gained thirty-eighty pounds in weight; another where great depression, fear, and insomnia were present, and all disappeared after the operation.

In closing, I wish to express my gratification for the manner in which the Fellows have brought out so admirable and full a discussion, knowing as I do that the opinions of the men present are representative of my branch of the profession.

THE TECHNIQUE OF THE DRY METHOD.

BY EDWIN WALKER, M.D.,

EVANSVILLE.

EVER since the era of antiseptic surgery the question of technique has been all-important. Changes have followed the growth of our knowledge of bacteriology and a more careful study of the means and avenues of infection. Much of the paraphernalia of the earlier work has been found unnecessary and even dangerous. The development has been toward simpler methods, and striving at asepsis rather than antisepsis. We know now that the chief avenues of infection are the hands of surgeon, the skin of the patient, the instruments, sponges, and dressings, and if these are rendered sterile there is little to fear. The simplest method we can find to accomplish this result, the one that employs the fewest details, will be the best. These conditions the dry method fully meets. By the dry method I mean a technique in which no water or other fluid is used. This does not apply to the preparation before the operation. The hands of the operator and assistants, and the skin or mucous membrane of the patient, require the free use of water; but after the first stroke of the knife, until the wound is closed, not a drop of water is used.

This is not a new method. It was proposed, so far as I know, first by Landere in 1889. His plan was to sponge out the wound with dry bichloride gauze. He used no water. Since that time many, perhaps all, surgeons have used less water than formerly, and a few have adopted the strictly dry method.' It has never come into general use, as I think it should, and for this reason I wish to call your attention to it, believing that you will find much comfort from its adoption. We have been gradually working toward the dry method for seven or eight years, and for three years

1 American Journal of the Medical Sciences.

past Dr. Owen and myself have practically used no other, and our results have been so satisfactory that we have been continually extending its use, until practically everything is done by this method. In order that you may judge of its value, I will give you briefly our entire technique.

In the first place, we avoid infection as far as possible. Our nurses are instructed to use every precaution to prevent soiling the hands in septic cases, and to thoroughly disinfect the hands after any suspicion of contamination. Every instrument used is sterilized before it is put away. In fact, in every possible way we try to keep ourselves, as well as our institution, free from infection.

The hands are scrubbed thoroughly with a brush with liquid soap (equal parts of green soap, glycerin, alcohol) and repeatedly rinsed in sterile water. Then they are wiped off with alcohol, then dipped for two minutes in bichloride solution 1:1000, and then washed off with salt solution. The latter is to take off the excess of bichloride, in order that it may not get into the wound or blacken or dull the instruments.

The field of operation is prepared in the same way, except that the scrubbing is repeated daily for two or three days before the operation, if possible, and a soap-poultice used at night. Care is observed not to unduly irritate the skin. Dermatitis does not favor asepsis.

The instruments have usually been sterilized in a hot-air oven at a temperature of 300° F. for half an hour; but recently we have abandoned this, at the recommendation of our bacteriologist, and they are now boiled in soda solution for five to ten minutes. They are wrapped in towels or placed in metal boxes, which are opened only at the time of operation. They are not immersed in any fluid, but laid upon dry, sterile towels in suitable dishes to keep them from rolling away or becoming displaced.

All sponges, dressings, cotton, towels, and gowns are sterilized by steam under fifteen pounds pressure (Kny sterilizer). These are placed in tin vessels or wrapped in towels and kept closed until ready for use. The sponges are made of gauze enclosing absorbent cotton, the flat ones several layers of plain gauze whipped together. It has been objected that the gauze sponges are not sufficiently absorbent. We have not found this to be the case, nor have we found any difficulty in rendering them absolutely sterile. Plain

gauze is used for every purpose except packing the uterus and those rare instances where drainage is used, when the iodoform-gauze is preferred.

The silk ligatures are wrapped on spools and placed in glass boxes, and the silkworm-gut and silver-wire in long, narrow glass tubes, and all sterilized by steam, as are the dressings. The plain catgut is boiled in alcohol, and the chromicized is prepared after Edebohls's method. Thus you see the aim is to thoroughly sterilize everything and bring all into the operating-room or the patient's house without having been handled or disturbed. This is a convenience for operations done in the patient's house, for you have all that is needed without using anything on the premises, and you know accurately the preparation of every article.

After the patient is placed on the table, the dressing, usually plain gauze, is removed from the field of operation and sterilized towels adjusted as usual. The instruments are unwrapped and everything is in readiness. The sponges are used dry, and thrown away when soiled; we never try to use them the second time. The flat sponges in the abdomen are also used dry, and are provided with a cord which is clamped with a pincette. The latter is left outside, so that the sponge cannot be forgotten and left in the abdomen.

In aseptic cases this method leaves nothing to be desired. The sponges are absorbent, the wound is easily kept free from blood, and when you are ready to close the wound it is covered with plasma and living cells of the blood. What better condition could we have for immediate union? I believe you will all agree in these cases it is the simplest and best method, for in aseptic cases there is really nothing to wash out. The whole object is to have a dry, clean wound in which blood does not accumulate. This the dry method accomplishes to perfection.

In septic cases there is some reason to doubt its efficacy, but experience has convinced us of its superiority in this class also, although there may be a few exceptions, which I will briefly discuss later on. We should remember, in the first place, that septic cases cannot be rendered aseptic by any amount of washing. Suppose we have a simple ulcer to deal with. We know full well that no amount of fluid will render it aseptic. The same is true in abscess. In a few instances in the latter it may be more convenient mechanically

to clean out the débris with water, but dry sponging will generally suffice. If the pyogenic membrane is to be dissected or curetted out the water is superfluous. Dry sponging will clean the whole

surface admirably.

In intra-uterine work it is entirely satisfactory. I have written an article, published in the Southern Surgical and Gynecological Transactions, which covers this branch, and I will not discuss it here. Suffice it to say that in curettements and removal of the products of conception, or in other intra-uterine work, it leaves nothing to be desired.

It is not my purpose to enter into an extended discussion of this method. I believe that all of you will readily grant that in a large number of cases it would be efficient. Its simplicity commends it. There is no other technique as simple and as free from unnecessary details as this. As I said before, in all aseptic cases it is certainly sufficient. The only doubt in any one's mind would be in those infected cases where there is much pus or débris to be removed. It is hard for us to let go of traditions, and water and cleanliness have been considered inseparable, hence our tendency to wash and irrigate has been irresistible; but experience as well as experimental study has fully settled that disinfection cannot be accomplished in infected cases by fluids.

There are two kinds of cases in which our experience has been thus far too meagre to give a definite expression. The first of these is puerperal sepsis. We have used this method exclusively in the treatment following abortions, and the results have been entirely satisfactory. Some of these have been after the fifth month, and many of them markedly septic, having temperature ranging from 100° to 104°. All of these did well, the temperature falling promptly to normal, and the patients rapidly recovered. From this we would be inclined to use it also in a puerperal case; but in this, the uterus being very large, it may not drain as thoroughly as the smaller ones, and experience must settle this. We have used it in a few cases, but in all of them some other plan of treatment had also been employed, so we do not consider them of any value in this discussion. The treatment of these cases by irrigation has been far from satisfactory; many have died, and not a few have been made distinctly worse by it. I have often seen a sharp rise of temperature after an intra-uterine douche and pelvic