The Secrets of Specialists/Chapter 24

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Of all the diseases which have offered the office specialists a fertile field, the ailments peculiar to women perhaps head the list; and there are very few women who pass through the span of life without requiring the services of the physician at some period, for the treatment of diseases peculiar to her sex, and the prevalence of these conditions are, apparently, increasing to an appalling extent. Visit any hospital or sanitarium in the country and you will find at least twenty-five per cent, of the patients are gynecological cases.

When God created woman from the rib of man, he evidently intended she would be his masterpiece, an improvement to man, or man modified and perfected, yet, in his last crowning handiwork, he has rendered her doubly susceptible to a class of diseases and injurious influences from which the other sex is entirely exempt; therefore, from puberty to the menopause may be considered the critical period of her life. During these thirty or more years the functional derangements, physiological changes and pathological conditions constitute the greatest number of any classified diseases the physician is called upon to treat.

Surgery, of later years, has entered into gynæcological practice to such an enormous extent that nowadays it is, apparently, a fashion, other than a necessity. Out of idle curiosity I recently requested a fashionable club lady to "invoice" the members of her club, to ascertain the percentage who had undergone an operation; her report was, that of the eighteen members present, fifteen had been surgically treated for the diseases peculiar to their sex; of these, seven were laparotomies. She also stated that "this proved to be surgical day at the ​club," all discussing their ailments and operations, and the remaining three (who were not victims of the knife) were apparently jealous because they had not experienced the pleasure (?) of a surgical operation. This is a fair illustration of the extent of gynæcological surgery in our cities. In the country this practice is not carried on to such an extent.

I do not wish to be understood as condemning conservative surgical measures, for there is no class of ailments in which surgery has served a more noble purpose than in the diseases of women, but these special diseases have also offered such an inviting field to the "surgical grafter," that many highly respected Gynæcologists have created a breach in moral and medical ethics by advising surgery for the sole purpose of attempting to establish their reputations as surgeons, and fatten their purse.

These operations have not only been confined to ovariotomies for the prevention of conception, but in a large class of diseases in which non-surgical means would have produced better results. I will, therefore, discuss some of the therapeutic measures which have rendered me indispensable service in the non-surgical treatment of the diseases of women.

The non-surgical treatment of the diseases of women incorporates every means other than the knife; we therefore, have all the physiologic methods discussed in the preceding pages, combined with the medicinal measures at our command. These may be divided into internal medications, or medicines taken by the mouth. Extra-uterine medication, or medicines used by absorption by applications to the vaginal canal, at the mouth of the uterus, etc., intra-uterine medication by application to the uterine canal and cavity.

These three methods of medication, either used singly or combined, incorporate the means generally used by physicians for alleviating suffering and curing the diseases peculiar to ​women. It is, therefore, well to have a correct understanding of these therapeutic measures.

Of the remedies which interest us most, for the internal medications for the diseases of women, come under the classification of uterine tonics, alteratives and analgesics. It is beyond the scope of this book to discuss in detail all the remedies offered in this class. I will, therefore, give only two formulas, which are dispensed in tablet form, that have been of much service to me, and will be referred to later.

Each tablet contains:

Ext. Viburnum prun.	1	gr.
Ext. Viburnum opul.	1	gr.
Ext. Star grass	½	gr.
Ext. Squaw vine	½	gr.
Ext. Helonias	½	gr.
Caulophyllin	¼	gr.

Directions—A tablet four or more times a day, as required.

An exceptionally efficient combination in Dysmenorrhoea, Ovarian neuralgia, Uterine congestion, and all painful conditions of the pelvic organs, associated with anaemia and constipation.

Blaud's Mass	1	gr.
Ex. Black Haw	1	gr.
Ex. Blk. Cohosh	1	gr.
Ex. Hydrastis	½	gr.
Euonymin	½	gr. ​
Apiol	½	gr.
Ex. Gelsemium	¼	gr.
Strych. Sulph.	1/120	gr.
Aloin	1/10	gr.

One or two tablets three times a day.

That the external bath was succeeded at a very early period by the internal bath or douch, through the principal orifices of the body, the rectum and the vagina, is authenticated by one of the ablest early historical writers on bathing—Dr. John Bell—who states that women of the orient devised apparatus of dried skins and bladders of animals, with crude wood or bone nozzles, by the use of which they could take the vaginal douch. There was no improvement upon devices for the vaginal douch until the utilization of rubber in commerce. Since the introduction of rubber, there have been many styles of douch syringes; the old style double tube, hand ball syringe was the first to become popular. This was followed by the fountain syringe; both are deficient in their purpose when we consider the anatomical construction of the parts and the therapeutic uses of the vaginal douch. In conducting the vaginal douch for therapeutic purposes, there are many things to be considered. The first and most important is a properly constructed douch syringe; the second is the technique of the douch to accomplish its greatest therapeutic results; third, the use of the vaginal douch as a sanitary, hygienic and prophylactic measure; fourth, its utilization as a curative and restorative means in the treatment of many diseases peculiar to women.

In selecting a syringe to accomplish the best results from vaginal douch therapy, there are many essential things to remember. The first and principal object of the vaginal douch is cleanliness; to accomplish this, the syringe should be so constructed as to wash out and not in. This brings us to the point of considering the anatomical construction of the vag​inal walls, the lining membranes of which are arranged in transverse folds and pockets, instead of logitudinal, as is generally believed by those who are not familiar with the minute anatomy. It is these transverse folds and pockets which naturally detain the escape of effete matter; to thoroughly eliminate these accumulating impurities requires a douch current, which will be ejected from the syringe in a transverse rotary or whirling movement. The pouch which surrounds the cervix, known as the cul-de-sac, is also another favorite seat in which accumulation of effete matter accomplishes its destructive influence in breeding pathological conditions, and the only way to reach this part of the female generative tract is by distending the walls. Another very important thing to be considered in the mechanical construction of a douch syringe is its ability to maintain hot, cold or medicated solutions against the expanded walls of the vagina for a definite length of time; as all solutions are absorbed and receive their greatest therapeutic influence more rapidly with the walls expanded than they will while in a relaxed state. It will thus be seen that the only way to properly conduct a vaginal douch will depend upon three principal things, namely: Complete dilatation of the vaginal walls, a transverse rotary movement of the douch current, to dislodge and remove any and all destructive elements, and to retain the expansion of the vaginal walls long enough to allow the hot, cold or medicated solution to have a prolonged influence, if desired. While the double tube ball syringe has fallen into the relics of antiquity, the fountain syringe is fast following in its wake, as the only results accomplished by either of these syringes is a superficial flushing, which is sure to leave remnants of impurities, with their contaminative influence.

There is one syringe offered the medical profession which can be unhesitatingly endorsed and recommended, as fulfilling all the requirements mentioned above. This is known as the "Irrigating Syringe." This syringe is so constructed by a special device at the tip, that the douch current will be ​ejected in a rotary movement, which will immediately dislodge and remove all effete matter from the walls and transverse folds of the vaginal canal, from the cul-de-sac to the labio-vaginal orifice. At the base of the nozzle is a soft rubber adjustable shield, which anatomically conforms to the parts without injuring their delicate and sensitive structure. This shield prevents the escape of water, and allows the syringe to be used in either the recumbent, sitting or standing position, as may be required at times, without soiling the clothing. This device also allows complete expansion of the vaginal walls, and the prolonged effect of the douch solution, when desired. The bulb which is also the container for the douch solution, has a capacity of nine fluid ounces, and, although smaller in volume than the fountain syringe, the douch solution accomplishes greater results, as it covers every particle of space within the vaginal cavity, which would be impossible to do with a four gallon solution and the ordinary nozzle of a fountain syringe, that has to be continually moved from place to place, being likewise inconvenient, deficient and ineffective in its purpose and results. While the use of the fountain syringe generally requires the sitting position and a receptacle, this syringe may be used in any position, as the douch solution is drawn back into the rubber bulb by simply releasing the pressure upon the bulb. This syringe is also so constructed that it may be easily taken apart and rendered antiseptic at all times, with little or no inconvenience; in fact it is the only ideal and scientifically constructed syringe, in present use, which is based upon the anatomical conformation of the parts to conduct the technique of the vaginal douch. Our attention is now called to what conditions, class of ailments or pathological changes can "Vaginal Douch Therapy" be utilized to its greatest advantage. The first requisite is personal cleanliness; it was John Wesley who said "Cleanlines is indeed next to Godliness," and in no part of the female organism is the axiom of truth from this great divine better exemplified than in the use of the vaginal douch, as a hygienic and prophylactic principle; for the propagation of weakness and dis​ease often have their origin in the neglect of cleanliness of the vaginal canal, and the cause of the prevalence of ill health among many women, may be traced directly or indirectly to a deficiency in knowledge of the value of the vaginal douch. It is the general belief among many women that the vaginal douch is only necessary in diseased conditions; this is a great mistake, as the vaginal douch is the one principal means in our possession of obtaining and maintaining health to this generative tract, and requires the same precaution toward cleanliness, only in a greater degree, than any part of her body, for at this age the internal as well as the external bath will bear fruit in the health of the future generation. I feel justified in stating that fully fifty per cent. of the weaknesses and diseases peculiar to women could have been obviated by the timely use of the vaginal douch. To comprehend the value of the vaginal douch in the treatment of diseases peculiar to women we must know the value of tepid, hot, cold and medicated douch solutions; also their therapeutic relation and value in the different pathological conditions.

In considering the thermic influence of douch solutions we must always bear in mind that cold contracts the blood vessels, and retards the circulatory functions, while heat increases the circulation by dilating the blood vessels, and increasing the progress of blood currents. We therefore find that the cold douch has such a limited field of usefulness that it is hardly worthy of mention; this is also true of the tepid douch, and the medicated vaginal douch are of the greatest expected for cleanliness; therefore, the hot, prolonged vaginal douch, as there is no reaction, and neutral results are only value.

This will depend upon the functional or pathological condition we have to contend with, and whether we wish the douch for its immediate effects, as for cleanliness, or the pro​longed effect for its thermic influence or the extra-uterine medication. Should we wish the douch for an immediate flushing for cleanliness, the standing or sitting position may be preferred by many, as the vaginal canal in this position is at an angle of about forty-five degrees, with the apex pointing upwards, and the gravity of the douch solution would naturally fall downward with greater force upon withdrawing the syringe, and be more thorough in its purpose. If we wish a prolonged or medicated douch, the recumbent position is preferable, as the vaginal canal in this position is placed at an angle of forty-five degrees, with the apex downward, and the gravity of the water, together with the force from the pressure upon the bulb, and the prevention of the escape of the douch solution, by the protective labial shield will allow the thermic or medicated solution to remain for an indefinite length of time, which is one of the many advantages of the irrigating syringe.

In order that we may logically comprehend the value of vaginal douch therapy we must understand the technique of the different methods of applying the douch, and its therapeutic relation to disease. Undoubtedly the most valuable douch in vaginal therapy is often referred to as the prolonged vaginal thermic bath;" this douch was made popular at Luxeuill, France, by a special apparatus whereby 20 to 25 gallons of water was used to maintain its thermic influence. The same effect can be produced by nine ounces of douch solution with this syringe.

To obtain the full benefit of this bath the patient should be placed in the recumbent position with the legs drawn up, and the hips elevated; the bulb of the syringe previously filled with the douch solution at a temperature of 110 to 113 degrees F.; the nozzle is inserted into the vagina until the protective rubber shield is adjusted firmly against the labio-vaginal orifice to prevent the escape of the solution; pressure is now made, gently, upon the bulb, until the vagina is distended to its full capacity; the bulb is now relaxed, and the solu​tion is withdrawn back into the syringe. The operation should be repeated several times, as the dilation and relaxation of the vaginal walls have a very stimulating effect. Fresh douch solutions may be used each time if desired, although it is not necessary. This is the treatment, par excellence for many forms of pelvic affections. It will relieve pain in this cavity as a rule, almost instantly; any form of congestion and inflammation are greatly benefited, as it increases the activity of the circulation, and removes the inflammatory exudates. Its therapeutic influence is fully one hundred per cent. greater than hot fomentations and the use of the water bottle, to the external surface, as the vaginal douch brings the thermic effect in more direct contact with the disease and will penetrate the mucous membrane of the vagina more repidly than it will the integument and muscular layers of the external abdominal walls.

Space will not allow me to give the technique of the value of this douch in all the different pathological conditions within the female pelvis, but in emphasizing its therapeutic value will say that pain, inflammation or congestion from any ​disease within the pelvis is greatly benefited by its use; this applies not only to the surface in which the douch solutions come in contact, but the penetration of heat will reach the deeper structures, as it will by no other means, and will be found useful as a therapeutic application in metritis, localized salpingitis, ovaritis, cystatis, pelvic peritonitis, diffuse lymphangitis, without much swelling, etc. While these douches may not be the principal therapeutic curative process, they are especially valuable in preparing the way for other treatment. What is true in pathological conditions is equally true in functional disorders; its influence in curing amenorrhœa and dysmenorrhœa is almost specific at times, while leucorrhœa is only a symptom of other diseases; it abates the discharge by restoring health to the primary cause; this is also true in menorrahage, metorragia, etc., In all cases there is a palliation of symptoms, and douches of this character may eliminate the presence of exudates and tumefactions of the adnexa, especially when used in conjunction with extra uterine and intra-uterine medications.

It is this method of treatment which is most universally used by all physicians and consists of any and all medications applied within the vaginal walls, which are utilized in the form of medicated douches, tampions and suppositories. The suppository medication is, by all means, superior to any other form of extra-uterine treatment, as it has the following advantages: it may be used by the patient in the privacy of her home; it allows complete and continuous medication while the organs are at rest, during the sleeping hours, (as the best time to use this medication is before retiring), and also allows direct medication to the diseased parts, in many conditions, and its absorption reacts to a therapeutic advantage in the more remote diseases. We, therefore, find that with this form of treatment, we are able to reach the diseased conditions of all organs within the female pelvis. There are many medicines which ​have entered in this method of treatment, from time to time, but my experience, in the continuous use of the following medications, in their former and present modified form, has convinced me that it is superior to any other combination of medicinal agents, as a universal extra-uterine application.

Elaterium	1–6	gr.
Powd. Jequirity	¼	gr.
S. E. Belladonna	½	gr.
S. E. Hyoscyamus	½	gr.
S. E. Hamamelis	1	gr.
S. E. Calendula	1	gr.
S. E. Thuja	1	gr.
Quinine and Urea hydrochloride	½	gr.
Resorcine	2	gr.
Zinc Sulphate	2	gr.
Boric acid	4	gr.

I have the above medications prepared in two forms: No. 1, in a base of cocoa-butter and slippery elm, and No. 2, in tablet form, resembling in shape the ordinary suppository. The former is used where quick action is required, as in dysmenorrhœa, frequent and painful urination, the pain of cancer, etc. The latter is used where slow continuous medication may be required.

In reviewing the above formula, one would naturally ask: why are so may remedies incorporated in a single suppository? I can only say that each has been added, from time to time, with a decided improvement, and as a general extra-uterine application, it would seem almost impossible to dispense with any one of them. We will, therefore, resume the therapeutic value of each remedy, and point out its specific purpose.

Elaterium has long been recognized as one of the most efficient remedies we possess in extracting serum from the intestinal tract, and producing profuse watery discharges for the relief of ascites, anasarca, uremia and cerebral disorders. It has likewise been found to extract serum from the pelvic cavity, when in constant contact with the mucous membrane of ​the vagina, and accomplish the same results as glycerine tampions, used by nearly all physicians for the purpose of extracting serum, and thus relieving congestion and all inflammatory exudations. In fact, it is the pelvic antiphlogistic, "it bleeds, but saves the blood," and is a most valuable remedy in all inflammatory conditions, whether acute or chronic.

Jequirity is a counter-irritant. The temporary effect is to create a mild inflammation, which subsides and eliminates old inflammatory processes. This is generally controlled by the

other remedies in this formula. The local use of belladonna is well understood by all physicians, as an antispasmodic and anodyne, and as a remedy to relieve pain, particularly of the pelvic organs. Hyoscyamus is added for its anodyne effect. Hamamelis has a special influence over the veinous circulation, promotes the healing of erosions, ulcers, etc., and checks foul discharges, leucorrhœa and gonorrhœa. Thuja and calendula are also added to reinforce this influence. Quinine and urea hydrochloride has made a wonderful improvement in the origi​nal formula, as by the use of this remedy, we have a most valuable and prolonged obtundent, and when this is applied at the mouth of the womb, it will not only deaden the pain, which may be caused from dysmenorrhœa or cancer, but placed between two other important organs the rectum and bladder, will give immediate relief to any irritating influence which may exist, while other therapeutic measures are being carried out for their permanent results. It is, therefore, of great value in relieving the pain from hemorrhoids, frequent and painful urination, as a result of an irritable bladder. I have, also, added resorcine to this improved formula, as we derive all the benefit of carbolic acid in its non-irritating form; the zinc sulphate is utilized for its astringent properties and boric acid for its antiseptic influence.

This formula may have the appearance of a "shot gun prescription," but it will hit the target, at rifle range, so often, that it has become one of my strongest armorments in fighting many pelvic diseases; as morphine has the widest range of usefulness in general medicine, this covers the broadest area in pelvic disorders. By the application of this suppository we suppress all pain and distress within the pelvis, nearly as rapidly as with a hypodermic injection of morphine, and while we are receiving this temporary relief, we are removing inflammatory exudations, healing erosions and ulcerations, decreasing corrosive and purulent discharge, and permanently restoring these organs to their normal condition.

The diseases in which this medication will be found valuable will be described under their respective classifications.

It is this form of uterine medication which has been commended and condemned more than any other means of gynæcological therapeutics; although this offers us a valuable means of uterine treatment, it is not devoid of danger, when injudiciously used. The principal reason many physicians have failed to be successful with this treatment is not the quality of ​medicine used, but the quantity. They do not stop to realize that the normal unimpregnated uterus, when extended to its full capacity, will only contain about ten or twelve mimims, as graduated on the piston stem of a syringe, and any amount of medicine used, above this quantity, is either forced into the fallopian tubes, or perhaps through them, into the peritoneal cavity, where the most grave results may occur. This is the one principal thing which should always be remembered, and avoided, in all intra-uterine medications, as it is this state of

affairs which has made many physicians ignorantly condemn the method. Another very important thing to be considered is to have your instruments, and servical canal aseptic, before entering the uterus proper, as any infection which may enter this cavity is sure to rapidly multiply, until the entire walls, including the fallopian tubes, and perhaps the peritoneum, will be involved; therefore, always be on the safe side, and avoid these unpleasant and grave obstacles; never inject over eight or ten minims, as is regulated by the graduate on the piston stem.

In order to conduct intra-uterine medications successfully, it is necessary to have a suitable instrument. I prefer Baun's applicator, (or the one illustrated here), as this gives you full access to the uterine cavity, and control of your medication. I can only condemn the glass pipett, which resembles the ordinary medicine dropper, as with this instrument you never have control of your medicine, and almost always inject air into the cavity, producing "uterine colic."

Intra-uterine medication is divided into two sections: the cervical canal, and the cavity of the organ; treatment to the ​canal is by far in the greatest demand. Cocaine may be injected for anæsthetic purposes, in sensitive patients, to dilate the internal os; previous to dilation of the same, hemostatics and astringents may be used, where there is persistent and dangerous hemorrhage.

Menorrhagia and metorrhagia, dependent upon simple chronic congestion, and hyperplasia of the endometrium, are successfully treated by these medications. Gonorrhœa, and other septic infections, extending to the uterine cavity, may also be successfully treated by direct application of appropriate medication to the affected area; thus we find inflammation, congestion, infection and excessive hemorrhage the principal indications for intra-uterine medication. There are many remedies employed for this. Ichthyol alone, or in combination with other remedies, is one of the best medications; it is not a caustic, but its action upon the tissues will contract the blood vessels, and reduce inflammation or congestion, and also has a soothing analgesic effect. Protargol is another valuable nonirritant astringent and antiseptic. Phenol iodatum, which consists of iodine 20 parts, glycerine 20 parts, and phenol 80 parts, is also an excellent medication. These remedies either used singly, or in combination, constitute the greatest part of the medication used in office treatments. I use these in combination, in the following formula, which I refer to as:

Protargol, sat, sul.	2	dr.
Phenol Iodatum	2	dr.
Ichthyol	4	dr.

The above makes an indispensable preparation, as it has such a universal field of usefulness.

With the patient in the dorsal position, the speculum is introduced, and the cervix is exposed and cleansed with an antiseptic solution, by the use of the dressing forceps. In com ​mencing Intra-uterine medication, I always begin with the minimum quantity, to see if it will be tolerated by the patient. Many women are very susceptible to this treatment, and it seems that any form of treatment within the uterine cavity will cause distress; if the cervix alone is treated, there is never any complaint. The syringe is filled with the medication, and the tip pointed upwards, to force all the air out of the sound applicator, the set screw is adjusted on the piston stem, from five to ten minimum, and the applicator inserted to the point desired. Where gentle pressure is applied, to force out the medicine, and the instrument withdrawn, and a tampon of cotton applied to the os uterus, to absorb any superfluous medication which may come away later. This very simple means of treatment is applicable in many cases which will be reviewed later.

The word curette is taken from the word "cure," meaning to cleanse, as applied in surgery to scoop or scrape. In office practice, electricity provides us with a more convenient and agreeable means of accomplishing the same results. without the aid of an assistant. The object of curretting the uterus is ​to remove fungous degeneration, due to chronic endometritis. Retention of adherent placental villi, after miscarriage, etc. This is accomplished by the acid radical of the positive pole of the galvanic current, as it is by no other means. The technique of the operation is as follows:

The patient is placed in the dorsal position, with a large electrode at her abdomen, attached to the negative pole; a copper wire intra-uterine electrode is inserted to the fundus of the uterus, attached to the positive pole, and a current from 20 to 30 milliamperes is used, the electrode remaining

about ten minutes. The current is now turned off, and the electrode is gently rotated until it is loosened, then it is withdrawn, and you will find it covered with the endometrium, and you have accomplished the same results as you would by the more bloody and inconvenient method of curretting the organ. This is repeated once or twice a week, until you have removed every particle of diseased tissue.

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By the use of the foregoing treatments, either used singly or combined with the addition of electricity, and other physiologic methods, we are able to master many of the diseases of women and "stay the hand of the surgeon." In order that

the reader may readily comprehend the practical application of these different treatments, I will illustrate their use as applied to disease. ​

From puberty to the menopause, the functional diseases of women offers a very important part in the practice of medicine, and there are very few women indeed, who pass this period of womanhood without experiencing some of the disorders of the menstrual phenomena.

This condition is usually divided into two distinct classes. First, absence of the menses in girls who have never menstruated, and, second, suppressed menstruation where the flow having once been established fails to appear at the regular time. The absence of menstruation is a normal condition during pregnancy, and while the mother is nursing her child.

CAUSE.—Non-appearance of the menses is a frequent malady of girlhood, and may be due to a variety of causes, as lack of pure air, sunlight and proper exercise, improper and insufficient food. Anæmia, chlorosis, consumption or ​other wasting diseases; malformation of the generative organs. Suppressed menstruation is most generally caused by exposure, such as getting the feet wet and body chilled. Intense excitement and excessive study will cause it, but unless the excitement or study be constant the system reacts healthily, and the trouble soon disappears. Acute diseases, such as typhoid and scarlet fever, frequently suppress the menses, while displacements of the womb are among its causes.

SYMPTOMS are both local and general; some of the local symptoms are pain and a sensation of weight in pelvis; dragging feeling in groins, weakness and bloating of limbs. The general symptoms are such as languor and debility, palpitation of the heart, difficult breathing, dizziness, shooting pains and cramps in the different parts of the body, and a long train of both bodily and mental symptoms may ensue, indicating a derangement of one of the most important organs of the body. One of the most singular results of suppressed menstruation is a condition known as Vicarious Menstruation, where the discharge develops at some other part of the body. This flow may occur at the regular time from the nose, gums, breasts, bladder, or from sores that may be on the body.

TREATMENT of amenorrhœa requires the most discriminate care and attention to ascertain, if possible, the exact cause. Careful study should be made of the habits of life and mode of living. The patient should always have plenty of outdoor exercise, such as walking and riding in the open air, and indulge in such pastimes as conduce to good health and cheerfulness of mind and general tranquility of both mind and body.

If due to anæmia or chlorosis, the uterine tonic with Blaud's mass, is of the greatest value. The prolonged vaginal douch and sitz bath, before retiring, will also be of great assistance in establishing a normal circulation in the organ. This should be followed by the extra-uterine application, and another vaginal douch in the morning. This treatment, continued for some time, will generally suffice in a large percentage of cases, where mechanical obstruction is not present: if by the use of the speculum is revealed the "infantile" or un​developed uterus with congenital stenosis of the cervical canal, (see accompanying illustration), electricity is by far the best means of permanently dilating the canal, and assisting nature to develop this organ. The patient is placed in a dorsal position. A large, flat electrode, attached to the positive pole of the continuous current, is placed over the abdomen, and an olive shaped tip electrode, just about one size larger than the constriction, attached to the negative pole, is gently inserted into the uterine canal, until it meets the constriction; the current is now turned on, using from five to seven milliamperes, from five to ten minutes, interrupting it through the rheotome every two seconds, during the treatment; these interruptions produce a series of contractions and relaxations, (electric massage), and as a rule, the electrode will pass through the stricture; if it does not, repeat the operation, at the end of three days; as a rule, however, the electrode will pass the stenosed part. At subsequent treatments larger electrodes may be used, until the canal is permanently dilated. This is our most successful treatment for all forms of stenosis of the uterine canal. If the uterus is undeveloped, as is the case illustrated here, our attention is now called to the development of this organ.

The switch is changed to the induced current, and with the electrode en situ, the rheotome is arranged in circuit for forty or sixty interruptions per minute, with the rheostat. We supply sufficient current to be agreeably tolerated by the patient. Contractions should be distinctly felt, but not painful. These treatments should be continued from three to ten minutes. By continuing this treatment at intervals of three or four days, for a few weeks or months, we will succeed by this method, where other means have failed, as we have softened the indurated tissues, strengthened the muscular walls, dilated and increased the blood supply.

There are four varieties of dysmenorrhœa, which are ​classed as follows: First, obstructive; second, congestive; third, neuralgic; and fourth, membraneous.

THE CAUSE AND SYMPTOMS—In the obstructive variety some organic impediment hinders the exit of the menstrual blood from the uterus, which gradually becomes distended and painful from the spasmodic efforts to discharge the menstrual fluid. If these efforts prove successful there is an interval of relief.

Flexions and versions of the uterus may occlude the canal of the neck of the organ, thus preventing the free escape of blood, causing intense suffering. In fact, this variety of dysmenorrhœa may be caused from any constricted or narrowed condition of the neck of the womb, whether it be the results of inflammation, congenital malformation, or the improper application of strong caustics used by incompetent physicians.

In the congestive variety, the mucous membrane lining the womb seems to be the seat of irritation. The blood flows into the small blood vessels in greater abundance than is natural, these vessels become congested and enfeebled and so altered in their sensibility as to cause much excitement and pain. This variety may be associated with inflammation of the ovaries, peritoneum, bladder or other surrounding organs. Before the flow is established there is always a feeling of weight and heat in back or pelvis, headache, flushing of the face and some fever. These symptoms usually disappear after the discharge is thoroughly established.

The neuralgic variety of dysmenorrhœa is usually found in persons of a highly nervous temperament, who lead an indoor life, and are subject to neuralgia in other parts of the body, which at the time of menstruation instantaneously reflects upon the ovarian and uterine nerves, which seem to be the center of irritation and pain, and is at times so severe as to be almost unbearable. I have seen a number of women who affirm that the severity of labor pains were not so great as those caused by this disease. The neuralgic pains fly along the tracks of the nerves to different organs and may some ​times be transferred to the uterus or ovaries and sometimes elsewhere, producing nausea, headache and often delirium and convulsions. Ovarian dysmenorrhœa is applied to a class of cases which are associated with diseases of the ovaries. There is pain between the periods in the region of the ovaries, which is aggravated by pressure and exercise, and greatly increases at the time of menstruation. In the membranous variety of dysmenorrhœa the entire mucous membrane lining the cavity of the womb in consequence of some morbid process, is gradually detached and dispelled during menstruation. They are steady pains at the commencement of the menstrual flow, but they increase in violence and become decidedly expulsive. The mouth of the womb gradually dilates and finally the membrane is forced out, attended by a slight flow of blood and an entire subsidence of pain.

TREATMENT.—The treatment of dysmenorrhœa should consist of such means as will establish a normal and healthy circulation of blood in the parts, and thus relieve congestion and pain. For this purpose relief is obtained by means of using prolonged vaginal douch or hot sitz baths are of much benefit in relaxing the parts; this is followed by the extra-uterine application. This application alone will often give relief, nearly as rapidly as a hypodermic injection of morphine, and may be applied every three hours, if necessary, during the period, with marked benefit, and, by continuing this treatment in conjunction with the uterine tonic, during and previous to the menstrual intervals, has permanently cured many obstinate cases in my hands. I generally advise these patients to take one or two uterine tonic tablets four times a day, and each night before retiring, use the prolonged vaginal douch, and insert the extra-uterine application, which is allowed to remain until the next night. This treatment is continued each day, for a few weeks or months, until all distress at the period has disappeared.

In connection with this treatment, I have many patients visit the office twice a week, where I keep the cervical canal dilated, with the electric current, and treatment described in ​Ammenorrhœa. If the cervical canal continues to remain open, and we are sure there is no obstruction, the continuous current is applied only to the cervical canal, with the negative pole; the positive pole to the abdomen. This means of keeping the uterine canal open with electricity, and relieving the congestion by the other medications, will establish a permanent cure in fully ninety per cent. of all cases of obstructive congestive and neuralgic dysmenorrhœa. In the membranous variety, which, fortunately, is not very common, we have a different condition to deal with, and electricity alone will usually destroy and prevent the formation of this membrane, if used as described under the caption of "electric currettment," to which you are referred.

Menorrhagia, or excessive flow at the menstrual period, and metorrhagia, a flow during the interval of the period, are not diseases within themselves, but are symptoms of disease, bearing different classifications; thus we find these conditions existing in fibroid tumors, cancers, retention of the secundines after miscarriages, endometritis, etc. Whatever may cause these profuse hemorrhages requires our attention to check the flow, and remove the cause, if possible; this will be thoroughly discussed in treating the diseases in which this condition occurs.

Endometritis is an inflammation of the mucous membrane lining the womb, while Metritis is an inflammation involving the entire organ. The latter is generally the extension of the former. Their symptoms are so near alike that they can well be discussed together.

CAUSE.—Catching cold or imprudence at the menstrual period, the extension of simple or specific inflammation of the vagina or other pelvic organs, injudicious or unclean intrauterine medicated injections. The unskillful use of instruments and appliances, such as sounds, curettes and stem pes​saries in the hands of inexperienced physicians, bear the responsibility in many cases. Improper and neglected attention during child-birth, miscarriage, and the lying-in period, deformities of the womb and canal, tumors, etc.

In making a speculum examination of the external os, the first thing which attracts our attention is the enormous amount of glairy, tenacious, semi-fluid, ropy substance, oozing from the external os, (see accompanying illustration). This is the condition referred to, by the older writers, as "Uterine Catarrh," and is the pathognomonic symptom of these diseases. There is, of course, profuse leucorrhœa; as the result of this discharge, derangements of menstruation, especially menorrhagia and dysmenorrhœa are often present, due at times to the obstruction of the canal by the tenacious substance.

Sterility is also traced to the same cause. There are, also, bearing down pains and sensations of weight and dragging in the back; sensitiveness over the womb. Nausea and vomiting may be present, indicating a sympathetic irritation of the digestive organs.

TREATMENT.—In this condition we have a diseased ​ ​membrane to deal with, and our only means of establishing a permanent cure is to remove this old, diseased tissue, in much the same way as we build new skin on the face with the ecorchement treatment. This is done by a combination of medical agents with electricity. By this, apparently, simple method, "currette" the uterus with a copper electrode, attached to the positive pole, as previously described. After this treatment, inject about eight minims of the extra-uterine application. This treatment should be repeated about every four or five days, for a month or longer, or until the discharge has ceased, and the organ resumes its normal condition. During this time the patient is advised to use the vaginal douch before retiring, followed by an extra-uterine application, and the uterine tonic tablets, or whatever other treatment is required; this is a remarkably successful treatment. We have "curretted the uterus, and stimulated the tissues by electricity, and reinforced this treatment by depleting effete matter and reorganizing the circulatory nervous system of the female gencrative tract.

In making all speculum examinations, the first thing the physician observes is the condition of the os uterus, as this is the "tell tale" of many diseases. These objective symptoms often allow us to determine, at a glance, the exact condition of local or more remote disease; it is therefore, one of the methods of diagnosing disease without asking any questions.

Simple erosions are usually the result of excoriating discharges, and usually heal after we cure their primary cause. They may be produced by injury from syringe nozzle and other instruments, or the extension of inflammation from the vagina, too hot or corrosive injections, etc., on the other hand, the neck and os of the uterus may picture out morbid conditions, cancer, (see tumors), or benign tumors, polypus, fibroid, etc., many of which are illustrated in this chapter. Where an erosion exists uncomplicated it may be readily healed by a few applications of the Fitzhugh electrode, (illustrated here), attached to the ​ ​positive pole, using thirty to forty milliamperes, after which they are painted with the intra-uterine application; generally three or four treatments will establish the desired results. Follicular erosion should be opened with the knife, and afterwards treated in the same manner.

Corporeal endometrist is a diseased condition involving only the membranes of the cervical canal. This is treated with the intra-uterine copper electrode, attached to the positive pole, and the same technique carried out as when the cavity is treated, previously described.

The formation of the cicatricial tissue at the cervix, as the result of laceration during child-birth, was formerly removed only by surgical means. The cataphoric use of thiosinamine promises a means of revolutionizing this practice, as these cicatrices may be dissolved and removed by this more agreeable procedure. The technique of which is as follows:

Dr. Nieswanger, to whom is credited this valuable procedure, has designed special electrodes for this and similar cataphoric operations, which consist of a brass stem, with a platinum terminal, isolated its entire length with hard rubber, and the platinum tip surrounded by a perforated hard rubber ball, which can be removed for the purpose of covering the tip with medicated cotton. The medication used is the same as given in treating scar tissue, on another page. With the abdominal pad in position, attached to the negative pole, and the cataphoric electrode connected to the positive pole, previously saturated in the thiosinamine solution, is placed in contact with the cicatricial tissue on the cervix, and fifteen to twenty milliamperes of the continuous current turned on through the rheostat, and the treatment continued about ten minutes. It is often surprising to note the action this remedy seems to have in softening this tissue; it has a tendency, however, to abrade the healthy mucous membrane, if the current is too strong, and these treatments should be continued at least once a week, to insure success.

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Vaginitis and urethritis are so closely related that they may be discussed together. They consist of a simple or specific inflammation of the mucous membranes of the vagina or urethra. These diseases may be caused by the use of too hot, medicated or caustic injections, misfitted pessaries, and other mechanical appliances. Gonorrhœa infection is, however, responsible in the greatest number of cases.

The patient will complain of pain, heat and swelling in the vagina, and upon examining the parts, it will be observed the mucous membrane of the vagina is highly inflamed, with numerous granulations upon the surface, (see accompanying illustration B above, A below). By making pressure upon the urethra, (see A above), a few drops of greenish pus will ooze from the cavity. The inflammation may extend upwards, and the uterine canal will be filled with a muco-purulent discharge, (see B below), which will later develop into chronic endometritis. If there is any one condition in which the extra-uterine application will prove its specific value, it is in the treatment of Vaginitis. Within ten minutes after the treatment is applied the distress will subside by its palliative effect, and by continuing this treatment, a thorough and permanent cure will rapidly follow. Each treatment should be preceded by the vaginal douch, and in severe cases, the application should be applied four or five times a day, in a cocoa-butter base; if the cervical canal and urethra are affected, they should also be treated with bougies, containing protargol, during the acute stages.

If the healing process is retarded, from any cause, or the case has developed into a sub-acute or chronic state, involving the deeper folds of epithelium, electricity is one of the most potent measures. The germicide and astringent effects of copper, when cataphorically deposited by the copper electrode, from the positive pole, and continuous current, is so powerful it will rapidly destroy gonorrhœa, or other existing germs; usually, three or four treatments will be sufficient to establish a ​ ​complete cure. The technique of the operation is as follows: A local anæsthetic should be injected into the urethral canal, as the patient will not be able to withstand the pain, in many cases. The copper electrode is now introduced, attached to the positive pole, and from five to ten milliamperes of current used, for about five minutes, repeating this operation every four or five days, until a cure is established.

As a consequence of vaginitis or injury, inflammation and suppuration of the glands of Bartholin is of very common occurrence. These glands lie beneath the labia minora and majora, and are about one-half inch long; sometimes develop, especially ​in prostitutes, as large as an almond. They contain a duct of sufficient size to admit a bristle, which is about one-half in long. The accompanying illustration (Fig 1) shows the gland in the acute stage of inflammation; the upper right hand cut shows a dissection of the parts, exposing the glands, and right lower figure, the formation of a cyst, as the result of the closure of the duct.

The polliations in women are due to this gland.

A simple cyst (Fig. 3), may develop, varying in size from a nut to a goose egg, and contain a colorless fluid, sometimes mixed with blood. The contents have been evacuated, and after aspiration, treated like a hydrocele, by injecting thuja, (see hydrocele), or ten or twelve minims of a chloride of zinc solution. Another later procedure, is to evacuate the contents, and fill the cyst with paraffin, which outlines the cavity, which is thoroughly dissected away, like a fatty tumor, using cocaine to obtund the pain.

Inflammation and suppuration of this gland is, however, of the most frequent occurrence following gonorrhœa, (Fig. 1); by pressing on the duct, a greenish or milky pus is expelled. These may be freely opened, and treated as a common abscess, and, if the inflammatory action re-occurs, complete extirpation of the gland is necessary.

Is an inflammation of the urethral glands, at the orifice of the urethra, generally caused by gonorrhœa, and other irritating discharges. This is one of the most painful, apparently little, affections of the female organs. The papillæ around the mouth of the canal are deep red, and will often not allow the gentlest manipulation. These irritating ulcers may often be exterminated by the use of nitric acid, or nitrate of silver, if only superficial, but the best and most rapid means is to treat the growth with an electric needle, from the negative pole, in the same manner that warts and moles are destroyed. ​The parts should be previously anæsthetized with cocaine; carbon dioxide snow is also a very rapid and efficient means of destroying these growths.

While text books for the treatment of diseases of women are prolific in discussing the pathological conditions of the female sexual system, very little is said regarding impotency or sexual frigidity and sterility; yet these two conditions, more than any other, are subjects which greatly concern the marital happiness of man and wife. If we were to trace the court records, we would find stringent laws regarding impotency in the male that incapacitate manhood; yet the unwritten law regarding sexual frigidity, or apathy in the female, remains silent with the physician, who is constantly consulted regarding this subject. It is, therefore, his duty to look the subject square in the face, and institute such means as will cultivate this active function of love," which is so essential to conjugal peace and happiness. I am satisfied that the physician can diminish the frequency of divorce, domestic infelicity and social evils, by correcting many physical defects and pathological conditions of the female sexual system. Our Creator has designed the functions of these organs for the harmonious procreation of the species, and any apathy which may exist by either sex, cannot be corrected by law-makers or statesmen, as these unwritten laws are only revealed to the physician, whose duty it becomes to advise and treat these patients. Every physician is familiar with the fact that congenial sexual relations are conducive to happy unions, and any deviation from this law is usually followed by domestic infelicity. What is true of sexual apathy is likewise the rule with sterility. It is the heart's desire of nearly every man and woman to procreate, and be blessed with sons and daughters, to smooth the rough roads at the decline of life, and there is nothing quite so disgusting to a well-bred physician as to listen to a woman boast of the number of abortions she has had performed, and ​later meet her on the street, leading a poodle dog, which she calls "baby"; really the string which unites the two links together species which is often difficult to differentiate, from a moral and mental viewpoint, yet some "pin-headed" philosopher has the courage to call this a typical American family.

There are two degrees of sexual frigidity in women. The first is where there is absolutely no desire, no feelings for or during the sexual embrace, and the second is where this function is partially developed but without gratification, and the question arises: what can be done to awaken these organs to life and activity? There is only one remedy, which, apparently, has a specific aphrodisiac effect upon the female sexual system, and that is galega; the evolution of this drug is somewhat interesting. Galega grows in its natural state, in large quantities, in Switzerland, and is also cultivated to a great extent,

and given cows, for the purpose of increasing their supply of milk. Its stimulating effect upon the mammary glands induced many women to use the remedy for the purpose of developing the bust, and rounding out the form; it was discovered that the women who used the drug for this purpose found their sexual appetite was also greatly increased. It is this evolutionary proceeding which has introduced galega as ​one of our foremost remedies in the treatment of sexual apathy, in both male and female, and by combining this drug with other remedies, bearing a therapeutic action upon nerve centers, as is given in the "pill that will" in the succeeding chapter, much can be done by internal medication to develop and awaken this dormant function.

The surgical treatment consists of denuding the clitoris. This operation is analogous to circumcision in the male. The technique of the operation is simple; the hood is pinched up with the thumb and forefinger, and an injection of cocaine is given to obtund the pain; after the anæsthesia is completed, the hood is lifted from the clitoris, and a V-shaped incision is made from the apex downward, (see accompanying illustration) and the denuded edges of the integument and mucous membrane are united by four sutures, two at the apex and two at the base, (black silk was used in the accompanying illustration, which may be confused with the line of incision), the wound is dressed in the usual way, and the sutures removed as soon as healing has taken place. This medical and surgical procedure has been the means of restoring this function in a great many cases in my hands, and you will find your efforts greatly appreciated by both husband and wife.

Although sterility is frequently found in women with sexual apathy, these conditions are in no way related, as there are several causes why women cannot conceive and bear children. The principal of these is stenosis of the uterine canal, due to endometritis, where the uterine canal is obstructed with the thick tenacious secretions, preventing the entrance of the spermatozoa, as is illustrated on a preceding page. The history of many of these cases are the results of criminal abortions; on the other hand, where a woman has never conceived, the uterine canal will often be found in a contracted state, as in the infantile uterus. These two conditions are conservatively estimated to be the cause in ninety per cent. of all cases, and ​by establishing a healthy condition of the membranes of the uterus in the former, and using either mechanical, or other dilatory means, in the latter, a great number of barren women may be made fertile. The method of maintaining dilation of the uterine canal by electricity has been previously described. Many physicians prefer, however, mechanical dilators, of which Outerbridge's stems offer the best means. These instruments are only used where the uterine membranes are in a healthy condition, for the purpose of keeping the canal continuously dilated,

and are of equal service in many cases of dysmenorrhœa, due to a constricted canal. Of course if any form of uterine catarrh exists, occluding the canal, they will not accomplish their purpose in sterility, and the diseased condition should be treated and cured first.

Dr. J. Marion Sims was the first to introduce artificial impregnation by injecting semen with a intra-uterine syringe; although this method has never become popular in medical literature, it is more frequently practiced than is generally supposed, and will be found successful in a great many cases.

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When a physician becomes too enthusiastic regarding a special treatment he is often branded as a "crank." If this

caption applies to my case it will be accepted very gracefully, and I only wish I could be as "successfully cranky" with many ​other treatments in the practice of medicine. I consider this treatment, either used in part or combined, as the case may require, one of the most successful treatments in present use for the diseases of women commonly met with, and far superior to the caustic remedies or the fashionable cautery, electricity. As a rule I do not believe in "stereotyped therapeutics" and occasionally I modify this treatment to meet the requirements of some individual case, but in a large majority of cases I know of no means of improvement, and use it as given here. With a large number of patients I find the best results are obtained from the combined treatment, and usually I have a patient visit my office once or twice a week, and that I may apply the intra-uterine application and watch the progress of the treatment. During the intervals she is instructed to take a douche of warm or rather hot water each night before retiring and apply the extra-uterine application; throughout the treatment she also takes a tablet of the Viburnum tonic compound six times a day, or whatever other internal treatment her case may demand. By the judicious use of these remedial measures I am convinced that they will effect a cure in many cases where other methods of treatment have failed to be of benefit, and it will excell the numerous routine treatments, proprietary preparations and nostrums often used by physicians. To demonstrate its wide range of usefulness, I will point out its value in the following illustrated cases:

Miss G., an actress appearing at one of the theaters in this city, consulted me regarding this troublesome and painful condition with which she had been suffering at different times for about two years. She stated that it was almost impossible for her to fulfill her engagement, as she was in such distress; between each act she would attempt to urinate, but there would be only little urine and such unbearable, spasmodic pains afterwards. This was about 5:30 p. m.; I instructed her to take a vaginal douche of two quarts of hot water, as hot as she could ​comfortably endure, and apply an extra-uterine application (in cocoa butter and slippery elm base) and to repeat the operation at 7:30, just before the performance. She followed my advice and reported the next day that in about twenty minutes after she made the first application all of her distressing symptoms left her and she passed the evening in perfect comfort. The following day I washed out the bladder and instructed her to use the extra-uterine application three times a day. She continued the treatment during her week's stay in this city and took sufficient medicine with her to last two months, making one application each night before retiring. I did not hear from her again until the following season, when she visited my office and informed me that she had never been troubled since. She wished me to prepare some more medicine, however, to be used in case of emergency as she was in constant fear of the old trouble returning. I relieved her mind, however, by telling her that in all probability she would never be troubled that way again.

Miss H., aged 16, applied for treatment for irregular menstruation. The menstrual periods were established when 13 years of age. At this time she thought she "took cold" from bathing; at least, the periods did not return again for four months; since this time they have always been irregular, appearing at intervals from two to three months. The patient was anaemic and complained of having much backache. Her anæmic condition was, no doubt, one of the primary causes of her condition. I prescribed the "Viburnum compound" three times a day, and after each meal she was given a five grain Blaud's pill combined with arsenic and strychnine. I instructed her to use a hot water douche each night before retiring and insert an extra-uterine application. She continued this treatment nearly five months; at the end of this time she was menstruating regularly; her complexion became florid, and her general health was seemingly good. She continued the inter​nal treatment for several months, omitting the iron tablets at intervals. She has been constantly under my observation, and at this writing is perfectly well, strong and healthy.

Mrs. H. consulted me regarding her daughter, 19 years of age, who had always suffered from dysmenorrhœa. Menstruation was not established in her case until 16 years of age, and during the menstrual period she was confined to her bed the greater part of the time. She was a very plethoric girl

and appeared rather timid in disposition, although she frankly informed me she "hated doctors." If I had suggested examination in her case she no doubt would have been out of the office before the words left my lips. After briefly discussing her case with her mother, I pronounced it congestive dysmenorrhœa, and prescribed a douche of two quarts of hot water each night before retiring, and instructed her how to use the extra-uterine application (in a cocoa-butter and slippery elm base). After the douche I also gave her a tablet of the "Viburnum tonic compound" six times a day. She promised to carry out the treatment persistently and report after the next menstruation; in due time her mother called and informed me she had suffered some pain, but it was not so severe as at former periods. She continued the treatment as above, and the next pe​riod was passed with still less pain; the next period was passed in perfect comfort. She continued the treatment altogether about five months, and has never suffered since. It is now a year since she has abandoned all medication.

This is only one of many cases which have come under my observation which has demonstrated the curative value of this treatment. Had I prescribed the application during the first two periods she no doubt would have not suffered at all, as will be illustrated in the following case:

Miss B. I was called at the bedside of this lady, who was suffering intensely. She informed me that she always suffered this way, but the pain was less severe after the appearance of the menstrual discharge. I immediately gave her a douche of hot water and she inserted an extra-uterine application; in less than half an hour nearly all the pain had left her. She repeated the operation twice during the night; in the morning the menstrual flow had made its appearance, but she continued the application twice a day throughout the period, with but very little pain.

This lady continued the treatment for about four months, with the aid of the "Viburnum compound," and occasionally dilating the cervical canal, and she was discharged and pronounced cured.

I was called to see Mrs. P., aged 47, who was flowing excessively. She had been advised by another physician that her condition was due to the change of life, although he had never examined her. Speculum examination revealed the fact that she was suffering with a cancer of the cervix, involving the lower third of the fundus and the upper walls of the vagina. I informed the husband regarding her serious condition and also told him that I believed operative procedures ​would be of no value, as the destruction of tissues was so great, and the only treatment would be to offer her as much comfort as possible until the end. She was suffering much pain, which was very severe at times. I gently curetted the sloughing surface and applied the intra-uterine application to the abraded surface, and advised her to take a douche of warm water and apply the extra-uterine application every two or three hours as her case required. It was suprising to note how rapidly this treatment relieved the pain and seemed to control the hemorrhage and abate the odor. This treatment was continued until the very last, when morphine had to be resorted to. Although the treatment in this case was only palliative, it offered all that can be accomplished in such cases.

This lady was 29 years old; was married and had never become pregnant, very much contrary to her wishes. Her general health seemed excellent, but she said she had been troubled with leucorrhœa for years. After reading some domestic medical book she became alarmed at her condition, thinking the discharge was a sure means of destroying her life. I made a speculum examination and, with the aid of the sound, I found the diameters of the uterus and the internal os about normal. The external os, however, was ulcerated, everted and enlarged. By passing the sound the mucous surface would bleed very easily, showing the mucous membrane was very much congested. It was easily determined that she had endometritis limited to the cervical canal. I applied ten minims of the intra-uterine application to the entire length of the canal, and also thoroughly covering the external ulcerated surface with the medicine, after which I inserted a tampon saturated with glycerine and thymol at the external os before removing the speculum. These local treatments were continued twice a week; during the intervals she used the extra-uterine application, with warm water injections each night before retiring, and the Viburnum compound. This treatment was continued ​about four months. At the end of this time the mucous membrane of the canal seemed to be perfectly healthy, and the external erosions entirely healed. In order that I could watch her condition I had her visit my office once a month for several months, but the old condition never returned.

Mrs. D., 41 years of age, came to my office, stating that "It seems as though beavers are building a dam in my womb, there is such a constant gnawing." By examining her with a speculum I found the external os and cervical canal in apparently a healthy condition, but on entering the uterus with a sound she complained of some pain, and said "that is the very place which is causing me so much discomfort." The surface would bleed easily at the most gentle manipulation. Menstruation was irregular, but when it did appear it was too profuse and lasted longer than it should. She also had leucorrhœa, which at times was offensive. I decided that she had endometritis limited to the uterine cavity, which is not of common occurrence. I treated her twice a week with the intra-uterine application, and curretted the surface occasionally, and also had her use the extra-uterine application and "Viburnum compound." At the end of three months all symptoms of the disease had left her, and she was discharged as being cured.

Mrs. J.—This was one of those complicated cases not unfrequently met with, where the inflammatory condition seemed to involve the entire pelvic cavity, and had she fallen into the hands of the modern gynæcological surgeon, she no doubt would have parted with much of her anatomy. Congestion and hyperthesia was manifest everywhere within the pelvis; the ovaries were sensitive, and at times she would have frequent and painful urination, backache and constant pain in the pelvic region. Speculum examination revealed an enlargement of the cervix, which was fairly purple in color, showing retarded ​circulation. There was a large erosion on the external os, the lining membrane of the cervical canal and uterine cavity were sensitive and bled very much when touched with the sound. There was large quantities of mucous oozing from the canal, which was often streaked with blood. Menstruation appeared too often and was too profuse; her general health was very much impaired; she was weak and anæmic, had disturbances of the stomach, and was extremely constipated and nervous. It was not difficult to see she was suffering with metritis and endometritis, involving the entire membranes of the uterus. She was placed upon a thorough course of reconstructive and tonic internal medication, and the intra-uterine application was

applied to the entire uterine cavity and cervical canal, by gradually increasing the amount of medicine at each application until ten or fifteen minims were used, which was sufficient to cover the entire surface. She was also instructed to use the extra-uterine application and a hot water douche each morning and evening, as an intermediate treatment. The extra-uterine application seemed to have a wonderful effect in her case; at the end of one week she declared she had not a pain or discomfort in the pelvic region. Often when she would take a douche there would be large pieces, amounting sometimes to entire casts of the vagina, of coagulated serum, come away, which demonstrated the value of the application as a depilatory in curing these conditions by exosmosis.

​After she had continued the treatment for several months, she had gained about 25 pounds in flesh, the size of the uterus was gradually diminished and the endometrium was apparently in a healthy condition, when an accident occurred which ended in her death, by falling down an elevator shaft in one of the large department stores in this city.

Mrs. C., a refined lady, 32 years of age, contracted gonorrhœa from her husband, who was "rather sporty inclined." I did not inform her the cause of her condition, as I did not wish to take an active part in a family disturbance, as I was treating the husband for the same disease. (I think St. Peter will pardon a few prevarications under such circumstances. She was suffering intensely with vesical and rectal tenasmus, had a profuse discharge and all the accompanying symptoms of the discase. She was instructed to use a douche of two quarts of warm water in which 2 drachms of borax had been dissolved, 5 or 6 times a day. After each douche she inserted an extra-uterine application. She experienced great relief from the first, and at the end of ten days the symptoms of the disease had left her and she was practically well. She continued the local treatment, however, once or twice a day for about three weeks.