determined by an instrumental examination, the patient having been previously placed under the influence of chloroform; indeed, it seems to me that medical men are incapable of well attending insane women, unless they thoroughly understand diseases of women.

Pudendal neuralgia. It is easily understood that morbid lesions of the pudenda should give rise to more or less heat, aching, or itching; but occasionally at the change of life one or other of these sensations assumes a very distressing and longcontinued intensity, although no structural lesion of the pudendal tissues can be detected. Many patients complain that for a few nights after each menstrual period, there is an intense itching and skin irritation, unaccounted for by any cutaneous eruption. Such cases explain why cessation is sometimes followed by itching of the pudenda, or of the whole surface, the prurigo latens of Alibert, to which Aran believed women at the change of life to be particularly subject, and to indicate some form of uterine disease. In some of the most distressing cases of pruritus and perverted feelings, there is, however, nothing morbid to be detected, as in a woman of sixty, who was subject to hysterical attacks if a young man came near her, and in whom Biett could discover nothing amiss, although he inspected the pudenda with a magnifying glass. Lisfranc and Tanchou have drawn attention to vulvo-vaginal neuralgia; and the last thinks it occurs most frequently at the change of life. He mentions the case of a lady of forty-eight, who had never suffered from uterine disease, in whom the menstrual flow ceased at forty-six, and ever since she had been afflicted with pruritus and darting pains in the pudenda. These sensations were increased by walking and over-exertion; no morbid lesions could be found to explain the sufferings; and they were relieved by the internal exhibition of assafoetida and valerian, combined with the external application of opiates and belladonna. It must be confessed, however, that some of these cases stubbornly resist remedies, and yield only to those influences that have power to strengthen the nervous system, and to those nutritial transmutations of tissue that time alone brings about.

Ovario-uterine neuralgia—I am not aware that cases similar

to mine have been described by gynæcologists, but Dr. Handfield Jones has recorded two similar cases in his work on functional nervous diseases. One of his patients was thirty-eight years of age, the other younger still, but four of my cases occurred at the change of life, and two after cessation. These cases were characterized by a most distressing burning sensation in the vagina and pelvis, with a considerable amount of tenesmic action, shifting from the rectum to the bladder or to the womb, and sometimes felt in the three organs at once, the sensation being sometimes so well localized as to impress the patient with the conviction that there was a solid body pressing on the rectum or the bladder, or à tumor on the womb. These pelvic symptoms are said to bring on exhaustion and prostration referred to the pit of the stomach, followed by sleeplessness or pseudo-narcotism, despondency, apathy, and other forms of cerebral neuralgia described in a previous chapter as gangliopathy and ganglionic dysæsthesia, for these pathological conditions are closely related to that form of neuralgia of both sensory and ganglionic pelvic nerves which I think right to call ovariouterine. I am strengthened in the belief that the ovaries are greatly implicated in this neuralgia, by my having observed a somewhat similar train of pelvic symptoms to occur in man as the result of concussion of the testicle. Very nervous women are most liable to the complaint, but I have seen it assume its worst form in strong-minded women, who, through life, had always enjoyed good health. I have always found the neuralgia accompanied by a certain amount of vaginitis, and its cure always alleviated the symptoms, but seldom cured it. Vaginal injections were often useful, but sometimes an injection brought on a fit of neuralgia, and for a time injections had to be left off. Worry, mental anxiety, and fatigue made the symptoms worse. A tranquil tenor of life, rest, particularly in the recumbent position, with the feet higher than the pelvis, quieted the symptoms for a time; and they sometimes yielded speedily to opium and belladonna suppositories introduced into the vagina, or the rectum, but the cure of the complaint must be sought for in whatever can strengthen the system, such as change of scene, travelling, more cheerful circumstances, the exhibition of our ordinary tonics and those called nervine, like

arsenic and strychnia. Although I have only met with six aggravated cases of this description, I believe that in a less degree the complaint is far from uncommon, remaining unnoticed, because many women effectually conceal their sufferings. The following cases give a good idea of the disease:

CASE 43. Ovario-uterine neuralgia.-Miss X., was fortyseven when she first consulted me. She is small but well proportioned, has been highly nervous all her life, and is so still. Menstruation was irregular, and there was a muco-purulent discharge, vaginitis, and decided ulceration of the cervix, and a most irksome sensation of heat and irritation in the passage. I cured the vaginitis and ulcération by surgical measures without relieving the vaginal heat and pruritus, so I sent the patient out of town When she returned after many months, the pruritus was as bad as ever, and would come on after any excitement of fatigue or standing about, and would be relieved by resting with the feet higher than the pelvis.

This vulvo-vaginal irritation would sometimes disappear on the coming on of a similiar pruritus, on the palms of the hands and on the soles of the feet, showing that however much the chief seat of neuralgia might be in the womb and vagina, the extreme nervous expansions in other parts of the body might suffer in like way. When this irritation affects the feet and hands there is nothing to be seen there, and she refrains from scratching them, because it would make the irritation last for hours. As might have been predicated, the symptoms are worse at night, and lead to great exhaustion and despondency. I have watched this state of things for ten years and often could give no relief. She was always better for plenty of food and wine, and for such small quantities of citrate of iron and quinia as she could bear. I tried all sorts of injections; tar-water did most good, but it has been repeatedly advisable to leave off all kinds of injection, for they seemed, for a time, to do more harm than good. I syringed the vagina with a solution of nitrate of silver, and touched the passage with the solid caustic with questionable benefit. A rectal suppository containing a grain of opium and one of extract of belladonna often gave temporary relief, but this remedy could not be relied on. Many a daughter has, by the sacrifice of her own

health, repaid her mother the gift of life, and a year ago, my patient lost a mother who had been long a cripple, requiring anxious and fatiguing nursing; and afterwards she went out of town and got fat, and now suffers much less, having a slight return of the old symptoms when she gets weaker and more

nervous.

CASE 44. Ovario-uterine neuralgia.-A very strongly constituted lady, aged forty-seven, is said to have had some acute uterine disease twenty years ago, while residing in France, when forty leeches were applied above the pubis. With the exception of not being able to retain the urine so well as previously to this attack, health remained so good that every year she was able to take long pedestrian excursions with her husband. She never conceived, and menstruation ceased suddenly at forty-four; for the following months the nose bled very frequently and the bowels became constipated; for this she went to Homburg, and was restored to health. On returning to town, in December, 1868, she took very cold enemata for constipation, which was so great that a wineglass of Friedrichshall water, taken every hour, failed to produce watery motions, but irritated the bladder, and was followed by anomalous abdominal sensations, that have lasted ever since. She feels as if there were a heavy body in the pelvis, bearing down upon the rectum, with a burning sensation, referred sometimes to that organ, sometimes to the vagina, or to the bladder. When in bed, and lying down, with the feet up, the patient feels comfortable; by the time she has half done dressing, the burning sensation begins, and lasts until the bowels have been moved; soon after this the burning comes back; it is aggravated by standing or sitting, by indigestion, flatulence, constipation, and repletion of the bladder; also by worry and bad news. The sensation is relieved by walking, by lying down, and by regularity of the bowels. Homburg was again tried, and did good, but on her return the lady was as bad as before, and consulted several doctors. One attributed the sufferings to stricture of the rectum, another to irritation of the bladder, a third to displacement of the womb. In due course of time Homburg was tried for a third time, but the waters were soon left off, as they aggravated all the symptoms, and after the patient's return to

town Dr. Beale sent her to me. In addition to the pelvic symptoms already described, there was considerable cerebral disturbance, for a strong-minded, sharp, matter-of-fact woman, was in a state of mental confusion, her brain felt muddled, and she would sit for hours dozing or doing nothing; despondency being doubtless increased by finding herself helpless as a child, after having passed all her life in doing everybody else's business as well as her own. She forgets where she puts things; once thought she had taken out a large sum of money in her purse, and that she had lost it, whereas a month afterwards she found it in some out of the way place. On examining, I found the rectum perfectly healthy, notwithstanding the pain and stricture ascribed to it. The vagina was so narrow that I could with difficulty introduce part of my index finger, and I gave so much pain that I desisted from all further investigation; ordered linseed tea and laudanum injections, three times a day, and henbane internally. A few days afterwards I was able to reach the os uteri with the tip of my finger; I found the womb exquisitely sensitive; and wishing to ascertain how far the bladder was implicated, I sounded it; found nothing. abnormal except great pain when the sound passed over the urethra, but the pain was not caused by inflammation, for the finger in the vagina did not enable me to feel the urethra as a hard and round body, giving pain on pressure. Injections with acetate of lead and laudanum, as well as opium and belladonna, rectal suppositories, enabled me a little later to examine the womb without giving pain; there was no ulceration, and all along there had been very little vaginal discharge. The pain was most felt at the opening of the vagina, which looked sore, red, and injected, a condition that may account for an unusual hardness of the intervagino-rectal tissues, a hardness of which the patient is sensible, and complains of as something wrong with "the bridge." This is caused by long-continued congestion, and the parts are now without heat or redness. This sore state of the vaginal opening was relieved by the application, twice a day, of zinc ointment, to each ounce of which was added a drachm of diluted hydrocyanic acid. Vaginitis becoming worse, I swabbed the vagina once a week, with a solution of nitrate of silver, and I ordered alum and