spaces, little traumatism, nonuse of antiseptics in fresh wounds, absolute control of bleeding, proper apposition and care in the application of dressing.

In conclusion, I wish to thank you for your attention. to this paper. My attempt has been merely to present the few surgical details which would appeal to one in his daily routine of operative work; the consideration of which may change the tide of infection into good results.

DISCUSSION OF DR. BATTEY'S PAPER.

Dr. McRae: This is one of the most important papers that we have had before this section, and Dr. Battey has brought out so many interesting points that I would like to discuss some of them.

Every man who has done much surgery has gained from his failures as well as from his successes if he has been judicious enough to blame himself and not some one else. There is a tendency among us to blame others rather than ourselves. We are sure that a nurse or some one else is responsible for some things, but we should remember that we are responsible for the operation because the patient submits himself to us and we are responsible for our assistants.

As to cleansing the hands, my skin is very tender. I wear beard in the winter because I have such a tender skin. My hands are without an abrasion because I have learned to take care of them. This is the most important thing that I have learned in twenty years of surgery. i can not stand to scrub them with a rough brush. I use gauze to scrub my hands and arms, and I can get them cleaner in this way because I can get more friction. The man who scrubs with a brush will strike the high places of the skin and jump over the low places, and his cleansing is not uniform. The way to do is to go over each

finger systematically, and you soon get into the habit of doing this.

As to the "twenty-four hour preparation," the Doctor did not say what he meant by the twenty-four hour preparation. If he meant local preparation I would say that I used to do a forty-eight hour preparation, but now I do the two-hour preparation. My attention was first called to this by Dr. Mayo. He said that he had noticed that the results after the rough work in emergency cases where he had to operate at once were better than in the cases in which the twenty-four hour preparation was employed. And I recall that the rough clinical work at the college was better than at the Grady Hospital. Therefore I have adopted the two-hour preparation.

Welch has shown that the staphylococcus epidermidis is in the deep layers of the skin, and begins to multiply when the skin is injured, and therefore severe scrubbing does more harm than good. I get better results than I did with the twenty-four hour preparation. I found that we more frequently over-prepare rather than under-prepare, and I do not want my patients prepared more than two hours before the operation.

In reference to the mouth: It has been shown that the meconium is sterile, and that the alimentary canal of a child becomes infected by taking in food. Cushing showed that you could keep it sterile by feeding sterile food, emptying the alimentary canal thoroughly and cleansing the mouth. We all see cases of Riggs's disease which result from uncleanliness of the mouth. I have the mouth of the patient thoroughly cleansed, as I think that ether pneumonia has been due more to the infectious material in the mouth than to the ether.

The muscle-splitting operation is a good one, and I hesitate about doing the lateral incision when this oper

ation will do. In 1904 I began doing a little operation which has given me a great deal of comfort, and which my coworkers like very much. I have been watching the results since 1904, and have not seen any case of hernia following it.

I do not think that there is any procedure in abdominal surgery which should be condemned more heartily than the use of hydrogen peroxide.

As to ligatures, the principal point is to have proper material. If you have not good material in which you have confidence, you can not tie a knot with any satisfaction.

I never attempt a general flushing of the peritoneal cavity except when there is a general soiling of the cavity, as otherwise a local infection will become general.

It is almost inexcusable to have a post-operative hernia after a clean operation. It can be avoided by making small incisions with muscle-splitting operation and incisions that do not get a scar across the muscle fibers. As the Doctor has said, you should have accurate closure without any dead space.

Dr. Battey (in closing): I want to thank Dr. McRae for his favorable comment, and the many valuable points he has added.

As to the post-operative treatment, after abdominal preparations I frequently give my patients a little codeine. I do not care to give morphine, and I never give a cathartic until the second night following the operation, in order to prevent intestinal adhesions. I use the alum enema and it is usually successful and makes the patient comfortable. Sometimes I give this before giving the cathartic. I put the patient on semi-solid diet, and the next day on regular digestible food, after bowels move well.

SURGICAL ANESTHESIA-METHODS AND

COMPLICATIONS.

BY J. M. SIGMAN, M.D., SAVANNAH.

The indifference so often shown by surgeons concerning anesthesia, the lack of attention accorded by patients before, during, and just after anesthetic has been given, seems to demand some consideration of this subject.

No patient should ever be anesthetized without thorough preparation, so far as the circumstances of the case. will admit. This preparation means a thorough cleansing of the alimentary canal, complete rest for at least twentyfour hours before the anesthetic is given (longer if possible), and an examination of the products of the eliminative organs. In emergency cases it may be necessary to deviate from this rule, but with a stomach-pump, high colon irrigation and catheter, much can be done to insure comparative safety. An autointoxication can be easily induced by absorption of products from the intestines, and the danger almost certain to result from such a condition should be sufficient to make surgeons more careful.

An examination of the urine should be regarded, in every case, as a necessary routine feature; that the presence or absence of degenerative changes in the kidneys may be known. Every one will admit that this should be. done, yet how often have we seen patients rushed to hospitals and an anesthetic given without any preparation whatever, and in some cases the patient doing badly afterwards, this condition could have been prevented had proper attention been given the patient.

Ether and chloroform seem to be the principal anes

thetic agents in general use. Other combinations have been produced, tried and discarded. We have used the scopolamin-morphine ether sequence, and have followed this combination in some cases with chloroform. This method is too depressing, both to the circulation and the respiration to be given much consideration; there seems to be nothing gained by its use, but on the contrary, a great deal of anxiety incurred, both to the surgeon and to the family of the patient. This method will often require but very little ether, and but little chloroform, if any. Ether and chloroform have been given in combination, chloroform being given until surgical anesthesia is produced; then changing to ether.

We have also used the nitrous-oxide-ether sequence, and have found this to be a comparatively safe method. Chloroform, nitrous oxide alone and with chloroform, and chloroform and ether have all been used. At present, I prefer giving ether alone, by the drop or open method. As a second choice I would give nitrous oxide and ether, using Bennett's inhaler.

In the administration of an anesthetic, one should understand that he is giving his patient a poison which may result fatally at any time during its administration; also that danger is not passed until a week or ten days afterwards. Any drug capable of producing anesthesia will cause, degenerative cellular changes in the internal organs producing a toxemia varying in severity, but in direct proportion to the strength of the drug, length of the anesthetic, and the presence or absence of predisposing causes, as sepsis, starvation, hemorrhage, chronic wasting diseases, and products of dead material, as a dead fetus or tumors which have become gangrenous. As a rule, however, any patient fit for operation can take ether properly given, but no anesthetic, for however trivial a cause is free from danger; in fact, statistics show that