GENTLEMEN :-I offer you a short paper under the above title, not because I think three cases of abdominal section are sufficient to claim your attention, or because abdominal surgery can be done better "on the wing" than in a well-appointed hospital, but because the three cases aptly illustrate the three most common conditions for which abdominal surgeons are called to operate, and to show that a keen appreciation of aseptic surgery will enable a man to do good work anywhere under any circumstances. As I write this sentence the vision of Ephraim McDowell mounting his horse and riding from Lexington, Ky., to

*Being the paper accompanying Dr. Long's application for membership in the American Association of Obstetricians and Gynecologists, at its Toronto meeting, September, 1894.

near the Hermitage, Tenn., and with the aid of old Andrew Jackson removing an ovarian cyst, rises in my mind. I wish I could say, like McDowell, I feel the delectation of a fifteen hundred dollar fee in my pocket, but alas !

"Do I decry hospitals?" Never a time I stickle for them; but must we let men and women die because forsooth they are not in a hospital?

I have been spending a short while at the old home place, Randlemann, N. C., and while here did, among other operations, the following sections:

CASE 1.Appendicitis. - Frank H., married, aged 35 years, had suffered with "cramps and colic in his bowels" at intervals for three or four years. On Friday he had quite a severe attack. Saturday and Sunday he was better.

Tuesday he cut wheat all day That night he was seized with an intense pain in the right iliac region, "drawing him double." His attendant, Dr. W. A. Fox, promptly diagnosed appendicitis. I reached home the following Thursday. The next day I was asked to see the case. I confirmed the diagnosis and urged immediate operation. My "kit" had not yet arrived from Richmond. But that man needed an operation, and, like the fellow in Texas who needed the pistol, he needed it bad. Dr. Fox and his associate, Dr. J. O. Walker, put their armamentarii together, and, putting the patient on a dining table, rapidly anæsthetized him. Cutting carefully down, I came upon the appendix distended to the bursting point; the pus could be seen through

together by sutures, thus virtually turning the stump into the cæcum. The abdomen was thoroughly irrigated, about half of the incision closed with interrupted sutures and a Mickuliez drain used. The recovery was uninterrupted.

This case is a fair sample of the vast multitude of appendicitis cases, which are occurring daily, and yet men, good men, too, shut their eyes and say: "I don't have cases of appendicitis." I do not believe every case (nor even half the cases) of appendicitis should be operated upon, yet, while holding this conservative view, I have numerous operative cases, and they all get well when I operate prior to the advent of general suppurative septic peritonitis.

T. C. Walker, a member of our graduating class.

The operation possessed nothing unusual, except that I had failed to take my ovarian trocar with me, and rather than puncture the cyst with a scalpel, I made a long incision, notwithstanding the assertion by competent authority that it is better to puncture with a scalpel than to make a long incision. The recovery was perfect.

It may be said that ovariotomy is so simple that any tyro can do it; but what sane man is so rash as to assert that any but a master hand should do it?

the tubes thickened and the ovaries enlarged and prolapsed. The retroflection could be overcome bimanually, but there were evidently tubal and ovarian adhesions which would prevent the retention of the fundus in its normal position by non-operative measures. Here was a condition, rather than a disease, which justified and indicated an operation-a poor man's wife is bed-ridden; she suffers not intensely, but continuously; she ceases to be a helper as wife and mother, but is a burden to her family; the lesions present are, without exception, progressive; the sepsis inaugurated at her first labor and augmented at her second

Fig. 4.-Piece of omentum removed from Case 3.

will continue to exert its injurious consequences till, if not already so, tubes and ovaries will be totally destroyed functionally, and largely so

organically, and inseparable adhesions shall bind the fundus in an abnormal position. An operation would remove the diseased tubes and ovaries and put the uterus into a position favorable for drainage; besides, the patient lives far away in the country, and could not go to a hospital, rather must continue at home in bed; besides, I was there with my "gun loaded."

Operation was done at once with no assistance save the attending physician, Dr. C. H. Lewis, who gave the ether, the husband and two neighbor women. The tubes and ovaries were removed and the posterior surface of the fundus attached to the anterior abdominal wall.

The recovery was uneventful, except for the formation of an intra-mural abscess, which did not materially retard convalescence.

This case is the only one of the three in which the results were not absolutely

as good as if the operations had been done in the best-appointed hospital in the land. Indeed, I have yet to meet the abdominal surgeon who does not occasionally have suppuration at the site of the abdominal incision, whether he operates in a hospital or "on the wing."

This class of cases is a very numerous one in my experience, and nothing relieves them like curettage, removal of tubes and ovaries and suspension of the fundus. The curettage was omitted in this case because of a lack of assistance and because I could see the patient only the one time.

As evidence of the rapid progress of gynic surgery, I will add that, if I had this case to operate on now instead of then (only a few months ago), I would certainly remove the uterus as well as the appendages. The reasons for this I will set forth in another paper.

It never rains but it pours. It has often happened in our experience that we get what might be called a run on a certain class of cases: Recently there has come under our care five club feet for treatment, no great number to be sure, if they had occurred in the practice of a specialist, but enough to tax our ingenuity as to the best manner of managing them.

Our method, although very simple, has proved highly satisfactory. But simple as it is, it did not come like an

inspiration, but was the result of painstaking care.

We have often experienced trouble in the management of the foot, whenever having a fracture near the ankle joint we wanted to put the limb up in plaster of Paris. The assistant, by grasping the heel and front of the foot, always had his hands in the way while we were applying the bandages, and afterwards a great deal of trouble in holding the limb straight and stiff until the plaster was well hardened,