praise too much the treatment followed in the cases which get well, nor condemn too much the treatment followed in those which do not.

DISCUSSION.

DR. SAMUEL M. GARLICK (Bridgeport): Dr. Monagan has presented the subject of puerperal sepsis in manner not only enlightening but also in a way that appeals to the general practitioner. It is well that it is so, for, after all is said and done, it is the general practitioner of medicine upon whose knowledge, skill, and art the community must depend for the preservation of health and upon whom the sick must rely for restoration to health.

No more important or sacred duty can fall upon any one of us than is that of the obstetrician, upon whose wit and wisdom must depend the health, even the safety of the mother, the life and well-being of the child, the permanent and enduring life of the community. Permit me to ask if it is well that we as physicians, and Connecticut as a state, are committing so much of all this care to half-educated and mostly foreign midwives?

Dr. Monagan strikes the keynote in his first sentence, "The ideal treatment .. is preventative." To whom are we delegating that prevention?

In giving all due credit to the young German, Semmelweiss, we must not forget a young American whom we all delight to honor, a man of careful observation, accurate interpretation of facts and the logical deductions therefrom, my honored instructor in anatomy, Dr. Oliver Wendell Holmes.

As early as 1843 Dr. Holmes strenuously maintained the contagiousness of puerperal fever and was laughed to scorn by the Philadelphian authorities of that day. At that time Philadelphia was perhaps the center (in America) of the greatest influence in medical opinion and medical education. Just then Samuel Gross was coming forward from his comparative seclusion in eastern Pennsylvania, and his star was rising to be the brightest in the galaxy of early American

surgeons.

Neither Von Ziemssen or his American editor, Albert H. Buch of New York, as late as 1878, refer to Dr. Holmes's work: both tentatively admit the probable truth of the infection theory, but are "opposed to the teaching" of Semmelweiss in its too strict limitation.

Concerning the gloved hand I would say that since the pathogenic microbes are found mostly without the introitus vagina, it is not so much a question of gloving the obstetrician's hand as it is of general cleanliness. And, indeed, while I would not abate an iota of the need

ful care in all cases of labor, I am far from convinced that every maternity case should have the same preparation and management as does an abdominal section. It has often appeared to me that the modern woman with an highly apprehensive organism, and brought up in the habits of our greatly complex and strenuous life, is often brought to the verge of, if not actually into a state of, nervous breakdown by the anticipation, worry, and fear engendered by such elaborate, detailed and expensive preparation. I am sure that equal care, more simplicity with less apprehension, conduces to a more healthful condition, less complicated labors and a more natural puerperium.

In case of inducted or accidental abortion I have found the curette, both blunt and sharp, very useful if wisely used. But even here it should not be used indiscriminately, nor without due aseptic precaution and with antiseptic surroundings. So often has my hospital service shown me the bad effects of indiscriminate or routine curettage that sometimes I am led to cry out, as did Dr. Emmett about his vaginal douche, "I almost wish it had never been introduced." In cases of sepsis after premature delivery or labor at term, I have found it an even more dangerous procedure. It should be resorted to almost solely in cases of sapræmic origin.

Antistreptococcic serum has been only disappointing in my hands, or under my observation. With autogenous vaccine treatment I have had no experience. Two cases of hysterectomy for septic metritis have proved fatal, as they would have done anyway, because of the already extended parametric and pelvic infection. With unguentum crede I have had no experience.

A healthful and hopeful attitude on the part of the patient, cleanliness and care on the part of the attendants, intravaginal manipulations limited to that which is necessary and useful, ergot at close of third stage, continued later if necessary, the hot cleansing douche, vaginal or intrauterine or both on the first symptoms of infection, then swabbing the endometrium with iodized phenol, open bowels, enteroclysis (à la Murphy), ichthyol and cold externally, in conjunction with a tonic and supporting and symptomatic stomachic treatment, have served me personally very well and few indeed have been my cases that have come to the gynecologist.

I thank Dr. Monagan for his excellent and practical paper, as indeed I thank sincerely any one of our number who takes the time, and is at the labor and effort to prepare and present such a paper.

DR. THOMAS G. SLOAN (South Manchester): I recently saw in consultation the case of a woman who had been delivered by a very careful man, using all antiseptic precautions. He wore rubber gloves, and saw that no nurses came in contact with the patient in a way to infect her;

yet in eighteen hours she had a chill, and her temperature then went up to 104°. She died at the end of ten days, of puerperal septicemia. It did not seem that she could have been infected by the man who delivered her. A nurse, who was put on the case several days after delivery, got an infection. Where the infection came from it was impossible to say, except from the vagina. I do not think that any douches were used previous to the confinement. A sister of the woman, and also her mother, had both died in the same way, of puerperal septicemia.

DR. ALLEN H. WILLIAMS (Hartford): Dr. Garlick's discussion, admirable in other respects, I disagree with in one point-the worry and danger of scaring the patient by taking antiseptic precautions. Any man who remembers the frightful cases of puerperal septicemia seen in hospitals, though they do not often occur in private practice, will agree with me that there is no precaution that should not be taken to prevent them. If the patient realizes that she is going to go through an illness, and that perfect cleanliness will insure her recovery, she will be very glad to have clean sheets, clean drawers, and sterile stockings. She will not be scared by these precautions when she knows what they mean. The boiling of the instruments can be done out of the room. Care of that sort will not scare a patient, if it is properly explained to her.

The Surgical Treatment of Gastric and Duodenal

Ulcers.

EVERETT JAMES MCKNIGHT, M.D., HARTFORD, CONN.

The occurrence of three cases of perforating ulcer, two of the duodenum and one of the stomach, in the private practice of the writer within a short space of time, suggested the subject for this paper. We shall endeavor to discuss impartially the relative merits of medical and surgical treatment with reference to the cure of the ulcer and the prevention of complications and sequelæ, with some consideration of operative procedures.

Leube has said that one-half or three-fourths of all cases of gastric ulcer will be cured by four or five weeks of medical treatment, but if not cured by that time they will not be cured by medical treatment alone. With this statement we agree, and it is probable that the percentage of cures of gastric ulcer by this means would be far greater if an early diagnosis could be made in all cases and appropriate treatment instituted. Failures are often due to the fact that the medical attendant does not realize the gravity of these conditions and does not sufficiently impress upon the patient the importance and necessity of a rigid discipline as regards dietetic, hygienic and medicinal measures.

In duodenal ulcer, which occurs, as we now know, much more frequently than was formerly supposed, while probably some cases may be relieved by medical treatment when detected early, it is doubtful if many are cured by such means after the ulcer has progressed to the point where it can be recognized by definite symptoms. Statistics in relation to the results of medical treatment of ulcer are in the main unsatisfactory, in that the results of different reporters vary between such wide limits and they are often misleading, as relapses so frequently occur in cases reported as cured.

Mayo Robson, in Keen's Surgery, states that gastric ulcer recurs or relapses in at least two-fifths of the cases which are apparently cured. When we consider that this does not take into account the after results, the complications and sequelæ, we can readily admit that the percentage of cases actually cured is much smaller than is generally supposed. Robson estimates that in hospital patients between one-half and twothirds of the serious cases relapse and that the percentage of real cures is under 25 per cent. He adds that we may on ample evidence accept the fact that at least 50 per cent. of all cases of ulcer of the stomach treated medically ultimately succumb to the disease, or to one or other of its complications.

Deaver, in a recent article (American Journal of Medical Sciences, May, 1910), states that the mortality of gastric ulcer treated medically is about 20 per cent., that at least 50 per cent. of so-called cures relapse and that probably not 25 per cent. of patients treated medically are really cured.

Turning now to the results of surgical treatment, in Robson's 300 operations of various kinds for ulcer of the stomach and its sequelæ which had failed to yield to medical treatment, a total mortality of all operations in this worst class of ulcer, including hourglass contraction and hemorrhage but excluding perforation, was only 3 per cent., and the cases completely relieved of all symptoms were over 90 per cent., a proportion which he states will be still better as experience increases.

Moynihan (Proc. Roy. Soc. Med., 1910, III, Surgical Section, 79) reports 197 cases operated upon from 1900 to 1908. There were II cases of perforating ulcer, with 3 deaths; the remaining 186 cases were for chronic ulcer of the duodenum or stomach or both; 78 were treated by posterior gastroenterostomy with simple suture and 84 with infolding of the ulcer and posterior gastroenterostomy. The mortality was 2.15 per cent.; 79 per cent. were cured.

In the report of Saint Mary's Hospital, Rochester, Minn., for 1909, we find that there were 43 gastroenterostomies for chronic gastric ulcer and its results, with 42 recoveries and I death; 58 gastroenterostomies for chronic duodenal ulcer, with 57 recoveries and I death; 4 gastro-gastrostomies for