peral sepsis from one case to another. I go from a case of puerperal sepsis seen in the morning, and do an abdominal section the same afternoon; go home, take a hot bath, cleanse myself thoroughly, change clothing, and then do the operation, and I have never had any more difficulty in such cases than when I have not been near a case of sepsis. If you are thorough in washing your hands and cleaning yourself, then you must be clean when you get through. The idea of carrying sepsis from one case to another has been a cloak for carelessA doctor attends his own daughter or niece, and she has a rise of temperature, and he begins to think it is because he happened to have a case of puerperal fever the day before. It is not so, but because he has not been careful enough in his aseptic or other details.

ness.

With reference to the removal of retained placenta. I remove the placenta left after miscarriage in many cases, and I never think of doing so without douching the vagina. I wash my hands and sterilize the vagina. The woman is placed on the table, the parts are thoroughly cleansed, and my finger is then introduced into the interior of the uterus, when the placenta is stripped off. If this is necessary in cases of miscarriage, it should be done in cases where the placenta is retained and adherent at full term, if the patient can tolerate the delay. With reference to the use of the sharp curette in cases of puerperal sepsis, I am opposed to it, and I quite agree with Dr. Longyear in that respect. Whether the membrane be diphtheritic or not, I do not care to use a sharp curette when the uterus is softened by pregnancy.

DR. ALBERT Vander Veer, of Albany.-While I do not practise obstetrics, yet I am quite frequently called in consultation to see a case in which the physician has a fixed idea in his mind. When I have a case of putrid pyosalpinx, one that needs immediate operation, and I come to get the history of the case, and look into the surroundings carefully, I am satisfied that I reiterate the experience of every abdominal surgeon, that it is sad to see the amount of ignorance that exists in regard to careful aseptic obstetric work. I did not hear all of Dr. Longyear's paper, but the part I did hear interested me. I believe he touched upon the correct point in making an early diagnosis, if possible. A careful examination should be made as early as possible. This can be done in a large majority of cases on account of the facilities that are now presented in our large and fair-sized cities for bacteriological work. If we use serum-therapy we must make a differential diagnosis. The serum must be used correctly, and I fancy the future history of this work will be in this direction; but in order to get beneficial results from the serum of streptococci the

cases must be seen and treated as early as possible. The essayist has therefore brought out a strong point in that direction-early diagnosis.

In regard to Dr. Duff's admirable paper, I wish it could be sent to about 80 per cent. of the practitioners of this country who have been in practice over ten years. I am called occasionally in consultation where I know just about what the surroundings of the case are going to be when I read the telegram and notice the name that is signed to it. We must recognize that there has come into our work a new profession, the profession of nursing; that we have nurses who are honest and thoroughly up in their work, and I believe the young practitioner who is so fortunate as to be located in a city of some size ought to encourage, and we ought all to encourage, the system that is made use of in my own city of what we call district nursing. We have there a home for nurses that are employed by a benevolent society, and who are ready to respond at any moment to the calls of practitioners to go and put a house in proper condition for a surgical operation or a case of obstetrics. If the people have nothing better than a horse blanket, then better material will be furnished them. If they have grandmother's linen, properly sterilized, they are fortunate. We should encourage these nurses, as they are doing a great work. They are willing to go for a certain consideration to the houses of patients who are not able to employ nurses for a considerable time, and put the rooms in proper condition for a case of confinement or an operation. They should remain sufficiently long to do their work fairly well, and this will assist the physician very much. Dr. McMurtry has said that when we are called upon to do an abdominal operation we are very careful to look to every point. We see that the drainage is correct, and above all we go for the good grandmother of today who has had cases of measles and scarlet fever and all sorts of conditions to contend with, and expects her daughter to be confined in a valuable, nice mahogany bed. This bed is selected because it is the handsomest bed in the household; it is in the best room, and what does it do? It does just what Dr. Duff has brought out so faithfully in his paper. The surroundings we, as abdominal surgeons, have learned to study carefully. Obstetricians are not yet up to this work, and I rejoice in this discussion that has taken place today. I think the Association ought to be grateful; we ought to feel thankful for the advanced views that have been presented here, and I am sure they will go out and do good among the profession that we need to work earnestly and faithfully with in bringing them up to the point of doing better aseptic obstetrical work.

Dr. Albert GOLDSPOHN, of Chicago.-Just a word as a matter of scientific exactness: It has been stated by one of the speakers that the gonococcus is the most important cause of puerperal sepsis. I am not disposed to say that it is not so. Perhaps it is. It is a very great cause, but it must be understood that it is not the exciting, but merely the predisposing cause of puerperal sepsis. There are no cases of puerperal fever, so-called, on record in which the gonococcus alone as a pure culture exists. Whenever the gonococcus was found present, other pus-microbes were found also-in other words, there is always a mixed infection.

DR. LONGYEAR (closing the discussion on his part).—I am glad Dr. Vander Veer touched upon the point in my paper of making a diagnosis by cultures. That was not touched upon in the discussion, and yet it was the principal point that I wished to emphasize. If we would do that as a rule in all cases of puerperal infection, we would get down to the principles of treatment better; we would know what we are treating. It is of passing interest only to know where the infection came from, but to know exactly the variety of infection that we wish to treat, and that we must know if we are to treat intelligently, is another thing. We can only get at this by a bacteriological examination.

DR. DUFF (closing the discussion).-There are several points I would like to discuss, but I do not wish to consume too much of the time of the Association. I want to say a word with reference to the training of young men. I have charge of a hospital in Pittsburg which is devoted entirely to obstetrical work. I divide my medical classes into sections of eight, letting eight students see a case of obstetrics at one time. The delivery-room into which the students are admitted is perfectly clean and modern in every respect. It is as perfect as we can make it. These young men are required to make preparations before they are admitted to the delivery-room, and this is a very important part of their obstetric education. When they go out to practice afterward they have a full and clear knowledge of what obstetric asepsis is. In the last three years, by paying attention to every detail, notwithstanding that this number of medical students is always present, we have not had a single case of puerperal sepsis. I do not deliver the cases myself, but I see that the rules are strictly carried out. I simply attend to the operative work, and my assistants do the rest. In the Gynecological Department of the Pittsburg South Side Hospital, of which I have charge, I enjoin the same aseptic precautions. I regard this as a part of the students' education as much as learning to diagnosticate and operate.

There is one other point. Dr. Baldwin spoke of the causes of puerperal sepsis. I do not want to wander from the particular point I tried to make in my paper, namely, the source of sepsis. In one-fifth of the cases reported, those in which I could not ascertain what the source was, some were cases of auto-infection. A lengthy and elaborate paper might bring out several interesting points regarding this phase of the subject.

TOXEMIA OF PREGNANCY.

BY ADAM H. WRIGHT, M.D.,

TORONTO, CANADA.

ORDINARY health is a very precarious and uncertain thing. Today one is well; tomorrow he may be sick, with perhaps a headache, a furred tongue, and a high temperature. The cause may be from without; it may be from within. Assimilation may have gone wrong; secretion and excretion may have lost their balance; poison of some sort may have come into existence and may be retained; it may be a bilious attack-whatever that is—or it may be something much worse. The equilibrium of health appears to be more easily disturbed during pregnancy than at other times. I will not undertake now to discuss the nature of the poison or the poisoning which occurs so frequently in pregnant women, but I will presume that in those cases there is a general systemic toxemia, with a toxin or toxins affecting many of the organs and tissues of the body, if not the whole body. In connection therewith I will simply express the opinion that the liver and intestines are mostly at fault, but that in a certain proportion of cases insufficiency or inefficiency of the kidneys is a serious element in the disturbance. It is difficult in a few words to say anything more definite, after considering the mass of evidence which has been adduced during the last few years; but I will add that I believe that the offending toxins are found chiefly in the blood, liver, and muscles.

There can be no doubt as to the great importance of the earliest recognition of the toxemia of pregnancy. The chief symptoms are salivation; disorders of digestion, with sometimes peculiar taste, and constipation; general malaise; anemia; nervous disturbances, with headache, disorders of vision, irritability, etc.; deficient excretion of urine or some of its constituents; albuminuria.