States enacted any statutory laws for the regulation of practice. The people had only a quarter of a century before proclaimed the republic, and naturally revolted against anything with the semblance of restriction. Both laymen and physicians lay dormant until 1832, when New Orleans lost eight thousand of her fifty-five thousand population from cholera. This made the necessity for some method and organization.

In 1848, the American Medical Association was formed, which at first endeavored to take care of everything which pertained to the practice of medicine in the United States.

In 1865, we find a State Board of Health in Louisiana, to be followed, in 1870, by one in California and Massachusetts. In 1872, a National Board of Health was formed, under the auspices of Congress. While our science was gradually growing on the people through its branch of sanitation, the people were gradually increasing in number, prosperity, wealth and liberty. This growth, of course, broadened their mental horizon and culture, but the full necessity for recognition, organization and legislation was not felt until 1877, when yellow fever spread its ravages over the entire seaboard.

In New Orleans alone, more than fifteen thousand people were infected. This gave an impetus to medical thought and medical education; our profession was regarded as a distinct body, demanding recognition and legislation. The profession at once began to form themselves into State, county and municipal societies, and by a liberal policy proposed to further the science of medicine, and protect the health of the people, and by liberal grants from the people, to protect themselves.

Medical education since then has taken on new life and growth. The four medical schools which existed at the beginning of the nineteenth century have gradually extended their influence until we now find in almost every city in our land a medical institution, equipped with the best corps of teachers, and the most scientific methods.

This progress has been especially great in the Central, Western and Southern States, which only a few years ago were isolated from home medical education.

Until recently, it was customary for all medical geniuses, discovered in these States, to go eastward to seek great opportunities, but to-day their physicians, their medical laws, their organizations, their societies, their teachers, their schools, their medical pupils, are the peers of any country.

This great spreading and growth of medical education in the United States has been due, first and foremost, to the high esteem with which the physician is held by the people; to the great progress in public education, thereby stimulating the physician to greater effort and greater demand, and at the same time furnishing him with opportunities for better preliminary education; to organization and judicial legislation, thereby making a unit of the profession, by which joint effort may be made in promoting their welfare, and for public protection; to specialization, by which the several different branches of medicine have reached a state of perfection, which could hardly have been otherwise attained; to the postgraduate schools those institutions which, though of recent origin, have spread their influence over the entire United States; and which have eliminated the necessity for two generations of waiting and experience in order to make a doctor; which have placed competent surgeons in every city, town and hamlet; to the greater number of medical schools, and to higher standards of medical education, thus increasing facilities, and stimulating effort; to the untiring efforts of State and county and municipal societies in their endeavors to perfect organization for the protection of public health; to the loyalty and devotion of the medical press by means of which medical thought has been exchanged, investigation and research stimulated, and the relations of physicians and society made stronger.

In reviewing the science of medicine as a whole, we find that it has grown into a magnificent structure, whose base was formed centuries ago by the founders, whose superstruction has been builded by the artisans of the past century, whose adornment must be made by the artists of the twentieth century. The field for adornment is unlimited, and as it in

creases the structure will grow in beauty and magnificence.

It may be asked when will these structures have been completed? The answer comes-never. So long as Nature holds in her bosom untold secrets, so long as scientific researches continue to be made, so long as the spirit of sympathy throbs in the human breast, so long must this structure be adorned.

It may also be asked when will progress in our medical education be completed. The answer comes, not until the structure of scientific medicine can be no longer adorned; not until our schools instead of conferring the M. D. may confer the LL. D., and the physician is no longer doctor of the laws of the science of medicine, but doctor of the laws of all science; not until Death has ceased his ravages, and man is made immortal.

Enclosed find one dollar for the BRIEF for 1905. I admire your independent journal. It looks a little like personal liberty.-W. S. HART, M. D., Bowling Green, Fla.

[Written for the MEDICAL BRIEF.] Report of Two Abdominal Cases.

BY A. VANDER VEER, M. D., Professor of Surgery in the Albany Medical College; Surgeon-in-Charge of the Albany Hospital, Etc., Etc. Albany, N. Y.

Case 1.-Multilocular Cyst.-Mrs. A. B., married, housewife, aged forty-six. Family history excellent, except paternal grandfather died of cancer. Usual diseases of childhood. No history of traumatism. Bowels usually constipated. Menstruated at fourteen. She did not notice anything unusual until last January. Then observed some soreness through her abdomen, which became enlarged. More or less pain on the right side, and was troubled greatly with intestinal indigestion. She suffered with occasional chills. Enlargement of the abdomen continued; of late she has had some stomach disturbance, being unable to take her food with any comfort. Physical examination showed some fluctuation of left side, feeling of some irregularity with distinct

fluctuation lower down toward the right side. Pelvic examination showed the neck of the uterus normal. Diagnosis: multilocular ovarian cyst. Immediate operation advised, because of the great distress and pressure against the diaphragm. Operation, July 23d. Median incision. On opening peritoneal cavity, a large cyst had ruptured, filling the abdominal cavity with a gelatinous-like mass of fluid, extending up behind the spleen under the diaphragm and liver. Other smaller cysts were found, and finally the tumor and cyst contents were thoroughly removed. No washing. Pelvis dried as well as possible with soft gauze sponges, and tumor found to arise from the left ovary. This together with the tube removed. Also right ovary and tube removed, as the right tube gave the appearance of a hy drosalpinx. Peritoneal toilet prepared with as much care as possible, and peritoneum closed with chromicized cat-gut No. 1, layer sutures and skin closed with chromicized cat-gut. The usual dressings applied.

This case is an unusual one, and rarely met with; the gelatinous fluid undoubtedly aseptic. In the treatment of the cavity of the peritoneum I found it far more satisfactory not to wash out, but to remove as much as possible with the hand, then dry the peritoneum, and not drain.

Case 2.-Fibroid Tumor.-Mrs. B., aged forty-five, married, housewife. She had had usual diseases of childhood. Menstruated at fourteen. Suffered for several years from constipation. Has not menstruated since last March. Regular up to that time. A year ago last April, noticed some irritation of the bladder, with frequent desire to urinate. The movements of the bowel were flattened, and at times it was very difficult to secure a good passage. About this time she observed some enlargement of the abdomen. Suffered a good deal from headache. Complains of some difficulty in getting up and down stairs. Some swelling of the feet, and thinks she has heart trouble. Physical examination showed the heart to be in normal condition. The tumor is made out filling the pelvis, extending very low down, pressing the cervix far into the vagina, and posteriorly the mass can be felt per rectum, and extends up beyond

the reach of the finger on both sides; the pelvis seems to be blocked; there is pressure against the neck of the bladder. This condition accounted for her difficulty in getting a movement of the bowels, and irritation of the bladder. Diagnosis of fibroid tumor, possibly a dermoid cyst. Patient has had no severe hemorrhage at any time since she noticed the enlargement. Operation: median incision. Patient placed in Trendelenburg position, and with considerable difficulty the tumor was loosened from its attachment in the pelvis, adhesions were very strong, but tumor finally lifted up into the abdominal cavity. The tumor was the size of a child's head. After loosening all the adhesions, a superficial hysterectomy was done. All vessels carefully ligated, but a continuous oozing deep down in the pelvis was noted. Hot gauze sponges had good effect in controlling it, and it was not found necessary to leave in any gauze tampons. A long glass drainage tube, reaching well down into the bottom of the pelvis gave continuous drainage. Incision closed, with layer sutures of chromicized cat-gut, except at the lower point two interrupted silk sutures were placed around the glass drainage tube to hold it firmly in position. Hemorrhage was found to be somewhat profuse before she was placed in bed. The head of the bed was raised, and directions given to pack the tube every half hour. Operation complete at two P. M.; at 2.30 the drainage was found to be quite profuse; at four the patient showed some evidence of exhaustion, and her pulse became somewhat weaker. fusion was done, one thousand two hundred cubic centimeters.

In

Rectal enemas of whisky and normal salt solution; hypodermatic injection, onehalf grain strychnine every three hours. After this the patient rallied very satisfactorily, and at eight P. M. was in excellent condition, with good pulse, drainage very much less, perfectly conscious, expressing herself as feeling very comfortable.

The use of the drainage tube in these cases undoubtedly is of great value. The oozing usually ceases in from twelve to twenty-four hours, and the tube is removed, just leaving a strip of iodoform gauze in the tract to relieve any serous

accumulation. Though not at all unusual, this case exhibited most delightfully the benefit of the Trendelenburg position. One was able to see all of the cavity of the pelvis, and note that there were no bleeding vessels; it was the oozing from the many adhesions which caused the hemorrhage. The use of the drainage tube is of great help in relieving the possibility of internal hemorrhage in these cases.

28 Eagle Street.

Enclosed find one dollar money order, for which please send me the MEDICAL BRIEF another year. I like the journal very much, and wish you continued success.L. HAWKINS, M. D., Winchester, Okla. T.

[Written for the MEDICAL BRIEF.] Are the Teeth of Diagnostic Value in Systemic Disease?

BY WILLIAM J. LEDERER, D. D. S., Instructor of Oral Surgery in the New York School of Clinical Medicine. New York City.

It is a well-known fact that lesions of peripheral organs can often be linked with systemic disease, and in the course of the progress of medicine many symptoms that were formerly treated as local disease, have been recognized as being produced by systemic conditions. In this progress of the recognition of disease, its symptomatology, etiology and treatment, a factor has been overlooked, or rather its various conditions and relations to systemic disease have not been allotted the prominence in symptomatology it actually deserves.

This factor is the condition of the teeth, and the relationship these organs may bear to systemic disease.

Dentistry, as an individual calling, has within the last twenty-five years made greater strides than perhaps any other branch of the art of healing, and from the mere mechanical replacing of lost organs for the sake of cosmetic effect, it has developed into dental and oral surgery, with a symptomatology and materia medica of its own.

From year to year less teeth are sacrificed, oral conditions are better recognized, and more successfully treated from

the oral specialist's point of view, but the actual coherence of certain dental, oral and systemic conditions has not been as fully recognized as is necessary to obtain perfect results from both the medical and dental point of view.

That the teeth are affected by systemic conditions is true, for any pathological condition that will alter the metabolism of the body is bound to bring about changes here as well as anywhere else, as the teeth are part and parcel of the human economy, and receives their blood, lymph and nerve supply from the same sources as any other part of the body. Were it not so, how can we account for the variations in the dental organs of different temperaments, as one finds variations in cranial contour, general framework, muscular development or quality of the voice. Thus the long, fine, bluish tooth is found in subjects with a prominent, not broad, but expansive chest; and the rather broad, unshapely, opaque and muddy-colored teeth in subjects with a large chest, though lacking in expansive power, showing that all factors exercising influences upon the system at large will also reflect upon the teeth.

Hutchinson long ago recognized the peculiar appearance of the teeth in inherited syphilis; and the atrophic changes affecting the teeth after diseases like typhoid, rickets, and sometimes scarlatina and measles, are also well enough known. Odontalgia in a sound tooth, as the result of some distal irritation, so often met with in pregnant women, hardly needs any mention. Still all these dental affections were at some time considered local lesions, and only in course of time was their true etiology recognized. Thus there are conditions which the dentist meets to-day, and often hopelessly tries to combat with local treatment, which undoubtedly will some day be recognized as associated with and caused by some systemic trouble. Thus pyorrhea alveolaris, Rigg's disease, is frequently met with, and very poor results obtained; in fact, at times only temporary relief is enjoyed by the patient. If this be a truly local disease, it certainly ought to yield to faithful local treatment. If all local factors are eliminated, and the disease does not abate, it is therefore a local

manifestation of a systemic disease. I have frequently found it associated with diabetes mellitus, arthritis uritica, and there is no doubt but that these diseases of metabolism reflect upon the teeth in some way.

Another condition met with, such as spontaneous loosening of the teeth in subjects where senility is out of the question, what causes this? Local conditions excluded, it is no doubt caused by atrophic affection of the nervous system; some disturbance, such as one would be apt to find in tabes dorsalis, and, therefore, the question arises, is not this symptom of diagnostic value? It must be, for every effect must have a cause.

The writer is at present engaged in research bordering on these subjects, and will later publish the results obtained. There are other conditions met with in the mouth apparently of local origin, which now trace their cause to systemic derangements, and though not understood to-day, will undoubtedly, when more is known about their etiology, be recognized as buccal manifestations of systemic disease. The recognition of this will prove of benefit to all, the patient, the physician and dentist, and will serve to ameliorate pain and shorten the period of disease. 150 East Seventy-Fourth Street.

[Written for the MEDICAL BRIEF.] Two Cases of Empyema of GallBladder, With Some General Remarks on Gall-Stones.

BY HOWARD HILL, M. D.,

Professor of Surgical Anatomy, University Medical College; Fellow Kansas City Academy of Medicine; Member Jackson County Medical Society, Member Mississippi Valley Medical Association, Member American Medical Association. Kansas City, Mo.

Case 1.-Mrs. V. C., aged sixty-five. Seen with Dr. J. H. Laning, at St. Joseph's Hospital, January 24, 1903.

The history of this case was that on January 20th she was taken suddenly ill with pains all over the abdomen, accompanied by vomiting. At the end of twenty-four hours the pain had localized in the right iliac fossa, where the Doctor noticed a lump which seemed to him to be almost in the abdominal wall. The

patient's temperature at this time was 101° F. Her condition remained about the same for the next forty-eight hours. The tongue became exceedingly dry and brown, the pulse intermitting every three or four beats, and the patient presenting the appearance of profound illness. I saw her at five o'clock in the afternoon. Examination showed a mass in the right iliac fossa, the most prominent part of which was at McBurney's point. It shaded off in all directions from this point. It was immovable, and the abdominal wall was rigid over it. It did not quite extend to the median line, nor did it extend up to the ribs. Palpation gave a deep-seated sense of resistance, showing that there was fluid well walled off.

I concluded from the history and physical signs that we had to deal with a large periappendicular abscess, in all probability adherent to the abdominal wall. There was heard, over the whole precordial area a loud diastolic murmur. Operation was very clearly indicated, but the patient's general condition made it a somewhat hazardous undertaking.

It was pointed out to her and to her friends that on account of the cardiac lesion she might not survive the administration of the anesthetic. She and her friends decided to take the risk, however. Dr. Abram Miller was called, and gave the patient morph., one-fourth grain, ten minutes before he administered the anesthetic, which was chloroform. put her under the anesthetic with great care, and I must say that he is deserving of the highest praise for the skill he exhibited in this case, for at no time during the operation were we annoyed by rigidity of the abdominal wall, due to insufficient anesthesia..

He

Operation.-A three and one-half inch incision was made through the right border of the rectus muscle, down to the peritoneum. On retracting the abdominal wall, it was seen that a mass was adherent to the peritoneum in the outer portion. To the inner side, however, the parietal peritoneum rose and fell with inspiration, showing that it was not everywhere adherent. In order to determine the nature of the mass more accurately, I made an incision through the parietal

peritoneum, internal to the mass, that I might palpate it from within.

I found a mass attached to the parietal peritoneum of an area of, probably, an inch in diameter. I thought it best to separate this, and after doing so, the peritoneum was opened the full length of the incision. After separating some omental adhesions, I found the mass was a livid, distended gall-bladder of almost a plum color. There were numerous adhesions of omentum to the gall-bladder. These being separated up to the neck of the gall-bladder, it was found that the duodenum was also adherent to the side of the gall-bladder. After separating these adhesions, the gall-bladder was walled off with gauze packs, and as we had no trochar to tap the gall-bladder, the patient was turned on her side, and the gall-bladder opened with a cut of the scissors, when an enormous quantity of pus and bile-stained mucus was discharged-probably a half pint.

After removing eleven large, black, smooth, facetted stones, one was found impacted in the neck of the gall-bladder, which was dislodged and removed after considerable difficulty.

Palpation of the common, hepatic and cystic ducts showed them to be free from concretions. The opening being rather low for a cholecystostomy, a puncture of the abdominal wall was made at the point where the fundus came easily up to the parietal peritoneum, and the gall-bladder brought out at this point and fastened.

On account of the friability of the gallbladder, it was impracticable to use a purse-string suture in fastening the drainage tube in the gall-bladder, so the gallbladder was attached to the transversalis fascia by a few interrupted sutures, and the drainage tube surrounded by gauze was inserted into the bladder, and for fear there might be leakage into the peritoneal cavity, gauze drainage was introduced through the lower wound which was now sutured, up to the gauze drain.

The patient was put to bed in fairly good condition, after having received one and one-half pints of hot saline solution under the mammary gland. There was profuse drainage from the gall-bladder during the next forty-eight hours, but the pulse and general condition, especially the