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a judicial estimate of their value. It is, moreover, essential to appreciate two other facts: First, the evidence on this most complicated question, although sufficient to lead to the greatest apprehension, is not yet sufficient to establish definite and undeniable proof on the extreme side of the question; second, many excellent clinical observers in private practice are disposed on the whole to qualify the danger of the situation, and to conclude that it is vastly underestimated. If the question involved matters only of scientific interest, their solution would properly wait for further and more exact observation. But the "danger and duty of the hour" is concerned with moral not scientific problems, and the moral obligation is serious enough to lead the writer to present it, even from the ex parte standpoint.

"Why do large numbers of apparently healthy young women date their pelvic infection from the marriage week?" Is it, as one author declares, the “fatigue and excitement of the wedding journey?" Why do so many women with perfectly developed reproductive organs remain sterile from the time of marriage or after the birth of a single child and a dangerous "child bed fever?" The causation of too many of such cases of hopelessly diseased uteri, tubes and ovaries, not to mention proctitis with sometimes rectal stricture, urethritis, cystitis, pyelitis and nephritis, has been explained by the word idiopathic. Their histories, if written, would often tell of an apparently cured gonorrhea before or after marriage in the husband. If the most destructive infection may follow contact with a subject of gonorrhea after the discharge has ceased, how perilous must be the slight gleety discharge so often disregarded. Young men are sometimes advised to marry in order to improve their sexual hygiene, and so to cure an intractable chronic but "innocent" gleet. Such advice may result in the destruction of the reproductive organs of an innocent woman. It is doubtless possible, perhaps not unusual, for gonorrhea to be so cured that the individual cannot transmit the disease. Failure, however, to cultivate the gonococcus from the urethral secretions does not prove its absence. So long as it can be cultivated marriage is prohibited. Repeated attempts should be made in every suspected case. Marriage should be deferred at least until after repeated efforts have failed. A gonorrheal record does not necessarily settle but it always complicates the question whether the individual may safely marry.

PATHOLOGY AND COURSE.

Bacterial invasion and consequent infection may spread and may involve any or all of the genito-urinary organs by either or both of two

routes:

1. By continuity of surface or tissue. 2. By the lymphatics or blood vessels.

By continuity of surface the course is usually upward from the vulva or vagina, through the uterus and Fallopian tubes to the ovaries and peritoneum or through the urethra, vagina, bladder and ureters to the kidneys. The numerous glands of the vulva are strongholds where the virus may intrench itself and whence the constant supply may find its way to the organs above.

The vagina advantageously covered with pavement epithelium is relatively smooth, like skin, and supplied with an acid secretion. Bacteria, therefore, find lodgment there less easily than in the vulva. Moreover, the acid medium is unfavorable to the culture of about 90 per cent of all pathogenic microbes. This also makes the vagina a difficult barrier to pass.

The uterus, although protected by these anatomical and physiological conditions of the vagina, is itself especially vulnerable, on account of the loose arrangement and thinness of its epithelial covering, the villous network of its arbor vitæ, the confluence and ramifications of its glands and the richness of its periglandular and perivascular network By reason of these conditions the cervix uteri is adapted to receive, retain and distribute infection. Were it not for the tonic muscular contraction at the external and internal ora and at the utero-tubal constrictions, the frequency of infection of the endometrium, already great, would be much greater. 5

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The Fallopian tubes are embryologically and anatomically continuous with the uterus, are in fact, a part of it, and subject to the same causes of infection. The ovaries and pelvic peritoneum in direct communication with the tubes may receive infection from below. fection by continuity of surface, however, although usually from that direction, does not always come from below; it may reach the ovaries and pelvic peritoneum from above and descend through the tubes, uterus and vagina to the vulva. Tubercular infection, for example, usually goes in this direction.

Infection by the Lymphatics and Blood Vessels is undeniable in puerperal women. The trumatisms of parturition, often very exten

sive all the way from the uterus to the vulva, may open wide the door for infection to be transmitted by this way. The destructive influence of the inflammation, phlebitis and lymphangitis, on the vessels themselves may seriously and permanently impair the nutrition of all the pelvic organs.

The route by continuity of surface, save in puerperal cases, is generally accepted, and that by the lymph and blood-vessels is often denied.

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If infection is often transmitted from the genitals by way of the lymph vessels to the inguinal glands—the bubo is proof of this—it is evident that it may also travel by way of the lymph vessels a much shorter distance from the vagina or cervix to the parametria, perimetria and tubes. This reasoning by analogy has been verified by experiment. Some observers, notably Lucas Champonnier, claim that this is the more common mode of infection. Wert heim, from experimental investigation on white mice, rabbits, dogs, guinea pigs, etc., concludes that the gonococcus infection can pass through pavement epithelium and connective tissue, and thus reach and be carried by the lymphatic and vascular channels from the vagina or cervix to the ovaries, tubes and peritoneum, producing thus ovaritis, salpingitis and peritonitis. Giglio also experimentally demonstrated that infection may travel from the vagina, cervix and bladder to the broad ligaments, and may produce extratubal pelvic abscesses. He maintains that infection by the vessels is more frequent than by continuity of surface. When the latter occurs, he claims that it is more commonly in the descending order from the tubes to the uterus. This statement may have to be revised.

Continuous infection does not always mark the course of the microbes through the vessels. They colonize at the points of least resistance, hence the tubes may suppurate and the ligaments and ovaries go free. When, however, the microbes travel by way of the mucosa, a continuous inflammation is usual, though not invariable.

Infection by the veins is specially common in puerperal cases. It has often produced general septicemia and pyemia through very slight lesions. The arteries also may carry infection. This is proven by the fact that bacteria have been found in p aces where they must have been carried by the centrifugal circulation; for example, the gonococcus in the kneejoint. Hetero infection of the genitalia-that s, infection from without- s not the invariable rule.

Diseased organs may send their germs

by way of the lymphatics or blood vessels, and produce secondary infection of the pelvic peritoneum, ovaries, tubes and other genitalia. Tubercular infection of the tubes, secondary to that of the lungs, is a familiar example.

Experiment and clinical observation both show that puerperal and non puerperal infection may travel by blood-vessels, by lymph channels and by continuity of surface. The relative frequency, however, of these modes, of transmission is a matter of speculation. Possibly the route by continuity of surface is really a superficial lymph route-that is, the infection may travel along the lymph channels of the mucosa.

CLASSIFICATION.

Let us now raise a question relative to the looseness and confusion of the current classifi cations. The term simple infection as distinguished from septic, for example, has no strict pathological meaning. It is not yet settled whether the so-called simple infection is aseptic or whether it is only slightly septic. We know that an inflammation seemingly very mild may readily take on a decidedly infectious character.

We may think of the infective or inflammatory process in several ways: (1) As having gone only into the congestive stage; this would be a mild form. (2) As having gone on to the stage of effusion or suppuration. (3) As being the result of a mild or virulent in fection. (4) As occurring in structures of greater or less resistance. What is there in such conditions to designate on the one hand as simple, on the other as septic? In the present state of our knowledge we must use for descriptive purposes an adaptable and therefore flexible nomenclature. In this nomenclature words like simple and septic can have only a loose clinical significance. They cannot be u ilized as the outcome of scientific classification. We might simplify the subject by throwing out such words as simple.

A distinction between acute and chronic inflammation, since these conditions enter extensively into the pathology of the diseases of women, is most important. Many deny altogether the existence of chronic inflammation, for example, of the endometrium. Some attribute the condition which is usually classed under that name to congestion; others call it a subinflammatory state. It may be well in passing to remark that an essential factor of inflammation-round cells-is found in these chronic conditions, and that they may therefore be properly classed as inflammatory. We shall

avoid the question whether certain conditions should be called congestive, inflammatory or subinflammatory. The discussion of this question is long, tiresome and unprofitable, a contest largely of words. The following outline of some of the phenomena of inflammation will help to make clear the distinction between acute inflammation and the conditions which are commonly grouped under the name chronic inflammation.

The inflammatory reaction which living tissue exhibits to morbid irritation is first defensive and then constructive or reparative. The defensive process is an effort to circumscribe the disease by throwing around it a limited wall of exudate; the morbid action thus confined and concentrated within narrow limits, is within those limits more or less intense or destructive. It may result in the sacrifice of a part for the safety of the whole. The force of the disease is spent in the destructive process, and may be active only or chiefly within the limiting wall. Finally normal conditions of nutrition are re-established, the constructive or reparative process becomes active and the limiting wall is absorbed. If the constructive process continues until repair is complete and then ceases, the part will resume its normal functions; the inflammation will be at an end.

Acute Inflammation.-If the infection is of such virulence or of such character as to call forth the defensive processes just described and to produce blood stasis, with more or less severe swelling, pain, heat and redness and finally to produce local destruction, the inflammation is acute. The disease may terminate with resolution or go on to suppuration.

Chronic Inflammation.—If the irritation is of minor intensity, or in any other way of such character as to fall short of provoking much defensive action, there will be little or no limiting wall, and consequently no intense destructive process concentrated within a circunscribed space; heat, swelling, pain and redness if present will be more diffuse and less pronounced. Under these conditions there is a minimum of defense and an excess of construction, and the inflammation is chronic.

Chronic inflammation may follow acute inflammation, or may have been sub-acute or chronic in the beginning. The excessive constructive action which belongs to it explains the hyperplastic and hypertrophic results of so-called chronic metritis. It also explains certain morbid nutritive changes in the blood

and lymph vessels of the pelvis and in the cellular tissue of the pelvis. Sclerotic changes in other organs, such as arterial sclerosis and interstitial nephritis, offer a close analogy.

It is unprofitable to speculate on the question whether the conditions just described under the name chronic inflammation would better be classified as congestive or as subinflammatory states. They are recognizable under either of these names. They occur more frequently in neuropathic women, and especially in cases of the various diatheses, anemia, lithemia, gout, cholemia. Diabetes also is a strong predisposing cause. They are usually less dangerous to life and often more destructive to health than the acute infection. They constitute a large proportion of the ailments of women and include some of the most distressing ailments. They are persistent and hard, often impossible, to cure. In such cases it is often difficult to draw the line between those congestions which fall short of inflammations and actual inflammation. One of the most common forms of so-called uterine catarrh is that which occurs in women of deficient eliminative power; that is, the bowels, kidneys and other eliminative organs fail to throw off sufficiently the waste products. Under these conditions the mucous glands of the uterus, for example, whose function is not excretory, may vicariously undertake to make good the deficiency. An infinite amount of misdirected and injurious local treatment is constantly being applied to the endometrium in such cases.

The significance of pelvic infection varies according to the resistance of the patient, to the location and nature of the structures involved and to the virulence of the causes which produced it. Strong predisposing causes make the women less able to resist morbid irritation, and infection once established is more likely to be severe and progressive. If infection is confined to superficial areas, its gravity is relatively much less than when deeper structures are diseased. Endometritis, for example, is less serious than an inflammation involving the parametric lymphatics and veins. Moreover, the same infection may be somewhat more serious in some places than in others. This may be illustrated by the case of a inan who picked his teeth with a vaccine point and experienced a most distressing result. Some bacteria are useful, some harmless, and some only mildly virulent. The gonococcus, for example, is more general and therefore more disabling than the staphylococcus. The strepto

coccus pyogenes is more dangerous than either. From the foregoing it is easy to explain why an infection, even in the deeper structures, if not from very destructive bacteria, may present in the more acute stages most of the subjective and some of the objective appearances of a fatal disease, and yet after a few days terminate in a complete return to health. The reason is also obviods why a superficial vulvar infection, apparently innocent, may be the result of a gonococcus or of a streptococcus invasion, and may by continuity of surface or by way of the lymphatics or veins finally destroy life or render it miserable and useless.

DIAGNOSIS AND PROGNOSIS.

The symptoms are often utterly disproportionate to the lesions. An infection of little danger may cause the greatest misery; another which directly threatens life may be almost painless. Objective examination should, therefore, especially in acute cases, be thorough. The subjective symptoms may be misleading. The prognosis depends upon the region infected, the general and local resistance of the patient and the nature and extent of the infection.

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PHYSICIANS AND APOTHECARIES IN PURITAN NEW ENGLAND.
BY HERBERT C. VARNEY, ST. PAUL, MINN.

Of physicians and apothecaries in early New England it may almost be said that for the first hund ed years there were none; that is, in the sense of the word as we understand it.

It must not be inferred from this, however, that our Puritan forefathers were without medical attendance; far from it, but the physicians in those days were the ministers; these were men of education and learning, nearly all of them being graduates of the University of Cambridge in England, and those of a later date of Cambridge in New England.

Many of them had been ejected from their livings for non-conformity, and some of them had taken up the practice of medicine to obtain a living. Others, after coming to this country, in order to support themselves—their pastoral salaries being insufficient-studied a few med. ical books, and then ministered to their neighbors in both spiritual and temporal things. It was in the hands of such men that the practice of medicine was placed for nearly the first hundred years of New England's history.

The first New England physician of whom I find any record is Dr. William Gager, who came out in the spring of 1630, probably in the same fleet with Winthrop. Not being used to

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life in a new country, he could not endure the
hardships of his new surroundings, for his death
is recorded at Charlestown in September of the
same year. John Dean, or as he styled himself
"John Dean Chirurgeon," was an early physi-
cian of Ipswich, Mass. He died in 1648. His
son, Philemon Dean, was one of the early
physicians of his native town, renowned both
for his skill in medicine and for his standing in
the meeting house. His gravestone, with its
quaint Puritan epitaph, still stands in Ipswich.
Here lyes ye body of Doctor Philemon Dean who
died October ye 18th, 1716, aged 70 years.
O Lord, by sad and awful stroaks,
Of man's mortality;

O let us all be put in mind
That we are born to dye.

Grave saint behind that cannot find,

Thy old love night or morn.

Pray look above, for there's your love

Singing with ye first born."

The last two lines of this stanza were quite popular among Puritan epitaph makers.

Another famous physician of Ipswich was Dr. Thomas Wells, more often spoken of in the old records as Deacon Wells. He died in 1666. By his will he left to his son "phissic bookes" valued at about nine pounds.

Some of the early physicians who came to New England found the practice of medicine but a "meene help," at least Giles Firmin of Boston found it to be such He came in 1633, and is spoken of in the records as a "godly man, an apothecary of Sudbury in England." In an account of his life written by himself he says: "Being broken from my study in the prime of my years, from eighteen to twentyeight, and what time I could get in those years, I spent in the study and practice of physick in that wilderness." The wilderness afforded him but a very "meene" living, for in a few years we find him back in England again, and exchanging the profession of medicine for that of theology, when he became quite a noted minister. He has left one tribute to his early New England neighbors which is worthy of repetition. Before a meeting of divines held at Westminster in 1654 he said: "I have lived in a country seven years; all that time I never heard one profane oath and all that time never did I see a man drunk."

The most famous of the early physicians of Boston was Dr. John Clark, who had also settled for a time at Newburg. He was the first physician in this country to perform the operation of trepanning the skull. Dr. Clark died in 1664, aged sixty-six years. He had a son, also a doctor, who was one of the early settlers of Rhode Island.

James Minott was a physician at Concord, and from the inscription on his gravestone must have been a little of everything else.

"Here is interred the remains of James Minott, Esq., A. M., An excelling Grammarian, Enriched with the gift of Prayer and Preaching, a commanding Officer, a Physician of great Value, a great lover of peace as well as of Justice, and which was his greatest glory a Gentleman of distinguished Virtue and Goodness, happy in a virtuous Posterity, and living Religiously died Comfortably, Sept. 20, 1735, aged 83 years."

The first women who tried to engage in the practice of medicine in Massachusetts do not seem to have met with very good success. The famous Anne Hutchinson tried her hand at medicine, but on account of her religious opinions was banished from the colony. Another, Margaret Jones of Charlestown, was indicted and found guilty of witchcraft upon the following evidence:

1. She was found to have a malignant touch, so that whosoever she touched were taken with deafness and vomiting.

2. She prac.iced hysic; her medicines being

harmless, such as anise seed and liquors, yet they had extraordinary and violent effects.

3. She told those who would not use the "physicke" that they would never get well, and accordingly their diseases continued, contrary to the efforts of the physicians and surgeons.

4. She had the witches' marks.

In spite of her protestations of innocence, poor Margaret was hanged as a witch on Boston common in 1648. Those were the days when this law was on the statute books: "If any man or woman be a witch, that is, hath or consulteth with a fainiliar spirit, they shall be put to death."

Almost without exception in all the early settlements of Massachusetts and Connecticut the practice of medicine was carried on to a greater or less extent by the ministers. This union of medicine and religion was called by Cotton Mather "an angelic conjunction." The first medical treatise published in America was by one of these minister physicians, Thomas Thatcher, and is entitled "Brief Rules for the Care of the Small Pocks," 1677.

Probably the most famous minister-physician was the Rev. Michael Wigglesworth, who was born in Yorkshire, England, October 28, 1631, and was brought to this country when a very young child. He entered Harvard College in 1647, and graduated with the class of 1651. After his graduation he was appointed a tutor at the college, and during that time prepared himself for the ministry and was ordained minister at Malden in August, 1656. After his ordination his health became so poor that he had to spend some time abroad, and was never of a very strong constitution. For nearly fifty years he served the church at Malden faithfully, both as minister and physician, as Cotton Mather said of him, “lively unto death." He died in 1705. Wigglesworth will always be remembered for his production of that sulphurous poem. the "Day of Doom," which was very popular in its day, and also of a book called "Meat Out of the Eater." An extract from the "Day of Doom" may be interesting. The following is one describing the punishments of

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