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operation. As to the influence of anaesthetics upon the condition called shock there is a difference of opinion. I will not attempt to discuss the subject here. Further investigation and observation are required to elucidate this point. The surgeon who believes that they relieve or diminish shock will be inclined to proceed earlier with his operation than the one who holds the opposite opinion.

3rd. The amount of blood lost at the time of injury, or before the arrival of a surgeon must necessarily have a marked influence on the condition of the patient. The chances of surviving a serious operation are diminished in proportion to the hemorrhage, but the loss of a moderate amount of blood is no contraindication to an early operation. It is well known that contused wounds do not bleed freely. Most wounds in railway service are of this class. The amount of blood contained in a crushed extremity is, of course, lost. This alone would be sufficient to produce quite severe shock in some persons. The amount of hemorrhage can only be estimated approximately and must be described by such relative terms as slight, moderate, severe, profuse, etc. If the surgeon is quite certain that the hemorrhage has been severe, he should be cautious about proceeding at once with an operation. No fixed rule can be established, but due consideration should be given to the loss of vital fluid, in determining the question of prognosis.

4th. Habits. It has been said; "Happy is the man whose habits are his friends." This is true and, perhaps, never of more significance than when the individual has sustained a severe personal injury. It frequently happens that the railway surgeon meets his patient for the first time when called to render his assistance, and knows nothing of his habits. Careful inquiry will often fail to elicit the desired information. If, however, the marks of dissipation or syphilitic disease are plainly manifest, they should serve as notes of warning, indicating that the patient is in poor condition for an operation. Although these circumstances are unfavorable, they should not be allowed too much weight. Such patients are poor subjects upon which to practice conservative surgery. They are the very cases where it is important to proceed, with any required operation, as soon as the second question I have indicated can be answered in the

affirmative. Any habits tending to impair vitality or lower the tone of the system are unfavorable for sustaining a serious operation.

5th. Constitution of the individual: Strength of constitution is not determined by the weight or stature, or even muscular strength, but by the vitality or powers of endurance. Previous acquaintance with the injured person will enable the surgeon to form a sufficiently accurate estimate of his patient's stamina or vitality; in other words, his constitution. Without such acquaintance, the surgeon should search for organic disease of all important organs, especially for renal disease. The person with weak constitution succumbs, while the one possessed of good powers of endurance survives an important operation. The importance of a correct opinion regarding the patient's constitution should be duly appreciated by the surgeon. Having intimated to our president that my paper would not exceed ten minutes, I must close, having but briefly indicated the chief points that should be given consideration in estimating the prospects of an injured patient surviving an important operation. Having decided that an operation is necessary and that it appears quite probable our patient will survive, if we proceed at once, there is but one thing for us to do, and that is to operate. I do not mean that we should be hasty and operate wherever we may. We should take what time is necessary to remove the patient to a suitable place and make suitable arrangements, but should not delay unnecessarily. With the conditions I have just indicated all complied with, I can imagine no cases to which the rules I have formulated do not apply.

It is a common saying: "There are exceptions to all rules," but I would urge you not to seek for exceptions. I am fully satisfied that it will be better for your patient and will save you much anxiety and mental strain, if, having decided that an amputation is required and that your patient will probably survive, you follow the advice suggested in this paper and proceed.

Order a purge for your brain; it will there be much better employed than upon your stomach.-Montaigne.

One asking a Lacedæmoniann, what had made him live so long, he made answer: "The ignorance of physic."-Montaigne.

A COMPLETE EMERGENCY OUTFIT.

BY ARTHUR DEAN BEVAN, M. D., CHICAGO. Professor of Anatomy at Rush Medical College; Professor of Surgery at the Women's Medical College; Surgeon to the Presbyterian, St. Luke's and St. Elizabeth's Hospitals.

The introduction of asepsis and antisepsis has So completely revolutionized the technique of operative surgery, that the general surgical operating cases formerly used are now practically worthless. Experience has taught us that, with proper preparation and proper precautions, aseptic surgery can be done as well in a farmer's kitchen as in the most modern operating room.

To accomplish such results, however, a surgical outfit is required which is so complete

that with the addition of water and a place to boil it, the surgeon has at his disposal everything necessary to perform an aseptic operation. The value of aseptic or antiseptic surgery has been so fully demonstrated that the operator who neglects to full carry out its essential principles is to be held negligent. This fact is generally admitted and yet how few surgeons possess and have ready for instant use a complete aseptic surgical outfit with which they can go at once to an emergency operation as fully prepared as a fire company is when it answers a fire alarm. Such an outfit must be recognized as a necessity by all men doing surgical work.

Many surgeons and instrument makers have pondered over the problem of devising the best complete emergency outfit, but as a rule their attempts have failed because of

their efforts to make very small and compact cases, and as a result the outfit is incomplete and not suited to grave emergencies. After devoting some considerable time and thought to this subject I have devised an outfit so complete, that I could handle with it any emergency surgical case and practically all surgical operations, except such as litholopaxy, osteoclasis, etc., which require cumbersome instruments and which are of a nature requir ing ample preparations.

A considerable experience with this outfit in cases of appendicitis, strangulated hernia, tracheotomy, mastoid disease and brain abscess, laparotomy for intestinal obstruction, ovarian cysts, stone in the bladder, retention demanding external urethrotomy amputations, osteomyelitis, fractures of skull and long bones, and in all general surgical cases performed outside of my hospital operating room, has taught me its great value. The outfit consists of two cases one containing the instruments, ligatures, sutures, anæsthetics and antiseptics; the other containing the dressings, sponges, bandages, aprons, towels, laparotomy pads, etc. The list of instruments is based upon a careful study of the instruments required for all the various operations described in one of our most complete text books on operative surgery. The list of dressings, bandages, etc., contains the essentials as found in our modern hospital operating rooms.

The outfit is very complete and rather expensive, but it contains practically all the instruments required by a general surgeon and in such shape that they are ready for instant

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use.

Not a little reputation may be gained for the surgeon by demonstrating to his patients and fellow practitioners that he is possessed of such a complete surgical outfit and is at all times prepared to meet any surgical emergency. But far above such considerations is the fact that such an outfit will enable the surgeon to give his patient the benefit of aseptic surgery under practically all circumstances, which means often the saving of life and suffering by the prevention of wound infection.

My experience in railway surgery, both as local and chief surgeon, has demonstrated to me that very few railroad surgeons are equipped as they should be with a complete emer

gency outfit to do aseptic work. And yet the railway surgeons in each community are the men who do not only the railroad surgery, but the bulk of the general surgical work in the localities in which they live. Therefore I do not hesitate to emphasize in the columns of The Railway Surgeon the importance of being prepared with a complete. outfit to do aseptic emergency surgery.

I would ask every man who reads this article to ask himself if he is so prepared, and I would urge every one who is not, to study the subject carefully and furnish himself with

I Buck's lithotomy staff,

1 Rongeur forceps with spring,

I pair Ferguson's bone holding forceps, I lead mallet,

I Van Buren's bone chisel,

I Van Buren's bone gouge.

I mastoid chisel,

I Galt's trephine,

I metacarpal saw (movable back), I Kocher's director,

I Sayre's periosteotome,

2 aneurism needles (metal handled). 3 hard rubber trachea tubes,

2 mouse tooth forceps, I Volkmann's curette,

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the necessary emergency outfit, not necessarily the one I outline below, but one which is equally complete and efficient.

The complete outfit consists of the following articles:

One emergency bag containing

I amputating knife for hip and thigh, I amputating knife for leg and arm, 6 minor operating knives,

I Emmett's uterine needle holder,

12 Tait's artery forceps,

I pair Collin's retractors,

2 plated probes,

2 grooved directors,

I pair strong scissors,

I pair curved scissors,

I pair strong scissors, 6 inches,

I pair of Liston's bone forceps,

I pair of curved lithotomy forceps,

I bone curette,

I set Brainard's bone drills,

I Smith & Sharp thermometer,

I wooden case for two amputating knives,

I wooden case for 8 smaller knives,

I razor in case,

I dozen assorted uterine needles,

I dozen assorted surgeons' needles,

I hypodermic syringe and tablets in an aluminum case.

I set of Murphy's buttons,
I Knight's stethescope,

I razor strop,

I Bouchard's syphon syringe,

I -ounce hard rubber syringe,

I papier maché catheter case, 6 dressing splints,

2 plated male catheters,

2 Nelaton's catheters (soft rubber),

3 filiform bougies,

2 Hunter's wedges,

I bottle of assorted drainage tubes,

I large aspirating syringe,

I Esmarch's bandage,

I eight-ounce metal cased bottle for chloroform,

I four-ounce metal cased bottle for alcohol. pound of ether,

I bottle of sublimate tablets,

I coil silkworm gut,

I hard rubber iodoform duster,

2 bottles of assorted catgut,

I bottle kangaroo tendons,

I Esmarch's chloroform inhaler.

3 duck rolls for instruments,

I Esmarch's tongue forceps.

One 16-inch telescope case containing

6 plaster of Paris bandages, (3 inches by 6

Notes of Societies.

American Association of Obstetricians and Gynecologists.

The ninth annual meeting of the American Association of Obstetricians and Gynecologists will be held at the Hotel Jefferson, Richmond, Va., Tuesday, Wednesday and Thursday, September 22, 23 and 24, 1896.

The proprietors of the Jefferson offer special rates to the Fellows of the association, their families and guests, as well as to any physicians who come to attend the meeting. It is confidently expected that the railways will offer transportation at a uniform rate of a fare and a third on the certificate plan to all in attendance. Let all obtain certificates from

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I can of sublimate gauze,

I can borated gauze,

pound of absorbent cotton,

dozen gauze bandages (2 inches by IO yards),

dozen cotton bandages (2 inches by 8 yards),

dozen flannel bandages (4 inches by 8 yards),

2 brass pulleys,

3 dozen safety-pins,

I pure rubber bandage (2 inches),

2 rolls adhesive plaster (1 and 2 inches), 6 sterilized laparotomy pads,

8 sterilized towels,

I can of iodoform gauze (10 per cent), 20 tubes of sterilized silk,

Needles for intestinal sutures,

2 aprons,

I nail brush.

100 State street.

their local ticket agents, or from the nearest point where certificates are granted.

OUTLINE PROGRAMME.

The association will meet in executive session with closed doors on Tuesday, September 22, at 9:30 o'clock a. m., for the election of new Fellows. The open session for the reading of papers will begin at 10 o'clock a. m. Recess for luncheon at 1 o'clock p. m. Afternoon session at 3 o'clock p. m. An evening session will be held Tuesday at 8 o'clock.

Morning session will begin Wednesday at 9:30 o'clock for the reading of scientific papers. Recess at 1 o'clock. Afternoon session at 3 o'clock. Adjournment at 5 o'clock. Executive session at 6:30 o'clock. Annual dinner at 8 o'clock p. m.

Thursday morning the session will begin at 10 o'clock. Recess at 1 o'clock. Afternoon session at 3 o'clock. Final adjournment at

5 o'clock. A full attendance is specially requested at the final session.

PAPERS PROMISED.

Note. No attempt is made to arrange papers in the order in which they are to be read. That will be done in the permanent programme.

1. "Principles and Progress in Gynecology." President's address. Joseph Price, Philadelphia.

2. "Vaginal Hysterectomy by the Clamp Method," Sherwood Dunn, Los Angeles.

3. "Further Experience With Appendicitis," A. Vander Veer, Albany.

4. "Relation of Malignant Disease of the Adnexa to Primary Invasion of the Uterus," A. P. Clarke, Cambridge.

5. "Treatment of Puerperal Septicemia," H. W. Longyear, Detroit.

6. "Treatment of Posterior Presentation of the Vertex," E. P. Bernardy, Philadelphia.

7. "Relation of local Visceral Disorders to the Delusions and Hallucinations of the Insane," W. P. Manton, Detroit.

8. "Differential Diagnosis of Hemhorrhage, Shock and Sepsis," Eugene Boise, Grand Rapids.

9. "Movable Kidney: Local and Remote Results," A .H. Cordier, Kansas City.

10. "Pathology and Indications for Active Surgical Treatment in Contusions of the Abdomen," W. G. Macdonald, Albany.

II. "Some Causes of Insanity in Women," George H. Rohé, Sykesville.

12. Subject to be announced, John Milton Duff, Pittsburg.

13. "Shall Hysterectomy be Performed in Inflammatory Diseases of the Appendages?" L. H. Dunning, Indianapolis.

14. Subject to be announced, Rufus B. Hall, Cincinnati.

15. Subject to be announced, Geo. Ben Johnston, Richmond.

16. "Dynamic Ileus: With Report of Cases," J. W. Long, Richmond.

17. "Faradic Treatment of Uterine Inertia and Subinvolution," Charles Stover, Amsterdam.

18. "A Plea for Absorbable Ligatures," H. E. Hayd, Buffalo.

19. "Treatment of the Stump," J. F. Baldwin, Columbus.

20. "Limitations in the Teachings of Obstetrics and Gynecology as Determined by State Medical Examining Boards," William Warren Potter, Buffalo.

21. Subject to be announced, Walter B. Chase, Brooklyn.

22. (a) The Philosophy of Drainage;" (b) "Treatment of the Pedicle in Hysterectomy or Hystero-myomectomy in the Abdominal Methods," Geo. F. Hulbert, St. Louis.

23. "Removal of the Uterine Appendages for Epilepsy and Insanity; A Plea for Its More General Adoption," D. Tod Gilliam, Columbus.

24. "Albuminuria of Pregnancy," A. Fr. Eklund, Stockholm.

25. Subject to be announced, Lawson Tait, Birmingham.

26. "Unnecessary and Unnatural Fixation of the Uterus and Its Results," James F. W. Ross, Toronto.

27. "Sarcoma of the Urethra," Charles A. L. Reed, Cincinnati.

28. "Appendicitis as a Complication in Suppurative Inflammation of the Uterine Appendages," L. S. McMurtry, Louisville.

29. "Gunshot Wounds of the Abdomen With the New Gun," J. D. Griffith, Kansas City.

30. Subject to be announced, Walter B. Dorsett, St. Louis.

31. Subject to be announced, W. E. B. Davis, Birmingham.

32. Subject to be announced, E. Arnold Praeger, Los Angeles.

33. "Tubo-ovarian Cysts, With Interesting Cases," A. Goldsphon, Chicago.

34. "Obstruction of the Bowels Following Abdominal Section," Geo. S. Peck, Youngstown.

35. Memorial of Dr. Hiram Corson, Traill Green, Easton.

Correspondence is pending concerning additional papers. All titles must be offered before August 25, when the permanent programme goes to press. The executive council directs attention to the following by-law:

PAPERS.

VI. The titles of all papers to be read at any annual meeting shall be furnished to the secretary not later than one month before the first day of the meeting.

No paper shall be read before the association that has already been published or that has been read before any other Body.

Not more than thirty minutes shall be occupied in reading any paper before the association.

Abstracts of all papers read should be furnished to the secretary at the meeting.

All papers read before the association shall become its sole property if accepted for publication; and the executive council may decline to publish any paper not handed to the secretary complete before the final adjournment of the annual meeting.

Dr. Geo. Ben Johnston, 407 E. Grace street, Richmond, Va., is chairman of the committee of arrangements, who should be addressed in regard to hotel accommodations and railway. fares.

Joseph Price, President. William Warren Potter, Secretary.

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