"The Soul knows only Soul, the web of events is the flowering robe in which she
is clothed." - Emerson.

"Furnish the government with neither a kopek nor a soldier."
- Final appeal of the Russian Douma, dissolved by the czar, July, 1906.
 

    For over a decade I have been attempting to make prominent in gynecologic teaching, pathologic physiology, disordered function, rather than pathologic anatomy, changed structure.  It seems to me that disorder - functions or pathologic physiology of the tractus genitalis impresses itself more indelibly on the student's and practitioner's mind than pathologic anatomy.  Besides, in gynecologic practice pathologic physiology occurs tenfold more frequently in the genital tract than pathologic anatomy.  For the gynecologist pathologic physiology presents innumerable views of practical interest.  Pathologic physiology teaches that the circulation of an organ is a fundamental factor in comprehending its disease and administering rational treatment.  It takes an inventory of the volume of blood which streams through the organ as a fundamental factor in comprehending its diseases and administering rational treatment.  It takes an inventory of the volume of the blood which streams through the organs at different stages and conditions.  We wrote years ago that the arteries of different viscera were supplied with automatic visceral ganglia, and we christened the peculiar nerve nodes found in the walls and adjacent to the uterus, oviducts and ovaries, as "Automatic Menstrual Ganglia." The automatic menstrual ganglia complicate the blood supply of the tractus genitalis by changing its volume during the different sexual phases.  In pueritas the blood stream of the tractus genitalis is quiescent as well as its parenchymatous cells; in pubertas it is developing as well as proliferating parenchymatous cells.  In menstruation the blood stream is active with active parenchymatous cells.  In the puerperium there is retrogression of blood stream and an involution of parenchymatous cells.  The climacterium is the opposite of pubertas - subsidence, the decrease of blood volume and parenchymatous cells.  Senescence is a repetition of pueritas - the quiescence of the genitals, their long night of rest.  The circulation of an organ quotes its value in the animal economy.  It rates its function.  Observe the enormous volume of blood passing through the kidney or pregnant uterus in a minute.
    To study pathologic physiology of any visceral tract we must possess clear views as to its physiology.  The physiology of the tractus genitalis is: (1) ovulation; (2) peristalsis; (3) secretion; (4) absorption; (5) menstruation; (6) gestation; (7) sensation.
    (1)  On account of the numerous theoretic views connected with OVULATION and lack of space we will omit the general discussion on the pathologic physiology of ovulation. it is well known that ovulation has a wide physiologic range.  We do not know the life of an ovum or corpus luteum.  It was once supposed that a corpus luteum was a sign of pregnancy and the supposition gained legal or judicial position.  We know that this is an error.  I have found two corpora lutea on one ovary of a lamb which had not been pregnant.  The internal secretion of the ovary is important and chiefly manifest by marked symptoms on removal of both ovaries - neurosis, accumulation of panniculus adiposus, extra growth of hair, diminished energy and ambition.  These symptoms may occur in women possessing both ovaries, hence, we would conclude that pathologic physiology of ovarian secretion existed.  The sensation of the ovary occupies a wide zone of pathologic physiology in the mental and physical being.  Forty per cent of women visiting my office remark, "I have pain in my ovaries." On physical examination we find the following conditions: First and foremost in the vast majority of women who complain of pain in the ovaries, palpation of the ovaries elicits no tenderness on pressure.  However, the pain of such women is located bilaterally in the area of the cutaneous distribution of the ileohypogastric and ileoinguinal nerves.  It is a skin hyperesthesia - a cutaneous neurosis.  The bilateral iliac region of cutaneous hyperesthesia corresponds to the segmentation or somatic visceral (ovarian) area, and presents a frequent varying zone of sensory pathologic physiology.  In the vast majority of women complaining of ovarian pain no disease of the ovary can be detected - it is cutaneous hyperesthesia of the ileoinguinal and ileohypogastric nerves.

(2)  PERISTALSIS (EXCESSIVE, DEFICIENT, DISPROPORTIONATE).

    (a) Excessive peristalsis of the tractus genitalis (uterus and oviducts) may occur at menstruation, during gestation, parturition by the presence of myomata, during the expulsion of blood coagula, placenta during congestion.  The phenomenon of peristalsis in the uterus and oviduct differs from the form and distribution of the muscularis.  The myometrium during gestation is in continual peristalsis - uterine unrest.  By placing the hand on the abdomen of a four-month gestating woman one can feel the uterine muscular waves.  The gestating uterus is always prepared for an abortion, but the cervix, the sentinel on guard, checks the proceeding.  Fright will produce such violent, disordered myometrical peristalsis as to break through the guarding cervix.  Many women during gestation experience considerable pain (supersensitive uterus) from excessive uterine peristalsis - it is pathologic physiology.  Uterine peristalsis may be sufficiently excessive to rupture the myometrical  wall.  The "after puerperal pains, is excessive peristalsis in an infected myometrium.  Frequently the severe pelvic pain during menstruation is excessive uterine and oviductal peristalsis due to its extramenstrual blood supply.  It is chiefly the excessive peristalsis at menstruation that forces many women to assume rest in bed, for, with anatomic rest (maximum quietude of bones and voluntary muscles) and physiologic rest (maximum quietude of visceral muscles) the uterine peristalsis will exist at a minimum.  Excessive oviductal peristalsis may produce pain of varying degrees.  In excessive peristalsis the automatic menstrual ganglia are stimulated by extra quantities of blood or by other irritation.
 

PELVIC BRAIN (ADULT)       Fig. 119.  Drawn from my own dissection.  A, pelvic brain.  In this case it is a ganglionated plexus possessing a wide meshwork.  Also the pelvic brain is located well on the vagina, and the visceral sacral nerves (pelvic splanchnics) are markedly elongated; V, vagina; B, bladder; 0, oviduct; Ut, uterus; Ur, ureter; R, rectum; P L, plexus interiliacus (left); P R, plexus interiliacus (right); N, sacral ganglia; Ur, ureter; 5 L, last lumbar nerve; i, ii, iii, iv, sacral nerves; 5, coccygeal nerve.  Observe that the great vesical nerve (P) arises from a loop between the ii and iii sacral nerves.  G S, great sciatic nerve.

    (b)  Deficient peristalsis of the tractus genitalis (uterus and oviducts) is not uncommon.  Uterine inertia is an example known to every obstetrician.  Deficient uterine peristalsis allows hemorrhage in the fourth and fifth decades of woman's life.  Deficient peristalsis allows extraglandular secretion (leucorrhea).
    (c)  Disproportionate peristalsis is disordered, wild muscular movements in different segments of the uterus or oviduct.

(3)  SECRETION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE).

    (d)  Excessive secretion from the genital tract, pregnant or non-pregnant, has an extensive range and varying quantity.  The excessive secretion zone in the tractus genitalis has an important bearing in practice.  Typical pathologic physiology may be observed in the pregnant woman from whose uterus may flow several ounces of white mucus daily - no pathologic anatomy is detectable.  Excessive uterine secretion is a common gynecologic matter.  The glands may not be embraced sufficiently firm by the myometrium.  The automatic menstrual ganglia are diseased, insufficiently supplied by blood or the myometrium is degenerated.  Flaccid uteri secrete excessively.  Excessive secretion and its fluid currents allow insufficient time for localization of the ovum.  Excessive uterine secretion is, from apt bacterial media, liable to become infected.  During excessive secretion physical examination frequently detects no palpable pathologic anatomy - merely physiology has exceeded its usual bounds.
    (e)  Deficient secretion of the tractus genitalis is not so manifest as its opposite.  The mucosa of vagina and uterus present excessive dryness, desiccation, practically as visceral functions are executed by means of fluids, pathologic physiology is in evidence; dryness and abrasion of the mucosa, local irritation, chafing, local bacterial development, dysparunia, dysuria, defective import of spermatozoa and export of ova ending in sterility.  Deficient secretion means that waste-laden fluids are bathing and irritating the thousands of lymph channels in the body.  Deficient secretion or excessive dryness of the genital mucosa - pathologic physiology with no perceptible pathologic anatomy - is not uncommon in gynecologic practice.  Oily applications to subjects with deficient genital secretion may be required for protection of exposed nerve periphery, as abrasion, fissure, ulcers, and also for relief.
    (f)  Disproportionate secretion may occur in the different segments of the genital tract, unequal, excessive, deficient, irregular.

(4)  ABSORPTION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE).

    (g)  Excessive absorption presents two views, namely, a dryness of the genital mucosa from excessive absorption of the mucal fluids.  This resembles the conditions arising in deficient secretion of the genital tract (see e).  Again the mucosa of the genital tract excessively absorbs deleterious substances lying on its mucosa - septic or toxic.  Excessive absorption in the genital tract, pathologic physiology, resembles excessive absorption and conditions in other localities, as the absorption of poison ivy, lead, arsenic, among art workers.  The pathologic physiology possesses a wide range, for some experience no ill-effects while others are severely or even fatally ill from absorption ,of same substance under similar conditions.
 

Fig. 120.  This illustration demonstrates the vast amount of nervus vasomotorius it requires to ensheath the arteries of the uterus.

    (h)  Deficient absorption in the tractus genitalis produces an excessive discharge, the decomposition of which lays the foundation of bacterial multiplication and excoriation of mucosa and skin.
    (i)  Disproportionate absorption occurs in the different segments of the tractus genitalis and presents pathologic physiology.  However, lack of space makes it impractical to discuss it.

(5) SENSATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE).

    (j)  Excessive sensation in the tractus genitalis presents a wide zone of pathologic physiology.  Vaginismus is the extreme type of genital hyperesthesia.  The introitus vaginae of perhaps fifty per cent of women is supersensitive.  When I was a pupil of Mr. Lawson Tait he had a patient, a recently married woman, from whom the husband was suing for divorce as her genital hyperesthesia was so excessive that coition or examination was intolerable.  She had to be anesthetized to be examined, which was also suggested for impregnation with the hope that gestation would relieve the condition.  Supersensitiveness of the pudendum is not an uncommon matter in gynecologic practice and without demonstrative pathologic anatomy.  The pathologic physiology of excessive sensation in the tractus genitalis has a wide range of variation and degree of intensity.  Some subjects may be afflicted with excessive sensation in the pudendum for many years.  The excessive sensitive genitals may be manifest in the uterus or ovaries.  A small number complain of tenderness and soreness in the internal genitals which cannot be detected as pathologic anatomy - simply excessive sensation.  The gestating uterus may be so sensitive that it disorders adjacent viscera by reflexes.  The treatment of subjects with excessive genital sensation requires unlimited time with continuous patience.
(k)  Deficient sensation of the tractus genitalis is encountered.  With such subjects practically no organism occurs during coition to which they are indifferent.  Practically little or no treatment is required.
    (1)  Disproportionate sensation in the genital tract is irregular, indefinite, disordered sensation arising and disappearing in its different segments practically without reason or rhyme.

(6) MENSTRUATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE).

    I will present this subject through a clinical patient.  Brief remarks on common examples of pathologic physiology in the tractus genitalis will suffice to illustrate and suggest.  As the most apt subject to illustrate pathologic physiology in the tractus genitalis I will choose that of menstruation.
To illustrate the value of pathologic physiology and the methods of teaching it we will place a gynecologic patient before a student to elicit clinical data in reference to menstruation as landmarks for diagnosis.  A landmark is a point for consideration physiologic, anatomic, pathologic.  To teach gynecology we should instruct by means of disordered function as a base.  Menstruation is the first practical function of the genital tract.  Hence the student asks in menstruation four questions, namely: (a) How old were you when the monthly flow began?  The patient may answer: eleven (premature), fifteen (normal), or nineteen (delayed) years of age.  This answer presents a wide range of beginning of the menstrual function.  Now, the girl who begins to menstruate at eleven generally represents pathologic physiology, but not pathologic anatomy.  For example, the girl who begins at eleven (menstratio precox) will in the majority of cases menstruate profusely and prolonged.  She will experience a late climacterium.  An early menstruation indicates a late climacterium.  Though one can palpate practically no pathologic anatomy, the tractus genitalis is prematurely developed at eleven years of age, premature in dimension (nerves, blood, lymph, parenchyma) and function (menstruation, gestation).  The blood stream to the genitals is prematurely excessive, the automatic menstrual ganglia are large and prematurely active.  Her menstrual life is accompanied by excessive blood supply and hemorrhage, disordered function, active parenchymatous cells, prolonged reproductiveness.  It is pathologic physiology, exaggerated function. but practically not pathologic anatomy.  The girl who begins at fifteen is practically normal during her menstrual life.  No pathologic anatomy nor pathologic physiology is manifest.  The girl who begins to menstruate at nineteen (menstratio retards) is delayed with her menstrual function; late menstrual appearance means early climacterium; it frequently indicates amenorrhea and dysmenorrhea.  It generally means defective genital blood supply and limited parenchymatous cellular activity.  It is pathologic physiology, disordered function, limited productiveness, but frequently no palpable pathologic anatomy exists.  It is a fact, however, that in some cases atrophy or myometritis is palpable pathologic anatomy and should not be confused with subjects possessing pathologic physiology.
    (b)  The student asks the patient: Is the monthly flow regular?  The answer may be, regular or irregular.  The patient with irregular menstruation is afflicted with pathologic physiology but no pathologic anatomy may be detected.  It may be stated, however, that the automatic menstrual ganglia require about eighteen months of vigorous blood supply to become sufficiently strong and established to act regularly monthly.  The same condition exists in the automatic visceral ganglia (Auerbach's and Billroth-Meissner's) of the tractus intestinalis of a child.
    (c)  The student, thirdly, asks the patient: Is the monthly flow painful?  The answer may be, yes or no.  A normal menstruation should be painless.  Dysmenorrhea or painful menstruation is pathologic physiology, disordered function, but frequently no pathologic anatomy can be detected.  At menstruation the blood volume in the tractus intestinalis rapidly increases, blood pressure is raised, compressing or traumatizing the nerves to a degree; limited hematoma may occur in the endometrium, congestion is intense, inciting vigorous and disordered peristalsis of the uterus and oviducts.  In short the trauma or shock of menstruation of the genital tract irritates it into a state of pain.  It is a state of pathologic physiology, disordered function, but no pathologic anatomy may be palpable.
 

TRANSVERSE LONGITUDINAL SECTION OF UTERUS       Fig. 121.  This illustration presents the endometrium (secretary and absorptive - glandular - apparatus) ; the myometrium peristaltic or rhymic-muscular-apparatus) ; the perimetrium (secretary, absorptive - lymphatic - gliding apparatus).  The uterus is richly supplied by sensory and motor nerves.

    The affliction is functional.
    (d)  The student finally asks the patient: How many days does the monthly flow continue?  The answer may be, two to eight days.  Two days is deficient (amenorrhea or oligemia); four days is normal, eight days is excessive (menorrhagia).  I have examined scores of gynecologic patients with over a week's flow, menorrhagia, but in many of them no pathologic anatomy or change of structure could be detected.  It is typical pathologic, physiology, disordered, unusual function.  The subject is like a watch with an excessively powerful mainspring.  The watch has no detectable pathologic anatomy, no change of structure.  The mainspring, the automatic ganglia, is excessively active.  The organ is working excessively, the watch is gaining time.  The automatic ganglia are prematurely powerful, the watch spring is too strong.  Menorrhagia in many subjects is typical pathologic physiology.  The pathologic anatomy, if it exists, is too subtle for us to detect.  The adult life of the tractus genitalis presents an excellent field for study and teaching in pathologic physiology.  Its several periodic functions, its changing volume of circulation, the limited life of its parenchymatous cells and its automatic menstrual ganglia afford a useful field for study and development of pathologic physiology.

(7) GESTATION.

    Gestation presents many phases of pathologic physiology.  There is the typical pathologic physiology, namely, emesis, albuminuria, hypertrophy of left ventricle, pigmentation, capricious appetite, constipation, increase of panicular adiposus, the peculiar gait, venous engorgement (edema), excessive glandular secretion, osteomalacia.  The vomiting of pregnancy may present a vast zone from slight regurgitation of food to profound anemia due to limited nourishment - where pathologic physiology alone tells the tale.  The normal physiologic nerve relations between the tractus genitalis (uterus) and tractus intestinalis (stomach) have become disordered.  No pathologic anatomy is demonstrable.  Constipation (pathologic physiology) is liable to arise during gestation because the normal physiologic blood supply of the tractus intestinalis is robbed to supply the increasing demand of the gestating genital tract.  The albuminuria of pregnancy is doubtless partially due to pressure of the expanding uterus on the ureters and veins, obstructing venous and urinal flow.  The normal physiologic relations between the tractus urinaria and the gestating tractus genitalis have become projected into the field of pathologic physiology.  Pathologic anatomy is not in evidence except as ureteral dilatations secondary matter.  A comprehensive view of pathologic physiology aids in diagnosis and treatment.  It will impress the practitioners with the utility of visceral drainage, the administration of ample fluids at regular intervals to relieve the system of waste-laden blood-irritating substances.  Pathologic physiology teaches us to restore function and frequently pathologic anatomy will take care of itself.
 

PELVIC BRAIN IN RELATION TO THE NERVUS VASOMOTORIUS       Fig. 122.  General view of the nervus vasomotorius (sympathetic).  B. Pelvic brain.  H.  Interilia nerve disc. 1 and 2. Abdominal brain.

TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS GENITALIS.

    Since pathologic physiology is the zone between physiology and pathologic anatomy, it should be amenable to treatment.  A diagnosis by exclusion should be made.  It must be remembered that in the physiology the entire six abdominal visceral tracts are balanced harmonious, functionating without friction - no reflexes dashing hither and yon disturbing the exquisitively poised visceral physiology.  In the treatment of pathologic physiology of the tractus genitalis it should be remembered that the genitals are not vital for life, but that the richly nerve-supplied genitals dominate the mental and physical existence of woman.  In the treatment of pathologic physiology there are the subjects of periodic hyperemia, congestion, hemorrhages, excessive glandular secretions, disturbed sensation (hyperesthesia).  First and foremost in the treatment of pathologic physiology of the tractus genitalis, the adjacent visceral tracts must be regulated to normal states as to drainage, but especially as to the physiologic condition of blood.  Frequently by producing daily evacuation of the digestive tract and increasing the renal secretion by ample fluids the pathologic physiology of the genital tract improves.  The genitals should be examined for adherent prepuce, pudendal fissure, pruritus pudendoe, or other point of irritation.  The other five abdominal visceral tracts (urinarius, intestinalis, vascularis, lymphaticus, nervosus) should be examined for points of visceral irritation.  The frequent splanchnoptotic condition must be studied and remedied.

I.  VISCERAL DRAINAGE.

    For many years I have applied a treatment to such subjects which I term visceral drainage.  Visceral drainage signifies that visceral tracts are placed at maximum elimination.  The waste product of food and tissue are vigorously sewered before new ones are imposed.  The most important principle in internal medication is ample drainage for every visceraltract.  The residual products of food and tissue should have a maximum drainage in health.  I suggest that ample visceral drainage may be executed by means of: (A) Fluids; (B) Food.

(A) Visceral Drainage by Fluids.

    The most effective diuretic is water.  One of the best laxatives is H20.  One of the best stimulants of renal epithelium is sodium chloride (one-half to one-quarter physiologic salt solution).  Hence I administer eight ounces of half normal salt solution to a patient six times a day, two hours apart. (Note. - Sodium chloride is contraindicated in parenchymatous nephritis.) Forty-eight ounces of half normal salt solution daily efficiently increases the drain of the kidney.  It maintains in mechanical suspension the insoluble uric acid; it stimulates other matters; it aids the sodium, potassium, or ammonium salts to form combination with the uric acid, producing soluble urates.  The half normal salt solution effectively stimulates - the peristalsis and epithelium of the tractus intestinalis, inducing secretions which liquefy feces, preventing constipation.
 

ARTERIES OF PUERPERAL UTERUS       Fig. 123.  Illustrates the arteries of a puerperal uterus 5 days post postum.  It is a half-tone - a so-called bromine photograph.  It well illustrates the enormous amount of nerves it would require to ensheath the numerous arteries of the uterus.  The uterus was injected with red lead and starch and X-rayed.  It represents excellently the author's circle.

(B) Visceral Drainage by Foods.

    The great functions of the visceral tract - peristalsis, absorption, secretion, sensation - are produced and maintained by fluids and foods.  To drain the tractus genitalis and adjacent visceral tracts which should be excited to peristalsis, foods which leave an indigestible residue only are appropriate.  All visceral tracts must be stimulated to maximum peristalsis, secretion and absorption in order to aid that of the tractus genitalis.  Rational foods must contain appropriate salts whose bases may form combinations which are soluble, as sodium, potassium and ammonium combined with uric acid and urates to form soluble urates.  The proper foods are cereals, vegetables, albuminates (milk, eggs), mixed foods.  Meats should be limited as they enhance excessive uric acid formation.  In order to stimulate the epithelium (sensation) of the digestive and urinary tracts with consequent increase of peristalsis, absorption and secretion in both I used a part or multiple of an alkaline tablet of the following composition: Cascara sagrada (1/40 grain), aloes (1/3 grain), sodium carbonate (1 grain), potassium carbonate (1/3 grain), magnesium sulphate (2 grains).  The tablet is used as follows: One-sixth to one tablet (or more, as required to move the bowels freely, once daily) is placed on the tongue before meals and followed by eight ounces of water (better hot).  Also 10 A. M. to 3 P. M., and at bedtime one-sixth to one tablet is placed on the tongue and followed by a glassful of any fluid.  In the combined treatment one-third of the sodium chloride tablet (containing eleven grains) and one-sixth to three alkaline tablets are placed on the tongue together every two hours, followed by a glass of fluid.  The eight ounces of fluid may be milk, buttermilk, eggnog - nourishing fluid.  This method of treatment furnishes alkaline bases (sodium, potassium and ammonium) to combine with the free uric acid in the urine, producing perfectly soluble alkaline urates and materially diminishing the insoluble free uric acid in the urine.  Besides, the alkaline laxative tablet increases the peristalsis, absorption and secretion of the intestinal tract, stimulating the sensation of the mucosa-aiding evacuation.  I have termed the sodium chloride and alkaline laxative method the visceral drainage treatment.  The alkaline and sodium chloride tablets take the place of the so-called mineral waters.  I continue this dietetic treatment for weeks, months, and the results are remarkably successful, especially in the pathologic physiology of the visceral tracts.  The urine becomes clarified like spring water and increases in quantity.  The tractus intestinalis becomes freely evacuated, regularly, daily.  The caliber of the tractus vascularis becomes a powerful fluid volume to carry oxygen and food to tissue, while the effete matter and waste products are rapidly swept into the sewer channels.  The blood is relieved of waste-laden and irritating material.  The tractus cutis eliminates freely and the skin becomes normal.  The appetite increases.  The sleep improves.  The patient becomes hopeful, natural energy returns.  The sewers of the body are drained and flushed to a maximum.

II.  VAGINAL DOUCHE.

    (1)  The kind of instrument to employ is a fountain syringe of fourteenquart capacity.  The simplest and most economic vaginal syringe is a fourteen-quart wooden pail, the kind generally used in transporting candy or tobacco.
    (2)  The location of the syringe should be four feet above the patient.
    (3)  The quantity of fluid administered in the beginning should be two quarts for patients unaccustomed to its use and four quarts to those accustomed to its use.  The quantity should be increased a pint at each administration to fourteen quarts.
    (4)  The temperature of the douche should be 105o in the beginning and increased one degree at each administration until it is as hot as it can be borne (115o to 120o).
    (5)  The duration of the douche should be ten minutes for each gallon.
 

HISTOLOGY OF PELVIC BRAIN       Fig. 124.  A, drawn from the pelvic brain of a girl seventeen years of age.  The ganglion cells are completely developed.  B, drawn from the pelvic brain of a three months' normal gestation.  The ganglion cells are completely developed.  Observe the enormous mass of connective tissue present.  C, child 11/2 years old.  A nerve process courses within the ganglion.  Few and small ganglion cells incompletely developed.  D, girl 11/2 years old.  A nerve process branches and reunites itself with the intercellular substance.  E, girl 6 years old.  The ganglion cells are presenting development. (Redrawn after Doctor Sabura Hashimoto.)

    (6)  The time to administer the douche is in the evening immediately before retiring and in the morning (after which the patient should lie horizontally for forty-five minutes).
    (7)  The position of the patient should be lying on the back.
    (8)  As to method of administering the douche the patient should lie on a sufficiently inclined plane to allow the returning fluid to drain into a vessel (pail, pan).  The ironing board, wash-tub or board resting on the bath-tub serve convenient purposes.  The douche should not be administered in the bed (unless ordered), standing or sitting postures or on the water-closet.
    (9)  As to ingredients a handful of sodium chloride and a teapoonful of alum should be added to each gallon, the sodium chloride to dissolve the mucus and pus, to act as an antiseptic and to prevent reaction, while the alum is to astringe, check waste secretions and harden tissue.
    (10)  The vaginal tube employed in administering the douche should be sterilized, boiled, and every patient should possess her own vaginal tube.  The most useful vaginal tube is the largest that can be conveniently introduced or the one that distends the vaginal forces so that the hot fluids will bathe the greatest surface area of the proximal or upper end of the vagina.
    (11)  The utility of a vaginal douche is: (a) It contracts tissue (muscle, elastic and connective); (b) it contracts vessels (lymphatics, veins and arteries); (c) it absorbs exudates; (d) it checks secretion; (e) it stimulates; (f) it relieves pain; (g) it cleanses; (h) it checks hemorrhage; (i) it curtails inflammation; (j) it drains the tractus genitalis.  The utility of the vaginal douche depends on the quantity of fluid, the degree of temperature, its composition, the position of the patient during administration, and on systematic methods of use.
    (12)  Disinfectants in a vaginal douche are secondary in value to solvents of mucus, pus, leucocytes.
    (13)  The objects to accomplish by a douche are: (a) The dissolving of the elements in the discharge, as mucus, pus and leucocytes; (b) the mechanical removal of morbid secretions, accumulations and foreign bodies;  (c) antisepsis; (d) diagnosis (and it includes number 11).
    (14)  The requirements of a douche; (a) It should be nonirritating; (b) it should be a clear solution; (c) it should possess solvent powers of pus, and especially mucus; (d) it should be continued for months; (e) omit the douche for four days during menstruation.
    (15)  A vaginal douche, administered according to the above directions, will prove to be of therapeutic value in the treatment of pelvic disease, a prophylactic agent and a comfort to the patient.
    (16)  The vaginal douche is contraindicated in subjects with oviductal gestation or acute pyosalpinx, as it is liable to induce rupture of the oviductal wall, abortion or leakage of pus through the abdominal oviductal sphincter.

III.  VAGINAL TAMPON.

    (1)  The composition of the vaginal tampon consists of a roll of medicated cotton (hen-egg size), tied to a twelve-inch string, placed in a solution of sixteen ounces of glycerine and two ounces of boracic acid.
 

TRACTUS VASCULARIS AND TRACTUS NERVOSUS OF THE TRACTUS GENITALIS       Fig. 125.  Illustrates the tractus nervosus of the genital tract, pregnant 5 months.  The utero-ovarian vascular circle (circle of author) is ensheathed by a rich nodular, fenestrated, anastomosing nerve plexus.

    (2) The duration of preparation of vaginal tampon should be to lie in the boroglyceride solution forty-eight hours before using.
    (3)  The utility of the vaginal tampon is: (a) It is hygroscopic; (b) it serves as a mechanical support; (c) it contracts tissue (muscle, elastic, connective); (d) it contracts vessels, (lymphatics, veins and arteries); (e) it hastens absorption of exudates; (f) it checks secretions; (g) it stimulates; (h) it curtails inflammation; (i) it drains the pelvic organs; (j) it cleanses; (k) it dissolves mucus, pus and leucocytes.  The utility of a vaginal tampon depends on its composition, the quantity employed, the duration of its application and on systematic method of use.
    (4)  The methods of introduction consist in placing three to five vaginal tampons (with or, better, without a speculum) in the vaginal fornices in the direction of least resistance.
 

PELVIC BRAIN (1, 2.)      Fig. 126.  Dissected from a subject about 37 years old.

    (5)  Disinfectants in a vaginal tampon are secondary to its other qualities, especially that of hygroscopy.
    (6)  The object to accomplish by a vaginal tampon is: Maximum hygroscopy, dissolving the elements in the discharge, as mucus, pus, leucocytes, the mechanical removal of morbid secretions, accumulation and foreign bodies, diagnosis, and mechanical support.
    (7)  The diagnosis is aided by the use of a tampon by collecting and preserving the uterine discharge (as pus, blood, debris).
    (8)  The requirements of a vaginal tampon are: (a) It should be nonirritating; (b) it should possess hygroscopic power; (c) it should be a solvent of discharges (mucus, pus, leucocytes, blood); (d) it should aid in the dissolving of the mechanical removal of morbid secretions, accumulations, and foreign bodies; (e) it should be aseptic (not necessarily antiseptic); (f) it should not indelibly stain the clothing (this is objection to its use as, for example, ichthyol); (g) it should be reasonably economic.
    (9)  The frequency of application of the boroglyceride vaginal tampons should be in general, twice weekly; more frequent employment may cause irritation.
 

SACRO-PUBIC HERNIA       Fig. 127.  This illustration demonstrates how the ureters, bladder and vagina are distorted and consequently how the accompanying sympathetic nerves are traumatized.

    (10)  The time to apply the tampon is at night during maximum anatomic and physiologic rest.
    (11)  The duration the tampon may remain usefully in position is ten to twenty-four hours.
    (12)  There are no special contraindications to the application of the vaginal tampon (in pelvic disease).
    (13)  The boroglyceride vaginal tampon may be beneficially applied in: (a) inflammatory pelvic disease (vaginitis, endometritis, myometritis, endosal pingitis, myosalpin-itis, pelvic peritonitis, proctitis, cystitis); (b) sacropubic hernia (support for the uterus, cystocele and rectocele); (c) in genital ptosis it depletes the lymphatics and veins.
    (14)  A vaginal tampon applied according to the above directions will prove to be of therapeutic value in the treatment of pelvic disease, a prophylactic agent and a comfort to the patient.

I .  HABITAT

    The value of fresh air was never realized so much as at present.  Fresh cold air cures pulmonary and other tuberculoses.  The success of the sanitarium is the continued use of fresh (cold) air.  The subject should sleep with fresh cold air passing through an open window space of three by three feet.  It appears to be demonstrated that cold fresh air is more beneficial than warm fresh air.  It is common talk among people that one winter in the mountain is worth two summers for the consumptive.  The curative and beneficial effect of cold fresh air continually, day and night, for the family must be preached in season and out of season by physicians.  The windows should be open all night.  Fresh cold air is one of the best therapeutic agents in pathologic physiology of the tractus genitalis.
    Exercise is an essential for health.  Muscles exercise a dominating control over circulation (blood and lymph).  The abdominal muscles influence the caliber of the splanchnic vessels.  They exercise an essential influence over the peristalsis, secretion, absorption of the tractus intestinalis, urinarius, vascularis and genitalis.  The muscles massage the viscera, enhancing their function and the rate of circulation.  In the uterus, the most typical example, it is prominently marked how the myometrium controls the blood currents like living ligatures.  The habitat that furnishes opportunity for abundant fresh air and ample exercise is the one that affords the essential chances for recovery of pathologic physiology in the tractus genitalis.