There is another very important point in connection with this, and that is the time to study. A man who is a general practitioner and has to make many calls can not be a good student and keep up with the progress in all branches. Therefore, when a man gradually emerges from general practice to surgery he must devote himself exclusively to the latter. If he attempts to do general practice he will not have time to study; hence, will be a fossil in a short time. In my own experience, where I limit

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... myself exclusively to abdominal surgery, I hardly have time enough to read what is written on this branch , of surgery alone and also keep up, to a limited extent, with the general progress of medicine. Always bear in mind that my remarks refer to special surgery, not simple everyday occurrences, such as fractures and injuries of all kind, and the simpler operations; these the general practitioner must attend to. What I am pleading for are so-called cases of special surgery, which generally are not emergency cases, and where there is plenty of time to select the best surgeon for that particular case. I refer to delicate operations on the eye, the most difficult operations in the throat, and the complicated operations in the abdominal cavity. Finally, you will ask me: "Who could or should be a surgeon?" In answer I will say that he must be a well-educated physician, must have been a general practitioner and a good therapeutician. He must take up surgery early and gradually develop a surgical hand; he must be an assistant of a first-class surgeon for at least a year, where he will see hundreds of operations of various kinds. Such a man may be a good surgeon. He ought to be in some large town, say a county seat, and, as his surgical practice grows, he ought to give up absolutely general practice and devote himself to surgery exclusively, and then his colleagues in the county would support him. Hence the requirements of modern surgery are: 1. A patient brought to the highest state of resistance to microbic infection and made as clean as possible. 2. An operating-room, preferably in a hospital, where everything has been made thoroughly sterile. This includes anesthetizer, assistants and nurses. 3. A surgeon who has a mechanical hand and has received a long, thorough training. The fact that I was able to find fat necrosis in three cases, and to learn of a fourth case in the course of two weeks, all of such cases either coming to autopsy or observed during surgical procedure, would indicate the probability that fat necrosis is not infrequently associated with gallstones, and that there is a necessity for more effort to differentiate gallstones with necrosis from gallstones without it. So far as our information at the present time would indicate, the only immediate value of such a differentiation would be in the line of prognosis. It is reasonable to conclude that more accurate and extensive observation would eventually lead to betterment of treatment, either in the matter of improved surgical technique, new surgical procedure or improved treatment along medicinal lines. Many authors have written of gallstones as prominent etiologic factors in fat necrosis, and in lesser measure in pancreatic auto-digestion. The most striking contribution to the literature of the subject is that of Halsted and Opie in the Johns Hopkins Bulletin, for 1901. The condition is usually unrecognized prior to operation or autopsy. In the case occurring in the service of Dr. Herrick, at Cook County Hospital, the clinical diagnosis was cirrhosis of the liver, and the comparatively localized fat necrosis was found at postmortem examination. In the case of Drs. Roehr and O'Byrne the preoperative diagnosis was gallstones, with suppurative cholecytitis. The diagnosis of complicating fat necrosis was made by the examination of a specimen removed at the operation. It was confirmed by postmortem examination. In the case of Drs. Wells, Lewis and Davis, the diagnosis was gallstones, and the complicating fat necrosis was not suspected until it was revealed by the operative procedure. In the case of the Drs. Beck the diagnosis was gallstones, but there was quite a general conviction that there was some morbid entity in the abdomen other than stones. Some of the consultants suggested that there was an appendicitis, and others had noted this vague something without being able to assign a reasonable explanation for it. At the operation, after the gall-bladder had been drained, the foci in the omentum were observed, while a search was being made for the appendix. The appendix was found to be normal. Some of these foci were removed, and sections of them are shown here. This case proceeded to a somewhat uneventful recovery. It is probable in this case that the presence of fat necrosis as a complication would have been overlooked, both in the diagnosis of the case before operation, and in the diagnosis as made at the time of the operation, had it not been for the fact that it seemed advisable to explore the peritoneal cavity in the direction of the appendix. The bearing of this point is this: Is it not possible that a moderate amount of fat necrosis is very frequently overlooked, both in the diagnosis made before the operation and in that made at the time of |he operation ? HISTORY OF THE CASES. Case of Drs. Davis, Lewis and Wells: A woman, 45 years old, had had several attacks of gallstone colic during the last eight years; only one of these was associated with jaundice. The last attack of gallstone colic did not seem to differ from the preceding attacks. After the acute pain had subsided in this case, there remained a great distress. A feeling that it was difficult for the patient to describe; a painful disagreeable sensation in the upper segment of the abdomen, but impossible of accurate localization. After three or four days symptoms of localized peritonitis developed. Five or six days after development of these symptoms the patient was operated. Two hundred and fifty calculi, approximately, were removed from the gall-bladder. The gall duets were explored, but no stones were found therein. There were found adhesions, comparatively recent, in the upper abdominal segment. The omentum was studded with yellowish-white nodules. These were soft and mealy in consistency. Two were removed for microscopic examination. The patient seemed to do very well for twenty-four hours subsequent to the operation. Then there came vomiting and fever, and six hours later, or thirty hours after the first operation, a secondary one was done, during the course of which the patient died. Prior to the first operative procedure the pulse ranged from SO to 100, the temperature was essentially normal, and the only point that attracted the doctor's attention as out of the ordinary was the general feeling of unrest and the demand for relief from a somewhat illy differentiated something.