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La proporción de mortalidad para los niños de menos de 1 año establece que eila es de 17 por ciento entre nosotros, en tanto que en muchos países de Europa llega hasta 34, más de la tercera parte de los nacidos. El siguiente cuadro revela el número de nacimientos, niños muertos de 0 a 2 años, y sobrevivientes desde 1875 á 1890:
Más adelante analizaremos estas cifras que son en sí muy desconsoladoras. De las investigaciones del Dr. Coni resulta que desde 1875 á 1890 han muerto 53,221 niños de 0 a 2 años, clasificados así: Aparato digestivo. 12,320 Enfermedades de la nutrición 3 78 Aparato respiratorio. 10,002 Enfermedades génito-urinarias 184 Aparato circulatorio 298 Enfermedades de la piel 164 Enfermedades del sistema nervioso 8,101 Enfermedades de la sangre 4 46 Enfermedades infecciosas ó localiza Sin clasificación 7,391 ciones típicas 10,500 Enfermedades infecciosas ó localiza Total. 53, 221 ciones variables 2 4. 134
El predominio de las enferinedades infecciosas es notable; las 14,634 defunciones que ellas han producido representan el 27.4 por ciento y están así divididas según diagnósticos : Tétanos 4,983 Disenteria 279 Viruela 3, 356 Fiebre tifoidea. 214 Difteria y crup 2,529 Erisipela 1722 Sifilis 802 Escarlatina 127 Tuberculosis (escrofulosis, tabes mesen Varias enfermedades 25 térica, meningitis tuberculosą, etc.).- 201 Sarampión 759 Total. 14,634 Coqueluche 557. Las del aparato digestivo son también frecuentes, 12,320 (23 por ciento), están así.clasificadas :
Gastro-enteritis 4,233 Hepatitis. 97 Enteritis 2.838 Gastritis 86 Atrepsia 2, 484 Fiebre gástrica 82 Entero-colitis 1,314 Colerina. 57 Colera infantil. 359 Diversas enfermedades. 394 Indigestión 249 Diarrea 126 Total. 12,320 Las del aparato respiratorio, 10,002, representan el 18. por ciento y son estas: Neumonia 5,140 | Pleuro-neumonia y pleuresia. 152 Bronquitis 2,575 Diversas 110 Bronco-neumonia. 1,575 Laringitis. 140 Total 10.002 Congestión pulmonar 130
Sarampión, escarlatina, tifus exantémico, crisipela, herpes, viruelas, reumatismo articular, fiebres palúdicas, coqueluche, grippe, parotiditis, fiebre tifoidea, disenteria, cólera asiático y nostras, fiebre amarilla, tétanos y meningitis cerebro-espinal. Page 3
Las del sistema nervioso abarcan 8,104 (15 por ciento) y son las siguientes:
Meningitis Congestión y derrame cerebral Eclampsia.
5,248 | Hidrocefalia.. 1, 172 Meningo-encefalitis. 978 Encefalitis
De los cómputos mensuales se deduce que la mortalidad infantil entre nosotros ha llegado hasta 52 por ciento de la general, pero oscila al derredor de 44 y 46 por ciento. Estos datos son por demás alarmantes, y deben llamar la atención de las autoridades. En nuestra opinión las causas que obran para producir la gran cifra de mortalidad infantil en Buenos Aires son principalmente dos: el poco cuidado que muchas gentes tienen en la alimentación de los niños, y la ignorancia de parte de los encargados de administrarla. Coni (de Buenos Aires) dice que si el abandono de la lactancia materna ejerce una poderosa influencia sobre la mortalidad infantil, la alimentación prematura-causa de un gran número de enfermedades—suministra también á la mortalidad un contingente igual. Las familias y especialmente las de las clases pobres tienen la perniciosa costumbre de dar a los niños en la primera edad alimentos de toda naturaleza, sin preocuparse si estos son poco ó no son nada asimilables. De allí, alteraciones profundas en el aparato digestivo (vómitos, diarreas, etc.), alteraciones consideradas de poca importancia y encerrando á inenudo el principio de graves enfermedades. Las madres que recurren á la lactancia artificial, medida justificada ó no, ignoran casi siempre ciertos preceptos, tan sencillos como indispensables, para que esta manera de alimentación no ocasione malos resultados. Un hecho averiguado en el dominio de la patologia infantil es la influencia de la alimentación, cuando esta se hace insuficiente ó defectuosa; y para salvar en lo posible este inconveniente se han establecido en Paris, Loussane, Berlin, y Stockolmo servicios especiales, habiéndose comprobado en la primera una disminución de las enfermedades del aparato digestivo en la primera infancia, desde que se cuida prolijamente de evitar la falsificación de la leche, sin que por lo que respecta á las dos últimas ciudades se pueda afirnar nada en absoluto, si bien hay que esperar buenos resultados de las medidas adoptadas. En Francia existe una práctica que sería muy benéfica si las madres de familia se dieran el trabajo de obedecerla. Consiste ella en distribuir en las oficinas del registro civil, á los padres de los niños cuyos nacimientos se inscriben, un folleto conteniendo instrucciones sobre la higiene de la primera infancia; pero a menudo sucede que tales instrucciones no son leidas, y por consiguiente quedan ignoradas. En cuanto á las estaciones en que mueren más niños, tenemos que las 53,221 defunciones de 0 a 2 años, producidas de 1875 á 1890, han ocurrido así:
14,808 Invierno. 14, 088 | Otoño...
Es el verano la estación en que mayor número de muertes tiene lugar y aquí hay que considerar la acción del calor, la leche muchas veces alterada, las frutas, las malas aguas, los cambios de temperatura, y en muchos casos la falta de cuidado y de aseo. No hay más que penetrar en un conventillo para ver el triste espectáculo que ofrecen los niños, y comprender así la causa de la enorme mortalidad de la primera infancia. La ignorancia y el abandono de los padres son los elementos que más intervienen en este lúgubre cuadro. En el mismo término (1885–1890) han muerto 3,858 niños de 5 á 10 años, así clasificacios:
Coni: Causes de la morbidité et de la mortalité de la première enfance à Buenos Aires, 1886.
Aún cuando el exámen comparativo con otros países nos sea favorable, debemos reconocer que estamos lejos aún de presentar datos que sean consoladores, y es satisfactorio decir que en este sentido se comprueba un movimiento que más tarde dará excelentes resultados. El Patronato de la Infancia, institución creada á semejanza de algunas que existen en Europa, tiende en sus fines primordiales á disminuir los estragos de las enfermedades infantiles, fundando maternidades y asilos, consultorios médicos, vigilando la lactancia mercenaria, las fábricas donde los menores trabajan, y tratando por todos los medios posibles de poner la salud de estos en buenas condiciones para que se desarrollen fuertes de cuerpo y con el espíritu de trabajo que necesitamos para prosperar. No serán inútiles algunas consideraciones sobre el tétano infantil, muy frecuente en otro tiempo en Buenos Aires, y cuya disminución se acentúa hoy felizmente. Los datos del siguiente cuadro hasta 1890 pertenecen al Dr. Coni, y revelan la cifra de mortalidad que ella produce:
1875 1876 1877 1878 1879 1880.
436 1881. 412 1882. 430 1883 372 1884 308 1885 255 | 1886
1887 1888 1889 1890) 1891 1892
En estas cifras predomina el sexo masculino. En cuanto al momento de la vida en el cual la mortalidad es más crecida, es entre la primera y la segunda semana del nacimiento; en este período se produce más de la mitad de las defunciones que corresponden al tétano. El otoño y el invierno son las estaciones en que más niños mueren por esta enfermedad. Antes de las teorías microbianas, el létano era en Buenos Aires de una frecuencia aterradora. Hoy que las parteras reciben buena instrucción práctica, y que los beneficios de la asepsia se desparraman y multiplican, se reducen notablemente sus víctimas. Siendo como es, el resultado de una infección (bacilus Nicolaier) la curación antiséptica y la conservación de una absoluta higiene se imponen. La proporción de mortalidad infantil al año, en varios países, por 1,000 nabitants, es esta:
Según este cuadro Grecia é Irlanda presentan la estadística mortuoria infantil más reducida, en tanto que Wurteinberg, Baviera y Sajonia ofrecen cifras muy elevadas. Sabemos ya que en Buenos Aires la cifra de niños de 0 á 1 año que mueren es de 17 sobre 100 nacidos vivos, lo que le asigna condiciones mejores que muchos países de Europa, en vonde ese número es mayor. De los sobrevivientes al primer año en Buenos Aires muere el 9 por ciento en el segundo año. Desde el año 1885 á 1890, inclusive, han fallecido aquí 5,386 niños de 2 á 7 años, por las siguientes enfermedades: Infecciosas á localizaciones variables, 1,797 ; infecciosas á localizaciones típicas, 1,153; aparato respiratorio, 885; enfermedades del sistema nervioso, 729; aparate digestivo, 432; enfermedades génito-urinarias, 92; enfermedades de la nutrición, 62; aparato circulatorio, 23; enfermedades de la sangre, 10; enfermedades de la piel, 6; sin clasificación, 195; total, 5,384.
En los últimos años nuestra mortalidad infantil de 0 a 1 año ha oscilado entre 24 y 28 por ciento de la general. Comparemos los datos que á este respecto ofrece Paris, según Landouzy y Napias, y veremos lo siguiente:
Así pues la mortalidad en los niños de 0 a 2 años en la capital de Francia, varia entre 23 y 25 por ciento de la total. Los nacido-muertos en Buenos Aires han llegado á ofrecer muy lúgubre estadística, pues no solo interviene en ello el accidente natural de la muerte, sino que muy frecuentemente esta es el resultado del crímen. Las casas particulares de partos, que hasta hace muy poco escapaban á la vigilancia de la asistencia pública, han sido en muchos casos los principales contribuyentes de esta entidad que la moral, la buena policía y la conveniente inspección harán disminuir. Otro factor que obra poderosamente para aumentar esta cifra es la ilegitimidad y con esta la miseria. El cuadro que sigue revela la proporción que los nacido-muertos representan en 100 defunciones generales en Buenos Aires :
Comparando los nacido-muertos en Buenos Aires y otras ciudades argentinas, tenemos:
Media de nacidomuertos en 100 de funciones generales.
Media de nacidomuertos en 100 de funciones generales.
1887-91 1889 1889 1889 1889 1889
San Nicolás. Santiago del Estero Bahia Blanca Concepción del Uru-
Y haciendo la misma comparación con algunas ciudades europeas, resulta .
París y Buenos Aires ocupan los primeros lugares en esta estadística de mortinatalidad. Buenos Aires, junio, 1893
METHODS EMPLOYED FOR THE PREVENTION OF DISEASE AND PRESERVATION OF THE LIVES OF THE INHABITANTS OF THE DISTRICT OF COLUMBIA.
By CHARLES M. HAMMETT, M. D.,
Health Officer of the District of Columbia. I have the honor to appear among you as health officer of the District of Columbia, delegated to this congress by the honorable Commissioners, and I will proceed to state in as few words as possible the methods employed by the health department for the prevention of disease and preservation of the lives of its inhabitants. The ordinances of the health department, covering nearly all nuisances likely to occur injurious to health, were legalized by Congress and approved by the President on April 24, 1880, and we are now acting under these laws. The important features that may be spoken of are the system adopted for the issuance of permits for burial; the obtainance of information concerning births and marriages for statistical and other purposes; the method of inspections, especially that pursued during the present summer, of house-to-house visitations; the collection of garbage; the service of surveillance of houses infected with smallpox, scarlet fever, diphtheria, and other contagious diseases; the pound service; and the inspection of vessels arriving from foreign ports. The domiciliary inspection service was originated with a view to ascertain the sanitary condition of each and every house and premises within the District lines. It has been successful beyond my utmost expectations. During the period from March 17 last to the present time there have been 39,330 houses inspected. In these houses there resided 39,627 families. consisting of 190,718 adults, children, and infants. The number of rooms for their accommodation was 274,133. Closets and privies numbered 55,942. The water supply from the reservoirs from the Potomac River is 18,244; from hydrants in the public streets, 3,055; from wells, 4,619; cisterns, 69, and springs, 315. Over 13,000 nuisances of a minor character were found, which have been abated. This work has been done with an average force of twenty nien. The deaths for the following months, this and last year, were as follows:
Figures such as these, showing a gradual decrease in the number of deaths as compared with the increase in the population with the great finality of 196 less deaths during the month of July this year than last, is a most important evidence that house-to-house inspections, vigorously and faithfully carried out, as have been done here, with a competent force of inspectors, is one of the vital agencies to be employed. This, I consider, is one of the inethods described so aptly by Dr. Mapother in his treatise on sanitary science for the maintenance of the health and life of communities by agencies in “common and constant use." The principles of physiology, pathology, and biology may be well carried out in this direction, supporting the cardinal idea of cleanliness. There are other' agencies employed for the protection of the health of the inhabitants of the District of Columbia relating to sewers, drains, disposal of garbage and dead animals, disposal of the dead, etc., which inay be spoken of as follows: Seventy-two thousand one hundred and thirty-eight healthy and vigorous trees are now growing upon the street lines of this city, and it is any belief that these trees have an important share in the healthful conditions surrounding us. We also have a free public bathing beach, which is used to the fullest extent whenever the weather will permit. More than 300 miles of underground sewers have been laid in the District of Columbia, at an approximate cost of $6,800,000. These afford ample drainage for our present needs and have much to do with our good sanitary condition. The work is still progressing and large appropriations have been made for its continuance. Since the commencement of the large system of improvements 3,500,000 square yards of various pavements have been laid and the appearance of our streets and alleys always strikes the eye of the observing visitor with surprise, the miles upon iniles of smooth pavement affording excellent drainage toward the sewer openings. Most of the streets are kept scrupulously clean, and filth upon any street or alley is the exception rather than the rule. The condition of our public school buildings is also about all that could be desired in such structures, the closest attention being paid to ventilation, heat, closets, etc. They are inspected frequently and anything in the shape of unsanitary matters is speedily abated. As a consəquence, the breaking out of epidemics or the spread of diseases through the agency oï the public schools is nearly impossible. Relative to the vital statistics of the District of Columbia, will say that to the casual observer deaths, as they occur in a community, seem to present no order nor law in regard to age, sex, or social condition. Individuals seem to fall as the leaves of autumn fall. Old and young, in the alley or on the boulevard, in the tenement house or Executive Mansion, pass away one by one. But when the death certificates are arranged and classified, either according to age or cause of death, it will be seen that chance plays no part in this draina, and that fixed and unchangeable laws govern the whole matter of life and death. Statistics post the account and strike the balance. They disclose how age and social relation, and even meteorological conditions, influence the rate of inortality. They point out the advent and growth of strange maladies and novel phases of old ones; how some seem refractory and incurable, whilst others may be met and overcome. They designate where certain diseases linger for years around certain localities, and how the taint of blood may sap the fountains of life down through successive generations. In short, they furnish data from which science may deduce conclusions as wonderful as that by which Jenner enabled mankind to successfully fight smallpox, or as grand as that of Pasteur or Koch which taught how disease may be made to abort disease. It is upon the principle that statistics are valuable only when used as means of comparison that the tables contained in the annual report of this department are mostly arranged. They contain, in addition to the results of the immediate year, serial tables covering groups of years, arranged conveniently for reference. Besides these tabular statements, but deduced therefrom, Page 4
Respecto del presente, no siendo posible educar hombres, sí lo es corregirlos, y la manera más adecuada es servirse de la penalidad impuesta á la embriaguez. Debe tenerse presente que el que se expone voluntariamente á perder su razón y á entregarse á excesos cuya trascendencia ni él mismo puede medir, es doblemente culpable, primero, por la falta que comete privándose de su razón, y segundo, por los actos que en tal estado puede ejecutar y ejecuta de ordinario cuando se embriaga, circunstancia agravante y que debe tenerse en cuenta por el legislador, pues sabido es que individuos pacíficos se tornan pendencieros y aún asesinos con los vapores del vino. Que la legislación jamás atenúe el delito cometido por un ebrio de oficio ni del que voluntariamente y á sabiendas de los efectos del alcohol sobre el cerebro se exceda en la bebida, que la penalidad impuesta á los crímenes perpetrados por individuos en estado de embriaguez, sea mayor y efectiva, y puede asegurarse sin temor de engaño, que el número de consuetudinarios disminuirá. Habrá necesidad de algunos ejemplares, quizás podrá tacharse de severa esta manera de proceder, pero el resultado práctico vendrá á hacerle justicia, y las ventajas serán reportadas por la sociedad. Si la legislación moderna es tan indulgente con los criminales, buscando razones para excusar hasta cierto grado los delitos á la soinbra de la perversión de instintos, de la degeneración moral de ciertos individuos, del estado en que los coloca la embriaguez, la consecuencia forzosa es que la sociedad está desarmada delante de los agresores de sus intereses, so pretexto de no condenar al reo que en el acto inismo de perpetrar el crímen no disfruta del pleno uso de su razón. Cuando á los degenerados, epilépticos, locos de impulsión, etc., se les vigila y se les segrega de la comunidad para sustraerla de sus tiros, causa pena y extrañeza que no se proceda de igual manera con los ebrios de profesión. Todavía tratándose de estos últimos, tendría que ventilarse la cuestión de si tienen conciencia del acto criminal que ejecutan y el vino solamente los priva del temor natural de ejecutarlo por las penas con que se castiga un hecho de este género en un cuerdo, circunstancia que aumenta su audacia con la perspectiva de la inmunidad relativa, ó si realmente deben calificarse como privados de razón. La importancia del asunto demanda algunas consideraciones médico-legales sobre los efectos del vino en las facultades que constituyen la razón humana, y la apreciación que han hecho de ellos algunas legislaciones vigentes en la actualidad. Después de este estudio sucinto, sería del mayor interés para nuestras legislaciones y para la sociedad, que se fijaran reglas de conducta para el juez y el perito, á fin de poder determinar con precisión cuales de los actos cometidos en estado de embriaguez podían estimarse concientes, y cuales voluntarios en la causa, y por tal motivo siempre imputables. Los códigos de Austria, Prusia y Baviera dicen que ningún acto puede ser reputado criminal cuando su autor se encuentre en estado de ebriedad completa y accidental. En Inglaterra, según Blackstone, la legislación criminal afirma que la falta de voluntad en el ebrio en el momento del crímen, lejos de servir de excusa, agravará el delito porque debía no embriagarse y ser dueño de sí mismo. Eduardo Coke ha dicho: “Un ebrio es un demonio voluntario que es responsable de los males que pueda causar durante la vehemencia del vino.” La legislación norteamericana es análoga. La ley de Georgia, sin admitir como excusa la embriaguez, exceptua el caso de haber sido ocasionada por artificios de un tercero. El código de Wurtemberg establece una distinción entre el ebrio y el consuetudinario; teniendo indulgencia con aquel y siendo muy severo con este, para castigår el delito y el vicio. En general se cree que la frecuencia de actos criminales de tal o cual género debe suavizar la penalidad de los códigos respecto de ellos ; mas es muy importante tener presente la rigidez de la legislación inglesa que contraria S, Ex. 36--132 Page 5
La embriaguez periódica ó intermitente dimana de la perversión, la sensualidad, la imitación y la disolución de costunibres. (Marc.) La acción de la justicia contra ella es soberana y su fallo dependerá de la apreciación discreta de la moralidad del hecho. (Legrand de Saule.) La historia de las desgracias ocasionadas por la embriaguez es un largo y sombrío martirologio. (Dumesnil de Quatre-Mares.). Cinco siglos atrás, en 1349, á propósito de este asunto el prefecto municipal de Rouen dijo: De veinte bandidos ó salteadores, diez y nueve se han formado en las tabernas. Licurgo embriagaba á los ilotas para inspirar á los ciudadanos horror por la ebriedad. Aristóteles y Quintiliano afirmaban que agravaba al crimen y que debería castigarse con una pena independiente de la que aquel reclamaba, por ser una degradación voluntaria, la cual nunca podría ser medio de justificación ni
Se mejoran la plantas con el cultivo y el honibre con la educación. (Rousseau.) En el día, la educación es prodigada con largueza y sin embargo el inal hace progresos. La sociedad exije que se dicten medidas reprensivas; para tener buen éxito, preciso será herir el corazón. (Legrand de Saule.) Los progresos deplorables del alcohol y sus efectos desastrosos conducen a los más eminentes pensadores, no solo á rehusar á la embriaguez el carácter de excusa legal (lo cual había ya proclainado la jurisprudencia del tribunal supremno tiempo ha, considerándola en sus sentencias como hecho voluntario y reprensible que jamás podrá constituir una excusa capaz de ser acogida por la moral y por la ley), sí que también á reputarla circunstancia agravante del crímen y de la penalidad. La asamblea nacional en 1871 se ocupó de este punto, y entre los esfuerzos intentados en esta vía, los más enérgicos y mejor dirigidos fueron presentados por el Dr. Teófilo Roussel. (Tardieu.) El código francés hace punto omiso del estado de embriaguez, dejando en libertad á los jueces para calificar la responsabilidad (Briand et Chaude), medida muy sabia que puede poner á salvo los intereses de la sociedad y los derechos del hombre, porque el magistrado falla á impulsos de su conciencia y no de la ley escrita. La historia, la legislación de países demasiado ilustrados, y la opinión de médicos-legistas, tan eruditos y prácticos como los que hemos citado, vienen en apoyo de la moral y de la filosofía para demostrar una vez más que el individuo que voluntariamente se coloca en condiciones que puedan arrastrarlo á cometer actos punibles concientes, semiconcientes ó inconcientes, es doblemente responsable por renunciar á la razón deliberadamente y obedecer á ciegas los instintos de sus malos hábitos; que los delitos cometidos bajo la influencia del alcohol deben ser castigados, y que la embriaguez no debe estimarse circunstancia atenuante, ni atenderse al desarrollo que ha alcanzado en nuestra época, porque sieinpre que los códigos suavicen la penalidad por tal consideración, lejos de corregirse, crecerá á sus anchas, contando con la impunidad relativa de ser castigados como faltas, sin calificarse de crímenes imputables los atentados perpetrados á su sombra. Es bien lamentable que la trasgresión de las leyes del deber ejecutada por un hombre honrado en un moinento de desgracia en olvido de sus deberes, sea castigado con la severidad impuesta por la legislación, al paso que delitos mucho más repugnantes, llevados á cabo por individuos que corrompen y vician las costumbres sociales, encuentren una egida que les sirva de amparo, trayendo á colación en su defensa y á título de excusa, un vicio que corroe á las sociedades modernas, y que echará más hondas raíces toda vez que la legislación lo tolere y aún lo proteja indirectamente, atenuando las penas con que se reprimen los actos punibles de sus adeptos. Ya hemos referido la opinión de Taylor, en la cual se nota la confesión ingenua, del estado deplorable que ofrece el pueblo inglés por su afición á la bebida, y que si fuera admitida la embriaguez como excusa legal ante el jurado, tres cuartas partes de los criminales gozarían de impunidad. Que nos sirva de ejemplo esta lección para que jamás lleguemos á semejantes extremos; que nuestros legisladores fijen su atención sobre cuestión tan importante y opongan un dique á los avances de un vicio que después de destruir al individuo, disolver la familia y perturbar el orden y decoro social, se perpetúa en la descendencia marcando sus huellas con lesiones cerebrales y faltas de desarrollo físico y moral; que declaren responsables de sus actos á los consuetudinarios, para que si no obtienen la desaparición de la intemperancia, hayan cumplido, por su parte, la alta misión que desempeñan, vigilando por el bienestar de la comunidad y reprimiendo los actos que la trastornan. Page 6
(7) Borrajórt (Heliotropicum indicum).- Planta como de media vara de alto, de la cual se usa la cataplasma de las hojas como resolutiva y la infusión como sudorífica, (8) Brusca (Cassia occidentalis, leguminosas).–Planta de media á una vara de alto. Se usa como antiespasmódico, febrífugo y emenagogo. El cocimiento se aplica en la dismenorrea, cólicos uterinos, supresión de los loquios y el reumatisino. (9) Bejuco de cadena (Schenella splendens). -Se usa como sudorífico y antiblenorrágico. Entra en la preparación de casi todos los jarabes depurativos que se preparan aquí. (10) Calaguala (Planta cryptogama, Polypodium crasifolium).-Se utiliza la raiz, que es cilindroidea, bermeja, cubierta de fibras largas en cocimiento, como diurética y sudorífica. Contiene una sustancia que parece goma, una resina roja, amarga y acre, una sustancia parecida al almidón, ácidos málicos y silícicos, cloruros de sodio y materias colorantes. (11) Chiquichique (Cassia indecora, leguminosas).-Se usa el zumo y el cocimiento de las hojas y flores como febrífugo, en bebidas y lavativas. Contiene mucho mucílago y se reconiienda especialmente para el tratamiento de las fiebres biliosas. (12) Coco (Cocus nucifera).- La cubierta fibrosa de la nuez contiene tanino y gran cantidad de aceite. El perispermo de la fruta contiene albumina, un aceite fijo, goma, azúcar no cristilizable, sustancia colorante, fibrina, caseina y agua. El agua de coco se usa como diurético, especialmente adicionada de ginebra, contiene azúcar, albumina y agua. Del fruto verde se prepara un jarabe de gusto agradable y que recomiendan como pectoral. (Véase la fórmula.) (13) Conopia (Rencalmia, sylvestris.)-El pericarpio del fruto da una tinta inorada. Se prepara un aceite usado como resolutivo y calmante. (14) Cruceta real.–Arbol mediano que crece con abundancia en todo el oriente de la república, donde goza de mucha fama como amargo estomático y febrífugo. El Dr. E. Fernández lo ha usado en Caracas para el tratamiento de las fiebres intermitentes inveteradas, con buenos resultadas. (15) Congrina.-Esta sustancia tiene propiedades antireumáticas de gran valor, machacada y puesta en maceración con alcohol, obra eficazmente en los dolores musculares. (16) Dividive (Cesalpinea coriara, Cesalpinaceas). Los frutos contienen de un 30 á 40 por ciento de tanino. El polvo y el cocimiento se usan con ventaja en las gangrenas, en las cardialgias y dispepsias, y tiene las demás aplicaciones de los tánicos. (17) Durazno.—El cocimiento de las hojas de esta planta se usa en las afecciones herpéticas y en el exema. (18) Eneldo (Fæniculum vulgare, Anethum feniculum).-En los cólicos ventosos ejerce notable acción la infusión de esta planta, especialmente en los niños de pecho, asociado al bicarbonato de soda ó la magnesia. (19) Espadilla (Crotalaria stipularia, leguminosas).-Yerba de más de media vara de altura, habita sobre las colinas secas, da flores amarillas, sus frutos son legumbres de algo más de media pulgada de largo, oblongadas, sin divisiones y con varias semillas de forma semilunar, prendidas á la sutura superior de la legumbre. Se usa como antiflogística y sudorífica, el zumo de las hojas, en el tratamiento de las fiebres inflamatorias y en el de las insolaciones. (20) Esponjilla (Luffa purgans, cucurbitaceas).–Planta rastrera y abejucada, habita lugares cálidos y húmedos. El tegido reticular exterior puesto en infusión con agua caliente, hasta que tome un gusto amargo, es purgante enérgico. Se usa como antireumático, como contraveneno general y en el tratamiento del tétano. Page 7
mangotina, y la cree superior á la quinina en el tratamiento de las fiebres intermitentes. Con el fruto se prepara un jarabe pectoral, y con las seinillas otro muy encomiado para el tratamiento de las diareas crónicas. (31) Orégano (Lippia micromera).-Esta planta aromática, anti-espasmódica, es áltamente estomacal, y se usa con ventajas en la disuria espasmódica. (32) Pasote (Chenopodium ambrosioides, salsolaccas). -Domina en esta planta un principio aromático, nauseabundo y muy picante. Se emplea el zumo ó la infusión de las hojas contra las indigestiones, y se prepara un aceite anti-helmintico. En cataplasmas como resolutivo. (33) Piñón (Jatrapha curcas, euf orbiaceas).-La almendra de esta planta encierra un aceite acre de acción vomipurgante enérgica. (34) Raíz de mato (Aristoloquia barbata, aristoloquius).-Se usa con gran ventaja en todas las hemorragias, principalmente en las que se producen en las fiebres infectivas, como la remitente hemorrágica, amarilla, disentérica, gangrenosa y fiebre hematúrica. Tiene propiedades estimulantes y astringentes y un principio aromático. Es superior á la trementina y á otros astringentes, según el Dr. J.M. de los Rios. De esta planta solo se usa la raiz, bajo la forma de infusión, tintura y extracto. (35) Rosa de montaña (Brownea, leguminosas).- La madera del tronco y las hojas contienen un principio astringente que la hacen utilizable en polvo y en cocimiento como astringente y hemostático. (36) Sauco (Sambucos virginiana).-Las flores de esta planta usadas en infusión son sudoríficas, los tallos y las hojas tienen propiedades vomipurgantes, y entra en la poción conocida con el nombre de antidisentérica, cuya benéfica acción diariamente explotamos y que ha sido vendida por tanto tiempo como remedio secreto con el nombre de “ Específico del Dr. Laloubie." (37) Totumo (Cresentia cryete, cresentiaceas).-Se utiliza el fruto para la preparación de un jarabe muy recomendado en la tisis, abcesos hepáticos, y contusiones internas. (38) Torco.-El polvo de esta planta se usa en la gastralgia y en todas las formas de dolores espasmódicas también se aplica en la diarrea atónica. (39) Tamarindo (Tamarindus indica, leguminosas).-La pulpa del fruto del tamarindo se usa como laxante y atemperante. Es de un color rojo oscuro, de un gusto ácido azucarado; entra en la composición de la conserva de Vargas, preparación del célebre médico venezolano de este nombre, y que se aplica con excelente resultado para el tratamiento de las afecciones hepáticas. (40) Túatúa (Yatropa gossipifolia, cuforbiaceas).-Se usa con frecuencia la infusión de esta planta como laxante, y según la energía con que se quiera obrar se aumenta la dósis. (41) Verdolaguilla.--Esta planta crece en los tejados, tiene un principio amargo pronunciado, y es muy usada como diaforética y febrífuga en las formas maláricas no muy intensas. (42) Yerba mora (Solanum nodiflorum, solariaceas).- Esta planta tiene propiedades narcóticas, y se usa en cataplasmas con sustancias grasosas, en todos los casos en que es necesario atenuar el dolor con aplicaciones locales, dando muy buenos resultados en el tratamiento del herpes, zona, erisipelas, etc. (43) Yagrun (Ceropia peltata, artocarpeas).-Se usan las hojas, yemas y parte leñosa del tronco del yagrumo morado, recomendádolo como sucedaneo de la digital. Esta planta ha sido estudiada especialmente por el eminente Dr. G. Michelena, el cual refiere haberla usado siempre con muy buen resultado para disminuir el número de los latidos cardiacos. En el asma lo usaba mucho el Dr. Antonio Rodríguez, catedrático de terapéutica y materia médica, y el Dr. Rísquez lo usa como antiasmático, cuando hay intolerancia por el yoduro de potasio. La planta es muy mucilaginosa, y no se ha podido encontrar en elļa ningun alcaloide, Page 8
Erythroxylon pulchrum, St. Hil. This near relative of the well-known Erythroxylon Coca seems to have received but little attention so far. It is met with abundantly in the mountainous region about Rio de Janeiro. Mr. Theodor Peckolt has experimented with this Brazilian species of Erythroxylon, and has obtained from the fresh leaves a very small percentage of cocaine, a strongly bitter extractive principle, and a crystallizable acid. These leaves would seem to deserve a careful therapeutic study.
Cedron seed: Simaruba cedron, Planchon. The cedron tree appears to be confined to the United States of Colombia, ranging from the fifth to the tenth degree of north latitude, and from 75" to 80' of west longitude, but is always rather rare. The drupaceous fruit is about the size of a swan's egg, and has the appearance of an unripe peach. Each drupe contains one seed, the cedron of commerce, which is easily separated into two large cotyledons, resembling blanched almonds, but larger in size, and plano-convex in contour. Leroy, in 1851, discovered a bitter principle in the seeds which he named " cedrine." More recently Tanret has isolated from them an alkaloid of very great activity, cedronine, the dose of which is a milligram. Cedrine was also found to be poisonous in large doses. Cedron seeds have been used extensively by the natives and the physicians of Mexico and Central America. They are so intensely bitter that a fluid or solid extract is generally preferred to the crude drug. The dose of the fluid extract is stated at 1 to 8 minims. The drug is used as a remedy for the bites of insects and serpents; for hydrophobia; it is of service in intermittent fever, dyspeptic affections, cholera morbus, colic, facial neuralgia, and gout. Almost incredible reports have been published of its marvelous effects in the treatment of hydrophobia and the bites of venomous reptiles, such as rattlesnakes, moccasins, copperheads, and tarantulas. It is claimed for cedron that it possesses tonic, antiperiodic, and antispasmodic virtues of so decided and pronounced a character that the drug is fully entitled to a prominent place in the classification of the materia medica of the future. (Parke, Davis & Co.'s Brochure No. 25.) Cascara amara Picramnia, spec. indet.; also known as Honduras bark. The plant furnishing this bark is indigenous to Mexico, Honduras, etc. It has been chemically examined by F. A. Thompson, who procured an alkaloid from it, for which he suggested the name of picramnine. (Am. Journ. Pharm., 1884, p. 390.) This active principle has the peculiar taste of the bark, and is believed to represent its virtues. Numerous clinical reports on cascara amara tend to confirm its value as an alterative. It is credited with achieving cures of chronic cases of syphilitic eruptions, syphilitic tubercles, chronic eczema, and gummy tumors. Although slow in its action, it is regarded almost as a specific in syphilis. The assertion is made for it that it eliminates the specific poison from the system. The fluid extract is given in doses of one-half to 1 dram, and the powdered extract in doses of 5 to 10 grams. An illustration of Honduras bark and a number of clinical reports on it are given in Parke, Davis & Co.'s Brochure No. 12.
Creosote wood: Tah-sun-up of the Pah-Ute Indians. Larrea Mexicana. It is quite common in southern California, Lower California, Arizona, and southern Utah. An infusion of the plant is used with benefit for open sores on men and animals. The powdered leaves are said to be valuable as an application to chronic A peculiar gummy substance exudes from the old wood in abundance, and is used by the Apaches as a styptic. The peculiar odor of the fresh plant has earned for it the name of creosote wood. (Dr. E. Palmer in Am. Journ. Pharm., Dec., 1878.) Page 9
Eupatorium Ayapana, Ventenat. This very aromatic Brazilian composite has a coumarin-like odor, with a slightly bitter and astringent taste. L'Heritier and Martius report that it is used in Brazil as an antidote for snake bites, both internally and as an external fomentation. The leaves are also recommended for indigestion, pectoral affections, and cholera. They appear to have been used in Europe for similar purposes in the early part of the present century. (Am. Journ. Pharın., Mar., 1877.) Guaco.—Robert B. White, of Salada, New Grenada, claims that Mikania Guaco furnishes the guaco of commerce. Other observers insist that the true origin of guaco has not yet been definitely determined, as quite a number of species of Mikania, Eupatorium, and Aristolochia are indifferently known as guaco in Mexico and Central America. The root is regarded as a specific in rheumatic affections in Mexico, a fluid extract of it being used both internally and externally. The pain and stiffness are said to be often relieved by a single application of the preparation, provided that the parts are kept well covered with it all night. Mr. Robert B. White, who has lived in Choco and other snake-infested regions for many years, testifies that guaco leaves, properly and promptly administered, are a cure for the bites of the most venoinous serpents of that country. (Pharm. Journ. Trans., Nov., 1880.) Topas aire (botanical name not known) is used in the Argentine Republic in the treatment of ophthalmia. Nio, probably identical with mio-mio, from Baccharis cordifolia, Lam. This shrub is a deadly poison to cattle. According to P. N. Arata, it contains an alkaloid, baccarine. The plant is indigenous to the Argentine Republic. (Zeitschr. d. Oestr. Apoth.-Ver., 1881, No. 27. Raiz del Pipitzahuac: Perezia Dugesii. The root of this plant has been used for a long time in northern Mexico as a powerful laxative. This action was found by Prof. Rio de la Liza to be due to a peculiar acid, which he named pipitzahoic acid. Dr. Weld determined its ultimate composition to be C2, H2,06. The same acid has also been obtained from Perezia Wrightii, Gr., and from Perezia nana, Gr. (Am. . Journ. Phar., Apr., 1884.) Parthenium hysterophorus is much esteemed in the Antilles as a substitute for quinine. It is found in waste places throughout tropical and subtropical America. It is characterized by extreme bitterness, due to the presence of a glucoside, which has been called “parthenine.". Dr. Torar has found the drug to be decidedly efficacious for neuralgia, both intermittent and non-intermittent, especially for the cranial form, but to be utterly without effect as an antipyretic. (Gaz. Médic., May 29, 1886:) Mutisia vicicfolia, Cavanilles. Dr. Saco, of Bolivia, reports this plant to enjoy the reputation of curing phthisis and all pulmonary diseases. The plant is indigenous to the western part of South America from Chile to Peru. It belongs to the labiatifloral compositæ, which are confined chiefly to South America. (Journ. d'Hygiène, 1886.) Haplopappus Baylahuen, C. Gay. Used in the province of Coquimbo as an antihysteric remedy, and in veterinary practice in the treatment of wounds. The plant has been found to contain a volatile oil, a fatty oil having the odor of the plant, a brown resin of sharp taste, and tannin. The taste of the drug is said to resemble that of pichi. (Drug. Bull., 1890.) Zinco or Chinchilla: Tagetes glandulifera, Schrk. A native of the Argentine Republic, but not found very plentifully there. It is reputed to have tonic properties. Carqueza : Baccharis articulata. Found abundantly in the same country. Said to be useful for indigestion, sterility, etc. Page 10
Lucuma rivivoca, Gärtner. This fruit has a mucilaginous, agreeable, sweetish a , pulp, and constitutes a popular dessert. It is used medicinally in the form of confection and syrup in the treatment of dysentery and catarrh of the lung. The emulsion of the seeds is a popular diuretic. Lucuma torta, Mart. A syrup is made from the edible fruit, which is used in bronchitis, catarrh, and affections of the lungs, Lucuma psammophila, A. D. C. The agreeable, sweet' fruit is regarded as a delicacy, and is used in the preparation of a confection. The bark enjoys the reputation of being a tonic. Lucuma glycophlæa, Mart. et Eichl. This may be viewed as the most important of the group, as it is the source of the commercial extract introduced from Brazil under the name of inonesia. The bark of this tree was imported into Europe as early as 1555, and it is the part which is now principally exported. Dr. Peckolt has succeeded in crystallizing monesin from it. (Pharm. Rundschau, Jan. and Feb., 1888.)
Thevetia neriifolia. Indigenous to the West Indies, New Granada, and Peru. The bark and the seeds of this tree are regarded as a powerful febrifuge. According to De Ury, the seeds contain 75 per cent of an almost colorless fixed oil, and a crystalļizable glucoside, thevetine, which can be split up into glucose and theveresin. (Journ. de Ph. et Chim., Mai, 1869.) Thevetia yccotti, D. C. Joyote. Found in the damp, hot regions of the fertile mountains of the great Mexican Cordillera. The Aztecs believed the seeds to cure the bite of the rattlesnake. The ancient Mexicans made use of the milky juice of the tree for curing deafness and cutaneous eruptions. They applied the leaves topically for toothache and as an emollient and resolvent to tumors. The fruit was used by them for healing ulcers. At present the fruit is called in Mexico "huesos ò codos de fraile," bones or friar's elbow, from its resemblance to the human elbow. The seeds have a high reputation among the people in hæmorrhoids. They are first triturated, then mixed with suet, and applied locally. Prof. Alfonso Herrera obtained a well-defined glucoside from the seeds, which he named thevetosin. Physiological experiments made by Luis Hidalgo Carpia with thevetosin proved it to be very venomous, acting as a powerful emetic and paralyzing the respiratory organs, and possibly also the general muscular system. (Am. Journ. Pharm., Apr., 1877.) Pao-Pereira : Geissospermum laeve, Bouillon; Picramnia ciliata, Vallesia punctata, Tabernæmontana lævis, Geissospermum vellosii. A tree native to Brazil. An alkaloid was discovered in it in 1838 by Santos, and named pereirine. About 1830 Prof. Silva made known the febrifuge and antiperiodic properties of the bark. The alkaloid, which is now sometimes called geissospermum, is used in Brazil in an impure form. It occurs there as a brownish yellow, amorphous mass of extremely bitter taste. (Compt. Rend.) Quebracho.—The bark of Aspidosperma quebracho-blanco, Schlecht. An evergreen tree, 14 to 20 meters high, growing in the Argentine Republic, in northeastern Bolivia, northern Patagonia, and southwestern Brazil. The same name seems to be also applied to Quiebrachio morongii, Britton, N. O. Terebinthaceae, which is known to the natives as quebracho colorado, and is used largely for tanning purposes. Quebracho has been introduced as a sovereign remedy in dysp It relieves the cyanosis and the sense of suffocation due to embarrassed respiration, as in emphysema, capillary bronchitis, phthisis, and chronic pneumonic processes, and in asthma. It appears to assist in the oxygenation of the blood, and at the same time to stimulate the respiratory centers. Quebracho bark is said to contain at least six different alkaloids, the most important of these being aspidospermine, quebrachine, hypoquebrachine, and aspidosamine. The commercial aspidospermine seems to be a mixture of all of the six alkaloids, so that it fairly well represents the activity of the drug. It is probably the most valuable remedy known for dyspnea in its various forms. The dose of it is given at one-fourth to one-half grain. The crude drug and its corresponding fluid extract have of late become sufficiently popular to warrant their recognition by the new United States pharmacopæia of 1890, which has bestowed the official title of aspidosperma upon the remedy. Page 11
Euphorbia pilulifera, Linn.— This plant has long been used in tropical countries in the treatment of asthma, bronchitis, and cardiac dyspnea. The dose of the fluid extract is from 30 to 50 ininims. The drug has been analyzed by Charles G. Levison, Ph. G., of San Francisco, Cal. Dr. C. C. Baker, of New Mexico, has used the plant in two cases of asthma with prompt and satisfactory results. As far as he was able to judge from the sensible effects, however, the virtues of the plant are probably not superior to those of the closely allied indigenous weeds, Euphorbia maculata and Euphorbia hypericifolia. (Therap. Gazette, Jan., 1884.) Pallillo. Croton morifolius.—This Mexican plant has been experimented with in France by Messrs. Dugees and Armendaris. Two or three drops of the oil expressed from the seeds acted similarly to a moderate dose of castor oil. The Mexicans use an infusion of the leaves of this plant as a remedy for gastralgia and atony of the stomach. The tincture is of benefit in facial neuralgia, either used as a liniment or dropped into the ear, or taken in 10 to 15 drop doses with orange flower water. (Am. Journ. Pharm., 1884, 476.) Velamen: Julocroton Montevidensis, Klotz. An herb somewhat rare in the Argentine Republic, where it is prescribed in cases of syphilis and syphilitic rheumatisın. (Amer. Drugg., Nov., 1889.) Jatropha macrorhiza, Benth. A Mexican plant, said to resemble podophyllum in its action. Dr. A. H. Noon, of Oro Blanco, Pima County, Ariz., recommends it as a new hydragogue cathartic, with cholagogue and other properties worthy of investigation by the medical profession. (Med. World, Oct. 1889, p. 421.) Balsamo.-The latex obtained by incisions into the Jatropha multifida. This is a popular vulnerary employed in Brazil for wounds. An infusion of the seeds of this Brazilian plant, or the fixed oil obtained from them, is used as a purgative. The dose of the oil is 10 to 15 drops. (Rev. Pharm. de Rio de Janeiro, 1886.)
Celtis Tala, Gill. A tree found in the Argentine Republic. In infusion is used there in pectoral catarrhs. (Zeitschr. d. oestr. Apoth. Ver., 1881.)
Carnaüba root, Carnahuba: Copernicia cerifera, Martius ; Corypha cerifera, Arruda da Camara. This species of fan palm is indigenous to Brazil and Peru. It is also met with as far south in Paraguay, La Plata, and Chile as the thirtyfirst degree of latitude. The tree is illustrated in the proceedings of the American Pharmaceutical Association for 1878. The natives of the extensive plateaus in the northern provinces of Brazil derive from this palm nearly all their means of subsistence and comfort. The wood, leaves, leaf fibres, leaf stalks, fruit, terminal leafbuds, and the hollow stems are all of them used for numerous domestic purposes. The roasted fruit kernels furnish an agreeable beverage, known as café de carnauba. The most valuable product of all is the carnauba, or palm wax, which has become an important article of commerce. The root of this palm enjoys a high reputation in its habitat as an efficient alterative and diuretic. Possibly it may at some time in the future become equally popular with sarsaparilla, stillingia, etc. Lescher's “Recent Materia Medica,” 1888, mentions carnauba root as an alterative and diuretic, used as sarsaparilla in decoction of 1 part to 16, in doses of an ounce. (Parke, Davis & Co.'s Brochure No. 11.) Page 12
alkaloid. Jaborandi: Of the two varieties noted, the Rio is very inferior to the Pernambuco, but the latter is not yet in abundant or steady enough supply to speciiy it solely in the United States pharmacopoeia. Rhatany: The drug now sold for Savanilla Rhatany is not genuine. It is a Rhatany, but not the old Savanilla. Baccharis: There is another species than the Mio-Mio, which yields an alkaloid, very bitter, and which acts as an anthelmintic.
THE PHARMACOPEIA AND ITS STUDY.
By ROBERT W. GREENLEAF, A. M., M. D., of Boston, Mass.,
Professor of Materia Medica and Botany, Massachusetts College of Pharmacy ; Physician, Boston Dispensary.
Pharmacology, in common with other departments of medicine, is in a transitory stage. We must recognize that a new era is arising in the treatment of disease, coincident with the advance in knowledge, especially in the department of histology and pathology. Certain members of our profession, carried away by their studies in bacteriology, have been tempted to forget that drugs and their preparations still have a place in the armamentarium of the practicing physician. On the other hand, gentlemen trained in the encyclopedic methods of the past find it difficult to realize that many of their treasures from the animal, the vegetable, and the mineral kingdom are fit only for the departments of some museum devoted to the history of medicine. Between these extremes the pharmacology of to-day desires to take its stand. It desires to equip the physician, whose specialty it is to administer at the bedside of the sick, with a proper knowledge of the weapons he is to employ. With a consideration of the important classes of remedial agents other than drugs this section is not occupied. Suffice it to say that the therapeutic instruction of to-day is incomplete without full attention to such agents as electricity, water, food, etc. In regard to that special class of remedial agents which we designate as drugs while the number in use is much less numerous, yet the knowledge regarding them is on a far more advanced plane than hitherto. The time has come when a course of lectures on materia medica and another somewhat similar but less descriptive course on therapeutics will not suffice for the needs of the medical student. Our medical schools must provide instruction in the department of pharmacology corresponding in value to that in other scientific branches, or their duty is unfulfilled. Courses in pharmacology must be equipped with facilities for demonstrating practically the effect drugs are capable of producing in the animal economy, and for investigating the properties of new drugs as discovered. It is not enough to tell a student that digitalis is the leaf of such and such a plant, that it contains certain active principles capable of producing such and such effects on the circulatory system. The student must at some time in his course see for himself the sphygmograph inscribing its altered record. Would a college tolerate a professor in geology or botany who confined his instructions solely to the amenities of the lecture room, however eloquent or inspiring his words might be? Shall we, as physicians, tolerate or content ourselves with less from the teachers in our departments of science? Already our medical schools are facing this question. Already are our leading schools inaugurating successful courses in experimental pharmacology. It is not a part of this discussion to say what shall or shall not be taught in this department. Let us limit ourselves still further to the simple question, How shall the medical student become familiar with the pharmacopoeia? Here again the progressive hand of science commands us to initiate the student into the mysteries of the drugs he is to use just as the chemist or the botanist does in his chosen fields, and here it is that we find that our profession, in its specialization, has not fully adjusted itself. Let me briefly indicate the old way which appears to persist in many localities, and then outline what I conceive to be a wise method of treating this subject. We all know of instances where the young medical student, too often ignorant of biological methods and knowledge, moreover, ignorant as yet of the pathology of disease, is introduced to a jargon of technicalities ; in the early part of his course is informed that the pharmacopoeia is the official organ of a learned committee representing the various medical and pharmaceutical societies and that it is revised to date every ten years ; is treated to a learned course of descriptive lectures; is shown from the lecture table a host of bottles or a meaningless array of lantern slides or gaily colored plates. The wild Indian thought of killing a photographer because he found himself represented as a half man, he being unable to appreciate the effects of light and shade. It is hard to realize that the young student of science is no better off and must first be taught to read. His early steps in science are as those of the crawling infant. Is it to be wondered at that at the close of such a course, however eloquent the teacher, the average student votes materia medica a bore, throws away his pharmacopæia, if he ever had one, and, except for the purposes of an examination, knows absolutely nothing of that remarkable, erudite, and most useful work, the pharmacopoeia, save in relation to a dozen or so drugs, which even then he is able to administer only in the crude, often offensive, ways of his hospital or dispensary experience? Is it any wonder that in his innate sense of the fitness of things, when he finds his private patients demanding agreeable-tasting and sightly preparations, he falls an easy prey to the first manufacturer who floods his office with attractive and plausible circulars, samples, and other baits of enterprising business greed? It is extraordinary that this matter has received so little attention at the hands of the profession. And it is a striking commentary on our carelessness, I may even say on our credulity, when our medical societies, even our great medical congresses, will content themselves with an exhibition of so-called pharmacy represented solely by the pretty preparations of a few manufacturing concerns, with here and there a patent food or water thrown in to vary the scene. The bait of a neat $12 case with dainty tablets of all the drugs he remembers having heard his professor laud so highly is too much for him, and in his ignorance the medical tyro begins his career regardless of the fact that medicines change their properties with age, that pills will not always dissolve when wanted, that some may even pass the exit gate without effect, that the pretty tablets may irritate where soothing was indicated. He is fortunate if in giving two different kinds he does not some day blow up his patient by some unforeseen explosion; or if the unwitting patient, having been told to dissolve the compounds, has not saved most of the drug for a last, perhaps a fatal, dose.
There is no reason, gentlemen, why this subject should not be made as attractive and as valuable in a medical school as it is in the colleges of pharmacy. In them a new era has begun. We cannot all teach as Agassiz taught. Such a genius is one of a century, but any true teacher can make his student enjoy his study and come to it and take from it with the zeal and profit of the naturalist. This is done in our colleges of pharmacy, and can be done in our medical schools as well. The steps are the same in kind, the only difference being that the pharmacist in his line of specialization must travel further, Now, let us consider what these steps The young student of pharmacy is required to know enough of elementary botany and chemistry to understand the main anatomical and chemical features of the drugs studied. Should the physician be less well prepared? He is then given actual specimens, not merely lecture-table specimens, but actual hand specimens for his personal study-to taste, smell of, and look at, inside and out, to examine microscopically as well—then to keep for his private ownership, review,
and comparison with later specimens, to his heart's content. Having made his own observations, sometimes, to be sure, under the guidance of his teacher, he is then required to compare his data with the descriptions of an authoritative treatise. Such is our pharmacopæia. If he chooses to improve his phraseology by adopting that of those of greater experience than his own, he inay do so, but that is of secondary importance. The fact is what is wanted, and the fact studied in such a way is the student's own. Instead of passing in one ear and out the other, it has come to stay, and has come in wisdom's way, which is a way of pleasantness. Our pharmacopæia describes all drugs now regarded as of value in language descriptive of results derived from study of such a character. Each student of pharmacy must practically make his own pharmacopæia in precisely the same way. Each medical student should make his own pharmacopæia, which of necessity must be still smaller, according to his special needs, in practically the same way also. Not having time enough for all he must learn types—for example, as digitalis leaves-then, though it would be well, he need not carry out every step in the study of other leaves as belladonna and stramonium. It is not his function to purchase fine specimens for the preparation of their active principles, nor to detect adulterants, etc., but before understanding the use of tinctures, fluid extracts, pills, etc., he must know something of the crude drugs from whence they camne. Next as to how he shall master what he should know regarding those preparations; and it is just at this point that our medical schools are most liable to fail, excepting a few who demonstrated, perhaps, a single percolate from their lecture tables. The older teachers contented themselves for the inost part with stating that the pharmacopæia contained specific directions as to how these classes of preparations should be made. So it does, and soon the student of pharmacy learns to admire the care and painstaking with which the best methods for making the many preparations of the pharmacopoeia are presented. It is important for the pharmacist to be familiar with all. It is not so for the medical student. . Nevertheless, he must know the types, or he will soon be making the needless errors which make him present so pitiacle a spectacle of ignorance to the pharmacist, and become so dangerous or obnoxious to his patients. The neglect of instruction in such matters in our medical schools is a discredit to our profession. If it is worth while using tinctures, etc., in our practice, it is worth while knowing-something about them; and, as with every other objective study, there is no better way of learning about a thing than to see it and study it objectively. I would have every medical student understand the classes of preparatives of our pharınacopæia. I would have him make in the laboratory at least one illustration of each. I would have him blend them in various ways just as he is to order them blended in his later practice. Thus he would soon learn the beautiful and nice proportional relations presented in our pharmacopæia as existing in the strength of these various preparations. He would soon learn to avoid incompatible and unsightly inixtures. He would soon know what he wants to use and how to direct its preparation. Fancy a captain ignorant of the manual of arms. That is about the position of inany a student of the old régime regarding the mixing and prescribing of drugs. But a new era is at hand, and it is noteworthy that those colleges which equip their students in such a practical, scientific way furnish our profession with men who find their studies full of interest and have become the foremost physicians and therapeutists of the country.
DISCUSSION. Dr. H. H. RUSBY. The idea has been advanced that the possession of this knowledge of pharmacy would tend to induce the physician to dispense his own medicine. My own idea has always been that, on the contrary, it would give him an adequate idea of the importance of the subject, so that they would not “rush in where angels fear to tread." I always tell my students and inquiring friends that the University of Pennsylvania has the best inedical course in the country. The institution which has the wisdom to introduce this study has good wisdom for use in other directions.
Dr. A. W. MILLER. The paper to which we have just listened reminds me very forcibly of the remarks which I am in the habit of annually making to the students of the University of Pennsylvania. As near as I can recall, I have there for years advocated the same reforms which he has recommended. It is a part of the educational plan of the medical department of the University of Pennsylvania to make the study of pharmacy obligatory on all of its students, excepting those who are either graduates of pharmacy or have had several years' practical training in drug stores. During the first course of medical instruction the student is compelled to devote one whole evening, that is, from 7:30 to about 10 o'clock in each week, to practical work in the pharmaceutical laboratory, including practice in the writing of Latin prescriptions. I have again and again been assured by many of our graduates that they have found the practical instruction in the pharmaceutical laboratory to be of greater benefit to them than that of many other laboratories,
SECTION XX.-MEDICAL JURISPRUDENCE.
Dr. JUAN JOSÉ R. DE ARRELLANO, City Hon.M.C.GEORGE, Portland, Oreg. of Mexico, Mexico. Dr. ALEXANDER E. MCDONALD, New Dr. MANUEL C. BARRIOS, Lima, Peru. York, N. Y. Hon. WILDER.L. BURNAP, Burlington, Dr. PERRY H. MILLARD, St. Paul, Minn. Vt. Hon. CALVIN E, PRATT, Brooklyn, N. Y. Dr. CHAS. F. CHANLER, New York, N. Y. Dr. JOAQUIN QUILES, Havana, Cuba. Hon. J.D. B. DE Bow, Nashville, Tenn. Dr. H.J. LAUNDERS, Toronto, Canada. Dr. WENCESLAO DIAZ, Santiago, Chile. Dr. A. N. BELL, Brooklyn, N. Y. Dr. R. OGDEN DOREMUS, New York, Hon. CLARK BELL, M. D.. New York, N.Y. N.Y. Hon. LUCELIUS A. EMERY, Brunswick, Dr. MAURICE J. LEWI, New York, N. Y. Me. Executive President.
Dr. ALONZO GARCELON, Lewiston, Me.
Dr. HAROLD N. MOYER (English-speak- Dr. PLUTARCO ORNELAS, San Antonio, ing), 834 Chicago Opera House, Chi Dr. ALBERTO MOLINA, Guatemala City, Dr. PODESTA (Cuyo 424), Buenos Ayres, Guatemala. Argentine Republic. Dr. WALTERS, Lehui Kaui, Hawaii. Dr. FRANCISCO HARRI, La Paz, Bolivia. Dr. NICHOLAS R. DE AVELLAN (Consejo Dr. A. J. DE LONZA LIMA, Rio de Janeiro, de salubridad), City of Mexico, Mexico. United States of Brazil. Dr. M.J.BARRIOS, Rivas, Nicaragua. Dr. N. A. POWELL, Toronto, Canada. Dr. José R. ROMEN (Plaza de Cogancha Dr. EDUARDO PLA (Reina 105), Havana, 38), Montevideo, Uruguay. Cuba. Dr. FRANCISCO CHOPARRO, Mérida, Dr. LEONCIO BARRETS (carrera 7, núm. Venezuela, 397), Bogota, Republic of Colombia.
ADDRESS OF THE PRESIDENT OF THE SECTION, HON. ALONZO GAR CELON, M. D., LEWISTON, ME.
Although four centuries have elapsed since the discovery of this continent and its.occupancy by the civilized nationalities of the world, now for the first time since that important event the medical profession of the various governments into which it is subdivided have, by their delegates duly appointed, assembled this the 5th day of September, 1893, for the purpose of conferring together and discussing subjects of especial importance not only to themselves but to the communities they represent. With the end in view that the best results attainable may be Page 13
Apart from the liability to be connected with medico-legal examinations previously alluded to, and to which every physician is subject, there are others of great importance demanding a thorough education of the practical practitioner. In cases of divorce, protracted gestation, premature labor, and impotency important interests are often at stake and the knowledge of the medical witness put to a severe test. The very earliest work found in looking over the bibliography of medical jurisprudence is one published in 1612 by Tagereaux, entitled, “ Discours sur l'Impuissance de l'Homme et de Femme. In 1714 an important case was tried in Paris involving the question of impotence which gave rise to the publication of two volumes entitled “ Impotentia ; the Case of Impotence Debated in the Late Trial at Paris.” Closely allied to this question are those of protracted births, naissances prétendues tardives. About 1765 a contested case for divorce or inheritance gave rise to several treatises by such authors as Bouvart, Barbeaux, Bas, Bertin, and a year or two later a work in two volumes by A. Petit. I doubt if any better résumé upon the subject can be secured in works of more recent date if such are in existence. In a community when great wealth and loose morals are frequently allied, when criminal abortions are numerous, and injudicious marriages frequent, divorces easily obtained, maternity revolting, and attention to the care of a family incompatible with social life, the dance hall, the theater, the card table, and other amusements, it would not be surprising if meclical men were more frequently summoned to give evidence in medico-legal trials involving some one of the various crimes to which allusion has been made. Enough, however, has been said upon this branch of the subject to give a hint at least of its importance, and we will pass to the consideration of cases of a different type, but of vast importance to municipalities, corporations, and individuals, which very frequently require the testimony of inedical men to secure settlement. I allude to those arising from defects in the public highways, railroad accidents, explosions, want of proper supports or defective hoisting apparatus in mines or manufactories. In cases of injuries of this nature, whenever the municipal officers, railroad officials, or agents of corporations refuse to settle upon terms which the injured party believes to be just, and where there was an absolute defect or gross carelessness on the part of the corporation, he appeals to the courts, and a medico-legal investigation becomes a matter of necessity to determine the extent and nature of the injury. In many instances medical experts, in addition to the injured party's attending physician, are called upon to give testimony in the case. It is now a common practice with our railroad corporations to enter into a contract with one or more surgeons to attend upon cases of injury occurring on their respective lines, and such is human nature that almost constantly the weight of their testimony is found to favor the interests of their employers and minimize the degree of the injury sustained by the sufferer. On the other hand, the injured party is quite as apt to magnify his suffering, and with the hope of obtaining excessive damages sometimes claims to suffer from causes not apparent and which are without foundation. Particularly has this tendency been observed among those who have brought actions against municipalities. Municipal officers, like railroad surgeons, have an interest at stake, and oftentimes very unwisely refuse to do that, as expectants for future election, which they would do as disinterested parties. They refuse to .make a reasonable compensation, if any. The injured party is determined to have a pecuniary remuneration not only for injury, but for suffering endured, lapse of time, and for anticipated infirmity. The attorney is consulted, perhaps a shyster ever seeking to encourage suits, who advises that no settlement should be made, but that action. be brought at once. This done, the plaintiff's difficulties make no improvement. Indeed, they seem to.increase. He can not step with the same firmness. His spine is now painful. His lower extremities have lost their feeling, and he feels he is perinanently injured and.a confirmed cripple for life. The case comes to trial. Experts are consulted. Every physician who has had aught to do with or examined it is summoned. He goes upon the witness stand, and with lugubrious countenance details his condition and sufferings. The jury is touched by his narration. The weight of evidence favors his plea, and a handsome verdict is the result. He leaves the court room with the sympathy, it may be, of the mass of spectators. In a few weeks a remarkable change has taken place. His general appearance has improved. He moves with greater certainty. His cane, or crutches, as the case may be, is laid aside. Some good lady has recommended a favorable panacea, it may be goose oil, or stork's oil, or some wonderful plaster, from which he has received great benefit. It is truly surprising what an effect it has upon him, and he now has great hopes of a permanent cure. This is no burlesque description of actions of this type, and I doubt not its parallel has fallen under the observation of every man who has been an observer of cases of the kind described. Quite a number have occurred under my own observation during a half century's practice. I trust you will pardon me if I give a single instance, one of actual occurrence, in all its details and from which a deduction valuable to every medical witness may be drawn: Page 14
the broken shaft whenever there was a movement of the body. The upper extremity of the shaft was drawn forward and the limb shortened nearly or quite 2 inches. A gentleman from a distant State, on a business tour, was thrown from his carriage, receiving a compound comminuted fracture of one of his legs near the iniddle, while passing through a neighboring village, some 20 miles distant from my residence. The accident occurred directly against the residence of the village physician, who kindly proffered the use of his house and his attentions in the treatinent of his case. Two weeks later I was called for consultation. The surroundings were comfortable; the bed a mattress on which was a bed of feathers, and across this a folded comforter, so called in New England, the lower folded edge of which was so placed as to come about on a line with the fracture of the limb, permitting the heel and lower extremity of the fractured limb to drop several degrees and causing quite an angle at point of fracture. Two strips of board were used, 24 inches in width and long enough to extend from upper extremity of the tibia to the bottom of the foot. Short pieces of red tape were attached to the top edge of these strips and the apparatus was placed by the side of the limb and not confined to it in any manner save by tying the strings of tape together over the top of the leg: A long piece of similar tape was tied in the middle around the great toe of the fractured liml) and the end of the strings were attached to opposite footposts of the bedstead. A poultice was applied over the wound, which being removed, a denuded portion of the upper extremity was brought to view, and beneath, a large collection of pus. Two attendants were present, who stated that they had been in constant attendance from the first hour of the injury, either one or the other constantly holding the limb to control its spasmodic action, which was extremely frequent and intensely painful. The suffering of that fortnight can be imagined quite as well as described. A lad of 12 or 13 years of age playing with other boys fell from a sidewalk to the street and both bones of one arm were broken. The doctor of the village, with some claims as a surgeon, was called to attend the case. He claimed to have reduced the fracture, but as there was a tendency to a little more bulging or prominence over the region of fracture, he thought to remedy the defect by tightly applying the bandages over the splints. Notwithstanding the young patient suffered extreme pain, he declined to make any examination or remove the dressing before the eighth day, when to his astonishment the entire hand and arm was in a state of gangrene as high up as the fracture, except a little strip along the under edge of the ulner to the wrist joint, three-fourths of an inch in width. The result was an amputated arm. The bones were found overlapping each other, and without question reduction had never been made. It would seem that nothing short of ignorance could be pleaded as an excuse for such a mistake and a want of that faculty commonly called “common sense. I have not cited these as unique or without a parallel, but on the contrary their type is found in every community, and I have the impression that there are but very few professional men of long experience who have not met their counterpart in one form or another. And let it not be said that these men were “wicked beyond all who dwell in Capernaum,” for they were all graduates of some reputable medical college and stood on a par with a large majority of those who annually go out upon the community with diplomas in their pockets. Nor let it be suggested that they were graduates of a bygone generation who had not the facilities of a medical education in a reputable college. If the report of the qualification of a graduate given in the Journal of the American Medical Association be true, as it unquestionably is, no limit can be given to the stolidity that may be rewarded with the prize of a diploma, even at the present day. The truth is these men, like thousands of others, had mistaken their calling. They had no mechanical ingenuity, and you might as well attempt to make a musician out of a child with a cleft palate as a surgeon out of a man deficient of mechanical ingenuity. Natural abilities, supplemented by the best education with assiduous application and perseverance through a long course of study secure, are absolutely essential to qualify any young man for the duties and the responsibilities of the practice of medicine, and with all these can give him he will soon find that he has but just entered upon the threshold of the temple of knowledge, and when he enters upon the domain of surgery he will find that something more is wanting than a knowledge gathered from books. Page 15
clinical characteristics. A current impression prevails that a broken back or fracture of the spine is always a very grave injury, which necessarily must entail a permanent crippling ; but this is erroneous, as a general rule, as has been repeatedly demonstrated. It is only when the cord is simultaneously damaged that paralysis succeeds in consequence of the fracture. Fractures of the spine follow direct and indirect force; the latter more frequently. When they occur as a consequence of Cirect concussive force, the consequences are more serious. Fracture of the lingual or hyoid bone is an exceedingly rare lesion. I have never met with one in more than 3,000 fracture cases. In modern times, since the rapid and enormous extension of the railroad, very many are crushed or maimed by the vehicles which are rolled over them. These fractures are commonly compound when the wheels roll over the limb. But there are many exceptional cases, in which the integuments are unbroken, yet the bone has sustained extensive shattering, the neural or vascular trunks being seriously damaged at the same time. The extent of damage to the limb after having been run over by car wheels will depend on many factors directly connected with the condition of the patient, but more often with the weight of the car, whether a street car or a steam railroad car, freight or passenger, whether or not it was loaded or empty, whether one or both wheels passed over the injured limb, and whether the car was in rapid or slow motion. So many cases have come under my observation in which one or both wheels have passed over a limb on a street railway without destroying its integrity or even causing a fracture, that we certainly can no longer entertain the view that an accident of this description will always irretrievably destroy the limb. In all cases in which shamming is suspected we should carefully examine the clothing and look for abrasions, ecchymoses, or discolorations of the integument. This class of accidents seldom occurs except to young and heedless children, to those physically incapacitated, or to the intoxicated. Steam railroad injuries of the limbs constitute practically a separate class of fractures. With these are fixed sets of symptoms seldom associated with tramway accidents. There is commonly bodily and organic injury as well as the local disorganization. This former may quite overshadow thelatterin importance andgravity. It is well in all these cases to determine the extent and degree of bodily injury present in all cases, if possible, at the first examination. Another element of farreaching importance is that of a psychological character, the element of fright and of nervous shock. It has long been noticed that when those injured on railroads are employed on them, the extent of shock is not so great as when the same degree of traumatism is borne by a passenger. A limb run completely over by the car wheel on a steam railroad of a trunk line must inevitably be greatly damaged, and in the vast majority of cases completely destroyed. I have no recollection of having ever seen a limb survive which has been rolled over by the wheel of one of those freight or passenger cars, though there are records of such injuries wherein the limb has escaped destruction. It is almost needless to say that in all this class of injuries the fractures are compound. But it is well to note that the living integuinent is a very tough tissue; and hence in many, while there may be but a small opening in the integument, the inclosed bone and muscle are ground to a pulp, while the main arterial trunks and nerves are completely torn through. FRACTURE-DISLOCATIONS.
The etiology of fracture-dislocations is generally definite and simple. With the exception of machinery accidents, they are seldom if ever induced except by indirect force; but at the elbow they more commonly are occasioned through violence acting immediately over the seat of injury. The causative factors in a Colles's or a Pott's fracture are so well understood and so constant that we would regard Page 16
seriously imperiled. It is very probable that such few cases as have been reported were those in which the bones were broken in their passage through the canal of emergence at the time of delivery. Fractures of the femur during delivery are not uncommon, but they alınost invariably promptly unite and leave no trace of deformity.
FRACTURE OF BONE IN MORTAL INJURIES.
The question as to the precise date of fractures which have been found postmortem has occupied an important position in many inedico-legal cases, but as they pertain, in the greater number, to skull injuries, an extensive consideration of them is not now necessary. Ogston (Forensic Medicine, p. 5141) alleges that " the presence or absence of a blood-clot in a fracture detected post-mortem is of no definite value in determining whether a bone was fractured before or after death,”and says that's the only realtest is the presence of reparative processes;” and that “this, only, can the medical jurist rely on.” He adds, though, that a clot found between the ends of a fractured shaft is decisive proof that it was of an ante-mortem character. In this, however, Casper does not concur. Devergie (Médecine-Légale, Vol. II, p. 101) tells us that every shaft of bone fractured completely after adult years are attained, results in a diminution of the volume of the bone, which, in the living or the dead, is easily appreciable in thin subjects, but in fat subjects, particularly women, it is not easily detected. In the absence of a well-defined callus, this, he says, is important to remember. In concluding this part on the etiology of fracture from a forensic standpoint it is well to always determine, if possible, by a thorough scrutiny intu the patient's or subject's history, whether he had a predisposition to fracture, had a preternatural fragility of the bones, or had previous fracture. On inquiry in fracture cases in my hospital service, many instances have come to my knowledge in which the patient has previously fractured other bones of the skeleton. Many have coine under my care in which the most trifling sort of force had broken the bone. Ogston (loc. cit., p. 210. Vol. II) cites the case of a carter who, in jumping from the shaft of his cart, fractured both of the femora in their centers. He mentions another case, which ended mortally, in which but a slight blow on the shoulder so shivered and shattered the head of the humerus and upper third of its shaft that the man succumbed to it. On autopsy it was found that the bone was composed wholly of a friable; spongy tissue, with only a thin shell of compact tissue to enclose it. In all these cases, on examination, we should sedulously inquire into the patient's general condition, with a view of learning if he were in any way invalided by a preëxisting local or constitutional infirmity, as anchylosis, the wearing of an artificial limb, rheumatism, or paralysis, or any other infirmity which would in any manner interfere with locomotion, as these should each and all be regarded as indirect but important factors in the etiology of many fractures and other injuries.
As previously stated, it is of fundamental importance that a correct diagnosis be reached, if possible, on the first visit. Many a medical attendant has come to grief through neglect to rigorously observe this rule. It is true that there are often many obstacles in the way at one's first visit. First, the fracture; if recent and close to an articulation, may be of such a character as to defy detection, and if many hours have elapsed before it is seen inflammatory changes, with intumescence of the adjacent parts, may be so greatas to quite completely mask the indubitable symptoms. The bone may have been fractured transversely without any displacement, and the temporary muscular spasm, always present when reactory inflammation has set in, holds the fragments in firm apposition. It may be said that with many fractures their recognition is indispensable rather from a medicolegal standpoint than with respect to treatment. Many fractures, from their situation, are extremely difficult to recognize without the aid of an anæsthetic and one or more assistants. This is particularly true of the proximal end of the femur and fractures which involve the elbow joint. A fracture of the anatomical neck of the hunerus may be mistaken for a dislocation if great care is not exercised. There are types of luxation and subluxation of the radio-carpalarticulation which on superficialexamination presentsome of the characteristics of fracture, and viceversa. Secondly, we may encounter impediments from the patient and the environment. The patient, if a female, may, through a sense of modesty, be reluctant to permit the medical attendant to expose her in his examination. She may allege that she has but a sprain, and that such examination is not necessary. Her word may be unwisely taken and an examination not insisted on. Such a case occurred in New York very recently. The patient, an actress, had been kicked by her husband in an altercation, the blows falling on the leg and knee joint. Very great pain following, a neighboring physician was called in, who hastily examined her limb under her garments. He prescribed a liniment and made light of the case. Later, another physician was called, who detected a fracture of the patella with some inches of separation of the fragments. I was invited in to verify the diagnosis. A civil action was instituted against the first medical attendant, through which a verdict was found for the plaintiff. One may be called late in the night, far away from associate medical aid, or to one wholly unable or unwilling to pay the expenses of a consultation. Our patient may be hypersensitive, intoxicated, boisterous, or unmanageable, but the law holds us equally responsible for all. In large cities and populous towns there is some relief for us in these cases by sending them to a hospital, but in small villages and scattered country sections we generally can not shift the responsibility. Most of our mistakes in fracture diagnoses arise from haste or an imperfect knowledge of the anatomical and physical qualities of the lesion. A few years ago a vigorous young laborer came to me to attend him for a fractured clavicle. He had a few hours before been at one of our most noted dispensaries, and the shoulder was already firmly adjusted by a modified Sayre's dressing and enveloped in several deep layers of a copious dressing. But he had great pain and demanded a redressing. I sent him back to the dispensary from whence he came, reminding him that most public dispensaries are schools for instruction and that what he got for nothing must be generally valued accordingly. In a little while he returned again, begging me to examine the distrained joint. He had been at the dispensary, but besides nicking the edges of the dressings with scissors nothing had been done. On removal of all the dressings, I discovered no injury of any description. We can well imagine the consequences to a healthy limb and articulation in such a harness for six or eight weeks. An elderly woman, out marketing one winter night, slipped on the curbstone of a sidewalk and was unable to rise. An ambulance was called, and she was entered in the surgical ward of one of our principal hospitals. The house staff, wearied after a heavy afternoon clinic, made a hurried examination, pronounced her case one of fracture of the head of the femur, and put the limb up in a Buck's extension apparatus. She was informed that she must keep the bed for six or eight weeks and that she would be lame for the remainder of her life. Her friends sought her out, and, in spite of the protests of the doctors, brought her home the same night. At about midnight I was called, and on examination discovered that there was no fracture of any kind, but a dislocation of the head of the femur backward on to the dorsum ilii. With the employment of a strong clothesline and three strong young men, boarders in the house, I was able to readily reduce the displaced bone. In two weeks she was about as usual with scarcely a perceptible limp. In doubtful cases of fracture we should always insist on a consultation or advise the patient of our doubt. Then, should deformity occur, we are not responsible for it or the error through which it exists. Surgeons and practitioners are sometimes called in after a case has been under the care of another practitioner, and in which possibly it may be alleged that there was no fracture, but that the practitioner had tried to make a case” of it with a view of extorting a fee or aiding the patient to secure damages for a spurious injury. Page 17
attendant is served with a notice of a suit; when abundant expert and other testimony is forthcoming to incriminate him for the neglect through which the patient suffered in consequence of unskilled, protracted treatment, or perhaps now he has a deformed limb. Malpractice essentially consists of two phases. First, the passive, in which one's course is not sustained by general authority. Second, when those measures in treatment are omitted which might have approximated to secure perfection in results. Very naturally those fractures which lie close to or involve the joints, and those which engage the major shafts, are the class which most often are attended with unsatisfactory results; and hence the subject of malpractice suits. Fractures when improperly treated, or when they occur in patients of unsound health, may terminate in (a) non-union ; (6) deformity; (c) anchylosis; (d) muscular atrophy; (e) shortening, or (f) gangrene. Non-union.—There are no means known to art by which we can predict non-union or prevent it in many cases; hence, we can not be censured for failure of union when our treatment has been on the right lines. Deformity.-While, as a rule, particularly in the young, deformity can and should be prevented, in the adult, in certain types of fracture, its suppression is often quite impossible. Anchylosis.-Muscular anchylosis is a general sequence of all fractures, and shortly disappears. Arthritic anchylosis is the phase which most commonly disables the injured and leads to lawsuits. It is well to bear in mind that in even the most aggravated types of this, use of the limb and time practically overcome it; more so, it is true, in some joints than in others. Muscular atrophy.—Atrophic changes in the soft parts follow all fractures. But it is only when muscular wasting is persistent and permanent that complaint is heard. But it must be a very rare event, as I have never seen a case of that exaggerated type of trophic destruction of muscle mentioned in the text-books. As acute temporary atrophy is always a curable affection after fracture, it is quite inconceivable how its presence could be made the pretext for litigation. Shortening.–Moderate shortening is a usual event in many fractures; hence it is only when the reduction in length is excessive that it can afford a pretext for damages, and even then, with young, restive patients, or those ungovernable to treatment, no fault can attach to the medical attendant. Gangrene.—But few cases of gangrene have come under my care in fracture cases; but five, as nearly as I can remember, in all. It must be admitted that it occurred through too tight bandaging. With the exception of one, it occurred under the gypsum bandage. In three the limbs had to be sacrificed. This is an accident which, while the most deplorable, is fortunately the most rare. My impression is that a limb is seldom lost in a simple fracture from gangrene or asphyxiation of the tissues except through ignorance or carelessness on the part of the medical attendant. In considering the treatment of fracture from a forensic standpoint, a regional division of the body may somewhat simplify its study.
Shoulder joint.-Fractures which involve the anatomical neck of the humerus have been mistaken for dislocation. The epiphyseal disk sinks under the deltoid, and the shaft is greatly displaced by muscular action. A violent blow on the shoulder may paralyze the arm, occasion a fracture or dislocation. Only a most careful examination will always enable one to differentiate in this event. In any case, if in doubt, a consultation should be requested and an adjustment applied. Civil actions seldom arise in consequence of fracture through the center of this humeral shaft, but as we approach the insertion of the digital muscles and the anchyloid ridges the case is different. Page 18
death. (Montgomery v. Scott, 34 Wis., 338; Batten v. State, 80 Ind., 394; McDaniel v. State, 16 Ala., 1; Noblesville, etc., Gravel Road Co. v. Ganse, 76 Ind., 142; Davis 1. State, 38 Md., 15; State v. Crenshaw, 32 La. Ann., 406 ; Armstrong v. Town of Ackley, 71 Iowa, 76; Rash v. State, 61 Ala., 16; Doolittle v. State, 93 Ind., 272.) d. A non-expert can not testify as to the effect of wounds or injuries. e. Physicians shown to be qualified may testify and give opinions. (1) As to the cause of death of a person. (Boyle v. State, 61 Wis., 349; Eggler v. People, 56 N. Y., 642; State v. Clark, 15 S. C., 403; Citizens' Gas Light Co. v. O'Brien, 118 Ill., 174; Sullivan v. Cowen, 93 Pa. St., 285; Boyd v. State, 14 Lea (Tenn.), 161; Comin v. Piper, 120 Mass., 188; Eidt v. Cutler, 127 Mass., 523; State 1. Cross, 68 Iowa, 180.) (2) In malpractice cases, as to whether the treatment complained of was proper. (Quinn v. Higgins, 63 Wis., 664; Kay v. Thompson, 10 Am. L. Reg. (N. Brunsw.), 594; Boydston v. Gittner, 3 Oregon, 118; Williams v. Poppleton, 3 Oregon, 139; Wright v. Hardy, 22 Wis., 348; Mertz v. Detweiler, 8 W. & S. (Pa.), 376; Roberts v. Johnson, 58 N. Y., 613.) (3) In cases of rape, after an inspection and examination of the parts as to health, physical condition; and from the condition, whether there had been an actual penetration, the capacity of the defendant to resist, and the effect the crime would produce upon the sexual organs. (State v. Smith, Phill. (N.C.), 302; State v. Knapp, 45 N. H., 148; Woodin v. People, 1 Park. Crim. Case (N. Y.), 464; Cook v. State, 24 N. J., 843. See also Com. v. Lynes, 142 Mass., 577, in a case of alleged incest.) (4) As to whether an abortion has been performed or attempted. (State v. Smith, 32 Me., 370; State v. Wood, 53 N. H., 484; Regina v. Still, 30 U. C. (C. B.), 30; Com. v. Browne, 14 Gray (Mass.), 419.) (5) As to the nature of a disease with which a person is or has been afflicted; its continuance; its severity and probable duration; the probability of its recurrence; its effect upon the general health; its cause; the remedy; its characteristics, whether hereditary; and as to the probable state of health of the person examined. (Napier v. Ferguson, 2 P. & B. (N. B.), 415; Jones v. White, 11 Humph. (Tenn.), 268; Flynt v. Bodenhamer, 80 N. Car., 205; Polk v. State, 36 Ark., 117; Hook v. Stovel, 26 Ga., 704; Cock v. Potter, 68 Pa. St., 342; Linton v. Hurley, 14 Gray (Mass.), 191; Cooper v. State, 23 Tex., 336; Litch v. McDaniel, 13 Ired. (N. Car.), 485; Edington v. Ætna Life Ins. Co., 77 N. Y., 564; Eckles v. Bates, 26 Ala., 655; Wiley u. Portsmouth, 35 N. H., 303); Filer v. N. Y. Central R. Co., 49 N. Y., 42; Pidcock v. Porter, 68 Pa. St., 344; Anthony v. Smith, 4 Bosw. (N. Y.),503; Matteson v. N. Y., etc., R. Co., 62 Barb. (N. Y.), 364; Cooper v. State, 23 Texas, 336; Jones v. Tucker, 41 N. H., 546; Welch v. Brooke, 10 Rich. (S. C.), 124; Lake v. People, 1 Parker's Crim. Cases, 495; Pitts v. State, 43 Miss., 472; U. S. v. McGlue, 1 Curtis (U. S.), 1; Napier v. Ferguson, 2 P. & B. (N. B.), 415; Washington v. Cole, 66 Ala., 212; Janes v. White, 11 Humph: (Tenn.), 268; Moore v. State, 17 Ohio, 521 ; Morrissey v. Ingham, 111 Mass. 63; Sanderson v. Nashua, 44 N. H., 492.) f. Experts in the use of the microscope, the micrometer, or familiar with the scientific chemical tests, may give opinions as to whether blood is human, or that of animals, birds, or amphibia. (Knoll v. State, 55 Wis., 249; s.c. 42 A. M. Rep., 704; Com. v. Sturtivant, 117 Mass., 122 ; State v. Knight, 43 Me., 1.) g. The confusion into which expert testimony in this respect has fallen in American courts is worthy of notice. (1) Certain experts affirm that they can discriminate between human blood and that of all the domestic animals, save a dog, and from all mammalian blood, except the opossum, the guinea pig, the rabbit, the wolf, seal, beaver, monkey, and a few others, by the diameters of the red blood corpuscles, under à microscope of very high powers. Others deny this, and assert that, while all mammalian blood can be distinguished from that of birds, fishes, and the amphibia by the shape of the red corpuscles and their structure, the extent to which the expert can go is to state that the blood is mammalian and is consistent with and similar to human or other mammalian blood. (R. U. Piper, in 15 Amer. Law Register, 561; 16 Amer. Law Register, 257; 19 Amer. Law Register, 529 and 593; 10 Central Law Journal, 183; 26 Amer. Law Register, 20; Thomas v. State, 67 Ga., 460; Reese, Text-Book Med. Jur., 20 Ed., 133; Wormley on Microchemistry of Poisons, 735–6; 1 Tidy Legal Medicine, Phila. Ed., 231; Prof. Richardson, in London Lancet, II, p. 210, 1875; I, pp. 321 and 700; Prof. M. D. Ewell, of Chicago, Micrometric Study of the Red Blood Corpuscles, Amer. Practitioner, of Chicago, 1890, pp. 79 and 173; Prof. H. F. Formad, of Phila. Studies of Mammalian Blood, Journal of Compar. Med. and Surgery, July, 1888; Clark Bell, Blood and Blood Stains, Med. Legal Journal, Vol. 10, No. 2.) Page 19
a. As to the disposition, characteristics, or idiosyncrasies of a person any witness who knows is competent to testify and need not be an expert. (1) As to whether he was fickle minded. (Mills v. Winter, 94 Ind., 329.) (2) Whether he was intoxicated. (City of Aurora v. Hillman, 90 Ill., 66; State v. Huxford, 47 Iowa, 16; Stacy 2. Portland Put. Co., 68 Me., 279; Pierce 2. State, 53 Ga., 365; State v. Pike, 49 N. H., 407.) (3) Whether he was angry at a certain time. (State 1. Shelton, 64 Iowa, 333.) (4) Peculiar affection for a third person, if known to the witness or observed by him. (McKee v. Nelson, 4 Cow. (N. Y.), 355; s. C. 15 Am. Dec., 384.) b. Masters of vessels or experienced seamen may give their opinions on questions pertaining to nautical science or affairs. (Delaware & Co. v. Starrs, 69 Pa. St., 36; Baird v. Daily, 63 N. Y., 547; Western Ins. Co. 2. Tobin, 32 Ohio, 77; Perkins v. Augusta Ins. Co., 10 Gray (Mass.), 312; Parsons v. Mig., etc., Ore Co., 16 Gray (Mass.), 463; Zugasti v. Lainer, 12 Moore P. C., 331 ; Reed v. Dick & Watts, (Pa.), 479; Jameson v. Drinkala, 12 Moore, 148; Fenwick v. Bell, 1 C. & K., 312; Carpenter v. Eastern Trans. Co., 71 N. Y., 574; Dolz v. Morris, 17 N. Y. Sup. Ct., 202; Steamboat Clipper Co. v. Logan, 18 Ohio, 375; N. E. Glass Co. v. Lovel, 7 Cushing (Mass.), 319; Eastern Trans. v. Hope, 95 U. S. 297; Walsh v. Walsh, etc., Ins. Co., 32 N. Y., 427; Guiterman v. Liverpool, etc., Ins. Co., 83 N. Y., 358; Ogden v. Parsons, 23 Howard (N. S.), 167; Lapham v. Atlas Ins. Co., 24 Pick. (Mass.), 1; Paddock v. Con. Ins. Co., 104 Mass., 521 ; Moore v. Westervelt, 7 Bosw. (N. Y.), 558; Price v. Powell, 3 N. Y., 322; Leitch v. Al. Mut. Ins. Co., 66 N. Y., 100.) c. Opinions may be given by persons skilled therein concerning the running and management of railway trains, and as to questions concerning railway construction, repairs, or management. [Bellefontaine, etc., R. Co. v. Bailey, 11 Ohio, 333; Seaver v. Boston, etc., R. Co., 14 Gray (Mass.), 466: Cinn., etc., R. Co. v. Smith, 22 Ohio, 227; Mobile, etc., R. Co. v. Blakely, 59 Ala., 471; Jeffersonville R. Co. v. Lanham, 27 Ind., 171; Hilton v. Mason, 92 Ind., 157; Fitts v. Creon City R. Co., 59 Wis., 323; Baldwin v. Chic., etc., R. Co., 18 Am. Law Reg., 761, and note; s. c. 50 Iowa, 680.) d. Generally an artisan, mechanic, or person skilled in any pursuit, avocation, or calling, may be examined as to matters relating to his avocation, concerning which he is shown to have peculiar and especial knowledge. (Sheldon v. Booth, 50 Iowa, 209; Scattergood v. Wood, 79 N. Y., 263; Burns v. Welch, 8 Yerg., (Tenn.), 117; Inpitz v. People, 34 III., 516; Union Pacific R. Co. v. Clopper, 102 (U. S.), 708; Woodruff v. Imperial Fire Ins. Co., 83 N. Y., 133; Ward v. Kilpatrick, 85 N. Y., 413; Campbell v. Russell, 139 (Mass.), 278; Terre Haute v. Hudnut, 18 Am. and Eng. Corp. Cas., 302; Folkes v. Chadd, 3 Doug. (Mich.), 157; Barnes v. Ingals, 39 Ala., 193; Davis v. Mason, 4 Peck (Mass.), 156; Knox v. Clark, 123 Mass., 216; Brantly v. Swift, 24 Ala., 390; Phelps v. Terry, 3 Abb. Dec. (N. Y.),607.) e. Competent experts, qualified by study and experience, may testify as to the identity or genuineness of handwriting. (Plunkett 2'. Bowman, 2 McCord (S. Car.), 139; Morrison 1. Porter, 35 Minn., 425 ; s. C. 59 Am. Rep., 331; Moore 2. United States, 91 U. S.; 270.) Page 20
SECTION XXI.-MEDICAL PEDAGOGICS.
Dr. WM.C. DABNEY, University of Vir ginia. Dr. L. B. DUROCHER, Montreal, Canada. Dr. FIFE FOWLER, Toronto, Canada. Dr. WALTER B. GEIKE, Toronto, Canada. Dr. J. W. HOLLAND, Philadelphia, Pa. Dr. FELIPE HARTMAN, Santiago, Cuba. Dr. GEO. A. KETCHUM, Mobile, Ala. Dr. FERNANDO LATASTE, Santiago, Chile. Dr. Jos. M. MATHEWS, Louisville, Ky.. Dr. Thos. MENEES, Nashville, Tenn. Dr. Jas. H. ETHRIDGE, Chicago, ni. Dr. JAMES W.MCLANE, New York, N.Y. Dr. THOS. OPIE, Baltimore, Ma. Dr.JOHN PARMENTER, Buffalo, N. Y.
Dr. CHARLES INSLEE PARDEE, New York, N.Y. Dr. R. C. STOCKTON REED, Cincinnati, Ohio. Ky. Dr. JUAN M. RODRIGUEZ, City of Mexico, Mexico. Dr. FRANCISCO ROSAS, Lima, Peru. Dr. GEO. L. SINCLAIR, Halifax, Nova Scotia. Dr. VICTOR C. VAUGHAN, Ann Arbor, Mich. Dr. ADAMH. WRIGHT, Toronto, Canada.
Dr. J. COLLINS WARREN, 58 Beacon street, Boston, Mass.
Dr.CHARLES L. SCUDDER (English-speak- Dr. WM. F. HUTCHINSON (Spanish-speak ing), 94 Charles street, Boston, Mass. ing), 159 High street, Providence, R.I. Dr. SUSINI (Piedad 1012) Buenos Ayres, Dr. SAMUEL GONZALEZ, Guatemala City, Argentine Republic. Guatemala. Dr. FRANCISCO HURRI, La Paz, Bolivia. Dr. WALTERS, Lehui Kaui, Hawaii. Dr. CARLOS DE VASCONELLOS, Rio de Dr. LUIS E. RUIZ (San Pedro y S. Pablo Janeiro, United States of Brazil. 14), City of Mexico, Mexico. Dr. T. S. WALLBRIDGE, Georgetown, Dr. ALEJANDRO BOLAÑOS, Masaya, NicaBritish Guiana. ragua. Dr. FERNANDO GONZALEZ DEL VALLE, Dr. ANGEL CONAVERIS (18 de Julio), Havana, Cuba. Montevideo, Uruguay. Dr. JORGE VARGAS (Calle 13, núm. 109), Dr. CARACCIOLO PARRA, Merida, VeneBogota, Republic of Colombia, zuela. Dr. CARLOS DURAN, San José, Costa Rica. Page 21
instruction. Although the work of these licensing boards is far from uniform, a great deal has been accomplished by them. There are at the present time fifteen States with practice acts that require an examination of all persons desiring to practice medicine in the respective Commonwealths. These States include nearly 50 per cent. of the entire population. In many States the whole complexion of the medical practice has been changed by the clarifying influences of these bodies. The reports on medical education by the Illinois board, I do not hesitate to say, have exerted a more powerful influence on the inovement in education than any other publication which our medical literature has produced. The effects of these medical-practice acts, which establish a minumum of time spent at medical lectures and provide an examination for those who wish to become practitioners, are shown in the statistics which have just been given. At the present time State examinations are required in Minnesota, North Dakota, Montana, Washington, North Carolina, Alabama, Florida, Virginia, New Jersey, New York, Nebraska, Maryland, and Utah. Millard, who has had experience in framing the act of Minnesota, believing that it would be an improvement upon the medical-practice acts at present in existence to separate the two functions of the board, the licensing power and the educational supervision, thinks that the best interests of the public will be subserved by assigning the duties of the State licensing power to the various State boards of health. The regulation of all forms of education should, on the other hand, be vested in a central power consisting of a single board, to be known as a State bureau of education, with power to regulate all educational institutions granting degrees, together with the power of granting charters, and revoking the same. Particularly should this apply to all institutions wishing to afford the community any of the various forms of higher or special education. Having thus sketched the progress of medical education up to the present time, let us now glance at some of the points of the present system in which it is desirable that further improvement should be made. The importance of a preliminary training for the study of medicine is a problem which has occupied the attention of our most prominent teachers. That the medical student should have received a fair amount of education goes without saying. The importance of a proper preliminary education is thus forcibly stated by that most experienced of German medical teachers, Prof. Billroth. He says in reply to the objection to a preliminary study of the natural sciences as a basis of a medical education: The educated of all nations should not fail to encourage to their utmost knowledge and study in all countries and stations of life. They should not fail to maintain and increase gradually the standard which they have set up both for themselves and others. They should not fail to support the Government in all efforts directed toward this end. The physician, the lawyer, the school-teacher, and the clergyman form the true nucleus of culture in the community. They are, especially in the country and small towns, the representatives of the educated elements of society. The people seek their advice in time of need, and they are their sole source of knowledge in many things. To neglect the education of such persons, to lower their mental and scientific standard, to brings them up so that they have no better education than the tradesman, the tailor, and the cobbler, would be, in my opinion, the suppression of the educational development of a nation, and is a policy both corrupting and immoral in principle, as it would inevitably ruin a nation and bring it prematurely to that point of decadence when it would become the prey of others. The importance of these views is fully appreciated in Germany, where the professional schools are integral parts of the university, and entrance to the professional schools depends upon the previous completion of the course in philosophy, a course which corresponds to that of our academic degree. In Dr. Holmes's suggestive article on this subject? it is shown that while the increase in the total num
1 Millard. The Necessity and Best Methods of Regulating the Practice of Medicine. Journal Amer. Med. Assoc., July 30, 1892. 2 The forthcoming report of the Bureau of Education on professional education in the United States, Journal American Medical Association, January 14, 1893. Page 22
The productive funds in the hands of medical schools, both those connected with and those independent of universities in the United States, was, in 1889, $249,200, while at the same time there was in the hands of schools of theology productive funds to the amount of $11,939,631. The value of buildings and grounds used by medical schools at the same time was $4,047,618, and the theological schools were accommodated with buildings and grounds valued at $7,762,095. The medical schools had, in 1889, 12,238 students, who paid tuitions to the amount of $763,761, while at the same time the theological schools enrolled 6,989 students. I am able to reinforce these figures by an abstract of the statistics for medicine, theology, and technology as reported to the bureau in June, 1892. The medical schools possessed buildings and grounds in 1892 valued at $7,507,937, and productive funds amounting to $611,214. Medical departments of State universities also received State aid in 1892 amounting to $40,500, which, if capitalized at 5 per cent, would be equal to an endowment of $810,000; making a total endowment of $1,421,214. There were 16,731 medical students in attendance. The theological schools report productive funds amounting to $17,599,979, and stated, at the same time, the value of their buildings and grounds was $10,720,860. They had 7,672 students in attendance. Technological schools report productive funds amounting to $13,229,940. These institutions received from State appropriations or municipal aid, in 1891–92, $747,504, which, if capitalized at 5 per cent, would be equivalent to an endowment of $14,950,080; making a total endowment for schools of technology of $28,180,020. There were enrolled in the schools of technology 10,921 students, about one-third of whom were in preparatory courses. It will thus be seen that the endowment of theology is increasing at the rate of about $2,000,000 a year. The technological schools are well provided for, but medicine has scarcely raised its endowment, even at the most liberal estimate, to a million and a half. Probably the available funds procured by our medical schools are somewhat larger than these statistics show, but they give the proportions which are needed to impress upon us how little financial encouragement medicine receives. When we realize what a valuable factor the medical man is in the rapidly increasing development of the territory of a vast and prosperous country like ours, it seems as if his claims to receive encouragement should be listened to. He does not build railroads or organize societies in new lands, but he is in the foremost rank of pio With the complete equipment which our teachers can give him to-day he becomes a most valuable member of society. He protects the young colony from epidemics; without him State medicine could not exist, and States could not be founded on a basis which would insure prosperity. These ideas should be impressed upon our men of wealth and upon the State governments as well. In the meantime it is important that we should adopt as a principle in our new departure in education that the medical faculty should have personal control of hospital wards and management. Let this work begin in a small way at first, but with a view to future development. Such a change can only be brought about by a slow process of evolution. The sooner, therefore, the principle is recognized and adopted, the better. It is difficult for a prosperous school, which has abundant opportunities for bedside teaching, to realize this, but it can not develop beyond a certain point until it has established its own independence. I can not help believing that in this direction lies one of the greatest avenues of development of our system of medical education in the future. Page 23
simply present my own. First, I believe that the student should be taught, in the laboratory, of course, the general reactions and properties of the various albuminous or proteid bodies, studying likewise their more common decomposition products, their relationship and chemical constitution, so far as known. Next in order come the various forms of epithelial and connective tissue, the student separating for himself and studying the various albuminoids which give character to the respective tissues, as the collagen of white fibrous tissue and the gelatin derived from it, the elastin of yellow elastic tissue, the so-called chondrin from cartilage, together with mucin and neuclo-albumin from the mucous tissues. Adipose tissue naturally comes next, and the several fatty acids are separated and studied, melting points determined, and the differences between the natural fats noted. This preliminary work, which involves much more chemistry than can be readily indicated by this short description, is followed by a study of the more important muscle tissue; the properties of muscle-plasma and muscle-serum are noted, and the various proteids and crystalline extractives characteristic of this ue are prepared and examined. Myosin, the proteid of muscle clot, is especially studied, and its resemblance to the related globulins of blood-plasma noted. Again, it must not be forgotten that in order to make such a course as I am outlining of the highest value no opportunity should be lost to show the physiological bearing of all the results obtained ; to try and instill into the mind of the student the idea that the facts of physiological chemistry have a wide application. Thus, in the chemical study of muscle tissue, for example, many lectures and recitations may properly be interspersed, sections, for instance, from Foster's Physiology making an admirable addition to the laboratory work; the object being to teach the student to make use of physiological chemistry as a means toward a broader and more accurate conception of physiological phenomena. Muscle tissue is followed by a study of nerve tissue, the various bodies especially characteristic of this tissue, such as lecithin, myelin, cerebrin, protagon, and cholesterin, being separated and their general properties and reactions ascertained. The chemical differences between the gray and white matter are also noted, the neuroglia, neuro-keratin, and brain proteids are studied, while chemical and anatomical relationships are compared in this as in all other tissues examined. The study of digestion is taken up next, the various secretions, salivary, gastric, pancreatic, and intestinal, being thoroughly examined. Artificial digestive juices are prepared, and their action on the various classes of food stuffs notedand compared, this serving likewise to illustrate the general action of enzymes orsolubleferments in distinction from the organized ferments. The many products of amylolytic and proteolytic digestion are prepared and separated, their chemical and physiological properties ascertained, and a thorough study made of both the chemical and physiological side of digestion in its broadest sense, it being the writer's custom at this point to have the students study and recite, in connection with their laboratory work, nearly all of Book Second of Foster's Physiology, which treats especially of the tissues of chemical action with their respective mechanisms, and of nutrition in general. In a similar manner the liver with its secretion, the bile, glycogen, and glycogenesis, the spleen, blood, milk, and urine are all studied, and the proximate principles giving character to the several organs and secretions separated and examined. Further, the metabolic activity of the hepatic cells, and likewise of the kidney cells, is demonstrated by appropriate tests, such as the synthetical production of hippuric acid through the agency of the cells of the tubuli uriniferi. The chemical changes incidental to respiration are also experimentally studied, and the detection of blood stains by spectroscopic and other methods duly considered. To the urine special attention is given, students being taught not only to make examinations of this important excretion but likewise to determine quantitatively the urea, uric acid, phosphates, chlorine, sulphates, combined sulphuric acid, hippuric acid, creatinin, indican, sugar, albumin, and other abnormal constituents. Further, by daily quantitative examinations of the twenty-four hours' urine, opportunity is given to demonstrate many of the truths of nutrition or general metabolism, such as the influence of various forms of diet on the excretion of urea, uric acid, phosphoric acid, and combined sulphuric acid, the influence of drugs on proteid metabolism, etc. Page 24
a useful one. It is a matter of honor that the work on the case should be really that of the student himself. Under the four years' course, instead of one I hope that each student may receive a number of cases to look up in this way. I believe that the future is bright with promise. The progress in a century has been enormous. At first we depended almost wholly on Europe or Great Britain for a first-rate medical education. Then students crossed the water for clinical advantages in hospitals, as these were non-existent or small in this country. Then a prime inducement was the chance for laboratory work-physiological, pathological, histological, and biological. Just as our hospitals have become second to none, so will our scientific laboratories. It will always be enlarging to the mind to visit foreign schools and study their methods. But it is no longer necessary for the attainment of an excellent equipment alike in practical and scientific medicine. We should bear in mind the fact that we have many possessors of large fortunes who can quickly see that in no way can they so usefully and with so much credit to themselves dispose of their surplus as by promoting medical education within as well as outside of hospitals. But the matter must be laid before them, as it can not be expected that they should be familiar with the requirements of clinical teaching. Who is so fit to explain the matter and can exert more influence than the family physician? Even if a teacher himself he can not be considered a specially interested party if he is an officer of a university, which goes on forever, and the management of which can be depended on to administer funds intrusted to it strictly within the purposes and wishes of the donor.
A DEMONSTRATION OF THE CÆSAREAN AND THE PORRO OPERA TIONS,
By GUSTAVE ZINKE, M. D., of Cincinnati, Ohio.
This includes: (a) Preparation of the patient, her bed, and room in which the operation is to be performed. (b) What anæsthetic shall be employed ? (c) What instruments and other articles are necessary for the operation? (d) Best time for the operation. (e) The operation itself. (f) The after treatment. (a) Much will depend upon when, where, and how we find the patient; whether she be in the country, town, or city; whether she is already in labor, and whether her condition is such as to demand prompt interference, with little or no time left for preparation. But it should always be remembered that an aseptic condition of the mother, as well as of the operator, his assistants, and instruments, are most essential to success, Whatever little time the operator may have at his disposal should be employed in washing thoroughly, with soap and water, those parts of the mother's body which are concerned in the operation. The instruments, too, as well as the hands of the operator and his assistants, should receive thorough aseptic treatment. Antiseptics play an all-important part under such circumstances. The rest, such as cleansing the patient's body, changing her clothes on the bed, and cleaning the room, all may, in an emergency, be postponed until after the operation. If the case comes under observation at a period of gestation which gives time for preparation, say a few days, weeks, or a month or more, nothing should be left undone that may render the patient and her surroundings most favorable under the circumstances. If she can be removed to a special hospital, one devoted to abdominal surgery, it should be done. A general, especially a public, hospital should be avoided; unless it be provided with a building and an operating-room appointed and set apart especially for work of this kind. There can be no doubt the chances for recovery are much better in special hospitals. The patient's home, though the humblest in the world, is preferable for the performance of the operation to a hospital filled with patients of every description and having but one operating room. The question of premature delivery is hardly to be considered here, since it is self-evident that if the patient can be safely deliverecl of a seven or eight months' child this procedure should be adopted in preference to Cæsarean section. As soon as the performance of hysterotomy has been determined upon, whether in a hospital or at the home of the patient, every precaution should be used for the purpose of insuring safety. Thus it will be well if the patient receive a daily vaginal douche (ory solution of bichloride), a warm bath, and a change of underwear for several days prior to the operation. Saline cathartics are the best for the purpose of securing free and daily evacuations. Rectal injections of tepid water will assist in relieving the bowels of their contents. On the evening before, the abdomen, mons veneris, and labia should be shaved, and an abdominal binder with perineal pad, antiseptically prepared, should be applied. The bed which she is to occupy after the operation should also be absolutely clean, the bedstead taken apart and thoroughly scrubbed, the mattress and bedclothes furnigated, then well aired, sheets and pillowslips rendered aseptic and antiseptic by boiling and subsequent dipping into a potou bichloride solution before drying. If she is in her own home the same apartment may be used for bed and operating room. The room is to be prepared as follows: If walls and ceilings are painted they should be washed ; if papered, wiped; if neither, whitewashed or whitened. Windows and frames should also be washed and the floor thoroughly scrubbed and subsequently kept sprinkled with a roho bichloride solution. The temperature of the room should be kept between 60° and 65° F. for at least twenty-four hours prior to and between 170° and 75° during the operation. A temperature of between 80° and 85° is preferable, for the reason that the patient maintains her own temperature better, and consequently the breathing continues more regular, and the heart's action is less apt to fail. The operator, his assistants, and the nurse should be strictly aseptic. This means a bath and clean clothes in the truest sense of the word. No other patients ought to be attended by them previous to the operation. Instruments, sponges, dressings, and towels must be rendered aseptic and again sterilized before using. Operating gowns or jackets and aprons to be worn by the operator, assistants, and nurse should also be sterilized. An ordinary kitchen table, properly cleaned and supplied with an aseptic blanket or comfort, pillow, rubber and linen sheet, is amply sufficient for the purpose of an operating table. The patient should be dressed as "for the night," an undershirt and sleeping gown being all she ought to wear. On the morning of the operation no food is to be permitted, except, perhaps, a small cup of very light coffee and a small piece of toast. Some operators prohibit even this. Before or while the anæsthetic is administered from one-eighth to one-fourth of a grain of codeine or morphine may be given subcutaneously. Placed upon the table, her clothes are rolled up under her shoulders; the lower extremities are wrapped up in warmed, clean blankets, and after the antiseptic abdominal dressing, worn by her during the previous night, has been removed and her bladder emptied, towels wrung out in a warm bichloride solution are so placed across and along the sides of her body as to cover her clothes above and the blankets below. The abdomen remains exposed to the operator. Enough sterilized water should be on hand for all purposes. The hands of the operator and assistants are best rendered aseptic by the method suggested by Howard Kelly. Page 25
from food and drink during the twenty-four hours following the operation there will be but little, often no, disturbance from vomiting. (c) Instruments and other articles necessary for the operation may be briefly enumerated as follows: (1) An ordinary scalpel and elbow scissors for the abdominal incision. (2) A grooved director. (3) A tongue and half a dozen hemostatic forceps (less may answer the purpose). (4) Ligatures of different sizes (silver, silk, silkworm-gut or cat-gut). (5) Needle-holder. (6) Sponges (antiseptic gauze or cotton may take the place of sponges). (7) Rubber tourniquet to throw around the uterus before it is incised (not absolutely necessary). (8) Abdominal irrigator (may not be needed). (9) Iodoform powder ; iodoform or antiseptic gauze for dressing the abdominal wound. (10) Adhesive plaster. (11) Abdominal bandage and perineal pad. (12) Hypodermic syringe and whisky or brandy for subcutaneous injections. (13) Hot water bags or bottles. (d) An all-important question is, What is the most favorable time for the operation? Without entering into a discussion of the subjects and citing the different authors and their reasons for selecting either a period immediately before, during, or after dilatation of the os, I will simply state that the most favorable moment for interference is, in my judgment, when the os is sufficiently dilated to admit of a ready discharge of the lochia. If the operation is performed before this stage has been reached the os will have to be dilated artificially. This must necessarily be deficient, to say nothing of the fact that it prolongs and complicates the operation. Still, there may be good reasons for operating earlier, as in the cases of convulsions, or hærcorrhage due to placenta previa or malignant disease of the cervix; or later, as in cases where the contraction at the inlet suggests the possibility of spontaneous or forceps delivery. The various steps of the opera tion will be shown upon the manikin: The abdominal incision is made directly in the median line, about 6 inches in length, commencing immediately above the umbilicus, and continued toward the symphysis pubis. It is not absolutely necessary to make the cut directly through the linea alba. Pean and Tait prefer to penetrate the peritoneal cavity just to one or the other side of it. They claim it is difficult to bring and hold in apposition the two aponeurotic edges of the cut, and, if this fail, hernia easily results as a consequence; this can be obviated, it is said, by entering at one side of the linea alba. This argument suggests itself as plausible. After the peritoneal cavity has been reached, the incision is best coinpleted and elongated by the elbow scissors. If it is the aim to eventrate the uterus before incising it, a 6-inch abdominal opening will not suffice. But eventration of the uterus prior to delivery of the child does not commend itself, because it necessitates a very long abdominal incision ; again, it is difficult to turn out the uterus, even when the wound is 8 inches in length, nor is there much to be gained by eventration of the organ at this stage of the operation. To prevent excessive hæmorrhage a rubber tourniquet may be thrown around the uterus sufficiently low that no part of the foetus may come within its grasp. The application of the tourniquet, however, requires the introduction of at least one hand into the peritoneal cavity. It is often difficult, and frequently impossible, to bring the tourniquet into position, and, after this is accomplished, its purpose may be defeated by that part of the foetus which presents at the os, especially if the membranes have ruptured previously. For these reasons, and the loss of valuable time, the tourniquet is not often employed by experienced operators. Hence, eventration of the uterus, as well as the application of the tourniquet, may be safely omitted during the progress of the operation. After all hæmorrhage from the abdominal wound has been arrested, and three or four sutures introduced in the upper angle of the wound, the ends of which should be fixed by forceps and the loops withdrawn from the wound and retracted upwardly, the operator is ready for the uterine incision. The uterus, now exposed by the abdominal wound, is to be palpated to determine whether or not the placenta is attached to the anterior uterine wall; if it is, the wall will feel thick, and the parts of the fætus will not be so easily outlined as when the placenta is not situated in this region. If only a section of the margin of the placenta be present, the incision should be made immediately outside of it. But when the placenta has its attachment more or less directly upon the anterior wall the incision should be made as nearly as possible in the median line, and from above downward. If the placenta is not present, this is easily done. The womb may first be punctured with a sharp-pointed scalpel and the opening quickly enlarged with a blunt-pointed, curved bistoury. The hæmorrhage which follows, though great, is not as excessive as might be supposed; but when the placenta has been so implanted that even its margin can not be evaded, there is nothing to be done but to cut through both structures and deliver as quickly as possible. The extraction of the child is best accomplished by taking hold of one or the other extremity. Some writers have tried to lay down the rule: “Always deliver the head first." Experience has shown that this is not always practicable. In a vertex presentation the hand of the operator would have to pass down over the head to lift it out of the wound. The instant the uterus is opened and the hand introduced, it contracts, the amniotic fluid escapes, and the cavity of the uterus, as well as the wound, rapidly diminishes in size; so that, unless the head is promptly and easily liberated before this occurs, considerable force will be required to deliver in this manner; so inuch so that there is great danger of increasing the length of the wound by rupture in a downward direction, an accident which ought to be avoided for self-evident reasons. When there is a large amount of liquor amnii in a vertex presentation, delivery of the head in advance may, perhaps, be free from difficulty; without it, or when the fluid has already drained off, and the uterus is firmly contracted around the child, no risk should be incurred or time wasted in this direction, but delivery effected by the feet. In breech presentations, especially dorso-posterior positions, the head readily finds its way out of the wound; not so, however, when the back of the child presents anteriorly, in which case, for similar reasons, it may be better to deliver by the feet. The only apprehension in a footling Cæsarean delivery is that the uterus may contract around the neck of the child before the head can be removed and thus the life of the child be sacrificed before it is extracted. When this danger is borne in mind, however, the uterine opening may be quickly enlarged by scissors or knife kept ready for the purpose. The same rules which guide us in the delivery of the after-coming head per vias naturales should here be observed; the object of which is to throw the smallest diameters of the head across the passage. During delivery of the child eventration of the uterus may be effected and the three sutures, previously introduced into the upper angle of the abdominal wound, closed by an assistant to prevent intestinal prolapse. The child delivered, the cord is tied in the ordinary way. The removal of the placenta may be effected by gentle traction upon the cord or, if adherent, the fingers may be introduced into the cavity and the organ separated from its attachment. The uterine cavity is then irrigated and dusted with iodoform powder. Proper suturing of the uterine wound is, next to strict asepsis, the most important features of success in this operation. It consists of bringing the wound together by both deep and superficial sutures. Silk, silver wire, and catgut may be employed for this purpose. Catgut, unless absolutely aseptically and antiseptically prepared, is dangerous for reasons evident to all experienced surgeons; silver wire, because it can not be absorbed, may become a source of irritation and annoyance; silk is, in the opinion of most operators, the most satisfactory, because it creates no irritation and its absorption is only a question of time. The deep sutures should be passed, half an inch apart, through the peritoneal coat and the musculature only. The inner decidual surface must be avoided in every instance. The superficial sutures are passed between the deep sutures and grasp the peritoneal surface only, after the method of Lambert. The object to be attained is not only to bring the wound surfaces to close and exact apposition, but to cause its peritoneal edges to dip down into the wound, and thus secure a rapid union and prevent oözing from the uterine cavity. The uterus is now dropped back into the abdomen, which, if deemed necessary, may be irrigated with warm, boiled water. The abdominal incision is closed and the toilet made as in an ordinary ovariotomy. As a rule, no drainage tube is needed. A hypodermic injection of the fluid extract of ergot is then made and the patient placed in bed. Page 26
Turning from clinical medicine to that branch which has to deal with problems of the general health of the people at large, the same intimate connection between bacteriology and many of these problems is then found. The general principles governing the development of the bacteria must be well understood by public health officers in order that they may properly discharge their duties, and persons competent to carry on an effective manipulation of these microorganisms must be at command for the proper investigation of subjects constantly demanding it. The volumes of the reports of the Massachusetts State board of health bear constant witness to this, as do those of other States and countries that have appreciated the importance of the developing facts of scientific investigation. The instances in which work of importance has been carried out in this direction are almost innumerable. That showing that the milk of tuberculous cows may contain the bacilli of the disease, even if the udder be apparently unaffected (done under the auspices of the Massachusetts Society for Promoting Agriculture and supported by parallel investigations in other countries), is one instance; the great work being done upon the filtration of water and sewage, the study of the nitrifying organisms by the German, French, and Massachusetts boards of health is another; and the reports of the national bureau of animal industry furnish many more. All of these results, and many others like them, are of necessity spoken of with more or less elaboration in any instruction that may be given in surgery, medicine, hygiene, physiology, or pathology, they form a part of all such subjects, but in no one of them is there a proper place for the fundamental instruction necessary to a proper comprehension of what the bacteria are, or what their importance in connection with disease may be. This is as true in bacteriology as in regard to anatomy, without a specific knowledge of which no medical curriculum is complete. That bacteriology can not be properly included under any of the present divisions of medical instruction seems also to be almost self-evident; to include it under the head of pathology shuts out at once a consideration of that part of the subject that relates to general hygiene and the broader subjects of the fermentations; while, if it be included under the head of hygiene, the limitations of the subject are again closer than its natural scope demands. Biology, from the standpoint of the general scientist, would of course include bacteriology, but here, instead of being too narrow, the danger would be that the extent of the instruction given would be too broad. For it is always necessary to remember, in laying out a course of instruction for medical students, that the important things for them to know are, first of all, those that can be practically applied in the management of disease in human beings, and that then should follow whatever may tend to make these practical things easier of comprehension. The facts of general biology are of great importance for the sum of human knowledge, but so many of them may be ignored for medical purposes that it would seem to be inappropriate to speak of biology where bacteriology alone is what it is desired to teach. Lastly, and perhaps more important from a practical point of view, the necessity for some sort of systematic training in bacteriology is made manifest almost daily in hospital work. The idea that ready methods of staining are all that are needed to enable the house officer to make bacteriological diagnoses is a very common one, and leads constantly to disastrous failures or mistaken conclusions. Ready methods are meant only for the expert, and can only be properly applied by him; to teach them to the beginner is sure to lead to misinterpretation. Perhaps no better illustration of what is meant can be given than that of tuberculosis. Rapid methods for demonstrating this organism are in constant use, and are taught to beginners everywhere, so commonly, in fact, that no single protest is likely to be of any avail against it; and yet my own experience and that of the gentleman working with me have shown conclusively that there is no method of staining that may be constantly relied upon except the old one of Koch. Of course it is true that some of the others will demonstrate the bacilli in most cases, and when they do no more can be asked. But when the organism is not shown by these methods one is not justified in saying that it is absent. Now, this is an exceedingly important point for the patient, and yet it is one that the student is almost certain to lose unless he has been brought along by proper gradations to realize the use of what he is doing in attempting to stain the bacilli of tuberculosis. What sort of instruction, too, can that have been that will permit a senior house officer to attempt to get middle cultures in gelatine so hard and dry as to be able to turn the edge of an ordinary scalpel, or to wonder why a similar fresh medium does not remain solid and show expected peculiarities of development when planted in a breeding well? Experience shows universally that these and similar blunders are the constant results unless the student has a foundation of systematic training in the best methods of bacteriological work before being trusted with these shorter methods that should never be employed except after much training; if at all. Therefore, because the subject seems part of so many others, and because in no one of these others does there seem to be a fitting place for systematic instruction in the principles and methods of bacteriology, it has seemed best, in the minds of many experienced instructors, to set aside a special department in the medical course for the special study of this branch; and the example set a few years ago by one or two of the most progressive inedical schools of this country is being rapidly followed, until to-day there is a special department of bacteriology, or special instruction in that subject, offered by a large majority of those of the better class. So that the question seems to have been fairly well settled already that, in the minds of those most competent to judge, there is a necessity for specific instruction in bacteriology for the complete education of the modern medical man ; and this instruction is offered with more or less completeness. |
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