and grow up in the streets. A similar epidemic in the institution some years before had nearly led to its permanent closure. The diagnosis was confirmed by microscopic examinations and cultures, and a laboratory was organized for both methods and the control of results. Proper isolation was enforced, and observation wards were instittued in which apparently cured patients were kept for three weeks after treatment was ceased. No case was discharged until cure had been repeatedly proved. All other necessary sanitary and therapeutic arrangements were made; 150 of the infected girls were transferred to Dr. Gottheil's skin service at Lebanon Hospital.

The patients were divided into squads. Every head was closely shaved once a week as soon as the inflammation had subsided sufficiently to permit it. Twice daily each head was thoroughly scrubbed with brush, green soap and hot water.

The remedies employed were chrysarobin, formalin, croton oil, bichloride of mercury, carbolic acid, iodine, and ethylenediamine-citrate of mercury and sublamine in various strengths.

A most determined effort was made to have proper records kept; for here was a chance to determine by comparative tests which plan of treatment gave the best results. Dr. Gotineil was not successful in this, however. Lack of discipline and the fact that often the names of the children were unknown or imperfectly known, or interchanged, helped to create confusion. The patients were scattered in four buildings and at least a dozen wards. Lack of room necessitated incessant transfers of well and sick children. Changes in staff and servants further complicated matters. Hence the records were in a very unsatisfactory state when the epidemic was ended. Chrysarobin was soon abandoned. It was impossible to keep the children from getting it into face and eyes, and there was a good deal of trouble with dermatitis and conjunctivitis. The diffuse brown stains on the skin doubled the time required for examination. The same objection was made to iodine. This, in combination with goose grease, has lately been highly recommended by Dr. Jackson, of New York, and is undoubtedly an effective preparation. The menstruum is comparatively expensive, however, for use on a large scale, and it caused coloration. At Dr. Fox's suggestion a number of cases were put upon it, but treatment was soon changed.

No definite results were obtained from salicylic acid in any form and concentration. The same is true of pure carbolic

acid, followed by alcohol when too irritating. Pure formalin was used in some cases by a house physician without Dr. Gottheil's consent. It cured the patches to which it was applied, of course, but at the expense of sloughing and destruction of scalp tissue. In 10 per cent. solution, which was well borne, it did not seem to make much change in the patches.

Bichloride, sublamine and croton oil were found sufficient for all cases. The first was employed in 1 1-000 solution, but many could not stand its vigorous use twice daily, and often only 1 2-000 could be used. Its effect was very slow, probably because of deficient penetration, but we persisted in its use for purposes of comparison. In most cases final recourse was taken to 33 per cent. of croton oil. This was applied several times in succession until a vigorous reaction took place. Then an ordinary soothing application (usually 3 per cent. salicylated oil) was used until the inflammation subsided, when the bichloride was again employed.

Of the two ethylenediamine-mercury compounds, sublamine was more largely used. At the time the epidemic began the citrate was the only preparation obtainable; but since the properties of the two are similar they can be considered together. They are much less irritant than bichloride. All stood 1:1,000 sublamine very well; indeed, in obstinate cases 1:750 was used without trouble. Stronger solutions than that, however, gave trouble. It is possible, of course, that the shaving and scrubbing rendered the scalps hypersensitive. But sublamine is much less obnoxious to tender or inflamed skins than bichloride and can be used in about twice the strength permissible of the latter.

Over 100 cases were treated with sublamine. As with the other drugs, they were not selected, but included cases in all stages of the affection; some had merely a single patch, whilst others were in an advanced and generalized stage of the disease. In the latter class were a number of older children who had had ringworm of the scalp for years and whom we suspected with good reason to be uncured cases from an epidemic of several years ago. They had been for months and years at Randall's Island, the city institution for orphans, and had been sent back to the asylum as cured. That this was not the case, however, is shown by the fact that some of them formed

part of the contingent of chronic scalp cases that were always present in the asylum and which undoubtedly formed the nucleus of the present epidemic. Some of the cases were not cured when the epidemic ended. Dr. Gottheil believes that they belong to the small number of really incurable cases and that their retention in the institution will lead to further trouble.

All others did very well indeed under sublamine. Its action was more rapid than that of bichloride, as might be expected from the fact that with equal bactericide power it has greater penetration, and can be employed in much stronger solution. There can be no doubt that it was the most effective treatment employed.

Dr. Eckstein assisted in the microscopic and bacteriologic test for the presence of ringworm at the beginning of the epidemic. The astonishing fact was noted that a parasite indistinguishable from that of ringworm could be cultivated from scalps that were apparently perfectly healthy. The trichophyton was seemingly present on most or all the scalps, possibly in an attenuated or non-virulent form. Perhaps it was the usual form kept in depressed growth by prophylactic measures. The bacteriologic test of cure was therefore abandoned and only misroscopic evidences relied upon. Cases in which repeated cultures had been made with negative results, and which were therefore discharged as cured, gave positive cultures later, though their scalps were apparently healthy.

INTRAVENOUS COLLARGOLUM INJECTIONS IN
SEPTIC AFFECTIONS. *

BY GEORGE TUCKER HARRISON, M.A., M.D., oF New York. A young married woman who had an abortion procured without antiseptic precautions, came under the care of Dr. Gessner Harrison with a severe form of pyaemia. She had a weak pulse, a remittent fever, the right knee joint was very much swollen with extensive effusion, and there was an abscess of the gluteal region. As the patient was growing

*Read before the Medical Society of Virginia, 34th Annual Session, Roanoake, Va., Sept. 15-17, 1903; abstracted from The Virginia Medical Semi-Monthly, January 22, 1904.

progressively worse under ordinary treatment, I suggested to Dr. Gessner Harrison, whom I met in consultation, the intravenous injection of collargolum, which was performed. The next day improvement was manifest, not only by temperature and pulse, but also by the greatly altered general condition; the patient expressed gratification at the cheerfulness and hopefulness of which she was now conscious. Two more collargolum injections were given in the following two or three weeks. The fever continued, as a large abscess developed in the thigh. In August I incised this abscess in the middle of the thigh and evacuated an immense quantity of pus. The incision was made on the outer side of the thigh, a counter opening being made on the inner side. Through and through drainage with aseptic gauze was effected; and the cavity was filled and irrigated with hydrogen peroxide. When the gauze was taken out of the cavity the following day, I was surprised to find that not a drop of pus came out, but only a serous or lymph-like liquid; and from that time on a similar condition existed. So rapid a recovery after the evacuation of an abscess of this size I never before witnessed, the effusion in the knee joint having nearly disappeared, though there was yet some stiffness, and the condition of the patient being excellent. The knee joint affection was evidently septic arthritis.

The difference in the course of the gluteal abscess from that of the abscess in the thigh shows the effect of the collargolum. Again and again the patient remarked that it was wonderful how rapidly the abscess had healed; it seemed like magic. To appreciate the splendid results achieved by collargolum it is necessary to bear in mind the clinical picture at the time of the exhibition of the remedy-the rapid pulse, the elevated temperature, the extreme emaciation, th dradful paroxysmal pains in the lumbar and sacral region, the sensitive septic right knee joint and the swollen right thigh.

The author then details a puerperal case treated in consultation with Dr. George T. Myers at the New York Infant Asylum. The history so clearly evidences the brilliant action. of collargolum, that Dr. Myers remarks: "In my experience at the New York Hospital with puerperal sepsis treated by curettage and the various intra-uterine douches, I have never seen such brilliant results as followed in this case after the administration of collargolum."

THE TREATMENT OF PUERPERAL SEPSIS.

BY DR. HIRAM N. VINEBERG, New York.

In a patient whom I had under observation a couple of years ago, and who was ill for a long time, I made the diagnosis of septic thrombosis of the pelvic veins on the right side. The patient was very seriously ill, had repeated severe rigors, followed by high temperature. The uterus behaved normally and involution progressed as it should. There was no pelvic exudate, but I could feel a round, hard cord along the infundibulo-pelvic ligament; the adnexa were apparently normal; there were no signs of peritonitis. At one time during the illness a prominent internist who saw the patient in consultation concurred in my diagnosis of pelvic phlebitis and thought he found evidences of septic endocarditis. The patient was in a precarious condition for weeks but finally made a good recovery, the treatment consisting of the usual stimulating and nourishing agents employed to combat sepsis, together with free inunctions unguentum Crede. There were no external metastatic abscesses. There wes no bacteriologic examination made of the uterine discharge for the reason that when the sepsis became manifest, which was rather late in the puerperium, there was practically no discharge from the uterus. I had reason to suspect a gonorrheal infection, as the husband had suffered from an acute attack of gonorrheal urethritis a short time before the wife conceived, and during the early stages of the pregnancy there was a marked erosion of the cervix with a copious mucopurulent discharge.

It may be appropriate here to say a few words in reference to the use of collargolum or unguentum crede. I am in the habit of using unguentum crede in cases of sepsis where I can find no Tesion which demands surgical intervention, or in those cases in which the gross source of infection has been removed by surgical means and the manifestations of sepsis still persist. I have gained the impression from its use that it is of some service either in aiding the system to eliminate the toxines produced or in some way counteracting their deleterious effects. Certain it is that several desperate cases in which the

*Abstracted from the Journal of Obstetrics, September, 1903.