may, and I think generally does, become chronic, unless removed by appropriate applications made directly to the membrane.

There is reason, too, for believing that the vaginal inflammation, in which profuse leucorrhoeal discharges originate, arising from other than contagious causes, may pursue the same upward course, and leave behind the same grave chronic difficulties. It is well known that vaginal discharges are sometimes the result of general conditions, such as the scrofulous, for instance, so that we may have scrofulous vaginitis, and this may spread to the mucous membrane of the genital canal. Vaginitis may also arise from immoderate coition, masturbation, or the introduction of foreign bodies from perverse habits. What I have said above of the effect. of vaginitis in causing cervical inflammation of the uterus, was intended to apply more particularly to this disease occurring in adults; but there is another condition under which it occurs, that I think has escaped the attention of medical men, or at least has not attracted sufficient notice, viz., the vaginitis of children.

Vaginitis of Children.-I think I have observed several instances in which, before the appearance of the menses, the cavity of the cervix must have been affected with inflammation extending from the vagina. Indeed, if the history of patients who very early commence to complain of signs of inflammation of the cervix be properly traced, it will be nearly, if not always, found that they were to some extent the subjects of leucorrhoeal discharge during their childhood. The kind and locality of the disease arising from infantile vaginitis is almost peculiar. It is situated inside the cavity of the neck, and if the os uteri is examined with the speculum, when the disease is not great there will be found but little, if any, unnatural appearance, save the issuing of muco-pus from it. The os is often contracted in size; it is very seldom enlarged.

These young patients do not generally complain much of suffering from their vaginal inflammation until the commencement of their menstrual visitation, when they have severe pain at each time. The suffering ordinarily increases as the functional activity of the uterus increases, until the patient is a confirmed sufferer with dysmenorrhoea or menorrhagia. At other times, instead of having much direct uterine suffering, the general nervous system is most affected, or the vascular or nutritive systems become seriously deranged at the period when the menses should appear.

It is not the usual opinion, but I am, nevertheless, inclined to the belief that chlorosis and chorea are sometimes the effect of derangements thus produced.

The above short and imperfect sketch of the causes of inflammation of the mucous membrane of the uterus will give but an inadequate idea of the vast number of causes which produce the inflammation in question. There is no mucous cavity in the body that is subject to so many causes of intense excitement, arising from the nature of its functions, from its accidents and abuses, as is that of the cavity of the female genital canal. Hence it is not wonderful that this cavity is very much more frequently the seat of disease than any other mucous cavity in the human body.

CHAPTER XII.

PROGNOSIS.

PROGNOSIS WITHOUT TREATMENT-NOT OFTEN FATAL-SOMETIMES INDIRECTLY SO-PROGNOSIS OF DIFFERENT VARIETIES-ULCERATION-ENDOCERVICITIS-SUBMUCOUS INFLAMMATION, ETC.-PROGNOSIS UNDER TREATMENTIS THE INFLAMMATION ALWAYS CURABLE?-WILL GENERAL SYMPTOMS ALWAYS SUBSIDE?-HOW LONG WILL IT TAKE TO CURE INFLAMMATION? PROGNOSIS AS INFLUENCED BY AGE OF PATIENT-PROGNOSIS AFFECTED BY PREDISPOSITION TO OTHER DISEASES-PROGNOSIS AS TO RESTORATION OF UTERINE FUNCTIONS-STERILITY-ABORTION-PROGNOSIS WHEN COMPLICATED WITH CONSUMPTION, THROAT DISEASE, SKIN DISEASES, ETC. ETC.— PROGNOSIS WITH REFERENCE TO PERMANENCY OF CURE.

A JUST estimate of the chances of making a cure, or of spontaneous recovery; or, in other words, correct notions of the prognosis of a disease in any given case, has necessarily great influence upon our treatment; and a correct prediction of the progress of a case, or of its ultimate result, has an important relation to our reputation and to the confidence of our patient. It is especially important to be able to give a reliable prognosis in cases in which the profession as well as the patients are not perfectly satisfied about the pathology and therapeutics in reference to them. Too unfavorable an opinion discourages our patient, and precludes us from having a fair opportunity of exercising our efforts; too favorable an opinion, one not justifiable by the result, brings disappointment to the patient, injures the reputation of the practitioner and the profession, and is also apt to influence improperly the inexperienced medical man against the treatment adopted. The general principle that should govern our prognosis is temperance. We should temperately encourage our patient, if we can conscientiously do so, and if our judgment will not allow us to do this, we should express, temperately and cautiously, an unfavorable prognosis; and hope should never be extinguished until a patient is moribund. Too many good reasons will suggest themselves for the last course to require any argument in support

of it. What I have said of a guarded prognosis, and the necessity of not giving a sweeping and absolute opinion, seems to me peculiarly applicable to the diseases of which I am now treating. Physicians have not all been convinced of the propriety of treating uterine diseases with the speculum; a large number are entirely, and conscientiously, opposed to it. They are made so, undoubtedly, by the failure of local treatment to fulfil the hope originated by its most ardent advocates. It does not do what they are told it will do; it certainly does not in all cases. The only grave error I think committed by that benefactor of womankind, Dr. Bennett, in his work on the Unimpregnated Uterus, is that his book leads his readers to believe that he scarcely, if ever, fails to cure his cases. This is the impression made upon most physicians who read his book. However true it may be, with reference to the practice of so able a master, I think it would be an unjustifiable expectation on the part of the profession at large. From what I have heard and read of the opposition of medical men to local treatment in uterine disease, I think this unrealized expectation of success from local treatment, is one of the main causes of it. Upon trial, medical practitioners become disappointed with the results as they were led to expect them, and abandon the plan as a failure. While I cannot coincide with Dr. Bennett as to the almost universal success of local treatment for uterine inflammation, I am of the opinion that it is greatly superior to any other with which I am acquainted. Prognosis must depend for its reliability, to some extent at least, upon a correct and complete diagnosis of the whole condition of the patient.

Uncomplicated Case Favorable.-The probability of recovery of health will depend upon the absence of any important general diseases in conjunction with the local. We should remember that the patient aims at recovery of health, instead of merely the cure of any one part of the ailments. An important matter is to determine the pelvic complications, if any exist, and how far they are curable, before we pronounce a prognosis.

Prognosis without Treatment.-What is likely to be the progress and result of the disease when allowed to go on without interference? Generally, it will go on from bad to worse. This is particularly the case with the child-bearing woman; it is almost equally true of the menstruating unmarried woman.

In the lat

ter, however, if she avoids the causes which aggravate it, she may not get worse; but if her situation, or her inclination, subjects her to the aggravating causes, she will also become worse. Not unfrequently the patient recovers after the "change of life" takes place. The cessation of the menstrual congestions, if other things are favorable, seems to determine a gradual recovery. This I fear, however, is far from being as frequently the case as we might suppose from reading, and judging physiologically of the matter. Indeed, some of the most obstinate cases I have met with were patients in whom the disease had outlasted the change of life.

Not often directly Fatal.-Notwithstanding the tendency of the disease to get worse during the whole menstrual life of the patient, and to subside only with the subsidence of uterine activity, it seldom proves fatal directly. Nor do the most common and immediate effects of it proceed to a fatal extent. The debility, the imperfect or perverted hæmatosis or the nervous energy, seldom becomes so great as to be the immediate cause of death. This, however, sometimes does occur, and we should indulge a false security to suppose that our patient could not thus die. I think I have seen more than one instance of death thus resulting. The nervous and muscular centres very rarely become so influenced by perverted innervation and hæmatosis as to assume dangerous or even fatal complicating conditions.

Indirectly Fatal.-As very correctly stated by Dr. Bennett, such an unnatural condition of the nervous system and blood is engendered by the disease as to destroy the capacity of the patient to resist or ward off the attacks of the acute diseases to which she may be exposed, or the chronic ones for which she may inherit a strong predisposition. It is difficult, also, to resist the belief, although I have not verified it by observation, that puerperal fevers and post-partum affections are more likely to occur and assume a dangerous or fatal state in patients affected with chronic uterine disease. I need hardly mention the increased hazard to married women from abortions, and the diseases intercurrent with them.

Prognosis in different Varieties.-There is some difference, other things being equal, in the gravity or seriousness of different varieties of inflammation. Some produce much worse effects upon