saries in connection therewith. The executive management is alike in all the same. as was in vogue over fifty years ago. There is the medical board that controls the workings of the hospital composed of the chief physician of each staff, a board of trustees to which it reports and which controls the finances, a superintendent whose duty is to supervise the running of the hospital and a registrar who records the names and addresses of applicants for treatment. Exception should be made to those hospitals under ecclesiastic control; they report direct to the church or religious societies which control them. Owing to the zeal of charitably disposed people of this community we now have in Brooklyn an over-supply of hospitals and as it is with commodities when there is an oversupply the competition is fiercest, so we find ourselves in the amazing situation of a competition among hospitals, not only for pay patients, but for charitable ones. This is an amusing and profitable situation for the public, and as for the pauper it gives him an added dignity, for he is in demand. He is welcomed with open arms by the superintendent and registrar for the more. patients shown in the annual report the less likely they are to lose their positions. No one need pay for medical or surgical attendance in this city unless he so desires. There is no adequate investigation of applicants to hospitals or dispensaries as to their ability to pay. What would be thought of a merchant who gave a line of credit to a prospective customer without first consulting Bradstreet's. This is certainly a starving proposition to the general practitioner and even for those who have hospital connections, their private practice is being ruined by such a system. We cannot blame the public for taking advantage

Series, Vol. XIX. 93 of this situation. It is human nature to refuse to pay for something that you see others receiving for nothing. Another cause of complaint from the general practitioner is the matter of consultation. For example: The general man has been the doctor of a family for years, their friend, confident and advisor in time of afflictions. He has brought the little ones into the world, has seen them grow up; the whole family thinks him the best and most skillful doctor the world ever produced. Suddenly an occasion arises, the doctor is called in, finds the head of the family ill. Symptoms are obscure, surgical interference seems to be indicated. Consultation is suggested. This rather surprises patient, as the average person thinks a doctor should excel in all branches. A consultant is brought in, of necessity a man with hospital connections and finds an operation requisite, takes the general man aside and tells him so, pockets his 10, 15, 25 or 50 consultation fee, and is off. The poor general man receives $2 for his call. Now the embarrassing time arrives for the family physician, that is, to break the news to his patient. He tells him as gently as possible that an operation is necessary, Well, go ahead and do it, replies the patient. This is where the family physician begins to hem and haw, he is plainly embarrassed, he feels his incapacity, he has never been able to secure a hospital position, for they are very difficult to obtain in first class institutions, so how could he know operative technique? He informs his patient the operation must be done at a hospital. Well, replies patient, all right, you can do it there, but I cannot, says the doctor, for the rules of the hospital permit only those on its staff to operate. The reputation of the family doctor in the mind of his patient is

now on the ebb. The doctor tells his patient, "now don't worry, I will be at the hospital and assist in the operation." He knows he is fibbing, for he will not be allowed to lay a hand on his patient when there. Patient goes to the hospital and is operated upon by the consultant with hospital connections. Family doctor is simply a spectator in the operating room. After the operation he calls on his patient, who naturally expects him to dress the wound, but no, that is contrary to the rules of the hospital. This pathetic little scene in sick rooms and hospitals occurs day after day in our city. What is the result? The surgeon receives his fee, the family doctor nothing. If he requests pay for time spent at hospital it is refused and he is told that as he had no hand in the operation his visits could not be considered in any other way than social ones. His reputation is shattered in that family, and when sickness comes again the surgeon who has demonstrated his skill is called for. He states out of courtesy to the family physician his consent must first be obtained. Consent is obtained, for what can the doctor do, if the family insists? He has lost his patient and is left a prey to his own melancholy reflexions. Troubles in the profession are not entirely confined to the general practitioner. It is the constant complaint of those on hospitals staffs that the chief surgeon does all the operating. To be sure he is responsible for the work of his staff, and he may have some men on it who are constitutionally unfit for the work; still where there is such general complaint there must be reason. How can we learn if the opportunity to operate never offers? There are men on hospital staffs in this city, have been there for years and have yet had no opportunity to do only the most

trivial operations. It seems as if there is some subtile fascination to some men for operations; is it the mechanical part? Is it the feeling of exhilaration which comes to the surgeon after a successful operation, or is it from a selfish motive to keep others out of the field? I do not know, but what I do know, is that on some hospital staffs very few operations are passed around. I recall the unfortunate experience of a man who has for five years been on the staff of one of our hospitals in this city. In all that time he had only been successful in securing a few trivial operations. At last, despairing of ever obtaining material in the hospital, he hustled around and sent in a patient from the outside, asked his chief of staff to be permitted to operate on the case under his supervision, which was agreed. Every surgeon can look back to the time when he first began to operate and can appreciate the emotions of this assistant with a prospective operation in sight. He studied his books diligently, held a knife similar to the one to be used in the operation in the necessary position day after day, his last thought at night and the first in the morning was of the operation, and being a church member, he prayed nightly to his Father in Heaven for sucThe eventful day of operation arrived. He went with his chief to the wash room, carefully scrubbed his hands and arms with neutral soap and sterilized them carefully. The two proceeded to the operating room, put on aseptic gowns. The member of the staff started forward to pick up the operating knife to do the operation, but suddenly his chief leaned over, picked it up, and did the operation, leaving him standing there rooted to the spot astonished and mortified before the operating room staff, but nevertheless perfectly

cess.

, 1913

, Vol. VIII,

sterile.

After hearing this man's story I am inclined to think the element of fascination enters into operative work, for he informs me that his chief was always kind in other respects and painstaking in giving information on the work, but when it came to operating, the line was drawn taut. Now, the remedy for present conditions: State Board of Surgeons should be appointed by the governor before whom the general practitioner could go and pass a clinical examination, receiving a certificate therefrom, entitling him to free material for operative work in any charity hospital in this state; that there be no combination hospitals, that is, they must be either pay or free; that all applicants for medical or surgical positions in hospitals and all applicants for promotion therein should pass a civil service examination; that the superintendents and registrar of hospitals be compelled to take a civil service examination; that all applicants for free treatment at hospitals be adequately investigated as to their financial condition and that this investigation be in the hands of those not interested in the hospital management. The writer would extremely regret, should any of his hearers think the purport of this paper is to condemn hospitals per se for we may well be proud of them and of the skillful men who compose their staffs, and who are constantly making great sacrifices for the welfare of the public. The medical and surgical work of our hospitals leaves nothing to be desired, but the business end cannot be too severely condemned. Any system of management which can permit favoritism and selfishness to be a controlling feature must surely fail. changes have come in every line of human endeavor during the past 50 years, yet hos

Great

pital management is the same as it was half a century ago. We are the laughing stock of the business world and the press on account of our business methods. Altruism has been overdone in our profession. We not only do harm to ourselves by the giving of indiscriminate charity but we do harm to the people at large by sapping their independence. For the great services we render to the community we are entitled to a dignified position therein. Wilkens Micawber was right when he said that a man financially embarrassed was with the generality of people at a disadvantage. Great unrest is now in the profession under present conditions. A change is bound to come. The handwriting is on the wall. Those who would resist the tendency of the times will find that reputations, which have taken years to build up, will fall as a house of cards.

J. T. AINSLIE WALKER, F. R. S. M., F. C. S., New York City.

We have become so accustomed to accept as matters of course the ceaseless vigilance and unfailing skill of our national health guardians, that the mere suggestion that any clearly defined and recognized prophylactic measure may not receive at their hands its due consideration appears little short of heresy. There are, however, reasonable grounds for questioning whether one at least of the weapons in the armoury of preventive medicine-to wit, disinfection-might not, to the great advantage of the public health, be utilized in a more thorough and systematic manner than is the case at present. With a view to enable the

reader to form his own opinion on the subject, it is the purpose of this article to present certain arguments in favor of a wider adoption of scientific disinfection as a practical means of checking the dissemination of infection. It should be scarcely necessary to point out that this task is undertaken in no captious spirit, for to few people have been given better opportunities than to the writer of fully appreciating the magnificent and unwearying efforts of public health officials—both here and abroad— to cope with the insidious onslaught of infectious disease; in this respect, it may be observed, no nation is better served than the American nation.

not

At first sight the subject of disinfection, viewed in the perspective of other sanitary reforms, may appear to be a somewhat unimportant one. Such, however, is not the correct view; for just as a chain is no stronger than its weakest link, so also is the efficiency of any system of hygiene limited by the least efficient of its items. Inasmuch as disinfection aims at the prevention of infectious disease, it may perhaps be desirable to explain that throughout these observations the term is used to signify the process, only as applied against known disease, but also as employed to prevent its incidence. In the former case there is very little to be said, for once an infectious outbreak has made its appearance, disinfection in one form or another is rarely omitted-albeit not invariably carried out in the manner best calculated to ensure beneficial results. In the latter, disinfection is seldom seriously contemplated, though on the principle that "prevention is better than cure," these are precisely the conditions under which it could be employed most profitably.

Disinfection Can Prevent Thousands of Cases of Consumption. As a preventive of consumption, more than of any other disease, disinfection is essential. In the words of Surgeon-Gen. Sternberg, the eminent bacteriologist: "there can be no tuberculosis without the tubercle bacillus." "Every child in school," he adds, "and every day laborer should be made to realize that the tubercle bacillus is present in the sputum of persons who have pulmonary tuberculosis, and that this is the source from which the vast majority of the cases originate." The French scientist, Cornet, has estimated that over 7,000,000,000 tubercle bacilli may be thrown off daily in the sputum from a single individual.

The danger of the spread of infection through tuberculous sputum is accentuated by the very nature of the disease. If it were practicable to treat all cases of consumption in their earliest stages, the control of infection would become an easy matter. Unfortunately, however, this is not the case, and usually until the disease is far advanced the sufferer pursues his ordinary avocation, a source of danger not only to all with whom he comes in direct contact but to the community at large. This statement should not be read as a reproach against the consumptive, who, powerless to seek relief in the treatment which his disease demands, is too often compelled, under his heavy disabilities to maintain the struggle for existence. Even though he exercise the utmost precaution in the disposal of his sputum-even though he never spit at all the danger of infection, though diminished, is by no means absent: for in coughing, in sneezing, even in ordinary conversation, he cannot avoid the diffusion of fine particles of spray which

cessively occupy that house, and it appears to make but little difference whether there are or are not previous family histories of consumption. The explanation of these successive tragedies is simply that due precaution against the transmission of infection from person to person has not been observed, or that infected rooms and things have been left without disinfection."

under microscopical examination are found to be impregnated with the germs of the disease. With these facts in mind the infective potentiality of every consumptive will be realized. He spreads infection in two ways directly, to persons with whom he comes in contact, and indirectly through the medium of the places which he frequents-his home, his office, the railroad car or other public vehicle, the church, the theatre, the restaurant-in fact, wherever he goes.

Of all places certain to be infected by the occupation of a consumptive, the most common is his own home. It is a well recognized fact that consumption is to a large extent a house disease, i. e., that it may be contracted by a person susceptible to the disease, through the occupation of a house which has been infected by a previous sufferer. The Scotch Local Government Board in a circular on Administrative Control of Pulmonary Phthisis, declares: "It has been clearly shown that new cases of pulmonary phthisis have originated from rooms previously occupied by phthisical cases, and this is now held to be one of the commonest sources of infection." Well authenticated proofs of the accuracy of this statement are not lacking. The most frequently cited is perhaps that of the French scientist, Brouardel, who relates that twenty-three clerks in one office succumbed to the disease in eleven years after it first occurred in that particular office.

The following grave warning is taken from a Bulletin of the Maine State Board of Health:

Endless examples could be cited of the appalling extent to which consumption may be spread through infected houses, but they are unnecessary, as there is no longer room for doubt that infection is disseminated in this manner.

In the face of this universal danger to the public health, it follows that the first preventive measure must be the destruction of the tubercle bacillus. In this connection Surgeon-Gen. Sternberg is most emphatic: "Every effort should be made to destroy the bacillus wherever it may be found." Now we know where the bacillus may be found, and we must ask therefore how it can be destroyed when it has been found. The indisputable reply is, in the systematic disinfection of all places known to harbor, or suspected of harboring the germs of the disease. Where fresh air and sunlight have free access, there is little need for other measures, for these natural disinfecting agents may be trusted to destroy the germs of consumption and other diseases. But where this is not the case (as in the majority of places which require disinfection) their functions must be performed by a chemical substitute.

Authoritative experience is clear on this

places habitually occupied by consumptives is imperative. The English Local Government Board, in a Memorandum on Administrative Measures against Tuberculosis