Society Proceedings.

BRAINARD DISTRICT MEDICAL SOCIETY.

The society met in the City Council room at the City Hall, Havana, Ill., April 27, 1899, President Hurst in the chair. Those present during the day were Drs. Barnett, Black, Coppell, Cargill, Diffenbacher, Fisher, Hurst, Hopping, Hole, Mills, Murphy, Mudd, J. W. Newcomer and Servoss.

Routine business was transacted, and the usual reports of the Secretary and Treasurer were presented. The latter reported all obligations met, and a balance of $48.92 in the treasury. On motion by Dr. Mudd, the Secretary's annual stipend was increased for the year just closing, and for the future, to $15.00. Bills for printing and postage, amounting to $3.85, were ordered paid.

The Committee on Nominations reported the following list of officers for the ensuing year: President, F. M. Coppell, of Havana; Vice-President, J. A. Barnett, of Lincoln; Secretary, Katherine Miller, of Lincoln; Treasurer, Chas. C. Reed, of Lincoln; Board of Censors, A. G. Servoss, A. L. Brittin and C. E. Black. On motion, the Secretary was ordered to cast the ballot of the society for the nominees proposed.

President Coppell then took the chair, and retiring-president Hurst gave an interesting address on "The Status of the Medical Profession." He spoke particularly of the advance in surgery shown in the statistics of the recent war, illustrating the value of "first aid," and of aseptic and antiseptic dressings. The small death-rate among the wounded who lived to reach a hospital, and the short period of absence from duty of many of those who had severe gun-shot wounds was beyond question far in advance of the record of any previous war. Illinois had especial pride in this result, as it was largely due to the efforts of our own Dr. Senn. The efficiency of the volunteer surgeons was a valuable testimony to the better equipment of the profession at large. There is no doubt that a larger part of the practitioners are earnestly working for greater personal efficiency and the whole average is thus raised.

The agitation in the leading medical societies in favor of a higher standard of qualifications is continually increasing, yet it seems to accomplish very little. Possibly this is because the legislative body is approached only by the representatives of a small part of the profession. Certainly it seems that if the local societies could agree on measures to be urged, through their membership, so much larger than that of the State society, a much greater influence could be exerted, and we might hope to see definite results of value. First, however, we must agree on some measure which will bear equably on us as well as on the other fellow."

Meantime the spirit of rivalry leads each to strive to equal or surpass his fellow in equipment, the medical journal of the better type has a wider constituency, more and better medical books are read and studied, and the body of the profession reach a higher level of qualification. The time will never come when the ill qualified and incapable will not find an entrance into our ranks, but the arrant quack may have the road made difficult for him, and the weaker, but honest member, may be helped to his best.

A board of health having a member from each county, and thus representing the profession of the whole State, could manage the interests far more efficiently, and could secure whatever might be desired, for it could influence the legislators in the most legitimate way, through the sentiment of the persons who are responsible for their election. If such a board were chosen by the profession it would be free from the domination of party politics, and could exert a great educational influence on the people of the whole State.

DR. CARGILL presented a case, asking a diagnosis and advice. The patient, a man about 30, had been sick since October, 1898. At that time he had an attack of sore throat, but did not consult a physician. A month later he called on Dr. Cargill, believing that he had a gathering in his ear. No signs of this trouble were discoverable. He continued to suffer at intervals, and after two or three months began to expectorate a foul sputum. The glands in the neighborhood of the mastoid became enlarged. The pain was referred to the ear, but lately it had been at the base of the brain. There had never been any bulging of the drumhead. He had never had ear trouble. At first there had been considerable trouble in swallowing, but the pain was rather in the neck than in the fauces. There is some swelling below and behind the ear, and the neck is quite stiff on the left side. Temperature has ranged from 99 to 102. Appetite has been fair, and no serious disturbance of the functions at any time. He has gradually lost flesh, and has been unable to work hard this spring, being disabled as much by the pain and stiffness of the neck as by weakness. The family history shows a tubercular taint. It has been impossible to locate the place whence the offensive pus flows which he expectorates. He does not cough it up, but it comes into his throat, and he hawks and spits it out.

Most of those present examined the patient, and it seemed to be the opinion of most that an abscess, possibly tubercular in origin, had formed in connection with the mastoid, and that surgery offered the only feasible means of relief.

Drs. Black, Mudd, Fisher, J. W. Newcomer, Dieffenbacher, Hurst and Murphy were appointed delegates to the meeting of the American Medical Association at Columbus, Ohio.

At noon society adjourned for dinner.

On reconvening at 1:30, the Presiden appointed as Committee on Program for the ensuing year, Drs. Irving Newcomer, Mudd and Hole; on Microscopy, Drs. Black and Brown.

The application for membership of Dr. O. P. Hopping, of Havana, was presented, endorsed by Drs. Coppell and Servoss. He is a graduate of the Missouri Medical College, class of '99. The application was referred to the Board of Censors, Dr. Fisher being appointed to fill a vacancy pro tem. After consideration, the Censors made a favorable report, and this was accepted on motion, and a unanimous election followed.

DR. COPPELL reported cases of gall-stone, showing the specimen from one case, removed post-mortem. The specimen included the gall bladder and pancreas with adjacent structures and forty-two calculi of various sizes.

The cardiac end of the duodenum was enlarged, and the tissues were thickened. The patient had refused operation. She was about 60 years old, and her mother died of cancer. For some time she had suffered severe attacks of epigastric pain, relieved by eructations of gas. No tumor was perceptible. The pain often followed eating, and caused fear of taking food. During one attack she passed a large amount of urine apparently very bloody, but chemical examination showed that the color was entirely due to bile and urates. The difficulty of accurate diagnosis, especially in fat people, was illustrated by a case. Some believe that the condition is often provoked by carcinoma. Is it possible that the thickening seen in the specimen is of a malignant nature?

DISCUSSION.

DR. BLACK.-The case illustrated the value of exploratory operation. If the patient had allowed this she might have been relieved. operation under aseptic conditions is so little serious that it should be often called for by the physician.

DR. SERVOSS.-Operation is indicated in these cases. In my opinion the best operation is by anastomosis between the gall bladder and the duodenum.

DR. NEWCOMER.-In an observed case the patient, a woman, had once passed a stone. The severe paroxysmal pains and nausea returned, but none of the distinctive signs were discoverable. One doctor thought the trouble was in the kidney. On operation a number of stones were found and removed. Recovery followed.

DR. BLACK presented a discussion of "Inguinal Hernia," illustrated by diagrams.

Much interest has been aroused by the investigations from dissections made by Dr. R. C. Turck. The whole question of the origin of hernia is still unsettled, and these careful studies throw valuable evidence on it. There is still a diversity of opinion as to the value of operations in hernia in cases which can be controlled by a truss Are we warranted in urging operation in cases where a truss renders life possible and endurable? The London Truss Society says, no, operations seldom cure, while trusses properly adjusted are often successful. With this opinion I cannot agree. Most hernias are congenital, at least in predisposition. It is thought that sometimes the testicle in its descent stretches the canal unduly. Turck thinks that this is controlled by the attachment of the internal oblique muscle.

In operating, the object must be to close the internal ring, so that the canal will be as nearly normal as possible. Lifting the cord forward and closing only the skin and fascia over (outside) of it does not accomplish this, and leaves the cord too much exposed. In view of these diagrams from Turck's dissections it seems desirable to bring down the fibers of the internal oblique and attach them to Poupart's ligament. In old hernias these fibers may have become completely atrophied, and in such a case the other operation may be the best that can be done.

Many operations suppurate and fail, especially in strangulated cases, because of the lowered vitality of the tissues. It has been demonstrated that the firmest line of union is that which has not suppurated, hence we must strive to secure primary union after putting the parts in as nearly normal position as possible. The laity feel that operations are unsatisfactory, and so decline to submit to them, unless in extremis. Thus only the least favorable cases for good results come under the surgeon's hands. Undoubtedly many cases might be absolutely cured by modern methods.

The diagrams show not only that in the female Poupart's ligament is longer than in the male, but that the attachment of the internal oblique is both actually and relatively longer, the external ring smaller, and the canal more oblique and longer. Comparisons in the male between herniated and normal cases, show that the attachment is practically always shortened in the former This feature was found to exist in cases at all ages, both congenital and acquired, and a marked difference was found where one side was normal and the other herniated, the latter having always the shorter muscular attachment. If further investigation confirms these observations we have a more definite basis for operative procedure than ever before.

DISCUSSION.

Several of those present stated that they had never seen a patient with hernia willing to submit to operation unless strangulation had occurred, and believed it would be difficult to secure such cases with which to give any method a fair trial in conditions controllable by a truss.

DR. DIEFFENBACHER.-The doctor who undertakes to treat hernia by any method should have a very thorough knowledge of the regional anatomy. The advancement of the muscle seems a judicious plan.

DR. HURST.-Have watched the results of operations for radical cure for years and have seen many cases. Park's cases were particularly promising for a year or two. Relapses occur, however; trusses must be resumed, and few cases have been finally successful. Quite a proportion of hernias cannot be satisfactorily held by a truss, and these patients will submit to an operation if they can be assured that a cure is probable. It is doubtful whether the advancement of the muscle will do this. In these cases s which need it most it will often prove difficult to secure firm union between the ligament and the muscle, and often the fibers are no longer there to be advanced. Suppuration must always be common in strangulated cases. The mistake is often made of applying the truss to the external ring, it should always be adapted to the internal ring, and with attention to this point there will be much better results in the use of trusses. The obstacles in the way of successful operation are so many that I fear the results will never be better than now. Many cases are hereditary, and the tendency is congenital. I often see cases in small infants.

DR. MILLER.-Had recently seen a case of double inguinal hernia in a girl of four years The unusual occurrence of such cases in females made the case interesting. The child's brother is also ruptured, but no history of such trouble in the older members of the family could be elicited.