which was in the liver; the irascible, having its seat in the heart, and the rational, having its seat in the brain. He taught that the heart was the source of animal heat, and the center of anger and violent passions. In common with this he believed the mucous discharge from the nasal cavity came from the brain, that it passes through the cribriform plate of the ethmoid, and that it was the excrementitious matter from that organ.

The physician's fee at this time was fixed by law, and he was compelled to visit his patients twice daily, and once at night if called upon. For this he was allowed to collect a fee equivalent to fourteen cents if the patient lived in the city, while without the city the legal charge should not exceed one dollar, and then he was expected to defray his own expense. One of the physicians to the Countess of Germany only received $25 as his annual fee. The early American physician and apothecary were often paid in tobacco, powder, lead, and wampum. In those dark days of the Middle Ages, when profound ignorance and superstition prevailed and the practice of medicine was relegated to the ecclesiastics who upheld the efficacy of charms and relics, arose many of the absurd and peculiar notions which exist among the laity to-day. The prejudice ran so high against dissection that there could be no such thing as the profession of the surgeon. There was almost a total lack of anatomical knowledge, and hence the practice of surgery fell into the hands of a certain ignorant class of barbers and bonesetters who knew nothing of its mechanical and technical nature. They traveled from place to place, only stopping long enough to complete what work they could get or until by some reverse they were compelled to depart. These men were most all specialists: some would operate on cataracts, others for stone, and some for hernia, each one having a secret method which was not made known until hist death, and then only to some one of his posterity. Not until 1837 was there a single ray of intellectual light thrown upon surgery. Pare, whose name will ever be remembered as long as the art of surgery is taught, introduced the ligatures to check hemorrhage instead of the actual cautery. By his vigilance and sagacity he placed the practice of surgery upon a higher plane and established for himself a reputation which has never been surpassed by any man before or since. At this time surgery, which had been naturally separated from medicine, began to approach it, the combination thus brought about inuring to the benefit of all. There are many more interesting facts con

nected with this subject, but time and space will not allow them to be recited here, but I can not close without a word of eulogy for these brave men, who by their vigilance, industry, and originality of thought have made their names illustrious for all time. Yet for them we have a feeling mingled with disappointment and respect-disappointment at the waste of so much intellectual labor and power, and respect for the zeal with which they sought for the truth. Yet but for that pregnant past the great present would not have been born. It was the womb of the present. All science is first a conception, then a birth, and then a growth. That dark, mysterious past is the mother of the illustrious present. To her we owe our being and a debt of gratitude which can be discharged only by making the present a parent of a still grander future. "Others have labored and ye have entered into their labors;" they have sown and we are reaping, let us also sow that posterity may reap.

MORGANTOWN, KY.

OPERATIVE SURGERY.*

BY I. A. SHIRLEY, M. D.

I thank you for your kind invitation to read a paper on "Operative Surgery" before your august body. I can at most only hope to recall a few of the "up-to-date" well-known surgical principles and laws, and not to offer any thing new to any of you. How very different the conduct of surgical cases to-day and twenty years ago, when some of us began the practice of the healing art! Who can not recall with what enthusiasm and ardor we used to apply the ice-bag, ice-cap, and a perpetual running stream of cold water to a wound accidentally or intentionally made, the constant care and unrelinquishing renewals of cold to prevent fever infection and sepsis. And how often the hot weather was charged with every ill result conceivable. Reviewing all this, we can readily discern that we were often, yea, many, many times, the innocent cause of all the woes we were so anxious to avoid by applying uncleanly cloths, or impure water, and in numerous other ways disregarding the all important principles of asepsis and antisepsis, so well known and practiced in perhaps every civilized country on the globe to-day. The practical surgeon of to-day, the emergency man I mean,

*Read before the Kentucky Valley Medical Association at Clay City, Ky., September 24, 1897.

goes about his work as unhesitatingly and with as much hope as to final good results in August as in November, if equipped for the religious observance of asepsis and antisepsis. He cleanses the wound, applies the dressings, and goes about his business as unconcernedly in hot as in cold weather. The originator of this wonderful idea deserves at the hands of a grateful profession, and it should be of a still greater laity, far more praise than can possibly ever be bestowed upon a mortal man. If Lord Joseph Lister could only calculate the one ten-thousandth part of the men, women, and children throughout the wide, wide world saved through the evolution of his wonderful surgical brain, he certainly could of a truth exclaim that he had not lived in vain.

And yet, Mr. President, you will occasionally, even in this good day, find men who believe or at least pretend to believe that there is nothing in antisepsis, but they are so few and far between that they can neither prevent nor retard this great surgical truth. There is in some quarters, and very properly, a tendency to a stricter regard for asepsis, disregarding to a considerable degree and with some entirely the all-important antisepsis. Granting for the sake of argument, if you will, that cleanliness alone will suffice (a belief entertained certainly by a small minority), in the event that they should be wrong, what possible harm can accrue from a proper understanding and practice of both asepsis and antisepsis? Any man who will not first thoroughly cleanse will certainly come to grief, for no amount of gauze or powder of any kind can atone for uncleanliness. Therefore it is the improper use or abuse of antisepsis that is objectionable. If we could always have a pure atmosphere after thorough cleansing and mild antiseptic douching, I can understand how a protective dressing alone, such as tin foil, now so much lauded by some laparotomists, can be accompanied with the best results. And permit me to say just here that, so far as the atmosphere itself is concerned, I think it is purer in almost any country farmhouse and retired city residence than in any wellappointed general hospital; for who has ever ascended to the second story of one of these buildings without encountering the odor of burnt or decayed cabbage and bologna sausage, and running up against attendants and cooks just from foreigndom, redolent with odors very much unlike that of the spices and cloves of biblical days or Hoyt's German cologne of this good day! The hospitals have the advantage of us, however, in armamentarium, in having every thing conceivably necessary at hand and trained assistants to do your bidding. There

fore, considering our less experience, deficient help and appliances, we are not yet prepared to depart materially if at all from strict antisepsis and asepsis-save perhaps a lighter load of gauze and a thinner film of powder.

With reference to what we believe will ever be recognized surgical practice, subject perhaps to occasional modifications, we will proceed to discuss some of the operative features of modern surgical practice and tendencies. Shock confronts us at the very threshold of our discussion, for whatever has been accomplished along the lines above mentioned nothing has been or can be done to prevent surgical shock after injuries, although the car-wheels should be covered with bichloride gauze, or the knives and bullets with iodoform or carbolic acid. And as we must ever have it with us, as we must the poor and the counterfeit dollar, we must determine what to do with the manyheaded monster when brought face to face with it. Rest, rest, absolute rest is the first never-to-be-neglected law in its treatment; if a bleeding vessel is "comeatable," secure it at once and immediately give a hypodermic of strychnia, with warmth and perhaps counter-irritants to various parts of the body, hypos. of ether and alcoholics are of considerable good and may be used in addition to the strychnia, but are certainly of secondary importance.

It has been demonstrated again and again that the degree of shock is not always proportionate to the injury inflicted; in other words, one individual may receive an injury really trivial in character and suffer more shock than another whose injury is severe; and again one person receiving a wrench or sprain of an extremity or a non-penetrating wound of the abdomen will be more profoundly shocked than another whose limb is crushed or abdomen penetrated, the difference is probably due to the peculiarity of that strange mechanism that we call the nervous system. Women as a rule, "God bless them!" foremost in every good word and work, and the first at the tomb after the crucifixion, likewise lead here and resist shock far better than the masculine gender. Heat to the extremities and body, strychnia, nitroglycerine, and alcohol hypodermatically, and, if continuous, normal salt solution by infusion, and preferably beneath the mammary gland, are the indications. There is a condition, however, yet unfortunately not rare, in which it is folly and fatal to wait on these procedures. I allude of course to ruptured ectopic pregnancy in which the bleeding is internal. In these cases, the cause being present and con

tinuous, the only thing to do is to at once and rapidly open the abdomen and secure the bleeding vessels; in this exceedingly unfortunate condition of affairs acute, sudden abdominal pain followed by shock, with a possible or probable presumption of pregnancy, is the only means of diagnosis, for the physical vaginal signs are negative, hematocele of the external or broad ligament, which is generally harmless, being the only one that the finger can detect per vaginam.

Within a month a poor woman lost her life in a not far distant city from this very cause, in which pregnancy had not been suspected. What a great misfortune that every community hasn't at least an available man who has the temerity to tackle these emergency cases, thereby occasionally and perhaps frequently saving useful wives and mothers; for while the city specialist is being communicated with, much less secured, a human life is being wafted to the "great beyond." I do not for a moment contend that these cases, as well as all other abdominal sections, can be as well done as by the city specialist; but when life can not wait for their arrival, let's do the best we can, leaving the result to "Him" who overlooketh many imperfections.

Drainage after amputation and other operations in which considerable tissue is removed is to be resorted to only long enough to be sure that nature can take care of the secretions, for, be as careful as you may, drainage-tubes and gauze are in a sense foreign bodies, and as such interfere with primary union. Ligatures, non-absorbable ones, also act as irritants, foreign bodies, and pus-producers in many cases.

At the West Pennsylvania Hospital, Pittsburgh, no ligature of any kind has been applied to any vessel after any amputation for the last four years, and notwithstanding numerous hip-joint and other thigh amputations have been done during this period not a single case of secondary hemorrhage has occurred. The method is to pull the vessel well out from the tissues, say half an inch or an inch, and while it is held firmly by forceps diagonally applied at its proximal end twist it on itself three or four times, or till the coats of the vessel are felt to give way. As fortunate as the result has been, I confess that I am afraid of it, and consequently have never tried it. I once was so fortunate as to have immediate union, union without suppuration, in a case of amputation at middle and lower thirds of leg, with amputation through instep of the other foot, where silk ligatures were used. This was the only instance of the kind in my personal experience where non-absorbable ligatures were used. In my humble judgment we are coming to the