frequently met with near the menstrual periods than at any other time, and is probably always owing to the congestion of the vascular tissue of the cervix and about the os.

Endocervicitis with Diminished Size.

I have, undoubtedly, seen many cases of this endocervicitis, in which neither the os nor cervical cavity was in the least enlarged, and others, in which the os uteri was contracted much below its natural size. The secretions of the mucous membrane are always modified; generally they are very much increased, and often changed in character. They may become purulent or sanguineous, owing to the grade of the inflammation and the degree of congestion. The inflammation situated external to the os, on the end of the uterus, between the labia or their external surface, is very common, but it is not often limited to this part. It is almost always combined with endocervicitis.

Special forms of these mucous inflammations are found more frequently in certain sorts of patients.

Endocervicitis in Virgins.

Virgin patients seldom have inflammation external to the os uteri; their disease is endocervicitis almost always; very rarely there is a little rim of inflammation around the os upon the end of the uterus.

Endocervicitis in Aged Women.

Again, in senile patients, we find the inflammation in the cavity of the cervix. The os uteri in the aged is normally small, and simply looking at it will seldom convey a correct idea of the state of the cervical cavity, but the introduction of the probe in cases of endocervicitis will give rise to very great pain. The endocervicitis of old women is extremely difficult to manage, and is always protracted.

External Inflammation combined with Internal in Childbearing
Women.

In married, childbearing women we find the external combined with the internal uterine inflammation of the mucous membrane. They are the kind of patients in whom most frequently the enlargements, indurations, and fibro-cellular inflammations are observed. The form of disease in persons who have been married, but never have been pregnant, partakes to some extent of the character of that of the virgin and the childbearing woman. They often have external combined with internal mucous inflammation, but not often fibro-cellular. Now, what I mean by these statements is, that these patients are likely to have the forms of disease which I have ascribed to them, but there certainly are exceptions to all of them.

CHAPTER XIX.

ETIOLOGY OF UTERINE DISEASE.

THE genital apparatus of woman is in a constant state of predisposition to disease. The very turgid condition of these organs for so many days in every month is one that in appearance borders so closely on the pathological that in other organs it would be taken for one of disease, and the symptoms are equally like those caused by disease.

This similarity between menstrual hyperæmia and morbid congestion is so great that it makes it impossible to distinguish the difference by sight and touch alone. The color of the menstruating uterus is greatly deepened; the organ is larger, heavier, and less easily moved. in the pelvis, and we know that it requires only a prolongation of this condition to constitute a state of disease. Another degree of nervous and vascular excitement would be morbid congestion of the uterus, and all experience shows that cold applied to the person when the organs are in this condition seldom fails to add that degree of excitement, or that the same thing may be brought about by standing too much or by other unusual exertion.

The position of the genital organs at the lower part of the body, much below the heart, having veins without valves and of weak contractile powers, is another cause of exceptional hyperæmia.

Add to these the frequent erotic excitement to which they are subjected in consequence of the peculiar sexual life a woman lives, and we have another predisposing condition of great influence.

By the peculiar sexual life of woman I mean a comparison of her life with the sexual life of other animals.

Female animals do not cohabit night and day the year round, during pregnancy and nursing. The interval between the acts of sexual intercourse in animals is long, and comprises all the time during preg nancy and nursing, while women observe no time of abstinence except the few days occupied by the menstrual flow, labor, and the period of lying-in.

Pregnancy and parturition are strongly predisposing conditions.

The long-continued and very great hyperæmia of pregnancy as elsewhere shown causes abrasions and ulceration before labor, while the pressure of the uterus upon the bladder, rectum, etc., sometimes gives rise to permanent pelvic difficulties.

Parturition is so generally recognized as a predisposing cause of disease that the greatest care is and ought to be taken to conduct ра

tients through it and the post-partum condition in order to avoid subsequent difficulties.

Unusual duration of labor is to be avoided because of the damage that may arise from too long pressure by the child's head or pros tration of the nervous system from violent exertion. But in the normal labor there are many conditions that predispose to disease. The uterus is left large, hyperæmic, and in a state of degeneration, with the cervix bruised, lacerated, and denuded of its mucous mem brane.

The vagina and all of its surrounding tissues have been stretched, pressed, and bruised, and the vulva and perineum are torn and bleeding. While all these are conditions necessarily attendant upon a natural process, and consequently must be regarded as normal, yet they are certainly upon the verge of disease, and are predisposing conditions prolific of disease. They predispose to acute disease, as metritis, perimetritis, cystitis, vaginitis, etc., but their influence is more frequently observable in the chronic affections resulting from an incomplete recuperation from the normal accidents of labor.

But abortion is another strongly predisposing as well as exciting cause to disease of the uterus. In many cases of abortion the organ is repaired of damages as well as after natural labor. This, however, is an exception to the general rule. Abortion is generally followed by either acute or chronic disease, and sometimes both. The reasons for this are too obvious to require any farther consideration. Other and very grave predisposing causes may be found under the head of puberty and change of life.

In a state of predisposition from any of the causes above mentioned, the application of cold is often productive of congestion and chronic inflammation of the uterus and ovaries.

This is often proved by the results of a cold during the congestion just preceding menstruation or at the time of the flow, and in childbed, or for some weeks afterward.

There are other causes which act in conjunction with the predisposing conditions I have mentioned above, but are sometimes independent in their effects: the abuse of the organs by the practice of vicious habits, masturbation, excessive intercourse, etc., standing too long, working the sewing-machine, and the pursuit of other employments that keep up a stasis of blood in the pelvis. School-teachers, sales-women and sewing-girls come within the influence of these

causes.

Still other causes are accidents, violence, gonorrhoea, etc. Gonorrhoea is a very fruitful source of chronic endocervicitis and endometritis. Dr. Emil Noeggerath,* of New York city, believes that

* First volume Transactions of the American Gynecological Society.

gonorrhoea is a frequent cause of several forms of inflammation in the pelvic organs of women, as of the Fallopian tubes, cellular tissue, ovaries, and peritoneum. He finds evidence that it remains in a latent condition or form in the mucous membrane, and in consequence of the influence of some exciting cause is awakened into an acute form of disease, which probably more frequently attacks the pelvic peritoneum or cellular tissue. He thinks that gonorrhoea often persists in this chronic form in the male, and although apparently cured, the husband is capable of infecting his wife for years afterward. I am quite convinced that his views in this respect are not without foundation and deserve the serious consideration of the profession. If Dr. Noeggerath's teaching should be demonstrated by further observation it will place gonorrhoea as a latent source of mischief on the same footing as syphilis. However this may be, I am quite sure that chronic endocervicitis, in which the glands of Naboth are the principal seat, and when the cervical canal is filled with a tenacious mucus of so tough a consistency as to make it difficult to remove, is frequently of gonorrheal origin.

We cannot always trace these chronic cases to an acute attack of gonorrhoea, but when we can get at the facts we will generally find that the husband has been the subject of gonorrhoea, and probably yet has gleet or the chronic form of that disease.

Under the head of puberty I have pointed out many deleterious influences under which the girls of this country are placed, and which lead, primarily or secondarily, to the development of sexual disease in consequence of natural and social conditions which cannot be escaped.

CHAPTER XX.

DIAGNOSIS OF UTERINE DISEASE.

Characteristic Signs of Inflammation.

THE signs of inflammation of the submucous tissue or substance of the neck of the uterus are, increase of size, tenderness, and generally hardness; of the mucous membrane, increased color and secretion; of ulceration, still more intense redness, purulent discharge, tenderness, and not much enlargement. The former conditions may be ascer tained by the touch, the latter by the sight, and when they are mingled, by both combined. Open external abrasion or ulceration of the uterine cervix, after the parts are well exposed, and cleared of mucus and pus by wiping, cannot be well mistaken or overlooked; and the practitioner must not be led to believe the case one of no importance because the ulceration is not very extensive. This raw scarlet surface is always indicative of mischief, and we should expect any amount of suffering from even a small patch of it.

Diagnosis of Endocervicitis.

There are cases where the appearances are not so obvious, where, in fact, all the parts exposed by the speculum and within reach of our vision have a natural appearance. No redness, rawness, or other discoloration can be detected on the neck, in the mouth of the uterus, nor on the vaginal surfaces; they are quite healthy in appearance and reality, but there is an obvious and, in many instances, a copious secretion of tenacious mucus flowing from and lying in the os uteri; wipe this away and all looks right. This is a case of endocervicitis. In some instances this mucus is colored with streaks of yellow by the presence of pus, or it is wholly yellow; here there is loss of integrity in the epithelium of the cervical cavity. The mucous membrane in the cervical cavity is ulcerated. If we remember that the mucous membrane secretes only enough mucus for lubricating purposes in the natural condition, we can arrive at no other conclusion than that the membrane is in a state of hyperexcitement when its secretion is abundant or altered, or both. When we see mucus in even small, yet perceptible quantities, issuing from the anus, what is the inference? If this is abundant, persistent, and colored yellow, however healthy the anus might appear externally, we could not believe that the rectum was in a healthy condition. Why not then positively determine that he mucous membrane is inflamed, which floods the os uteri with