Many of us say we never had a case of puerperal infection. But we are confounding mortality and morbidity. We have had a patient frequently on the third or fourth day with a little fever, and we know we have infected the patient. Finding our patient with only 100 degrees of temperature instead of 105, proves us none the less guilty of that morbidity, caused I believe, through our frequent improper examination. You know why we make most of our vaginal examinations; it is because we are in a hurry to get home. We want to see how much the last pain has brought down the head, and if the bag of water is ready to rupture, or something of that kind. I think that not a paper will appear on the program to-day so important as this, and one lesson we should bring home to ourselves, is, that we have been lying to ourselves and to our brethren about our record on puerperal infection.

Dr. Loomis: I agree with the statements of the writer of the paper. I examine externally with the hope of educating myself to obtain the position of the fetus without the digital examination. But when in doubt I do not hestitate to make the digital examination, with clean hands and a clean body; then I cannot believe we are in any very great danger; but I think we should all educate ourselves by the external examination to obtain these points definitely and so avoid as many digital examinations as

we can.

Dr. Leith: One point has not been touched on that might be brought out. I refer to the use of the stethoscope in these cases. If you have never used it, try it, and you will be able to predict the sex of the child before that child is born, and if you did not have the confidence of the people before, you will certainly get it at that time. I never found a case yet (and I do not care how thick the abdominal wall was) but that I could find the fetal heart-sound with a stethoscope. But you cannot always detect the fetal heart-sound with the ear without the stethoscope. It

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may be that some of us have more acute ears than others—I think that mine are rather acute. I have correctly predicted the sex many times from the number of heart-beats per minute. If you never tried it, try it. If the heart beats about 140 per minute, or over 140, you will pretty nearly always find a girl; or else a very small boy, you can get out of it afterwards by telling them that. If you find the fetal heart-sounds about 124 to the minute or less than 130, you tell that family they are going to have a boy. Now this is not something that I have tried only once or twice. I was first told that by Professor Edgar of New York City, who probably does as much obstetrical work as any man in this country. It is not always that you are right, but you are nearly always right. I have tried it many times and nearly always it succeeds, and the stethoscope you will find is a pretty good thing to have along at such times.

Dr. Kaumheimer: I would like to take issue with Dr. Evans in his statement that all cases of rising temperature after the third or fourth day, indicate infection. We find cases on the third day, when the milk comes in, that show temperature which disappears in 24 hours without treatment. We must remember this patient has gone through a severe trial, through severe muscular effort, the placental site is filled with sinuses, filled with thrombi, a large uterus weighing from a pound and a half upward is undergoing rapid involution and the absorption is very active. These materials, which are more or less toxic in their nature, are thrown into the blood, and there is no doubt in my mind that we can just as well have an aseptic fever (and I do not mean the reactive fever due to increased muscular effort after labor) under these conditions, as we can have an aseptic fever after a fracture of the tibia. The fever is due to the increased absorption of products of the retrograde metamorphosis of the uterus, and of the pelvic structures generally, which we are told in pregnancy are hypertrophied. I do not doubt but what Dr.

Evans, as well as others, has seen such cases which disappeared inside of 24 hours or more, without the least treatment, and in which the patient insisted in spite of the most close questioning, that she felt firstrate, cases in which there was nothing to indicate anything wrong except the temperature. Such cases I think we can hardly call infection.

Dr. Scollard: I am very glad to see that the gentlemen and ladies who have discussed this subject, recognize its importance, and the possibilitiy of conducting these examinations externally instead of by digital manipulation.

Now I did not intend at all to say that no vaginal examination is necessary, but I did intend to say that not one-tenth, or much less of the number of examinations per vaginam that have been made are necessary, and I did intend to say that the unnecessary repetition of these examinations is in itself pernicious, and that that is the chief cause of infection taking place, when it does take place, in most cases.

I will admit that no one is so skilful that he can make an examination of every case by any method and always be correct, but the point that I wish to emphasize is that this method of examination will give a correct diagnosis in the vast majority of cases and render repeated vaginal examinations unnecessary. These patients should be given to understand that the doctor is not doing anything for them except the possibility of something harmful, when he makes repeated vaginal examinations, and the repetition of such examinations is simply an index of his inability to make a correct diagnosis in a harmless way.

Now the occurrence of fever on the third or fourth day, I think is always an indication of infection. The rise of temperature which occurs in a few hours after labor is not a septic fever at all, while the rise of temperature which occurs on the third or fourth day is not due to absorption of waste material as the result of labor, nor to the entrance of milk into the glands, but it

is due to actual infection having taken place, and to our multiple examinations, numerous examinations, unnecessary examinations, which have contributed to and probably have produced the infection.

It has been demonstrated that every pregnant woman in the normal condition of health who has been untouched in the way of vaginal examinations is practically aseptic; that the vagina does not contain pathogenic germs of any kind unless the woman has been suffering from a gonorrhea or has had the gonococcus introduced, and that may be found. But other pathogenic germs will not remain or be found there; and where the woman becomes infected at the time of labor, some one practicing these digital examinations is the cause of the infection; and I do maintain that if those examinations are dropped practically, almost entirely dropped, and the external method of examination practiced, we will avoid infection, but this is not done and has not been done, and that is why we are not skillful in practicing external examination to-day, because when we come to a case of labor we are in the habit of disinfecting our hands more or less incompletely and then proceeding to make a vaginal examination and pay no attention to the external conditions, and of course we are not skillful and able to make the diagnosis in this way.

In regard to the sex of the child, the doctor must have rather acute hearing, because I have practised auscultation a little myself, and while I have guessed the sex of the child right sometimes and won the applause of the relatives and friends by being correct in the prognosis, it is not possible to always be correct by that method, with a stethoscope or without it. We may be able to determine the sex of the fetus in utero by the number of its heart-beats, but we cannot always be correct in that method of making a prognosis of the sex of the child. However, there is no harm in practising the method, and I have often found it possible to make a correct prognosis.

GASTROPTOSIS.

BY M. E. CORBETT, M. D., OF OSHKOSH.

Gastroptosis, or descensus ventriculi, is the most frequent anomaly of the stomach, and is usually but a part of a general splanchnoptosis.

Frequently with gastroptosis we have a ptosis of one or more of the other abdominal viscera.

While this condition of the stomach was described by Virchow, Leube, Landau and other authors, it was left to Glenard to first publish in 1885 an exhaustive study of its clinical significance. He emphasized its importance and established it as a distinct affection.

Meckel first observed in antopsies the so-called vertical position of the stomach, and also that this occurred more frequently in females.

Kussmaul was the first to give a clinical description of the vertical position of the stomach, of which he distinguished two kinds the first, congenital and represented an arrest of fetal development, and the second acquired, caused by pressure of lacing.

Gastroptosis is frequently encountered, as shown by the observation of Meinert. Of fifty girls examined at a public school at the age of twelve, almost half presented dislocated stomachs. Among girls examined at the age of fourteen, he found gastroptosis in eighty per cent., and among the women presenting themselves at his private gynecologic clinic, ninety per cent. presented gastroptosis. While this disease is found so frequently in women, he estimates that this dislocation occurs in only five per cent. of the male population of Dresden.