form is absolutely contra-indicated, as Dr. Leonard Guthrie has pointed out, that chloroform may itself in case of children, induce a degeneration in the heart muscle, a grave condition when superadded to initial disease. Hypertrophied hearts are in practice usually dilated heart's and should be handled as above.

In extensive arterial disease and in aneurism it is best to use chloroform or one of its mixtures to avoid the increased blood pressure induced by ether in the initial degrees of anesthesia. When apoplexy has occured or is feared, ether should be avoided and chloroform used.

Luke says, "In condition of renal inadequacy, both chloroform and ether are to be used with great caution, for ether congests the kidney unduly, aggravating the albuminuria, while chloroform often increases the degenerative changes in the kidney substances; if there be really advanced renal diseases, they are both contra-indicated.

In deciding in the presencse of renal disease between ether and chloroform we should be influened by th secondary effects of the disease. If, in any case there were pronounced degeneration of the heart muscle, the selection should fall upon ether. If on the other hand, there were any reason to believe that there was a tendency to serous exudation the danger of ether producing edema of the lungs, though its local irritant action would be sufficient reason for the selection of chloroform.

Diabetic patients are bad subjects for chloroform, for after regaining consciousness, they frequently become comatose and die from acetonemia (Luke).

In diabetes mellitus use chloroform. The use of ether in diabetic aptients has been followed by diabetic coma, Hare, DeCosta, Heineck.

Patton says: "The unqualified statement is often made that diabetics take anesthetics well, but the experience of most observers agrees with the statement of Pavy, that if diabetics who are in good condition with little or no sugar in the urine, the administration of anes

thetics is attended without any special risk, but in those who show large amounts of sugar the administration of anesthetics, especially for protracted operations, is liable to be followed by diabetic coma. The patient, therefore, should have careful preliminary treatment; the anesthetic should be chosen with a view to avoiding excitement, after vomiting and complications; the administration should be made as short as possible. Eastes says that diabetics take ether and chloroform well.

Probably the latter or the C. E. mixture is safest for these patients.

L. G. Guthrie has called attention to the excessive fatality attending the use of chloroform in children suffering from chronic fatty degeneration of the liver.

There is sufficient grounds for the generalization that anesthesia should be induced with the greatest reluctance in all persons suffering from chronic fatty degeneration of the liver, and that when anesthesia must be produced ether and not chloroform should always be selected.

Brain tumors and other organic forms of cerebral disease are very serious contra-indications to the use of anesthetics; even where there is no demonstrable brain lesion, if there be reason strongly to suspect atheroma of the vessels, anesthesia should be induced with the greatest reluctance. In a number of cases apoplexy has resulted during or immediately after anesthesia. Moreover, death has often abruptly occurred immediately after the sudden removal of a large cerebral tumor, or the introduction of the finger between the lobes of the brain, or other procedures which af fect the intracranial pressure. These deaths have resulted both from respiratory failure and from sudden cardiac arrest, and are probably the result of the loss of the resisting power of the respiratory and vasomotor centers, making them unable to withstand variations of the brain pressure, which in their normal condition would not serious influence them.

In regard to the choice of the anesthetic in a cerebral case there would seem to be more danger of apoplextic

hemorrhage from the use of ether than from chloroform, on account of the increase of arterial pressure produced by ether, but the persistence of chloroform, the depressing influence which it has upon the heart are much more serious disadvantages than any possible increase in blood-pressure by ether; and in a discussion which took place in the College of Physicians of Philadelphia, November, 1902, a number of cerebral surgeons of large experience were unanimius in asserting that in cerebral surgery ether is the least dangerous anesthetic (H. C. Wood).

Peritonitis, intestinal obstruction, ascites, ovarian cysts, etc., may mechanically alter the type of respiration to the thoracic type. Anesthetic must be carefully given. C. E. followed by ether is the anesthetic of choice. Patients with marked intestinal obstruction are bad subjects for anesthetics. The stomach is frequently not empty, they vomit readily and syncope and collapse are frequent; nitrous oxide is not admissa

ble, chloroform or C. E. followed by ether is the preference. Exhaustion, shock and collapse are frequently present when the necessity for anesthetization arises. As a rule such patients require small amounts of anesthetic, especially when there is exhaustion from chronic disease. The pulse is generally improved by the anesthetic, but depression may follow its withdrawal. Eether, cautiously given, by an open inhaler, is very satisfactory. McCardie thinks that ether is strongly indicated in shock or collapse. Subjects suffering from chronic nervous diesase are liable to respiratory disturbances during the administration of an anesthetic. Epileptic subjects may be safely anesthetized. There may be a tendency to muscular spasm, or epileptic paroxysm may occur during the early part of the administration. Ether is probably the best agent generally for patients with nervous diseases. According to Savage, the insane take anesthetics well and take the various anesthetics with equal safety. Chloroform produces marked after effects in mani

It is a statistical fact that more real harm is done in every community by the so-called mid-wife and more deaths di

rectly produced by her meddlesomeness than from all other misfortunes combined, in confinement cases: Especially is this true in Mormon communities where the woman posing as mid-wife is the main support of a large family, as is usually the case, and is therefore required to do the housework, scrub, milk the cows, make the bread, clean the stable, chop the wood and incidentally act as accoucheuse.

The Mormon woman posing as midwife is, unfortnately, not the only offender though she may personally be responsible for a large number of deaths. traceable to her unclean hands and meddlesomeness. She surely should not be blamed when she is uneducated, does not know that she is doing any harm, imagines she is qualified in every way; she is permitted to ply her dangerous vocation and no well directed attempt is made by the law makers nor by legal medical practitioners to prevent. Her education is usually limited to a knowledge of how to provide for a large family by good hard labor and she possesses only in rare instances the ability to read or write; why should she be censured for what she does not know and could not possibly learn? Her hands are nec

*Read before the Sunshine Society, Challis, Idaho, as being the best possible method of giving it rapid and wide circulation and wonderful possibilities of enlargement.

essarily unfit for the work of assisting around the bed of a confined woman; her daily work as housewife and utter ignorance of the necessity of surgical cleanliness only add to the danger but do not lessen the frequency of her attendance on obstetric cases.

In the great majority of cases the confined woman presents purely a normal condition and requires no interference; would be vastly better off without a doctor, even though he be a qualified one. The case being a normal one should require no examination; in fact each examination made, whether by a qualified physician or a sublimely ignorant so-called mid-wife, endangers the life of the patient. The mortuary record would be much less appalling if physicians and laity alike could be taught to refrain from making a normal parturient canal a dangerously abnormal one by exploring with uneducated and improperly cleansed fingers.

The routine practice in the country is as follows: Dr. arrives at a breakneck speed, jumps out of buggy, gets his grip out and nearly dives into the house (just why I never could quite understand, unless he is afraid the case will get away); overcoat and gloves are practically torn off and hot water called for. At about this juncture somebody hunts for and may find a bowl for his use instead of the wash basin the family uses regularly, this is done presumably because it is the general impression that doctors are more cleanly in their obstetric practice than the laity (just why this should be generally believed is another of the things I don't understand). The bowl or basin being produced a little water is slushed around in it and thrown out and then the surgical cleansing (?) of the hands begins; one, two, three, maybe a half-dozen half-dozen good rubs and splashes and an extra dip or two for good measure and while he is wiping his immaculately clean (?) hands on the towel which has been especially kept for his advent upon the scene the old lady who has been there for several hours in order to notify the people when the opportune time arrived

to send for the man of science tells him: "Everything is all right doctor, the womb is dilated and the baby is all right; I told 'em it wasn't no use to send for you but she wanted a doctor because her sister died last week when she was confined and it kinda skeers her." The dear doctor now proceeds with deep wisdom depicted on his grave countenance to make the examination so essential to making a show of earning his fee and agree with his equally meddlesome associate in the crime that "everything is all right" probably adding that the "cervical dilation is progressing nicely and the presentation is normal." This adds much to the impression made anyway whether he really knows what he feels or not. Another dip into the wash bowl and the doctor goes out to see if the overheated team has been properly cared for, his big sympathetic heart is touched with feeling and he yanks off his coat and goes after the horses with an old gunny-sack, dries them nicely, gets the pitchfork and cleans out the stall, puts in some dry straw, curries the horses and goes back to the house. Another little wash now which may or may not remove the little tetanus germ or another material accumlated upon his hands, another examination to note progress, a chat of half an hour and a pleasant smoke, another examination; then the appeal from the sufferer: “Oh, doctor, can't you give me something, I can never live through this, won't you give me chloroform?" Another hour or so and the doctor gets busy. He puts the obstetric forceps on to boil, puts his pipe away, rolls up his sleeves, (forgets to remove his ring) gives his woman assistant some learned discourse on the importance of the surgical operation about to be undertaken and some special pointers on the administration of chloroform by the most recent method, takes another dive at the wash bowl and as soon as the anaesthetic seems to have done its work the forceps are applied and the cause of all the work and worry is brought into the world. The cord is now tied and the babe is given to the handiest woman to give further atten

tion; a dose of ergot given to the mother (of course not until the doctor has carefully wiped at least his right hand on the towel which was placed on the bed within easy reach for him) and the placenta receives the undivided attention of all present, except the woman who is washing or greasing the baby; some suppose disease has apparently been at work inside the womb and theafter-birth does not act right so one or two or more fingers must be introduced to discover why; after a time part or all of the placenta is removed. The mother's pulse is now carefully taken and mental note made of same and after some preliminary arrangements the doctor makes his departure; still in a big hurry. At the office or in one of the rooms of his residence he uses for that purpose he makes a book entry.

Jan. 9, 1896. Mr. J. debtor to Dr. W. $100 for services rendered in confinement case, surgical operation. Note -Mother and babe doing nicely.

A resume of the affair two days later would show this:

The doctors team not much the worse for the trip, owing to the doctor's care of them at the proper time. Mr. J. quite well except for the grief which would be very natural in him as he is human. House of representatives still passing laws and drawing their pay. The old woman who made the first ten or twelve examinations of the patient not feeling very well on account of loss of sleep. The doctor as well as usual and the state medical board in good health. The new-born baby living. The mother dead.

Notation in the doctor's book January 12. Mrs. J. died yesterday at 5 p. m.; a very peculiar case; "inflammation of the bowels cause of death."

Now who killed her? The meddlesome old woman? The doctor? The legislature? Or was it just the state board of medical examiners?

Fortunately the foregoing citation is not the rule among doctors who are called upon to attend confinement cases in a country practice but it is astounding how often this or some equally care

less method is adopted and by men who are not careless because of lack of technical knowledge; just why they are careless at all in these cases I am unable to guess unless possibly upon being informed that some woman has made the field dangerous the practitioner realizes that no effort of his will avail to correct the condition and an effort on his part to obtain and maintain surgical cleanliness would be wasted energy.

I am thoroughly well satisfied that any man who has successfully passed

an

examination by the present state board of medical examiners and been granted a certificate to practice medicine in the state of Idaho is qualified in every sense to properly attend a case of confinement with absolutely no risk to the patient from septic conditions produced by carelessness on his part.

With every known precaution he may take their occasionally occurs a case of blood-poisoning where no interference prior to his arrival has been committed and in such a contingency it ought to teach him to not get meddlesome; but if he must make any kind of an examination to do so only under the most rigid aseptic conditions. The fact that most obstetric cases recover from the normal condition regardless of the numerous and unnecessary examinations by both the attendant old woman and the doctor does not justify the doctor in being careless of his actions and in no wise should the fact be used to palliate his conscience in case he has even a death in ten years that might be credited to his making an unnecessary examination with improperly and insufficiently cleansed hands.

While probably the parturient canal is not so easily infected as an open wound it only seems just to our patients that we give them every opportunity to recover without any infection from our neglect to do our duty as we know it. No examination should ever be made of the vagina during a confinement unless it is absolutely necessary and then only under aseptic conditions, as near as we may attain them. My belief is that it is a serious error to take chances on de

livering with forceps simply to lessen the suffering of the patient or to save time, my rule is to use forceps only when I am convinced that due to some abnormal condition the delivery may not be consummated without interference, or when the life of the mother is endangered. It matters little how we strive to attain asepsis the proof is constantly before us in the reports of the most able men that they sometimes fail and therefore so may we, then why take the chances of promiscuous use of the forceps? Better give nature a fair chance to finish the work she so successfully has carried to that point and not let our knowledge of the use of instruments give us something to be conscience smit

ten over.

OPSONINS.

There is perhaps no subject which, in recent years has been more prominently before the medical world than that of Opsonotherapy. The object of this paper is not only to give a general idea of this work as it has been done in our laboratory; but also to consider whether or not this great interest has been justified from the practical results which have been obtained up to the present.

Before entering upon a discussion of the subject as suggested above, it will hardly be out of place at this time to give a brief account of a few of the underlying principles of immunity which had been worked out before opsonins were discovered.

It has been generally known for many years, that following an attack of certain of the infectious diseases there remains a certain amount of resistance to a second attack of the same disease. Jenner knew this, and when in 1798 he obtained immunity against smallpox by vaccination, he was simply attempting to put this principles into practical use. Later on Pasteur tried to bring about immunity from other diseases by the artificial inoculation of attenuated or killed cultures of the micro-organisms, which had been found to be the cause of these diseases. We can hardly enter here into the work he did and the success he

obtained in certain diseases of animals, although we are familiar with the success he had in immunizing against hydrophobia. The length of the incubation period and the accuracy with which the date of infection can be told make rabies especially suitable for such a form of treatment. But, since immunization can be begun in most infections only after the disease is manifest, it was thought that the inoculation of attenuated cultures would only add a mild infection to the more severe one, so for a long time this method was given up in the treatment of infectious diseases. The nature of immunity has been the battle ground upon which many scientists have fought and bled for the past twenty-five years, the chief leaders of the two opposing armies being Metchnikoff and Ehrlich.

Metchnikoff claimed that the leucocytes were the chief defensive of powers the body and that it was upon the activity which they displayed in engulfing and thus destroying the invading germs that the resistance of the individual depended. Ehrlich, on the other hand. thought that the fluids of the body, especially the blood serum, contained substances which, being increased during the process of healing, had the power of neutralizing or destroying the toxins of germs which were causing the disease.

When Denys, Denys, Bordet and other French observers discovered in the blood serum substances called "stimulins,” which they thought stimulated the leucocytes to phagocytosis, they, to a certain extent, brought harmany between the two great leaders.

It was to these so-called "stimulins" of the French writers, that Sir A. E. Wright gave the name of opsonins (opsono, I prepare the food for). He also showed that these opsonins did not have any effect upon the leucocytes, but that they united with the bacteria and got them in proper shape, so that they would be ingested and destroyed by the most fastidious leucocytes. Opsonins, therefore, are substances existing in the blood, the function of which is to act upon the invading bacteria and so pre