Part 2

The margins of the internal oblique and transversalis muscles were sutured to Poupart's ligament by a mattress suture. The aponeurosis of the external oblique was re-established into normal position by suturing, and the skin closed by subcutaneous silver wire suture silk having been used for all other sutures.

Sterile dressings were then applied and cardboard splints to keep limb immobile. Then bandaged with crenolin. The patient left the operating room at 1 P. M. in good condition.

_Notes of Interest_—

That a hernia, apparently congenital, should not have made an earlier appearance.

The presence of a Meckel's diverticulum in the sac, this being the condition that gives rise to a true Richter's hernia.

That a hernia of so large proportion should have caused so little trouble to the patient.

Patient recovered in very short time, leaving the hospital in good condition.

THE TEACHING OF THE SPECIALTIES.

BY HIRAM WOODS, M. D.

_Read Before the University of Maryland Medical Association, April 21, 1909._

Teaching specialties to undergraduates must be carefully separated from the same teaching to post-graduate students. The latter may be supposed to have given such thought to their future career as to have reached the conclusion that they wish to devote themselves to a certain line of work. It is not these men whom I propose to discuss, save to say, in passing, that the average six weeks' or two months' course offered by post-graduate schools is totally inadequate. As a rule such courses attract a large number of men who do little more than follow the clinical work of some well-known specialist and pick up what they can. Either prolonged hospital experience, as interne or clinical assistant, or a special _individual course_, with a competent teacher, is needed for a decent foundation in special work.

It seems to me that with undergraduate work the first important step is to secure the attention of the men, and convince them that there is something in the special course worthy of notice. There is a state of mind, not unnatural to the undergraduate, regarding specialties. Most of them propose to begin professional life as general practitioners. They think they will never have use for knowledge in the so-called specialties, and that the little they will need in order to get a passing mark can be easily crammed at the close of the session. As a matter of fact, it is easy to frame questions so that this “crammed” information is of little use, and the most liberal grading hardly ever brings such men _up_ to a passing mark. The mental attitude of these men is unjust to themselves, their teacher and the patients who, in the near future, will entrust to them their physical welfare. The very term “general practitioner” implies a general knowledge of medicine. If one lives in a city, where the services of specialists are readily obtained, he may, if he desires, refuse certain cases, and take only such as he wants—say such as belong to internal medicine. But in so doing he becomes a specialist himself, and if he has neglected a properly prepared special course for undergraduates while a student he will miss information of great use to him as an internist. Many men, however, do not practice where specialists _are_ easily obtained, and, perforce, _must_ take cases which would logically come under one or other of the recognized specialties. Here is a professional responsibility which it is the aim and duty of a special teacher to enable his student to meet. May I illustrate by directing attention to two troubles which it is my own privilege to explain to our students? Iritis, in eye, and acute otitis media, in ear diseases, are very common troubles. Both are, as a rule, readily diagnosed, and both offer good prognosis. Yet the responsibility for eyesight in one, and may be life in the other, may depend on the diagnostic ability and therapeutic resources of the man who _first_ sees the case. Men are blind and children dead because a general practitioner has not known enough of what was offered him when a student to make a correct diagnosis. The red eye has been called conjunctivitis and treated with nitrate of silver, in spite of the absence of purulency, while the small, inactive pupil has escaped notice. The ear pain has been called “earache” without an aural examination, a hops bag and opium have been ordered, and the doctor has gone home with that false sense of security which is so dangerous. Why? If his teacher has known his business, it is not because he was not told how to look for iritis and acute inflammation of the drum, but because he had not given the subjects sufficient thought to get them drilled into his thinking apparatus. Probably he could tell the diagnostic points of iritis, if asked, or the signs of ear-drum inflammation; but this was “crammed” information, not part of his real knowledge.

If it is the duty of the student, anticipating general practice, to think about the specialties taught during his undergraduate course, it is still more the duty of his teacher to present him only such things as the general man needs. He will make a grievous blunder if he tries to make specialists of his men. His selection of subjects should be limited to the diseases which are of common occurrence, and stress should be laid on _diagnosis_. If one knows, first, what to look for, and secondly how to recognize signs and symptoms, he will generally find proper treatment. Troubles which would lead the patient to go to the specialist _primarily_, without consulting his family physician, should receive little attention.

Two other classes of lesions in such organs as are usually handed over to specialists should receive attention in the undergraduate course—those which are apt to cause remote or reflex disturbances, and those which are definitely symptomatic of central lesions. The first should, in my judgment, be dwelt upon only to such an extent as to enable the student to know causative relation and method of diagnosis. Treatment, unless very simple and easily within the reach of the medical man—i. e., the general practitioner—should be given little time. As to the second class, every neurologist knows that Tabes Dorsalis would often be diagnosed early, and proper treatment instituted, if the physician had known the meaning of association of gastric crises with Argyll-Robertson pupil, and had seen enough of these things to have them in his every-day thoughts. One could present many other illustrations, but this shows what is meant. With the student convinced of the necessity of thinking about the specialty taught, the instructor careful in selection of his subjects, a duty rests on those who fix the curriculum.

It is unfair to students to use four years for work which can be done in three. I believe that the object of the establishment of a four-year course was to furnish a year in which students, freed from the responsibility of examinations, might have time for guidance in clinical observation. The ideal plan, in my judgment, is to get rid of didactic lectures and examinations by the end of the third year, and to devote the fourth to clinical observation. Genito-urinary work, gynaecology, rhinology, neurology, ophthalmology, otology, cannot be learned from text-books or lectures, at least in such a way as to become integral parts of a man's daily thinking. And to my mind this is the only special information which will help the general practitioner in his daily work. A few hours spent in a large clinic brings more instruction than a whole year of lectures. The personal contact of man to man, the exchange of thoughts and impressions, are what sink in. A student is not to be blamed if he fails to attend these opportunities when he knows that in a few weeks he must face the ordeal of examinations on the didactic work, and that the result of these will determine his graduation. To put into a few words my idea of teaching specialties—it is the duty of the student to realize that nothing is put into the undergraduate course which is not important to _him_; it is the duty of the teacher to select only what _is_ important to the general practitioner; it is the duty of the school authorities to so arrange the curriculum as to give students enough time to observe special practice personally, in small sections, so that what is taught may be so impressed by observation as to become a real factor in their medical thought.

A CASE OF SPORADIC CRETINISM.

BY E. SANBORN SMITH, M. D.

_Class of 1900, Macon, Mo._

Karl B. is the son of sturdy parents, both of whom were born and reared in the Swiss Tyrol. He had never developed like the other children—was, in fact, much smaller at five and a half years than the fourteen-months-old baby. He was dull, placid, taking no note of his surroundings, sitting or lying just where he was left, and never evinced any disposition to play or converse with the other children. I saw this child on the 4th day of January, 1908, in a purely accidental manner. The parents had been told by their attendant that the child had either rickets or was an idiot, and they in consequence had kept the child in the background for two or three years, being very much chagrined and mortified at the prospect of bearing through life the burden of hopeless idiocy. The child had such classical symptoms of cretinism that I asked permission of the family to treat him for awhile, though it required some persuasion, because of the fact that they felt it was time and money wasted. On the 5th day of January, 1908, the child was five years and a half old, twenty-eight inches in height, circumference of chest twenty-one, abdomen twenty-three. He was given one and one-half grains of thyroid extract twice daily, the dose being gradually increased until he showed signs of irritability, with accelerated pulse. The child's extremities soon warmed up, the circulation became better, the hair began to grow, the child for the first time in its life walked and talked, began to take note of surroundings and to play with the other children.

Just one year after the beginning of the treatment—January 5, 1909—the child was thirty-five and three-quarter inches in height, chest twenty-three, abdomen twenty-three.

This disease, sometimes known as cretinoid or myxoedematous idiocy, was first described by Fagg in 1871. Since then a number of cases have been published, both in England, on the Continent and in America, showing that the disease is not confined to any one country. While the disease is comparatively rare, cretins are more common than was formerly supposed. The disease seems to be in reality a pachydermatous cachexia, and it is now, I believe, well established that it is caused by congenital absence of the thyroid gland or to the presence of something which abolishes its functions. Little is known as to the causes of its destruction or abolishment of function. As a rule only one case occurs in a family, the other members presenting nothing abnormal in their mental or physical development, hence the term sporadic. It has been more frequently reported in the Tyrol, in Switzerland, a coincidence which makes this child's case all the more interesting, in that both its parents are physically and mentally well up to par and the other children possess even more than the average intelligence.

_Symptoms_—The symptoms are practically identical with those of the myxoedema which follows the removal of the thyroid gland in adults. The symptoms of cretinism in most cases in infants make their appearance during the first year, occasionally, however, not until the child is three or four years of age. The appearance of the cretin is very striking, and so characteristic that when once seen the disease can hardly fail to be recognized. The child is much dwarfed, the fingers and toes are short and stumpy, the cutaneous tissues seem to be thick and boggy, but do not pit on pressure, as in ordinary oedema. The facies is extremely characteristic. The head seems large for the body, the fontanel is open until the eighth or tenth year, the forehead is low and the base of the nose broad, so that the eyes seem unusually wide apart. The lips are thick, the mouth half open and the tongue protrudes slightly, the cheeks are baggy and the hair is coarse, short and straight, and the skin has the peculiar leathery feel of elephant skin. The abdomen is pendulous, large, streaked with prominent veins, and reminds one of rickets. The skin is dry, the voice husky and rough. There is but one word which describes the peculiar clumsy manner of walking—that word is waddle. The child actually waddles like a duck. The temperature is always subnormal, and one of the things the mother will always call to your attention is the fact that the child has such cold hands and feet and requires so much more cover than the other children. Cretins are dull, placid and good natured, never quarrelsome.

_Treatment_—There is no tendency toward spontaneous improvement. These cases have until the last few years been considered hopeless and condemned to a life of idiocy. Really, in the treatment of cretinism in the adult marvelous results have been got from the administration of the dried and dessicated extract of the thyroid gland of the sheep. This has led to its use in the myxoedema of infancy. The results are astounding. The child grows mentally and physically, takes note of surroundings to which it formerly paid no attention whatever, and can be taught almost as well as a perfectly normal child. In all cases the thyroid extract must be kept up indefinitely, the dose being gradually increased, otherwise the improvement ceases at once.

ITEMS.

At the commencement of the University Hospital School for Nurses, held May 5th, the following nurses received their diplomas. The address to the graduates was delivered by Dr. A. M. Shipley:

Miss Elizabeth Getzendanner was the president of the class, and Miss Lucy B. Squires was the secretary.

Those who received diplomas were:

Miss Catherine Mabel Dukes, Maryland.

Miss Anna May Green, North Carolina.

Miss Laura Schley Chapline, West Virginia.

Miss Louise Dorsey Pue, Maryland.

Miss Grace Schoolfield Tull, Maryland.

Miss Annie Lou Wahm, South Carolina.

Miss Eva Sidney Chapline, West Virginia.

Miss Beulah Ophelia Hall, Georgia.

Miss Elizabeth Getzendanner, Maryland.

Miss Emily Lavinia Ely, Maryland.

Miss Lucy Bright Squires, North Carolina.

Miss Gertrude Hedwig Tews, Germany.

Miss Helen Mary Robey, Maryland.

Miss Blanche Almond, Virginia.

Miss Lillie Booker Carter, Virginia.

Miss Mary Barton Saulsbury, Maryland.

Miss Vera Wright, Maryland.

* * * * *

The alumni of the University will be pained to learn of the recent illness of Prof. S. C. Chew. THE BULLETIN is glad to report that he is now convalescing. No member of the Faculty is more esteemed and beloved than is Professor Chew.

* * * * *

Dr. Leonard O. Sloane, of Juneau, Alaska, who has been visiting Baltimore for several weeks, has left the city. He came to this city to avail himself of the opportunities for clinical instruction offered by this University, and was much pleased with the work he was able to see at the University Hospital, the Woman's Hospital, the Hebrew Hospital and at Bay View. He is physician to St. Ann's Hospital, at Juneau, and is a progressive and able member of our profession.

* * * * *

In the recent examinations held for commissions in the medical corps of the United States Army, Dr. J. S. Fox, one of the surgeons at the St. Francis Xavier Hospital, was a successful contestant, and the War Department has notified him that he will be commissioned a first lieutenant and will be ordered to proceed to a post in the West. One hundred doctors took the examination for the appointments, but only thirteen were successful. Dr. Fox, who will be one of the youngest surgeons in the Army, was high up in the list of the fortunate ones.

Dr. Fox is a son of the late Dr. T. S. Fox, of Batesburg, who was a distinguished surgeon in the Confederate Army. He is a nephew of Mr. J. T. Fox, of that town. Dr. Fox is twenty-nine years of age, and was born in Batesburg, S. C. After completing the high school at that place he entered Richmond College, Richmond, Va., and was there for three years, when he entered the Medical College at Baltimore. Fourteen months ago he came to Charleston to accept an appointment as one of the house surgeons of the St. Francis Xavier Infirmary, and during his stay in this city has made a fine record for himself, and now has many friends here.

As soon as his commission arrives he will leave here for Fort Sam Houston, Texas, the station designated in the orders of the War Department. There are at present several troops of the Third Cavalry and a battalion of light artillery from the Third Field Artillery Regiment stationed at this important post, which is considered to be one of the most agreeable army posts in the South. On October 1, Dr. Fox will be ordered to report to Washington, where he will be detailed to attend the Army Medical College for a period of eight months.

* * * * *

The Council on Pharmacy and Chemistry and the Board of Trustees of the American Medical Association have adopted a vote of thanks to Daniel Base, Ph. D., professor of analytical chemistry, Department of Medicine, University of Maryland, for his co-operation and assistance in investigating products and for special research work done at the request of the Council.

It has been definitely decided that the new operating room which is to be built at St. Joseph's Hospital is to be dedicated to the memory of Dr. Isaac Ridgeway Trimble, who died of septicemia after performing an operation upon an infected kidney at the hospital, as a result of which the patient lived. A tablet bearing Dr. Trimble's name and the incidents surrounding his martyr-like death will be placed in the operating room.

* * * * *

Dr. John R. Winslow read a paper on “A Case of Tuberculosis of the Fauces and Lingual Tonsils, Caused by Tuberculin Injections,” before the Section on Laryngology and Rhinology, Friday, March 26, 1909. At the same meeting Dr. J. N. Reik read a paper on “The Present Status of the Surgical Treatment of Purulent Disease of the Nasal and of the Aural Cellular Spaces: a Comparison.”

* * * * *

Dr. and Mrs. A. Duvall Atkinson, who have been spending a few days in Washington, have returned to their home, 924 North Charles street.

* * * * *

Under the title of leading men of Maryland, “The Star” has this to say concerning Dr. Louis McLane Tiffany:

Dr. Louis McLane Tiffany is not only one of the best-known men in Maryland, but enjoys a reputation that is international as an operating surgeon. He has performed successfully many unusual and difficult operations, and has contributed much to his profession by original research. He was born in Baltimore, October 10, 1844, and is related to the well-known McLane family of Maryland and Delaware. He received his bachelor of arts degree from Cambridge University, England, in 1866, and upon his return to Baltimore entered the University of Maryland as a medical student, his degree as doctor of medicine being conferred upon him in 1868. He soon attained prominence in his chosen work. For many years he has been professor of the principles and practice of surgery at the University of Maryland. He has been operating surgeon of many of the Baltimore hospitals, has performed operations on prominent persons all over the country, and is the author of a number of treatises on particular phases of surgery. Dr. Tiffany helped to found the Maryland Clinical Society, is a member of the Medical and Chirurgical Faculty of Maryland and an active or honorary member of many other societies.

* * * * *

Recently there was unveiled at St. Timothy's Church, at Catonsville, Md., a beautiful memorial window designed and executed in Favrile glass to the memory of Dr. Charles G. W. Macgill, who was president of the First National Bank of Catonsville and a physician widely known in that part of Baltimore county. This memorial, the subject of which is St. Luke, is in three panels, the figure of the evangelist being in the center opening, while a splendid landscape is carried out in the two side panels. On a scroll carried by St. Luke is the text: “For to one is given by the Spirit the gifts of healing.” 1 Cor., xii: 8-9. At the base of the window is the dedicatory inscription: “In Loving Memory of Charles G. W. Macgill. Born May 10th, 1833. Died April 28th, 1907.”

* * * * *

At the coming meeting of the American Medical Association Dr. Henry D. Fry, of Washington, will read a paper on “An Ovarian Abscess Containing a Lunbricoid Worm Within the Cavity;” H. D. Hynson, Phar. D., “The National Formulary: Its Genesis, Character and Exigent Utility.”

* * * * *

Dr. W. L. Hart, class of 1906, first lieutenant, United States Army, has been ordered to accompany Company G, Engineers, to San Francisco, Cal., and then to return to Washington Barracks, D. C.

* * * * *

The following physicians have consented to act as admitting physicians, Maryland State Sanatorium: Dr. Gordon Wilson, Baltimore; Dr. Charles H. Conley, Adamstown; Dr. Guy Steele, Cambridge; Dr. Paul Jones, Snow Hill; Dr. Henry Fitzhugh, Westminster. Drs. Guy Steele and C. H. Conley are members of the Board of Managers.

Dr. A. M. Shipley, class of 1902, has been elected consulting surgeon to the Sydenham Infectious Hospital, and Dr. H. O. Reik, of 506 Cathedral street, consulting otologists.

* * * * *

Dr. H. E. Palmer, of Tallahassee, has been elected president of the Florida State Medical Association for the ensuing year.

* * * * *

The marriage of Miss Elizabeth P. Elliott, daughter of Mrs. Warren G. Elliott, to Dr. Gordon Wilson, associate professor of medicine in the University of Maryland, will take place on Saturday, June 5, 1909. The ceremony will be performed at 6 o'clock at Old St. Paul's Protestant Episcopal Church, Charles and Saratoga streets, by the rector, Rev. Arthur B. Kinsolving. Owing to mourning in the bride's family, the marriage will be a quiet affair.

* * * * *

Another wedding of interest to take place in June is that of Miss Lila Holmes Trenholm, daughter of Mr. Glover Holmes Trenholm, a graduate of the Training School for Nurses of the University Hospital, and granddaughter of the late Prof. Julian Chisholm, to Dr. Walton A. Hopkins, class of 1903, of Annapolis, Md.

* * * * *

At the annual meeting of the Cecil County Medical Society, held in Elkton, Md., April 29, 1909, Dr. C. P. Carrico, of Cherry Hill, was elected president for the ensuing year.

* * * * *

Dr. George H. Steuart, class of 1898, is located at Ottoman, Va.

* * * * *

Prof. Samuel C. Chew, the nestor of the Medical Faculty of the University of Maryland, is confined to the University Hospital with a bad attack of grip. Dr. Chew is one of the oldest and most beloved of the medical fraternity of Baltimore. He has been connected with the University of Maryland for more than fifty years, graduating with the class of 1858. All of us wish Dr. Chew a rapid restoration to his former good health.