CHAPTER II In the later eighties, I had about determined to make my (Part 2)

to send some patient who can pay, and would split a fee so quickly that one could almost hear the fragments hum. He will not have a great amount of surgery to do, because too many people are familiar with the fact that he is not proficient in that field, but whatever surgery he does obtain will be on a basis of its financial possibilities, without keen regard for the interests of the patient. On occasions when I have wanted to "try a case over again just once more," it may be said that some "physician and 64 TO-MORROW'S TOPICS surgeon" who was engaged in general practice might have done the work better in the first place. That may be quite true, but the principle remains unchanged. We are just at present amongst rapidly changing conditions. Internists have seen their old line of "profitable illnesses" drop away as a result of preventive medicine. They have not as yet adapted themselves to the idea that preventive medicine, which is saving the double rose, is in that very fact introducing great new questions in diagnosis and therapeutics which will require keener interest, wider knowledge, and more detailed attention than are required for surgical cases, in which judgment and manual technic are the chief desiderata. Doctors do not as yet know what it means to trace a case of neuralgia or of high blood pressure to its protein (in cases in which high blood pressure is due to such a cause). They have not planned systematically to hunt out a specific reason for the develop- ment of that poison. During this transition stage general practitioners have not as yet adapted themselves to the idea of charging by the case, instead of by the visit. How can people know unless we teach them? "Doctor" means "teacher" in direct descent from the derivation of the word. The doctor is not a teacher when he allows the people to tell htm what they think they want. ■ They think they want some simple surgical operation which ftwill decapitate the demon of all their ills. They think they ■want to slip a silver dollar into the doctor's pocket to pay for his visit, and have him pleased and surprised when he finds it there. The doctor is not a teacher when he allows all this. I He is not a teacher when he trims his sails to what the people l-think they want, and as a result personally profits through his ■own prudence. Prudence is a sort of universal solvent for lard lumps in rectitude, but the hard lumps are diamonds and vbies. TO-MORROW'S TOPICS 65 A doctor who felt very self-sufficient once asked me if I thought he ought to assume the role of general distributor of cases that came to him, sending each one to the best authority instead of keeping it for himself. The reply was that I myself acted in that sort of capacity. In the early days of practice while feeling a way to the best field of action, my work in- cluded all kinds of cases. In the field of ophthalmology there were cases of cataract, strabismus, glaucoma, and in fact almost everything in the way of eye work, and the results were pretty satisfactory, but it was evident that one could not comprehend the whole of any field and do thorough work without dropping most of the other subjects and sending these other patients to authorities upon their respective require- ments. Consequently my eye work was given up on moral grounds. If one lives in some part of the world in which experts are not available in any special subject, then he has the moral right to do that sort of work without help — other- wise not. In nose and throat work, I devised several pro- cedures that seemed to be ingenious, but other men could take better care of the cases, and they were sent to these men. Much attention had been given to developing orthopedic surgery, through a natural bent that goes with Yankee mechanical instinct; but it seemed best to drop this special work because specialists who did nothing else could do better for my patients. Genito-urinary work was extremely attractive, because of my two wonderfully clever teachers in that specialty. It is so closely related to and involving so many of the principles of general surgery that it was the last special subject from which I cut away, although some of its operations belonging to general surgery are still enjoyed and accepted. The field of neurology and psychiatry was particularly fascinating to me because of its speculative side and its bearing upon certain phases of pathologic surgery. It was difficult to give up I I TO-MORROWS TOPICS medical practice, for the reason that cvenp' doctor forms a circle of patients who have confidence in him, and who believe that he can do better things for them than anrane else can do. He himself believes that he can do certain things for some of his old patients that no one else in the world could do for them, because he understands them so well. A surgeon must, however, separate his applied work entirely from its medical side, provided that he practices in the citj-. because his time will be absolutely taken up with special work as soon as he has found his position. It is altogether a moral question, on the whole. Anyone who plans to take up a specialty should do all kinds of work at first, .\nyone who has the intention of devoting himself to surgerj- should have an apprenticeship in all specialties at the outset, even though he will do work for his patients that is far from tlie best at that time. The "occasional operator" seldom has a right to do any surgery, provided that he lives where skilled men are already in the field; but he has the moral right to do this provided that he has given himself the best possible equipment, and provided that he has a definite intention of working toward the practice of surgery exclusively. Under such circumstances his failures and accidents will be legitimate, and the public which suffers in part is on the whole the gainer from his presence in the end. If an "occasional operator" has eight recoveries in ten cases of pyosalpinx. it seems to him like a result of which he may be proud or even boastful. This is one way of looking at the matter. The other side would be this. The loss of two cases out of ten by an expert operator would be a twenty per cent, death-rate, and this would mean such a fearful mortality that it would be a matter of very unfavorable com- ment at the present day in the higher professional circles. The saving of eighty per cent, of his cases by one operator is looked upon as a triumph, and the losing of twenty per cent. TO-MORROW'S TOPICS 67 by the other is looked upon as a disaster. Yet both these men are at work right now in large numbers, at this very minute. Even when one has become highly skilled in the surgery of some special field there are many cases that he does not manage in the best way. This proportion slowly becomes smaller and smaller. Mishaps and unfavorable results are not so commonly the result of error in application of princi- ples, as of neglect to apply minute points in technic. Ten thousand people have died after well conducted operations because of some trifling ligature fault. If there are 150,000 doctors in the United States and each one of half that number knows of a single instance in which fatal hemorrhage has followed some ligature fault, my estimate of the number of deaths in this connection would appear to be conservative. Ten thousand people have died because a drain was not arranged for best mechanical efficiency, although the leading principles were well observed by the operator. If there are 150,000 doctors in the United States and each one of only ten thousand of them knows of a single instance in which fatal complications have followed defective wound drainage, one may imagine that the sum total of deaths from this cause is at least large. Just a little of the "fine Italian hand" here and there gives the artistic touch that brings success, or turns the course toward unfavorable results. In abdominal surgery, for instance, one must cut down his percentage of mishaps a very little year after year and lessen his death rate at least half of one per cent, a year, for many years consecutively. It is very much like the business man's way. The necessity for experience in operative work is appreci- ated by every surgeon who finds himself employing some bit of experiment in almost every operation. If these experiments are of high order, the chances are that all will make for the benefit of the patient, but unless they are based upon previous vious m 68 TO-MORROW'S TOPICS experience any one of them may go wrong, and jeopardize at least the morbidity statistics. The amateur in surgery likes to quote the examples of those who began work with small and poor equipment, but who finally arrived at positions of renown. He feels that he must begin at some time just as these few men whom he quotes began. There would be a great deal in this excuse were it not for the fact that full opportunities are now given students for becoming proficient. In former times such opportunities were difficult to obtain. In Germanv the Prussian Minister of Public Instruction has addressed to the medical councils the suggestion, on which they are expected to take authoritative action, that the right to use the title of specialist be restricted to those who have had a requisite amount of post-graduate training — three years as a rule — obtained at officially recog- nized and approved institutes or under approved specialists. In Austria a similar ruling has been submitted to the profes- sion by the Ministrj* of Education, with the additional pro- vision that no one is to be recognized as a specialist in more than one branch. No one should be permitted to do surgical work unless he has a special license, but in this country the time has not as yet arrived for the state to take cognizance of what this means. We are to have a gradual readjustment. There is no more valuable man in the communitv than the well-trained honest family physician, no man is more secure in his position, or less envious of the s|Mrcialist, or more needed at the present moment. The education of physicians is Nxvming a ver>" expensive undertaking. In former years, a tew months at some medical oolkge, and two or three years of apprenticeship imder some older practitioner sufficed for prei^iring a man for beginning Us occupation, but at the present time, a student commonly three or four years in his literary or scientific course. TO-MORROW'S TOPICS 69 then three or four years at some medical college and two years in hospital service before attempting to engage in practice. In addition to the eight or ten years of preparatory work the student often thinks it best to spend a year or more in foreign coimtries, in order to become familiar with the work in such countries before taking charge of a clientele here. This is only one of the many changes that have taken place during the thirty years of my work in practice. Thirty years ago the subject of anesthesia was almost in its infancy and there were few places in the world where one could have the refinements that are now furnished by the special anesthetist, with his expert knowledge and proficiency in applied science. Cocaine and local anesthesia were at that time "being discovered." It was well toward the end of the nineteenth century before the influence of men like Bennett in New York had resulted in placing administration of anesthetics upon the plane of a high- class specialty. Gwathmey's History of Anesthesia shows that Americans have stood in the forefront of progress in this field. During the past decade skilled anesthetists have become abundant, and the natural rivalry in this subject between edu- cated men is bringing out inventive talent which may revolu- tionize our ideas of the present decade within the next decade. The X-ray had not been thought of thirty years ago. Anti- sepsis and asepsis were just beginning to gain a foothold in this country, and few of the present younger members of the profession know anything about the violent controversies over the subject of antisepsis that kept the profession in a turmoil at that time. Gynecology and orthopedic surgery were fairly under way as specialties, but the eye, ear, nose and throat furnished about the only subjects recognized as presenting legitimate fields for branch work to which one might give his entire attention. A few men were devoting themselves to dermatology, but that usually included syphilis, arid syphilis -JO TO-MORROW'S TOPICS incidentally includes pretty much the entire field of medicine. Vaccination as applied to infections belonging to the field of surgery was wholly unknown during my student days. At that time vaccination was applied empirically for the preven- tion of smallpox only, and its employment was based upon an accidental observation which had been made by Jenner. Now we vaccinate understandingly, not only to prevent many kinds of disease, but also to control several of the infections after they are under way. The subject has developed with such rapidity that thousands of well educated physicians have been too busy to comprehend the subject, or to foresee the new fields into which vaccination may extend. During the present stage of our progress much harm is being done by the indiscriminate or ineffective employment of this resource of tremendous power. Vaccination means briefly a planned introduction into the body of a certain kind of protein which can cause a certain kind of disease. This par- ticular protein which the doctor introduces has been previously prepared in such a way that it does not quite cause the disease, but serves to wake up the body cells which have the responsi- bility of looking after that particular kind of disease. The aroused body cells immediately prepare ammunition in the form of a ferment which will destroy the kind of protein which the doctor has introduced. This ammunition is subse- quently kept in stock in the armory of the patient and is used for destroying more virulent protein, if the bacteria of that particular kind of disease really try to attack the body cells of a vaccinated individual later — the body cells having been forewarned are forearmed. Bacteria which cause disease had I to become highly organized in the struggle for existence. They t^re highly organized chemically although simple morpho- ^0|fica]ly_ and in the course of evolution have become quite "C peers of the body cells with which they enter into conflict. TO-MORROW'S TOPICS 71 The cell is not the physiologic unit of life, but only the mor- phologic unit ; the physiologic unit is a protein molecule within the cell. Physiologic imit of microbe is pretty evenly matched against physiologic imit of body cell. Morphologic units do not count so very much in the warfare question. Nature plays with the latter tmits and fights with the former. Every living cell has to feed and it forms ferments which split up proteins of other cells upon which it feeds. Only those bacteria which have the power to split up the proteins of our body cells are the ones which are capable of causing disease. The ferments with which cells of bacteria or cells of our bodies split up materials for their food arc the "extra-cellular" ferments. Following the laws of osmosis and other ordinary diffusion laws these ferments extend from the cell into its "victim ma- terial" and cleave out of that victim material whatever the cell wishes to eat. In addition to extracellular ferments which are the hunters, living cells have intracellular ferments which do not travel away from home. These latter are the builders. They take the materials brought to them by the extracellular ferments and build it into cell tissue. When the bacteria of a certain kind of disease enter the body of an individual, their extracellular ferment splits up body cells of the individual, and the protein food thus obtained is used by the intracellular ferments of the bacteria for their own purposes. Meanwhile the body cells of the individual are waking up. They proceed to manufacture extra and intracellular ferments of their own to be used defensively. The whole theory of vaccination centres about the physician's diplomacy in arousing these body cells of the individual by crying "Wolf!" just often enough so that the individual is all ready to meet the wolf should it appear. In an increasing number of kinds of disease we may now arouse the whole village of body cells and destroy an invader which has actually appeared unawares. We sound 72 TO-MORROWS TOPICS the tocsin and the toxin is annihilated. We must not forget that the study of the protein poison was first worked out by an American investigator. Dr. Victor C Vangfaan. In addi- tion to the influence of protein poisons from bacteria, disease may be caused by other proteins ; for instance, hay fever from the pollen of artemisia, or ivy poison from glandular secre- tions of rhus. An hypothesis for which I am somewhat responsible includes the idea that such \i'idely different ail- ments as some forms of skin disease, of cholera infantum, of intussusception, of some insanities and of certain peritoneal adhesions, are caused by proteins from imdigested or un- metabolized products of food, or from morbid protein prod- ucts from a patient's own body cells. We may some day vaccinate against many