child. There is a close analogy existing between tuberculosis and syphilis in this manifestation. Frequently it is difficult to differentiate as to whether a given lesion is tuberculous or syphilitic. Especially is this so in joints and bones. We have certain rules to follow in making the diagnosis, but too often the rules will not work. Reasoning, therefore, by analogy, it seems rational that better law can be applied to tuberculosis as well as to syphilis. How often do we see double infection in the negro, yea, triple infection-gonorrhea, tuberculosis and syphilis, all existing at the same time. They are the tripod upon which his animal fabric rests. In the majority of scrofula cases seen in my clinical work a history of syphilis, as well as tuberculosis, can be gotten. In fact, some of the German schools are teaching that scrofula is often as much a syphilitic disease as tuberculosis.

Much literature pertaining to tuberculosis in the negro has been circulated. The question is always asked, why is he such a prey to the disease? Various reasons have been assigned which we need not mention, but in your reviewer's opinion the question can be fairly well answered in a few words. Very often at the time tuberculosis manifests itself he is already below par, his vital forces are handicaped by syphilis to such. an extent that tuberculosis has the right of way. Consequently he succumbs. I believe the day is close at hand when tuberculosis will be checked in its appalling course.

Immunity and infection could well be discussed. The relationship existing between the two is one of the most interesting subjects in medicine. What immunity is, and how produced, constitutes a theme too broad to mention here. I refer you to a most classical review upon the subject by Ludwig Hektoen, of Chicago, in Hare's Progressive Medicine.

Appendicitis.

Finally, gentlemen, appendicitis can now be discussed among physicians and surgeons without acrimony. Both physician and surgeon are becoming more conservative in their views. It is both a medical and a surgical disease. After reviewing all the literature obtainable we believe the concensus of opinion among surgeons is to operate in the interval of attacks.

Czerny thus expresses the sentiment of a large number: "The patient with the first attack of appendicitis belongs to the physician; with his second attack, to the surgeon, all things equal in the interval." Roberts and Deaver, of Philadelphia, take opposite views. Roberts is conservative; Deaver still claims appendicitis for the surgeon. Brewster and Richardson have given the largest statistical reports. Their deductions are, that the time to operate is in the interval of attacks. In practical application and in conservative thought the American physician leads the world.

AMERICAN GYNECOLOGY.*

BY BYRON ROBINSON, M.D.

CHICAGO, ILL.

American gynecology had its birth ninety years ago, when Dr. Ephraim McDowell performed the first ovariotomy in 1809. He had practiced medicine in Danville, Ky., for fourteen years. He was the pupil in 1793 and '94 of John Bell, who taught him the pathology of ovarian tumors and suggested their possible removal. He also studied with the Lizars in Edinburgh. An ovarian tumor of twenty-two pounds was removed from Mrs. Crawford, aged 47, who rode on horseback sixty miles to Danville. The operation was completed without an anesthetic in twenty-five minutes. He tied the pedicle with silk, allowing the ligature to hang out of the distal angle of the wound, and closed the incision with interrupted sutures. On visiting the patient on the fifth day he found her making up her bed. She returned home on the twenty-fifth day and lived to the age of 79. This was the first great event in gynecology. Dr. McDowell published a defective report of the case seven years later, in 1816. He performed thirteen ovariotomies, of which five resulted fatally. He died at the age of 59, perhaps from appendicitis. He was not a graduate of medicine, but had an honorary degree conferred on him by the University of Maryland in 1825, sixteen years after the greatest triumph in surgery the world had ever

A toast delivered at the recent annual meeting of the Southwestern Iowa Medical Association.

witnessed. Dr. McDowell incurred chiefly discredit and abuse from the medical profession. None now disputes his right to be called the pioneer gynecologist.

The second successful ovariotomy was performed by Dr. Nathan Smith, professor of surgery in Yale College, July 15, 1821.

The third successful ovariotomy was performed by Dr. Alban G. Smith, in 1823, at Danville, Ky.

The fourth successful ovariotomy was performed by Dr. David L. Rogers, of New York, in 1829. The operation lasted two hours, and the patient was about in two weeks.

The fifth successful ovariotomy was performed by Dr. S. Billinger, in 1835.

From 1835 to 1843 no ovariotomy was reported-dark days for women with abdominal tumors.

In 1843 Drs. Dunlap and the Atlees began their career as ovariotomists, after which ovariotomy was a frequent occur

rence.

In 1830 Hodge gave the profession the Hodge pessary, and stated that the conditions of the uterus characterized by enlargement, dislocation, congestion, hypersecretion and tenderness is not inflammation, nor should it be treated as such. The uterus should be supported to allow the congestion to disappear. This is one of the most important contributions to American gynecology.

In 1845 Dr. Marion Sims invented the Sims speculum, which he made out of a pewter spoon by bending it into shape. He then went home, told the slave Anarcha to get on the table in the knee and chest position, when, by the use of the speculum, the perineum was drawn toward the rectum, the air rushed in with a puffing sound and distended the vagina, and Sims said he saw what man never saw before. Sims' bent pewter spoon was the real instrument which began American gynecology, and enabled Sims to see the vesico-vaginal fistula of Anarcha, on whom he operated thirty times to cure during four years. At first the physicians of Montgomery were enthusiastic in assisting Sims to operate on the fistula of the half-dozen slaves kept by Sims for experimentation, but soon or late every doctor tired out, and Sims was obliged to train the patients to

assist him in the operations. Think of the persistence and expense of thirty experiments on one person for one kind of operation, lasting from 1845 to 1849! At the last operation on Anarcha, the slave girl, Sims used silver wire and cured the vesico-vaginal fistula-one of the most important discoveries of the age. All this made Sims the father of gynecology.

In 1853 the Atlees reported enucleation of uterine myoma. In 1841 Dr. G. S. Bedford established the first gynecologic clinic in New York.

In 1855 a great event in gynecology was the establishing of the Woman's Hospital of New York, when systematic methods in treating diseases of women was adopted.

In 1855 Dr. Thomas Addis Emmet became associated with Dr. Sims. Dr. Emmet's service to American gynecology is second to none but that of Sims. Emmet's operations are based on rational principles and founded on anatomical knowl edge. He withdrew from general practice in 1859 to pursue gynecology alone, presenting to the profession the cervical operation, enucleation of uterine myomata and vesico-vaginal fistulæ and perineorrhaphy. He has done a meritorious service to American gynecology.

In 1870 Dr. T. Gaillard Thomas removed an ovarian cyst per vaginam. Dr. Thomas has served American gynecology well.

In 1870 Dr. E. Noeggerath did excellent service to American gynecology by demonstrating the widespread existence and incurability of latent gonorrhea.

In 1876 John S. Parry enriched gynecology by his labors, especially on extrauterine pregnancy.

In 1871 a great event in gynecology occurred when Dr. Reeves Jackson founded the Women's Hospital of Chicago, where he and Dr. W. H. Byford pursued systematic labors in gynecology.

Three great events occurred in 1872-Hegar, of Freiburg, Lawson Tait, of Birmingham, and Batty, of Rome, Ga., receiving credit for them. Hegar litigated the ovarian artery for myoma. Tait removed suppurating oviducts, and Batty removed ovaries to anticipate the menopause. Tait's operation alone of the three will survive.

Dr. Mary Harris Thompson, who was one of the pioneers in gynecologic surgery in the West, was a contemporary of the elder Byford. Mr. Tait said of Wm. H. Byford that he wrote like a philosopher.

The introduction of vaginal hysterectomy in American gynecology by Lane and Fenger and its persistent cultivation by a colleague, Henrotin, is perhaps the most substantial advancement in modern gynecology. Baer, of Philadelphia, introduced abdominal hysterectomy by covering the stump with peritoneum as a valuable addition. The more recent cultivation of medical gynecology by the vaginal tampon and the vaginal douche is aiding to restore health by less resort to the knife. Many other celebrated names have enriched American gynecology, as Jenks, Kelly, Mundé, Edebohls, H. T. Byford, Dudley, Mann, Coe, Wathen, Reed, Johnston and Hodra.

Many attempts have been made to sacrifice gynecology, as a speciality, to general surgery and to internal medicine, but gynecologic surgery, as a special branch, has come to stay, and all attempts to absorb gynecology into general surgery and general medicine must fail.

Too many great minds have made the study of gynecology the object of their lives, and the field for further original work and experimental research is too comprehensive to be grasped by those engaged in the already wide domain of general medicine and surgery. Furthermore gynecology, to be properly taught and practiced, should be considered as a whole. There are no sharp lines of division between medical and surgical gynecology. It is folly to undertake to divide them. Like the division of Poland; Poland divided is Poland still. The exclusive practice of either branch could not fail to make me biased in practice and dogmatic in teaching. It is only by keeping the judgment trained and the conscience clear by a broad view of both the medical and the surgical side that the true gynecological surgeon may apply the knife when necessary and at the same time save from the knife many a one who might fall a victim to a warped judgment. The progress in gynecology, as in all other branches of the profession, has been made by the specialist.

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