"Uneasy lies the head that wears the crown." - Shakespeare.
 
 
    The testimony in favor of the production of reflex neurosis from dislocated genitals is ample for the gynecologist.  To the physician foreign to gynecology from lack of knowledge and experience, clinical and anatomical facts, comparisons, methods of successful treatment, the domination of the sexual system and instinct and controlling power of genital reflexes over other viscera, in fact, all legitimate arguments of cause and effect, should be presented. Distorted mechanism of the pelvic structures causes genital dislocation.  Dislocation of structures compromises circulation by the strangulation of vessels and thus induces malnutrition.  Dislocation of structures traumatizes nerve-trunks and nerve periphery, causing pain and reflexes which radiate over nerve-tracks to other viscera and there disturb motion, secretion, absorption and sensation.  Tension placed on a woman through dislocated genitals, by compromising circulation and by trauma of nerve periphery, devitalizes her system and exposes her a prey to intercurrent disease and to the great functional neuroses (neurasthenia and hysteria).  The gynecologist by removal of the gynecologic dislocation, i. e., the focus of reflexes, can demonstrate that the reflex neuroses will disappear.  In view of the prevailing difference of opinion between neurologists and gynecologists as to the consecutive reflex neurosis of genital dislocation a careful weighing of the data is demanded.  Careful, comparative examination of gynecologic cases gives a definite series of reflex neuroses.  It is admittedly difficult in each individual case to establish genuine genital reflex neurosis.  The diagnosis must be made by exclusion. Improvement of the dislocation and lessening of the reflex neurosis under rational treatment is ocular proof.  Certain rare cases arise in which no palpable, pathologic anatomic changes are perceptible and still apparently the gynecologic reflex neurosis exists.  There are no exceptions to the rule.  If an organ becomes diseased secondarily to genital dislocation through reflex neurosis a correction of the dislocation may not always cure the organ.  For example, if a round ulcer appear in the stomach secondary to gynecologic dislocation and consequent menorrhagia, the cure of the genital disease would not cure the round ulcer of the stomach, which, if it bleed profusely, could be excised from the stomach wall, i. e., requires a specific treatment.  If a general disease, such as a cardiac valvular lesion, create genital dislocation through congestion, the dislocation may produce reflex neurosis, but cure of the genital lesion does not involve the valvular lesion.
    The logical force of circumstances impresses the practical gynecologist that genital disease gradually spreads over the other abdominal and thoracic viscera, disturbing visceral rhythm, circulation, absorption, secretion, and sensation by means of arcs of reflex action.  Step by step, through compromised circulation, trauma of nerve periphery and infection of the genitals, the woman acquires indigestion due to perverted secretion-excessive, disproportionatc, or insufficient.  Malnutrition and anemia follow from continued indigestion and finally neurosis, the inevitable consequence of progressive disturbed pelvic mechanism.  It requires careful observation to discriminate the onward march of genital disease, since many complications arise to throw one off guard, such as lumbo-sacral pain, tenesmus of sphincters (anus, vagina, and bladder), hyperesthesia of the pudendum, tearing and dragging pain in the thighs (anterior branches of lumbar plexus), pain in coccyx, intercostal neuralgia, especially on the side of the diseased genitals, pains in the breasts and irregular muscular contractions.  All these are only incidents in the onward march of a disease of dominating viscera, whose reflexes unbalance life's physiologic laboratory.  My observation places 70 per cent of disturbed pelvic mechanism on the left side; however, the neurosis shifts from side to side according to the renewed invasions of the genitals by disease.  It is significant that the neurosis falls chiefly on the side of the disturbed pelvic mechanism.  It is plain that the genitals have quite an independent nerve supply and also stand in intimate relation to definite regions; in other words, diseased genitals have a predilection for certain nerves and nerve lesions.  This fact is patent in the functional crises, at puberty, during pregnancy, at menstruation, and at the menopause.  In pregnancy the irritation from the genitals invades the stomach in a physiologic rather than the pathologic degree.  The grade of the genital irritation of pregnancy and menstruation seldom reaches a pathologic condition.  During puberty, menstruation, pregnancy, and the menopause certain organs suffer, as the stomach, breasts, larynx and thyroid glands.  The cranial nerves deserving mention for a special share during the above periods are the trigeminus and vagus, which may manifest not only excessive physiologic activity but an actual pathologic condition (physiology).  The lack of mathematical demonstration of the share of the viscera and nerves in the above-mentioned conditions is because this sympathetic disturbance does not occur in every case.  The close relation existing between ovarian disease and breast and iliac pain is often noted by the gynecologist, as well as dragging pelvic pain and stomach disturbance in retrodeviations of the uterus.  The significant and dominating influence of the genitals on the life of the individual is manifest by the exacerbation of the nervous conditions at puberty, menstruation, pregnancy, and at the menopause, i. e., at the sexual crises.  If the genitals are healthy, distinct neuroses (functional) at the above phases of sexual exacerbation give a definite clue to the source of the nervousness.  No other viscera except the genitals produce through physiologic activity exacerbated phases of neuroses.  The sexual is the most denominating instinct in animal life.  The physiologic exacerbation of neuroses is the most definite proof of their source, since the pathologic exacerbation of neuroses is so complicated that errors arise in tracing the origin.  The coincidence of neurosis and menstruation induced Battey to perform castration in order to anticipate the menopause.  However, it is my opinion he began at the wrong end of the genitals, for nothing stops menstruation like removal of the chief part of the organ of menstruation, viz.: the uterus (the oviducts may be left).  Menstruation is a vascular periodic wave and belongs to the uterus and oviducts, not to the ovary.  Hence, menstrual neuroses are cured by removal of the menstrual organ and not by removal of the ovary.  Considerable worth should be placed on certain relations between neuroses and special phases of sexual life.  It may be suggested that these sexual phases of exacerbation belong to life during the active existence of the uterus and oviducts, i. e., or the menstrual organs - not during the active life of the ovary, for activity of the latter persists from before birth until the ovarian tissue is worn out at sixty or seventy years.  It is an error to perform castration because the menstrual process coincides with the neurosis.  In such a case, should an operation be performed, it ought to be hysterectomy and not ovariotomy; the organ which induced the neurosis should be attacked.  However, it is simple justice to the patient to be morally sure before performing any operation that the organ to be attacked is the definite etiologic cause, for other etiologic factors may arise to unbalance the visceral nerves of woman; a stitch-abscess, a corn, or domestic irritation may simulate genital neurosis.  Extreme precaution is required in diagnosing the neuroses of the sexual organs.  This fact is observed from the varied time that a neurosis may arise during menstruation.  Menstruation is a complicated process; in other words, what is superficially known as menstruation is perhaps only a part of a comprehensive physiologic mechanism.  During menstruation we observe swelling of the mucosa of the uterus and oviducts, supposed maturation and rupture of follicles (?), and various degrees of congestion of the pelvic vessels peculiar to the wave movements or vascular pelvic rhythm, indicating blood-pressure.  Almost any of the above factors may induce a menstrual neurosis, as the neurosis may occur in the premenstrual, intramenstrual, and postmenstrual period.  Some neurotic factors may be displaced by exacerbation, and neurosis arises.  The secretion, blood, may occur at, before, or after the highest neural menstrual wave. Menstruation is a change of symptoms in which now one line and now another is put on tension.  The tension link manifests the character of the menstrual neurosis.  Another factor of menstrual chain, as accentuated by Kirro (1878), is that during menstruation hypertrophy of the thyroid gland occurs, followed by passive congestion of the cerebrum and consequent psychosis.  Perhaps hemorrhage from the nasal mucosa during menstruation is from congestion due to the sharing of the thyroid in menstruation and its capacious power of blood storage.
    With the above noted complication and many others it may be observed how careful the physician must be to establish menstrual neuroses or psychosis.  Continual psychosis can, no doubt, be exacerbated by the menstrual periodicity; also, in the periodic diseases there is frequently a neuropathic constitution that results from congenital defects or existing pathology.  For example, who can measure the burden of a woman with non-development and atrophy, i. e., before the uterus was fully developed it was attacked by inflammation, producing at first hvpertrophy and ending in defective growth and atrophy?  Such are among the saddest patients in my practice.  They suffer not only from dysmenorrhcea and other painful neuroses, but from a psychosis due to inevitable sterility.  Rachel mourns and will not be comforted.  The nervous irritation issuing from the sexual organs may be from disease or change of blood-pressure; in other words, from functional or anatomic changes.  In neurotic individuals the neurosis exists not only at the menstrual wave but also in the intermenstrual time, when pelvic disease is liable to exist.  When a certain congruence exists between the neurosis and the menstrual rhythm it is a strong indication that the neurosis is of sexual origin.  Experimentally the congruence of neuroses with phases of the sexual organs is demonstrated by the disappearance of the neuroses after hysterectomy or correlation of the uterus and uterine deviations or the destruction of pelvic peritoneal adhesions or the removal of a pelvic tumor.  Gynecologists frequently note that a neurosis will begin with anatomic changes of the sexual organs and the neurosis exacerbates the sexual disease.  The extent and the intensity of the pathology of the genitals may not stand in definite relation to the neurosis.  One may observe large ovarian tumors without a trace of neurosis.  From this clinical fact some have falsely argued that castration does not cure neurosis because disease of the ovaries does not produce it.  There are factors in large ovarian tumors which explain partly, at least, why they do not produce a neurosis.  First, the tumor has sufficient room to glide out of the way of pressure; second, the style is sufficiently long to avoid trauma from dragging or torsion of the pedicle; and doubtless the sensory nerves which supply the walls of the ovarian cyst have been stretched beyond their integrity and have ceased to transmit sensory disturbances.  It is the small genital tumors located in the pelvis which are likely to be accompanied by neurosis.  Such small tumors have a short style and are liable to dragging and torsion.  They are subject to pressure from their immobility.  The filling of the bladder and rectum traumatizes them and frequently a neurosis and a small pelvic tumor exist in casual relations.  The life and action of nerves cannot be measured by the yard.  Extreme neurosis may arise from the genitals by an irritation of the clitoris, a slight uterine deviation or a small scar, while no neurosis may be detected from extension, of sarcoma or carcinoma of the uterus or large ovarian tumor.  Abdominal or pelvic tumors that give rise to a tendency to neurosis are generally from small, fixed growths (especially located in the pelvis) with short pedicles, situated within the range of trauma by muscular activity and by the expansion and contraction of organs.
    The excitation or the inhibition of nervous attacks by artificial irritation is known to gynecologists.  Mechanical irritation of other viscera seldom or never creates a nervous attack.  This experiment indicates that the capacity of the genitals to dominate the nervous system is greater than that of other viscera.  I was called in consultation in a typical case - a young woman in whom slight pressure in the ovarian region induced a wild hysteric attack, while vigorous pressure would inhibit it.  Such cases, not rare, are a close demonstration of the dominating influence of the genitals over the system and also of the origin of the neurosis.  To show how carefully one must discriminate the sources and kind of neurosis, a case from Professor Hegar may be placed in evidence.  She was a young, non-neurotic individual who had a fist-sized right ovarian tumor with a long style, which allowed extraordinary mobility; when the tumor glided into the pelvis she suffered from pressure and dragging sensations.  She complained daily of dragging on the pedicle, pains in the lumbo-sacral region, shoulder, and iliac region.  To be relieved from these tormenting pains she besought Professor Hegar to operate on her.  She was without fever or pain for the first nine days - well and happy.  On the tenth day she was found with tears and sorrow, claiming that all her former troubles had returned, and all embittered because the operation had not relieved her.  The neuralgia, the cramps, the pressure, dragging symptoms, etc., all had returned back.  Professor Hegar noted that the patient had fever and, on examining the abdominal incision, discovered a stitch abscess; this was opened and the pains disappeared and returned no more.  This was a suggestive case, confirming the rule that when a subject is neurotic for a long time any bodily irritation may be set going the old train of neurotic symptoms.  In other words, a primary, complex neurosis, long continued, may be initiated by some distant local irritation.  The secondary cause may be slight, such as a fright, an abscess, an injury, a disappointment or an exacerbation of disturbances in a menstruation.  Doubtless, in the long continued neurosis a disturbed mechanism arises in the nerves, they lose their fine balance of integrity in motion, absorption, secretion, or sensation, and, being in a state of irritability, they are put to riot by any source of attack.  It is in such unfortunate cases that the neurologist has lost sight of the primary cause, which was trauma and infection of the genital system, the dominating neurovascular viscera.  For example. those who have much toothache know that any disturbance in health, as colds, getting wet, etc., will finally end in the old disease of toothache.  The dental nerves having once become chronically unbalanced by trauma and infection. it is easy to light the old flame again.  Observe the man who is suffering the remote effects of an ancient gonorrhea, the stricture fires up with a cold, an extra drink of whiskey or slight excess in coition.  The old flame in the disturbed urethral mechanism may be initiated by remote secondary causes.  The genitals are defective and do not resist.  Demonstrations, by experiment, can be made to show that the neurosis depends on the genital disease.  The reposition and retention of a dislocated or incarcerated pregnant uterus is frequently accompanied by a disappearance of the neurosis, while paresis of the lower limbs or uterine cough allows the pathology to recur and the neurosis is again set afoot.  Paint the cervix with AgNO3, solution and vicious vomiting follows.  No doubt can arise as to the cause of the vomiting.  But the terrific vomiting would not occur by painting other viscera not so richly supplied with nerves, such as the rectum or larynx.  Professor Hegar had a case where he could repeatedly check a "uterine cough" or irritable cough by introducing, a intrauterine stem which straightened an anteflexed uterus.  In the amphibia, in dissecting animals that require a day to die, one can demonstrate ocularly that irritating the rectum, cloaca, will start muscular contractions about the stomach.  Doubtless the irritation to the sensory, absorptive and secreting nerves is just as severe but is not so easily seen.  But every gynecologist knows that some women with disturbed pelvic mechanism suffer from exacerbated stomach secretion and motion.  It is important to demonstrate the causal relations and establish the location at the beginning.  This is difficult from the complex, yet somewhat independent, sexual nervous apparatus that gives rise to the neurosis, from the peculiarly highly organized nervous system of women and from the further fact that reflex neuroses are quite indirect and slow in their progressive march.  The original cause which may be years old is overlooked in the exciting symptoms.  It is not difficult to connect a fresh anal fissure with its accompanying wild disturbance, but when the disturbed pelvic mechanism (the anus and bladder have intimate nerve connection with the genitals) progresses for long periods the cause is buried in the grave of years gone by.  Long experience in digital examination is the prerequisite for accurate diagnosis of disturbed pelvic mechanism and for the interpretation of its reflex effect.  The disturbed pelvic mechanism, the primary cause of sexual neurosis, begins from simple disturbances in the genitals, such as pressure or dragging of nerves.  These two conditions may be combined and we cannot always discriminate one from the other.  For example, in the frequent vomiting of early pregnancy it is impossible to say whether it is pressure dragging upon the vesical or uterine distension nerves that induces uterine contractions and is followed by vomiting.  After dragging or pressure (trauma) of nerves has become initiated another more distressing trauma of the genital nerves follows from catarrh, erosions, ulcerations, and wounds which expose the periphery of the nerves - all inducing reflexes which radiate to other viscera, unbalancing their rhythm, secretion, absorption and sensation.  The compression (trauma) of the nerve periphery arises from dislocation of organs, edema, exudate, or tumor pressure.  Such traumatic (compression) neurosis is common in gynecology.
    Compression of the periphery of the nerves may be due to cicatricial tissue of both the pelvic peritoneum and subserosium.  Rich sources of nerve compression may be found in the inflamed posterior and lateral ligaments of the uterus, as shown by Freund and others.  The hyperplastic deposits and subsequent contraction found in the uterus, ovaries, and connective tissue needs but be mentioned to be recognized.  The contracting tissue of the uterus painfully compromises its expansion at the monthly period and the excessive ovarian cicatrices obstruct the expanding ovum and induce painful reflexes.  The type of dragging (traumatic) neurosis is observed in sacropubic hernia or uterine prolapse and in retrodeviations of the uterus, the visceral prolapse gradually developing a complex neurosis of the lumbosacral region and thence spreading to unbalance the general abdominal viscera through reflexes of the abdominal brain.  Dragging on the style of pelvic tumors is another cause.  One may be able to measure, to some extent, the disturbance of dragging on nerves, on over-filled rectum or bladder.  I have seen the pelvis, at autopsy, full to the brim with feces.  The dragging of free tumors on styles must be considerable, for strangulated axial rotation is not infrequent.  The best illustration of suffering from a free tumor on its style is the right kidney.  Its dragging and rotation give rise to nausea, vomiting, pain in the back and thigh; excessive, insufficient or disproportionate secretion or absorption in the tractus intestinalis, inducing disturbances of digestion, and to similar disorders in the renal secretion.
    Compression neurosis is indelibly associated with dragging neurosis.  With inflamed peritoneal and subserous uterine ligaments reflex symptoms occur on standing, walking, and coughing.  The reposition of the pelvic organs and their retention by a support relieves the symptoms.  The cicatrices of the cervix and vagina may present compression or dragging neurosis, often accompanied, however, by endometritis, with exposed nerve endings, on which play visceral secretions.  In acute flexions connective tissue changes cause pinching of the peripheral nerves, which manifest the neurosis chiefly as dysmenorrhea.  In endometritis with exposed nerve periphery the irritating secretions induce painful uterine colic, calling up reflexes which reorganize in the abdominal brain and radiate to all abdominal and thoracic viscera, vitiating rhythm, secretion, and sensation.  From the swollen endometrium the uterine contractions are futile to expel the secretions.  The uterine contractions produce pain by compression of the nerves imbedded in diseased tissue.  The gynecologist has a typical case to show the traumatic neurosis of nerves compressed in exudates in the old operations of amputation of the oviduct and ligation with silk, where the silk ligature becomes infected from diseased oviductal mucosa and an exudate arises with monthly exacerbations.  It is not uncommon for such cases to last for three years, with terrible complex neurosis and untold misery.  Hysterectomy cures such cases by stopping menstruation and relapses.  If the uterus and bladder become imbedded in exudates their expansion and also that of the rectum is hindered, and severe reflex pains follow.  Collection of secretions in the uterus induces contraction to expel them, and in contracting, the uterus drags on the adjacent fixed exudates.  All motion of the uterus, bladder, and rectum is accompanied by compression or dragging pains - neurosis from trauma.  In connective tissue hyperplasia of the uterus the uterine contractions are often very painful for compression of the nerves imbedded in the cicatrizing tissue.  In myosalpingitis may be observed the recurring monthly exacerbations, the old train of neurosis from the oviductal colic, from congestion, contraction, or compression; lumbosacral neuralgia, however, the associated uterine congestion from adjacent disease, must not be overlooked.  In some cases I have noted terrible neurotic symptoms from the amputated end of the oviduct being connected to a loop of a sigmoid by a peritoneal band.  In one case in which Dr. Lucy Waite and I operated we found a thin peritoneal band extending from the amputated oviductal extremity to the center of the sigmoid flexure; this woman was bedridden for nearly two years with the most terrible neurosis. The severing of the thin peritoneal band enabled her to recover and gain some thirty pounds six months after the operation, with apparent perfect health.  Her neurosis disappeared like magic.  Peritoneal adhesions may bind the intestines and genitals together.  Irritation of either the genitals or intestines influence peristalsis, and dragging pain and intense neurotic symptoms often follow in the wake.  Visceral secretions and sensations are perverted.  In such cases disturbances are after mealtimes and evacuations, and are caused by the induced peristalsis traumatizing nerves, imbedded in exudates and congesting vessels.  In some young women following castration and in some others following the menopause, the pudendum and vagina atrophy.  This doubtless is consequent upon vaginitis and atrophy of bloodvessels.  The vessels atrophy irregularly (one can observe red, injected patches among the pale ones on the vaginal wall) and this irregularity causes local congestions.  In cases of vaginal atrophy coitus enhances the neurosis on account of the narrow and sensitive vagina, and a kind of vaginismus occurs.
    Nervous irritation may be occasioned by exposure of the genital nerve periphery from vaginal catarrh, papillary swellings at the vaginal introitus, or the meatus urinarius externus, or from fissures or erosions about the urethra, pudendum, or anus.  Such lesions are often exacerbation by urination, defecation, coitus, or scratching, and may be accompanied by severe neurosis if allowed to persist for a long time.  Progressive nervous affections rapidly radiate from the local lesion to the general visceral system.  The irritation may remain isolated in the nervous system of the genitals for a longer or shorter period, but if long-continued or severe the neurosis eventually spreads to the general nervous system and is followed by indigestion, constipation, sleeplessness, and a state of more or less high nerve tension; in other words, a peculiar nervous irritability.  Entirely isolated neuroses from the genitals are quite rare because the nervous apparatus of the genitals is so intimately and profoundly connected with both the cerebrospinal and the great sympathetic systems that disturbance in the rich nerves of the genitals spreads over the whole nervous system.
    Besides, the disturbed pelvic mechanism often sooner or later invades the psychical apparatus and directs the mind to the diseased genitals with additional disadvantage to the individual.  The general practitioner is very liable to treat the psychical or mental symptoms, forgetting that the disturbed pelvic mechanism is the rock and base of the neurosis.  Not infrequently the psychical symptoms play the chief role in the disease.  How often does the gynecologist observe the general practitioner treating the psychical or superficial symptoms - cardialgia, sacrolumbar neuralgia, or sexual disease with little idea of its etiology - though palpable in the pelvis?  In short, the psychosis, which has a mental base, and the neurosis, which has a physical base, should be carefully differentiated.      However, the psychosis is generally secondary to the neurosis, which latter generally has a palpable pelvic origin.  It is what I shall term a vicious sexual circle, viz. : (a) disturbed pelvic mechanism, (b) neurosis, and (c) psychosis.  This is accentuated in other ways by Hegar, Freund, Krantz and others to whose excellent labors I am a debtor.  More in detail, this vicious sexual circle consists of (a) disturbed pelvic mechanism (trauma and infection); (b) indigestion (from disturbed visceral motion, secretion, absorption, and sensation); (c) malnutrition; (d) anemia; (e) neurosis, and (f) psychosis.  From the disturbed pelvic mechanism to the psychosis is a long progressive march, a vicious sexual circle, direct and indirect, due to repeated reflex pelvic storms flashing over the other abdominal visceral plexuses.  The viscera (as the stomach, kidney, and liver) possessing the greatest number of connective nerve-cords and hence, the least resistance, will suffer the most in their rhythm, secretion, and sensation.  After this vicious sexual circle becomes established there exists a neuropathic condition.  Primary and secondary symptoms then become difficult of differentiation.  Direct and indirect symptoms become mixed and the clinical picture becomes obscured by its complexity.  The causal connection between pelvic disease and neurosis (psychosis) becomes darkened and one cannot tell what is primary and what is secondary, especially when the patient comes to the physician late in the course of the malady.  It is difficult to pick up any segment of the vicious sexual circle.  Action and reaction are equal.  We now have the degenerating influence of the general nervous system on the original disturbed pelvic mechanism.  In the vicious sexual circle one should never disregard blood losses, as these often play a significant role.  An ordinary monthly period makes women pale and, if slight additional losses occur, the effect is geometrically exacerbated.  Excessive, deficient, or disproportionate blood supply to the abdominal brain and its automatic visceral ganglia due to reflexes, deranges visceral motion, secretion, absorption, and sensation.  It would create in single viscera local disorderly reflexes.  Aside from the vicious sexual circle I know of no experimental method to demonstrate it, except the disease itself, which gynecologists see daily.  We must, as Hegar observes, be limited to the indexes of its course in order to diagnose and treat, it.      We must weigh each indication found in the progressive march of symptoms throughout the vicious sexual circle from genital disease.  We must have definite stigmata to diagnose hysteria and not call every nervous woman a hysteric.  The exclusion method must be employed for each and every diagnosis, and the treatment must include medical, electrical, surgical, and hydrotherapeutic measures as required.  Treatment is experimental but should be rational.  The rational diagnosis is to first establish some etiologic pathologic factor and attempt to improve or remove it. Sometimes a secondary factor, as constipation or gastric disease, requires attention in order to trace our steps to the original pelvic disease.  We must attempt to retrace on the links of the causal chain to the swivel where the reflexes began and broke their bounds.  Deficient renal secretion may be another secondary symptom which requires improvement before the waste-laden blood will cease traumatizing the innumerable ganglia which it bathes.
    In the diagnosis one must observe local diseases in the body which are not of sexual origin.  The sexual organs are not the only viscera capable of producing neurosis.  Be always on the alert for visceral ptosis, tuberculosis, nephritis, cholecystitis, peritonitis, and appendicitis.  Of course, the nonsexual diseases may be coincident with sexual diseases, and both influence the neurosis and general nourishment.  Make careful bodily examinations for diseases outside the genitals.  Do not overlook heart lesions which allow congestions, hepatic sclerosis which induces some ascites, chlorosis which induces general paleness, with a large glandular system, yet coexists with a well-developed panniculus adiposus, headaches, and breathlessness, anemia, etc., etc.  In my experience nothing has been so successful as visceral drainage - draining the skin by salt baths, the kidneys by drinking ample fluids, and the bowels by salines, with set hour for evacuation.  Drainage of the bowels, skin, and kidneys is the rock and base of the therapeutics which will benefit the vicious sexual circle.  It is rational hydrotherapy.  Thus, by treatment, we are often enabled to run over one difficulty after another until the etiologic factor is reached, which is disturbed pelvic mechanism, the beginning of the viscious sexual circle.  In other words, the microscope aids to diagnose tuberculosis, or mercury to diagnose syphilis.  In diagnosis and treatment the gynecologist must always hold in his mental grasp every abdominal organ.
    With the entrance and establishment of the neurosis and psychosis the sexual pathologic circle is completed and persistent rational treatment is required to break it.  Now, any segment of the pathologic circle has a degenerating influence on the others.  Pathologic processes can arise in other portions of the body, either coincident, independent, or as a result of the pathologic sexual circle.  The gynecologist not only should have every abdominal organ in mind but should be able to exclude all other pathologic processes.  Among the abdominal organs requiring special care in diagnosis are the stomach and colon.  Stomach and colon diseases may lead to reflexes, hypochondria, neurosis, and even psychosis.  Note what intense neurosis follows secretion neurosis of the colon (mucous colitis); also, that slackening or paresis of the abdominal wall - splanchnoptosia - accompanied by visceral ptosis and dragging on the mesentery, can lead to lumbosacral symptoms.  For example, for years I have noted the hyperplasia of the genitals and hemorrhage therefrom in mitral lesions of the heart.  In this case the heart disease is primary and the pelvic disease secondary.  The genitals show varicose veins and the pelvic disease and hemorrhage may become so severe that a neurosis results.  In this neurosis the diseased genitals were only a link in the chain.
    Of course, these conditions - variously known as neurasthenia, neurosis, spinal iritation, or hysteria - may exist without palpable sexual disease, but any gynecologist knows that sexual disease plays an important factor and often enters in combination in their production.
    Bibliography: Professor Hegar, Lohmer, Krantz.