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habitually any of the uterine symptoms before mentioned, there is generally local uterine disease; its existence being generally the key to their ill health, and its removal a necessary preliminary to their permanent recovery.

In the first class of females, viz., those who have local uterine symptoms without a general break-down of health, the test as to their having or not having actual structural uterine disease is to be found in the nature and duration of the uterine symptoms. If they are recent, fugitive, and give way to general treatment, we may conclude that the cause is also recent, fugitive, and that there is merely functional derangement; but if, on the contrary, they are chronic and confirmed, and obstinately resist ordinary treatment, we may conclude that there is some chronic confirmed local mischief existing, which ought to be thoroughly investigated and treated. With them the general health remains good, because the constitution is vigorous, and resists the local disease, so that the usual visceral and cerebrospinal sympathetic reactions are not roused.

In the second class of females, viz., those who are weak and debilitated, and have but little local evidence of disease, the test again is general treatment. If they are merely dyspeptic, chlorotic, anæmic, rheumatic, gouty, &c., the uterine symptoms ought to improve and eventually disappear under the usual treatment of these morbid conditions. If they do not, we must look out for some other cause, and it will frequently be discovered in the uterine organs themselves. To this class belong a large proportion of the population of sofa, bath-chair, nervous, debilitated, dyspeptic females, who wander from one medical man to another, and who crowd our watering-places in summer: most of them are suffering from chronic uterine inflammatory disease, unrecognised and untreated, and most of them would, if their disease were only discovered and cured, become amenable to the resources of our art, and eventually recover their health, spirits, and powers of locomotion. It is a singular and instructive fact that amongst the male part of the community there is no similar invalid population, always ill, unable to walk or ride, constantly requiring medical advice, and yet living on from year to year, without their friends or themselves knowing

what is amiss with them, beyond the evident weakness, dyspepsia, &c.

When both the local and general symptoms are combined, there is really no element of error left for those who are acquainted with these forms of disease, and there must come the day when such cases will be recognised and properly treated by all educated medical practitioners, as surely as a case of pneumonia or rheumatism.

As I have before stated, inflammation and the lesions which accompany and follow it may occur at any period of female life, from the dawn of menstruation until old age. As the female progresses through the various phases of her existence, the position in which she is physiologically and socially placed, varies with reference to the uterine organs. In the unmarried state, she is spared all the dangers to which marriage renders her sex liable; but she is still exposed to perturbations of the menstrual function and to mental influences which combine to produce, occasionally, even early in life, aggravated forms of uterine inflammation, and of mucous membrane ulcerative disease; as was first pointed out by myself. Many of the worst cases of hysterical convulsions, spinal irritation, dysmenorrhoea, dyspepsia, debility, &c., observed in young unmarried females, may be traced to this cause.

In the married, inflammatory affections of the uterus, but more especially of the cervical mucous membrane, are very frequent; and in addition to the symptoms and conditions above enumerated, are amongst the most frequent causes of sterility, miscarriages, false conceptions, and premature confinements; of sickness, uterine pain and hæmorrhage during pregnancy; of non-dilatation of the cervix during labour; and of puerperal metritis, hæmorrhage, &c., after labour.

Even after the cessation of menstruation, inflammatory and ulcerative disease of the uterine mucous membrane may persist, and be the principal cause of that agonizing backache of which elderly women sometimes complain, and which resists every means of treatment, unless its true cause be discovered and removed.

Inflammatory affections of the uterus, but more especially of

the cervical mucous membrane, often complicate polypi, both vascular and fibrous, and fibrous tumours of the uterus,— an important fact which I believe I was also the first to discover.

Functional derangements of the uterine system, existing independently of uterine lesions, inflammatory or other, occur, as I have already stated, in everyday life, but they seldom come under the cognizance of the consulting medical practitioner. Being essentially fugitive and temporary in their existence, like the causes which produce them, and being unattended with confirmed sympathetic reactional symptoms, they are not complained of in a general way, or are viewed as mere epiphenomena of the disease the course of which they chequer.

Ovarian inflammatory lesions, thickening, hardening, &c., are frequently met with in the dead, and consequently we may presume that they not very unfrequently exist in the living. That they may and do occasion all the symptoms of deranged vital and functional uterine action above enumerated is certain; and I occasionally see cases which illustrate and prove this fact. Judging, however, from careful observation and lengthened experience, I do not believe that these morbid uterine symptoms are generally, or, indeed, very frequently, occasioned by actual ovarian disease, notwithstanding the all but constant existence of ovarian pain when they are present. What proves that in these cases it is not really the ovaries that are, generally speaking, the seat of disease, is, that however long and actively you may treat the ovarian pain, tenderness, &c., they persist; whereas, if you leave the ovaries entirely alone, and treat and remove the uterine lesions which co-exist, the ovarian symptoms rapidly subside. A partial key to this practical fact is probably to be found in the absence of a mucous membrane element in the ovaries. Consequently its pathology is likewise absent.

Although fibrous tumours of the uterus and polypi frequently co-exist with inflammatory lesions, we cannot connect them cause and effect. Polypi appear to develop themselves as a result of erratic nutrition quite independently of inflam

as

mation.

Cancer in the uterus, as elsewhere, is a disease per se,

and has, in my opinion, no link or connexion whatever with inflammation, which neither leads to it, nor usually complicates it.

If the views which I have here briefly developed are correct, the therapeutics of uterine pathology must necessarily be totally altered. If, in confirmed uterine suffering, existing alone or along with general derangement of health, the cause is mostly to be found in chronic uterine inflammatory lesions, it is clear that the paramount and primary duty of the medical attendant is to get rid of these lesions once their existence has been ascertained. If general therapeutic treatment, combined with dietetic and hygienic management, rest, functional repose, &c., fail, or have failed, to remove such confirmed inflammatory lesions (and this is usually the case), recourse must be had, simultaneously, to more energetic means of treatment. The more energetic means of treatment then required are those which surgery resorts to in the treatment of chronic local inflammatory disease in other accessible parts of the body-the throat, the eye, the anus, &c.—viz., local depletion, emollient, sedative, and astringent injections, counter-irritants, the use of stimulating vitalitymodifying agents, such as caustics of variable strength, &c.

From what precedes, it must have become clear to my readers that uterine pathology, as I have interpreted it, in its more aggravated and confirmed forms, passes, in a great measure, from the domain of medicine into that of surgery. Instead of

having to rely on drugs, on the agencies of general therapeutics, and on skill in their administration, we are called upon to have recourse to surgical instruments and agencies; and we want in the medical attendant skill in their use, a knowledge of local diseases, of the treatment local diseases require, and an acquaintance with their reactions on the economy at large. So true is this, that in France, since the new light broke on uterine pathology, it has fallen, by general consent, into the domain of surgery to such an extent that the leading authorities have principally been surgeons. I have only to mention Lisfranc, Marjolin, Velpeau, Jobert de Lamballe, Ricord, Huguier, &c., to corroborate this assertion.

No class of maladies, indeed, more aptly illustrates how arti

ficial is the barrier between medicine and surgery than uterine disease, as illuminated by modern research. In their earlier stage, and in their simpler forms, they are medical, and fall all but necessarily under the eye of the physician; but, in their later stage, and in their more aggravated form, they are essentially surgical. No medical practitioner, therefore, who is not at the same time a sound physician and a good practical surgeon, is competent successfully to struggle with the difficulties which have to be encountered in their treatment.

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