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women as housework, both physically and mentally. Most of her work can be turned into efficient physical culture, but should be supplemented with methodical gymnasium work, stair climbing, wheel riding, lifting of graduated weights, so increasing ability to lift. The wearing of a moderate heel on shoe, cranks to the contrary, gives a desirable tilt to the pelvic plane, throwing the line of abdominal pressure in front of pubic bone. A good, well-fitted corset helps this position, developing the upper air passages and throwing chest line front, also shortening abdominal lines in multipara. Improve on nature? Yes, when she has taken thousands of years to evolute a perfect woman and has not yet succeeded.

As doctors, then, we will remember two facts: Involuntary muscles are called into action by stimulation, reflexly, and that such action continues in waves or cycles after the application of the irritant for some time; secondly, that to increase the life, power and nutrition of a muscle, use it.

Injuries to the pelvic floor are superficial or deep, one or the other, or both. Both are generally caused by labor, yet the former sometimes present themselves for our consideration, caused by rape, first coitus, accidental entrance of foreign bodies, as fragments of wood and iron in falls and wrecks. The deeper injuries from labor are more serious in their remote effects; they are not so quickly recognized, and so are often overlooked, the woman going on to her life of invalidism until she falls into the hands of the gynecologist, ignorant of the cause of her trouble. Separation of the tissues may follow some time after the completion of labor, an experience of my own making me more charitable about the statement of other doctors to their patients that they were not torn. I examined my case, a sixteen-year-old girl, after the birth of child and the removal of placenta, in a good light and with all of my senses awake, completed her toilet and occupied myself for half an hour with the baby, being called in the course of an hour for hemorrhage, and found a deep ragged tear through the left side of perineal body, down along the sphincter muscle.

There is but one course to pursue, and that is immediate repair of every wound when it possibly can be done. Often in failing to get a so-called primary union, which we need not expect, we will secure a scar tissue that is firm and answers the purpose. It is well to remember that injuries to the tissues during labor possess practically no healing properties of their own, and the doctor who practices episiotomy has indeed fortunate patients.

Vaginal douche.-On no question is there probably an opinion so universally contrary to common sense as on a vaginal douche. And we believe that its general use has led to a widespread injurious knowledge of the location and accessibility of the uterine mouth. We know of no condition requiring a vaginal douche other than the infective one, in which the normal bacteria of the vagina are incapable of combating the invasion. The daily irrigation of the stomach, the bowels, the bladder or nasal cavity would be just as plausible and proper. A douche will never cure an ulceration or erosion, a displacement or a congestion depending thereon, or a leucorrhea. The offensive discharges from a woman are all from the external parts and are accessible to soap and water. Any chemical wrong with vaginal discharges must be met with internal treatment and local applications other than a douche.

I am not a bacteriologist, but I believe that they have found a law in existence in bacteric history which means, in substance, that repeated cultures of a colony weakens the bacteria in reproduction and virulence, thus changing their ability to perform their life work. Apply this law to the normal vaginal bacteria and we have a continual damaging of their defensive powers from a douche, especially an antiseptic solution. In other words, the maintenance of a healthy bacteria in the vagina of a woman is necessary for the defense of her generative organs.

Weaken her defense and you render her liable to external invasion.

When it becomes desirable to wash away uterine or septic discharges, or detritus from malignant growth, the former consideration must take the ulterior place. Taboo all return-flows, combinations and complications in a syringe, selecting a plain rapid-flow fountain type, of red rubber, with a smooth surface, and a glass nozzle. The last, if you cannot find on market, keep them in stock, ordered from your instrument house. Instruct your patient to lay a board about three inches wide on a pail and seat herself comfortably thereon, inserting the nozzle over front edge of board. If the case demands instruct how to place a folded towel on the board and hold it against the vulva to balloon the tissues that the fluid will enter every fold.

Never allow your office outfit to include a fountain syringe or any apparatus for the giving of a vaginal douche; you get enough dirt therein without and you carry more than you should from one to another.

The tampon.- Probably the most important part of the treatment of any case is the tampon. The general conception of this article, I should judge from those which I have removed from patients, is very amusing, to say the least.

We will first discuss the kind of material suitable for a tampon; its integral parts should be made of material selected for the purpose for which that special part is designed, the holding of medicine, support either firm pressure or elasticity, porosity and so forth. For drainage from a cavity flax fibers are the best, but they become heavy from the enmeshed moisture. A long fibered absorbent cotton is the best for medication, and its softness allows it to be used next to an eroded or an ulcerated surface. For support wool, long fibered lamb's wool, with its natural oil, does not absorb moisture, and retains its elasticity for several days. We like Merrit's comfort batt, which we sterilize ourselves by exposing to steam for several hours. Tidy cotton of a white, even quality wound around a board and cut thirteen inches long furnishes the strings. All of these materials should be kept absolutely clean, stored outside of office in dust-proof compartments, small quantities being taken to office as needed. Each part of a tampon should not be a chunk, but should be flat and whispy; each part should suit the place it is going to occupy, and the place it occupies should select the material. In making the wooi part of tampon pull the fibers longwise from the batt and tie near one end; never put wool next to an eroded or tender surface, and you cannot use wool at all on some women.

A tampon to be effective should be so placed that it will remain until removed and should be so well fitted mechanically that it can be removed with difficulty by the patient herself, and yet it should be comfortable.

Effect of tampon.—The effect on the vaginal wall of the tampon is to contract it, as paradoxical as it seems. Nature's efforts are uniform to try to expel a foreign body from any cavity, both by contractions and the pouring out of lymph to coat it over. This contraction of the muscles gives to them an added blood supply and lymphatic activity, hence an increased nutrition. The irritation of the tampon causes a reflex action on the involuntary fibers surrounding the genital organs clear over the uterus and out to the extremity of the tubes. Thus we find a general activity set up through the pelvic viscera. The circulation is improved, old material is carried out, the uterus becomes small and firm and ascends to a normal position, normal functions gradually are established, and our case blossoms into beauty and strength.

Placing of a tampon.-Every case is a law unto itself and must be packed with its specific demands in view. On general principles we would say that the knees, chest and Sims were the only positions, but a man without an assistant must use knee-chest position, and then he will once in a while find a case with a sharply curved sacrum, which will have to be packed in the dorsal position.

Pack the medicated whisp in over the cervix, snugging the fibers around in the vault; grasp the tied end of long wool whisp and place it firmly with forceps in the vault where you want most pressure; slip string under thumb holding speculum, pack crosswise and firmly, tighter at points desired, carrying all of tampon above levator muscles; remove speculum and pass the finger under tampon, arranging lower fibers well out on the shelving inner surface of the bony framework. When job is done, gather up all fragments and dispose of them in a receptacle for that purpose and place all instruments that were in sight in a granite box container; leave nothing that your patient might think that you would use on another case; also sheet and towels. Have an absolutely clear field for next case.

Care of instruments and lubricators.—Vaseline or oil of any kind should never be used in general work. For the occasional case that we meet a fine quality of vaseline used from small collapsible tube will do. The market furnishes us two desirable preparations, both of which can be made in the office and put into two-ounce tubes, one "luborine," a gum tragacanth preparation, with eucalyptus and antiseptics, the one I prefer, a green soap, mild and pleasant, can also be made at home. It goes without saying that you should have a sufficient number of instruments to last you through hours devoted to gynecology. These should be placed dry in a container; we use a china jardiniere. When ready to clean, sort into bowl and allow to stand in boiling suds a few minutes; lay out on marble stand top and scrup vigorously with Sapolio and asepsin soap; separate all parts, wash again in boiling water and wipe dry on clean towels.

Procidentia.—There is no subject on which the general practitioner is as painfully ignorant, and on which he makes such fearful breaks, and the cure or palliation of which in all its degrees and with all its reflex misery so nonplusses him. Some even assert that no woman is ever cured, and some evidently seem to think that the whole operation resembles the placing of a potato on a shelf, with the absurd supposition that like the potato it will lie there. These are the men who believe in nothing, repair work, local treatment, appliances, massage, physical culture, postural treatment, medication.

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They tell an old woman that she has no womb; no, honestly, she can have no such thing after her change. It has dried up and floated away, although the poor mortal has a womb hanging in an everted vagina from six to ten inches out of her body and has not sat on anything for years, only on a bottomless chair; yet she straightway believes it all and goes on her weary way rejoicing in the fact that she has no womb.

Sometimes we think that from the mistreated cases that drift our way that a woman will eventually evolve an external pouch and carry her organs in a manly way.



Achievement in surgery establishes new methods in practice and makes many changes in the old and established methods. In the surgery of today, an operation is not considered an adventure, even though the operator has not seen the operation performed, nor heard of the method, provided the operation is founded on good judgment and executed by the careful hand of an experienced surgeon. Not long since, it was common among medical men to hear the statement that “This patient is too young to stand the operation.” The methods of today which are founded on practical experience, in a large number of operations and for a wide range of troubles has proven that the surgery for infants gives as good and for many troubles better results than the surgery for adults.

The experienced operator does not find it difficult to execute even the most minute surgical detail on the delicate structures in the child. If the elasticity of tissue be taken into consideration, it at once becomes evident that if care be used in the manipulation of structures many things may be accomplished in the child that cannot be brought about in a similar operation on an adult. A tabulation of the good and bad results following operations in children will establish the fact that for a large number of surgical troubles, the younger the patient is when the operation is performed, the more perfect the results will be. It can be further stated that for some troubles there is an age limitation, after which, if the operation be performed a good result cannot be expected.

Prof. Lorenz in his explanations in regard to the results following the operation for the reduction of congenital dislocation

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