directed a little outward and almost directly backward to avoid striking with force the upper meati and the septum, which are much more sensitive than the inferior turbinates and the floor of the nose.

Many children have apparently healthy nasal passages, save for occasional hard, dry secretions found in the anterior part. Parents should be taught to look for such crusts and remove them when found. If the crust is not readily dislodged by a spray and gentle blowing of the nose, assistance may be given by using a suitable instrument. One frequently used is a very light, small hair-pin. Great gentleness is imperative, lest the little one learn to dread such interference. When a child takes cold frequently and makes a good and complete recovery apparently, it is only apparently. Such a child should have a careful rhiniscopic examination, and, as a rule, some small local spots of trouble will be found, which, if properly treated, will return to the normal healthy state, and the child will be kept out of the ranks of sufferers from so-called catarrh.

If a child takes cold frequently but does not fully recover, it has a more serious local trouble, probably involving the inferior turbinate bodies and the septum, and it is here we find such grand results from rational treatment. For building up such a child's health and developing a constitutional power to endure atmospheric changes of all kinds, we should give close attention to the hygienic principles referred to in the first part of this article. In addition to such hygienic efforts, the nares should be frequently cleansed with a suitable detergent, and the physician should apply to the diseased spot stimulating alteratives. Iodine and chromic acid have well deserved popularity. An excellent formula for the form is one or two grains with twice as much potassium iodide in an ounce of water. The strength should be lessened or increased to cause a little burning or smarting and some turgescence. It may be used with an atomizer, but it must not be given to the patient to use as freely or lightly as the father or mother may judge right. The physician should use and watch the effects. The directions for the use of chromic acid could not be given in an article like this. Much damage may be done by the unskillful use of so powerful a remedy.

Another child has the snuffles from earliest infancy, which, if not treated, causes flattening of the nasal arch, distortion of the nasal passages, and narrowing of the chest. The flattening of the nasal arch spoils the personal appearance, the distortion of the nasal passages tends to keep up and produce the worst forms of rhinitis, while the narrowing of the chest lessens the general physical strength. Such a child requires great hygienic care, and internal treatment as well as local. As a rule it has some dycrasia, and if properly treated is quickly restored to health. For it, boric acid with a little glycerine in water forms an excellent cleansing and strengthening wash.

Some children have a habit of picking the nose, and will not, or rather cannot, stop the disgusting practice. Here we find dry crusts, and very frequently small but irritating abrasions. The scales should be removed, and a mild ointment of oxide of mercury, flavus, or ten to twenty grains solution of silver nitrate, applied to the abrasions. It is cruel to whip such children. Many adults with the same trouble are forced to seek relief in the same way.

Another class is the mouth breather. The expression of the face is weak, vacant, and in extreme cases almost semi-idotic. The voice has lost its nasal resonance, and the consonants, m and n, are not well articulated. Here we have

the post-nasal adenoid growths, which should be promptly removed as they serioulsy interfere with mental, as well as physical, development. After removal, astringent detergents, with general constitutional treatment, completes the cure. All children should be taught to not hold the nose tightly when blowing it, lest the blowing force some of the secretions or medicinal applications into the accessory cavities, or eventually lessen the tension of the membrani tympani. The handkerchief should be held at the end of the nose, but not pressed against it. Forcible blowing of the nose excites secretions and tends to keep up local troubles. Salt and water is a very popular remedy which often does much good, but it is a dangerous one and should not be used. For some reason salt solutions have a very evil influence on the ear if any passes into the Eustachian canal.

TUBO-OVARIAN DISEASES.

BY HOWARD W. QUIRK, M. D., CLEVELAND, OHIO.

To treat diseases of the ovaries and tubes successfully requires a knowledge of three things, namely, a knowledge of the social environments of the patient, a knowledge of the causes of these diseases, and a knowledge of the remedies and procedures that will alleviate or cure them in the various and manifold forms in which they present themselves. That social status does figure in the direction of our therapeusis may be questioned by some; but it is self-evident that, as in orthopedic surgery, we must abopt that method which will leave our patient the best fitted to fill that vocation in life of which from necessity she has made a choice; and no fixed rule can be laid down for every case, but each must be a law unto itself, and each be equally within the realm of proper treatment. We cannot wisely resort to and take the risks of conservatism and expectancy with a patient who does menial labor as we can with one of affluence, one upon whom a kindly nature has smiled, blessed with all the care and comfort that wealth can bestow. Nor can we trust a case that is caused by non-development the same as we can one due to extrinsic causes, for one requires an intimate knowledge of general or systemic therapeusis, a knowledge of the laws of growth and development, not only of the physical being, but also psychologically. Perhaps there is no other class of diseases in which mind and body are so intimately blended. It is perhaps the highest ambition of the human female to be womanly in the broadest sense of the term; to feel, and to have others feel, that she has been endowed with all the graces and powers that make her an ideal Eve. Her maternal feelings are sacred to her; and why does she continually retain this happy mental picture? Because her reproductive and generative processes are healthy, and sending perfect images to the retina of her mind's eye. But allow these to become diseased, and at once this force which in health has been a stimulus and a tonic to all the other processes of nature's economy, now acts as a poison, and if the case is of long duration, we have a diseased nervous system, a deranged digestion, an impoverished blood; a state of chronic invalidism, if you please, which the removal of the diseased parts will not always correct; at least, we must expect nearly as long a course of treatment for its correction as it has taken nature to produce these changes. We must divert the mind into. healthy channels at the same time that we are correcting the pathological

changes, and make use of this force to aid us in accomplishing a cure.

The reason that so many of the laity are skeptical about all gynecological procedures, both major and minor, is because they are unable to realize why, after the removal of a diseased ovary, they cannot as quickly recover as after the amputation of a diseased toe, or other offending member. And perhaps the surgeon may in part be responsible for this state of affairs by giving too sanguine a prognosis, and losing all interest in the case as soon as the operation is accomplished. We must tell our patients frankly that time is a great element in accomplishing a cure, and not take all the glory unto ourselves, lest we lose it all. A case of this nature came under my observation not long ago, in which Dr. Joseph Price, of Philadelphia, had removed one of the appendages. The patient and her family expected a rapid cure, and after waiting several months in vain. for the relief of the pain, sought solace in a faith curess, who diverted her mind into the proper channels, gave her sympathy and encouragement, good care and good food, and in a few months she was well. But the faith cure doctress received the credit of curing her which rightly belonged to Dr. Price.

Of the three great plans of treatment, namely, medicinal and expectant, electrical, and surgical, each has had its ebb and flow tide in popular thought, and each has been sufficiently tried to warrant us in saying that all are good, and have a useful sphere. At present there seems to be a slight wave towards conservatism, that has followed a perhaps somewhat radical surgical period. Of the three methods, possibly the surgical will serve us the best and most often, until such a time as preventive measures shall tend to make these conditions less virulent and less frequent, or until the people shall become educated to seek relief at an earlier stage of the disease.

That the medicinal and expectant plan of treatment will prove useful is too often illustrated to be disputed in those cases of subinvolution where the uterus, tubes, ovaries and broad ligaments are all subject to this hyperplasia, for we have the same hyperplasia or subinvolution existing in the ovaries, tubes and broad ligaments, as we do in the uterus. We may have this condition wherever there is muscular tissue; it frequently follows abortion. The continuous use of the vaginal douche, the packing of the vagina with glycerized, boro-glycerized or boro-alum-glycerized wool, if there is much relaxation, or a tampon composed of both cotton and wool, the center composed of elastic wool (but in the great majority of cases a long strip of wool will serve a better purpose, if applied properly, than any special form, and be more easily worn and removed without any trouble to the patient), the occasional application of iodine to the endometrium and vaginal vault, and avoiding the elevation of the uterus above the normal line, and in some cases the administration of ergot, with proper attention to the general health, will cure a large per cent. of these cases. Weir Mitchell's rest cure, which I have found not possible to carry out in many cases, may aid us; still we must not expect too much from it. I recall a case which came under my observation about five years ago-a young woman, who had been in Dr. Mitchell's hospital for a number of months for the relief of a condition of this nature. A forced recumbent posture, and forced alimentation had been practiced. She improved, and gained considerably in flesh, and returned home; but as soon as she again resumed the erect posture, her muscles being weak and flabby, her former condition returned in a more aggravated form than before. The glycer

ized tampon serves two purposes; it elevates the contents of the pelvis to its proper level, thus allowing the ligaments to contract. The glycerine, by virtue of its strong affinity for water, depletes the tissues, at the same time the turgescent blood-vessels are emptied by osmosis and pressure or support. It thus lessens the tendency to menorrhagia and metrorrhagia, which are frequent accompaniments, if not always present. This condition is subacute, one of passive hyperæmia, and as an adjunct the stimulation of the faradic quantity current will prove useful, with the cup electrode applied to the cervix, the other to the sacrum or abdomen. Currents of intensity, and the galvanic current, should be avoided, as it is a general action that is aimed at, and not local; they cause destruction and inflammation, just the condition we are trying to prevent.

Where the appendages are dragged down and prolapsed, as a result of a retroverted and prolapsed uterus, then the cause of this must be sought and corrected, either by tampons, suitable pessary, or repairing the vaginal outlet, if torn. But the performing of perineorraphy will not correct a great many cases where the ligaments have been long stretched; then the combining with it of Edebohl's modification of the Alexander-Adams operation of shortening the round ligaments presents itself as the proper treatment. Of course, this can only be done where there are no adhesions. In this connection I wish to refer to a condition which I have never seen described; that is, inguinal hernia dependent upon a displaced uterus, and the dragging open of the canal by the round ligaments at the same time that the natural plug to the canal, the round ligament, is stretched out into a thin cord. The canal is thus left open at the same time as the intraabdominal pressure is directed from the back of the pelvis to its anterior aspect by the uterus and broad ligaments. The knuckle of intestine thus readily finds. its way into the canal. A case with this seeming explanation has come under my care recently, and I have advised, and shall perform, Edebohl's modification of the Alexander-Adams operation, and thus, while the displacement is corrected, a radical cure of the hernia also secured. She has a lacerated perineum, and perineorraphy will be done at the same sitting. This is the second case of this kind that I have seen that could be readily explained in this way, and I believe it to be a potent cause of inguinal hernia.

In that class of cases due to non-development, the infantile uterus and imperfectly developed ovaries and tubes, a small anteflexed uterus, the tubes will often be shorter, convoluted and tortuous, the ovaries not painful or sensitive to the touch. The uterus and appendages will not have that elastic feeling which we notice in health; the vaginal mucous membrane is often dry, and its epithelium lustreless; sometimes flakes of inspissated mucous are found. The uterine ligaments, broad ligaments, tubes and ovaries are held so taut as to lead one to almost suspect adhesion. Anæmia, amenorrhoea, dysmenorrhoea, cold extremities, sallow skin, aversion for exertion or society, palpitation, constipation, etc., these many little deflections from the normal health line that serve to make up this condition, must receive our patient attention separately and collectively. The digestion, bowels, and skin must be stimulated to a more healthy action. Iron and arsenic are the sheet anchors as a blood tonic, while cantharides will soon relieve the coldness of the extremities. Apiol, and others of its class, may prove useful, but should not receive the laudation given them by some. At the same time that these sytemic measures are being carried out, we must dilate the uterus,

stimulate its endometrium with iodine, and wash out the vagina with mercuric bichloride. But we must not, as is often done, use the glycerized tampon, as it is too depleting and will cause a local anæmia, or an aggravation of that condition which already exists and which we are trying to correct. It is in this condition that electricity can be brought so serviceably into use, by both local and general electrization. There is another condition that comes properly under this class. It is that of those patients whose vital forces are diverted from ovulation and the generative organs in general, to the production of adipose. These patients are always fat, and may or may not be anæmic; if not, the local stimulation of these organs, by electricity and otherwise, is the proper course to pursue. This is the class of patients that Lawson Tait calls non-development of the ovaries, and thinks that the largest class of non-development of the ovaries exists in those otherwise perfectly developed. I prefer to consider it a mal- or miscarriednutrition, as the local stimulation and direction of nutrition to the parts proves. Massage is useful, especially to those contorted and paretic tubes. At the same time that this treatment is being carried out, these patients must be placed in the most healthy and stimulating mental surroundings by being kept in a mixed society.

The treatment of salpingitis will be governed in part by the stage in which it comes under observation, and in part by the social status of the patient. The danger to life in these cases, if left to nature, has been, I believe, greatly exaggerated. That there are cases that are dangerous to life is admitted, but they are rare as compared to the great number of cases. That electricity or massage cannot be used in this disease without doing harm is undoubtedly true. squeezing or pounding of an inflamed and perhaps distended tube by massage is as foolish as it is illogical, cannot be gainsaid. There are cases in the catarrhal form, which are seen before the exuded plastic lymph has become organized into adhesive bands, and these resulting cicatricial bands have contracted. In this stage of the disease, like the acute, we can, by the use of the hot vaginal douche, the above-referred-to glycerized tampons, filling of the rectum daily with warm water, and allowing it to remain as long as it can be retained with the pelvis elevatedwe can by these means expect a relief from those distressing symptoms, such as the dragging feeling in region of ovary, tube and sacrum; also of the pain in pelvis, and along the course of the crural and other nerves. The patient may not be rendered sterile, even though the cilia of the epithelium of the tube are destroyed, if the vermicular or peristaltic action of the tubes is preserved, and the tube has not been rendered impervious; for I believe that we may have stricture of the tube the same as we have in the male urethra; and that the inflammation of the tube caused by the gonorrhoeal gonococcus of Neiser is peculiarly liable to cause this condition. And I think that sterility more frequently follows the gonorrhoeal inflammation of the tube than after abortion or parturition, but that the latter is more liable to cause pyosalpinx than the former. But a woman suffering from a pyosalpinx following abortion frequently contracts gonorrhoea; then we have a condition that is unfortunately difficult to cure, and it is in these pus sacs that gonococci have been found upon removing them. The percentage of pus tubes in those who have never either aborted, or passed through the parturient stage, is particularly small. If endometritis, as there commonly is, the proper treatment will depend somewhat upon the existing condition there found.