Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

ASEPTIC SURGERY FOR THE COUNTRY PRACTITIONER.

BY JAMES B. BULLITT, M. D.

The frequent use of the terms "antiseptic" and "aseptic" in surgery leads to the conclusion that there exists some cloudiness regarding the exact meaning of the two words. Formerly, since the days of Lister's first carbolic-acid spray up to a very short time ago, the general talk was of "antiseptic" surgery; that is, surgery in which chemical poisons were used of a sufficient strength to destroy living germs with which they came in contact. The use of such poisons was based chiefly on the belief at first entertained by Lister that the air was largely responsible for the infecting of wounds; hence his method of operating under a carbolized spray, and use of a most complicated and elaborate dressing. Carbolic acid was the agent first employed, and afterward bichloride of mercury played the chief rôle. The tanks of glass and other wares that adorned every well-regulated operating room attested the extent of the faith placed in these antiseptics. At this time the nail-brush, the pot of hot soap-suds and water, the kettle of boiling water, and the steam sterilizer were unimportant, and an operating room containing only them and no large bottles labeled "poison!" smelling of carbolic acid, or having the property of turning the hands black and rendering them rough as a day laborer's, would have been looked upon with holy horror by the ardent disciples of "antiseptics" in surgery, and the director of such an operating room would have been regarded as not in touch with the spirit of the times. Gradually the

truth began to dawn that it was not, after all, any thing but simple cleanliness that makes the difference between old-time mortality and that of the present day, and this simple cleanliness, not so very simple in attainment, however, constitutes the essence of the aseptic surgery of to-day as opposed to the antiseptic of a few years ago.

This distinction between antiseptic and aseptic may seem at first glance like hair splitting to some, but it is nothing of the kind. There is a difference in the terms, and a further difference in the technique of the adherents of the two kinds of surgery that is practically of the utmost importance. To state the difference briefly by example: The man who believes that antiseptics are the thing dissolves a tablet of corrosive sublimate in a pan of water, dips his hands therein, and proceeds to operate, and his surprise is great if such a thing as pus occurs or death from sepsis, and he is at a complete loss to account for such an event, because he remembers distinctly having made use of that magic tablet of corrosive sublimate. On the other hand, had he known that asepsis is the thing, had he expended five minutes brushing his nails with hot soap and water, had he been assured that his instruments. were sterile, had he known that his dressings had been rendered likewise by dry heat or steam, he would have had no pus nor sepsis to marvel at, and would have spared his hands the roughening of the corrosive sublimate. It is not only the country practitioner who does not always know this; it is also quite a goodly number of "surgeons in even some important medical centers, who are, happily for their own conceit, ignorant of these facts. Ocular evidence is the best of witnesses.

No longer than four years ago it was quite a novelty to see Robert Abbe flush out the abdominal cavity with simple boiled water. To-day it is the rule. He observed that strong antiseptic solutions acted on the tissues as well as upon the presumably present germs, and that the damage to the tissues was about as great as the feared damage of infecting germs. Gradually there came the dawning that if all articles, if hands and instruments, sutures, and dressings, and fluids which came in contact with wounds are sterile, aseptic, the result is the same, as regards sepsis, as when the most virulent antiseptics are employed, and the tissues are spared an injury from which they not infrequently have great difficulty in recovering. The only place which antiseptics properly have in surgery is in rendering some of the accessories (catgut, for instance) aseptic, sterile. Here disinfectants should be excepted, per

haps, which are certainly useful in washing out stinking cavities and the like, and their action is in a certain sense antiseptic as well as disinfectant.

The statement can be made with impunity that, so far as aseptic surgery is concerned, carbolic acid and corrosive sublimate could be stricken from the armamentarium with advantage. This is not because they have no uses, though their uses are at best limited, but because their use gives a fancied security which constitutes a real danger. If the surgeon knew that their use alone, without the proper cleansing of hands, instruments, sterilizing of dressings, and the like, was exceedingly unreliable and dangerous, the matter would be different; but such is not the case. He has been led to believe that a corrosive sublimate tablet is all that is necessary, or at least that the only really necessary adjuncts are the stinks of carbolic acid and iodoform. If he has not been taught this, he has at least arrived at such a conclusion. Open ears at any meeting where the State is represented and heard will attest the truth of this statement. Our medical society brother must also wake up to a recognition of the fact that the frequent employment of the phrase "every antiseptic precaution" by no means guarantees that the described operation was aseptic.

All this, we beg, will be considered as preliminary. We will now consider how the country surgeon can satisfy his conscience by doing aseptic surgery. Not infrequently we hear a case described, an abdominal perforating wound perhaps, to which a city surgeon was called, or which was sent to a city surgeon because the country surgeon did not have the necessary appliances to do "antiseptic" surgery. When the proper idea of aseptic surgery supplants the erroneous one of antiseptic, we trust the voice of this excuse will cease to be heard in the land. It is quite legitimate and proper to lack courage or skill, but no one need lack the proper means and appliances to do aseptic surgery. Coats and cuffs can be removed, sleeves can be rolled up. If clean aprons are not handy, a clean towel can be pinned over the front. Hands and arms can be scrubbed for ten minutes in hot soap and water, particular attention being given to the nails, which have previously been cut short. The hands can now be rinsed in boiled water or alcohol, and the operator is ready. The patient can have had a bath (in set operations), or the field of operation can be thoroughly washed with soap and warm water, any hair being shaved. This can be followed by alcohol or ether. The table can be covered with a clean sheet, and the patient's

body or limbs with clean towels, and table and patient are ready for operation. These sheets and towels do not need to be soaked in any antiseptic solutions. Such wet cloths cool off the patient and are unnecessary.

Von Bergmann's assistant, Schimmelbusch, in his most excellent small work on the technique of Bergmann's clinic, relates the result of the bacteriological examination of sheets and towels which had been washed in the ordinary way by ordinary washer-women. Such sheets and towels are scrubbed and then boiled in a soda solution, afterward being ironed. This is the washer-woman's routine the world over. He found that such sheets and towels are rendered completely sterile. Of course care must be taken that no infection occurs after they leave the washerwoman's hands. In very important operations towels, etc., should be treated as the dressings are, to be hereafter described. This led to an investigation of the sterilizing properties of soda solutions. It was found that a boiling five-per-cent solution of ordinary washing soda is by all odds the best sterilizing medium yet discovered. All instruments that are to be used can be boiled for five minutes in this soda solution, and can then be regarded as safely sterile, provided they were already ordinarily clean. If they were afflicted with concretions. and the like, they must first be scrubbed with soap and water. Boiling in this soda solution also prevents rusting, and keeps instruments beautifully clean and bright. It requires no fancy piece of machinery in which to do this boiling. An ordinary fish-kettle or any kind of pan or pot large enough to hold the instruments will answer perfectly. All this can be done, if necessary, in the house of the patient, or the instruments can be sterilized at home, wrapped in towels, and carried to the place they are to be used.

Dressings must be prepared at home. For them a steam sterilizer is necessary. This can be procured from any good instrument-maker. The ordinary cheese cloth or butter cloth, which can be bought from dealers at five cents a yard, answers perfectly for absorbent gauze. It is cut up into desired lengths, folded, put in the sterilizer, and steamed for one hour. It is then transferred to glass jars or metal boxes previously sterilized by steam or boiling, and set aside until needed. The fastenings of these jars must be air-tight, so as to let in no dust. Gauze so prepared serves all the purposes of borated gauze, salicylic gauze, sublimate gauze, etc., and can be so prepared at trifling cost. If iodoform gauze is desired, it is prepared on the spot by dusting iodoform

powder over this sterilized gauze. It is absolutely unnecessary to go through the troublesome process of preparing iodoform gauze with glycerine so as to render it permanently moist. Absorbent cotton, as procured from the supply man, is safe enough for ordinary use, but in very important places (abdomen, for instance) the proper thing is to put gauze, cotton, bandages (complete dressings, in other words,) in the sterilizer, pinned close up in a towel. This is steamed for an hour, allowed to dry out in the sterilizer, and not opened until required for use. Such dressings can be depended upon to be absolutely sterile.

The best, safest, and cheapest sponges are made from absorbent cotton and butter cloth. A bunch of cotton, larger or smaller as desired, is put on a square of butter cloth cut the size of a lady's handkerchief. The four corners are tied over the cotton and the "sponge" is complete. Such balls are steamed in the sterilizer and are then ready for use. They should be used dry; or simple pieces of gauze cut the size of large napkins answer also very well. The cotton balls and the gauze are much better than sponges because they are cheaper, more easily prepared, and can be thrown away after being once used. The cleaning of sponges is difficult, and when once infected they are always to be regarded with suspicion, and had best be thrown away.

In place of the large flat sponges, which are ordinarily considered essential in abdominal sections, Czerny, of Heidelberg, used square or rather slightly oblong pieces of heavy linen, cut about the size of a large sponge. A heavy silk thread is tied to one corner, and a pair of forceps snapped on to this when the cloth is introduced into the abdominal cavity, so there is no danger of losing it. These cloths, after being sterilized, are kept warm until ready for use. They serve to protect the intestines, which is the chief object of the broad flat sponges. Such sponges are very expensive, and the country surgeon can not very well afford to keep a supply on hand ready for use, waiting for a case to use them on. But he can prepare the linen cloths in an hour. Czerny's outlay of dressings, etc., was very elaborate and lavish, and it was not through economy he employed these cloths, but because he found they answered the purpose better than the sponges.

This leaves only sutures, ligatures, and drainage-tubes to be considered. The small consumer will do best to buy catgut already prepared and ready for use in glass bottles. If from a good house it is fairly reliable, and saves somewhat troublesome manipulations. Silk is to be wound on reels, glass or wood, and boiled for fifteen minutes in the