sufferers from "adenoids" frequently belong to an abnormal constitutional type that has been found peculiarly susceptible to chloroform narcosis.

3. In view of the statistical and pathological data presented, the general use of chloroform in the operation for hypertrophied tonsils or naso-pharyngeal adenoids is inadmissible.

Gottstein Curette in Position for Removing Adenoids.

But despite these facts, chloroform presents so many advantages in anesthetizing young children that I dare say it will be but slowly superseded by any of the other and generally regarded safer anesthetics. In my operations I have always used chloroform, but will confess that its convenience and adaptability for children have chiefly induced me to rely upon. it. In operating on older children local anesthesia with a 10 to 20 per cent. solution of cocaine may be used; or, what certainly appears a somewhat barbarous custom, the child may be held by an assistant and the adenoids removed without any form of anesthesia.

To relate a typical case :

The patient, a boy aged 2 years, was brought to me with the statement that he slept interruptedly and with his mouth open. He would start up in bed as though suddenly affrighted. At intervals he bled a little at the nose. The boy was fairly well nourished, but pale. He constantly kept his mouth open, and his voice was decidedly nasal. Wrapping a napkin around my finger for protection, I ran it back of and up behind the soft palate, where it encountered a soft, irregularly-surfaced mass, and on the withdrawal of my finger the end was found covered with blood. The child being chloroformed, I passed a Gottstein curette into the pharynx and removed a quantity of adenoid tissue. I then scraped the

vault of the pharynx smooth with the nail of my forefinger. He was then put to bed for twenty-four hours. The general physical improvement of this child during the next two or three and successive weeks was remarkable to note. He now has no further difficulty in breathing, all of the symptoms mentioned having disappeared, and he is otherwise quite well.

It is remarkable to contemplate the physical and mental change wrought in an adenoid sufferer after operation, and each operated case is an object lesson. It is also interesting to note that Francis, the observer already mentioned, has reported in the Australian Medical Gazette, January 20th, 1898, four cases of severe petit mal in children entirely and promptly cured by the removal of adenoids. Besides, this author quotes frequent and well-authenticated cures of nocturnal enuresis after the removal of adenoids, and he reports a case of severe asthma in a child cured by him with a similar operation.

In closing this paper, permit me to urge that the examination of the pharynx for adenoids be made a part and important feature in the routine examination of every child presenting the least indication of this condition, and in the light of the experience of others, it would not be inadvisable to look for pharyngeal tonsil hypertrophy as a reflex cause of many recognized disorders of infantile and juvenile life. Continental Building.

WHEN TO ASEPTICIZE IN MIDWIFERY.*

BY E. E. HAYNES, M.D.

MEMPHIS.

It has seemed to me that in an association of this kind it should be the endeavor of the members to present, where practicable, such subjects as shall touch upon the daily labor of the greatest number rather than the curious and exceptional phases of medical experience. It is with this idea that I present this paper.

It may seem to you that such a subject has been fully treated, and that consideration of it now would be but trampling upon ground already thoroughly discussed. Certainly

*Read before Tri-State Med. Assn. (Miss., Ark. & Tenn.), Memphis, Dec. 21, 1898.

there is no subject of which the physician should have a more practical knowledge. For every child that is born there should be some competent person to attend the mother at that critical period. Mismanagement of the lying-in patient will, and justly so, injure the physician's reputation in his community more than anything I can now think of. Therefore it is very necessary that we understand fully the management of a condition we are so frequently confronted with.

What I wish to impress upon your minds is as to the proper time for the use of antiseptics, and the importance of asepticizing in obstetrical cases. I am satisfied that there is no condition more overtreated than the puerperal state. I am also of the opinion that in too many instances they are treated as if the puerperium were a diseased condition instead of physiologic.

I shall confine my remarks to normal labors, for to get out of that path would necessitate too voluminous a paper.

My experience has taught me that the proper time to asepticize is before parturition. In normal labors there is no pathologic condition present in the uterus to cause septic infection. The parts to be rendered aseptic are the vulva and vagina. The vagina is the habitat of many bacteria, and it is through this organ of generation septic material must pass before infecting the patient. If called upon to open the abdomen for any condition the surgeon and assistants first render their hands aseptic. All instruments, dressings and towels are asepticized. The abdomen is thoroughly cleansed. With these precautions we can proceed with the operation, fearing no septic infection within the abdominal cavity. We would not think for an instant that it would be necessary to use antiseptic irrigations in the abdominal cavity in the absence of septic material, nor is it even necessary to irrigate the abdominal cavity every day after the operation.

First see that the woman has a bath, and that clean clothes are put on. They too often leave on their soiled gowns, reserving their clean ones to put on after the birth of the child. Have her take an enema to empty the rectum of any fecal matter. See that the bed is clean. All these instructions should be given the patient some time before the expected

time of delivery. Thoroughly cleanse your hands and place your patient across the bed, introduce a Sims' speculum into the vagina, and with green soap and water cleanse the vulva and vagina as you would when preparing to do a curettement or any operation in the vagina or uterus. After scrubbing the vulva and vagina thoroughly with soap and water, take a 1-2000 solution of bichloride of mercury and rinse out the vagina. This being done your patient is now in a safe condition to be delivered. When examining your patient from time to time always immerse your hands in a 1-2000 bichloride of mercury solution before making the examination.

Remember that puerperal fever is produced by microörganisms which get into the system through wounds made in childbirth, and that these organisms are transferred by contact. The transference of organisms is prevented by cleanliness, and the organisms are killed by antiseptics. The hands are the usual poison-bearers; next in frequency, clothes and instruments. Therefore, if your field of operation is clean to start with (and I claim that before delivery is the only time you can thoroughly cleanse the vaginal canal), and your hands are clean, you have nothing to fear during the lying-in period.

Now, your patient being delivered and cleansed of whatever discharge on the person, the soiled gown removed and replaced by a clean one, you place an aseptic pad over the vulva, made of sterilized gauze or cloths that have been sterilized, and to be replaced by a similar one when necessary by the nurse, who has been instructed as to scrubbing her hands before touching the patient or pad, and to be instructed that everything that touches the vulva is to be aseptic, your patient, with the proper diet and attention to bowel movements, is ready to await in safety the proper day to get out of bed, and do not subject her to the extra risk of infection by giving her douches every day.

If your cleansing has been faulty, and you have left microorganisms in the vagina, and after delivery your patient develops a septic fever, do not delude her and yourself by hiding behind a douche, occupying valuable time with the hope that it has happened that you have washed away

the septic material. This cannot be accomplished by mere irrigation with antiseptic solutions, for the uterine cavity is lined with debris, the surface only of which is affected by irrigation, while in the deeper portions germs continue to multiply and ptomaines develop. The proper plan of procedure would be the curetting of the cavity of the uterus with a sharp curette, subsequent irrigation with sterilized water, after which, in order to make sure of separation of the uterine walls and thorough drainage of the cavity, the uterus should be packed with a good-sized twist of iodoform gauze. This serves several purposes; it affords drainage through its capillary action; it keeps the surfaces of the uterus apart; it stimulates increased discharges of serum and consequent depletion of the walls, and, finally, by its presence as a foreign body, it stimulates uterine contractions, thus diminishing the facility with which the material can find entrance into the sinuses.

If, however, the cleansing has been thoroughly done before parturition, and clean hands have attended the patient during the lying-in period, and douches have been left alone, the curettement will not be necessary. Douches, bearing any antiseptic in solution, do but wash away the accumulated discharge, and do not invade the folds of the mucous membrane, the place where microorganisms and ptomaines find lodgement and make their fatal entrance into the system.

Johnson Building.

REMARKS UPON THE TREATMENT OF HERNIA, STRANGULATED AND REDUCIBLE.*

BY F. D. SMYTHE, M.D.

Attending Surgeon City Hospital.
MEMPHIS.

The surgeon is confronted with but few conditions requiring what might be termed operative interference of a capital nature, as in the case of hernia. It is not my purpose to quote statistics showing the percentage of the human family thus afflicted, but I will endeavor to impress upon the Asso* Read before Tri-State Med. Assn. (Miss., Ark. & Tenn.), Memphis, Dec. 21, 1898.