OBSERVATIONSAND

REFLECTIONSON

ABDOMINAL SURGERYBY

PROF. A. C. BERNAYS,St. Louis, Mo., U. S. A.

An address delivered to the Oregon StateMedical Society at its annual meet-

ing in Portland, Oregon, 1899.

Reprint from Red Cross Notes. New Brunswick, N, J.

RED CROSS NOTES.

Observations and Reflections on AbdominalSurgery.

An address delivered to the Oregon State Medical Society at its Annual Meeting inPortland, Oregon, 1899.

Prof. A. C. Bernays, of St. Louis, Mo., U. S. A.

There is a threatening tendency no-ticeable in the development of the sur-gical art towards such refined techniquethat the general practitioner will be leftout, because he cannot compete with thesurgical specialist in respect to the out-fit of most expensive apparatus andprophylactic arrangements, which aredeemed necessary to carry out asepsis.The logical consequences of operativeasepsis demand that besides the usualsterilizing apparatus and instrumentsthe operator and assistants must be fittedout with linen gowns, caps, beard-band-ages, respirators to cover the mouth,aseptic gloves, etc. The operating roomis also approaching the ideal of a sterileglass box with air filtering apparatus,hot and cold water flow and electricalmachinery for illuminating and cauter-izing, etc.

All of these demands no doubt havea tendency towards crowding out thegeneral practitioner and making surgerya monopoly for the wealthy specialistand for those who hold hospital ap-pointments in larger towns and cities.The general practitioner is even to-dayunable to successfully compete with therichly endowed State, municipal or pri-vate institutions that are located in thegreat centers. It is apparent thereforethat the general practice of medicinewill suffer a great hardship, if it is thusmade to abandon the most remunerativeand also most satisfactory or gratifyingdepartment of its usefulness. There isnothing which will so effectually help a

physician in the beginning of his careeror that will reestablish the sinking pres-tige of a physician among his patientsas the successful results of surgicalwork. This is the only department ofmedicine into which quackery and news-paper advertising has up to date madebut small inroads, and if anywhere thecompetent physician is able to prove hissuperiority over the scheming quack, itis in the realm of surgery. I desire toopen the eyes of the profession, withoutwishing to tread upon the toes of anyparticular interests, to the dangers aris-ing to the general practitioner from thisdevelopment of surgery.

I do not wish to be misunderstood,and hence must say that nothing is moreremote from me than to advocate thatphysicians who have had no adequatetraining and who have no taste or talentfor surgery should undertake to performall surgical operations. The best inter-ests of the public and of the professionare undoubtedly subserved by sendingchronic surgical cases to well equippedinstitutions where they can have the ben-efit of the most skillful surgeons. Butthere are many surgical cases which arenot able to stand transportation to dis-tant cities, and many emergency caseswhich demand prompt interference. Aphysician must, therefore, contrary tcthe dogmatic rules of science which in-dicate that surgery must only be donewith all the surroundings and apparatusabove mentioned, often take the risk ofoperating under circumstances which do

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not fulfill the demands of science andwhich are pronounced baneful and indeed are said to contraindicate the undertaking of an operation such for in-stance as coeliotomy.

In the following I shall attempt togive such rules as in my opinion willhelp to insure success in cases where thegeneral practitioner is compelled to treatintra-abdominal lesions, such as are pro-duced by acute appendicitis, internalstrangulation and obstruction of thebowels, and intestinal perforations.

The first and most important principleupon which are based all our moderrsurgical manipulations and interference;is the fact that normal repair is pre-vented by bacteria and their products,the toxines. Hence these must be keptaway from a wound. Where there areno pathogenic bacteria or toxines, pre-cautions may be unnecessary and evenharmful. The sources from whichthese death-dealing organisms and theirproducts come are either the body ofthe patient or some external place, a;

for instance, the physician himself, hisassistants, and what is directly or indi-rectly connected with them, or finallyfrom the air of the apartment in whichthe operation is done.

The idea that pathogenic bacteria areübiquitous is erroneous; they are fre-quent in large hospitals, rare in countrytowns, and absent in the wilds of theRocky Mountains. Culture media spreadon broad surfaces and exposed in themountains by competent bacteriologistsfor days and weeks failed to show colonies of pyogenic bacteria, and in thevast majority of the plates exposed nocolonies of any kind of bacteria couldbe detected at all. If a healthy boy or agrizzly bear were to sustain a compoundfracture of the forearm caused by a fallin the mountains and were not seen bya physician but left to nature for aperiod of three or four months thewound would most likely be found in

an aseptic condition or perhaps entirelycicatrized.

The most striking example to provethis unorthodox assertion is found in amost interesting paper published abouttwelve years ago by Prof. Robert P.Harris, of Philadelphia, in The Ameri-can Journal of the Medical Sciences. Inthat paper the author, who is known asthe great statistician of the caesareanoperation, has collected twenty-onecases of caesarean section performed onthe prairies or in the woods, by thehorn of an infuriated bull or a steer,upon women in the last months of preg-nancy; of these cases, fourteen womenrecovered. These cases were collectedwith great care and after much laborand correspondence. Harris succeededin getting them fairly well authenticated.You may judge of the amount of laborconnected with this research when I tellyou that in some cases there was noth-ing to start on but a newspaper item,and that some occurred in old Mexico,some in India, one in Missouri, one inRussia, and several on the plains in ourown territories. Twenty-one were suf-ficiently well authenticated by lettersfrom reliable sources to be tabulated byProfessor Harris and used in his sta-tistics. After reading the remarkable;paper of Harris I undertook a further-investigation by correspondence and by-personal visits to some of the authori-ties, and although for obvious reasons;

I will not give details I found that of thefourteen who recovered only six wereever seen by competent physicians, andof those who died all were handled byphysicians except those wdio died ofshock immediately after the attack.Contrast, with fourteen recoveries in thewoods or fields, the most of them farfrom hospitals or anv kind of medicalaid, the statement made by Sir James Y.Simpson in 1850, that not a single caseof caesarean section made bv a physi-cian or surgeon in Great Britain hadrecovered. We know that physicians in

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Great Britain and Europe previous tothe time spoken of by Simpson worelong peruques and ruffled garments withlarge ruffled sleevs—the more elaboratethe surgeon, the more hair and rufflesdid he have on—and of course in theabsence of any knowledge of infectionand its causes and effects we can understand how it was that no woman escapeddeath who was operated upon by one ofour unfortunate colleagues. I have inmy possession an old print dated 1663.showing the picture of a shoemaker,knife in hand, making the caesareansection on his own wife. He had beeninstructed how to cut by the physicians.These physicians in their robes andwigs, the preachers, together with somerelatives are represented on the print inthe adjoining room anxiously prayingwhile the brave shoemaker cuts openhis wife’s bellv. It is recorded in quaintlanguage in the accompanying text, thatby the miraculous aid of God, motherand child recovered. We know that sherecovered because the physicians whowere daily in contact with disease, didnot touch the wound in the woman’sbody. Permit me to observe that itwere good for suffering humanity ifphysicians of all times, who pray morethan they bathe, were kept out of oper-ating rooms.

From the examples cited and the rela-tion of facts we may conclude, caeterisparibus, that the country is a better anda safer place to perform a surgical op-eration than a densely populated place.Other things being equal, a newly-builtprivate house in a city would be a saferplace than a hospital or place wherepatients congregate in large numbersThe greater safety in both cases is pred-icated unon the probable absence ofpathogenic bacteria in the country andin the new house. Infinite care andwatchfulness are required to keep ahospital or infirmary free from thesources of infection, and I would preferto work in a private house if I can have

assistance, trained nurses, and such anarmamentarium as I have at the hos-pital.

We will proceed with the subject now,having decided that the country or pri-vate house are suitable "laces for thesuccessful performance of surgical op-erations in emergency cases or suchcases that cannot safely be removed toa well-equipped operating room.

In preparing a room and a table foran operation the preparation will bedone with an eye single to the object ofpreventing infection. In cases requiringprompt and quick action I think it willbe safer not to tear down the curtainsand pictures, and it will be better toleave the carpet on the floor. Tearingup things will most likely stir up andliberate germs and dirt that wouldotherwise be harmless in their innocu-ous desuetude or quietude.

The preparation of the hands of theoperator and his assistants has been thesubject of much study and experimenta-tion. After all has been said, the objectof the various methods of disinfectingthe hands can only be to remove thedirt and the bacteria and not to destroythem. Any method which aims at thedestruction of the bacteria will fail inits object. It seems to me to be an im-possibility because the skin is moreeasily destroyed by chemical and physi-cal means than the bacteria which in-habit it. I am also convinced that thetoo forcible use of a stiff brush doesmore harm than good. The endermaticparasites are safer when left alone in thedeeper layers of the stratum malpighithan when brought to the surface byviolent brushing. Every operator knowswhether or not his hands have been incontact with infected patients and willconsciously or unconsciously estimatethe danger of infecting a wound by hisown hands in accordance with hisknowledge of his own past experience.I have several times refrained fromwork for one or more days because I

6 RED CROSS NOTES.

did not consider myself clean.Cleanliness in every possible meaningof the term, not referring to the intend-ed destruction of bacteria, but to keep-ing away from contact with organic fermenting or sunpurating and infectedareas at all times and avoiding the con-tact of the hands with anv kind ofchemical irritants, must be aimed at bythe surgeon. Cleanliness in a kind ofreligious or ethical sense, attainable bymeans of physical methods, is what Jpractice and recommend. My assistantsoften wonder at my aversion to chang-ing dressings, or in any way coming incontact with the lesions of a patient un-less absolutely necessary. I often walkfrom bed to bed, never touching a casewith my own hands but leaving the management, under my direction, to an assistant or a nurse. This is an invariablerule when I know that I must performan operation on an afebrile patient thesame morning.

In my opinion the best method ofcleansing the hands is the thorough useof a strongly alkaline soap for a periodof not less than eight or ten minutes;using one soaping for two minutes, rins-ing this off in clear water, and repeatingthe operation four or five times. Afterthis has been done the hands may be im-mersed for two or three minutes in a

bichloride of mercury solution and driedin alcohol. The bichloride must not bestrong enough to irritate the. skin of thehands, certainly not stronger than I to1000.

The skin of the patient over andaround the place of operation must betreated in the same way. Coming nowto the operation itself, I notice that thescope of this paper limits me to generalconsideration more than to details; andI believe that I can do more good bygiving more time to the principles thanto details, particularly as time will notpermit my going into special cases. Inorder to become familiar with the de-tails of surgery there is but one method

and that is to serve for a time as an as-sistant to a master. The most dangerousphysician as well as surgeon is the onewho draws his information and knowl-edge from a text-book or two. Theman who is turned out of a medical col-lege with little more than a text-bookeducation is in a most pitiable condition.He is compelled to put into practice thatwhich he has only read or heard about,but has never seen and felt. The menwho by necessity start out in this waysoon feel their helplessness, and bv vis-iting hospitals and getting instructiondirectly from a master, become fitted forthe work. We should strive to havelaws enacted compelling all graduatesin medicine to take a course of at leastone year in a general hospital beforethey can become legally registered prac-titioners. Such men would probably becompetent to operate in an emergency.After all has been said the text-book isa necessary evil and for the purpose offurnishing information in minor detailshas a useful place, but whenever I havereferred to a text-book for help in asurgical emergency I throw it away indisgust. Text-books are not written bythe original thinkers. As a rule thepathfinder has no taste for the almostclerical work of compiling a text-book.For information which is of value, wemust all return to first principles, wemust interrogate nature, and in surgerythat means nothing more than to closelyobserve our cases, using our senses andsuch instruments of precision as we cancommand.

The diagnosis in an abdominal case isthe first thing that will come up and 1can console you by saying that evenafter an experience of more than fourthousand coeliotomies the diagnosis isoften a mere guess. If from the historyand objective examination the diagnosisis not clear, but an indication for coeli-otomy exists, the indication had betterbe fulfilled at once than to wait for anautopsy to clear up the diagnosis. A

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mere explorative coeliotomy will do noharm in itself and if it leads to a diag-nosis may be followed by life-savingwork in the cavity. In most cases ofobstruction of the intestines, the seatand cause of the obstruction are mattersof mere conjecture before the operationand sometimes are troublesome to locateafter the belly is open.

From the standpoint of prognosis Iwish to call your attention pointedly tothe matter of whether or not opium ormorphine is indicated in any form ofabdominal pain or disease. I do notonly mean opium and its derivatives,but I wish to extend my remarks to anyand all of the narcotic drugs, but par-ticularly to those which have a tendencyto stop the peristaltic action of the in-testines. The older men used to treatperitonitis by “putting it in an opiumsplint.” Of course the mortality wasterrific, but then some did get well inspite of the treatment. If in anv case inwhich a coeliotomy is contemplated youare informed that the patient has beengiven opium or morphine and is consti-pated, you may multiply the ordinaryexpected mortality by ten. In cases ofappendicitis you may safely multiply bysix; in other words, the chances of re-covery from an attack of appendicitisare six times greater if the patient istreated by means of cathartics and noopiate in any form, than if treated bythe old opium method.

The mortality following coeliotomy ofany kind on patients who have beentreated with opium up to the time ofoperation is enormously increased. Ifthere is time to give thorough purgationand if the opium is discontinued tenhours before operation the chances ofrecovery are greatly increased, but arenot as good by half as where no opiumhas previously been given.

I would lay down the rule, that in allcases of abdominal lesions whether ac-companied by pain or not in which anoperation may be contemplated or be

among the remote probabilities, as forinstance in colic, opium or any consti-pating drug must be avoided. If thepain is excruciating the inhalation ofchloroform or ether will be less harm-ful, but as a rule a large hot pack willbe sufficient to make the pain bearable.

Of all departments of surgery, ab-dominal surgery is perhaps the onewhich has the most devotees. It hasbecome a specialty, and there are moreabdominal surgeons “limited” than thereare brain and nerve surgeons.

There are more abdominal surgeonsthan there are bone and joint surgeons.I know any number of surgeons whowould not attempt to do a neurectomyof a branch of the trifacial, and whowould not for any consideration removethe tongue or the larynx for cancer andwho would not attempt an excision ofthe elbow joint. But there are somemen who will cut open bellies, removeovaries and tubes, operate for appendi-citis, “between the attacks,” and per-form operations on the gall bladder andfor hernia, and will have a low mortalityin their coeliotomies. I have noticedhowever that these same men will notoperate on the stomach and will hesitatelong before “refusing” to do hyster-ectomies, and I have also noticed thatif they do hysterectomy the result is notas good as in their other work. I canexplain the very large number of ab-dominal surgeons by giving away toyou a little secret which has been prettywell kept, up to this time. The truth isthat of all the departments of surgicalwork, none is so easy to learn and souniversally successful as the work whichthe abdominal surgeon (limited) hasselected for his specialty. It is a factthat the mortality of appendicectomydone during the quiescent stage, i. e.,between the attacks, is less than one percent. I cannot see why there should beany mortality at all in this operation,never having seen a death under suchcircumstances.

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Why should a healthy man die fromwhom we remove a practically normalappendix, one that has been diseased andmight become troublesome again? Thetruth is that the peritoneum of all thetissues of the body is the one, whichcan successfully dispose of more debris,take care of and render inocuous moredirt and bacteria, toxines, etc., than anyother. You may conclude then that ifyou have to operate at all, the abdominalcavity is the place where you can mostsafely risk your maiden effort, only besure and select a case of appendicitis inthe quiescent stage for the first attempt.Just as easy as is the work of the abdom-inal surgeon (limited), just so difficultis the work of the surgeon who under-takes to do that surgery in the abdomi-nal cavity which is indicated by malig-nant and benign tumors, by acute in-flammatory and infectious processesand by many obscure lesions such as forinstance, adhesions and malformations.To do successful work in this depart-ment requires a man who has a goodpathalogical training as well as a per-fect mastery of surgical technique.

The incision into the abdomen re-quires no particular instruction beyondsaying to the casual operator who oper-ates in an emergency, make it largeenough and make it anywhere over theseat of the trouble. In emergency casesthe'median line cannot often be chosenand a good rule will be to cut down onthe greatest prominence if there be atumor or a bulging plainly visible ortangible.

Cut down to the peritoneum, thenstop and check the hemorrhage fromthe parietes before opening the cavity.If the parietal peritoneum is normal cuta small opening into it with scissorsafter picking it up from the underlyingintestines. The finger can now be in-troduced and the diagnosis may be madein some cases. If it is found that thediagnosis cannot be made by the intro-duction of one or two fingers the wound

in the peritoneum must be enlarged soas to permit the whole hand to be intro-

S duced while both edges of the incision| are separated by a pair of broad retract-ors. During this time the patient must

| be profoundly anesthetized so as to pre-vent vomiting and prolapsus of the in-testines. The diagnosis having beenmade, the indications must be promptlymet, and they are so very numerous anddifferent that I cannot take time toenumerate the possibilities.

If the parietal peritoneum is not nor-mal and is found adherent to the under-lying intestines then it should not beincised, but exploratory punctures witheither a trocar or a pointed grooveddirector must then be made. This willlead to the detection of pus in the vastmajority of cases. In a few cases theadhesion may be due to some non-sup-purative process and the operator mustdecide whether to extirnate the mass ornot. If pus be not found, I would ad-vise an inexperienced operator to desistfrom further surgical effort and sew upthe wound. The patient will be noworse off than before the operation andthe diagnosis will be much cleared up.It will be the duty of the physician totell the patient and her people that theoperation, could not be completed underthe circumstances and that nossibly anexpert surgeon might still be able tobenefit the case bv a second much moredansrerous operation. It is always ad-visable for an emergency operator totell the people that he would much pre-fer to have an expert surgeon, but willmake the attempt to do the best he canunder the circumstances. He will thusget the gratitude of the patients and willescape censure in case of failure.

Should the operator find pus, then hiscourse of action will be on the followinglines: The finger must be made to doall the work, the pus cavity or trackmust be followed to its end by bluntwork with the finger, the knife and thescissors being put awav, The edges of

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the wound must be well retracted sothat the eye can follow the operatingfinger. When the bottom of the sup-puration has been found the cause inmost cases will be apparent. It willeither be the appendix, the tubes, thegall-bladder or some tubercular diseaseof the intestines, in at least nine out often cases. Should it be some other raretrouble with which the general practi-tioner is not at all acquainted, then fur-ther action must be abandoned and thewhole exposed pus cavity must bedrained. Should the trouble have origi-nated in one of the first named organsthe treatment in the majority of caseswill be extirpation of the appendix, ortubes, or of the gall-bladder, or againonly the drainage by means of gauzepacking. Drainage by means of tubesalone should never be practiced by any-one. If a tube seems a desirable drainit must always be surrounded by gauzewicks or strips, but in the vast majorityof cases gauze alone will be best. I ad-vocate extirpation of the offending or-gan whenever possible, but I cannotadvise the general practitioner who op-erates only rarely to attempt the totaleradication of an adherent tube or ap-pendix. By thorough drainage manycases will be radically cured, at leastwill be free from serious trouble for therest of their lives. In some a radicaloperation may become necessary lateron, but the drainage will at least havegiven temporary relief and may havesaved a life.

We come now to a class of cases,where a patient has an enormously di-lated abdomen, is vomiting and passesneither faeces or gas. He is said tohave “peritonitis” or “inflammation ofthe stomach or bowels.” The historygives no clew to the cause of thetrouble, and the diagnosis has beenmade impossible or at least much ob-scured by the constant administrationof some opiate. This condition has ex-isted from one to six or more days, the

vomit is getting to smell like feces, thepulse which has been good is gettingweak and rapid. About eighty per cent,of these cases are what I call opiatedcases of appendicitis, the rest are due tovolvulus, invagination or some form ofinternal strangulation by bands or ad-hesions or to a small perforation or leakin the hollow intestine. A coeliotomyof any case of tympanitis, with the intes-tines distended by gas and putrid, is anoperation that is fraught with more dan-ger and requires more skill than anyother I am acquainted with. The prog-nosis is bad, the mortality after opera-tion is more than sixty per cent. Thetechnical difficulties are enormous be-cause after the incision has been madethe distended intestines will roll out ofthe belly, and it will be almost impossi-ble to bring them back after the obstruc-tion has been found and relieved. Theresult is that even in the hands of anexpert and under most favorable cir-cumstances in a hospital about fifty percent, die of shock. If opium were takenaway from the general practitioner inabdominal cases and epsom salt and cas-tor oil put in its place, eighty per cent,

of these dreadful cases would nevereven occur.

I am of the opinion that these casesare better treated by washing out thestomach every two or three hours, andby rectal nutrition and total abstinenceof food through the mouth. Of coursecathartics must be freely given and allother medication stopped.

I have succeeded in saving severalcases by making two, and in one casethree enterostomies, so that the intes-tinal tract could be freed from its pu-trid contents and the fatal autointoxica-tion ended. This operation leaves thepatient with two or three intestinal fis-tulas, or if you like that name better,with several artificial anus. Should thepatient survive, these supernumeraryopenings can be closed at a convenienttime and place.

10 RED CROSS NOTES.

I recommend that in cases of thiskind after milder measures have failedto make two artificial openings into thegut, the one in the right iliac fossa intothe coecum, and the other in the leftiliac region into any distended loop ofsmall intestine that may present itselfin the incision.

The operation is so simple that anyphysician can perform it with nothingbut a knife and a needle and thread. Ionce saw a man awake from the chloro-form upon whom I made enterostomyand discharged about two gallons ofliquid feces, get up from the operatingtable and declare that he never felt bet-ter in his life. His abdomen had beendistended so much that he measuredfifty-eight inches around the girthWhen we placed him upon the operat-ing table his pulse was 140 and he wasin a collapse.

In making a fecal fistula, the incisionin the abdominal wall need not be overan inch and a half long, and the incisioninto the gut need not be over one-fourthor three eighths of an inch long. Thegut must be fastened to the abdominalwall by means of four stitches carriedclear through all the layers of the guland the abdominal wall. These stitchesmust not be tied tightly, because theymight cut through the weakened wall ofthe intestine. The after-treatment con-sists in washing out the canal of the gulbut not the wound. A little gauze isplaced in the incision and a gauze stripor rubber tube closed by a clamp maybe left in the gut. The whole abdo-men is then covered by a large hoiwet pack, which is kept moist by pre-venting evaporation. This is done bymeans of a piece of oil cloth or rubbeitissue.

The next subject that will engage out

attention is the closure of the woundAfter having tried all methods and visited all the surgical clinics of Europeand America, I recommend for expertas well as for the casual emergency op-

erator the old through and throughsuture. It gives the best results pri-marily, and is followed by as few hernias as any of the many methods thathave been advocated by means of whichthe belly wall is closed by three or moretiers of sutures closing the layers, sin-gly over each other. I recommend, in-cluding merely the very edge, about onetwentieth of an inch of the peritonealmargin on each side, while the muscleand fascia are well grasped by thesuture. The stitches can be removedon the fifth day, and there will be noburied sutures left to cause abcesses orsinuses.

In cases where the wound is not closedbut is left open for drainage I recom-mend for expert as well as for amateur,that only gauze drainage be used, neverthe tube alone; but if the tube is usedlet it be used together with gauze. Ifall of the pus, gangrenous tissue, etc.cannot be removed at the operation,means for its escape by drainage mustbe furnished. The operator must seethat the wound is so well drained thata retention of secretions or tissue shallbe impossible. The drainage must befree, and the opening must be so ar-ranged that the gauze drain or packcan be changed easily without causingpain to the patient. If you are sure offree drainage, irrigation of the woundis useless, indeed it is very harmful, andI have abandoned it altogether in mywork. I never used it even in empyemacavities; it is utterly superfluous if thecavity is well drained. As long as yourdrainage is sufficient there will be norise of temperature. The wound maybe left alone for days if there is no feverand no pain. Pain in the majority ofinstances in these cases is due to bad orinsufficient drainage, and is absent whereyou have free outlets for the discharge.The after treatment of coeliotomy casesfor the first twenty-four hours consistsin total abstinence from food and drink.Great thirst may be relieved by enemata.

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Pain must be borne and the patient mustbe told by the operator after she awak-ens from the anaesthetic that unless shewill lie as still as a stick of wood andbear all the pain without a murmur fortwenty-four hours, she will surely die,and that as surely will she make an easyrecovery if she remains quiet and doesnot ask for drink. Under no imaginablecircumstances give opium or morphineor any other similar preparation. Onthe morning of the second day give one-tenth grain calomel every hour or halfhour, until there is a discharge of gasor feces per rectum. This may be fol-lowed by a mild saline aperient. Liquidfood, first in small quantities, is per-missible after the second morning.Coeliotomy cases should remain in therecumbent position three weeks orlonger in order to minimize the chancesof a hernia in the scar. The wearing ofan abdominal bandage after getting upis not necessary, but it seems to be com-fortable to some natients.

About suture material and dressingsI have this to say to the casual operator;Use nothing but silk of different sizesfor all purposes —do not use catgut—-silk can always be easily sterilized.About gauzes and cotton, in fact allwound-dressings, the general practi-tioner will do well to use those made byone of the great manufacturers andpacked in such a manner that they can-

not become infected or unclean beforethey reach the physician’s hands. I amconvinced that the use of these beauti-fully made articles will give better re-sults to the casual operator than thosehe can make himself at his residence oroffice. I have personally tested thegoods made by Johnson & Johnson intheir magnificent plant at New Bruns-wick, N. J., and can recommend themas safely sterile and aseptic. No doubtthe product of other firms are also relia-bly sterile, but I can only vouch forthose I have tested.

Finally, gentlemen. I would like tosuggest that in all smaller towns andvillages an operating room and perhapsa few sick rooms be maintained, in whichall of the local practitioners, or a con-sulting physician if one is called in froma distance, can do the necessary opera-tions. Permit me to say again that itseems to me the proper time to call at-tention to the fact that good and suc-cessful work can be done in the countryor in a private house or on a farm, andthat my object in this naper was to throwout some hints and suggestions whichwould have a tendency to encourage thecountry practitioner in his hard andoften poorly remunerated efforts in be-half of those who are too poor or too illto be removed to one of the palatial andexpensive institutions in large cities.

3623 Laclede Ave., St. Louis, Mo.