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THE MEDICAL STANDARD.

VOLUME XX. NUMBER 2.

CHARTER LAWS.

FEBRUARY, 1898.

Under our form of government, restrictions of enterprise are intended to be as limited as the welfare of the people will permit. This policy finds expression in the legislation of the states, and under what are known as charter laws very wide scope is given to the activities of the people. Often the latitude in this respect is such that not only is it equivalent to no restriction whatever, but directly nullifies other statutes which have been made imperative by the experiences of organized society.

Just such an illustration is now afforded by the state of Illinois. The attorney-general, on information submitted by the state board, has applied to the courts for the revocation of the charter of the Independent Medical College of Chicago. Some time ago the court annulled the charter of the Illinois Health University, which concern, though possessing a valid charter, was conducting its operations in direct opposition to the spirit of the act of the legislature regulating the practice of medicine in the state, and bringing reproach upon the state of Illinois throughout the civilized world. The medical practice law was for the time being effective, but the same persons who ignored every requirement of reputable medical educational institutions on the authority of the Illinois Health University charter, immediately on the revocation of that charter, secured another for the Independent Medical College, which enabled them to continue the same policy of selling physicians' certificates by the authority of the state of Illinois.

The state board of health now asks the annulment of the charter of the successor to the notorious Illinois Health University on the same grounds that the first charter was cancelled. It may be that the board considered the revocation of that charter sufficient to prevent further offenses in this line, but it would seem that the proper thing to have done was to have requested the legislature at the last regular session to so amend the charter laws of the state as to prevent absolutely the further violation of the act which it is the board's duty to enforce. The board of health is to be commended for having secured evidence which

CHICAGO:

G. P. ENGELHARD & CO.

undoubtedly will secure the revocation of the charter of the Independent Medical College, and it is sincerely hoped the matter will not be dropped there, but that the board will consider it a special duty to have the state charter laws so amended at the next session as to put an effectual stop to this exploitation of persons whose notorious practices are an affront to the medical profession and a standing reproach to the state.

THE LAY PRESS AND SURGERY.

The question of the Old Testament, Why do the people imagine a vain thing? may be answered, at least in regard to medical matters, by reference to the lay press which, undoubtedly with the best motives, publishes as news everything from osteopathy and operations, which the uninformed reporter chronicles as absolutely unique, up to the much-vaunted extirpation of the stomach, enthusiastic reports of which have been scattered by special correspondents and the press agencies broadcast over the country.

Dr. Schlatter s report of the operation in the Correspondenz-blatt fuer Schweizer Aerzte, is very complete and most modest. He states that in his case the total extirpation of the stomach was possible only on account of the length and great elasticity of the esophageal end of the stomach. The patient was a woman, fifty-six years of age, a silk-weaver by occupation, who had suffered from pain in the stomach from childhood, and had a family history of cancer of the stomach. The clinical history and physical examination pointed unmistakably to cancer of the stomach. The tumor which could be easily felt, seemed to involve the entire stomach. Schlatter operated on September 6, 1897, under morphine ether anesthesia, in the following manner: Incision in the median line from the ensiform cartilage to the umbilicus. The stomach immediately presented in the wound. The entire organ was diseased and converted into a hard mass; it was not adherent. The stomach was first freed from all its attachments at the greater and lesser curvatures; the omentum excised between Pean forceps, and silk sutures applied..

The stomach was then forcibly dragged downward, a Woelfler clamp applied as high up as possible and a Stille forceps secured to the cardiac end of the stomach. The stomach was then severed directly below the esophageal extremity. The same steps were repeated at the pyloric extremity of the stomach. The duodenum was next moved as far as possible toward the pancreas. After compression of the duodeum with tumor clamps, the entire stomach was removed between the two points of compression. A few lymphatic nodes were also dissected out of the greater curvature of the stomach. The patent lumen of the duodeum was protected by iodoform gauze. He next tried to pull the duodenal opening upward toward the esophageal cleft. It was only with coniderable difficulty that the two could be made to touch. They could not be joined by direct suture; therefore the duodenal rim was invaginated and closed by a double suture. A coil of the intestine about fifteen inches below the severed end was then sutured to the end of the esophagus. A longitudinal incision about one inch in length was made in the bowel and the intestinal mucosa united to the mucous membrane of the esophagus by a continuous circular suture. Above this an outer circular suture was placed through the muscularis and serosa. The union was completed by a Lembert suture. The clamps were then removed, and the abdominal wound closed in the usual manner with silk. The operation lasted nearly two hours and a half. The specimen proved on examination to be a small-celled alveolar glandular carcinoma.

The patient made an uninterrupted recovery and at the time of the report was apparently in good health and was working daily in the hospital.

Dr. Schlatter prefaces his report with a brief statement of the work previously done in this direction. Kroenlein excised 22 cm. of the greater and 13 cm. of the lesser curvature of the stomach, with recovery. Maydl removed more than one-half, and Von Hacker more than two-thirds of the stomach. In the more recent so-called total extirpations, small portions-one or two square inches of the cardiac extremityhave invariably been left. In a case reported by Ewald in 1881 as total extirpation, the author was informed by Lindner that 2 cm. remained. The woman died of hemorrhage on the third day. In 1894 Langenbuch made a probably total resection of the stomach, but the woman died on the sixth day. In another

case he removed seven-eighths of the stomach, the remainder, consisting of the cuff-like esophageal and cardiac ends, being united by sutures; this patient recovered. Schuchardt removed all but "three fingers" of the cardiac portion, and the patient enjoyed perfect health for two and one-half years and then died. At the autopsy the stomach was found to have enlarged to a capacity of 500 cc.

Experiments on animals have been performed by many operators. Czerny, in 1876, performed gastrectomy on five dogs, four of which promptly died; the fifth was fed at first on small portions of milk and pulverized meat, and later, after two months, was put on a full diet. This animal's weight at the time of operation was 5,850 grams; a month later, 4,490 grams, and ten months later 7,000 grams. The physiological functions were perfectly normal. Six years later the dog was killed, and a very small piece of the cardiac end of the stomach found remaining, which formed a spherical organ filled with food. Pechon and Carvello reported in 1893 a gastrectomy on a dog performed five months before. The dog ate slowly, but his diet was not limited. Since the operation he had gained 500 grams. In 1896 Monari reported a total extirpation of the stomach in a dog. The operation was followed by occasional vomiting, which finally ceased. The animal was put on regular canine diet and had decreased slightly in weight. Filippi made a similar report in 1896. The dog was killed a year later. Autopsy showed enlargement of the lower portion of the esophagus and the upper portion of the duodenum, and in the upper two-thirds of the duodenum the microscope revealed thickening of the annular muscular fibers.

From Dr. Schlatter's article Dr. C. C. Wendt (Med. Record) draws the following conclusions: 1. The human stomach is not a vital organ. 2. The digestive capacity of the human stomach has been considerably overrated.

3. The fluids and solids constituting an ordinary mixed diet are capable of complete digestion and assimilation without the aid of the human stomach.

4. A gain in the weight of the human body may take place in spite of the total absence of gastric activity.

5. Typical vomiting may occur without a stomach.

6. The general health of a person need not immdiately deteriorate on account of the removal of the stomach.

7. The most important office of the human stomach is to act a reservoir for the reception, preliminary preparation and propulsion of food and fluids. It also fulfils a useful purpose in regulating the temperature of swallowed solids and liquids.

8. The chemical function of the human stomach may be completely and satisfactorily performed by the other divisions of the alimentary canal.

9. Gastric juice is hostile to the development of many micro-organisms.

10. The free acid of normal gastric secretion has no power to arrest putrefactive changes in the intestinal tract. Its antiseptic and bactericide potency has been overestimated.

In striking contrast to the modest statements of Schlatter are the lay comments on his article. One prominent daily paper in Chicago stated in effect that Chicago would soon show the old world that American surgeons could do at least as much as the European operators in this department of surgery, the implication being apparently that in this country we would not only extirpate the stomach, but the entire digestive tract.

Since the matter has become public property, at least two American surgeons have performed the operation, which has been duly exploited by the lay press. In both cases the operation is said to have been a brilliant success, but unfortunately both patients died. "Many surgeons," says the report, "were present at the operations, and they all declared that the women would have lived had they been a little stronger."

CLEANSING THE HANDS.

At first thought it might seem unnecessary to discuss this subject, upon which so much has been said and written. Observation, however shows that there is still great need of emphasizing the importance of thorough preparation of the hands for surgical and obstetrical purposes. Very few physicians who are not either teachers in surgery or surgeons to hospitals thoroughly clean their hands and keep them clean until the operation is completed.

It is not uncommon to see physicians scrubbing their hands without removing their rings. After their hands are prepared, they at times handle articles that are not sterile, such as their spectacles, or the clothing or parts of the patient, etc.

It has been well said that it is easy to cleanse the hands, but very difficult to keep them clean.

It is not uncommon for physicians, after contaminating their hands, to simply rinse them in an antiseptic solution with the belief that they are again made clean. This simple procedure is of little or no value, and has been aptly designated as "making the sign of the cross." Technique. The nails should be trimmed or preferably filed moderately short. The hands and arms to above the elbows should be systematically scrubbed with a clean, stiff brush, green soap or tincture of green soap and running water for fifteen to twenty minutes. The time should be accurately noted and not estimated. Very active scrubbing does not take the place of prolonged scrubbing, as it requires time for the epithelium to become thoroughly softened. The space under the nails should be thoroughly wiped out with sterile gauze or with a thin sterile towel. If the space is scraped the nails should afterward be again thoroughly scrubbed with soap and water. The variety of antiseptic used is of little importance if the scrubbing has been thoroughly done; alcohol, bichloride of mercury 1: 1,000 or lysol 1 per cent may be used. If bichloride is used, the soap should be thoroughly removed from the hands, as soap tends to make the bichloride inert. The hands and arms should be scrubbed in these solutions, and not simply rinsed. The antiseptic solution should be washed off the hands with sterilized water before they come in contact with a wound.

Should the hands touch anything not sterile, they should be again scrubbed in soap and water, an antiseptic solution and sterilized water. It is true this is a long, tedious preparation to make to examine pregnant or puerperal women, to dress wounds and to do minor operations. . The hands, however, are not safe to touch wounds directly or indirectly without such preparation.

We would suggest in cases where this preparation requires too much time or is especially inconvenient, the use of thin rubber gloves, such as are used by a few surgeons for operating. These could be kept sterilized and in an antiseptic solution, and the danger of infection from the hands could thus be minimized without loss of time or much inconvenience.

"PURE DRUGS" IN OHIO. The enactment and enforcement of laws against dangerous proprietary medicines is one of the necessities of the times, but inadequate laws and ill-advised measures of enforcement unquestionably do much more harm than good,

We referred last month to the prosecutions in Ohio of druggists selling "Scott's Emulsion," which, it was charged, contained morphine. The manufacturer at once came forward with an affidavit in which he declares that "he has never in his business career used a single grain of morphine or any of the alkaloids of opium in Scott's Emulsion. I make this statement from personal knowledge derived from the personal care and supervision of the business and manufacture of the emulsion from its inception down to the present date."

That the charge is wholly without foundation is further evidenced by the report of our special chemist, who states that he has been unable to find any trace of a foreign alkaloid in the specimens analyzed. The other preparations analyzed by the Ohio commissioner's chemists were found to contain morphine or cocaine, but there was never any attempt at concealment of this fact by the makers. The commissioner's action has the sad appearance of having included certain notoriously guilty compounds for the specific purpose of shielding its attack on the innocent. The Ohio law is a single illustration of what foolish legislation on this subject can accomplish in defeating the very results it professedly aims to secure.

Rush Medical College and Chicago University. -Rush Medical College has decided to sever its connection with Lake Forest University and to become an affiliated college of the University of Chicago, on the following conditions:

1. That the trustees, who are members of the faculty and consequently interested in the earning capacity of the college, shall resign and appoint in their places men of well-known integrity and business capacity who are friendly to the university and interested in higher medical education.

2. That the debt of the college be paid on or before June 1, 1898.

3. That the entrance examination to the college must be raised by the year 1902 to the equivalent of an entrance examination to the junior year of a literary college.

By this change Rush college hopes to be relieved of its debt and in that way to occupy the position which is an absolute condition of affiliation with the university. The affiliation is to commence June 1, 1898, providing the condition relative to the debt is carried out; the existing relations with Lake Forest University terminate by mutual agreement on the same date.

Rush College is to be congratulated upon its prospect of freedom from debt, its intimate connection with so liberally endowed an institution as the University of Chicago, and upon the probability, not remote, that with President Harper's well-known ability as a money-getter for the university, an endowment will be provided for the college adequate to its needs.

The third condition of affiliation, that of raising the qualifications for admission, will be welcomed by all interested in the higher medical education.

Health Legislation by Congress.-The present session of congress is being called upon to enact a number of laws relating to health regulations. Senator Caffery's quarantine measure; a bill for the investigation of leprosy, and another for the pollution of water supplies; one for the erection of a building for the hygienic laboratory of the Marine Hospital Service, and a bill providing for the establishment of a department of public health, have been introduced.

The bill creating a new department of health is a measure very comprehensive in some respects, but is believed not quite what the American Medical Association had in view when action was taken at the annual meeting held in Atlanta. There does not seem to be any prospect of the passage of this measure, and its introduction, it is feared, may cause delay in action that might be secured from the present congress.

Official Registration.-The secretary of the state board of health announces that the nineteenth and twentieth annual reports of the board, to be published very shortly, will contain an official register of all licensed physicians practicing in Illinois. As the reports are sent to every state in the union and are largely called for by professional and business men interested, he desires that the register be as correct as possible, hence asks that we request every physician who wishes to have his name and address correctly reported, to send the information to him on postal card at once, mentioning number and date of certificate.

The Dead of the Month.-During the last days of January three medical men, each eminent in his particular line, have died: Pean, the great abdominal surgeon, of Paris; Theophilus Parvin, the obstetrician of Philadelphia, and Dr. G. C. Paoli, with one exception the oldest practitioner in Chicago.

THE RELATION OF GENERAL MEDICINE TO THE SPECIALTIES.
BY FRANK BILLINGS, M.D., CHICAGO.

Twenty years ago it was the rule to find in medical schools the following chairs: Anatomy, Physiology, Chemistry, Materia Medica, Pathology, General Medicine, General Surgery, Gynecology and Obstetrics, and Diseases of the Eye and Ear. As our knowledge of medicine and surgery has advanced, these various principal chairs have become divided and again subdivided until a modern American medical school has thirty or more chairs, filled by as many professors. In the fundamental branches this has been necessary and of great good to the advancement of medical knowledge. Histology, physiological chemistry, bacteriology, special pathology, surgical pathology and general and special therapeutics are some of the offshoots of anatomy, physiology, chemistry, materia medica and pathology. These special chairs became necessary as our knowledge increased. Important as these special studies are individually, they are but parts of the fundamental branches of medicine, and should never be studied entirely separate and alone. Physiological chemistry is a part of chemistry and of physiology; histology, normal and pathological, a part of anatomy and of pathology, respectively; bacteriology a part of pathology, and so on through the list. A full knowledge of the fundamental branch implies an equal familiarity with the special subject related to it.

I think no one will dispute the fact that the fundamental studies of medicine are more thoroughly taught now than formerly. The student is better drilled and is taught in a more rational way. There are faults, very gross ones, still which need correction. Specialism in the fundamental studies is too often separated from the main subjects, and the relation between them is lost. Bacteria are properly studied in the laboratory as interesting individuals or families, and important and necessary as this special study is, it is practically worthless to the student if he is not taught how the bacteria may affect animals, what chemical changes and anatomical lesions may be produced by them, and the result of these bodily changes upon the animal.

The so-called practical branches have also been divided and subdivided. General surgery has had separated from it, the surgical diseases of women, orthopedic surgery, venereal diseases,

diseases of the skin, diseases of the nose and throat, rectal diseases, and there are so-called experts or specialists in abdominal surgery. brain surgery, etc. General medicine has been shorn of mental and nervous diseases, of diseases of children, of diseases of the stomach of the kidneys, of the lungs and heart, etc.

On the whole, this division has no doubt been a wise one, and has been made because the teachers found it the best means of drilling students. The result has been in many ways good. The graduate has commenced practice with a better knowledge of special subjects than in years gone by. His knowledge of how to do his work is better than formerly. He will recognize a kidney, a heart, a lung or a stomach disease, with his instruments of precision in diagnosis, better than his brother of twenty years ago. His education has been special in many ways, and often at the expense of a general knowledge, as I shall try to show. This is one of the faults of the modern method of medical teaching.

Formerly much time was spent upon the principles of medicine and surgery and these principles were applied to all the specialties which now exist as parts of general medicine or of surgery. The division of the principal chairs and the assignment of hours for the purpose of teaching the specialties resulted in two things: First, the curtailment of the time formerly alloted to general medicine and to general surgery; and second, the necessity of lengthening the college course to make sufficient room for the special teachers. The abbreviation of the time given to the general subjects necessitated, or at least resulted in a change of the method of teaching. The principles of medicine and surgery now receive but scant notice. The time assigned to the teachers of the general subjects is filled by a simple description of the individual general diseases assigned to the teacher. In other words, the general teacher has become a specialist in a sense. Even the books upon general medicine and surgery have changed in the same way. The writers of most of these books confine themselves to the special cause, morbid anatomy, clinical course, diagnosis and treatment of individual diseases.

We may say that the time now given to the fundamental branches makes it unnecessary to any longer teach principles. I think this is not

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