amount of actual disease, as they will suggest themselves to every intelligent practitioner.

But, recurring to the sympathies of the uterus, we find that while some patients are not affected at all by pregnancy, and others favorably affected, their health being better then than at any other time, that some absolutely perish on account of the functional derangements inaugurated by pregnancy; and, as is shown on a former page, organic diseases are not unfrequently lighted up. We shall probably always be at a loss to understand precisely this difference; but there can be no doubt that it is more on account of constitutional differences than local ones. The concatenation of sympathetic influences may be caused by the greater susceptibility of the organs secondarily affected. In fact, the only mode of accounting for it is by supposing this increased susceptibility. I am convinced that this great but inexplicable diversity of sympathetic effects is as likely to result from uterine disease as from pregnancy. We must, therefore, expect a very great range of difference in the extent of sympathetic derangement from uterine disease. It is interesting to observe the rise and development of the sequences to diseases of the uterus. How far can the uterus produce a direct effect in creating this large amount of sympathetic disorder? Are most of the symptoms produced by the direct sympathetic relation of the uterus to other organs, or does the diseased uterus first affect some other more influential organ detrimentally, and then this last the organism generally? I am inclined to think, from a large observation, that the uterus has close sympathy with only a few organs, and no one probably is so powerfully affected by it as the stomach. It is the first organ affected in pregnancy, being brought into a morbid condition in a very few weeks. The well-known, powerful, and almost universal sympathetic influence exerted by the stomach upon other viscera is sufficient, when it is diseased, to account for the great variety of subsequent symptoms. The stomach is the great centre from which radiate abdominal, thoracic, cerebral, and spinal disturbances almost ad infinitum; and there can be no reasonable doubt that it is an active agent in originating the disturbances of the great vital organs. The subject of the sympathetic influence of the uterus then becomes the more interesting and important, from the fact that a very slight deviation from its ordinary condition arouses the most influential of all the organs to a state of disease, which depresses the functional energies and increases the susceptibilities of almost all the rest of the organism. In addition to the chain of sympathetic susceptibilities produced by this state of the stomach, frequently the digestive powers of that organ are impaired or perverted, so as to supply the chyme in deficient quantities or in deteriorated quality, and in this way injuriously affect the composition of the blood, inducing anæmia or oligamia. Imperfect nutrition will follow, as a

matter of course, in the one case, and perverted nutrition in the other, so that emaciation or obesity will be ordinarily present. Another organ, probably, in direct sympathy with the uterus is the cerebellum, as it seems to me to be as frequently affected as the stomach. The mammæ are, of course, in direct sympathetic relation with the uterus, and yet they are not uniformly affected in all cases when the uterus is very seriously diseased. I do not believe that we are able to say at present whether there are other organs that come directly under uterine influence. A proof of the powerful and very ready effect upon other organs, of irritation of the uterus, may be found in the fact, that very often when the patient is in a condition of comfort, so far as her general suffering is concerned, an application of nitrate of silver to a morbid os uteri will give her excruciating pain in the head, render her exceedingly despondent and irritable, and very much aggravate the symptoms with which she is affected. This I have so often observed to be the case that I cannot but regard it as one of our diagnostic means. After such an application, the patient will generally complain of an aggravation of the general symptoms, whatever they may have been, and say that all the pains are made worse by the application of the caustic. When an organ has been the subject of irritation or functional derangement for a long time, in consequence of sympathy with the uterus, it may become the subject of organic disease, which may continue as an independent affection of, perhaps, a dangerous character; or, if organic has not succeeded to functional disease, the power of habit, which is so frequently thus engendered, will perpetuate morbid action for an indefinite period after the cause of it has been removed.

LOCAL SYMPTOMS.

Pain in the Sacral or Lumbar Region.

Pain in the sacrum is one of the most constant, and when persistent indicates, with a good deal of certainty, disease of some kind in the pelvis. The pain in this region, caused by the diseases of the uterus, is ordinarily central, being in the middle of the sacrum at its lower extremity. It is sometimes at its upper extremity, or it extends the whole length of the bone. Not unfrequently a painful spot may be found on one side, over the sacro-iliac junction. Some patients describe the pain as if a bundle of nerves were pulled upon from the inside of the sacrum, and others describe it as an aching or burning pain. Accompanying the pain in the sacrum is often a sense of soreness upon pressure, an inability to sit with comfort, on account of the tenderness of the lower part of the sacrum.

Pain in the Loins.

Pain in the loins is probably not so common as that in the sacrum, but is quite as various in its nature. Very frequently there is great weakness in the loins, so great in degree sometimes as to prevent the continuance of the erect posture for any length of time. I have had a number of patients who were unable to stand long enough to dress their hair on account of a weak back.

It is remarkable that patients often feel this weak back more when standing than when walking; and they are sometimes able to walk a distance without any great inconvenience, but as soon as they stop, the weakness is apparent to a distressing degree.

Inability to Walk.

Ordinarily the weakness disables the patient for walking. The pain in the back is almost always increased by walking or standing, and on this account the patients avoid being on their feet, although the back is strong enough. But there are many patients who have severe disease of the uterus, who do not experience any of the inconveniences in the sacrum and loins already described; but some of them are very generally present.

Great pain in the back, closely resembling that arising from a diseased uterus, is also caused by hemorrhoids, prolapse, or inflammation of the rectum. The pain caused by diseases of the rectum, I think, is much more frequent on the left side of the sacrum and in the left nates or hip than in a central position; in fact, I have come to regard pain, confined to the left nates and hip, as indicating, with considerable probability, rectal disease, and I always inquire into the functions of that organ when such pain is present. It differs in position from the pain in the iliac region, so common as the result of uterine disease. It is situated near the sacrum, and more in the side of the pelvis than the latter.

Pain in the Iliac Region.

Pain in the iliac region is very common. In frequency it is next to pain in the back. The pain is commonly situated a little anterior to the superior spinous process of the ilium, and below the level of it. It is not referred to the iliac bone, or fossa, but to a place a little above the groin. We often meet with it on both sides, but much more. frequently on one only; on the left side much oftener than on the right. Dr. Dewees considered pain in the left groin, or a little above it, as almost diagnostic of prolapse of the uterus. It is certainly very frequently indicative of inflammation of the uterine cervix.

Soreness in the Iliac Region.

This pain is generally accompanied with soreness upon pressure, and sometimes there is soreness upon pressure when there is no constant pain. Walking, standing, or riding generally increases it. A severe shock or strain from lifting will sometimes cause pain suddenly to appear in this region when it had not before been observed.

Pain in the Side, above the Ilium.

Instead of the pain situated as here described, there is often pain higher up in the side, or in the iliac fossa, or along the crest of the ilium, and even midway between the crest and ribs of the side. These pains are not in the ovaria, although they seem to point to the ovaria more directly than to the uterus; and are by some regarded as a symptom arising from ovarian inflammation. Dr. Bennett admits that it may be a sympathetic painful condition of the ovary. It is not material whether this is true or not; it is certain that it is very frequently present in uterine disease, and is almost invariably cured by remedies addressed to the uterus instead of to the ovaria.

Weight, or Bearing-down Pain, or Uterine Tenesmus.

Another indication of uterine disease, of less frequent occurrence, is a sense of weight in the loins or pelvis. This sense of weight is experienced in the loins and iliac regions more frequently than elsewhere; but it is often felt at the pelvis, and oftener in the perineal and anal regions. Patients express themselves as feeling a heavy weight dragging upon the back and hips, and others feel as though the insides were dropping through the vagina. Occasionally we meet with such urgent uterine tenesmus that the patient is obliged to keep the recumbent posture in order to enjoy any comfort. In such cases the patient in the erect position cannot resist a constant desire to "bear down," resembling the tenesmus of dysentery. This sensation is sometimes more distressing than any other symptom, and obliges the patient to desist from walking.

Leucorrhoea.

Leucorrhoea is one of the symptoms usually relied upon as an evidence of disease of the uterus. In the healthy condition of the uterus and vagina there ought to be no discharge; the vaginal canal is merely moist, and no mucus should make its appearance externally. When the mucous membrane is temporarily excited, there is more than ordinary secretion; but it ceases as soon as the cause of excitement passes.

We should a priori expect increased vaginal discharge to be ac

companied with some form of disease, especially when it continues for more than a few days. Our knowledge of the discharge from mucous membranes lining the cavities elsewhere will afford us enough data to confirm these views. We do not expect to see a constant flow, however moderate it may be, from the male urethra when it is perfectly healthy; and we take gleet as an evidence of chronic urethritis, and it is generally the sequence of an acute attack of that disease. A constant discharge from the nose is an evidence also of more or less disease. It is just so with the vagina. The indications from leucorrhoea are derived from the color or consistence of the discharge, or both. The discharge from the vagina, resulting from mere excitement of the vaginal crypts, is thin, glairy, and not very tenacious. It is ordinarily acid in reaction. There is no color, and but little consistence to it. When a moderate excitement of the internal mucous membrane of the neck of the uterus produces a discharge of mucus, sufficient to appear at the orifice of the vagina, the discharge is white, not unlike milk, and when examined closely, will be found to consist of minute coagula swimming in a little clear fluid. When the mucus flows from the mouth of the uterus it is thick, and resembles very closely the albumen of an egg, and is alkaline in reaction. When it passes into the vaginal canal, it meets with the acidity of the vagina and is coagulated, and the whole changed from a colorless translucency to an opaque white. The reason that the coagula are small and so numerous may probably be found in the fact that the mucus arrives in the vagina in such small quantities; each coagulum. represents a minute drop of mucus, changed in quality. As, however, the mucous membrane of the vagina furnishes only a small quantity of acidity, when this alkaline discharge from the cervix is copious it soon neutralizes the vaginal acid, and passing through this cavity unchanged, appears at the external parts possessing its characteristic qualities. We then hear the patient complain of a tenacious albuminous leucorrhoea; she will nearly always compare it to the white of an egg, but state that it is more tenacious. Unless the quantity is considerable, the mucus from the internal cervical membrane does not appear at the external orifice unchanged, but passes into this curdled condition. There is often a considerable quantity of this creamlike leucorrhoea in the whole length of the vagina, and hence it has been supposed by many that this is the vaginal mucus in its natural condition, and they have called it vaginal leucorrhoea.

Amount of Leucorrhoea not always Proportioned to Extent of Disease. The abundance of this discharge is no criterion by which to judge of the amount of disease or its intensity, but it will scarcely remain colorless after the integrity of the membrane is invaded. When the