A Few Points of Interest to 
the Family Physician. 
Read in the Section of Obstetrics and Diseases of Women, at the Forty 
fourth Annual Meeting of the American Medical Association. 
BY JOSEPH EASTMAN, M.D., LL.D. 
INDIANAPOLIS. IND. 
REPRINTED FROM t 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
SEPTEMBER 16, 1892. 
CHICAGO: 
PUBLISHED AT THE OFFICE OP THE ASSOCIATION. 
1X93. A FEW POINTS OF INTEREST TO THE FAM- 
ILY PHYSICIAN. 
It is more or less presumptuous for a specialist to 
attempt to teach the general practitioner for two 
reasons: First, a large per cent, of general practi- 
tioners are capable of furnishing more pointers to 
the specialist that he could use in his business than 
the specialist could furnish to the general practi- 
tioner. Secondly, so many epistles have come from 
gynecological apostles in the past few years intended 
for the edification and education of the general prac- 
titioner that the man who makes his living by doing 
family practice is beginning to seriously reflect upon 
what relation he bears to the specialist. 
Had I not for fifteen years been actively engaged 
in general surgery and medicine, nothing could have 
induced me to place my foot in this field which is 
actually suffering from intense cultivation, but now 
that specialists in gynecic surgery are starting up 
in almost every county seat I think it might be well 
to "tap the wheels" and elicit, if possible, the ring of 
solid metal or perchance the dull sound which indi- 
cates a crack in the wheel of our rapidly moving train. 
Those of us who have opened the abdominal 
cavity many hundred times and tested our asepsis in 
the great lymph sac have picked up many little 
points pertaining to aseptic and antiseptic precau- 
tions of much value to the general practitioner. He 
has, however, often been led to believe that there are 
two separate and distinct factions; the one contend- 
ing for and the other against antiseptics. There are 
no differences. "All are but parts of one stupen- 2 
dous whole." Therefore he has the right to throw the 
blame on the coeliotomist for his having committed 
a sin of omission, not using enough soap and water; 
or a sin of commission, having depended too exclu- 
sively on his bichloride solution and failed to 
scrub (sterilize) his hands, and even poisoned his 
patient with the deadly drug. The greater our expe- 
rience and the more marked our success; the keener 
we should feel the weight of responsibility resting 
on us for what we teach. Reckless expressions as to 
methods of operating, treatment of cases, or results 
obtained are most reprehensible, even criminal, for 
in this way lives are sacrificed. 
The student of human nature and the earnest 
seeker after truth can see the motives of those who 
insist that any kind of water is as good in surgical 
cleanliness as that which has been sterilized, or 
teach in their published statements and attempt to 
prove by their success that private hospitals are use- 
less ; that the same success can be obtained in the 
filth hovels of the city; that nurses who have had a 
large experience in supplementing the efforts of the 
abdominal surgeon with their wisdom obtained by 
observation are no better than such nurses as one 
can pick up. What is the difference, if in the use of 
chemical agents which destroy microorganisms, we 
advance a step farther and say prevention is better 
than cure; or that the prevention of fermentation- 
"sterilization," "asepsis," "clean surgery" are better 
than allowing fermentation and putrefaction to 
swarm with microbes, and then seek to kill them 
with chemic agents? 
There is no difference in the ultimate aim of those 
contending for antiseptic surgery, and those who 
claim to be content with clean surgery, for the reason 
that cleanliness can not be secured and maintained 
without the aid of chemic agents of some kind. No 
wonder some of our surgical friends get blinded in 
the technique of antiseptic surgery. While wander- 
ing in their blindness they forget the principles 3 
enunciated by the great masters like Lister and 
Keith. These men proved by scientific research that 
all fermentation is molecular life. What use would 
there be in the sterilization of every instrument used 
in the pelvic abscess if we forget that pus cavities, 
after being exposed to the air, become a hot-bed for 
the production of germ life through fermentation 
and putrefaction? Of what use would all the anti- 
septic dressing over an abscess be, as compared with 
perfect drainage-that precious safeguard against 
absorption? Our apostles of clean surgery are 
exceeding careful as to who clean their sponges; do 
not allow any decaying organic substance in their 
private hospitals, knowing that no sooner does one 
decaying substance die than it begins to live again 
in molecular germ life, the prolific offspring of fer- 
mentation and putrefaction. Clean surgery is what 
we want. How shall we obtain it? By water? No; 
it can not be thus secured. Suppose one of these 
gentlemen drops blood, pus or serum on his clothing, 
or gravy on the lapel of his coat. Will water remove 
it? No; try soap, ammonia, ether, benzine. Ah, it 
takes chemicals to secure cleanliness. The differ- 
ence between those favoring and those opposed to 
antiseptics is largely imaginary, a play on words. 
We can get it but not without the aid of chemicals. 
By this, I do not mean such agents as are usually 
considered germicides. I doubt the propriety of 
killing germs lest we irritate the tissues. These 
pretended differences between sepsis and antisepsis 
can but confuse the average general practitioner or 
the beginner in surgery. For example: My friend 
who had located in the far west and had been doing 
some surgery, returned to make his friends a visit; 
found his way up to my operating room and was 
noticing our preparations for work. As I had once 
been his teacher I began answering his questions by 
explaining to him that the hands were the most fre- 
quent source of conveying septic material into the 
peritoneal cavity, and that for the past ten years I 4 
had been studying how to clean my hands; that now 
I had a soap made by a chemist, with olive oil and 
caustic potash, practically the green soap of the 
pharmacopoeia. I showed him my scrub brush for 
the hands which is boiled every time after being 
used and then kept in alcohol and ready for use 
again. 
I explained how it takes repeated rinsings to get 
rid of the soap suds from the pores of the skin before 
we place the hands within the abdomen. He answered 
me, "I have no use for all your details. I simply 
put my hands in the solution of bichloride of mer- 
cury and then I know that I am safe." I attempted 
to reason with him, stating that if I used a germi- 
cide for the hands it would be aqua ammonia, which 
would not only bring tears to the eyes commensu- 
rate to the solemnity of the occasion, but would pene- 
trate deeply into the pores of the skin chasing the 
microbe home, and by its extreme alkalinity, if not 
killing him outright, weakening him until he would 
be comparatively harmless. Whereas, his bichloride 
of mercury by its astringency, would close the pores 
of the skin, thereby shutting the door after the 
microbe which it had frightened into its den. This 
doctor believed that there were two factions and had 
chosen the chemical side of the question. 
I read in a medical journal an article by one evi- 
dently willing to teach the average doctor. In this 
article he describes the bleaching method much 
used in the Johns Hopkins hospital and other places. 
He says: "Making the hands brown in a solution of 
permanganate of potash, then immersing them in a 
solution of oxalic acid until the color of the potash 
is removed ; the hands will be of a pink color." Here 
it is that "a little knowledge is a dangerous thing." 
The pink color is evidence that the acid is retained 
deeply in the pores of the skin of the hands, even 
after repeated rinsings under a stream of running 
water. Such hands put into the peritoneal cavity 
would be dangerous. Aqua ammonia applied freely 5 
will prove the presence of acid by making as much 
lather as could be made with a good article of soap. 
This repeated a few times the pink color is gone and 
the hands are anemic. This alternate flushing and 
shrinkage of the capillaries, making the pink color, 
no doubt helps to sterilize the hands. It could be 
as well done by alternately immersing the hands in 
cold and hot water. 
Another friend asks me to meet him in consulta- 
tion, his patient having been confined a few weeks 
before. He fears peritonitis and yet thinks it not 
possible, as the temperature has not been above 101, 
though the pulse is 140, wiry and feeble. The abdo- 
men is badly distended. The pulse, the tongue and 
the countenance all point to septic peritonitis and 
death. Following the doctor I made a careful exam- 
ination of the case. I asked for some soap and water 
to wash my hands. They furnished soap which had 
probably been selected, not because of its known 
chemical composition, but because of its recommend- 
ation in the newspapers, including a certificate from a 
Brooklyn minister. The water given me was hard, 
containing much lime, magnesia, etc. I whispered 
to my friend that I could not remove septic germs 
from my hands with such material. He immediately 
brought his satchel, and after handling nearly every- 
thing in it gave me some tablets of bichloride of 
mercury to put in the water, and thereby to increase 
the chemical composition of the water and render it 
more worthless in cleansing hands. 
After handling everything in his satchel he washed 
his hands in a solution of bichloride. Now, had he 
carried a hand brush boiled every time it had been 
in doubtful use, a vial of aqua ammonia to soften 
the water and a piece of soap made of olive oil and 
caustic potash, imitating the time honored soft soap 
of his grandmother, his armamentarium for steriliz- 
ing hands would have been nearer to my notion. 
There is something in soap. I ask the man in the 
alley back of my stable what he is going to do with 6 
the putrefactive, maggotty carcass of a dead dog he 
has laid in his cart. His answer was that he hauled 
them to the soap factory. I repeat there is 
something in soap. I insist there was a good deal 
in th at soap. The nearer we stick to the religion 
and soap of our grandmothers the nearer we will 
approach moral and physical cleanliness of body 
and mind. 
This good doctor was deceived as to the disease 
by too implicit reliance on his thermometer. I have 
many times seen a patient with septic peritonitis 
lie down and die, while I have never known 
a pulse to deceive me. We had in the profession 
more good pulse feelers before we had so many 
thermometers. 
I get into my friend's buggy to ride home. He 
buttons up two coats, strokes down his long full 
beard, with hands and sleeves teeming, as I believe, 
with germs of septic peritonitis, then puts on a 
heavy pair of warm driving gloves which had done 
him service two winters,-surely nothing but fire 
could ever sterilize them. Five days later my good 
friend rushed into my operating room as we were 
getting ready for an abdominal section waving these 
same driving gloves in his hands. I asked him to 
retire. He did so, but remarked that he had changed 
his clothes. 
This doctor's antiseptic precautions were faulty 
because of. too implicit reliance on germicides which 
led him to overlook the fact that any microbe, hav- 
ing a particle of self-respect, would not attempt to 
stay where soft water, clean scrub brushes, plenty of 
elbow grease and repeated changes of clothing were 
customary. 
The doctor's change of clothes was not satisfactory 
to me, so long as the gloves were used into which he 
had placed his hands after examining the case of 
puerperal septicemia. It requires the utmost pains- 
taking to have our chain of antiseptic precautions 
strong in its entirety. "No chain is stronger than 7 
its weakest link." In studying septic precautions 
and applying the principles in our practice we often 
strain at a gnat and swallow a camel. This being 
true of those who are specially engaged in intra- 
peritoneal work so that the least deviation from the 
strictest asepsis will be detected in the results ob- 
tained, how much more likely is he who is engaged 
in general work to overlook some important detail 
in the change of clothing, and especially in what he 
is handling with his hands, including the gloves. 
It was taught in former years that the obstetrician 
should stop practice after attending a case of epi- 
demic child-bed fever. 
These cases we now believe to have been puerperal 
septicemia, and despite my unbounded confidence 
in soft water, soft soap, scrub brush, ammonia, tur- 
pentine and alcohol, I am of opinion that no 
man is warranted in opening the abdominal cavity 
or attending an obstetric case within five days after 
his hands have been in contact with a case of septic 
peritonitis, if that peritonitis is at all in any possi- 
bility during its acute stage; and not even after the 
expiration of five days unless in this space of time 
there shall have been repeated changes of clothing, 
daily scrubbing of the hands and arms with soft 
soap, soft water, with ammonia poured into the brush 
and the hands immersed in turpentine afterwards. 
In this purification the hair and beard should receive 
due attention. 
This statement may be challenged by those who 
make abdominal sections in cases of pus tubes, but 
I must draw the line between cases of sub-acute and 
acute septic peritonitis whether the same be puerperal 
or not. In a recent conversation with Dr. Dudley of 
Chicago, I find that this conscientious man has been 
thinking in the same line and arrived at the same 
conclusions as myself in this regard. Have we not 
erred in publishing to the general practitioner what 
numerous lives we could save by abdominal surgery? 
Would it not be better to give him the benefit of our 8 
experience and some of the details of our aseptic 
precautions, and thereby enable him to avert the 
probability of carrying the death warrant of his pa- 
tients in the hair follicles on his hands, under the 
finger nails and in the gloves? Is it not time that 
we quit contending that there are two factions in 
antiseptic surgery, one depending on water, the other 
on chemicals? Inasmuch as chemicals are useless 
without water and water without chemicals, even a 
soap of known chemical composition, the systematic 
combination of the two in the proper way of their 
use upon the hands is what the average physician 
needs to know. The man who is daily dealing with 
the peritoneal cavity has a store of knowledge of 
great utility to the general practitioner. And yet 
we must forget seif and publish only that which we 
have proven to be right and safe, like Dr. Kelley who 
discarded the American Journal of Obstetrics when he 
found that his bleaching solution of potash would 
not kill .bacteria in a skein of silk. 
I meet my friend in consultation. He had told 
me to bring all kinds of probes to get entrance into 
the cervical canal as he had failed to find an en- 
trance into the uterus, notwithstanding he had used 
the speculum many times. I found the uterus 
crowded up behind the pubes by an ovarian cyst as 
large as a water bucket which the doctor had not 
detected; secured the consent of the patient and set 
the day to remove the cyst. As we were about to 
leave, the doctor asked if I had not better use the 
speculum to see if we could not pass a sound. I 
replied that fingers were made before forks, specu- 
lums or sounds and that conjoined manipulation 
gave so much information that sounds were going 
out of use. A very large majority of practitioners I 
meet are capable diagnosticians. A few are sadly 
deficient in physical diagnosis of abdominal disease. 
It is often a lack of persistence in abdominal palpa- 
tion and determination to master the subject. They 
have not the art of moving the fingers over the 9 
viscera carrying the skin with fingers. And some- 
times they do not even obtain a knowledge as to 
whether the tumor grew from above downwards or 
from below upwards. If from above downwards, can 
it be manipulated back, as in floating kidney, or 
moved from side to side, not upward, as in distended 
gall bladder. They do not understand that palpa- 
tion of an ovarian cyst should give signs of fluctu- 
ation, and a fibroid of a solid ; that in both there 
would be dullness on percussion. Whereas, in 
ascites there would be resonance. I mention these 
points because there is some danger of inspection, 
palpation, auscultation and percussion becoming a 
lost art. There are so many anxious to make ex- 
ploratory abdominal section. 
One of the ablest practitioners of my State calls 
me in consultation. His telegram suggests that I 
come prepared to make an abdominal section. The 
case is a boy and he has been suffering three days 
from inflammation with excruciating pain in the 
region of the vermiform appendix. The doctor has 
made postmortem examinations, finding a gangre- 
nous vermiform appendices, and from his knowledge 
gained by the postmortem and by his reading the 
current literature of the day2 especially the teaching 
of Morris of New York, that all cases of appendicitis 
should be operated upon, believed that success would 
follow and life be saved if we only operated early 
enough. I, having seen a few operations followed 
by death because the inflammation was yet in an 
acute stage, that is to say while the circumscribed 
septic peritonitis, which sometimes accompanies 
csecitis and appendicitis was acute not sub-acute, 
believed that an operation would surely be followed 
by death, and that if by opiates we could arrest the 
progress of inflammation and seize the opportunity 
in the interval of the attack, operative interference 
might do some good. Knowing also that some of 
these cases make fairly good recoveries without ope- 
ration I declined to operate. Neither the doctor nor 10 
myself were satisfied with the results in this case, 
and this subject is of such vital interest to the gen- 
eral practitioner that I quote from a recent article 
by Dr. Schaefer as being in point: "It has been 
asserted by McBurney of New York, that 90 per cent, 
of all cases called perityphlitis are really cases of 
appendicitis, and this statement seems to have been 
almost universally accepted by the profession of our 
country, for the term perityphlitis has been almost 
entirely dropped from the textbooks and the writ- 
ings of most surgeons, and appendicitis adopted as a 
substitute. This change of terms has been accepted 
with too great haste in our judgment and is in all 
probability one of the chief causes which lead to 
the great differences of opinion relative to the ques- 
tion of operating; for we shall find upon searching 
the literature of this subject that various conditions 
may be and in all probability are described under 
the term 'appendicitis.1 I am led to believe through 
my experience that a larger percentage of cases of so- 
called appendicitis than we are aware of are inaccu- 
rately diagnosed. This, of course, will be difficult to 
prove, but when we look at the facts produced by 
practical experience, enough presumptive evidence 
can be brought forward to indicate that the assertion 
is not without foundation. How do we arrive at the 
facts concerning the statistics of appendicitis? 1, 
by noting operation. 2, by recording results of 
autopsies. But is it not reasonable to suppose that 
the greatest source for statistics for lesser diseases 
of the caput coli is lost in the fact that they recover 
(it is claimed by Treves that 90 per cent, of all cases 
get well spontaneously) so that no autopsies are 
made? I feel convinced that a simple catarrhal 
csecitis with an accumulation of fecal matter, is mis- 
taken for appendicitis much more frequently than 
is generally conjectured, having had at least five 
cases of this kind recently myself which recovered. 
In each, after the acute symptoms were subdued, re- 
peated colonic flushing brought away large quanti- 11 
ties of dry, lumpy, fecal matter and the tumor van- 
ished. In considering this subject we are at once 
confronted by two problems : 1, diagnosis. 2, the 
question of operation. In perusing the literature of 
perityphlitis and appendicitis which during the past 
few years has become extraordinarily voluminous, 
one is struck with the fact that most writers and 
operators take a radical stand for or against opera- 
tive procedure, and those who favor operating are 
again divided upon the issue of 'early or late' ope- 
rations. It seems strange to the casual reader that 
minds experienced in the same line of work should 
differ to so great an extent in considering questions 
of so practical a nature. There is an old maxim, 
'whenever pus is discovered let it out if possible.' 
That the indications for the evacuation of pus in 
this instance are of greater import than in any other 
conditions or locations no one will dispute. What, 
then, causes the hesitation? 1, the difficulty lies 
in finding the pus. 2, the great danger to the peri- 
toneum and its sequelae. The first difficulty the sur- 
geon will always be confronted with in a proportion 
of the cases. The second difficulty will be more and 
ignored as we become more familiar with the work, 
and more perfect in antiseptic surgery." 
Here is common ground where a wise general 
practitioner with large experience and much reading 
meets the specialist, both determined to do the very 
best thing for the patient, and yet they can not see 
alike. 
A man's business is likely to control his thinking 
and induce him to look at every subject from the 
standpoint of his life's work. The farmer deals with 
many-sided questions in a general way. He may 
have a good crop or the seasons may be unfavorable. 
If his crop is good he can not fix the price. The 
price is fixed for him in Chicago or New York. He 
thinks in a general way, not a special way; trusts 
to the seasons and becomes accustomed to many 
disapppintments. The shoemaker looks at the 12 
passing jumbo elephant in no other light than to 
think that if his loose hide had been lasted it 
would cover two elephants. It is the same 
between the general practitioner and the special- 
ist; the one looks at the thing in a general way and 
the other in a special way. They are both instructed 
by association together over a given case. The ideas 
of the specialist are widened. The ideas of the gen- 
eral practitioner are narrowed to a closer study as to 
the particular stage of the disease suitable for opera- 
tive interference; and ultimately we shall, as I believe, 
unite in a mutual faith that when to operate is a 
vital question requiring much skill and surgical wis- 
dom to answer, and even then we will sometimes find 
that our best judgment and conscientious actions 
have failed to save a life. I believe that the special- 
ist should concede much to the experience and judg- 
ment of the general practitioner. What success I 
have had is in a measure due to association with suc- 
cessful, intelligent, general practitioners. I believe 
the specialist should be as a hand maid to the family 
physician, by no means supplanting her mistress 
nor yet usurping her rights but always assisting her 
to maintain them.