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his family enjoys as a result of the labors and sacrifices of the noble and good that have gone on before.

When the medical profession fully realizes its duty along these lines then every medical college will have a chair on medical sociology and make it one of the most important branches in its curriculum. In it will be included preventive surgery as well as preventive medicine.

In order to be brief and to the point, we will only mention disconnectedly a few of the conditions in which the physician may prevent or cause surgery and conclude with some instances in which the physician should refer cases to the surgeon.

In obstetric practice most physicians recognize the necessity for clean aseptic work, yet many neglect the little details necessary to prevent at last a mild infection that frequently leaves behind chronic trouble requiring the services of a gynecologist.

Thorough disinfection of the hands in all cases, the wearing of rubber gloves when in doubt, immediate aseptic repair of perineum, be it slight, with aseptic care of patient during puerperium, is essential to prevent surgical work later.

If infection occurs, thorough irrigation of uterine cavity and free drainage-not the curette-are essential if the generative organs are to be preserved in tact for future physiological functions.

In abortions uterine cavity should be thoroughly emptied and disinfected to prevent disease of adnexa. In every case of labor or abortion after delivery during the puerperium patient should assume the exaggerated Sim's position on right or left side, twelve to eighteen hours out of the twenty-four, and if patient have retro-displacement of

uterus at end of third week, it should be corrected. Appropriate treatment at this time with hot douches and tampons, followed later by properly adapted and adjusted pessaries, will correct fifty to seventy-five per cent. of the cases without surgical operation.

Introduction of uterine sound and intra-uterine treatment in the office and curetting uterus without aseptic measures, has done much damage. Pelvic massage and trachelorraphy in pus cases has developed surgery.

During pregnancy many cases of kidney lesion develop and cause operative work at delivery and afterwards directly or indirectly that might have been prevented by judicious treatment which would have been indicated by use of the microscope at the proper time.

I say microscope, because the qualitative chemical examination of the urine, as usually made, is of but little value in many of these cases, and without the use of the microscope you will be misled as to the true condition of the patient.

The direct and ultimate results of the let-alone, donothing, constipating plan of treating typhoid fever tends to the development of surgery. To the rational mind it favors increased germ development, and toxines in alimentary canal, adding autointoxication, toxemia, distention of abdomen, irritation from accumulating and hardened feces, all depress vital powers of patient, check secretions, increase delirium, pervert nutrition and favor directly perforation and hemorrhage, later complications of kidneys, appendix, liver, joints, and last, but not least, infection of gall ducts, some of which at times require surgical intervention for relief which might have been prevented by a more rational plan of treatment.

Chronic constipation, indigestion, distention of colon

tend to produce complications with appendix, which can often be prevented by judicious treatment, dieting and regulating habits of patient.

In cases of acute appendicitis too active catharsis and food by the stomach often produce serious surgical complications which might be avoided. Even in severe cases, with perforations and other complications withholding food from stomach, lavage, if necessary, using concentrated nourishment by rectum, with complete quiet, will tide most cases over to a comparatively safe period for operation. The general practitioner in these, as well as in many other conditions, must be competent to decide when operation will be most judicious and for the best interest of his patient, else have a surgeon associated with him in the case that is competent to decide.

In typhoid fever, appendicitis, colitis and even indigestion, emptying alimentary canal at first by the least irritating method, give such remedies as tend to disinfect the intestinal tract, aiding digestion and assimilation, will prevent many serious complications and much surgery. Some one, no doubt, will say it is impossible to disinfect the alimentary canal; so is it impossible for the surgeon to disinfect his hands or the field of operation, but he who fails to make an effort to approximately do so is criminally negligent.

In nearly all cases of ectopic pregnancy, ovarian cysts and malignant disease, operative measures are indicated, and the sooner the better, especially in cancerous conditions.

It is here the general practitioner so often makes the fatal mistake of procrastinating and waiting to be positive of malignancy before advising immediate operation.

In all cases where there is even the suspicion of malig

nancy the case should be sent at once, without delay, to the surgeon or to one specially qualified to handle the organ or part involved. The physician who fails to so instruct his patient neglects his duty, and in some instances is indirectly responsible for the death of his patient.

Every physician should be conversant with the late developments in diseases of the stomach, gall bladder and ducts, movable kidney, etc., so as to be in a position at least to advise his patient to seek relief at a time when it will be of most benefit, and not when it is too late to prevent death.

There is a border-line between surgery and medicine in which there is a demand for a closer association of the surgeon and physician.

The physician does not see enough of the pathological conditions disclosed by surgery, while the surgeon often does not see enough of the primary conditions that lead to the necessity for surgery, and to fully appreciate the responsible position in which the physician is placed.

Here, it is manifest, the surgeon needs a broad foundation and knowledge of general medicine, while the physician needs to understand more fully the primal causes that lead to the demand for surgery as well as the results, direct and remote, that can be attained by surgical measures. With this knowledge on the part of both, and a closer association in work, then "preventive surgery" will be elevated to a higher point than it has yet attained.

To secure the best results, and place surgery and medicine on a higher scientific basis, the work of the physician and surgeon should be more closely associated and combined with that of the anatomist, physiologist and pathologist.



My reason for presenting this paper is the comparative rarity of Addison's disease in this section of the country, and some special points in this particular case that came to light during a rather close observation extending over a period of nearly two years.

This disease is probably the most important of those that produce a discoloration of the skin, not from that symptom alone, but from the train of symptoms that accompany and precede it, and from the peculiar pathological condition that causes it. This importance is further increased as a result of our lack of knowledge of the manner in which disorders of the suprarenals produce this characteristic discoloration.

It is more than probable that all the functions of these bodies have not yet been discovered, but we may presume upon at least three: 1st. The secretion of a material necessary to proper blood production. 2d. Destruction of hemoglobin. 3d. Intimate association with the sympathetic nervous system. Considering these three functions as established, we may more readily understand how the "bronzing" as well as all other of the varied symptoms of this disease occur. It might occur as a result of the circulation of the products of the disintegration of hemoglobin. Brown-Sequard claimed that the pigment consequent upon this disintegration was destroyed in the suprarenal

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