it work to the advantage as well as to the disadvantage of a family. Dr. Oliver Wendell Holmes once referred to a family, now of the highest standing and of great service to humanity, the progenitor of which was considered a man who would never be of value to society. While in a state of depression. this man met a young lady in whom he became interested, and in due time they were married, and from that union sprang this most useful family. This law of heredity has for its working the benefit of humanity; it is that which makes for the survival of the fittest. May we not look for a social advancement that will reduce this 20 per cent., which the author mentions as due to alcoholism? It is a study that will require the efforts of the schoolteacher, the minister, the judge-in fact, all who have to deal with the public-in a careful study of genetic and social psychology. The author's statistics are apt to be misleading. He states that in Illinois, while the population has increased but 89 per cent., the number of people treated in institutions has increased 369 per cent. Let me explain: This statement applies to the treatment of all mental cases. Up to a few years ago Illinois had many mental cases in the county houses. Recently most of these patients have been placed in institutions, and consequently this gives a misleading view, from a statistical standpoint, of the situation. I dare say there has been an increase of insanity in Illinois, but there has been a very great increase in the number of patients placed in institutions. It is the plan ultimately in Illinois to have all of these patients placed in institutions. As to treatment, the statistics from one hospital will give a percentage of recovery of 2 per cent., while another will give 10 or 12 per cent., or more; but in a hospital where the cases are thoroughly studied and classified, as in New York, we will see that there is a hopeful aspect to the statistics. Yesterday Dr. Russell, State Inspector of New York hospitals for the insane, informed me that in New York State 47 per cent. of the patients who have come to the State hospitals are able to return to their homes. Of that 47 per cent. it has been stated that 25 per cent. have recovered, 22 per cent. have recovered sufficiently to be at home. Of the other 53 per cent. a considerable proportion are senile and more or less dependent. So statistics are somewhat misleading. We need social legislation, but I doubt very much if we are ever going to legislate effectively on sterility and marriage. But we must teach what constitutes the defective state, and in that way interest our legislators. One of our most advanced legislators delivered an address as a result of observations abroad. He stated that it would take some time to get the people sufficiently educated to bring them to the Doint of asking for social legislation. In Illinois we have a committee on social legislation in our State Conference of Charities, with Prof. Henderson, of Chicago University, at its head. We hope some day to be able to present a wholesome, reasonable and humane plan of legislation that will work for the gocd of humanity along legislative lines. Do not let us plan for the unreasonable, nor go off on tangents which will only react to the discredit of our profession and the good we hope to accomplish. In regard to the inspection of public schools, St.

Louis perhaps leads in the United States on the question of school inspection, outside of New York. Dr. James Stewart has four or five schools for defective children under his direction which are certainly worthy of investigation.

DR. A. E. STERNE, Indianapolis, Ind.: I must say that both sides (both the paper and Dr. Norbury's remarks) are open to discussion. I am inclined to believe that what Dr. Norbury has said in regard to Dr. Craft's paper should not be taken too literally. While Dr. Norbury may have overlooked the fact that in all our States we are trying to segregate our insane, nevertheless I think there is a general increase in insanity; yet I agree with Dr. Norbury that the outlook is not so gloomy as Dr. Craft's paper would indicate. First of all, no disease is hereditary. I do not believe even syphilis is hereditary. It may be congenital, but it is not hereditary. In saying that a disease is hereditary, we mean that the disease exists in its primary conception that it is "born in," that it exists in the ovum or the spermatozoön before they have become united. But when a disease is hereditary, the ovum is killed, and we see that in syphilis. That syphilis can be congenital there is no doubt, but when the child is born syphilitic the mother is syphilitic. Furthermore, we deal with predispositions in all our tendencies as human beings, but I believe that in looking at it in an educated manner we should be careful to look thoroughly into this question of heredity, but we should not teach it. I believe many a man and woman has become insane or committed suicide because there was some insane member in the family. I believe a great deal of damage is done by this doctrine. We should understand it thoroughly. I take it as a duty of mine not to preach the theory of heredity to a patient whose father or mother has had some psychosis. I think it is true that an organic disease cannot be transmitted. The offspring of a paretic is not necessarily in danger of paresis. The offspring of a person suffering from a psychosis pure and simple is in more danger of suffering from some psychosis than the offspring of an individual suffering from an organic disease.

DR. L. H. MONTGOMERY, Chicago, Ill. Regarding immigration mentioned by the author, I dwelt somewhat at length on that subject in a paper read at Atlantic City last summer. Some other points will be mentioned in a paper to be read this afternoon, which I refer to in my paper, so I will not discuss those now.

DR. J. A. STUCKY, Lexington, Ky.: No more important topic will come before the Society than the one we have before us now, because of its broadness. I have been watching the negroes very closely in the last fifteen years, and I have found that adenoids and sinus disease are increasing, and the more civilized they become the more frequently these conditions occur. We have the problem of educating the masses, and we must be careful, as Dr. Sterne says, what and how we teach the masses. I do not believe we inherit anything that we cannot overcome. But we must begin with the motherhood of this generation. The average mother is not a fit companion for her child. She is morally and socially, but from a sanitary standpoint she is not. Before the child is born the mother should be taught

not only something about maternity but about raising children. They have in Europe schools for mothers. As to what has been said about alcohol and the venereal question, we must handle both subjects, and handle them without gloves, but, as Dr. Sterne has said, we must be careful not to suggest the very thing we want to prevent. Many people become insane because a grandparent was insane, and they expect to inherit the disease.

DR. NATHAN ROSEWATER, Cleveland, O.: I feel that I must call attention to one point, and that is in reference to the time at which Dr. Crafts would start children to school. I do not think there is anything to prove that any of the children are injured in health by going to school at six years. On the contrary, I believe that children are better off under teachers that have been trained for the proper care of such children than if they were left at home until ten years old and then do all that they are expected to do now-a-days. I believe they must get this preparatory training and teaching early. Mothers, especially the nervous ones, are often glad to get rid of their children by having them sent to school. The school is a better environment for such constantly nagged children. Children that have been absolutely unmanageable at home will go to school and see everybody quiet and orderly, and they will gradually become orderly too.

DR. C. W. STILES, Marine Hospital Service: One statement has been made here which I can hardly let pass without qualification, namely, that there is no such thing known as an hereditary disease. We know of a number of infectious diseases among the lower animals which have been demonstrated as hereditary in the strict embryological sense of the term. Thus certain spirochetes, pebrine disease, and certain plant cell infections come within this class. It seems best, therefore, to be careful in generalizing on this subject, for since hereditary infectious diseases do exist among the lower animals, it is entirely possible, theoretically, that we may find such in man also.

DR. CLARENCE N. FRAME, Ewing, Mo.: We may not have hereditary disease, but we certainly do have hereditary conditions or tendencies. Those who were almost if not quite idiots have married, and they have brought into the world children no more intelligent than themselves. I have yet to see a case of the feeble-minded who brought into the world children of intelligence. I doubt if the feebleminded individual is capable of a sentimental love, but he is capable of sexual love, and for this reason I am heartily in favor of legislation on this subject. DR. F. B. TIFFANY, Kansas City, Mo.: Relative to subject of heredity, I wish to say that in a very large percentage of cases of cataract I have found that one or both of the parents had cataract. No child is born myopic. That comes on later, and they are usually the offspring of myopic people. All babies are hypermetropic. In most cases of mixed astigmatism one or both parents has some error of refraction. Frequently one has hypermetropia and the other myopia. Emmetropic people do not have myopic children. These conditions are not induced by disease or trauma, but are inherited.

DR. H. N. MOYER, Chicago, Ill. It seems to me we are getting into pretty deep water. When you

come to treat the subject of heredity statistically, we are at sea. You cannot separate heredity and environment. Take the case of the drunkard. What does drink do for the family? It changes for the family the environment; it means poor food and lack of care, and a large number of the tuberculous have drunkenness in the ancestry. Does drunkenness cause tuberculosis? No; but it alters the social status, it means poor dwellings and poor food, and the result is tuberculosis. There is where heredity and environment are hopelessly intermingled. In conclusion, I would ask the essayist whether he considers civilization an advantage. Does he consider that we are civilized, and does he think we have reached the top, are we standing still, or are we going down?

DR. STERNE: Dr. Stiles said there was no hereditary disease. I took care to say that when there is a disease in the ovum of the human there is an abortion. That there are congenital diseases it is true, but at present we know of no strictly hereditary disease in the human subject. We are, of course, talking about human beings, and not of lower ani

mals.

DR. STILES: It is entirely in comparative medicine that hereditary infections have been demonstrated. DR. SANGER BROWN, Chicago, Ill. I think the consideration of such topics as the relation of bodily or mental defect to marriage belongs more to medicine than elsewhere, but it is a very important matter to the whole community. We are sometimes unjustly accused of being chimerical for presenting such views as the essayist has presented as to what should be done in regard to the question of marriage. I agree that the situation exists, and that something should be done to improve matters, if practicable. We should not lose sight, however, of what the legislator has to consider when these subjects are brought before him. He represents the whole people, and he cannot with any benefit enact a law until the mass of the people are ready to understand and insist upon it. I confess I cannot see far enough ahead, unless our social system should be entirely changed, when it would not be productive of far more harm than good to compel every one to get a certificate of health in order to get married. It would tend to do away with all sentiment, and when we study these matters carefully we begin to realize how much we are controlled by sentiment. I doubt if it would be beneficial to reduce this matter to a stock-raising proposition. If a family shows a tendency to some hereditary disease, the intelligent members of that family will frequently decline to marry, so that no legislation is required so far as they are concerned.

DR. CRAFTS (in closing): The paper was given to bring out just the thought and discussion it has elicited. The case referred to by Dr. Norbury is the shining exception that proves the rule. His interpretation of the Illinois statistics does not explain. All cases under care in all institutions were enumerated. A part of the increase is accounted for by the freer use of State hospitals by the people, but only a part. And all statistics at hand show that insanity is steadily on the increase. As to the question of school age, every child should have sound physical development first, which is best ob

tained in the outdoor world. Our teachers have no suitable training whatever in fostering the nervous and physical unfolding of the child. Sentiment or blind prejudice should not be permitted to interfere. It is not intended to reduce marriage to a "stockbreeding basis," as has been suggested, but only effectively to prohibit the union of the manifestly unfit. Whatever may be the fact as to the inheritance of actual disease, we all know that cell protoplasm takes inherent tendencies, and nowhere is this more true than of the brain cell.

As to Dr. Moyer's queries, I will return his question by asking him first to define what civilization is.

SOME ELEMENTS OF SUCCESS IN SURGERY.*

BY A. H. CORDIER, M.D., KANSAS CITY, MO.

N selecting a topic to write on for this meeting it occurred to me that to recite some of the causes of surgical failures and their remedy would, at this time, not be altogether out of place. At one time, not so long ago, the line between the surgeon and the practitioner was a distinct one. Yet, scattered over the country, were to be found some practitioners who were recognized in a limited territory as possessing special surgical skill, McDowell, Dudley and others, as an illustration. Had these same men lived in this age their work would rank with the best. At the time they lived their work was justly stamped as the very height of surgical skill and progress. No surgeon at this time has equalled Dudley's percentage of recoveries in stone operations. He had neither anesthetics, antiseptics nor modern hospital facilities. There must have been something about his work that stamps him as a surgeon of much skill and good judgment, or else our modern surgeons are deteriorating from

some cause.

I trust I may be able to call attention to some of the causes of our failures and the remedy for the same. Modern asepsis and anesthetics are in a measure responsible for some failures, but who for an instant would think of doing surgery without both these aids?

If your surgical technique is done in a masterful way, you will have only four ever present dangers to combat-that is, time, sepsis, hemorrhage and the anesthetic. Of course, there are the accidental deaths from unusual causes that must be thought of, but there is no way to foretell or forestall them only in a general way.

The older operators were skilled and dextrous to an esthetic degree, as their work was done on patients who were conscious and suffered from the delay of a slow operator.

What is meant by the term surgical success? Surgical success does not stop at the end of the an

*.Read before the Thirty-fifth Annual Meeting of the Mississippi Valley Medical Association, October 11-14, 1909.

esthesia, neither does it cease with the expiration of the possible shock, hemorrhage and inflammatory period; the work is not completed at the end of the ordinary convalescence. Surgical success is far reaching in its true meaning. True surgical knowledge can be gained only by comprehending the basic principles of anatomy, physiology and pathology, to which must be added the ability to execute in a surgical manner the mechanical procedures necessary to restore these disturbed, changed organs and tissues. Many surgical operations are strictly lifesaving procedures, while others are only comfort giving, and a third class are function restoring. The complications following a primary disease are often far more disastrous than the original disease. An appendix may become inflamed, suppurate, form an abscess, open into the cecum and the patient recover from his attack, yet within a few months die from intestinal obstruction. The same is true following many surgical operations where the work is incomplete. Thorough surgery should be carried out when possible. If not at the primary operation, owing to the condition of the patient, the procedure should be completed soon thereafter. No one has a moral, surgical or other right (with rare exceptions) to begin a surgical procedure in any part of the body unless he is surgically qualified to compete with any unlooked-for complication liable to be met with in that locality.

Our medical schools, the teachers, the short postgraduate courses and the surgical demonstrations to transients, of individual operators, are in a measure responsible for the many disasters in surgery that are of daily occurrence. This is no idle fancy of mine, but can be seen any day if you will visit the open-door hospitals or the many private sanitariums that are springing up all over the country. I do nct desire to do an injustice to the well-qualified surgeon, with his private hospital, he who has by hard conscientious labors fitted himself for this great work. All credit is due him, and of such there are many. It is the young graduate who, with no practical experience as an assistant, with no hospital training; or the older practitioner who takes a post-graduate course of six weeks in all branches, suddenly blossoms out as an universal specialist; or he who witnesses a few operations. by a skilled surgeon, goes home, takes a night's sleep and awakens the next morning a full-fledged surgeon, in his mind. I am dealing in truths, not exaggerations, when I make these statements.

Now, what are the results of this state of affairs? Operations are begun that if completed are attended with a high rate of mortality; if they are not completed, the case is pronounced an inoperable one, and the patient goes from bad to worse, and either dies or seeks a surgeon who completes the operation with much difficulty and an increased mortality, caused by the previous failure and delay. Organs are sacrificed and functions are destroyed by untimely delay and bad surgery. The patron of the

surgeon has much coming to him, and our every effort should be to give him all that skilled modern surgery implies.

Honesty and sincerity of purpose should ever be the aim of the surgeon. It is not right to let any other than surgical indications dictate the course to be pursued in any case. No one should operate on any case where he expects only to get “a rare specimen, surgical calisthenics and a fee." There is always something coming to the patient. It might seem to some that this part of my paper is an unjust slur on the good name of our grand and noble profession. The good and noble are not hurt, the other fellow should be.

That anesthetics have reduced the premium on quick work may be demonstrated in many public clinics and private operating-rooms. Too much time is often consumed in discussing Bill Jones's operation, John Smith's needle or Brown's theory, during an operation. It is better to all concerned. to demonstrate pathology in the laboratory or in the specimen basin after the patient has been put to bed, than to waste valuable time in the midst of the operation, sectionizing a tumor, or to discuss pathology, at the patient's expense, with onlookers.

I am a firm believer in extending all courtesies to my visiting doctor friends, but my first duty is to my patient, which can be best subserved by observing strictly surgical principles and avoiding that which jeopardizes his or her safety. It is only too often necessary to discuss a pathological condition early in an operation in order to determine the course of surgery; however, this should be gone over as carefully as possible before beginning the operation. Everything else being equal, the quicker a surgical operation is skillfully done the less the mortality and the more comfortable the convalescence. Reckless surgical haste is not quick skilled surgery.

More deaths are caused from the anesthetics after the patient has been returned to the bed than while on the table. There are some patients whose general or local condition is such that the anesthetic may prove disastrous in spite of all precautions. This class is rare. Besides this class there are two principal reasons why the anesthetic brings disaster. One is the fault of the surgeon, the other the want of skill in the anesthetizer. If the surgeon orders his patient anesthetized before he is ready to begin his operation, he is wasting valuable time and disregarding the interest of that patient. I have seen patients ready for the operation while the surgeon was deliberately getting his instruments out of his kit to be put in the sterilizer. If the surgeon prolongs the operation, the patient will have an increased danger from the ether or the drug used as an anesthetic.

I find many anesthetizers who seem to lose sight of the fact that they are giving the ether to a hu man patient and not to an animal. Even with the patient profoundly anesthetized, the ether is poured

on until the patient is completely saturated-"etherlogged," so to speak. The work of the surgeon and his anesthetizer should go hand in hand, both looking to the interest of the patient, not each looking out for his individual reputation. Ever have the patient's welfare at heart, and your good name and reputation will not suffer. At the same time your mortality will decrease.

The advent of some surgical procedure, like a recently discovered explosive, usually claims a few victims until placed in a gun of a proper caliber. There is a disposition on the part of some surgeons to overload their patients with novel and untried procedures. It is essential that the surgeon avoid the rough handling of delicate tissues and important organs. Many a simple, safe and curative procedure is converted into a complicated and dangerous one, resulting in a failure, by unnecessary and unsurgical manipulations. If the surgeon in the midst of any abdominal operation is rough in his technique, he will have an added mortality.

The convalescence of any patient will be uncomfortable and prolonged in proportion to the manner in which the operation was performed.

We are (or should be) all about equally informed on the limitations of the proceedings for the relief of cancer, yet do we always observe strictly this line of demarcation between the non- and operative cases?

Cases of widespread malignancy are subjected to surgical procedures, with a high primary mortality, with no temporary relief and no expectation of a cure. Such procedures are neither warranted, just nor surgical.

Lutz, of St. Louis, at the Missouri State Medical Association, said of cancer: "The charlatan only, and quacks and ignoramuses, instill false hopes of recovery into the hearts and minds of the doomed victims in exchange for their gold." While a little overdrawn, there is an element of surgical truth in the statement when one sees the hopeless cases being operated on by some surgeons who are not classified as charlatans or ignoramuses.

No stumbling block should be placed in the uphill and hard-to-navigate path of those who are faithfully and patiently travelling toward the discovery of the cause and a remedy for this terrible disease.

It has been shown that in some individuals there exists a peculiar and dangerous idiosyncrasy to the inhalation of chloroform. This condition is known. as "status lymphaticus," is not easily detected beforehand; hence, as an anesthetic, ether should be given the preference. I am afraid of chloroform in any case. The presence of a thymus, bowing of the femurs, and, in the male, pelvic hairs of a female type, have been enumerated as aids to a diagnosis of this condition.

A surgeon, to be successful in his work, should. be able to skillfully perform any operation he undertakes. In other words, the surgeon should recognize the fact that the concentration of one's work

along a given line brings special skill in that department, be it eye, brain or throat surgery. Our patients are entitled to the best class of work they can obtain in their vicinity. I have never yet been quite able to accept the dictum, “Operate on any case in any department of surgery when you get an opportunity."

Too much stress cannot be placed upon the importance of keeping the patient's blood in his vessels during the operation and the necessity of securely guarding against post-operative bleeding. Improper ligature material in a large number of cases, or a wrongly applied ligature on a large vessel in closed cavities, as the abdomen, has, with rare exceptions, increased the surgeon's mortality. Where you find a surgeon reporting several deaths from the shock following an abdominal operation, probably simple in its character, you may rest assured that some of these deaths were due to undetected post-operative hemorrhage.

With the advent into the operating-room of rubber gloves, gauze mask and lawn tennis suits, thorough asepsis suffered. This may seem strange to many of my surgical friends. I will only ask them to go into several public clinics and use their powers of observation. It is nothing unusual to see the gauze sponges, the instruments and dressings, pass through eight pairs of rubber gloves on as many nurses and assistants. I have witnessed the putting on of the gloves by hands not surgically clean; I have seen large areas of exposed abdominal walls or other operative fields handled by the gloved hands. In fact, under the mask of rubber insulation you may at most any time get a severe shock from the septic short circuits. I say this in all due and profound admiration and respect for those using these adjuncts to clean surgical work in a consistent manner. No one has a right to masquerade in such a garb unless he can be surgically clean while wearing the same.

I cannot refrain from offering a protest against the custom of getting patients out of bed and having them walk the afternoon following an operation for appendicitis, gall-stones, etc. A few patients out of a thousand will be killed by this practice. One may be a cardiac paralysis, another a thrombus. or embolism of brain. A patient with a freshly closed incision in his abdomen does not feel any more like getting out of bed than a uatient with tonsillitis, and will not be any improved by exercise. Exertion and exercise are often the exciting cause of sudden death.

Mental tranquility of the patient on the eve of a serious surgical operation is an element of success in the favorable outcome of that case. tions enter into the cause of sudden death in about one in five cases. The anesthetic is not the cause of all the sudden deaths in surgical work, by any means. Dr. Crile has called attention to the importance of mental tranquility in operations for disease of the thyroid. If the surgeon, his assistant,

nurses and operating-room help make their preparation in the presence of the patient, with a display of instruments, the patient will not go into the operation in as good condition as if he or she was given the anesthetic in a room free from this exhibition. If the patient desires prayers or other spiritual consolation, it is far better to the patient's salvation and the surgeon's reputation, as well as the physical well-being of his patient, for the patient and the patient's friends to hold divine services a few weeks or the day before, than to hold. these services at the side of the operating-table. I respect prayers and the one who makes the supplication, but I would much prefer these services be held far enough in advance of the surgery not to interfere with the various functions of the body, such as the heart and thyroid.

Far be it from my desire to place one stumblingblock in the road of progress toward ideal surgery. My object in writing this paper is to plead for a careful and strict adherence to that known to be good, to assist in elevating the work of the surgeon and maintain it on the highest plane.

DEDUCTIONS.

1. The field of surgery is a vast one, and is best covered by the specialist in some of its departments, the eye and the ear especially.

2. Surgery and medicine should go hand in hand in the treatment of border-line cases, but should be divorced in the strictly surgical or medical cases.

3. The selection of a surgeon for a given case should be made from no other standpoint than that of his recognized ability.

4. A surgical operation should be performed as quickly as possible, consistent with good and completed technique.

5. All unnecessary and rough handling of important tissues should be avoided.

6. Careful, short anesthesias will help to keep the death-rate low.

7. Careful hemostasis with proper ligature material is an important element in successful surgery. 8. Thorough aseptic technique should be carried out, and may be obtained either with or without rubber gloves and mask.

9. Lawn tennis suits and gloves are only too often the avenue leading to wound infection.

10. Short post-graduate courses instill false surgical confidence, and lead to many surgical disasters.

11. Honesty and sincerity should ever be the keynote in deciding as to the advisability of performing any surgical operation.

12. Mental tranquility of the patient is of much importance preceding the performance of some surgical operations.

DISCUSSION.

DR. J. HENRY CARSTENS, Detroit, Mich. : This paper is so complete that I really have nothing to add to it, as I agree with everything that Dr. Cordier has said.