ing treatment in a sterile wound is that we cannot treat the tissues with any liquid without lowering their natural capacity to defend themselves against the infection that enters more or less into every operation. Nature is competent for this, and we make a mistake if we attempt with our art to clean a wound that nature will handle better herself, if we will not lower her capacities to deal with infection. The dry method for aseptic cases is ideal, but it is different altogether when we are dealing with wounds that are in themselves infected previously, and therefore require not merely aseptic, but also antiseptic surgery. Then, as a general rule, we get great assistance from the mechanical effect of a current of water in cleansing the wound of all débris or infected material, or germ-carriers. This general experience of the majority of operators declares a fact, as Dr. Mathews says, that will stand. It will never be displaced. This is a fundamental division for antiseptic surgery. We need it in infected wounds, and water or other solutions that are better, because they are either more innocent or more active than water, will remain staples. An exception, however, in this category of infected wounds arises prominently in case of the abdominal cavity. The abdomen cannot be washed out -that is, microscopic quantities of filth or germ-carriers cannot be removed by any amount of washing; but macroscopic quantities of dead matter which would furnish pabulum for germs to feed on can be washed out when clean portions of the abdominal cavity are previously walled off by sponges. Exhaustive physiological study has taught us that the principal lacteals that absorb infective matter in the abdominal cavity are in the upper stratum in the neighborhood of the diaphragm. Fortunately for us, the pelvis is proportionately poorly endowed with them; consequently we can leave a great deal of septic material without washing, and everything goes well. But when we wash the general abdominal cavity indiscriminately for small quantities of pus or other germ carriers we wash more of it up into the upper part against the diaphragm, where it will do proportionately greater harm and produce shock from which the patient is less likely to recover. Therefore, irrigation of the abdominal cavity I practice exceedingly little, and only when I am very sure I have walled off the general peritoneal cavity by sponges, or that it is otherwise walled off by nature. DR. WALKER (closing the discussion).-I have two or three points to speak of in replying to the remarks that have been made. I did not attempt to cover this whole question in my paper. I have written two articles before on this subject, in which I go more into details. One objection I have to water in connection with the technique is, that if we can dispense with any one thing in our technique we are better off. That is to say, the simpler we make the technique the less liable we are to infection. In the work we do we try to have as few assistants as possible; we try to shut off every avenue of infection. Water is more frequently an avenue of infection than we suppose. If you will consult the literature of the subject you will find cases of infection that occurred from the water used. In order to test this, I had a trained nurse prepare water that was supposed to be sterile, yet bacteriological tests proved it was not in a number of instances when we were doing operations in the home of patients, where we were not absolutely certain every vessel containing the water was perfectly clean. In wounds that are aseptic the water diminishes the resisting power of the tissues. When we come to septic cases there is a question for experience to determine; but it does seem to me that in the septic cases it is impossible to render them aseptic by washing. I have opened abscesses and pressed out the pus to see how they got along without any water. The distention of the abscess cavity itself in a measure breaks up the barrier between it and the general system. I have seen a rise of temperature after irrigating large abscess cavities. I do not irrigate these at all now. If those cases do not do well, as a rule, you have inefficient drainage. If you lay the abscess wide open and let it drain well, the powers of the system will overcome what septic matter is there. In reply to the remarks of Dr. Mathews, I imagine in the work he does about the rectum he might be inclined to irrigate, because most of the surgical work that he does is more or less septic; still I have excised fistulas running with pus and sewed them up and had union by first intention by the dry method. In regard to the peritoneum there is another large field in which we have much to settle. I was led to use the dry method in the peritoneum by losing a puerperal case upon which I operated for pus-tube. Although I used every precaution, washing out the cavity thoroughly, the patient died so soon after the operation that I felt the irrigation had something to do with her death. I have not used irrigation in the abdominal cavity since that time, many years ago. We know the peritoneum can dispose of a considerable quantity of septic material. We know, on the other hand, the washing, such as we may resort to, will not remove all of the septic material. It seems to me more rational to remove the débris by dry sponging. In regard to the remarks of Dr. Baldwin, I fully agree with him. If the intestines are exposed long, it is better to cover them with a wet towel. I have not had occasion to do it, although in a case in which the intestines were exposed for twenty minutes I would do so. SURGICAL SHOCK AND HEMORRHAGE, WITH REFERENCE TO PREVENTION AND TREATMENT. BY WALTER B. CHASE, M.D., BROOKLYN. AMONG the serious complications of surgical operations shock and hemorrhage are frequent and ofttimes serious accompaniments. A clear conception of the manifestations, prevention, and treatment of these conditions is of the highest importance, both as regards the safety of the patient and the success of the surgeon. Shock may be defined as loss of innervation, dependent on either physical or mental causes, or the two operating simultaneously, induced by profound irritation of the sympathetic nervous system. A reflex of this irritation is witnessed in depression of the cerebro-spinal nerve centres. In a paper presented by a former Fellow of this Society, Dr. Eugene Boise, at a late meeting, a concise and rational distinction was made between the symptoms of vital depression attending shock and those resulting from hemorrhage. While in this discussion I may not, from a clinical standpoint, follow with nicety the scientific distinctions there laid down, I shall endeavor to formulate the rules for treatment of the two conditions, so far as they can be differentiated. Shock results from serious traumatic injury, as seen in contusions, lacerations, fractures, injury to the vital organs either accidental or inflicted by the surgeon. In the article to which I have referred the writer justly attaches the highest importance to the quality of the pulse as the means whereby the difference between shock and hemorrhage may be clearly defined. This includes a critical study of the pulse prior to, at the time of, and subsequent to operation. There is doubtless difficulty in distinguishing between rapid hemorrhage and shock, but between shock and ordinary hemor rhage the distinction can be made. The rapidity of cardiac contractions, with small pulse and low arterial tension, slow and irregular breathing, coming on before the operation is completed, points to the presence of shock. Under hemorrhage (not rapid) these symptoms manifest themselves gradually and progressively. In shock there is usually tendency to reaction, while in hemorrhage no such rallying power manifests itself, and the pulse grows weaker and more frequent. Another diagnostic point of great value in differentiating between the symptoms of shock and hemorrhage immediately subsequent to an operation is this: if a previously good pulse becomes rapidly weak and compressible the patient is suffering from shock; whereas if, under similar conditions, the heart gradually loses its power and volume, hemorrhage is present. In shock there is pallor with lividity, and the intellectual faculties are sluggish in their operation. The pallor of hemorrhage is more pronounced and the patient is apprehensive as to the consequences. One other distinction should be noted in hemorrhage both arterial and venous anemia are present, while in shock the anemia is arterial with more or less venous stasis. : So, too, the shock from injury to certain organs is more pronounced than from injury to others. Traumatism to nerve-trunks, injuries in the immediate vicinity of the solar plexus, injury to the testicle or compression of the ovary, as well as opening of the peritoneal cavity, serve as illustrations. From the surgical standpoint, especially after celiotomies, doubt as to the presence of shock or hemorrhage is not often present, but in the tubal ruptures of ectopic gestation and accidental hemorrhages into the peritoneal and other cavities, and extravasation of blood into yielding structures, the suggestions already made will be of the highest value. In the clinical study of most cases of celiotomy and the surgery of other closed cavities of the body, and in capital operations generally, the symptoms are composite, due to both shock and hemorrhage; so that while the procedures suggested hereafter apply to either the one or the other condition, as may be present, yet in many cases the effort of the surgeon must be directed to the combined influences of both causes operating simultaneously. The treatment of shock divides itself into those measures which are preventive and curative. The physical and mental condition of the patient bears a constant and close relation to the degree of shock likely to be induced by a given operation, so it is a self-evident proposition that whatever will fortify the patient in bodily and mental health, either by dietetic, therapeutic, or hygienic measures, is worthy of the most careful consideration, and in elective operations time thus spent is well spent. The physical condition, functional activity of all the organs of the body, should be a matter of careful and conscientious study. Bodily secretions and excretions must, as far as possible, be known, especially with reference to lithemic and uremic conditions. Failure, by quantitative and qualitative tests, to know all that is knowable in these particulars, may not only place the surgeon under serious embarrassment, but do the patient grievous injury. To estimate the recuperative power of a given patient study his heredity, his expected longevity; learn his powers of vital resistance and recuperative energy as manifested in recovery from serious injury or dangerous illness. By so doing an intelligent judgment can be given as to the advisability and risk of operation in grave conditions, and this knowledge should be communicated to the patient or friends, as policy and justice may demand. The deleterious influence of shock is chiefly manifested upon the nervous system and the heart. To fortify these latter organs, if below good maximum standard of health, strychnine should, if practicable, be administered a few days prior to the operation to the extent daily of one-twelfth to one-sixth grain. This drug is particularly applicable in cases of fatty and atheromatous degeneration of the heart and blood vessels. If the arterial tension is low, with small volume, and fatty and atheromatous degeneration of the circulatory organs is absent, digitalis fulfils the indication and should be given with moderation until its physiologic effect is apparent. In muscular weakness of the heart the administration of sparteine sulphate in one-eighth grain doses every two or three hours for twenty-four or forty-eight hours before an operation is indicated. Like strychnine, it is not contra-indicated in degenerative changes of the heart and blood vessels. If surgeons would make it an invariable rule to have the alimentary canal absolutely empty in all elective abdominal operations, they would escape much annoyance and improve the patient's chances by obviating to a large degree the liability to |