I am indebted to Prof. Reamy, of Cincinnati, for the first intimation of the practicability of this proceeding, and I have practiced it so often myself that I no longer hesitate to recommend it as the crucial test in all obscure cases. It is true there would be no particular pleasure to a patient to have an average sized fist forced abruptly into an average sized vagina; but with the muscular relaxation which the anaesthetic affords, and the gradual dilitation of the ostium with well-oiled fingers, the feat will be accomplished with far less trouble than one would imagine, and with no inconvenience to the patient beyond a certain degree of soreness that will last for a few days.

Nor is this practice to be confined to married women or those who have borne children, for it is likewise applicable to virgins; and we should not allow false modesty or popular prejudice to cause us to withhold anything that will add to our knowledge of disease, or that will promise the slightest relief to our patients.

About eighteen months ago a young lady was sent to me by a prominent membea of this society to be treated for ante-flexion of the uterus. After two or three examinations by the ordinary methods, which were very unsatisfactory on account of the obesity of the patient, as well as her nervous irritability and native modesty, I determined to resort to my favorite test, and did so to my extreme satisfaction and her great benefit.

Grasping the uterus in my hand and passing the thumb and fingers around it in opposite directions, a small fibroid tumor could be distinguished as growing out of the anterior wall of the body of the organ, so symmetrical in form as to closely resemble the uterine dome; hence the erroneous judgment of a generally careful and acurate diagnostician.

Fibroid tumors seem to possess a peculiar affinity for the uterus, and for this reason their frequency should always be borne in mind in making examinations for any pelvic disorder. Bayle has said that 20 per cent. of all women dying after the age of thirty-five are afflicted with fibroids and Klob, in more recent years, says that " undoubtedly 40 per cent. of the uteri of women dying after the fiftieth year contain fibroid tumors."

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Then, inasmuch as so many of the symptoms that are found in areolar hyperplasia may be due to the presence of one of these growths, we should never consider an examination complete until we have detected or excluded so frequent a factor, and as has already been intimated, this can sometimes be done only by the mrans above alluded to.

It is to be borne in mind that while the causes of hyperplasia are numerous and varied in their character, there is one which not only heads the list in point of frequency, but stands pre-eminent above all the others combined, it will be the only one considered in this paper, namely: "Subinvolution of the uterus after parturition."

This furnishes a reason for the fact that a vast majority of the women coming to us with female disorders, date their illness from a child-birth or miscarriage. The responsibility for subinvolution may in general terms be divided between the accoucheur and the patient, although there are many cases in which the stern hand of fate seems to over-ride the best skill and intentions of both. The retrograde metamorphosis perhaps begins promptly in all cases; but its frequent arrest, as first described by Sir James Y. Simpson, in 1852, leaves the organ very much enlarged, heavy, flabby, and with such slight contractile power that a displacement and subsequent engorgement would follow as natural consequences.

The want of contractility is doubtless due to the fact that in this bulky organ there is now a vast preponderance of connective tissue, many of the muscular fibres having undergone fatty degeneration, and been absorbed, as first mentioned by Kolliker, Virchow and other German writers. The hyperplasia of connective tissue, then, is at first a physiological condition in common with that of the other four component parts of the uterine parenchyma, and it only becomes a pathological state when it is arrested in the process of resorption.

In the nulliparous we would have to look for a far different condition of things, but as uterine hyperplasia is quite rare in these, it is not necessary to consider them at this time.

Then, having exhausted all our means of investigation, and being satisfied as to diagnosis, it is our duty to institute such measures of treatment as our ingenuity can devise and the circumstances of the patient permit. These must of necessity seem somewhat empirical when we consider the complex nature of the disease, and the large number of symptoms we have to contend with, and yet if we will properly study our cases we can arrange our treatment with such a degree of system that we will not be continually doing the right thing at the wrong time. And first of all, if there be a displacement, we should correct that and keep the organ in place by a suitable pessary. Some of our authorities, and many of our practitioners, condemn the use of these instruments without discrimination, and never allow them a place in their cabinet of prac

tice.

That much harm has resulted from their use there can be no doubt; but the same thing can be said of ligatures, of splints, of bandages and of almost everything in the list of surgical appliances. But we are speaking about a suitable pessary now, and by this we mean one that is of the right size, of proper shape and applied with an intelligent idea of what it is intended to do.

We will occasionally run across a case where the hyperaesthesia is so

intense, and the irritation so great that we cannot make use of the pessary at first. In such an event we have a splendid substitute in the cotton tampons as recommended by Tait.

The use of these, properly medicated and applied, will usually accustom the parts to the forced correction of the displacement in a few days, and then the pessary may be employed without further trouble.

In the selection of an instrument for a given case the skill of the physician will surely be put to the test. In general terms, it may be said that Smith's modification of the Hodge pessary is the best for retroversion, it being the lightest and most gracefully curved of any that have been invented for this purpose, besides being made of a material that admits of moulding to any desired shape. For anteversion, the improved Gehrung is undoubtedly the best, while for lateral displacements there is none that will compare with the Fowler. Exceptional cases will be found in which various changes will have to be made in all these varieties of displacement.

A pair No. 6" Foster" kid gloves will not fit every feminine hand, and so our Hodge and Smith and Fowler pessaries will frequently have to be thrown aside for one more suitable to a particular case.

Having done this much we are ready to begin our constitutional remedies with some hope of their doing good. Before this they are worse than useless, for with a 'displaced uterus making pressure on one part and tension on another the nervous irritation is so great that the digestive organs, by reflex action, will simply refuse to do their part in the process of nutrition. Everything should be done to improve the general condition, and for this purpose there are three specific tonics that may be used with wonderful benefit.

The first is beef-steak, the next is very moderate exercise in the open air, and the third is the companionship of a kind, considerate, sympathetic husband. Beef steak is frequently rejected on account of the reflex irritable condition of the stomach just mentioned; but having removed the cause of this trouble, we may soon expect it to subside. That which we design for gentle exercise is often converted into the hardest kind of labor. We will frequently spend half an hour in giving a patient permission to step out among the flower beds in her own garden, and before we have finished our instructions, hear her ask if it will hurt her to run down to the Postoffice and back. A woman's trip to the Postoffice is an anomalous creation; it includes several dry goods s ores, the Dime Museum, and all the millinery shops in town. Arriving at home from such a jaunt, she is thoroughly exhausted and racked th pain. sends for her physician, tells him she has obeyed his ins ructions to the letter, and expects him to have her in condition for another walk to the

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"Postoffice" on the following day, and for the Charity Ball on Thursday night.

The third of our favorite tonics is a rare drug, and we cannot expect our patients to employ much of that which the market supplies in such small quantities.

Of course there are a number of adjuvants to the natural remedies above mentioned, and some of them may often be used with marked benefit.

The vegetable tonics and simple bitters in particular, might be named as being of the greatest service, as by their use we create an appetite for the beef-steak, as well as promote its digestion after it has been taken.

Iron in some form is without a peer in a very few cases, but when we consider that an individual weighing one hundred and forty pounds can only contain about forty five grains of iron at one time, we can readily see that the indications for its employment must be very limited, and furthermore, being assimilated in such minute quantities, it should be given in correspondingly small doses, for that which is not appropriated by the system, will exert its well known powers in deranging the digestive apparatus. The success of chalybeate waters in building up the system is doubtless due to the fact that they contain iron in such a state of dilution that they are incapable of doing harm, and the dyspeptic patrons of "mineral" springs and like resorts, by leaving off their patent nostrums during their sojourn at such places, allow their systems to become regulated by Nature's own process, and they return to their homes in the innocent belief that three or four hundred dollars worth of "iron water" has been the saving of their lives.

During the time we are using the systemic remedies we may also be doing good work in allaying the vaginitis and local irritation by the frequent use of emmolient and slightly astringent injections. For this purpose a decoction of poppies and the officinal glycerite of tannin, diluted with warm water according to the severity of the inflammation, will be found most useful remedies.

The next condition to consider is that of engorgement; and if it exist in a marked degree, it should be treated by prompt and ample depletion. This may be done by applying from two to four leeches to the cervix by means of a Fergusson speculum; but there are so many objections to the use of leeches in this locality that I never would recommend their employment for this purpose.

A far better method is to make the depletion by using a scarificator or the blade of an ordinary bistoury. A number of punctures may be made around the os externum, or the mucous membrane and a few of the underlying muscular fibres may be divided in the cervical canal, and the

flow of blood established in this way. An ounce or two of blood may be withdrawn in a very few minutes, and the relief afforded the patient is often so quick and decided that she will express her surprise and thanks

Occassionally, when the congestion is not severe, it will be necessary to dry cup the cervix before attempting to draw the blood; but the cupping should never follow the cutting in this locality. In some cases this process will have to be repeated several times, but in many the congestion may be controlled by other means after the first operation, chiefly by the use of hot water injections.

And to be efficient, these must be used punctually and systematically. In the first place the water must be as hot as it can be borne and must be used in large quantities. The first action of this remedy is to relax the parts and make the congestion worse; and it is only after the lapse of several minutes that the vessels begin to contract and the blood to be forced out. As an illustration of this let us take the case of a washerwoman. When she first dips her hands into the hot water her fingers become red, swollen and congested, but after she has continued her work for half an hour or more the most radical change has taken place. The fingers are now white, shriveled and bloodless, and it will be several hours before all signs of this local anaemia have passed away. It is just this condition. of anaemia that we wish to create in the uterus, and it can only be done by keeping a copious supply of very hot water applied directly to it for twenty or thirty minutes. The details of this process may be left to the ingenuity of the patient, and the only general directions I have to offer are that the application should be made while she is lying upon her back, so that the water may remain in contact with the cervix until forced away by a fresh supply, and that she should remain in the recumbent position for at least an hour after each treatment. Walker's Vaginal Dilator is of untold value in assisting to carry out the purposes of this treat

ment.

Cervical or corporeal endometritis may be much benefited, if not entirely cured by the local application of various remedies. But it must be remembered that these should never be applied in the form of intrauterine injections, for these are always attended with great danger, and frequently with the most alarming symptoms. The best way to apply medicines to the cavity of the uterus is by means of a swab of absorbent cotton held by a pair of very narrow uterine forceps, or sponge holders, such as I show you here. For this purpose Lugol's solution of iodine or the compound tincture of iodine may be used, or a twenty or thirty grain solution of the nitrate of silver, or a mixture of equal parts of carbolic acid and glycerine, or the fluid extract of yerba reuma. This last named preparation is among the somewhat recent discoveries in therapeutic