fections-tonsils, adenoids, lungs, alimentary tract, etc., should be looked after in every child. Children should be removed from contact with tuberculous individuals. Active. Most of the treatment is symptomatic. Keep patient in a quiet, dark room and attempt to keep up the nutritition by rectal feeding if necessary. Counter irritation blisters, etc., do no good and only tend to make the patient more uncomfortable. Surgical methods, trephining, opening up spinal canal have not met with sufficient success to warrant their use in every case, although the principle is logical. Crouse (10), found hexamethylenamin given patients by mouth invariably appeared in spinal fluid in 30 minutes and that, following a subdural inoculation of dogs and rabbits with the streptococcus. 60 to 80 grs. of hexamethylenamin, given under conditions that would insure absorbtion, markedly deferred and in some cases prevented a fatal meningitis. Brun and Zeiler (11) report two cases of influenzal meningitis treated in this way. In one case late in the course a needle was inserted into the spinal canal and left there. The temperature fell to normal in 24 hours and remained there till just before death when it rose again. Post mortem it was found that the needle had worked out and drainage had ceased. They think the combination of hexamethylenamin with continuous drainage of the spinal canal a valuable method of treating those cases of meningitis for which we have no specific. Hatgar (9) believes that energetic prophylactic lumbar puncture will reduce to a minimum the optic neuritis, the deafness, the oculomotor disturbances and some of the psychopathies all of which are the mechanical effects of pressure. Of the literature available I was only able to find one case reported by Lessner (12), where the fluid obtained by spinal puncture was sterilized and reinjected subcutaneously upon the theory that one is using an autogenous vaccine, providing, of course, that the tubercle bacillus has been demonstrated. In this case it was used too late in the course of the disease to have any effect. Suite 409, Brandeis Theater Building. 1. 2. 3. REFERENCES. Holt. Amer. Jour. Diseases of Children, Jan., 1911. Hektoen, Amer, Text, Pathology. Connor and Stillman, Abst. Jour. A. M. A., May 27, 1911. Hemenway, Ame. Jour. Diseases of Children, January, 1911. 4. 5 6. Cabot, Clin Exam. of Blood, 1904-303. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Whytt, p. 17. 18. 19. 20. Hatgar, Ame. Jour. Med. Sciences, March 10, 139. Crouse, Johns Hopkins Hospital Bull., April, 1909. Brun and Zeiler, Ame. Jour. Diseases Children, June, 1911. Takemina, Kwai Med. Jour., August, 1911. Langley Porter, Archives Pediatrics, January, 1910. Pfaundler and Schlossman, IV. Whytt, Observations on Dropsy of the Brain, Works of Robt. 7 25. Brudzinski, Arch. de med. des enfants, 1901, xii., 745. Morse, Archives Pediat., xxvii., 561. Seitz, Die Meningitis Tuberculosa Der Erwachsenen, 1874 Papavoine, Prop. sur les tubercules consideres spec. chez. les infants, 1830. 21. Gee, Reynolds' System of Medicine, 1872. Treatment of Puerperal Infection. By J. S. LANCASTER, M. D., York, Neb. In presenting a paper on the treatment of puerperal infection, a subject as old as the practice of medicine itself, the writer is not attempting to advance anything new or original, but merely to provoke a discussion on and to emphasize some important and fundamental parts of the treatment of this terrible condi tion. The subject is a large one and no attempt will be made to enter into minute detail. The etiology, pathology, symptomatology and diagnosis are equally important, but will not be discussed in this paper. What is puerperal infection? De Lee says: "Puerperal fever or puerperal infection is a general term comprising all the conditions, usually of a febrile nature, but sometimes non-febrile, originating from infection of the genital tract of a puerperal woman at any point of its extent. ›› Thus, it matters not whether the symptoms be mild or severe, lasting a few hours or many days, whether the causative agent be a mild saprophyte or a virulent streptococcus, whether the lesion be an infection of a slightly lacerated perineum or a generalized sepsis if the infection originated in the genitals the woman has a puerperal infection. Further, this excludes such infections as mastitis, acute tonsilitis, typhoid, throat diphtheria and others that might come on during the puerperium. Prophylaxis. The prevention of puerperal infection is far more important than the actual treatment once it has begun, yet the writer will pass over this part of the subject with only a few general remarks. At this time the etiology of wound infection is so definitely worked out and the principles of antiseptic and aseptic surgery so widely known and practiced that it seems unnecessary to go into the details of a proper obstetrical technique. We all know how to prepare ourselves, our patient, our instruments, gauze, etc. We all know the danger of going from a case of erysipelas, scarlet fever, diphtheria or the like to a confinement case. An obstetric case should have every surgical precaution of a major surgical case, for in reality that is what we are dealing with. Besides using careful asepsis and antisepsis to prevent wound infection, we should use good obstetrical judgment and prevent as far as possible wounds to become infected. We should interfere as little as possible in the course of labor. Operate only because of real necessity-the indication must be definite and the conditions present. In normal cases we should avoid all practices to cut short the labor, like manual dilatation of the os; we should make as few examinations as possible; we should use great care to prevent laceration of the perineum. It is some consolation to us to know that every infected puerpera is not caused by the person who delivered her; undoubtedly cases occasionally arise where the infection already existed in the genital tract and was lighted up by the trauma of labor in spite of every precaution. Other cases arise through circumstances over which the physician has no control. Husbands have been known to demand and have sexual intercourse a few hours after the woman was confined. Actual Treatment. Given a case where everything else has been excluded and a diagnosis of puerperal infection made, how are we going to treat it? The treatment depends on the pathology, of course. It may need only some little local measure or the treatment may be general, it may be symptomatic or specific. The object of treatment is to prevent extension of the infection and to place the patient in the most favorable condition for combating her infection. The following are some of the ways by which we can help prevent extension of the infection: (a) We can remove sutures in the perineum and allow free drainage of an infected perineal wound. (b) We can put the patient up in the Fowler position and help drainage from the uterus and vagina. (c) We can help to make the uterus more resistant to infection by giving ergot-plenty of it and for a sufficient length of time. A firmly contracted uterine wall with the blood sinuses obliterated is far more impervious to infection than a loose flabby one. (d) We can keep the patient quiet in bed with an ice bag over the uterus and possibly prevent a local peritonitis from becoming a general one, or a septic thrombus in a vein being dislodged and setting up a general pyemia or sepsis. (e) We can refrain from curetting and douching the uterus, thereby opening up new avenues of infection. The following are some of the ways by which we can increase the patient's general resistance: (a) We can by good nursing make her comfortable in bed and exclude external agents, like visitors, noise and children which irritate and worry her. (b) We can give her a nutritious and easily assimilable diet, and also plenty of fresh air and sunlight. (c) We can procure sleep and rest for her by the use of morphine or other drugs if need be. (d) We can increase her elimination by appropriate means. (e) We can give her stimulants that may turn the tide in her favor. (f) Occasionally specific treatment may do some good. Worth mentioning are diphtheria antitoxin, streptococcic vac. cine, antistreptococcic serum, autogenous and stock vaccines,.the colloidal silver preparations, mercury bichloride intravenuously. The writer has been taught particularly in the clinic of Dr. T. J. Watkins at Wesley Hospital and as house physician in the obstetric service of Dr. H. M. Stowe at Cook County Hospital that local and operative measures are seldom indicated in puerperal infections and that they usually do more harm than good. Passing by the infections of the vulva, vagina and perineum, let us consider briefly operative and local measures in the more serious conditions. Sapremia. Here is an infected blood clot or piece of tissue causing symptoms by absorption. To the writer this condition is the only one in which cleaning out the uterus is permissable. If it is known that there is no piece of placenta or membrane in the uterus, a clot might probably be expressed. Then the uterus should be kept contracted with ergot and an ice bag. Drainage should be helped by the Fowler position. If a piece of placenta or clots must be removed by intrauterine means the finger should be used and never the curette. If the os must be dilated it should be done by means of a cervical and vaginal pack and not by mechanical dilators. These always produce some injury and open up new areas to infec tion. Septic Endometritis. Many text books and physicians recommend and practice curetting and douching the uterus for this condition. The histologie structure of the uterine mucosa shows us that we cannot remove it without taking a large amount of submucosa. and even some muscle tissue. If the infection be only in the endometrium, by the curette we break down whatever barrier nature had thrown up against it and permit a rapid advance of the infection. If the infection is beyond the mucosa the curette cannot reach it anyway. The operation does more harm than good. Place the patient in the Fowler position, put an ice bag over the uterus, give her ergot, increase elimination, give her good general and supportive treatment and she will have best chances for recovery. Miscellaneous. Scarcely anyone would advocate curetting and douching the uterus for an infection that had extended beyond the uterine walls, yet this is done frequently. If the case is one of parametritis, local or general peritonitis, septic venous thrombosis, salpingitis, general pyemia or sepsis, the best treatment is the general hygienic and supportive forms mentioned above. If there is a general peritonitis laparotomy seems indicated, but the fact remains that operation only hastens the end in a great many cases. Localized abscesses, septic arthritis, etc., need to be opened and drained. After days, or, better, weeks, have elapsed a definite pelvic abscess should be opened and drained through the vagina. Pus |