DR. RICHARDSON said that he had seen the condition several times at the hospital or with the students, always in multiparæ and in women in a markedly debilitated condition, and preceded by trouble with the bladder which was in the fold. DR. LYMAN said that the patient had had no trouble with her bladder previously. She had consulted him a year before for a very badly lacerated cervix and perinæum, and almost universal eczema, owing to which she was advised not to undergo operation. Under general treatment she improved, went home to Minnesota, got well of the eczema, conceived, and came on again to be confined. Dr. Lyman remarked that the case illustrated how well women get along sometimes with badly lacerated perinæum, cervix, etc., the cervix showing complete eversion. All the uncomfortable symptoms disappeared, and since her confinement the patient has been as well, almost, as any woman. DR. C. ELLERY STEDMAN remarked that he had seen the same appearance, the vaginal fold being as thick as his thumb. DR. GREEN thought it strange that with prolapse of the anterior vaginal wall and a torn perinæum there was not more trouble. As to treatment, if the fold could be pushed up, that would be sufficient; otherwise, in his opinion, the forceps should be used at once. DR. RICHARDSON remarked that version would be better, as avoiding a dragging down, with forceps included, of the very thing it is desirable to avoid. DR. LYMAN said that if he had put in forceps he would have risked vesico-vaginal fistula; but he would not interfere unnecessarily. DR. GREEN observed that the head might be too low for easy version, and it was a fair question whether forceps or the continued pressure of the head were the worse. It seemed to him that the forceps might have been used, the perinæum being torn, if the head were depressed somewhat so as to avoid pressure against the anterior wall. Either one or the other process should be adopted rather than let the case go on a long time without aid. DR. RICHARDSON observed that it should be recollected that in version a different diameter of the head is coming through the pelvis, and the rotation need take place only at the last minute. DR. J. L. SULLIVAN, of Malden, said he would like to call attention to the different experience of different physicians. He had had twenty-five hundred cases of labor and never a face presentation. DR. RICHARDSON said that in the lying-in hospital three of the six cases of face presentation were in women with deformed pelves. In answer to a question by Dr. Lyman, he should think it was very seldom that a woman would suffer from hæmorrhage in case of low attachment of the placenta before the sixth or seventh month. He never would allow a case to go on without delivery if the child were viable. DR. LYMAN gave an account of a case of immense suppurating unilocular ovarian cyst. The woman died twenty-four hours after ovariotomy. DR. SULLIVAN reported a case to which he had been called in consultation, and asked what ought to have been done. The woman was six and a half months pregnant, not for the first time. She had a convulsion, being in the advanced stages of Bright's disease. It was impossible to dilate the cervix in consequence of a whipcord like contraction during the hour or hour and a half of effort, but she was not under ether. Suddenly she became comatose, and died in ten minutes. The urine was scanty, moderately albuminous, and perfectly loaded with casts of all descriptions. There had been no uterine action. In another case, not long ago, Dr. Sullivan succeeded in dilating and inducing labor, and everything went on well. DR. RICHARDSON suggested that the uterus might have acted differently under complete anæsthesia. DR. SULLIVAN questioned further what course should have been pursued had ether been administered without result. The question propounded was this: What ought to be done in such a case provided a whipcord constriction persisted after bleeding and etherization, or any other suitable means, had proved useless in causing relaxation and dilatation. In the case related the patient suddenly died just as ether was brought into the room. The remarkably feeble pulse and feeble condition of the circulation led him, right or wrong, to postpone venesection until the effects of ether had first been ascertained. Before ether could be procured death occurred, probably from cerebral hæmorrhage. The question actually propounded, or intended to be propounded, by him was this: Would it be proper to deeply incise the os uteri in such a case should the whipcord constriction of the internal os persist after bleeding and ether had been pushed to the full extent of safety. In other words, the inquiry relates to a hypothetical case, the possibility of such having been suggested by an actual one. DR. ABBOT observed that it was well known that apoplexy was a not uncommon result in such cases, and if it was the cause of the symptoms in the one reported nothing could probably have been done to relieve it. He had had a patient, however, a boy, who was comatose, completely, for a week, in the course of Bright's disease, and recovered entirely so far as the coma was concerned. DR. SULLIVAN remarked in regard to venesection that it was contra-indicated, yet if the patient had lived and the ether had failed he would have bled. As to the condition of the cervix he could dilate so far, but no more, with repeated efforts. Leaving a total (given in the corrected catalogue) of Total number of votes recorded For the National Code (corrected number) Total .. 83 201 5286 States. We made no movement looking to the formation of a loyal State Association until the most 5286 vigorous efforts to redeem the existing societies had signally and hopelessly failed. We are now cast out of 5002 fellowship with the regular profession of this great country, as represented in the American Medical Association and in the medical societies of other States. We must redeem the State of New York. There remains 1040 but one course to pursue, and that is to form an asso239 ciation of our own. The bitter fight, the disgraceful 1142 3860 2547 34 3860 The canvass of the State Medical Society showed the following figures: For the National Code For the "New Code" Uncommitted 193 19 36 382 spectacle of a contest between members of a devoted and honorable profession, are things of the past. The war is ended. Let us organize and live together in peace, working hand in hand for the advancement of the science of medicine. Let the men who are so blind or so 134 misguided as to think their course is right, or who cannot resist the temptation to take tribute from those who persist in supporting the enemies of truth and of our universal science of medicine, go their own way and In some remarks on the report of the canvass Dr. consult on terms of equality with any and all 'legally Gouley urged speedy action in the formation of a sep-qualified practitioners of medicine,' whatever form of arate association on the ground that there was not the least chance that the National Code of Ethics would be reenacted by the Medical Society of the State of New York as long as a two-thirds majority was required. There was not a two-thirds majority, and he did not believe such a majority could be obtained in five years or more. DR. FLINT'S ADDRESS. charlatanism they may assume! I hope, Mr. Chairman, that a New York State Medical Association will be organized to-night in affiliation with the regular profession of the United States; that the existing county societies whose membership is loyal will put themselves at once in affiliation with the new State Association; and that in counties in which the existing societies cannot be brought in bodily new associations will be promptly organized, to be composed exclusively of members of the profession who uphold the National Code of Ethics." PLAN OF ORGANIZATION. DR. AUSTIN FLINT, SR., made an eloquent address, in which he gave the recent history of the conspiracy which culminated in the adoption of the New Code by the State, and which first publicly made its appearance in the medical law of 1880, and also some account of The plan of organization adopted provided: (1.) the measures taken to counteract its baneful influence. That the State should be divided into five geographical It opened as follows: "It is more than a year since I districts. (2.) That a nominating committee of eleven have publicly spoken to an audience of friends on the members should be created. (3.) That the nominating questions which have at last divided the medical profes- committee should name the various officers, subject to sion of the State of New York. As you all well know, the approval of the Association, and also two members thus far the battle-field in the warfare against the honor from each district, who, together with the titular offiand dignity of the profession has been mainly in the cers and one member appointed at large by the Presicity of New York. In the city of New York the dent-elect should constitute the Council for the manconspiracy which brought about this deplorable con- agement of the affairs of the Association. (4.) That flict that has been forced upon us, had its inception. the Council should complete the organization, prepare The attack upon the most sacred traditions of our pro-a constitution and by-laws, in accord with this plan, to fession was there made with a malignant rancor that can only be fully appreciated by those who have been personally involved in this unhappy contest. I say it in all modesty, but we of the city of New York come before you as veterans from the front, bearing scars. If we venture to offer suggestions with regard to future action, if we beg you to learn a lesson from our experience, it is because we are unhappily too familiar with the arrogance and the unscrupulous methods of our enemies within the profession. Our experience teaches us that but one course is now open to those who are unwilling to remain in the false and humiliating position in which we are placed. The proper course is for us to organize a new State Association, to be composed exclusively of those who refuse to countenance professional relations with irregular practi tioners." The address was concluded in the following words: "The issue has been forced upon us. We stand in the actual fact of a divided profession. The State Society and Society of the County of New York have seceded from the regular profession of the United be presented at the next meeting of the Association, and file articles incorporating the New York State Medical Association and also county associations as branches of the latter. . . (8.) That the initiation fee should be five dollars, and the annual dues three dollars. (9.) That the Code of Ethics, which should form an integral part of the By-laws of the Association, should be the same as that adopted by the American Medical Association. (10.) That the Association should hold annually one session, which should last three days or more. committee on the preparation of a constitution and bylaws for the Association. Dr. A. Flint, Jr., Dr. Van de Warker, and Dr. Gouley were appointed a committee to secure the coöperation of a medical journal in sympathy with the wishes and interests of the Association. On motion of Dr. Van de WARKER it was resolved that the members of the Association should be designated Fellows, and Drs. E. M. Moore, A. Flint, Jr., and the Treasurer, Dr. J. H. Hinton, were appointed a committee to prepare a seal for the use of the Association and a form of certificate of fellowship. Accent Literature. Many interesting cases will be found reported in more or less detail. Of course the different papers vary in importance and in value, there may be some statements which the author would now modify if he were writing on the subject again; but there is much of permanent value in the book, apart from the interest to be found in it as the record of the mental and professional growth of one of our foremost neurologists. Transactions of the American Gynecological Society, Vol. 8, for the year 1883. New York: D. Appleton & Co. This volume appeared with commendable promptOpera Minora, A Collection of Essays, Articles, Lec-ness less than four months after the meeting of which tures and Addresses, from 1866 to 1882, inclusive. it is the report. We regret to see that in the change By EDWARD C. SEGUIN. New York: G. P. Put of publishers, whether inadvertently or intentionally, nam's Sons. 1884. X., 687 pages. the color of the paper has been changed from that of the preceding volumes to one several shades nearer to a pure white: the typography of the title page is also Dr. Seguin has been a voluminous writer, has done much to bring to the notice of the profession the latest results of research in nervous pathology and therapeu-changed, not to our taste for the better. tics, and has himself aided in the extension of our knowledge. His papers and reported cases are to be found in many medical periodicals, scattered widely and not always easily accessible. It is, therefore, a satisfaction to have them collected in one volume. About eighty essays, etc., are reprinted, beginning with three published while Dr. Seguin was house physician of the New York Hospital. The majority of the subjects either relate to or are closely allied to the nervous system; one of the earliest of these is a paper in regard to aphasia published in 1868, which is one of the longer articles. Among the more important subjects may be mentioned Description of a Peculiar Paraplegiform Affection (tetanoid paraplegia), the first cases of spastic spinal paralysis reported as a distinct affection. Contribution to the Study of Localized Cerebral Lesions and a second article on the same subject. Lecture upon the General Therapeutics of the Nervous System. A paragraph at the close of this lecture is well worth quoting, "Let me close this rather fragmentary lecture, by calling your attention to some thing which is not wholly extra-medical. I allude to the care of your patients' spirits, their emotions and fancies if you will. Never let alarm be one of your medicaments. If necessary, in order to bring about a reform of bad habits, lay the picture of consequences before your patient truthfully, but not in the language of exaggeration. Even in hysterical cases you need not be so frank as to hurt your patient's feelings; it will often do if her relatives know precisely what you think of the value of the symptoms. In cases of mental disorder, pray do not forget that even very maniacal or melancholic patients attend to and remember all your words and actions, and will treasure any kind and careful behavior of yours as well as bitterly recall any unkind or hasty phrases and acts. As a general therapeutic rule, I would have you be as anxious to avoid wounding the sensibilities of your poor or wealthy patients as of injuring their tissues." There are eight lectures on the Localization of Spinal and Cerebral Disease, several articles on the diagnosis of different diseases, and the importance of an early diagnosis. The papers relating to the value of certain drugs and the dosage in treatment of nervous diseases are well worth reading. 66 The President, Dr. Gilman Kimball, gave as his annual address A Biographical Sketch of Dr. Nathan Smith, Founder of the Dartmouth Medical College, who was the second in this country to perform ovariotomy successfully. As Dr. Smith was at the time unaware that McDowell had operated at all, his operation was as truly original as the first although performed nine years later. Ephraim McDowell is certainly to be regarded as the "father of ovariotomy" in point of time; but Dr. Kimball pleads with much justice that "in point of absolute merit Nathan Smith is entitled to the same honor as that accorded to McDowell." Dr. R. S. Sutton's paper on Cleanliness in Surgery shows how generally the principles of Listerism have been adopted, although all surgeons do not accept them in their entirety. To the greater attention to cleanliness and the avoidance of contamination of wounds, brought about by Lister's teachings, are to be ascribed the greater measure of success in the surgery of the present day. Dr. A. H. Smith calls renewed attention to the great value of hot water in secondary hæmorrhage after pelvic operations, especially in plastic operations, even when the bleeding occurs from moderately large vessels. The water should be at a temperature of 115° to 120° F., and to be most efficient should be carried directly to the bleeding surface. As operations are sometimes lost by the supposed necessity of cutting stitches in order to reach and tie bleeding vessels for secondary hæmorrhage, the efficiency and easy application of this hæmostatic should not be forgotten. Dr. C. D. Palmer contributes an excellent paper on the etiology and treatment of dysmenorrhoea, in which he expresses the belief, now held by many gynæcologists, that, although undoubted cases of so-called obstructive dysmenorrhoea do sometimes occur, painful menstruation is essentially a neurosis. Organic disease may or may not be associated with dysmenorrhoea; but the neurotic condition is the only feature in most cases. This condition is generally an expression of a disordered or highly developed nervous system: treatment should therefore be directed to the constitutional disorder, and local treatment be resorted to only when general treatment has failed. Dr. E. W. Jenks suggests a New Method of Operating for Fistula in Ano which he has twice employed with complete success. The method is briefly as follows: The fistulous tract is incised in the usual way, care being taken to incise the muscular fibres of the sphincters at right angles. The pyogenic membrane is then carefully dissected out, bleeding vessels secured by torsion or ligature, and the parts thus laid open are then closed with deep sutures much in the same way as in the operation to close a ruptured perineum. Dr. Jenks does not claim that this method is applicable to every form of anal fistula; but he believes it to be the best method in a majority of cases. The advantages of the method are that a long convalescence is avoided, union is secured by first intention, and subsequent incontinence prevented. The principal organs of the body are considered in the second part, commencing with the liver. A description of the normal histology is first given, and then follows a consideration of the most ordinary changes, which are met with. Then the methods best adapted for the preservation of each particular speci men for microscopic examination are dwelt upon; and lastly the appearances as seen under the microscope. These last are illustrated by beautifully colored plates, which add greatly to the attractiveness of the book, as well as giving an admirable idea of how really good sections should look when properly treated and colored. The importance of always associating the gross appearances with the histological changes is a practical point strongly insisted upon by the author, and one often overlooked. For it is hard to realize that the aggregate of such slight changes as can be detected in the ultimate constituents of an organ can give rise to such marked differences in its color, size, or shape when regarded as a whole. Dr. C. C. Lee contributes a paper of great interest on the Management of Accidental Puncture and Other Injuries of the Gravid Uterus as Complications of Laparotomy. Nothing can be more appalling to the operator than to plunge a trocar into the gravid uterus, thinking it to be an ovarian cyst; yet this accident has The book will be of value to those who wish a ready happened to careful surgeons. Dr. Lee shows, how-reference for practical work, and who have only occaever, that this accident is not necessarily followed by sional opportunity for it. It is to be feared, however, abortion, especially if the ovisac is not opened: he that the style in which the work is issued will enalso formulates the treatment that should be pursued hance its cost so much that it will place it beyond the according to the nature of the injury. reach of many to whose library it would be a welcome addition. Dr. R. B. Maury's paper on Rectal Disease Considered in its Relations to Disorders of the Uterus is an inquiry as to what extent certain morbid affections of the rectum are due to uterine disease. Since the rectal, uterine, and vesical circulations are parts of one and the same vascular system," it is easy to see that any important disturbance in the nutrition of one of these organs must have a marked effect on the others; and Dr. Maury illustrates this effect by cases under his observation. The remaining papers are by Dr. Johnson on Superinvolution of the Uterus; Dr. Reamy on a Rare Form of Abdominal Tumor; Dr. Campbell on Congenital Fissure of the Urethra, with Exstrophy of the Bladder; Dr. Jackson, Is the Extirpation of the Cancerous Uterus a Justifiable Operation?; Dr. Emmet, A Study of the Etiology of Perineal Laceration, with a New Method for its Proper Repair; Dr. Byford, Remarks on Chronic Abscess of the Pelvis; and Dr. Engelmann, Ergot: the Use and Abuse of the Dangerous Drug. Dr. Barker's memoir of the late Dr. James Dowling Trask concludes the volume. We are sorry that it has seemed good to the Society to omit the valuable index of gynæcological and obstetric literature which has previously found a place in these Transactions, and hope that the omission is only temporary. C. M. G. Practical Pathology: A Manual for Students aud Practitioners. By J. SIMS WOODHEAD, M. D., F. R. C. P. E. Edinburgh: Young J. Penthead. 1883. This work is intended rather as a guide in the preparation of specimens for microscopic examination than as a systematic treatise on pathology, and as far as it goes is admirably adapted for its purpose. The first part of the book is devoted to a description of the modern methods of preparing and coloring tissue. The value of the aniline colors for differential staining is prominently brought forward, and numerous formulas for their use are given. An American edition of this work has just been issued by Henry C. Lea's Son & Co., which shows a little the wear of its English predecessor, but which from its lower price will probably be more popular. Bacteria. By DR. ANTOINE MAGNIN and GEORGE M. The first part of this book is a translation of Dr. Magnin's work, and gives the classification of bacteria, from a botanical point of view, as presented by Cohn. This part of the book has value as affording a means of identification of the different forms that come under observation. The morphological characteristics of these parasites are now recognized to be of very uncertain value since the great variation in form under different conditions of growth has been discovered. This is fully recognized by the author, who devotes considerable space to a consideration of their physiological action and its value in determining species. The latter part of the book is devoted to a résumé of the work done upon each of the diseases with which the micro-organisms have been found to be associated. With this is joined some original investigations undertaken by Dr. Sternberg, which, however, are so incomplete as to fail to carry conviction that all sources of error were excluded. There is also a marked tendency on his part to see in any rather indefinite form de scribed by others a close resemblance to a micrococcus discovered by himself in a form of septicemia produced by inoculating rabbits with human saliva. This has not been accepted as yet by the most competent observers as differing essentially from other forms of septicemia following the introduction of putrefying substances. At the end of the book is a very valuable and complete bibliography of the works on these minute parasites. Medical and Surgical Journal. THURSDAY, MARCH 20, 1884. The man had the appearance of one able to comprehend the true state of affairs could he only be allowed time to return to himself, but the venous hæmorrhage was so great and so difficult of control that delay was impossible; it was immediate amputation or A Journal of Medicine, Surgery, and Allied Sciences, published weekly by death. In this instance the surgeon proceeded with a year, including postage. addressed to the Editors of the Boston Medical and Surgical Journal. Subscriptions received, and single copies always for sale, by the under signed, to whom remittances by mail should be sent by money-order, draft, or registered letter. HOUGHTON, MIFFLIN AND COMPANY, No. 4 PARK STREET, BOSTON, MASS. THE DRUNKARD AND THE DOCTOR. "FOR the gentlemen of the faculty of physic, I must frankly own that I see no special reason, why they in particular should apply themselves to the study of the law; unless in common with other gentlemen, and to complete the character of general and extensive knowledge; a character which their profession beyond others has remarkably deserved. They will give me leave however to suggest, and that not ludicrously, that it might frequently be of use to families upon sudden emergencies, if the physician were acquainted with the doctrine of last wills and testaments, at least so far as relates to the formal part of their execution." Such was the opinion of the learned Blackstone as expressed in his lectures at Oxford one hundred and thirty years ago, and we have no desire to express a contrary opinion. We doubt if a little knowledge of the law is any less dangerous than a little knowledge of medicine. But certainly we believe, and no one will deny, that it is desirable for a physician to consider how his actions would appear in the eyes of twelve individuals selected at random from his peers. Every surgeon, certainly, though gifted with but a sluggish imagination, must sometimes picture himself as a defendant before an intelligent jury and his now grateful patient transformed into an indignant plaintiff. It is not wholly superfluous to consider some of the possible conditions in which the vagaries of a jury may be perilous to the doctor's pocket and peace of mind. He who has considered beforehand will act most intelligently when action becomes necessary. In what follows there is no desire to interpret law, but simply to suggest some unusual questions that may be presented to the surgeon at any moment and the possible position that may be taken by a jury in refer ence to them. Not long ago a drunken man was the victim of a severe accident to his arm which necessitated amputation. He had suffered a compound fracture with severance of arteries and nerves. The arm hung only by ribbons of the soft parts, and the venous hæmorrhage was restrained with difficulty. The accident had not entirely sobered the unfortunate. He had no friends with him at the time of the accident, and it could not be found that he had any relatives in the city. The necessity for amputation seemed evident to any man in his senses, but the operation was persistently refused by this inebriated individual. his preparations, and received at last a somewhat reluctant consent to be sure, but one that justified him in the necessary action. But the refusal was sufficiently delayed to raise the question how far the surgeon may proceed in opposition to the will of a patient whose reasoning powers are temporarily destroyed by the effects of alcohol. It is an axiom in surgical practice that no operation, not even the slightest, can be performed against the will of the patient or his or her guardian. It is the surgeon's duty to advise whatever procedure may be necessary, but before doing any operation it is imperative that he shall receive consent. If he does otherwise he invades the right of the individual and lays himself open to a criminal charge for assault or to a civil suit for damages. If a man deprived of his senses by a fracture of his skull were taken to a hospital, the surgeon would be justified in doing what seemed necessary; if he retained his senses sufficiently to remonstrate nothing could be done without the consent of friends. Were the patient entirely deprived of his senses by alcohol, in other words dead drunk, possibly the surgeon might be justified in removing an arm so evidently destroyed as the one described above, especially where his inactivity would be so manifestly the cause of death. In such a case the law would demand of him only the exercise of ordinary judgment and skill if he chose to act, though we doubt if it would hold him responsible if he refused. Certainly he would run some risk in either case of being called before a jury to answer for his judgment. If the case will admit of delay there is no doubt the individual should be allowed to regain consciousness. Only in the plainest case and after all possible precautions in the way of consultation and explanation to by-standers should the surgeon snip the few shreds of skin that connect the crushed member with the body. Were the patient only deprived of his reasoning powers, and did he protest against what seemed to him mutilation, however evident his drunkenness no surgeon would be justified in touching him. He might advise and entreat, and perhaps threaten, but further than that he could go only at his peril. A merely drunken person does not lose his responsibility for his own acts. Responsibility presupposes the ability to choose one of two lines of conduct, and inferentially the right to accept or refuse medical aid for himself. He may be held responsible for the failure to provide such aid for those under his care but not for himself, and any one who dared put in force the most evident principles of surgery should expect to find himself face to face with a jury worked up to frenzy at so evident an outrage on the independence of an individual. Any person must interfere to prevent an active at |