ological aspect. The laws controlling their results, evil though the latter are, are the laws of normal life. Between the normal and the abnormal there is no line of demarcation. The normal passes insensibly into the abnormal, however apparent the latter may be as the climax is approached. Of all the forms of stimulation here discussed in their excessive exhibition, only one, the chemical stimulation of the bacterial toxins, can be absolutely eliminated as a factor outside of normal life, and in place of that there is the chemical stimulant with which we almost universally start the day. We are aware of that but we are not so aware how surely each has its share, infinitesimal, small or large, in the inevitable effect. On the other hand, there is anatomical indication that the tissue which receives the brunt of it varies in its quality just as much as one individual varies outwardly from another. In a more active capacity as the curator and educator in health, which he has only to assert himself to attain, the physician may find equally as high a scope for his art and science, his judgment and insight as in the capacity of an assistant in the recovery from disease. Summary. In numerous abnormal conditions there is a common anatomical basis of those identical nerve cell changes which are peculiar to normal functional activity. The common exciting cause affecting the nervous system which is thus predicated is to be found in the physiological factor of stimulation. From this, work and finally over-work result. The types which are thus classified under their form of stimulation, for undoubtedly still other conditions remain to be thus grouped, are: from trophic stimulation, anemia; from thermal stimulation, heat exhaustion; from mechanical stimulation, traumatic shock and at least some traumatic neuroses; from chemical stimulation of the bacterial toxins, a group of infectious diseases, again broadly typified; from an undetermined stimulation, either trophic, chemical or psychical, exophthalmic goitre; and from an excessive spontaneous stimulation of everyday life, which in its normal display leads finally and inevitably to natural senescence, neurasthenia and allied disorders. The Treatment of Septic Abortion. By E. O. HOUCK, M. D., Visiting Obstetrician, St. Ann's Hospital; Visiting Gynecologist, City Hospital; Assistant Visiting Surgeon, St. John's Hospital, Cleveland, Ohio. It is estimated that one out of every eight or ten pregnancies terminates in abortion, accidental or otherwise. The importance, then, of the proper management of abortion is apparent. Further, the majority of patients ill because of an abortion are usually treated at their homes and for this reason the proper management of these patients is of as great importance to the general practitioner as the management of appendicitis. About 25 per cent of abortions become infected and of these about 10 per cent die. It will be noted from the latter figures that they again do not vary much from the mortality of appendicitis. Varying degrees of morbidity are also frequently associated with and result from an abortion, for many women date their ill health from a miscarriage, even though perhaps a pelvic lesion may have antedated the abortion and been a considerable factor in causing the abortion. Pelvic pathology is often greatly aggravated by an abortion. The treatment of abortion depends largely, of course, on whether the uterus has emptied itself or not. Some abortions, as is well known, terminate spontaneously with complete expulsion of the ovum and the entire decidua. The earlier in the first half of a pregnancy an abortion occurs the more likely is this to be the case. Such patients need no special treatment except perhaps rest in bed and ordinary hygienic care. More than half the cases, however, do not terminate so favorably and are associated with either hemorrhage or infection. These latter cases are also more likely to be incomplete abortions. Of late the correctness of the usual mode of procedure in the treatment of inevitable abortions has been called into question, particularly in so far as these procedures are responsible for postabortal infections. I refer especially to the employment of vaginal or cervical packs, whether the same be a gauze or cotton tampon, or whether it is a laminaria tent. There is no doubt as to the efficacy of these measures in promoting evacuation of the uterus and checking hemorrhage, Read before the Charity Hospital Medical Society, January 17, 1912. but Klengel, in examining case histories in the Leipziger Klinik found that fully one-fourth of abortion patients developed infection when tampons were employed as against only 17 per cent of infections when no tampons were used. It must not be forgotten here that the packing was done under strict aseptic conditions. Certainly these figures are sufficient evidence that packing is not altogether a harmless procedure. On the other hand packing must be resorted to in private practice either as a temporary measure to check hemorrhage or as a means of emptying and dilating the uterus when conditions are not such that a clean operation can be undertaken. There are still other measures which should be employed to lessen the chances of infection. Not only the external genitals should be kept clean but also the vagina. Blood clots and masses of decidua hanging out of the uterus into the vagina should be douched out, for these serve as excellent "bridges" on which microorganism can develop and go over into the uterus. Small doses of ergot frequently repeated also favor emptying the uterus. These measures may properly be termed prophylatic in that they lessen the chances of infection. However, it is not my purpose to deal so much with prophylaxis of infection as it is with the infected patient. Infection postabortum and postpartum are essentially the same, both being types of wound infection. In either case the uterus may or may not be empty, however, in postabortal infection it is less likely to be so. What then shall be the management of an abortion that has become infected? Shall the treatment be active or expectant? There are many doctors who curette every abortion case without any particular reason for so doing, except that the patient has aborted. No one, I think, will justify this course. I think, too, all well-informed physicians will agree that the uterus should be carefully and completely emptied whether digitally or by means of a blunt instrument in the presence of a serious hemorrhage, whether the patient is septic or not. We should also exercise caution in manipulating the uterus, avoid rough handling thereof by severe traction, or unnecessary injury with Volsella forceps. Shall we evacuate the uterus in the presence of an infection when no alarming hemorrhage exists? The reason for emptying the uterus is the supposed removal of the source of the infection. Williams, in his writings and in his textbook on obstetrics, showed conclusively that once an infection has developed in the uterus it does not long remain in the cavity of the uterus or even in the endometrium, but that the infection soon extends beyond the myometrium. and becomes general. It is difficult to understand, then, how the source of the infection can be removed. The expectant plan of treatment would, therefore, seem to be based on a correct appreciation of the pathology of the condition. The answer as to whether the expectant or active plan of treatment gives the least morbidity and mortality must be found in clinical experience. My own experience has been too small to justify a conclusion, but so far as this experience goes no harm was done by pursuing the expectant plan of treatment in the presence of an infection. In Winter's Klinik (Koenigsberg) of sixty-three patients treated actively during their infection 15.8 per cent died, whereas of seventeen treated expectantly only 5.8 per cent died, and if I add my own cases to his the mortality is reduced to 4.7 per cent. While I admit that the number treated expectantly is small the relative improvement in the mortality is striking. It might be reasonably objected that even though the expectant plan of treatment is followed evacuation of the infected uterus does not always take place and that an operation must eventually be undertaken before the patient can be cured, thereby prolonging the stay in bed and making it possible for the infection to further develop and spread. By means of bacteriological examinations Winter demonstrated that virulent microorganisms disappear in from four to twenty-three days, at which time evacuation of the uterus. may be undertaken. In estimating the virulence of the in |