since the better knowledge of treating those morbid conditions which check, in general, the menstrual flow. I have not seen a case to warrant the statement of Siebold, that abortive remedies had a decided influence on the production of ovarian disease. The mention of such an opinion, or the suggestion that such remedies as ovarian specifics might possibly exist, would, a few years since, have been treated as absurd; but, after the light which has now been thrown on ovarian physiology, it is worth while inquiring whether or not the action of ergot of rye, savine, or cantharides, is solely confined to the uterus, or whether such medicaments do not primarily influence the ovaries, which, by reacting on the uterus, incite its contractions? It appears that women who manufacture india-rubber goods, and are obliged to pass many hours a day in the fumes of camphor and turpentine, suffer much, during the first three months of their employment, from dysmenorrhoea and menorrhagia, and occasionally from ovaritis.

Such is the result of my own experience, combined with that of others, but if I merely take into consideration cases of which I have lately kept notes, I find that, with regard to the predisposing causes, fourteen out of fifteen had brown, red, or auburn hair, with hazel or grey eyes, and only one light hair; that only two were above thirty years of age, and ten had not attained twenty-five; that eight were of a sanguine constitution; in ten menstruation was habitually irregular or remittent; and in eight the disease began during the time of menstruation, or a little before or after it. With respect to the determining causes, cold produced it in three cases, marriage in two, abortion in one, in one over-fatigue in going up and down stairs, but in seven no cause could be detected.

CHAPTER XXVI.

The same morbid lesions determine different symptoms in accordance with the constitutional peculiarities of patients.

SYMPTOMS OF SUB-ACUTE OVARITIS.

ON considering the physiological conditions of menstruation, and inquiring into the symptoms by which it is attended, I find that in some women this species of parturition is productive of no more pain than is the act of oviposition in the fish. Generally speaking, however, it is preceded and accompanied by certain phenomena, which present the diminished but faithful portraiture of what has been called uterine disturbance-sense of fulness in the pelvic region, pains in the loins and in the ovaries, pains of an expulsive character, and therefore well termed bearing-down, for they typify the labourlike pains of a similar nature, by which a fœtus may one day be expelled. These do not depend on any mechanical pressure, but are merely nervous, and owe their existence to the communications which have been shown to exist between the hypogastric, uterine, and spinal nerves distributed to the surrounding pelvic viscera, and are often accompanied by heat and swelling of the organs of generation, by cephalalgia, plenitude of the pulse, and other signs of fever. These pains are often extraordinarily aggravated; and when this is the case, it may be inferred that the ovarian or uterine excitement is passing from the physiological to the pathological type. This inference is confirmed by an increase of heat, sometimes remarked over the site of the ovary, when examining with the hand, or by the finger, during a vaginal exploration. Morbid menstruation, with its attendant uterine symptoms, having once taken place, there will be a tendency to its repetition at each succeeding period; thus giving pertinacity to a disease which, in any other organ, would cease by degrees. I shall

first give the symptoms which are common to ovaritis under all its forms, and afterwards sketch the peculiar phenomena by which the local disease itself is often so masked as to cause it to be neglected.

PAIN. This is nature's cry for help, being often felt more in the containing walls of the cavity than in the diseased organ itself. It is so with diseases of the generative apparatus, the sufferings of which are communicated by the hypogastric to the lumbo-abdominal nerves, which give sensation to the abdominal walls, and which remain painful until the disease be cured. Disease of the ovario-uterine apparatus is, therefore, indicated by lumbo-abdominal neuralgia, characterized by distinct foci of pain. Valleix, however, who has thrown so much light on the study of nervous affections, admits, with Dr. Beau, that in some cases of uterine disease there are acute pains in the sacral and ovarian regions, without any distinct foci of pain; and the converse is equally true. Whenever there exists lumbo-abdominal neuralgia, morbid menstruation, ovarian or uterine disease, may be predicated; thus, in all the cases of lumbo-abdominal neuralgia cited in Valleix's work, there was some amount of uterine disease. Beau confirms this statement, and adds, that the occurrence of lumbo-abdominal neuralgia has, in several instances, enabled him to foretel the reappearance of menstruation in chlorotic patients. Pain being thus a symptom common to many diseases, I must see if that of ovaritis has anything specific. The patient experiences a dull pain in the ovarian region, often imperceptible when she is in a state of repose, but brought on by walking, riding, by any sudden movement, or even by pressure on the side. The pain is also increased by straightening the thigh upon the pelvis, as in the erect posture, by which the integuments are put upon the stretch, and pressure is thus exerted over the part. Some patients are unable to maintain the erect posture without resting the foot of the side affected on a stool, so as to keep the thigh more or less bent upon the pelvis, whereby the integuments, &c., are relaxed. There is sometimes, in the earlier stages of the disease, a morbid sensation of numbness or of pricking in the corresponding limb. Again, to protect the ovary from external pressure, the patient often assumes a peculiar posture when sitting. For instance,

if suffering from sub-acute inflammation of the left side, she will not sit home on the chair, but sideways on the left tuberosity of the ischium, with the body bent forward. With respect to the quality of the pain, it has been compared by some authors to that by which the testicle is affected. Dr. Rigby has dwelt on its sickening nature; Dr. Woolley of Brompton frequently noticed sickness as one of the symptoms of cases similar to those above described; and Dr. Laycock alluded to it long ago as a symptom frequent in this, as in all ovarian states, both physiological and morbid. The pain frequently radiates from the ovarian region, is felt across the loins, and descends towards the thighs and fundament. It is of a dull, dragging, throbbing, and sometimes of an overwhelming nature, and distinguished by the patient from other pains resembling colic, and which depend on uterine contractions, although both species may be experienced at the same time. It is not to be confounded with the lancinating pains of the acute stage of peritonitis, which may be occasionally superadded to the ovarian pain, so I do not agree with Scanzoni, that all the pain of ovaritis is peritoneal. The patient may submit to this pain for years, but should she find it so wearisome to mind and body as to be led to seek advice upon her case, she is frequently treated for uterine discase, which may co-exist. Should she be married, connexion awakens and renders more or less acute the pain I have described. Ocular inspection, and an attentive manual examination, however, will often prove that the womb is not tender when touched, or that it does not present any appearance of disease. In sub-acute ovaritis, the hands placed on the iliac regions can sometimes detect an increase of heat; but these symptoms of ovarian inflammation are overlooked, or attributed to disease of the womb, inflammation of its neck, or to that scapegoat of uterine pathologists in England, irritable uterus, which has many of the symptoms of sub-acute ovaritis ;—indeed, Dr. Ingleby noticed that the descent of the ovaries on the vagina produced in one of his patients all the symptoms of the disease called irritable uterus. This ovarian pain may last with little intermission for months; it has lasted for years in a case in which ovaritis had been diagnosed by several other authorities. I have seen pain and swelling of the side coincide with pain and

swelling of the corresponding ovary, and this has sometimes aided me to a diagnosis. Should, however, medical advice be asked in cases of sterility, or when tenesmus, a desire of passing water, or an inability to do so, alarm the patientor when the bearing-down pains and impossibility to pass the fæces cause the medical attendant to fear stricture of the rectum, then I have sometimes discovered by a vaginal exploration, an increase of heat in the upper portion of that passage; but unless the ovaries be considerably swollen, their increase of dimensions may not be detected by this mode of investigation. It may, however, afford an indirect intimation. of diseased ovarian action: thus, if one of the ovaries be inflamed, the patient's sufferings are greatly increased by forcibly inclining the neck of the uterus towards it, so as to direct the fundus uteri to the opposite side. The exasperation of her sufferings is then caused by the stretching of the inflamed broad ligament. If both ovaries be inflamed, slight lateral movements, communicated to the uterus by its neck, will greatly increase the pain felt in the ovarian regions. More direct evidence may, however, be obtained by a rectal exploration, for then the finger can often reach the ovaries, which generally, when inflamed, descend lower into the pelvis, are from twice to three times their original size, and are more or less painful on pressure, supposing a shallow pelvis permit their being attained, which is not the case when these organs are in their healthy state.

The greatest suffering is produced by the descent of the ovarian swelling, of about the size of a small apple, into the recto-vaginal cul-de-sac, thus impeding defæcation, or bearing down the uterus, so as to produce its complete retroversion. Such cases have been noted by Boivin, Denman, and M'Intosh. To admit, with Dr. Rigby, that a difference of symptoms depends on whether the anterior or posterior half of the ovary be the seat of the affection-the symptoms of derangement of the bladder being chiefly observed in the former, and those of the rectum in the latter case-seems to me quite impossible; and I object most emphatically to his describing, as cases of displacement of the ovary, those wherein the displacement is caused by inflammation. In a case related under this name-Medical Times, July 6, 1850—