-a most common source of infection; feeling the pulse in a critical case and neglecting to again sterilize the hands before resuming operative work. All these and other similar derelictions may be noted here and there, for the technique of perfect asepsis such as seen in the work of Joseph Price, for example, is a habit which can only be acquired by long and patient toil, and maintained only by the most careful watchfulness. But I take it for granted that such operators are the exception, not the rule, and that consequently the reason assigned by my friend why the railroad surgeon should not try to practice aseptic surgery is not the correct one.

Further, I do not wish to condemn cleanliness in surgical work. It is, above all other things, the secret of success in our most hazardous undertakings. Indeed, under certain conditions and in certain classes of cases the surgeon must rely solely upon perfect, ideal asepsis to secure perfect results. Notably is this the case in abdominal and cerebral surgery, where, after the incision through the skin has been made, antiseptic agents must be ished. But to obtain the best results in most cases of acute trauma, something more than simple surgical cleanliness, something more than mere hot water, is essential. It is not right to depend upon asepsis alone; and in most of his operative work the modern surgeon has gone too far in attempting to depend upon asepsis alone. Antiseptics of known and tried value have been too hastily discarded in the desire to use nothing but hot water or normal salt solution, "the best antiseptic in the world," as has been erroneously said by some enthusiastic crank. In other words, we have been trying to do "aseptic surgery" where "antiseptic surgery" should have been practiced. Indeed, it has seemed as if in following the fashion set by Lawson Tait and Joseph Price, that is, in trying to apply the rules of abdominal work to general surgery, antiseptics were about to be relegated to "the glories of the past."

I myself have the greatest faith in antiseptics. The reason is not hard to give. I have seen too many cases get well, and without trouble, in the work of surgeons who were positively filthy in their methods, yet who used strong antiseptic solutions, to allow any doubt as to the efficiency of the medicinal

agents employed. Antiseptics and prayer have saved many patients who would have died if the operators had relied upon asepsis alone. More than this, I have seen many times the most favorable termination in cases where dirt was ground into the wound, where death would inevitably have occurred had it not been for the life-saving properties of the antiseptic agents used. An instructive case

in this connection was this:

George E., 24 years old, was struck upon the head on the morning of April 2, 1891. During the day he was seen by at least three prominent surgeons of the city, each of whom refused to operate because there seemed to be absolutely no hope of recovery. At about 4 p. m., six or eight hours after the injury, he was still breathing and partially conscious, and Dr. W. S. Allen asked me to see him as I had a reputation for doing operations against desperate odds,-if there was even one chance in a thousand, regardless of my "death rate;" or, as Dr. Allen put it: "You are noted for fixing up a mangled body so it will look well at the funeral." So I saw him

at 6 p. m. At that time his appearance was frightful in the extreme. The whole scalp and pericranium were torn away, hanging by a narrow strip less than three inches across near the occiput. In the wound were cinders, earth and grease in such quantities that it appeared as if it never would be possible to clean the surface. The flange of the drivewheel had struck near the coronal suture on the right side, driving the bone down into and badly mangling the frontal convolutions. A fracture extended downward into the orbit gaping widely, and blood was oozing from eye and nose. It was one of those cases of "diffuse injury" in which the text books direct not to operate. Nevertheless he was given a little chloroform by Dr. Callaghan and we proceeded to clean the wound. After scraping off as much as possible of the dirt. and blood we industriously scrubbed with soap, water and a stiff brush, dried it and washed with sulphuric ether, then with turpentine, and finally with sublimate solution I to 1,000. We next washed the bone and brain for at least ten minutes with boiled water and then with saturated solution of boric acid. After removing all fragments of bone we trimmed up the brain and dura with scissors, cauterized such bleeding points as would not check on the application of hot water, 115 degrees, applied a very large quantity of iodoform, replaced and sutured the scalp and inserted large drainage tubes. About the orifices of the tubes and along the line of sutures an immense amount of iodoform was dusted and gauze wrung from 1 to 1,000 bichloride

solution used as dressing. Recovery was remarkable. The next evening, April 3, his temperature was 99, pulse 100, no paralysis and but little mental disturbance. The drain was removed on the fourth day, when his temperature and pulse were normal. The next day he insisted upon sitting up and on the fifteenth day after operation he was discharged in perfect health, although there was a very large opening in the skull. There was not a drop of pus visible at any time.

From such cases as this (and this is not an isolated instance) I draw the conclusion that when the operator is not sure there will be no break in the chain of surgical cleanliness, or where there is known infection of the field of operation, in every capital operation antiseptics should be employed in such quantities as to guarantee the safety of the patient. The lesson is more firmly impressed when, in a ward common to several surgeons, I see my patients treated in the manner this one was recovering without a symptom of local infection or inflammation, while upon adjoining beds are patients with wounds reeking with pus as the result of the attempt upon the part of some misguided and careless man who is relying upon so-called "asepsis."

Now do not misunderstand me. I do not mean the exclusion of attempts at perfect asepsis, or as near approach to it as possible in every operation of any magnitude. I believe it the duty of every operator to: Ist, boil all instruments in a strong solution of washing soda (sal soda) before every operation of importance; second, to sterilize his hands by thorough scrubbing for five minutes, drying them and trimming the nails down to the quick; then scrubbing again for another five minutes, then immersing them for at least one minute in alcohol, or if that be unobtainable, in turpentine, and finally in bichloride solution for a minute; or by the permanganate of potash and oxalic acid method familiar to most of you; and, third, to prepare the field of operation by practically the same cleansing process. Any surgeon who goes into a major operation without taking these precautions should be deemed guilty of malpractice and held responsible in case of an unfavorable result dependent upon septic processes. I repeat that this process should be gone through even for already infected wounds, but that in addition to it the operator should make use of certain antiseptic solutions

during the progress of operation, for sponging purposes, for repeatedly washing the hands, for irrigation, etc., in every case where the wound is already infected or the possibility of infection during operation may arise.

But, says the skeptical one, why use all these precautions for a wound that is already infected, that already may be filled with pus? There are two reasons, one scientific, the other practical. As to the first, there are two classes of micro-organisms chiefly concerned in the production of inflammation and in pus formation: the streptococcus pyogenes and the staphyllococcus pyogenes aureus, or other variety of staphyllococci. These are entirely different in their mode of action, danger to life of the tissues and in other ways. Now if we have a simple staphyllococcus infection it may amount to little, possibly only to the appearance of what the old authors called "laudable pus" in the wound, and a slight amount of systemic disturbance; but if upon this, by careless methods or want of antiseptic agents, we engraft a streptococcus infection we render the inflammation more spreading in its character and far more dangerous in degree because we have added to the wound that peculiar germ which under certain circumstances gives rise to erysipelas, under others to puerperal sepsis, and other grave disorders. On the other hand if we already have a streptococcus infection, and by our unsurgical measures permit conjoint infection with some of the staphyllococci, which possess strong peptonizing properties, the extensive infiltrate depending upon the streptococci will melt down into pus with wholesale destruction of tissue, perhaps with the development of a fatal septicemia. So the use of strong antiseptic or even germicidal agents is distinctly indicated in wounds produced by accident. As to the second, it gives better results than can be obtained by any other course; as in this case:

George R., of Independence, Kan., was admitted to the Baptist Sanitarium some three weeks ago, suffering with an old, discharging ulcer of the leg, due to trauma. Many ineffectual efforts had been made to heal it, but no cure seemed possible. Examination showed a large amount of dead tissue lying in the bottom of the indolent ulcer, infiltrated edges, a stinking discharge, etc. The ulcer was about one inch wide by two inches long. Under chloroform I shaved the leg, scrubbed the surrounding area and the ulcer itself, after curet

tage of all the debris and weak granulation tissue. After most thorough scrubbing I dried the surface and then washed it with sulphuric ether; then applied a saturated solution of permanganate of potassium, rubbing it well into the sore, the edges of which were pared at the time of curettage; then applied strong oxalic acid solution until the stain disappeared and then hot water. After drying the wound it and the surrounding skin were washed with alcohol and finally with normal salt solution. I then completely excised the ulcer and all the underlying tissue down to healthy muscle. This left a wound two and a half inches wide by four long which had to be closed. Two six or seven inch incisions, one on either side at a distance of a little more than two inches from the margin, allowed the two edges to be brought together without much traction on the ten sutures introduced. The central wound was then hermetically sealed with iodoform collodion, and the two widely gaping ones closed by Thiersch skin graft from the thigh. Healing by primary union has been secured in the site of the old sore and the "side issues" are nearly well, without one drop of pus and no other sign of inflammatory reaction.

This is an undoubted triumph of antiseptic surgery. The excellent results can be ascribed to nothing else. It required nearly two hours to complete the work, but the success is worth the trouble. It is, however, in cases of minor surgery that I must urge reliance upon antiseptics, together with all possible cleanliness.

Most of the minor injuries with which the railroad surgeon has to deal are inflicted at a time when the surface which is the site of trauma is dirty, often foul; further, in the accident itself septic material is very apt to be ground into the tissues. Here is the condition which calls for the strongest possible antiseptic agents. It will not do to try to rely upon cleanliness alone; it is insufficient. By employing the strong antiseptic remedies after cleaning the wound as thoroughly as possible we may frequently get healing by primary union where it would seem that such a result would be impossible. To illustrate:

March 21, 1896, a boy was brought into my office suffering from a crushed finger. The accident occurred while the hand was very dirty and in such a way that a lot of earth was pressed in among the fragments of bone and injured skin, tendons and muscles; at first glance a wound that would necessitate amputation, but upon careful examination I found the blood supply still good and determined to try to save the finger. With complete anæs

thesia I scrubbed the wound itself very carefully with ethereal soap, itself a good antiseptic; then trimmed away all ragged fragments; then washed with alcohol, rubbing it into all the interstices and between bony fragments; then saturated it with boro-lyptol, the latest germicidal agent, which consists of a five-tenths per cent. solution of formaldehyd in combination with boro-glycerid, eucalyptol, etc., a most valuable association of antiseptic drugs. Using this also to wash away the blood during subsequent procedures, I sutured the skin and other tissues into place with catgut, introduced catgut drains in two or three directions and applied a dressing of bichloride gauze saturated with boro-lyptol. As there was no pain and no fever I did not remove the dressings until the twelfth day, when I found that primary union had occurred. A gauze dressing on a finger with a splint for support to the injured bone constituted the sole remaining treatment.

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Now from my observations in the work of those who are treating such cases by "asepsis" alone I am sure I would have lost this finger if I had not employed the strong germicide, or at least antiseptic agents and dressings. The reason is not hard to understand. Howsoever industriously we may labor with soap and water and scrub-brush we cannot rid the wound of the pus-producing germs which have been introduced before the wound is seen by the surgeon. "Nor can we reach and destroy them by antiseptic solutions," exclaims the exponent of asepsis. That is quite true. We who advocate the use of strong antiseptics do not expect to kill the germs ready in the wound-that is not at all the object of their application. Nature can readily take care of the few micro-organisms which have found lodgment upon the tissues. The purpose of the antiseptic agents and the antiseptic dressings is to prevent the development of more germs from those already there. The life history of this species of plant life shows that the pyogenic bacteria increase with an almost incredible rapidity under favorable conditions, and infective troubles arise not from the original seed, but from the wondrous crop that soon follows if the soil and surroundings be propitious. The use of simply sterile gauze or dressings saturated with normal salt solution, as urged by Professor Outten, gives a most favorable soil and surrounding for the development of pathogenic micro-organisms; whereas the application of antiseptic dressings following an antiseptic

operation will completely arrest the growth and propagation of the dreaded germs, that is, we render them sterile, innocuous. Possibly in the hands of an Outten it may be possible in most cases to secure such perfect cleanness of the infected field so as to give primary union under simply sterilized gauze; but even in his work the employment of the antiseptic plan would do no harm, while in the work of men less careful in practice or where surroundings are less favorable than those in which his patients are placed, it is imperative.

It will be noted that I have advised the use of sublimate gauze as the dressing for all infected wounds. This has been done purposely, for the use of iodoform gauze has become entirely too common. Iodoform gauze is not strongly antiseptic; in fact iodoform powder is not germicidal at all, though it does act advantageously in preventing the rapid proliferation of pus organisms by its drying (and other) properties; so while it is a most valuable dressing for aseptic wounds, particularly when a considerable amount of wound secretion is anticipated, it is practically valueless in a wound already infected. But bichloride gauze not only sterilizes the little air which passes through to the wound surface, but effectually prevents the increase in the number of the microbes which may be in the serum escaping from the seat of injury.

Now please understand the position I take. In every wound made by the surgeon himself (under favorable circumstances) asepsis is perfectly safe and should be invariably practiced, as it is the ideal method, and gives the best results in careful hands.

But in every accidental wound and in operations where it is impossible to secure and maintain perfect asepsis (such as operative procedures in already infected tissues as well as in the rectum, etc.) reliance must be placed upon antiseptic agents.

In conclusion, I wish to repeat that however fascinating it may be to see a Joseph Price simply scrub his hands with soap and water, prepare the field of operation in the same way, use nothing but boiled water upon his sterilized instruments, and apply only sterilized gauze as a dressing,-in other words, relying upon perfect asepsis to secure perfect results,it will not do to follow his example in managing the cases which usually come to the

railroad surgeon. To use the words of the title of my paper: "Railroad surgeons should not try to practice aseptic surgery in emergency work," because better results can be obtained by recourse to antiseptics.

DISCUSSION OF DR. LANPHEAR'S PAPER.

Dr. Geo. W. Crile: I do not know that I can add anything new to this subject, but I wish to say a few words relative to some of the points brought out by the essayist. With reference to what has been said on the question of asepticism and antisepticism, I will say that it is necessary for the competent surgeon to use one or both, although many will try to reach asepticism through the agency of antisepticism. First of all, I would say that we must not lose sight of the fact (in the process of repair) that the tissues repair themselves by their cellular action and reproduction, and cells can only repair themselves when properly nourished. The only proper food for the cell is the serum of the blood. I maintain that in our efforts to carry out asepticism we should in all cases avoid the uses of douches, of using water and saline solutions. If we use normal saline solutions on a wound we dilute the food upon which the cells live, and the ideal method of repair in a wound is by making use of the normal food--the blood plasma. It is better, in my judgment, to dry the wound, make absolutely perfect hemostasis and leave no so-called dead spaces in the tissues. Do not douche the parts with saline solution.

As to antisepsis the same thing holds true. Bichloride of mercury in strong solution will precipitate the food upon which the cells depend and will certainly do much damage in the hands of one who is inexperienced with its use. In infected cases use bichloride of mercury, but use it in small quantities.

Dr. W. H. Elliott: I believe in this matter Dr. Lanphear has taken the correct position, . and were it left to me for decision, I would state the case in these words: Asepsis when you can; antisepsis when you must.

Dr. Fulton: I am not on my feet to discuss the paper, for I believe there is nothing to disIts title was misleading. He gave us The practice

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a title but did not follow it out. of antisepsis in railway surgery is always a necessity. The practice of antiseptic surgery in Mr. Tait's practice to which Dr. Lanphear referred is not necessary; that is to say, antisep

tics are not necessary in the practice that Mr. Tait follows. He is not dealing with the kind of cases that railway surgeons encounter, and when we discuss a question like this we probably discuss it from one standpoint. If we discuss it from the standpoint of Mr. Tait's work, we will practice asepsis, but if from the standpoint of the railway surgeon, who cannot get his patient in an aseptic condition prior to operation, he must, in addition to aseptic precautions, practice antiseptic surgery. Everybody knows that, and there is no dispute upon that point.

Dr. S. S. Thorn: It seems, from the investigations and researches of Lister, Pasteur and other biologists, from whom we have learned so much, that the germs are not autogenetic. They must be planted in order to be there. I do not believe that railway dirt, such as oil and other stuff that comes from the cars and track, is necessarily pathogenic. If we have pathogenic germs we should treat our cases antiseptically. If we have not, then all that work is unnecessary, and not only that, but positively injurious. We have all seen the pendulum swing to the other side, and we have followed it there. That pendulum is back again and is. going the other way. I do not for a moment deny the benefits that have come to railway surgery from the antiseptic work which has been done, for we all know that we were surrounded by filth from head to foot at one time, and surgeons then were not so particular about cleanliness of person as they are now. At present we go into our cases reasonably clean. I am opposed to any cast iron rules. There are no cast iron laws to govern our manipulations and treatment.

Dr. P. Daugherty: Like Dr. Thorn, I practiced surgery when we did not use antisepsis or asepsis; when we had wounds reeking with pus, and it took not only days, but weeks, for the wounds to heal. I do not care about going back to the old days any more. I agree with Dr. Lanphear in the main, and could cite, if necessary, cases illustrating and substantiating the points he has brought out.

Dr. MacCrae: It seems to me that Dr. Lanphear's paper is correct in every respect, and that Dr. Outten's paper of last evening is a dangerous one to be promulgated before a society of this kind. All cases of injury on the railroad track are septic. If they are not sep

tic we cannot prove that they are not so. We should treat them as septic cases. What has made surgery what it is to-day? Antiseptics. As we learn more and more of these things, we resort to antiseptics in order to make ourselves aseptic. It is impossible to perform an aseptic operation without the aid of antiseptics. I hope no gentleman here will go away from this meeting and try to render injured limbs aseptic without the use of antiseptics.

Dr. James T. Jelks: It is an accepted fact among modern surgeons that the micro-organisms of inflammation are everywhere, in the dust we breathe, and in the dirt beneath our feet. It must be a fact that the dirt of the railroad track and the oil with which it is mingled, is septic. We have acted on that basis for thirty years, and the results have been marvelous in modern surgical work. One gentleman has said that the pendulum is swinging the other way, and that we are attempting to foist upon the profession aseptic surgery in septic cases. If we have an operation to do in a clean peritoneal cavity, it is an accepted fact that we should not pour antiseptics into that delicate cavity. We all know that, and hence should not bring Tait's dictum, or that of Joseph Price into a congregation of railway surgeons. All of our cases are septic. Antiseptic precautions in lacerated, infected wounds are the only road to safety.

Dr. Lanphear (closing): I am astonished at the unanimity of opinion of this association after hearing the paper of Dr. Outten last night and the enthusiasm which it seemed to provoke. I wish, first of all, to give attention to the remarks of Dr. Fulton. He says there is no dispute about this subject. Surely he is not familiar with the work of men in this city, or he would have heard the cry of those who are clamoring here, there and everywhere throughout the land for the hot salt solutions exclusively. Men are advocating in this city the use of nothing but hot water and soap and brush in preparing for operations. The same thing is being done in Chicago. It is being done in Junction City, where Dr. Daugherty lives. It is being done everywhere and it is a dangerous thing.

In reply to the assertion of Dr. Thorn that we must have no cast iron rules in operative surgery, I will say that we are dealing with cast iron laws as fixed and immutable as the