equilibrium by Chittenden with a much lowered proteid diet, but with sufficient calorie value to prevent any under-nutrition, the subjects showing slight gain in strength and physiologic activity rather than a loss.

2. Long continued under-feeding, aside from very slight degrees of calorie deficit, lead to constant loss, not only of body fat, but also of body proteid, immaterial whether the proteid intake be large or small. The absolute height of the N-excretion depends on the amount of proteid but the maintenance of nitrogenous equilibrium is independent of the amount as a balance is established to suit the intake. A calorie poor diet, which is rich. in proteid, may protect the N-loss or may even raise it for a time, but the final result will be the same as if all parts of the diet were simultaneously reduced.

3. Whenever the addition of food lessens the calorie deficit, a building up of cell material takes place, although the calorie need, at this time, may not be completely satisfied.

This condition lasts until the body is aocustomed to the new equilibrium, when N. loss begins anew unless the calorie need is absolutely covered.

I will reserve for a later paper the discussion of the changes occurring in the secretions and excretions of the body in underfeeding and in over-feeding, inasmuch as a discussion of these factors would alone consume my time. I would, however, interpose a word of caution concerning the referring of every variation in the output of nitrogenous constituents to an abnormal tissue-proteid 'metabolism. We must, today, lay more stress upon the nitrogen partition than upon the determination of any one nitrogenous constituent and, moreover, it seems to me, the time is almost ripe for a more detailed investigation of the excretion of the amido-acids. in under-feeding, overfeeding, and in various diseases. If a former contention of the writer be substantiated, that a variation in the chemical properties of albumins may be shown by the quantitative examination for various amido-acids, then we may have more light thrown upon the nitrogenous exchange of the system.

It can only be self-evident that the metabolic changes arising from over and underfeeding are in part traceable to direct tissue decomposition and in part to normal and abnormal decomposition of food. Without a knowledge of such changes, we cannot judge of the specific changes of a concomitant dis

ease.

CONCLUSION.

In these remarks I have not attempted to bring out any new facts, but have tried, solely,

to present what we know regarding some phases of the metabolism in the conditions under discussion. Criticism may be advanced against some of the statements herein contained, but as they are all based upon experimental data, we must, at any rate, give them our earnest consideration. That many conditions, now recognized as obscure, may soon be traceable to simple over or under feeding, is probable and it is the object of this paper to present certain facts, which may enable us to refer such conditions to their proper nosological position. A more thorough study of many points not yet clearly defined, will permit us to understand more definitely with what we are dealing and how it may be corrected. My plea is, merely, for a more scientific and more intelligent recognition of the advantages and disadvantages of a dietary in bringing about a more normal condition of our patients, whether they be racked with disease or whether they be suffering with malnutrition, excessive or deficient.

100 State street.

PRACTICALLY all the best fish-hooks in the world-and nearly so of all qualities-are made at Redditch, England. The annual output is probably 500,000,000 hooks, about 10,000,000 per week, ranging in size from enormous and ferocious-looking shark hooks to the tinniest hooks for very small trout-flies, with a "bend" diameter of about one-sixteenth of an inch, a thousand of which will not more than fill a good sized thimble.

THE SALE OF ABSINTHE has been forbidden in the Swiss canton of Vaud; and this is good temperance reform. No doubt the other cantons will fall in line. This drug induces not only the ordinary alcoholic craving, but also a habit peculiarly disastrous to the brain. The Swiss, however, show themselves a canny folk in manufacturing the stuff for those who don't know better than to use it, but forbidding their own citizens to touch it.

THE WORLD'S PHYSICIANS. There are 228, 234 doctors in the world, declares L'Illustration. 162,333 are distributed over Europe, as follows: In England, 34, 967; Germany, 22,518; Russia, 21,489; France, 20,348; Italy, 18, 245. The proportion of phypopulation; France 51; Turkey, 18. sicians is: In England 78 to 100,000 of the With regard to cities: In Brussels the proportion is 241 to 100,000 of the population; Madrid, 209; Budapest, 198; Christiana, 181; Vienna, 140; Berlin, 132; London, 128; Athens, 123; Paris, 111; New York, 74; Constantinople, 35.

FLORUS F. LAWRENCE, M. D., D. SC., LL. D.

COLUMBUS, OHIO,

Clinical Lecturer, Diseases of Women and Abdominal Surgery, Starling Medical College; Chief of Staff and Surgeon to Lawrence Hospital: Ex-President Central Ohio Medical Society: Ex-Secretary Section on Obstetrics and Diseases of Women, American Medical Association: Ex-President Columbus Academy of Medicine.

FIRST, there is no class of men which from ancient past to present day has lived and worked for more worthy ideals than the medical profession.

Second, there is no more representative body of the medical profession that represents the best in the profession to a higher degree than does the Mississippi Valley Medical Association.

Third, to be chosen to deliver the surgical oration before this representative body is,

DR. FLORUS F. LAWRENCE.

therefore, an honor equal to any in the gift of the profession, hence an honor for which I have not words to thank you. It is I assure you an honor which I prize now and shall cherish in the future. However, there is in it an element which detracts from its pleasure, viz., that I am compelled to stand in comparison with the brightest lights in the surgical world, Murphy, Mayo, Ochsner, Haggard and the other equally great men who have preceded me.

You may not agree with all I say, it would be strange if you did, but every word comes from an honest and abiding faith that prin

Address on Surgery delivered before the Mississippi Valley Medical Association at Hot Springs, Ark., November 6. 1906.

ory or fad, and equally strong belief that in recent years our profession has been controlled or actuated too much by fanciful theory and popular fad. To verify this, look through your text-books of surgery; visit frequently any or many of the great surgical clinics, and then tell me how much you find, hear, or see relating to the minute details of treatment following the operation. Tell me how much instruction you receive relative to the detail of preparation for the operation. As a particular mark of this deficiency find me ten pages of practical printed instruction regarding the treatment of those not infrequent cases of suppression of the urine-of the real pathology or etiology. No, all the spectacular, all the patent part of surgery is constantly shown, written and talked about. The all-important drudgery and life-saving part is a blank. Another vacuum is found when you look for the consideration of the psychological element. We all know that fright will, and does, produce as dangerous a shock as traumatism, but the effect of the mind upon the sympathetic is not mentioned in our surgeries or in our clinics. Men send suffering, nervous patients to the hospital today, and operate tomorrow, regardless of the fact that the mind of the patient would be more tranquil, and his sympathetic more stable after a few days of hospital regime. These are only a few of the important features of which more should, and must be taught. Others are the dietetics of surgery, the abuse of ice, and many more of equal import. Instead of being leaders we have been followers.

The ideal in surgery may never be completely attained. We can, however, make little or no progress without an ideal. It is an old but trite saying, that "The river never rises higher than its source." It is equally true that as the stream flows farther from its source, becomes wider and deeper, the danger of pollution increases, and while it grows more useful with increase of power, to human needs, it also becomes an increased source of kept within strong and safe embankments. danger unless guarded from pollution, and It is also true that a stream having its source in polluted territory and flowing through marsh land is never fit for human use.

The source of every stream in science ever has been and ever will be the ideal. If that be high and if the outflows be guarded, as it widens and deepens, its draughts are healthful, its increasing power becomes a constant benediction. While if the ideal be in the slough of commercialism and its source through the fields of personal vanity and greed, the reverse is true.

Among the wise meditations of Marcus Aurelius is: "Be always provided with principles for these two purposes: First. To engage in nothing but what reason dictates, what the sovereign and legislative part of you should suggest, for the interest of mankind. Secondly. To be disposed to quit your opinion, and alter your measures, when a friend shall give you good grounds for so doing. But then the reasons of changing your mind ought to be drawn from some consideration regarding justice and public good, of some such generous motive, and not because it pleases your fancy, or promotes your reputation."

No better statement of the position surgery should occupy can be found.

From the ruins of the cities in the Holy Land, much that verifies the best traditions of the past has been recovered. From the history of ancient Greece and Rome, much that makes for a sturdier manhood, a broader citizenship and a truer philosophy, finds revelation. From careful study of the ancient writers in medicine and surgery we may find inspiration to higher aims, truer philanthropy, and less of self-centered interest, which will make for a great art founded upon a science illuminated by the accumulated wealth of the great intellects of centuries. We cannot today lay claim to much that has not been anticipated. The philosophy of the past has undoubtedly been to a large degree supplanted by the push and press of the commercial spirit of today.

The

Surgery has not escaped unscathed. days when teachers instead of schools provided means of qualification were not the darkest days of the profession. The wig and cane have gone, but pedantic character still finds a following. The shrewdly veiled mystery of a Sir John Long, a Mesmer, or an Aikenside is re-embodied today in the assumed manipulator of public sentiment who is frequently to the front in the daily papers with some "wonderful operation," or "the knife rescues Mr. Blank from a horrid death," etc., ad nauseum. The medical society does not escape the basketful of specimens which bespeak the operator's popularity, while they add not one jot or tittle to the knowledge of surgical principle and elucidate not one single surgical theory. They serve usually only one purpose, viz., to exploit the prowess of the individual, hence are no more to be commended than John Long's wildest escapade. I do not mean to decry the presentation and study of pathological specimens, but every specimen presented to a medical society should have careful study and should serve the purpose of demonstrating some surgical principle, or of

proving some fact in pathclogy. The cursory case report never has or will accomplish any honest good to the profession. The "Usual uninterrupted recovery" statement is of no scientific value if the facts as shown by daily record of the case shows that the pulse, temperature and respiration were abnormal any or much of the time during convalescence. The value of a method of operating, a system of care before and after operation is only to be determined by the absence or presence of even slight untoward symptoms. It is worse than folly for us to expect thinking men to accept as a scientific opinion one full of inaccuracies or untruth. The principle cannot suffer by thorough and frank study and report of the sequence of its application. Theory can never assume the dignity of principle by any system of oratorical or rhetorical exploitation unsupported by thoroughness and frankness in detail. The statement so frequently made, "I cannot talk freely and frankly with my patient about his condition" is an acknowledgment of lack of faith in the correctness of our own position, and if a man has not faith in his own efforts he cannot reasonably expect the other fellow to have faith in him.

Hence the importance of distinguishing between surgical principles and surgical theories. Principles are always life-saving. Theories have sacrificed many in the attempt to prove. Principles always subserve the patient's interests. Theories frequently have as their chief support the personality of the theorizer, For centuries theories have proved profitable from a financial standpoint in proportion to their fanciful or mysterious character.

It is probably true that no man can understand pathology who has not a pretty fair knowledge of philosophy, embryology and physiology, if indeed he need not biology. How then can a surgical theory which is not based upon sound philosophy and which is not proved by correct pathology ever become a surgical principle. Are we drifting too much with the tide of clinical empiricism and placing too much stress upon the operative clinic.

The

The age at which a principle was established does not detract from it, whether in the fourteenth or twentieth century. enthusiasm with which a theory is announced or received will never suffice to convert the theory into a principle. From these corollaries the deduction is that all established principles should have our respect and command our practice, while all theories, no matter how attractive and no matter by whom promulgated, should be measured by the scale of logio, weighed by the balance of

philosophy, squared by the square of competent experience, and set by the plumb line of results. This and this only can ever demonstrate that a theory is founded upon principle. The scale of logic will measure all arguments by first determining whether the premises upon which our conclusions are based are false or true, hence we will determine the truth of the conclusion. The best illustration of the absence of logical measurement is to be found in the various operations devised for correcting uterine deviations, wherein the fallacy of the conclusions (which are based upon empiricism) lies in the false premises, that by converting one pathological condition into another we effect a cure, as in fixing the uterus to the abdominal wall or to the anterior vaginal wall. If the reasoning If the reasoning had been based upon logical premises the authors of these barbarisms would never have coined the terms ventro-fixation and ventrosuspension. This may seem radical, but we must remember that an argument involving a philosophic principle cannot be a logical argument if in either of its premises, or in the conclusion there be false or unsound philosophy. The mad race for some form of notoriety which will bring consultation business may possibly in some instances have led to a theory being put into practice without due consideration. Until this incentive is subordinated to that higher motive which leads us into the paths of truth, we must expect the criticism of the lay mind, "That doctors never agree There is no disagreement among surgeons except where the opinions rest solely upon theories.

The evolution of surgery has been one of the most interesting and at the same time one of the most peculiar of the past. Interesting because, like man's faith in Diety, certain fundamental principles have been recognized for ages. There is probably a most unfortunate tendency to ignore the great masters of former years who were given to certain analysis and concise teaching the principles which they evolved, and to follow the man of today whose book is too often embellished chiefly in the binding. In the light of modern research some of these older books probably do contain some false doctrines, but could we say that all, or even a large percentage, of recent books promulgate no false doctrines? The knowledge of medicine or surgery without a comprehensive study of its development is at best a very limited and unreliable thing. This is true of any science, but it is particularly true of medicine and surgery. Many of the claims at present put forth for originality may be found to have been very lucidly taught, so far as the principle involved is concerned, by some of the

writers of many years ago, although the modern author has added to or perfected details of technique. For instance the work now being so satisfactorily done in intestinal surgery and accredited to modern teaching. There is not a single philosophic principle, anatomic detail or mechanical manipulation which. manipulation which was not thoroughly worked out and taught by Benjamin Travers one hundred years ago. The only thing of real value which modern teaching has added is asepsis and the Murphy button, and this latter does not add any new surgical principle, any more than does the McGraw elastic ligature, Senn's bone plates or the Robson bobbin. These are all simply mechanical devices to aid in applying the surgical or pathological principles of intestinal union taught by Travers, Sir Astley Cooper and Percival Pott. The decalcified bone plates or bobbins were used long years before (in the thirteenth century) by the "five great masters." Every principle which has proved of life-saving value in abdominal and pelvic surgery was worked out a quarter of a century ago by Lawson Tait and Thomas Keith, and while some of our present-day surgeons ignore and sneer at these men and their teachings there is not today a man in this country who is doing successful abdominal surgery who does not follow, either consciously or unconsciously, the teachings of these two great masters.

Lord Lister gave the world antiseptics, but Lawson Tait Lawson Tait more than any other man taught the world the value of asepsis and how to maintain it. In hernia while many new and useful methods for closure of the hernia opening have been introduced not one strictly new principle, not one iota of anatomic knowledge or one single philosophic addition has been placed before the profession in the literature of surgery since the great work of Sir Astley Cooper. Much of it was taught in the latter part of the eighteenth century by Percival Pott.

Again, while there have been development of inestimable value in recent years, yet it is a question of very grave doubt whether there has ever been any material addition to pathology since Virchow gave to the world. his cellular theory, except Koch's tubercle bacillus and antitoxin. Men have been chasing germs hither and yon which constantly prove as elusive and delusive as the Will o' the Wisp.

A principle when thoroughly evolved is a fact, not a theory. Theories change, facts never. It would be better if men were taught how to study for principles in their textbooks, both on medicine and surgery, and to remember that the treatment of any given

case cannot be outlined safely by any textbook for the reason that a patient must be studied. His condition of life, his environments, his habits and his necessities must be taken into consideration before a sound therapeusis can be established. Another thought worthy more than passing notice is that some years ago the authors of our text-books were all men whose work, study and opportunities rendered them authorities before they wrote text-books, while it is equally true that today many of our text-books offer the only evidence that the writer is an authority. And as to the value of text-books written some years ago by one who was before writing an authority and a text-book written today with the sole object of making the writer an authority it is not hard to choose.

ASEPSIS AS A PRINCIPLE VERSUS ANTISEPSIS AS A THEORY.

We visit fifty surgeons. One uses all the antispetic solutions of the Johns Hopkins teaching. Another relies solely upon solution of iodine, another still some other chemical, while here and there we will find one

who scorns to use any chemical germicide whatever. All are getting good results. Their mortality is practically the same, with probably a slight favor to the one using nothing. Stitch abscesses are found in the practice of all, but strange to say with much greater frequency in the practice of the man who uses chemical germicides to sterilize his field of operation. Here there is probably more than one principle involved.

First, is the one that recognizes that a chemical which will destroy or inhibit septic organism will destroy or inhibit white blood cells, will destroy or devitalize epithelial cells,

will convert red blood cells and fibrin into a culture medium.

Second. That traumatism whether chemical or mechanical, performs an important part in every wound infection.

Again, we hear strenuous arguments in favor of a variety of methods of wound closure, each asserting that his particular method is superior to all others in the prevention of hernias, etc. Some claiming that by certain methods it is safe, in fact far better to put patient out of bed and put a strain upon the wound in two or three or four days than to protect it until complete union has taken place. Ye gods! to think that a better and stronger union of a wound can result when during that process of union the wound is placed under increased tension, the stitches are made to whip-saw through the tissues, etc. This is theory against principle with a vengeance.

Again, a man uses all and every antiseptic method, then losing sight of traumatism makes an opening as long as the moral law, immediately inserts broad bladed metal retractors and hands to assistants to pull, push, batter and bruise the tissues, and then wonders why his patient's shock, have infection, stitch abscesses and hernias. Principle forgotten, theory run riot. Again the wound is. closed in two, three or four layers (I think some people enjoy sewing) a large amount of foreign substance is left in the wound. What can we expect?

We frequently hear the layman scoff at doctors because of disagreements and caustic arguments indulged over the treatment or pathology of a given case. These criticisms can only be justified by our own weakness ie., if we argue or haggle over non-essentials, instead of studying principles. In this lies a most important suggestion, viz. First, the profession of surgery is fast approaching that stage when it should be an art founded

upon exact science.

Second. The man whose education has not equipped him with a working knowledge of natural philosophy, embryology, pathology and physiology, together with an accurate conception of human anatomy, should not into practice upon the living human being be expected or permitted to attempt to put those principles of which he knows nothing.

It is utterly out of the pale of sound reason to expect any man who knows nothing of philosophy to apply a correct philosophy to a surgical condition. He may possibly imitate the work of another mechanically, but he cannot quickly and safely adjust his work to the needs of the individual case expathology and the principle necessary to recept he knows development, construction, pair the damage.

Third. Our methods of teaching surgery must be so adjusted that each pupil shall have ample time and opportunity to study the case from every standpoint, and be taught to reason out treatment from known anatomy and recognized pathology. This cannot be in amphitheatre clinics, and it cannot come through the printed page. The large numbers of operations in an amphitheatre make a great impression upon the onlooker, very often the most difficult and hazardous piece of work looks easy, and this tempts the tyro to justify the adage: "Fools rush in where angels dare not tread." The master hand of Mayo, Ochsner, Murphy, Ferguson, Price, or any of a host that might be named makes difficulties seem trivial, but could the student follow a close range all the steps before and after as well as during the operation the delusion would soon be dis