to observe over a space of time the effects of the injuries received, and especially with reference to two points: First, the nervous disturbances excited in workingmen who have sustained an injury; and, secondly, the differences between these effects in workingmen and in the better classes.

In thirty-four persons who were injured in the two accidents cited, apart from three who were killed, not one presented the symptoms of the "traumatic neurosis" in Oppenheim's sense. Of thirteen cases of the first accident, six were absolutely free from bad results; four had light neurasthenic symptoms, slept more irregularly than before, complained of occasional headaches and fretfulness; two boys appeared to have lost intelligence to some degree, and one patient suffered in memory. In three employes, who suffered no severe injury, outspoken hysterical symptoms developed, in one of whom pronounced neurasthenia continued for two years. In two locomotive engineers with severe injuries marked mental irritability disappeared after a few weeks, and only sleep was disturbed. In one switchman neurasthenia ensued through anxiety and without any traumatism. In one brakeman severe neurasthenia appeared only during occupation.

From this it appears that the nervous consequences of severe railway accidents do not offer so bad prognosis as has been assumed. Above all it is quite noticeable that the results are much more pronounced in railway employes than in private individuals. This is shown by the cases in which nervous symptoms developed, where no bodily injury had been sustained. The anxious service, the generally diminished and irregular sleep, the dread of disciplinary correction, the exacting answerability, predispose to nervous disease. In addition to these are often hereditary taint, which is not seldom accompanied by abuse of alcohol and tobacco, under-feeding, early syphilis, all of which tend to the development of arteriosclerosis. Finally comes the dread of retirement from active work, with insufficient compensation and a moderate pension.

From these considerations the writer concludes that the "individuality" has much the most to do with the form and severity of the functional nervous conditions. which follow accidents; and, furthermore this "individuality" must be considered in its widest and most comprehensive sense. Not only the individual personality, but also the individual conditions before, at the time of, and following the accident, must be taken into account.

In the estimation of the individual case, must be taken into account the personal constitution, the inherited

predisposition to disease of the nervous system, preceding

diseases, abuse of alcohol and tobacco, the social condi

tions, the financial state, the occupation, and the probable injurious effects of all these factors. Finally, due weight must be given to the general situation of the victim at the time the injury was sustained.-Albany Med. Annals.

Always relax the abdominal wall after suturing a wound of the parietes.-Fenwick.

.

SOME PHASES OF LOCAL ANESTHESIA.

BY WALTER C. WOOD, M. D.

Not infrequently a patient comes to us asking surgical assistance which we would gladly render, were it not for the fact that an examination reveals cardiac, pulmonary or nephritic conditions that absolutely forbid the use of the anesthesia usually accompanying the operation indicated. In another case, the need of relief may be so urgent that we are forced to proceed, although we well recognize that the immediate and remote dangers of the general anesthesia in this particular case exceed the peril of the surgical procedure itself. Again, the well known and, alas, not ill-founded reluctance of patients to submit themselves to general anesthesia causes them to delay seeking and following surgical advice even when delay is dangerous, and, in less vital conditions, this same reluctance is often the determining factor in deciding them to submit to present discomfort rather than risk the stages of unconsciousness. The many devices and attempts of recent years to improve the methods of giving ether and chloroform, amply prove that we are cognizant of the dangers attending their use. Hence we are ready to wel

come any advance in the use of local anesthetics. Thus, on account of the importance of the subject, I desire to call attention to a most excellent communication by Matas of New Orleans, first published in the Transactions of the Louisiana State Medical Society for 1900, to report several cases of my own as examples of what can be done along the line of his suggestions, and to show a simple and easily extemporized apparatus for use in producing infiltration anesthesia according to the principles of Schleich.

Case I.-Amputation of the forearm. On December 10, 1900, a blacksmith, 57 years of age, was injured by an electric car. The wheels had passed over his right hand and crushed it beyond repair. He had also a compound fracture of the left tibia and fibula, fractures of three ribs with dulness in the pleural cavity, a contusion of the abdomen with apparently a retro-peritoneal hematoma and was in a condition of shock. By stimulation in the usual manner, he was in such condition six hours after admittance that it seemed necessary to remove the tourniquet at the elbow and amputate just above the wrist, yet his chest and other injuries made him an unfavorable case for general anesthesia. I therefore gave him onethird of a grain of morphine and proceeded to anesthetize the arm by the combined infiltration and intramural method. An elastic constrictor was applied around the arm at the axilla and the band at the elbow removed. The skin was then infiltrated in a circular ring around the arm, three inches broad and just above the elbow.

This required an ounce and a half of Schleich mixture

minutes, when local anesthesia was established, I made No. 1, or one-fifth of one per cent cocaine. After five three longitudinal incisions along the courses of the ulnar, median and musculo-spiral nerves; these were painless. The ulnar and median nerves were easily found and about ten drops of a one per cent cocaine solution were injected directly into the nerve trunks. Owing to the patient's wel-marked muscular development, and probably also to the wrong position of the incision, the musculo-spiral

nerve was not promptly recognized, so I infiltrated its locality with about two drachms of the No. 1 Schleich mixture. The time required to produce anesthesia of the arm in this way was twenty minutes. Familiarity with the method would shorten it one-half. I then amputated through the forearm just above the wrist point. This procedure was painless but he did complain of the elastic constriction which was unnecessarily tight and therefore removed as soon as the vessels were secured. The patient showed some excitement. He had received whiskey and strychnine in large doses since the accident and the gross amount of cocaine used was one and three-fourths grains. A large portion of this was released by the incisions and no depression followed the excitement, which was temporary and slight. Yet I am sure the anesthesia could have been produced with less than a grain if I had been more accustomed to these methods. The patient made an exellent recovery. The four wounds healed by primary union. I think there has been a little more tingling in the stump than is usual in amputation cases, but it has not been marked. The sensation of the forearm has not been impaired by the intramural injections. The patient has been under constant observation because in March it was necessary to resect the tibia and fibula for non-union and necrosis.

Case II. Drainage of deep abscess of the neck. In February, I saw Mr. D., aged 62, who had an increasing abscess deep in the neck of about ten days' duration. The patient was weak from low sepsis, from inability to swallow, and difficulty in breathing. He was unable to open his mouth, and the arterial tension was low. My experience with these cases under general anesthesia has been unfortunate, one dying from asphyxia on the table, another from pneumonia on the second day, a third stopped breathing and was revived with difficulty, while others. have caused me much anxiety. It has, therefore, been my custom for several years to use a 4 per cent cocaine solution for the skin and obtain the pus by the HiltonRoser method. The patients have often complained bitterly of pain, yet the safety of the plan has induced me to continue it. But in this case I used the infiltration method, using half an ounce of the one-fifth per cent solution. It was a marked improvement, for the pain was much less and it was possible to provide more complete drainage, which much shortened the convalescence.

Case III.-Femoral hernia. I operated on Miss S. for radical cure of a painful femoral hernia. As she had a distinct mitral murmur with some cardiac dilatation, a slight bronchitis, and very little strength, it seemed as if a general anesthetic was not free from danger. I therefore used by infiltration an ounce of No. 1 Schleich mixture and did the usual Bassini operation. There was no pain in isolating the sac, ligating some adherent omentum, removing it and closing the sac. Some slight momentary pain was caused by passing the deep sutures through the pectineus attachment. This, I think, could have been avoided by infiltration of the muscle. I think as complete an operation was done as I could have done under general anesthesia and she avoided the vomiting, the prostration, the increase of her bronchitis as well as the possible dangers to life not inseparable from the usual methods in a person of her unsound condition. The wound healed perfectly.

Case IV. Supra-pubic cystotomy. I did this operation for Mr. M., who was suffering acutely from a complete retention of two days' durations due to a carcinoma of the prostate impassable to our efforts at catheterization. As such cases occasionally develop complete suppression after general anesthesia, I used the infiltration method. The patient was quite fleshy and required a three-inch incision, which was painless after the use of an ounce of the solution. The examination of the malignant growth with the finger in the bladder caused some temporary discomfort, but the operation as a whole gave both patient and operator much satisfaction.

Case V. Ovariotomy for multilocular adenocystoma. Mrs. V., age 67, came to me in April with an ovarian cyst that reached the free border of the ribs, filling the abdominal cavity and said to be rapidly increasing in size. The lower left quadrant was hard and irregular but the major portion of the tumor was smooth and gave a wave of fluctuation. The patient showed extreme emaciation, her pulse was feeble and her arteries calcareous. I decided to commence the operation under local anesthesia and expected to give chloroform and oxygen to complete the delivery of the sac, and ligation of the pedicle.

Taking especial care to keep the chest and extremities warm, she was placed on the table and given a fourth of a grain of morphine with a needle. Infiltration of the abdominal wall with six drachms of Schleich mixture No. I was then done for five inches in the line of the proposed incision. The peritoneal cavity was opened by a fourinch incision without any pain. The larger cysts were then tapped in the usual way and eight quarts of fluid obtained while the sac was drawn out. It was soon evident that all manipulation of the sac itself was absolutely free from pain and that, if traction on the abdominal incision was avoided we could proceed as boldly as if the patient was anesthetized. Many of the smaller cysts were punctured and the entire sac delivered. As the abdominal incision was too short to permit this to be done without traction there was some pain caused. This could have been avoided by enlarging the incision. The pedicle was about two inches broad. It was as devoid of sensation as the sac itself and even traction upon it did not cause pain. It was clamped and cut across and ligated in the usual way. The abdominal cavity was filled with salt solution and the wound closed by cross sutures. The patient's pulse did not go above 90 during the operation and she readily lifted herself from the table to permit the nurse to apply the binder. The after-course of this case has been free from all anxiety. She asked to get out of bed on the second day and was permitted to sit up on the third day to facilitate the taking of food which she refused to do lying down. This case was instructive as proving that uninflamed peritoneal tissue is devoid of sensation and that intra-abdominal operation can be done without pain if peritonitis is absent, provided that the abdominal wall is anesthetized and no traction permitted.. This patient said that the pain in her back during the first night exceeded the pain on the operating table. I am certain that the method used gave the patient far less distress than the recovery from a general anesthetic would have caused and the risk involved was, I believe, lessCase Vi.-Laparotomy for inflamed intra-ligamentous cyst. On April 29 I saw a woman 71 years of age who

had a large and painful abdominal tumor that had caused her distress for four days. Previous to that time she knew she had a tumor but it caused her no inconvenience until she slipped and fell on the day mentioned. From the size, shape, feel and location it seemed to me to be an ovarian cyst with a twisted pedicle. In a manner similar to that described in the previous case I infiltrated and incised the abdominal wall and tapped the tumor. Fiftysix ounces of a dark foul-smelling fluid was obtained. On withdrawing a portion of the sac, no pedicle was found and its intra-ligamentary character determined. Then chloroform was administered for about ten minutes, less than half an ounce being used, while the abdominal wall was retracted, the broad ligament incised and the cyst delivered entire. On account of the large cavity left behind, her advanced age and he possibility of having infected the wound from the septic contents, I thought it wise to drain the case, which was done, after stitching the edges of the redundant ligament to the abdominal wall. So little chloroform was used that the patient regained complete consciousness while the dressings were being applied. I have mentioned this case as an example of morphine-cocaine-chloroform anesthesia, which combination from the practical standpoint is of great value, combining as it does many of the advantages of both local and general anesthesia, while lessening the dangers of a prolonged period of general anesthesia.

It is unnecessary for me to report additional cases, as many such can be found in recent literature from the enthusiastic workers in this line. Concerning its practical application, a few words may not be amiss, as it is only by a painstaking attention to details that successful local anesthesia is secured. As the result of many discoveries in physiology and many successes and failures in practical surgery, it is now possible to formulate certain principles that underlie its use. These briefly stated are:

1. To produce skin anesthesia, intra-dermal and not hypo-dermal infiltration is necessary.

Intra-neural or para-neural infiltration in the trunk of a nerve is equivalent to complete section of the nerve as far as sensory impulses are concerned.

3. Elastic constriction prolongs the anesthesia.

4. Proper infiltration permits the use of very dilute and non-poisonous solutions, for pressure on the nerve ends will alone produce numbness.

5. All tissues and organs of the body except the skin and nerves, when uninflamed, have little or no sensation. 6. Morphine should be used systematically as a preliminary to all local anesthesia to lessen the psychic pain. 7. Local anesthesia can be supplemented when necessary by chloroform or ether for a brief period in certain steps of an operation with less danger than if the general anesthesia was given continuously. There are many other interesting points, but these seven facts appeal to me as axioms.

One reason why infiltration anesthesia has not come into more general use is the troublesome technique. Keeping syringes in order, frequent refilling them, and many puncture holes are annoying. Matas some time ago published a method which provided a bottle to contain the solution and to be filled with compressed air before using. This I attempted. It gives a greater pressure at the beginning of the infiltration than at the end, the reverse,

however, being indicated. It requires also a perfect pump and valves that do not leak. I think the principle of air pressure is correct. It is possible, however, to apply it in a more practical way. The cases reported, as well as many others, I have done with this simple apparatus, which can easily be extemporized from the supplies in any surgeon's office. The principle is that devised by Matas. It differs only in providing a constant supply of air during the infiltration process, which can be increased if the resistance in the tissues demands it, or to compensate for leakage. The two-way cork of the Potain aspirator is inserted in an ordinary bottle, with a rubber tube extending to the bottom. The cork can be secured by a bandage but I have used a clamp made for the purpose, which is convenient but not necessary.

It

To one arm of the cork it attached a tube and the needle, which can be laid in boiling water for sterilization. To the other end is attached the double bulb of a Pacquelin cautery. There is ample power in this bulb for infiltrating the ordinary tissues, but not a heavy scar. Care should be taken to avoid the injection of air. The solutions used have been made from water that has just been boiled and the commercial tablets prepared according to Schleich's formula. I have not yet seen an infection. There is no advantage in using a small caliber needle. In presenting this brief report of the use of the newer methods of local anesthesia I do not wish to be understood as an advocate of its use as a routine measure. will be noticed that in the cases mentioned there was a distinct and definite reason why general anesthesia was undesirable and it is for this class of cases that I would advocate its use. It must be compared with the CorningBier method of spinal injections. In the face, neck, and arm the spinal method is not applicable and I think rather unreliable in the chest wall. In abdominal work either can be used with success when the peritoneum is not inflamed, and neither with success when peritonitis is present. The difference between the two is that when the abdominal wall is infiltrated traction on the incision must be avoided. This is a drawback. Yet the occasional nausea, depression, excitement and temperature that have followed the spinal method are avoided. Even if we grant, as claimed by its advocates, that no death has yet been traced to its use, the possibility of a spinal infection still remains, and the abdominal method of infiltration appeals to my judgment as the safer course. For hernia, as described by Cushing, it is equally satisfactory. For plastic surgery about the genitals I would think the spinal method the most practical, as also for deep operations in the thigh. For all operations below the knee-joint, the infiltration and intra-neural methods combined, as first demonstrated by Crile, are completely successful. I suggest that we give a general anesthetic from force of habit when in certain cases the local method is safer. Yet I do not believe that these methods will soon become very popular. Operations done in this way require more time, demand a more definite knowledge of regional anatomy, a gentler handling of tissues, and, because unusual, are more exhausting to the operator. Quiet, orderly methods, the confidence of the patient and absence of all excitement are important factors. It is more suited to the intelligent than to the ignorant and supicious.

Concerning the safety of cocaine solutions I may say

that I have used the drug constantly for ten years and never yet have I seen alarming symptoms in a case of my own. I have usually preceded it by morphine, and have preferred to operate when the patient has recently taken food or stimulants. I have considered one grain to be well within the limits of safety and have often used two, three, or even four grains when it was soon to be released by incisions and a constrictor could be applied. In the male urethra, on account of some observations of the work of others, I have been glad to use Beta eucaine, but for general use it seems to me no better. The more one uses local anesthesia the weaker will become his solutions while the quantity will be increased.-Brooklyn Med. Jour.

FAULTS IN NEEDLES AND NEEDLE HOLDERS WITH IMPROVEMENT.

BY J. E. LANGSTAFF, M. D.

Of all instruments used by members of the medical profession none is in more universal demand and none gives more satisfaction that the needle holder. During the last thirty years there have been designed more than 200 varieties, and at the present time many of our busiest surgeons have thrown aside these instruments and prefer to use the fingers with a needle four times its proper size. This condition of affairs shows clearly something radically wrong in the principle of the mechanism of the instrument. So little is required of the needle holder that one is led into experiments which cost a great deal of time and money, and end in a very slight, if any, improvement on the last design. The purpose of my paper is to analyze this subject and if possible destroy the principle on which the present needle holder is built, hoping to start out on a new line and endeavor to attain the object of simply holding a needle. Some have said that the word needle holder is a misnomer, as there is no instrument that will hold every size and shape of needle. To hold a needle two conditions are required. First, to obtain a sufficient amount of contact of friction surface between the needle and holder, and, second, sufficient amount of pressure on the needle. The more contact surface the less pressure required and vice versa. A straight needle between two broad flat surfaces requires very little pressure, as the surface contact is great. Before the days of abdominal surgery these needles were used and the artery tortion forceps was generally used as a holder. Now that we are forced to use the full-curved needle we find it necessary to design an instrument for the sole purpose of holding the needle. But we contented ourselves with simply improving on the old forceps until we have exhausted our ingenuity in an almost useless device.

I have with me 120 varieties, the product of one manufacturer (Tiemann & Co.), and the great difference in shapes and sizes shows that every effort has been put forth to attain the desired object. Sizes vary from 4 to 10 inches in length, and from 7% of an ounce to 10 ounces in weight.

For convenience of analysis the needle holder may be divided into three parts; the jaws or clamp which holds the needle, the lever which applies the pressure, and the catch or lock which retains the pressure.

In placing a curved needle in a flat-jawed holder we notice three points of contact. The convex part of the needle comes into contact with the center of the lower jaw, the concave part of the needle with the outer edges of the upper jaw. When pressure was brought to bear either the needle broke or turned on to its flat surface. To prevent this turning the surface of the jaw was roughened, serrated, or grooved, and to prevent breaking the jaw was narrowed. This is well illustrated in Kelly's holder which, having great lever power, is one of the few that holds the round needle securely, but it has not accommodation for the small Hagedorn, or flat-needle, and the jaws project 1⁄2 inch beyond the notch for the H needles.

Sixteen of this list of 120 have roughened surfaces and only 2 have serrations. Twenty-five have notches which are intended to hold both the flat and round needle, the number of notches varying from 1 to 8, as is seen in the Abbe holder. A serious objection to this is the projection of the jaws 3/4 of an inch beyond the largest needle. Abbe has increased the width of jaw and lessened the amount of pressure. His instrument does not equal Kelly's in holding the round needle, but exceeds it in being fitted for all flat needles. Geo. R. Fowler has designed a holder in which jaws are V-shaped, the upper one fitting down into the lower. The round needles drop into the apex and the flat are placed on the side of the V-shaped notch. Tiemann & Co. place a small plate between the jaws which slides forward and clasps the flat needle while the remaining part of the jaw, which is roughened, is expected to hold the round one. In this latter respect it fails. Eight in the list have adopted this sliding plate combination device.

The latest improvement is to hollow out or make concave the lower jaw, making the concavity follow the curve of the needle. This satisfies the curved needle but the straight one must bend or break, and when one takes hold of an Emmet cervix needle in which 1-5 the length of the needle is eye there is no possibility of using the holder. The late Jarvis Wight had remedied this defect by making convex the upper jaw; his holder is very popular and considered one of the best in the market. One minor objection is the distance of the largest needle being one-half inch from the point of the jaw.

Realizing the importance of having as much contact. surface as possible, I have used four plates of glass-hardened steel instead of the solid jaw; each plate has a hooked notch not larger than the size of the largest needle. In closing the holder the blades slide alternately in opposite directions far enough to close the space made by the notches. In this way I provide for every size of needle with one notch, which is situated within one-eighth of an inch of the end of the jaw. The combined thickness of these blades does not exceed that of Kelly's holder. The amount of spring in the blades produces a flexibility in the jaw that provides contact even in the fullest curved needle throughout its length in the jaw. The Emmet cervix needle can be held safely either at the eye or point.

In regard to the lever part of the holder; during the thirty years of experiments nothing has been done to improve the simple lever power which requires so firm a pressure from the hand that a lock has to be provided to retain this pressure. The distance between the joint or

fulcrum and the end of the jaw is so great that the lever or handle requires to be long and heavy.

Kelly & Hanks have the most rigid levers, and the pressure required to lock and unlock when using a large needle is one objection. I have changed this form of lever by removing the fulcrum and short end of the lever to the other end of the holder and combining the two parts into one, making what might be described as a lever bolt; in this way the short end of the lever is reduced from three-fourths of an inch, as in Kelly's, to three-sixteenths of an inch; the long end of the lever from seven inches to two and one-half inches. The amount of pressure is reduced from that of the hand to the thumb, and is only the amount that would be necessary to press the needle through the tissues. I have thereby done away with the catch, and not only simplified the mechanism but the convenience with which the holder can be manipulated.

Having started out with the idea that the more pressure the better, I made the lever bolt with a one-eighth inch lever, with the result that not only needles were cut but the jaws snapped. I would like to have retained this amount of pressure because the instrument could then be held more lightly in the hand and be used with more dexterity. By making another notch in the holder and putting a cutting edge on the two inside blades, I make a suture cutter, in this way dispensing with the scissors.

The various locks, catches, and springs on holders show a great deal of ingenuity. Out of 100 instruments 18 are without spring or lock, 19 without spring and with lock, 12 have link catches that are released by the thumb, 12 with Tiemann's thumb-tilting catch, 10 with thumb sliding catch, 16 with spring ratchet catch at end of lever or handle, 5 have a special mechanism for releasing the catch. All these attachments to the holder are made necessary by the lack of power or pressure on the needle. The needle itself is to blame for a great deal of this mechanism in the holder. There are at present about 100 varieties of needles.

The object of the needle is to simply carry the suture through the tissues. To accomplish this the point and eye are essential. The long, round point of the original needle, except for intestinal suturing, has been abandoned because of the amount of pressure required in passing it through the integument. The flat or Hagedorn needle has become popular because it overcomes this fault. It has a knife-cutting edge of one-eighth of an inch in length, which ensures its passing through the integument with the freedom of a knife, and if it follows the curve of its shaft no damage will be done to the dilicate adipose tissue beneath, but if it is pushed in a straight line to the opposite side of the wound it will probably cut a channel. one-eighth inch wide and seriously interfere with that necessary coaptation of the lips of the wound. After the point has emerged on the opposite side the necessity of placing the finger behind the point endangers the surgeon to infection. A number have discarded the needle altogether on this account. The lance-pointed needle has about the same amount of cutting edge on either side, and, although able to do nearly as much destruction to the adipose tissue, cannot injure the operator. The trocarpointed needle which answers so well in piercing the cervix tissue causes a good deal of bleeding on account of its three sharp sides.

We all know the ease with which the hypodermic needle does its work and the freedom from bleeding or injury to the tissues. The cutting distance on this needle is equal to the diameter of the needle, and it cuts on the sides. I have used a curved needle with the bevel (as in the hypodermic) on the concavity, and am pleased to say it does very well in every respect. The shaft of the needle has been changed to suit the needle holder. Dr. Fowler has given the Hagedorn needle a twist where it comes between the jaws of the holder, and Dr. Wm. Butler has squared the round needle at this point for the same purpose. I find one fault with the shaft of all needles: that it does not protect the loop of suture from catching or dragging in the tissues as it passes through, and I have enlarged the shaft at this point so that the tissue is stretched over the loop.

The majority of surgeons have adhered to the old form of eye, which is egg-shaped and in some needles long enough to accommodate four sutures. This is particularly the case in the Emmet cervix needle, where in one case the eye is one-fifth the length of the needle. This is certainly a most serious objection on account of the danger of breaking. At the same time that the long eye is allowable, no objection has been made to the round eye of the flat or Hagedorn, which is made only large enough to admit the suture.

The condition of the metal of the needle is a consideration. One Hagedorn needle will snap like glass while another will bend like tin. This is cntirely the fault of the maker. To make a good needle requires a little extra time and care. All needles in course of construction are first glass hardened; then the temper is partly removed by passing it through an alcohol or colorless flame. Too much heat softens and too little leaves it too hard or brittle. A good needle is spring-tempered throughout the shaft and left very hard at the point or cutting edge.

A soft-pointed needle dulls very soon and is then practically useless. It is possible to draw the temper from the point in the process of sterilizing by putting the needles in the vessel without the precaution of first putting in a towel. The heat coming directly from the fire to the needle will often give enough heat to soften the metal. Needles can be made cheap enough to be useless, and it is great extravagance on the part of the surgeon to buy such.-Brooklyn Med. Jour.

THE WEARING OF GLOVES AT OPERATIONS AND THE INFECTION OF WOUNDS FROM

THE ATMOSPHERE.

Alexis Thomson, M. D., F. R. C. S. Ed.: While all surgeons are agreed as to the necessity of reducing to a minimum the number of organisms gaining access to any wound, a considerable proportion are prejudiced against such refinements of technique as the wearing of gloves during operations. To these we cordially recommend the perusal of an interesting communication on this subject by Heile of Breslau. Having arrived at the conclusion that it is impossible by any method to get rid of all the organisms from the skin of the hands, Mikulicz adopted the practice of wearing cotton gloves at aseptic operations, not with the object of doing away with the necessity of disinfecting the hands as thor