The Hospital Bulletin, Vol. V, No. 3, May 15, 1909
Date: 2016-09-02T00:00:00+00:00
Keywords: Medicine -- Periodicals; Medical colleges -- Alumni and alumnae -- Maryland -- Baltimore -- Periodicals

The Project Gutenberg eBook of The Hospital Bulletin, Vol. V, No. 3, May 15, 1909

This ebook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this ebook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.

Title: The Hospital Bulletin, Vol. V, No. 3, May 15, 1909

Author: Various

Release date: September 2, 2016 [eBook #52967]
Most recently updated: October 23, 2024

Language: English

Credits: Produced by Richard Tonsing, The Online Distributed
Proofreading Team at http://www.pgdp.net (This file was
produced from images generously made available by The
Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK THE HOSPITAL BULLETIN, VOL. V, NO. 3, MAY 15, 1909 ***

Transcriber's Note:

The cover image was created by the transcriber and is placed in the public domain.

THE HOSPITAL BULLETIN

Published Monthly in the Interest of the Medical Department of the University of Maryland

PRICE $1.00 PER YEAR

Contributions invited from the Alumni of the University. Business Address, Baltimore, Md.

Entered at the Baltimore Post office as Second Class Matter.

Vol. V | BALTIMORE, MD., MAY 15, 1909 | No. 3

THREE ESOPHAGEAL CASES.

By Richard H. Johnston. M. D.,
Lecturer on Laryngology in the University of
Maryland, Surgeon to the Presbyterian
Hospital, Baltimore.

The esophagoscope has passed the experimental stage in the diagnosis and treatment of esophageal lesions. Its usefulness has been demonstrated so often that it would seem superfluous to dilate upon its value. Its use, however, is not as general as it should be. There are still those who consider esophagoscopy unnecessary or impracticable. At the Presbyterian Hospital we have had numerous instances of its practicability, and with us it has become the routine practice to examine all patients complaining of obscure esophageal symptoms. Dr. Chevalier Jackson records the case of a patient whose only symptom was a lump on swallowing. She appeared to be a neurasthenic, and his advice to have the esophagus examined was ignored by the family physician. Two months later, with the patient etherized for a radical antrum operation, he passed the esophagoscope and found a malignant growth.

Three interesting cases have recently come under my observation, and they illustrate so well the value of the esophagoscope I shall report them somewhat in detail. The first patient was seen with Dr. E. B. Freeman; she was 67 years old. The morning before she came to the hospital, while eating ham, she swallowed a large piece that had not been sufficiently masticated. It lodged in the introitus esophagi and remained there. When she came to the hospital she had swallowed neither solid nor liquid food for nearly thirty-six hours. A half hour before examining the esophagus she was given a hypodermic of morphia and atropia. With the patient in the sitting position the throat and upper end of the esophagus were anesthetized with 10 per cent solution of cocaine. Jackson's laryngeal speculum was introduced and the larynx pulled forward. A large mass resembling somewhat an ulcerative epithelioma was seen, and proved to be the piece of ham. Dr. Freeman and I removed it piecemeal with Pfau's foreign body forceps. It required about forty-five minutes to remove it entirely. The patient stood the ordeal well, and was able to go home the same afternoon. For about a week she had temperature, cough and expectoration, but ultimately made a good recovery. In this case the esophagoscope probably saved the patient an esophagotomy. The second patient was a female, thirty-three years old, referred to me by Dr. J. F. Chisolm, of Savannah. While at an oyster supper she attempted to swallow a large oyster, with the result that she choked for a few seconds and then had a sense of fulness in the region of the larynx. The next day she had some difficulty in swallowing, so that she took only liquids. The second day afterward swallowing was decidedly painful; she grew rapidly worse, until the fourth day her condition was serious. She reached this city the morning of the fifth day, with a temperature of 100 degrees and extreme prostration. The examination of the esophagus was made under ether with the head in the extended position. No foreign body was found, but the upper end of the esophagus was red, swollen and edematous, and seemed to be closed. The patient was given cold milk and ice bags to the throat. For two days she suffered excruciating pain on swallowing, and it looked as if we would have to resort to rectal feeding. The next day there was slight amelioration of the pain, which gradually disappeared. In this case the esophagoscope enabled us to see at once that a foreign body was not present, and that the symptoms were due to a severe, acute inflammation, probably caused by a piece of shell attached to the oyster.

I was asked by Dr. A. M. Shipley to examine a patient who had been referred to him for probable cancer of the stomach. The man was sixty years old and had had some trouble in swallowing for about two months. Attempts to pass the stomach tube were unsuccessful. The patient was examined in the sitting position after cocaine anesthetization. No difficulty was experienced in passing the esophagoscope. About three inches below the cricoid cartilage the progress of the instrument was arrested by a tumor partially closing the esophageal lumen. The esophagoscope showed that the tumor was too low for removal. In this case the patient can be dilated through the esophagoscope and made more comfortable for the short time he has to live.

919 North Charles street.

SYPHILITIC OSTEO-PERIOSTITIS.

By C. G. Moore, '09.

Senior Medical Student.

The bony manifestations of syphilis occur as secondary and tertiary lesions, and as Keyes, of New York, has pointed out, these so-called “nodes” are simply local periosteal congestions, accompanied by serious effusions without cell hyperplesia. Any bone in the body may be affected by syphilis, but certain of them suffer by preference, such as the thin bones of the nose and pharynx—that is, those exposed to climatic changes and injuries, such as the bones of the skull, ulna, tibia, etc.

We must call special attention to injury as a powerful pre-disposing cause of bone syphilis, for, when we consider that bone lesions may be the only manifestations of existing syphilis, with the presence of a bone lesion before us, with an antecedent history of an injury, we must not forget that we may overlook the true nature of the disease, and hence must be constantly on the alert for the syphilitic taint.

Lancereaux classified the bone lesions under three heads, viz.:

(a) Inflammatory osteo-periostitis.

(b) Gummy tumor of bone.

(c) Dry caries, atrophic form.

(1) Inflammatory osteo-periostitis is the most frequent form, and is characterized by inflammatory phenomena, vascularization and exudation of a serio-glutinous material. It may be either diffuse or circumscribed, and located, as its name implies, in the area of contact with the osseous and periosteal surfaces. The pain is aching, acute, throbbing or boring in character, while tenderness upon pressure and percussion is most exquisitely excruciating. The diagnosis of inflammatory osteo-periostitis is comparatively easy, if we remember the characteristics, viz., an oval, painful, boggy or even hard bony lesion, accompanied by nocturnal exacerbations of pain, with a concomitant or antecedent history of syphilis. Ostitis with parenchymatous thickening is somewhat less positive in its character, but with nocturnal pains which are usually constant.

(2) Gummy tumor of bone develops either under the periostum, in the substance of bone, or in the medullary canal. It is simply an intensification of the process found in the inflammatory form just described, the difference being that the cell hyperplasia is more abundant. Much of the new material collects in a circumscribed space, and being more rapidly formed and less capable of organization, it entails more profound lesions by its retrograde metamorphosis. Generally tumor of the bone is, therefore, a much more serious form of disease than osteo-periostitis.

In the long bones the medullary canal is the usual seat of deposit. The bone becomes hypertrophied in a porous manner, the Haversian canals and canaliculi become enlarged and filled with a gummy material which resembles a solution of gum arabic. In the flat bones, especially the cranial bones, the cancellar tissue is attacked, and may cause a separation of the two tables, and often necrosis of one or the other plates results. If it happens to be the inner one which undergoes carious degeneration, brain symptoms will develop.

(3) Dry Caries.—According to Virchow, dry caries is always due to syphilis. This affection is a miniature gummy ostitis. Around one of the vascular canals the gummy material is deposited, this gummy material being later absorbed, leaving a stellate induration. This goes on leaving a funnel-shaped depression, its point leading into the diploe, which may be plainly appreciated by palpation. The essential features of this caries is the fact that no sequestra are formed, no pus extruded, nor is the skin but rarely involved.

The following is a case of syphilis in which osteo-periostitis developed:

On January 22nd, 1909, R. B., age 35, white, a housewife, applied to the Medical Department of the University Hospital Dispensary for treatment, complaining of rheumatism in her back and a sore shin. The patient has been married 14 years and has had four children; the two eldest are the only ones now living. Three years ago she gave birth to a full-term child which only lived a few minutes after expulsion.

One year later she gave birth to another child, which was not at full term, but about six months advanced. She says two days previous to this birth she fell down stairs and struck on her abdomen. When the child was born its thigh was fractured, and the physician who attended her said the fracture was caused by the fall.

Her father died nine years ago, at the age of 68 years, of apoplexy; her mother was killed a few years ago in an accident. She has two brothers and three sisters, all living and in good health, as far as she knows. She is at present living with her husband, and says he is apparently well and sound, but drinks heavily, and when under the influence of liquor abuses her a great deal. Patient denies ever having had tuberculosis, syphilis, diphtheria, typhoid, scarlet fever, malaria, grippe, gonorrhoea, or any of the nervous or malignant diseases. She sometimes has a sore throat when she takes cold, but it only lasts a few days. She has complained of rheumatism in her back and limbs for the past three or four years, and thinks it is worse at night.

Patient never complained of any trouble other than those mentioned until three years ago, when her third child was born. She says that at that time her hair fell out, and an eruption, which itched slightly, broke out all over her body, including her face, but only extended down her arms as far as her wrists. This lasted a few weeks, then seemed to subside, but never entirely disappeared, and when she gave birth to the still-born child, one year later, it broke out again worse than before. She went to Dr. McElfresh, who treated her for about three weeks, giving her some medicine to take internally, also some sulphur ointment. She for a time got some better, but owing to her circumstances was unable to continue treatment with Dr. McElfresh, and has done nothing for her condition until the present time. For the past four months she has been suffering with a pain in her right shin; this has been gradually getting worse, and one week ago began to swell and cause her considerable pain, being worse at night, and sometimes hurting her so much that she is unable to sleep, hence her reason for coming to the dispensary.

Upon questioning her in regard to her general health, she says she feels as well as she ever did, with the exception of the previously mentioned pain.

Her appetite and digestion are good, and her bowels are regular, and she has no lung, heart or kidney trouble. She has had no headaches, nausea, or vomiting, and her menstrual periods have always been regular and painless.

Upon examining patient I found her to be well nourished and well developed, weighing 142 pounds. Her color was good and her pupils about normal in size, reacting to light and accommodation. Both patella reflexes were absent, also Romberg's sign, and there was no enlargement of the mastoid, epitrochlear, post-cervical or inguinal glands. Her pulse was 84 to the minute, regular in rate and force. The tension and volume was good; her temperature was 98.6°. Her heart was normal in size, and on auscultation the sounds were clear and no murmurs were heard. The expansion of both lungs was good, the respirations being 20 to the minute.

Percussion and auscultation were negative; all the abdominal organs seemed to be normal. There was an ecchymotic area under her left eye, which she says was caused by her husband striking her two years ago when intoxicated.

There was a circular reddish macular papular, non-itching eruption which does not disappear on pressure, varying from the size of a bird shot to that of a nickel, and is confined to her back, chest, shoulders and arms, most profuse on the left side, and is not seen on the lower limbs at all. On her left shoulder some of these lesions have developed into pustules, which have become infected and slightly ulcerated; these give her slight pain.

In the corner of her mouth is a scar which looks like the initial sign of lues, but she claims it appeared a few weeks after the breaking out on her body. On examining her mouth no mucus patches or scars were found.

She now has an osteo-periostitis on the anterior aspect of her right tibia. It is moderately swollen, slightly reddened, and is very painful (the pain is aching, acute and boring in character) on pressure, and on tapping the bone with my finger above and below this point it caused her intense pain. (Patient claims she has never received any injury in this location.)

Upon consulting Dr. McElfresh, he remembered the case and said that he had treated her for a short time about two years ago for the initial symptoms of syphilis, but since then has never seen her.

She is now receiving the mixed treatment of protiodid of mercury, gr. ¼, with a saturated solution of potassium iodid three times a day, starting her on ten drops, then increasing it one drop each time taken. I requested her to return when the medicine is finished.

DISCUSSION BY DR. WARNER HOLT, OF WASHINGTON, OF THE PAPER ON THE CHEMICAL CO-RELATION BETWEEN THE SALIVARY GLANDS AND THE STOMACH, BY JOHN C. HEMMETER, OF BALTIMORE.

Read Before the Society for Experimental Biology and Medicine, of New York, Meeting in the Rockefeller Institute for Medical Research, on December 16, 1908.

Dr. Holt said in part: “This experimental study by Dr. Hemmeter is not, as it might appear to be, only an inquiry into the physiology of a limited part of the digestive apparatus, but it is an attempt to solve a biologic problem and to get at the broad basic principles that underlie the chemical co-relation of the organs.

“When a worker occupies himself with the effect of the extirpation of one organ of digestion upon the organs in the next segment of the digestive apparatus, he naturally thinks of phenomena of exclusion or loss of function in one or the other of the segments following the one extirpated, but instead of phenomena of exclusion it is conceivable that those of exaggerated activity in the other segments of the digestive tube might result.

“For 'a priori' we cannot know whether the influence that one segment of the digestive tract exerts upon the succeeding segment is that of stimulation or of inhibition, or of both, viz., of stimulation under one set of conditions and inhibition under another set of conditions. In the investigation of the problem of a chemical co-relation between the salivary glands and the stomach, Dr. Hemmeter has done meritorious work, a great part of which it has been my good fortune to observe and assist in personally; though I am a physician in the employment of the government at Washington, I consider myself a post-graduate student of Professor Hemmeter. I have seen personally four of his animals that had successfully been nursed through the Pawlow operation and extirpation of the salivary glands after months of the most trying work. It required a great deal of perseverance to persist in this kind of work, especially when some of the best animals that had emerged safely from the vicissitudes of the operation for an accessory stomach and from the removal of all the salivary glands on one side of the head succumbed to the third operation in the attempt to remove the remaining salivary glands on the other side.

“The history of these operative failures, though they will never be told, constitute a large part of the merit of those who have worked with Dr. Hemmeter in this research. No matter what the final outcome of the future investigation of this problem will be, whether affirmative or negative, the intrinsic value of such work will be appreciated by all who are to the least degree conversant with the history of physiology. Nowadays we are too liable to forget the hard plodders in experimental work who have started the solution of a problem, and when the last word has been said the worker of the beginning is generally forgotten.

“In this connection I desire to quote an expression of Prof. William H. Welch concerning the merit of the work of ex-Surgeon General Sternberg, done since the first Yellow Fever Commission was appointed, in 1879 (see Medical News. June 21, 1902. p. 1198). Dr. Welch said 'that Sternberg's work with yellow fever would stand forever; that it was a common thing in these busy days to forget the steps which led up to an important discovery. All that Dr. Sternberg had done in the study of yellow fever was necessary work, and it had to be done just in the way that he did it. The ground had first to be cleared. If it were not so, the discovery had not been possible; and later discoverers themselves would have had to hunt out the large host of microorganisms which Dr. Sternberg had described and laid aside.'

“And similarly I can say of Dr. Hemmeter's efforts that, no matter what the eventual outcome of this problem will be, all that he has done was necessary work, and it had to be done just in the way that he did it.

“Just one more idea and I shall have finished. It concerns the demonstration of such research work in places at a distance from the experimentor's laboratory. Such demonstrations are always attended with great difficulty. They usually require four animals, two or three janitors to transport them, and as many laboratory assistants as the director of the laboratory can manage to take with him. The technique of these operations, the high-grade sensitiveness of operated animals, the refinement with which chemical tests should be made, all require for their safe conduct that the experimentor should work only with those men who are used to his system. The animals themselves are always influenced in one way or other by the presence of strangers. I remember in one animal which was demonstrated on March 17th, at the University Hospital, the demonstration at which Dr. Satterthwaite was present, a most unexpected change in the quality of the gastric secretions took place. This was a control animal which had undergone no operation whatever. He was simply taken along to show the proteolytic power of a normal dog and compare it with the operated dogs. His gastric juice had been previously tested on several occasions, and always found to be of regular standard, but on the night of the demonstration before the Medical Society this animal's gastric juice was practically inactive, containing no HCL nor pepsin.

“Dr. Hemmeter has already informed you that in some animals the loss of gastric juice after extirpation of the salivary glands is only temporary, and that in varying time—in some cases three weeks, in other animals three to four months—there is a gradual resumption of gastric secretion. This resumed secretion, however, never becomes as effective as it was in the same dog before an operation. The question when to begin to make observations on an operated animal depends entirely upon the state of this animal; if the dog eats his food with appetite, he has no fever, and his digestion appears to be satisfactory; then the observations may be begun, even if it is only one week or ten days after the last operation. One of the most valuable animals that was used in this series of experiments was so injured in the effort to transport him to another laboratory that he could not be used for further experimentation. The dog struggled so in his holder while he was being transported in a wagon that the partition of true mucosa which separates the accessory from the plain stomach was broken through. This had happened once before in transporting a dog from the laboratory to Dr. Hemmeter's country place, and his associates in the Medical Faculty, becoming aware of the great labor and cost involved in such operations, and the rarity with which they succeed, advised that no further Pawlow dogs be sent to other laboratories.”

AN INTERESTING CASE OF SCROTAL HERNIA.

By G. E. Bennett, '09.

Senior Medical Student.

Patient—George Kolubaher.

Age—Sixty-six years.

Occupation—At present a farmer; formerly worked as laborer in stone quarry.

Complaint—Patient entered the hospital on January 21, 1909, complaining of great pain and discomfort in the right inguinal region and in the scrotum of the same side.

Physical Examination—Inspection showed an enormously enlarged scrotum, more marked on the right side, and a prominent swelling along the right inguinal canal, which was most marked when standing. Marked discoloration on the skin of the scrotum and inner side of both thighs, probably due to use of counter-irritants.

Palpation—Mass soft and freely movable, showing no skin attachments; slight impulse on coughing. Slightly painful on pressure. Some gurgling when manipulated.

Percussion—Slightly tympanitic.

Remarks—Contents of the sacs were forced into abdominal cavity after prolonged manipulation, returning to original condition as soon as pressure was taken away.

History of patient shows nothing of interest except that of the present condition, which began suddenly twenty years ago. While lifting a heavy block of stone had a feeling as though something had “given away” in his right side. This sensation was immediately followed by one of intense pain and general discomfort. The day following the patient noticed a small lump in the right inguinal region that disappeared on pressure, returning when he lifted any heavy object.

For eighteen years the condition gave him no serious discomfort except for the wearing of a truss and becoming larger. Two years ago the truss was discarded as being useless.

One week ago conditions grew suddenly worse, and patient was confined to bed. Has suffered a great deal of pain and has been unable to sleep.

On January 22, 1909, patient was operated upon by Professor Winslow. Operation as follows:

Patient was brought to the operating room at 11.30 A. M., anesthetized and prepared for an aseptic operation.

Incision about five inches in length was made parallel to Poupart's ligament and immediately over the inguinal canal, passing through the skin and subcutaneous fat. The external ring having been exposed a grooved director was passed into same, passing under the aponeurosis of the external oblique muscle; fibers of same were split, using the director as a protective guide. The sac was exposed and carefully dissected free from its surrounding tissues, and upon examination was found to be continuous with the covering of the testacle (giving the appearance of a congenital hernia). The sac was next opened and found to contain small intestines and a Meckel's diverticulum. Following this the intestines were replaced in the abdominal cavity. Digital examination through the internal ring showed the bladder to be adherent to the peritoneum at the margin and toward the median line. The sac was tied close to the internal ring, cut free. The distal portions of the sac were drawn upward, bringing the testacle into view; sac was cut close to same and sutured so as to enclose the greater part of it.

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.

Forty professional men were present May 1, 1909, at the Colonial Hotel, where the fourth annual reunion and banquet of the Pennsylvania Branch of the General Alumni Association of the University of Maryland was held. Dr. Eugene F. Cordell was one of the guests; others were Dr. Charles P. Noble, president of the Pennsylvania Branch, and Dr. J. C. Beale, secretary and treasurer, both of Philadelphia.

The banquet was held in the new assembly room, which was tastefully decorated with plants, flowers and the colors of the University. The banquet committee consisted of Drs. Z. C. Myers and S. K. Pfaltzgraff, of York; J. S. Classen and J. C. Beale, of Philadelphia.

It is reported that Dr. John Cox Keaton, class of 1907, of Georgia, has been shot in the abdomen by an irate husband.

At the annual meeting of the Cecil County Medical Society, held at Elkton, Dr. St. Clair Spruill spoke on “Surgical Conditions of the Right Side of the Abdomen.”

The New York Medical Journal says concerning the April 13th meeting of the Philadelphia Pediatric Society: “The paper of the evening was read by Dr. Compton Riely, of Baltimore, on 'The Early Diagnosis and Treatment of Pott's Disease.'”

The following of our alumni are upon the staff of the Hospital for the Women of Maryland, John street and Lafayette avenue, Baltimore: Dr. Charles H. Riley, Dr. J. Mason Hundley, Dr. Archibald C. Harrison, Dr. Robert T. Wilson, Dr. Samuel T. Earle and Dr. George W. Dobbin. Dr. G. W. Billups, class of 1906, is resident physician.

Mr. and Mrs. William T. Schultze, of 822 Newington avenue, Baltimore, have announced the engagement of their daughter, Dr. Anna D. Schultze, a graduate of the Woman's Medical College and resident physician of the Good Samaritan Hospital, to Dr. John R. Abercrombie, dean of the Woman's Medical College, a graduate of the University of Maryland of the class of 1895, and at present instructor in diseases of the skin, University of Maryland. No date has been fixed for the wedding.

At the coming meeting of the American Medical Association Dr. I. S. Stone, of Washington, will read a paper on “Some Minor Gynecologic Matters Which Are Often Overlooked.”

Dr. Charles H. Medders, of Baltimore, who sued the Western Maryland Railroad for $5,000 for services rendered in a collision four years ago, was rendered a verdict for $150.

At the annual meeting of the Montgomery County Medical Association, held in Rockville, April 20, 1909, the following of our alumni were elected to office for the ensuing year: Vice president, Dr. Wm. L. Lewis, of Kensington; secretary-treasurer, Dr. John L. Lewis, of Bethesda.

The Baltimore City Medical Society has elected our alumni to the following offices for the ensuing year: President, Dr. Jacob Hartman; board of censors, Dr. Randolph Winslow.

Dr. G. Lane Taneyhill, of Baltimore, is a member of the House of Delegates of the American Medical Association from Maryland at the present meeting of the American Medical Association, at Atlantic City.

Dr. A. E. Ewens, of Atlantic City, was a member of the Committee on Section Meetings at the recent meeting of the American Medical Association. Dr. Daniel Jenifer also had the honor and pleasure of serving upon this committee. Dr. Jenifer was also a member of the Committee on Post-office and Telephone. Dr. A. E. Ewens also served on the Committee on Badges.

Dr. Thomas A. R. Keech, class of 1856, and Mrs. Keech, of Washington, D. C., celebrated at their home, 416 B street, northeast, on April 13, 1909, the fiftieth anniversary of their marriage. The house was beautifully decorated with cut and potted plants. A collation was served. The family are of English descent, having emigrated and settled in Southern Maryland about 1750. Dr. Keech is a son of the late Rev. John Reeder and Susan P. Keech.

Dr. John Herbert Bates, class of 1907, of Forest Park, Baltimore, a former resident physician of Bay View Hospital, and until recently a resident physician at the Church Home and Infirmary, has located at 4002 Main avenue, Forest Park.

The third annual banquet of the General Alumni Association of the University of Maryland was held Thursday, April 22, 1909, at the Eutaw House, Baltimore. About 90 were present. The affair was a thoroughly enjoyable occasion, but more enthusiasm would have been evident if more of the members of the various faculties had been present. The Pharmaceutical Department, with less professors than the other departments, had most members present. The speeches were witty and instructive, and teemed with expressions of loyalty to the University. As oft iterated and reiterated, this body is the only real live alumni body at the University of Maryland. It has been doing since its inception, and is still doing, and if the University ever be rejuvenated much of the credit will be due to the constant agitation of this body for a larger and better university. Most alumni banquets consist of a feed, good, better or worse, as it might happen to be, and a slew of speech artists of more or less renown, who bubble over with big words of encouragement and prediction, but rest on their oars here. Indeed, the societies exist for a banquet once a year and a cyclone of hot air. What do words accomplish? Nothing. It is action that the University of Maryland needs, and more than anything else men of action—strong men, broad-minded men, men who can subordinate their success to the success of the institution, men in every sense of the word. I am glad to say the General Alumni Association has an abundance of men of such character among its membership who are doing something for the good of the Old University, and who have an object in view. What is this object? The creating of ways and means for the betterment of the University.

At the business meeting immediately preceding the banquet the following recommendation of the special committee appointed for the purpose of formulating a plan for the participation of the alumni in the management of the University was adopted unanimously.

The plan provides that the Board of Regents of the University shall be enlarged by the addition of five members, one each from the five departments, who shall have had their degrees for 10 years or more. It provides for the election of a committee on nominations, to consist of the president of the association and one representative from each of the five departments. This committee shall select three representatives from each of the five departments as nominees for the alumni in good standing in the association to vote upon. Votes may be cast in person or by mail. After the election of the five members of the council they shall determine by lot who are to serve for one, two, three, four or five years, respectively.

Any vacancy is to be filled by the remaining members of the Alumni Council from the department from which the member was originally chosen. The secretary of the General Alumni Association shall act as the secretary of the alumni regents, who shall select their own chairman for one-year terms.

The committee consisted of the following well-known alumni of the five departments of the University:

Medical—Dr. B. Merrill Hopkinson and Dr. E. F. Cordell.

Pharmacy—Dr. John F. Hancock and Dr. J. Emory Bond.

Dental—Dr. L. H. Farinholt and Dr. Joseph C. Heuisler.

Law—Messrs. B. Howard Haman and Jas. W. Bowers, Jr.

Academic (St. John's College)—Dr. J. Frederick Adams and Dr. A. L. Wilkinson.

No further action, however, can be taken in the matter until approved or vetoed by the Board of Regents.

The president, John B. Thomas, Phar. D., introduced the toastmaster, Henry P. Hynson, Phar. D., who was in a particularly bright and witty mood. The speakers were: Hon. J. Barry Mahool, the Mayor of Baltimore; John C. Hemmeter, M. D.; Addison Mullikin, Esq., LL. B.; Charles Caspari, Phar. D.; Joshua W. Hering, M. D., Comptroller of the State of Maryland and a graduate of the class of 1855, of Westminster, Md.

Those who were not present do not know what they missed. It was a live banquet, something doing every minute, and the committee in charge of the arrangements are to be congratulated upon the thoroughness with which they accomplished their task.

Committee—T. O. Heatwole, chairman; Oregon Milton Dennis, LL. B.; Eugene Hodson, Phar. G.; Arthur M. Shipley, M. D.

Among those present were: William Tarun, Dr. J. W. Bird, J. Huff, Dr. Compton Reilly, J. Cromwell, Dr. Randolph Winslow, Dr. R. B. Hayes, C. V. Mace, L. M. Allen, Dr. R. H. P. Bay, Dr. I. J. Spear, H. H. Richards, Dr. J. F. Hawkins, Dr. W. V. S. Levy, T. Marshall West, S. W. Moore, I. H. Davis, Dr. C. V. Matthews, F. J. Valentine, E. B. Howell, A. P. Scarborough, G. F. Dean, G. A. Bunting, John C. Uhler, C. S. Grindall, Dr. J. C. Hemmeter, Dr. A. M. Shipley, John Henry Keene, Dr. Robert L. Mitchell, Judge H. Stockbridge, N. H. D. Cox, Dr. J. H. Holland, Dr. Charles Caspari, Jr., H. P. Hynson, F. V. Rhodes, J. E. Hengst, O. C. Harris, A. S. Binswanger, Dr. St. Clair Spruill, Dr. E. F. Cordell, Dr. Nathan Winslow, Dr. J. M. Hundley, Daniel Base, Dr. Charles E. Sadtler, Addison Mullikin, H. W. Jones, Dr. G. Lane Taneyhill, Dr. L. B. Henkel, Jr., Dr. I. G. Dickson, F. J. S. Gorgas, Dr. T. O. Heatwole, J. W. Bowers, Jr., Dr. J. W. Hering, Alfred E. Kemp, Oscar B. Thomas, J. B. Thomas, Eugene W. Hodson, John F. Hancock, W. M. Fouch, D. R. Millard, Emory Bond, C. A. Volkmar, Frank Black, H. P. Hynson, J. W. Westcott, Dr. C. H. Medders, B. Elliott, Dr. Eugene Cordell, Leroy Oldham, A. R. Dohme, B. A. Lillich, Oregon Milton Dennis, L. W. Farinholt, T. E. Latimer, Ambrose Murphy, Dr. Henry Kennard, Dr. Herbert Zepp.

The “Clinic,” the year book of the College of Physicians and Surgeons, Baltimore, which has just been issued, is dedicated to the memory of the late Dr. Isaac Ridgeway Trimble, who gave his life that another's might be saved. Dr. Trimble was a graduate of the University of Maryland, class of 1884, and at the time of his death was Professor of Anatomy in the College of Physicians and Surgeons.

Dr. A. J. Edwards, class of 1898, of Bristol, Tenn., is spending a few days around the Hospital renewing old acquaintances.

Dr. Luther Bare, of Westminster, Md., was a recent visitor to the University Hospital.

The banquet of the Medical Alumni Association will be held on the evening of May 31, 1909.

Dr. and Mrs. B. Merrill Hopkinson, who have been spending the week at the Hotel Chamberlin, Old Point Comfort, Va., have returned to the city.

The University of Maryland baseball team defeated the Midshipmen on the Naval Academy grounds recently by the score of 2 to 0. Anderson, the box artist, struck out twenty of the middies. The team this year has been more than successful, and compares favorably with the teams of the larger colleges. It is undoubtedly the premier team of Baltimore this year, and in any other institution would arouse untold enthusiasm by its notable victories.

Dr. Fitz Randolph Winslow, class of 1906, of Hinton, Va., paid a flying visit to the Hospital recently.

Dr. J. W. Hering, class of 1855, of Westminster and State Comptroller, who has been visiting his son and daughter-in-law, Dr. and Mrs. Joseph T. Hering, at the St. Paul, Baltimore, has returned to his home, in Westminster.

Amongst those who responded to toasts at the recent banquet of the local branch of the Haverford College Alumni Association was Dr. Henry M. Thomas.

Dr. Fitz Randolph Winslow writes from Hinton, Va., in the Valley of the Shenandoah, the garden spot of Virginia, and for picturesque scenery unexcelled in no part of the world, that he is doing nicely. He has seen three goitres and heard of a wonderful cure for the same from an old mountain woman. She took her own medicine, and claims to have been benefited, so he gives the recipe: Put your hands behind your back, bend over and take a horse's head between your teeth. Unfortunately, he forgot to find out the statuo quo of the horse, so you might try the dead or the quick, as suits your convenience. Her goitre is still very apparent, but, sad to relate, she has no teeth left with which to finish the job. This is only one specimen of the gross ignorance and superstition of the hill people. They treat or mistreat themselves often when ill principally by making teas of various herbs, such as boneset, etc. Skunk oil is a panacea both internally and externally. He expects no respectable disease can live in the same neighborhood with such an odoriferous medicament.

Dr. John Chaplain Travers, class of 1895, of Cambridge, who recently left for the Philippines, where he will enter the government service, gave a farewell entertainment before leaving at the residence of Capt. James C. Leonard.

Dr. J. Clement Clark, superintendent of the Springfield State Hospital, presided at the third meeting of the Maryland Psychiatric Society, which was held at the Sykesville institution. Among those present were: Drs. J. C. Clarke, Marshall L. Price, Wm. F. Wohwartz, R. R. Norris, F. J. Flannery.

It gives us pleasure to announce that Dr. Charles H. Mayo, of Rochester, Minn., one of the renowned Mayo brothers, has accepted the invitation of the Faculty of Physic to deliver a course of lectures on diseases on the thyroid gland in the fall.

Dr. Lee Cohen, of Baltimore, will read a paper at the coming meeting of the American Medical Association on “Post Operative Tonsillar Bleeding: Its Surgical Control, with Mention of Cases;” Dr. R. L. Randolph, of Baltimore, on “Rodent Ulcer of the Cornea;” Dr. Samuel Theobald, of Baltimore, on “Reflex Aural Neurosis Caused by Eye Strain, with Report of Cases.”

One of the marked developments of the Democratic State Central Committee was a practically unanimous sentiment in favor of the renomination of Dr. Joshua W. Hering, class of 1855, for State Comptroller. State and county leaders were outspoken in their opinion that Dr. Hering's popularity throughout the state, as well as his excellent record as Comptroller, make his nomination virtually a matter of course.

The condition of Dr. R. A. Warren, of Hot Springs, Va., class of 1907, who was operated on recently at the University Hospital for appendicitis, is reported to be favorable.

Dr. Randolph Winslow desires to acknowledge cards from Drs. M. Zaki and M. Teufik, 166 Mohamed Aly street, Cairo, Egypt. These are two of our popular Egyptian students, and are located as noted above, where they have met with unexpected success. Drs. Heilig, Moose, Kerr and Pearlstine, four of our recent Southern alumni, paid their respects to the University recently. The three former are located in North Carolina, the latter in South Carolina.

The last regular meeting of the University of Maryland Medical Association was held in the amphitheatre of the University Hospital, Wednesday, April 21, 1909, and the program was as follows: 1. “Preliminary Training Necessary for Those Contemplating the Study of Medicine,” Dr. Randolph Winslow; 2. “The Teaching of Therapeutics,” Dr. C. W. Mitchell; “The Teaching of the Specialties,” Dr. Hiram Woods.

The meeting was well attended and the papers were both instructive and interesting. Dr. A. M. Shipley, the president, occupied the chair. This is the last meeting of the society until the fall. Dr. Woods' paper appears elsewhere in this number.

Dr. Richard H. Johnston, of Baltimore, will read a paper on “Benign Tumors of the Turbinate Bodies Clinically and Pathologically Considered,” at the coming meeting of the American Medical Association.

The Council on Medical Education of the American Medical Association in its annual report has this to say concerning college mergers:

Another encouraging fact to be noted is the mergers being made among medical schools whereby stronger schools are resulting. Notably in Indiana, all of the regular schools in the state merged into the medical department of Indiana University, while in Kentucky all of the medical schools merged into the University of Louisville. In Cincinnati the two regular schools merged into the University of Cincinnati; in Minnesota Hamline merged into the medical department of the University of Minnesota.

There are numerous other cities where mergers might be brought about if those interested in general education and those in medical education in each city would work together to secure them. For example, if all the medical colleges of any large city, such as Chicago, Philadelphia, St. Louis or others, could be merged into one great university medical school, such as are to be found in Berlin, Paris or Vienna, it would be of the greatest possible advantage to medical education in America.

In the evolution of general and medical education in this country it is becoming more and more evident that a well-rounded university needs a strong medical department, and it is now equally clear that a medical school cannot reach the highest stage of its development except as the medical department of a strong university. It is evident that within a few years the medical schools of this country will, with few exceptions, be the medical departments of universities. Fortunately for the medical school, the university needs the medical school quite as much as the medical school needs the university, so that almost any independent medical school of real merit can secure desirable union with a university. And this change will solve most of our present problems in medical education.

Since our last conference there have been five important mergers of medical colleges by which nine medical schools are replaced by four stronger ones. These mergers were as follows:

1. At Louisville, Ky., the Louisville and Hospital Medical College, the Kentucky School of Medicine and the University of Louisville Medical Department united, retaining the name of the University of Louisville Medical Department. This leaves but one regular medical college in Louisville, where there were five colleges two years ago. As a direct result of this merger, the school has received $25,000 from the city of Louisville, and steps have been taken to build a new city hospital, which is to be largely under the control of the medical school.

2. At Cincinnati the merger between the Medical College of Ohio and the Miami Medical College has been completed, the new school to be the Medical Department of the University of Cincinnati. The building of an enormous new city hospital has already been started near the university campus, and a new medical college building will be erected adjoining this hospital. The outlook for this new school is very encouraging.

3. The Keokuk Medical College, College of Physicians and Surgeons, located at Keokuk, Iowa, has turned all its property and good will over to the Drake University, College of Medicine, at Des Moines, Iowa.

Amalgamation of the Cooper Medical College with Leland Stanford University is announced. Henceforth the San Francisco institution will be designated the School of Medicine of Stanford University. The affiliation was given approval sometime ago, and it only remained for the board of trustees of the University to formally accept the gift.

Why can't the independent medical colleges of Baltimore come together? Such an event would accrue to the best interests of all concerned, and would greatly tend to eliminate Baltimore as one of the dark spots upon the medical educational horizon.

NURSES WIN DIPLOMAS.

In spotless white and amid a bower of flowers, 16 pretty young women were handed their diplomas yesterday as graduates of the University Hospital School for Nurses by the Dean, Prof. R. Dorsey Coale. There were 17 nurses to graduate this year, but one of them, Miss Catherine M. Dukes, is seriously ill and could not attend.

After the conferring of degrees Dr. Arthur M. Shipley gave the young nurses advice as to their future. The opening prayer was delivered by Rev. Edwin B. Niver, rector of Christ Protestant Episcopal Church, and benediction was pronounced by Rev. Dr. Hemsley, of Oakland, Md.

The hall of the University was crowded with friends and relatives of the graduates. It was decorated with carnations and potted palms, and around the pillars was twined black and red bunting, the University colors. The nurses, preceded by Professor Coale and Dr. Shipley, entered the hall in pairs, carrying bouquets of Marguerites.

Dr. Shipley said that much of the nurses' training had been under his supervision, and he felt a personal interest in them. Women, he said, invariably scared him, but someone informed the physician that was not always so, for Dr. Shipley is to become a benedict today.

“You have chosen a work that is second to none in the world,” said Dr. Shipley. “You have before you possibilities that are almost limitless. You are on the threshold of a life that is to be of your own making, for the chief danger of the individual nurse is drifting. It is so easy to forget the old-time standards and call them old-fashioned. Old-fashioned they may be, but they have stood the test of generations of correct living and thinking.”

At night the graduates were given a farewell reception and dance by the undergraduates.

Dispensary Report, April, 1908, to April, 1909.
OF
UNIVERSITY HOSPITAL

Department. | New Cases. | Old Cases.
Surgical | 1,703 | 4,448
Medical | 1,709 | 3,199
Genito Urinary | 765 | 2,933
Nervous | 399 | 1,971
Women | 733 | 1,279
Stomach | 421 | 1,108
Throat and Nose | 622 | 1,039
Children | 761 | 997
Eye and Ear | 712 | 903
Skin | 473 | 907
Tuberculosis | 190 | 703
Orthopedic | 31 | 120

| 8,519 | 19,609
Total new cases | 8,519 |
Total old cases | 19,609 |

Grand total | 28,128 |

JOHN HOUFF, M. D.,

Dispensary Physician.

DISPENSARY PHYSICIANS AND CHIEFS OF CLINIC.

Medical Department—Dr. J. M. Craighill, Chief of Clinic; Drs. W. H. Smith, G. C. Lockard, J. F. O'Mara, R. C. Metzel, H. J Maldeis, A. B. Hayes, H. D. McCarty, E. S. Perkins, J. F. Adams, H. L. Sinsky, Clarke, Todd.

Surgical Department—Dr. John G. Jay, Chief of Clinic; Drs. M. T. Cromwell, T. A. Tompkins, Jr., J. F. Adams, J. H. Smith, R. B. Hayes.

Stomach Department—Dr. R. A. Warner, Chief of Clinic; Dr. W. W. Eichenberger.

Nervous Department—Dr. J. F. Hawkins, Chief; Drs. G. M. Settle, F. J. Wilkins, N. M. Owensby.

Throat and Nose Department—Dr. H. C. Davis, Chief of Clinic: Dr. L. J. Goldbach.

Eye and Ear Department—Dr. E. E. Gibbons, Chief of Clinic; Dr. Wm. Tarun.

Women Department—Dr. Wm. K. White, Chief of Clinic; Drs. H. W. Brent, E. S. Perkins, R. L. Mitchell.

Genito Urinary Department—Dr. Wm. D. Scott, Jr., Chief.

Skin Department—Dr. J. R. Abercrombie, Chief.

Children's Department—Dr. A. B. Lennan, Chief; Dr. H. Schoenrich.

Tuberculosis Department—Dr. Gordon Wilson, Chief.

Orthopedic Department—Dr. Compton Riely, Chief; Dr. S. Demarco.

JOHN HOUFF, M. D.,

Dispensary Physician.

MARRIAGES.

Dr. Wm. B. Warthen, class of 1905, of Bartow, Ga., an ex-resident gynecologist in the University Hospital, and one of the most popular members of his class, a hale fellow and one of the most loyal alumni of the University of Maryland, was married at Macon, Ga., April 15, 1909, to Mrs. Sallie Bell Newsom, of Davisboro, Ga. The Bulletin and friends of Dr. Warthen extend to him their best wishes for a long, successful and happy marriage.

Mrs. Lavinia E. Thomas has issued cards announcing the marriage of her daughter. Miss Alice Saunders Thomas, to Dr. Edward Barney Smith, class of 1907, on April 21st, 1909, at Creeds, Virginia. Dr. and Mrs. Smith will be at home after May 1, 1909, at Woodleigh, N. C.

The marriage of Miss Helen Ashby, daughter of Prof. Thomas A. Ashby and Mrs. Ashby, to Mr. Harry T. Giddings, of Baltimore, took place April 28, 1909, at the residence of her parents, 1125 Madison avenue, Baltimore.

Miss Edna Wright, only daughter of Mr. K. J. Wright, a prominent merchant of Hurlock, Md., and Dr. G. Roger Myers, a well-known physician of Hurlock, were married Wednesday afternoon, April 28, 1909, at the home of the groom's parents. Rev. L. F. M. Myers, of Philadelphia, a brother of the groom, officiated at the ceremony. After a honeymoon spent at Atlantic City and other Northern points of interest, the couple will make their home at Hurlock.

Miss Julia C. Cherbonnier, of Baltimore, and Dr. Eugene F. Raphel, class of 1906, of Wheeling, were married at St. Ann's Catholic Church March 12, 1909, by Rev. C. F. Thomas, assisted by Rev. Wm. M. Clements. The bride was given in marriage by her father, Capt. A. V. Cherbonnier. Her maid of honor was Miss Jeannette Raphel, sister of the groom. The groom was attended by his brother, Alexis A. Raphel. Among the ushers were Dr. J. Holmes Smith, Jr. Dr. and Mrs. Raphel will make their home at Wheeling, W. Va.

Dr. Arthur Marriott Shipley, class of 1902, for a number of years assistant resident surgeon, and later superintendent of the University Hospital, now associate professor of surgery, University of Maryland, was married May 6, 1908, at Eutaw Place Baptist Church, at 8.30 P. M., to Miss Julia Armistead Joynes, daughter of Mr. Tully Armistead Joynes, of Baltimore.

DEATHS.

Dr. Hugh A. Maughlin, class of 1864, of Baltimore, died Saturday, April 17, 1909, at his home, 121 North Broadway, Baltimore. Dr. Maughlin was a prominent member of the Grand Army of the Republic. Rev. J. Wynne Jones, pastor of Abbott Memorial Church, Highlandtown, who is the chaplain of Wilson Post, of which Dr. Maughlin was a member, conducted the funeral services. Burial was in Greenmount Cemetery.

Dr. Newton Clark Stevens, class of 1875, a member of the Louisiana State Medical Society, died at his home, in Ama, January 28, 1909, aged 62.

Dr. Howard E. Mitchell, class of 1882, of Ellerslie, Md., died at the Western Maryland Hospital, Cumberland, Md., April 6, 1909, 48 hours after having been struck by a train, aged fifty-four.

Recently at Cavite, Philippine Islands, Mrs. Mary Gibbs Morris, wife of Dr. Lewis Morris, class of 1890, surgeon United States Navy, was gathered unto her father. Her husband was born in Baltimore, and is the son of the late Capt. C. Manigault Morris, commander of the Florida, Confederate States Navy.

Dr. William Hungerford Burr, class of 1884, a member of the American Medical Association, for four years surgeon in charge of the Santa Fe System Hospital and surgeon to the Clark Coal Company, Gallup, New Mexico, died in the Santa Fe Hospital, Albuquerque, New Mexico, April 13, 1909, from pneumonia, aged forty-nine.

Dr. Edgar T. Duke, one of the most prominent physicians of Allegany county, died April 3 at his home, on Bedford street, Cumberland, the result of an attack of pneumonia. He was 43 years old, a son of Major and Mrs. J. E. Duke, and was a native of Charlestown, W. Va., coming to Cumberland with his parents when a young man. He studied pharmacy with the late Dr. John F. Zacharias, and later read medicine under the late Dr. G. Ellis Porter at Lonaconing, graduating at the University of Maryland in the class of 1891.

Dr. Duke was in love with his profession, and was for a number of years secretary of the Allegany County Medical Association. He was prominent before the association for his special papers, and was also prominent on the church lecture platform. Hardly a church in Cumberland but that has had Dr. Duke's services.

He was a member of Chosen Friends' Lodge, No. 34, Independent Order of Odd Fellows, of which body he was secretary for some years, and also a past presiding officer, and was connected with other fraternal organizations.

Dr. Duke was also a member of the American Medical Association, the Medical and Chirurgical Faculty of Maryland and the Tristate Medical Association. He assisted in organizing the Western Maryland Hospital Training School for Nurses and was one of the lecturers. He was an elder and the Sunday school superintendent in the Presbyterian Church.

He was noted for his kindness. He was also active in the Young Men's Christian Association and was chairman of the boys' work committee. His father is a prominent Confederate veteran. His funeral took place Thursday afternoon, April 15, from the First Presbyterian Church. At the present time Dr. Duke's aged mother is very ill.

Dr. Duke leaves a widow, formerly Miss Gardner; his parents, one brother, Mr. Harry K. Duke, and one sister, Mrs. Mary Campbell, all of Cumberland.

Dr. Edward Pontney Irons, an alumnus of the University of Maryland, and one of the oldest physicians in the city, died Sunday, April 4, 1909, at the home of his sister, Mrs. William P. Lowry, 1023 Harlem avenue. He was 84 years old.

He was born in this city, a son of Dr. James and Rebecca Irons, who were of English and French-Irish ancestry, and descendants of the earlier settlers of the state. He entered business and was variously employed in a number of the Southern States. In 1863 he returned to this city and entered the University of Maryland.

After graduation in 1865, when the Civil War was nearing its end, he acted as assistant surgeon in the Officers' Hospital at Annapolis. A year later he went to Alabama, but remained only a short time. He returned and opened a practice here, which he maintained.

He retired from active work about seven years ago. At that time he was subordinate medical examiner for the Royal Arcanum, of which he was a member. He was also a member of the Masons, the Baltimore Medical Society and the Medical and Chirurgical Faculty of Maryland.

In 1857 he married Miss Anna Rebecca Sewell, a daughter of Thomas H. Sewell, a Baltimore manufacturer. A daughter, Mrs. James W. Ramsey, is the only survivor.

Dr. Benjamin Franklin Laughlin, class of 1904, died at his home, at Deer Park, Md., aged 31 years. He first located at Blaine, W. Va., where he practiced. He was taken ill at Kingwood, W. Va., some months ago, and was later sent to a Baltimore hospital, but he showed no signs of improvement. He was a son of Dr. and Mrs. J. W. Laughlin, Deer Park, and a brother of Hice Laughlin, a prominent Baltimore and Ohio official, Grafton, W. Va.

Dr. George C. Farnandas, class of 1852, of Baltimore, died Sunday, April 4, 1909, at his home, 1721 Maryland avenue, Baltimore, of old age. The funeral took place from his late home, 1721 Maryland avenue. Dr. Farnandas was 80 years old. Before the Civil War he had a large practice, but gave it up so that he might travel. He was well known to the older generation of Baltimoreans. The services were conducted by Rev. J. H. Eccleston, rector of Emmanuel Church.

The honorary pallbearers were Dr. N. K. Keirle, Dr. James M. Craighill, Dr. Samuel T. Earle, Mr. Thomas H. Robinson and Mr. Wm. P. Trimble, of Harford county. Burial was in Greenmount Cemetery.

Mrs. Virginia Blackwell Carder, aged 38 years, wife of Dr. George M. Carder, class of 1891, of Cumberland, Md., died March 17, 1909, after a struggle of two weeks against the ravages of a mastoid abscess.

Mrs. Carder was preparing to visit her sister, Mrs. Gay Breton Leroux, in Douglas, Ga.

Suddenly she was stricken, and when an operation became necessary Mrs. Carder insisted that her husband, a surgeon who has kept constant vigil the last two weeks, perform the operation. The operation was apparently very successful, and Mrs. Carder was improving, when complications in the form of typhoid fever set in. Prof. C. W. Mitchell, of Baltimore, and Drs. J. T. Walker and Harry Hyland Kerr, of Washington, were called by Dr. Carder, and all said everything possible was being done for her, but held out no hope.

Mrs. Carder was the daughter of Thomas Callan, of Narrows Park, and, besides her husband, leaves a little son (Robert Callan Carder), two brothers (George S. Callan, of Duffields, W. Va., and Charles T. Callan, of Little Orleans, Md.), and one sister (Mrs. Leroux). Miss Mary L. Callan, a sister, was accidentally drowned in the Potomac at Little Orleans.

In Pneumonia the inspired air should be rich in oxygen and comparatively cool, while the surface of the body, especially the thorax, should be kept warm, lest, becoming chilled, the action of the phagocytes in their battle with the pneumococci be inhibited.

Antiphlogistine

(Inflammation's Antidote)

applied to the chest wall, front, sides and back, hot and thick, stimulates the action of the phagocytes and often turns the scale in favor of recovery.

Croup.—Instead of depending on an emetic for quick action in croup, the physician will do well to apply Antiphlogistine hot and thick from ear to ear and down over the interclavicular space. The results of such treatment are usually prompt and gratifying.

Antiphlogistine hot and thick is also indicated in Bronchitis and Pleurisy

The Denver Chemical Mfg. Co. New York

Certain as it is that a single acting cause can bring about any one of the several anomalies of menstruation, just so certain is it that a single remedial agent—if properly administered—can effect the relief of any one of those anomalies.

¶ The singular efficacy of Ergoapiol (Smith) in the various menstrual irregularities is manifestly due to its prompt and direct analgesic, antispasmodic and tonic action upon the entire female reproductive system.

¶ Ergoapiol (Smith) is of special, indeed extraordinary, value in such menstrual irregularities as amenorrhea, dysmenorrhea, menorrhagia and metrorrhagia.

¶ The creators of the preparation, the Martin H. Smith Company, of New York, will send samples and exhaustive literature, post paid, to any member of the medical profession.

TRANSCRIBER'S NOTES

1. Silently corrected typographical errors.

2. Retained anachronistic and non-standard spellings as printed.

*** END OF THE PROJECT GUTENBERG EBOOK THE HOSPITAL BULLETIN, VOL. V, NO. 3, MAY 15, 1909 ***

Updated editions will replace the previous one—the old editions will be renamed.

Creating the works from print editions not protected by U.S. copyright law means that no one owns a United States copyright in these works, so the Foundation (and you!) can copy and distribute it in the United States without permission and without paying copyright royalties. Special rules, set forth in the General Terms of Use part of this license, apply to copying and distributing Project Gutenberg™ electronic works to protect the PROJECT GUTENBERG™ concept and trademark. Project Gutenberg is a registered trademark, and may not be used if you charge for an eBook, except by following the terms of the trademark license, including paying royalties for use of the Project Gutenberg trademark. If you do not charge anything for copies of this eBook, complying with the trademark license is very easy. You may use this eBook for nearly any purpose such as creation of derivative works, reports, performances and research. Project Gutenberg eBooks may be modified and printed and given away—you may do practically ANYTHING in the United States with eBooks not protected by U.S. copyright law. Redistribution is subject to the trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE

PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free distribution of electronic works, by using or distributing this work (or any other work associated in any way with the phrase “Project Gutenberg”), you agree to comply with all the terms of the Full Project Gutenberg™ License available with this file or online at www.gutenberg.org/license.

Section 1. General Terms of Use and Redistributing Project Gutenberg™ electronic works

1.A. By reading or using any part of this Project Gutenberg™ electronic work, you indicate that you have read, understand, agree to and accept all the terms of this license and intellectual property (trademark/copyright) agreement. If you do not agree to abide by all the terms of this agreement, you must cease using and return or destroy all copies of Project Gutenberg™ electronic works in your possession. If you paid a fee for obtaining a copy of or access to a Project Gutenberg™ electronic work and you do not agree to be bound by the terms of this agreement, you may obtain a refund from the person or entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be used on or associated in any way with an electronic work by people who agree to be bound by the terms of this agreement. There are a few things that you can do with most Project Gutenberg™ electronic works even without complying with the full terms of this agreement. See paragraph 1.C below. There are a lot of things you can do with Project Gutenberg™ electronic works if you follow the terms of this agreement and help preserve free future access to Project Gutenberg™ electronic works. See paragraph 1.E below.

1.C. The Project Gutenberg Literary Archive Foundation (“the Foundation” or PGLAF), owns a compilation copyright in the collection of Project Gutenberg™ electronic works. Nearly all the individual works in the collection are in the public domain in the United States. If an individual work is unprotected by copyright law in the United States and you are located in the United States, we do not claim a right to prevent you from copying, distributing, performing, displaying or creating derivative works based on the work as long as all references to Project Gutenberg are removed. Of course, we hope that you will support the Project Gutenberg™ mission of promoting free access to electronic works by freely sharing Project Gutenberg™ works in compliance with the terms of this agreement for keeping the Project Gutenberg™ name associated with the work. You can easily comply with the terms of this agreement by keeping this work in the same format with its attached full Project Gutenberg™ License when you share it without charge with others.

1.D. The copyright laws of the place where you are located also govern what you can do with this work. Copyright laws in most countries are in a constant state of change. If you are outside the United States, check the laws of your country in addition to the terms of this agreement before downloading, copying, displaying, performing, distributing or creating derivative works based on this work or any other Project Gutenberg™ work. The Foundation makes no representations concerning the copyright status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other immediate access to, the full Project Gutenberg™ License must appear prominently whenever any copy of a Project Gutenberg™ work (any work on which the phrase “Project Gutenberg” appears, or with which the phrase “Project Gutenberg” is associated) is accessed, displayed, performed, viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is derived from texts not protected by U.S. copyright law (does not contain a notice indicating that it is posted with permission of the copyright holder), the work can be copied and distributed to anyone in the United States without paying any fees or charges. If you are redistributing or providing access to a work with the phrase “Project Gutenberg” associated with or appearing on the work, you must comply either with the requirements of paragraphs 1.E.1 through 1.E.7 or obtain permission for the use of the work and the Project Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted with the permission of the copyright holder, your use and distribution must comply with both paragraphs 1.E.1 through 1.E.7 and any additional terms imposed by the copyright holder. Additional terms will be linked to the Project Gutenberg™ License for all works posted with the permission of the copyright holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project Gutenberg™ License terms from this work, or any files containing a part of this work or any other work associated with Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this electronic work, or any part of this electronic work, without prominently displaying the sentence set forth in paragraph 1.E.1 with active links or immediate access to the full terms of the Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary, compressed, marked up, nonproprietary or proprietary form, including any word processing or hypertext form. However, if you provide access to or distribute copies of a Project Gutenberg™ work in a format other than “Plain Vanilla ASCII” or other format used in the official version posted on the official Project Gutenberg™ website (www.gutenberg.org), you must, at no additional cost, fee or expense to the user, provide a copy, a means of exporting a copy, or a means of obtaining a copy upon request, of the work in its original “Plain Vanilla ASCII” or other form. Any alternate format must include the full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying, performing, copying or distributing any Project Gutenberg™ works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing access to or distributing Project Gutenberg™ electronic works provided that:

- • You pay a royalty fee of 20% of the gross profits you derive from the use of Project Gutenberg™ works calculated using the method you already use to calculate your applicable taxes. The fee is owed to the owner of the Project Gutenberg™ trademark, but he has agreed to donate royalties under this paragraph to the Project Gutenberg Literary Archive Foundation. Royalty payments must be paid within 60 days following each date on which you prepare (or are legally required to prepare) your periodic tax returns. Royalty payments should be clearly marked as such and sent to the Project Gutenberg Literary Archive Foundation at the address specified in Section 4, “Information about donations to the Project Gutenberg Literary Archive Foundation.”

- • You provide a full refund of any money paid by a user who notifies you in writing (or by e-mail) within 30 days of receipt that s/he does not agree to the terms of the full Project Gutenberg™ License. You must require such a user to return or destroy all copies of the works possessed in a physical medium and discontinue all use of and all access to other copies of Project Gutenberg™ works.

- • You provide, in accordance with paragraph 1.F.3, a full refund of any money paid for a work or a replacement copy, if a defect in the electronic work is discovered and reported to you within 90 days of receipt of the work.

- • You comply with all other terms of this agreement for free distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™ electronic work or group of works on different terms than are set forth in this agreement, you must obtain permission in writing from the Project Gutenberg Literary Archive Foundation, the manager of the Project Gutenberg™ trademark. Contact the Foundation as set forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend considerable effort to identify, do copyright research on, transcribe and proofread works not protected by U.S. copyright law in creating the Project Gutenberg™ collection. Despite these efforts, Project Gutenberg™ electronic works, and the medium on which they may be stored, may contain “Defects,” such as, but not limited to, incomplete, inaccurate or corrupt data, transcription errors, a copyright or other intellectual property infringement, a defective or damaged disk or other medium, a computer virus, or computer codes that damage or cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the “Right of Replacement or Refund” described in paragraph 1.F.3, the Project Gutenberg Literary Archive Foundation, the owner of the Project Gutenberg™ trademark, and any other party distributing a Project Gutenberg™ electronic work under this agreement, disclaim all liability to you for damages, costs and expenses, including legal fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a defect in this electronic work within 90 days of receiving it, you can receive a refund of the money (if any) you paid for it by sending a written explanation to the person you received the work from. If you received the work on a physical medium, you must return the medium with your written explanation. The person or entity that provided you with the defective work may elect to provide a replacement copy in lieu of a refund. If you received the work electronically, the person or entity providing it to you may choose to give you a second opportunity to receive the work electronically in lieu of a refund. If the second copy is also defective, you may demand a refund in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied warranties or the exclusion or limitation of certain types of damages. If any disclaimer or limitation set forth in this agreement violates the law of the state applicable to this agreement, the agreement shall be interpreted to make the maximum disclaimer or limitation permitted by the applicable state law. The invalidity or unenforceability of any provision of this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the trademark owner, any agent or employee of the Foundation, anyone providing copies of Project Gutenberg™ electronic works in accordance with this agreement, and any volunteers associated with the production, promotion and distribution of Project Gutenberg™ electronic works, harmless from all liability, costs and expenses, including legal fees, that arise directly or indirectly from any of the following which you do or cause to occur: (a) distribution of this or any Project Gutenberg™ work, (b) alteration, modification, or additions or deletions to any Project Gutenberg™ work, and (c) any Defect you cause.

Section 2. Information about the Mission of Project Gutenberg™

Project Gutenberg™ is synonymous with the free distribution of electronic works in formats readable by the widest variety of computers including obsolete, old, middle-aged and new computers. It exists because of the efforts of hundreds of volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the assistance they need are critical to reaching Project Gutenberg™’s goals and ensuring that the Project Gutenberg™ collection will remain freely available for generations to come. In 2001, the Project Gutenberg Literary Archive Foundation was created to provide a secure and permanent future for Project Gutenberg™ and future generations. To learn more about the Project Gutenberg Literary Archive Foundation and how your efforts and donations can help, see Sections 3 and 4 and the Foundation information page at www.gutenberg.org.

Section 3. Information about the Project Gutenberg Literary Archive Foundation

The Project Gutenberg Literary Archive Foundation is a non-profit 501(c)(3) educational corporation organized under the laws of the state of Mississippi and granted tax exempt status by the Internal Revenue Service. The Foundation’s EIN or federal tax identification number is 64-6221541. Contributions to the Project Gutenberg Literary Archive Foundation are tax deductible to the full extent permitted by U.S. federal laws and your state’s laws.

The Foundation’s business office is located at 809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up to date contact information can be found at the Foundation’s website and official page at www.gutenberg.org/contact

Section 4. Information about Donations to the Project Gutenberg Literary Archive Foundation

Project Gutenberg™ depends upon and cannot survive without widespread public support and donations to carry out its mission of increasing the number of public domain and licensed works that can be freely distributed in machine-readable form accessible by the widest array of equipment including outdated equipment. Many small donations ($1 to $5,000) are particularly important to maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws regulating charities and charitable donations in all 50 states of the United States. Compliance requirements are not uniform and it takes a considerable effort, much paperwork and many fees to meet and keep up with these requirements. We do not solicit donations in locations where we have not received written confirmation of compliance. To SEND DONATIONS or determine the status of compliance for any particular state visit www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states where we have not met the solicitation requirements, we know of no prohibition against accepting unsolicited donations from donors in such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot make any statements concerning tax treatment of donations received from outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg web pages for current donation methods and addresses. Donations are accepted in a number of other ways including checks, online payments and credit card donations. To donate, please visit: www.gutenberg.org/donate.

Section 5. General Information About Project Gutenberg™ electronic works

Professor Michael S. Hart was the originator of the Project Gutenberg™ concept of a library of electronic works that could be freely shared with anyone. For forty years, he produced and distributed Project Gutenberg™ eBooks with only a loose network of volunteer support.

Project Gutenberg™ eBooks are often created from several printed editions, all of which are confirmed as not protected by copyright in the U.S. unless a copyright notice is included. Thus, we do not necessarily keep eBooks in compliance with any particular paper edition.

Most people start at our website which has the main PG search facility: www.gutenberg.org.

This website includes information about Project Gutenberg™, including how to make donations to the Project Gutenberg Literary Archive Foundation, how to help produce our new eBooks, and how to subscribe to our email newsletter to hear about new eBooks.

Table of Contents

- THE HOSPITAL BULLETIN

- THREE ESOPHAGEAL CASES.

- SYPHILITIC OSTEO-PERIOSTITIS.

- DISCUSSION BY DR. WARNER HOLT, OF WASHINGTON, OF THE PAPER ON THE CHEMICAL CO-RELATION BETWEEN THE SALIVARY GLANDS AND THE STOMACH, BY JOHN C. HEMMETER, OF BALTIMORE.

- AN INTERESTING CASE OF SCROTAL HERNIA.

- THE TEACHING OF THE SPECIALTIES.

- A CASE OF SPORADIC CRETINISM.

- ITEMS.

- NURSES WIN DIPLOMAS.

- Dispensary Report, April, 1908, to April, 1909. OF UNIVERSITY HOSPITAL

- DISPENSARY PHYSICIANS AND CHIEFS OF CLINIC.

- MARRIAGES.

- DEATHS.

- TRANSCRIBER'S NOTES

- THE FULL PROJECT GUTENBERG LICENSE