frequently the eye. Outside of this we can go occasionally to the organs. of the body below the head for the cause.

Frontal headaches arise from the stomach, from eye-strain, from coryza, and from gravedo. When we have determined which of these produces the headache, its cure can be easily suggested.

General headaches depend commonly upon general causes. In this way we oftentimes find rheumatic headaches, gouty headaches, neuralgic headaches, and syphilitic headaches.

The rheumatic headache is easily distinguished by exacerbation upon the falling of the barometer.

The gouty headaches are recognized by the accompaniment of uric acid in great quantities.

The neuralgic headache is indicated by the presence of hyperæsthesia. The distinguishing characteristic of syphilitic headache is its nocturnal visitation. When we have determined the cause of the general headache, the remedies necessary to cure it will be easily forthcoming. It is well to add in passing that we will oftentimes be astonished at the improvement, under the diathetic treatment, of other symptoms complained of by the patient, which symptoms we had, perhaps, been led to believe were of gynecological origin.

The next symptom offered by the nervous system to which attention is directed is the backache. Nearly all gynecological patients complain of backache, but the merest tyro soon learns that there are backaches and backaches. A great many backaches exist which are not gynecological, and it is very desirable to distinguish them, and treat them successfully. We will be aided greatly in the study of backaches if we take them up regionally. We will thus find that we have the dorsal backache, the lumbar backache, and the sacral backache. It may be said, in a general way, that all backaches are produced by organs anatomically, not topographically, in front of the seat of the pain. Bearing this fact in mind enables us to unravel a backache that has resisted all former treatment.

The dorsal backache, in the great majority of cases, has the stomach or liver for its cause. The particular variety of stomach trouble most. commonly found as a cause of this form of backache is the fermentative dyspepsia, which invariably produces, sooner or later, dilated stomach. The physical symptoms of dilatation of this organ are well known. In organic diseases of the stomach, as gastric ulcer or malignant disease, the symptoms need scarcely any consideration here. The form of trouble met with in the liver which produces this form of backache is congestion. With the knowlege of these two causes before us, the treatment of dorsal backache becomes, in the majority of instances, a very easy matter. On the same plane with the dorsal region are the pleura, lungs, the insertions of the diaphragm, the spleen, and the pancreas.

But it is so seldom that diseases of these organs demand our attention that they will not be considered here.

Lumbar backaches, in the majority of instances, depend upon the bowels and the kidneys. Where a protracted constipation exists, its removal will almost always cure this form of rachialgia. It is only occasionally that it is necessary to consider the kidneys as a cause of lumbar backache. Now and then we will meet with a more or less persistent pain at the juncture of the lumbar and sacral regions, which is uniformly attributable to malposition of the uterus.

The sacral backaches almost always find their cause in the pelvic organs, and for their relief we will have to consider the uterus, tubes, and ovaries. Oftentimes the rectum will have to be taken into consideration. The persistent gnawing pain at the extreme lower end of the sacrum is usually explained by disorders of the anus. No reference is here made to coccygodynia.

The backaches found in cases of neurasthenia may be considered as a disorder, to a greater or less extent, of the central nervous system. There is a form of backache that is invariably muscular, which depends upon the rheumatic or gouty poison for its cause. Its exacerbations in changes of the weather indicate its origin. Anti-lithic and anti-rheumatic remedies and plasters will relieve it.

THE RESPIRATORY SYSTEM.-The next general division of the human system is the respiratory organs. The first things that attract our attention are the nasal tract and the pharynx. I think that it may be laid down as a general fact that chronic rhinitis and chronic pharyngitis are caused reflexly by imperfect alimentary excretion. I fail yet to find a man or woman, the victim of chronic rhinitis, who has not had in the past intestinal disorder. This fact is mentioned simply for the purpose of calling attention to the possible reflex relations existing between these points. We want no better evidence of this relation than the fact that brisk purgation relieves acute attacks of congestion of the nose and throat. Consequently, it is easy for us to conclude that the patient with gynecological trouble sufficient to demand treatment ought, as a victim of chronic pharyngitis or rhinitis caused by constipation, to receive medical attention before we can hope to cure her.

Passing on further down the respiratory tract, we find that patients suffering from pulmonary troubles, in the way of repeated attacks of bronchitis, pneumonia, or pleurisy, are the subjects of diathetic tendency sufficiently strong to most urgently demand attention medically. Patients inclined to bronchitis challenge our attention to the gouty and rheumatic diathesia.

"Winter coughs," so often seen in gynecological patients are more often relieved by lithium, potassium, and the alkaline diuretics than by

any other class of remedies. Renal insufficiency is surprisingly often connected with them.

THE CIRCULATORY SYSTEM.-Passing on to another division of the human system, we come to the circulatory apparatus. It is needless to advert to the fact that the integrity of the human heart is greatly impaired by prolonged lying in bed. The weakness of a weak heart is of the greatest possible consequence-demanding iron, digitalis, nux vomica, and other tonics for the anemia which we encounter, and which aggravates all the nervous symptoms. Very many times we know that patients, sick enough to receive special treatment, will have many of the alleged reflex symptoms from the pelvic organs relieved by hæmatic remedies. The condition of the cold extremities indicates a weak heart. The anæmic condition often indicates excremental poisoning. It is scarcely necessary to mention the value of iron, digitalis, strychnine, quinine, and the hypophosphites in patients with weak hearts.

THE DIGESTIVE SYSTEM.-The next division of the human body to which our attention is directed is the alimentary tract. This leads us to take into consideration gastric, intestinal, and hepatic disorders. The well-known tendency of our patients, subjected to inactivity, is to take on hepatic disorders, or perhaps disorders of the portal circulation. It is needless to mention that a certain amount of daily exercise is necessary to human beings to preserve the integrity of their digestive organs. The common links of the chain of disorders in these patients are constipation-the filling up of the portal circulation with excretive matter -and the perversion of the secretions and excretions of the intestines, which mean gastric and intestinal dyspepsia. It is a well-known fact that the liver secretes from two to five pints of bile every twenty-four hours. We all know that in a condition of health there is never passed off from the bowel any such quantity. This large quantity of hepatic secretions is reabsorbed, resecreted, and reëxcreted, passing around through the portal circulation no one knows how many times. In all cases of constipation there are absorbed certain amounts of excrement, and we thus have quantities of filth continually circulating through the liver, which must lead to functional disorder. This disorder manifests itself in the imperfect functioning of the stomach and intestines. We have thus the beginning of dyspepsia. Nature indicates to us in many cases a relief for this condition in permitting these patients to have an occasional diarrhoea. Consequently, we will find that the beginning of all treatment for the cure of the majority of alimentary disorders, in gynecological patients, should be the daily laxative.

I suppose it is a fact beyond dispute that the majority of cases of dyspepsia present the phenomenon of fermentation. Where stomachs are dilated much, indicating impaired propulsion, gas is eructated and

acidity presents itself. The best initial treatment is gastric lavation. I know of nothing so simple as the washing out of the human stomach. It is only now and then that we meet a patient who cannot tolerate it. Such a patient will permit the passage of the tube into the stomach a couple of hours after having taken a dose of bromide. I am in the habit of teaching the most delicate and sensitive patients to wash out their own stomachs. They do it very easily and simply, and all that is necessary is to have some one pour the water into the tube for them. Some patients are so terrified at the use of the stomach-tube that they threaten to never consent to its use. When they get over the dread of its use, after a few times they insist upon introducing the tube themselves. Such patients will have no difficulty in performing gastric lavation upon themselves. I have some patients who have kept up the use, once or twice a week, for months consecutively, after experiencing the limitless advantage which it procures. It is best to use the water as hot as it can be borne. At first oftentimes it will be impossible to syphon out the stomach, because of the large quantities of mucus which will block up the tube. All that can be done is to fill the stomach with hot water until vomiting occurs, or to remove the tube to provoke vomiting by titillation of the fauces. Occasionally it will be found necessary to use some prompt emetic, as a teaspoonful each of mustard and of salt in a glass of hot water. In very many cases the first washings will bring away an astonishing mass of mucus. In such instances it is best to wash out the stomach daily, until it seems comparatively free from mucus. Afterward the lavations can be used twice a week. It is best to use them in the morning when the stomach is empty. In cases of acid dyspepsia we can use the bicarbonate of soda, one drachm to the quart. In putrid dyspepsia the best remedy is the permanganate of potassium. When there are vegetable parasites phenic acid is a suitable remedy. Boric acid is an excellent disinfectant. Tincture of myrrh can be used in the atonic dyspepsia. After the daily lavation fails to bring away any evidences of stomach fermentation, it is well to keep up its use once or twice a week for several weeks, during which time the use of antifermentative remedies, as salol, salicylate of bismuth, corrosive sublimate, or sulphocarbolate of zinc, together with artificial digestants, as pepsine, lacto-pepsine, papoid, and especially ingluvin, will hold out the best promise of permanent cure.

Time will not permit me here to speak of the use of electricity applied through the gastric electrode to the stomach-wall, the application of which has the effect of contracting the stomach, just as the scrotum can be contracted, thus relieving the condition of impaired propulsion.

One of the most common of gynecological patients that we meet with, is the vast class presenting constipation, dyspepsia, and anæmia. In these patients the use of the daily laxative, with pepsin or its congeners

and the bitter tonics, will be found of the greatest possible advantage. It may be laid down as a simple clinical fact that patients who pass dark feces are patients who need daily laxatives. Patients who have now and then a diarrhoea for a day or two are always in need of a daily laxative. Patients who possess chloasmic spots are patients who are generally the victims of fecal anæmia the result of fecal impaction, and are always benefited by colonic flushings and the daily laxative. It is wise to persist in the use of daily flushings until the dark feces give way to the yellow-colored feces. It is well to bear in mind. that patients taking iron or bismuth will void dark feces; but when the feces are habitually dark, it is always best to resort to the flushings and the daily laxative.

THE RENAL SYSTEM.-The next division of the human organism is the renal system. Two things in disorders of the kidneys are worthy of the attention of the gynecologist. One is the presence of a superabundance of lithic, now commonly called uric, acid. The persistent presence of too much uric acid in the system leads to grave functional disorders of the nervous system, joints, and the mucous membranes. Lithæmic patients, predisposed to gastric disorders, very easily take on gastro-duodenitis in all its phases, from simple gastric disorder to the most intractable gastric irritation, constituting the most persistent dyspepsia we have to deal with. The presence of gastro-duodenitis is most easily indicated by pressure toward the body of the vertebræ at the junction of the middle and lowest third of the space, in a straight line between the umbilicus and the ensiform cartilage. If this pressure produces pain and nausea, the presence of gastro-duodenitis is inferred. The tendency of lithæmic patients to neuralgia is well known. We find more cases of renal colic in this disorder than in any other urinary trouble. The citrate of potassium in as large doses as the stomach will bear produces very satisfactory results. Many patients can take as much as a drachm four times a day. It is best administered in some carbonated preparation, as the effervescing Vichy salts. The better, but more costly, remedy is the granular effervescing salts of lithium. less obnoxious to the stomach, and will dissolve a larger percentage of uric acid, than citrate of potassium. It increases the amount of urine. It does not possess the depressing effects on the heart, of the citrate of potassium. It is always advantageous to administer at the same time small doses of mercury daily for some days or weeks. The triturate tablets, containing grain of calomel, are an eligible preparation of

mercury.

Another form of renal disorder, and perhaps the less appreciated in its importance, is renal insufficiency, about which much has been written in the past five or six years. The average human adult passes anywhere from five to eleven hundred grains of urinary solids every twenty-four