the median line, extending from and through the vulva to near the coccyx, was made. Then the edges of the rectum opening in the vagina were carefully dissected free from the surrounding attachments, and with one finger, which I could now introduce into the rectum, the dissection, or freeing of gut, was cautiously continued, great care and patience being necessary in separating the bowel from the thin wall of mucus membrane, or posterior column of the vagina. In this way about three inches of bowel was freed. The loosened rectum was then pulled backward to its normal anal position, and transplanted between the separated muscular fibers of the external sphincter, which had been divided in the middle in the median incision. The rectum was then fastened to the skin by silk sutures passing through all coats of the bowel except the mucous. The perineum (about 34 of an inch in extent) was then repaired with silk-worm sutures, and lastly the vaginal floor with fine silk. The operation lasted nearly one hour. Enough chloroform to keep the child quiet was given. There was quite a little hemorrhage; shock was considerable; and the baby kept the nurse busy the first twenty-four hours. The temperature chart on the second day showed 101°, (axilla). The bowel discharges were kept carefully removed and the wound kept clean and dusted with a little powder, subiodide of bismuth. The child gave little trouble after the first few days. The wound healed without infection, and at the end of three weeks the patient was discharged from the hospital with a very satisfactory result. There is reason to believe in this case that the sphincter muscle will develop, and perform its normal function. The photographs show, in a manner, the child immediately before, and three weeks after, operation. In Fig. 29, p. 85, Vol. 5, of Von Bergman's Surgery is found a good diagram which illustrates this case. The infrequency of this condition and the meagre literature to be found in our American works on surgery, make the report of each case interesting. On examination every indication of ovarian cyst was present. The fluid did not change its position with a change of posture. There was dulness all over the abdomen, with some tympany in the flanks, particularly in the right, and slight tympany in the epigastrium. The vaginal examination was unsatisfactory, owing to the pressure of fluid in the pelvis. The patient was sent to the hospital for operation. The incision was as short as possible. An enormous quantity of clear fluid escaped, and it was evident that the condition was that of ascites. The liver was found to be enlarged, its thickened nodular border extending down to the umbilicus. The surface was nodular; the nodules were for the most part small, the largest being about the size of a filbert. There were numerous adhesions about the intestines and omentum. The peritoneum was redder than normal but it seemed possible that this might be due to the sudden filling of the vessels after the tension from the fluid was relieved. No tubercles could be found although a very thorough search was made. The tubes and ovaries were normal. With the exception of a rise of temperature her convalescence was wholly satisfactory. Throughout her three weeks' stay at the hospital, her temperature rose about one degree every afternoon, sinking often. to subnormal in the morning. This naturally was very suggestive of tuberculosis. The liver, however, had resembled so strongly a syphilitic one, it was decided to administer potassium iodid. The result was an immediate improvement. The interest of this case, of course, centers about the diagnosis. Not only did the extreme obesity of the patient and the enormous quantity difficult, but in this instance the physical signs of fluid present, make all examinations unusually most commonly depended upon, pointed to ovarian cyst. A CASE OF TORSION OF THE TESTICLE enlarged, 10x16 cm. The skin over the tumor IN THE SERVICE OF DR. G. G. EITEL Mr. M came to the hospital Sept. 23d. His family history stated that one brother and one sister had died from cancer. Otherwise it contained nothing of interest. PERSONAL HISTORY.-The patient is 58 years of age. He is a farmer, of German descent, and for the last 18 years he has been a widower. While in his teens he suffered severely from epistaxis. He states that other members of his family suffered in the same way. He has had a right inguinal hernia for the last 16 years. For the past two years he has noticed a dragging sensation in the left groin, together with pain in the corresponding testicle. This pain became more marked upon lying down. On Sept. 15th he received a severe jolting in jumping from a wagon while the horses were on the run. That evening he felt far from well. In the morning he was unable to get up. The scrotum was much enlarged and was the seat of dragging sensation. There was no vomiting. no vomiting. After a few days he got up but the pain and swelling had increased. It continued to increase until the 21st when he applied cold applications. Up to this time the mass had felt soft on palpation, but now it became tense. It remained in this condition until he was operated upon. At the time he entered the hospital he was suffering very little discomfort. He was somewhat constipated, and for the past two days had had a little difficulty in micturition. On examination the left testicle was found to be enlarged, measuring 11x8 cm., the long axis maintaining its normal position. The testicle was very hard. Posteriorily the epididymis could be palpated. No fluctuation was obtainable. Urinalysis showed a specific gravity of 1027, a trace of albumin and a few finely granular casts. OPERATION.-On Sept. 26th he was operated upon for inguinal hernia on the right side. The tissue in the inguinal region was atrophic and pigmented. On the left side the scrotum was was not tense, and was freely movable. The vessels in the cord above the tumor were distended. The testicle and epididymis were not palpable. There was some fluctuation. A diagnosis of cyst, probably varicocele, was made. On cutting in and puncturing the tunica a bloody fluid escaped. The tumor mass was removed, including a portion of the scrotum. The vessels and cord were ligated near the external ring. PATHOLOGICAL REPORT.-On section of the tumor mass, which is in a collapsed state, the tunica is found to be fibrous and much thickened. In the sac is a dark hemorrhagic fluid. The testicle and epididymis appear tense and somewhat enlarged, and dark-blue in color. The epididymis is cystic, and on section a hemorrhagic fluid escapes. The cut surfaces of the tense testis bulge, and are dark-brown in color, and are almost diffluent in consistency. From the larger to the lesser pole of the epididymis it is seen that the epididymis is twisted nautilus-like on the testicle, and that the apex of this ends in a fibrous cord which communicates with the vessels and cord of the upper portion of the tumor mass. For 2 cm. the cord is a hopeless tangle of fibrous tissue, with here and there a slightly patent vessel. Above this the vessel and cord appear normal. On unwinding the spiral-like twist of the epididymis on the testicle, it is found that the two organs and fibrous mass above had been turned one and a half times on their axis. DIAGNOSIS.-Torsion of cord and epididymis, with degeneration of cerd and vessels. There was atrophy of the two organs, the testicle and epididymis, which were in the last stages of a very old congestion. When scissors become "catchy" their edges can often be surprisingly smoothed by carrying each blade repeatedly from lock to tip between the firmly pressing thumb and forefinger. Each kind and size of scissors has its own capacity, and should be used only for what it is intended. Opthalmic instruments are not intended for ordinary dissections, tissue scissors should not be used for cutting bandages, nor bandage scissors for plaster of Paris. -American Journal of Surgery. himself justice when he speaks off-hand and NORTHWESTERN LANCET without preparation. It seems to be an almost in variable rule that those who discuss papers speak too long and ramble too much. A poor paper that draws out a good discussion is often better, more helpful, than a good paper that brings out none. A good paper that draws out a free and full discussion, in which men give their experience, their failures and their success, is worth while. One such paper at a county or state meeting furnishes ample reason for a man's attendance upon that meeting, while the absence of such papers, accounts, in a large measure, for the small attendance upon medical meetings. Let us have, in all of our meetings, more brief, pithy, meaty discussion, which has been well thought out in advance, and there will no longer be complaint of lack of interest or of small attendance. We shall begin in our next issue the publication of the Minnesota transactions, and we hope to find in the discussions a marked exception to the rule above stated. ANONYMOUS PATENT MEDICINE PRO MOTERS An editorial on alcohol in patent medicines in THE LANCET for Oct 1st. evidently interested some one in Columbus, Ohio, and this "some one" is undoubtedly a manufacturer of patent medicine contaming alcohol. He wrote. an unsigned typewritten letter asking for fair treatment, and encloses in the envelope a circular Two years ago THE LANCET was selected by showing the percentages of alcohol in the tincthe Utah State Medical Association as the ture and drug compounds of the dispensatory of medium through which to publish its transacthe U. S. P. tions, and as the association meets in May, we had hoped to furnish the publication early in the autumn, but this year the stenographer was slow in getting his report into our hands, and the result has been that our pages have been crowded with these papers. We give the last of the papers, except one short one, in this issue. The discussions of these papers emphasize a very important lesson which has been learned only in part by the members of the Minnesota Association. The lesson is that no man can do The list is more or less accurate, but the circular, judging from the spelling, is compiled or copied by some one unfamiliar with drugs. For the sake of argument the percentages are accepted as correct. As an illustation, with the spelling copied fom the circular, we are told that tincture of asafetida, sweet orange peel, ferric chloride, guaiac, fresh herbs, myrrh, tolu and ginger, and liquid extract cimicifuga and cubebs, each contains 94 per cent of alcohol. The doses of these various high grade tinctures and extracts vary from a few drops to one or two teaspoon- drug it contains. This rule does not hold good fuls. in the secret medicines. Other tinctures and preparations contain a smaller amount of alcohol, most of them more than is found in the average patent medicines. There is a possibility that patients may become addicted to the tincture or extract habit through the frequent refilling or the physician's prescription. Such instances are deplorable, and no one would regret it more than the physician. There is a wide difference between a known pharmaceutical preparation and a patent medicine of unknown composition. The former contains a drug of known quantity, dissolved or preserved in alcohol; the latter is made up of alcohol and a drug of unknown quantity and quality. The tincture or extract is compounded for the physician to prescribe for a specific case, and if the drug is reliable and active, certain results may be anticipated. The patent medicine is put on the market to sell to everybody, and is frequently guaranteed to cure from five to thirtyfive diseases. The diagnosis is left to the patent medicine man and the too responsive patient who is ready to be cured for 67 cents or its multiple. Many drugs are recognized as unstable and inert even by the U. S. Pharmacopeia. Who is to say whether the patent medicine contains active or inert drugs? There is no denying the benefits of suggestion, and perhaps patent medicines do some good in some cases by their persuasive testimonials and flim-flam promises, but why not educate the public in a better plane of medicine? The physician is the one to make an examination and diagnosis, as well as to suggest the remedy, and it seems unreasonable for the patent medicine to attempt either diagnosis or remedy at such a great distance from the patient. Reputable physicians do not make rash promises to cure many of the diseases that the patent medicine man belittles into trifling and curable ills by a secret and unreliable nostrum. Physicians will continue to prescribe tinctures and extracts, but they cannot expect that patients will swallow them as confidently or continuously as the patent medicine is absorbed. The alcohol in the chemist's tincture may be excessive, but it is chemically proportioned for the The fight against patent medicines that contain an excessive amount of alcohol will continue, not only against the alcohol, but against the methods of the patent medicine advertiser. It is still safer to consult a physician than it is to rely on the promises of an unknown agent who sells an unknown compound to an unknown person who is supposed to have an unknown disease. CLASSIFICATION AND DIAGNOSIS OF INSANITY The text-book on insanity twenty-five years ago and the latest publications of the day show very plainly the modern trend of the psychiatrist. In the earlier publication the classifications and definitions of insanity were appalling to the student of medicine. Almost every symptom represented a type of the insane; perhaps it would be better to say that the classifications were divided and subdivided until they resembled a genealogical tree with the trunk unnamed, but with each branch labelled. To-day the trunk represents the individual, to be carefully observed as to its construction and constructive properties; the large branches represent a few important symptoms similar in appearance to the trunk itself—a part of the individual more or less changed according to environment; the smaller branches are the minor symptoms gradually fading into space. The older writers told us of the varied types. of mania each form separate and distinct and sharply defined. Today mania and melancholia are merged into one form of the disease with the same predisposing and exciting causes, but manifesting themselves by excitement or depression or they are so interlaced as to be impossible of separation. To cover the uncertainty of definition, or rather, to embrace excited and depressed states the term manio-depressive insanity has been coined. It is a name that suggests uncertainty and doubt or a name used to cover confusion in diagnosis. Gradually, the term "circular insanity," first described by the French psychiatrist, will cover the field so as to embrace all of the types in which excitement and depression are the predominating features. Fortunately, the simpler classification is adopted by the later writers, and the subdivisions that were formerly employed are rapidly disappearing. What is more important, the individual is recognized rather than his chain of mental symptoms. The study of insanity can be carried to a satisfactory diagnosis only by adopting the standards of the clinician and his study of the organic structure of his patient, together with his knowledge of the histology, function, and pathology of the nervous system. This can be obtained only by anatomical and physiological analysis of discase processes and a study of the normal and abnormal minds of everyone supposed to be insane. Psychiatry is the highest branch of internal medicine, and it is one that calls for the widest knowledge on the part of the physician. The most detailed methods of examination are demanded before a reasonable conclusion is possible. A layman may make a diagnosis of the ordinary forms of furious insanity, but it requires the closest and most experienced observer to recognize the borderland cases, and to determine the cause and diagnosticate the form of the disease in a majority of the cases. The psychiatrist who is trained in the study of man and his inherent tendencies as applied to disease in general, is the man who should be recognized as the highest type of the internalist. Such a man is broad in his applications of the principles of medicine. Nothwithstanding the fact that the insane are relegated to the care of hospitals for their protection, as well as for the protection of the public, the study of insanity must be encouraged from every possible standpoint, in order that the public and the physician may be in sympathy for the betterment of the insane. A higher percentage of recoveries, and the disappearance of the supposed stigma that surrounds the insane, would follow if the claims of the student of mental disease were more keenly appreciated. NEWS ITEMS Dr. L. O. Johnson, has moved from Granite Falls to Winthrop. Dr. O. G. Wicherski, a graduate of Rush, has located at New Ulm. Dr. W. V. Gulick, of Rochester, was married last month in Canada. Dr. J. B. Muir, formerly of Hallock, has decided to locate at Roseau. Dr. D. A. Sutton, a Rush graduate, has located permanently at Rushmore. Dr. Lewis Little, a recent graduate of Rush, has located at Lake Wiison. Dr. L. H. Kermott, a 1904 Hamline graduate, has located at Towner, N. D. Twenty-nine physicians took the State Board Examinations in North Dakota last month. Dr. Heinrick Tillisch, of Canby, was married last month to Miss Maud Stokes, of Watertown, S. D. Work will not be begun until spring upon the building for the Lutheran Hospital at Mankato. Dr. John Knight, who has practiced for a number of years at Sebeka, has decided to locate in Canada. Dr. Mary E. Pittman, of Springfield, Ill., has formed a partnership with Dr. Goodfellow, of Aberdeen, S. D. Dr. Frank C. Todd, the Minneapolis oculist, has returned from Europe where he has been doing special work. Dr. E. E. Barrett, of Glencoe, has purchased a lot upon which he expects to erect a hospital building next spring. Dr. W. J. Benner, who recently located at Willow Lake, S. D., was married last month to Miss Mary Peeler of Anna, Ill. Dr. A. J. Krahn has purchased the practice of Dr. Birkelund, of Phillips, Wis. Dr. Birkelund will practice in Chicago. Dr. C. L. Larson, of Murray Hospital, Helena, visit of several Mont., has returned from a months to Europe for special study. Dr. John J. Catlin, of Buffalo, a State University graduate, class of '03, was married last month to Miss Edith Larkin, of Allen. |