down of this fatty layer. I think this incision with the stripping away of so much fat, does sever many of the nourishing vessels of that fat, which possibly may, in some cases poorly nourished, interfere with a good union, I judge from Dr. Roberts' reports that he has had little trouble of that kind, yet it has appealed to me as a possible objection.

I believe the doctor acknowledged that this method took a little more time, and that has been my experience in it.

In regard to enlarging the incision after we make our initial incision. The objection might be raised that this incision did not allow of that. To the extent of working to the umbilicus, I think it is not an objection. It is very easy to increase this incision in lateral directions, the lines running up towards the anterior superior spinous process, without changing the method, but where the whole abdominal cavity is needed there might be an objection to the incision, although I see no reason why work could not be continued by old methods, as though the incision had not been made.

I have not quite confidence enough in No. 1 plain catgut to trust all this sewing to that fine material. I have for years given up the use of any buried nonabsorbable ligature. I at least want No. 1 if not No. 2 chromic acid gut for at least the central portion of that work. I believe Stimson advocates a few strong sutures in the middle, then some catgut for the work outside. I should want that dressing on the outside not alone to cover the wound but to furnish a little extra abdominal pressure when the patient wrenches or vomits after the operation.

The value from the inconspicuous scar is one we should not overlook. The incision nine times out of ten will be covered by the after-growth of hair on the pubes.

I think there is no question but that this furnishes a better protection against hernia than the older method. On the whole, I am very glad to add my little mite in a commendatory way.

DR. WARD:-I have just had the pleasure of observing Dr. Roberts' incision in my brief stay in New York, and after observing the work at the time of the operation and in the post-operative care have come to the conclusion that his method marks a distinct advance in the treatment of the abdominal incision. Our ideal always in making the abdominal incision and in closing it is to aim at as perfect an abdominal wall after the operation as before. I think Dr. Roberts' incision and closure by reason of the cross incision produces a firmer and better closure than the incision in the median line.

As the result of the skin graft method we have a less painful convalescence for the patient; the convalescence is shorter. Another pointthe simplifying of the after treatment-no dressings. Whatever brings a greater simplicity in technique usually means advance. No dressings being used, it would seem that the line of incision is exposed, but if you stop to realize you will see that the incision is made slanting, the upper graft comes down over the lower edge of the incision so that we have the upper graft absolutely protecting, and we have the absolute closure of the two skin edges, so that there is hardly any possibility for any infection taking place. I observed carefully those incisions in cases following the operation and not in one of the cases was there any infection whatever; simply the slight dry serum marking the edge, then later simply a thin scratch upon the skin.

Therefore the patient has no dressings, there is no removal of the suture, and we have almost no scar whatever as a result of the skin graft incision. I think it is a distinct advance and one that will be used with great advantage in other parts of the body.

DR. WHITMARSH:-I would like to ask Dr. Roberts what his experience has been in suppurative cases. It seems to me that if a case has to be drained it is undesirable to have a wound in which so many layers of tissue have been separated.

DR. PACKARD:-I think it is the experience of every surgeon to once in a while have suppuration in a wound where he has not counted on it. I should like to ask Dr. Roberts, if he has ever had such an unfortunate sequel to this operation, what the result has been. It seems to me that the whole strength of the abdominal wall being dependent upon union of the fascia, in cases of suppuration there must be very defective repair, and as great weakness as we get in longitudinal wounds under similar conditions.

DR. NEWTON:—I should like to ask Dr. Roberts why he calls this skin graft, for there is nothing except what he has cut and lapped

over.

DR. BELL:-I hope there will be a full discussion of Dr. Roberts' paper, although I feel a certain delicacy in undertaking it myself, for I do not quite see how I can agree with the Doctor, and I am also not quite sure that I fully understand his method, especially in the deeper parts. I certainly want to thank Dr. Roberts for endeavoring to break out any path of progress, but I must say that up to the present moment I do not see any advantage or progress in this incision. It seems to me that it is taking a great deal of pains to do something which is not worth doing.

In the first place, this incision is based upon the McBurney incision in a way. Now the McBurney incision I do not believe in. In the ordinary median or central incision, you get rid of all the extensive dissection of Dr. Roberts' incision, and you meet all the apparent points and indications for this operation by going in through the rectus muscle, or through the right or left side of the rectus.

This operation takes longer. We should make an incision ordinarily in fifteen to twenty seconds. We all know that time is a very important factor in the success of abdominal operations.

It does not seem to me that the cut can be extended with any satisfaction or any good results. It is certainly a surgical principle not to expose any more surface for infection than possible. This must expose six to nine square inches of surface, with a bleeding surface more than necessary, thus making a much larger field for infection.

If

This method also prevents entirely all drainage of the wound. you have suppuration you are going to have a very great complication. I am sorry that I am unable to say anything more commendatory of the incision. Of course, I do not set my opinion against Dr. Roberts' experiences, but I will say that our incision and closure by buried removable sutures give a wound satisfactory in every way, and the results are perfectly satisfactory; no hernias so far as I know, and I can see nothing to be gained by departing from that method of incision. DR. POWERS:-Just one point I want to speak of-ordinarily we depend entirely upon the closure of the fascial layers to support the wound, while here there has been so wide a dissection as to weaken the fascial layers of the abdominal wall.

Dr. Bell has already suggested that we depend considerably upon the rectus muscle acting as a splint after the operation.

Another point-hernias after operation are almost invariable in our suppurative cases. I have not seen a case of hernia following a clean case for a good while, either from my own or other operations. It is the suppurative case which gives the most difficulty, hence it is on this point that I ask the experience of Dr. Roberts.

DR. SMITH:-I have two friends in the far West who have experimented a good deal with this incision and are very much given to it. I am, I think, a little inclined to be very conservative. I should want to go on to New York and see Dr. Roberts attain his results before I should adopt it as a regulation thing. I do not think we have as many hernias at present as we formerly had; our patients have better care. It always seems to me necessary to have something beside a light suture

in the skin. I think I should be a little doubtful if this is the best method of making an incision in this region.

DR. BRIGGS:-Regarding this incision I have thought of one thing which comes to us quite frequently, that is, the commencing of an abdominal operation with the expectation that it is going to be a clean case and finding a septic condition present. I think this incision of Dr. Roberts might be an excellent one in certain clean conditions in pelvic surgery, but in a case where sepsis is present my impression of the incision is that it would become a very ugly wound when infected. I think I shall try this very soon, following Dr. Roberts' directions, but I want to ask these questions. How do wounds act when they become septic? If it is a serious thing to find a septic condition in the pelvis when you are not expecting it?

DR. WESSELHOEFT:-I have been very much interested in the little I have heard, and I think it very kind of Dr. Roberts to come on here and give us an illustration of his method. I see nothing in it that would lead me to abandon the methods described by Dr. Bell. I have adopted these after a great deal of thought, because I think we as surgeons are not acting righteously unless we take into serious consideration the very great danger, in abdominal operating, of weakening the abdominal wall. I think our conclusions have given us results so satisfactory in the point of strength of the wall-so far as I know absolute in clean cases or in the absence of sepsis-that I see no reason for changing methods, certainly much more simple and direct than his.

A factor very important in our results is, I believe. the use of silk worm gut strands to drain the layers. These provide for escape of serum, however little, which is always a culture medium, and these strands are absolutely without danger of introducing possible infection from without.

DR. ROBERTS:-I may not be able to find time to answer every question; however, I am very pleased to have real strong, earnest criticism.

I cannot agree with Dr. Wesselhoeft when he says that he has become a crank on the question of serum, because the serum business does not alarm me very much. As the wound is opened and tied up tightly with sutures, the serum has free access, and the moment the serum has run out there is the very slightest layer left at the edge of the incision and that dries in a moment. I know that in thirty-seven cases we have had infection in only one case.

I agree with Dr. Wesselhoeft that it is our duty not to weaken the abdominal wall. That is why we are making this incision. It is made in lines parallel to the line of cleavage of the abdominal wall and for that reason it gives a stronger result.

The gentlemen here are more fortunate than we if they never see ventral hernia following a clean wound. We do. The number of cases is not very large and it is of course far more common in the septic cases. Now I have been asked what I would do in pus cases. I am quite convinced from what I saw today in Boston that we do not drain our cases nearly as much as you do. We very often operate our pus cases and close them up; the peritoneal cavity takes care of them.

Some one referred to the muscle being divided. I think the doctor misunderstood me, as the two recti are not divided nor are any of the muscular fibres divided; they are stretched.

I was glad to hear Dr. Bell's criticism, especially as he has had so long and so wide an experience. I think the majority of the surgical profession is pretty well committed to the McBurney incision. It is very widely followed. Personally I believe very strongly in the theory, whenever we can, of splitting muscular fibres rather than cutting them.

Time, so far as it relates to the operation, has ceased to be an important factor with me.

As to suppuration. I had one case of very severe suppuration. The patient had a large fibroid tumor and a most marked purulent cystitis preceding the operation. We washed out the bladder until we found we could never get it clean until we operated. The patient was prepared in the usual manner. I operated and in three or four days the whole wound showed that it was infected. The infection was comparatively mild, though deep. We opened into the wound and found in this case that the infection did extend underneath my flap and undoubtedly was on the recti muscles. I succeeded in putting my finger down through the wound and letting it follow its way through the fat to the deeper layer of suture, and following the suture and lifting it up the pus began to run out. We carried a drainage tube in there, and there was an exudate of five or six ounces of pus. The patient began to recover and has recovered from that time. I am inclined to think that it is unnecessary anxiety in regard to the pus. I do not believe that edge will heal together quickly enough to form a very strong barrier against the pus.

This incision does demand a strict technique. It seems to me that the incision that demands the strictest technique is the best incision.

I have used skin graft in a number of different forms of operation. I cannot say that I have in everything. I use it in any operation on the face or parts of the body likely to be exposed. It is easy of operation on almost any surface. It takes a little longer than to make a straight incision.

Regarding the approximation of the skin. The ordinary straight incision is frequently not approximated at both surfaces. It certainly could not be approximated by plaster strips like this. One of the gentlemen in New York has for many years been using adhesive plaster, but in this incision where the incision goes obliquely, the pull just on the very edge of the skin is enough to make those surfaces lie in contact and it is no trouble whatever to keep them in contact.

In regard to the nine catgut. I cannot understand the use of the large catgut. I have given it up. I do not think there is any advantage in it and I think if the doctors did not use such large catgut and did not tie it so tightly they would not be so afraid of serum. I think the mistake is not in using the fine catgut but in using large catgut and then tying it tight. When the suture has approximated the two surfaces it has accomplished every single thing it can accomplish.

I do not wonder that Dr. Martin said it rather shocked him to leave off the dressings. It certainly did shock me. In the first place, by this method I get absolute approximation and there is a wide layer of skin which is very well supplied with blood vessels and which is approximated with the delicate laying together of the little pieces of plaster. If the serum did collect there is nothing to hinder it from coming out between the plaster strips.

To me the strongest part of it is that so far everything has come out all right.

THE STUDY OF GREEK.-We are glad to note in the November copy of "Education" an article emphasizing the importance of the study of Greek to the scientist. From the medical standpoint, certainly, a knowledge of this language is of great value in intelligently understanding large numbers of the new words that are being almost daily coined. If for no wider reason than this, a working knowledge of the language should be demanded.

ANAESTHESIA.*

Report of two deaths-one following the administration of ether and one during the administration of chloroform.

BY WINFIELD SMITH, M.D., BOSTON.

of surgery was

Until the advent of anaesthetics the field narrowed to such a degree that operations, even of a minor nature, were undertaken with a great deal of trepidation on the part of the surgeon, and fear on the part of the patient. Under these conditions it was manifestly impossible to invade the deeper portions of the body, and hence anything approaching the surgical work accomplished during the past half century was out of the question.

Directly the use of ether and chloroform was proven to be practically harmless, the scope of surgery became unbounded, and the development along general and special lines was beyond all precedent. Since the discovery of general anaesthesia it has been universally understood and acknowledged that a certain amount of danger is present in every case, and the investigations and experiments of scientific men the world over have led to statements that these dangers must be taken into account in each instance in which an anaesthetic is administered.

Reports will be made later in this paper from medical bodies in different parts of the world illustrating the various dangers attending the use of the several anaesthetics and demonstrating the many points to be taken into consideration when a choice is to be made in a given case.

I feel that a few words are necessary in excuse of my action in presenting these cases in a bureau of gynaecology, but the chairman assured me that as anaesthetics are as needful in gynaecology as in any other branch of surgery, this paper would be not altogether out of place.

Moreover, I personally feel that all of these cases should be reported and thus put on record; in order, in the first place, that those compiling statistics along these lines may have proper material from which to draw conclusions, and secondly, that the fact may be properly emphasized that there is danger in the administration of any anaesthetic.

Before these two cases, reports of which will follow, came under my observation, I had had an experience barren of any such results, although hundreds of patients had been subjected to the action of local and general anaesthetics.

I venture to say that all of those present have likewise had an experience devoid of accidents, and I am sure that the majority of surgeons are liable to minimize the fatal possibilities which may lie in the use of nitrous-oxide, ether and chloroform.

*Read before the Massachusetts Surgical and Gynaecological Society, December 12, 1906