occasional attacks of diarrhoea. Such was the state of things, when domestic annoyances and over-exertion near a menstrual period brought on an attack of acute metritis, which required two successive applications of twelve leeches, continual hot poultices, and mercurio-belladonna ointment to the abdomen, baths, &c. Before this patient had recovered her strength, she became again feverish, and both breasts became swollen, the right very much, being hard, red, and glistening, the swelling and pain extending to the right arm. Menstruation soon occurred, and with it a relapse of inflammation. When the patient got over this attack in the summer of 1860, I made a careful examination, and found the neck of the womb in a healthy condition, though its body was still enlarged and exquisitely painful to the touch. Surgical treatment to the neck of the womb, which had been long abandoned, would have then done more harm than good, so I merely continued the injections, and determined to try the occasional application of leeches to the womb, continuing the use of the mercurial ointment. This plan of treatment was sanctioned by Dr. H. Bennet, who met me in consultation.

The result of a first application was to me satisfactory, as it prolonged the menstrual interval, but the debility caused by disease was laid to the credit of the remedy, and I was not allowed to renew the application. Nevertheless, in the winter of 1861 there had been a gradual improvement in every way, relapses were less frequent, less severe, and were generally brought on by over-exertion; they were frequently accompanied by considerable inflammatory swelling of the breasts, particularly the right, which had been the seat of an abscess many years before, but they no longer emitted a muco-lacteal discharge from the nipple. For these mammary symptoms I freely applied to the breast, extract of belladonna diluted with glycerine, and afterwards an ointment with iodide of lead and opium.

In the summer of 1861, the patient was well enough to go into the country for two months, and about that time I met an eminent physician of Calcutta, who agreed with me in the utility of trying the long-continued action of small doses of blue pill and the application of leeches to the womb

after the menstrual periods; but I was not permitted fairly to carry out this plan, palliatives being the only treatment continued up to the spring of 1862; and if they have not succeeded in preventing an occasional severe relapse at a menstrual period, still there is a marked improvement in the liability to bilious attacks, to rheumatism, and to the swelling of the breast, which often accompanies uterine disturbance. The patient has exhibited great perseverance, and still, if I had been allowed free scope, I think I could have further improved her condition by the repeated application of leeches and by dilatation of the neck of the womb, as in the preceding case.

The principal interest of the next case lies in the fact that the patient ultimately made a perfect recovery.

CASE 38.-E. B-, admitted to the Farringdon Dispensary, Nov. 21st, 1851; was twenty-three years of age; of middling stature, very delicate appearance, and she has been sickly from childhood. The menstrual function began at fifteen, after three years of continued headache, giddiness, and drowsiness. The flow was at first very abundant, and returned once again at the regular time. Although the daughter of a major, she brought endless trouble on herself by marrying a workman, by whom she had a child at sixteen and three months, and three more children afterwards. She weaned her children at nine months, because she felt weak; but she never menstruated until about twelve months after parturition, and then in consequence of some fright or domestic altercation; pregnancy always followed the appearance of the flow. Deliriousness attended her confinements, but she made good recoveries. When first admitted a patient, she was suckling a child four months old, and was suffering from mild hysterical symptoms, which were soon subdued. On the 28th of April, 1852, she returned with an attack of menorrhagia, which yielded to cold aluminated applications, and to the internal exhibition of acetate of lead. In May there was slight leucorrhoea, burning pain in the back and in the left ovarian region; the patient felt a swelling there-I could not; but on making a digital examination, the body and neck of the womb were uniformly tender, but no lesion could be seen in the neck of the womb. I ordered alum injections, and mercurial in

unctions to the ovarian region; sedatives, opiate enemata; the bowels were kept open by small quantities of sulphur and borax. June 16th.-The same symptoms persisted; the neck of the womb was more congested. I painted it internally with nitrate of silver, in hopes of modifying whatever morbid condition might remain unseen, high up in the cavity of the neck. This was repeated every week, several times, without ill effects. July 14th.-Flooding returned, and resisted cold applications and the injection of a solution of acetate of lead, as well as its internal exhibition. It was at last checked by ten grains of ergot of rye three times a day. When no blood came away, a serous fluid did; but this did not come from the vagina—which was seen to be healthy; it did not come from the neck of the womb, for the absence of pain on lateral pressure showed it was not diseased, and when chronically inflamed the secretions of that part are viscous. The uterine sound entered freely, and seemed to move on the smooth surface of an enlarged uterus. I left off the application of caustic, and as the liver was out of order, I gave blue pill, and ordered inunctions with mercurial ointment to the lower part of the abdomen. In September salivation came on; the sero-sanguinolent flow suddenly stopped, and she became delirious. The next day the discharge came from the womb, at first sero-purulent, then bloody, and then again sero-purulent with flakes of coagulated mucus, described as "skins." Saline draughts, opiate injections and applications, iodide of lead ointment to the abdomen, were then tried, to allay the abdominal pain. During this time the strength of the patient diminished; but little emaciation had taken place, although even when she was not feverish, scarcely any food was taken or sleep enjoyed. Hysterical attacks became more and more violent, and, for a few months, it was necessary to draw off the urine every day. Active uterine treatment was out of the question, for if, while lying quietly in bed, a digital examination was made, she would go off in an hysterical attack, so soon as the finger touched the womb. Tonics, steel, and acetate of morphine were given. About February, 1853, Dr. Bennet saw the patient with me, and we agreed on the urgency of pushing the exhibition of morphine to saturation point. For several weeks she took from

two to three grains of acetate of morphine daily, at first without any appreciable result, then the pains in the hypogastric region gradually abated, and some time after sleep was induced. The dose of morphine was then diminished. After the uterine discharge had lasted for more than twelve months, sometimes as a flooding, at others to a trifling amount, it ceased towards the end of August, and about the same time the patient brought up a considerable quantity of blood from the lungs; and notwithstanding repeated hemorrhage to a less amount, she had all the appearance of health, and was able to keep a day-school. In October menstruation returned, being attended by great pain and a clotty discharge. Thus, a highly nervous temperament, early marriage, repeated pregnancies, were the predisposing causes of a complaint for which it is impossible to trace a determining cause. She was often despaired of, and the cure is perhaps to be attributed as much to nature as to art. Although cured, the patient's constitution remains unaltered, and she is liable to relapses from over-work and over-excitement. As a proof that in such cases one must never despair, it is well to state that, in 1854, this patient was well enough to emigrate to one of the back settlements of Canada, lost all trace of uterine disease, and became a strong and healthy woman.

I have seen several instances more or less resembling this, in which long-continued hemorrhage was the principal symptom of a low type of internal metritis. One is related at page 387 of Dr. Hennen's translation of Boivin and Dugès. Light is thrown on such cases by those in which the uterus being inverted, the effects of stimuli on its internal surface could be demonstrated. The irritation of this surface was always followed by a sanguineous discharge.

CHAPTER XIX.

PURULENT INTERNAL METRITIS.

BEFORE admitting that pus comes from the cavity of the body of the womb, it is absolutely necessary to ascertain that it cannot possibly come from its neck; and this may be taken for granted when the cervix is only found congested, slightly painful, and without stricture. In the following cases there was little or no habitual leucorrhoea; pus was only passed on rare occasions, and always with such an amount of forcing pain, as to leave no doubt in my mind that it was expelled from the body of the womb: indeed, in one case, the womb itself appeared between the labia; and in two cases this passing of pus was preceded by a shivering-fit.

No cases have ever given me so much anxiety; none have so much puzzled my powers of discernment; none will afford more instruction to those who may study them; and they would have been called irritable uterus by Gooch. They show how fatal is the result, when innate morbid tendencies of the generative organs are associated with a highly excitable nervous system. All four were young, three unmarried, and the fourth has scarcely lived a married life, and there was ovaritis in two cases. In all, menstruation was scanty, having stopped prematurely in one, and very painful; one passed decidual membranes, and they had been previously passed by another. At other times, pelvic pains were severe. There was nausea, nervous exhaustion, and neuralgic phenomena. They can scarcely walk, and suffer much from mammary pains. They offer instances of what has been called the accumulative temperament of the nervous system, as opposed to the excitable, a condition in which consequences are so out of proportion with antecedents, that events defy calculation, and surprise by their eccentricity. All are still invalids; three have improved, but one is not much better than when she first came under my care.