very intense, being augmented by walking or pressure, and tired by the pertinacity of the case, I made an exploration per anum, and found the ovaries swollen, and very painful when touched. I immediately changed my plan of treatment, and ordered ten leeches to each inguinal region, and the regular rotation of blisters and ointment, besides cold enemata twice a day. The pains subsided, the leucorrhoea stopped, and a few weeks after, the neck of the womb was merely congested. After the succeeding menstrual period, I ordered a repetition of leeches, blisters, and ointment: and now the cervix is sound, the ovaries are painless, and the patient is well. In this case, I think that ovaritis produced the inflammation of the neck of the womb, and kept it up until the primary disease was discovered and energetically treated.

CASE 63.-E. W., aged twenty-two, of middling stature, with red hair and grey eyes, was admitted to the Paddington Dispensary, July 14, 1851. She menstruated at twelve, and has ever since been regular every month, even during pregnancy, and the ten months she suckled her child. For several months previous to, and since weaning the child, she has suffered much from pain in both ovarian regions, which pain was always increased by menstruation, by walking, by pressure, by ascending the stairs, or by any sudden jar. Lately, the left ovarian region has become the most painful, and the left breast has been likewise sore and swollen. For the previous weeks, the legs swelled at night; there is slight leucorrhoea, little fever, and she complains of feeling "heavy for sleep," and would sleep all day if she were permitted. On making a digital examination, there was no sign of uterine disease, but pressure directed towards the left ovary was intensely painful. I ordered the following compound camphor mixture:-Solution of potash and tincture of cardamoms, four drachms each; tincture of hyoscyamus, six drachms; camphor mixture, to six ounces; a table-spoonful to be taken three times a day, and a small quantity of the following powder to be taken in a little milk at night :-Sulphur, two ounces; biborate of soda, one ounce; while three or four drachms of the following ointment were to be applied, not rubbed, over the lower portion of the abdomen :-Strong

mercurial ointment, one ounce; extract of belladonna, two drachms. I then directed a thin linseed poultice to be applied over the anointed surface, and over that a piece of oiled silk, with the understanding that this application was to be removed and re-applied as soon as possible in the morning, at two or three in the afternoon, and before disposing the patient for her night's rest. July 17th. The patient was better; the pains were only violent at times; there was no leucorrhoea, and the bowels were comfortably moved. 21st. Ovarian pains were all gone; the mercurial ointment was therefore discontinued. 28th.-I learnt that on the 22nd, after an attack of diarrhoea, menstruation returned ten days before it was due, but unaccompanied by ovarian pains. I prescribed the following pills, to be taken at night :Sulphate of quinine, one scruple; extract of opium, five grains; extract of liquorice, a sufficient quantity to make ten pills. But upon leaving, and before this treatment could be begun, menstruation again appeared, and there was a throbbing and swelling of both breasts, and pain referred to the pubis. On making an examination, the neck of the womb was found hot and swollen; I ordered injections with a solution of acetate of lead, and returned to the application of the compound mercurial ointment. I saw the patient after the subsequent menstrual period, which was normal as to time, quantity, and pain; the womb was ascertained to be healthy, and the patient was quite recovered. This case was first one of sub-acute ovaritis, lasting for months, until the increased uterine activity, swelling of the womb, and irregu lar and prolonged menstruation necessitated the employment of local measures to remove uterine congestion. The mercurial applications, however, should not have been discontinued on the subsidence of the ovarian pains; for as the womb was in a healthy state on the 14th inst., if they had been continued, the slight attack of uterine disease would have probably been avoided. If I had not positively ascertained, on the 14th, that the womb was in a healthy state, I should, on finding it slightly diseased on the 28th, have concluded that the previous pains were to be attributed to the beginning of undiscovered uterine affection, and not to ovaritis, which I believe to have been the primary affection,

determining the uterine inflammation in the same way as the physiological congestion of the womb in menstruation.

CASE 64.-C. K. was sent to me in 1819 by Mr. Pughe of Aberdovey; was about twenty-six years of age, her constitution was lymphatic, but her hair and eyes dark. In childhood she had several abscesses in one of her legs and in the groin. Menstruation appeared at fourteen, but at sixteen was suspended, from her catching cold; and when it returned, it was three-weekly instead of monthly, as before; was either profuse or scanty, and was preceded for a week by great pain in the ovarian regions, which was aggravated by pressure, walking, or stooping. This state, lasting for several years, had brought on dyspepsia, palpitation, hysterical symptoms, and there was often leucorrhoea. Digital examination was so painful that I contented myself with having ascertained that the vagina and neck of the womb were swollen, hot, and inflamed. Pressure on the ovarian regions was also very painful. Leeches had been applied to them a fortnight previously, and with great benefit; I therefore ordered twelve more to be applied, prescribing the usual treatment, with the addition of aloes pills, and cold-water injections per rectum. Oct. 28th.-I was able to make a speculum examination, and ascertained that there was no ulceration of the womb, which I was led to expect from the persistence of leucorrhoea. When the finger in the vagina was directed towards either of the ovaries, a sickening pain was determined; and when the left hand was pressed moderately on the ovarian region, so as to compress the mass of intervening tissues between both hands, the pain became intolerable. This patient was for several months under my care. After each menstrual epoch, six leeches were applied to each ovarian region; when the leech-bites had healed a blister was applied to the same part, and when these were healed, the same surface was anointed with mercurial ointment until the time when men

struation made its appearance. Feb. 13th, 1850.-She was without pain or discharge, menstruation had assumed its normal type, and with little pain, and she returned to Wales quite well.

Under the influence of chronic ovaritis, the walls of the womb may be soft, compressible, and very painful to the

touch; after repeated engorgements the tissue becomes harder, more solid, very much like the tissue of an erectile tumour, or that of a fibrous growth, and at the same time the sensitiveness of the neck of the womb becomes morbidly increased. The following is a case published by Prof. Recamier-Gaz. des Hôpitaux, Feb. 12, 1850:

CASE 65.-I was consulted by Madame R., who for the last eight years had suffered considerably from ovarian irritation, attended by much pain in the right iliac fossa. Sexual intercourse also produced intense suffering. Such had, in general, been the state of the patient's health, though it varied for better or for worse. On examination, I found to the right, a little above the uterus, an inflammatory tumefaction of the right ovary, about the size of a hen's egg, which was very painful, even if touched ever so gently. This tumour was distinctly felt by the double-touch, the left hand pressing on the hypogastric region. There was also considerable erectile swelling of the anterior lip of the os uteri; little fever. I applied leeches to the right inguinal region, ordered poultices, baths, &c. &c. When the ovarian tumefaction was diminished, as there still remained some engorgement of the neck, it was cauterized three or four times, at four days' interval. After seven weeks' treatment, the patient returned home perfectly cured.

Nonat makes the following remarks-Gaz. des Hôpitaux, March 16, 1850:-" Inflammation of the lateral ligaments may exist alone; at other times, it may be complicated by metritis, or ulcerations of the neck of the womb, or by granular inflammation of the same-complications which render the diagnosis more difficult, and which have frequently given rise to mistakes. Very often the whole treatment has been directed to these secondary lesions, without its being in the least supposed that they owed their origin to inflammation of the broad ligaments. When such uterine lesions are found, it behoves us to ascertain whether the lateral ligaments are not the seat of inflammatory action."

CHAPTER XXVIII.

"If diseases of the ovaria could be detected in their earliest stages, they might often be cured."-ASTRUC.

DIAGNOSIS AND PROGNOSIS OF SUB-ACUTE OVARITIS.

THE length to which I have extended my remarks on the symptoms and terminations of sub-acute ovaritis, renders it unnecessary to protract this chapter. Cases similar to those related in the preceding chapters have doubtless been of frequent occurrence, but they have been differently interpreted, according to the state of medical science.

I. Formerly when they were met with, and sometimes even now, particularly when not occurring at the monthly periods, they were confounded with diseases of the womb, and called inflammation of the bowels-a name which will doubtless be. considered erroneous, so far as the localization of the disease is concerned, but which, being fortunately correct in the indications of its nature, often led to antiphlogistic treatment.

II. When cases similar to those I have reported, took place at, and in connexion with, the menstrual periods, they were, and are even now, confounded with many other morbid states, under the name of dysmenorrhoea. They are considered to be merely an increase of that pain by which menstruation is usually attended, and generally left without treatment.

III. Some would be inclined to explain my cases by incipient uterine disease, and might be impelled by theory to resort to measures, excellent in uterine, but unnecessary in ovarian disease. Being in doubt as to some of the cases which fell under my own observation, a digital examination convinced me that there was no uterine disease; and in the history of many others there was nothing to make me suspect its existence. Admitting that the cases I have related were neither those of inflammation of the bowels, of dysmenorrhoea, nor of uterine disease, they can only be explained by sup