CHAPTER V Every ambitious man has been impressed by certain lessons (Part 2)

have ever done, and they explain very well why admission to the University Club or to the Centurj' Association was not permitted. Inimical attitude on the part of colleagues is naturally distressing to any man of friendly disposition, and it would have been dis- turbing were it not for the fact that I recognized the work- ing of a natural law, and knew that every one of the adver- saries was having or had had very much the same sort of experience himself. A young man must prepare to have pre- cisely this sort of experience and to place any feelings in the matter to the profit and loss account at the beginning of practice, so that he may be free to go ahead in his own way. Almost any successful lawyer, engineer, banker, actor, mer- chant, publisher, teacher, clergyman, editor, artist or legislator would be enabled to present about the same sort of history. My purpose in detailing personal data in cameo form, relates to a couple of chief objects. The first of these is an attempt at cheering up young men by showing them what is to be charged to profit and loss account if they desire to become good natured free lances. The second object in view is the idea of persuading some lawyer, engineer, banker, actor, mer- chant, publisher, teacher, clergyman, editor, artist or legislator to record his joys and jolts in a To-morrow's Topics of his own. Each one of these men may tell his publisher that one copy has been ordered by nie in ad'ance. Success in almost any occupation is such a purely personal 248 TO-MORROW'S TOPICS I matter that we seldom hear of even a son following in his father's footsteps, although a son of equally good general mentality may obtain the enormous advantage of prestige and parental advice. We must remember that none of the editors who made adverse comments upon the book did so from any mean or personal motive, nor were the men who would have black- balled me at clubs or associations moved by any small ob- jections. They were all representative men of established position which was merited by their work, and who felt that my work was a menace to the traditions of their beloved profession. At various times friends in various social clubs asked me to. become a member, but there seemed to be no time for making use of the clubs in those days. The tendency was to retire deeper and more deeply into one's work, and to miss the very delightful features of social life. Old college friends were allowed to propose my name as that of a candi- date for membership in the University Club. It had not oc- curred to me that efforts at developing new methods of work would have any bearing in this matter, because the club was the one place in which a man was expected to get entirely away from shop, and into large and generous human views. When my name came up before the committee on admissions, one doctor on looking over the list said, "Oh, Ah I there's one name I'll swat." Other members of the committee who were per- sonal friends of mine asked for the reasons. The reply was, "Oh, he is always in a row with the profession." My friends on the committee being laymen and not understanding what the nature of the row might be did not think to ask if it referred to the setting of any standards. They were obliged to let the matter drop because of this member's assurance that several black balls from colleagues might be counted upon. He was ^^ite right about it. I had not realized previously that men J TO-MORROW'S TOPICS 249 feel personally injured when one forces them to change their points of view, having trained myself not to take offense at anyone who differed with me. It was my supposition that other men had trained themselves in very much the same way. That was a misconception. Subsequently I became a member of the Alpha Delta Phi Qub in which old chums were not inter- ested in professional questions, — and also joined other clubs like my favorite Camp Fire Club, which related to special interests. I had so frequently been asked to join the Century Association that notwithstanding the history of experience with the University Club, Centurians planned to have my name proposed for their membership list. One of them, Dr. D., who had twice served upon the committee of admis- sions, volunteered to take the matter in charge. He was a member of the medical profession, and knowing both the club ways and professional ways, believed that he could persuade the "chess room crowd" to see that my name was not black- balled. After we had discussed various features his sug- gestion was that, the proposal should be made by a surgeon. Dr. B., who was very popular in professional circles in New York, was chosen for this part. For a seconder we chose a favorite man of letters, Rev. Dr. Van D. My adviser sug- gested that only five letters be written to the committee by other friends, but that the men to write these letters should be representative men in different callings outside of medicine. This entire list — ^proposer, seconder, and five members who were to write letters — were all from our mutual friendship list, two of them university presidents who were particularly popular. My adviser was then given the names of four men in the Association who it was believed would oppose my election. After making inquiries he reported that we were wrong about two of them, and they would favor my admis- sion. Two others would not only oppose my election but 25© TO-MORROW'S TOPICS one of them would go far out of his way to see that I was not admitted. He and I happened at that time to be engaged in a special field of new work and this member's views were different from mine all along the line. He feU keenly that my presence anywhere was a menace to the welfare of the com- munity and he was perfectly conscientious in his efforts at keeping me out of any social club, or any other field of activity in which he could have a voice. As a man of very high posi- tion, which was merited through his accomplishments, his opinion naturally carried great weight with a large circle of followers. When my name came up before the Century Asso- ciation committee, having been rushed ahead of a number of others on the waiting list, the committee decided that my elec- tion would be out of the question. It was so desirable however to become a member of some first rank social club, that one was again selected. The committee on admissions watched for an opportunity when my name would be least likely to be black- balled, and this effort was successful. A man should really get in line for such club membership before he has attempted to do much. As a matter of fact it would be still better if committees on admission were to make analysis of the exact nature of the opposition to men whose names are proposed, but this is not al- ways the custom at the present time in American clubs, nor even in the older established European clubs. When one has dis- turbed certain members to such a point that they wish to black-ball him it is generally considered that he is likely to disturb a great many other members when elected to mem- bership in the club. As a result of the present system some men who are "not accustomed to being defeated" lay plans which eventually place them in their chosen club "if they have to fight for it." Others who are much occupied with many matters, fail to take the necessary steps. The result is a tendency to have in the exclusive social clubs an element that TO-MORROW'S TOPICS 251 on the whole is most agreeable but not the most tolerant of active men whose views arouse controversy. When the question of my candidacy for membership in the American Surgical Association had been brought up, some of the members said to me afterward: "We wanted you in, old boy, — and your sponsors were loyal, — but two of the other New York men made such determined opposition that we could not overcome their influence, You understand ! Come up again later." As a matter of fact no good oppor- tunity has offered itself. Hardly a year has passed without my noting that colleagues were grouping themselves comfort- ably about tradition,— following a sort of periodic law. It has seemed necessary to ask them to arrange their atoms in form for undergoing continued mitosis, instead of becoming fixed in crystalline tradition form. My book "Lectures on Appendicitis and Notes on Other Subjects" (published in 1895) included the history of inci- dents belonging to a very long hobequs ride. Shortly after Fitz of Boston had published his paper on the subject of appen- dicitis, in 1886, surgeons began to give attention to better diagnosis in cases that had formerly passed as peritonitis, perityphlitis, and in fact under a long list of misleading or incomplete diagnoses which need not be enumerated here. In the early nineties operating for appendicitis was well under way, and the methods belonging to the third or pathologic era of surgery were naturally the ones which were applied, as this era was then in the height of its glory. The principles of this era happened to be particularly unsuited for many cases of appendicitis, and it was a fact that the statistics of cases treated surgically were very little better than the statistics of cases treated without operation. At one time I collected the official reports from a number of typical hospitals, and found that the deaths after operation for appendicitis ran i 252 TO-MORRO\l~S TOPICS froin 15 to 27 per rmt . Apfrwtlflg sooKwiBt upuu the dass of cases treated at <fiffcrcct huaptuK^ but mocc pofticii- larljr upon the mcdiods wlndi w^err qu pl uye d hf infiridnal snrgcoosu A fatber large p ropor ti on of cases of mfectiTe appendicitis were m aoiauced stages nutn Aer to the ho^Mtak at dot time. Appemficxtis in afl of its and stages is nov recognized fredr, and the snitiiiwnt in r^ard to operation has brromc aitiid% changed. Too nmnr operations are jnst nov beii^ done under dnt dagnosisw It was dBtomarr accor di iy to the p r in c ip les of the diird era, for surgeons to treat cases of appendiotxs in which there was infection of the peritoneum to Tarious d^^rees. br malring Icmg incisions which caused shock. They made muldple in- cisions for purposes of drainage, which also caused diock. The extensive and daborate use of germicides and antis ep ti cs and various mechanical means for removing p i u d u c ts of in- fection were all harmful This work was often done with painfully conscientious detail, — die patients suffering mean- while in consequence. At that time gauze packing and gauze drains were used in great quantity, and the mere presence of such material in the abdominal cavity prevented the patient from quiddy summoning his own resistance factors. In addi- tion, iodoform gauze was commcmly chosen, and this had a special death-rate of its own because of insidious iodoform poiionii^ — the sympUxns of which are so closely those of iqitis that deaths were often set down to the account of sqisis when really due to poisoning by iodoform. It was observed that patients who had been operated upon throt^ short incisions and with moderate d^;ree of Kft^dling of viscera, — (avoidance of features which cause diock), did very much better than patients who were sub- jected to the customary operative procedures of the day. Beside that they did not have post-operative hernia excepting TO-MORROW'S TOPICS 253 for some special reason. Beginning from this observation it was possible to work step by step toward the position of em- ploying short single incisions and avoidance of gauze packing or the use of extensive drainage apparatus, even when wide infection was present. Examination of purulent material in these cases showed it to be frequently sterile, because bacteria were at work in the tissues rather than in large collections of fluid, no matter how malodorous the latter might be. It was observed that when in the course of separation of extensive adhesions purulent material was spread over the normal peritoneum in the vicinity, it did not excite peritonitis, for the reason that this fluid commonly contained comparatively few bacteria. In addition, the peritoneum in the vicinity had called out a protective hyperleucocytosis. It seemed best not even to take the trouble to remove purulent material that had become spread over the normal peritoneum in the vicinity. This avoided the shock which commonly went with elaborate pro- tective resources. As a result of work based upon such observation I was enabled to present at the Academy of Medi- cine in 1896 statistics of 100 consecutive unselected appendi- citis cases with a death-rate of 2 per cent., and the report was shortly afterward published in my treatise on the subject. At the time when this report was made most of the leading surgeons in New York assembled for the purpose of combat- ing my views. They made a special effort to be present at the meeting, believing that my influence must be strongly opposed. Some of the speakers who discussed the paper accepted the report as presented. One or two who were present intimated very politely that a selection of cases had been made for statistical purposes, and one of the most prominent surgeons in this field of work complimented me upon my statistics, placing an emphasis upon the word "statis- tics" which left no doubt as to his meaning. The chairman ?.^sL»:c^»w^ T not to be takoi as ibcv* rcpRseniBd tiie impossibfe, A ni oot dcjd d^ loo abdxzsEzal opcntions of anjr sort a zairalirr rare as jom as 2 per ccdl (Since that time b ri-c3 *S2'"gTCS ?1mti iifiir IiaTe been 4it<ainpd by many odier sargccics. aad the prindpSes hare b cf m ne gcneralhr aooqUed and nxzpFovcd iq»o br later sorjeoDSLt At diat time this cSon to serve the profcs^oo by bia^ii^ forward a sooccssful new method of work caused me an iim i wusr loss of prestige and cut down my practxe tctt distinctly. Sodi must com- monh' be the experience of an innovator, and the yoonger men are to remember not to anticipate nmcfa personal advantage when doing work which is not along established lines of pro- cedure. The>' must expect on the other hand, to suffer actual loss. This loss may be disTtgatrdtd for the compensating satis- faction of knowing that thousands of lives may be saved. When first advocating the emploj-mcnt of short incisions and the avoidance of shocking drainage devnces, personal friends among the laity who knew of the effects upon my practice, came with kindly advice to change my position. They had learned in conversation with doctors how injurious it was. One surgeon, whom I did not know personally, felt that the amenities of the situation made it proper for him to publish in the Medical Record of December 12, 1896, a statement that "such fanciful statistics meant selection of cases" and that ''operation must have been refused in the TO-MORROW'S TOPICS 255 class of cases really needing the surgeon's help." He wrote that ''such figures are vainglorious cheats as attests of comparative skill." There is no way in which one can malign a surgeon more than by stating that he has refused to help people needing his skill, for the purpose of making a report favorable to himself. While such an imputation is sometimes heard, my confidence in our profession is such that I believe very few surgeons of standing have ever made any such selection of cases for such purpose. As a matter of fact my list consisted of a consecutive series of all the appendicitis cases that I had seen during the period covered by the statistics. No patient had been refused operation. The presentation of the report had not been made with any thought of describ- ing superior skill, but rather for the purpose of showing surgeons how they might be enabled to make even better reports. To have such a presentation taken in personal bear- ing would have been disheartening for men of some tempera- ments. In none of my work has there ever been a feeling of wish for personal credit. I have always seemed to myself to be like an outside disembodied agent that was pressing into action better men who would carry forward the needed reforms. The Medical Record article placed a distinct obstacle in the way of acceptance of the principles involved, and reference was made to it in a way which carried unmistakable meaning by writers and speakers of that time. It was generally assumed that any one who would publish such a statement as that which appeared in the Medical Record of December 12th, must have had some incriminating facts at his disposal, or he would not have dared to publish his statement. The writer of the letter had no such facts, and he was simply quoting the ordinary hearsay remarks that go the rounds when men are trying to escape from an uncomfortable situation. TO-MORROW'S TOPICS 257 Another expression which I employed in connection with unusually long incisions, "the ghastly gash," likewise happened to start agoing a series of vibrations which were effective over long distances. At that time it was called "alliterative sensationalism" and brought out much unfavorable criticism on that basis. The expression seemed to remain however in the minds of surgeons. It was repeated frequently in