account I have adopted the rule that where a thorough and complete examination is required to make it at the patient's home where they can properly disrobe. Of course, I realize that a table cannot always be had and the examination must be made with the patient on a bed or couch, but I believe this inconvenience is offset by the advantage gained by having the patient properly undressed.

Another point which I would like to emphasize is that by the introduction of two. fingers into the vagina we can explore a wider range of territory and acquire a much more extended knowledge of existing conditions than with one finger. The importance of making rectal examinations in gynecological cases with one finger in the rectum and the other in the vagina should not be overlooked.

In regard to pulling the cervix down to the vulva, I wish to say that while I have made a few mistakes in diagnosis I have, as a rule, been able to make very satisfactory examinations without resorting to this method.

DR. LEAVELL: There can be no doubt that most mistakes in diagnosis are due to the fact that examinations are not made sufficiently thorough. The methods which the doctor advocates in his paper are certainly very complete so far as gynecological examinations are concerned. I wish to emphasize the importance of the use of the head-mirror particularly in making examinations of the cervix and vagina. It is a common belief that the head-mirror belongs to the eye, ear and throat specialist, but with it a rectum may be inspected through a tube eighteen inches long and it can be done thoroughly.

As to the fixation of the uterus, this is another most important point. Whenever we find that the uterus is fixed we know that we have some abnormal condition to deal with and it is most likely a pelvic condition. Of course, there are other intra-abdominal lesions which might cause fixation of the uterus, but it is generally a pretty clear indication that there is some pelvic disorder.

If all examinations were conducted in as careful a manner as Dr. Kelsall advocates in making gynecological examinations, our mistakes would be a great deal fewer.

DR. TULEY: Dr. Hendon's remarks about making examinations at the homes of patients are timely, and he might have gone a little farther. We all know that our reputation is in the hands of our patients and even in this city there have been a number of cases of blackmail as a result of the fact that there were no witnesses present at the time examinations were made. For the physician's own protection all gynecological examinations should be conducted at the home of the patient where some member of the family can be present, or if in the office of the physician, always with a third person present.

DR. OSCAR BLOCH: I enjoyed Dr. Kelsall's paper very much and will add only one or two things which I consider essential to a complete examination; particularly, do I think that an examination is incomplete without a thorough search for a dislocated kidney.

The excursions of a movable kidney can be readily detected by means of bimanual palpation, one hand being in the posterior lumbar region and the other hand opposed to it, anterior, causing the recumbent patient to make deep inspiration and exhaustive expiration, the kidney can be felt as it passes between the opposed hands. Often, it is well to have the patient lie on first one side and the other while these efforts at palpation are being made. I believe that movable kidneys are much more frequent than generally thought and that many vague nervous and gastric symptoms are due to this condition.

The hernial orifices should be examined for a possible hernia and I think it well to cause the patient to cough while the hand is placed over the openings; in this way, often, one can detect a small hernia which is reduced by the recumbent posture of the patient and which may explain the abdominal or pelvic symptoms of which the patient complains.

Much information, especially, as to the position of the uterus and adnexa is to be obtained by an examination while the patient is standing, and I consider an examination incomplete where the patient has not been examined in this position.

Dr. Kelsall's paper this evening recalls to me a patient upon whom I recently operated, with complete relief of all of her nervous and gastric symptoms, who had been, according to her own statement, treated for "stomach trouble" by several physicians.

Examination revealed that she had rectocele, an ulcer of the rectum, an urethral caruncle and a lacerated cervix uteri.

I report this, merely, to emphasize, clinically, as it were, Dr. Kelsall's opening statement about the importance of a thorough and regular examination of each patient.

DR. FREEMAN: In regard to using the fingers in making gynecological examinations, I have never, except on very rare occasions, attempted to use two fingers. I

can usually reach as far, if not farther, with one than with two; besides, in some women trouble will be experienced in getting two fingers into the vagina and if there is much inflammation about the vulva it will elicit considerable pain, especially in a nullipara.

In regard to pulling the uterus down with a tenaculum, I believe that this is dangerous when a woman is suffering with some pelvic derangement. We are liable to break some pus sac and serious trouble may follow. I like the erect posture especially when ballotment is to be practiced.

DR. KELSALL: In regard to the various remarks about pulling down the cervix, I believe I stated in my paper that this method was always to be used with caution and should invariably be preceded by the ordinary bimanual examination. Of course, if we ascertain by the last mentioned examination that the uterus is more or less fixed by adhesions, it is dangerous to pull it down, but when we do attempt it great care should be exercised. This method was particularly applicable to the case reported in the paper where the entire surface of the uterus, tubes and ovaries were covered by tubercular nodules.

Elevating the hips is a very good plan but the same purpose is served by having the buttocks on the edge of the table and placing the feet in vertical stirrups.

Dr. Tuley makes a very good point in reference to having witnesses present while examinations are being conducted.

I have found by experience that the generative organs can be examined much better with two fingers than with one, and with very few exceptions the introduction of two fingers will cause no more discomfort than one.

DR. BLITZ: 1 have a case in which I have been unable to make a satisfactory diagnosis. The patient, a man, gives the history that several years ago after eating bananas and cream he experienced a very severe pain in the back. Several times after that he ate bananas and cream and each time thereafter he suffered from pain in the back and came to the conclusion that the dish mentioned was the cause of it and did not touch it any more. A week or ten days ago he ate some salmon salad and upon getting up to leave the table he discovered that his legs were very weak and he had to have somebody assist him to his room. There was no cramping or anything of that kind; they simply became very weak and numb. This weakness disappeared in about two days, but a day or two after that while he was going upstairs they commenced getting weak again; this time it only lasted one day. When I saw him he was very nervous. He was a man who smoked about fifteen cigars a day and drank a good deal of coffee. I would like to ask whether it is the opinion of any one present that the man's stomach could produce the condition described or whether it is simply a hysterical condition.

DR. HENDON: I wish to inject into the discussion a fact that has been very forcibly impressed on my mind, and that is that the incompatibility of fish and ice cream seems to be established among the laity. I have never heard them say anything of ice cream and bananas but I have been asked several times about the incompatibility of fish and ice cream.

DR. HUGH LEAVELL: Two weeks ago I was called to see a man who was suffering with cramps in the lower extremities. There was no fever and no history of digestive disorder of any kind and no headache; merely cramps in his lower extremities from the knees to the ankles. I thought perhaps he had a little autointoxication of some kind, probably due to the liver, and gave him free purgation. Four days later I was called to see him and found that he had facial paralysis on the left side, involving also the left half of the trunk. He denied positively the existence of syphilis; he has never imbibed excessively and particularly is this true of the last year during which time he stated he had taken no intoxicants. The facial paralysis is to-day in the same condition that it was a week ago; there has been no cessation, no involvment of the

ear, no tenderness in the region of the mastoid and no evidence of any involvment of the facial nerve. The man has been taking iodide of potassium in ascending doses until he now takes twenty drops; he has also been taking strychnia.

It is a question what causes this facial paralysis particularly at this season of the year. The cramps were intermittent coming on at intervals of an hour or two, and lasted only three or four days. The man is thirty-eight years of age and is employed as an engineer in one of the railroad offices here, which, however, does not seem to have any bearing on the case.

DR. MOREN: Can he shut his eye or raise his eye-brow?

DR. LEAVELL: He cannot shut his eye, but he can move his eye-brow.

DR. MOREN: The chances are that this will prove to be peripheral neuritis and independent of the cramp in the limb. The lesion must be very extensive to affect both centers of the seventh nerve. The branch that goes to the upper face is separate and a little bit away from the branch to the lower face. In cases of apoplexy the lower face is usually the part affected. The eye may be involved for a short time but it soon passes away and leaves paralysis of the lips only, while in peripheral paralysis the whole face is affected.

DR. TULEY: I wish to exhibit a temperature chart in connection with a case of typhoid fever which presents two unusual features. The patient, a boy about nineteen years of age, developed a typical case of typhoid fever in every respect. On the twentyseventh day of the disease the temperature, in about five hours, dropped from 103 4-5 to 96 2-5 without any hemorrhage and apparently no cause for the reduction. Within the same twenty-four hours it rose again to 103 2-5 and dropped to normal the next day. For four days it ranged between 100 and 101. On the nineteenth day the boy developed paralysis of the external muscle of the right eye and this exists to a certain extent to-day, although it is gradually improving. There was double vision for a week or ten days after it was first noticed.

me.

The enormous drop in temperature without hemorrhage was a new experience to This case emphasizes the importance of the use of temperature charts.

DR. LEAVELL: The condition described by Dr. Tuley might be explained by the theory that a central lesion developed causing the paralysis of the abducens nerve which supplies the external rectus and also involving the heat center just at the time the temperature dropped. There must be close relationship existing between these two conditions.

THE

A STUDY OF BURNS.*

BY T. K. VAN ZANDT, M. D.

HE term burn signifies those cutaneous trumatisms due to the action of heat or caustic chemic substances upon the skin. The importance of the local lesion, relative to the course, symptoms, sequelæ, prognosis, and treatment, varies with the degree of the causative temperature, the duration of its influence, and the extent of the burn. We, therefore, for practical reasons, divide burns into three classes, or degrees, which represent, not separate and distinct forms of the pathological condition, but merely grades of intensity.

The first degree, or combustio erythematosa, is simply a slight inRead before the Louisville Society of Physicians and Surgeons, April 20, 1905.