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well qualified from experience and knowl After sufficient time he should render edge in their special branch should be an opinion to the party engaging him. selected by lawyers or others to give ex If this opinion be favorable he is then pert testimony.
ready to testify at court in his behalf. In the third place, it is a duty physi If it be adverse his connection with the cians owe their own consciences, the case should end there, unless he be recommunity, and the profession itself, tained in an advisory capacity. that they do not consent to testify un A matter of great difficulty should be til they have thoroughly examined into mentioned here, and that is the imperthe merits of the legal case, and then fect and biased information which the testify only in conformity with their physician is apt to get from the party convictions.
employing him. This party is about to It is a shame and a disgrace that there enter the trial from his point of view, are those who always see a case just as be it prosecution or defense, and his it is presented by the lawyer first engag- opinion is naturally one-sided. The ing their services, and consequently tes- physician should take heed lest he be tify just as he wishes. What wonder is unconsciously influenced, and find himit then that medical testimony of some self, when on the witness stand, plainly character can always be gotten on any
side. side of a case.
Much tact and perseverance will be The course of medical men under required to get a thoroughly reliable these circumstances should be perfectly statement or examination on which to plain.
base a final opinion. When first requested by an attorney or There are, of course, other means of other persons to testify in a case, the elevating the standard of expert testiphysician should insist on having all mony, but these three ways occur to the facts obtainable ; and the testimony me as worthy of mention. , of witnesses, if the trial has begun.
ANTITOXIC TREATMENT OF DIPHTHE the next thirty days only i very mild RIA.— At the meeting of the British case occurred, in the following thirty Medical Association, Dr. Hermann days another case was reported, and Biggs, Bacteriologist to the Board of shortly after 5 more patients were atHealth, New York, stated that he had tacked ; 225 units were then injected, had under his charge in New York be with the result that no more cases OCtween 400 and 500 cases which had been curred. The same result was obtained treated with antitoxin for diphtheria in three other institutions, showing the in their own homes. These had all extreme value of the immunizing power been severe cases, and the mortality had of the serum. Dr. Biggs considered been slightly over 16 per cent.
The that the protective period was a short mortality for the whole of New York, one, probably not extending over thirty he added, had been reduced by over 40 days, but within this time it was almost per cent. The speaker then proceeded absolute. to deal with the importance of antitoxin The speaker then concluded by sayin preventing the spread of the disease ing that in over 800 patients treated by rendering those who were exposed for the purpose of rendering them imto the infection immune. In one insti. mune, he had in no case observed any tution in New York there had been a unfavorable symptoms. In a few palarge number of cases of diphtheria, 107 tients, rashes, apparently urticarial in cases having occurred during the 108 nature, had occurred on the eighth day, days preceding the injection of the and in some there had been a temporary serum. The antitoxin was then in rise of temperature, which, however, in jected, 200 units of Behring's prepara no case had resisted treatment for more tion being used in each case. During than twelve hours.
CLINICAL LECTURE DELIVERED AT THE Jefferson HOSPITAL, APRIL 9, 1895.
By E. E. Montgomery, M. D., Professor of Clinical Gynecology in the Jefferson Medical College; Gynecologist to Jefferson and St.
Joseph's Hospitals ; President Alumni Association Jefferson Medical College. GENTLEMEN I bring before you to dicates that degenerative processes are day a woman fifty-four years of age, present. A retroverted uterus would whose mother died of tubercular, and increase the tendency to inflammation father of Bright's disease. Her brothers of its lining membrane, and the congesand sisters are healthy. It is not an un tion of the organ would favor the probfrequent occurrence to find in the mem- ability of discharge. It is possible the bers of a family that some have pulmo- position of the uterus in this patient innary, others Bright's and others, again, creases the tendency to congestion and suffer from malignant diseases, such as the continuance of discharge. Upon exepithelioma and carcinoma. Such an amining the uterus with the speculum association is so frequent as to lead to you notice a spongy appearance of the the recognition that there is a vulnerable lip, an eversion of the cervical mucous trait running through such families, membrane, with a spongy appearance of making them susceptible to the develop the surface that indicates a degenerative ment of such influences.
process. Our patient enjoyed, during her early Taking the history of the patient, the life, good health. Puberty occurred at character of the discharge, the more or fourteen, the flow was regular and pre- less pain and discomfort, I consider it ceded by pain. The discharge was pro the wiser plan to remove the uterus, befuse, lasting three to five days. She has lieving it the inception of a disease been married thirty-four years and had which would very soon result in the three pregnancies, in all of which she breaking down of the uterus and develwas delivered at full term. The last opment of a very serious condition. As child was born twenty-four years since, the organ is drawn down, you see the the labors were normal and after the last peculiar condition upon the posterior child she was confined to bed for three lip which is very much like a cyst and weeks and for three weeks subsequently undoubtedly contains cysts, and on had profuse bleeding. After this, how closer investigation of the surface, the ever, she enjoyed good health. About appearance leads me to believe that we five years since, she ceased to menstru have the beginning of malignant disease, ate for six months. The flow reappeared consequently I prefer to remove it. spontaneously, since which she has had In performing the operation we expose a bloody discharge every three weeks. the uterus, drawing it down with a tenShe has a slight pain and profuse leucor aculum, to secure a good hold with the rhea, which is yellow and has quite an volsellum, then make an incision around offensive odor. The uterus is retro the cervix, completely encircling the flexed. This is not exactly the history organ at such a distance from the os as we would consider as characteristic of will preclude the possibility of any dismalignant disease, but she is fifty-four eased tissue remaining unremoved. years old and continues to have a bloody other words, going as far beyond the discharge every three weeks, a profuse, diseased tissue as possible without inoffensive leucorrhea, which certainly in- jury anteriorly to the bladder and ure
ters. So far as the posterior tissue is now free on that side and it can be drawn concerned, it would be rather difficult, down outside, when the other clamp and not pleasant to the operator, to open can be placed in position with much less into the rectum. In every such opera difficulty. You can see the difficulty tion it is important to have a good, experienced from the size of the fundus strong volsellum, in order that in seiz of this uterus. The second clamp is aping the parts we make sure of securing plied outside and turned back, after the tissue sufficiently firm that it will not broad ligament cut through, but I find tear out. After having cut through the the clamp has caught against the antetissues anteriorly, I am particular to rior wall of the vagina, pushing it up and make sure that the bladder is not in the the end of the clamp can not be passed way, so that it will not be opened as we into the abdominal cavity without putproceed. It is pushed off from the an ting this tissue upon so great strain as terior wall until we reach the perito to endanger it, so we will ligate the neum. It is sometimes difficult to ac broad ligament outside the clamp in complish this separation, owing to en three parts, loosen the clamp and tie the croachment upon the uterine tissue in ligatures and thus prevent hemorrhage. our effort to avoid the bladder, which, The vagina was small, the uterus large of course, increases the difficulty in the and consequently the application of the separation.
clamp rendered a difficult procedure. Having opened the peritoneum ante Having examined carefully and washed riorly, the dissection is made posteriorly out the cavity to ensure there is no until the peritoneum is again opened. bleeding, we will pack with iodoform The peritoneum is a little more difficult gauze, carrying the gauze over the end to reach anteriorly in this case on ac of the clamp. The clamp will be recount of the retroversion, and we are a moved at the end of twenty-four hours, little more anxious about injuring the the gauze will be permitted to remain bladder and consequently have kept too for seventy-two. The external surface closely within the uterine tissue. Hav is packed with gauze, which will be reing opened into the peritoneal cavity in moved in order to empty the bladder. front and examined carefully to ascer This operation of vaginal hysterectain the presence of disease in the broad tomy by the application of clamps is ligaments, and finding none, I now open generally a very easy and rapid one, alinto Douglas pouch. You noticed there though in this patient I carelessly apwas quite a considerable serous dis plied the clamp in such a way that I charge when I opened into the perito could not return the end of it into the neum, so much, indeed, as to lead me pelvis after the uterus had been removed, to believe I had opened the bladder, but consequently had to ligate and remove the posterior incision disclosed an accu it. This lengthened the operation some mulation from the peritoneal cavity. I five, possibly
ten, minutes. The operaam endeavoring to pass my finger over tion of vaginal hysterectomy, in cases the broad ligament and bring it down where the uterus is movable, easily posteriorly, which I have now done. brought down, and the vagina large, You can see how my finger passes di rendering the separation easily made, rectly around the broad ligament on can be done in a very few minutes. either side. I have now passed in a In a case with a small vagina and clamp, one blade posteriorly and the large uterus, the operation may be quite other in front; bringing these together, difficult. In such cases it is necessary they are screwed down upon the left to secure the broad ligament in sections broad ligament close to the uterus. either by ligation or by the use of forThe uterus is cut off flush with the ceps. If desirable to secure additional clamp, as I feel certain there is no pos room, an incision may be made through sibility of the ligament slipping.
the perineum, back to one side of the Having cut through the broad liga rectum, thus enabling us to considerment on one side, we have the uterus ably enlarge the outlet and come near
to the tissues under consideration. An thus reaching the uterus. We are thus opening in this way may be secured enabled to see the parts, ligate the large enough to introduce the hand. broad ligaments, remove the ovaries and Where the uterus is quite large it is tubes, first upon one side, then the wise to consider the resort to abdominal other, and cut away the uterus, seeing operation.
everything as the operation proceeds If for any reason we desire not to and thus avoid injury to the ureters. open through the abdomen, it is well to In fact, we know of no plan by which remember we have another method of the uterus can be more thoroughly exprocedure. The shortest direction to plored and removed under sight than by the uterus is directly through the sa sacral resection. The objection to the crum, and by doing a sacral resection we operation is the extent of the incision, may reach and remove the uterus. the more or less injury to the pelvic This is a particularly proper procedure structures and the long convalescence, in cases where disease of the uterus is resulting from bone injury. I have complicated by involvement of the rec done the operation five times with one tum, where it is necessary to remove a death. The death occurred in a woman portion of the latter. In one case in who was in this house, who had suffered this clinic, we removed the uterus, tubes, from cancer of the rectum and for a ovaries, rectum, posterior wall of the number of weeks had had so much ob. vagina and the perineum. In making struction as to render it a constant disan incision for this purpose, the patient comfort. The posterior wall of the vashould lie upon the left side and a bow- gina was involved. The rectum and a shaped incision be extended from the good part of the vaginal wall were releft side of the sacro-iliac-synchondrosis moved. across the median line, terminating The patient died within forty-eight alongside the anus. This incision lays hours from renal insufficiency. . This is bare the lower end of the coccyx. Dis the first death in five cases, and one of secting off the tissues, we have the coc these, as has already been mentioned, cyx exposed. The latter may be re constituted the removal of the uterus, moved and an incision made through ovaries, tubes, entire posterior wall of the the sacrum in two directions, cutting vagina, five inches of the rectum, and transversely or making an elliptical in the perineum. The rectum was stitched cision, leaving one side undisturbed. fast to the anterior wall of the vagina and The objection to the transverse incision to the skin over the sacrum, thus forming is that we remove the fourth and fifth an artificial anus at the upper end of sacral nerves on both sides. We may the vagina. Of the five cases operated approach here to the third sacral fora upon, four have been done for disease of mina without any special injury to the the rectum, in three of them making an pelvic viscera excepting those nerves artificial anus some three or four inches that supply the buttocks and skin ex higher up, and in one, removal of the ternally, the anterior branches that are uterus. sent to the bladder and vagina. If we In those cases in which the operation leave one side and particularly the fourth can be done with hope of removal of sacral foramina untouched, it is suffi the diseased tissues, it is preferable to cient to compensate for the loss of the have the artificial anus posteriorly opposite side. If both sides were in rather than in the inguinal region, for jured, we might have incontinence of the reason that the patient will not have urine, cystitis and trouble with the blad to assume an unnatural attitude to evacder.
uate the bowels. She is better able to If upon removal of the sacrum we de keep in place the dressing and to consire to operate upon the rectum, the en trol the evacuations, to keep herself tire rectum is drawn out. If the rec clean and consequently she also suffers rum is healthy, we would push it to one much less inconvenience from the oper. side and open into the peritoneal cavity, ation.
Empyema of the gall-bladder by the
history of chills, fever, etc., with liver RICHMOND ACADEMY
trouble. OF MEDICINE AND SURGERY.
Adhesion of the gall-bladder may so
form as to cause discharge of bile into MEETING HELD AUGUST 13, 1895.
the duodenum direct, and there may be Dr. V. W. Harrison, First Vice-Presi. no suspicion of stone. Symptoms of dent, in the chair.
typhoid and other fevers and of maligDr. Landon B. Edwards read a paper nant and benignant tumors are simulated on the DIAGNOSIS, SPECIAL AND DIF by stone. It is said that when the stone FERENTIAL, OF CHOLELITHIASIS. Stone passes from the cystic to the common may sometimes be formed in the liver duct pain is lessened, and as soon as the itself. The position of the gall-bladder passage occurs, mucus begins to be varies with that of the liver. It can be dammed into the body of the liver, causrecognized by palpation. Cholelithiasis ing its enlargement. This is diagnosed is rare in children under 12, becoming from hepatitis by less pain in the latter. more frequent as age advances, and Heredity may lead to differentiation being more common over 30, and in of stone. It is seldom that repetitions women. It is comparatively frequent of hepatic colic do not occur. in the insane.
Operations for removal should not be The characteristic symptoms suggest- performed unless the typical symptoms ing gall-stone are: Multipara seized with are present. Cases occur more frequently a grinding pain radiating over the whole than is supposed, giving rise to sympbody. There is perspiration, retching, toms elsewhere. There is no medical vomiting, dyspnea, pulse lessened in treatment efficient for the disintegration volume, expression of pain, no rise in or removal of gall-stones. The indica. temperature. The symptoms do not in tion is to relieve pain, and for this the termit, and pain is not relieved unless best agent is, by far, hyoscyamine. the stone passes. It lasts two or three
DISCUSSION. days and leaves
leaves soreness. Ease is Dr. Hugh H. Taylor quoted Robson, brought about through a form of pres who lays stress on the characteristic sure paralysis. Jaundice is not always suddenness of the paroxysmal pain. present, but may occur gradually from Vomiting may be continuous or paroxocclusion. Mahogany urine may be ysmal. In some instances, pain is represent. The flow of bile being pre ferred to the left shoulder ; often, above vented, the skin becomes darker and the umbilicus, differing from that of apdarker, vomiting ceases to be bilious, pendicitis. Subsequent attacks may be stools become pasty and distension of from the same stone. The direction of the gall-bladder by mucus may occur, growth of the tumor is diagnostic, being simulating floating or displaced kidney. obliquely toward the umbilicus. It may
Cholelithiasis is diagnosed from ma be enormous sometimes, then being laria by the mild fever, scarcely jaun- mistaken for ovarian tumor. Distension diced hue, chills, etc.
of the gall-bladder without jaundice From catheterization the chills may means obstruction of the cystic duct, as become rigors, the fever rises, pulse by enlarged gland, stricture or stone. slow, 40 to 50, irregular and not in keep- Sometimes a diagnosis may be made by ing with the fever.
the presence of stone in the feces. HemFevers, especially malignant pancre- orrhage, when present, is due to poisonatic, and pancreatic stone. Hemorrhage ing incident to cholemia. In this latter from the stomach, bowels, etc. ; de we have continuous jaundice, which struction of the common duct, dam means neoplasm of the duct, or head of ming of the fluid in the gall-bladder the pancreas. Stone, by its change of and ducts producing jaundice. Indiges- position, etc., will allow the escape of tion of fat is present in pancreatic some bile, jaundice accompanying it, betroubles.
ing thus intermittent: