Miscellany.

Relations of Medical Examining Boards to the State, to the Schools and to Each Other.

Dr. William Warren Potter of Buffalo, president of the National Confederation of State Medical Examining and Licensing Boards, chose this title as the subject of his annual address at the sixth conference of this body, held at Atlanta, May 4, 1896.

He said there were three conditions in medical educational reform on which all progressive physicians could agree, namely, first, there must be a better standard of preliminaries for entrance to the study of medicine; second, that four years is little time enough for medical collegiate training, and third, that separate examination by a state board of examiners, none of whom is a teacher in a medical college, is a prerequisite for license to practice medicine. It is understood that such examination can be accorded only to a candidate presenting a diploma from a legally registered school.

He further stated that a high school course ought to represent a minimum of academic acquirements, and that an entrance examination should be provided by the state for those not presenting a high school diploma or its equivalent.

He did not favor a national examining board, as has been proposed, but instead thought all the states should be encouraged to establish a common minimum level of requirements, below which a physician should not be permitted to practice; then a state license would possess equal value in all the states.

In regard to reciprocity of licensure, Dr. Potter thought it pertinent for those states having equal standards in all respects to agree to this exchange of interstate courtesy by official indorsement of licenses, but that other questions were of greater moment just now than reciprocity. Until all standards were equalized and the lowest carried up to the level of the highest, reciprocity would be manifestly unfair.

He urged that the states employ in their medical public offices none but licensed physicians. This, he affirmed, would tend to stimulate a pride in the state license, and strengthen the hands of the boards.

He denied that there was antagonism between the schools and the boards, as had been asserted. He said that both were working on parallel lines to accomplish the same purpose, that there could not possibly be any conflict between them and that they were not enemies, but friends.

The medical journals of standing, from one end of the country to the other, he affirmed, were rendering great aid to the cause of reform

in medical education, and the times were propitious.

He concluded by urging united effort by the friends of medical education, saying that "the reproach cast upon us through a refusal to recognize our diplomas in Europe cannot be overcome until we rise in our might and wage a relentless war against ignorance, that shall not cease until an American state license is recognized as a passport to good professional standing in every civilized country in the world."

Vivisection.

From the minutes of the American Academy of Medicine for May 4, 1896.

(Advance sheet from the Bulletin of the Academy.) The following resolutions, presented by Dr. Gould, and recommended by the council, were discussed and adopted unanimously:

Resolved, That the American Academy of Medicine desires to express its opinion that no legislation is required or desirable in the United States in regard to the so-called practice or subject of "Vivisection," and for the following reasons:

1. Because only by careful discrimination and collection of facts can public and legislative opinion be truthfully formed. To illustrate but a single of many popular errors upon this subject: the dissection or use of dead animals by scientific men is termed "vivisection," when the same proceeding carried out by the butcher, the hunter, the restaurant keeper, cooks, etc., does not enter into the consideration, neither do the cruelties in the use and keeping of domestic animals, nor those in the deaths of animals for other purposes than those of experimental medicine.

2. While admitting and deploring the facts of abuses in the past and in some European countries to a very limited extent also in America--it is the conscientious belief of the members of the academy that at present with us such abuses do not exist, nor are they in danger of occurring, to a degree justifying or calling for legislation, as, under the circumstances, the evils that would inevitably result from such legislation would greatly exceed the benefits to be obtained by it. The charge implied or openly made that physicians, either in theory or in practice, are more cruel than other classes of the community, is a fancy or prejudice of ignorance which cannot be proved, and which we strenuously deny.

3. Legislation upon the subject of cruelty to animals should be so framed as to include consideration of cruelties infinitely greater and more extensive in many other fields of human activity at present not actively objected to by those who urge legislation as regards ex

President.....

.F. J. LUTZ, St. Louis, Mo. First Vice-President. W. R. HAMILTON, Pittsburgh, Pa. Second Vice President.... J. H. LETCHER, Henderson, Ky. Third Vice-President. .....JOHN L. EDDY, Olean, N. Y. Fourth Vice-President....J. A. HUTCHINSON, Montreal, Canada Fifth Vice-President... ..A. C. WEDGE, Albert Lea, Minn. Sixth Vice-President.. RHETT GOODE, Mobile, Ala. Seventh Vice-President...E. W. LEE, Omaha, Neb. Secretary.. .C. D. WESCOTT, Chicago, Ill. Treasurer.. ...E. R. LEWIS, Kansas City, Mo. Executive Committee:-A. I. BOUFFLEUR, Chicago, Ill., Chair

man:

J. N. JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa.

BY W. S. CALDWELL, M. D., FREEPORT, ILL.

That greatest of American teachers, Prof. Gaylord Thomas, was in the habit of exhibiting before his class a confused looking female, whose case illustrated the subject of his day's lecture, and though none of us ever examined this woman, her presence before us helped, in a marked degree, to impress upon our minds the subject matter that fell from the lips of this great master. So I hope to-day that the interest in the paper that I am about to read to you will be fortified in a way and its monotony and want of merit obscured, in part at least, by the increased interest that you will take in the subject, from the fact that you have before you, in my own person, a patient who was for years the victim of the disease upon which I propose to discourse.

The history of my case dates from a period that is coeval with my earliest recollection; and as the operation for its relief was performed when I was in my 64th year, I believe that I am warranted in the assertion that I carried this calculus longer than any other authentic case on record, where the diagnosis was confirmed by the removal of the stone from the kidney. Up to my 18th year the paroxysms of pain came on at irregular intervals, varying from a week to two or three months.

Between these attacks I was well and strong and prided myself upon the fact that I could ride the wildest horse and could outrun anyone of my age. The pains came on suddenly and were most excruciating in character.

To relieve these paroxysms, my father, who belonged to the most orthodox of the old school in medicine, although he had no definite idea of the true nature of my trouble, gave me

*Read at the ninth annual convention of the National Association of Railway Surgeons, at St. Louis, May 1, 1896.

calomel and bled me on general principles. Between the ages of 17 and 21 I was tolerably free from suffering, though I always had a sensation of weight and soreness in the lower portion of the lumbar region on the left side. About this time I quit school and chopped wood for a month. The violent movements of the muscles of the back and the friction upon the kidney itself, that this unaccustomed labor involved, rekindled my old trouble with a tenfold intensity, and I was compelled to take to my bed, where I lay for six months, free from pain only when under the influence of large doses of opium. During this time I had one severe attack of hæmaturia.

The best medical counsel that I could procure diagnosed my case as one of simple neuralgia, and one of them believed that quinine in sufficiently large doses would cure me, and of this drug I took one ounce in eight days, the only effect of which was to render me nearly deaf for a month after I discontinued its use. At the end of this period I left my bed and by the aid of one or two doses of opium every day was able to pursue my studies in medicine and teach school in the intervals to defray my expenses. At Ann Arbor, Professors Gunn and Ford thought my case to be one of a deep abscess produced by some lesion of the vertebral column and tortured me by making a deep exploratory incision. For a period of many years after I began the practice of medicine I suffered moderately every day with severe exacerbations that could not be relieved by opiates, and I had to resort to the inhalation of chloroform, of which I would often use as much as from 4 to 6 ounces in a few hours.

In the spring of 1866 I went abroad for the purpose of rest and study and to get counsel of the best men in Europe in relation to my case. In London every man I consulted said my suffering had no relation to my kidneys. The great Dr. Syme of Edinburg said I had an aneurism of the left iliac artery and was likely to die suddenly at any moment. One of the objects I had in view in taking a trip abroad was to quit the use of morphine, which I thought I could do, when I could quit work and take things quietly. The effort was a failure, but years later, after having taken opium for five years and morphine for 15 years, I gradually discontinued the use of the latter while doing 16 hours hard work every day. As

a pointer in the management of cases of the morphine habit, let me suggest giving your patients coffee and milk every hour and keeping them busily at work.

In the early seventies I spent two winters in New York City and consulted such men as the elder Flint, Alonzo Clark, Hamilton, Willard Parker and Van Buren, all of whom said I had no kidney lesion and no renal calculus. The thermo-cautery at that time was a new fad and Dr. Sieguin burned my back three times a week for months together. At the time I consulted these eminent men in New York I had a firm conviction in my own mind that I was suffering from a renal calculus, but when no pus could be found in my urine, coupled with the fact that I was doing a large practice, mostly on horseback, which exercise did not seem to aggravate my symptoms, I was told flatly that such a condition of things as I suspected was not possible. What these men overlooked in my case was the fact that the stone I was carrying was encysted in the substance of the kidney, and, being fixed, the concussions of the body incident to horseback riding did not affect me.

In the spring of 1877 I went to Vienna, to pursue my studies and, among other private courses, took one given on the diseases of the genito-urinary organs in the male, by the late Prof. Ultzman. About this time I had my second attack of hæmaturia. I called Ultzman and he diagnosed my case as one of renal calculus, the first opinion of the kind I had ever gotten, though I had up to this time consulted the best men on two continents. Though one of the best authorities living at that time on bladder and renal troubles, he did not even suggest an operation for the removal of the stone that he was quite sure was the source of all my suffering. In fact, the surgery of the kidney was at that time in its infancy. I went on for the next decade and a half, with little change in my symptoms until, in the spring of 1895, I jumped from a moving train at night, was thrown to the ground with great force and was terribly shaken up. From this time on the pain I suffered was increasel in a tenfold degree. I had no ease day or night and had again to resort to morphine, from which I had abstained for nearly twenty years.

I went to the northern lake resorts, hoping that rest and quiet might afford me some

relief, but I only grew worse.

I therefore determined to submit to an operation, which was performed on the 19th day of September last by Drs. Danforth, Murphy and Steele of Chicago and Dr. Stealy of Freeport, who removed the stone I now show you.

On the fourth day after the operation I was taken with a violent chill, followed by a high fever that came near carrying me off. Suppuration around the stitches that were employed to partly close the incision in the external wound was the cause of the infection from which I suffered, an illustration of the difficulty if not impossibility of disinfecting the cutaneous surface.

There is probably no field in surgery that has been so enriched and widened in its scope during the last two decades as that of the surgery of the kidney. It is true that even Hippocrates and his pupils speak of, and advise nephrotomy, but they limited the operation to cases of nephritic abscess that pointed upon the back and were ready to open themselves. Through these openings sometimes calculi passed. The earliest recorded case of nephro-lithotomy was performed by an Italian surgeon in the early part of the seventeenth century upon a Mr. Hobson, a British consul at Venice. It was done by the extra-peritoneal lumbar incision, and though the patient exhibited himself to the London surgeons, who did not doubt the skill and success of the operation, none of them were brave enough to repeat it. A Mr. Paul, a surgeon living upon the Strand, is said to have removed a stone as large as a pigeon's egg, from a woman's kidney, in 1733, but whether or not this stone had nearly reached the surface by a process of ulceration, we are not able to determine.

How new the subject of nephrotomy, as practiced to-day, really is, is shown by a paper read by Mr. Thomas Smith before the Royal Medical and Surgical Society of London on the 27th of April, 1869, the subject of which was, "Nephrotomy as a Means of Treating Renal Calculus." Mr. Smith's paper was from beginning to end simply interrogative in character, not urging or recommending the operation at all, and he closed by advising anyone who proposed to do the operation, to first operate on a dead subject who had died of renal calculus. Mr. Holmes, Callender and Spencer Wells all took part in the discussion of

this paper and all were as reserved and guarded in their views as to the advisability of the operation as was the author of the paper himself. In the second English edition of Holmes' work on surgery, issued in 1871, a work at that time the peer of any treatise on this subject in any language, nephro-lithotomy is not even mentioned for the relief of renal calculus. He treats of chronic suppurative pyelitis, and says it may be caused by a calculus, but only advises a resort to the knife when an abscess has formed, and points in the direction of the loin. In the edition of Gross' Surgery for 1872, speaking of nephritic calculus, he says: "When the stone is large and productive of incessant pain nephrotomy has been recommended, but such a procedure could only be thought of when the concretion was of immense bulk or when it had worked its way partially through the loin by ulceration." In 1870 Mr. Bryant did an operation for renal calculus at Guy's Hospital, but found no stone and his patient died of the operation. About this time the history of a case is related in which a surgeon poulticed his patient's loin until one day, when changing the dressing, he found the stone upon the poultice, showing the extreme timidity of surgeons at that date in their dealings with the kidney. Mr. Henry Morris of London claims that he, in 1881, did the first nephro-lithotomy for the removal of a stone from a kidney not the seat of an abscess.

In a given case of supposed renal calculus. what are the diagnostic symptoms upon which we can rely? Unfortunately, there are none. Absence of all symptoms does not prove that a patient has not a stone in his kidney. I have in my possession over twenty small calculi that were removed from the kidney of a patient in the dead house in Vienna who died of acute pneumonia and who had, during his life, no symptoms of a renal character. Pain and hæmaturia, so much relied upon, are misleading for they may both originate from a variety of causes, not connected with any kidney lesion whatever. In my own case, the situation of the pain was misleading, for it was severest at the upper part of the sacro-iliac junction, and never radiated down the course of the cord into the testicles; as to hæmaturia, I had only two attacks in half a century.

Dr. Henry Morris gives the history of 28 cases where the symptoms pointed to the exis