membrane is congested, and sometimes slightly ulcerated, but there is nothing to be seen like acne. Another lady has been more or less subject to psoriasis all her life, and for the last few years to uterine disease. The mucous membrane is sometimes much inflamed, and sometimes there is simple ulcer round the os uteri. Another patient has suffered for many years both from pseudo-membranous ulceration of the tongue and from uterine disease. There is sometimes a slight ulceration of the neck of the womb, but it is never covered by a false membrane.

VARICOSE ULCERS OF THE NECK OF THE WOMB.

Varicose ulcer, in the unimpregnated, differs from the varicose ulcer of the pregnant. In the unimpregnated there is a more or less extensive and very red ulcer on one or both lips of the womb; enlarged capillaries surround the ulcer, which bleeds on the slightest touch, and freely, if nitrate of silver be applied to its surface, whereas loss of blood is restrained by acid caustics.

Dr. H. Bennet first pointed out that, in pregnant women the os uteri may be externally surrounded by a red, mammillated ulcer, bleeding freely on the slightest touch, secreting pus, weakening the patient, and compromising pregnancy by sanguino-purulent discharges. I have found it safe to treat such cases by the application of the acid nitrate of mercury, and I feel confident that I have thus promoted the patient's safe delivery at the full time; but I consider such cases exceptional, and that they are the exaggeration of a physiological condition, requiring no treatment except astringent injections. The knowledge of this condition led Caseaux to make the somewhat paradoxical assertion, that "ulceration of the neck of the womb was the normal state in pregnancy." The Société de Chirurgie of Paris named a committee to inquire into this subject, and they found this red, mammillated state of the os uteri in every one of the pregnant women who were examined at l'Hôpital de l'Ourcine.

PSEUDO-MEMBRANOUS ULCERATIONS OF THE NECK OF THE WOMB.

Prof. Forget, of Strasburg, writing on diphtheria, observes

that the blistered surface of the skin often becomes covered with a thick membrane, most difficult to remove, and that he has several times seen the same kind of membrane form on the surface of an ulcer of the womb, after nitrate of silver had been applied to it, but that this circumstance was only inconvenient by interfering with treatment. This does not accord with my experience, nor with that of Dr. Bennet, nor of Dr. Ellis, who has lately written on the subject, nor with that of numerous French authorities. The difficulty of curing pseudo-membranous ulceration, rather than its frequency, induces me to dwell on the subject for I have not seen more than seven or eight cases, nor Dr. H. Bennet more than two or three, every year for the last ten years. It is utterly im

possible to understand the subject without reference to wellexecuted drawings of the various kinds of false membranes that may cover uterine ulcers; and I am indebted to the kindness of my friends Drs. Bernutz and Goupil for the accompanying illustrations which are destined to adorn the third volume of their work on Diseases of Women.

Various ulcerations of the neck of the womb, more particularly of the gravid womb, are sometimes covered with pultaceous concretions, like those that form on varicose ulcerations of the legs; but this substance soon falls, and is not reproduced.

When the neck of the womb is the seat of herpes, as represented in figure 1, after the bursting of the vesicles, their membranes remain as white concretions, which, however, soon fall, leaving an ulceration. Some chancres, called diphtheritic by Dr. Bernutz, as seen in figure 2, are more or less covered with a croupy-looking false membrane; but this soon falls, disclosing a healthy-looking ulcer. The preceding kinds of pseudo-membranous ulcers are of slight import; but there are two other kinds to be noticed, in which the concretion is, as it were, the badge of intractability.

The figure 3 represents what Dr. Bernutz considers to be a psoriasis of the neck of the womb, on which there are milky white patches entirely formed of epithelium. In one of Dr. Bernutz's cases, this coincided with psoriasis of the skin in a scrofulous subject; and although the neck of the womb had been cauterized with the actual cautery, this did

This

not prevent the re-appearance of this singular membrane. I have never met with such cases, but they have been called Diphterite du col, by Boys de Loury and by Costilhes, a bad name, as there is nothing diphtheritical in the false membranes. The cases that I have seen resembled figure 4, which represents the ulcero-membranous neck of the womb. form of disease exactly resembles the ulcero-membranous stomatitis of children and of soldiers, which has been so well described the first by Rilliet and Barthez, and the second by Bergeron. This would seem to imply that the ulcero-membranous neck of the womb is a result of a cachectic disease of the system. Dr. Bernutz adopts this view, and mentions a case in which it coincided with an exactly similar state of the velum palati and of the gums. There was nothing cachectic in the constitution of the patients in whom I have observed this form of disease. Its peculiarities, its intractability, and its best mode of treatment will be exemplified by the following case:

CASE 33. The widow of a clergyman, aged thirty-six, is in good condition, and looks healthy. After her first confinement, eleven years ago, there was ulceration of the neck of the womb, which was cured; but there was a return of it two years afterwards, on her being again confined. About three years ago she was attended by Dr. Bennet, who soon recognised the pseudo-membranous peculiarity of the ulcer, by the fact that it was made worse by the application of nitrate of silver. As the cure did not progress rapidly, she consulted a surgeon, who advised leeches to the neck of the womb. Becoming worse, she returned to Dr. Bennet, who found that each leech-bite had been converted into a pseudomembranous ulcer. He tried various caustics; relieved the patient of the irritable, irksome abdominal sensation by which the complaint was attended, but had not prevented its relapsing. On the failure of his health, the patient came under my care. What I found to do most good, during the few days that she occasionally came under treatment, was the application of potassa fusa c. calce, dressing the sore afterwards with tincture of iodine. Once, after leading a very quiet life, the ulcer was quite linear; while nursing a dying friend, it became much larger and crept on to the vagina. I

then applied freely the acid nitrate of mercury, which evidently did good, although the ulcers were not quite healed when the patient left town. When I again saw the lady in conjunction with Dr. H. Bennet, in August, 1861, there was still one small spot of ulceration with the usual false membrane, and we then made up our minds to use no local measures, and to give half a grain of blue-pill three times a day; being guided in this by the recent practice of French practitioners in such cases, and not by any circumstance that could in the least warrant the belief in a syphilitic character of the disease. After this treatment had been continued eight days, the ulcer healed, almost too soon to ascribe the result to the small quantity of mercury exhibited. The mercury was continued for six weeks without causing salivation, and the patient left town seemingly cured; but on returning a few weeks afterwards, there was another patch of false membrane on one of the uterine lips, which patch disappeared after several dressings with tincture of iodine; and when she left me in October, there was only a red stain in the place of the false membrane; and as she did not suffer at all from the pains and abdominal distress which used to attend the ulcer, there was fair ground for hoping the disease was cured; but on examining the patient in March, 1862, I found at the upper part of the vagina an irregular-shaped excoriation about the size of a shilling and patch of false membrane on one spot, and this had caused disturbance in the action of the bladder. Although not cured, the disease does not much interfere with the patient's enjoyment of life.

SYPHILITIC ULCERATIONS.

"There is a great deal of syphilis in the common run of uterine cases," is an occasional remark, but I can find no ground for this assertion, either in the records of what I observed in a large City dispensary or in the range of an extensive practice in the upper and middling classes of society. My conviction is strengthened by the fact of its being entertained by men like Drs. Bernutz and Goupil, who have lately studied the whole subject in the hospital especially set apart, in Paris, for the treatment of women who suffer from syphilitic diseases and are not prostitutes. In answer to my

question on this point, Dr. Bernutz said that syphilitic diseases of the womb are very rarely met with in ordinary practice, and that of all the syphilitic diseases of the neck of the womb, the true Hunterian chancre is the most frequently met with; and as in nineteen cases out of twenty, chancre on the neck of the womb is accompanied by chancre on the external organs of generation, the diagnosis is singularly simplified. Secondary affections of the womb are much less frequently observed-I mean mucous tubercles similar to those better known to appear on the velum palati, roseola, and a papulo-squamous eruption similar to what appears on the skin. Tertiary symptoms are even still more uncommon on the neck of the womb. What has deceived many pathologists is, that women suffering from syphilis are often affected with uterine diseases which are not at all syphilitic.

It must not be forgotten that women who contract syphilis, usually lead a life, in which misery and debauchery succeed each other in turns; that, besides its poisoning influence, syphilis brings on a cachectic condition of the fluids; that mercury and the exigencies of a prolonged treatment are powerful debilitating agencies; and thus one can easily understand that syphilitic women, more frequently than others, suffer from uterine catarrh, which is not at all syphilitic, and from ulceration of the os uteri, which is no more syphilitic than the soreness of the nostrils caused by coryza.

PROGNOSIS IN DISEASE OF THE NECK OF THE WOMB.

Whenever there is a large amount of mischief in the neck of the womb, the result of uterine disease having been misunderstood and neglected for years, or when there is frequently a sanguinolent discharge, much sickness, and difficulty of walking, it is ten to one that diseased action has spread from the neck to the body of the womb, and care should be taken not to promise a speedy recovery. One may state, that if disease be limited to the neck of the womb, it can be cured in about such or such a time; that in all probability the body is likewise affected, and that its inflammatory state may for long prevent the patient's perfect recovery, even when the neck of the womb has been brought to a healthy condition.