physicians and surgeons. The Supreme Court of Pennsylvania held in the case of McCandless v. McWha, that the skill that was required was such "as thoroughly educated surgeons ordinarily employ." This is now denied by the weight of authority. As to what constitutes a "thoroughly educated surgeon" would be left to that eminently qualified body, a petit jury.

The Supreme Courts of the States of Indiana, Massachusetts, Wisconsin, Iowa, and Pennsylvania have held that the locality in which the physician or surgeon practices should be taken into account; and that one living in a sparsely settled district is only bound to exercise the average degree of skill possessed by the profession generally in such locality. This I cannot concede to be the true rule to govern either the profession or the public. It localizes ignorance, and makes it a protection for those who have not acquired and do not care to acquire any higher or greater degree of skill. Ignorance and want of skill should not be made a question of geography.

I hope to see the day come in Ohio when the requirements of the legislative standard are made so high for an entrance to the profession that the very possession of the required certificate will be a sine qua non to the world of the skill of its possessor, and that he will only be held bound to give to his patients the results of his best judgment.

To an enlightened bar you are compelled to look for a more charitable judgment upon your actions. You, as members of so noble a profession, can claim no privilege of absolution for wrong-doing. This is more than you ask. Rules of law, which should be certain and definite, must govern all our relations in order to insure mutual protection to the personal rights of each member of society; and surely none would seek, in any profession, to be exempt from the laws which govern all. It was unwise, illogical and wrong to hold the surgeon liable for errors, and to withhold from him the protection of the law in the procurement of material for the dissecting-room. The day of such hysteric legisla

tion is passing. Your profession is being viewed with more favor by both the legislative and judicial branches of the government. Upon questions affecting your rights and interests the courts are employing the powers confided to them with prudence and moderation, and when they are called upon to intervene between you and the public, to preserve the rights of each, they judge you with caution, not hampering the advance of your science nor delaying its onward progress. To an enlightened bar, and to the wisdom and honesty of the bench, you can safely trust the highest interests of your personal and professional welfare.

The Effect of Rest Upon the Progress of Septic Infections

By A. J. OCHSNER, B. S., F. R. M. S., M. D., Chicago Surgeon-in-chief of Augustana Hospital and St. Mary's Hospital, and Professor of Clinical Surgery in the Medical Department of the State University of Illinois

My subject is so old that it scarcely seems worthy of your attention at this time, for I believe every surgeon will admit at the outset that absolute rest is theoretically one of the most important means to be employed in the treatment of conditions which are due to septic infection. In practice, however, my observations have taught me that this condition of rest is but rarely secured, and but seldom systematically striven for, except in the treatment of inflamed joints; and for this reason it seems worth the effort once more to direct attention to this important therapeutic aid.

In the clinical observation of septic infection in any part of the human body, no feature stands out so prominently as the beneficial effect of rest applied to the part involved. It seems most important for the practical surgeon not to overlook this, because its recognition must point out the proper treatment in many of these cases,

Sepsis is extended by the lymphatic circulation, and to retard as much as possible the circulation of lymph by inhibiting motion of the surrounding structures is an important aid in keeping the sepsis localized, and in causing the infection to subside. If through a free incision the lymph-stream is directed away from the body the infection subsides, the infectious material being no longer in a position to do harm. These features can be observed most readily in infections of the extremities resulting from pin-pricks, scratches, dissecting-wounds, etc. A most simple infection of this kind may become exceedingly violent, if the patient continues to use the extremity and thus forces the infectious material through the body, for we know that the muscular contractions force the infectious material through the lymph-channels toward the body. The infectious material may progress slowly or it may advance with great rapidity. If, for instance, it is at the tip of a finger, it is very likely to enter the palm of the hand unless the extremity is kept at rest. Further motion, extending over a period of a few hours, may force it into the forearm. In the same manner it may be forced on into the arm and then into the axilla.

Without this pumping of the septic material through the lymphatics by means of muscular contraction, the septic material would have caused the formation of a small circumscribed abscess, which might contain a drop of pus and whose emptying by a slight incision would be followed by a rapid

recovery.

In one case the new field of invasion gives greatly increased vigor in the activity of the septic microorganisms; in the other its confinement to a circumscribed location seems to make the microorganism harmless.

Every practical surgeon has made the following observation upon patients many times and probably also upon himself. A slight infection of the finger occurs from a prick with a needle or from some other slight injury. During the day the finger and even the hand become painful. The next morning the pain has entirely disappeared and the patient

imagines himself well; but during the day the pain returns, possibly a little more severe than the day before, and, on the following night, it again disappears, only to a less extent. After a few further repetitions, a serious infection may become established, resulting in the destruction of a considerable amount of tissue, which will probably be followed by a marked impairment of the function of the extremity.

The explanation is very simple. During the day when the extremity is frequently moved the infectious material is carried from its circumscribed area to the points further up the arm. The following night this progress is again inhibited, and there is a corresponding diminution in the symptoms. If the rest is continued, the progress is permanently inhibited, and the patient recovers completely. If this is not done it will ordinarily progress until the patient is so ill that rest is compulsory.

I have had all the histories of cases of serious infection of the hand which have been treated in the Augustana Hospital during the three years from January 1, 1899, to the present time, reviewed (52 cases in all) in order to illustrate this principle. I find that all those cases which came under treatment at the hospital before incisions had been made, recovered without deformity or stiffness of the fingers, while of those which had been treated without being kept at rest, in which abscesses had formed and had been drained by free incision previous to their admission to the hospital, a considerable proportion recovered with more or less deformity, some with very severe deformity and with more or less impairment of function. In the cases that were admitted to the hospital, the treatment consisted in obtaining as nearly as possible complete rest for the extremity, by placing the patient in bed, applying a large dressing composed of sterile gauze and absorbent cotton saturated with a mild antiseptic solution. The solution most commonly employed being hot saturated solution of boric acid, to which one-third by volume of strong commercial alcohol had been added. The whole dressing is covered with oiled silk or rubber cloth. Even in cases

in which only the end of a finger is involved the entire extremity up to the shoulder is included in the dressing. This makes motion of the extremity almost impossible. It is likely that the hot moist antiseptic dressings are beneficial in themselves, but I am positive that the enforced rest is of equally great importance, because if this part is neglected a rapid and perfect recovery does not occur.

The value of this treatment can be seen from the fact that in this entire number of 52 cases there was not one in which the infection was not inhibited in its progress. Moreover there was not a single death, although among this number many patients were brought to the hospital. in an extremely septic condition with high temperature and pulse and frequently delirious.

Aside from the treatment by means of enforced absolute rest on account of the large moist dressing, the general hygiene of the patient was always given proper attention. The elimination was encouraged by means of cathartics, and proper nutrition was employed. There can be no doubt but that the moist antiseptic dressing and the hygienic conditions had something to do with securing such satisfactory results, but in cases in which all of these measures excepting rest had previously been employed without benefit, speedy improvement followed as soon as the element of rest was added.

The dressings were never disturbed more than once in 24 hours, and usually they were left in place for two to four days, fresh fluid being poured upon the dressings every six hours.

For a time we attributed most of the good result to the action of the antiseptic fluid which was applied, but I am more and more impressed with the greater part which rest has to do with the improvement of these infections. I have observed frequently that an examination accompanied with much manipulation for the purpose of determining any points` of fluctuation would invariably result in an increase in the infection.