The final suturing was done on two planes, the deep peritoneal and the superficial, including the skin and muscular coat. At 11:45 the operation was completed. The condition of Rosalina was encouraging; that of Maria was much less hopeful.

Little by little they were awakened, and, upon opening her eyes, Maria, who awoke first, said, "Where is Rosalina." And Rosalina, upon awakening, asked the same in regard to her sister. When they saw each other and realized that they were separated and still alive Maria, looking toward Dr. Chapot, exclaimed, "Oh, doctor, how good you are!"-he had received his fee.

The children both vomited three times after the operation, and were given ice-water several times. Both during and after the operation they were given injections of artificial serum. They urinated without difficulty. After 5 o'clock they slept tranquilly with but slight interruption. At 8 o'clock Rosalina wanted to say her prayers, and put on a new dress the doctor's daughter had given her. The following is the schedule of temperature, pulse, and respiration for the first twelve hours:

On the second day both slept well, though Maria, whose temperature ran up to 38° C. at 4 a. m., was somewhat disturbed. Her pulse at this time was 160, respiration 56; but at daylight these all had gone, down somewhat.. At 2:30 p. m. her temperature again ran up to 38.5°. She was then given injection of artificial serum and inhalations of oxygen, after which she became better, and at 9 p. m. was quietly sleeping. Rosalina remained in good condition all day, and several times asked to sit up.

Third day: During the night they both slept well, and during the day the general condition of both improved, and they closed the day in good condition, the temperature of neither going above 38.2° At midnight Maria was given inhalations of oxygen.

Fourth day: Until 2 p. m. both girls were doing finely, when Maria's temperature ran up to 39°, with pulse 172. She became quite weak and could not take nourishment. After taking inhalations of oxygen and a small dose of digitalin she became better. Her bowels were washed out and she passed a large worm. At 9 p. m., temperature, 37.9°; respiration, 36; pulse, 150. At midnight both were sleeping, though Maria was somewhat restless.

Fifth day The unfavorable symptoms of Maria of the day before did not return, and although very weak she was in every way better,

taking with relish some broth at different times. The intestinal washings were continued with marked benefit. Oxygen was also administered throughout the day. The temperature did not get above 38.6°, and fell to 37.9°. Pulse, highest 150, lowest 137; respiration, highest 40, lowest 30.

Rosalina was in fine condition; she ate a little chicken and was anxious to sit up.

Sixth day: In the early part of the day Maria's condition was so flattering that the surgeon announced her to be out of danger. However, at 2:30 p. m., she began to vomit, and although this was checked, she became so prostrated that she could not rally under the supportive treatment given her, and at 1:30 a. m. of the following day she died.

At 3:30 p. m. the autopsy was held, at the request of Dr. Chapot, by the police physicians. He asked them to testify as to the following points, in addition to the regular facts of cause of death, etc.: (1) Had there been hemorrhage of the liver? (2) Had there been infection? (3) Was death due to lack of skill, imprudence or neglect.

The examination, made in the presence of a large number of physicians, revealed a state of inflammation of the pleura and pericardium with more or less exudate from each, but no inflammation of the peritoneum, while the liver was completely healed and cicatrized, as were all the external wounds. All present agreed that everything possible had been done that could have been done, but, of course, there were some who could find something to criticise, either in the method of operating or in the after treatment. The experts have not yet made formal report.

Rosalina continues to improve without any drawback so far.

THE NAME OF GOD IN FORTY-EIGHT LANGUAGES.

Hebrew, Elohin or Eloah; Chaldaic, Elah; Assyrian, Ellah; Syriac and Turkish, Alah; Malay, Alla; Arabic, Allah; Language of the Magi, Orsi; Old Egyptian, Tuet; Armorian, Teuti; Modern Egyptian, Tenn; Greek, Theos; Cretan, Thias; Aeolian and Doric, Llos; Latin, Deus: Low Latin, Diex; Celtic and old Gallic, Diu; French, Dieu; Spanish, Dios; Portuguese, Deos; Old German, Dist: Provencal, Diou; Low Breton, Douc; Italian, Dio; Irish, Die; Olalla tongue, Deu; German, Gott; Flemish, Goed; Dutch, Godh; English and old Saxon, God; Teutonic, Gote; Danish and Swedish, Gut; Norwegian, Gud; Slavic, Buch; Polish, Bog; Polaca, Bung; Lapp, Jubinal; Finnish, Jumala; Runic, As; Pannoman, Istu; Zemblian, Fetizo; Hindostanee, Rain; Coromandel, Brama; Tartar, Magatel; Persian, Sire; Chinese, Prussa: Japanese, Goezur; Madagascar, Zannar; Peruvian, Puchocamae.-Med. Talk.

Vol. II.

Original Articles.

THE MATTER OF SPECIALTIES IN MEDICINE.

By Franklin Staples, M.D., Winona, Minn.

The subject of specialties and specialists in medicine appears to have commanded considerable attention among the profession of late. Medical societies and medical journals have taken part in considering and presenting to the profession important facts concerning the present, at least, of specialties in medical practice; the influence of which has seemed to be for the most part in the right direction. It is believed that legitimate specialties, in their cultivation and practice, have had and are having important parts in promoting the higher progress in various departments of science and art pertaining to medicine. In making an estimate of the value of such means and aids, care is required at times to exclude certain acquired abnormalities and unnatural belongings, that, without much reason, have claimed relationship.

In this brief mention, no reference is intended to what belongs to the various sects or socalled schools, that have claimed recognition and the right of way in medical practice. The intention is rather to notice certain natural divisions, that have come to exist as legitimate parts of practical medicine and surgery; this for the general advantage.

There is a history of specialties in the art of medicine, much of which has been written. The early Greek historian, Herodotus, says of the physicians and practice of ancient Egypt, where medicine is thought to have begun: "The art of medicine is divided amongst them; each physician applies himself to one disease only: some are for the eyes, others for the head, others for the teeth, others for parts of the belly, and others for internal diseases." By this it would appear that even the separate department of internal medicine is not altogether a new one.

Concerning specialties in the medicine of the ancient Greeks, the distinguished German historian, John Hermann Baas, says: "Most physicians occupied themselves with general prac

No. 11.

tice; as the science of medicine itself was still quite simple, and midwifery was not as yet separated from surgery; a separation not made until after the Middle Ages. A few only were specialists, chiefly the lithotomists, whose occupation, as is manifest from the terms of the Hippocratic oath, was generally regarded as a disreputable one: yet oculists and dentists seem to have been specialists." The substance of this account would seem to indicate that the time had not then come for the division of general medicine into departments to any considerable extent. The period of Universal Rome followed the Grecian; then the period of Arabian medicine in the Middle Ages; with decline rather than advance in all departments of science. The events of medical history in the later mediaeval and the early modern periods are notable. Surgery was divorced from medicine, and assigned to the hands of ignorant laymen. The guild of barbers took formal possession of the surgical art, and held it largely in abeyance until its revival, principally in the sixteenth century. It was then that such men as Fallopius, Vesalius, and Eustachius of Italy, Paré of France, and others of these times, laid the foundations and began the structure of modern surgery.

The German author above quoted gives his view of specialties in medicine early in the nineteenth century. After noticing in favorable terms the works of the French teachers of this time, Andral, Louis, Magendie, Trousseau and others, states the case in this wise: "A result of the French tendency to pathological anatomy, to be regarded in many respects, and especially in a practical point of view, as an unfortunate outgrowth, was the cultivation of specialties." After noticing the fact of this tendency and what he considered its results, he observes that it subsequently spread to other countries, but particularly to Germany; so that at last," he says, "there is scarcely any organ of the body which found, not its special scientific students (which is perfectly proper), but likewise its special representatives in practice." "In the latter point of view," he continues, "the question is frequently mostly one of new sign-boards, though the practice leads to one-sidedness." He says further, "Through the specialism introduced from France, the position of German physicians has

been gradually undermined, and the public conception of the profession has been partially degraded to that of a trade in the art of healing." There is some difficulty in determining the value of this comment. It is the view of a learned German writer of what he regards as an unfortunate importation from France into Germany. It speaks of an unworthy commercialism in medicine, and makes it the outcome of specialism. May it not have been, in part at least, a post hoc, rather than altogether a propter hoc? From the representation, it is certainly fair to conclude, that it found in the new soil what was favorable to its growth. We may come to a later period and nearer home to find something that might be thus credited, and this with equal reason. The question has been raised as to the matter of compensation to be received by the general practitioner from the specialist for passing the patient to the latter. For such as this there can be but one worthy conclusion, viz.: that the practice of such commercialism is without exception unworthy; this alike in case of both parties. Fortunately, so far as the custom may exist, it does not necessarily or generally belong to the practice of a specialty-is a pathological condition, may be hereditary, not likely infectious, and affecting, it is hoped, the small minority only.

A few words may be said concerning what has been recently said and recorded on the subject. The American Academy of Medicine, at its meeting in June of this year, took favorable action upon a report, the substance of which is summarized as follows: "First, specialism is not only desirable, but is unavoidable. Second, It is proper for a physician to seek to perfect himself in the direction of his greatest ability. Third, A specialist, as well as a general practitioner, may have a practice directly with his patients, or indirectly through consultation." A part of a further proposition says: "Specialism, per se, does not create discord in the harmony of professional intercourse."

Professor Frederick C. Shattuck of Harvard Univeristy, in an address delivered before the Canadian Medical Association in September last, had for his subject, "Specialism in Medicine." With an account of what specialism is and what it should be, he gives in outline something of its varied history. A brief extract from the address, as it appears in the Journal of the American Medical Association, is here in place. Speaking of the principal divisions in practice. the Professor says: "A line of cleavage appeared first perhaps between medicine and surgery; and it is curious to note that nowhere has the line, at least in name, in the past been so clearly drawn as in England, where more minute specialism has met with considerable opposition." Again, speaking of the present outlook, he says: "The real line between medicine and surgery is one thing; the practical line is another. The last quarter of a century has seen them approximate notably, but they will not coincide until knowl

edge is perfect." He then mentions the fact as interesting, that a German journal has been established, devoted to the border-lands of medicine and surgery.

Concerning the present and future of gynecology as a specialty, the Professor is led to remark: "Gynecology is of almost unique interest from the point of view of a specialist in medicine, and a medical Gibbon could write an interesting book upon its Rise and Fall." In furtherance of the idea of the decadence of gynecology, Prof. Shattuck quotes from Prof. Howard Kelly of the Johns Hopkins University, as saying, "The general adoption of the principles of asepsis leaves the barrier between general surgery and gynecology a purely artificial one, and one which must inevitably, sooner or later, be broken down."

Finally, after discussing many of the pros and cons of specialties in medicine in the past and present, Prof. Shattuck states his conclusion in words as follows: "One fact stands out clearly-that specialism in medicine has come to stay. Its advantages infinitely outweigh its disadvantages, and we have faith that all things work for good in the long run. * We all sometimes feel as did the late Dr. Hagen, the great entomologist-I should like to be my own great grandson."

*

The development of specialties in medicine, as in other departments of science and art, has come in modern times with the extension of the fields of knowledge and the means of education. A single individual cannot now constitute the whole or a greater part of a college faculty. The work in the vast field of modern natural science must be divided, that it may be accomplished, and the better results obtained. The specialist and his work should not and may not replace the person or the work of the general practitioner. The former may aid the latter both in educational and practical ways. Reciprocities are not impracticable. The family physician in the large community of the city, as well as in the broad field without, must remain. His place is in the life of the home. Our civilization and best social life have made it so, and so it shall continue.

In this observation we are considering the sphere, works, merits of physicians. Charlatans have no place. There is no unworthy conflict in the upper strata of professional life. As we ascend, our vision broadens, the air becomes clear, and the light unobstructed.

PRIZE FOR AN ESSAY.

The Mississippi Medical Record is offering to its subscribers a Clarke & Roberts, No. 80, $100 surgical table for the best original essay on any medical or surgical subject. Contest closes April 1, 1901. For particulars write to the Mississippi Medical Record, Vicksburg, Miss.

TOXIN.

By Edwin Rosenthal, M. D., Philadelphia.

Of the many recent advances in medicine not one is as important to the pediatrist and the general practitioner as the clinical use of diphtheria antitoxin. It can be said that to the pediatrist belongs the honor of placing the serum where it justly belongs, and any improvement in its method of preparation, or in its use, should be investigated with more than passing interest, and the results should be known, thereby widening its field of application and increasing its lifesaving power.

Diphtheria is pre-eminently a disease of childhood, the greatest frequency occurring between the ages of 2 and 10 years, and the proportionate number of cases diminishing very rapidly as the age increases. Its frequency in childhood; its constant presence in the cities of our land; the very accurate knowledge of its character in regard to its etiology, prevention and cure, which have become the common property of the layman; and above all, its being the most deadly and frequent disease that is met with by the pediatrist and the active practitioner, can be considered as prominent factors for its consideration in this address.

INVESTIGATING THE SUBJECT OF DIPHTHERIA.

Beginning my work, I found that during the year, various questions had arisen which were vital to the standing of antitoxin as a remedy in diphtheria, and to users, if they be members of this Association or suscribers to the "Code of Ethics": 1. The original discoverer of the antitoxin had obtained a patent for his product. 2. That at the Pharmacopeial Convention at Washington the question of having a certain "test" embodied in the next revision of the United States Pharmacopeia had been voted down, thereby making the remedy uncertain, and instead of offering an inducement for the further improvement of its physical character, had permitted the chance of inferior products taking the same standing as the best, thereby lowering the standard of all. This question, however, is still open, hence a factor for further investigation by

myself.

quent in medical associations, no substantial results were obtained until collective investigations showed the truth or falseness of its specific value. The investigations are still too new, and their value is too well known, for me to repeat them, but they are sufficient to show me that such work was of the greatest importance, and in a measure gave me a method to further pursue my work.

OBJECT OF MY INVESTIGATION.

As there appears a certain reason that antitoxin should receive a thorough and complete investigation, and as this reason was not alone the clinical value of the remedy but also its ethical standing, I thought it proper to pursue my work in both directions, and not confine myself to the users of the serum, but to include its makers as well.

,

For the purpose of demonstrating the value of the remedy and to find out if it still retained the same virtues as at its beginning, early in January of this year I addressed the following communication to some 4,000 teachers and leaders in medicine in this and other countries:

"Dear Doctor: Will you kindly report, at the earliest possible moment, on the experience you have had in the treatment of diphtheria, with and without diphtheria antitoxin? If you can give me the number of cases of diphtheria treated by you without antitoxin, and the number of cases treated with antitoxin, with the results, it will be of especial value.

"Should you have no record of your cases, will you kindly advise what is your feeling toward the treatment of diphtheria wtih antitoxin?

"If you have any items of particular interest in your experience in the treatment of diphtheria (with or without antitoxin), I shall consider it a personal favor if you will report to me in full.

"It is my purpose to read a paper at the meeting of the American Medical Association, and I am asking the information from you since it will be of material assistance in securing data for my paper.

"Have you any preference as to what make of antitoxin to employ? Very truly yours, "Edwin Rosenthal."

Briefly, I wished to obtain information as to the following:

What is the protective or immunizing value of diphtheria antitoxin; 2, what have been the results in general (private) practice with it; 3. what influence has the antitoxin exerted on the mortality records. The unanimity of evidence obtained regarding the value of antitoxin has been most remarkable. I shall not attempt to give full data from the replies, but will briefly summarize.

VALUE OF IMMUNIZATION.

I received many reprints and direct communications upon this question alone, and the consensus of opinion can be summarized thus: An

titoxin prevents diphtheria; if given early enough and in sufficient dosage, it prevents the appearance of the disease. If the serum be given as an immunizing agent, and in doses insufficient, it will modify, that is, prevent a graver manifestation of, the malady. If immunization be practiced, and the dosage be insufficient, that is, the disease manifests itself, it permits the application of a remedial dose, thereby preventing a more serious type. The statistical evidences were both pertinent and numerous; fol. 253, New York Health Department was most characteristic.

A very practical point brought out was the dosage. This was somewhat larger than we were led to believe. Five hundred units should be the dose, except in cases that have been exposed for a number of days or where the vitality or strength is seriously impaired, and natural immunity consequently nil. In such cases, irrespective of age, from 750 to 1,000 units is a more certain prophylactic.

RESULTS IN GENERAL PRACTICE.

I was deeply impressed in receiving letters from physicians who have passed through serious epidemics of diphtheria, and know from practical personal experience the changes brought about since the advent of antitoxin. I may add that some of my correspondents have given information regarding other plans of treatment with results, and that if a complete compilation were made, the general result would be so conspicuously in the favor of the antitoxin that its simple repetition would suffice. My replies were of three kinds: One set I should class as consultants, teachers or writers on this subject; the second set were from active family doctors, and the third were from those connected with hospitals or other institutions in which diphtheria was treated. As the first and last class could not in truth answer the question as above, I gleaned from the mass, only those whom I deemed answered my purpose, to wit, the active practitioners, and present the result as follows:

Total number of physicians reporting.
Number favorable to antitoxin...
Number expressing no opinion.

Percentage of mortality, 5.23.

.673

.622

26

5

Number opposed to antitoxin.

Number of cases reported without spe

These results, as just given, are, perhaps, a repetition of what is now so universally known. This, however, teaches us that the antitoxin still retains its position, and that the results now are not different from what they were at the beginning. I might add that some of my replies were simply a sentence placed at the end of my letter of inquiry, short and to the point. An example of many is as follows: "No question for further debate; its position is settled."

THE INFLUENCE ON THE MORTALITY RECORDS.

To obtain accurate information upon this point, I called to my aid every health officer in American cities having an organized bureau of health as well as hospitals for contagious diseases and pest-houses. I also wrote to foreign countries, and to such institutions or individuals as I had learned of in my readings or otherwise. The following letter was sent to each:

"Dear Doctor: Will you kindly furnish me with the number of cases of diphtheria and the mortality of the disease from 1885 till 1899, inclusive? If you do not have the statistics for each year, kindly furnish the years for which statistics are available. Should you have no record of the cases, will you kindly advise, from your experience, what value you consider antitoxin possesses?

"If you have any items of particular interest in your experience in the treatment of diphtheria (with or without antitoxin), I shall consider it a personal favor if you will report to me in full.

"Have you any preference as to what form of antitoxin to employ?,

"My object in writing you is to secure positive and accurate information upon the treatment of diphtheria, with and without antitoxin, as it is my purpose to read a paper before the coming meeting of the American Medical Association. Your data will be of great benefit to me if you will kindly furnish them. Very truly Edwin Rosenthal."

yours,

One hundred and fifty-seven cities replied. A summary reveals the following figures: Number of cases previous to the serum

period ...

With a mortality of 38.4 per cent. Number of cases since the antitoxin

period....

. 183,256

....132,548

With a mortality of 14.6 per cent.

The latter were not all treated with serum; in computing those cases treated with the serum alone the mortality was 9.8 per cent. A characteristic reply, I append: