well qualified from experience and knowledge in their special branch should be selected by lawyers or others to give expert testimony. In the third place, it is a duty physicians owe their own consciences, the community, and the profession itself, that they do not consent to testify until they have thoroughly examined into the merits of the legal case, and then testify only in conformity with their convictions. It is a shame and a disgrace that there are those who always see a case just as it is presented by the lawyer first engaging their services, and consequently testify just as he wishes. What wonder is What wonder is it then that medical testimony of some character can always be gotten on any side of a case. The course of medical men under these circumstances should be perfectly plain. When first requested by an attorney or other persons to testify in a case, the physician should insist on having all the facts obtainable; and the testimony of witnesses, if the trial has begun. ANTITOXIC TREATMENT OF DIPHTHERIA. At the meeting of the British Medical Association, Dr. Hermann Biggs, Bacteriologist to the Board of Health, New York, stated that he had had under his charge in New York between 400 and 500 cases which had been treated with antitoxin for diphtheria in their own homes. These had all been severe cases, and the mortality had been slightly over 16 per cent. The mortality for the whole of New York, he added, had been reduced by over 40 per cent. The speaker then proceeded to deal with the importance of antitoxin in preventing the spread of the disease by rendering those who were exposed to the infection immune. In one institution in New York there had been a large number of cases of diphtheria, 107 cases having occurred during the 108 days preceding the injection of the serum. The antitoxin was then injected, 200 units of Behring's preparation being used in each case. During After sufficient time he should render an opinion to the party engaging him. If this opinion be favorable he is then ready to testify at court in his behalf. If it be adverse his connection with the case should end there, unless he be retained in an advisory capacity. A matter of great difficulty should be mentioned here, and that is the imperfect and biased information which the physician is apt to get from the party employing him. This party is about to enter the trial from his point of view, be it prosecution or defense, and his opinion is naturally one-sided. The physician should take heed lest he be unconsciously influenced, and find himself, when on the witness stand, plainly on the wrong side. Much tact and perseverance will be required to get a thoroughly reliable statement or examination on which to base a final opinion. There are, of course, other means of elevating the standard of expert testimony, but these three ways occur to me as worthy of mention.. the next thirty days only 1 very mild case occurred, in the following thirty days another case was reported, and shortly after 5 more patients were attacked; 225 units were then injected, with the result that no more cases occurred. The same result was obtained in three other institutions, showing the extreme value of the immunizing power of the serum. Dr. Biggs considered that the protective period was a short one, probably not extending over thirty days, but within this time it was almost absolute. The speaker then concluded by saying that in over 800 patients treated for the purpose of rendering them immune, he had in no case observed any unfavorable symptoms. In a few patients, rashes, apparently urticarial in nature, had occurred on the eighth day, and in some there had been a temporary rise of temperature, which, however, in no case had resisted treatment for more than twelve hours. CLINICAL LECTURE. CARCINOMA UTERI. CLINICAL LEcture delivered at the Jefferson HOSPITAL, APRIL 9, 1895. By E. E. Montgomery, M. D., Professor of Clinical Gynecology in the Jefferson Medical College; Gynecologist to Jefferson and St. Joseph's Hospitals; President Alumni Association Jefferson Medical College. GENTLEMEN :-I bring before you today a woman fifty-four years of age, whose mother died of tubercular, and father of Bright's disease. Her brothers and sisters are healthy. It is not an unfrequent occurrence to find in the members of a family that some have pulmonary, others Bright's and others, again, suffer from malignant diseases, such as epithelioma and carcinoma. Such an association is so frequent as to lead to the recognition that there is a vulnerable trait running through such families, making them susceptible to the development of such influences. Our patient enjoyed, during her early life, good health. Puberty occurred at fourteen, the flow was regular and preceded by pain. The discharge was profuse, lasting three to five days. She has been married thirty-four years and had three pregnancies, in all of which she was delivered at full term. The last child was born twenty-four years since, the labors were normal and after the last child she was confined to bed for three weeks and for three weeks subsequently had profuse bleeding. After this, however, she enjoyed good health. About five years since, she ceased to menstruate for six months. The flow reappeared spontaneously, since which she has had a bloody discharge every three weeks. She has a slight pain and profuse leucorrhea, which is yellow and has quite an offensive odor. The uterus is retroflexed. This is not exactly the history we would consider as characteristic of malignant disease, but she is fifty-four years old and continues to have a bloody discharge every three weeks, a profuse, offensive leucorrhea, which certainly in dicates that degenerative processes are present. A retroverted uterus would increase the tendency to inflammation of its lining membrane, and the congestion of the organ would favor the probability of discharge. It is possible the position of the uterus in this patient increases the tendency to congestion and the continuance of discharge. Upon examining the uterus with the speculum you notice a spongy appearance of the lip, an eversion of the cervical mucous membrane, with a spongy appearance of the surface that indicates a degenerative process. Taking the history of the patient, the character of the discharge, the more or less pain and discomfort, I consider it the wiser plan to remove the uterus, believing it the inception of a disease. which would very soon result in the breaking down of the uterus and development of a very serious condition. As the organ is drawn down, you see the peculiar condition upon the posterior lip which is very much like a cyst and undoubtedly contains cysts, and on closer investigation of the surface, the appearance leads me to believe that we have the beginning of malignant disease, consequently I prefer to remove it. In performing the operation we expose the uterus, drawing it down with a tenaculum, to secure a good hold with the volsellum, then make an incision around the cervix, completely encircling the organ at such a distance from the os as will preclude the possibility of any diseased tissue remaining unremoved. In other words, going as far beyond the diseased tissue as possible without injury anteriorly to the bladder and ure ters. So far as the posterior tissue is concerned, it would be rather difficult, and not pleasant to the operator, to open into the rectum. In every such operation it is important to have a good, strong volsellum, in order that in seizing the parts we make sure of securing tissue sufficiently firm that it will not tear out. After having cut through the tissues anteriorly, I am particular to make sure that the bladder is not in the way, so that it will not be opened as we proceed. It is pushed off from the anterior wall until we reach the peritoneum. It is sometimes difficult to accomplish this separation, owing to encroachment upon the uterine tissue in our effort to avoid the bladder, which, of course, increases the difficulty in the separation. Having opened the peritoneum anteriorly, the dissection is made posteriorly until the peritoneum is again opened. The peritoneum is a little more difficult to reach anteriorly in this case on account of the retroversion, and we are a little more anxious about injuring the bladder and consequently have kept too closely within the uterine tissue. Having opened into the peritoneal cavity in front and examined carefully to ascertain the presence of disease in the broad ligaments, and finding none, I now open into Douglas pouch. You noticed there was quite a considerable serous discharge when I opened into the peritoneum, so much, indeed, as to lead me to believe I had opened the bladder, but the posterior incision disclosed an accumulation from the peritoneal cavity. I am endeavoring to pass my finger over the broad ligament and bring it down posteriorly, which I have now done. You can see how my finger passes directly around the broad ligament on either side. I have now passed in a clamp, one blade posteriorly and the other in front; bringing these together, they are screwed down upon the left broad ligament close to the uterus. The uterus is cut off flush with the clamp, as I feel certain there is no possibility of the ligament slipping. Having cut through the broad ligament on one side, we have the uterus now free on that side and it can be drawn down outside, when the other clamp can be placed in position with much less difficulty. You can see the difficulty experienced from the size of the fundus of this uterus. The second clamp is applied outside and turned back, after the broad ligament cut through, but I find the clamp has caught against the anterior wall of the vagina, pushing it up and the end of the clamp can not be passed into the abdominal cavity without putting this tissue upon so great strain as to endanger it, so we will ligate the broad ligament outside the clamp in three parts, loosen the clamp and tie the ligatures and thus prevent hemorrhage. The vagina was small, the uterus large and consequently the application of the clamp rendered a difficult procedure. Having examined carefully and washed out the cavity to ensure there is no bleeding, we will pack with iodoform gauze, carrying the gauze over the end of the clamp. The clamp will be removed at the end of twenty-four hours, the gauze will be permitted to remain for seventy-two. The external surface is packed with gauze, which will be removed in order to empty the bladder. This operation of vaginal hysterectomy by the application of clamps is generally a very easy and rapid one, although in this patient I carelessly applied the clamp in such a way that I could not return the end of it into the pelvis after the uterus had been removed, consequently had to ligate and remove it. This lengthened the operation some five, possibly ten, minutes. The operation of vaginal hysterectomy, in cases where the uterus is movable, easily brought down, and the vagina large, rendering the separation easily made, can be done in a very few minutes. In a case with a small vagina and large uterus, the operation may be quite difficult. In such cases it is necessary to secure the broad ligament in sections either by ligation or by the use of forceps. If desirable to secure additional room, an incision may be made through the perineum, back to one side of the rectum, thus enabling us to considerably enlarge the outlet and come near An to the tissues under consideration. opening in this way may be secured large enough to introduce the hand. Where the uterus is quite large it is wise to consider the resort to abdominal operation. If for any reason we desire not to open through the abdomen, it is well to remember we have another method of procedure. The shortest direction to the uterus is directly through the sacrum, and by doing a sacral resection we may reach and remove the uterus. This is a particularly proper procedure in cases where disease of the uterus is complicated by involvement of the rectum, where it is necessary to remove a portion of the latter. In one case in this clinic, we removed the uterus, tubes, ovaries, rectum, posterior wall of the vagina and the perineum. In making an incision for this purpose, the patient should lie upon the left side and a bowshaped incision be extended from the left side of the sacro-iliac-synchondrosis across the median line, terminating alongside the anus. This incision lays bare the lower end of the coccyx. Dissecting off the tissues, we have the coccyx exposed. The latter may be removed and an incision made through the sacrum in two directions, cutting transversely or making an elliptical incision, leaving one side undisturbed. The objection to the transverse incision is that we remove the fourth and fifth sacral nerves on both sides. We may approach here to the third sacral foramina without any special injury to the pelvic viscera excepting those nerves that supply the buttocks and skin externally, the anterior branches that are sent to the bladder and vagina. If we leave one side and particularly the fourth sacral foramina untouched, it is sufficient to compensate for the loss of the opposite side. If both sides were injured, we might have incontinence of urine, cystitis and trouble with the bladder. If upon removal of the sacrum we desire to operate upon the rectum, the entire rectum is drawn out. If the recrum is healthy, we would push it to one side and open into the peritoneal cavity, thus reaching the uterus. We are thus enabled to see the parts, ligate the broad ligaments, remove the ovaries and tubes, first upon one side, then the other, and cut away the uterus, seeing everything as the operation proceeds and thus avoid injury to the ureters. In fact, we know of no plan by which the uterus can be more thoroughly explored and removed under sight than by sacral resection. The objection to the operation is the extent of the incision, the more or less injury to the pelvic structures and the long convalescence, resulting from bone injury. I have done the operation five times with one death. The death occurred in a woman who was in this house, who had suffered from cancer of the rectum and for a number of weeks had had so much obstruction as to render it a constant discomfort. The posterior wall of the vagina was involved. The rectum and a good part of the vaginal wall were removed. The patient died within forty-eight hours from renal insufficiency. This is the first death in five cases, and one of these, as has already been mentioned, constituted the removal of the uterus, ovaries, tubes, entire posterior wall of the vagina, five inches of the rectum, and the perineum. The rectum was stitched fast to the anterior wall of the vagina and to the skin over the sacrum, thus forming an artificial anus at the upper end of the vagina. Of the five cases operated upon, four have been done for disease of the rectum, in three of them making an artificial anus some three or four inches higher up, and in one, removal of the uterus. In those cases in which the operation can be done with hope of removal of the diseased tissues, it is preferable to have the artificial anus posteriorly rather than in the inguinal region, for the reason that the patient will not have to assume an unnatural attitude to evacuate the bowels. She is better able to keep in place the dressing and to control the evacuations, to keep herself clean and consequently she also suffers much less inconvenience from the operation. SOCIETY REPORTS. RICHMOND ACADEMY OF MEDICINE AND SURGERY. MEETING HELD AUGUST 13, 1895. Dr. V. W. Harrison, First Vice-President, in the chair. Dr. Landon B. Edwards read a paper on the DIAGNOSIS, SPECIAL AND DIFFERENTIAL, of CholelithIASIS. Stone may sometimes be formed in the liver itself. The position of the gall-bladder varies with that of the liver. It can be recognized by palpation. Cholelithiasis is rare in children under 12, becoming more frequent as age advances, and being more common over 30, and in women. It is comparatively frequent in the insane. The characteristic symptoms suggest ing gall-stone are: Multipara seized with a grinding pain radiating over the whole body. There is perspiration, retching, vomiting, dyspnea, pulse lessened in volume, expression of pain, no rise in temperature. The symptoms do not intermit, and pain is not relieved unless the stone passes. It lasts two or three days and leaves soreness. Ease is brought about through a form of pressure paralysis. Jaundice is not always present, but may occur gradually from occlusion. Mahogany urine may be present. The flow of bile being prevented, the skin becomes darker and darker, vomiting ceases to be bilious, stools become pasty and distension of the gall-bladder by mucus may occur, simulating floating or displaced kidney. Cholelithiasis is diagnosed from malaria by the mild fever, scarcely jaundiced hue, chills, etc. From catheterization the chills may become rigors, the fever rises, pulse slow, 40 to 50, irregular and not in keeping with the fever. Fevers, especially malignant pancreatic, and pancreatic stone. Hemorrhage from the stomach, bowels, etc.; destruction of the common duct, damming of the fluid in the gall-bladder and ducts producing jaundice. Indigestion of fat is present in pancreatic troubles. Empyema of the gall-bladder by the history of chills, fever, etc., with liver trouble. Adhesion of the gall-bladder may so form as to cause discharge of bile into the duodenum direct, and there may be no suspicion of stone. Symptoms of typhoid and other fevers and of malignant and benignant tumors are simulated by stone. It is said that when the stone passes from the cystic to the common duct pain is lessened, and as soon as the passage occurs, mucus begins to be dammed into the body of the liver, causing its enlargement. This is diagnosed from hepatitis by less pain in the latter. Heredity may lead to differentiation of stone. It is seldom that repetitions of hepatic colic do not occur. Operations for removal should not be performed unless the typical symptoms are present. Cases occur more frequently than is supposed, giving rise to symptoms elsewhere. There is no medical treatment efficient for the disintegration or removal of gall-stones. The indication is to relieve pain, and for this the best agent is, by far, hyoscyamine. DISCUSSION. Dr. Hugh H. Taylor quoted Robson, who lays stress on the characteristic suddenness of the paroxysmal pain. Vomiting may be continuous or paroxysmal. In some instances, pain is referred to the left shoulder; often, above the umbilicus, differing from that of appendicitis. Subsequent attacks may be from the same stone. The direction of growth of the tumor is diagnostic, being obliquely toward the umbilicus. It may be enormous sometimes, then being mistaken for ovarian tumor. Distension of the gall-bladder without jaundice means obstruction of the cystic duct, as by enlarged gland, stricture or stone. Sometimes a diagnosis may be made by the presence of stone in the feces. Hemorrhage, when present, is due to poisoning incident to cholemia. In this latter we have continuous jaundice, which means neoplasm of the duct, or head of the pancreas. Stone, by its change of position, etc., will allow the escape of some bile, jaundice accompanying it, being thus intermittent. |