and irritable, will give great relief. "In several instances every other measure was fruitlessly employed: but the use of a circular box-wood pessary, for three or four months, seemed really to have cured the affection."

GENERAL REMARKS ON THE ORGANIC DISEASES OF THE UTERINE

SYSTEM.

In investigating organic diseases of the uterus we avail ourselves of several means of inquiry, such as the history of the symptoms, the touch, speculum, stethoscope, and inspection of the discharges. The degree of Pain present in the early stages is frequently so slight, as to prevent attention being drawn to the affections until too late to remedy them, while, in some cases, even the latter stages are attended with very little suffering. In functional and inflammatory disorders acute pain early manifests itself. Even when pain does occur it is not characteristic as regards each affection, but, arising chiefly from increased bulk and the displacement of other organs, it is common to several.

Emaciation is almost always present, in malignant disease, but in hard tumors of the uterus it frequently does not occur until the latter stage. The examination by the hand is most important, not only to detect what description of organic disease may be present, but also whether this be complicated with pregnancy: "for, if there be no fœtus in utero, a palliative treatment will be proper, whereas, if the patient be pregnant, her safety mainly and almost solely depends on the induction of premature labour." In regard to the mode of making the examination.

"The patient must be placed on her left side, the usual obstetric position; and the labia and nymphæ being carefully separated, the forefinger of the right hand will commonly reach and touch the parts satisfactorily. It must, however, be remembered, that the sensitive part of this finger can only examine with nicety that portion of the neck and os lying opposite to it. To examine the whole circumference of the neck, the index finger of the left hand must also be used; and then it is scarcely possible that any morbid spot, or induration, can escape detection. As in the operation of lithotomy, a deep perineum increases the difficulty, so in the internal examination, an unusually long vagina, a broad perineum, and large and fat labia, present obstacles to the investigation by a single finger. In such patients, two fingers, or perhaps the whole hand, must be used -having been previously lubricated by oil, rather than by any unctuous substance." 264.

Provided we can assure our diagnosis the fewer means we make use of the better, for, while in almost every case, the touch may be employed at least once, the speculum sometimes give rise to injury of both the unhealthy parts, and the sound vagina, into which it is introduced. It is very important to remember that there may exist varieties in the cervix as to size and shape, quite independently of disease, for many, by reason of their not knowing these anatomical varieties, have supposed disease to exist which has not been present. A considerable elongation is frequently found, and women, even who have borne children, may have the cervix

compact and small, and perforated by a small circular aperture instead of the normal os. Moreover, Dr. Ashwell states,

"A large uterus, especially at its lower part, a large and soft cervix, a patulous os, fissured, indurated, and cicatrized, may all exist, without organic, and especially without active organic disease. Prior to, during, and even soon after the catamenial flow, the body, and particularly the neck of the uterus, is larger, and more supple than natural; and imparts to the finger a similar sensation to that communicated in the early months of gestation. Frequent sexual intercourse will also induce this state of parts. During natural and healthy menstruation, the orifice of the neck is very dilatable, and easily allows the passage of the finger: this will but rarely occur at other times, independently of disease; and the opinion will be unfavourable, if the finger, on passing into the canal of the cervix, shall touch a puckered, coarse, and rough membrane. Induration and cicatrisation, in slight degree, may result from lacerations during labour, and from the inflammation attendant on their union. In old women, it is especially important to remember, that the cervix naturally diminishes in size, and the contraction of its structure is almost invariably associated with considerable induration; but still, without disease. It will not be difficult to appreciate morbid changes in the consistency of the neck: for although the cervix possesses the firmness of a gland, this may, by a practised examiner, be easily distinguished from the induration, with tenderness, of chronic inflammation: and still more easily from the almost stony or marble hardness of a scirrhous tumor. I cannot forbear to caution the practitioner against a hasty and alarming prognosis, where unhealthy softness is connected with losses of blood and irregular catamenial discharges. Such a condition is curable; and occasionally, where little has been done, it has continued for years, perhaps till the final departure of the catamenia; and the cervix has then acquired its usual hardness. Pain and heat, (absent when the os uteri is in a healthy condition) in high degree, are both present in inflammation of the cervix; while in the early and more advanced stages of organic disease they are often, if not generally, absent." 269.

The Speculum.-By gently overcoming the resistance of the sphincter vaginæ, and avoiding stretching the fourchette, the instrument may easily be introduced, but some care is then required in availing ourselves of it.

"The position of the neck is occasionally changed, being placed more forward or posteriorly than natural. To obviate this difficulty, and to bring the cervix within the end of the tube, the speculum must be elevated or depressed. Sometimes from spasmodic contraction, induced by the passing of the cylinder, a fold of the mucous membrane of the vagina is forced into the aperture of the speculum, and may be mistaken for the cervix: the least movement, however, of the instrument, will cause the slipping away of the portion thus placed; and the recognition of the neck, which is glandular, smooth, and without rugæ, and paler than the vagina, is not difficult. The whole circumference of a very large cervix cannot be examined at once: the position of the speculum requires attention; and if the parts are not morbidly sensitive, the instrument is easily and safely turned in the vagina: this caution is important, as very lately I overlooked a rather large ulcer on the inferior and posterior surface of the cervix, from a neglect of it." 271.

The appearance of the cervix is thus described:

"In health the cervix uteri is, externally, of pale colour, having the aspect of polished skin; and it is easily distinguished from the lining membrane of the vagina, which, from its different structure, and greater supply of blood, has a much deeper tint of red. These parts are naturally covered with a thick mucus;

a fact of importance, as, if it be not removed by lint or a soft brush, abrasions or ulcerations, being thus obscured, might be overlooked."

The author looks upon the speculum as a most valuable instrument both for the detection of the diseases of the cervix, and for the application of the appropriate remedies, and regrets its application is sometimes delayed so long. In slight cases of leucorrhoea and uterine irritation it is prejudicial. In the very young and very old its introduction is often difficult and dangerous, and therefore not to be attempted. When the cervix is much inflamed, or the vagina very irritable, these conditions must be removed before employing the speculum.

The Stethoscope is of value in aiding in the detection of pregnancy, complicating organic disease of the uterus. But the placental souffle may be exactly imitated by the pressure of a tumor upon any of the large abdominal vessels.

The Discharges.-Much information, which can be relied upon, cannot be obtained from these independently of an examination.

"It may with truth be affirmed, that until an examination has been allowed a serous discharge has often been thought to be the proof of a malignant disease of the os, when it has really only been leucorrhoeal; and a discharge of pus, mixed with blood, and slightly odorous, has equally often excited painful anxiety, lest structural disease existed, when in fact neither the finger nor the speculum could detect any mischief."

Prognosis.-The author truly observes, that the practitioner often finds himself in the dilemma, of delivering such a prognosis as will effectually cast down those energies of the patient, on which he relies for assistance in delaying the progress of the disease, or of risking his own reputation, by holding out hopes which the case does not warrant. He especially cautions against a too hasty and unfavorable prognosis, which the difficulty of diagnosis of some of the affections, and the increased chance of curing others, in their early stage, his investigations hold out, should alike forbid.

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Occasionally, when a quickly fatal issue has been predicted, marked relief or at least many years of life, not without comfort, and sometimes even of enjoyment, have falsified the too unfavorable and hasty opinion.

"Doubtless if there be predisposition to adventitious heterologous formations, such causes will favour their development; but if there be no such constitutional tendency, these unhealthy states may continue long without assuming an incurable character. In women, the mothers of numerous families, I have several times, independently of any change in the body of the organ, found the cervix large and hard; and when treatment had been long laid aside, I have, years afterwards, ascertained that although these conditions continued, yet that there was no development of malignancy." 279.

THE TUMORS OF THE WAlls of the UTERUS CHARACTERIZED
BY INDURATION.

These tumors of a fibrous or even calcareous hardness present every

variety as to size. They frequently do not excite attention until by their magnitude they cause pelvic obstruction. The author considers them as a scirrhous variety of carcinoma. They present different symptoms accordingly as they arise from the external or internal portion of the uterus. In reference to those growing externally it may be observed, that, sometimes after reaching a certain magnitude, they may remain stationary for years, while, in other cases, after a period of quiescence, their progress becomes inordinately rapid. They do not prevent conception, and this indeed sometimes happens when they have existed for years, and when the period for its occurrence might be supposed to have passed. Notwithstanding the author entertains a strong opinion that these growths are of a cancerous nature, he recommends their treatment by means of iodine.

"The inferences I have drawn from the use of this medicine are as follow. 1st. Its internal administration, and its use, by inunction, is decidedly beneficial; the advantage, if the remedy be judiciously employed, being rarely attended by constitutional injury. 2nd. In hard tumors of the walls, or cavity of the uterus, resolution or disappearance is scarcely to be expected; since the growths are adventitious or parasitic, and are not imbedded in glandular structure. Here the prevention of farther deposit-in other words, the restraint of the lesion within its present limits, and the improvement of the general health-will be the extent of the benefit derived. It must not be supposed that the use of iodine is empirically to preclude the employment of other means: cupping on the loins ; a mild, animal, unstimulating, and often, for a time, a milk diet; gentle aperients, and the warm poppy hip-bath, are important adjuvants. In the appended cases it will be seen that I have employed leeches and setons, with marked advantage; and there can be no doubt that sexual excitement must often exercise a prejudicial influence." 293.

The Submucous Variety.-Although of less size and induration, yet projecting towards the uterine cavity, and covered with its mucous membrane, these give rise to more dangerous consequences than the tumors already mentioned. It is well known that they rarely ulcerate, unless they occupy the neck or mouth of the womb; but, independently of ulceration, they cause alarming symptoms by the violent hæmorrhages they induce the blood proceeding, not from the substance of the tumor itself, but from the mucous membrane covering it. It is not common for the tumors to encroach much on the cavity of the uterus. Their indurated structure, traversed with white lines, the circumstance of their being sometimes numerous, and the thickening and induration of the uterus near their site, distinguish them from polypi, into which they are never, as imagined by some, converted. The polypus is vascular and easily injected, but not sensible, while the contrary is the case with the hard tumor. Pregnancy may co-exist with the tumor, but rarely with polypus. A ligature which would remove a polypus, would probably include a portion of the contiguous uterine structure, if applied to the tumor. The dangerous hæmorrhages so frequent in these cases, render the adoption of palliative means even, and which is indeed all they admit of, of great consequence. Rigid abstinence from sexual intercourse, the recumbent posture, and a moderate antiphlogistic treatment are required. Narcotic suppositories, and anodyne vaginal injections are useful. Iodine may be employed, but

the author possesses no evidence of its utility. By such means, when the disease is discovered sufficiently early, life may usually be prolonged, the progress of the tumor may be arrested for a time, and the congested state of the uterus become diminished. Mere palliation, and partial exemption from the hæmorrhage form usually the extent of the benefits conferred.

ON THE INDUCTION OF PREMATURE LABOUR IN PREGNANCY COMPLICATED WITH ORGANIC DISEASES.

The propriety of this practice the author considers to be established by the two following propositions.

"1st. That when death occurs, after a labour so complicated, the result is only slightly, if at all, referible to the uterus, which rarely sustains any mischief; but is mainly produced by inflammation, softening, and unhealthy suppuration in the growth itself: these pathological changes leading, in some instances, to rapid sinking; while in others, the powers of the system having been less impaired, death ensues in a few days, from the constitutional collapse, induced by the protraction and difficulty of parturition, and by the contusion and injury done to the tumor and other soft parts. And 2ndly. That premature parturition, artificially induced, rarely occasions constitutional mischief; is easily accomplished, and affords the best, and, in many instances, the only chance of a safe result to the mother." 323.

In reference to the first of these, he observes, that tumors obstructing parturition give rise to some of the most serious of obstetric difficulties, for the extent of the obstruction cannot be ascertained with the same facility as when such arises from a contracted pelvis: and even, when the mere difficulties of parturition have been overcome by instrumental assistance, instead of the woman quickly recovering, as she usually does after ordinary instrumental labours, a new train of symptoms, originating in the violence which has been done to the tumor, become developed. In all the cases Dr. Ashwell has seen, and in most he has perused accounts of, the uterus itself, in patients dying under these circumstances, has been found unaffected. If these observations hold good in reference to tumors, characterized by mere bulk and induration, they do so in a yet greater degree when a malignant character of the growth prevails. The best practice, prior to the discovery of inducing premature labour, consisted in puncturing and evacuating, as far as possible, the contents of the tumor, and thus relieving it from the injurious and destructive pressure alluded to.

As to the second proposition, the author's attention was first drawn to the operation by his having, in one or two cases of labour, complicating tumors of the uterus, during his examinations, separated accidentally the membranes to some extent from the os uteri-a happy accident, indeed, for premature labour coming on, the patients escaped the ill consequences, which would have attended, had they gone to their full period. Dr. Ashwell has no doubt as to the complete safety of the practice. He has induced premature labour in a great number of cases, and has rarely found the operation followed by sufficient excitement to give rise to the least anxiety.