avoidable, but desirable and even necessary. Surgeons were never satisfied until good "laudable" pus had been obtained; and the relations between fever, blood poisoning and suppuration were unrecognized or disregarded.

To have a leg amputated, even in the twentieth century, is not a luxury, nor a thing to be strongly desired; but it is not the horrible, blood-curdling experience now that it once was. Some wet morning, for instance, when you least expect it, you slip and fall in front of a trolley car on the corner of Seventeenth and Curtis. You find yourself on your back in the street, your leg crushed below the knee, skin the color of white wax, and clothes muddy and torn. After a wild ride in the ambulance, with swinging slides around the corners, and painful jolts over the car tracks, you reach the hospital. A hypodermic of morphine is given, and in a few minutes you are perfectly easy and free from pain, although weak, pale and bloody. A surgeon examines your affected exteremity. The skin is burst open, exposing the lacerated muscles and splintered bones. The circulation is destroyed and the whole dreadful wound is smeared full of the dirt of the street. An amputation is necessary. Before you fully grasp the horror of your position, for the mind is hazy at such times, chloroform is administered * * * And then you find yourself back in bed, gazing at a sweet young woman in a white cap and spotless apron, and trying to realize that your wounded leg is no longer attached to your body. When the effects of the anesthetic have worn off, you are quite comfortable, and in two or three weeks you are well and about on crutches. From the time you entered the hospital there was practically no pain, no fever, and comparatively little discomfort.

Some years ago 222 major amputations were reported from the Heidelberg Clinic, 200 of them progressing in this eminently satisfactory manner, and the results are even more brilliant to-day.

The achievements and possibilities of twentieth century surgery are so well known that I am tempted to rest my case here, for even the uninitiated must appreciate the contrast between the old and the new, without further elucidation.

Our present superiority, however, does not depend, as some believe, upon greater skill in the use of the knife, for our more recent ancestors could operate just as skilfully as we do, and some of them even outclassed us in dexterity. But the brilliant success of modern surgery rests upon improvements in hos

pitals and in nursing, upon surgical cleanliness and a knowledge of bacteriology, and upon advancement in methods of diagnosis with the resulting increase of "surgical judgment."

The fear of hospitals has largely disappeared, and people are so rapidly learning to regard them as havens of comfort and safety that the numerous institutions can scarcely find room for those who are constantly applying for admission. Cleanliness, neatness and cheerfulness reign where formerly existed dirt, contagion and despair.

The trained nurse has added much more to the comfort and safety of operative procedures than is perhaps generally appreciated. Our palatial operating rooms, with their plate glass and polished marble, would be but foolish pretense without the intelligent supervision of a well-trained nurse.

Diagnosis has advanced with gigantic strides within the last few years. To be able to recognize a disease with certainty, and to recognize it promptly, is of the utmost importance, perhaps involving the life of the patient. Microscopic examinations of the blood often enable us to detect deep-seated suppurations and to distinguish one disease from another; they may even tell us whether the individual is strong enough to bear an operation. From laboratory study of the bodily excretions and secretions, the pathological secrets of internal organs are exposed, and even the most ignorant are familiar with the wonderful possibilities of the Roentgen rays. All accessible cavities of the body, even the stomach, may be explored by means of mirrors and electric lights, and operations performed within them which could scarcely have been imagined by older surgeons. Experience has taught us that various diseased portions of the body can be removed with benefit-not only arms and legs, but kidneys, bladders, spleens and even stomachs. It is no uncommon thing for surgeons to take out a section of intestine, a portion of the liver, or even a part of the lung or brain.

However important other things may seem, bacteriology is really the hub around which the spokes of twentieth century surgery revolve. Without the foundation of bacteriology and the knowledge of surgical cleanliness which it involves, the entire superstructure of modern surgery would tumble into fragments. Bacteriology is sometimes spoken of as a theory. It is not a theory. It is a science, the facts of which are as absolutely demonstrated as those of chemistry, when certain germs are invariably found in diseased wounds, when we can cultivate

them on gelatine in pure cultures through many generations, and then inoculate them into animals and produce the same sort of inflammation containing the same germs-when we can do these things as often as we please, we are dealing with facts. and not with theory-facts which are practically supported by brilliantly successful surgery.

The art of surgical cleanliness, which means the exclusion of germs from wounds, has added largely to the sum total of human happiness and longevity. Much physical suffering, which was formerly endured with what fortitude we could command, is now dissipated by a few painless strokes of the knife, and with a minimum amount of danger and discomfort. Especially should women be thankful for the blessings which have been conferred upon them.

The twentieth century has opened most propitiously as far as surgery is concerned, and the horizon is replete with suggestions of further discoveries and improvements. And one of the greatest advances will be an increase in our knowledge of what to do and what not to do-a clarification, as it were, of the surgical atmosphere.

SOME THOUGHTS ON ABDOMINAL SURGERY,* With a Brief Report of Cases Operated Upon Since January 1, 1899.

By I. B. PERKINS, M.D.,

Denver, Colorado,

Professor of Clinical Gynaecology, Denver College of Medicine; Surgeon and Gynaecologist to St. Luke's Hospital; Gynaecologist to Arapahoe County Hospital.

The brief report of cases which I give you to-day I shall give from a purely statistical standpoint. I take the date January 1, 1899, because my last statistical report ended at that time.

In this report are included all the cases that I have operated from that date to the present time—a period of nearly two and a half years. A few of these cases I have already reported in detail and some of them I shall include in similar future reports. I have divided them into three classes, viz.: "Favor

*Read before the Colorado State Medical Society, Denver, Colo., June 18, 1901.

able," "Not so favorable," and "Desperate." In the "Favorable" class I have included all the cases in which there appeared little or no doubt as to the patient's chance of recovery. In this class are all clean cases, not especially complicated; hysterectomy for fibroid tumor; hernia, not strangulated more than twentyfour hours; tubal pregnancies, ovarian cysts, appendix cases operated in the interval, those operated sufficiently early as to admit of closure without drainage, as well as all cases in which a walled-off abscess was present and was simply opened and drained without invading or infecting the free abdominal cavity.

In the second class are placed the cases which were considered not so favorable, but were not so bad as to be classed as desperate. In this class are hysterectomy for carcinoma; strangulated hernia, if of more than twenty-four hours' standing; appendicitis, where the abscess is intra-peritoneal or where in an extra-peritoneal abscess the appendix was removed, endangering or infecting the free abdominal cavity; also any other case already septic.

In the third, or "Desperate" class, are placed only those cases which were considered to have no chance whatever for life without an operation, and to have very little chance with it. In this class are included all cases of general abdominal infection, such as appendix and tubal cases where an abscess has broken into the general cavity, badly strangulated bowel cases of long standing, severe hemorrhage into the abdominal cavity from any cause, etc.

There were 173 cases operated in the time stated. Of these, 152 recovered and 21 died.

In the "Favorable" class there were 81 cases, with no deaths.

In the "Not so favorable" class there were 70 cases with 7 deaths, and in the "Desperate" class there were 22 cases with 14 deaths. Considering the 173 cases as a whole, with the 21 deaths which occurred, gives a mortality of a little more than 12 per If the "Desperate" cases are taken separately, and the first two classes taken together, we have, in these two, 151 cases with 7 deaths, a mortality of about 42 per cent.

cent.

The operation in the 173 cases was performed for the following conditions, and, owing to more than one disease being frequently present, one case will occasionally appear under more than one heading, as, for example, in a case of removal of an ovarian cyst, the uterus may also be ventro-fixed.

There were 45 cases of appendicitis, 21 of hysterectomy, 27 of ventro-fixation, 26 of ovarian cyst, removal of diseased ovaries and resection of a part of an ovary, 2 cases of tubercular ovaries, 7 tubal pregnancies, 14 cases of suppurative peritonitis, 8 gall-bladder operations (stones being found in all but one), and 16 cases of hernia. In one case of hernia an ovary was found in the sac. The ovary was returned into the abdominal cavity. There were 13 cases of pyosalpinx, 2 of intra-ligamentous cyst, 3 where small myomata were removed and the uterus left, and one gun-shot injury in the abdomen. In II cases exploratory operation was made for the purpose of completing the diagnosis and aiding in other operations and in nearly all of these there was other work found necessary. In some of them, however, there was no other operation, but by means of the exploration I was able to remove all doubt as to the existing condition. Ventro-fixation was performed for the most part, in connection with other operations.

APPENDICITIS.

The 45 cases of appendicitis I have tabulated below. They were distributed as follows:

The death which occurred in the intra-peritoneal abscess case, died nearly a month after the operation, of septic pneumonia.

In the posterior part of his right lung was a large abscess, considerable of the contents of which he expectorated during the last few days of his life. The lower lobe of the left lung was also quite solid and a large ante-mortem clot was found in the heart. It will be plainly seen from these cases that the deaths in appendicitis operations nearly all occurred in cases that were allowed to go too long before operation was performed.