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 deñcient 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.

(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 segment 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 vagina 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 sueing 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 vis

C

cera 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 orgasm occurs during coition to which they are indifferent. Practically little or no treatment is required.

FIGURE III.-HISTOLOGY OF PELVIC BRAIN.

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 12 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 Hashmoto).

(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 retarda) 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 presents. 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 patho

FIGURE IV.-SYMPATHETIC NERVES.

Dissected with extreme care under alcohol, showing origin of the genital nerves from the abdominal brain, from the plexus ovaricus O on the right, and from the plexus ovaricus P on the left. On the right, M presents the anastomosis of the plexus ureteris with the plexus ovaricus. Ph is the plexus interiliacus arising proximally from the plexus aorticus, and ending distally in the bilateral pelvic brain.

logic 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 peristalisis 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. 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 pathologicl 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 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 has become projected into the field of pathologic physiology. Pathologic anatomy is not in evidence except as ureteral dilatation-a 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.