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simply with an idea of getting into heaven. According to the very best authorities, a great many very disagreeable, mean and narrow-minded individuals are sure to go to heaven, and you don't want to spend your earthly existence with such a one, even if he will finally be renovated.
First of all, let us consider out and out quackery. There is nothing essentially sinful in having a large sign or in mailing cards, dodgers and almanacs to persons whom you do not know, nor in paying for newspaper advertisements, nor in bragging about yourself as wonderfully gifted, nor in making a partnership with some fancy name. All of these methods are used in other businesses. Some are, in and of themselves, perfectly straightforward, others are merely the harmless exaggeration and distortion of the literal truth, that people expect and discount in advertisements. Why are they unethical? Why are they unethical? Let us answer this question with another: Why are you tempted to resort to them? Because you expect they will increase your trade. But why will they increase your trade? Because most physicians are too gentlemanly to employ them. There you have the gist of the whole matter of ethical objection to quackery. It is not that any one means of advertising is, of itself, sinful or dishonorable but merely that the man who resorts to these means is competing unfairly and is relying on the fact that the majority of his opponents are too honorable to resort to his own tactics. The quack is like the man who looks at his opponents hand in a game of cards, like the pugilist who strikes a blow when his opponent is giving him a generous chance to recover himself, like the man who slips into a seat in a crowded car that the man ahead of him is offering to a woman. Don't tie yourself for life to this kind of a companion, rather pick out an honest thief or square burglar.
However, if you are going to be a quack at all, at least be honest enough to proclaim yourself as playing an unfair game. Don't compound your dishonesty by pretending to be ethical. If you want newspaper advertising, pay for it like a man, don't pull the legs of editors and reporters for puffs. Or, at least, don't be a hypocrite of the third degree who gets his assistant to look after the press notices and then proclaims to his students and colleagues that he hates newspaper no. toriety, who indirectly sends word to the papers that he will operate on a rare case at clinic, and then makes a sensation that will certainly invite public comment, by ejecting a reporter. It is unpleasant to live with an openly unfair man, it is worse yet to live with a second or third degree sneak.
Just a few words about sexual morality. Without regard to abstract right or wrong, human experience has shown that anything approaching free love is incompatible with either advanced savagery or civilization, although in a very low state of savagery or in a state of barbarism with virtual or actual slavery for part of the people, various phases of free love or, at least, polygamy, may exist. But it is a crude, hard fact, that in any large community, there is very nearly one woman to each man, and that whenever the stress of living is great enough to make the life worth while, the necessary effort of taking care of the weaker and dependent part of the race, will not be made unless the average man is sure of his own wife and his own offspring. It is true that a great many persons are too weak to resist temptation, and that peculiar circumstances and, especially, the application of excellent general laws to exceptional cases, do occasionally almost seem to justify the violation of the general principles of sexual morality. But society can exist only as these principles, are generally adhered to. However, as a man, you must observe or break these rules according to your own understanding of right and wrong. As a physician something more is expected of you.
The Hippocratic oath fully covers the ground. It is one thing to be morally bad, as a man; quite a different matter to take advantage of the peculiar trust imposed in you as a physician. If you are going to play this game, at least play it fairly, against a woman fairly armed to resist you, mature enough to judge for herself, and with no sense of obligation to you for favors of employment as your assistant in any capacity, and not disposed to yield to you by reason of a confidence or affection due to your professional ministrations.
The gross violations of morals have no special relation to medical practice, but there are many little ways in which this life companion ought to be trained. Don't live with a man that has a petty, jealous disposition. If you find that it hurts your feelings to learn that a friend is sick and has employed some other physician; if some one praises a rival and you have to pull hard to get up kind words from your throat; if the news of another physician's downfall comforts you, go and kick yourself until you are cured, other. wise, eventually, others will kick you.
Don't be narrow. There is something seriously wrong with a physician who is simply an appendage to a sign and an obstetric bag. You should always be advancing in your chosen art and science and, unless you are so unfortunate as to justify the most modest estimate of yourself, you should be a pro
ducer, as well as a consumer of medical knowledge. Be both a user and a maker of medical societies and medical journals.
However broad a physician, a man maybe, he is narrow if he remains only a physician. A thoroughly well rounded man must be mediocre in everything but every man should have at least one hobby, intellectual or social, selfish or philanthropic, outside his life work. We cannot all be a poet like Holmes, or a genealogist like Stiles, or a muscial composer like Hemmeter, or a novelist like Doyle, or an executive or politician like Wood. But be something or do something, however humble and useless, so that you will know somebody besides those who are sick.
In short, spend your life with a man who is not only a fairly good and conscientious doctor, but a decent man, a gentleman and, not necessarily a scholar but an active, interesting fellow.
PUBIOTOMY AND ITS RELATIVE INDICATIONS.*
E. B. MONTGOMERY, M. D.
AFTER a brief sketch of the history of symphysiotomy from which pubiotomy is an outgrowth, both accomplishing the same object of equally enlarging the pelvic diameters, the author gives an extended review of the literature of the subject giving all cases reported in medical journals and transactions, as well as verbally and by letter. The number has now reached about 300, with a total mortality of 2-3 per cent, and a mortality in cases aspetic before operation of 0 per cent. There has been no morbidity or impairment of gait. Comparing these figures with those given in Rubinrot's exhaustive study of symphysiotomy, the author concludes that pubiotomy should absolutely replace the former in all cases in which it would otherwise have been done.
On account of smaller mortality it should replace Cesarean section where that would otherwise be chosen, in all cases having a conjugata vera of 7 cm. or over in rachitic or contracted pelves. It should absolutely replace embryotomy in the living child, presenting practically no greater risk to the mother and saving the life of the child. It should largely replace induction of premature labor, or by combining pubiotomy labor may be induced at eight months, or later, increasing the chances of the living child and making
Abstract of a paper read before the Mississippi Valley Medical Association, Hot Springs, Ark., November 7, 1906.
The Medical Society of City Hospital Alumni
President, LOUIS H. BEHRENS, 3742 Olive Street
Secretary, FRED. J. TAUSSIG, 2318 Lafayette Ave.
Scientific Communication, Wm. S. Deutsch, 3135 Washington Ave. Executive, A. Ravold, Century Building Publication, W. E. Sauer, Humboldt Building Entertainment, Frank Hinchey, 4041 Delmar Ave. Public Health, R. B. H. Gradwohl, 522 Washington Ave
A CASE OF CANCER OF THE CERVIX AS-
FRED. J. TAUSSIG, M. D.
ST. LOUIS, MO.
THE patient, Mrs. W., aged 71 years, came into my charge at the St. Louis Skin and Cancer Hospital on April 21, 1906. There was no history of cancer in her family. Menstruation began at the age of 15, and was in every way normal until she was 35 years old. At this time she began to notice a decided increase in the menstrual flow and the growth of some tumor in the pelvic region. This her doctor declared to be a uterine fibroid. Treatment consisted of ergot given internally. The tumor remained stationary in size until the menopause, which set in between the forty-fifth and fiftieth year. The tumor rapidly diminished in size after this. Noteworthy is the fact that although the patient had been married since her twenty-first year,
there had resulted no pregnancy. Every thing went well until July, 1904, when she began to notice a slight blood-tinged discharge. Soon thereafter she observed upon. taking a douche a moderate hemorrhage. From this time she grew steadily worse, but it was not until October, 1905, a year and a quarter after the first onset of her trouble that she consulted a physician. He did not advise operation, but prescribed a wash. The discharge now became odorous and the bleeding was hemorrhagic whenever the growth now felt protruding into the vagina was touched.
In general appearance the patient was rather emaciated, appetite, poor but not very anemic, considering the duration of her bleeding. A cauliflower mass, the size of a man's fist was found obliterating the vagina. Much to my surprise I found that the uterus was still freely movable, and that by recto-vaginal examination there was seen to be no infiltration of the pelvic connective tissue. The pathologic examination made by Dr. McConnell of a piece of the tumor showed a medullary carcinoma of the cervix.
*Read at the meeting of Oct. 4th, 1906.
On May 3 I performed a radical abdominal pan-hysterectomy. The uterus was
found adherent to the rectum with several myomatous nodules upon its surface. In freeing the tissues about the right ureter, according to the method of Wertheim, a ligature was accidentally slipped around this structure. The mistake was shortly afterwards recognized and the ligature cut, but in so doing the ureter was necessarily exposed for some distance. About one inch of the vagina with its connective tissue was removed with the uterus and adnexa. The operation lasted one hour and fifty minutes.
Outside of post-operative urine retention with a resultant cystitis the patient for the first twelve days made a good recovery. On this day there was noticed the escape of some It soon became urine through the vagina. evident that a partial necrosis of the right ureter had taken place and the fistula resulting in spite of all endeavors, refused to close. 23, her general condition was excellent. When the patient left the hospital, on June A secondary operation for the relief of the fistula was advised, but the patient refused to have this done. The last examination, made two and one-half months ago, showed no return of the cancer.
The further microscopic examination of the specimen removed showed that apparently the excision had taken place in healthy tis
The special points of interest in the case city has been done only three or four times, outside of the type of operation, which in this are: (1) The unusually slow growth of the cancer, being operable two years after the onset of bleeding; (2) its occurrence in a nulliparous woman associated with fibroids of the fundus; (3) the necrosis fistula resulting from undue exposure of the ureter.
REPORT OF CASE OF ENCEPHALO-CYSTO-MEN-
TION OF SPECIMEN.
Two days ago I was called to a confinement case. Before delivery nothing abnormal was noted, but the indistinct fetal heart beat, which was about 115 or 120 per minute.
As the head dilated the perineum I noticed a swelling in the region of the posterior fontanel. It was readily recognized as a meningocele. The child breathed ncrmally. The opening in the cranium was hardly larger
than the end of one's thumb. For the next six hours there was no seepage of the meningeal fluid, but after that it soaked the gauze, and as there was beginning necrosis at the top of the mass I decided after consultation with Dr. Fry, to do an operation, as leaving it meant certain death. Yesterday at noon. when the child was thirty hours old I cut away this meningeal sac. The specimen is in three pieces. You can see how thin the skin is at the point of beginning necrosis. Within the meningeal sac was found a small piece of brain tissue. This was ligated, a catgut purse-string suture put at the base of the sac and the skin was closed with interrupted silk-worm gut sutures. The child showed but little immediate shock. It passed a good night, taking one or two ounces of milk diluted with water every two hours as well as rectal saline enemas. This afternoon there is a temperature of 102 deg. but it nurses, retains its food, and there is a possibility that the child will pull through.
Dr. Allison, who kindly assisted me in this operation, has assisted Dr. Lovett, of Boston, in two or three similar operations, and I understand the results are not discouraging, though none of Dr. Lovett's cases were as large as this one, or done so soon after birth.
Dr. Walter B. Dorsett.-I have had no experience in meningocele in the new-born. As far as the other specimen is concerned he spoke of a necrosis of the ureter. Were the glands that were taken out along the ureter enlarged or attached to it? The question is, was the ureter involved in the malignant disease? Not long ago I had a case something like this. The growth seemed to be on the posterior wall of the uterus, and it had assumed the shape of the pelvis. It went around the ureters like a horseshoe, but I was enabled to remove it. Had it enclosed the ureter entirely I doubt if I could have removed it. This case was of particular interest to me on account of the absence of pain while there was great destruction of tissue. While it looked like a fibroid, microscopically it was found almost entirely carcinomatous in character, with very few fibroid elements. The question has long been discussed whether fibroid tumors become malignant, or whether they facilitate the growth of malignancy. This case may throw some light on the subject.
Dr. Henry Jacobson.-Where it is necessary to dissect the tissues outside of the uterine proper it would be much safer to introduce catheters into the ureters before the operation and leave them there throughout the operation. Then if the growth extends around the ureter it can be more readily removed, and there would be no danger of ty ing the ureter.
Dr. Taussig, in closing. In reply to Dr. Dorsett, I found no enlarged glands in this case. I made, a search for them. I have given up trying to take out normal glands. In an old woman (over 70 years of age) I did lymphatic glands. As to the use of the not feel like trying to remove the normal catheter in the ureters, it is very dangerous for the reason that we often have to use clamps, and if we catch the ureter in the clamp the catheter may be broken. I know Dr. Sampson spoke to me about such an accident at Johns Hopkins.
Dr. Jacobson.-I believe he would be a careless surgeon to say the least, to clamp a ureter, when his fingers would so easily feel the ureter with the catheter inside. If he would clamp the ureter, the crushing of the delicate tissues would cause a necrosis, and as a result almost surely a fistula, and later if the fistula closes a stricture of the ureter.
PRESENTATION OF SPECIMEN OF FIBRO-MYOMA.
HENRY JACOBSON, M. D.
This was removed last month. The patient, age 39, never had children, a poor woman, had had severe pressure symptoms, which made an invalid of her and had been treated for sciatica and lumbago. I found upon examination an enlarged nodular uterus pressing against sacrum and diagnosed fibromyoma, and I operated. on the 16th of last month. She made an uninterrupted recov ery, and is entirely free from pain. You will see that the specimen is intermural would soon have become subperitoneal. There was no hemorrhage in this case, because it was not growing towards the endometrium. This tumor was situated in the inferior posterior wall of the fundus of the uterus; in this situation the growths always call for early removal on account of the distressing pains in back, and radiating reflex pains down the thighs. It also illustrates that too much stress must not be laid on uterine hemorrhage in suspected growths of the uterus.
THE PHYSICAL CARE OF SCHOOL CHILDREN.
ROWLAND GODFREY FREEMAN, M. D. NEW YORK.
Lecturer on Pediatrics, University and Bellevue Hospital Medical School; Attending Physician Foundling Hospital and Nursery and Child's Hospital. The Seaside Hospital of St. John's Guild, New York.
IT is probably the opinion of most physicians of this city who have the care of children that almost all school children are overworked, and that this is true in all grades of school life, in the kindergarten, the primary school, the secondary school; and the same is true of young men in the professional schools. This overworking is a natural tendency, because children are sent to school to learn certain facts and to receive mental training, and each institution is striving for a high standard of scholarship. Such a practice is apt to cause some physical wrecks, as we know is the case in New York, through a straining of the nervous system or on account of the lack of physical exercise caused by continuous application to studies, while indirectly by overworking the teachers who are apt to become neurasthenic, there is set up a reflected nervous irritabiilty in their pupils.
Under good surroundings that can be regulated, the care of children, both by parents and physician, is a source of considerable satisfaction and pleasure until they enter the kindergarten or school. Until that time they may be troubled occasionally with slight colds, with constipation, or with adenoid hypertrophy, but as a rule they may be kept in good health. As soon as the child is entered in the kindergarten infections are more apt to occur. Colds recur more frequently, and the ordinary acute infectious diseases of children are apt to break out. Whooping cough, mumps, chicken-pox, and measles usually occur within a few years after the entrance at the kindergarten. As the child leaves the kindergarten and enters the prim. ary school this liability to contract contagious diseases persists, while the prolonged concentration required in the school regime produces frequently, toward the end of the school year, certain nervous disorders, of which chorea and hysteria are the more common varieties.
The question naturally arises whether these disadvantages of our present school system are due to any defect in school methods, or whether they are only an accompaniment of a system of education that is necessary for each generation, and whether school life
could in any way be modified to impart aufficient knowledge without impairing the health of the child, and with less liability of exposing the child to contagious diseases. Let us first consider what are the essentials of the preservation of good health in children.
First, they need ample rest. They should have ten or twelve hours in bed at night, and often with advantage a nap after the midday meal.
Second. A proper diet: A moderate breakfast, a substantial but digestible dinner, and a simple supper. All these meals to be eaten slowly and well masticated.
Third. Fresh air. A child should be outof-doors several hours a day, and when in the house should be in rooms well ventilated and provided with at least 1,500 cubic feet of air space per person.
Fourth. Freedom from dust and exposure to disease. Infections due to dust and the direct exposure to contagious diseases cause a large part of the sickness of school children.
Fifth. Freedom from worry and fatigue. Neurasthenia exists in earliest infancy and is common in school children. It is induced by anxiety, and particularly in children by prolonged application. The child can exert itself intensely for short periods without harm, but prolonged application produces marked fatigue.
Our experience tells us that when these five essentials of good health can be maintainedample rest, proper diet, fresh air, freedom from infection and freedom from worry-there is usually little difficulty in securing prolonged good health. Our problem, then, is to ascertain whether such conditions are practicable for our school children. They are certainly not offered now to any school children. Can private or public schools be organized that would afford them?
The first condition, ample rest, may be ob tained with our present school arrangements, except that with most classes no opportunity is allowed for a nap after dinner. This is not necessary in all cases, but is always desirable. The diet is also a matter for home regulation, except in public school children, but this opportunity for the children to take their hearty midday meal at leisure is often prevented by too small an allowance of time for the noonday recess. In some of our best schools but forty-five minutes are allowed for the child to go to his home, eat the most substantial meal of the day with meat, and return to school. One hour would seem to be too little for such a recess. The question whether our public school system should not provide one nourishing meal a day, at least to those children who are poorly fed at home, is a