During

pletely failed, and a sea-voyage was recommended. the sea-sickness the uterine discharge had almost ceased, and the patient rallied; but a few weeks after her arrival in England, the old symptoms returned, and the patient, when I saw her, had been for some time confined to her bed or the sofa. On examination, the neck of the womb was found larger than usual, but pressure gave no pain; the os uteri was patulous, but the mucous membrane lining the neck was pale, and the os uteri without any lesions. The body of the womb was double its usual size, and very painful on pressure. On introducing the curette, the os internum was found dilated, and the end of the curette evidently moved in an enlarged womb; its internal surface felt rough. I gently moved the instrument backwards and forwards, and brought away about half a teaspoonful of what I could only compare to proud flesh, broken off from the surface of a wound. This was followed by considerable pain and flow of blood, but both abated during the next day, and there was evident improvement during the week. Ten days after, the operation was repeated, and I removed about a teaspoonful of similar products. This operation was also followed by great pain and loss of blood, but both symptoms soon abated, and the patient had no more sanguineous or serous discharges. The abdominal pains and tendency to hysteria lasted for a long time, but steel and tonics removed them at last. About three months after the last operation, menstruation returned, and on making an examination some time afterwards, I found that the os internum admitted the curette with difficulty, and the body of the womb had contracted to little more than its habitual size. In this case, the adherence of the placenta seems to have originated the disease, and the menstrual nisus gave it a first impulse. The flooding and the serous discharges were evidently caused by the morbid products on the internal surface of the womb; after their removal the patient rapidly recovered.

In two instances I removed the vegetations from the internal cavity by means of the curette, and nature did the rest. In another, after applying the speculum, and removing as much as possible of the uterine mucus, I covered the

U 2

extremity of the uterine sound with cotton wool, which, when saturated with tincture of iodine, I introduced into the cavity of the womb. The neck of the womb absorbed part of the tincture; on removing the sound, I again saturated the cotton, re-introduced and pressed it about in various directions. This was not followed by much pain, and three days after some of the vegetations came away, with a sero-purulent discharge. I repeated the operation with similar results ten days afterwards, and then the case did well. This plan of treatment has been followed by Dr. Routh, who has published several cases, in which, after dilating the neck of the womb, he brought it down by means of a hook, so as to be able to examine its inner surface with the finger, and then scraped the mucous membrane and injected tincture of iodine. has been thought necessary by some to repeat the abrasion of the uterine mucous membrane more than once; thus, out of twenty-six instances

One abrasion was made in

Two or three abrasions in

One abrasion and subsequent cauterization

with nitrate of silver in.

10 cases.

2

It

4

In dealing with internal metritis, one must bear in mind Sydenham's observation, that in the treatment of chronic disease we often wish to go too fast, and trust too little to nature, and Abernethy's remark, that chronic diseases require chronic remedies. I do not know a more difficult task than to buoy up the hopes of patients reduced to despondency by repeated relapses. It cannot be done without great faith in the powers of nature and in one's own skill, added to the patient's belief that her medical adviser is also a friend. Even if constitutional peculiarities are such as to cause remedies to fail, one may truly hold forth the hope of ultimate recovery at the change of life, for internal metritis almost always disappears at this period.

One must, however, be aware that this disease retards cessation beyond the average age of forty-five, and that one out of my fifty patients, in whom the change occurred a year ago, still continues to suffer, although not so severely.

As it ascends from the os to the fundus uteri, disease becomes less and less frequent, but more and more difficult to understand, to detect, to cure; and it will be found that obscurities thicken and difficulties increase as I proceed to investigate the diseases of the ovaries.

PART III.

ON INFLAMMATION OF THE OVARY.

CHAPTER XXIII.

Inflammation is more frequently subacute than acute.

SUB-ACUTE OVARITIS.

SYN.-Chronic ovaritis; secondary pelvic inflammation.Dr. Kennedy. Folliculite-Vesiculite simple.-Négrier. Abdominal inflammation-Menstrual colics-AmenorrhoeaDysmenorrhée hystéralgique.-Gendrin. Dysmenorrhœa— Menorrhagia Hysteria.

DEF.-Swelling of the ovaria, with increase of heat, and pain upon pressure, accompanied by intermittent or permanent pain or uneasiness in the ovarian region, radiating to the loins and thighs, and producing, according to the constitution of the patient, an arrest of menstruation, or its profuse flow, intense local pain, or hysterical symptoms.

I accept the term inflammation as it is usually defined, and submit that in the present state of our knowledge it would be unjustifiable presumption to deny the existence of inflammation, except when proved by purulent or solid deposits. When mucous membranes are inflamed, as in gleet or ophthalmia, the anatomist can often discover nothing but doubtful hyperæmia. Mr. Simon, in his paper on "Subacute Inflammation of the Kidney "-Transactions of the R. M. and C. Society correctly observes, "that what is notoriously true for mucous membranes is no doubt equally so, though less notoriously, in respect to glands. No intestinal effusion of lymph need exist in a gland to warrant its being accounted inflamed; its inflammation may consist only

in functional derangements, and may be recognised by admixing its albuminous products with those of normal secretion; but while a mucous membrane sheds its inflammatory secretions, and gets rid of them, the glands are embarrassed by the retention of these secretions, and thus an irritation, insignificant as it may be on a mucous membrane, in a gland may serve to originate its complete disorganization." Leaving the reader to apply to the ovary Mr. Simon's train of reasoning on sub-acute inflammation of the kidney, I proceed to state that, by sub-acute inflammation as distinguished from acute, I do not so much imply a difference in the intrinsic nature of the morbid phenomena, as a lower type of the same phenomena, and in other cases a limitation of the inflammatory action to certain distinct parts of the ovaries, as the ovarian follicle, and to portions of the ovarian tissue so small, that they give rise to little swelling, and to no febrile action; and here I may point out, as a peculiar property of the sexual system in women, the liability to inflammation of very limited portions of the generative apparatus, the others not participating in it—a peculiarity to which the ovary is still more liable, on account of its isolated position. Sub-acute ovaritis, whether primarily developed as such, or supervening on the acute inflammation of the ovaries, is generally a chronic disease, from the circumstance of the ovaries being subject to a periodical augmentation of nervous and sanguineous excitement. Chronic ovaritis is always sub-acute; and as sub-acute inflammation of the ovaria is often present without being chronic, I have thought it best to adopt an appellation which suits both, and draw attention to the low condition of the inflammatory process. It is a general law that acute inflammation of organs is very rare in comparison to the frequency of their sub-acute affections. The kidney does not escape this law, neither does the ovary, although, as will be seen, its sub-acute affections may be unnoticed or confounded with others.

It is evident, however, that in the determination of causes, in the symptoms, and in the treatment of these two diseases, there will be great similarity, and they may pass the one into the other, the sub-acute being exasperated into the acute, while acute ovaritis sometimes becomes sub-acute or chronic,