is carried down into the trachea through the speculum or through the tracheoscope after its introduction. When one has become expert in direct laryngoscopy, the passing of the tracheoscope between the vocal cords is usually easy. With the larynx and trachea cocainized, the tracheoscope is passed through the laryngeal speculum until the larynx is reached. patient is now told to breathe deeply, and at the instant of the separation of the cords the tube is pushed gently into the trachea. Once in the trachea, the entire respiratory tree can be examined by cocainizing in stages as the tube is pushed down.

The

Passing the instrument straight down, the walls of the trachea can be examined by changing the position of the patient's head. The trachea is about six inches long in adults, and when this distance has been traversed we come to the bifurcation, which appears as a narrow, whitish ridge with the openings of the bronchi on either side. After cocainizing the bronchi, the tube is pushed down into the right or left bronchus and the secondary bronchi examined.

Up to a short time ago the chief usefulness of tracheobronchoscopy was in the removal of foreign bodies. Von Shrötter in Europe and Jackson in this country have demonstrated the great value of the method in the diagnosis and treatment of diseased conditions in the trachea and bronchi. The former has shown that in certain stenoses of the respiratory tubes it is possible to introduce, by means of the bronchoscope, metal dilators which are left in place for variable periods of time, and the gradual dilatation of the strictures. successfully accomplished. The latter has treated pathological lesions such as stenoses, ulcers, etc. It is not too much to hope that as we become more expert in the introduction of the tubes into the smaller bronchi we may be able to study pathological conditions in the living which thus far have baffled investigation. Al

ready foreign bodies have been removed practically from lung tissue by inspection through the tubes, and the patients have made prompt recoveries. The usefulness of tracheo-bronchoscopy in the removal of foreign bodies is well illustrated in the following case:

M. P., ten years old, was wearing a hard rubber tracheotomy-tube for stenosis of the larynx. One afternoon the tube was removed, cleaned and replaced into the wound. Two hours later, while the patient was sitting up eating a cake, she suddenly had an attack of severe coughing and became cyanosed. This was followed by another attack not so severe. The nurse in attendance summoned a physician, who attempted to remove the tube. To his surprise, only the outer plate came away. The tube was evidently in the trachea. When I saw the patient, not long after the attacks, she was lying on her back, with some dyspnea and a peculiar tubal cough. On examining the plate the cause of the trouble was apparent. In some way the tube had become unscrewed and was almost ready to leave the plate when it was inserted into tthe wound. The act of swallowing caused it to drop into the trachea, and the paroxysm of coughing followed as nature's effort to dislodge it. The patient was at once chloroformed with the mask over the nose and mouth, the tracheal wound cleaned and enlarged for half an inch, and Jackson's small tracheoscope passed through the wound. Blood and secretion were wiped away, cocaine and adrenalin applied to the mucous membrane and the tube passed gently downward. In a few moments the dark edge of the foreign body was seen. The lower end lay in the right bronchus, while the upper end was in the trachea at the bifurcation. Forceps were introduced through the tracheoscope, the edge of the tube seized and all three instruments pulled out through the tracheal wound. The patient made a rapid recovery.

Esophagoscopy as a means of diagnosis and treatment has in the last few years reached a high state of development. On account of the ease of passing the esophagoscope and the certainty with which lesions may be diagnosed and treated through it, it should be in more general use. In many cases, if the patient be fortified with a good dose of morphine and atropine, the examination can be made. with cocaine anesthesia.

The diagnosis and treatment of diseased conditions in the esophagus are well illustrated by the following cases:

October 24, 1907, E. R., forty-four years old,

came to the Presbyterian Hospital complaining of difficulty in swallowing. Some weeks before he had had trouble swallowing solids, and this had gradually grown worse until only a small amount of liquids passed into the stomach. The patient pointed to a spot about four inches below the cricoid cartilage as the point where the food stopped. He had always been a healthy man, but for the past seven years he had been a hard drinker of all kinds of alcoholic liquids. There was no pain, and the physical condition was good. The esophagoscope was passed under the guidance of the eye. About three inches below the cricoid cartilage further progress of the tube was stopped by a large, round, red, nodular mass which seemed to fill the lumen of the esophagus completely. Palpation with the probe revealed a small opening through the tumor, and this was at once enlarged with Bunt's esophageal bougies, beginning with the smallest and gradually increasing the size. These bougies are passed through the esophagoscope under the guidance of the eye, so that there is no danger of making a false passage or of penetrating into the mediastinum. Three days later the operation was repeated. The opening was now large enough for the careful passage of a French bougie. The patient was made fairly comfortable and saved a gastrostomy by the above treatment. The growth was undoubtedly malignant. The patient died six months after his entrance into the hospital from general weakness. He swallowed liquids until his death.

Mr. H., fifty-seven years old, was referred to me April 2, 1908, for diagnosis. In December, 1907, he had some trouble swallowing solid food. Dysphagia steadily increased, and in four months he lost 115 pounds. He was troubled with a cough and often spat blood. Examination of the sputum showed no tubercle bacilli. He stated that at times he could swallow fairly

well; at other titmes the esophagus seemed

completely closed. His voice had changed in character from a low- to a high-pitched tone. The patient was examined under cocaine (10 per cent.). The left vocal cord was found immobile in the middle line of the larynx; the right cord moved normally. In anesthetizing the esophagus preparatory to passing the esophagoscope, blood was invariably found on the cotton. The patient localized his trouble just below the cricoid cartilage. For fear of doing some damage with the adult esophagoscope the 7 mm. tube was passed through the separable speculum. The progress of the tube was soon stopped. There was much blood in the esophagus, which was wiped out. The application of adrenalin stopped the bleeding. A large, red, nodular growth could then be seen through the esophagoscope. The tumor was located not more than two inches below the cricoid. This would have been a favorable case for operation if the patient could have been seen in the beginning of his dysphagia. He was advised to consult a surgeon, but it is doubtful if anything can be done at this late day. The growth is undoubtedly malignant. As the patient came for diagnosis, no attempt was made to dilate the stricture.

In another patient with suspicious stomach symptoms the gastroscope was passed into the stomach. Though nothing was found that could be diagnosed as a malignant growth, it was demonstrated to the satisfaction of all present that a straight tube can be passed into the stomach with little shock and a certain area of the walls examined. I believe the gastroscope is destined to play an important part in the diagnosis of certain diseased conditions in the stomach. Deep ether anesthesia is necessary for the examination.

919 N. Charles Street.

thereto; provided that a medical student may be matriculated with a condition in not more than one full-year subject, or two half-year subjects, and provided further, that the condition or conditions be made up before beginning the second annual course counted toward the medical degree."

The adoption of this rule constitutes a significant step in the forward movement of medical education, for it raises the entrance qualification higher in Minnesota than it is in any other State in the Union. In connection with this it is interesting to note that President Thompson, of the Ohio State University, four years ago proposed that the standard for entrance to medical colleges in Ohio be made the same as for the College of Law of the Ohio State University, which is completion of two years' work in any recognized college of arts, or in any college whose course is equivalent to that of the Ohio State University.

It has not been possible to obtain a catalogue of the University of Minnesota, so it is impossible to state what work this course comprises, but if this State were to adopt as its entrance standard the first two years' work in the Arts or Science course of the Ohio State University, it should be made to embrace complete chemistry and a larger amount of zoology, physiology, and also some vertebrate anatomy, embryology and possibly osteology.

It is interesting to note that this step toward a higher preliminary standard was taken by a State located so far up in the northwest that it was thought but recently to mark the line of the frontier, but it indicates that the profession of that State has a pretty clear vision as to its duty relative to qualification for entrance to medical practice. There is little doubt that the influence of this action will be widely felt among other States in elevating the standard of entrance qualification, and seems to mark the trend of sentiment to a graduate standard of entrance. Whether this is true or not, it does suggest the importance of arranging a combination course by the baccalaureate and medical colleges so that one preparing for medicine may have a certain amount of the so-called culture studies and yet be able to complete his medical course within a reasonable time.

A reasonable amount of post-graduate hospital work, which is so important a part of the training of the physician, should be required of every student before he is admitted to practice; perhaps it

should be included in the regular course and thus be made compulsory. It does not require the gift of prophecy to predict that some time this post-graduate hospital work will be required before entrance to practice is permitted.

The question of entrance standard will have to be taken up in Ohio in the near future, the action of Minnesota having made it necessary. This State now requires a diploma from a first-grade high school whose course covers four years, or credits equivalent to the same. This is the entrance qualification to the Ohio State University. There are but two other States, New York and Michigan, which have this standard, and there is no State at this time whose qualification is higher. It is the standard recommended by the American Medical Association, with an additional year after 1910 of not less than nine months to be devoted to the study of physics, chemistry, biology and one language (German or French) to be taken in a college of liberal arts, or in a recognized medical college having a preliminary year devoted exclusively to the subjects mentioned. If objection is made to the establishment of a better standard in Ohio, there is no likelihood that it will come from the profession at large. The profession does not suffer from the accession of educated men to its ranks; it would now be stronger and have a larger influence in public life were it not for the low standards that have prevailed in the past.

That it is to-day more respected and taking a larger part in public affairs will hardly be questioned, nor will it be denied that this increase of power is due to the admission to its ranks in recent years of a better class of men. The educated physician is rarely a discredit to the profession; abortionists and quacks are not, as a rule, recruited from the ranks of college men, but almost always from the ignorant and inefficient, or from those morally unworthy public confidence. The objection. to the adoption of this standard is not likely to come from the laity, for the discrimination now shown in favor of the educated physician is a matter of daily observation; the exception can often be cited, but the exception only proves the rule, for the physician who has lacked education and yet has succeeded has possessed inherent qualities that have won, notwithstanding his limitations. In the majority of such instances, however, there has been only a relative success, as the lack of edu

cation always circumscribes influence and power.

The colleges of this State should carefully consider it. Many colleges, as has been stated, are already requiring a graduate standard for entrance, and they are the colleges that are attracting the class of men the profession needs. The times demand that this be done. The intellectual growth of this country is such that the highest type of physician is required, and a moral obligation to use every endeavor to turn out this class of men devolves upon our medical colleges.

Society Reports.

OBSTETRICAL SOCIETY OF CINCINNATI.

OFFICIAL REPORT.

Meeting of April, 1908.

THE PRESIDENT, MAGNUS A. TATE, M.D., IN THE CHAIR.

J. H. LANDIS, M.D., SECRETARY.

Case Report.

DR. SIGMAR STARK: I wish to report one of the most unique cases I have met with in the practice of medicine. I am unable to explain the condition found, and for this reason bring it before the Society, so that you may throw light on the subject. It is the case of a young woman twenty-four years of age, who was delivered about four years ago of a large child after a very difficult labor. Since then the mother has been in good health. She again became pregnant, and in about what would correspond to six or seven weeks of gestation she was taken with severe pain in the abdomen on the right side. It was a pain of a colicky nature, which continued at intervals for a few weeks and then subsided some. After a week, bleeding sat in, and then irregular bleeding continued for a matter of two months. The patient came here and I examined her and found down in the right side of the pelvis a fluctuating mass. unable to make out the uterus distinctly. There was something on the left side, but I could not make it out, as the woman was very sensitive both physically and psychically. The abdominal wall was rigid. I made a diagnosis of tubal pregnancy. The next morning she went to the Jewish Hospital, and on the following morning I operated. On opening the abdomen, the intestine was seen to extend low down into the cavity of the pelvis, so that the uterus was at first obscured. On the right side a distended tube immediately came into view. After the patient was put in the Trendelenburg position,

I was

which was pushed to the extreme, so that the intestine was carried up into the abdomen, the uterus was seen to be of normal size, occupying the pelvis to the extreme left. On raising the uterus there was found to be absolutely no broad ligament on the right side. The whole right border of the uterus was as smooth as my arm. There was no connection of the right tube with the cornu, nor any sign of a broad ligament between the uterus and tube or ovary. There was only a small fold of peritoneum, extending from the brim of the pelvis down a short distance. The fold was not over threefourths of an inch in length. The tube and ovary, suspended from the fold, hung in the cavity of the pelvis. The tube was of normal length, but distended with a bloody mass. Freiberg was in the building and he saw it, as did likewise Dr. Ransohoff. The suggestion was made that we had a unicorn uterus to deal with, but the uterus had no connection with the tube and rudimentary ligament. There was a complete absence of tissue on the right side of the uterus. Running from the broad ligament fold, an unusually thick round ligament, short in length, extended into the inguinal canal. The interesting features were:

Dr.

First, how could the upper third of the duct of Mueller become separated from the uterus? I can find no reference to it anywhere. I cannot imagine that fetal peritonitis could bring this about. There were within the lower peritoneal cavity no old adhesions that would have indicated the existence of a previous peritonitis. The tube itself was perfectly round.

A second interesting feature was the manner in which the spermatozoa got into the right side. They must have migrated across the pelvic cavity and got into the tubal orifice. We know that the ovum will migrate from one side to the other. Leopold determined this by experiment twenty-eight or thirty years ago. This case proves that the spermatozoa can migrate from one tube across the pelvis into the tube of the other side. I likewise removed the ovary of the right side to prevent future trouble.

DISCUSSION.

DR W. D. PORTER: May not the spermatozoon have reached the ovum on the left side and then have been carried across to the other side?

DR. STARK: That is contrary to our knowledge. The ovum gets into the tube first ordinarily. But in this case, if the ovum got into the tube it would have stayed there. It would not go backward.

DR. PORTER: Suppose it was on the right side.

DR. STARK: While still in the ovary? fore it got into the right tube?

DR. PORTER: Yes.

Be

DR. STARK: That would mean that the fecun

dated ovum migrated over. That would be extraordinary. It is more reasonable to believe that the ovum got into the tube and the spermatozoon went over.

DR. PORTER: The ovum had to make the trip. Could it not have carried the spermatozoon with it?

DR. STARK: That is all theory, of course. DR. J. A. JOHNSTON: What was the shape of the uterus?

DR. STARK: It was a little smaller on the right side. The uterus hung from a fold of peritoneum running from the left border of the pelvis. The tube and ovary hung down into the pelvis from a fold of peritoneum before described.

DR. WM. GILLESPIE: It may be that the two tubes failed to mature. One developed partially and the other wholly.

DR. STARK: But the growth or development

was wrong.

DR. GILLESPIE: The question of separation may be explained by fetal inflammation. You would not expect adhesions found at that time to last.

DR. STARK: There may have been a fetal peritoneal inflammation. There may have been some band that cut the tube right off. What could be seen of the cervix was normal. The whole of the cellular tissue was normal.

DR. J. H. LANDIS: I got the idea that you think the ovum migrated from the left to the right side.

The

DR. STARK: Only the spermatozoon. question is whether the impregnated ovum traveled into the tube or only the spermatozoon. There was a perfectly normal right tube. First I removed the tube. Then I thought that the spermatozoa would get into the ovary. Then I removed the ovary.

DR. GILLESPIE: You cannot make a law on a thing that does not follow the law.

DR. PORTER: I should think it possible that an ovum from the left side could be impregnated.

DR. STARK: The only objection is this: When an ovum becomes impregnated it immediately becomes tied. It locates. If it is in the peritoneal cavity, it will stay there.

DR. GILLESPIE: I do not believe that. The theory is that it becomes impregnated in the tube. It only stops in the tube because there is something to keep it there. An ovum that is fertilized might go across the peritoneal cavity.

DR. LANDIS: Was it any casier for an ovum than for a spermatozoon?

DR. STARK: The most plausible theory is that a spermatozoon went into the right tube.

Puerperal Eclampsia.

DR. J. C. CADWALLADER read the paper of the evening, with the above title.

Next to hemorrhage, eclampsia is the most dangerous complication of child-birth. Even the milder forms are of sufficient gravity to cause the medical attendant much anxiety and apprehension, while the severer forms show a maternal mortality of 14 per cent., though handled by able practitioners. The infant mortality is still higher, depending largely upon the severity of the seizure and upon the interval between the attack and full term.

The pathology is still involved in doubt and uncertainty. Autopsies on patients who have succumbed to eclampsia show conditions so various that they do not teach us much in regard to the true nature of the disease, and often it remains doubtful whether the changes found should be looked upon as cause or effect of the disease.

Many theories have been advanced to explain the cause of this condition, but so far none of them cover all cases. Some of these theories have been so ably and plausibly advocated as to suggest the probability that the disease is due to several causes whose relative prominence varies in different cases.

There are likewise considerable d'fferences of opinion as to the management and treatment of this malady, as will be noted in some of the case reports to follow.

Prophylaxis is by far the most satisfactory chapter of the whole subject. Fortunately, the onset of eclampsia is usually preceded by danger-signals which are quickly observed by the careful and pains-taking practitioner. Headache, dizziness, indistinct vision, pain in the pit of the stomach, restlessness, insomnia or scanty urination will at once be reported to the family physician by the patient who has been properly warned of the import of such symptoms.

The occurrence of eclampsia is usually proof positive of carelessness-carelessness on the part of the physician who has neglected to carefully instruct his patient, or carelessness on the part of the patient in neglecting to engage the services of a physician, or in failing to report symptoms as instructed to do.

Fortunate are we in the fact that, once warned as to the danger in a given case, we are usually able to avert the attack, unless the warning had come too late. Treatment during the premonitory period is very effective.

Most men are agreed that eclampsia is dependent upon toxemia. While this term is far too indefinite to be of much value in treatment, yet we know enough in a general way to enable us to institute prophylactic measures which, if supported by good judgment, are usually effective.

Much has been written on prophylaxis-so much that we shall not attempt to enumerate the various recommendations. They arrange themselves logically, however, under three headings.

The first of these is increased elimination. In an urgent case an effort is made to stimulate to the utmost all the emunctories of the body, including the kidneys, skin, liver and intestinal tract. In a vast majority of all these cases the most important is the intestinal tract.

The injunction should be impressed upon