Schönberg whom he quotes. Knowing the antero-posterior diameter of the thorax, the position of the median plane of the heart, and the distance of the source of X-rays from the plate, it is a simple matter to compute the factor of reduction and obtain the parallel ray silhouette area. The patient is examined in the sitting position because the heart is then subject to the smallest physiologic variations in size. In the standing position the heart was found to be, on an average, 13 per cent. smaller than in the prone; while in the sitting posture it is, on an average, 6 per cent. smaller. These changes in size are associated with changes in the hydrostatic pressure in the inferior vena cava and with the volume of blood accumulated in the venous systems. Bandaging the lower extremities materially reduces the differences in heart volume due to changes in body posture. It is a reproach to clinical methods that so little regard has hitherto been placed upon these changes in heart volume. Hereafter the clinician as well as the roentgenologist must specify the position of the patient in dealing with the size of the heart. It is apparent that the sitting position is the natural standard and is particularly to be chosen so that comparison of results may be made with the Bardeen tables. The one inherent weakness of the Bardeen method is the necessity of completing the outline of the heart from auricle to auricle across the aorta and from apex to right auricle where the liver shadow joins that of the heart. To minimize the possible error Bardeen advises that the patient be given an effervescing drink before the X-ray exposure is made so as to distend the fundus of the stomach with gas. The apex and a part of the lower heart border will be defined by this maneuver. Bardeen made repeated tracings from the cadaver and by subsequent dissection demonstrated that the error from this source in estimating the true size of the heart is negligible. Nevertheless a personal equation is here introduced and the judg ment and experience of the examiner became factors in the final result. Various intrathoracic diseases may obscure the outlines of the heart to a greater or less degree so as to make the Bardeen method impossible. Examples are pulmonary tuberculosis, pleuritic effusion, empyaema, mediastinal tumor and aneurysm. Fortunately in such conditions heart volume is not often of diagnostic importance. Such diseases also interfere with the usual clinical methods. Prior methods of X-ray estimations of heartsize consisted in the measurement of one or more diameters of the heart silhouette obtained by some specified technique. Such a diameter was compared to the diameter of the chest or to the size of the patient but no recognized tables existed and no standard method was agreed upon by roentgenologists. Likewise in works on clinical diagnosis no tables of heart volume compared to weight and height of the individual are to be found, doubtless because the determination of heart size by percussion and auscultation is so admittedly inaccurate that a table would be a supererogation. The position of the apex beat in relation to the nipple line is the almost universal criterion of heart volume used by the average clinician. This might be of more value if the apex beat represented the true apex and if the nipple line bore anything like a constant relation to the anatomy of the thorax. In short, prior X-ray and physical methods were so wanting either in standardization or in accuracy that the Bardeen method finds itse' virtually without a competitor in furnishing the most fundamental datum in the clinical examination of the heart. ETHICS.* R. H. SPENCER, M.D. The wrong-doer never lacks a pretext. No matter how crooked and insincere his ways, no one would be able to prove that he acted from unworthy motives and not from ignorance or error of judgment, even if the most flagrant violation of the glorious Golden Rule laid down by Confucius and quoted by our Saviour: "Do unto another what ye would he should do unto you, and do not unto another what you would not should be done unto you.". Truly a world of ethics in a nut shell, an ocean of morals in a drop, yea, the essence of all religion. The absence of the above code is no doubt the cause of the bloody war through which we have just passed, as the German motto was: "He may take who has the power, and he may keep who can." Dr. Thomas Percival, an English physician, in a small book published in London in 1807, proposed an admirable code of ethics which, excepting a few alterations made necessary by the advance of medical science, is the identical code adopted by the A.M.A. and which from then *Retiring President's address, Kent County Medical Society, December 18, 1918. until now has instructed and guided our profession. In 1903 by unanimous vote of the A.M.A. at New Orleans the old code of 1847 was rescinded by setting it aside and substituting a series of suggestive and advisory aphor isms designated as: Principles of Medical Ethics, among which is the following noble paragraph: "The broadest dictates of humanity should be obeyed by physicians, whenever and wherever their services are needed to meet the emergencies of disease or accident." The highly important change secures every man's liberty and removes all clannish restrictions and penalties, and leaves Surgeons, Specialists and all others absolutely free to consult with Dr. Orthodoxy or Dr. Heterodoxy, or Dr. Homeopathy or Dr. Eclectic, or Dr. Anybodyelse, when either emergency or any other impelling motive inclines him to do so. This great change is not only like a ladder let down from Heaven to hundreds of thousands of the afflicted, but it also forever frees the reg ular profession of America from the old charge of "bigotry" and starts it on a still greater path of progress. Of the prevailing tendencies in medicine, the one most to be deprecated is that to commercialism. It is perhaps not surprising that our profession, in common with other callings, should feel that baneful influence of this spirit of our age. It is an evidence of the fact that, in the public mind, financial success has come to overshadow every other form of achievement. The law, it is said, has almost ceased to be a profession and has become only a business, adopting business methods and business standards. May this never be true of medicine. It is perhaps not to be expected that human nature should be changed by attaining the dignity of affixing to one's name the letters "M. D." There are several ways in which the commercial spirit may manifest itself in medicine. One of the most common springs out of an inordinate ambition for immediate success. It is not natural, it certainly is not desirable, that great professional success should come at once to a young physician just out of his college or hospital. Time is necessary for experience to accumulate and judgment to ripen. "He who makes undue haste to succeed shall not be blameless." That shrewd advertising may bring business in medicine as well as in trade, the success of the numerous chalatans bears witness. But he does not wish to become an advertising quack and see his card in the morning paper. He adopts other devices. He advertises himself to his friends and acquaintances. His wife bends all her energies towards placing him before the public. He cultivates the acquaintance of the newspaper reporter, and soon his name finds its way into the Public Press. He is interviewed in regard to the prevailing epidemic, to remarkable operations, or with some new ideas on the subject of the treatment of T. B. He is apt to advertise to his patients and acquaintances that he is upto-the-minute on the latest treatment and is injecting serums of various kinds into nearly every patient that he sees because it appears to be something new, without regard to any proven merit in the serum. This has two purposes it makes a mental impression on the patient, and is an excuse for exacting a larger fee. There are ways innumerable in which the advertising doctor seeks to advance himself. To narrate is neither profitable nor interesting. To some, such practices as those described may seem only in bad taste; others, possibly, may regard them as examples of an enterprise almost meritorious. But it is difficult to draw the line as to how far one may go and yet preserve his reputation. Vaunting ambition and a desire for financial success lead to and finally end in practices absolutely dishonest, and soon lead on to the policy of doing operaations which are not positively indicated for the sake of the fee. This is a subtle temptation to every physician or surgeon whose eye is always upon the almighty dollar; but it comes. with increased force to one whose financial needs are great, his vision of right and wrong must be very clear and his ethical standards high not to be biased in such emergencies. He begins by contrasting his own small fees and income with those currently reported of the specialist or surgeon. "Why should I not receive a suitable commission for the business I can control? There are plenty of skillful men who are willing to divide the fee with The patient is well served. Who then can complain?" Such a man belongs in business, not in a profession. me. serious and even criminal abuse of professional confidence if physicians were not what they are as a class honest, upright men who desire to do the best for their patients. Unfortunately, it is equally true in this, as in other folds, there are black sheep-dishonest men who ought to be drummed out of the profession. But this cannot be laid as a charge to the physician, as a class. Is there any class of men free from undesirable members? Even among the angels, we are told, "there was one who fell." Mind you, I do not defend secret fee splitting. I think it is wrong and undignified. I believe it secures something to the doctor in an underhanded way to which he is justly entitled and which he should receive openly. That I may make my meaning clear, I shall here make a statement which probably will be followed by some criticism, as it will illustrate my meaning better than in any other way. I will cite a case in point. A woman consults her family physician for an acute abdominal trouble; the doctor makes a shrewd and correct diagnosis of ovarian cyst with twisted pedicle; the patient is ordered to the hospital and a surgeon called; the surgeon accepts the diagnosis of the attending physician; patient is prepared and operated upon; operation reveals that attending physician had made correct diagnosis; surgeon does not see the patient again. Physician looks after all postoperative treatment for two or three weeks till patient returns to her home, fully recovered. Now comes the fee splitting part of the recital. Patient asks, the doctor for her bill; he makes a bill for $250, this to include the surgeon's fee; surgeon receives check for half the above amount, $125. Patient knows that the fee was divided and was perfectly satisfied. Surgeon was satisfied and stated that the fee was $25 more than he had expected. All parties interested were perfectly satisfied and there was no secrecy. The family physician had received a fee commensurate with the accurate diagnosis and the after treatment, to which he was entitled. If the above method of fee splitting is followed to the letter, I can see nothing that is unethical about it, and the case illustrated is only one of many, in which I have followed the plan above stated. People have become accustomed to think rather lightly of the general practitioner who, however strenuous and anxious in time. stress, is usually unobtrusive and anything but spectacular. Compare with it the compli cated machinery and the strange surroundings, and the whole array of awe-inspiring instruments, further the skilled and deft attendance of nurse and assistant, all combined to create a deep impression on the patient and his friends. The subordinate patronized position of the family physician, in the presence of the surgeon and his corps of assistants, who may not be half as capable as the modest country doctor, further contribute to lower him in the estimation of his clients. The attending doctor's fee is too frequently forgotten, or if remembered, set aside. All the money is needed for the surgeon and the hospital. An operation is something definite, something tangible. Notice how in a meeting of a lot of old women, some of whom "have had an operation," had one or the other organ removed, and conversation turns into an "organ recital" with obligato reflections on the shortcomings of the attending doctor. People are not, or are only in a measure, afraid of operations. At least they like to have been operated upon. It confers a sort of distinction and furnishes an unending supply of material for conversation and gossip. Nor is the money question considered of paramount importance. A surgeon's bill of two or three hundred dollars with all the fixings of hospital expense is a delicious morsel. People pay without hesitation far greater fees to Christian Scientists, Osteopaths and advertising quacks than they would stand from their home doctor. Just a word at this time about fees. Several of the members of the Kent Co. Society have asked me if I would not bring up the matter ground that the high cost of everything that of establishing a fee bill for the Society on the we use has increased from 50 to 100 per cent., thereby justifying raising the fees that we have been hitherto charging. My personal view of the matter is that physicians of all classes must learn to make charges commensurate with the value of their services. Fee bills hinder in this. The fee bill is the Union scale. It bolsters up the incompetent and often prevents the high class, scientific man from getting his desserts. A hide-bound fee bill and an increasing lack of appreciation of the practitioner's value dwarfs him and compels him to resort to questionable methods for playing even. He must learn to elevate his standing by special fees for his improved methods of diagnosis and treatment. These have been acquired, perhaps by special post-graduate courses, time abroad, and special equipment, and yet his price per visit or consultation must be governed by the fee bill. I see no objection to establishing a skeleton fee bill which would be something to refer to, as a reason for increasing our fees at the present time to keep up with the high cost of living. As an illustration, I have sent out on my monthly statements to my patients that "since Sept. 1st, house-calls, $3.00; office-calls, from $1.50 up." Thus far, no complaint has been made. An address on ethics would not be complete without a word concerning criminal abortion. In a book entitled "The Physician Himself," published in 1906, written by D. W. Cathell, M.D., I have found the following from which I quote: "When you are importuned to produce abortion, on the plea of hiding from the world. the yet-undiscovered guilt and saving the poor girl's character; or preventing her sister's heart from being broken, or her father from committing murder or suicide, or him who has taken criminal advantage of her from being disgraced; or to avert the shame that. would fall on the family; or the church scandal about one of the weak brethern; or to limit the number of children for married people who already have as many as they want, or who are just married and do not want the inconvenience of children so soon; or to accommodate ladies who assert that they are too sickly to have children or that their suckling child is too young to be weaned; or that they have been pregnant only a short time; to dry the tear that falls from beauty's cheek, or to avoid other anticipated evils; and that if you do not do it some one else will, we beg you, brother, by all the gods at once, not to stop to discuss the subject with a 'h'm' and 'haw' but meet such entreaties and arguments with a refusal prompt, strong and positive and don't even let yourself appear to entertain the proposition. If they are too importunate, inform them that they have entered the wrong door, and express your sentiments in unmistakable, upright, downright, outright American frankness; and then bow them out; but remember that these are terrible secrets, and seal your lips doubly tight. It is always safe to do right and never safe to do wrong." With victory in the war against German autocracy, is the war against venereal disease to cease? Have you read extracts from letters to civil authorities from W. G. McAdoo in behalf of the U. S. Public Health Service? If so, you have been impressed with the fact that Mr. McAdoo knew something about health measures as well as selling "Liberty Bonds" and running railroads. I append a few quotations from him: "Under the protection of the military authorities, four million soldiers and sailors received greater protection against venereal diseases than they received before the war in civil life. The cities and towns through which they go and to which they will return upon demobilization must be made safe. The fight ** ** must be vigorously continued. Extract from telegram to governors from Newton D. Baker, Secy of War. "Signing of armistice in no way lessens responsibility of civil communities for protection of soldiers from prostitution and sale of liquor. Our states and cities ought never to lose the control which has been established or stop so vital a work. War Department is determined to return soldiers to their families and to civil life uncontaminated by disease." Extract from statement by Josephus Daniels Secretary of the Navy. "One of the compensations for the tragedy of war is the fact that an enlightened opinion is behind the organized campaign to protect the youth against venereal disease. The campaign begun in war to insure the military fitness of men for fighting, is quite as necessary to save men for civil efficiency." All of the above will show that venereal diseases are a peace problem, and our Society should take hold of it and give it the attention which it deserves, and we should use our best endeavor to extinguish the light in the Red Light District. In writing of ethics, one becomes enthused by the topic and is apt to go on at too great a length, consequently I will close by saying that the preceding is the situation which is now confronting us and it is high time to separate the sheep from the goats, if medicine is a profession that stands for something more than mere commercialism, if it possesses every quality that is honorable and noble. Let us do nothing to disgrace it. We should rather raise it until it has reached the climax of ethics and its standard has become the highest obtainable. REPORT ON SIX HUNDRED AND THIRTY-EIGHT HERNIOTOMIES PERFORMED DURING MAY, JUNE, AND JULY OF 1918. W. T. DODGE, M.D., F.A.C.S., Maj., M.C.U.S.A. CAMP SHERMAN, OHIO. (Chief of Surgical Service, Base Hospital, Camp Sherman, O.) May 1, 1918, the Surgical Service at this hospital was notified that the 158th Depot Brigade contained approximately five hundred men who were awaiting operation for hernia. During the previous existence of this hospital a few herniotomies were performed but on account of the existence of various camp epidemics involving a tendency to bronchial and lung infections, no attempt had been made to clear up the large number of hernias admitted to the Camp for remediable purposes. It was the order of the Division Surgeon that only such cases be operated upon as presented a reasonable prospect of success from a military standpoint and that large hernias with weak abdominal walls should be refused operation. A member of the Surgical Staff was designated to examine all the cases and as a result of his examination, approximately 10 per cent. of the cases were rejected and discharged from the service. The number of cases remaining was four hundred and ninety-two, presenting six hundred and thirty-eight hernias, classified as follows: Inguinal, right, complete Inguinal, left, incomplete 128 190 83 207 7 12 11 638 The personnel of the Staff at the Base Hospital is constantly changing as its function is not only to care for the sick and injured, but to serve as a Training School for Officers, Nurses and Enlisted Personnel. Consequently officers are frequently leaving on assignment to overseas units and others are as constantly reporting from civil life or from Training Camps. It was the custom of the Chief of this Service, (during the period covered by this report Major C. T. Sturgeon, now Chief of Surgical Service in Unit No. 108) to assign each. member of the Staff for his turn in the Operating Room, either as operator or assistant, the usual practice being to assign two as a team at one table, who alternated as operator and assistant. Therefore the number of operators concerned in this series was very large. It was also left to each operator to decide on his own technique. It would then be reasonable to conclude that the results in a large series of cases would not be so favorable as in a similar series operated by one skilled and experienced surgeon. There were numbered among our operators many distinguished and experienced surgeons, but there were also many young men fresh from internships. It was the custom to associate these young men with the experienced and thus afford them instruction in operative work. At first there was much difference in technique used, but later the practice became quite uniform. In the majority of cases the sac was separated and ligated high up and permitted to slip up under the Internal Oblique and was not Kocherized. The shelving edge of Poupart's Ligament was attached to the Conjoined Tendon with No. 3 chromic catgut sutures and the cord transplanted, the External Oblique being sutured with continuous chromic gut. Skin and superficial fascia were closed with interrupted silk worm gut sutures. In ninety-four cases the cord was not transplanted, this being the only distinction between the socalled Bassini and Ferguson operations. The routine of preparation for operation was the same for all and was as follows: The patient's abdomen was scrubbed the day before and shaved and the abdomen covered with sterile gauze, which was removed in the operating room. Castor-oil was given two days previous to operation if the patient was in the hospital in time. Under no circumstances was |