gruous to present a paper that is not devoted to the consideration of some purely gynecological topic, but he expects to be excused from stepping aside from gynecology somewhat because it is well nigh impossible to draw the therapeutic line rigidly between this specialty and general medicine in the vast majority of gynecological patients.

The writer has been in doubt as to a suitable title for this paper. By the one used is meant that part of the subject which deals with internal medicine in addition to purely gynecological work.

The most natural order of consideration of topics for medical gynecology is the topographical one, passing from above downward, which begins with the brain and spinal cord. It is perhaps proper to state that very many symptoms herein to be considered are by no means purely and exclusively gynecological; they are the symptoms found very commonly in gynecological patients, very many of them doubtless being reflexes from functional derangements arising possibly from the original gynecological malady. To illustrate, we find time and again frontal cephalalgia to be a reflex from gastric dyspepsia produced by a constipation that results from the physical quietude enforced by an acute metritis. No one will contend that the metritis produces that form of cephalalgia directly, yet without the metritis the intervening links in the pathological chain would not have existed and the headache would not have tormented the patient.

THE NERVOUS SYSTEM.-The commonest symptoms that the gynecologist meets in the nervous systems of his patients, are nervousness, headaches, and backaches. It will be seen that no mention is here made of the many and highly refined neuroses, as no attempt is made to present anything at all of an extensive treatise on the topic. The foregoing symptoms mentioned herein will comprise all that this article desires to include.

Concerning nervousness, it must be said that, if it be regarded as arising from an imperfect capillary circulation in some part of the nervous centres, notably in the spinal cord, and that it is very often associated with deficient excretion from the skin, kidneys, or bowels, and with defective cardiac action, we shall be able to treat the great majority of cases satisfactorily. A sudorific will make many nervous patients less nervous. A diuretic properly selected is often of the greatest advantage. That protean monster, constipation, can derange more lives with nervousness than any other one pathological condition that can be named. Its treatment will be considered later on. The share in producing this symptom attributable to a weak heart is much greater than is generally accorded to it. A weak heart means lessened arterial pressure, over-distended capillaries and turgid veins, a vascular condition found with astonishing frequency in the brains and cords of nervous women. Therapeutic agents will abundantly confirm this fact. Stro

phanthus, digitalis, strychnine, and heat all tend to stimulate such hearts. No better remedy can be suggested than the protracted sponging of the spine with water as hot as can be borne, in cases of nervousness associated with insomnia. Heat thus applied reflexly empties the crowded vascular areas in the cerebral and spinal centres and increases the cardiac tonicity, for hours at a stretch. Alcohol at bedtime for a few nights can be used to great advantage because it produces an improved circulatory condition, brings needed sleep which in turn strengthens every function, and again rebuilds the strength of the heart-centre in the medulla, thus securing the removal of the cardiac debility.

Cold water, drunk in quantities in the evening, will dissolve and flush out blood impurities, which, producing cerebral irritation by their frictional contact in their passage through the capillaries, thus causing insomnia and nervousness, now find their way out of the body through the kidneys.

In considering headaches, organic cerebral or cranial perversions will not be included, functional headaches only will be taken up. Where we have one cephalalgia dependent on organic cerebral conditions we have hundreds that are functional or reflex, consequently the latter only will fall within the scope of this paper.

It is a wonderful aid to consider the region of the head that aches. Accordingly we find occipital headaches, coronal headaches, temporal headaches, frontal headaches, and general headaches. In the majority of these varieties, it will be found that cause and effect are so simply manifested that their investigation and treatment often bring the greatest satisfaction. Many patients have only one variety of cephalalgia, a few have two varieties, and occasionally a patient will be found who has three distinct and separate varieties, each one as easily recognizable as a floating kidney and a prolapsed ovary can be detected in the same patient.

Without going into tedious detail, it will be well to state, somewhat dogmatically, perhaps, the causes of the varieties of headache, knowing that each practitioner's knowledge of therapeutics will furnish the necessary remedy. The enumeration of these causes is suggestive rather than exhaustive.

With occipital headaches we may always question the heart, kidneys, and bowels. A weak heart will permit venous congestion at the base of the brain, which can produce a persistent sickening pain in that region. A patient, a victim of this form of suffering for years, aggravated at times to an extent beyond endurance so that the nearest physician was often called in to etherize her for relief, once called my attention to her blue finger-nails and blue lips when under the influence of phenacetin given for her suffering. Recognizing the presence of the well-known effect of this drug in producing cardiac depression, digitalis was pre

scribed with the surprising effect of at once relieving her headache. Ever since then the same drug has been administered in similar attacks always with complete relief. For years she has been told that her retroverted uterus with its deep cervical laceration caused her cephalalgia. Many cases similar to hers have been treated with cardiac tonics with as marked relief.

Renal insufficiency is often accompanied by occipital suffering. This condition will be considered later on. The possibility of its presence necessitates an extended analysis of the urine. When found, it calls for a stimulating diuretic.

Bowel derangement, as costiveness, constipation, loaded colon, chronic diarrhoea, or intestinal dyspepsia, is perhaps the commonest cause of occipital headaches. When found, often dependent on a gynecological disorder, the gynecologist must treat a simple medical case with common remedies, or he will fail to relieve his patient. To suggest remedies for costiveness and constipation to practising physicians sounds very elementary, but the fact that said physicians are very often defeated in relieving this condition permanently, perhaps warrants a few words hereupon. Where a sufficiency of well-recognized rectal or anal irritation. exists to produce an unusual amount of sphincteric activity, daily laxatives can be administered fruitlessly for a century. It is surprising to see how almost uniformly a failure to cure a constipation with the patient administration of daily laxatives is associated with such an irritation. It is needless to insist that its removal is a sine qua non to the successful treatment by remedies. Cascara sagrada administered daily for six to twelve months will relieve a large percentage of cases of constipation. It is accompanied by fewer drawbacks in its prolonged use than any other remedy that can be mentioned. Patients with plethoric habit are very satisfactorily treated with a morning dose of the salines. One of the most eligible preparations is the granular effervescing Hunyadi salt, followed by a glass of hot water, taken upon arising in the morning. The compound glycyrrhiza powder and the compound piperine pill are also excellent remedies. Massage and electricity occasionally answer but they are too often inapplicable.

One point to be borne in mind is, that the prolonged daily use of a laxative remedy is the surest to bring desired results.

The loaded colon exists much oftener than is supposed. One would naturally think that it would be found in constipated people only, and not in those who have daily bowel movements. Observation shows that it exists very often in people who have daily bowel movements, as well as in those who are constipated. A colon that contains feces in large quantities impacted in its loculi, can produce reflex symptoms in the nervous system all the way from nervous irritability up to insanity. Loculi thus embarrassed with impacted feces, for months at a time, can

take on a condition of irritability and ultimate reflex possibilities that lead to astonishing diagnosis.

A patient recently came under observation, who had been under gynecological treatment for the past five years. She passed the menopause four years before. She had been treated without relief for uterine malposition, for metritis, for ovaritis, for salpingitis, and for how many other inflammations no one knows. She suffered from more or less constant pain from her right iliac region to the right shoulder. Starting from the pelvis the pain had been regarded as surely gynecological. Examination revealed the fact that the ascending and transverse portions of the colon were greatly impacted with feces. The utmost tenderness was elicited upon bimanual palpation, so that a thorough examination was very difficult. Examination of the pelvis was entirely negative beyond an abundant leucorrhoea. The experienced gynecologist would not have made the mistake of calling this patient a gynecological patient. This case is entirely in the line of the argument in favor of medical gynecology and the thorough examination demanded to determine what is best for patients. Suffice it to say, that the unloading of the colon was immediately followed by the relief from the symptoms complained of. The patient had daily bowel movements, and always had had, and it was difficult to convince her that it was not womb trouble that she had until she saw the enormous quantities of black, ancient, and offensive feces, that she had been so carefully carrying around. The abundant leucorrhoea entirely disappeared within a month after unloading the colon. I do not know how to account for its presence, except upon the hypothesis that the uterine and vaginal mucous membranes were attempting, vicariously, to play the part of bowel in active excretory efforts. Detecting a loaded colon is a very easy matter, excepting in very obese patients. With the fingers of one hand placed in the hypochondric region, and the fingers of the other hand pressed deeply in the loins, between the floating ribs and the ilium, one can push the loaded colon forward toward the anterior abdominal wall, where it can be at once detected. Daily bowel movements in such patients can be easily accounted for by the fact that such movements pass down through the accumulation of feces impacted in the loculi. The best means to relieve a loaded bowel are colonic flushings administered with the patient in the genu-pectoral position. The patient placed thus with the shoulders much lower than the nates, can be made to receive anywhere from two to six pints of water. The water should always be as hot as can be borne. If it is used tepid or cool, it may cause the most violent tormina. Used hot it almost never produces it. After the colon has been filled the bowels should be thoroughly kneaded until, by pressure, the loculi are distended, when their contents will drop out into the volume of water. As a rule, it is safe to advise daily colonic flushings until no

more dark-colored feces come away. I have seen the worst-looking and most offensive discharges pass away on the twelfth or fifteenth day of the daily use of flushings that I have ever encountered. After yellow feces are daily produced the flushings can be given twice a week. After administering them at least a month, strychnine in some form should be given in as large doses as can be borne. The improvement of patients with colonic flushings is immediate. We do not have to wait for a month or even a week to see this improvement. Two symptoms, without abdominal examination, are always suggestive of a possible colonic impaction, and when present they always lead to examination; and they are the presence of chloasmic spots, and the voiding, habitually, of very dark or black feces. No attempt at an explanation of the reason for the appearance of chloasmic spots in such patients is made beyond the suggestion that they may arise from the efforts of the skin to excrete fecal material absorbed by the bowel from its impactions. Why patients with loaded colons should pass black or very dark feces I cannot explain. The clinical fact is all that is offered.

No reference is here made to the extremely common form of occipital headache arising from a lacerated perineum. In such lacerations the veins of the pelvis become distended because of their loss of support in the torn pelvic fascia, thus permitting enormous quantities of venous blood to accumulate in the pelvis. In this way within the pelvis is produced reflexly, through the intricate mechanism of the spinal cord and medulla, the often found occipital headache. I do not speak particularly of this form of headache, for the reason that it is a well-known gynecological symptom.

Chronic diarrhoea is best treated by antiseptic measures, the diarrhoea resulting in most cases from fermentations. Accordingly corrosive sublimate, salol, or salicin will relieve the majority of cases of chronic diarrhoea.

Intestinal indigestion must be met and relieved by remedies before gynecological patients afflicted therewith can be relieved. Fermentation is found at the basis of this disorder, and with this pathological idea. in view, the anti-fermentative remedies will suggest themselves.

The next form of headaches to which attention is directed is the coronal variety. There are two kinds of this disorder; those caused by the condition of the stomach and those arising from the condition of the pelvic organs. Accordingly, when we have a distinctively coronal headache, the treatment of the stomach and the pelvis should at once be considered. It will be found that the stomach produces this form of headache a great many more times than the pelvic disorder.

The temporal headache can be produced by almost any organ upon the side of the body where the cephalalgia exists. The throat and nasal canal produce this form of headache; also, the teeth and ear, but most