Effects upon the Post-partum Condition. Of its effects upon the childbed, or post-partum condition, a favorable opinion cannot be given from my observation. A good getting up is not to be expected with much confidence in patients affected with uterine disease. The most common effects in childbed is retardation of the processes of involution. The congestion consequent upon labor is protracted, the uterus remains larger and more sensitive than is usual, so that instead of the organ recurring to its primitive dimensions and susceptibility in one month, two or more may be required. The lochia, instead of subsiding in fourteen or twenty-one days, continues for weeks, or even months, after it should have subsided; and when it goes off, it is apt to merge imperceptibly into leucorrhoea, which becomes persistent. Inability to walk or stand without great distress is the effect of the size and sensitiveness of the organ. A sense of bearing down, or of weight in the pelvis, pain in the sacrum, down the sciatic nerve or in the hip, harass the patient greatly, and these symptoms pass off so slowly that she is kept in bed an unusual length of time. Acute metritis not unfrequently supervenes, or acute inflammation of the cellular tissue at the side of the uterus. Phlebitis, pyæmia, and phlegmasia dolens are more likely to arise in patients who have chronic inflammation of the cervix.

On the other hand, it is a fact that these subsequent acute inflammations sometimes operate very favorably upon the cervical inflammations. Instances are not uncommon of patients being entirely cured of ulceration by the effects of gestation and labor upon the tissue of the neck and its mucous membrane. We are to hope for this favorable result only as a remote probability, because, as already stated, the condition of the parts is generally left in statu quo, or, if any difference is perceptible, it consists in an aggravation of the disease, and the patients get up from childbed rather worse than better.

CHAPTER XI.

ETIOLOGY.

SEXUAL INDULGENCE-READING

STANDING-ABDOMINAL

IMPROPER BOOKS-COLD-CONSTIPATION

SUPPORTERS-PESSARIES-SEVERE

EXERCISEHEMORRHOIDS-PREGNANCY-ABORTIONS, FROM VIOLENCE ESPECIALLY— BAD MANAGEMENT AFTER ABORTION-LABOR-DECOMPOSING SUBSTANCES IN THE VAGINA OR UTERUS AFTER LABOR, OR AT OTHER TIMES—VAGINITIS OF INFANCY AND CHILDHOOD-GONORRHEA, ETC. ETC.

Sexual Indulgence.-The unnatural social habits of woman, and the circumstances which surround her, render her extremely susceptible to uterine disease. Coition, indulged in by the lower animals only for the purposes of generation, and periodically, at long intervals, is resorted to by man as the most common indulgence of his lower nature. The continued and extreme excitement in the sexual system ruins many of both sexes, but it produces the most disastrous effects upon women for obvious physiological reasons.

Improper Reading.-Less powerful but still efficient sexual excitement is found in the influence of lascivious books, so generally read by the young, as well as in the nature of the associations connected with most of the amusements of society.

All this is aided by heated rooms, stimulating diet, improper clothing, &c. At or near the periods of menstrual congestion these excitements operate with much more efficiency than at any other time.

Cold. During the menstrual congestion, the application of cold to a large portion of the surface is also a fruitful source of uterine inflammation in very young girls.

Constipation.-Chronic and obstinate constipation keeps up a predisposing uterine congestion, and I have long since been led to regard continued constipation as a condition the most deleterious to female health.

Standing.-Constant standing also produces much evil; it is much worse than walking, or even than going up and down stairs.

Abdominal Supporters, Pessaries, &c.-Pressure upon the abdomen by miscalled uterine supporters, the improper use of pessaries, sponges, &c., may be enumerated as causes in certain cases of uterine inflammation. There can be no doubt, also, that prolapse of the uterus, when considerable, and other displacements, are sometimes the cause of inflammation of that organ. This, however, is a rare occurrence, as I think displacements are much more frequently the effect than the cause. Circumstances occur which may mislead us, if we are not careful, as to the proper relation between displacement and inflammation.

Severe Exertion, Jolts, &c.-We not unfrequently meet with patients who tell us that they were "perfectly well" up to the time of some severe exertion, jolt, or lift, when suddenly they felt something give way in the lower part of the bowels, succeeded by pain in the back, hips, loins, groin, accompanied by a sense of prolapse and weight upon the perineum. Soreness and great permanent inconvenience persist thereafter, until the case becomes chronic. In such cases, the patient dates the beginning, not only of her trouble but her disease, from the strain or jolt; and believes it to be the whole cause of her disease. A critical inquiry into the history of the case will convince us that inflammation had preceded the accident, and that the uterus was probably rendered susceptible of the sudden depression by its increased size and weight. However this may be, the inflammation is greatly aggravated, if not originated by the circumstance.

Hemorrhoids.-The turgidity of the pelvic vessels, kept up by hemorrhoids, prolapse of the rectum, vagina, or bladder, or inflammation of any of these organs, must contribute largely to swell the number of uterine cases.

Pregnancy. Although pregnancy is a physiological condition, and, in the nature of things, ought not to even predispose to disease of the uterus, recent investigation seems to indicate it as a prolific cause of ulceration. Dr. Cazeaux and other French obstetricians have examined a large number of cases of pregnancy, with a view to determine the frequency of ulceration in this condition; and having found ulceration almost always present, they have determined that the leucorrhoea of pregnancy caused ulceration of the uterine mucous membrane. As well might we expect to see ulceration of the bladder in consequence of diabetes mellitus,

or ulceration of the skin in diaphoresis. Inflammation, undoubtedly, has the effect in this case, as in all others, of giving rise to the profuse and perverse secretion of mucus as well as the ulceration. There is no doubt but that, in consequence of the dependent position of the uterus in its relations to the vascular system, it is more liable to congestions of both a transient and persistent character than any other viscus, not even excepting the rectum. These congestions are the predisposing conditions of inflammations generally, and if they are persistent and long continued, they excite as well as predispose to inflammations. Constipation, standing on the feet for a long time, tight dressing, &c., act by impeding the upward tendency of the blood, causing it to leave the pelvis tardily, and thus keep hyperæmia in the uterine vessels until organic disease occurs. I cannot but believe that anything which will keep up these congestions for a sufficient time will bring about inflammation of the uterus in some part.

Abortions.-Abortions are both the cause and effect of inflammations of the uterus. It is unnecessary to point out the deleterious effects of abortions produced by violence.

Abortion from Violence.-All the circumstances exist that are required. The violence is nearly always sufficient of itself at once to give rise to more or less acute disease. In cases occurring from other causes than intentional or accidental violence, there are many efficient causes of congestion and inflammation. Probably one cause not usually thought of, is the too early assumption of the erect posture.

Bad Management after.-Being nothing but an abortion at an early period, it is not considered important by the physician that the patient keep the horizontal position; the patient sits up, walks about, &c., and the congestion existing continues sufficiently long to produce inflammation. Now, I think it is quite as necessary for the patient to remain quiet in bed, until involution is well advanced, in cases of abortion, as in labor at full term. Many of the conditions inducing inflammation in cases of abortion are the same as arise in parturition. I shall, therefore, speak of them under that head, and the intelligent reader will at once perceive them as they are brought forward.

Labor. The uterus, at the time of labor, is predisposed to vascular disease, on account of its extremely vascular condition; when

labor comes on the excitement is tumultuously increased, the nervous susceptibilities are enhanced, while the forcible contraction of the muscular part of its composition greatly adds to its excitation. When we remember the powerful compression of the os and neck by the child's head in passing through them, and even the frequent lacerations to which the mouth is subjected, it is astonishing that nature is competent, under the circumstances, to so completely restore so many parturient women to their former condition of perfect uterine health.

Decomposition of Productions of Labor.-In addition to all these, however, there is generally more or less decomposition of organic matter in the vagina, near the os and neck, giving rise to irritant products which, without proper cleanliness, might remain long enough in contact with the highly sensitive parts to cause inflammation. I know that nature should, and may, in most instances, safely be trusted to repair all the damage done in these ways when other circumstances are favorable; but these favorable circumstances are often wanting. The erect posture is too early assumed in many women, on account of their necessitous condition, or thoughtlessness and ignorance. This prolongs congestion of the dependent uterus, arrests or retards involution, and excites the uterus to inflammation; this inflammation is often prolonged by the continuance of the same cause until it becomes a fixed condition. The number of circumstances which cause and increase inflammation, in cases of parturition particularly, will be seen and understood without dwelling further upon them. We should remember them, and give our best care to patients passing through the conditions of the lying-in month, and thus avoid much suffering.

Vaginitis.-Inflammation originating in the vagina often spreads to the neck of the uterus, and occupies its mucous membrane externally, passes into the cavity of the cervix, and often, I think, to the cavity of the body of the uterus.

Gonorrhoea.-Gonorrhoeal vaginitis is very prone to do so, and if not arrested while yet in the vagina, and that soon after its commencement, the neck of the uterus is seldom left without permanent damage; and after gonorrhoeal vaginitis is cured, it is frequently the case that the cavity of the neck is left inflamed. This