has thrown on the uterine pathology of former days. I, for my part, think I may claim the credit of having sifted the data furnished by those who preceded me; of having still further pursued their investigations, and accumulated fresh materials; of having pursued the local history of uterine inflammation throughout all the ages and phases of female life; and of having built up in my work on Uterine Inflammation a scientific edifice, founded on the faithful observation of Nature, sufficiently practical and comprehensive to explain nearly all that is obscure in the observation of uterine diseases, and calculated to afford a true guide to the practitioner in his attempt to restore the health of his patients.

I will now give a concise and at the same time complete view of the doctrines I profess, and, having done so, I intend to examine the objections that have been raised to these views, and the opinions respecting uterine pathology generally that clash with them; thus giving my readers an opportunity of judging for themselves.

CHAPTER II.

A SKETCH OF UTERINE PATHOLOGY.

I ADMIT, to the fullest extent, that the nutrition, vitality, and functions of the uterus are susceptible of being modified by. general causes, or by general morbid conditions, without the existence of any description of local mischief, inflammatory or other, of the uterus or ovaries. So fully, indeed, do I admit this fact, that I believe few women can have their health profoundly modified by any disease or by any morbid state, without the uterine functions being modified. At the same time I believe, as a result of lengthened experience, that the great majority of instances of confirmed uterine suffering that come under the observation of the medical practitioner, are cases in which the primary and principal evil, the morbid centre, is inflammation of the mucous membrane or of the proper tissue of the neck or body of the uterus, with their varied sequelæ. Around this inflammatory disease, when accurate physical examination has proved its existence, may generally be grouped the principal symptoms the patient presents, both local and general.

The expression confirmed, which I have used in speaking of uterine suffering, is of vast importance; for in it lies the distinction between morbid conditions of uterine vitality and of uterine functional activity the reflex of general pathological states, and the same morbid conditions the result of actual local disease, inflammatory or other. When these morbid conditions are the indications of local disease, they are confirmed, varying in intensity but constant. When they are the reflex of general pathological states they are changeable;—arriving and

departing with the "general" cause, and giving way under the influence of the appropriate treatment of the general states of the system to which they owe their existence.

Although thus fully admitting the influence of general pathological causes in disturbing the vital and functional activity of the uterus, it will be seen, by what precedes, that I consider such modifications as essentially temporary, and as remediable by the general treatment of the disease or diseased state of which they are the symptom. On the other hand, it must be equally evident that I consider confirmed uterine suffering, confirmed derangements of vital and functional uterine action, which resist the treatment of the general morbid conditions. that accompany them, as the decided result, generally speaking, of local disease, and in the great majority of cases, of chronic inflammatory lesions.

From the dawn of menstruation until a very advanced period of female existence, the uterine mucous membrane may be attacked by inflammation, and is very frequently so attacked; more especially between the ages of twenty and fifty. The inflammation may be limited to the cervix, but most generally it passes into the cervical canal, where it has a great tendency to perpetuate itself, owing partly to the numerous follicles which the cervical mucous membrane contains, and partly to menstrual influences. It may also pass into the uterine cavity, but this comparatively seldom occurs, as I believe I first pointed out. Inflammation may exist for months or years without ulceration ensuing, but in a very large proportion of cases ulceration does ensue at an early period, and has also a tendency to perpetuate itself indefinitely, if not treated. By ulceration I mean the result of destructive inflammation, characterized by the destruction of the epithelium, and the exposure of a muco pus-secreting surface. The characteristics of the ulceration vary from those of a mere abrasion, to those of a bleeding, fungous, foul-looking sore.

Inflammation and inflammatory ulceration of the mucous membrane lining the cervix and its canal are generally attended in their early stages by swelling and enlargement of the cervix. If the disease is not discovered and treated, the swollen cervix

may remain indefinitely soft, but it more frequently becomes hardened, indurated, and consequently larger and heavier than in the normal state. The hypertrophy may be confined to the cervix alone, or extend to the body of the uterus. These enlargements of the cervix and of the uterus give rise to a train of important secondary symptoms-viz., to displacements. If the enlarged and heavy cervix remains in a normal position, it drags the womb down, and produces prolapsus. In the married female it is frequently thrust backward, and retroverted on the rectum and sacrum, the uterus being at the same time more or less anteverted. The recumbent position or its own weight produce occasionally the same result in the non-married female. This tendency to hypertrophy, owing to physiological causes easily appreciated, is greater in the married than in the unmarried-greater in women who have had children than in those who have not.

Acute and chronic inflammation of the proper tissue of the body of the uterus and of the cervix are not unfrequently met with, quite independently of mucous membrane inflammatory conditions. They are, however, of very much less frequent occurrence than these latter lesions. Both the cervix and body of the uterus may become enlarged and heavier, as a result of acute and chronic metritis, and be secondarily displaced, without the existence of inflammation or of inflammatory ulceration of the mucous membrane. Chronic enlargement of the uterus posteriorly, and its retroversion on the rectum, are frequently thus produced.

The tendency of the neck and body of the uterus to become hypertrophied under the influence of chronic mucous membrane inflammation, or of acute and chronic inflammation of the uterine proper tissue, is explained by the extreme physiological facility with which the uterus enlarges under the influence of physiological and morbid uterine stimuli. Passive hypertrophy of the cervix and uterus, in women who have had children, is often merely the result of the powers of transformation and absorption, which, after confinement, reduce the uterus from forty ounces to two in four or five weeks,-flagging, from some cause or other, before entire resolution is obtained. This arrest

is often owing to the presence of some mucous membrane lesion of the neck of the uterus, either existing before the confinement, or occasioned by it. Hypertrophy of the neck and body of the uterus may also occur as a result of mere modified functional activity.

Whatever the cause of the hypertrophy, it is attended with displacements, which are merely the result of gravity, in the great majority of cases, the womb being prolapsed, retroverted, or anteverted, according to the region of the uterus or its cervix which is the seat of enlargement. These displacements I consider to be only curable, generally speaking, by the removal of the conditions which produce them—that is, the enlargement, induration, or hypertrophy. If the latter cannot be removed, I believe that mechanical means of replacement or sustentation nearly always prove useless as means of effecting a permanent Displacements may, however, it must be remembered, be produced by other causes, such as laxity of the vagina and vulva, or of the ligaments, pressure of surrounding organs, tumours, &c.

cure.

These local morbid conditions, inflammation, ulceration, hypertrophy, and displacements, are generally found connected in practice with local or uterine symptoms, such as intractable leucorrhoeal discharges, ovarian, sacro-lumbar, and hypogastric pains, bearing down, and inability to stand or walk with ease; with functional uterine derangements, such as amenorrhoea, dysmenorrhoea, menorrhagia, sterility, abortions, uterine inertia, &c.; and with general symptoms, such as disordered states of the chylopoietic viscera, of the nutritive and assimilative functions, and of the cerebro-spinal system, as indicated by dyspepsia, debility, anæmia, hysteria, &c.

I have no hesitation in stating as a fact, in my mind fully established, that when females present the above-enumerated local or uterine symptoms, in a chronic, confirmed manner, even without the general symptoms, the local diseased conditions described will be generally found, on examination, in a more or less developed state. Conversely, when weak, debilitated, dyspeptic, hysterical females do not recover their health under judicious medical and hygienic treatment, and when they present