and carry her through the stage of three or four or possibly eight weeks, and that is just exactly what you have to do in cases of puerperal sepsis. I saw a case of puerperal sepsis last winter in consultation, the woman having a continuous fever for ten weeks. The success of that treatment depended wholly on the ability of that physician to sustain the vital forces of the woman. Surgical treatment alone would have been of no avail, and nothing short of the best sustaining treatment was of any avail. That woman recovered and is well today.

DR. J. M. BELL, St. Joseph: In the last few years there has been a new class of disease introduced which I think we ought not to lose sight of, and that is preventable disease. We have heard a good Ideal about it. A number of diseasesamong them typhoid fever are classified as preventable, so that the existence of such diseases reflects discredit as the result of ignorance or carelessness bordering on criminality. It is that one phase of this condition that ought not be overlooked. This condition is in many cases a preventable one. If we will bear in mind not to be in a hurry, as most of us are, to get through as quick as possible, both in the delivery itself and the removal of the placenta, and become indifferent or careless, overlooking numberless little things that can be attended to, we will be able to accomplish much more for these patients than we do at present. I think that is one side of the question that ought not to go without some comment. In the vast majority of cases, it is a preventable condition, and a good deal depends upon the fellow who is attending the case.

DR. MARY STRONG, Omaha: I disagree with one statement that has been made, and that is with reference to the advisability of waiting in these cases to see what nature will do. I think one cause of sepsis in the puerperium after labor is neglect to use forceps when they ought to be used. When a woman needs forceps, she needs them badly. If you wait until she is completely exhausted, her condition is such that her natural resistance to infection is gone. We ought to be clean about our work. In practicing obstetrics the doctor who treats these cases in the old fashioned

way, I was going to say, ought to be

hanged, but that is a little too strong, but as for waiting and waiting until the patients are edematous and their general vitality is greatly reduced sometimes by pressure and sometimes by the pain, I think it is the very worst policy we can pursue.

DR. D. S. FAIRCHILD, Clinton, Iowa: I discontinued obstetric practice about the time of the beginning of the aseptic era, and for seventeen years I attended obstetric cases without knowing there were any germs, and during that time I had no cases of puerperal infection. (Laughter.) I have seen some cases since then, or since

germs have been discovered, and I have seen some cases in consultation. I have seen a great many things done in the way of treatment in these cases, and I am sorry to say in many instances they were harmful. The washing out of the vagina before confinement and doing a lot of things of that kind have seemed to me to be harmful. Washing out of the vagina and uterus after confinement has seemed to me deleterious. At the Denver meeting of the A. M. A. I read a paper on "The Use of the Curette in Infected Uteri." There was an expression of dissent by some of the members of the profession, and some of them did not seem to agree with the proposition that we ought not to inflict additional trauma by the use of the curette. Labor seems to be a physiological process, and one which is able to take care of itself. So I am inclined to think that if reasonable care and cleanliness are observed on the part of the practitioner, these unfortunate results will not occur. It has seemed to me, that the harder the obstetrician works, the more cases of infection he has; so I feel almost like going back to the old times of practicing obstetrics, as it was done before the time of the discovery of these germs. Of course, this is not a criticism upon our recent knowledge, because undoubtedly there will be a number of cases of infection if we do not adopt some of these aseptic methods of cleanliness, as has been advocated, but the indiscriminate use of the curette for separating and removing pieces of adherent placenta is attended with considerable danger. During the seventeen years I speak of, while I was actively engaged in general practice, I saw no cases of adherent placenta, so I imagine they do not occur very often.

To curette these infected uteri is useless in my judgment, and you establish additional foci of infection by so doing which I consider bad practice. The placenta should be removed, if possible, but it should be done with gentleness, otherwise trouble will arise in the nature of infection. We can not get rid of germs altogether, but we can do a great many things to prevent the germs around from getting into the uterus if we do not introduce any of them ourselves. When we irrigate the vagina or the uterus and find the patient's temperature goes up two or three degrees, what does it mean? It means we have introduced additional poison into the system of the patient. It is like irrigating infected wounds, after the irrigation is over the patient's temperature goes up two or three degrees, showing we have done no good but positive harm, and so, it seems to me, in cases of infected uteri, or in germ conditions in the vagina, if we use the curette and traumatize the uterus, we establish additional points of resorption.

DR. WILLIAM F. MILROY, Omaha: This subject is very interesting to me from an historical standpoint, and I am going to

ask you to listen for a moment to some reminiscences. As I have mentioned in the hearing of some of those present, I happened to be an interne in the New York Maternity Hospital during the time when an epidemic of puerperal septicemia prevailed there. I remember very well when the treatment designed to prevent it, the same treatment that is now in use by all of you, was introduced by Dr. Garrigues, who was at that time visiting physician to the Maternity, Puerperal sepsis prevailed to such an extent in that institution that we lost in one month 35 per cent of all patients who were confined, and scarcely a woman was confined at that time who escaped infection. A study of puerperal septicemia had been carried on in Europe, and the method of prevention adopted over there was introduced by Dr. Garrigues, namely, the use of bichloride of mercury chiefly along with a surgical dressing, and the epidemic was arrested. The local treatment that we now use is practically that which Garrigues introduced at that time. The older practitioners, those who practiced during the period when puerperal sepsis was far more common than it is nowadays, are familiar with the fact that in the lyingin institutions there was a great deal more danger of this trouble than in isolated

cases.

The point I want to mention particularly is this: The treatment at that time was most energetic. The last speaker has referred to it in speaking of the zeal of practitioners in trying to do everything possible to cure our patients. There we did everything in the way of cleansing with intrauterine douches and removal of placenta, everything that could be thought of, and yet in many instances without success. It is very interesting to recall that experience in view of the present treatment and the present experience in escaping this terrible disease.

DR. V. L. TREYNOR, Council Bluffs: It has always seemed to me that if the average physician would pay more attention to himself and observe personal cleanliness, we would have fewer cases of puerperal sepsis. The practitioner should avoid making unnecessary examinations. He should repair lacerations and apply forceps when they are indicated.

DR. W. L. ROSS, Omaha: I want to emphasize what I believe is necessary, namely, whenever we find a woman with puerperal sepsis running a temperature from day to day, which we believe to be due to some uterine infection, we ought to go over that case the same as we would any other infected wound and make it as clean as

possible. I believe that where a man is accustomed to using the blunt curette, and knows how to use it carefully and gently, he can use it with as much intelligence and skill and ease and with less danger to the patient than he can the gloved finger. Why? With me I find it necessary to make bimanual pressure over the fundus in order to sweep intelligently the inner parts of the uterus with the finger. We are handling a diseased organ, more or less roughly. If you resort to the vulsellum forceps, you will create a new wound. You should render the uterus as clean as possible with the curette and the use of water or normal salt solution, or use very mild bichlorid solution. I do not think it is right to say that the practitioner should not use the curette or should not irrigate, but try to rely upon the gloved finger or the instrument Dr. Palmer Findley speaks of, because with the curette in the hands of one who is accustomed to using it, he can remove pieces of retained placenta, and can take away these pieces of retained placenta with good. results. Let us make the wound as clean as possible and follow that up with treatment which the symptoms demand.

DR. LITTIG (closing): My paper made about 4,000 words. You cannot read 4,000 words in twenty minutes. There were about 1500 words which I did not read, and in that part of the paper the views of Michel were given, who says that puerperal fever may be due to infection from the intestinal canal direct to the uterus. That is pernicious teaching, and there is only one condition in which I would consider it for a single moment. If I were called in consultation in a case of puerperal sepsis, I might admit such a method of infection was possible, but do not believe it really occurs. I do not want any one here to get the impression that I do not believe in microscopical examination or bacteriological diagnosis. Many years ago I spent a number of months in the Koch laboratory in Berlin, and in the Pasteur laboratory in Paris, also in Vienna Bacteriological Laboratory, and I have some bacteriological notions But it is my idea if you have a patient and it is not possible to make bacteriological and blood examinations, you need not feel guilty, because you can treat a patient of this kind intelligently without these examinations, but I believe it is the duty of every practitioner to make these examinations whenever it is possible to do so. We must do that as scientific and progressive men, but as practitioners at the bedside, if we cannot make these examinations, we can get along in a few cases without making them.

hunger of our humbler neighbor is as imperative, and his body nourished, as ours. He, too, needs air, light, and warmth, and without them must die. He, too, must produce in offspring his physical form that his race may not become extinct.

Not only in physical phenomena, however, do we find man united to other life. As his body is an unfolding of the possibilities of protoplasm, that common basis of all living forms, so are his intellectual and moral faculties an unfolding of certain possibilities discernible in the lower life. Not a single power resides in man whose roots cannot be traced down into that great world of animal life of which he is the natural product.

In one particular alone does man differ essentially from the lower life. To him has come a transcendent development of those nerve and brain centers by which he is better enabled to comprehend the world about him, and by means of which he has become master of all other animals beneath him. The constitution of consciousness, its functions, and the laws governing its activities in the relation ship and adjustment between the organism and its environment is what primarily interests us in the study of the human species. The mind is regarded today as an adjustive mechanism, or, more properly, as a complex of adjustive mechanisms.

The fact that consciousness comes into existence only at a relatively late stage in evolution and in association only with relatively complex organisms would seem to indicate that it had some function in connection with adjustment of the organism to its environment and it is from this viewpoint that we can best consider its activities.

Even the simplest organic functions of the human being illustrate the evolution of a consciousness that distinguishes him from lower animals, and even from lower types of his own species, in its adaptation to conditions of existence. Hunger in the highly evolved man is no longer the cravings of a mere animal for food, to be appeased at the first opportunity of satisfying it. It is subordinate to the laws of the social organization. The

higher type of man will do without food for a considerable length of time rather than violate these human laws.

Hunger, too, has been made a means of satisfying a certain esthetic feeling connected with it which has made its gratification a social event and surrounded with beautiful objects. And thus the whole physical life has been placed upon a new level to meet the esthetic requirements of the individual. His pleasures become those of the intellect rather than those of the body, and physical gratification of any sort is complicated by the most subtle and powerful emotional phenom

ena.

The human mind brings about not only adjustments to external conditions, but it also exerts a marked influence over those internal adjustments as well. While the higher nerve centers constitute the physical basis of the mind in the adjustment of the individual as a biological unit to his environment, these also influence and regulate the inter-relations of the various bodily functions in a far greater degree than is generally supposed at the present time. So much so is this statement true that we do not in the least exaggerate when we speak of intelligent physiological designing.

It is by education that we are enabled to free the individual, to a considerable extent, from the fetters cast upon him by the limitations of the body or of the primitive instincts.

Through the development of the intellect the purely physical desires cease to be all powerful, and the body becomes under the control of the mind. Instead of being governed by external accident, or haphazard circumstance, we can, by retraining, make it to a new and marvelous extent subject to the intellect. By this means the power to vary, to exercise choice, to be one's self is developed.

Without this conception of himself the human being is left to the factors of unselected environment to determine his development. "The child born into the world has no mind, no consciousness. It has, however, a central nervous system and special sense organs. From the moment of

receive sensaworld and to other way can

its birth it begins to tions from the outer react to them. In no the impressions out of which mind is made find its way to the brain except by the sensorium. Whatever man may become must in the last analysis depend upon this material and so no conception of mind can fail to take it into account. A person at any given moment is the end product of all the processes that have been at work since his conception and in the same way a given state of mind can only be conceived to be what it is because of all that has gone before-it is the result."

"Our assumption then is that every psychic fact has an efficient psychic cause; that an idea does not spring into existence without having been the logical outcome of other ideas; that for every mental state, for every idea or feeling, there is an adequate explanation whether that explanation can or cannot be found. It implies for example that every psychosis, if all the facts were known, by that is meant internal, conscious facts, would be found to have arisen as a logical necessity step by step; that every state. of mind should theoretically be capable of reconstruction from the elements that analysis shows it to consist of."

"If this is true it should hold under all circumstances, normal and abnormal, for we must always remember that there is no qualitative difference in the mental processes in disease and health-the difference is only quantitative."

It is important to bear in mind that what is true in the realm of mind is also true in reference to diseased physical processes, i. e., tumors for instance, they are not importations into our bodies, but like all other morbid processes, are perversions of cellular activity, as the result of mal-adaptation to environment. Diseased physical processes obey the laws that regulate normal structures, yet to some extent they develop independently of the surrounding tissue. But we must not forget that it is impossible for normal cellular elements to take on a parasitelike property in the presence of any

other environment except that of reduced resistance afforded by other elements which permits of their extension beyond normal limits.

Be they mental or physical processes, those that assume a parasitelike property are capable of existence only in the presence of a lessened resistance afforded by the elements comprising the totality of the organism, resulting from a misadaptation to environment.

The two fundamental primitive instincts which most largely determines the development of the species are developed side by side-reproduction and nutrition. Since reproduction and nu trition are so intimately connected, it is not surprising to find that at a very early age the rapidly developing reproductive system, biologically and physiologically considered, so largely determines the conduct, habits, and mental attributes of the individual in adult life, as has been conclusively shown by the investigations of Freud. Nor is it surprising to find out how those factors which hinder the nutrition of the organism at a very early age so markedly influences the mode of the reaction of the individual to the psychic and physical factors of environment at a later period in life. In all departments of life physical and psychic development go hand in hand, each mutually dependent upon the other-one and inseparable.

The psychic life of the infant is very nearly the same as that of the lower animals beneath us and abundant nutrition, warmth, comfort and all other requisites for the sustenance and development of the animal infant contributes to the gratification of both the instincts of reproduction and nutrition, and influences their modes of expression in the psychic and physical life of the individual at a later period in life. There is, therefore no grounds for conflict between the biological, the physiological, and the psychological methods of approaching the factors that make us what we are in adult and mature life. They deal with one and the same thing, whether expressed in psychological or biological terms. They refer to different phases of experience in the develop