The

were given. It was stated that a pianist in playing a presto of Mendelssohn, played 5,595 notes in four minutes and three seconds. striking of each of these it was estimated involved two movements of the fingers, and possibly more. Again, the movement of the wrists, elbows, and arms could scarcely be less than one movement for each note, as twentyfour notes were played each second, and each involved three movements, there would be seventy-two voluntary movements per second. Again, the place, the force, the time, the duration of each of these movements was controlled. All these motor reactions were conditioned upon a knowledge of the position of each finger of each hand before it was moved, while moving it, as well as the auditory effect to force and pitch, all of which involved at least equally rapid sensory transmissions. To this must be added the work of the memory, the placing of the notes in proper position, as well as the fact that the performer at the same time participated in the emotions the selection describes, and felt the strength and weakness of the performance, a truly bewildering network of impulses coursing along at inconceivably rapid rates was arrived at.

The value of whitewash in destroying infection has been investigated. The experiment was tried on the microbes of cholera, typhoid, carbuncle, and tuberculosis. Portions of the walls of a room were infected with the various microbes, and covered with a coat of white wash, the room being closed hermetically for twenty-four hours. It was then found that the whitewash effectually destroyed the cholera and typhoid bacilius, but the microbes of the other diseases survived several repeated appli

cations.

Providing new noses is quite an art in the district of Kattywar in the Bombay Presidency. Cutting off an enemy's nose is the favorite mode of vengeance throughout the state of Junagadh, where jealous husbands inflict the same punishment on their wives. Sometimes the nose is bitten off and part of the lip will be taken also. A Hindoo doctor at the Junagadh Hospital has had so much practice in mending noses that now he can restore the injured feature in a most wonderful manner leaving very little

disfigurement. He has perfcried one hundred successful operations in "rhinc plasty."

At St. Mary's Hospital there has been a cure of simultaneous fracture of both clavicles, which has attracted much interest on account of the extreme rareness of such an injury. The patient, a woman aged fifty, was going down some steps, carrying in one hand a pail of water and in the other a jug; she tripped, and in falling dropped the pail and jug and put out both hands to break the shock. When admitted to the institution it was found that she had sustained a simple fracture of both clavicles, the fracture being in a similar position on either side-about the junction of the middle and outer thirds, with the usual displacement of the outer fragments. In order to rectify the malposition, a figure-of-eight bandage was first tied round the shoulder, later a handkerchief round each shoulder was tried, tied together behind, as recommended by Syme. Neither plan succeeded, the patient being too restless. Nothing else was tried, she simply being kept on her back. At the end of a month from the date of the accident there was firm union on both sides, with no unevenness on the right, but considerable displacement of the left clavicle.

It is proposed to hold an International Congress of Hygiene and Demography in London in 1891. Six congresses have already taken place, biennially as a rule, in various cities of Europe, when delegates from all parts of the world have attended. A meeting under the presidency of the Lord Mayor has been held at the Mansion House, when a resolution was passed expressing entire approval of the objects of the congress and of London being visited next year. next year. A subscription list was opened to provide funds for defraying the expenses.

Professor Ray Lankester has been elected to the post of deputy and acting Professor of Anatomy in the University of Oxford.

Thiol, a substance very like ichthyol, but without its unpleasant smell, has been used in a large number of skin diseases with remarkable success. The part affected is painted with a solution in distilled water of one to four

twice a day, the application not to be washed off for two or three days.

LONDON, July, 1890.

Abstracts and Selections.

ON THE CONSTRUCTION OF SMALL LYING-IN HOSPITALS, WITH REFERENCE TO SEPTIC INFECTION. The subject to which I invite your attention to-night was suggested to my mind several months ago by a conversation with members of the staff of the Woman's Hospital.

You are all aware that this institution has in contemplation the erection of a new building, in which shall be the best modern arrangements for the care of pregnant and lying-in women and their offspring.

The question was discussed among some of us as to whether it was advisable to put up a pavilion separated from the main hospital, in which all cases of so called "purperal fever," etc., might be placed, or whether isolating rooms might not be arranged in some part of the building itself.

My own opinion has been that the pavilion system, while admirable for general hospitals and barracks, is wholly unnecessary in small lying-in institutions; and I have thought that the discussion of this subject, although perhaps somewhat hackneyed, might not be wanting in interest and profit to most of us.

In the case of the Woman's Hospital the question of expense is an important one. The main building must be as complete and perfect in its arrangements as the funds will allow, and the erection of a pavilion, which, at most, would probably not be used over two or three times a year, would necessitate the further expenditure of several hundred dollars.

As this question of expense, however, does not particularly concern us, I shall pass on to the discussion of the main point-septic infec

tion.

Up to within the last forty years, one of the most prevalent and fatal scourges known to affect human beings was the so-called "puerperal fever." Woman after woman died the civilized world around, until, in some localities, a time was reached when it was little less than suicidal to become a mother. In those days the profession went about in mourning, as it were, helpless, hopeless, and utterly unable to account for or cope with the terrible distemper. Here and there during this somber period, feeble points of light appeared in the darkness of night, flickered, cast a waning halo, and went

out.

In 1770 White saw in lying-in hospitals the habitat of "puerperal fever," and traced its source to foul matter generated in the individual's organism, or conveyed there by the putridladen air.

The celebrated Gordon, of Aberdeen, advanced still stronger opinions not many years

later, and here and there like theories were stated.

In 1848, however, the blow was struck that opened the eyes of the profession to new light, but even for years afterward its vision was dimmed, but it saw not clearly-but "men as it were trees walking."

It is unnecessary for me here to rehearse the achievement of that great man and keen observer, Semmelweis. You all know of his struggles, victories, failures, and final death; of the criticism, ridicule, and contumely heaped upon him by his fellow countrymen and others. So great was the aversion to Semmelweis' theory, so against nature for man to accept the dictum that the mischief was owing to his own dirty fingers or unclean instruments, that I believe, had it not been for the uncontrovertable experiments and tests of Pasteur, Tyndall, and Lister, even with the clearly enunciated propositions of Semmelweis before our eyes, we should to-day still be groping in the dark.

It is to guard against this same "puerperal fever" that the pavilion isolation of patients was introduced first, I believe, by Tarnier. By granting that isolation in such cases is desirable or even necessary, we acknowledge that the disease is contagious and liable to become epidemic. But in order to clearly understand the philosophy of isolation, and the treatment of the condition, we must not fail to appreciate what the disease really is; and, as the term puerperal fever means pyrexia in a lying-in woman, we must drop it from our vocabulary as having no etymological significance in describing the disease or diseases which we have in mind, and apply right names to the conditions present. "For," as Robert Barnes has recently said, "as fevers of various kinds may assail nonpuerperal persons, so they may assail puerperæ. We must abandon the attempt to find one definite puerperal fever, and we must recognize the clinical truth that there are puerperal fevers.

The investigations of a large number of observers have now placed it beyond dispute that the disease so fatal in the past, and so dreaded by every accoucheur, was no other than bloodpoisoning, surgical or wound fever, septic infection.

These observations have also shown that the source of the infection is direct, that is to say, from external sources which can be traced, or indirect, also called auto-infection, where the source is from within the organism but which it is not always possible to locate or explain.

The number of believers in self-infection is, however, gradually decreasing year by year, for the real cause of infection has been indisputably proven to be nearly always introduced from without.

I say nearly always, for there is a class of cases, namely, those in which the woman suffers from disease of the uterine appendages where the infection may and does originate within the organism. This condition has been admirably described by Grigg, who believes that puerperal disease from such source is far more frequent than is generally supposed, the paucity of post-mortem examinations on women dying in childbed being responsible for this. The stand taken by Kaltenbach, who is an advocate of self-infection, is that the microbes which exist in the genital secretions before labor develop their energy or virulence after that act has taken place.

Now, as Winter and others have found in the vaginas of healthy women staphylococci and streptococci, etc., the same organisms, and indifferentiable from those found in septic peritonitis, metritis, etc., and which (streptococci) Legrain has also discovered in the vagina of a syphilitic woman suffering from subacute vaginitis, it is difficult to understand how these germs can acquire their virulence unless from some external source. As a matter of fact, Szabo has shown that the nearer to the external world the parturient canal is injured the more frequently does puerperal disease result, a point hardly in favor of the auto-infection theory. Moreover, in cases where the disease originates higher up in the genital tract-as most of the micro-organisms are found in the lower third of the cervix and vagina, and have no power of locomotion-it is hard to account for their presence above unless we grant that they have been carried upward on fingers or instruments. As far as the ordinary lying-in case is concerned then, we may at once concede that all her dangers from septic infection lie from without; that though she may be a hot-bed for the generation of germs, if these germs have not become contaminated by outside matter, she is practically safe.

"Thomen investigated the lochia of normal puerpera (seven cases) and found that—

"1. Vaginal lochia contain, in normal conditions, innumerable germs of different kinds (Doderlein). In three cases streptococci were found in the vagina.

"2. Micro-organisms are more numerous in the vicinity of the introitus than in the upper third of the vagina.

"3. The number of micro-organisms in the vagina is considerably larger during the first days of childbed than immediately following labor. (During menstruation the number of bacteria is larger than before.)

"4. Lochia from the cervix was sterile in two cases; in one case the number of bacteria was exceedingly small; in two more incon

siderable, while in another they were abundant.

"5. Lochia from the cavum uteri was sterile in four cases, but in the remaining three there were different micro-organisms-among which the streptococcus was found twice. (Archiv. für Gynäkologie, Band xxxvi, Hefte ii, p. 231.)"

From this it is obvious that the first duty of an institution is to protect its patients from infection. This result can be obtained only by the most careful observance of cleanlinesscleanliness of the building in general, but particularly of the lying-in room-the accoucheur, the nurse, the clothing, instruments, and utensils employed, and last, but not least, of the patient herself. To aid in this we make use of antiseptics; but as I have already presented this subject for your consideration I will not dwell on it at the present time. Without the most scrupulous care in all details the most perfect architectural design in building would avail little or nothing. As soon as a patient develops septic infection, or any disease which is known to be contagious, she should be isolated. Now the statements which have already been put forward to make it plain that isolation means simply separation-that is, out of contact. I hold, therefore, that a patient placed in a room separated by a plastered brick wall from other lying-in women is as isolated as if placed in a pavilion, provided all contact between the sick and the well can be prevented. In the discussion of this subject I refer only to small maternities, where not more than fifty to one hundred women are delivered annually. This may be readily accomplished by having all doors of communication between the two parts of the building on another floor, or at least on another hall, and prohibiting nurses in attendance on sick puerperæ from visiting or coming in contact with other nurses or well puerperæ. Utensils, instruments, washing, etc., should also be disinfected and cleansed by themselves.

The walls of lying-in rooms and hospital wards, or isolating chambers, should be well plastered and painted, and the floors constructed of well-matched hardwood lumber, to admit of thorough washing and disinfecting. As little furniture as practicable should be in any of these rooms, and all upholstery, hangings, etc., entirely done away with. Water-closets should be placed as far as possible from maternity and lying-in wards, and should be frequently inspected to insure their sanitary condition. The ventilation should be as perfect as possible, and to assist in this an open fire-place in each room is recommended.

Light, air, and cleanliness, these three are the sine qua non in the prevention of septic infection, but the greatest of these is cleanliness.

But it was not my intention in preparing this paper to enter into a discussion of architecture. I had in my mind simply the idea that unless the cases in any maternity are conducted on what is known as the modern antiseptic midwifery principle, pavilions and isolating rooms will be built in vain, for, as Kucher has so sensibly remarked, immunity from puerperal fever does not depend upon location, but on the care taken to prevent septic contact."

Appended are paragraphs taken from the letters of several distinguished foreign teachers of midwifery which I have received since commencing this article :

Professor Credé, Leipsic: I am certain that infected patients can lie beside and be cared for along with healthy puerpera without infecting them, providing all contact between the sick and well can be wholly prevented-that is, I believe the common atmosphere to be devoid of danger, and only the direct contact of their secretions on new and fresh wounds in the healthy to produce infection. As it is, however, impossible for attendants to absolutely avoid such contact, it is prudent to place the sick in partly or wholly disconnected rooms, and to provide them with entirely separate nurses, and especially washing, etc. In my institution the hospital department was arranged in this way in the third story of the building.

Professor F. Winckel, Munich: I allow all puerperal patients, excepting those affected with puerperal erysipelas, to remain with the healthy lying-in women. Separation in these cases is unnecessary; those affected with erysipelas, however, must positively be placed in a separate room-and best in a separate building.

Professor Olshausen, Berlin: The safest way is, of course, to place the sick puerpera in a special building, pavilion or barrack, and I would strongly recommend this in planning a large hospital. Yet undoubtedly it is quite sufficient if the sick puerperæ remain in the same building but separated as far as possible, and the attendants kept from the well puerperæ. It is so in Halle, where the sick puerperæ are removed to the gynecological department. In Berlin they are taken to the separate station. Professor Leopold, Dresden: In my clinic there are three different lying-in rooms, two for healthy women only, and one for the sick, that is, such as are received infected into the clinic. These latter are at once placed by themselves and are delivered by a special physician and midwife. Although these three lying-in rooms are in one large building, it would be better if the sick, that is those infected, could be placed in a small separate pavilion, where they could be delivered and afterward remain. Having the lying-in rooms in the same building saves

much time for physicians and midwives, but the danger of contagion is very great, and the isolation of attendants is maintained only at the expense of great pains. I would therefore recommend that besides the lying-in room for healthy parturients, there be also a pavilion in which all sick patients be confined.

Professor Alexander R. Simpson, Edinburgh, believes that it is the best arrangement to have a ward for puerperal cases apart from the main building. Edinburgh maternity does not possess this advantage, but in cases of a suspicious nature the patient is, of course, isolated in a special room in the building.-Dr. W. P. Manton, Physician and Surgeon.

ETIOLOGY OF CHOLERA INFANTUM.-Passing by such predisposing causes as age, constitutional feebleness, bad hygienic surroundings, impure air and water, dentition, etc., there remain two causative factors in the production of cholera infantum which deserve careful study, namely, high temperature and the food supply.

It is a matter of common observation that the mortality from diarrheal diseases in children is greatest during the summer months. The studies of the effect of heat upon these affections, which have been made by Seibert for New York, by Bajinsky for Berlin, and by Meinert for Dresden, are in striking agreement. Seibert (quoted by L. Emmet Holt, in his admirable article on "The Diarrheal Diseases of Children," in Keating's Encyclopedia) has shown that, taking the average of a large number of years, the mortality from diarrhea increases rapidly from May to July, and then steadily decreases. Thus, from 1877 to 1887, in a total of thirty-one thousand and forty-eight cases, the average mortality during May was six hundred and sixty, during June, four thousand one hundred and three, while during July it reached the enormous number of twelve thousand four hundred and sixty-eight. The mean daily temperature of these three months was respectively 54°, 61°, and about 65° Fahr. It would appear from these figures that after the atmosphere, and from it the ground and the dwelling-houses, had become heated to a certain point, say from 55° to 58° Fahr., the addition of a very few degrees produced an enormous increase in the mortality.

It is admitted that heat exerts an unfavorable influence, but just how does it act? Some have supposed that it is by heat stroke or heat exhaustion. Long-continued high temperature is exhausting to adults as well as to children. Its debilitating effects, however, are not due to the heat alone, but to derangements in digestion also. Increased heat means increased perspiration, increased thirst and increased, and often

indiscriminate, drinking. In children the results are more marked because their digestion is feebler; they are more apt to be overfed and given milk instead of water when they are thirsty (and milk is very prone to decomposition), and because they have less chance of a change in air and hygienic surroundings. The smaller number of deaths during June, notwithstanding the slight difference in temperature, is best explained by the fact that by June the heat has not continued long enough to make the houses hot continuously throughout the twenty-four hours, and the spring months have left the children, in most instances, with considerable resisting power. The fall in mortality which occurs in August and September is due in part to the fact that the deaths which have occurred by that time have diminished the number of children liable to be affected, and to the fact that we have, as a rule, cooler nights and early mornings, though the temperature at midday may be higher than during July.

When we turn to the food supply, one circumstance stands out more prominently before all the rest-it is that breast-fed infants are almost exempt. According to statistics collected by Holt, of nine hundred and forty-three fatal case, only sixty-one, or about three per cent., had the breast exclusively. This fact is conclusive evidence that high temperature in itself is not the most important of the two causes under discussion, and indicate that the heat is harmful chiefly by bringing about certain changes in the food supply of hand-fed children. It is well known that all organic matters are prone to decomposition and putrefaction in summer time, and that cow's milk, which forms the most frequent substitute for mother's milk, is especially liable to these changes, the cause of which is bacteria. Milk is subject to so many sources of contamination from the time it is obtained from the cow to the time it reaches the child that the marvel is that it is not more frequently the cause of illness. Sterilization of the milk has accomplished much in preventing and in overcoming attacks of cholera infantum, but it has not accomplished all its warmest advocates would have us believe. For there are at all times in the intestines certain bacteria, particularly the bacterium lactis aerogenes, or aceticum and the bacterium coli. Under a slight catarrh of the bowel or a dyspeptic diarrhea, which usually precedes an outbreak of cholera infantum, these bacteria multiply in number, and a large number of new forms appear. These have been described and cultures of them demonstrated by Baginsky (Transactions of the Berlin Medical Society, 1889, p. 139). When these have developed before the

milk has been sterilized, it is manifest that subsequent sterilization of the milk will not cure the disease which they have produced. Some of them are undoubtedly capable of producing disease, as experiments have proved, but no one of them has been found invariably associated with the disease. Two groups of bacteria are seen in the intestinal wall in cholera infantum; in some places bacilli occupy the glands of Lieberkühn and the interstitial tissue, and in other places the glands are filled with heaps of cocci. This being the case, cholera infantum probably is not due to the actionof a particular bacterium; in other words, is not a specific disease. Holt believes that the symptoms are produced by toxic alkaloids, ptomaines, developed by the action of the bacteria on the food. Baginsky has gone further. Having discovered that the bacillus which liquefies gelatin and colors it green develops ammonia by its action on meat, he investigated the stools of cholera infantum for ammonia, and found it in considerable quantities. But the abnormal bacteria found in cholera infantum are saprophytes, that is, produced by putrid docomposition, and when Baginsky spread meat with the stools of cholera infantum, ammonium was produced in greater degree, as was to be expected from the combined results of different bacteria having a common action. Undoubtedly ammonium in the intestines would be a violent irritant, if in sufficient quantity; but we do not see that its absorption would produce a toxic effect. The experiment, therefore of killing a frog by injecting carbonate of ammonium proves nothing, especially when we recollect how much of this salt can be taken internally by children without harm. Nevertheless, Baginsky's observations are important as showing that cholera infantum is not a specific disease, but depends upon the local and systemic action of decomposition products developed by the action of bacteria upon the food. Children are more susceptible than adults for the reasons mentioned in an earlier part of this editorial, and because in them there is a relative deficiency in the secretion of hydrochloric acid, and the bile contains less bile salts. Holt appears to adopt the view that bile is not an intestinal antiseptic, but the later investigations of Kossel, referred to by Baginsky, indicate that it is.

It is impossible to overestimate the importance of a correct etiology of cholera infantum. Upon it depends the saving of thousands of lives through intelligent efforts in preventing the disease and well-directed methods of treatment. Until recent years too little attention has been given to the food supply as the most important cause. The food may

cause it by being spoiled, as is the case with