under some circumstances the puerperal woman is a surgical case, she is not as a rule any thing of the sort, she is in a physiological condition. Parturient tears may make the case surgical since they are often the starting points of the sepsis. While there are pus-making microbes found in the vagina, they are not those which rapidly proliferate. If you bring in one of those foreign pus-making organisms it will proliferate with great rapidity, and you will have all the symptoms of puerperal sepsis. Nature's way of protecting the woman is by the formation of granulations; there is a glazing over of the wounds, and if they are left alone whatever septic material there may be in the vagina passes over them and does no damage. If you use a douche or break up the surface in any way infection is invited.

A good deal has been said lately about auto-infection, and I read an article the other day about the bacillus coli commune as a cause of sepsis. I think that too much honor has been thrust upon our little intestinal scavenger. Auto-infection may be possible, but its occurrence must be rare indeed.

In catheterization of the puerperal woman I believe there is only one rule that should be followed: Never undertake to introduce a catheter by the sense of touch. See what you are doing.

Dr. Enright: I am glad Dr. Cottell mentioned the subject of catheterization. For the last four or five years I have never used a catheter of my own upon a patient, but always have the attendants get a catheter of their own. I fully agree with Dr. Bailey that as a rule vaginal douches should not be used.

Dr. Louis Frank: I wish to agree with what most of the gentlemen have said, that the vaginal douche as a general practice, should not be used out of hospitals. I think Dr. Cottell struck the key-note when he said that normal labor is not a surgical condition, but that it may become surgical when there is a laceration or obstetric operation of any kind. In such cases the vaginal douche may be used with benefit, and I refer especially to cases in which operations have been done or forceps. applied. I think the secretion of the vagina and the amniotic fluid rid the vagina of any bacteria which may have been present, and there can not be any infection from these secretions, but infection must be resident in the vagina or introduced by the accoucheur. If there are microorganisms there which will produce infection, they must be gotten rid of before the child is born. I do not think this can be done by the douche; it can be done only by thoroughly washing out the vagina as

is done before vaginal operations. The only thing that the douche can do after labor is to infect the female. In one of the clinics in Europe, which I visited often, it was the custom to douche the woman after each examination, and I saw no puerperal fever there.

During my service as visiting physician at the City Hospital upon some cases I used a douche of plain water, upon others bichloride, and others no douches at all. In those cases where the douche was used there was invariably an elevation of temperature, in the others there was none at all.

As to the intra-uterine douche, I do not believe it should be used at all alone. Where infection has occurred the treatment is curettement, and then the douche. Without the curetting the douche would be of very little value.

As to the use of the Davidson syringe, I think it is the most abominable of all. It is a syring with a valve and is allowed to hang up. As we know water is a suitable soil for the growth of bacteria, and probably at the second injection we will introduce septic matter into the vagina. I do not believe we can do much with the douche itself, and it has been my custom to allow the water to balloon the vagina; merely letting the water run in and out does very little good. In conclusion I will say that I heartily agree with what Dr. Bailey has said, that the douche as a routine practice in private work is not to be advised.

Dr. Bailey (closing the discussion): It seems that the vagina can take care of all microbes in the vagina, and with the douche there is danger of carrying septic material up into the uterus where the vaginal secretion can not take care of it. I think the method of ballooning the vagina, spoken of by Dr. Frank, is particularly dangerous after delivery. One of the advantages of the antiseptic douche before labor is the prevention of eye troubles in children.

JOHN L. HOWARD, M. D., Secretary.

Abstracts and Selections.

TREATMENT OF ARTIFICIAL ANUS. - Chaput (Archiv. Gen. de Méd.) records thirty-five cases of artificial anus and stercoral fistula which he has treated. After an exhaustive survey of these cases he has formulated the following conclusions concerning the treatment of this class of cases: He says that artificial anus can be treated by four different methods: (1) By the application of enterotomy, followed by obliteration of the fistula. (a) Enterotomy is indicated when the cases are uncomplicated and the aperture is easily accessible, together with a thin and long partition. When the spur is long and thin it is advisable to adopt Richelot's method, that is, section between two pairs of forceps and immediate suture. If, however, the spur is long and somewhat thickened, it is better to make the suture between two long pairs of forceps, which are allowed to remain in position. Enterotomy is contra-indicated when the spur is very thick or inaccessible, or when the aperture is closed by the mechanism of angular wounds. (6) After destruction of the spur, the stercoral fistula is closed. Small fistulæ are closed by lateral enterorrhaphy, during which operation the margins of the fistula are freely separated from their surroundings, and then united with two tiers of sutures, the peritoneum being opened or not according to the requirements of each individual case. In the case of large fistulæ lateral enterorrhaphy may be employed, but the peritoneum should not be opened. (2) Resection: Resection is as a general rule contra-indicated, but when in the course of a lateral enterorrhaphy the intestine is easily friable and is largely lacerated it is necessary to resect the two ends and reunite them by appropriate sutures. (3) Longitudinal enterorrhaphy: When the enterotomy is for some reason contra-indicated, it is sometimes advisable to employ longitudinal enterorrhaphy without resection. This operation is done by making a circular incision in the skin around the artificial anus and opening the peritoneal cavity. The two ends are drawn out, a longitudinal slit is made in each, and then the margins of the slits of the same side are sewn together with sutures. This operation is indicated when in the course of a lateral enterorrhaphy considerable constriction is met with just below the lower end. When the intestine is very friable it is contra-indicated. (4) Entero-anastomosis: Entero-anastomosis, followed by ligature of the two ends between the point of anastomosis and the stercoral aperture, is a simple, easy, and benign operation. It is indicated when the intestine is very friable at the seat of the artificial anus, or when there is a considerable constriction of the bowel in the neighborhood of the external aperture, and also when the inferior end is obliterated at the level of the artificial anus. British Medical Journal.

TYPHOID SEPTICEMIA AND PSEUDO-TYPHOID Infection.-Cases occur which in their course and chief symptoms closely resemble typhoid, but which on minute pathological examination show an absence not only of the ordinary typhoid characteristics, but also of any other signs which could lead to a certain diagnosis as to the nature of the affection. Banti (Rif. Med.) describes some cases of this nature, of which the following notes will give the chief characteristics. The first case was exposed to typhoid infection, and shortly after she became ill with headache, loss of appetite, and afterward fever. She had the typical typhoid facies, with dry tongue, slight delirium, subsultus tendinum, etc., but all through the course of the affection there was a complete absence of diarrhea, cutaneous rash, meteorism, and enlargement of the spleen. The case terminated fatally after the third week. The post-mortem examination showed a complete absence of enlarged follicles in the intestines, a single minute ulcer in the end of the duodenum, a small spleen, a normal liver and mesenteric glands. The kidneys were slightly enlarged, and showed cloudy swelling of their epithelium. The blood and juices of the organs yielded typical cultures of the typhoid bacillus. The reason for the absence of the usual pathological signs of typhoid in the above case is difficult to find, but the author suggests that perhaps the body became infected through the small ulcer found in the jejunum, "giving the infection a septicemic character and preventing the usual lesion of the intestinal lymphatic apparatus. The cases of pseudo-typhoid described in the same paper all occurred in one household, the members of which were affected one after the other with an affection clinically almost impossible to distinguish from true typhoid. The only symptom failing was the usual petechial rash. One case ended fatally, and on examination showed a complete absence of bacilli from the blood or exudations. The spleen was much enlarged, also the intestinal solitary glands. Typical typhoid ulceration was wanting, but there was an extensive intense enteritis. This group of cases would be extremely difficult, if not impossible, during life to differentiate from cases of true typhoid, unless one insists on the presence of a rash as a sign of this disease; yet the pathological examination excluded the possibility of considering them as such. The author prefers to group them under the heading "pseudo-typhoid."-Ibid.

Puerperal POLYNEURITIS.-Lunz (Deut. med. Woch.) refers to the recorded cases of this disease, especially by Moebius, and reports the following case: About three weeks after delivery a woman, aged twenty-four, had some difficulty in swallowing, diplopia and vertigo. Two or three days later there was numbness in the right hand, then in the left arm and hand. Fluids came back through the nose. About a month later, when seen by the author, she had diplopia, some weakness of both abducens nerves, slight paralysis of the left facial nerve and of the lower branches of the right facial. There was paralysis in both arms and less so in the legs. Sensation was but very slightly affected. The knee-jerks were absent. Reaction

to galvanism and faradism was lessened but not qualitatively altered. During the next fortnight the condition got worse. Attacks of dyspnea supervened. Then the disease came to a standstill and the patient began gradually to improve, the ultimate recovery being complete. At first there was some difficulty in distinguishing the disease from a cerebral lesion, or even from a poliomyelitis and policencephalitis. The resemblance to diphtheritic paralysis was striking, but there was no evidence whatever of diphtheria. The question arises as to whether the neuritis is of an infective nature, or whether it can occur after normal delivery. The author believes that local infection plays the chief part in the disease. Puerperal polyneuritis may be divided up as follows: (1) The greater number belong to the pyemic and septic group. (2) Some cases occurring during or after pregnancy must be looked upon as cachectic. (3) There is a third group neither due to the above named infection nor to cachexia. Here the labor acts as a predisposing factor to the penetration of the actual causes setting up the neuritis. The general anemia, the psychical effects of pregnancy and labor, and the overloading of the blood with effete products due to the regressive metamorphosis must be considered here. Thus puerperal polyneuritis does not consist of a single type. The author thinks it more common than is generally believed.-Ibid.

DYSPHEMIA (STAMMERING).—This subject is discussed from the neurological standpoint by Coxwell (Intercolon. Quart. Jour. of Med.). After showing that the stammerer is never amnesic, and that the trouble of utterance is aggravated by ill health, nervousness, etc., he states that the fault lies in a paralysis of some part of the articulatory or phonatory mechanism plus excessive activity or even spasm of other parts. It is different from affections like writer's cramp, which are brought on by overuse of the organ; dysphemia does not result from overuse. Singing, from its rhythm and coutinuous flow, is easier to the stammerer than ordinary speech, which changes rapidly in time and rate of flow. The author locates it in Broca's center, and postulates two conditions to explain it, namely, (a) a want of power (paresis) in some of the articulatory nerve mechanisms of that center, and (b) a want of accurate regulation of that center owing to defective control of it by higher centers. Hence the treatment is twofold, namely, generally tonic; and specially gymnastic. Generally tonic: Regulated outdoor exercise, shower baths, and nerve tonics (quinine, strychnine, phosphorus, or Fellowes' syrup). Vocal gymnastic: Daily practice in uttering the simple vowel sounds, at first slowly and then more rapidly, and after good proficiency is attained to add consonants. The patient should next practice reading aloud daily, mastering every difficulty only by slow and assiduous practice. Simple narrative reading should precede dialogue. Patience and steady. practice (including vocal or singing exercises) should be combined, but always stopping short of actual fatigue. The author states that he has cured many in this way, the treatment taking several months.-Ibid.