a man, when in health, like the rest of us, but then moaning with pain, or in harmless delirium reverting to the home of his childhood--with face, whose early softness had been hallowed by the holy tears of a mother's affection, or dimpled with delight at a mother's joy, now so changed that none might know his family, or lineage, or nation, or race, or even his manhood itself. Without act of a brother's sympathy or a father's pity, without the tender touch of a sister's hand, without a word of love from a mother's heart he died. "No reckoning made, but sent to his account with all his imperfections on his head." That death was unnecessary-the disease was preventable. If by his own fault he died, "It were a grievous fault And greviously hath the dead man answered it"-if by the folly of his parents, then did they doom him to a painful, dreadful death-if by the negligence of the state, then was it "a blunder which is worse than a crime." Small-pox from a preventable, has become a prevented disease; until all preventable diseases receive a similar quietus, let us cry aloud. An absent-minded doctor recently took unto himself a wife. During the marriage ceremony when she held out her hand for the ring, he felt her pulse and requested to see her tongue. A CASE OF LAPAROTOMY FOR A Societ T the November meeting of this Society I reported a case of extrauterine pregnancy in which I had performed abdominal section with a successful result. To-day I present the specimen of my second case of tubal pregnancy, removed by laparotomy, on February 14th of this year. The history of this case is, briefly, as follows: Mrs. M., 27 years of age, married, two children, the youngest 16 months old, has been suffering with periodical attacks of severe abdominal pains for times required medical treatment. Duralmost a year, for which she several ing the five or six weeks preceding the operation, these attacks increased in frequency and severity, making her unfit to do her ordinary household duties. Walking almost always produced a great deal of suffering. On January 26th, of this year, I was consulted for one of these attacks of pain, which was referred to the pelvic region, principally the left side. Making a vaginal examination, I found the uterus. enlarged to the size almost of a two months pregnancy and to the left of this, in the region of the left tube, a soft, extremely tender mass, which was slightly movable. A careful bimanual examination could not be made, on count of the very great sensitiveness of these parts. She had menstruated regularly every four weeks during the last eight or nine months, and was at this time still nursing her baby. At the two subsequent examinations I found no change in her condition, except, per ac า haps, that this tumor was slightly larger than before. The diagnosis was not quite clear, but I was inclined to the opinion that it was either a hydrosalpinx or a pyosalpinx, more probably the latter. As her suffering at times had almost become unbearable, I advised laparotomy, to which she readily consented, but the operation was deferred until after her next menstrual period, which was now very close at hand. Menses lasted five days, and presented nothing unusual. In the afternoon of the 13th of February, the day preceding the operation, she came to my office in a carriage, from her home for the purpos of going to Mercy Hospital. On examination I found her condition unchanged; the mass, however seemed now decidedly larger. The riding on the rough country road from her home did not seem to have caused her as much suffering as expected, and she was cheerful, and feeling better than for several days previously. But on her way to the hospital the pains returned in unusual severity, and she arrived there faint and nearly collapsed. Several hypodermic injections of morphia made her more comfortable, but she continued very sick and sore all night. On my morning visit before the operation, she looked very pale, and was very feeble, still suffering considerable pain. Vaginal examination was not made. On opening the peritoneal cavity dark blood escaped from the wound, and the abdomen was found containing a considerable quantity of blood, liquid and coagulated. In reaching down the sac, on the left of the uterus, I felt a small rent in it, probably one-half inch long, which, however, in trying to bring it to the surface, was enlarged, so that all its contents escaped into the abdominal cavity. The bleeding was now very free, the blood being bright red, and easily distinguishable from the old dark blood already contained in the abdomen. The sac was now tied off, and the clots contained within the pelvic cavity turned out. After washing out the abdomen with hot distilled water, it was closed, leaving, however, a glass drainage tube. Blood continued to discharge from this tube for three days, when it was removed. The patient rallied very nicely from the operation, and made an uninterrupted recovery, her temperature and pulse remaining perfectly normal after the fourth day. She left the hospital on the 21st day, and is now in good health. Rupture of the tube must have taken place on her way to or at the hospital, probably as a consequence of the jolting of the carriage. This evidently was the cause of the faintness and slight collapse after her arrival at the hospital the evening before the operation. Comparing the histories of the two cases operated on by me, we find the first case an almost typical one of ectopic pregnancy, and one of comparatively easy diagnosis to one at all familiar with this interesting anomaly, while the second case is as atypical as possible, in which I claim a diagnosis to have been entirely impossible, for there was not the slightest reason to even suspect a pregnancy, as the patient had been menstruating regularly, her last catamenial period terminating just a few days before the operation, and she was still nursing her baby at the time she came under observation. This case illustrates again the great difficulties in diagnosing extra-uterine pregnancy, and I cannot agree with Hanks, when he states that the diag nosis can be made in at least 95 per cent of cases. The case also demonstrates that this interesting affection is by no means such a very rare condition as some seem to suppose, as this is the second case occurring in my own practice within the period of four months. That this was a case of tubal pregnancy there could be very little doubt, but in order to be perfectly certain, I sent the specimen to Dr. Wm. II. Welch, of Johns Hopkins University, Baltimore, for examination, and he verified the diagnosis. The specimen, he states, consists of an ovary, part of a Fallopian tube, the intervening broad ligament, the fatal membranes and a placenta. with umbilical cord. The most intelligent audience, however, is often the least given to criticism, hence I venture to address you with some slight degree of confidence, yet, at the same time, with a full appreciation of the honor conferred upon me. It is useless to comment further upon the power which this Association may yield, not only as regards the medical profession of which it forms so important a part, but in other fields, where energy and influence are no less urgently demanded. It remains for me only to indicate the reforms which seem to be most urgently needed, with the full confidence that by the assistance afforded by the medical profession they will be brought to a happy termination. What then shall be our line of action during the years to come? What changes should be inaugurated? What projects already undertaken, should be carried on to completion? These are questions which it becomes us at this time to consider and decide upon. In their treatment, however, we are hampered by the superabundance of facts and suggestions which present themselves, and which by reason of their importance, demand special consideration. Let us, however, study those requirements which may be held as essential to the prosperity and healthful growth of the medical profession. The subject of medical education as it exists in this country to-day, has been often commented upon and held up to criticism. It is a widely recognized fact, that year after year there go forth from our colleges hundreds of young men, who are totally and manifestedly unqualified for the work before them. As candidates for admission, they are, in many cases, unfamiliar with the first principles of English composition, to say nothing of the other primary branches of learning. As graduates they have been found familiar with not one-half of the diseases observed in general practice, much less with the various specialties of medicine. Not only are such men allowed to enter the colleges, but they are solicited and encouraged so to do, by inducements without number, so that no one, of whatever race, nationality or condition, be he moral or immoral, ignorant or well informed, can have any plausible excuse for not studying medicine, and not taking a diploma after receiving two courses of lectures. now exist, will be compelled to go into bankruptcy from lack of support. To bring about such reforms is to excite much hostile feeling and adverse criticism, for both money and influence are pledged for the maintainance of diploma mills, and sympathy is often enlisted even for an unworthy cause; yet with the means at its disposal, it certainly lies in the power of the profession to protect itself and the public as well, from the dangers which have been so long in active. existance. Recognizing as we do the many shortcomings of the medical colleges and the men they graduate, it seems urgently required that some remedial measure should be at once advocated and put into operation. We are practically aware of the fact, that many of the existing laws govern For these reasons, our system of medical education has become unfavorably known throughout all foreign countries, and such reputation is working us irreparable injury. The presenting the practice of medicine, are of state of civilization, demands for our profession, not stock companies which derive their revenues wholly from the fees of their students, and which consequently make large pecuniary demands without any adequate returns, but rather, institutions which are able to exercise independence and can, to a certain extent, choose their own students, and can insist upon a four year's study of medicine. There should be three years of clinical work beside such instruction, with frequent examinations by the Faculty, and no student should be awarded a diploma who has not a good knowledge of Practical Anatomy, Surgery and Obstetrics, as well as a fair clinical acquaintance with the various specialties of medicine. I believe that by proper legislation, such a curriculum will be adopted and carried out by every college in the country, while the various mushroom institutions which very limited application and avail little as regards the suppression of quackery in its various forms, and the protection of the medical profession. Most harmful and disreputable systems of practice are thus allowed to exist and indeed to flourish, and it is difficult and at times impossible to secure the conviction of any one guilty of malpractice. Those who hold diplomas and are now engaged in medical work are, to a great extent, beyond our jurisdiction. It is in the prevention as much as in the treatment of these evils, that we are specially concerned. To prohibit the manufacture of ignorant and unscrupulous practitioners, no less than to convict and punish those who already exist, should form our chief aim and purpose. One of the measures which promises the best results is the establishment of State Boards of Medical Examiners, which might be appointed by the Gov ernor of each State, upon the recommendation of its own Medical Society. To such bodies should be entrusted the sole licensing power, with the privilege of rejecting all applicants who are found to be notoriously incompetent. Such action has already been taken by at least four States and in a modified form by five others, all of whom have recognized the fact that it is only in this way that satisfactory results may be attained. We have over one hundred medical colleges in the United States and the number is steadily increasing. In most, there are no preliminary examinations worth mentioning, indeed so great is the competition among the latter, that the college which should presume to demand any thing but money of the applicant, would soon find itself supplanted by the great number who demand nothing at all. Again, in the various schools of a higher grade, there is a disposition to insist upon technical and purely theoretical points, and a disregard of the more practical aspects of medicine. To these various faults and deficiencies there may be applied a like remedy. State examining boards, requiring of the applicant a high standing of scholarship and a thoroughly practical acquaintance with the duties of the profession, would quickly eradicate the worthless institutions, would institute improved methods of instruction and would enhance the value and the dignity of those medical schools of the first class which are now taking the lead in these measures of reform. Thus with the increased preliminary requirements an extended and graded college course, with its many improved facilities for instruction, and the final test exercised by an independent ex of amining board, there is an absolute certainity of limiting the number schools and the number of graduates and likewise of bringing to the profession a degree of dignity and status unequalled at any time in its past history. The policy of protection holds good in the case of medical practitioners as well as in the importation of foreign labor and manufactures. While American physicians are prohibited by the most stringent laws and regulations from practicing in Europe, yet on the other hand, a foreigner with little or no education may come to this country and practice his calling without fear of molestation. The result is, a large influx of incompetent and otherwise undesirable men, who come to join the three thousand or more graduates who are turned out yearly by the various medical colleges of this country. The laws governing the practice of medicine in Europe are most stringent and effective and few, if any, enter the profession there, before attaining a fair knowledge of its duties. In Germany, Russia, Switzerland, Italy, Spain, Portugal and other countries a rigid state examination it demanded. In France the requirements are equally high, while in some parts of Europe the applicant for a license, in addition to his other qualifications, must be a naturalized citizen. In short, we have nothing, in this part of the United States at least, which compares in efficacy with the requirements adopted by most other countries. The consequence is, we receive upon our shores, not only those who have failed to obtain licenses, but also those who have never applied for them; moreover, many of the medical immigrants have little or no knowledge of our institutions or language. |