Dr. Lanphear. I do, however, wish to recommend the use of oil of wintergreen, a two minim capsule every two hours until five or six doses have been taken daily. If the patient objects to taking the oil by mouth, it may be given by the rectum by mixing a teaspoonful of the oil with four tablespoonfuls of cool milk. This should be injected into the rectum every two hours from four to six times a day. An energetic, but well directed use of Merck's or Fisher's oil of wintergreen in all septic conditions, will be found of great benefit.

Dr. Fenton B. Turck (Chicago): I wish to say a few words in reference to the two papers that were given here this afternoon, the first dealing with treatment after parturition and the other with the accidents of infection. In the conditions described in Dr. Lanphear's paper, the expectant plan of treatment is now generally adopted. In the first paper where we have a description of normal labor, the after-treatment is a subject that is particularly interesting, because so much can be accomplished and so many ill after-effects avoided by a little care. From the fact that I see a great many cases showing the results of improper care after parturition, I am interested in this class of cases. Landau calls attention to the fact that a large proportion of cases of gastroptosis and enteroptosis are the direct results of lax abdominal walls following parturition. He calls attention to the folly of letting the abdomen go without a bandage and the lack of care given these cases, and makes the sweeping assertion that all cases of enteroptosis are the result of lax abdominal walls. Other observers acknowledge this as an important etiological factor, but not the only one. Another important one is defective development. Following Dr. Patrick's remarks, it might be well to call attention to one or to methods for the prevention of bad effects following parturition. I shall discuss a little the therapeutics indicated in these cases.

The arterial bandage does not increase arterial pressure, relieves the vascular system, but does not cause hypertrophy of the abdominal muscles. I have found that an extension system of exercises is of almost inestimable value in these cases, and should be generally adopted. Extension movements can be made that will wall into use the abdominal muscles and may be practiced several times a day without fatigue, and I have devised a little arrangement that can be used in bed. I call it my H exerciser. This apparatus consists of two double cords stretched from the head of the bed to the foot, running parallel to each other, from two and a half to three feet apart, a horizontal bar being placed at about the distance of the extended arms. Hence the name, "H" exerciser. The double cords are so attached to the bar that this may silde up and down with friction resistance. The extended arms, grasping the horizontal bar, push it forward and withdraw it, in a motion similar to turning a grindstone. The arms and legs should not be flexed, but kept rigid, thus throwing the work upon the body. As the body is bent forward and downward, there is resistance from the cords above and below, and as the circle is completed in coming backward and upward, there is again resistance, but in the opposite direction. A period of rest occurs when the cycle is complete, giving ample time for equalization of the circulation. In the beginning, a

pause of about two minutes should follow after five cycles, the number of which are to be increased day after day until twenty-five cycles are made between rest periods. The physician should regulate the amount of exercise according to indications. These exercises can be begun by the parturient woman after the third day, from a few minutes in the beginning and gradually increasing, repeating the exercises two or three times a day.

Dr. Campbell (Chicago): The paper read by Dr. Patrick is commendable. The general technique of obstetrical practices is not too well understood. There are a few points in Dr. Lanphear's paper that I wish to consider. He furnished us with a report of a case following child-birth which had been curetted with a sharp curette, which terminated fatally, ascribing the death to the sharp curette. I am of the opinion that it is not so much the curette as the method of using it. I had thought the profession were pretty well agreed as to when curette, and as to the best kind of instrument to use. I believe less harm is done with the sharp curette than with the dull one. Dr. Ries has given us a report from the German hospitals in which he claims that all of the usual methods of treatment, as mentioned by Dr. Lanphear have been tried and discarded in the treatment of infection following labor. Have the Germans offered us any better treatment? or have they lowered the mortality in this class of cases by the do nothing treatment as advocated by Dr. Ries? I believe my own clinical experience justifies me in the use of the curette for the removal of retained portions of placenta, especially where there is evidence of saprophytic infection.

Dr. C. H. Andersen (Chicago): This discussion reminds me of the time I was going to Asheville and we were switched off. I wish to compliment Dr. Lanphear on his paper, and I wish to speak of those cases that died. I believe as Dr. Ries does, that if the patient has a high temperature, the infection has gone beyond the uterus, and I believe in treating not the cause but the effect. What does the patient die of? She dies of infection of the blood. I believe that every one of those cases should be bled, and they should be transfused with hot, normal, saline solution. It cures some of these cases- at least 1 per cent are cured. The patients die of toxicity of the blood, and if one pint of this blood is removed and the patient is injected with hot salt solution, the heat stimulates the central nervous system, stimulates secretion of the kidneys, throws off other toxic elements, and there is a general thinning of the toxic material by the salt solution. I have seen in Dr. Ferguson's clinics many such cases, and we have cured a few of them. It is a valuable way to treat these cases that are going to die, and it seems to me that it is a very practical thing to do.

Dr. H. A. Leipziger (Burlington, Ia.): It is interesting to note from this discussion, and also from the feeling of the profession in general that it seems preferable nowadays to take a parturient woman to a hospital. I think it was late in the 70s that the Semmelweis method of using chlorinated water as an antiseptic was introduced into the Vienna lying-in hos

pital, and changed a veritable slaughter house of death by puerperal sepsis into a harbor of safety. Garrigues read his paper on antiseptic midwifery in 1883, and at that time introduced the treatment into the Maternity Hospital of New York. I was interne at that time and had the pleasure of carrying out Dr. Garrigues's treatment. In September, out of fifty women in the ward, ten had puerperal sepsis. On October 1, he introduced antiseptic treatment, and the result was that for six months following there was not alone no fatality, but scarcely any morbidity in the hospital referable to sepsis. At that time I remember that at the Academy of Medicine of New York, it was stated that the country doctors said they never seen puerperal sepsis-that it did not exist outside of the city hospitals; and now we look for our puerperal sepsis cases outside of the hospitals in country towns and homes.

I think the impression has gone out from Dr. Ries' remarks that he would not go into the uterus for anything excepting hemorrhage. I think that it would be unwise if this were given out as advice to men in the beginning of treatment in a septic case. A man who is called to a case where he suspects that there is a piece of placenta remaining in the uterus, would act unwisely or dangerously if he were constrained by such advice to leave that alone. Certainly quality as well as quantity cuts some figure, and if you cannot remove all the foci of infection by curetting, it must be of decided advantage to remove as much as possible of the material that gives rise to that poison. If we could qualify our cases, as Dr. Lanphear has stated, then we should know how to treat them, but coming across them as we do, it must be admitted that the home obstetrician and the general practitioner must, if not with his fingers, then with the dull curette, or some other instrument, remove the material that produces sepsis.

Dr. J. C. Murphy (St. Louis): I was a little amazed at the statement of Dr. Ries that he would not go into the uterus for but one cause, and that cause hemorrhage. Any one who has had a dozen cases in the whole course of his career, has seen what beautiful results were obtained from curettage. We have heard a little about the eight or ten kinds of bacteriological infection, but I am willing to bet $50 to 5 cents that there are not 15 per cent of the general profession in this country who could tell a piece of infected tissue from a piece of wall paper, under the microscope; they "all look alike to them." They know that their patient had a baby a week before, and now has had a chill and a temperature, and that there is an offensive discharge from the uterus. The practitioner's main object is to get rid of it. It is not possible that a man of Dr. Ries' undoubted ability would say that it is the wrong thing to try to clean out a uterus that he finds in that condition. He did not mean that, but a good many people will take him literally.

Regarding the use of the dull curette, I would as soon try to shave with a dull razor as to curette a uterus with a dull curette. But it is the man behind the curette, as it is the man behind the gun, who, if he knows his business can go into the uterus with the sharp curette, and he won't

go too far. It is very doubtful if we have an antiseptic that will be powerful enough to overcome infection that has gone into the blood, and it seems to me to leave the infected uterus entirely alone is like having a break in the water-pipe in the other room and standing in this room with a mop and attempting to take up the water with that as it flows in, when, if we went back and repaired the pipe, the overflow would cease. There are so many undoubted evidences that we do get rid of infection by taking it at its site, that it seems to me almost criminal if a doctor has a puerperal infection, for him to leave the uterus alone. I don't believe in intrauterine douches, because if there is a local infection, by pouring large quantities of antiseptic solution over it we are liable to wash the infection up into the tubes and then somebody will have to operate for pus tubes, sooner or later. The curette has a certain field of usefulness, and when the right man has hold of it, he can do a great deal of good. We would not give a shot-gun to a four-year-old boy, and we would not give the sharp curette to a man who has had no experience with its use in the treatment of cases of puerperal sepsis.

Dr. Florence Patrick: I wish to thank you, gentlemen, for the discussion and criticism of my subject. It is gratifying to know that the objections made are not that the radical change suggested is not necessary, but that the question is a hackneyed one and the change impracticable. The general opinion as expressed by this convention in the discussion of papers kindred to mine, is that the objectionable and undesirable accompaniments and sequelae of pregnancy and parturition occur outside of the maternity hospitals, in those sections where hospitals facilities are impossible. Therefore can we deduce that such hospitals are a necessity and a possibility, and I think that the gradual education of the people to the necessity of lying-in hospitals, is inevitable, and sooner or later must prevail.

Dr. Emory Lanphear: In reply to my good friend, Dr. Ries, I am sure he was thinking of my words of praise and my recommendation that the society elect him to its presidency very soon, as a tribute to his good work for the society, as well as for our profession at large, instead of listening to my remarks on the treatment of puerperal infections of various types. Those who closely followed my paper will recall the fact—which I presumed indeed, would meet with opposition on the part of some-that I advised against the use of the curette or intrauterine medication in every variety of infection excepting that single form dependent upon retention of decaying material in the uterus (so-called sapremia; better, saprophytic infection) and for this condition I recommended the use of fingers, a large Volkmann's spoon, or a dull curette-anything to remove the decomposing, putrid mass without injury to the endometrium. Just as earnestly as does Dr. Ries, I condemn the ordinary "curetting.' Curetting may be proper treatment for some forms of chronic endometritis, but in acute infections it is worse than useless, and so I said, "the sharp curette often means death." Personally, I do not like a dull curette; I never use one. A large Volkmann's spoon removes the debris far better,

but it must be used with care, as its sharp edge may easily wound the endometrium. There is nothing wrong with the endometrium in these cases of saprophytic infection; the indications are to remove the decaying matter from the uterus by the most convenient means, with irrigation to assist in getting the fragments out. Dr. Ries surely does not, cannot oppose such a practice! If he were called to see a woman on the third or fourth day after confinement and found her with a temperature of 105 or 106; and a nasty, stinking discharge from the uterus, and on examination by vagina found a lot of putrid placenta, or decomposing blood-clot, or membranes protruding through the os, does he mean to have us infer that he would not gently dilate the cervix and remove the decomposing stuff from the womb? Surely not. And after so doing, or while doing it, would he not use an irrigator to wash out the debris? If not, he will lose a large proportion of his cases of saprophytic infection, as Nature unaided is not capable of caring for many of these patients. I do not advise an “intrauterine douche;" I said that 'if'-which must be rare-'conditions are such that the attendant feels that an intrauterine, or even a vaginal douche must be again employed, he must give it himself-never trust it to a nurse. The danger of engrafting a streptococcus or staphylococcus infection upon an already injured membrane, is far greater than leaving a little decaying material in the uterus.' Hence, intrauterine irrigation should not be practiced except in extreme cases, and never by a nurse or an assistant.

So much for saprophytic infection. Relative to the curette in puerperal sepsis due to the streptococcus, bacillus coli communis, staphylococcus, gonococcus and other forms in which pelvic peritonitis or pelvic cellulitis play an important part, I said that in almost every instance the curette is worse than useless; the infection has passed beyond the uterus long before the symptoms become alarming. Experience taught many of us this long ago- we didn't have to go to Germany to learn it. So too of hysterectomy. It is only in the rarest of cases, where the uterine wall is filled with multiple abscesses and the patient has passed the dangers of acute sepsis, that removal of the uterus is justifiable. I have long ago abandoned hysterectomy in the acute cases, save for one class: When the pelvis is filled with pus and the uterus is in the way of perfect drainage, it may be removed merely as a matter of convenience in hastening the operation and securing better drainage; not with the idea of curing by the operation alone.

On the whole, I am convinced that when Dr. Ries reads my paper he will agree with practically all my points. I know the pathological portions are in part new to medical literature. The treatment in each variety is that which I have found best adapted to each, based upon a consultation practice in a city where unfortunately such cases do much abound.

I am glad Dr. Futterer has called attention to the remedies from the internal use of which benefit may be expected. The medical side of these cases is too much neglected by the surgeon; thus, on the other hand, the average general practitioner is apt to rely too much upon internal medication and to lose valuable time in the use of quinine and opium instead of resorting to prompt and proper surgical measures. And this is especially