years, was an inflammation of lung tissue that never fully healed, leaving instead, adhesions, thickened, softened mucosa, or catarrhal discharge, that later made good soil for any germ that desired a good resting place.

INFANTILE PNEUMONIA.

BY G. A. MELLIES, M. D., St. Louis.

The phase of Infantile Pneumonia that I wish to call attention to is the treatment and general care of these cases. In consideration of the morbid anatomy, we have two classes of pneumonia cases, i. e., those where there is a gradual extention of inflammation and infiltration along the smaller bronchioles, resulting in an occlusion of the alveoli with exfoliated epithelial cells and mucus secretion; designated catarrhal pneumonia, and those cases where there is a rapid engorgement of blood into one or more lobes of the lung, resulting in an inflammation of the parenchymatous tissue, compression of and transudation of leucocytes, erythrocytes and serum into the air cells, technically termed Lobar Pneumonia.

These two pathological conditions must necessarily be met by different measures and remedies. The general care and comfort of the patient should first occupy the physician's attention, and instructions must be given accordingly. If the child has been frequently allowed to become exposed to drafts of cold air, or perhaps improperly clothed, this should be corrected. The patient should be placed in a well ventilated room and an equable temperature maintained in the room. The child must be warmly clad although there is often danger of keeping it too warm, and in that way cause the patient to be constantly in a state of perspiration and to become chilled when uncovered, by the lowered thermo-taxic power. This is a frequent cause and often a factor in the unsatisfactory progress of a case of catarrhal pneumonia. Frequent warm baths are often a source of great relief and comfort to the patient suffering with this form of pneumonia; where these can not be administered without risk of chilling, a warm or hot pack, entire or around the chest, frequently changed and applied with the greatest dexterity, are valuable adjuvants in the treatment of these cases. Poultices consisting of the best heat retaining qualities and covered with oiled silk, are some of the means that should not be forgotten. The cases of pneumonia that are characterized by suddenness of onset, rapid infiltration of lung tissue with hyperpyrexia must be met by prompter measures than those of the cataarhal form. These cases can usually be quickly relieved by a cool or tepid immersion bath. The temperature of the water should vary according to the constitution of the child. Where the patients show a feeble constitution or where the heart manifests signs of weakness, a bath of about 95 degrees Far. and a 10 to 15 minutes' immersion accompanied by constant friction of the surface of the body, will usually relieve the hyperpyrexia promptly. In cases where the resisting power is better, in children of robust character, a bath of 80 to 85 degrees Far. will be found more beneficial and prompter results and better reaction follows. During the

bath the child should be constantly rubbed to stimulate the circulation and prevent rigors. Some stimulants should be given in the form of whisky or brandy, or if the heart is very rapid and weak in proportion to the rate of respiration, a hypodermic injection of 1/60 gr. of Strych sul. and 1/100 gr. of Digitaline will overcome the shock that results when the patient is first placed in the bath. These baths should be repeated every three or four hours or as often as the temperature increases two or three degrees, or there is increased restlessness and anxiety. The cool or tepid baths are only applicable in the first 24 or 36 hours of the case; after that time or in the stage of hepitization warm baths are more beneficial. The baths should only be administered under the direct supervision of the physician or by an experienced nurse. The impracticability of these baths is in homes that are not supplied with the proper facilities for heating water and maintaining it at the proper temperature, but in hospitals and in homes with the necessary facilities, there is nothing that will equal the bath, as adjuvants in the rapid relief of cases of pneumonic fever.

In the advocacy of the baths or cold packs in the treatment of pneumonia I do not wish to convey the impression that I discard the use the indicated remedy, but to show the value that may be derived from these adjuvants in the care of these cases, which if not relieved in the first 24 to 36 hours, will usually result in inflammatory products in the affected lung tissue, after which the good results obtained by the baths are not so speedily obtained in the second or stage of solidification.

THE RELATION OF PROFESSIONAL SLOVENLINESS TO PUERPERAL COMPLICATIONS.* BY L. C. MCELWEE, M. D., ST. LOUIS.

It is by no means pleasant to be admonished concerning personal appearance or habits, even though they be pronounced, or annoying to othere and I only obtain my own consent in the present instance to do so because of the enormous gravity of the results involved and the impersonal character of my admonition. I want to awake all who hear or read these words and who are guilty of the offenses herein charged from their slumbers of carelessness to a realization of the gravity of actual conditions, so that knowing them, they may be avoided.

From our earliest professional infancy, we have been taught to dread puerperal complications, particularly the so-called fever sometimes incident to that period. Whoever has seen the wan, haggard, miserable, regretfully distressed, jaundiced, pain-distorted, sunken, pinched, and awful face of a patient suffering with puerperal fever must have burned into his or her memory a picture of misery of cameo-distinctness-one that seen today haunts the observer for a long time after the patient, herself, has ceased from troubling and is where the weary are at rest. Contemplating this picture, one cannot refrain from shuddering at the thought that the family doctor is probably the most frequent cause of this calamity. Next to him will be found the professional but mostly ignorant, or careless mid*Read before the Southern Homeopathic Medical Association at Louisville, Ky., Oct. 30th, 1903.

wife, and after her the causes are accidental mostly and are not often operative. Since I have practically indicted the whole medical profession for a most serious offense, it devolves upon me to prove my assertions. To begin with, I wish to assert with all possible emphasis that the most dangerous element to puerperal patients is the index finger of the aforesaid family physician, who is generally not a surgeon. It must be admitted that the very occupation of the general practitioner predisposes to the conversion of the doctor from the benign individual he ought to be to the dangerous creature he often really is. This is accomplished in the process of his ordinary examinations, by palpation, of every condition presented to him for treatment, needing this means of physical diagnosis. His hands, and particularly his right index finger become chronically and habitually infected with virulent microbes which, in turn, infect every fresh uninfected culture medium they come in contact with. It is only necessary to call attention to the habit, usually common to most doctors, of running their forefinger over the surface of every point of eruption of almost any skin disease presented. They palpate about every boil and carbuncle or chancre coming under their observation and massage more or less every erysipelatous patch they come across; they explore each rectum or vagina, complaining of any kind of mucous discharge, and if, perchance, they have an individual nasal catarrh, or otorrhea, use the index finger to pick or scratch the affected organ with,-infection therefore is the habit of this finger and it serves the same surgical function as a fire brand in a powder mill. The calamities incident to its indiscriminate use being as great in the one case as the other. The practice of cleanliness after any of the above manipulations is mostly perfunctory and carelessly performed by persons other than surgeons. The hands of the doctor may be clean enough so that they look clean, and are sufficiently so to make bread with. or even to put into his mouth, but they are still a firebrand when in contact with a culture-medium, or clean cut fresh or unprotected wound surfaces. To cleanse them properly after one of the infections, mentioned above, they should be washed with strong soap in a stream of running water (under a tap if possible) and the nails trimmed closely and with the bristles of a nail brush full of soap, brush out until the line of mourning is replaced by the natural pink of the skin or the white clean skin beneath. This should be followed by taking a table-spoonful of commercial chloride of lime in the palm of the left hand and a lump of washing soda the size of a hen egg in the right and mixing these together by aid of a little water into a thick paste which is smeared and rubbed over the hands, front and back for ten minutes or so, when this is washed off with running, sterile water, this to be followed by a copious effusion of commercial grain alcohol, when the hands will be safe for any ordinary surgical or obstetrical manipulation. In order that the alcohol remaining on the hands may not burn the patient, the excess may be washed off by sterilized water in a clean wash bowl or poured from the spout of a teakettle after being allowed to cool sufficiently so as not to burn the hands. After being once cleaned,

they may be kept clean by being encased in a fresh laundered towel, napkin or handkerchief, while not engaged in making diagnostic explorations. Should the medical attendant not have an operating gown to wear, while attending a case of labor a clean freshly laundered apron belonging to the patient or some of the other women of the house, is nearly always at hand and should be worn to protect the patient from the filth of the trousers of the doctor as he is sure, from force of habit, to allow his hands to rest on his lap, be they covered or uncovered during the interim between his active ministrations. Should they be encased in the towel, it will become infected or soiled from contact with the front of the trousers and the soiled portion more than likely to be rolled next the skin on being applied the second time. Should circumstances permit, the pudenda of the patient should be shaved and afterwards washed with soap and water, this usually being all the preparation of them that is really necessary under the circumstances. I should say that wherever it is necessary to use forceps this precaution can and should always be observed. The forceps, of course, are sterilized by being boiled in weak sodium bicarbonates, and kept so by being placed, fenestrated end down, in a wash pitcher half full of a 7-10 per cent hot lysole solution and set beside the operator on the floor. Should his hands become covered with partly dried secretions and blood, during the manipulations, they should be frequently rinsed in a bowl of hot lysol or carbol solution, held by an assistant. The pudenda should be frequently and copiously douched by the same kind of a solution from a douche bag so arranged as to be under the absolute control of the operator. After delivery, the placenta should be pressed by the Crede method and examined carefully to ascertain if it has been all removed and if satisfied of its completeness no further vaginal exploration is advisable. But should it be deemed best to examine for shreds of membrane or lacerations of the cervix or perineum, (invisible from the outside) careful rinsing of the examining hand in fresh, hot lysol solution must be practiced, when the exploration may be safely performed.

It should be borne in mind that frequent vaginal explorations are not, per se, harmful if the exploring finger is clear of infection, which means filth, but because of the enormous difficulty of keeping that member sterile, after once putting it in that condition, renders the advisability of seldom examinations imperative. These hints will protect the patient from both doctor and mid-wife and if observed consistently will result in the experience that no case of puerperal infection will ever be found in the practice of the practitioner observing them. I am glad to say that in twenty-one years practice I have never had a case of puerperal infection develop in a case of parturition entirely my own. Someone is now asking what has all this fol-de-rol to do with the personal slovenliness of the accoucheur? I wish to reply, everything. The doctor may dress in all the latest approved fashion and appear a perfect Beau Brummel, yet from a bacteriological standpoint be reeking with filth. Illustrating this point, I wish to relate a story told me once by a berth-mate on board ship. Speaking of his family,

his wife and only daughter, whom he was going then to meet in Rome, he said that he had always deeply regretted that Providence had only blessed him with one child but, he added, it may perhaps be as well, for we had such a time when this one came that my wife had liked to have died and only by the exercise of the most consummate skill was the doctor able to save her. Fever, said I? Yes, said he, for six weeks, life hung by a thread and that threatened to snap at any moment and while she has been able to be about most of the eighteen years since, she has been a semi-invalid, full of pains and aches, and miserable much of the time. "The familiar picture" said I to myself! I said to him, "How did the doctor reach your house"? why, he drove down in his buggy," said he, and as labor was progressing rapidly, he hurried into the house and the baby was there in a few moments. "I said I'll bet my letter of credit against a cigar that he didn't stop to wash his hands before touching the patient." Come to think of it, no I don't think yes, I know he didn't for I ushered him in, and I know it was not by the water route.'" Think of it! Ladies and gentlemen, handling the filthy lines of a buggy harness and then without so much as a threat of washing them, carrying the fingers and accompanying filth into the vagina or uterus to wreak its havoc upon a defenseless and innocent patient! In excuse of the doctor, it may be said that little or nothing was then known about bacteriology and only a little bit about antisepsis but plain ordinary cleanliness has always been held to be next to godliness, while we of the present day believe it to have the precedence, in a sanitary sense, anyway. The doctor can wear about whatever clothing he pleases, so long as he complies with the civil law, his suit may not even fit in high places but if he observes the technique outlined above will never be shown guilty of professional sloth; he will have no case of puerperal sepsis to contend with but he may have and we believe almost always will have a slight hyperpyrexia at sometime during the lying-in period. The chief causes of this, as far as I have been able to determine, are:-constipated bowels, malaria and superæmia. The constipation is easiest relieved by ten or twelve ounces of solution of citrate of magnesia, given at five o'clock on the morning of the second day, i. e., when the baby is one day old. This unloads the bowels and prevents an auto-intoxication and stercoremia from the intestines. On account of the reduced vital force from the succusions and traumatisms incident to parturition, malaria, which has probably been dormant in the system sometime, frequently develops on the second or third day. This is not the fault in any way of the attendant because though he may, he usually does not forsee it and therefore cannot be expected to avoid it all the time. This condition will readily yield to the indicated remedy all right, but it is so much easier to give twenty or thirty grains of quinine and thus exterminate it, that I'll wager that when this condition is met, the patient gets the quinine and homeopathy the credit oftener than she gets the indicated remedy and the doctor the satisfaction of having made a scientific prescription. Some patients and families, after a while, are willing to help to find some deceptive excuse for a