course, every surgeon prefers general anaesthesia where the patient can stand it. He can do his work more thoroughly and more easily and does not add the additional risk of infection from the solution. Where you are absolutely sure that the suture and solution are sterile, you run no risk. However, we know that everything used about the wound adds to the chances of infection.

With the weak solution of cocaine one can use a sufficient quantity to do almost any operation. You may do a herniotomy or laparotomy, if necessary. In fact, after you have gotten through the skin, there is usually very little pain. I remember doing a laparotomy on a child without any anaesthetic at all. However, I did have the child under an anaesthetic when the incision was made, which would have been very painful, of course. In the strong solutions which we formerly used, you could not do a major operation without poisoning your patient. When I began practicing, I poisoned several patients before I found that a weak solution would do as well. I discovered this through a mistake of the druggist. I ordered of the druggist and he diluted by ounces instead of drachms. I used it, as we had no opportunity of getting stronger, and it anaesthetized as well as the stronger solutions. I believe there are many cases in which we may operate under local anaesthesia where the general is contra-indicated.

I prefer the general anaesthetic if the patient is able to take it. I think there is practically no danger where the heart, kidneys and lungs are in reasonably good condition.

Dr. Riggs: It seems to me that the essayist has omitted the chief indication. There is one condition where the operation is now generally done under local anaesthesia. I refer to exopthalmic goitre. I do not think any physician would hesitate in adopting local rather than general anaesthesia in these cases. I believe this condition would be excluded entirely from operation but for the adoption of local anaesthesia. I have been in the habit of using weak solutions as recommended by Schleich. You will soon become so adept, that you can anesthetize any surface and work for almost any length of time. It seems to me that if we only used it in goitre, it would have a good field. I never use it unless there is some reason for not using general anaesthesia.

Dr. Henderson: (Closing). My purpose in bringing this subject before you is to elicit discussion. So far as I am con

cerned, were I to be operated upon, I would prefer local to general anaesthesia, if I could have it done without pain. There is very little danger in giving ether or chloroform, but we have all seen patients die after using chloroform. We have also seen them die after using ether. When I want to take time, I use local anasthesia. Of course, I must be certain of my aseptic conditions. I get as good results as under general anesthesia.

Dr. Porter: Ether was discovered in 1846 in the Massachusetts General Hospital; so that, if anything I say does not seem quite fair, you will understand the reason. It has been extensively used since that time and I think that some of the objections to it arise from its incorrect application. We have man not well instructed. Our ether experiences are good. We have tried all the anaesthetics in our work and have come back to ether except in special indications. Instead of using of the various forms of inhalers, we are coming back to the earlier and simpler methods. We have always tried to combine air with ether although the tendency has been to the closed method of anaesthesia. Undoubtedly, the open method is of all methods, the safest. I think if equal care were taken from the beginning, we would come back to the more general

use of ether.

Dr. Mason: Choloroform is generally credited with one fatality out of 3,000. Two years of interneship in New Orleans Charity Hospital, where we used choloroform practically all the time, made me favor its use. I think we gave ten anæsthetics a day; as a fair average that would be 3,650 for a year, or 7,300 for two years. During that time I was in position to observe these anesthesias and five deaths occurred. That gives an average of one every 1,400 under chloroform anaesthesia. I am pround to say that none occurred while I was acting as assistant there, although I was frightened many times. Now, I never use it when I can possibly use any other.

Dr. Jordan: I think there is no more important subject that could come before this Association for consideration. One year ago, in Montgomery, you will remember that Dr. Abbey, of New York, gave us a very interesting address upon unsettled problems of surgery. To my mind, this is one of the great Unsettled points. Dr. Lull has treated the subject too well for

me to try to add anything. I have had one case where death resulted. The patient died some 36 hours after the first symp

toms.

Dr. Harkness: I am very sorry that this paper has not brought out a more complete discussion as to certain points. I think it is certainly a very timely paper. I should like to have heard more about pneumonia which is frequently supposed to follow the use of ether. As Dr. Lull intimated, it is by no means proved that ether is responsible for the pneumonia in these cases. Within the last three years I had an excellent opportunity to illustrate this fact. There was brought to me a man suffering from gunshot wound. The question arose as to whether the bullet had penetrated the stomach. The skin was punctured on both sides. The injury had been received some twelve hours before the patient was admitted, and there was no evidence of the stomach having been perforated. I decided that no harm could be done by watching him a little longer. Twelve hours after I saw him the temperature was normal. Then it began to rise; thirty-six hours after the injury occurred the pulse was high as well as the respiration. I thought possibly I had been mistaken. The abdomen was soft, no rigidity, no vomiting and no pain. In going over the chest, the left side was normal, but in the posterior apex of the right lung there was evidence of beginning pneumonia which was in twelve hours fully developed. If an anaesthetic had been used, the trouble would have been ascribed to that. In this case, the pneumonia would have been a coincidence. As to the immunity against chloroform by parturient patients, so far as I know, I hold the unenviable reputation of having lost a patient from chloroform. I had been taught that the parturient patient enjoyed immunity. This case occurred several years ago. It was undoubtedly a case of the toxemia of pregnancy and I had not recognized it at first. After the onset of labor, the woman became desperately sick, and I decided to empty the uterus. I admit that the anaesthetic was not given by a skilful assistant, but perhaps the result would have been the same. Without difficulty I dilated the cervix and applied the forceps, but when I got the head down to the perineum, the respiration ceased. I abstracted the child and tried to resuscitate her, but failed signally.

Dr. Iull (in closing): I want to express surprise that my views, which are somewhat radical, were not attacked. I am pleaseci with the endorsement I received. In regard to the remarks of Dr. Jordan the subject becomes a spirited one because we have our opinions formed and fixed.

THE RESPONSIBILITY OF THE PHYSICIAN IN THE PREVENTION OF TUBERCULOSIS. .

CHARLES A. MOHR, M. D., Mobile.

Member of the Medical Association of the State of Alabama.

All that has been written on the subject of the prevention of tuberculosis in the last few years supports the idea that education and philanthropy occupy an important place in the minds of thinking men. This I believe to be a logical expression of Its value in the cause of the best interests of humanity cannot be questioned, but this is not now the subject of cur discussion.

our civilization.

The consideration of the best way to meet the problems of the prevention of tuberculosis is not an academic one but rather is it a problem of practice and application of scientific facts to habits and modes of life among a certain class of people.

During recent years no disease has received more attention, perhaps, than has tuberculosis. Its causation, modes of propagation, treatment and prophylaxis have all not only been extensively studied, but all facts gained have been placed before the peop! e in such popular style that all might be informed. A superficial analysis of this great problem still discover three important elements which must be considered individually and relation to each other; namely, the tubercular subject (the patient); the attending physician, and the public. By the latter I mean not only the people as a whole, but the State, the family or the group of persons in proximity to the patient, each of whom is more or less threatened by, and exposed to, the inEach one of these factors bears a certain degree of

also in

fection.

responsibility which must be fully appreciated in order that any effort made by any or all in the direction of the prevention of the disease may be successful.

The interest of the State, the public, is in the preventibility of the disease; the interest of the patient is almost entirely centered in its curability, the interest of the physician is for his patient and his treatment and also in the preventibility of the disease. The present discussion will concern itself principally with the responsibility of the physician in the prevention of tuberculosis. In such a discussion none of his relations can be ignored, least of all his interest in the welfare of his patient.

In no class of men does the prevention of any disease bring greater responsibility than on the physician. This is natural, and therefore is it essential that we should fully realize wherein these responsibilities rest if we would direct our efforts to the best advantage in the fight against the advance of the White Plague.

The first is early diagnosis-the recognition of the disease in its incipiency. What can be of more value in the fight than preventing the occurrence of what might otherwise become a focus of infection to others? This may be accomplished if an early diagnosis is made. It is claimed that the patient, in neglecting himself by not seeking medical aid sooner, is often responsible for a late diagnosis; this may occur, but I believe it occurs but seldom, especially among the more intelligent class of people. The large majority of the victims of the disease, long before pronounced and well defined lesions occur giving rise to corresponding symptoms, suffer from complaints for which they seek medical aid, which, to a careless practitioner, may mean little or nothing and if a thorough examination is not made, a tubercular infection is overlooked. The patient, fortified by the opinion of his trusted physician, is secure in his belief that he is suffering from a temporary indisposition, perhaps from a slight stomach trouble or nervous prostration, debility or chronic malaria, depending on the symptoms presenting. It would be well here to draw attention to the irrational habit of accepting the patient's diagnosis of his own case; for instance, he will say that he is suffering from dyspepsia, and forthwith a corresponding remedy is prescribed. Nothing less than a thorough investigation can disclose an incipient tubercular trouble. It cannot be denied that the only positive pathognomonic diagnostic sign is the presence of the tubercle bacillus, but I should feel sorry for the patients of a man who denies the probability of the occurrence of tubercular infection in all