danger where men are actuated by honest impulses. In devoting my remarks in this address to surgical outrages, I again reiterate that my purpose is not to discourage honest effort, where the means employed in preliminary preparation are in keeping with the responsibilities of the work, but to "hold the mirror up to nature,” and by condemning, or if needs be restraining, this wild stampede of incompetent aspirants for perquisites and honors unearned and unmerited, lessen the evil which now exists. THE HUMAN ELEMENT IN MEDICINE.* BY PHILIP ZENNER, AM., MD., Professor of Neurology in the Medical Department of the University of Cincinnati. We, as practitioners, are too prone to overlook the human element in disease. It is not alone that we may overlook the characteristics of the patient, his special physiological or pathological reactions, but we are apt to forget that great factor in health and disease, his mental attitudes and aptitudes. It has been said that one-half the impaired health is of mental origin. Of paramount importance here are the painful and depressing emotions, and the fears or mental representations which appear in the patient's mind as the result of external conditions or present symptoms. The chief mental states the physician should bear in mind, for it is thereby that he influences his patient for good or ill, are joy and sorrow, hope and fear, expectation or mental representation of good or ill, and mental absorption and brooding. The influences we are now considering naturally play the largest part in the neurotic and in those suffering with various forms of nervousness, but yet they are important factors everywhere, even in acute infections and in serious organic disease, for the nervous element is everywhere present. A I wish to speak of modes in which physicians use these influences for good or ill. A powerful therapeutic agency is the mode of examination of the patient. thorough examination is likely to create the idea that the physician understands the case, and thereby to give the patient full confidence in him. If at the same time the physician has instilled into the patient's heart that he has his kindly interest and sympathy, he has already administered a powerful and helpful tonic in every case, and put the case of nervousness far on the road to a cure. mind the harm that may be done by a thorough examination. Firstly, it may alarm the patient, may suggest to him disease or danger of which he had not formerly thought. Such alarm is especially aroused by the examination of certain organs, the heart above all. In this way, too, gynecological examination is often a source of harm, especially vaginal examination of young girls, which could mostly have been avoided. Such sources of harm should be eliminated by the physician, through his knowledge of his patient, through care and tact, and ofttimes through reassurance of the patient before the examination is undertaken. Again, the physician may harm his patient by neglect or delay in telling him the result of the examination-of the urine, for instance the idea arising in the patient's mind that he has serious disease, of which his physician is unwilling to speak. Another mode of doing harm, the physician should bear in mind, more than many of us are accustomed to do, is showing the patient the doubt which is in his own mind. We find symptoms that puzzle us, or doubt may have arisen in other ways, doubt which often need play no part in the conduct of the case, and may have proven to be of little consequence. But this doubt, transferred to the patient's mind, is very commonly a source of worry, and may materially influence his condition. Now let us see how this human element figures in diagnosis and prognosis. A reassuring diagnosis and a favorable prognosis on the one hand, and an alarming diagnosis and grave prognosis on the other, are the most powerful mental agencies for good or ill which the physician possesses. And how lightly he sometimes But the physician should also bear in handles them! Perhaps on vague and un* Read before the Thirty-fourth Annual Meeting of the Mississippi Valley Medical Association, Louisville, Ky., October 13-15, 1908. defined symptoms he mentions a disease which fills the heart with terror, or tells a woman, comparatively young, that she will lose her nervous symptoms after the menopause, thus taking surest means of indefinitely prolonging incapacity and suffering. I do not wish to enter into the discussion of the question whether it is the duty of the physician to always tell the patient his true condition, but right here there are certain facts he should constantly bear in mind. Firstly, he is called into the case to help, not to harm it; secondly, errors in diagnosis, and especially in prognosis, are exceedingly common, of which fact the patient should have the benefit; thirdly, there is a great difference in individuals, some are brave and bear bad news stoically, whilst others are driven to distraction. A bad prognosis is oftimes the means of its own fulfillment; for while the disease itself should not have ended fatally, the patient dies as the result of his fears, or voluntarily ends his life. Some of the most dread diagnoses, for instance, heart disease and locomotor ataxia, might, through careful explanation of the physician, be robbed of much of their terror. It should be made clear to the one that compensatory hypertrophy may avert all ill effects, so that length of life need not be affected, and to the other, that many with locomotor ataxia scarcely interrupted in life's activities, nor their lives shortened thereby. are Next, as to the human element in therapy. What I have to say now applies mostly to the functional nervous diseases, hysteria, neurasthenia and hypochondriasis. It is a very common custom to attribute many conditions of nervousness to various local diseases, those of the stomach, uterus, etc., and to direct the treatment chiefly to those organs. That the relationship of cause and effect really exists in these cases is very doubtful, that is, farther than in so far as the local disease mars the general health. But there is no doubt that this local treatment often influences the nervous disease, an influence that may be for good or for ill. It is almost as certain that that influence is chiefly mental, that the local treatment does good or harm in these cases chiefly through its effect on the mind. When they are benefited or cured it is largely due to suggestion. When they are injured-and this occurs just as often, if not more frequently it is largely because the local treatment keeps the patient's mind fixed on the disease process. How often distracting the mind, altogether ignoring the disease, causes it to disappear. Who has not seen cases of "nervous dyspepsia" where the disease was prolonged by a careful and restricted diet, frequent examinations, local treatment and the like, while it quickly disappeared with a generous diet and the neglect of symptoms? What we have been considering belong to the most powerful means by which the physician can influence his patient's mind for good or ill. But permit me, in addition, to speak very briefly of some direct modes of mind cure. First, suggestion. This mode of treatment, the oldest and most universally applied, we are using constantly, either consciously or unconsciously. There can be no doubt that drugs and medical appliances, and even surgical operations, often produce their effects partly or altogether through their influence on the mind. This is even seen, and not rarely, in organic disease, perhaps because the symptoms removed were brought on by suggestionno uncommon occurrence in organic disease-though this is not the whole explanation. How much suggestion means, and its practical effects, we see when our patients pass from us into the hands of those outside the realms of scientific medicine, and see all their symptoms disappear, to the credit of some "ism," whatever it be, and the discredit of scientific medicine. Though he is constantly using it unconsciously, the physician should study carefully and aim to make the most of this powerful agency. To do this and at the same time avoid the pitfalls thus placed before him, he should know well both his patient and his disease. The other mode of mind cure of which I wish to speak, is that of education or persuasion. It consists in explaining to the patient the nature and origin of his symptoms, in order that they may be removed by his own insight and effort. It is applicable to those in whom the symptoms are due, in part or altogether, to the mind; that is, they are produced by suggestion, or are intensified through the mind, or are caused by fears or kindred mental states. This means chiefly cases of nervousness, but not them alone, for it is often applicable in cases of serious organic disease. Treatment by suggestion is very simple. It taxes neither physician nor patient; in fact, both are usually unconscious that it has been called into play. Treatment by education is a very different matter, and may tax to the uttermost both physician and patient. The physician should know his patient well, his disposition, intelligence and power of insight. He must know his power of insight, that the explanation, which he gives him, fully satisfies his needs; and he must know his disposition, for it is necessary to address. very differently the mind of the sensitive patient to whom his diagnosis may appear to be a personal reflection, and the open-minded one, looking only for the means of health. In every case the physician must have the full co-operation of his patient, or his own efforts will be futile. Again, he must know what is in his patient's mind, for the better understanding of his suffering and its causes. On the one side are the sorrows, worries, fears, obsessions, and the like, possibly locked up in the patient's heart, while knowledge of them might enable the physician to give relief, if not speedy cure; on the other, are the many suggestive influences that are producing and intensifying symptoms. The latter, the suggestive influence, may be hidden and hard to find. It may have been something felt, seen, heard, read or only dreamt, now forgotten, though still having its blighting effects. rarely it is something that originally was, or appeared to be, the cause of certain symptoms, and thereafter produced those symptoms merely through the patient's idea, that is, the belief of this relationship of cause and effect. Very often, too, while a bodily cause of symptoms is present, it only becomes effective because fright fixes it, or suggestion strengthens it, or in other ways it is intensified by the mind dwelling. upon it. Not All these possibilities the physician should bear in mind. There are cases in which treatment by education or persuasion is very simple, the physician assuring the patient there is no basis for his fears or symptoms, and therewith they disappear. Other cases tax to the uttermost the resources of the physician, his knowledge, his efforts and his patience. His first aim must be to give his patient full insight into his case, often no easy matter. The patient's feeling that his symptoms. appear quite independently of any act or thought of his, whether or not that opinion be correct, makes it hard to bring home to him that suggestion, and expectant or fixed attention are mainly respon sible for his condition, and that their elimination will permit of a speedy cure. it is not enough that the patient have insight into the nature of his symptoms, he must have and exert the power of removing them; again, no easy matter. Here the great need is building up in the patient. confidence in himself, in his power to master himself and his illness. The physician must prove his case to him; show him by examples what he can do; demonstrate to him improvement that has taken place in him, when his mind is perhaps given to other symptoms that appear to be worse; commend his efforts and prophesy favorable results; point out how his fears or mistrust of treatment is retarding his progress; try to get his attention away from symptoms and sources of suggestion, and the like more. Sometimes the physician will accomplish most by carrying the discussion to a higher plane of thought, the philosophy of life, truth and duty, and ignoring the symptoms altogether, wherewith they disappear. Not rarely the physician needs address the patient in this higher plane, for ofttimes false views of life and duty, faults in disposition and character, faulty use of will power, all supplemented by faulty education and environment, are the basis of the nervous malady. Withal, while suggestion tends rather to weaken than strengthen will power, even though it removes symptoms or the disease itself, treatment by education should strengthen every mental and moral fibre, and therefore lead to a more radical and permanent cure. All that has been said in this paper is not to detract from those great aids in mental treatment: rest, isolation, overfeeding, diversion, amusement, and wholesome occupation. Finally, I wish to emphasize how frequently the mental element plays a large or controlling part in the case, a frequency not usually dreamed of, and to make the following suggestions: Let each of us take an inventory of his cases, and by careful study or treatment test the question, what of present suffering is due to the mode of examination, the diagnosis or prognosis given, or the treatment instituted, and how much can be gained by remedying any harm thus done, or by well-directed suggestions, or by a heartto-heart talk with the patient as to what his mind has done and may do in the way of mental and physical health. DYSMENORRHEA.* BY HUGH MILLER MOORE, M.D., Dysmenorrhea is menstruation associated with pain either before or during the flow. It is caused by anatomical or functional changes, or neurotic temperament, and is often associated with amenorrhea or menorrhagia. The fact that we are ignorant of the real cause of menstruation, although many theories have been advanced, makes the treatment of dysmenorrhea very imperfect. As early as 1832, the two noted English gynecologists, Simpson and Sims, studied and wrote about dysmenorrhea. The latter stated, "The absence of dysmenorrhea was assured, if the cervical canal be straight and free for the passage of blood." They recognized the importance of mechanical obstruction in the production of pain, but not the cause of obstruction. Normal menstruation is painless; woman should have her menstrual flow without pain or other body discomfort if she is healthy and normal anatomically. We know that the uncivilized woman suffers but little, and this function, like childbirth, is of small consequence and alters her daily life but seldom; however, as civilization advances, and woman changes her manner of living and her body is altered by dress and lack of exercise, she begins to suffer during these periods of uterine function. The reason for this is that woman is more neurotic, her muscles less developed, and pain which affects her uncivilized sister slightly, becomes serious or prominent and the consequences far-reaching. We know that as the brain develops, so also does the entire nervous system, especially the sensory system. portion be retained, menstruation contin- Menstruation is the periodic hemorrhage from the uterus. The flow of blood is truly a diapedesis of blood from the uterine mucosa; the blood is changed by passage through the mucosa, and really is of the nature of an excretion. The cells of the mucosa act as secreting gland cells, only a little hemorrhage occurs, and this is due to small tears in the thickened mucosa around the internal os. The mucosa consists of long, columnar epithelial cells, lying directly upon the muscle with no submucosa; but crypts or uterine glands. are formed lined by similar epithelial cells. These cells are partly cast off during menstruation and form part of the menstrua; capillaries lie under these cells and during menstruation enlarge and become gorged with blood. en The muscle bands are very irregular, but form usually whorls or bundles which contain large venous channels.. It is difficult to give a good classification of the different varieties of dysmenorrhea, for we have many kinds merging with others, either from anatomical or physiological causes. For convenience in dealing with the subject I have arranged the causes of dysmenorrhea as follows: 1. Constitutional: (a) anemia, chlorosis; (b) rheumatism or gout; (c) neuralgia, nervous hypersensibility. 2. Local: (a) pathological (inflammation, myoma); (b) non-pathological (positions, obstruction). We have two important factors in the causation of this pain, the first being some anatomical change, the other hyperesthesia or hypersensibility of the nervous system. We know also that the ovaries have a great effect upon the function of menstruation, as experiments upon baboons show, in which transplantation of ovaries caused continued menstruation, while extirpation stopped it; and so, too, in humans, if in taking out the ovaries a small * Read before the Warren County Medical Society, at Lebanon, October, 1908. 3. Special: membranous dysmenorrhea. The special form of membranous dysmenorrhea is entirely distinct from the other varieties, and has a distinct pathology; however, it is not a disease sui gencris, but is due to varying conditions producing an exfoliative endometritis. Those who have carefully studied this disease say some inflammation of the endometrium precedes the precedes the condition, either as a vaginitis of childhood, an in Proving the identity of these forms, cases have been reported where first one then the other cast would be thrown off. The diagnosis between this and the decidua of an early abortion is often difficult, about the only difference being the size of the decidual cell which is larger than the epithelioid cell of the membrane. Both the clinical history and microscopical appearance must be considered before a diagnosis is assured. The treatment is unsatisfactory, as only temporary relief can be obtained, although curettage be performed or applications made directly to the uterine mucosa. In the treatment of all the other forms of dysmenorrhea, those cases classed as local and pathological, including the inflammations and myomata, are best relieved by surgical means; the removal of myoma being necessary, particularly if of the submucous variety. Surgery is also useful in removing the inflamed and disseased mucosa, or the uterine appendages, i.e., ovaries or tubes. Electricity, which for a time was heralded as the panacea for all of woman's ills, fell into disrepute, but if used in a selected variety of cases certainly is very beneficial. This powerful agent, like surgery, should only be used by those skilled in that particular branch, for as much harm can be done by improperly applied electricity as by a dirty surgeon. Electricity may be used for purpose of massage, or for destroying obstructions in the cervical canal and hypertrophy of the uterine mucosa. The sedative action is also useful, but of minor importance. Then, again, in dysmenorrhea, we have such a distinction as that given by Dr. H. A. Kelly: 1. Increased menstrual molimina (meaning those local and general disturbances which ordinarily accompany normal menstruation, consisting of some general malaise, backache, bearing down feeling even to the extent of being pain, and most often the general nervous excitability; these last during the first few days and may precede menstruation by a few hours). 2. Pain more severe and of an entirely different character. Whichever classification may please, it is my purpose to explain but one form with its treatment, which has been selected to-day because this certain class of patients can be helped after the failure of other treatments. The variety of dysmenorrhea referred to is that occurring in voung girls, generally unmarried, who may or may not be anemic, but are the product of our higher education. All of my cases are either high school or college students. The pain generally comes during the forty-eight hours preceding the flow, and lasts from two days to end of menstruation generally, though only during the first twenty-four hours. However, by this time they are so weakened and nervous that they are ill during the entire period. Cer After trying many surgical methods and medical treatments it was apparent that some other plan must be used to find some one pathological or physiological factor governing the majority of cases. tainly we must recognize and correct any constitutional trouble, as the anemia, chlorosis, rheumatic or gouty tendencies, but after these are better we still lack entire relief. One prominent factor was the lack. of muscular development. The patients might be plump and well formed, but the muscles were small and ill developed, and pelvic examination showed the uterus to be small, hard and generally anteflexed. Often the cervix was hard with a small opening, very sensitive, often giving pain when touched, similar to that of the dysmenorrhea. Taking into account the anatomy of the uterus it certainly is analogous to a gland; in fact, very much like the mammary gland, in that part of the cell is lost during the functioning of the gland. The peristalsis and trophic changes are largely under the control of the ovarian secretion. The blood supply is controlled by the ovaries, thyroid gland, blood condition and nervous system. Menstruation has been compared to miscarriage, and Sellman (American Journal of Obstetrics) thinks dysmenorrhea is caused by recurring colds, producing a thickened mucosa; but this is theory, as involution occurs only with destruction of muscle cell. As stated before, the uteri among these |