That the danger of the transmission of infections in hospital wards is really serious-much more serious than is ordinarily thought, I am sure-is shown by some statistical and other personal observations that I have reported. A great deal of evidence from many sources has demonstrated the general importance of contact-infection with typhoid fever; and the figures that I have given show that this applies very forcibly to hospitals, the nurses in three hospitals being in 6.3 to 8.9 times greater danger of acquiring the disease than are the general community in the cities in which these hospitals are situated. Nurses on duty in medical wards appear to be in two or three times greater danger still, namely, in 15 to 25 or more times the danger of the general community. In the two hospitals in which approximate figures could be obtained, the patients in the medical wards were found to be, respectively, in 2.5 and 5.7 times greater danger than the general community. In other words, they were in much greater danger of acquiring the disease than if they had stayed out of the hospitals.

Considering that people in well-managed hospitals. are pretty thoroughly protected from water-infection, these figures really mean even more striking conditions. than they apparently do; and they mean also that practically all these infections are contact-infections.

I have presented evidence, likewise, that gastrointestinal infections are frequently and readily transmitted about adult hospital wards, as is only too well known to be the case in infant wards; and I believe that this is of much influence at times, and especially in typhoid fever, in which disease such secondary infections probably have much to do with producing the abdominal symptoms, and, hence, with the mortality. from the disease.

The experience of nearly every clinician suffices to demonstrate that pneumonia is sometimes transmitted. in hospital wards: I have mentioned the experience of several Philadelphia hospitals within a very few years as showing that this occurs with sufficient frequency to be very important, and the results are certainly very grave indeed when it occurs. With practically every

other infection in which we know anything accurate regarding transmission, there is evidence that infection occurs in hospital wards with sufficient frequency to make it a matter of really serious consequence to combat it.

The difference in the way in which medical and surgical clinicians regard such matters is, to my mind, a very striking one, and the contrast is usually to the disadvantage of the medical clinician. The surgeon continually attempts to improve his methods, and determines for himself upon the measures to be used in his wards, both as to their details and their principles. The medical man, on the contrary, very often has little interest in the matter, and frequently, for example, goes into service in new wards without even thinking of. asking what methods are used there to prevent the spread of infections, general routine methods that are used practically everywhere being considered satisfactory.

Not less important than the degree of interest shown in the matter is the fact that the surgeon's system is directed against all infections and is, most of all, intended to prevent the entrance of infectious material through the actual portals of infection, while the methods used in medical wards consist chiefly in the destruction of infectious material that comes from infected patients, comparatively little consideration being given to guarding directly the portals of infection in the uninfected, and the methods are applied to only a part of the infections that are admitted, not to all. In these points, it appears to me, lie the most evident opportunities for improvement in existing methods.

In justice to the medical man, it must be said that the surgeon has reached his superior methods largely through experience in work that readily demonstrates the existence of errors by the rapid occurrence of bad results; while the circumstances in which a medical clinician works make it very difficult to discover the existence of bad methods. Nevertheless, the surgeon's methods are the better, and can in large part be used to advantage in medical wards. The most rigid care regarding the disinfection of discharges and other clearly

infected objects will not suffice to prevent infection in medical wards, if the avenues of entrance in individual patients are left unguarded, any more than would similar kinds of care suffice in surgical wards, if it were not that, in addition to this wounds are covered with aseptic dressings to bar out stray bacteria, and hands and instruments scrupulously disinfected to prevent the direct implantation of bacteria.

The measures, therefore, that are of the first importance in preventing conveyance of infection in medical wards are those that aim to make the things that must enter the main avenues of infection as nearly free of infectious material as is possible. The supremely important avenue of entrance for most common infections is the mouth; to a less extent, the nose, in air-borne infections; while any of the body-cavities may, and occasionally do, serve as the means of entrance, if infectious material is introduced into it. Wounds are, in medical cases, an unusual portal of entrance; but for local infections, which are sometimes serious and occasionally lead to general infections, abrasions of the skin. are important, especially in cases such as typhoid fever, in which prolonged confinement to bed leads to maceration of the skin.

These, then, are the chief things to be protected—a much more complex and difficult problem than the surgeon's care of wounds. The method of protecting them must be the same in principle as the surgeon's, namely, the keeping out of all objects that are infected. This, again, is a much more complex task than the surgeon's, for, in the first place, the medical avenues of infection cannot be covered with bacteria-proof dressings, and, in the second, the things that necessarily come into contact with the portals of entrance are more numerous. The latter are chiefly air, water, food, human hands, and instruments of various sorts.

Water-infection nearly always comes from outside. It is therefore very rarely an actual ward-infection, is readily controlled by the proper and usual treatment of the water, and consequently is not suitable for discussion in this paper.

Infection through the air has come to seem of much

less importance in recent years than formerly, and is probably of frequent consequence only when persons are in close proximity to the sick. The chief methods of controlling it are fresh air and isolation or segregation. The latter measures will be discussed later.

As to the three remaining carriers of infection, there can be little doubt that food and human hands are most important of all in hospital wards; and yet, while great care is taken in disinfecting instruments that are to be used in the mouth or other body cavities, frequently very little attention is paid to the hands that are going to introduce these instruments or that are, perhaps, to be themselves directly used in treating or examining the same cavities, and the most dangerous sorts of food are very superficially cared for in a large proportion of hospitals. It is in these latter points, in particular, and in not using available opportunities for isolation or segregation, that customary methods seem to me most in need of reform.

The most important things to be said about food refer, of course, chiefly to milk. The care of the milk before it reaches the hospital and its condition when received are matters that are disregarded with woeful frequency, but I need not go into them here. The whole question up to this point is the same as the general public question of securing milk known to be produced and delivered under hygienic conditions. The question is of especial importance to hospitals, however. The very grave results that the use of unhygienic milk may produce in hospitals is shown by a report that I made some years ago on this specific subject; and it is extremely desirable that this should be recognized and that more general and earnest efforts be made to improve hospital supplies.

After milk is received in hospitals, its care demands certain special regulations. It should at once come into the hands of an intelligent and well-trained person, who is made responsible for its immediate and proper refrigeration, and for its quick delivery to the wards at suitable times. In the wards the milk and all other food that is not to be cooked just before it is eaten should be under the care of one particular nurse, whose duties,

aside from preparing and serving these foods, should not include anything such as the care of the person, the bedclothes, or the excretions of patients with any infectious disease that would lead to danger of her infecting her hands and, thence, the food. All other nurses should be entirely excluded from handling the milk and other such food.

This rule is extremely important; and yet the customary regulations frequently ignore it in a most dangerous manner-in a manner, indeed, that health boards would not permit in dairies. Furthermore, if milk produced and delivered in a thoroughly hygienic way cannot be secured, all that administered to patients that are ill of serious acute diseases should be pasteurized. This should preferably be done with all patients who have a tendency to digestive disturbances. It is especially important with those who have typhoid fever.

Next to the care of the food, the care of the hands of the doctors, nurses, and other ward-attendants, and of the things that may soil their hands, needs attention. It is, indeed, more important than the care of the food, as the danger of infection in this way is more direct and more imminent. It should be quite as much an act of conscience with both doctors and nurses to sterilize their hands or to put on rubber gloves before examining the mouth of a patient with their fingers, or handling instruments that are to go into the mouth, as it is to take similar precautions before examining an infected wound. More especially is this the case in carrying out hospital duties, where infectious diseases are always present. The preparation of swabs, etc., for cleansing or treating mouths or throats should be done by a nurse, such as the diet nurse, whose duties leave her free of infection, or by a nurse whose hands have just been sterilized, or who, preferably, wears rubber gloves in doing this work. In order, also, to prevent her from infecting her hands unnecessarily, and thus in order to protect both herself and the patients, the nurse had best wear special rubber gloves in caring for the soiled bedclothes, dejections, etc., of patients with serious infectious diseases, such as typhoid fever, pneumonia and dysentery, and in washing such patients,