by two India rubber washers, an India rubber piston, a rubber tube with adjustments and a needle little larger than an ordinary hypodermic. The adjustable rubber tube serves an evident purpose in case the child moves. This syringe is sterilized in boiling water for five minutes before using. When ready to administer the serum, thoroughly cleanse the site of insertion and charge your syringe with just the amount to be used. Gather a fold of this skin in the flank with the left hand, insert the needle with the thumb and index-finger of the right hand at the base of the fold, allowing the barrel of the syringe to rest between three fingers and the palm of the right hand. Now, taking the syringe into the left hand, the right is used in gently pressing the piston with a gentle rotary motion. Place absorbent cotton over the puncture and the serum that flows back through the orifice, meeting with the cotton, forms a good serum plug. No massage is necessary after the injection.

The age of the patient, duration of the disease and severity of the case must determine the dose. As a prophylactic it has a better record than as a remedy. There has been no failure to protect when genuine serum has been given in time and in sufficient quantity. Wherever children are necessarily segregated, as in the family, schools, asylums and other such places, an injection of 5 c.c. for children under 10 years, and over that age 10 c.c.. This is thought sufficient to protect for about two months.

In a suspected case of diphtheria administer a full dose of antitoxin. Make a culture at once, and in 24 hours you can tell whether you have the bacillus diphtheria. If not found, discontinue your serum. If found, the symptoms on the following day will indicate the size of the dose. Some give half dose if symptoms are mild, and others give none. If there is no improvement, give full dose during the day, preferably in two divisions, 10 c.c. in the morning and 10 c.c. in the afternoon. If there be found a mixed infection, streptococci with the bacilli, and the pulse, respiration and temperature indicate an alarming condition, you have to give full doses on two or three consecutive days. An ideal remedy would in such cases be an antistreptococci with the antitoxin. The presence of streptococci or other cocci does not interfere with the action of the serum, but the serum does not act on them, or remove the septic influences of the pyogenic microbes. If these poison and degenerate the cells beyond the reach of stimulation from antitoxin, your patient will die of septicæmia and not of diphtheritic toxæmia.

From 89 to 94 tracheotomies gave 85 p. c. mortality, while the serum treatment has not only reduced this rightful mortality half, but greatly reduced the number of cases requiring the operation. Given in time, paralysis, pneumonia, albuminuria are rare complications.

D. Kinyoun saw 82 cases treated with serum in Paris, of which 3 died, making about 4 p. c. mortality. Thirty cases in Berlin during two week's

stay, and he observed equally as remarkable results. The serum was exhausted and there was none for six weeks in August and September. During this time the disease increased the mortality. Out of 37 tracheotomies all died but 5. The following six weeks, with the use of antitoxin, there were only 8 tracheotomies and of these 4 died.

D. L. Emmett Holt has had 20 cases treated with antitoxin up to the middle of April, and all recovered except a baby suffering from marasmus.

My friend Dr. W. T. Pate and myself saw five guinea pigs inoculated with from to I c.c. of toxin, giving to three at the same time, c.c. of antitoxin, leaving the two receiving the least quantity of toxin as contral. The contral pigs, in 24 hours, were nigh unto death; the other three did not even even get sick. Two rabbits were inoculated with pure culture on trachea and left for 24 hours, when the sickest was given 1 c.c. of antitoxin and the other left as control and soon death controled him, and the other, by the aid of antitoxin, was enabled to gain the victory over death, diphtheria and degeneration.

We did not see it sufficiently tried on patients to express an opinion, but doubting as we were, to us venit vidit vixit our doubts. The following is what I have read from a personal letter: "Were I to have diphtheria I would have the serum administered, because I believe it the best agent we now have, remembering it is not a cure-all." Two hospitals in Paris—one not using the serum had 60 p. c. mortality-the other using it in the same epidemic and at the same time had 24.5 mortality, showing a difference of 35 p. c. in favor of antitoxin. Many months ago unbiased observers admitted,

and still admit, that the mortality rate has been divided by two since the use of antitoxin.

These are my deductions:

1. It acts as a specific against diphtheritic toxæmia.

2. The earlier administered the better to limit the disease and prevent complications.

3. It does not restore any degeneration produced by the previous work of toxæmia and septicemia.

Ophthalmologists who use the ophthalmometer and who ofttimes find the corneal reflection dull an obscure, with no apparent reason, will find that a drop of liquid albolene instilled into the eye will yield a brilliant result in making the images sharp and clear-cut and with no effect on the estimation. of the astigmatism.—Ex,

CLEAN MIDWIFERY, WITH REPORT OF A CASE OF UNCLEAN

MIDWIFERY.

By F. II. RUSSELL, M.D., Wilmington, N. C.

By clean midwifery is meant midwifery not encumbered with anything useless-perfect, complete. Its principles are simple, its practice easy, requiring the virtues, perseverence, patience, thoroughness. Its results are too well known to dwell upon, depriving child-birth of much of its former horror, robbing death of many of its fairest victims, women in the prime of life performing their office of mother and help-mate, the time of all times at which they could least be spared.

History. This dates from the time when the true pathology of diseases of the puerperium was first properly appreciated, which was the key-note to their prevention and successful treatment. In the time of Hippocrates and Galen the results of unclean midwifery were thought to be due to the suppression of the lochia, this doctrine holding sway for about twenty centuries. This was followed by the doctrine of milkmestassis. These in turn were followed by the doctrines of inflammation of the womb, peritoneum, veins and lymphatics. Many considered it a specific infectious disease, such as typhoid fever. In 1850 Sir J. Y. Simpson published a paper entitled "The Analogy between Puerperal and Surgical Fever," which was the beginning of the modern doctrine. Several years previous to this Semmelweis asserted that puerperal troubles were common in the practice of those who examined patients after performing post-mortems, or students attending patients while working in the dissecting room. He was considered a crank, and was rewarded by ridicule, but with the advance in other branches of medical science, this branch also advanced, and to-day it is an established fact that puerperal diseases are due to germs, either putrefactive or infective. The putrefactive germs are termed bacilli, and depend for.nourishment upon some foreign proteid substance, such as blood-clots, pieces of membrane, etc.

Their excreta are called ptomaines, which are capable of absorption by the uterus and are the offending agents. Puerperal troubles due to this cause readily respond to treatment, because as soon as the uterus is cleaned out the supply of ptomaines cease and the organism, with its wonderful eliminating glands, soon dispose of the dose it has. The infective germs are termed streptococci; these possess the power of invading living tissue and are in themselves poisonous. This germ is the cause of the true infective puerperal fever, although the putrefactive germs are found with it. These

*Read before the North Carolina Medical Society, May 15, 1895.

germs must get into the system before they can cause trouble. Their avenues of introduction are seven in number:

1. The genital passages, as by an examination with a septic finger, filthy clothes coming in contact with the vulva, or by the patient's scratching her vulva with a septic finger; it has been said that the water-closet has acted as a source of infection by the mucous membrane of the vulva coming in contact with the foul emanations from the sewer.

2. Wounds of the genital passages.

(a) Lacerations of cervix.

(b) Lacerations of vagina, the base of the clitoris, is a favorite place for laceration.

(c) The perineum.

(d) The head lying in one position too long, may cause sloughing of the underlying tissue.

3. The bladder, either introduced by a catheter, or may wander from the vagina; from the bladder they may wander through the ureter into the kidneys.

4. The rectum, as by a septic syringe nozzle.

5. The breast.

6. Respiratory organs.

7. Intestinal canal.

Having seen that there is a germ capable of introduction by the abovenamed avenues, and knowing the dire results which follow its introduction into the system, it became evident that if the germs were prevented from entering the system the puerperium would be robbed of its dangers. As we all know, this has been demonstrated by clinical facts. The prevention comprises clean midwifery, which involves three factors-the patient, physician or nurse, and the surroundings. The surroundings necessarily depend upon circumstances. It is those in the middle and lower walks of life whose surroundings we must modify. As to the room, it should not be too small; it should be exposed to sun-light, if possible, and be well ventilated. If the bed has been in use long, it should be scrubbed up and sunned. A mattress should be used and all unnecessary clothes. ornaments and furniture should be moved out. For a bed-protector there is nothing better than a piece of oil-cloth, or a piece of canvass which has previously been boiled. The bed linen is put on fresh, and then the bed is ready for the patient. As to the patient, she should take a thorough bath with warm water and soap. She should have a copious enema of warm water and soap. The vagina should be douched with a 1 to 2000 bichloride solution. She should clean and cut her finger-nails, and when the physician has prepared his antiseptic solution she should soak her hands. She should put on fresh linen; after this an antiseptic pad should be placed over the vulva; one may easily be made by wrapping a piece of absorbent cotton or oakum in sterilized

gauze, and the breasts and axillæ, after a thorough scrubbing with a boric acid solution, are to be covered with borated cotton, kept in place by a sterilized binder.

As to the physician, his hands and arms should be prepared as follows: Nails cut and cleaned, hands and arms scrubbed by means of a brush with hot water and soft-soap, then washed in plain water, next immersed in a hot bichloride solution, 1 to 2000, in which they should remain for three minutes; if they are simply rinsed it does not wet the several layers of dry, horny scales which form the stratum corneum of the epidermis, beneath which the germs may hide and remain unhurt. The hands should be allowed to drynever use a towel; next they should be immersed in a 5 p. c. solution of creolin, remaining for one minute. This is antiseptic and lubricant; in the lying-in hospital of the University of Maryland the rules relating to the time were very strictly observed. Some claim that it is unnecessary to use bichloride, soap and water being sufficient, but for the busy practitioner, who makes, possibly, a rectal and vaginal examination of one patient, lances a felon for another, is then summoned to a case of labor, for the benefit of his patient he should use bichloride. I mention bichloride because it is the neatest, least troublesome and among the best antiseptics. An apron should always be worn, pinned to which should be a sublimated towel, which is useful. In this connection it is well to remember that failure to carry out the minutest details in antiseptics may lead to disasters of the greatest magnitude. Remember the old expression, "omnia ex ovo." Vaginal examinations should be as few as possible. The third stage of labor should be carefully managed or clean midwifery may fail. In those cases where it becomes necessary to separate the placenta from its attachment or in any way interfere with its delivery, it should be carefully examined to see if any part has been left. At the end of the third stage a hypodermic of strichnine-nitrate, one-fortieth of a grain, should be given and a nose of ergotole or fl. extract of ergot.

The strychnine tones up the muscles, acts as a general stimulant and lessens the shock which necessarily follows labor. Ergotole insures better contraction of the uterus, thereby forcing out all clots which otherwise might be retained and become infected. This is more important in multiparæ, as with each succeeding labor the uterus becomes more inert. During the interval between the second and third state of labor sterilized gauze, wet with an antiseptic solution, should be kept over the vulva. After a normal labor it is unnecessary to use an antiseptic douche, as the placenta wipes out the canal, and this is followed by a douche of blood from above.

Nature's Antiseptic Fluid.--In many cases in which the strictest antiseptic precautions have been observed we will have fever, temperature 100°, but it will be noted that the patient is cheerful and does not feel sick; this is Volkman's aseptic fever, due to the absorption of blood serum. The nurse