probe or a punctum dilator. Cocain may be applied as a preliminary to this procedure, but the pain is inconsiderable.

In all such cases any accompanying conjunctival or nasal disease should by no means be neglected.

In obstinate cases where all other means fail to give relief the lachrymal sac may be destroyed by the galvanic cautery or may be extirpated. Removal of the lachrymal gland is also resorted to

in extreme cases.

IV.

The essential factors in age relations in regard to predisposition to disease are: (1) The crises, i. e., hyperemia with consequent function-peristalsis, absorption and secretion. Secretion is the culture bed for bacterial disease, e. g., gonococcus ; (2) the quiescence, i. e., the nonhyperemic condition with consequent limited secretion, hence limited opportunities for bacterial diseasegonococcus. In age relation the stage quiescence (resting) and crisis (functionating) should receive special attention.

I. PUERITAS (QUIESCENCE).

Childhood genitals; quiescence; duration, one to twelve years. Condition, non-hyperemic, slight secretion, hence bacterial disease slight. In childhood from infancy to puberty (say twelve years) the tractus genitalis and mammary glands remain practically stationary except a slight accretion of growth not keeping pace with the general body growth. The genitals are in a state of quiescence. Scarcely any attention to the genitals except cleanliness is required during this stage. The pueritas has no hyperemic condition and slight secretions of the genitals and hence, slight tendency to disease (bacterial).

II. PUBERTAS (CRISIS).

Genital development (utero-ovarian artery). Function, crisis. Duration three years (12 to 15).

Condition, hyperemia; limited secretion, hence bacterial disease limited.

This is the stage of rapid genital development.

(Author).-External muscular pelvic floor. The levator ani is plain with its three apertures.

(What is a "cold"? Answer: A "cold" is the multiplication of existing bacteria. The conditions of a "cold" are (1) congestion (hyperemia), (2) secretion, (3) bacterial multiplication and (4) should a wound exist as in the puerperium -placental site-grave consequences may arise.) III. MENSTRUATION (CRISIS). Reproductive genitals. Function, crisis, duration. Each crisis

10 days.

a. Premenstrual phase 3 days. b. Intermenstrual phase 3 days. c. Postmenstrual phase 3 days. d. Intermenstrual phase 20 days. The menstrual crisis continues thirty years (15 to 45). Condition, periodic hyperemia, secretion, hence bacterial disease active.

A complete explanation of sex life should be made to the young woman at this age. She now has a bloody monthly flow. The hyperemia and congestion of the genitals during the menstrual period makes her liable to contract colds, multiplying the germs in the tractus genitalis through hypersecretion, hence inflammatory conditions. The menstruating woman should assume as much anatomic and physiologic rest as possible for three

to four days. Dancing, journeys and unnecessary physical exercises should be avoided. Thorough daily cleansing of the vulva is an essential prophylactic. Vaginal douches during menstruation may be harmful, causing congestions and decongestions and should be omitted. The evacuations of the tractus intestinalis and tractus urinarious should be carefully regulated by diet and fluids. Should dysmenorrhea arise during menstruation the subject should be treated as it may become chronic and damage the genital apparatus. Aseptic menstrual pads are to be recommended.

IV. GESTATION (CRISIS).

Development of fetus. Function, crisis. Duration nine months. Condition, hyperemia, secretion, active; hence bacterial disease active.

During gestation an essential is to regulate drainage of the visceral tracts, diet and exercise. Eight ounces of half-normal salt solution should

(Author). Represents the endometrium in the first days of menstruation (decidua menstrualis). 35 years old multipara. The endometrium is almost doubled in thickness. Observe the change in the utricular glands. The myometrium becomes edematous. No submucosa, hence myometritis.

be drunk every two hours for six to eight times daily. The food should be of such a character that a large residue will be left in the tractus intestinalis so that peristalsis and secretion may be stimulated. Such foods are found in leguminous substances, fruit, cereals, graham bread and vegetables. Pies, pastry, cakes, puddings and sweets should be avoided. Salt rubs stimulates the nerve periphery and the sweat glands in the skin.

V. PUERPERIUM (CRISIS). Genital involution. Function, crisis. Duration,

(Author). Represents the endometrium and myometrium pregnant about 10 weeks. Note the vast changes in the utricular glands and myometrium. No submucosa, hence myometritis.

abdominal walls and to hold the abdominal viscera in their normal position. The child should nurse or the milk will be artificially drawn so that it will stimulate a normal involution of the uterus. The visceral tracts should be drained and evacuations regulated. Diet for the first week should be liquid. The puerperal woman on account of genital hyperemia, congestion and consequently hypersecretion is liable to rapid multiplication of germs in the tractus genitalis (a "cold"). A warm vaginal douche (eight quarts) should be employed work for three weeks after child birth. The lactadaily and the vulva cleansed. She should not tion period is important so that prophylaxis may be employed to prevent so called lactation atrophy. There is super-involution (which was first well brought to notice by J. Y. Simpson). Lactation atrophy may lead to pathologic involution or a

avoid

premature menopause and consequently to sterility. Frequent births especially if accompanied with operative interference and vigorous sexual activity late in life have an unfavorable influence on the course of the climacterium. Also severe infectious diseases, mental or physical shock, and sudden cessation of menstruation unfavorably influence the climacterium. The rational treatment of chronic endometritis and myometritis should be assumed in order to premature pathologic involution-premature, menopause. The early treatment of beginning genital functional disturbance is the rational hope of delaying the menopause and consequent sterility. All kinds of excesses-venereal foods, alcoholics, mental or physical labor, must be avoided. All visceral tracts must be drained so that no waste laden blood may irritate the arteries. Obesity, an enemy to normal genital function, must be overcome by diet. Fresh air and regular exercise is highly prophlactic against degeneration. The aloe-alkaline tablet and eight ounces of one-half normal salt solution every three

(Author). Eleven transverse sections of the uterus to demonstrate the circulation in the myometrium. The sections are numbered in order from the cervix (1) to fundus (11). The uterus was injected with red lead and starch, X-rayed in Dr. Harry Pratt's X-ray and electro-therapeutic laboratory, magnified by Dr. Wm. E. Holland and sketched from this model by the artist, Mr. Zan D. Klopper.

hours drains the system of waste laden blood and is an excellent preservative against pathologic genital involution or premature menapause.

VI. THE CLIMACTERIUM (CRISIS). Ceasing of genital function. Function, crisis. Duration three years (45 to 48). Condition, irregular hyperemia, secretion limited, hence bacterial disease limited.

The climacterium occupies about three years. It is the opposite of puberty. Puberty is the active birth of the genitals; climacterium is the stormy death of the genitals. The climacterium is more severe than puberty, especially psychically. The climacterium is the period when woman's nervous system may become manifestly disturbed. I have termed it a genital crisis. It is a trying

crisis. The climacterium manifests three peculiar conditions, viz: (a) the woman has flushes, i. e., the vasomotor circulatory center is disturbed; (b) she has flashes, i. e., the heat center is disturbed and (d) she has sweatings, i. e., the sweat center is disturbed. The treatment should be general and local. The tractus intestinalis, urinarius and cutis (perspiratorius) must be thoroughly and persistently drained and regularly evacuated. Skin salt rubs and fresh air are good remedies. Avoid active diets as meats, sauces and alcohol. The genital hemorrhages and secretions of the climacterium should be watched with extreme care for they may form the floor of subsequent neoplasms. Drain all tracts and tissues, remove all waste, employ wholesome plain food and assuage mental fears. The atrophy of epithelium may progress so extensive that desquamation arises and the wound for malignancy or infection exists. Disturbance in genital nourishment is manifest. Diseased condition in the climacterium demand careful treatment. Woman is more liable to disease in the climacterium because arteriosclerosis of her utero-ovarian artery has lessened the nourishment of the genitals and consequently lessened the genital vital resistance. VII. SENESENCE. (QUIESENCE.)

Cessation of genital function. Function, quiescence. Duration from 48 years until life terminates. Condition, non-hyperemic; secretion limited, hence bacterial disease limited.

Genital function has disappeared. Degeneration or pathologic atrophy exists. The genital parenchymous cells have been crushed. The ovarian artery is not only sclerosed but calcified and a minimum nourishment is given to the tractus. genitalis and it now possesses the least vital resistence. Its epithelium is so degeneratively atrophic that apertures may exist between the cells presenting a wound for malignancy or infection. In senescence pus discharged generally means senile endometritis. Hemorrhages are serious and serous discharges are grave. The genitals in senescence have assumed the pueritas stage. They have returned to childhood. Unfortunately the slacking and degeneration of genital supports in senescence causes genital prolapse or hernia which may generally however be controlled by pessaries. Degeneration of nerve periphery sometimes induces pruritis pudendi which may be ameliorated with bichlorid of mercury and carbolic acid. Chronic senile endometritis produces suppurative discharges which excoriate the vagina and vulva on account of ill nourishment and non-resisting epithelia, consequently thorough large vaginal douches should be employed daily. In general during the long senile rest of the genitals but slight attention is required.

PIN WORMS IN THE APPENDIX.-I. H. Berry (Post-Graduate) presented a case of a girl six years old. When first seen she had been vomiting, there was slight elevation of temperature (100° F.) and pain and dulness in the right iliac fossa. Failing to obtain relief by local applications, operation was advised and accepted. Upon examining the appendix after the closure of the abdominal wound, is was found to be filled with pin worms, or oxyures vermiculares. These were alive and wiggling, and there were a great many of them.

UTERINE.-Bearing down.

Acute Metritis.-Pain deep-seated, diffuse, cramping and bearing-down, radiating to loins, hips and hypogastrium, with vesical and rectal tenesmus; least severe in puerperal.

Treatment.-Hot colon douches in Sims' position. Ice-bag over hypogastrium (24 to 48 hours) if much pain and fever; hot fomentations later; morphin if required only; salines and other laxatives; alcoholic stimulants; concentrated liquid diet and quinin in septic cases.

From Sudden Suppression of Menses.-Warm, sitz-baths, mustard foot-baths and hot drinks soon as possible; then to bed and use hot fomentations to abdomen and inside of thighs for several hours; saline cathartic; sodium citrate gr. xxx every two or three hours; subsequent counterirritation; if menses do not reappear, keep quiet for a month with counterirritation, mild laxatives, bland diet, warm sitz-baths, and hot douches (115° to 120°) faithfully used.-Byford.

Gonorrhea or Decidual or Placental Remains.— Thorough curetage of uterus, swabbing out with 95 per cent carbolic acid, then douching with mercuric chlorid (1:2000) followed by sterilized hot water douche, and leaving a dram iodoform pencil in uterus; douche of bichlorid or carbolic acid (followed by plain douche) should be repeated twice a day if infection of some standing. -Byford.

Hysterical Metritis.-Suggestion; constant current of 3 to 6 m.a. with anode over hyperesthetic zones; Blaud's pill persistently for four months, and after an interval, as long again; valerian and asafetida in convulsive types; remove patient from too sympathetic surroundings and divert her attention from herself.-Richard Lomer.

Chronic Endometritis and Metritis.-Neuralgic pains and attacks of uterine colic, principally at menstrual periods; traction on cervix gives rise to lumbar pain.

Treatment.-Etiologic treatment (e. g., removal of placenta and membranes after delivery, curetage after abortion, etc.); a good deal of restnever walk so much as to increase pain; keep bowels open and restrict sexual intercourse; elastic belt around whole abdomen in stout women; warm bath twice a week; warm sitz-baths, using bath speculum; regular hydropathic treatment; curet in hyperplastic form studded with prominences; Apostoli's intrauterine chemical galvanocautery if whole membrane swollen; treat endometritis with Churchill's tincture of iodin, chlorid of iron (hemorrhagic form) or silver nitrate (catarrhal form), painting vaginal roof with tincture of iodin and have patient introduce a pledget with glycerin night and morning.-Garrigues.

Chronic Parenchymatous.-Same measures as for chronic endometritis; long continued use of small doses of chlorid of gold or corrosive sublimate; bipolar intrauterine faradization; massage: trachelorrhaphy or excision of cervix.-Garrigues.

Senile.-Tonics and good diet; correct displace

ments with medicated tampons; local application twice a week of powdered iodoform or tanninboroglycerid (20 gr. per oz.) or fluid extract with peroxid frequently and packing with iodoform gauze.-Skene.

Exfoliating.-Destroy endometrium by curetment, followed by application of tincture of iodin or iodoform pencils, or by galvano-chemical cauterization of Apostoli.-Garrigues.

Tubercular Endometritis.-Caseous leucorrhea containing tubercle bacilli.

Treatment. Total vaginal extirpation of uterus and adnexa.-Pryor.

Endocervicitis.-Numb, deep pain and sense of weight in pelvis; profuse, purulent, tenacious discharge from cervix; follicles enlarged, giving appearance of erosions or ulceration; Nabothian cysts in chronic.

Treatment.-Apply tincture of iodin on cotton to internal os every other day (daily in gonorrhea); if cervix markedly congested, puncture with a scalpel in a half dozen places and promote bleeding with of 1 per cent hot lysol vaginal douches every four hours for a day; vaginal douche of mercuric chlorid 1:10000 every three hours in gonorrheal cases; prick cysts and twist off polypi under cocain.-Pryor.

"Erosions."-Bathe vaginal portion in a tubuliform speculum twice a week for a couple of minutes with acidum pyrolignosum rectificatum or with 10 per cent sol. cupric sulphate.-Garrigues.

Ovula Nabothi.-Prick open and then paint with tincture of iodin; if very numerous destroy gradually with needle-shaped Paquelin's or galvanocautery.-Garrigues.

Uterine Retroversion.-Pain depends largely on complications; usually radiates toward rectum and is often accompanied by severe tenesmus, especially during defecation; greatest tenderness at posterior fundus; often lumbar and inguinal traction pains.

in

Treatment. Replacement bimanually or knee-chest posture; keep in place with cotton tampon (in cul-de-sac) soaked in boroglycerid or 10 per cent ichthyol-glycerin, and under this a lamb's wool tampon turned sideways; intrauterine application of tincture of iodin; hot water vaginal injections; repair pelvic floor and keep stools soft; Alexander's operation or hysterorrhaphy.-Am. Text-Book of Gynecology.

Uterine Anteflexion.-Premenstrual pain, diminishing as flow is established.

Treatment (Simple).-Dilate cervix, irrigate and curet uterus and pack with iodoform gauze, leaving in for six days-best done two weeks before period.-Am. Text-Book of Gynecology.

With Retroversion.-Dilate cautiously to onehalf inch, wash out, curet, irrigate again and pack tightly with iodoform gauze; remove pack on fifth day, leaving a light drain of gauze each time three days for two weeks; amputate cervix if much elongated.-Am. Text-Book of Gynecology.

Menopause.-Dilate cervix, leaving filament of

gauze in cervix for a week, with light vaginal hydrastis; careful dilatation if atresia, washing dressing.

Prolapse of Uterus.-Traction, lumbosacral bearing-down and sinking feeling in chronic; sudden, severe, bearing-down lancinating pain in acute, usually after a fall; often painful sensations in flanks and epigastrium; vesical tenesmus.

Treatment. Reduce hernia; treat ulcers with iodin; fill vagina with iodoform gauze and apply tight T bandage; after ulcers cured, support uterus with Braun's colpeurynter (wash bag thoroughly, anoint with zinc ointment and introduce an ounce of water, filling up with air; remove every night and keep vagina cleansed with boric acid solution); operative procedures to reduce organ in size and retain it in elevated position (keep patient recumbent for two weeks before).-Am. Text-Book of Gynecology.

Support uterus with hard pessary or aseptic wool tampon placed in mornings and removed at night; uterus best replaced with patient in kneechest posture.-Hawkins.

Acute. Return organ gently and pack vagina lightly with cotton or gauze; ice-bag to suprapubic region; Trendelenburg's posture and saline transfusion if symptoms of internal bleeding.Am. Text-Book of Gynecology.

Senile Prolapsus of Pelvic Organs.-Dragging down feeling; irritable bladder and dyschezia; relaxed pelvic floor; cellular and muscular tissue atrophied.

Treatment.--Astringent douches (zinc sulphate or tannic acid); rest after short periods of exercise; perineal pad and strap; plain or medicated tampons, followed by small size Peaslee ring pessary (change and clean every month or two) and continued douches.-Skene.

Carcinoma of Uterus.-Often painless until perimetric tissue invaded; uterine colic in corporeal; radiating pain in cervical, becoming continuous; characteristic sacral pain; pain in advanced stage neuralgic and violent, in back and shooting down legs especially at night; lymph glands in groin and left supraclavicular region may be enlarged; sometimes edema of one or both legs; blood-stained irregular discharges after menopause; hard nodules or crater-like ulcer, or friable cauliflower growth in cervix.

Treatment.-Hysterectomy if disease confined

Inoperative Cases.-Relieve pain and hemorrhage by occasional dilatation of internal os and scraping endometrium very carefully, then washing out debris carefully with copious injections.Winckel.

Uterine Sarcoma.-Pain usually severe; sometimes expulsive, radiates up and down.

Treatment.-Extirpation by wide enucleation. Uterine Fibroids.-Dragging or pressure with vesical or rectal neuralgia shooting down legs; rapid-growing tumors more painful than slow; pain increased by multiplicity or cystic degeneration; aggravated by menopause-often disappears later; slight local pain.

Treatment.-Fluid extract ergot and fluid extract salix nigra of each dram t.i.d.-Adams. Vaginal or abdominal extirpation if they cause

serious trouble. Iodid of calcium 2 or 3 gr. in water one-half hour before meals in interval of menses; aqueous fluid extract of hydrastis (with cinnamon water or tincture of cardamon) m.x. t.i.d. near and during menstrual periods.-Skene.

Mucous Polypi. - Neuralgiform pain and cramps; may be sacral pain, and irritation of bladder; patient cannot lie on one side; os dilated and tumor often projecting.

Treatment. If readily accessible, ligate pedicle with strand of catgut and excise; for those higher in uterine cavity, dilate cervical canal and remove with torsion or ecraseur.-Kelly.

Uterine Retention Cyst.-Hematometra, pyometra, hydrometra, physometra; constant pain and tenderness in lower abdomen with paroxysmal exacerbations at menses; rectal and vesical disturbances; may be dribbling of pus or blood and slight fever; uterus feels like tense bag; point of occlusion determined by finger.

Treatment.-Evacuate with sound and dilators and keep channel open. Kelly.

Hysteralgia.-Sudden, recurrent attacks of severe pain in uterus, often radiating to iliac fossa. and down leg; usual cause, menopause; also from changes of puberty, anemia, malnutrition, rheumatism, metritis, cancer of womb and hysteria.

Treatment.-Vaginal injections of potassium bromid, an ounce to the pint of water.-Munde. Menopause.-R. liq.. potass. ars. m.v.; ammon. (aut. strontii) bromidi gr. v-xv; ferri et ammon. cit. gr. viii; aquam cinnam. q. s. A teaspoonful in water t.i.d. after eating.—Allbutt.

Abortion and Miscarriage.-Periodic, numb, drawing, cramping, bearing-down, labor-like pains, with uterine discharge of blood and mucus, dilated os and presenting fetus.

Treatment.-Threatened.-Replacement of displaced uterus; absolute rest in bed; opiates in full doses for restlessness; ice to vulva; cold cloths to abdomen; hemostatics internally; fluid ext. viburnum prunifolium dr. i every two or three hours; keep in bed for a week after symptoms disappear. -Lusk.

Inevitable.-Profuse hemorrhage with clots, patulous os, and presence of embryo or portions of ovum in clots.

Treatment. First two months, rest in bed for a few days; third month, if ovum entire, warm vaginal douche and wait-if very long in primipara, dilate external os; if sac ruptures check hemorrhage by cleansing out uterus with finger, using vaginal tampon if cervix not sufficiently dilated (never leave in more than twenty-four hours) and giving antiseptic vaginal injections before and after introduction of tampon.-Lusk.

Death of Fetus in Utero.-Painful sensation of faintness; gaping os and movable cranial bones; peculiar putrid taste in mouth; temperature same as in vagina.

Treatment.-Dilate neck with fingers and inject 4 to 6 ounces of equal parts glycerin and boiled. water and pack neck with gauze; after labor, wash uterus once or twice daily with a quart of 1:4000 mercuric chlorid or Calvert's carbolic acid (40 or 60 drops to pint), gradually decreasing strength of solution; 2 drams 30 per cent ichthyol vaginal suppositories with lanolin and cacao butter; strvchnin, ergotol, bouillons.-Buchtel.

Cervical Lacerations.-Bearing-down feelings