zinc injections; but suppositories, whether administered by the vagina or the rectum, did harm. After thus treating the patient for a few months, the sensations of burning and weight had considerably diminished, but were often still very troublesome. Digestion was much improved by nitro-muriatic acid and pepsine; pseudo-narcotism and mental disturbance were not relieved by bromide of potassium, but were much reduced by henbane and Indian hemp, and for the last six weeks the patient has been taking, at three meals, the twenty-fourth of a grain of arseniate of iron, made into a pill with the eighth of a grain of Indian hemp; a combination suitable alike to the general nervous derangement and to the abdominal neuralgia. This leads me to the question of diagnosis. There was no organic disease of the bladder or rectum, nor of the womb, neither displacement nor ulceration of this organ. The disease was vaginitis, kept up by excessive walking at the change of life. The vaginitis causing neuralgia of both the sensory and the ganglionic pelvic nerves, the vaginitis and neuralgia causing pseudo-narcotism and the other forms of cerebral disturbance that usually attend the ménopause; the neuralgic element of the case being shown by the patient's often feeling the disturbance to ascend, as it were, from the pelvis along the spinal column, to the back part of the head, where there is most suffering. A residence at the seaside, and the continued use of injections and internal exhibition of strychnia will, I believe, complete the cure.

DISEASES OF THE CERVIX.-Hard hypertrophy of the cervix has been admitted to occur at the change of life by Gardanne and B. de Boismont, but whenever I have met with cervical enlargement at the ménopause it was evidently the legacy of bygone years. Hard hypertrophy may then last for a long time, with slight symptoms or none, and I have never seen it turn to cancer.

I have only twice met with soft hypertrophy or engorgement originating at the change of life, and it has been observed by Dr. Gunning Bedford and by Dr. Forget. The cervix was much enlarged, felt soft and boggy, as if constituted by erectile tissue. Examined through the speculum, the cervix presented a ragged wound which bled freely. In this form of disease,

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the repeated and abundant flooding principally comes from the cervix, and not from the cavity of the womb. My two cases had been taken for cancer, but the movability of the womb, the healthy appearance of the vagina, the absence of severe pain, and of the characteristic smell of cancer, enabled me to establish that it was not specific. Forget cured his case by repeated cauterization, and I mine by the alternate application of the solid nitrate of silver and its solution.

Ulceration of the os uteri.-It must be borne in mind that not unfrequently women have been suffering from undetected ulceration of the womb, for a variable period of time, when the sufferings of the ménopause cause it to be detected; and while this sheet is passing through the press, I have been consulted by a very strongly constituted widow, who has evidently been suffering from inflammation of the cervix ever since her last confinement, twenty years ago. The gradual ceasing of menstruation increased her suffering, and I found an ulcer about the size of a shilling at the os uteri, dipping into the cervix. Other women who had been well cured of uterine ulceration, many years previous to the change of life, then have relapses, and I have known some have return of this disease four years after cessation. A patient, now 60, had a first and severe attack at cessation, and has a slight return every year. Another who is married, but without children, had a first attack four years after cessation fifteen years ago, and ever since there is a tendency to vaginitis. When ulceration occurs after cessation there is frequently an hypertrophied womb, or a tendency to vaginitis, and I have repeatedly seen the point of insertion of small polypi to be the centre of a patch of ulceration varying in extent from the size of a shilling to that of a florin, and, in four cases, the inflammation and ulceration of the cervix seemed to have been caused by marriage during the dodging time.

I avoid repeating here, what I have written on the treatment of uterine inflammation, in my "Handbook of Uterine Therapeutics," but I will briefly state that, if the case be one of inflammation of the os uteri with erosions, it would be well freely to paint the diseased surface with the solid nitrate of silver, and after this has been repeated once, or more fre

quently, at five days' interval, a solution of the same salt might be applied. I have tried alcohol, vinum opii, chromic acid, carbolic acid diluted with glycerine, the styptic colloid, but I prefer the nitrate of silver, for it is the best mucous membrane improver with which I am acquainted. It is, however, well to have a change of topics, for whenever uterine ulceration occurs in advanced life it is much more difficult to cure, as Dr. Bennet has already stated. In all such cases vaginal injections should be made by the patient two or three times a day, with linseed tea; a solution of acetate of lead, or of alum, one or two drachms to the pint. The patient, using an India-rubber syphon syringe, lying down when using the injection, and prolonging its use for five minutes at least. It will sometimes, however, occur that injections do no good, and cause pains like those of impending menstruation, and such cases have made Dr. Marion Sims too much disparage injections. I remember two cases in which the mouth of an atrophied womb was surrounded by a distinct rim of ulceration, which I could not remove by this plan of treatment, nor by the application of the acid nitrate of mercury or potassa fusa c. calce, and I was obliged to content myself with keeping in check what I could not cure, though time may.

INTERNAL METRITIS.-Even in a chronic form I consider internal metritis to be a very rare disease at, or after the change of life, and I have only seen one case of acute internal metritis after the ménopause which deserves to be recorded.

CASE 45.—Mrs. T., aged sixty-four, was sent to me in 1868 by Dr. Smith of Weymouth. She was very stout and florid, and it appears that she miscarried several times when twentyfive, and that the late Dr. Lever told her that if she did not take more care of herself she would suffer for it later in life. When forty-four, she consulted Dr. Smith, who has thus kindly informed me of what occurred when the patient was under his judicious care.

"I first saw Mrs. T. in 1847, for menorrhagia and hysteria. The womb was greatly congested, and I applied leeches to it several times, and sent her home apparently cured in Sept., 1847. She returned to me, however, in Sept., 1850, with similar symptoms, and was a month under my care, with no other

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treatment than saline aperients and astringent vaginal injections, and she went home as before apparently well."

Menstruation ceased at fifty without bad symptoms, but when fifty-four she began to lose blood from the womb, and continued to do so more or less until the day of her death. As soon as menorrhagia set in, Mrs. T. went to Weymouth, and with reference to this period Dr. Smith writes me word:

"I heard nothing of her again until Sept., 1867, when she returned complaining of a sense of weight in, and bearing down of the uterus, with occasional discharge of blood, often attended with exquisite pain, vaguely described as being at one time in the uterus, again in the bowels, back, and hips. The uterine sound passed three and a half inches into the uterus, and did not give more than ordinary pain. I failed to check the bleeding, except for a time, though she was about seven weeks under my care. I dilated the os with sponge tents and tangle with the view of reaching any morbid growth, if any, in the uterus, but found none. I came to the conclusion the case must be one of fibroid tumor in the uterine wall, since all the ordinary mediums to check hemorrhage and allay pain had failed."

When I saw Mrs. T., in September, 1857, I found the womb about double its usual size, and painful when pressed; the cervix was much enlarged, and not at all ulcerated. I easily introduced three inches and a half of the uterine sound, and this gave great pain. If the flow of blood was checked for a limited time, a little pus would be passed in a gush and after great pain, leading me to believe that it had accumulated in the womb; but independently of the passing of blood or matter, Mrs. T. complained most of attacks of pelvic forcing pain, lasting from one to two hours. When she got worse, I saw her in one of these attacks, and nothing more resembled the pains of labor, as she lay on her back, with face injected, groaning or screaming, and tugging hard at a sheet tied to one of the bedposts. These pains increased, the paroxysms became longer, brought on vomiting, and they prevented sleep by coming on at night. The sickness was for a time relieved by an effervescing draught with prussic acid, but the various sedatives that I tried internally, externally, and by the hypodermic

method, muddled the brain without easing the pain or inducing sleep. Sulphuric acid, tannin, and ergot of rye did not check the hemorrhage, nor did various cold injections. I could not persuade Mrs. T. to let me inject the cavity of the womb with a solution of perchloride of iron until the plan was sanctioned by my friend Dr. Barnes. I easily injected from 2 to 3 ounces of equal parts of the strong perchloride and water, which caused very great faintness, but no increase of pains and marked diminution of blood loss. I repeated a similar injection a week afterwards, causing great aggravation of pain, which continued unceasingly; she gradually took less and less food, slept less and less, and died of exhaustion on the 17th of April, 1868. Notwithstanding my respect for Dr. Smith's opinion, neither I nor Dr. Barnes can see sufficient reason to suppose that this fearful pain was due to a fibroid developed in the substance of the womb. The paroxysms of pain were those of most acute metritis, and the tablespoonful of pus that gushed from the womb after increased pain could only have been generated in its internal cavity; but I could not prevail on the relatives to let me settle the point by a post-mortem examination. I cannot conclude the case without stating that I believe it would have had a fortunate termination if I had been able to persuade the patient to let me inject the womb at a much earlier period with a solution of perchloride of iron, or of nitrate of silver.

Before commenting on chronic internal metritis, I will state that I have never known uterine exfoliation to occur towards the ménopause, although singularly enough, in the first recorded case of uterine exfoliation, Morgagni mentions its continuing up to cessation, and Dusourd has met with similar cases. Those bodies called fongosités by Recamier being evidences of morbid action on the part of the uterine mucous membrane, it is easy to understand they may sometimes account for flooding at cessation; but it must also be remembered that the same bodies have been found in women who had no red discharge from the womb.

Chronic internal metritis.-During the last ten years I have seen three cases, in which, during "the dodging time," the patients suddenly passed more or less fetid pus at menstrual periods, after a moderate amount of uterine pain, and in one instance this was repeated at six successive menstrual periods.