son claiming to be a licensed physician. No such power was given in the old law. This will make it difficult for a person to practice on the license of a deceased physician, and will render it far easier to detect fraud in medical companies. It will also render it more difficult for quacks to combine and shelter each other, or hide behind licensed practitioners, as they have frequently done in the past. Prosecutions may now be conducted by the society under five sections of the penal code,

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... ad of one a$ formerly, and also under the special provisions of the new law. The restrictions of the old law making it impossible for a judge to impose a sentence of both fine and imprisonment for a first offense for the illegal practice of medicine has been abolished, so that much heavier and more deterrent penalties may now be imposed. For several years the volume of legal work has annually increased, and during the year now closing it has exceeded in every particular that of any former year. The number of prosecutions, convictions, fines, and imprisonments, and the aggregate amount of fines have all been greater than in any previous year. The work has not only been an evolution in principles and methods, but has yearly expanded in scope and volume. In the prosecution of this work all sorts and conditions of men have been revealed as doers of evil, some of whom have posed as moral citizens; many lucrative but corrupt business concerns have been disrupted; many influential citizens and powerful interests have been hard hit. As the work has'broadened and the number of such cases has increased, violent animosities have been engendered, not alone against individuals, but against the work itself. And so long as the work is aggressive and effective, opposition to it must be at times expected. To those who feel that the society should limit itself to scientific and professional work. I would call attention to the fact that legal work was one of the essential objects for which it was organized. The title of the legislative act which called this society into existence in 1806, read as follows: "An act to incorporate medical societies for the purpose of regulating the practice of physic and surgery in this state;" and this is incorporated into the constitution as a prime object of the society to-dav. With such a mandate from the state and in view of the results accomplished, it seems to me that the society should not shirk its duty as regards the legal work, for it has been a great work, it has been a good work, it has been a clean work. Before the use of anesthetics and before the introduction of aseptic principles, major surgery was limited almost entirely to emergency or imperative surgery. That is, operative procedures were employed only when severe, urgent symptoms could be relieved without too great risk from the operation itself, or when an immediate operation was imperatively indicated in order to save life. Formerly most operations were in themselves dangerous. Now, in the majority of cases, the risk from the operation itself is slight. The element of danger usually depends on the severity of the condition which makes the operation necessary. This reduction of the operative risk, together with the assurance which we have of obtaining good aseptic results in the great majority of cases, has created for us an entirely new surgical field, that of elective surgery. The operations of elective surgery are those operations which are usually done in order to relieve distressing symptoms, more rarely in order ultimately to save life. Their especial characteristics are that the operation does not necessarily have to be done immediately, and that there may often be a question as to whether or not the operation really is advisable. I will mention a few of the many conditions which may come into this field in order to make the conception of elective surgery more clear. Gynecology offers many instances. Displacements of the uterus, tears of the perineum or cervix, inflamed tubes or ovaries, and many cases of ovarian or uterine tumors are frequent examples. The great majority of such cases do not require immediate operation. Many of these patients do not need an operat^n in order to save life, and in others the question may be fairly raised as to whether or not it is advisable to do any operation at all. In general abdominal surgery we may consider nonstrangulated hernia, floating kidney, many cases of gallstone or gastric ulcer, and suspected chronic appendicitis which has never shown any symptoms of acute attacks. Without extending this list further, I think enough conditions have been given to impart a fairly clear idea of the sort of case coming in the province of elective surgery. In imperative surgery the diagnosis is often clear and the necessity for an immediate operation is usually apparent. In such cases there is but one major responsibility devolving on the physician. That is the responsibility of having a sufficiently skillful and satisfactory operation performed at once. In elective surgery, however, there are usually two major responsibilities. There is as great a need for a skillful operation as in imperative surgery, but of equal, if not of greater importance, is the responsibility of first deciding whether or not the patient actually needs any operation at all. Who is the man to settle this question ? The operator assumes the moral and professional responsibility for the operation. His judgment dictates the procedures used; his is the actual credit if the operation is successful, and his is the blame if it is not. Inasmuch as the operator will thus have to bear the responsibility for the results of the proposed operation, it is only fair that he be allowed to decide whether or not operation is necessary. To aid the surgeon to make a wise decision he must be given every opportunity for full and free examination of the patient. He should be permitted to express his opinion freely, and should be allowed to follow unhampered the dictates of his own best judgment. The surgeon who waives this privilege of prior examination, unless compelled thereto by extreme circumstances, who sees the patient for the first time after anesthesia has begun, and who does a certain routine operation at another's request, degrades himself and his profession. He assumes1 the status of a skilled mechanic rather than that of the scientific physician. His operation is human Downloaded From: http://jama.jamanetwork.com/ by a Northeastern University Libraries User on 05/26/2015