"Would you allow yourself to be operated on in a similar manner, by a surgeon with your own qualifications?"

DISCUSSION

DR. F. A. DUNSMOOR (Minneapolis): had the honor of posing as professor of surgery at the University of Minnesota while the distinguished writer from North Dakota was there at college, and also had the pleasure of being associated with him as surgeon for the hospital in which he had his hospital experience. I have to agree and disagree with him. I agree when he values the personal equation, whether swinging the baby, taking out gall-stones, or doing an operation for hernia. There is no man in the country or in the city doing general practice who can be so well equipped as he who is trained in and for a special department, whatever that may be, whether it be eye or ear, obstetrical work, neurotic work or straight surgery. It is the training he gets that counts, and it does not make any difference whether he has to take the hired girl out in the country as an assistant, if she is trained, and it comes down to using the dish-pan for a sterilizer, it is all in the training. He writes about cleanliness of the general practitioner. If the general practitioner is a busy man he has got to be exposed to all sorts of contamination. He has got to see diphtheria, smallpox, scarlet fever and every infectious disease to which he may be called. The theory, which the doctor advances that the person who is doing general work is as competent to do the work as the specialist, is not a true one. You might as well say that about a piano player. If doing business in a general way one could not be an expert pianist. I have been practicing medicine longer than the doctor is old. In my first years of practice I operated upon eye cases, but if a person came to me to-day to be operated on for cataract I should consider the advantages of the eye specialist, and refer the case to him, but when I operated for cataract there was not a specialist in Minneapolis to do it. I do not believe that Dr. Gerrish will advocate that the average farmer's home as a rule is the best place to do surgery. His theory about the comfort to the patient is all right. There is not one of us but what would prefer to be in our own homes when ill, but the place to go for surgical operation is to the hospital. In the first place we can on order immediately obtain all needed things; we have trained nurses to wait upon us in the hospital, we have resident assistants who are competent and we can rely upon the integrity of the employes of the hospital; but in the home we must be wholly dependent upon untrained help. Now to go back, it is a question of training, it is the question of the ability and experience of the individual. There is no one person who can be an expert in all of the departments of medicine, and if

he is an expert in surgery he must be an extraordinary man to keep up his surgical training, and take care of a busy general practice. As regards the advantage of the home influence, I am in favor of it during convalescence. As soon as the patient is able to get on his feet, let him go home in order to get more congenial surroundings.

DR. L. F. SCHMAUSS (Mankato): I can subscribe to everything that Dr. Dunsmoor has said except the reference to home comforts. They may be a benefit, and they may be a disadvantage. We can handle a patient more successfully in the hospital than we can in the home, where he is surrounded by friends that give way to every whim he may have. It is true that as soon as the patient is convalescent he should be sent home, but during a particular stage (immediately after the operation), he can be handled better in the hospital than at home. In a hospital they can keep a room clean because they are not handling pus cases in the same room. I do not think there is a first-class hospital that has not an operating-room and a dressing-room, so that claim falls altogether. Another point is, that it takes twice as long to operate at the home as it takes in the hospital, without considering the question of assistance and other facilities present. It makes such a commotion in the home many times that people will often back out. While I thoroughly agree with the doctor that the house can be made aseptic and clean enough, the practice should never be encouraged, because of the difficulty and length of time required to perform the operation. I think the stand he takes is a dangerous one, and should not be applied to general practice.

DR. J. A. DUBOIS (Sauk Center): I wish to say a few words on this subject. I have been impressed, as the years go by and I have been engaged in the practice of medicine and surgery, with the broadening of the duty which devolves upon the general practitioner. I do not think the specialist in the city sufficiently understands or estimates the responsibility which rests and ought to res: upon the general practitioner. I think the specialists in the city have seen time after time cases sent from the country by the general practitioner which should have been treated by the general practitioner. The general practitioner cannot rid himself of the responsibility of a knowledge sufficient in surgery to perform a great many operations which must be performed by him or the patient's life risked. We have seen cases of appendicitis travel miles and miles for operation which should never have left their homes, and unless the general practitioner is capable of performing that operation he has yet something to learn. I do not say that the general practitioner should experiment with his cases or that he should perform certain operations which belong wholly to the specialist,

but he should be able to distinguish between the cases which should be sent to the hospital and to the specialist and those cases which should not be.. He should also have another responsibility put upon him he should understand enough of the signs to know when to keep people away from the surgeon's hands and when to steer them in. I do not think I am unjust in saying that the surgeon who looks through a surgical light, whose whole professional life has been spent in surgery cases, is apt to be a more or less biased individual, and cases come to him which he considers his legitimate practice when sometimes they should have been sent elsewhere. Who in the country is not familiar with gynecological work where cases go to the specialist for operation and come back to the country physician, and he finds his hands full of trouble in taking care of these morbid people? There is danger of carrying the surgical instinct too far. The future of the patient should be a matter of consideration by the surgeon or operator. The general practitioner should be an honest man and a gentleman. In a case of special work, send it to the specialist, and if your patient has a surgical fad, which is prevalent to some extent, try to direct him the right way if you can see that the future of the patient is not to be made better by an operation. The general practitioner should be able to perform operations, not the most intricate, and he should know when to send patients to the proper specialists, and when to keep them away from the specialist.

Dr. R. C. DugAN (Eyota): I do not think Dr. Dunsmoor gave Dr. Gerrish exact credit for the stand he took in his paper. I do not think he meant to contend that surgery in the country home would compare with that in the city hospital, and that he would have the work done at home altogether. I fully agree with him there. I do not think a case of appendicitis on the point of rupture should be sent two or three hundred miles for the sake of being operated on by a specialist. A great many country practitioners

are not in a situation to get skilled surgery, except at a considerable distance. I think the point he makes that the general practitioner so far as cleanliness is concerned can keep himself just as thoroughly clean as the surgeon who handles all sorts of cases is a

correct one.

DR. W. A. GERRISH (Essayist): Dr. Dunsmoor evidently misunderstands the stand I took in my paper. I did not mean to say that the country practitioner is an all-round specialist. There is only one man who takes that stand, and he is in the Twin Cities. If we wanted to commit manslaughter we would go into someone's abdomen in a case of smallpox, scarlet fever, etc. We are not so inclined. We are rather inclined to direct cases along special lines to specialists, but there is no reason why the ordinary surgical

work should be considered special. So far as chasing gall-stones is concerned, I can see no reason why the gall-bladder could not be drained in a private house as well as in a hospital, although we generally have to take the scrub-girl as an assistant. I still maintain they can scrub a vessel, and with pure lysol they can get all germs out of it. They can also scrub the floor, but simply as a matter of ocular cleanliness. You can use twelve ounces of formaldehyde, and absolutely sterilize that room. It will absolutely sterilize any room. When health officers say that ten ounces will do it twelve ounces will certainly sterilize a room. The doctor, over here, says they do not have pus cases in the same room. They operate on all sorts of cases. How is he going to be clean when he operates on a septic gall-bladder, and the next case is an anterior suspension, and the next may be a hysterectomy, and at the same time the pus is in the room, and we know dried germs are blown through the air, and are helped by some interne who assists in dressings. I have been there; I know what I am talking about, and one cannot get around it. Practically none of the hospitals in the Northwest can keep internes to do the clean work, and others to do the dirty work. I usually use gloves, but I often get holes in them. A man has no business, I don't care whether the operation is done in the City Hospital, at St. Barnabas, in the city of Chicago, or elsewhere, to attempt an operation for which he is not skilled. Only a short time ago I had two cases very near together which impressed themselves very strongly upon my mind. The first was an abscess of a ruptured appendix. This case had an abscess, and there was perhaps a pint of pus behind the cecum. We operated, and that abscess wall was so light that the gentlest touch of the finger in exploring broke the wall down, and we got our pus out immediately. We had an uninterrupted recovery. Suppose we had sent that man to the hospital. He would have died; he could not have stood the journey. A couple of days afterwards I was called to see a woman at midnight. She was taken sick about 8 o'clock. She had classical symptoms of appendicitis, and I advised operation. At II o'clock the next morning we removed the appendix. She had a gangrenous appendix, and if we had attempted to send for a special surgeon we should have lost the case. I could cite case after case where, if we had stopped to send for special help, we should have lost the patient. I still maintain that a man with requisite skill to perform operations can do this work. I do not mean to say that a man who can perform an appendectomy is an abdominal surgeon, but a man with the skill to operate in the hospital has a license to operate in any house, I do not care how small or how great, or how rich or how poor the people may be. (Applause.)

TUBERCULOSIS

A PREVENTABLE DISEASE,

WITH ESPECIAL CONSIDERATION OF THE DISTRIBUTION OF TUBERCLE-BACILLI AND THE USUAL AVENUES OF INFECTION

J. FRANK CORBETT, M. D.

Minneapolis

Tuberculosis is undoubtedly infectious. Isolation is impracticable. In order to prevent the further spread of this disease we must understand the distribution of the tuberclebacillus and the usual avenues of infection. Baumgarten, in an article on immunity, says: "I have found that every guinea-pig and every rabbit is absolutely susceptible to infection by tubercle-bacilli. The size, age, nutrition and strength of the animal has no influence on result. * * * When bacilli are present in requisite virulence and number, infection invariably occurs."

That spontaneous tuberculosis is rare in guinea-pigs, in connection with the above emphasizes the importance of access to vital parts of virulent bacilli, and minimizes individual susceptibility.

In considering the distribution of tubercle-bacilli and other tubercle-like organisms, the most common are the grass bacilli, first mentioned by Petri. These include the species now known as mycobacterium lacticor planum and mycobacterium phlei. These organisms occur commonly in grass, hay, manure, milk, and butter. They stain the same as tubercle-bacilli, and on inoculation produce lesions somewhat similar. A guinea-pig inoculated with these will not die, but at the end of six weeks the viscera of the animal will present numerous nodules on the peritoneum and in the lungs. The structure of these nodules may be the same

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