Fauvel, that it is much more frequently a cause of pelvic abscess than is generally admitted, still it is comparatively rare. I repeat the statement, because the contrary may be gathered from Dr. H. Bennet's valuable work, and I cannot admit with him that the pus resulting from this cause, when it passes by the vagina, is frequently mistaken. for "the whites," for it is preceded and accompanied by symptoms too acute, in the majority of cases, not to attract great attention. Dr. R. Lee relates that in the course of his practice he has only met with four cases of idiopathic ovarian abscess.

I believe, with Neumann and Astruc, that sub-acute ovaritis is a common disease; and without admitting that it could always be found on the dead body, the morbid congestion leaving the ovary when life becomes extinct, still I refer to the frequency of lesions found in the ovaries. Mr. Pollock has shown that out of 583 women opened at St. George's Hospital, from 1841 to 1850, 265 presented lesions in some part of the generative apparatus, and in 116 were found the following lesions:

The thirteen adhesions were evident cases of ovarian peritonitis, and as I shall hereafter show that this is generally caused by ovarian inflammation, its frequency may be, to a certain extent, inferred from the frequency of these relics of pelvi-peritonitis, which is estimated at 70 per cent. of all bodies examined in the hospital dead-room by Dr. West, at 55 by Aran, 45 by Dr. Gaillard, and 44 by Drs. Bernutz and Goupil.

Such was the state of pathology when my first edition ap

peared in 1848, and the main points therein developed

were

1. The frequency of inflammatory affections of the ovaries and of the pelvic-peritonæum.

2. The influence of the ovaries in the production of pelvicperitonitis.

3. The influence of the ovaries in the production of uterine disease.

My first proposition has been confirmed by late writers. on diseases of women, and by contributions to the leading medical periodicals. The large hospital experience of Aran, Bernutz, and Goupil, has amply confirmed my statement that pelvic peritonitis in women is generally caused by ovaritis.

My assertion that the ovary has a powerful morbid influence over the womb, already admitted by Blundell, Rigby, Oldham, Recamier, Melier, &c., has been again asserted by Dr. Gaillard, and in a measure demonstrated by Aran, who observes, p. 613, "Acute and chronic ovaritis is much more common than is generally admitted. For the last few years, during which I have given more attention to the condition of the ovaries, never failing to examine them as well as the womb, in every post-mortem examination; I have become surprised at the frequency of ovaritis, alone, or associated with internal or chronic metritis; if when these are cured, the old pains survive, strong as ever, they are due to the persistence of ovaritis." And again, p. 602, he says, "Chronic ovaritis forms an important element in the most distressing cases of uterine disease, when it has told most severely on the general health, and if this remark has not been previously made (!) it is because the coexisting uterine disease seemed to render unnecessary the search after ovaritis."

My friend, Dr. H. Bennet, admits-Uterine Pathology, p. 52-the coexistence of chronic ovaritis and uterine disease in exceptional cases, but denies the practical import of ovaritis as a primary element in complicated cases, because the ovary has no mucous membrane, like the uterus. This argument has been disposed of by our mutual friend Aran, who says, p. 39, "I loudly protest against Dr. H. Bennet's pretension to sweep away ovarian pathology with one stroke

of his pen. How can we treat disease of the womb without at the same time treating disease of the ovary, should any exist? Have not both organs the same nerves and vessels, and are not they united for common action? What does it avail that the ovary has no mucous outlet? the heart and brain have none, and that does not prevent their having pathological manifestations, both numerous and dangerous."

With regard to the comparative frequency of uterine and ovarian disease, I have no statistical data to offer; but if I were asked to give the results of twenty years' practice, I should say, that congestion of the ovario-uterine organs with an unhealthy condition of the mucous membrane lining the neck of the womb, and erosions of its vaginal portion, is the most frequent of morbid uterine conditions, and being often cured by nature, is amenable to whatever treatment may be used. That the most numerous cases for which our aid is required are those in which there is more or less ulceration round the os-uteri, with more or less swelling of the neck of the womb, and inflammation of its lining membrane, cases which are seldom cured without surgical treatment. That in the majority of very severe cases there is internal metritis, which has ovaritis as a primary element of disease, particularly in virgins-the most difficult of all cases to

cure.

There is little written on the comparative frequency of uterine and ovarian disease, but in a paper on Sterility, Mayer, of Berlin, states, that out of 263 cases, the womb was either in flexion or version in 35, that there were 13 cases of internal metritis, 8 of chronic ovaritis, 7 of ovarian tumours, 4 of hypertrophy of the womb, 2 of uterine polypi, and 1 of fibrous tumour of the womb.

Taking at random 100 cases of uterine disease, Aran found it complicated by—

A still more important document was sent to Dr. H. Bennet by Dr. Stewart, late Professor of Midwifery at the Medical College of Calcutta. It is a memorandum of the

state of the genital organs in the bodies of fifty native Indian women, who died from various diseases, drawn up by Madoosudun Goopta. I there find that uterine disease was complicated by some disease of the ovaries or Fallopian tubes, in 31 out of the 50 cases, these organs being noted as healthy in only 19 women.

The ovaries were red and congested in

absorbed or atrophied
hard, horny, or scirrhous

3 cases.

I have depicted without exaggeration the still vacillating state of uterine pathology, and shown how difficult it is for beginners to acquire proficiency in this department of medicine. It is therefore obvious that the mind requires the assistance of every sense that can minister information, and nevertheless there are still some who praise the Stethoscope and Plessimeter, the Laryngoscope, the Ophthalmoscope, and who see no objection to the use of a Speculum for the ear, for the rectum, &c., but who have not words strong enough to condemn the use of one for diseases of the womb. It would be absurd to lose time in explaining the frequent necessity of this mode of examination, for the question is not, whether it has been abused by some, or too much neglected by others, but whether the diagnosis of surgical diseases has become so sure, that it can dispense with any means of throwing additional light upon the case under consideration. Should, however, practitioners require an explanation of the grounds which warrant such an examination, let them refer to Sir C. M. Clarke's work. Vol. i. p. 43. The principles of science, when once unveiled, may be obscured by false reasoning, but they cannot be obliterated, and the arguments by which, in 1814, this respected author advocated the digital examination of the womb, equally apply to its ocular examination in 1862.

I shall proceed, therefore, to comment on the several modes of exploring diseases of the womb and ovaries, after

C

reminding the reader of their anatomical connexions. The peritoneum in the female, after covering the posterior surface of the bladder, is reflected to the uterus; spreads over the exterior surface of the body of that viscus; covers its posterior surface; and is then again reflected to the rectum. As it passes from the anterior to the posterior aspect of the uterus, the membrane forms two wide folds, which contain the Fallopian tubes, the ovaries, and the round ligaments. The two folds of the peritoneum, which thus, by their juxtaposition, constitute the broad ligaments, are separated from each other, as also from the organs which they contain, by a certain amount of areolar tissue. This areolar tissue is connected with the sub-peritoneal cellular tissue of the pelvis, although in a great measure distinct from it; and it deserves more attention than it has hitherto received from either anatomists or pathologists. From its nature, it is prone to inflammation; and, consequently, it plays a most important part in inflammatory disease of this region. Its mechanical use is, no doubt, to allow the folds of the peritoneum to separate and glide one over the other, when the uterus increases in its dimensions during pregnancy. When the uterus is in its healthy and unimpregnated condition within the pelvis, the ovaries, with the intestines superimposed, are situated at the sides of the womb, behind the bladder, and anteriorly to the rectum; but, in consequence of their great mobility, and the laxity of their attachment to the uterus, they are so placed that, if at all increased in volume, they acquire a tendency to descend into the recto-vaginal space, and are then generally accessible to the finger introduced into the rectum. When, on the contrary, the uterus is enlarged, from impregnation, hypertrophy, or any other cause, it rises from the pelvis into the cavity of the abdomen, and the ovaries, following its ascent, are removed beyond the reach of a digital examination per vaginam. When the volume of the ovary is not such that it can be felt through the abdominal parietes, it may sometimes be appreciated by an examination per rectum, for in certain individuals the mucous membrane of the vagina is so relaxed in its connexion with the cervix uteri, that the finger may reach the ovary by depressing the cul-de-sac which exists at this spot.