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PRACTICAL TREATISE
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DISEASES PECULIAR  TO  WOMEN,



           ILLUSTRATED BY CASES,

      DERIVED FROM HOSPITAL AND %R1VATE PRACTICE.
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           >J BY
SAMUEL ASHWELL, M.D.,
   Obstetric Physician and Lecturer to Guy's Hospital, London.
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          BOSTON:
PRESS OF T. R. MARVIN, 24 CONGRESS STREET.
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PREFACE.
   It is  now nearly twenty years since the important branch
of  Medical Science which constitutes the  subject of the fol-
lowing pages, first occupied my earnest and almost constant
attention.  During a  great  part of this  period, Guy's Hos-
pital, with its extensive  Lying-in Charity, and my own pri-
vate  and  consultation  practice' in  female diseases,  have
afforded  me opportunities.falling  to  the lot of  but few prac-
titioners.   I  do  not,  however,  on this  account  urge any-
exclusive claim to the publication of a work of this kind, nor
do  I ask for its opinions and practice any exclusive and undue
deference.  But  still I trust that the truth of the principles,
and the treatment recommended  in  the book, will obtain for
it the sanction and confidence of my professional  brethren.
  I may also add, that the disposition to  publish has been
strengthened by  an  opinion  I  have  long entertained, that
practitioners  who hold important public  appointments, are
bound, so far as their sources of authentic  information can be
made subservient, to improve and increase the common stock
of professional knowledge.   It may, too, be urged in favor of
my attempt, that some production of its kind is really wanted;
for, while we  possess  many valuable single essays on female
diseases, there is  scarcely one complete and really practical
work. 
VI
PREFACF.
  I commenced this treatise, many years ago, and but for its
difficulty and extent, it would  long ere now have been com-
pleted.   It  must be  remembered, that it is  strictly devoted
to pathology and  treatment,  not to  anatomical  detail  and
physiological research.   The latter  sciences will therefore
be introduced for the sole purpose of illustrating disease and
the influence of remedies ; further they would be  irrelevant.
  Numerous cases are narrated, in order that their symptoms
may show whether the  histories of the various diseases are
accurately given, and that from their successful or unfavora-
ble issue,  the  danger of the malady and  the worth of the
treatment may  be  demonstrated.   These  motives will, with
practical men, and for them I have written, sufficiently apolo-
gize for the increased size of the volume.   Perhaps  it  may
be  also urged, that  cases add greatly to the interest of an
elementary work, tending to relieve the dulness from  which
a constant  repetition of principles, without such  portraits, is
nearly inseparable.
   The book will contain little which is not the product of my
own  practice  and  observation ; and if I  have  not  quoted
largely from the works of others, it  has not arisen from any
want of a due appreciation of their excellence, nor from any
unwillingness to acknowledge obligation, but because every
practical book  ought mainly to rest on what its author knows
and has proved for himself to be true and valuable.   Where
such is the case, a writer naturally uses a phraseology of his
own; the dress in which  he appears before the public  is seen
to  belong, not  to another, but to himself;  and  there  is, in
consequence, a consistency  of arrangement and character
 throughout the  whole.   Nevertheless, it  will  be  seen  on
 perusal, that I have not forgotten to mention the names of
 those from whom I have derived valuable assistance.
    Many formulae of remedies are  appended to  the  various
 chapters, and this has been done, because it  harmonized with
 the practical  plan that I had prescribed to myself; and be-
l 
PREFACE.
vii
 cause there  are young practitioners  without  sufficient the-
 rapeutical knowledge, and older men with too many demands
 on their time,  nicely  to  test the value, and accurately to
 determine the doses and other important conditions on which
 the efficient  use of remedies so much depends.
   My aim has been, to produce a treatise on female diseases,
 so  true, simple, and  practical, that  it may form a safe and
 efficient guide  to the  elucidation and curative treatment of
 many at  least  of these  intricate,  rapidly-progressing, and
 dangerous maladies.  If success  attend  the effort, that alone
 will be a sufficient reward  for the labor of the work.  I have
 endeavored  to write  in a  plain and perspicuous style ; with
 scrupulous accuracy as  to facts ;  andJn reference  to opinions
 and treatment, nothing  is recommen'fmd,  of the probability or
 worth of which  I am not myself convinced.
   The first part of my  undertaking is now before  the profes-
 sion,  and in  reference to it I may say, in the words of the
 great and lamented  Dr. Gooch,  " When an author attempts
 to execute his own view of a subject, he  is the last person in
 the world to judge  whether he has  succeeded or failed.
 WThen he has finished his book, it is impossible for him to see
 it in the same point of  view, and in the same light, as the
 public will;  and as he  himself would, if he could, forget its
 thoughts and  phrases, and read  it with a fresh and impartial
 mind:  he  may  show  it to a judicious and well-informed
 friend, but this is a poor thermometer of public opinion : the
 only one is  publication, and to this  I must  trust the fate of
 my volume."
  In  conclusion, I acknowledge  with  pleasure  valuable as-
sistance  afforded to me  by  Mr.  Tweedie,  Mr. Lever, and
Mr. Oldham, the Obstetric Assistants of Guy's Hospital.

    London, Grafton Street, Bond Street.
           September, 1840.
\ 
CONTENTS.
                                                 Page
Pathologv op Functional  Diseases of the Uterine
    System,     .    •  .   •
                   gtlAPTER I.
Of Chlorosis,        P......7
                   CHAPTER II.
Of Amenorrhea,.......®*
                   CHAPTER III.
Of Vicarious Menstruation,.....140
                ",   CHAPTER IV.
Of Dysmenorrhea,.......151
                    CHAPTER V.
Formulae of Remedies,......179
                   CHAPTER VI.
Of Menorrhagia,.......192
                   CHAPTER VII.
 Of Leucorrhoea,........238
                   CHAPTER VIII.
 Of the Disorders attendant on the Decline of Menstruation, 295
                                    -X
        t           CHAPTER IX.
 Formidte of ^envdi|&s      ."    .    •;«,.'•         •   305 
A  PRACTICAL TREATISE
                     ON THE

DISEASES PECULIAR  TO  WOMEN.
PATHOLOGY OF FUNCTIONAL DISEASES OF
          THE  UTERINE SYSTEM.
  I propose to arrange the diseases peculiar to wo-
men in three  great divisions.   In  the  first, I shall
place the functional ;  in the second, the organic dis-
eases ;  and in the third and last part of the work,
will be comprised the affections of  the pregnant and
puerperal states.
  A few preliminary observations on the pathology
of each of these classes may explain and  illustrate
what is subsequently to be advanced.   The  func-
tional are more  complicated and less easy of  accu-
rate diagnosis than  the structural  diseases.  It is
often difficult to assign a precise locality to the for-
mer, as  few of them are exclusively confined to  the
uterus,  but  exert, through the medium of the gang-
lionic system of nerves, an extensive constitutional 
 10        FUNCTIONAL  DISEASES OF THE

 influence.   The  difficulty is not so great in deter-
 mining the seat and degree of an organic lesion.  A
 functional disease is one which is dependent on de-
 viation from the  natural or healthy action of any
part of the organization, indicated by symptoms dur-
 ing life, which after death are found to  be  uncon-
 nected with discernible changes of structure.  Con-
 trast  such a disease with cancer or scrofula,  essen-
 tially organic  maladies, and  the  difference is strik-
 ing.   In the latter, any part  which  is attacked  will
 suffer conspicuous changes of its texture, and con-
 formation.  Function^ uterine affections are mainly
 dependent on  the derangement  of menstruation;
 such  for instance as  chlorosis, amenorrhcea  and
 dysmenorrhcea, profuse  menstruation, menorrhagia,
 and  in some measure leucorrhoea.   In all, there  is
 a deviation from  the standard of uterine health.   In
 chlorosis, amenorrhcea  and  dysmenorrhcea, there  is
 scantiness of  the  catamenial  secretion  and pain ;
 while in menorrhagia and its varieties there is pro-
 fusion and  excess ; results  indicative, probably,  of
 marked  difference in  the  nature  of  the primary
 affection, both  of the organic nervous system  and  of
 the circulation.   In health,  the catamenial secretion
 is generally of the color of the venous blood,  per-
 haps slightly more florid, but less viscid and without
 the power of coagulation, never separating, as blood
 does, into its component parts, however long it  may
 be kept.   Ordinarily, it occurs once in  every lunar
 month, and without pain, the process continuing for
 three, four, or five days, and the excretion amount- 
UTERINE  SYSTEM.
11
ing, in quantity, to  three, four, or five ounces ;  the
fluid having a faint and  sickly, and occasionally an
offensive odor, quite  different  from blood, and  but
little disposed to putrefaction.
   There is considerable  variety in these particulars.
In some  women, menstruation  is performed  more,
in others, less frequently.   In one individual,  the
amount of the secretion  exceeds, while in another,
it falls short  of the usual quantity, differing  also in
its quality or character.   So far, however,  as my
observation extends, at least within certain  limits,
regularity in  the periods  of menstruation  appears of
greater importance, than either the absolute quantity
or quality of the fluid.   Nor must it be forgotten,
in estimating the influence of menstruation on the
health, that the catamenial secretion  is peculiar to
the female of the human  race.  There is no analo-
gous  secretion  in  other animals.   Their uteri are
neither so thick, so capable of development  during
pregnancy, nor so vascular ; nor in any of them, not
even  in those species of  apes which walk nearly in
the erect position, have we any proof that  the  mu-
cus discharged during the  oestrum, is  furnished by
the uterus ;  it  is thought to be almost  entirely  a
vaginal fluid.
   Menstruation  may with  truth be  said  to be  a
function of the highest  importance to women ; so
intimately connected with the whole  of their econ-
omy, that its partial or entire suppression, may and
does often induce serious and  sometimes fatal dis-
ease.
A 
12
FUNCTIONAL DISEASES OF TIIF.
  It might have been supposed that there would be
structural or physical changes in the uterus, concom-
itant with these  affections.   But it is  not so ; for, if
the undeveloped organization of the uterus  and ova-
ria, in chlorosis,  be excepted, there is little discov-
ered by  post-mortem examination, to  account for
these derangements.
  Even  in  protracted and  incurable  menorrhagia,
which  occasionally  destroys life,  by  giving rise to
dropsies and other secondary diseases, if there  have
been no morbid growths co-existing, the uterus will
not yield evidence of  much  structural disease.   An
increased softness and  paleness of its  parenchyma
and  lining membrane, will  generally comprise the
whole  of the visible organic change.   The  same
may be  said  of amenorrhcea  and dysmenorrhoea.
Beyond  hypertrophy  and congestion in the  latter
affection  the organization  generally continues  unal-
tered.
  The local symptoms  accompanying  these  affec-
tions,  excepting  dysmenorrhoea,  are  usually  slight
and obscure.  The  constitutional  derangements, on
the contrary, although functional  and sympathetic,
are severe  and extensive.   Thus, it  is  common in
chlorosis, amenorrhcea and  dysmenorrhcea, as well
as in menorrhagia, but particularly in the former, to
have  marked disturbance of the  nervous,  vascular,
respiratory, and digestive  systems ; pointing to the
fact, that the womb and its  appendages derive  their
nervous  energy from  the organic  nervous system,
while the external genitals  derive  their supply, al- 
UTERINE  SYSTEM.              13
most entirely from  the  spinal marrow.  Thus are
the internal and external  organs  of reproduction, in
great  measure, functionally  independent of  each
other.   Even paralysis of the lower extremities and
external organs may exist, without a  similar want
of power in the  conceptive  faculty of the  ovaries
and uterus.
   The proximate cause  of these  functional mala-
dies has excited a good deal of controversy.   Chlo-
rosis ought to be attributed to an  impoverished circu-
lation and undeveloped ovaries.   Dr. Hamilton, see-
ing that costiveness  frequently precedes and accom-
panies  chlorosis,  erroneosly,  I   think,  regards this
state as its cause.   He also denies the  influence of
the genitals  on the general  health, and  says " that
castrated and spayed animals  suffer certain changes
of constitution, but  they retain  the enjoyment of
perfect health.  Reasoning  from this analogy," he
says, " I do not  understand  how  the  influence of
the female genitals can be  so great,  as that its par-
tial  suspension should  occasion retention  of the
menses, or  should induce chlorosis."  I think Dr.
Hamilton is  in error here.   In the case of castrated
and spayed  animals, puberty  was  either  already
present, or would have occurred, but for the castra-
tion.    In  early chlorosis, on  the contrary,  puberty
is absent when it  ought  to exist, and the subsequent
evils are not so much the  result of the absence or
abstraction of  the genital organs (for in  Mr. Pott's
celebrated case the woman  lived and did well after
the  removal of the  ovaries,) as of  the  early  defi- 
14         FUNCTIONAL DISEASES, ETC.
ciency of vital energy or power, of which  the cos-
tiveness,  equally with  the  chlorosis, is one of the
results.  This author overlooks, in the  conservative
effects of life, when important  organs have  been
taken away, the injurious and sometimes fatal  con-
sequences of such a  congenital deficiency  of vital
power, as shall permit the reproductive apparatus to
remain  partially or entirely undeveloped, and  who
can  measure  the  amount  of the  injurious  effect?
The examples, therefore, are  by  no  means analo-
gous.  Amenorrhcea is connected with a torpid and
inactive state of the generative organs, excepting in
those cases where, from a variety of causes, marked
derangement of the uterine circulation exists.  Dys-
menorrhcea, as a functional  disease, appears  to  be
most frequently induced  by irritation  more  or less
acute, by a low inflammatory state of the  uterine
mucous membrane, or by an  active, or even  slow
congestion of  the uterus.  Menorrhagia and profuse
menstruation may arise from different  conditions of
the capillaries ; which are sometimes over-distended
from repletion ;  and at others,  having lost  their
tone,  permit   the passive exudation of their  con-
tents. 
FUNCTIONAL  DISEASES  OF  THE  UTERINE
                    SYSTEM.
               CHAPTER   I.
                 OF CHLOROSIS.

   Definition.—A peculiar affection of the general
health; in  which debility,  languor,  and  deranged
stomachic functions  are  prominent symptoms; most
frequently occuring  when puberty is  or ought to  be
established, although it may exist at  any subsequent
period, always characterised  by ancemia of the sys-
tem, and a yellowish, dirty  green pallor of the sur-
face ;  when a disease of early youth, almost invaria-
bly connected, either with entire absence of menstru-
ation,  or  with  a scanty,  painful,  and  irregular
performance of the  function, and if  a  disease  of
later life,  in  addition  to these causes, it may have
been preceded and produced by  menorrhagia,  or leu-
corrhoza.

   History and Symptoms.—In furnishing these, pre-
cision  is  important, as chlorosis  presents itself in
three forms : as a mild  and incipient,  an  inveterate
and confirmed, and a complicated disease. 
16
CHLOROSIS.
  The incipient  and mild form commences almost
unobserved:  the patient has  been,  perhaps  from
infancy, or at least for  some years  previously, deli-
cate  and  feeble, so that anxiety has  existed about
her ; but  now, at the  age  of twelve, thirteen, or
fourteen  years—without any  obvious  exciting  or
morbid cause, other than a  negative  one, the non-
establishment  of puberty—a  series  of distressing
and perplexing symptoms are  ushered in, and  ob-
servation is more especially directed to  her, because
an important epoch in her life  has arrived.   Hither-
to she has  been delicate, but  there  has been pro-
bably no  disease.   Now she  excites  apprehension
from the gradual but evident  decline of her health,
in connection either  with the  entire  or partial ab-
sence of  menstruation.  She  does not pass on to
womanhood.
  Such  a patient is  languid, soon  fatigued,  and
therefore inactive ; she is not cheerful, but dull, and
listless ;  sometimes perverse  and sullen, and prone
to solitude.  Her appetite  is  capricious, it either
fails altogether,  or she  craves unwholesome food.
Her complexion  is  altered ;  although always pale,
it is now much more  so.  The bowels are consti-
pated ; the tongue is of a dirty, pasty white;  the
breath is offensive ;  she suffers from flatulence ;  the
slightest exertion fatigues and induces short breath-
ing ; frequent, severe,  and peculiar  head-aches,  pal-
pitation of the  heart and pain in  the  side, are com-
mon occurrences;  the pulse  is  quick, weak,  and
compressible, and sometimes fluttering.  The cata- 
CHLOROSIS.
17
menia,  if  not absolutely  retarded,  have scarcely
appeared, the discharge having been pale in color,
and scanty in quantity.
   The  symptoms already  described, in an aggra-
vated degree, and some  new  ones, attend inveterate
and  confirmed  chlorosis.   The  debility,  languor,
and listlessness, are  more marked.  The depression
is more complete, the appetite is more morbid, with
a  desire  very often for slate-pencil, chalk, acids,
pickles, and  other things  equally pernicious.   The
complexion becomes  still  more characteristic;  it is
a  yellowish,  dirty green, and the lips,  gums,  con-
junctivae, and lining  membrane of the mouth,  are
bloodless; the tongue, too, is of a still  paler white,
and being soft and  flabby, it  is easily  indented by
the teeth;  the  breath  is  more offensive; there is
nausea;  sometimes  vomiting  and   frequent heart-
burn; the bowels, although  generally  constipated,
are occasionally in  a state of irritable  and painful
diarrhoea.   There is acute  and anomalous headache,
attended by  every variety  of distressing sensation,
such  as heavy weight in the front or at the back of
the head, vertigo, fixed and intense pain in one par-
ticular spot,  paralytic feeling and neuralgia.   There
is a dark line  underneath the eyes,  about the alse of
the nostrils  and  at  the angles of  the  mouth ; the
eyelids  are  dark and cedematous  in the morning;
the ankles and legs are frequently so at night; the
cellular or soft tissues are  flaccid, and  the surface
generally, especially  of the  upper and  lower ex-
tremities,  is  cold.   If  menstruation has continued
               3 
18                 CHLOROSIS.
 up to this time, its intervals  become  more  distant,
 the discharge itself  is very scanty,  continuing to
 flow only for a few hours, and in quality it  is often
 serous  and pale, and of offensive odor.  There is
 sometimes a general dryness of surface; the skin is
 no longer resilient; there is a splitting  and brittle-
 ness of the finger-nails ; the hair loses its glossy
 brightness, falls off in large quantities, and alters in
 color.   It is  not  uncommon in advanced chlorosis,
 for the  abdomen to be full and painful; and  without
 decided phthisical complication, there  may be slight,
 short cough, pain under the left  mamma, and  hys-
 teria in a variety of forms.   At  this period, one or
 several  symptoms being confirmed, so  far mislead as
 to  induce  the belief, that the  lung, the brain, the
 liver, or  the heart  may be organically diseased.
 Such is the malady when fully developed.
   Complicated chlorosis consists in the presence, in
 greater  or less degree, of the general  symptoms of
 the disease, with a more prominent morbid affection
 of some distinct organ or part of the system.
   Predisposing causes.—A delicate, feeble, and un-
 developed  constitution,  where  the circulation  and
 nervous  power are inadequately exerted to perfect
 the organization of the  body;  in consequence of
 which  the evolution of  the  ovaries is  delayed, and
 their peculiar  influence  on the system, and  particu-
larly on the uterus,  is  withheld ; thus,  puberty is
only imperfectly or perhaps  not at all established,
and menstruation,  which  must be  preceded  by pu-
berty, is absent..  At a later  period  of life, when
:'K -••■*• 
CHLOROSIS.
19
even married  women  and widows are the subjects
of chlorosis,  its predisposing cause  is  most fre-
quently derangement  of  menstruation;  there  is
either  retention, irregularity, or pain and difficulty,
in the performance  of the function.  Nor  must it
be forgotten, that profuse menstruation, menorrha-
gia, and chronic leucorrhcea,  may induce chlorosis.
   A damp, cold, and  marshy locality, insufficient
and innutritious food, the late hours and excitement
of fashionable  life,  the sedentary employments of
the  poor  in  crowded  and  ill-ventilated factories,
where the temperature  is  high and the smells are
offensive,  in fact, whatever  relaxes and enfeebles
the  system, at  any period of life, and  especially at
an early age, predisposes to this disease.
   Chlorosis is  occasionally  met  with in our own
sex, and  I certainly  have  seen  one or two well
marked instances of it.
   Exciting causes.—Circumstances  which depress
the mind, and keep the feelings in a state of painful
suspense  or delay, unrequited affection, an  attach-
ment  which  is opposed on  account  of  its impru-
dence, separation from family and friends, the sad-
ness  occasionally induced by being at school ; ha-
bitual  constipation of the bowels, according to Dr.
Hamilton.  Amenorrhcea, leucorrhoea, and  menor-
rhagia, excessive venereal  indulgence, and  manu-
stupration,  weaken the powers  generally, and espe-
cially  the tone of the  sexual system, and thus con-
duce to chlorotic disease.   In all  these causes, the
impaired influence of the  organic ^ystam of  nerves 
20                 CHLOROSIS.
may be traced, not only on the  ovaries and uterus,
but also on the organs concerned in digestion, circu-
lation, and respiration.
   Pathology  of  chlorosis.—It  may  probably be
fairly  assumed, certainly  it is the most  prevalent
opinion, that chlorosis primarily depends on a mor-
bid condition of the blood, which secondarily affects
the ovaries  and uterus, by retarding their  growth.
This  opinion  is supported by the fact, that in the
blood of chlorotic  patients there is an increased pro-
portion of the serum, with a  marked  diminution of
the crassamentum.  This  has always been my view
of the disease;  nor would it be difficult to trace  to
this  morbid  condition of  the  blood, many—nearly
all  the different  theories  which  have  been  pro-
pounded.
   Gooch  and  Andral pointedly allude to the  dete-
riorated quality of the blood; the former in his pub-
lished lectures,* says,  "  If in girls who • have at-
tained the age at  which this change  is customary,
the  sexual  organs are not developed, a deranged
state  of the  constitution  occurs, characterized by
peculiar symptoms," &c.—" In addition to the other
circumstances just enumerated, the  quality of the
circulating fluid is, in chlorosis, altered ; blood has
been  taken by way of experiment, and it  has been
found to be of  a pale red color and watery, like the
juice  of a cherry."  After thus acknowledging that
the sexual  organs  are not developed,  and that the
blood is morbidly altered, Dr. Gooch, inconsistently,
* VI4« Ijiooob's Lectures by Skinner, page 7. 
CHLOROSIS.
21
I think, condemns, as entirely groundless, the opinion
that chlorosis depends on the absence of the physio-
logical influence of  the ovaries;  and  yet a little
further on, in explaining his own  views,  he says,
" that chlorosis depends  on a want of that  constitu-
tional  vigor,  by which  the sexual  organs  may be
brought into action ;  that to this deficiency may be
imputed the failure  both of  their development and
functions.  At the  period of puberty, the  constitu-
tion has not only itself to nourish, but it must have
energy to rouse  and  excite to action a new set of
organs; it must supply the materials for an increase
of their growth, and  all other purposes incident to
their functions."  Dr. Gooch could not  more accu-
rately have explained the course by which the blood,
when impaired  in  quality and diminished  in  quan-
tity, delays puberty and  menstruation, and in their
stead allows the establishment of chlorotic  disease.
   Andral' sobservations on the anaemia  of  chlorosis
are  so confirmatory of the  views  now expressed,
that I cannot resist their entire quotation.
   " The  expression,* general anaemia, if  taken in
its  rigorous signification, is  incorrect;  for the sys-
tem can never suffer the total and complete absence
of blood,  without the heart ceasing to act, and  the
other phenomena of  life becoming extinct.   The
term hypaemia  would  therefore  be more  correct.
The quantity  of blood in circulation may,  however,
be so diminished,  as no  longer to penetrate the mi-

  * Vide Pathological Anatomy, translated by Townsend and West.
Vol. i., pages 97 and 106.             .. »* & .,. • ■ 
oo
CHLOROSIS.
nute vessels of the  cutaneous surface, in  which its
place is supplied  by a  thin  serous  fluid ;  and  alter
death,  a deficiency or even total absence of  blood is
observed, not  only in the large arteries,  veins, and
right side of the heart, but likewise in the capillary
system, which is remarkably  pale and colorless.  In
these cases the membranous and  parenchymatous
tissues, such as the brain, lungs, liver, kidneys, ali-
mentary canal, and the parenchyma  of  the  heart
and  muscles, are also remarkably  pale and exsan-
gueous."
  Andral  again says, " In  chlorosis several of the
morbid phenomena  first recorded are constantly ob-
served  ; and if this  disease,  as is now generally ad-
mitted, frequently results from a defective formation
of the blood, the cause of which may reside exc\yf-
sively in the nervous system, can we with any  show
of reason  refer either to  irritation or sanguineous
congestion, the  proteus-like variety  of  functional
derangements which chlorotic patients so constantly
present, such as epileptic paroxysms, convulsions,
chorea, dyspnoea, palpitations, vomiting,  &c. ?  Or,
shall we not approach nearer the truth, in assigning
these different morbid phenomena to the same  cause
which  produces them in persons who are  reduced to
a state of anaemia  by the deprivation of  food,  light,
and wholesome atmosphere  ?   We may appeal to
the test of experience, to the laedentia and juvantia
for the further confirmation of this  doctrine.  Vene-
sections employed in such cases to  combat an irrita-
tion, which in reality does not exist, invariably pro- 
CHLOROSIS.
23
duce a marked aggravation of all  the  symptoms;
on the contrary, it frequently happens that by stim-
ulating the nervous  system of these chlorotic pa-
tients by the physical and moral emotions of matri-
mony, we  produce a more  natural complexion  and
color of the  whole  cutaneous  surface, thus indicat-
ing a correspondent  improvement  in  the process of
sanguification; and in proportion as the anaemia  dis-
appears under  the  influence of this  new modifica-
tion of the nervous  system, the whole train of  dis-
eased action, the difficult respiration, constant sen-
sation of uneasiness and listlessness, impaired di-
gestion, gastralagia,  vomiting, tympanitis and limpid
urine, together with  all  the strange nervous symp-
toms,  which  seemed dependent  on some  organic
alteration of the solids, gradually subside and event-
ually vanish,  as a fresh supply of  blood is generated
in the system."
  Diagnosis.—It  will  be  allowed,  after what  has
been advanced, that  chlorosis is not an inflammatory
disease.   It  is  indeed  most intimately connected
with  anaemia, and closely resembles (except in  the
pale greenness or  dinginess of the skin,) that state
of system which is the result of hemorrhage or  any
undue secretion.  Those symptoms, therefore, such
as severe headache, pain in the  side affecting  the
breathing, distressing action of the  heart, and  sev-
eral others, must not and cannot, where  proper cau-
tion  is  observed, be mistaken for  and  treated as
acute inflammatory affectious.  From the want of
this  caution,  I  have witnessed the very injurious 
24
CHLOROSIS.
consequences  of such  mistakes, the  practitioner
having forgotten, what in female disease it is pecu-
liarly important  to  remember, that the severity ot
the pain, and the rapidity of the  pulse, are  generally
indications of  irritability and excitement,  not of in-
flammation ; demanding  narcotics, carminatives, and
at the most, counter  irritation, not bleeding, active
purgatives, or  spare diet.  If my definition be  cor-
rect, amenorrhoea, which may, and  often does exist,
quite independently of chlorosis, cannot be regarded
as a  synonymous disease.   It  is  impossible,  that
there should  be chlorosis  without more   or  less of
amenorrhcea,  yet  it  is  often   seen,  that  there is
amenorrhoea without  any degree of chlorosis.   It is
quite true,  that when   amenorrhoea   has  not been
cured or relieved—when it has produced, by its long
continuance, extensive constitutional derangement—
that then chlorotic symptoms will  appear, and that,
ultimately, the series of morbid phenomena  consti-
tuting chlorosis  will  be  clearly seen.   Nor must it
be forgotten, that chlorosis is itself a frequent cause
of amenorrhoea, by its prevention  or  protraction of
puberty, on which menstruation depends ; and  sub-
sequently, even when  the  catamenial function  has
been established, leading to its partial suspension,
and occasionally to its  entire   suppression.   There
will be no difficulty in distinguishing chlorosis  from
chronic  affections  of the abdominal  viscera, espe-
cially from  hepatic,  splenic, and  renal disease, or
indeed from  any morbid  state, of  which  anaemia
and pallor are prominent symptoms.   The period of 
CHLOROSIS.
25
life, the peculiar aspect of  a  chlorotic patient, and
the derangement of menstruation, will ensure a cor-
rect diagnosis.
   In the complication of chlorosis with amenorrhea,
the ovaries and uterus are principally affected.   Here
the chlorosis  may have existed for  some time, pre-
venting the complete establishment of puberty and
menstruation, but allowing  both in a partial degree.
After some  months,  when  the function  entirely
ceases, there  is a marked deterioration of the gene-
ral  health, and  the  malady  becomes a  double or
complicated one.   It is chlorosis with amenorrhoea.
Or this combination may gradually occur, as the re-
sult of amenorrhoea produced slowly and insidiously,
after months or years of healthy and  natural  men-
struation.   I  need  not  say  that the  latter disease is
rare, the other is common, and, if protracted, dan-
gerous.  It is this complication with  amenorrhcea
which  has led  to  the confusion of names;  the
symptoms  of  menstrual suspension  being  so inti-
mately blended  with  the  affection of the general
health, as to have induced, in many minds, the  opin-
ion, that chlorosis and  amenorrhcea are  convertible
terms, and  that they really  denominate one and the
same disease.  It is almost  unnecessary to add, that
these are the cases  which  so frequently terminate in
health, if  early, well, and sedulously treated.  Un-
der tonic treatment especially, the  blood is improv-
ed, both in quality  and  quantity; the  pallor of the
surface disappears ; there is a vigor of system never
before possessed ; and, prompted and  sustained by
               4 
26
CHLOROSIS.
 this increased energy of the constitution, the various
 functions of  the system  are  better performed ;  pu-
 berty is  more  fully developed ;  and  thus, with or
 without the  assistance of emmenagogue  medicines,
 the  catamenial secretion  is regularly  and pretty
 abundantly established.   A few months demonstrate,
 that the  transition from disease to health is at length
 safely, though  tardily and with difficulty completed.
 Of course, in some  instances, the duration of these
 chlorotic  and  amenorrhoeal complications  will be
 painfully protracted, and  there will be an aggravated
 severity  of  symptoms, productive  of great alarm.
 In such  circumstances, it  will be  necessary to re-
 double, not  the activity of the  treatment,  but the
 care and  watchfulness bestowed  upon the  patient,
 so that we may discern immediately any indications
 of further complication ;  always  remembering, how
 probable it is, in  this climate at least, that  phthisi-
 cal disease may occur.
   If the  malady  continues, although  the treatment
 may have been ably and  perseveringly pursued, pa-
 rental  alarm and  professional anxiety will  soon be
 heightened.   There are  instances, however, where
 the critical point  in the  disease  may have  arrived
 before any  treatment  has been  employed.   Such
 maladies are prevalent, and present nothing unusual;
 delicacy of constitution, and imperfect menstruation
 are events of every day ;  and to the neglect and de-
 lay consequent on  the commonness of  the  disease
 many fatal results may be attributed.   I  have often
during the last few  years, been  requested to treat 
CHLOROSIS.
27
such patients, of whom, had I judged from what  I
heard,  I should not have predicted any danger; and
yet, on careful  inquiry—and,  in some instances, at
first sight—I have been convinced that the case was
all but hopeless.   Chlorosis,  combined  with ame-
norrhcea,  like other diseases, does not at once as-
sume an  aggravated form ;  the symptoms  already
described exist  frequently  for a  long  period  in  a
moderate degree;  and  it would be wrong to deny,
that there are  cases  in which,  independently of
treatment, the  mischief gradually  passes  away.
Change of air, a residence in  the country, and more
natural and  out-of-door avocations, seem, by their
combined influence, to lead to the  development of
puberty, and subsequently of menstruation and good
health.
   This however,  is not the usual course of events:
more  frequently after  unsuccessful  treatment,  and
peculiarly if there be entire  amenorrhcea, some or-
gan, the cerebrum, for instance, or the digestive ap-
paratus, or  the  lung, becomes especially  deranged ;
and the  functions, dependent for their natural per-
formance on the healthy condition of this structure,
are disturbed,  and, to a degree, marking the fact,
that this is the organ or part peculiarly affected.
   Complication of chlorosis  with  a  discharge of
blood from the stomach by vomiting.—This is not an
unusual   concomitant  of protracted chlorosis  and
amenorrhcea.  In  such cases,  the  treatment may
have been partially successful.  The nutritious diet,
and the  tonic remedies, especially if iron has been 
28                 CHLOROSIS.
used, may have improved both the quality and quan-
tity of the circulating fluid.  In this condition, the
suspension of the catamenia continuing, congestion,
or, according to the French, "engorgement," occurs
in some of the  organs of digestion  and nutrition;
irregularity of gastric  and intestinal action is the
result: constipation, pain, spasm, and nausea harass
the patient;  and, in an effort to cough or to vomit,
a quantity of dark,  venous-colored blood is thrown
up.    It often happens, that these dissharges observe
a catamenial period, recurring every three  or four
weeks;* there  being in the intervals more or less of
leucorrhceal secretion.  I have seen  patients alarm-
ingly anaemiated by  these hemorrhages, especially
where the  amenorrhoea has been of long standing,
and  where  it  has  been greatly neglected.   It is
sometimes  perplexing to  determine  whether the
blood comes from  the stomach, the lungs, or the
mucous surface of the fauces and trachea; its quan-
tity and  color will  generally determine  this point;
although there are cases, where pulmonary bleeding
is extensive, and  where, from some  quantity of the
blood having  been swallowed,  and  again  rejected,
by vomiting, it has acquired a dark hue and a clotted
form, involving the point in  still  more difficulty.
Doubt will not, however,  be  of long continuance  •
if the bleeding be pulmonary, there will be  a preva-
lent cough, and a series of symptoms plainly denot-
ing disease of the lungs.   It is scarcely necessary to
observe, that local emmenagogues are here peculiarly
         * Vide Chapter on Vicarious Menstruation. 
CHLOROSIS.                 29
useful:  the quantity of the blood  is increased suffi-
ciently to allow of the  advantageous elimination of
the menstrual secretion ;  and every effort must  be
employed to establish the  function.   Nor is it irrele-
vant to  remark, that  persevering  and active  treat-
ment is  generally successful, where  the bleeding is
not  pulmonary ;  and I  have seen  two cases, where
the hemorrhage has been  large,  and from the lungs,
both of which yielded to  persevering management.
   Complication  of chlorosis, with chronic  derange-
ment of digestion  and  nutrition.—In the  milder
form, there is always some disorder of these func-
tions :  but in its aggravated degree it demands much
professional attention.
   In these cases, we  do not wonder at the emacia-
tion which  may have  occurred :  our  only surprise is,
that the functions of life  should not have been even
more interfered  with.   Patients in this condition eat
scarcely any thing ; and  the little they do swallow,
is generally of the worst and least  nutritious kind.
I am aware that  families  and medical men are occa-
sionally deceived on  this  point;  but I  am also per-
suaded,  that in  many instances, where I have been
consulted, there  has  been no fraud, the patients  not
having  obtained food surreptitiously : and  I may be
allowed to  remark, that  although medical  scrutiny
and acuteness are never  more useful  than in these
cases, yet that it is unwise and unkind to express a
suspicion of this sort, without some tolerable  proof.
It is interesting to trace and to watch this complica-
tion.  An  impression every now and then exists, 
30
CHLOROSIS.
that such a patient cannot recover; she takes so lit-
tle, her strength  is so impaired, the whole  s\stem
is so emaciated, that she seems only to wait for some
favoring circumstances to  induce phthisis;  and  if
she be hereditarily or  constitutionally predisposed to
this fatal malady, the  probability is that she will not
escape it.   And yet I know of no  combination of
chlorosis which affords such ample scope and reward
to  judicious, persevering, and observant treatment.
It  is rare  for a structural  change to occur  in the
stomach, liver, or intestinal organs, in the most pro-
tracted form of the disease, although it is common
to  see the largest amount of functional derangement.
Nor  are the  attendant evils only physical.   The
mind, the disposition, the temper, are all  disturbed.
Gloom and despondency, ennui, irritability, and  dis-
satisfied feeling, oft times  exert an  irresistible con-
trol  over  such patients;   and when their  present
state is compared with what they were t welve or
fifteen months previously, the contrast is lamentable
indeed.  Seclusion and solitary habits are frequently
indulged, and require the watchfulness and penetra-
tion  of the  physician and  the family.   Nor are in-
stances wanting, in which  mental peculiarity has for
a  time assumed not only the appearance but the
reality of insane aberration.  Such  individuals are
seldom the  subjects  of high excitement;  they are
rarely violently insane.  More frequently,  they are
in error on a few points only ; or, giving up all for
lost, as to their recovery, they indulge in depression
and despair.  It is unnecessary, minutely to describe 
CHLOROSIS.
31
the various indications of digestive disorder.   They
are so common, that they must be well understood.
Nor can it be  too  strongly urged, that  disorder of
the  general health, on which, perhaps, delayed pu-
berty depends, and to which menstrual  irregularity
and suspension may be so often traced, is most inti-
mately  connected with the  condition of the alimen-
tary canal, and of the organs subsidiary to digestion;
and if the peculiarities of  the constitution, already
pointed out, together with puberty and menstruation,
especially modify the female  economy,  it may be
allowed that  the state of the digestive organs exer-
cises a  more extensive and  peculiar  power in them,
than in our own sex.
   Complication of chlorosis with functional affection
of the  cerebrum.—There is scarcely any complica-
tion more difficult to relieve than  this.   The varie-
ties, as to situation, and the differing degrees of in-
tensity of the pain, are worthy of observation.   In
 some individuals, the uneasiness of the head  is gen-
 eral, but not severe ; while in others, the site of the
pain is  limited,  and  so  agonizingly intense,  as
 scarcely to be endured.   In  not a  few  instances,
 the pain is periodical,  and  of neuralgic  severity,
 while in others, it is  so nearly constant, as  to pre-
 clude mental or physical exertion, and almost to in-
 duce the belief that it  must  be  connected with or-
 ganic affection.   Nor is it very uncommon to meet
 with fits of hysteria, chorea, and  epilepsy, attributed
 by  the patients themselves,  and  perhaps correctly,
 to the  long-continued and painful affections of the 
32
CHLOROSIS.
 head.   These diversified degrees of suffering will,
 of course, be associated with  a variety of morbid
 cerebral sensations: in some, there will be vertigo;
 in others, an overwhelming  sense  of weight.  At
 one time, there  will be paralytic sensation about the
 head and upper  extremities; at another,  a painful
 quickness of sensibility; and  with many  of these
 feelings, there  will be morbid sympathy,  of  the
 stomach especially, as  well  as of the  digestive or-
 gans and alimentary canal.   Let it only be remem-
 bered, how these morbid actions will become blend-
 ed, how irregularly and  extensively they will affect
 the entire system, and  it will not be difficult to con-
 ceive of the tedium and misery which these patients
 endure.  It is consolatory to  know, that, in  by far
 the majority of individuals thus suffering, the affec-
 tion of the  cerebrum  is functional, there  is  rarely
 structural disease ; and if  pressed for proof of this
 opinion,  we may point to the numerous instances of
recovery, even when the symptoms  seemed  clearly
 to indicate organic affection.
   It is  nearly impossible, within reasonable  space,
to describe the distressing  and intricate morbid  re-
sults attendant  on  this  complication.  There  are,
however, as already stated, not only shades of dif-
ference in the  amount  of suffering, but marked ex-
tremes ;  and I know nothing worse than the aggra-
vated cephalalgia peculiar to this disease : to call it
a nervous or a sick  headach, even of the worst kind,
gives only a faint idea of the  intensity of  the evil •
for I have heard many patients deliberately declare, 
CHLOROSIS.
33
that life  would be undesirable, were it to be contin-
ued  in association with this sad infliction.   Tempo-
rary loss of memory  and acuteness of perception,
physical irritability, torpor, and derangement of the
organs  of digestion are amongst its most common
consequences.   Yet it is  important to  know, that
there are, in most cases, limits, within which  the
morbid influence is confined.   There are functions,
with which, even this amount of suffering, does not
greatly   interfere.   Such  patients  sleep  tolerably
well; their appetite  is  capricious,  but  not  wholly
destroyed;  and,  although nutrition is  imperfect,
there is  not much or rapid emaciation—a circum-
stance in  decided  contrast with what  is  seen  in
chlorosis complicated with organic pulmonary change.
It is not meant  to be  stated,  that structural  altera-
tion  never occurs, nor  that ultimate recovery from
the  headache is invariable and certain.   But, after
having  treated  many of these diseases, and after-
wards having watched them for a considerable time,
I am disposed to believe that the cerebral structures,
for the most  part, remain unchanged ; and that the
cephalalgia of   many  months,  and,  in  some  rare
cases, of years' continuance, is eventually completely
lost,  provided puberty  and menstruation are fully
established.  The cerebral  affections attendant on
epilepsy  must be excepted from this statement, and,
perhaps,  that highly nervous and paralytic tremor or
shaking,  which  is sometimes  the  consequence of a
very protracted chlorosis.  Again,  it must  be re-
membered,  that  even  epilepsy may occur without
              5 
04
CHLOROSIS.
structural lesion, and that paralysis  may  sometimes
be cured.   There are  two cases (Nos. 10 and 11)
illustrative  of these opinions, and  confirmatory  of
the extraordinary curative effects attendant on the
development or restoration of the sexual  function.
   The vascular system, especially the capillaries and
the heart,  is  frequently implicated  in  protracted
chlorosis;  and, by patients and their  immediate
friends, such  complications  are  viewed  with much
apprehension.   Constipated bowels and severe head-
ache, are common circumstances;  but the  entire
loss of the natural  color of the  surface,  oedema of.
the face and  extremities,  palpitation of the heart
and syncope, are less frequent, and wear so formi-
dable an aspect, as to excite great alarm.
   Ascites,  I  have  rarely seen  connected with  the
oedema of chlorosis ;  certainly not  in early life.   At
a  more advanced period, derangement  and structural
change of the liver or kidneys may, combined with
chlorosis, induce  effusion  into  the peritoneal sac.
Such events are, however, rare.   No  doubt ascites
in diminished quantity does occur, in the general ten-
dency to serous effusion, which  is so marked, when
chlorosis is protracted;  but it  is  not a formidable
symptom in itself,  and yields to the remedies which
would improve  the quality of  the blood.   When,
however, the effusion is in greater amount,  distend-
ing the abdomen,  structural disease of the liver or
kidney, as already  observed, will be found to exist;
when only palliative remedies can be employed.   It
is right also to caution the attendant and the family, 
CHLOROSIS.
35
against supposing  that every  hue of  the  surface,
slightly more icterode  than usual, is to be regarded
as an indication that the liver is seriously deranged,
and requires for its restoration mercurial remedies.
   Complication of Chlorosis with structural change
of the Lung.—The malady rarely terminates fatally,
except in combination with phthisis ; and the ques-
tion is not unimportant, whether the  phthisis be in-
duced by it and amenorrhoea, or whether these lat-
ter affections  do  not  owe their origin, at  least in
part,  to the original phthisical  tendency of  the sys-
tem.   This predisposition may be dormant till the
epoch of  puberty ; and then its injurious influence
may pervade the entire system.  One of the imme-
diate results will  be a want of energy, an imper-
fect development of the-sexual  character;  and*this
failure of puberty will lead  to  chlorosis and ame-
norrhcea.   These latter affections will be the promi-
nent, but not the real  disease.   Yet it  is not aston-
ishing thac the chlorosis  should  principally arrest
medical  attention: it is the malady peculiar to the
age:  there are only few and slightly-marked indica-
tions of phthisis;  and these, and  even much worse
symptoms, would be viewed as within the  scope of
the curative influence  of menstruation.
   Occasionally, phthisis may be induced by chloro-
sis and  amenorrhcea;  but,  in by far the  greater
number of instances, the chlorosis  only excites into
activity, the previously latent tendency to this fatal
disease;  an opinion  which receives  confirmation
from the fact of the other complications rarely pass- 
36                 CHLOROSIS.
ing into this.  There may have been extensive vica-
rious hemorrhage, excessive and long-continued leu-
corrhceal secretion, intense pain of the head, hyster-
ical and even epileptic  seizures,  a highly morbid
condition of the digestive organs, and  a moderate
degree  of emaciation ;  and  yet there  shall be  no
phthisis.  The individual shall recover  from these
morbid states, without even an apprehension of con-
sumption.   Nay more, there may be fearful protrac-
tion of  these  maladies, and  yet there shall not  be
cough, pain  in the side, or expectoration ; so distinct
is  the  line  of demarcation between this and  the
other complications.   From  what I have seen, I am
convinced that structural disease  of  the lung, is
most  frequently  connected,  either with  chlorosis
alone, or with chlorosis  in connexion with amenor-
hcea.   For  instance : a girl  of consumptive family,
arriving  at  the  age of  puberty,  becomes slightly
chlorotic; and soon, instead of the negatively  mor-
bid state which may have existed  up to  this period,
there creeps on slowly,  but certainly, a confirmation
of  the disease.  There  is no menstruation ; or, if
the function be developed, it  is only once or twice,
and very imperfectly.   Then, there is  great  cause
for apprehension, not that the series of symptoms
belonging to the other complications will  occur, but
rather that the anaemia and want  of constitutional
power,  will favor the  predisposition to  structural
pulmonary change.  Such patients are not altogether
without appetite ;  the derangements of the stomach
and the alimentary canal are  not  prominent symp- 
CHLOROSIS.
37
toms, the cerebrum does not painfully sympathise,
and frequently there is an entire absence of  hyste-
ria.   But there is quickness of  pulse ;  irregular ac-
tion of  the heart ; rapidity and  difficulty of respira-
tion ; more or less thoracic  pain, frequently confined
to the left  side; a short, hacking cough, and ema-
ciation.  Inquire particularly, and it will sometimes
be found, that there is in slight  degree, both  expec-
toration and  perspiration.   When  patients haye ar-
rived so far,  and sometimes, happily, before they
have  reached  this point,  apprehension is roused, and
medical treatment is eagerly sought.
  Many such  cases are  occurring ; and I wish the
attention of practitioners, to be  particularly directed
to this  complication.  The  vicissitudes of an Eng-
lish  climate  predispose  to  phthisical disease; and
with  the physiological circumstances peculiar to the
sex, explain  how it is, that girls so frequently die,
at this  epoch, of phthisis, in connection with chlo-
rosis  and amenorrhoea.   If asked, what such a se-
ries  of symptoms as I have just enumerated indi-
cate,  the  reply must be, chlorosis complicated with
a tendency to phthisis.  And if it be inquired, what
is the chance  of entire recovery, a very guarded an-
swer  must be given.
  To say that  patients advanced thus far never re-
cover, would  be  untrue :  although  it is  perfectly
right, to give  a doubtful  opinion.  If the constitu-
tional power can be augmented, if the  blood  can be
improved in quality, and increased in quantity, then
the symptoms  may be arrested, and  renovation of 
38                 CHLOROSIS.
health may be slowly effected.  A symptom of im-
provement, of great value, is, diminution in the ra-
pidity of the pulse :  for so long as the pulse beats 130,
120, or even 110 in the minute, it must not be sup-
posed  that any real amelioration  has taken  place.
It will be necessary, also, to be guarded in the opin-
ion we ourselves form :  the same  self-delusion ex-
ists here, as in  phthisis at other periods.  The pa-
tient is convinced that there is no occasion for alarm;
and the disease often creeps  on so insidiously, as to
lead the family  to  believe, that there  is no imme-
diate  danger.   Let it, however, be remembered,
that so  long as there is a rapid pulse, short  hacking
cough, and a want of nutrition, there  is real hazard.
If, on the contrary, the pulse becomes slower, fuller,
and  softer ; if the  cough be less frequent;  if the
pyrexia disappear;  and  especially,  if  the   patient
gather flesh, in ever so trivial a degree; hope may
be entertained.
   Carefully treat such an  individual:  avoid  mer-
cury, drastic purgatives, and  emmenagogues.   Place
her in the country, where  she shall breathe pure
air:  let her diet be simple and nutritious (milk and
animal food), and her  medicine some  of the various
tonics;  and the expectation  may be cherished, that
the time is not far distant, when the  sexual charac-
ter will be  fully developed, and  the  danger  safely
passed.   From what has been stated, it must not
be inferred,  that this is the only fatal complication
of chlorosis ; but, comparatively, it is rare  for  the
others to terminate unfavorably.   Still, after con- 
CHLOROSIS.
39
tinued derangement of the viscera of nutrition and
digestion, the debility, pyrexia, and emaciation may
become  intimately blended with alteration  of the
pulmonary structure; and  the  cough, expectoration
and morning perspirations, may become prominently
influential, in bringing about final sinking.
   I have thus attempted to distinguish the morbid
circumstances appertaining to the different forms of
this prevalent malady.   And  although the leading
and distinctive features will generally enable  us  to
determine  the  complication, still, when  any  form
of the disease  has become aggravated, severe and
of long  duration, the  blending  of  symptoms may
perplex  the  diagnosis.  It ought to be  remarked,
that  leucorrhoea  in  various degrees  is an  almost
constant attendant on  chlorosis  and  amenorrhcea;
and, when excessive, so  seriously impairs the res-
torative  powers,  as  to  render the  cure long and
difficult.
   I wish to particularise, as  correctly as I can, the
ages, at which,  these  various complications  most
frequently occur.  Chlorosis  alone, independently
of amenorrhoea, is a  disease of early  life.  In con-
junction with  menstrual suspension, it may be met
with  at any period,  between  the  ages of puberty
and the  final cessation of the catamenia.  Chlorosis
conjoined  with phthisis, may be seen between pu-
berty and thirty years of age ;  sometimes later ; but
such  instances  are  very  rare, in comparison with
the numerous complications of this  kind, before the
attainment of the twentieth year.   Again, chlorosis 
40                 CHLOROSIS.
with amenorrhoea or phthisis, at  an  early age, are
forms of the malady, generally associated with  de-
bility and delicacy of system ; while  the other com-
plications may exist at  any period, and are not un-
frequently combined with plethora or congestion.
   Treatment of Chlorosis.—The treatment of chlo-
rosis, to be extensively successful, must be early and
most sedulously prosecuted.
   It cannot have escaped  observation, that the dis-
ease is one of almost  universal influence :  it is  not
confined  to a particular organ, but affects the entire
system :  and yet, it  is often productive of  so much
functional  derangement,  of so many isolated  and
painful affections, as to demand  local treatment;
which, while  it  shall  be  in  complete accordance
with the  main principles of the cure, shall still be
especially directed to ameliorate topical pain.
   The reader, then, will  be prepared  for a classifi-
cation of the means of cure ;—an arrangement ne-
cessary,  not  only to prevent  confusion and disap-
pointment, but equally so for the attainment of  that
correct view of the malady itself, and of the par-
ticular stage which  it  may have reached, on which
will depend the peculiar  fitness of the  whole treat-
ment.
   Thus, first, in mild chlorosis, either alone or com-
plicated  with amenorrhcea,  the remedies  will  be
principally of a constitutional  kind, directed to the
improvement of  the  general health, and  to  the  es-
tablishment of puberty.   If, when  these points are
gained, the uterine  functions are not developed, the 
CHLOROSIS.
41
delay may perhaps be  attributed  to torpor  of the
organs of reproduction,  and emmenagogues may be
employed.
  Secondly, When the disease is  variously compli-
cated, it often happens, that the organ, or part of the
system  principally  implicated, becomes so promi-
nently morbid, as almost  to  throw  into the shade
the original chlorosis and its accompanying amenor-
rhoea; but  it  must never  be forgotten, that  these
have been the source of the complications, the  soil
in which they have sprung up.  Here the treatment
will require  modification : it  will,  of  necessity, be
less constitutional, and must assume  more of a topi-
cal  and symptomatic character.
  And, lastly,  where  structural alteration of  the
lung  is  threatened or  suspected,  the  management
must have  especial  and almost exclusive reference
to this alarming  complication ;  every measure  being
adopted to avert this greatest of all dangers.   Still,
even  here, it must not  be forgotten, that if puberty
could be  sufficiently developed to allow of even the
partial establishment of menstruation, a  very  for-
midable feature of the complication would disappear.
  It is evident, that a  combination of  means is re-
quired ; medicine, alone, cannot accomplish all;  and
other  measures,  without  medicine, will generally
fail.  Again, if it be remembered, that the disease
is proteiform and of ever-varying degree, it will be
seen, that  constant and unwearied  efforts are re-
quired, not only  to vary the old, but to suggest new
resources.
              6 
42
CHLOROSIS.
   The treatment of the most common form of chlo-
rosis, namely, that accompanying puberty, may be re-
garded as the type of the treatment of all the others ;
embodying  the  principles, which,  with greater or
less  modification, are  universally applicable.   It is
here, at the very threshold of the disease, when its
character is not understood, or when  it is treated
empirically,  that the  greatest error is committed.
It is viewed as a local, not as a constitutional affec-
tion  ; and many are the individuals  who  have been
sacrificed to the vain and  ignorant  attempt of pre-
maturely establishing menstruation ; mercury, drastic
purgatives and  emmenagogues, having irretrievably
destroyed the constitutional power and paved  the
way for phthisical disease.
   It  is  not my intention  elaborately to comment
upon certain great mistakes in the physical educa-
tion  of female youth.  And yet,  I must be excused,
if I  direct  attention  to the diet, air, exercise, and
clothing  of  the  sex.   It  will  readily be  granted,
that if, in these  particulars, there is extensive devia-
tion  from the dictates of nature and common sense,
there must  be  a proportionate risk of debility and
disease.   In our own changeable climate, it behoves
the guardian of  female youth  to be  especially pru-
dent ; and I am one of those  who think,  that it is
scarcely possible to study these  matters too closely.
If the national  practices  in these  particulars could
be changed—and  the remark  applies with great
force to  the middle  and higher  classes of society
living in cities and  towns—chlorosis, imperfect pu- 
CHLOROSIS.
43
berty and amenorrhcea, would be uncommon, instead
of being, as they now are, extremely prevalent dis-
eases.
  Chlorosis is a rare affection in  rural districts,
where female youth are much in the open air, where
it is  not unfashionable to walk and  run, and where
it is  not considered a gross violation of  good  breed-
ing to sport and play  with activity and vigor.  Such
girls acquire energy of system, each organ is devel-
oped, the blood is abundant and of excellent qual-
ity ;  nutrition is healthy,  and puberty is attained
without difficulty.
  These remarks may serve as an illustration of the
principles on  which  the treatment of simple and
amenorrhceal  chlorosis   must be  conducted:  and
while it is  scarcely possible to present a succinct
and  specific history of the  pathology of this and the
other complications, it  is  not  difficult  to  describe,
with simplicity and tolerable accuracy, the order of
morbid events  and the medicinal  means, by which,
they are to be relieved if not cured.
  I  have  already observed, that  a  morbid  state of
the blood, of which  anaemia is  the prominent fea-
ture, lies at the basis of  the disease.  This may be
viewed  as the clue, by which the  intricacy of the
symptoms  may be  unravelled : and it  will equally
explain the nature of the malady,  whether the spe-
cific morbid  impression be in the  system generally,
in an isolated organ, a particular texture, or  in  any
of the fluids of the animal economy.
  But, to  be more  precise:—I   would commence 
44                CHLOROSIS.

the treatment, by special attention  to the digestive
organs and  alimentary canal ;  for I  regard the dis-
order of these, as second  only in pernicious  effect,
to the peculiarity of constitution, already mentioned.
Nor will the advantage of  their improved condition
be limited  to themselves :  the deteriorated quality
of the  blood and its defective quantity, may both
owe their origin to impaired digestion and nutrition.
I have already alluded to  the  jaundiced  hue  of the
complexion  and of the surface  generally,  as leading
to the suspicion of hepatic disease.   The diagnosis
will be  made, by a careful examination of the  region
of the liver itself, of the urine and the faeces ;  which
will prevent  the  possibility of  being misled  by the
color of the lips and conjunctivae.
   At first,  then, a due evacuation  of the  bowels
must be daily secured;  and much  will  depend on
the kind of  medicine  by which this  is  effected.   If
mercury and drastic^purgatives  be  frequently  and
largely  employed, intestinal irritation  will   ensue,
evidenced by unhealthy  and  undigested motions,
mixed with  mucus, and occasionally with blood.   If
the purging  be excessive—if it be exclusively relied
on for the cure—debility and exhaustion will  result,
and,  in  place  of amelioration,  the  whole of  the
symptoms will become aggravated and severe.  The
best aperients are aloes, rhubarb, the sulphate of soda
and  manna, and,  if an alterative be  necessary, the
hydrargyrum cum creta.   Nor  must we forget, that
an injection  of a  pint of warm  water, two or three
times a-week, into  the  rectum, is, of all measures, 
CHLOROSIS.
45
the most efficacious in aiding peristaltic action, and
in removing the load of the large intestines.   The
compound  decoction  of  aloes  with the  compound
tincture  of cardamoms ;  the compound aloetic pill
with  the oil  of cassia  and  hyosociamus, and the
vinum aloes with the compound tincture of rhubarb,
are the forms of these medicines I prescribe.   The
combination, with  any purgatives or aperient reme-
dies,  of mild  cordials,  is  exceedingly  important.
The following may be advantageously  exhibited :

    Pulv. Rhei  5 ss.  Magnes.  Subcarb. 3 ss.  Conf. arom.
       9 i.  Aquae Cinnamoni 3 ix.  Tinct. Card. C.  3 i. M.
      ft. Hausl. bis terve in septimana sumendus.
    Sodee Sulphatis vel Magnes.  Sulphatis. § iss.  Pulv. Rhei
       3 ii.  Magnes. Subcarb.  Sodae Subcarb. aa.  3 hi.  Pulv.
      aromatici  5 ss. M. ft. Pulv. aperiens.
    Sumat Coch. i. vel ij. parva, bis terve  in septimana, ex
      aqua pura.

   It  is superfluous, perhaps, to observe, that warm
 clothing, regular  exercise, by walking, if  it  can be
 borne, if not, on horseback, are valuable auxiliaries;
 and,  so soon as the repugnance to  them can be con-
 quered, nutritious  animal diet  and mild malt liquor
 will  be productive of benefit.  The   improvement
 of the digestive organs, indicated by return of ap-
 petite and  the natural and daily  evacuation of the
 bowels, are generally accompanied by alteration  of
 the complexion, and  by the partial disappearance of
 the chlorotic  hue ; rarely by the  immediate estab-
 lishment or return of the catamenial secretion.  At
 this crisis, some of the preparations of iron  may be 
46                 CHLOROSIS.
exhibited ;  and  the  sulphate  is  probably  the  most
efficacious, and  possesses  more  specific properties
than  any of the rest.   If the  order  of procedure,
now pointed out, be reversed—if the  iron be used
before the bowels have  been freely evacuated and
their functional action improved, or while the tongue
is  loaded  and foul—aggravation  of symptoms will
be  produced ; while, if there be only the peculiar
debility and pallor,  then  the iron may be most  bene-
ficially tried.   A single  grain, or even two, may be
given, twice  or  three times  daily,  combined with
extract of hop, aromatic confection,  and  a single
grain of extract of poppy or hyoscyamus.   Occa-
sionally, the  effect  of the iron  is  almost  magical,
especially where it  does  not 'confine the bowels  nor
induce  febrile heat.  The  following  form  may be
prescribed :—
    Ferri Ammon. 3 iss.  Extr. Humuli, Extr. Papav.  alb. aa
      gr. xv.
    Ol. Cassias rn. xv. M. ft. pil. xxiv.  Sumat. i. vel ij. bis terve
      quotidie.
   Where there  is  torpor of the  system, flatulence,
and hysterical depression, a  tea-spoonfut of the  an-
nexed  mixture,  in  water, may be  swallowed with
each dose of the pills :
    Tinct. Humuli, Calumbae vel Gent. C. § iss. Tinct. Lyttae
       3 i. Sp. Ammon. arom. 3 iii. ft. Mist.

   It is impossible  minutely to  describe  every  cir-
cumstance which may require medical management:
in  a  lecture,  much  more  may be  accomplished. 
                   CHLOROSIS.                 47

Still, we  must keep  constantly in view  the pecu-
liarity  and the  anaemia of the chlorosis itself.  It
will  not then, be  difficult to  vary and modify the
treatment.  In some  instances, iron cannot  be ex-
hibited, or it may have  been too early used : it may
not have been employed in the right dose,  or in the
most desirable form.  These, and numberless other
minutiae, demand sedulous attention.   Quinine and
sarsaparilla, gentian and  zinc, are remedies of ac-
knowledged power : and  in  a variety of instances,
where the sulphate and  other preparations of iron
were injurious,  I  have given, with decidedly good
effect, the following  powder, either  once  or twice
a-day :
    Ferr. Subcarb. gr. viii.   Pulv.  Ipecac, gr. i.  Hydr. cum
      Creta gr. ii. M. ft.  Pulv.
   I have already alluded  to  the  necessity for  con-
tinued care  in the progress of the treatment; and
the hope of cure must rest, not on the vigilance of
a  week, but on the  perseverance and skill which
shall keep in activity, for months, every part of the
prescribed plan; not only the  medicinal but likewise
that which  depends on air, regimen and  active ex-
ercise.  I do not  dwell on the value of travelling;
because it  is universally  admitted,  that  nothing
contributes  more  to  cheerfulness and  health, than
change of scene, of air, and of temperature.  Chaly-
beate  waters are   sometimes  extraordinarily effica-
cious ; and a sea voyage has, within my own knowl-
edge, been productive of  entire cure, not only  com-
pleting puberty but leading to perfect menstruation. 
48
CHLOROSIS.
At  what  time shall  emmenagogues be employed ?
When the health is  so far  improved, that  there  is
less pallor, regularity of bowels, and more and  bet-
ter blood.  Iron itself, is often an efficient emmena-
gogue.  The  use, every night, of the hip  mustard
bath, and the local salt shower bath across the loins,
topically affects  the  uterus, and  induces the cata-
menial secretion.  The ammoniacal injection, com-
posed of one  drachm of the pure liquor ammonias
to a pint of milk, daily injected into the vagina, has
proved efficient in the hospital.
  I am not aware  that  any variation in this   plan
will  be required in chlorosis complicated with ame-
norrhcea.   Caution will  be most needed in the se-
lection of the time for  the  use of  emmenagogues:
but after what has  been  said now, and  what is to
be said hereafter, the reader cannot  remain long in
doubt.
  The  iodide of iron has  been extensively tried,
both in hospital  and private practice, and with  un-
doubted success;   especially  when glandular  en-
largements and  other  indications  of  a strumous
habit, have been associated with the chlorosis.  I
give it in the subjoined form :
    Ferri Iodidi gr. xvi.  Tinct. Calumbae vel Gent. C. § i.
      Aqua? distillatse  § vii. ft. Mist.  Sumat coch.  ii. magna,
      bis terve quotidie.
  Three or four leeches have been applied to the
mammae, on alternate days, with very doubtful effect
as to  the restoration  of the menstrual function :  nor
can  I  speak more favorably of the  employment, to 
CHLOROSIS.
49
the same organs, of  mustard cataplasms.  Marriage
frequently cures chlorosis and amenorrhcea:  yet  its
good effects are not  certain and invariable;  nor is it
uncommon to witness  the aggravated forms of the
malady in  married life.  A passing  allusion is  all
that is necessary on its remedial  influence ;  as  in
the chlorosis of early life, such a connection is un-
likely and distant, and even at  later periods, its ex-
istence is  not a  matter for  medical  discussion  or
control.   Electricity deserves  to  be mentioned,  as
a local  uterine  stimulant;  and I  have  seen many
cases where its efficacy was decided.
   The complications of chlorosis  require  extended
and scrutinizing investigation ;  and perhaps enough
has not been said of hysteria and chorea, as its com-
binations.   The former, in  differing degrees,  is  an
almost invariable  attendant on the malady;  while
chorea is rarely seen after twenty, and seldom after
sixteen  or  seventeen  years of age.   The  observa-
tions on the treatment of the  various  complications
will be appended to the illustrative cases.   By this
method, the cases themselves will  be rendered more
interesting, and their peculiarities and plan of man-
agement more distinct and prominent.
   In conclusion, let it be remembered, that the pro-
gress  of these affections  is often interrupted; do-
mestic occurrences of  a vexatious or  painful kind
produce frequent  relapses ; and the family as well
as the patient, despond.   Repeated attacks  of cold,
errors of diet, and a neglect of especial attention to
 the evacuation of the  bowels, may be  enumerated
              7 
50
CHLOROSIS.
as  the causes  of delay.  These,  the address and
practical  skill of the attendant must control : and
it is no slight tribute to  his worth in such protracted
cases, that the confidence of the  invalid  and of her
friends is continued  to  him unimpaired.   He  must
repeatedly urge, that while there  is  only one con-
sistent  method by which  recovery can  be accom-
plished, there  are  almost  innumerable ways  by
which a simple case  may assume  an inveterate or
complicated form.
         CASES OF SIMPLE  CHLOROSIS.

MANY OF THESE  AND THE SUBSEQUENT CASES  WERE  RE-
  PORTED BY THE GENTLEMEN OFFICIATING AS CLINICAL
  CLERKS AT GUY's HOSPITAL.


                       Case I.

  Mary------  aged  14, an out patient (under Dr. Ash-
well's care), January 6, 1835, is  stated by her  mother to
have been from birth -a delicate sickly girl, and  frequently
the subject of cough with mucous expectoration and pain in
the left side.   Her symptoms are entirely chlorotic.  There
is pallor of countenance, coldness of surface and  especially
of the lower extremities, lividity of the hands and  of the  tips
of the  fingers,  and emaciation.  Puberty appears partially
established, as there is  some development of the mamms •
the  pulse is  120 and  feeble ; respiration quick  and short •
cough distressing at night with slight mucous  expectoration •
;at 
CHLOROSIS.
51
the bowels  generally constipated, but occasionally purged ;
appetite capricious, dislikes all animal food, is fond of pastry,
tea, and bread and butter.   She is one of nine children, two
of whom are girls and older than  herself; and  in both, the
same  symptoms  have attended the  establishment of puberty
and menstruation.  The tongue  is loaded and tumid, and the
mucous lining of the mouth is  pallid and  indented by the
teeth.  She resides in  a confined narrow street, and sleeps
in a small room, in which are three beds. There is at times
a slight leucorrhoeal discharge;  the  urine is scanty and high
colored.

    Pil. Rhei c.  gr. v. omni nocte hora somni.
    Julep. Ammon. cum Magnes. §i.  bis quotidie.

   To live on beef-tea and arrow-root, and if possible, to  be
removed to a healthier  residence.
   Jan. 16. Her mother states that she caught cold when
last out, but she thinks  her bowels  more regular.   She is to
continue the remedies.
   26.  The bowels  are  regularly and  more  healthily acted
upon ; the  pallor is less; and the pulse  does not exceed 98,
fuller and softer ; the tongue is  nearly clean.
   She is to continue the ammoniacal julep with  magnesia
two or three times weekly ; and  to take the following mix-
ture :
     Ferri  Iod. gr. xviii.  Tinct.  Calumbre gi.  Aquae distillatae
       §vii. ft, Mistura.  Sumat coch. i. magnum ter quotidie.

   A  pint of mild ale daily, and animal food.
   Feb.  10.  Is  greatly improved;  complains of headache
and  throbbing of the  temple ;  pulse 80, and  full; bowels
rather confined.   Is to  omit the iron for a few days; and to
take  ten grains of the eolocynth and calomel pill every other
 night.
   17.   The bowels are quite  regular;  the cerebral  symp- 
52
CHLOROSIS.
toms are alleviated;  but  she complains of languor and de-
bility.

    Rep. Mist, et Cerevisia ut antea.
    Julep. Ammon. cum Magnesia §i. bis quotidie.

  Is ordered to go in the  country, and to be out much in the
open air.
  March  1.   Is  better in every  respect; and is  now re-
quested, in addition to the remedies, to use  the mustard hip-
bath every night.
  8.  Has menstruated for  three  days, with  little  previous
indisposition ; and is so greatly improved, as  not to require
further treatment.

                        Case 2.

           reported by  the  clinical clerk.

  Jane-----aged 19, a native of London, a girl of ordi-
nary stature,  light hair,  fair  complexion, and  brown  eyes.
Admitted May 2.  She began to  menstruate at  16  years  of
age, and has regularly observed a period of three weeks, un-
til within  the  last two months.   The only peculiarity con-
nected with the  catamenia, has been  the  light  color of the
discharge.   Her situation, as a house-maid, exposed her to
very irregular hours; and her enumeration  of  the symptoms
which attacked her, when in  this capacity, seems to indicate
the commencement  of disorder of the general  health.   She
suffered from headache, pains in the side, languor,  and rest-
lessness, which were succeeded, in two months, by a sup-
pression of the catamenial discharge.   Since this  time, her
disorder has increased, and she  now presents  the  following
symptoms:—The surface is uniformly of a very light-yellow
color, and  in parts, assumes an icterode  hue.    Around the
eyes, there is a darkened areola, and the integuments appear 
CHLOROSIS.
53
puffy.   The prolabia, with the  gums and  the mucous mem-
brane of the mouth and  fauces, are  exsangueous.  Tongue
flabby, with indentations  from the molar teeth on each side.
The nails are brittle and  the cuticle around them peels off.
The legs are free from swelling.   She  experiences conside-
rable dyspnoea on any slight exertion, and is very susceptible
of fatigue.  The appetite is capricious,  but she has not man-
ifested any particularly vitiated taste.   Bowels  naturally cos-
tive.  The pulsations of the heart are loud, and the  pulse
full.  No leucorrhoea.  There is no fixed pain  in any part of
the  abdomen.
     Colocynth cum Cal. gr. x. statim.
   May 6.  Bowels well open.   There is  very little differ-
ence in the character of  her symptoms, and  the general sur-
face remains pallid.   There is a slight leucorrhoeal discharge.
A bellows sound accompanies the heart's pulsations.
     Ferri Iodidi gr. xvi.   Tinct.  Calumb. §i.  Aq. §vii.  Cap.
       cochl. ij. magna bis die.
     Habeat Cerevisiae Oct. ss. quotidie.
   She was kept on this tonic plan, with occasional aperients
 and daily exercise, until  the end  of the month.   At this time
 she felt considerably improved.   Appetite  good ; secretions
 natural;  countenance still pale,  although the  yellow  color
 and dark areola had  disappeared.  At  her  request, she  was
 presented.   A  week after her departure from  the  hospital,
 under the same  treatment, the catamenia returned, and her
 countenance assumed a more ruddy aspect.

                          Case  3.

            reported by mr. henry oldham.

    Harriet S------, aged 18 ;  a girl of strumous diathesis;
 short; thin made, and  rather  inclined to emaciation.   Ad- 
54
CHLOROSIS.
mitted May 11.   She was born  in  London; where she  has
continued to reside, being in service as a house-maid.   She
has always been delicate, but has not been the subject of any
particular illness.  She began  to menstruate at  16 years of
age, but has never accurately observed the regular periods.
About five months  ago the catamenia became  suppressed,
and have failed to appear since that time.  This  seems to be
the date of her present illness.  She now complains of fluc-
tuating pains  about  the  chest, left side, and  back ; some-
times in the loins, and which occasionally proceed  down  the
thighs.   She  suffers  severe headache,  giddiness,  vertigo,
muscae volitantes, singing noise in the ears, with other symp-
toms of imperfect cerebral circulation.   Her arms, too,  are
sometimes benumbed; and the fingers deadened, so that she
cannot grasp anything firmly.  Her manner is  hurried ; and
at times there  are movements about her like the  first indica-
tions of chorea.   Several of the teeth  have lately become
carious.  Her legs  swell;  appetite fickle; pupils  dilated.
There is a general pallid  appearance, although  this has  been
somewhat improved by a steel  mixture, and occasional ape-
rients, which she has taken as an out-patient.   Bowels well
open.
    Ferri Iodjdi gr. xvi.   Tinct.  Calumb.  §i.    Aq. §vij. ft.
       Mist. Cap. cochl. ij. magn. ter die.
   May 16.   Feels much better, looks more lively, and her
appearance has improved.   Complains of dyspnoea, on any
unusual exertion.  Bowels  open ;   pulse small,  quick,  and
vibrating.   Has continued the iron  mixture ;  was enjoined to
keep the surface warm by sufficient clothing and was ordered
to take exercise daily.   Under this plan, her  strength  in-
creased, she  became  stouter and of a more natural  color.
She suffered  headaches occasionally, which an aperient usu-
ally relieved ;  and on June the 4th, the following report was
entered.
   " The catamenia  appeared  two   days  ago, the  discharge
 
CHLOROSIS.
55
lasting only  twenty-four hours.   She has  felt great  relief
from  this circumstance ; her  general health has  greatly im-
proved ;  pulse 80 ;  bowels well opened daily ; tongue clean."
  July 4.   Presented cured.


                        Case  4.

                repored by mr. foote.

  Charlotte------, aged 26, an unmarried woman, with
dark hair and  eyes and  chlorotic aspect.  The menstrual
function  for the  last seven years  has been irregularly per-
formed, there having  been suspension for five or  six months,
and always a scanty flow.   Her present symptoms are, pal-
pitation,  dyspnoea,  cough, pains in the  chest  and  loins and
between  the  shoulders.  Her legs  are  oedematous: she has
no appetite ; her pulse is  80, and soft;  tongue clean; bow-
els confined.

    Cap. Jul. Ammon. cum Magn. et Tinct. Card. Co. gi. ter die.
    Beef-tea.  Arrow-root.

  June  20.   Appetite slightly improved ;  still there is pain
in loins and back.

    Ferri Iodidi gr.  xviij. Tinct. Calumb.  gi.  Aq. gvij. ft. Mist.
       Cap. coch. ij. mag. ter die.
    Allowed one pint of porter daily ; and  of wine, an  ounce
       and a half.

  July 5.   She has been  improving considerably under the
treatment, and  makes  but little complaint.  Her  bowels are
very confined.
    Pil. Rhei. co. gr. x. o. n. s.
    Tinct. Castor. Sp. Lavand. Co. aa gi.  Ammon. Subcarb.
       B'i. Aq. Cinnam.  § vii. ft. Mist. Cap. cochl. ij. magna ter
       quotidie. 
56
CHLOROSIS.
  26.  Face losing its chlorotic appearance ;  better in all
respects.
    Inf. Gentian. Co. Inf. Sennas aa 3vi. bis die sumend.
  Aug. 4.  The menstrual discharge, which appeared on the
1st, has lasted three days; complains now only of headache.
  12. She was discharged, with her health and countenance
very much improved.
  Sept. 6.  Returns to-day, to  say that she is well.  The
catamenia have again appeared, in proper quantity, and  for
four  or five  days.   Her cough,  dyspnoea,  and palpitation
have not returned at all since the last period.

   These few cases,   selected  from  many  similar
ones, are sufficiently numerous  to  ensure a  trial  for
the plan of treatment  pointed  out, and  to demon-
strate the importance of early and  unremitted medi-
cal care.   Neglect,  in these instances, would  proba-
bly have insured  aggravation  and  severity ; and in-
stead  of a cure  easily accomplished,  there  would
have been protraction, difficulty, and danger.   It is
worthy of remark, that the iron will not suit every
individual; and  although it  has a more direct and
salutary effect, where  the uterine functions  are tor-
pid, than any other known  remedy, yet the quinine
must occasionally be substituted.  I cannot forbear
especially to urge the daily use of mild ale or porter;
as,  independently of  its agreeable properties as a
beverage, it greatly assists in the restoration of flesh
and strength.  If these cannot be  taken, port, sher-
ry, or madeira wines,  with hot water  and  a little
spice, will  advantageously excite  the  stomach, and
promote digestion. 
CHLOROSIS.
57
   The temperature of the body is  often supported
with  difficulty in  chlorosis ;  and  as  cold induces
congestion, warm clothing and  exercise are import-
ant adjuvant  measures.   The circulation of delicate
girls  is  feeble and lymphatic;  their  stomach and
bowels are soon deranged;  and  by such causes the
uterine functions are interrupted and impaired.


 CASES OF INVETERATE AND  CONFIRMED CHLOROSIS.

   I shall  insert  only two such—because it is easy,
after  what has been already advanced, to imagine
an aggravated form of the  malady.   Still, it would
not be right altogether to omit its illustration by ex-
amples.

                       Case 5.

   Miss B-------, at. 27, March, 1833, began to  menstruate
 at 15, and till  within the last three  years has enjoyed good
 health.  Since this period she has  lived in town,  and  the
 catamenia have been  gradually diminishing  in  quantity and
in color, till now the  discharge scarcely lasts  more than a
a  few hours, and has lost all  sanguineous tinge.   The pulse
is 108 to 120, irritable and easily compressed; the breath-
 ing is  quick and short,  on the slightest exertion;  and  the
heart palpitates often and violently.  Her depression  is ex-
treme, and she entirely desponds as to her recovery.
   There is no acute neuralgic pain of the head,  but  she
 suffers much from vertigo and loss of memory.   Her aspect
 is a dirty, almost green yellow, very  much beyond the pallor
 of incipient chlorosis ; the bowels are generally constipated,
 but occasionally much  purged, the motions being highly
                8 
58
CHLOROSIS.
offensive and dark.  There is a fetid odor about the breath ;
frequent nausea, and sometimes  vomiting;  the cellular and
muscular tissues are flabby, and the alarm of her friends has
been especially excited  by  her  progressive  emaciation, and
her icterode hue; the tongue, lining membrane of the mouth
and  lips, are of unhealthy paleness ; there  is  a dark  mark
under the eyes, and at  the  angles of the mouth ; the nails
are  chipped and dark; and  the skin is dry.  In addition  to
these symptoms  she has frequent  hacking  cough ; and al-
though  it is thought to indicate  approaching  phthisis, it evi-
dently depends very much on nervous excitement;  emotion  or
hurry invariably  produces  it, and there is no expectoration,
pain in  the side, or morning perspiration ;  on the whole there
can be no doubt that this is a severe and  aggravated case  of
chlorosis, as yet a  functional  disease, and  one  which will
probably yield  to persevering and careful treatment.
   She was ordered the following :—

     R.  Ferri  Iodidi gr. xv.  Tinct.  Card. C. §j.  Aquas  distil-
      latae g vij. M. ft. Mist.
     Sumat Coch. i. magnum ter quotidie.
     R.  Pil. Rhei  C.  Extr.  Colocynth.  C. aa  3 ss.   Hydr.
      Chloridi gr. v.  OI.  Cassiae gtt. xii.  M.  ft.  Pilulae xiv.
      Sumat ij. vel. iij. alternis noctibus.
  Chocolate or  coffee and broiled bacon for breakfast; roast  or
     broiled  meats for dinner, with mild malt  liquor, especially
     a!e ; weak coffee or chocolate in the afternoon ; and a sand-
     wich, with a small quantity of ale for supper.

  March 14.   Is still  feeble ;  although in several  respects
better;  has less cough; breathing less quick;  nor does the
heart palpitate  so  violently.  Has more appetite; the bowels
are in a healthier state ;  and there is less leucorrhoea.
  She is strictly  to continue the same plan.
  April 1.  Is steadily  improving; there has  been a  very
slight menstruation.—Pergat.
  April 14.   Has had the  catamenia for two days and  a 
CHLOROSIS.
59
half;  the secretion of good color and large  in amount; pal-
pitation and pain of side much less ; appetite  improves very
slowly ; aspect clearer.   Thinks the iron produces headache;
pulse  100.

    Omitte. Mist, cum Ferr. lodid.  Cont. Pilulae.
    Be. Infus. Rosae C. gvij. Tinct. Humuli, Tinct. Card. C. aa
       3iv. Quinina? Sulph. B'u  Acid. Sulph.  dil. *n.x.
    M. ft. Mist.  Take one tablespoonful three times a day.

   May 26.  The catamenia have returned twice since her
last visit; and  the secretion has been altogether healthy.  Is
still far from strong;  but the cough and all  the distressing
symptoms  are  so greatly improved  as  to leave no doubt of
ultimate recovery ; she is about to visit  Tunbridge Wells.  I
saw this patient once more in the latter part of  the summer,
and she was entirely restored.

   The next case  is  one  of  aggravated  chlorosis,
complicated  with menorrhagia  and leucorrhoea.


                         Case 6.

   Mrs. B-------, act. 38, is the mother of six children, the
youngest now, July  1837, four years old; she has been for-
merly weakened  by over  lactation, and  by several bad mis-
carriages.   Has been menorrhagic for  the last  three  years,
the discharge not only being  profuse and clotted, but lasting
for eight or nine days, with  leucorrhoea in the intervals.  A
humid atmosphere has aggravated the disease;  the aspect is
highly chlorotic; the hue of the  skin  dirty white;  and the
dark marks  about the eyes and angles of the mouth and alae
of the nose are especially apparent.  It is scarcely necessa-
ry to  say more than that every symptom of the  disease ex-
ists in aggravated form, especially  vertigo.   She dare  not,
sometimes, for  a day or two, walk across the room; her body 
60                  CHLOROSIS.
seems to have been almost drained of its blood ; and  what
remains, judging from what is  lost  in  epistaxis,  is  very
watery and attenuated.
  Her great fear is that she shall become  entirely dropsi-
cal, as her  lower limbs are anasarcous and the arms oedema-
tous.  She is hysterical and nervous, almost to insanity.

   I  need  not detain the reader by  the daily and
weekly details;  suffice it to say, that a  year elaps-
ed before the disease was cured.   A variety of pal-
liative and adjuvant  remedies were employed ; but
the  great benefit was derived  from iron, ergot, and
camphor.
   The  form  of pill  most  frequently exhibited,  I
annex.

    R. Ferri Sulph. vel ammoniat.  gr. ij.  Camphorse gr. iss.
      Cons. Ros. q. s. ft. pilulae.  Take one pill twice or  three
      times a day, or
    R. Ferri Sulph. 9i. Secalis Cornut. (in pulvere) 9ii. Syr.
      Simp. q. s. ft. pilulae xii. Take one, or two pills, twice or
      three times daily.

   It  must  be borne in mind, that  the  ergot  is  a
remedy of variable power, although, in the  cases fit
for its use, it  more frequently  fails  from not being
fresh, and from  having  been  long in a  powdered
state and exposed  to  the light, in a white bottle,
than from a want of beneficial activity in the genu-
ine drug.
   The  menorrhagic and leucorrhceal form of the
malady is rare in early life.   It  generally occurs in
women who have borne  children, who have worked 
CHLOROSIS.                  61
hard, and who have lived irregularly and on scanty
and  poor food.   I  have  seen several  cases of this
form of the disease in  the  wards at Guy's;  and it
is worthy of  observation, that iron succeeds  almost
invariably in  their  cure.   Perhaps  this  may  prove
that they are chlorotic maladies.   Were they merely
cases of loss of  blood and  simple anaemia, nutritive
diet and a  restraint of  the  hemorrhage would cure
them ;  but I  am convinced they are more than this.
The indications  of  chlorosis are  really present, and
the  remedies  for chlorosis,  especially iron, will  be
required.
CHLOROSIS complicated with vicarious discharges of
  blood, and disorder of the stomach and bowels.


                      Case 7.

            REPORTED BY DR. JOSEPH  RIDGE.

  Aug. 9, 1836.  Eliza------, aged 16, a delicate, chlo-
rotic girl, with  pale cheeks  and exsanguine prolabia : has
always lived in London, and  has enjoyed  tolerably good
health.
  She has been engaged for the last four years in a sedentary
occupation (waistcoat-making); and has rarely quitted the
house, sometimes not for weeks together.  The catamenia
appeared first a year ago, continuing for three days, but were
of light color:  they observed  the natural period for five or
six months;  but on each successive recurrence were more
scanty and serous, with lumbar and pelvic pains, and great 
62
CHLOROSIS.
lassitude.   For the last twelve  weeks, the function has  been
entirely suspended ;  and she has suffered, for some time, from
dyspepsia, constipation of the bowels, and intense headaches.
Nine weeks ago, she had  a severe  attack  of haematemesis,
which was preceded  and attended  by considerable pain over
the stomach, and sickness after eating.   It continued for four
days ; and,  according  to  her  own account, she must  have
vomited altogether several  pints of blood.   There  has  been
occasional epistaxis since; and  once or twice, a slighter re-
turn of hemorrhage from the stomach.   She at present com-
plains of flatulency ; pain in the left side; of dyspnoea; dis-
turbed  action of the heart upon exertion ;  and pain in the
occiput.  The tongue is pale, moist, and flabby ;  pulse quick,
silky, and irritable.

    Sumat Pil. Colocynth. cum Calomel, gr. x. bis in hebdomadal,
      hora somni.
    Mist, cum Ferri Sulphat. gi. ter quotidie.
    Liq.  Ammon.  pur. 3iss. Lactis  tepid.   Oct. i. pro Injec-
      tione, quotidie utend.—Meat  diet, and a  pint of porter
      daily.

  Aug. 20.   Is relieved  from  many of  the symptoms;
slight epistaxis yesterday :  bowels well open.—Pergat.
  24. Complains of fullness and  pain  of  the  stomach and
head; her aspect is less anaemiated.
  27.  Considers herself much improved ; appetite good :
pulse stronger : complains only of headache : she was order-
ed to take air and exercise, in the square.
  30.  Makes  no complaint.   Some  color is returnino*  to
her cheeks; and though the catamenia have not yet a^ain
appeared, her  general  health  is so  rapidly improving,  that
she is allowed to become an out-patient.
  Sept. 8.   Has menstruated  fully and without pain, and is
rapidly recovering her  health. 
CHLOROSIS.                    63
                         Case 8.

             reported  by dr. joseph ridge.

   Eliza-------, aged  19; a girl with light hair; of pale,
 waxy, and  chlorotic aspect; and  under the middle stature :
 admitted as a patient of Dr. Ashwell, Jan. 7, 1836.
   She was born in London; has been occupied as a domes-
 tic servant;  and till  within the last twelve months  has en-
joyed good health.   Menstruation commenced  at the age  of
 16; and was perfectly natural till the commencement of her
 illness; at which time, the function was suddenly suppressed,
 the suspension still continuing.   Her general health has been
 gradually giving way, and there has been progressive emacia-
 tion.
   Vicarious discharge first occurred  during  the  last week;
 and on  three successive days she vomited  about half a pint
 of dark-colored  and  clotted blood.   Her  present symptoms
 are, pain in the head, accompanied, on assuming the erect
 posture,  by  violent  throbbing, giddiness,  swimming of the
 sight and singing in  the ears.  There is  palpitation of the
heart, increased  on exertion; inability to lie on the left side;
globus hystericus; dyspnoea with slight cough, but without
expectoration ; constant  pain of the right  side ; loss of ap-
petite ; occasional tumefaction of the abdomen ; constipation
of the bowels ; and, at intervals, abdominal pain and tender-
ness.   The tongue is clean, but pale and relaxed :  pulse 90,
compressible, yet jerking.
    Sumat Pil. Colocynth. cum Calomel, gr. x. ter in septimana.
    Mist, cum Ferri Iodido more solito praeparat, coch. ii. ma-
      jora ter quotidie.
    Utatur Injec. cum Liq. Ammon. pur. et Lacte quotidie.
    Diet, Beef-tea, and Arrow-root. 
64                   CHLOROSIS.
   Jan. 12.   Complains of pains in the sternum, in the region
of the heart, and of throbbing  pains in the head : sleepless-
ness.   Skin cool.

    Pergat.
    App. Cucurbitulae sine ferro nuchas.

   18.  Feels better, though the head  is still painful  and
dizzy.

    To be electrified.

   23.  Severe pain  in  the  left side, probably  hysterical :
head  is  very painful, and  throbs violently:  bowels open:
tongue clean.

    Omitte Mist, cum Ferro.   Sumat Decoct.  Aloes C. § iss.
       quoque primo mane.

   28.  Suffers still from dyspnoea, and  neuralgic pains in
the side : headache : abdomen tumid : bowels open.—Pergat.
   Feb. 4.   There has been considerable improvement:  she
has been freer from pain, and is active about the ward; bow-
els are well  relieved.
   6.   Continues to improve : is much less subject to dysp-
noea and palpitation :  the pains in the head and side are re-
lieved.  There has  been no appearance  of  the  menstrual
secretion.
   9.   Has a return of the former  symptoms, though not in
so aggravated a form.  Bowels open.

    Mist. Ferri c. §i. ter die.—Pergat.

   15. The pain  in the side  is  increased;  otherwise  she
continues the same.

    Emplast. Opii part. dol.

   22.  She now complains of a load at the  stomach, after 
CHLOROSIS.
65
taking food; and for the  last  day or two  she has vomited
about an hour after dinner.  Tongue clean : pulse feeble.
   27.  Since the last report, she has  been better until yes-
terday afternoon, when, after  dinner, she retched violently,
and brought up a small quantity of dark-colored blood, after
which the dyspnoea  and  pain  in the chest returned.   Pulse,
80, soft, but somewhat sharper.
   March 2.  The  oppression at the  chest  returned  again
last evening;  and this morning she  was  seized with another
attack of haematemesis, and vomited  half a pint of dark-col-
ored blood.  Bowels open : pulse 96, and feeble.

    Cont. Medicament.

   At her own request, she was made  an out-patient; and
under a similar course of treatment, in country air, the vica-
rious  hemorrhage was  subdued ; she returned  again  to the
iodide of iron, and after six weeks  the  catamenia  appeared.
I have seen this  patient several times since;  and, by  purga-
tives, iron, and exercise, the bowels, and  the  uterine func-
tions, are preserved in a healthy active condition.


                         Case  9.

            reported by mr. henry oldham.

   Eliza H------,  aged 24, a  woman of moderate stature,
dark  hair,  fair complexion, and spare  habit,  was  admitted
July 4, 1835, under Dr. Ashwell.    She has  been married
nine months, without pregnancy, and is employed in general
household  work.  She  began  to menstruate at 15 years of
a°-e since which time she  has had occasional attacks of ame-
norrhcea.  These never extended over many periods ; but the
discharge was usually restored  by taking aloes, with new-laid
eggs.   She has been in delicate health for four or five  years;
principally  complaining of a bad cough  with  expectoration,
                9 
66
CHLOROSIS.
occasionally accompanied  by pains  about the epigastric re-
gion.  For this she has been frequently blistered and leeched.
For  the last  half year,  at every  monthly period, she has
vomited a quantity of dark-colored  grumous  blood, and the
catamenia  have proportionally diminished  in  their  amount.
These attacks of haematemesis once or twice  supervened  on
coughing;  but usually  they  were the  result of vomiting.
She has  latterly abstained  from intercourse, as  it produced
intense pain in the vagina  and hypogastric regions.
   She looks pale and wan : complains of considerable head-
ache  and lumbar  uneasiness:  she  is weak,  and  unable to
perform her usual  duties.   There  has been  profuse  leucor-
rhoeal discharge for seven  or eight months, pain in micturi-
tion, and  a tenesmic  effort  to  evacuate  the  contents of the
bladder.  The skin  is  moist; but has lost its resiliency, so
that, when pinched between  the  fingers, it is slow in regain-
ing its  natural position.   Tongue flabby,  indented  at the
edges,  and rather foul.   Bowels  naturally  costive.  The
mammae  are  very tender, and there is occasional  nausea.
On examination, the uterus was  found of its  natural size,
and the os and cervix of their normal form and dimensions :
they were, however,  tender to the touch.  Abdomen  tumid.

     Col. cum  Cal. gr. xv. statim; et repet.  alt. noctibus.—Su-
       mat Inf. Rosae  cum Mag. Sulph  §i. bis quotidie.

   July 8.  The general uneasiness was  relieved by the free
action of the  purgatives.   The headache  has been intense,
and increased when  in  the recumbent posture.   She sleeps
heavily;  and being continually disturbed by frightful dreams,
she rises unrefreshed.  She complains of a fixed sharp pain,
on pressure, beneath  the margin  of  the lower ribs on  the
right side.   Leucorrhoeal discharge profuse :  pulse 100.
The pain  in  the  left mamma is severe  ; the left nympha is
elongated, and a superficial ulcer is seen on its inner surface.
Heart pulsates forcibly. 
CHLOROSIS.                   67
    Ferri Iodidi gr. xvi.  Tinct. Calumb. gi.   Aq. distillat. gvij.
      Cochl. ij. magna ter die.
    PH. Rhei c. gr. x. p. r. n.
    Liq. Ammon.  3i. Lactis Oct. i.  fiat Injectio, omni  nocte
      utenda.  Hirudines vi. mammae sinist. applicand.

   10.   She feels better.  The headache and pains in the
mamma have decreased.  Bowels open : pulse 90.

    Rep. Medicamenta.

   13.   There is heavy dull pain  in the  head; aggravated
on  lying down, and  preventing its  free movements.   The
pain in the loins occurs  in paroxysms; and is so severe as to
occasion sudden  and spasmodic starts, like those  produced
by  an  electric  shock.  Pulse 86,  soft and regular.   The
leucorrhoeal  discharge  is  lessened :  the  os is still tender.
The ulceration  on the  nympha is  healed.   Bowels  open :
countenance and general surface more healthy.
   15.   The white  discharge has  been  examined, and is
found to be mucus.   This is the period for the return of the
catamenia,  and  the  usual time for  the  reappearance of the
haematemesis.  She  has expectorated some gelatinous mu-
cus, but no  blood.   Bowels  open.  Pulse quiet: lumbar
pain diminished.

    Repetantur Medicament.

  20.   The paroxysms of lumbar pain have entirely ceased,
and she looks much more healthy.   The catamenia  have not
appeared, and there  has  been no premonitory symptom  of
the haematemesis.   Headache entirely relieved.  Skin moist;
bowels open.

    Omittant Injec. et Mist.—Capiat Ferri Carb. 3i. ter die.
    Electric sparks to be passed through the loins.

  24.   The  electricity has  been four times repeated ; and
was  to-day immediately  succeeded  by considerable  pain, 
68
CHLOROSIS.
both in the loins  and thighs.  The  leucorrhoeal discharge
greatly diminished.   She feels much improved.  Secretions
natural : appetite good.
  25.   From  her sensations, she  expected the re-establish-
ment of the catamenia :  in  other  respects the same as yes-
terday.
    Rep. Medicamenta, et Scintilla? Electr.

  26.  The catemenia appeared early this morning, accom-
panied by great pain  in the loins and thighs.

    Balneum tepid urn hac nocte.—Pergat.

  The discharge continued to flow until the evening of the
28th.   With its cessation  she  experienced considerable re-
lief, and quickly began to amend.   The  electricity was con-
tinued  on  alternate  days, with the daily exhibition  of the
carbonate  of iron.  On the 11th of August she complained
of severe  pain  at the scrob.  cordis, sore  throat, and  head-
ache,  the  effects of an imprudent exposure to  cold.  These
were  relieved  by antiphlogistic measures, and soon  disap-
peared.  Under a continuation of the tonic  plan of treat-
ment,  her strength  was renovated.  The surface lost  its
pallor, and the circulation  was  well and vigorously car-
ried on.
  Aug. 24.  The catamenia have  again  appeared, accom-
panied  by lumbar pain, and  sympathetic irritation  of the
mammae.
  On Sept. 2, she left the hospital, free from serious malady ;
and so greatly  improved  as to leave no doubt of her ultimate
recovery.
                  OBSERVATIONS.

   It will not be necessary to offer many remarks on
the  preceding  group of  cases.  Haematemesis  oc-
curs  more frequently than is supposed ;  and in con- 
CHLOROSIS.
69
nection with so much  pain, fulness, and congestion
in several organs, as might  appear to justify active
treatment.  I have seen bleeding, purging, and lead,
lavishly employed ;  but  with decidedly bad  effect.
In  all the  four  cases  narrated, there was anaemia,
quick  irritable pulse, and  excitement, precisely the
symptoms of chlorosis,  and such  as  may, without
difficulty, be  distinguished from similar symptoms
dependent  on acute  inflammatory disease.   The
transient neuralgic  character of the chlorotic pains,
notwithstanding  their  severity, the  amenorrhoea,
countenance,  and pulse, must lead  to a correct diag-
nosis, and to modified  and local  treatment.  The
great indication  is, either, to establish or to restore
the catamenial function ; and to attempt the  attain-
ment  of this point, even  by  the  empirical  use  of
emmenagogues,  bad as the practice may be, is less
injurious than a  full pursuance of the antiphlogistic
plan.   Blood-letting can  seldom  be required.   On
one occasion, I visited a chlorotic  patient who had
been bled from  the arm  for the  relief of thoracic
fulness  and difficult respiration :  she  was partially
and temporarily  relieved.   It was  thought advisable
to repeat the bleeding ; and nothing could be more
conspicuous than  its bad  effects.  Her prostration
of strength was  extreme ;  the  breathing  was more
laborious ;  and an anasarcous state of the body was
universally apparent.  Nor is  it  less important to
reiterate the caution against excessive  purging, es-
pecially where  mercurial  or drastic  medicines  are
employed.   The first  object, doubtless, is to pro- 
70
CHLOROSIS.
cure, by proper aperients, healthy and regular evac-
uations ;  but the anaemia  of  the  patient  must be
increased  by their undue exhibition—a practice so
common, that some individuals doubt whether more
harm than benefit  has not  accrued from their use.
Let this be as it may, it  is  quite true, that the  evil
results of such  a plan are  not confined to the sto-
mach and  bowels themselves;  the irritation  and
flatulent distension of the  intestines leading to ag-
gravation of the chlorosis,  and  to  nervousness  and
distressing  sinking, very difficult to be  borne :  and
yet, with such an increase of disorder, I have known
mercury and aloes persevered in  for  weeks.  So
strong is the prejudice in favor of a " good, active
purgation."
   Electricity, the mustard hip-bath, the ammoniacal
injection, leeches to the vulva,  moderate cupping to
the loins, the various emmenagogues, and  occasion-
ally a very active purgative, are the remedies pecu-
liarly appropriate to this  complication.

                     Case  10.
  chlorosis complicated with cerebral affection.
  Mary------,  aged 19, admitted as an out-patient under
Dr. Ashwell, Nov. 10, 1833.   She began to  menstruate at
13 years of age ;  and from that period was never quite well
frequently complaining of lumbar pain,  headache, indiges-
tion, &c.  These  symptoms  were disregarded for three or
four years, and then they became too acute to remain unno-
ticed.  She is now considerably emaciated, suffers  intensely
from pain in the head, is frequently unconscious, and her in- 
CHLOROSIS.
71
tellect is greatly impaired.   Her breathing is laborious, with
frequent palpitations  of the  heart, and pain  in  the cardiac
region.   If she lie down suddenly in  bed, and without two
extra pillows, her breathing is so interfered with, that she is
afraid of suffocation.   Her digestion is bad, her appetite ca-
pricious and depraved, caraway-seeds and  mint being favorite
articles of diet.  Aperients are  constantly given, and never
without the removal of scybalae.   Pulse  130, quick, irrita-
ble, and feeble ; pain in the  side  very acute:  has  not men-
struated at all for the last three months, and not properly for
the last year.   Her tongue is marked  by  the teeth, and the
lining membrane of the mouth is unhealthy.   Her  aspect is
blue  and  leaden, and  the prolabia almost bloodless.  Her
finger-nails are  cracked, and her extremities are of the chlo-
rotic hue.   Urine scanty,  and high-colored.

     Ordered, Cordial  aperients;  Leeches behind  the  ears; the
       iEther-wash to the  head ; and a Pill three times daily,
        composed of one  grain each of Quinine, Camphor, and
       Hop; with nutritious Animal Diet and mild Ale.

   Dec. 6.  Somewhat better.   The  catamenia  have not
appeared.
     Pergat.
   24.   Less headache; acute lumbar  pain ; spasms of the
lower part of the abdomen.
     Applicentur Hirud. x. labiis pudend.—Hot mustard  baths.
   Jan.  6, 1834.  Has menstruated  for  nearly four days,
plentifully, and without pain ; is, in all respects, improved.
     Pergat.
   20.   Headache nearly gone; acute pain  in  the  side, and
difficulty of respiration less; still emaciated,  and appetite
impaired ; bowels much constipated.

     Sumat Cal. cum Colocynth. gr. x. alternis noctibus. 
72                    CHLOROSIS.
   31.  Bowels well cleared, and more regular; improved
in appearance.
   Feb. 28.   Calls to say she is quite well.

                        Case 11.
   Jan. 23, 1836.   Miss------, aged  34;  of delicate  and
leuco-phlegmatic appearance ; menstruating irregularly  and
scantily, but especially for the last year ; devoted to reading,
and occasionally oppressed by anxiety, but never called upon
for any laborious exertion.  Bowels confined:  pulse quick
and feeble : appetite  never very good.   On the  whole, up
to twenty-five or perhaps thirty years of age, she was tolera-
bly healthy, and sometimes florid.  The complaint for which
she now seeks advice is  headache, which  has  existed more
or less severely for six or seven years.  It was unnoticed at
first,  and  was  accompanied  by  a jaundiced appearance of
skin,  and by retching ; but the vomiting never removed, and
scarcely  palliated  the  pain in the head.   There  was not
much done medically for the first few years ; but her health
became gradually  more  impaired ;  and about twenty-four
months since  the  pain  assumed  an intensity and constancy
never previously belonging to it;  every symptom since  this
period has been grievously aggravated ; and  the disease  now
absorbs her whole attention.   In October, 1835, new symp-
toms  arose—pain deeply seated  in  the orbit, tension of the
tympanum with soreness and painful hearing; throbbing and
beating of the head, and,  in a  few days, almost entire deaf-
ness,  lasting till  December; since which  time the  deafness
has only  recurred  during menstruation,  (which  is  almost
amenorrhoeal,)  alternating with a peculiar sensation of syn-
cope,  tension,  and  noise  in the  ear.   Remedies  have been
tried,  of  a  mercurial, depletive,  and  antiphlogistic  kind.
Pulse 110, quick and irritable.
    Good diet, principally animal food and ale, without wine or
      spirit, were enjoined. 
CHLOROSIS.                    73
    Iodide of Iron, and  Colocynth  as  an aperient, but without
      Mercury, were exhibited ; and the head was shaved, and
      the iEther wash applied.

  Feb.  20.   Considerably  improved in all respects.   To
use the mustard hip-bath before  the catamenial  period, and
continue  the same remedies.
  March 20.   Has  menstruated  for three days, and without
pain.   Her cerebral  symptoms less ; still very far from well.
  April  30.   Is certainly greatly better.  Her intense head-
aches return at very  distant intervals.   She  is gaining flesh;
and is able partially to  resume  her occupation of  teaching.
Bowels  regular; urine  natural; pulse  90,  but feeble,  and
easily compressed.   Still  continues the  iron, and the mus-
tard-bath, before the period.  Is  ordered to take much out-
of-door exercise.
   I have not since seen this patient; but during  the present
month, September, I have heard, from a relative who lives
in the same  town,  that there has been no  relapse.   The
catamenial function  is  well  performed ; and the headache
and the cerebral affections have entirely disappeared.


                        Case 12.

              reported  by mr.  blackburn.

   Emily-------, aged  17,  a tall thin  girl,  of  florid com-
plexion,  and  of intelligent appearance, was  admitted  under
Dr. AshwelPs  care, Feb.  5, 1836.   She  has  always been
weakly ;  and for the last four or  five  years has been subject
to chest affection, from  which she has  been free since the
existence of  her  present malady.   Two years  ago she had
phrenitis, and  has since  been in imperfect health, being often
seized with aggravated fits of hysteria, so that  she  falls  and
remains insensible and motionless for  hours together.   She
is now deaf, and has once  had otorrhoea;  but  its  presence
                 10 
 74                    CHLOROSIS.
             ■
 was attributable to an accidental injury of the meatus  exter-
 nus.   She has intense headache, chiefly affecting the occiput.
 The  cephalalgia  was unusually severe  in  Dec. 1835; and
 soon afterwards her right  foot  and hand were frequently in
 agitation.  A month subsequently she lost  all control  over
 them ;  and since this time there has been aggravation  of the
 pain.   Ten days ago she was delirious, and  remained so for
 a few hours.  Menstruation has been only once regular and
 natural.  Her present symptoms are—dulness, almost  imbe-
 cility of intellect; constant and rather acute occipital pain;
 frequent but not very violent agitation of the right side, with
 occasional spasms of the left;  little  or no  affection  of the
 face ; no difficulty of articulation.  Bowels  open by  purga-
 tive medicine ; skin soft, and moist.

     Pulv. Scam, cum Cal.  gr.  xv.  statim.   Ferri Subcarb. 3i.
       quarta quaque hora.
     To take  half-a-pint of porter daily, and use the flesh-brush.

   This treatment  was pursued for a fortnight with advantage;
 and the daily reports exhibit progressive amendment.   The
 agitation is decreased, and  the pain in the head diminished.

     Zinci Sulph. gr. ij. ter die.—Balneum pluviale omni aurora.

   Feb. 22.  The agitation is much less ; and she has re-
 covered considerable  power  of the left  hand, but not so
 much of the  leg.  Bowels open ;  tongue clean.
   25.   The  agitation  has somewhat  increased, and  she
 complains of pain  in the affected arm and leg.

    Augeatur dosis Zinci Sulph. ad gr. iv. ter die.

   She  continued  to  improve until March  11 ;  when  the
 nurse reported that she  had had a fit in the  night, in  which
 she appeared to have lost the power over her limbs, and  the
 legs were somewhat contracted : the hands were placed over
the occiput, where she appeared to suffer pain.   She is now 
CHLOROSIS.
75
rather  confused ;  pupils dilated, though obedient to light.
There is some involuntary movement  principally confined to
the left  side.   Bowels well  opened yesterday ; pulse small,
and soft.

    Radatur Caput.  Lotio frigida constanter applicand. Zinci
      Sulph. gr. iv. ter die.

   March 16.  Had another fit this morning, but much  less
severe than before.  Pulse  quick;  pain in the head not in-
creased.
   22.   Has  had  no  return  of the fits, and appears much
improved.  The  involuntary twitcbings are comparatively
slight.   She  is more "-collected, and  can articulate  clearly.
Bowels  open; pulse quiet;  still  deaf; her strength is so
increased, that this morning she  was able to walk twelve or
fourteen yards.

    Inf.  Rosae. cum Quin. Sulph. gr. ij. t. d.—Pil. Rhei C. gr.
      x. p. r. n.

   She remained  in the  hospital till April 21, when  she  was
presented quite  well.   During this  time she  gradually re-
gained her strength, losing all symptoms  of chorea.  The
general  health was confirmed ; her appetite returned ; the
catamenia appeared, though  scantily;  and  her countenance
assumed its natural aspect.
   Her intellect is still somewhat impaired ; but the  head  is
free  from the occipital pain, and there is  no symptom of
structural change.

   The cases narrated, illustrative of this complica-
tion, require little  comment.   They attest  the  ag-
gravated  severity  of  the cerebral  affection;  and
present indications so similar to those resulting from
structural change, as fully to demonstrate the diffi-
culty of correct diagnosis.   Although it  is very rare 
76
CHLOROSIS.
for organic affection of the cerebrum  to accompany
chlorosis, it must not  be forgotten,  if the  malady
continue, that  a complication  entirely  functional
at the commencement, may lead to change of struc-
ture ; and that whilst the greater number of accom-
panying  symptoms are merely functional, there  may
exist, in  some one organ  or viscus, organic disease.
Local cupping, not general blood-letting ; a blister
to the nape  of  the  neck;  moderate and  cordial
aperients ; change of  air;  and cheerful occupation
and  amusement of  the mind in  society, or active
out-of-door pursuits, are  means  the  most likely to
restore or to establish the  catamenial  function.
cases of chlorosis complicated  with functional or
  structural disease of the  thoracic viscera, es-
  pecially of the lungs.

                     Case  13.

         reported by the  clinical clerk.

  Mary ------,  aged 21, an unmarried  woman, spare
made, and of pale and emaciated appearance, was  admitted
into Mary's Ward, under Dr. AshwelPs care, Dec. 3, 1835.
  She has always been delicate, and  liable to inflammatory
attacks : she  began  to  menstruate at sixteen years of age,
but  the  function  has always  been  irregularly  performed.
Sometimes  a suspension of five months  has  occurred : at
others, the discharge has been suddenly checked j and rarely
has she had a full and healthy flow. 
CHLOROSIS.
77
  On  the 8th  of November last  the catamenia appeared,
which  terminated an  amenorrhoea  of five months duration:
yesterday there  was another attempt, which lasted  for eight
or nine hours, then ceased :  and  the discharge, although pale
and serous, has  this morning  returned.   She has  for some
time been subject to leucorrhoea.
   About two years and a half ago  she had  a  severe attack
of thoracic inflammation, and was greatly weakened  by its
treatment: there is now much  debility; the face is flushed,
and the surface  pale and  waxy  ; dyspnoea  and  pain at the
epigastrium.   She has had cough and mucous expectoration
for several years, from which she  is  still suffering.   Some-
times she coughs up three or four ounces of a  fluid slightly
muco-purulent, and occasionally  half  a pint in the  four and
twenty hours.   The heart beats violently, and is excited on
the least exertion : her appetite  is impaired; and the pain at
the epigastrium, occurring after food, is relieved by vomiting a
quantity of watery fluid, with a  remarkably sour taste ; urine
limpid, and secreted in large quantity ; pulse 72, rather full;
bowels constipated.

    Colocynth.  cum Cal. gr.  x. statim.  Infus.  Rosae   cum
       Magnes. Sulph. bis die.

   December  8.   Feels better.  The  cough is  less trouble-
some : pain diminished: appetite  improved : still  headache
and wakefulness.

    Hydr. cum Creta gr. v. cum Pulv. Tragacanth. Comp. gr. v.
       omni nocte.
    Mist. Oleosa cum Manna;  et Vin. Ipecac, ""t xv. bis die.

   11.  Is greatly improved in her feelings and general aspect.
Pulse  86, regular.   Yesterday she  ate meat  without  the
usual pain at the scrob. cordis.   Leucorrhoea still continues.
Rep. Medicamenta. 
78
CHLOROSIS.
   17.  There is an attack of pneumonia, cough, and dysp-
 noea ; severe crepitation at lower part of left  lung, involving
 a very small portion ; expectoration  not altered  in character
 or quantity ; skin hot.

     Cucurbitulae  Cruentae  ad  §x.  infra  mammam sinistram :
       postea Emp. Lyttae.
     Colocynth. cum Calomel,  gr.  xv.  statim.   R. Vin. Ant.
       Tart.  t»i xv. Liq.  Ammoniae Acet. 3iv.  Tinct. Hyos-
       cyam. *n. xx.   Mist. Camph. 3vi. ft.  Haust. ter die.
       sumend.

  27.  The inflammatory  attack readily yielded to the reme-
 dies, and she appears to have  gained  strength : complains  of
 nausea.

     Mist. Ferri Comp.  §i. bis die.

  The  tonic  treatment  was occasionally varied, but  perse-
 vered in; and  she  daily improved.   The pulse  beat regu-
 larly, usually 80 in the  minute.  Bowels open.   She  can
 eat, and easily digest meat.
  January 5.  The catamenia  appeared, accompanied with
less pain ; and of a more natural color than formerly, lasting
five days.
  The cough and expectoration daily  diminished.  She was
 able to walk about, and left the hospital Jan. 19, with a slight
bronchitis remaining, but the general  health almost entirely
restored.

                        Case 14.

  Feb. 28, 1S35.   Miss-----, aged  26, began to  men-
struate at  14 years of age ;  and  till within the last year and
a half has enjoyed  good health.   Since  this  period  she has
lived near town, and the catamenia have been gradually dimin-
ishing in quantity.   At first, the discharge continued for half 
CHLOROSIS.
79
a day, or a day less  than when  in  full health.   Now, the
flow does not last more than a day, but is unaccompanied by
uneasiness : there  is  no acute  pain of the head, but she is
frequently giddy;  her digestion has been interfered with, and
her appetite greatly impaired :  thirst is sometimes distressing:
the thoracic symptoms are,  however, the most  pressing ;  as
her breathing  is short, hurried, and  laborious,  and she has
frequent hacking cough.
   Still,  these  thoracic symptoms  precisely resemble  those
sometimes produced  by chlorosis complicated  with hysteria.
The  cough is excited  by any mental emotion; and  loss of
voice and  sudden difficulty of respiration are often induced
by the same cause.   Palpitation is of frequent occurrence.
There is  no expectoration  of phlegm,  but  frequent  water-
brash : the  bowels are constipated : the pulse is  quick and
irritable.  The aspect icterode : the tongue and lining mem-
brane of the mouth  are  unhealthy; and there is the  dark
mark under the eye : the conjunctiva  preserves  nearly its
healthy and natural  color:  the nails  are chipped and dark;
and the fingers partake of the general jaundiced hue.

     Ferri Iodidi gr. xvi.   Tinct. Calumbae |i.   Aq. distill. §vii.
       ft. Mist. Sumat. coch. magn. i. ter die.
     Pil.  Rhei. Co. 5ij.  Ol Cassiae gtt. xij. M.  ft. Pil. xxiv. Su-
       mat ii. vel iii. alt. noctibus.

  April  4.  Has had the catamenia for two days and  a  half,
and is more relieved by the flow than formerly.  Palpitation
less;  pain in side  diminishing:  more  strength : appetite not
much improved.

    Bacon with chocolate  for breakfast; roast beef and mutton,
       with mild ale, for dinner ; weak chocolate for tea ; and a
      sandwich, with  a  little mild ale, for supper : these  were
       the directions given Feb. 28 :  the result was as described
       above.  She was ordered to continue the same  diet. 
80
CHLOROSIS.
   May  16.   Bowels  irregular and confined: less cough:
pulse 100, fuller  and softer;  the  pallor continues, and  the
debility is  considerable.  Catamenia appeared at the usual
time, but continued only for a day.

     Cont. Remedia.
     To use for a week, previously to the period, the  strong mus-
       tard hip-bath, every night.
     Sumat Decoct. Aloes C. §ii. cum Pulv. Jalape gr. x. alternis
       matutinis.

   June 20.  Has menstruated fully, and without pain :  the
hysteria has nearly ceased.  Circumstances of a painful  na-
ture, relative to an engagement which she had formed, were
unexpectedly removed ; and cheerfulness and  vivacity have
succeeded to gloom and anxiety.

     Pergat.

   It is unnecessary to say more about this patient, than that
by a sedulous prosecution of the remedial measures, she en-
tirely recovered,  is  now married, and  the  mother of two
children.


                        Case  15.

        chlorosis complicated  with phthisis.

   Miss-------,  aged 15, a young lady of dark complexion,
intelligent countenance, and of great delicacy,  was attacked,
at the age of 13,  with  hooping-cough.   The  paroxysms
were frequent  and  violent; and, notwithstanding* treatment
and change of air, the disease lasted some months, with little
or no diminution of severity.   At first it was unaccompanied
by expectoration ; but shortly a mucous phlegm was thrown
up.  Her strength decreased; her  appetite was  capricious;
and it was feared that the lungs  would become phthisically dis- 
CHLOROSIS.
81
eased.   She was sedulously watched ; and her exercise, diet,
and clothing were carefully regulated.   Before she attained
her 14th year, the cough had lost its peculiar character, and
appeared  to  pass into  chronic  bronchitis.   The  generally
emaciated state of the body,  with the pallor and concomitant
symptoms, clearly indicated chlorosis; yet  it was hoped that
the establishment of puberty and menstruation might lead to
a restoration of health.  For a few months, remedies  to im-
prove the constitutional power, and induce the desired change,
were ineffectually  employed.   Her  countenance became
more chlorotic ; the  lips and mucous  lining  of  the  mouth
more pallid and unhealthy ; and  the anterior wall of the tho-
rax seemed daily to  approximate  more closely towards the
spine ; there was not the slightest enlargement of the mam-
mae ; nor did it appear at all probable that  puberty or men-
struation would  be developed.   The expectoration changed
its character, and, instead of  mucus, large quantities of dark-
colored pus were coughed  up, so offensively  fetid  as  to re-
quire immediate removal from the  apartment.  Every indi-
cation  was decidedly phthisical: there was hectic flush and
quick  pulse in the evening,  and exhausting perspiration  in
the morning:  the appetite  was, at limes, morbidly  great;
while  at  other  times scarcely  any thing  was eaten.  Her
strength  rapidly failed.  Pectoriloquy, gurgling  cough, and
cavernous respiration, were severally detected by the  stetho-
scope ;  and before she reached  her fifteenth  year, she sank
from phthisis complicated with chlorosis.

                        Case  16.

   April 1, 1838.  Miss  B., set.   19,  of light  complexion,
delicate from infancy, and frequently suffering from amenor-
rhcea, was exposed, in September 1837, to a cold, damp at-
mosphere.  The result  has been entire suppression of men-
struation, with its accompanying inconveniences,  and  severe
              11 
82
CHLOROSIS.
cough.  The aspect is entirely chlorotic, the skin being dirty-
white, the  conjunctivae, gums, and lining membrane  of the
mouth bloodless; nor is  there one indication of the malady
absent.
  The expectoration, which is  occasionally purulent,  the
pain in the left side, the  morning  perspiration, and the ema-
ciation, point very clearly to  phthisis.   There is also consid-
erable leucorrhoea.  The progress of this case has been in-
structive :  at first the  amenorrhcea did  not attract attention,
because it was unattended by important indisposition.  But, in
December  1837, some more serious symptoms showed them-
selves: the chlorosis was fully established, cough,  and  quick
pulse, with the icterode hue and gradual emaciation, alarmed
her medical attendants, who had carefully watched  and treat-
ed her.  Since  this period, it is unnecessary to  detail the
course of the  disease ; but it is sufficient to  add, that  men-
struation was never restored,  that tubercular  cavities formed
in the substance  of the lung, and destroyed  the  patient in
October 1838.

   Many similar  examples I  could furnish, scarcely
a  year passing  without my seeing  several  such
melancholy cases.  I forbear  offering many  remarks
on  the treatment  of this  most  fatal  complication,
having  already insisted upon the absolute necessity
of continued vigilance and care.   I  may, however,
suggest the  importance of early and  entire change
of air.   A sea voyage,  a  milder  climate,  frequent
travelling, and cheerful society, offer the  best pros-
pect of creating or renewing  the vigor of the system,
and  establishing  a  healthy condition of the pulmo-
nary  organs.
   I  have purposely  avoided  the  discussion of the
stethoscopic signs  of phthisis, not to dissuade the 
CHLOROSIS.                83
practitioner  from the careful examination of  the
chest, but because I am fearful of his attaching too
much  importance to  the  absence of physical evi-
dence of this disease.   His apprehensions should be
excited by  the peculiar condition  of  the patients
already described—a  condition favorable  to the de-
position of  tubercular matter in  the lungs.  To ob-
viate the probable  consequences of this condition
will require the utmost forethought.  If, however,
he wait till  these consequences  have ensued, or, in
other words, till auscultation  affords  proof that or-
ganic  change  is actually  commencing, all his care
and all his skill will be  unavailing. 
CHAPTER  II.
                 OF AxMENORRHCEA.

   DefinitiOiN.—The Absence of Menstruation.
   There are two principal forms of the disease.
   First,  The Amenorrhcea of Retention,  where, at
the appropriate age, menstruation is absent, including
three varieties.
   a. Amenorrhoea, dependent on  congenital  defi-
ciency,  malformation or  structural  disease  of the
genital organs.
   b. Amenorrhcea, where, independently of  defi-
ciency or malformation, there is either a  slow and
partial development, or an entire absence of puberty.
   c. Amenorrhoea, after puberty is fully established.
   Second,  The Amenorrhcea of Suppression, where
menstruation having existed  perhaps  for a length of
time, has, independently of pregnancy  or  lactation,
become suppressed, including two varieties.
   a. Recent and acute  suppression.
   b. Chronic suppression.

   a. Amenorrhcea,  dependent on  Congenital Defi-
ciency, Malformation or Structural Disease  of the
Organs of Generation. 
AMENORRHEA.
85
   History,  Pathology, and  Diagnosis.—These are
 happily  rare  cases, and the  cure,  under the most
 favorable circumstances, is hazardous and  difficult,
 and sometimes impossible.   It  is now almost uni-
 versally  acknowledged,  that menstruation,  as well
 as  conception, is dependent on the existence and
 influence of the  ovaries.  If, therefore,  the absence
 of  the  function  is connected with the  absence of
 these organs,  the disease is irremediable.  Nor will
 the chances of a  cure be augmented, if both ovaries
 have become  structurally diseased.  So  long as one
 of them, or even a portion of one of them, is sound,
 menstruation  may be performed ;  but  if there be
 entire disorganization, complete  amenorrhcea  will
 be  the result.  These  opinions receive additional
 confirmation,  from the development  of  the  ovaries
 not occurring  till the age of puberty, from the dimi-
 nution of their size, when the catamenial and repro-
 ductive functions cease ; and  from the gradual les-
 sening of the  menstrual  discharge, as disease of the
 ovaries progresses.  In  Mr.  Pott's celebrated case
 of the removal of both ovaries, menstruation entirely
 disappeared, although, previously to the  extirpation,
 puberty existed, and the  function had been well per-
 formed.   An  instance of complete scirrhus of the
 ovaries, attended by a similar result, and occurring
 in my own practice, will be narrated hereafter.
  The history of  these  cases is not encouraging:
 the health often  suffers, and  there is a  proneness,
 either  to irritability and  excitement, or  torpor and
depression.  I have now under  my occasional care, 
86
AMENORRHEA.
a lady of thirty-two years of age, who has  never
menstruated, I believe  from congenital deficiency of
the ovaries, and  she is never quite well.  Of late,
her health has  been more seriously deranged ; she
loses  flesh, has frequent febrile attacks, a trouble-
some  cough, pain  in the side, and embarrassed res-
piration.  The probable termination of this unhappy
condition is phthisis.   In this  instance, sexual de-
velopment and feeling  are entirely absent; nor has
there ever been leucorrhoeal discharge.
   I cannot,  without  more  qualification than  my
friend has  appended, entirely concur  in  the follow-
ing statement of Dr. Churchill, in his very able and
interesting  work  on  the  Diseases  of  Females.
" These patients," Dr. Churchill  says,  " have the
body generally well developed and healthy, the cir-
culation active  and regular, the  organic  functions
 (save one) fully performed.   But the breasts are not
 prominent,  the genital characteristics  and   sexual
 propensities  are not developed, the voice is  deeper
 than  usual, a slight beard  appears on the  upper lip,
 and there is  a  mixture of masculine with feminine
 peculiarities."   The latter part of this statement is
 fully borne out, but the author has  probably  under-
 rated the general amount of  ill-health in cases where
 the ovaries are wanting.   Other organic deficiencies
 and malformations produce amenorrhcea.
    There may be no uterus, or if it exist  it may  be
 anormal in  form,  its  cervix may be  wanting,  or
 together with the os, impervious.   The vagina may
 be entirely absent, or  so  imperfectly formed, that it 
AMENORRHCEA.                87
 shall not be  connected  with the uterus;  its sides
 may be  adherent,  solid growths may obstruct  the
 continuity of  its canal, or there  may be an imperfo-
 rate hymen.
   I have seen several cases where the uterus could
 not be ascertained  to exist ; although the  presence
 of the ovaries was tolerably certain.   One or two
 such will  be given.  Here the  health was  not
 seriously, and in  one case,  not at  all deranged.
 The  uterus did  not  exist, and, of course, healthy
 menstruation  was  absent.   No  mischief, therefore,
 arose from the retention of the catamenial discharge.
 But it is far different where there is a uterus, where
 menstruation  is  performed, but where  the escape
 of  the secretion is  entirely prevented  by malforma-
 tion.
   Distension  of the uterus, pressure on  neighboring
 organs, impeding  their functions, derangement of
 the  general health, and  periodical efforts  at  men-
 struation, occurring  probably at monthly intervals,
 clearly distinguish  these examples  of  retained men-
 struation  from cases  of  absent  ovaries  or  uterus ;
 and show the absolute necessity for a most careful
 examination.
  Prognosis.—This  must  be   unfavorable where
 there is a congenital deficiency or extensive organic
 disease of the  ovaries  or uterus.   In neither condi-
 tion can menstruation be  established.   It  is not,
 therefore, probable  that the usual amount of health
 shall be enjoyed,  although it is quite true, excepting
in  structural  disease,  if  such  individuals escape 
88
amenorrhcea.
phthisis, to which, in  early life,  and in our climate
they are  especially  prone, they may, and often do,
become vigorous and robust.
  Where the other malformations are  present, the
prognosis must  mainly rest on the nature and extent
of the obstacles, on the  practicability of a surgical
or any other operation for their relief; on the degree
of danger, not only in the  operation itself, but to
surrounding parts ;  and  especially on the risk, cer-
tainly the most serious of all,  of peritoneal inflam-
mation.  The more distant  serous membranes  also,
the  pleura and pericardium may become inflamed,
as a secondary result of any operation on the  geni-
tal organs.
  If a safe passage cannot be made, then a fatal or
very dangerous result may ensue from  immense ac-
cumulation in the uterine cavity, inducing  peritoni-
tis.   Nor, is  it perhaps  impossible that this organ
shall be ruptured, and permit the escape of its con-
tents.  Such a case  I have never seen ;  nor from
the acknowledged  distensibility of the uterus, can
I think it probable.   It is far more likely, the accu-
mulation being gradual, that the  parietes of the or-
gan  will  be  slowly and  sufficiently developed,  to
prevent rupture.  The derangement of health, and
the mechanical inconveniences consequent on reten-
tion, will almost certainly induce amenorrhoea.
  Treatment.—Where the  ovaries  or  uterus  are
wanting, the case is irremediable.   Where an im-
perforate  hymen, an occluded os, or a  thin septum
across the vagina,  prevents the exit  of the  men- 
amenorrhcea.
89
strual secretion, the knife, the bougie, or the finger,
may accomplish a  cure.   If the cervix uteri  exist,
without a  pervious canal, a trocar of small  size, or
a firm  bougie, may form an artificial one;  but in
the  other  and more serious malformations, where
there is extensive  obliteration  of the vagina,  or
merely a  rudiment of this passage, or  where there
is only a  space  between  the  urethra  and rectum
(vide cases), and where, although the uterus be pre-
sent, it cannot be  reached,  except by exploratory
incisions, in such complicated examples, the safety
of the patient will generally depend on the discreet
non-interference of the  surgeon,  while  her  cure
must be looked for, from his courage and enterprise.
It is almost needless to remark  that few men, quali-
fied  for such  operations, are unwise enough to un-
dertake them, without  the sanction  and assistance
of able professional colleagues and friends.
   A case of  M. Amussat, appended to this chapter,
will illustrate these remarks.   Among the means at
the disposal of the  surgeon, may be mentioned  the
formation by the knife, trocar, and bougie or sponge
tents, of artificial canals and passages,  the  removal
by incision, by caustic and ligatures of tumors and
attached growths;   and where the  uterus  suffers
from augmenting accumulation, so as to endanger
its rupture, all other means failing, it may be punc-
tured from the rectum.   It is impossible, in  a syste-
matic work, to lay down precise rules for the treat-
ment of such maladies.  Each  case must  be con-
sidered alone; its  peculiarities  must  be  coolly re-
             12 
90               amenorrhcea.

fleeted on ; and, while temerity is to be condemned,
enterprise, short of recklessness, where  the danger
of  non-interference  is  so  great,  is  deserving  of
praise.
  In the simpler obstructions, the operations, either
by the trocar, knife, or bougie, are  not  difficult ;  but
it  must not be  forgotten, that such patients, with
whatever facility the impediment may have been re-
moved, and  a mere  incision is often  sufficient, are
really exposed  to the danger of peritoneal inflam-
mation.   When the operation has  been successful,
which it almost  invariably is, in  the simpler and
more  frequent  cases, a quantity of  dark, uncoagu-
lated  secretion  escapes, and continues to drain away
for  several days.   At length the  uterus is emptied,
and under favorable circumstances menstruation will
occur  naturally at the  next, or at  a more deferred
period.
  Peritoneal or local inflammation, especially  the
former,  must  be  carefully  guarded  against; and
where it is  necessary to keep the  canal  open, by
bougies,  sponge tent or dossils  of lint,  the earliest
approach of abdominal  or local tenderness must be
promptly treated.   After such a warning, every ex-
pedient for preserving the aperture must be discon-
tinued.   If-the inflammatory symptoms are slight,
local  depletion, by cupping on the loins or hypogas-
tric region, leeches, numerously applied, purgatives
and narcotic  fomentations or poultices  may suffice;
but if the pulse be full  and hard, the  skin hot, and
the abdomen really  tender, in a  word,  if there  be 
AMENORRHCEA.
91
peritoneal inflammation, nothing short of large  and
repeated general  bleedings will avail as preliminary
to these milder measures.
   b. Amenorrhcea where there is either a  slow  and
partial  development or an entire absence of puberty.
   Causes.—As the age varies considerably, at which
puberty is established, not only in different countries,
but in individuals residing in the same country, the
absence of  menstruation, at  the usual epoch, must
not, at  once, be regarded as a  disease.  Its delayed
appearance  may be  caused by idiosyncrasy or deli-
cacy of constitution, by a tardy development of the
body generally, often dependent on impure air,  con-
finement in factories, or close apartments,  and many
other similar causes.  Or the health may  be so fee-
ble, owing to rapid growth and  excessive leucorrhoea,
that the development of the genital system is neces-
sarily delayed.   W7e ought  not, therefore,  hastily  to
conclude that  puberty will  not be established, and
still less that its non-appearance  depends on  con-
genital deficiency or disease ; every measure for the
invigoration of the  general  health should  be fairly
and long employed before the case is regarded  as
hopeless.   It is very remarkable that Lisfranc should
have met with fourteen cases  of  the total absence
of menstruation, where he was unable-to attribute
such absence to  physical obstacle or chronic affec-
tion of the  uterus.
   Pathology.—The pathology of this form of ame-
norrhcea is the  same as that  of chlorosis ; let the
amenorrhoea persist, and the  anaemia and pallor of 
92                AMENORRHCEA.
the latter disease, so  indicative  of attenuated and
impoverished blood, will  soon appear.   I  refer the
reader, therefore, to the chapter on chlorosis, where
he will find the subject fully explained.
  Progress and termination.—The majority of these
cases terminate favorably, especially if  violent em-
menagogue medicines, for they ought not to  be call-
ed remedies, are abstained from ;  months and years,
however, may elapse before  the  cure is completed,
during which the confidence  of the  patient and her
friends in medical skill will be severely tried.
  Exceptional  instances,  where  there never is pu-
berty and menstruation, are rare ;  but they do occur.
Nor  are  they always dependent on congenital defi-
ciency and malformation—the powers of the consti-
tution are sometimes entirely inadequate to the task
of developing the genital system.
  Treatment.—When the  ovaries are wanting, or
destroyed by disease, there is no remedy.  Where
only feebleness  and delicacy of  constitution delays
puberty, judicious  treatment  will avail.   I  forbear
to enter at large on the management, as I have done
it so fully in the chapter on chlorosis.
  c.  Amenorrhcea,  after puberty is fully established.
  This form may occur, either in
  a. The too plethoric, although  otherwise  healthy
and robust, or in
  b. The delicate, irritable, and hysterical.
  a. Amenorrhoea in the former  class  is invariably
characterized by symptoms  of congestion or active
plethora, and is not so common as the second form 
AMENORRHCEA.
93
of the malady.   It  is  not  often  seen in  crowded
cities or  large  manufacturing  towns, but in  the
country,  where  girls live more naturally, and  are
much in  the  air.  It is generally curable, although
often neglected.
  Symptoms.—Headache, tension,  and weight  about
the brain, with a sensation of fulness and throbbing
in the centre of  the  cranium, or about the cerebel-
lum, a florid  countenance, torpor,  lassitude, pain in
the  back and  loins, a  full, and  generally a slow
pulse, though  occasionally in  irritable females it is
rapid ; irregular circulation, evidenced by the feet
and hands being, the one hot, and  the other cold, or
both at short intervals remarkably  hot and  remarka-
bly cold.  The skin  sometimes  harsh  and dry, and
at others clammy.   It is not to be supposed, if the
amenorrhoea  continue,  that  these symptoms  will
pass  away, after the   attempt  at menstruation is
over.  They may do so for the first few periods, but
subsequently they will  continue,  during  the  cata-
menial intervals, recurring with aggravation as  the
menstrual epoch again approaches.   If the malady
has been  long  neglected, or  inefficiently treated, a
cure will not soon be accomplished.   The  constitu-
tion sympathizes so  entirely, that months and per-
haps years may  elapse, before it resumes its healthy
and natural actions.  Some  women, however, natu-
rally menstruate only at distant intervals;  and  I had
lately under my  care  a patient, who for two or three
years menstruated only  every four  months ;  and an-
other, who  never had  the  discharge oftener than 
94
AMENORRHCEA.
every six  months.   Instances  are also  recorded,
where  healthy  menstruation  occurred only  once
every year, or once every two years.  In  my pa-
tients, symptoms of plethora were  always present,
and the menstruation was painful.   Cupping, leech-
es, and  purgatives, with  narcotics, were the means
employed.
  Causes.—Exclusive of organic deficiency or mal-
formation, the most simple cause is  uterine conges-
tion ;  so active  as  to prevent the  secretion of the
menstrual fluid, and this  is most frequently induced
by exposure to cold, which suddenly arrests the se-
cretory process.   Less intelligible causes have been
adduced, such  as torpor of  the  secreting  uterine
arteries and spasm of their extremies.   In some of
these  examples,  the patients are indolent and seden-
tary, indulging in a luxurious and stimulating diet,
soft beds, warm  apartments, and too much  sleep.
  Diagnosis.—There is  little difficulty, where the
disease  is seen early,  in  forming a decided opinion
of its precise character.  At first,  there  is neither
anaemia nor pallor, and when subsequently present,
the history of the affection will  prevent error.
  From amenorrhoea, where the menstrual fluid  is
retained either  in  the uterus or vagina, it may be
easily distinguished.   In  the  former there will be
an  absence of  plethoric symptoms, the  particular
feature  of this species ;  while the increasing size of
the uterus, and  the mechanical  pressure on neigh-
boring organs, so characteristic of retained catame-
nia, will decide the diagnosis.  I need scarcely add, 
AMENORRHCEA.
95
that,  if there be  the  slightest suspicion  of preg-
nancy, examination per vaginam becomes  an  im-
perative duty.
  Course  of the Disease and Prognosis.—It is  rare
for  plethoric amenorrhoea  to  resist  all attempts at
cure.   In such  an  event the plethora most com-
monly disappears, and  the  patient  becomes chlo-
rotic, or suffering  no longer from  repletion, months
and years, or even the whole of the menstrual pe-
riod of life  may  pass over,  without the establish-
ment of  the function.  Occasionally chorea, hys-
teria, epilepsy, hepatic . and  intestinal  disease  may
occur, nor is it impossible  that the  patient  may be
destroyed by a general cachexy, tabes  mesenterica,
or phthisis.   The prognosis  must therefore depend
on the character of the complication.
   Treatment.—This  must primarily have  especial
reference  to the  plethora, abstraction of blood  and
purging being essential remedies.   It will rarely be
necessary to bleed generally, except there be marked
congestion of some of the more important  organs.
Such,  for instance,  as  the  brain,  the  lungs, the
liver, &c.  ;  in which case tw7elve, fifteen, or twenty
ounces of blood  may be promptly abstracted.   Lo-
cal  depletion, by  cupping on  the  loins or over the
sacrum, leeches  to the  labia, inner surface  of the
thigh, the groins  and os  uteri, are  ordinarily suffi-
cient, and give decided relief where there is severe
pain of the head,  back, or loins.  Active purgatives,
and  local  depletion, so rarely advantageous in chlo-
rosis, are  beneficial.  It is requisite  to  improve  and 
96                AMENORRHCEA.
increase the secretions of the whole  canal, and to
unload and  stimulate the lower  intestines.  Jalap,
rhubarb, colocynth  and scammony with calomel at
night, and a dose of salts and  senna or infusion of
rhubarb in the morning, answer the purpose exceed-
ingly well.  (Vide  formulae.)  These must be re-
peated with a frequency and  a modification of the
dose, suited to the urgency of the case.   Auxiliary
remedies must not be forgotten, such as the  mustard
hip-bath, at  96°  or 98°, every other  or every night,
the common practice being to enjoin its use for ten
or twelve minutes, instead of half an  hour, one or
even  two hours, taking  care  to  preserve the  high
temperature during the whole time.  The bath used
in this way is  a powerful remedy.  Nor is it  less
valuable sometimes,  when  the  feet only  are  im-
mersed, every night  and morning, especially where
the circulation is torpid and  irregular, and the pa-
tient suffers  much from cold,  flushing of the face, or
headache.   Exercise and a spare  diet  must also be
enjoined.  Such patients should not be  allowed to
ride in easy  carriages, which favors congestion ;  nor
is riding on  horseback so good  as a regular walk
of several miles per  diem, the length of the walk
and the degree of exertion being, of course, propor-
tioned  to the strength.   I have several  times wit-
nessed greater uterine fulness, and impaired  circula-
tion of the lower limbs, as  the result of horse ex-
ercise.  I invariably, therefore, strongly recommend
walking in this form of  amenorrhoea.
   Animal food, malt liquor, or wine, must be  spar- 
AMENORRHCEA.
97
 ingly  taken.   If they are freely used, under the
 impression that  they will excite  menstruation, fur-
 ther repletion must ensue.  I have  several times
 advantageously practised  small revulsive  bleedings ;
 four,  five,  or six  ounces of blood may be drawn
 from the arm, at  the period  when menstrual effort
 exists ;  leeches to the mammae have not, in my ob-
 servation, done good.  The treatment, therefore, so
 long as plethora continues, includes occasional vene-
 section,  revulsive and small  bleedings, cupping  and
 leeching, active purging, constant  and  careful regu-
 lation  of the  bowels, a spare and sometimes a vege-
 table  diet,  prolonged mustard baths,  and  walking
 exercise.
   The condition  of  the  system  may have been al-
 tered  and  improved,  the treatment may have re-
 moved the plethora, but there is  yet  no menstrua-
 tion.  It may be  asked,  whether  it be necessary in
 such circumstances  at once  to  employ emmena-
 gogues?   I think  not.  Some months  may elapse
 before the uterus shall perform its  proper  function,
 but eventually, menstruation will most  probably oc-
 cur.  If, however,  the health fails, and instead of  a
 ruddy  and robust,  there is a pale  and  wan counte-
 nance, and a gradually pervading debility, the ame-
 norrhoea  will merge into chlorosis : to  prevent such
 a termination  emmenagogues  may  be used.  But  I
 must also observe, that if,  when the plethora is re-
 moved, menstruation does not quickly occur,  the
 continuance of the  malady  must  not  always be
attributed to  debility.  Such  an  opinion  leads to
               13 
98
AMENORRHCEA.
 the premature and injurious exhibition of tonics and
 stimulants;  for although  weakness is  a cause  of
 amenorrhcea it  is  by no means its only condition,
 since  often, where debility  has been entirely  re-
 moved menstruation has failed to be established.   I
 shall at the end of  the  chapter  discuss the  various
 considerations, justifying and demanding the  exhi-
 bition  of emmenagogues.
   b.   Amenorrhcea, after puberty is fully established,
 in delicate, irritable and hysterical females.—What
 is there to distinguish  this form from  amenorrhcea
 in females  who, having  been  plethoric, are so no
 longer ?   I have observed  that the former are gen-
 erally  more healthy ; and  after the removal of the
 plethora they more  quickly and easily menstruate ;
 girls, on the contrary,  naturally delicate, if menstru-
 ation does not quickly succeed puberty, very often
 suffer for months and  years  from  non-performance
 of the secretion.
   In both forms of amenorrhcea now under  consid-
 eration, viz., where it exists after plethora is  re-
 moved, and in delicate females, it is understood that
 puberty is established:  but even  with this  advan-
 tage, presuming that the amenorrhoea persists, chlo-
 rotic symptoms will ensue,  and if emmenagogues
 have not been successfully  used or menstruation has
 not naturally occurred, the proper  definition of the
 malady is amenorrhcea complicated with  chlorosis ;
and to avoid perplexing  repetitions,  I  refer the
 reader  to the preceding chapter of the  work.
  Second, The Amenorrhcea  of suppression, where 
AMENORRHCEA.                99
menstruation having existed, perhaps for a length of
time, has, independently of pregnancy or  lactation,
become suppressed.
   There are two varieties.
   a.  Recent and acute suppression.
   b.  Chronic suppression.
   Causes and symptoms.—If it be somewhat  diffi-
cult,  in every instance,  correctly to discriminate the
complicated forms of amenorrhcea and chlorosis, it
is easy, from  the  history and symptoms, accurately
to distinguish a case of suppression.   Menstruation
is healthily suspended  only during  pregnancy and
lactation ; but it must not be forgotten that the nat-
ural termination of the  function may, from idiosyn-
crasy of constitution, arrive some years before the
usual age.
   The two great causes of acute suppression are
mental emotion and the application of cold.  Sexual
intercourse  during menstruation,  fever, either  idio-
pathic  or  secondary,  hemorrhage or  venesection,
severe trying or drastic and emetic  medicines, iced
water and confectioners' ices, are  auxiliary and less
frequent causes.  The  effect  of  cold in  suddenly
arresting menstruation  is well  known ;  whether  it
be  applied  by a stream of cold and  damp air, by
wet feet, by drinking cold water  when hot, or  by
undried linen.   Nor are we less  familiar  with the
injurious effects on  the sexual functions of joyous
and painful  emotions.   Not only  is the secretion of
the catamenia prevented, when about to occur, but
when  menstruation  is  present it is  often imme- 
100
AMENORRHCEA.
diately checked  by sudden  terror.   The  same  ob-
servation  is true also of the secretion of  the  milk.
Happily  the  effect of  several of  these  causes is
diminished by  the  frequency of their occurrence.
The bathing women go into  the  sea, during men-
struation, with perfect impunity ; and the habitual
exposure to the  casualties of life necessarily dimin-
ishes their injurious impression.   Dr. Gooch relates
that a patient of his  consulted him, long after  the
entry of the  Cossacks  into  Paris, for an amenor-
rhcea, which was solely produced by the  alarm she
then suffered.   And Dr. Churchill states that almost
all the women  who are sent up to  the Richmond
Penitentiary, near Dublin, after  having been tried
at the Recorder's  Court, labor under suppression,
in consequence of  the mental agitation and distress
they have undergone.
   If it be asked how these  causes  operate, I reply,
very differently.  The effects being modified  not
only by the intensity  of  the cause, but in great
measure also by the constitution of the individual.
   In a young or middle-aged woman, fleshy, of ple-
thoric  habit and ruddy complexion,  the immediate
suppression of   the secretion will  be  followed  by
congestion, if  not  by  inflammation.   While  in a
woman delicate, thin, and spare, of  sallow aspect,
and highly nervous, the more probable consequences
are irritation, attended  by spasm and paroxysms of
severe pain, with intervals of ease.    In the former
case there will be sensations of weight and pain in
the head and loins, tension and acute and  constant 
AMENORRHCEA.
101
pain in the region of the uterus aggravated on pres-
sure, short breathing, a  hot skin, and a full, hard,
and rapid pulse ; occasionally there will  be violent
hysteria, and I  have several times  observed deliri-
um.   It  is scarcely necessary to add that  suppres-
sion, accompanied   by such symptoms, is far  more
immediately  dangerous  than any of the other  de-
rangements of  menstruation.  Gooch, indeed, men-
tions an  instance of suppression, where, after death,
the uterus was found in  a state  of gangrene, the
result of intense inflammation.
   About  this form of suppression, then, there  can
be no doubt; neither the  symptoms nor the  treat-
ment are  at all masked  or perplexing ; it is much
more than irritation, it is decided inflammation of the
uterus.   Apoplexy is said, by Capuron, to result from
sudden  suppression:  this I have  never  met  with,
although I have seen seizures of a mixed kind, where
there was something beyond hysteria, an  approach
to epilepsy.  Partial and transient paralysis of the
lower extremities has occurred  once or twice in my
practice; and  Churchill mentions  that  the patient
may also be attacked by local inflammation,  either
of the brain, lungs, or intestinal canal.
   The  pathology   of acute suppression  is  clear.
There is in the  marked  cases, inflammation of the
substance  and  of  the  investing and lining  mem-
branes of  the uterus.  Of course,  a similar remark
is true of other viscera, when they are inflamed dur-
ing menstrual suppression.
   Diagnosis.—In plethoric and robust women the 
102
AMENORRHCEA.
diagnosis of the malady cannot be  difficult.   The
history of the case removes every doubt  as  to the
fact of suppression ; and the character of the symp-
toms is too  decided to  allow  any other  conviction
than that the disease is inflammatory.
   Treatment.—It  is essential to the  safety of the
patient,  where inflammation  of the  uterus, or  its
appendages,  really  exists,  that  general  bleeding
should be at once resorted  to.   If cordials be given
and fomentations applied, with the  view of restor-
ing the suspended  secretion, valuable  time  will  be
lost, and inflammation  may, during the interval, ad-
vance rapidly to an incurable  or gangrenous stage.
Even  were  menstruation to be re-established, the
inflammation would scarcely  be  diminished;  the
disease,  therefore,  being  so  dangerous,  must  be
treated as though it were quite  independent of the
suppression.  Of course, the amount of blood to be
abstracted must depend on  the intensity of the in-
flammation,  and  the strength of  the  patient.  It
may be  necessary  to bleed  largely, and, more  than
once : fifteen, twenty, or twenty-five ounces,  may
be abstracted, and  colocynth, with  calomel, must be
immediately  exhibited,  to  secure  a  full  purgative
effect; a powerful  enema should succeed the pills.
If, in  a   few  hours after the  first venesection, the
pain and the  pulse are unimproved, more blood
should be drawn; if, however, there  is less abdomi-
nal tenderness,  and a diminution in the number and
hardness of  the pulse, twenty  or thirty leeches  ap-
plied to  the  uterine region, may suffice, without the 
AMENORRHCEA.
103
 second bleeding.  A saline mixture with digitalis, a
 pill containing antimonial powder, opium, and  calo-
 mel,  (vide formulae) may be administered every two
 or three hours.  After  these  measures,  auxiliary
 ones  may be employed.   A general or partial warm
 bath, at  96°,  is  a  powerful sudorific,  particularly
 where the patient, being placed in an easy position,
 remains in the bath  thirty or forty minutes ;  fomen-
 tations of equal parts of gin and  strong decoction
 of poppies, and an injection into the rectum of half
 an ounce of  barley-water  and  thirty minims of
 liquor opii sedativ. often produce great relief.  Mod-
 ifications of this treatment will be suggested by the
 differing degrees  of severity, and consequently of
 danger, appertaining to each case.   Nor must it be
 forgotten, that  the suppression,  although the cause
 of the malady, is unimportant, when compared with
 active inflammation  in an organ highly vascular, and
 covered externally by a serous membrane.
   But suppression of menstruation occurs also, and
 perhaps more frequently, in delicate and spare wo-
 men, who are highly nervous and irritable.   Inflam-
 mation  may, even in them,  be the  product of sup-
 pression ; but in  the majority of  such attacks, the
 pain and other symptoms are  not  inflammatory, al-
 though  it is sometimes  difficult  to  distinguish the
 aggravated neuralgia and spasm of the different ab-
dominal  organs, and  of  the uterus  and  its  appen-
 dages, from real inflammation.  Still it may be done,
although it requires  some of that unwritten experi-
ence,  that incommunicable  tact, which a man can 
104
AMENORRHCEA.
 alone acquire  by long  and accurate personal obser-
 vation.  The  pain is  rarely  fixed,  attacking  first
 one and then  another  viscus, changing its  locality
 without the use of remedies ; and, if treatment be
 employed, such as  local  bleeding, a  mustard poul-
 tice, or a stimulant and narcotic embrocation, it  is
 remarkable how quickly the pain is transferred from
 the  uterus to the head, from  the head  to the chest
 or heart, and again from these parts to the intestinal
 canal.  The patient is prone, during these  attacks
 of irritation, to fits of hysteria, and syncope.
   Treatment.—General bleeding  is  inadmissible,
 nor  are leeches usually  advantageous :  metastasis of
 the  pain, but rarely its  permanent  removal, may be
 produced  by their  application.  Active purgatives
 are  necessary,  for the bowels are commonly loaded,
 and  hard scybalous faeces Ions: retained in the large
 bowels, excite  and. maintain painful  irritation.   A
 general warm  bath at  96° ; a warm  mustard  hip-
 bath, or mustard  pediluvia, may be  advantageously
 employed.    The  following antispasmodic draught
 may  be given  every three or four  hours,  till  the
 symptoms begin to subside.
    R Liq. Ammon. Acet 3ii vel. iii.
    Tinct. Castorei vel. Assafoetidae 3ss. ad 3j.
    Pulv. Ipecac.  C. gr. iv. vel. v.
    Mist. Camp. 3vii.  M. ft. Haust.

  Iii addition, if the pain be severe,  a pill, contain-
ing two or  three grains  of camphor, and two grains
of antimonial powder may be exhibited.
  Injections into the rectum sometimes produce an 
AMENORRHCEA.             105
almost magical effect.  Laudanum, assafcetida, and
poppy syrup are employed for this  purpose, (vide
formulae,) and as it is necessary that they be retain-
ed-for some time after their introduction, a piece of
sponge or  a napkin, should  be  kept  firmly and
closely applied  to  the  extremity  of  the  bowel.
When narcotic  enemata are injected, the quantity
should not exceed  two or three ounces, as more
will unnecessarily  dilute  the  anodyne  ingredient,
and by distending  the gut, induce expulsive action.
The pain and spasm, in this form of acute suppres-
sion, are thus relieved, and menstruation does often-
er recur during  the immediate period, in this, than
in the inflammatory species ;  but in neither can it
be invariably expected.   If, however, the treatment
has fortunately  re-established  the discharge, every
precaution ought to be employed to prevent  the ex-
posure of so susceptible a patient to any of those
causes which might induce  a  relapse.    It need
scarcely be remarked, that an  attack, either of in-
flammation or irritable suppression, is often the pre-
lude to more permanent menstrual obstruction ; and
if month after month elapses, without the perform-
ance  of the  secretion,  chronic suppression, to be
next treated of, will be the result.
  After a primary attack of suppression, unless any
symptoms of uterine  congestion remain, treatment
in the interval is  rarely necessary, but immediately
previous  to the  subsequent periods, every measure
should be adopted calculated to ensure natural men-
struation.   The  bowels should be kept free by mild
              14 
106
AMENORRHCEA.
laxatives: cold should be guarded against;  the feet
and  the surface  of the  body  generally should  be
kept  warm;  mental emotion  and undue physical
effort should  be avoided, and the mustard  hip and
foot-baths, should  be used on alternate  nights.   If
menstruation return at the expiration of  the  first or
second month after the suppression, anxiety is at an
end.  If not, and  leucorrhoea with other symptoms
shall  appear, then  more  active treatment must  be
adopted  in the intervals, so as to prevent, if possi-
ble, chronic suppression.
  b. Chronic suppression.
  Causes, Symptoms, and Pathology.—Chronic sup-
pression may result from an acute attack, or it may
gradually supervene, as the effect of some  perma-
nent irregularity in the secreting  power of the ute-
rus ; dependent on increasing constitutional delicacy,
or decided ill health.  It  may be the issue of  or-
ganic disease of the ovaries or uterus; or the natu-
ral  consequence of a premature cessation  of  the
menses.   It is not to be  expected that causes so va-
rious should operate uniformly, nor do they.
  In some women  the mischief having commenced
in an attack of acute suppression, healthy menstru-
ation cannot be restored, at least without difficulty
and delay.  A painful effort is made at monthly in-
tervals ;  but the discharge does not appear,  and  the
amenorrhoea  becomes chronic and inveterate.   In
others the function is, for some time, scantily, irreg-
ularly and painfully  performed;   but  the excreted
fluid is  pale and  serous,  and,  after  a  few more 
AMENORRHCEA.
107
months, the periodical molimen having died away,
chronic menstrual suppression is permanently estab-
lished.  There are, however, cases of healthy men-
struation,  where the quantity of the secretion is so
extremely small, that, but  for the  regularity of its
return, it might be believed that chronic suppression
was approaching.   Several examples  of this kind
are known to me.  Nor does such a state greatly
interfere either with  the health or conception.  In
one  patient,  whom  I  have attended in  numerous
confinements, the  menstrual  periods  have never
lasted more than a day ; yet she has been exempted
from anything beyond  the indisposition common to
women.   In another,  married  late in  life,  where
the menstruation was equally scanty, I tried, at her
suggestion, to increase the secretion ; but the various
remedies  employed, such  as iron,  sarsaparilla, qui-
nine, mercury, and iodine,  failed.   Her marriage,
however,  has been  prolific, and  she has become the
mother of  four healthy children  in  three  years.
Since her last confinement the same  sparing menstru-
ation again  returned, proving  that, in  her case at
least, the  peculiarity was  not  morbid, as neither
remedies,   pregnancy, nor  parturition, effected any
change.   Dewees says of  these  instances, if there
be no  ill-health, that infertility after marriage may
often be attributed  to an anticipation of final men-
strual decline.  He mentions three instances where
the function ceased  altogether before  the twenty
fifth, and two where it  terminated finally before the
thirtieth year.  In all,  the  health  was  perfect.   I 
108
AMENORRHCEA.
have now a  patient, in  her thirty-sixth  year, who
having  suffered from dysmenorrhoea up  to thirty-
one, ceased  then  to menstruate.   Her health  has
been gradually improving ever since.
   It is not difficult  to recognize  the  symptoms at-
tendant on chronic  suppression.   Among the head
symptoms there is occasional  vertigo, diffused  and
obstinate  headaches, muscae volitantes and dilated
pupil, with involuntary twitchings of the eyelids  and
muscles of  the face.  The surface  is  irregularly
cold, hot,  or dry, while there is a manifest suscepti-
bility to the  impression of cold, causing shuddering.
The prevailing state of the bowels is  constipation,
from weakened  muscular power;  and the accumu-
lations in  the bowels greatly interfere with nutrition,
as the flabbiness of the textures and the occasionally
rapid emaciation sufficiently prove.  The  urine is
abundant and limpid.  The thoracic symptoms are
dyspnoea,  palpitation, pains in the chest, &c.   If the
suppression  continue, these symptoms  may persist,
or if the constitution be  equal to the  task, it may,
aided by remedies, re-establish natural menstruation.
The health may, however, seriously fail; and phthi-
sis, organic  disease of the liver or other  abdominal
viscera, or secondary dropsy, may  destroy life.
   The pathology  of chronic  suppression, where it
does not depend on organic  disease, may be referred
to torpor or congestion in the earlier stages, and to
constitutional debility in its more advanced periods.
In the protracted and inveterate forms of suppression,
the ovaries and uterus, in common with other organs, 
AMENORRHCEA.             109
suffer from defective nutrition, the blood having be-
come too impoverished to excite the organic nerves,
and to supply the requisite secretion to the several
tissues of the body.
   Treatment.—It is important to determine, not only
the exact treatment to be  adopted, but the precise
period when  it shall be commenced.   It is not right,
for instance, to regard every menstrual suspension
as justifying  medical interference.  Many of  the
slighter irregularities arising from cold,  mental emo-
tion,  and other  causes, quickly  subside,  without
medicine  or  professional management.  If, there-
fore, the health does not suffer from the absence of
the discharge, the case may be safely left to nature,
excepting  where there is  excessive  leucorrhoea,
which so rapidly impairs the strength,  that it is
proper at once to  attempt the removal  of the sup-
pression.
   Where the amenorrhoea originates  from  a con-
gested state of the  uterine  vessels, the cure under
the  treatment recommended, will in  general  be
found more rapidly effected than in the other variety.
Among the irritable and  delicate women, where the
discharge has become gradually lessened, a series of
functional disorders, the  result of  sympathetic  de-
rangements have to be removed, which  generally re-
quires a prolonged treatment.
   It has been already remarked,  that debility is not
the  sole cause  of absent menstruation,  and  it is
peculiarly necessary, in  protracted  suppression, be-
fore entering upon  the  use  of  stimulant remedies, 
110               AMENORRHCEA.

clearly to ascertain whether there is not congestion
or latent inflammation of the uterus and its appen-
dages :  if there be, such medicines must do harm.
An examination of the uterus, externally and by the
vagina,   will  procure  the  requisite  information.
Dewees  strongly  insists, that emmenagogues fre-
quently fail from  this cause, and  adduces cases  to
show how  important it is, where  debility has been
only presumed  to  exist, but where there  really is
inflammation, that depletion should  precede the use
of this class of medicines.  During the first two or
three months of suppression, when the constitution
sympathizes but little, active treatment is unneces-
sary.  And the same remark  is applicable, so  long
as the question of  pregnancy is undecided.
   After  the  full  exposition  already  given  of  the
treatment of  the different forms of amenorrhoea, it
is scarcely necessary to say more,  than that  in
chronic suppression, the treatment will  principally
be determined  by  the  predominance of plethora  or
debility.   In the  former, depletion ;  in  the  latter,
tonics and  stimulants  will be required.
   The following remarks on complicated amenorrhcea,
I extract from my summary of obstetric cases treated
at Guy's Hospital.
   The  six cases of complicated amenorrhoea  were
very interesting.   In  one, it  was  associated with
chorea.  This  patient, after protracted treatment,
was eventually cured  by sulphate of zinc, and  the
injection  of  liq.  ammoniae  into  the  vagina.   In
another, amenorrhcea was complicated with epilepsy. 
AMENORRHCEA.
Ill
The medicine prescribed was ferri sulph. gr. i. pulv.
digitalis gr. i.  pulv. myrrhae gr. ij. mucil.   Acaciae
q. s. fiat pilula  ter die sumenda.   It is worthy of
remark, that these pills were persevered in  for three
weeks, without any injurious consequences  from the
use  of  the  digitalis ;  a circumstance attributable,
probably, to its  combination with the iron.   At this
period, the catamenia appeared ; and there  has  been
no return of the fits.   In a third  case,  hemiplegia
was attendant on the amenorrhoea.   This complica-
tion was tedious, and difficult to manage.   At first,
the  mist, ferri  c.  was  prescribed ; afterwards, the
sulphate of zinc ; and an iodine liniment was  well
rubbed  over the spine, night  and  morning.  Men-
struation was eventually established, and the patient
regained the entire use of  the side.   In the fourth
case there was taenia  with the amenorrhoea.  In
addition to the other remedies, the  ol. terebinth, was
curatively employed.   In the fifth patient there was
vicarious discharge from the mamma, in conjunction
with amenorrhoea : the mist, ferri c. was ordered, as
well as the  daily employment of  the ammoniacal
injection.  The last patient had, in addition to the
amenorrhcea, a  peculiar nervous affection of one of
her  lower extremities, which  completely  subsided
when the catamenial function was, by  appropriate
remedies, healthily established.
  It is right also to mention, that  amenorrhcea may
occasionally be  traced  to  hemorrhage during  and
after labor.   In one well  marked case, occurring in
my own practice, the patient had three times suffer- 
112
AMENORRHCEA.
ed amenorrhoea from this cause, lactation not having
been attempted.  Twice pregnancy recurred, inde-
pendently of the  return of menstruation.
   In the chapter  on chlorosis, ascites is enumerated
as one  of the  uncommon  results of that malady;
the same observation  is true  of amenorrhoea.   In
both, an improvement  in  the quality of the blood,
and  above all, the  re-appearance of menstruation,
are essential to the  cure.
   Dr.  Churchill  alludes to  several  cases of ame-
norrhcea, where a distinct  bruit de soufflet existed
without other evidence of heart disease, and which
disappeared spontaneously upon the reappearance of
the catamenia.
   Emmenagogues are remedies supposed to exert a
specific power over the uterus in exciting menstrua-
tion ;  or in other words, regarding the  menstrual
fluid as  a secretion, emmenagogues  are  the medi-
cines by which we endeavor to give to the secreting
organ the state or condition on which  the function
depends.   It is requisite, therefore, that these stim-
ulating  agents should be appropriate, and it would
be indeed fortunate, if  to aid the elimination of the
catamenial secretion, we possessed  a medicine, as
uniformly and beneficially  stimulant  as mercury is
in torpid  states of the biliary function.  Whether
any medicines certainly possess  this influence, is a
question to which my experience does not afford an
affirmative reply.   Still, although there are no drugs
positively emmenagogue in  their action, the proper-
ties of  some in stimulating the uterus, render  them 
AMENORRHCEA.
113
 important  auxiliaries in the  treatment of various
 states of diseased menstruation.
    In  chlorosis, and in amenorrhcea, where  there is
 deficiency or malformation, the local emmenagogues
 often  do  harm, never  any good.   In cases too of
 absent menstruation, where there  is either a  slow
 and  partial  development or  an  entire  absence of
 puberty, emmenagogues, if used at all, are impro-
 perly employed : and in chronic amenorrhcea compli-
 cated with dropsy or  phthisis, and  in  amenorrhcea
 with general and uterine plethora,  still further  con-
 gestion must result from their  administration.
    But where the uterus is  inactive  or  entirely qui-
 escent, puberty having been established, and neither
 plethora nor debility existing, emmenagogues may be
 acjvantageously tried.  Nor are they less valuable,
 where amenorrhoea continues, in delicate, irritable,
 and  hysterical women, after tonics  and  cordials
 have failed to produce the  menstrual discharge.  In
 chronic suppression, emmenagogues are clearly  indi-
 cated.   Plethora,  loaded bowels and  fever forbid
 their use ;  spare  diet, purging, local depletion, and
 occasionally a small  bleeding  from  the arm, prepare
 the way for their  beneficial exhibition.
   Emmenagogues are of two kinds  :
   First, Local or immediate Emmenagogues directly
 applied to the uterus  or  the neighboring organs.
   Second, Constitutional Emmenagogues, producing
 their effect through the medium of the system.
   Of the  first class,  Electricity  is  the  only agent
justly entitled to  the appellation;  the  only power
               15 
114
AMENORRHCEA.
by which the uterus can be directly stimulated.   It
is well known, that local pain is produced whenever
a sufficiently strong electric shock is passed through
a sensitive part.   Thus, if electricity, by shock, be
directly applied to the  uterus, a  highly stimulant
effect will ensue.  Nor is the organ less beneficially
affected, in  some  instances, by the electric sparks,
or by a continued current being passed through  it;
still it is an uncertain emmenagogue.  In the  ward
at Guy's, and  amongst  the  out-patients, it has  of
late  been used with more  than  the  usual  good
effects, Dr. Golding Bird  having  superintended its
application.   In some of the cases, where,  after the
condition of the alimentary canal had become heal-
thy, the amenorrhoea continued, with slight pallor
and  weakness, electric shocks  passed through the
loins  quickly induced menstruation.  In others, its
continued repetition three or four times a  week led
to a similar result; and  instances were not wanting
where a shock suddenly produced the flow.   Elec-
tricity  must,  however,  be  cautiously  employed.
Where  the  patient  really dreads its exhibition,  it
may depress the nervous  system, and still further
protract the malady.   Nor must it be forgotten, that
if syncope, sickness,  or  diarrhoea follow its use, it
ought to  be discontinued.   Electricity moderately
applied, frequently, rouses into activity the energy
of torpid organs and  parts, but when used in excess
it may altogether destroy their excitability.   1 rarely
trust to it alone, nor do I employ it in cases of gen-
eral  plethora or local congestion.   If pregnancy be 
AMENORRHCEA.
115
 suspected  to  exist, however  strenuously denied by
 the patient, electricity ought not to be used;  once I
 ordered it, quite ignorantly, where the amenorrhcea
 depended on concealed pregnancy; and abortion oc-
 curred within an hour.
   Of Galvanism as an emmenagogue I have no ex-
 perience, but it is mentioned  favorably, although
 cursorily, by several authors.
   The application  of leeches  to  the os and cervix
 uteri, where congestion exists, will frequently pro-
 duce menstruation ;  but it is somewhat difficult  so
 to employ  them, and in young unmarried women it
 is almost impossible.   Dr. Stroud strongly  recom-
 mends  the practice,  and  speaks  favorably  of its
 effects.  A proper  leech-glass  must be  used by a
 well-instructed nurse, a few days prior to the period,
 and  repeated several times.
   Stimulant Injections.—These were formerly much
 employed,  and  a variety  of irritating  ingredients
 entered into  their  composition :  at present, as a
 vaginal enema,   the Liq.  Ammoniae fort, in milk,
 is generally administered.  I have  often used  it
 with success during the last  twelve  years, both  in
 hospital and private practice  (vide  formulae.)   It
 rarely does good, if it is not  attended and followed
by a pungent  sensation of  heat, tingling, and some
pain in the vagina.   Its  use  should  be commenced
three days  prior to the expected period ; and the
patient, after  each  injection, should apply a napkin
to the vulva, so firmly as to cause the injected fluid
to be retained for ten or fifteen  minutes.   It is not 
116
AMENORRHCEA.
a safe remedy where there is uterine  congestion.
In two such cases dangerous inflammation of the
cervix and  upper  part  of the  vagina  followed  its
use.   Where, however, uterine torpor is unaccom-
panied by congestion and acute irritation, the am-
moniacal injection is often efficacious.   Occasion-
ally,  like electricity, it  produces  menstruation at
once, while, in  some women, in  common  with the
most approved  remedies, it is without effect.  The
strong mustard  hip-bath, used twice during the day,
the patient  remaining in it for nearly an hour  each
time,  at a temperature of 96° or 98°, is  an effectual
auxiliary remedy.
  Stimulating fluids have been, as  emmenagogues,
injected into the uterine cavity ; and they  may, per-
haps, by some  who  have not used them,  be yet
recommended.   Death,  from  peritoneal inflamma-
tion, has several times followed the practice ; and
in two instances, occurring under  my own  eye,
fatal results had nearly  ensued from most alarming
attacks of  this formidable malady.   It  has  been
supposed, but certainly without  due consideration,
that as cold water  alone  or with sulphate of zinc
may with impunity be injected into  the  uterus after
labor, so with equal impunity a similar injection may
be thrown into the interior of the uterus in amenor-
rhoea ; but  there is  little or no analogy to  support
the reasoning.   In  the  former instance it  may be
fairly presumed that the mucous membrane is  heal-
thy, and, uterine contraction being secured, restraint
of the bleeding will  be the consequence of the rem- 
AMENORRHCEA.               117
edy ;  but, in menstrual  suppression, there may be,
and often is, congestion and  irritation, and  perhaps
a diseased state of the tissue lining the uterine cav-
ity—here, on the contrary, inflammation will proba-
bly  ensue.   Excepting as a means of  arresting he-
morrhage, I never now inject the uterine cavity.
  Of  the   emmenagogue  properties of  medicated
bougies 1 have no experience ; when used, stimula-
tion of the lining  membrane of the  cervix  is in-
tended to be produced, with the hope that a similar
action will extend through the continuous membrane
of the uterus.   These, with  the exception of the
mustard  and the variously medicated hip-baths, are
all the local emmenagogues directly applied to the
uterus.   The  mustard hip-bath, if well employed,
seems at times to exercise  an almost specific influ-
ence over the uterus.  Nor is the exhibition of mus-
tard by  the stomach  without a similar effect.   I
have often  given eight, ten, and twelve  grains of
mustard, in  camphor julep, three, four and five times
daily, prior to the menstrual period, with good effect,
the  regularity and the quantity of the secretion be-
ing  beneficially  affected  by  it.   Dr. Rigby relates
that some school  girls, for sport, swallowed mustard
spread thickly on their bread, and in  all the elder
girls it  produced menstruation  in a few hours, al-
though the regular period for its appearance had not
arrived.
  It is right to allude to sexual intercourse as an
emmenagogue,  as marriage  often,  though  by no
means invariably, cures amenorrhcea. 
118
AMENORRHCEA.
   Stimulating  Injections into the Rectum are  much
 relied on by some practitioners, as emmenagogues,
 and certainly I have used with advantage an enema
 —recommended by Dr. Schonlein—composed often
 grains of aloes, and  one ounce  of mucilage,  twice
 or three times a day.
   Leeches to the Vulva, above the pubis, and at the
 upper and inner part of the thighs, are occasionally
 beneficial.  Nor are stimulating embrocations,  warm
frictions, and the flesh-brush  to the  hypogastic and
 lumbar regions, to  be entirely neglected.    They
 must, however, only be relied on as adjuvant reme-
 dies.
   Of the utility of  Pressure on the Iliac and Fe-
 moral arteries, as a remedy for amenorrhoea, I  have
 no knowledge.  Not once have I seen it tried.  Dr.
 Hunter, of Beverley, first  successfully  employed it
 about seventy years  ago.    It  was  subsequently
 practised in Edinburgh, and Dr. Home  reports that
 in his hands, it succeeded  once in six times.   It is
 not a satisfactory or rational  thing to  induce  con-
 gestion of the  uterus,  if it can be accomplished, as
 a remedy for amenorrhoea, since it is admitted that
 the disease in question  is  often  attributable to this
 very  condition.  The  plan  has  been long discon-
 tinued.
   The Second  class  of emmenagogues is The  Con-
 stitutional, producing their effect through the medium
 of the system.
   Mercury is our  most powerful  deobstruent, and
 deserves to be mentioned first amongst the remedies 
AMENORRHCEA.
119
of this kind.  It is not to be  used in slight  cases,
nor where there is extreme exhaustion, a  predomi-
nant irritability,  or a tendency to phthisical or stru-
mous disease. But, in obstinate amenorrhoea, where
other treatment  has failed, where  there is chronic
inflammation or  permanent congestion, and any evi-
dence of incipient  structural change,  there is no
remedy comparable to this.  In medicine,  however,
as in matters of less  moment,  there is a  fashion :
and  in obedience to its dictates, we too often pass
from  one extreme to its opposite.   The extravagant
employment of mercury at one time, and  its unde-
served neglect at another, the  indiscriminate praise
bestowed upon it by some, and  its  unjust  abuse by
others,  abundantly verify  this  observation.  As an
alterative I have  not used  it  successfully ;  but if
salivation be  produced  and  maintained,   mercury
often ensures decided and  permanent benefit.  The
inconveniences  of a  mercurial course, protracted
through three or four months, howTever modified and
lessened, are quite enough  to induce not only great
caution in the selection of  an appropriate  case, but
great watchfulness of its effects.   If the pulse be-
comes more rapid and  less strong;  if constitutional
irritation and  weakness daily increase ; if  there be
cough or diarrhoea, these not having previously ex-
isted, the mercury should   be at once discontinued.
No prudent  practitioner will administer it after such
warnings.   More frequently, in cases  warranting
its use,  improved  symptoms will  follow  moderate
salivation.   The tongue becomes clean, moist, and 
120
AMENORRHCEA.
of healthy color ; digestion  improves,  and there is
some return  of healthy appetite;  the complexion
loses  its dingy, icterode hue, and* becomes more
clear;  and the  entire  state is greatly improved.  I
am not aware  that the  form of mercury to be ad-
ministered is a  matter of much consequence.   The
Plummer's or  the  common  blue pill, calomel, the
grey powder,  or the inunction of the mercurial oint-
ment, may any of them  be  selected.  The mercu-
rial effect  should be  carried so far, as to produce
soreness of the gums and moderate  salivation ; and
these should  be kept  up  for twelve or  sixteen
weeks.
   The frequent daily use of the chlorate of soda as
a gargle, will dimish the  inconveniences of the sali-
vation, by  removing  the foetor of the breath and
cleansing the mouth, so as to  prevent the unpleasant
taste.  Sarsaparilla is a valuable adjunct;  it allays
irritability and prevents emaciation.
   Iron, in its various  forms  and in modified doses
and combinations, is a most valuable emmenagogue.
Its worth, in all diseases  where the blood is impov-
erished  and where there is general weakness, is
well known.   Its protracted  administration, instead
of injuring,  improves the health ;  and the  blood,
instead of remaining a watery and  attenuated fluid,
acquires from iron more healthy and nutrient  prop-
erties.   In this way its emmenagogue  power is
realized.   Nor must it be overlooked, that iron pos-
sesses this additional value ; that, as the cure of the
amenorrhcea, is  mainly dependent on the improve- 
AMENORRHCEA.
121
ment which has been effected in the general health,
so it is more likely to  be permanent, menstruation
not having been reproduced by powerful  and tran-
sient stimuli.   These  remarks are pertinent to  its
exhibition, whether in  a  form purely medicinal or
chalybeate water.  The  various  chalybeate  springs
contain different  quantities  of the  carbonates and
sulphates ; and their waters are certainly most effi-
cient when drunk on the spot.  The  regulations for
exercise  in the intervals of swallowing the water
ought to  be sedulously followed.  Nor must it be
forgotten, that  plethora and constipation should  be
removed prior to any form of iron being exhibited ;
and  if, during its use, giddiness, headache, sickness,
and  a quick or full pulse should occur, the iron must
be immediately discontinued.
   Of the  Ergot of Rye, or Secale Cornutum, as an
emmenagogue, I  cannot  speak  favorably ;  nor.is it
on principle easy to understand how  it should pro-
duce such an  effect.   As a powerful stimulant of
the muscular substance in the pregnant and puer-
peral conditions of the uterus,  it is, if judiciously
employed,  invaluable ;   but the  removal of uterine
torpor, and the arrest of uterine hemorrhage by the
excitement of muscular action, are entirely different
effects from  the  restoration of  a secretion, often
owing its  suspension" to plethora  and extreme  de-
bility.  Nevertheless,  Dr. Locock,  the brevity  of
whose papers,  on the  diseases of menstruation, is
their only  fault, speaks favorably of the deobstruent
properties  of the  rye.  I cannot say that  I have
               16 
122
AMENORRHCEA.
    never succeeded, when I have used it;  but it  is
    necessary to be  cautious,  not  only in selecting the
    case, but likewise  the precise  time when  it shall
•   be administered.   It  is most  to be  relied on in a
    somewhat relaxed and debilitated patient, and ought
    to be. given, not in  the  intervals of  menstruation,
    but when determinate efforts are being  made to es-
    tablish the secretion.   Occasionally, at these periods
    and in conjunction with strong mustard hip-baths, it
    has produced  the  menstrual  discharge.  I  rarely
    now  give  it, but never when these efforts having
    been  unsuccessful, subside.  Irritation and abdomi-
    nal spasm are almost sure  to  follow its continued
    use.   In one  or two instances  I  have witnessed
    alarming seizures of this  kind, where it  has been
    long  employed.  The powder  (see  formulae,) in
    doses of ten  grains, two  or  three  times  daily,  is
    probably more  efficacious than the tincture, although
    the latter induces less severe uterine and  intestinal
    spasm and pain.
      Iodine is occasionally a  good  emmenagogue ; but
    there is  no remedy of this class which in my hands
    has so frequently failed.  In patients predisposed to
    struma,  or  actually  suffering  from  scrofulous en-
    largement of the  glands, the iodine exerts an almost
    specific influence on nutrition, and by improving the
    blood, favors secretion.  Dr.  Coindet  was  perhaps
    scarcely correct in attributing to this drug such pow-
    erful  and certain emmenagogue properties.   I have
    made  numerous inquiries about its effects,  and have
    not discovered that others have used it more  sue- 
AMENORRHCEA.              123
cessfully than myself.   It may be given in doses of
five, eight, twelve, or fifteen drops, or even more, of
the tincture, twice or  three times daily, in sugared
water.  Or the iodine, in substance,  may be admin-
istered,  combined with  the  hydriodate  of potass.
(Vide formulae.)   Caution  must  be  observed after
plethoric amenorrhcea,  lest  a return of this state,
accompanied by  vertigo, cerebral  fulness, or slight
haemoptysis, may succeed its use.
   Strychnine  was  introduced  by  my friend  Dr.
James Bardsley,  of Manchester,  in cases  of  sup-
pressed menstruation.   In four  instances of amenor-
rhcea, occurring in delicate  females, I have unsuc-
cessfully used it.   In two out  of the four, one fifth
of a grain was taken four times a day;  but vertigo,
and spasmodic twitching of the muscles, with se-
vere headache, compelled me to  lay it aside.   The
late Dr. Cholmeley, of Guy's Hospital,  employed
the strychnine in several  cases of  amenorrhoea, in
the wards,  but without  any  success.   He began
with the sixth of  a grain three times a day.
   Of Madder, the root of  the rubia tinctorum, as
an emmenagogue, I have little  personal experience.
In the commencement of my professional studies, I
witnessed its successful use; but I believe it is now
very  rarely  employed.  Madder  tinges  the bones
and the urine of  a red color ; it is supposed, there-
fore, that finding its  way  into  the circulation,  it
directly  influences the  secretory function of the
uterus.  It is given  in doses of 3ss. to 3j. of the
powdered root, two, three, or four times a day.   Dr. 
124               AMENORRHCEA.
 Home  says  that  out of nineteen cases of amenor-
 rhoea  he cured fourteen by madder.  It does not
 quicken the pulse, or derange the stomachic  func-
 tions, but  appears to operate almost insensibly in
 producing the return  of menstruation.
   Rue, so much praised in former  times  for its em-
 menagogue properties,  is now scarcely ever used ;
 nor does the evidence in its favor prove  more than
 that it may be a cordial antispasmodic of uncertain
 efficacy.
   Savine, the juniperus sabina, is powerfully stimu-
 lant and emmenagogue; but its use is at present much
 restricted.   Its deobstruent power is  attributed  to a
 volatile oil, which is similar in its properties to tur-
 pentine.  Popular opinion is decidedly in its favor,
 and it is the  medicine most commonly employed to
 procure criminal abortion.   Dr. Davis,  in  his elab-
 orate work, mentions on the testimony of one of his
 pupils, who served his .apprenticeship at Tonbridge,
 that in the neighborhood of that  town  there was a
 remarkably fine savine tree, the decoction of the
 leaves of which was successfully used, not  only to
 remove menstrual suspension, but also  to  induce
 abortion.   Where  there is a feeble and  languid  cir-
 culation, savine is  a suitable  stimulant:  but  its use
 is injurious where  there  is  plethora  and  irritation.
 The powdered leaves, and the oil of savine, are the
preparations employed ; of the former from  four to
twelve grains, and of the  oil from two to  twenty
drops may be taken two or three times daily.
  Seneca Root, and Black Hellebore, are deobstru- 
AMENORRHCEA.              125
ents, but  they do not merit more than  a passing
allusion.
  Nitre,  by  stimulating the kidneys, is  a decided
emmenagogue.   It seems  to reach these latter or-
gans, judging from its  effects, without decomposi-
tion.   I  lately  gave to a patient,  whose mother
placed great  confidence in this  salt,  one scruple
three or  four times  daily, in a  wine glass full of
water.  It purged and produced bloody  motions;
but on the third  day there  was a copious flow  of the
catamenia after a suppression of seven months.
  The Infusion and the Tincture of  Digitalis, pro-
duce their uterine effect through the kidneys.
  Aloes is doubtless the most  efficient of the em-
menagogue cathartics, acting on the  uterus through
the rectum.   Even after menstruation has ceased,
the disposition to the  function often remains, but
the discharge can rarely be produced  by the natural
efforts alone—here, if a  drastic dose of aloes  be
given, the catamenia are  frequently, in  slight de-
gree, restored.  It may easily, therefore, be allowed,
that a similar effect may occur from  the  continued
exhibition  of the medicine, during  the  epoch of
menstrual  life.   Aloes  cannot, however, be always
administered.  If there  be an  irritable uterus or a
highly irritable  stomach and  alimentary canal, the
drug cannot  be  borne—sickness, intestinal tormina,
and extreme  irritation of the rectum  and  anus, for-
bid its use.   Several formulae will be given.
  Gamboge, serpentaria, wormwood, musk, myrrh,
castor, valerian,  and lavender, with several others, 
126
AiMENORRHCEA.
are regarded as emmenagogues, but the  majority of
these remedies can scarcely be viewed as more than
stimulant  antispasmodics,  and as  aiding the  more
direct and powerful medicines of this class.
CASES OF  AMENORRHCEA DEPENDENT ON  CONGENITAL DE-
   FICIENCY, MALFORMATION  OR DISEASE  OF THE GENITAL
   ORGANS.

                       Case 17.

  amenorrhcea  gradually  supervening on  diseased
                        OVARIES.

   October 10th, 1838, Miss  G-------, aet. 17,  a  patient of
Mr. Bailey, of Limehouse, is fair and  strumous  in  aspect,
rather thin, always delicate, but not sickly.   Puberty was
established at fifteen, and  menstruation  quickly supervened.
In February, 1838, nearly nine months before the  present
time, a tumor about the size  of a goose's  egg, hard,  uneven
on  the  surface,  and only slightly tender  to the touch, was
discovered low down laterally in the right hypogastric  region.
Up to this period the catamenia were regular in their return,
although the quantity was  lessened, and the color light.  A
few  weeks afterwards, in  March, a  similar though  smaller
growth appeared on the left side,  and several of the inguinal
glands were enlarged  and indurated.  Now, there are  two
distinct tumors, that on the right extends from the iliac fossa
to the umbilicus, while the left iliac fossa is entirely occupied
by the other and smaller  growth.  They are of stony hard- 
AMENORRHCEA.
127
ness, at times painful, independently of pressure;  mechani-
cally, they derange the action  of the  bowels and bladder,
while fever and defective nutrition are rapidly destroying her
strength.   Appetite is impaired, and there is a frequent dull
pain in the stomach, accompanied by acute  pain and cramp
in the backs of the thighs and legs.  The sleep is much dis-
turbed ; pulse from 100 to 110,  small and weak, and there
are nightly paroxysms of  fever; there is  neither cough, ex-
pectoration, nor morning perspiration.
   Since June, menstruation has progressively decreased, and
it has  been attended  with severe pain.   Six weeks ago, the
second growth  (both  are believed  to be ovarian) having at-
tained a large size, and having probably completely  destroyed
the healthy structure   of the organ, a painful  effort alone,
without any discharge, marked the menstrual period.
   Eight weeks subsequently  to my first visit in October, the
amenorrhoea continued.   Only  palliative  treatment was re-
commended, the extent of the disease forbidding active inter-
ference.
   In February, 1839, she died, worn out  by mechanical and
febrile irritation, and  by want of nutrition.   For six  months
before death  there was  entire amenorrhcea and  excessive
leucorrhceal discharge.
   A post mortem examination confirmed the opinion that the
uterus was perfectly healthy, and that the ovaries were entirely
scirrhous, so much so  as  to have obliterated every trace of
their natural organization.

   This case requires no  comment.   It confirms the
doctrine  that the ovaries are  the efficient  cause  of
menstruation. 
128
AMENORRHCEA.
                          Case  18.

   amenorrhcea with congenital malformation of vagina
                        and uterus.

     Hannah -------get. 22, was admitted  June 13th, 1832,
   into Dorcas Ward, Guy's Hospital.   The  following  particu-
   lars are taken from the case-book and my own notes.
     This patient  has  never  menstruated, but there is no ab-
   dominal  enlargement.   Has  suffered  severely  for  many
   months from headache, pains and tightness in  the chest and
   loins.   She has been plethoric, but is not so now ;  pulse 90 ;
   moderately full; tongue white, skin hot, especially at night.
     For these symptoms, subsequently attended by dyspepsia,
   she was bled and purged, and put on low diet; and on July
   7th, she left the hospital cured of her indisposition, but with-
   out having menstruated.  As it was thought  that malforma-
   tion existed, this patient was, at  her own request, carefully
.   examined, and the following is the report:—

     Hannah-------is well developed as to her general  wo-
   manly  structure, and has therefore probably perfect  ovaries.
   But the external aperture of the  vagina is closed by a firm
   membrane,  which being pushed up two or  three  inches
   towards the  sacrum, forms a shut-sac, without the slightest
   openening.   Neither the finger nor a probe can detect an os
   or cervix uteri  beyond  this closed extremity ; nor does the
   finger in the rectum when  pressing forwards, nor pressure
   downwards from above the  pubes, cause any firm body, like
   the uterus, to impinge upon the finger remaining in the vagina.
   It is quite certain that there is no large accumulation of men-
   strual  fluid either in the womb  or upper part  of the vagina.
   These  parts, if they exist at all,  must be of small dimensions. 
AMENORRHCEA.                129
No exploratory operation was  recommended, as any attempt
to lay open this shut-sac might expose the cavity of the peri-
toneum.   If catamenial accumulation shall heareafter render
an opening expedient, the containing parts will be so dilated
as to be felt by the finger;  then the knife may probably be
used with  a prospect of success.  I have, however, already
said that these operations are scarcely ever devoid of danger.

   Here  menstruation was not performed, because
the secretory organ, the uterus,  was wanting.   I
saw  this  patient  two years  afterwards,  when  she
had  quite recovered  her health, and  wished to be
married; but hesitated  because she had not  men-
struated.   I  declined to give any advice.


                       Case  19.

    amenorrhea  dependent on absent  uterus and
                        VAGINA.

   Dec. 20, 1836.  I visited Mrs.-------st. 27,  (a patient
of Mr. New, of Mile-end).  This lady has been married two
years, and is well  developed about the pelvis and  mammae.
Her general health is tolerably good, if a proneness to fever,
susceptibility to cold, and  hysteria  be excepted.   She has
never menstruated,  but in other respects  she is  sexually
healthy.   The genitals  are singularly anormal.  The mons
is  large, the labia are well formed,  and  the  fourchette  and
perineum do not deviate from healthy conformation.  There
is however, no vagina, and  I think,  no uterus.  On passing
the finger in the direction of the os externum, it may be car-
ried about an inch onward  between  the urethra and rectum.
The former canal  is very capacious  and distensible, for after
              17 
130                AMENORRHCEA.
overcoming  the contraction at  its entrance, the finger may
traverse it till it enters the bladder, the rugae of which viscus
are easily felt  in its empty state.   Examination  by the rec-
tum, the finger being retained in the urethra, detects no body
like the  uterus, the two fingers approaching  very closely to
each other;  a fold of membrane  only being  interposed be-
tween  them.  Intercourse  is imperfectly accomplished, and
yet not without gratification; the urethra being the recipient
canal.   That there are ovaries is certain ; but I feel confident
there is neither uterus nor vagina.
                        Case  20.

amenorrhcea with closure of  the vagina, consequent
       on protracted and instrumental labor.

   In August, 1837, Mr. Maccay, and a neighboring surgeon,
requested me to visit  Mrs. B., residing in Whitechapel; she
was twenty-one years of age,  had been married ten months,
and had been in labor nearly sixty  hours, under the care of
a midwife.  As there were not more than three inches and a
quarter of space between the sacrum and pubis, as the inter-
nal parts were hot, tumid and tender, and the abdomen tym-
panitic and extremely painful on the slightest pressure, I pro-
posed  perforation.  I brought the head of the child through
the pelvis with great difficulty, even after I had reduced it to
the smallest dimensions.  There  resulted, as I feared, from
the long  continued pressure of the head on the  soft parts,
vaginal abscess and ulceration ; and the subsequent cicatrization
was accompanied by contraction.  In July, 1839, not having
seen Mrs. B., since the  delivery, she called at my house and
told me that she had never menstruated since the labor, but
she was much weakened by constant leucorrhcea.   On ex-
amination, I had no difficulty in passing  the finger into the 
AMENORRHCEA.
131
vagina, for about two inches and a half, where it terminated
in a pointed  extremity.  The closure is quite  firm, and I
cannot discover, either by the speculum or probe, the slight-
est aperture.   In  front, beyond  this shut-sac, I  cannot feel
the uterus, but  through the  rectum, it is easily discovered,
nor is  it at all enlarged.

  This  patient  is failing in  health,  is  dyspeptic,
emaciated, and, since the  labor, has  become  entirely
devoid feof sexual feeling.   But  I  cannot persuade
her even to think of surgical aid.   It is an interest-
ing case as showing the increase of  constitutional
morbid effect beyond what exists in the examples of
congenital deficiency, where menstruation  was never
performed; and such an instance may be regarded
as the connecting link between the congenital cases,
and those where the menstrual fluid is  secreted,  but
retained.  The  examples of congenital  deficiency
are the least dangerous;  cases like the one now de-
scribed  are more hazardous ;  and  instances of se-
creted,  but retained catamenia  are full  of risk, if
the fluid cannot  be evacuated, and  even then there
is abundant cause for anxiety.

                     Case 21.

  amenorrhea dependent on malformation of  the
                      VAGINA.

           REPORTED BY MR. HENRY OLDHAM.
  Elizabeth R-------, aged 22, a well-developed girl, of
short stature, florid complexion, and fair  skin, was admitted
into Guy's Hospital in February, 1836, under Dr. Ashwell. 
132
amenorrhcea.
  At the age of 15, she had some affection of the eyes :  but
with this exception, she enjoyed good health until ten months
ago, when she first became troubled with headache, vertigo,
and lassitude, a sense of fulness in the hypogastric region,
with lumbar pain,  capricious appetite,  pain in the side,  and
irregularity of the  bowels, for  which she was  received  into
the Hospital, under Dr. Cholmeley.   At this time the cata-
menia had not appeared: and an examination was instituted,
to ascertain if any mechanical obstacle existed.  The parietes
of the  vagina, about two inches from the vulva, were found
closely adherent; and  fluid  could  be detected  immediately
above.    Mr. Key divided  the  septum ;  and a large quantity
of dark-colored, viscid  fluid, was evacuated.   The opening
was dilated  by bougies ; and  she shortly left the  Hospital,
feeling well.   There was  but  one scanty appearance of the
catamenia after this period ; but her health was not materially
deranged until six  weeks of the present time, a white mucous
discharge having  alone  occurred.   A recurrence of  the
above-mentioned symptoms induced her to  apply to me for
advice;  and, on examination,  it was found that the two di-
vided surfaces of the vagina had again firmly united, but that
the catamenial  fluid was accumulated in small  quantity only,
which  was  proved by  the  absence of a  fluctuating  tumor
above  the cicatrix.  Finding  her  general  health  somewhat
impaired, and the  morbid sympathies with  the uterus,  such
as sickness, headache,  &ic, continually present, I prescribed
laxative medicines, mild tonics, nutritious diet, and palliative
remedies, to remove urgent  symptoms.  The  symptoms be-
came more severe, as the quantity  of menstrual fluid increas-
ed ; and she was  readmitted  into  the Hospital  under Dr.
Ashwell.  At  this time, she complained of giddiness, head-
ache, and tinnitus  aurium, lumbar  pains, with a sensation of
fulness and  bearing-down, occasional  dyspnoea, uncertain
appetite, depression of spirits, and great  irregularity of the
bowels, sometimes being troubled with diarrhoea, followed by
constipation.  The uterus was not to be felt above the pubes ; 
amenorrhcea.
133
 but a feeling of fulness, not of distinct fluctuation, was com-
 municated to the finger, on examination.  The same class of
 remedies was used, under which her general health improved ;
 and in two months' time, theftumor above the united parietes
 was so distinctly bulging, as to warrant the evacuation of the
 retained catamenial fluid, which was less in quantity than on
 the previous occasion.  In twelve hours after the  operation,
 symptoms of peritonitis  were present,  which were met by
 active measures, such as bleeding, both general and  local,
 purgatives, calomel,  &c.   They, however, continued unsub-
 dued, and she died.
   The body was conveyed to the mother's  house, where an
 inspection was  obtained.
   On opening  the thorax, marked traces of recent pleuritis
 were universally  diffuse^!.  The  lungs, in some  portions,
 were found adherent to the opposed pleura costalis, by deli-
 cate bands of imperfectly-organized fibrin, which were readily
 broken down.   In other parts, layers of plastic lymph were
 found loosely attached to the pulmonary pleura, and within
 the  pleural sac:  on both sides there  were three  or  four
 ounces of serous fluid, with some flakes of lymph  floating in
 it.   The depending  parts of both lungs were  gorged  with
 blood and serum, which  ran  out from the two surfaces  of a
 divided portion.   The upper  lobes were crepitant, but  their
 edges were too rounded.   The heart and large  arteries were
 healthy.
  On opening  the abdomen,  layers of lymph were  found on
 the surface of the liver, particularly around the acute margin,
 and between the convolutions of the intestines.  This lymph
 varied in degrees of  firmness, appearing, at the under part of
 the liver, to be  converted  into  a tolerably well-organized
 band of false membrane, attaching  it to the opposed surface
 of peritoneum :  in other parts it was plastic, and  in the pelvis,
 some little flakes were seen, swimming in serous fluid.   The
 mesenteric glands were greatly enlarged, and also those along
the psoas  muscle  and brim of the pelvis.   Some of these 
134
amenorrhcea.
were of a scirrhous hardness, others of a chalky consistence.
Those on the brim of the pelvis were particularly enlarged,
so as greatly to encroach on the  dimensions of the  superior
strait.  The uterus and  its appendages  had not  contracted
adhesions, both anterior and posterior pouches being entire.
  The situation of the stricture  was a  little  more than an
inch below the os;  and above this part, the vagina appeared
thin and distended, forming a  continuous line with  the dilated
os, the circumference of which was above four inches.  The
cervix  rapidly became  thicker,  and, for upwards  of three
inches  towards the fundus,  the  parietes were fully double
their normal size.   The upper half of the body of the uterus
was somewhat more bulky than natural, and its cavity slightly
increased.  The broad ligaments were unaffected, but  their
appendages were much  less  delicate than  natural.  There
was a cavity within the cervix, which formed the  chief dila-
tation, so expanded as to be able to enclose a goose's egg.
The rugae and cells of the cervix were  greatly diminished,
and their surfaces  presented a slight appearance of  fibrinous
effusion.   Some few longitudual striae were visible, more par-
ticularly at the posterior part, apparently the result of a  re-
cently-contracted cavity.

   The  preceding  case  confirms the  opinion,  that
operations about the vagina and perineum  are occa-
sionally followed by inflammation of the peritoneum ;
and it ought  to induce  caution in  the  prognosis.
The first  division of  the  septum was not succeeded
by mischief of  any kind : yet,  although  there was
no difference in the mode of operating, a second  in-
cision through the parts led to a fatal attack  of peri-
tonitis.   The distention of the cervix, while  the
fundus and body of the uterus retained  their normal
form  and  size,  is  singular, and  corroborates  the 
AMENORRHCEA.
135
statements, lately made, as to prolapsus of the neck
of the uterus by stretching, and perhaps by growth,
while the parts of the viscus, above  the cervix, re-
main in their original state.   If, as this case proves,
effused fluid may distend and stretch the cervix, in-
dependently of other  parts   of  the  organ, it is not
difficult to conceive  that the  same result may occur
from other causes.
                       Case  22.


    amenorrhcea  dependent on congenital absence
                    of the vagina.

   Abridged from the case, as reported by M. Amus-
 sat in the Gazette Medicale for December 12,1835.

   A young lady, aet. 15, was hi bad  health, owing to ame-
 norrhcea.  The menstrual  effort occurred every month, but'
 without any discharge, and the abdomen was distended by the
 gradually enlarging  uterus.  There was  no vagina, but  the
 urethra terminated  naturally.  A finger  introduced into the
 rectum, and  a sound passed  into the bladder, detected  the
 uterus, large  and  fluctuating; and it was also ascertained,
 that there was so little,  space between the posterior part of
 the bladder and  rectum, as to render it  impossible, or very
 hazardous, to form an artificial vagina by the knife, lest these
 important viscera  should be  wounded.  M.  Amussat,  the
other medical  attendants having given up the case as hope-
less, proposed to separate the contiguous  organs by traction.
He began by depressing the mucous membrane of the puden- 
]36               AMENORRHCEA.
dum, just below the orifice of the urethra.  Guided  by a
sound in the latter canal, he carried his finger onwards in the
space between  the  rectum  and urethra,  and  secured  the
ground he gained each day, by a properly adjusted  sponge
tent.  At length he reached  the distended uterus, and, after
a small opening by a trocar, he enlarged the os uteri,  by a
bistoury,  keeping it open for some time by a canula.   Men-
strual fluid was evacuated, not only through the aperture thus
formed, but also by a spontaneous opening  through the rec-
tum.  The sequel  of  the case  is encouraging; the  patient
entirely  recovered,  and, when  the  acount was published,
was not  only menstruating regularly, but about to be  mar-
ried.
   Other cases of this kind may be found in  the  different
medical authors.


    I forbear to enlarge  the size of the book  by the
 addition of illustrative  examples of  the  other forms
 of amenorrhoea.   They are so common  and so well
 understood, and  in some respects  so closely  resem-
 ble chlorosis, that  the description of them  in the
 text will  suffice  for their ready  detection.
                      Case 23.

    protracted  amenorrhcea cured by mercury.

  Mrs. H.------, 83t. 23, a native of the north of England,
of dark and sallow aspect, and  evidently unhealthy, was
placed under my care in August,  1823.   Has been married
between three and four years, but without pregnancy.  Men- 
AMENORRHCEA.                 137
struation commenced  at fifteen ; but it has scarcely ever ob-
served the regular periods, and it has occasionally been absent
for several months together.
  Her present symptoms are amenorrhcea of seven or eight
months' duration:  profuse leucorrhoea,  sometimes of  bad
odor;  pruritus of the genitals, always severe, but occasionally
so intolerable as to compel  her to keep her own room.  Con-
stipated bowels, the  evacuations dark, scybalous, and highly
offensive; healthy appetite destroyed,  frequent craving  for
improper articles of food, and progressive emaciation.   Skin
of dark, icterode hue, lips and lining membrane of the mouth
colorless.   Pulse 95 to 100, feeble and  easily compressed;
frequent dyspncea, especially on  the slightest exertion, but
there is neither thoracic pain nor cough.
   On inquiry, I found that Mrs. H. had been under the care
of many practitioners, both in London  and the country, and
that nearly every plan of treatment had been tried, only ex-
cepting the mercurial.  After explaining to herself and  fami-
ly, that as medicine  had  hitherto been unavailing, it was im-
portant at once  to employ the most efficient means ;  I pro-
posed that mercury should be exhibited to such an extent as
to affect the  system,  and  that soreness  of the  mouth, and
gentle salivation should  be kept up for three or four months.
I was the more induced  to do this, because I found the ute-
rus  generally slightly enlarged,  and the os and cervix  hard,
uneven, and tender to the  touch.
   The patient  was  removed a  few miles into the  country,
and on August 20th,  1823, commenced the following treat-
ment :

     Sumat Pil.  Hydr. gr. iij. Pulv.  Opii gr. | in forma pilulae
       nocte, maneque.
     Infricand. Ung. Hydr. 9iss. inter femora quaque nocte.

   She was  allowed  wine and meat diet, and particularly en-
joined to keep in the house and avoid cold.
                 18 
138                AMENORRHCEA.
   Sept.  10.   Gums very tender  for the last  two or three
 days, and there is decided salivation.  There has been no
 menstrual effort.  Complains  of  the inconvenience  of the
 spitting, but the bowels are more regular, and the evacuations
 more healthy.
   Sept.  20.  The gums  are  not so tender, but they are
 slightly swollen and spongy.   Has only taken three grains
 of  Pil.  Hydr. occasionally, just  to  keep  up the  effect.
 There has  been no catamenial effort, but  the  pruritus  is
 nearly gone, and her aspect is certainly improved.  Appetite
 better.
   Oct. 20.   On the 17th of October, after  some suffering,
 menstruation returned, and the  flow continued for three days.
 In all respects better, and the family are  struck with  her im-
 proved  complexion.
   Nov.  28.  Was ordered to discontinue the mercury, as it
 was thought the effect would  be maintained  some  weeks
 without  its further exhibition.   The  catamenia re-appeared
 at the expiration of the month without  pain ; the discharge
 was abundant, and of sanguineous color.   No return  of pru-
 ritus.  On examination, I found the uterus  less heavy, and
 the  os and  cervix softer and less  tender.  Gargles  for the
 mouth, sarsaparilla and bark,  porter and  wine, were freely
 given during the continuance of the treatment.
   In January, 1824, Mrs. H. was quite free from all mercu-
 rial  influence, and in  better health than she  had been for
 many years.  In November, 1824, she gave birth to a boy,
 now (1839) living.


  "For several years this lady remained healthy ; but
 she  was subsequently so much exhausted by  exces-
 sive hemorrhage after childbirth, that  dropsy  super-
 vened, and she died  before  she reached her thirtieth
year.    I  could  add   similar   cases,  demonstrating 
AMENORRHCEA.               139
the value of  mercury  in  protracted  amenorrhcea,
and where there is congestion of the  uterus.  Dr.
Davis relates several such in the  first volume of his
Principles of Obstetric Medicine, one of the most
valuable works of reference we possess. 
CHAPTER  III.
        OF  VICARIOUS  MENSTRUATION.


   Definition.—A  discharge,  generally  of blood,
from other parts than the  uterus; superseding men-
 struation, and in its return, occasionally observing a
 menstrual period.

   History and Symptoms.—This vicarious discharge
 can scarcely be regarded as a  disease,  when  the
 hemorrhage does not really derange and exhaust the
 system.  Dr. Locock calls it a curious freak of na-
 ture.   I think he is right in doing so ; for the pro-
 cess, in most instances, equally wants the regularity
 of a healthy function, and the injurious influence of a
 disease.  It is an event entirely out of course ; for
 although it is scarcely  ever met with except in con-
 nection with amenorrhoea,  still by far the greater
 number of  instances of this latter malady are unac-
 compaied by vicarious  discharge.   Generally, it oc-
 curs  in the unmarried,  at least  my observation war-
 rants this conclusion, but quite as often in the weak
 and  delicate as  in the  robust.   When married 
            VICARIOUS  MENSTRUATION.         141

women  are its subjects,  conception  rarely  takes
place during its continuance, although  an interest-
ing case, in which pregnancy more than once  sus-
pended  the vicarious discharge,  is  recorded  by Dr.
Davis.  The sterility, depending principally on tor-
por of the  organic system of nerves, may likewise
be farther insured by the amenorrhceal state  of the
uterine  lining  membrane, incapacitating it  for the
formation of the decidua.   The vicarious discharge
is usually blood, but it may  consist in an excess of
the natural mucus of the genital organs, constituting
leucorrhoea.  Some portion  of the pulmonary and
intestinal mucous tissues are thought to be the more
common seats  of  the  vicarious loss;  but certain it
is, that the nipples, the ears, the gums,  the  umbili-
cus, the bladder, the axillae,  any part of  the skin or
the mucous membranes, or  the surface  of an open
ulcer, may occasionally by  gush,  more usually by
slow transudation for several days, furnish the vica-
rious blood.  In the regularity of  its periodical re-
turn, it seldom  resembles the   healthy function,
although  cases are recorded where the  menstrual
epoch has  been exactly observed.
  It has been assumed, but  without proof, that be-
fore furnishing the vicarious  discharge, the part must
be in a disordered, irritable,  or weak condition ; but
it has been frequently seen,  that so far  from struc-
tural change  taking place  in  the vicarious  organ,
even its functional  disturbance is  generally slight,
and the amount of subsequent  constitutional disor-
der, is only proportionate to  the blood lost.   Where 
142        VICARIOUS  MENSTRUATION.

the nipples or mammas are  the seat of the hemor-
rhage, there is often the formation of a  crust over
the affected spot, which being thrown off, the bleed-
ing occurs.
   The  time during which  vicarious menstruation
may continue to be  repeated, is very uncertain.   I
have admitted patients into Guy's, expecting its re-
appearance, and after keeping them in the ward for
many weeks, have been completely disappointed, the
amenorrhoea  persisting, and the vicarious flow  not
returning.   Local pain, constitutional  irritability,
and hysteria, are often premonitory of its  periodical
approach;  and in a patient, who was subsequently
a nurse in the Hospital, the surface  and edges of  a
large menstrual  ulcer on the thigh, were  invariably
more painful, hot, and  swollen, prior to its furnish-
ing the vicarious evacuation.   There are  cases on
record, by  Churchill  and Siebold, where excessive
salivation has supplied  the place of the catamenia.
Such an instance I have never seen.
   Causes.—The suppression of an accustomed se-
cretion, and the sudden, or even the gradual super-
vention of plethora  or  congestion,  may account for
these local  and vicarious losses.  But why this form
of menstruation should occur so rarely, if it be pre-
ventive or curative of these  morbid conditions, is  a
question which I cannot answer.
   Diagnosis.—The distinction can  scarcely be diffi-
cult,  between vicarious and common hemorrhage.
The  existence* of amenorrhcea, the  occurrence of
marked catamenial effort and the vicarious evacua- 
VICARIOUS  MENSTRUATION.        143
  tion, together with the absence of the local and con-
  stitutional  symptoms of primary hemorrhage, will
  remove all doubt.
     Prognosis.—I  am not aware  that  any case has
  ever terminated  fatally.  So far  as my observation
  has extended, the uterus has ultimately resumed its
  peculiar function, nor  has the vicarious organ ever
  suffered any permanent injury.  The  duration  of
  this curious process will much depend  on the obsti-
  nacy  of the amenorrhoea, the effect of  the vicarious
  loss, and the treatment.
     Treatment.—The extent to which remedies shall
  be employed, must be  determined by the amount of
  the hemorrhage,* the  effects of the loss,  and the
  warning of its  approach.   If the process has been
  frequently  repeated, and  there  are  premonitory
  symptoms, emmenagogues may be used, if there be
» no plethora or congestion.   If,  however,  there  is
  engorgement of the  uterus, cupping on the sacrum
  or loins, leeches to the os uteri, vulva or anus, must
  precede the use of any stimulants.   A  smart  dras-
  tic purgative may not only prevent  the vicarious at-
  tack,  but also induce menstruation ; and I have sev-
  eral  times,  after preliminary  depletion, witnessed
  the good effects of electricity and  the strong  mus-
  tard hip-bath, at a high temperature.
     If the hemorrhage, having come on suddenly and
  without any previous indication, is  moderate, inter-
  ference is  unnecessary, the advantages of healthy
  menstruation being partially secured by it.  But if,
  on the contrary, a large quantity of blood is lost, 
144        VICARIOUS  MENSTRUATION.
and  from an organ  important  to  life, then  similar
measures  must  be adopted as  in  hemorrhage, not
vicarious.  The infusion  of roses  with  nitrate of
potass, dilute acid and digitalis, cubebs and bismuth,
the acetate  of lead, ergot, turpentine, and opium
(vide formulae),  may be exhibited.
   In the intervals, the  treatment must be directed
to the removal  of  the amenorrhoea  : tonics, and es-
pecially iron, ought to  be  given.  A residence at
Tunbridge Wells,  Malvern, Buxton or Matlock, or
by the sea-side,  is often decidedly advantageous.
   Vicarious Leucorrhoea.—There is in health a se-
cretion, exceedingly small in  quantity, of colorless
transparent mucus, poured out by the uterine lining
membrane, for the purposes of lubricating the oppo-
site  surfaces of the organ, and preventing friction
and  adhesive inflammation.  When excessive, con-
stituing leucorrhoea, it is occasionally, and more fre-  •
quently  than  blood,  vicarious of  menstruation.
Strictly speaking,  there is amenorrhoea, because  a
mucous, instead of a sanguineous secretion, is  fur-
nished by the minute extremities of the uterine ar-
teries.   But there is activity instead of torpor ;  and
it will be found, on  inquiry, that all the  symptoms
denoting  menstruation  regularly appear,  especially
when this condition is vicarious of  the catamenia at
an early age.
   The disease is most common  in delicate and sus-
ceptible girls, at the epoch of commencing menstru-
ation.   I  have seen it also in weak and  exhausted
women,  and I  have now under my care a  patient 
VICARIOUS  MENSTRUATION.        145
nearly thirty-five years old, who, in consequence of
frequent abortion and protracted suckling, being ex-
ceedingly impoverished  and feeble, has  for the last
twelve months, suffered from vicarious leucorrhoea.
The regular menstrual  period  has  been  exactly ob-
served, and although the discharge has been fully as
abundant as the natural catamenia, and has lasted
three or four days, it  has never till the  last month
been colored.   Conception in these cases is not an
improbable  event, as in several  females who have
come under my notice,  where the menstruation was
colorless, pregnancy has occurred.
   In early life this vicarious leucorrhoea, if from its
amount and  periodical  return,  it  is believed  to  be
uterine and not merely  vaginal, removes all impres-
sion of congenital defect or malformation.   Nor, if
the interval be free from excessive mucous discharge,
is the health much deranged : a circumstance mark-
ing the  difference between this  form of  vicarious
menstruation,  and chlorosis and  amenorrhcea.  It
rarely happens that the uterine function is fully de-
veloped independently of medicine or change of air,
although it  is quite  possible that,  under favorable
circumstances, perfect  menstruation  may  almost
spontaneously occur.
   Pathology.—There can  be  no  doubt  that vicari-
ous leucorrhoea depends not alone  on  disordered
action of the secretory  apparatus of the  uterus, but
also on the impoverished and attenuated condition
of the  blood ;  and,  in   those instances  where the
discharge is always present, we may probably infer
             19 
146
VICARIOUS  MENSTRUATION.
the existence of sub-acute inflammation of the  ute-
rine lining membrane.  It is  difficult to explain by
what diseased action it  is, that  vessels accustomed
to eliminate a sanguineous fluid should so far  lose
their full secretory power as to furnish only an in-
creased amount of  mucus.   Some  years ago I
pointed out a  similarly perverted  action, occurring
after labor, where aqueous discharge, occasionally
in immense quantity, is poured  forth instead of the
lochia.  And in hemorrhage from the intestines, an
analogous phenomenon is sometimes presented, when
a large quantity of mucus, exhaled from  the villous
coat,  supersedes  the  sanguineous flow.   Dewees
regards vicarious leucorrhoea as a slow development
of the menstrual function.   Friend and Astruc were
both cognizant of  its occasional  existence.   The
former denominated it " the  lymph-like menses,"
and Astruc recognises it  as leucorrhoea  taking the
place of the  catamenia.  Nauche, in his compre-
hensive,  valuable  work,  " Maladies  propres  aux
Femmes," looks upon vicarious  leucorrhoea as  salu-
tary, thus confirming the  views I have  guardedly
expressed.   He says that  in 1824  he had under his
care a patient, twenty-four years old, plethoric and
robust, but  healthy  sanguineous menstruation  was
absent.  Instead of it, there  was  secreted every
month, and with satisfactory results as regarded the
health, a quantity of white mucus.
   Diagnosis.—The  occurrence  of the  leucorrhoea
at the monthly intervals, the  other  attendant cir-
cumstances, and the absence  of healthy  menstrua- 
VICARIOUS  MENSTRUATION.         147
tion will fully elucidate the character and origin of
the malady.
   Treatment.—This is nearly,  if  not  entirely, the
same as where hemorrhage  is vicarious of menstrua-
tion.   A nutritious and easily digested  diet, exer-
cise,  pure air, and tonics,  especially iron, will so far
improve the blood  and impart constitutional vigor,
as sooner or later to induce  healthy menstruation.
    CASES OF VICARIOUS MENSTRUATION.

                       Case  23.

          reported by mr. ebenezer  vorley.

   Sarah-------, aged  17, of short stature,  fair complex-
ion, and  unmarried, became an out-patient of Dr. Ashwell,
August 19th,  1836.  Excepting an  attack of intermittent
fever,  which  occurred  about  four  years  ago,  her  health,
though delicate, has been  generally good.  The catamenia
first occurred two years since, while engaged many hours in
the day at a sewing business ; twelve months elapsing before
their second appearance.  Since this period, the  function has
been irregularly and scantily performed.  Half a year sub-
sequently to this return of menstruation, she  had a vicarious
secretion from the breast, preceded  by an effusion of blood
under the skin of the  mammae.  The  cyst soon burst, and
discharged its contents :  a cicatrix partially formed, slightly
pitted,  and discolored round its  edges.  The same process
has been performed at every menstrual  period since; ex-
cepting on one occasion, when the catamenia appeared  more
naturally.   The  secretion is  almost invariably from the left 
148         VICARIOUS  MENSTRUATION.
breast;  the right  only once having been similarly affected.
The mammae  are  much enlarged, exceedingly painful, and
very tender a few  days prior  to the expected  period, at
which time there are severe pains in the lower part of the
abdomen, loins, and back.  There is also abdominal swell-
ing.   It  has several times  happened, that  there has been a
very slight catamenial show, but it has not proceeded  to  a
full menstruation;  and the breast, under these circumstances,
has  invariably performed its  vicarious function.  There is
moderate leucorrhoea  during the intervals, becoming exces-
sive  at the periods.  She has little appetite ; and, after food,
suffers greatly  from pain in the  epigastrium, flatulence  and
heartburn.  The bowels are very confined, requiring large
doses of  aperient medicine for their full evacuation.
  Pulse  108, feeble, and easily compressed.  The tongue is
coated with white fur ; and her sleep is disturbed by pain in
the inferior extremities and  lower part of  the abdomen.

     Let her use the Ammoniacal  Injection daily: take the Col-
      ocynth  and  Calomel  Pill  three times  a-week; and the
      Mist. Ferri C. twice a-day.

  The treatment was continued  for some months, her health
gradually improved,  the leucorrhoea  disappeared,  and  in
February, 1837, the catamenia were natural and regular.
                        Case  24.

  August 20th,  1838.  Miss-------, aged  17, a  native of
London, began to menstruate at 15, and after continuing to
do so for a year, the discharge entirely ceased.   Soon  after-
wards  she had  cough, and slight  hemoptysis.  The  latter
symptom disappeared, and  for  the  last six  months she had
vicarious hemorrhage from  the ears.   At the time I visited
her, the blood filled the external meatus, and  I was  told by 
VICARIOUS MENSTRUATION.          149
her mother, that the loss from both ears had never been less
than three  ounces at each  period, and that it  came  away
slowly.   By a  piece of sponge I cleared  the  meatus, and
afterwards I saw  the blood slowly exhaling from  the inner
surface.   As there were decided symptoms of chlorosis, and
a feeble  pulse, I ordered small doses of iron, an improved
diet, and a visit to Tunbridge Wells.
   I did not see this patient again till several months  after her
return, but  I  had  previously heard  that  the vicarious dis-
charge entirely ceased in two months, her health in the in-
terval  having  been  materially improved  by the return of
natural menstruation.
                        Case  25.

                vicarious leucorrhcea.

  Mrs. L-------, aged 40, residing in Kent, consulted  me
the 2d of August, 1838, for vicarious leucorrhoea.   She is
thin, pallid, and  extremely  weak, although formerly robust
and  embonpoint.  Menstruation  commenced  at  seventeen,
and after her marriage, which  occurred when  she was thirty
years of age, she frequently suffered from  its  scanty  and
painful return.   She has had two  children at the full term,
and five miscarriages, alarming hemorrhage having  attended
every abortion.  For the last year the menstrual  period  has
been regularly observed,  but the discharge  has been less  and
less  sanguineous ; and for nine months the secretion  has
been entirely bloodless.  There is  also considerable leucor-
rhoea in  the catamenial  intervals.   Complains  of extreme
giddiness, and cannot occasionally stand  upright.  Pulse
from 90 to  110,  weak and  small, appetite  nearly destroyed,
and the bowels never act without medicine.  Hysterical  fits
often occur, and  she is  nervous almost to insanity. 
150          VICARIOUS  MENSTRUATION.
   She was ordered to the seaside, a  nutritious  diet was en-
joined, with a small quantity of wine and  malt liquor; the
salt shower tepid bath, and constant exercise in  the open air.

    R Tinct. ferri. Muriat. Tinct.  Humuli. Spir.  Ammon. Aro-
       matic aa 5iv. M. ft. Mist.

   Take thirty drops in  a tablespoonful of port wine  three
times a day.
   A mild aperient when required;  and a  vaginal  injection
twice daily of sea-water.
   I  heard  from  this  patient  after  a month's  residence  at
Brighton :  she  was improved in many respects,  but the vica-
rious  leucorrhoea  continued.   She  followed the plan  laid
down, and  when she called at my  house  in  December, hav-
ing only a few  days previously returned from  the sea-side,
she said that her health was perfectly re-established, but that
the menstrual  discharge  was only slightly sanguineous.  I
enjoined a continuance of the iron. 
CHAPTER  IV.
            OF DYSMENORRHCEA.

  Definition.—Menstruation, preceded  and  ac-
companied by acute, and  often lancinating pain in
the  uterus and adjacent parts, and  occasionally in
the  mammce, with derangement of the secretive func-
tion ; the catamenia being usually, though not inva-
riably, scanty in quantity, and  in  the  severer  and
more chronic cases, clotted, shreddy or membranous.

  History and Symptoms.—Dysmenorrhoea  is  an
important disease.  It is  very  common, and pro-
duces extreme suffering—it often prevents concep-
tion ;  and  if  pregnancy  has occurred  during  its
continuance, the patient  is exposed to the risk of
abortion.  Although,  in  itself,  it  is  not a  fatal
malady,  yet it admits  of  proof, that  malignant  dis-
eases have followed its protracted  existence ;  and
lastly, it is exceedingly difficult  to  cure.   It is not
confined to one class  of  females ; the  married  and
the single, particularly the  latter, are obnoxious to
it.   It prevails  among women of irritable tempera-
ment, and of delicate, strumous,  and phthisical con-
stitutions.  The habits  of  the  rich,  therefore, by 
152             DYSMENORRHCEA.
fostering these tendencies, have  a direct influence
in promoting it.   There are examples too, although
rare,  among  women  of  sanguine  temperament.
Every case of  merely painful  menstruation must
not be regarded as dysmenorrhoea.  If, for example,
the pain and tightness of the head, the  pain  in the
lumbar and hypogastric  regions, which have pre-
ceded the menstrual period, diminish and pass away
as the secretion increases; such  a case is not dys-
menorrhoea.   Scanty  menstruation, is  not  always
painful;  nor is the opposite state, where the func-
tion  is copiously performed, always  free from suf-
fering.  Dysmenorrhoea  is  often  co-existent with
menstruation ; often  after a prolonged and healthy
continuance of the function,  a change in the general
system, or some of the exciting causes, to be  men-
tioned hereafter, induce its approach.
   The earliest symptoms of irritable or  neuralgic
dysmenorrhoea, where there  is neither inflammation
nor congestion are referrible to general  disorder  of
the health, such as impaired appetite, great languor,
gradual loss of flesh, and  uncertain  action  of the
bowels.  The catamenia  become  irregular,  some-
times appearing in excess, with a  prolonged  inter-
val ; while  at other times  suppression is an early
morbid indication.   The discharge is  emitted with
almost indescribable pain, being shreddy,  clotted,
and generally scanty in quantity.   These symptoms
vary much in different cases.   In some  individuals,
they are but temporary, continuing only for the first
day or two of  the period ; when after the expulsion 
DYSMENORRHCEA.
153
of a small clot  not always  firmly coagulated, the
discharge  assumes  its  natural  consistence,  and  is
unaccompanied by more than the usual local uneasi-
ness.   In others, the whole  time is one of intense
suffering, commencing  with sharp, darting, lancinat-
ing pain in the uterus and  vagina, and extending
apparently to the  uterine appendages.   There is
acute sympathetic pain in one or  both breasts;  the
lumbar pain, running down the sacrum to the thighs
and groins,  becomes  excessive: and during  the
emission of the  discharge,  the  expulsatory pains,
resembling  the  throes  of labor, add  much to  the
suffering.   The intensity and  duration of  the  pain
depend much on the  nature  of the  discharge, the
rigidity of the structures, and the nervous  suscepti-
bility of the patient.   In some instances, the cata-
menial period  is  preceded  for two, three, or four
days, or a week, by  severe pain in  the mammae.
When the menstrual period  has ceased, the suffer-
ing is for the  time at  an end, and  the  strength is
less reduced than might have been expected.  Dur-
ing the whole period, little febrile excitement exists,
and the amount of constitutional injury, from  one
or  even several of these attacks, is inconsiderable.
By and by, however,  if proper  treatment  be  neg-
lected, or if the disease  is so  inveterate, as not to
yield  to it, the general health becomes much im-
paired, and the reciprocal morbid  action of  the  one
upon the other greatly  aggravates the case.  With-
out any sympathies of the uterus, with  the excep-
tion of the mammary being  called  into prominent
              20 
154             DYSMENORRHCEA.
exercise, the  bowels become  uncertain in their ac-
tion, being sometimes constipated and then  unduly
relaxed, even  from a mild  purgative :  the  hepatic
secretions are variable in quantity ; and occasionally
there is pain  and excoriation about the  anus, from
their  acrimonious  nature.   The  appetite is capri-
cious and  small, food is almost  loathed, the blood
becomes impaired, and imperfect nutrition is evident
from paleness of the general surface, emaciation and
loss of physical power.   In  thisstage of the disease
leucorrhoea becomes profuse, if it has not habitually
existed; and sometimes amenorrhoea  supervenes,
thus entirely  suspending the uterine  suffering.   In
connection ?with the continuance of  this menstrual
suppression, the mammae become flaccid and almost
disappear; and the torpidity of the uterus excludes
that viscus from a healthy discharge of its functions.
   In plethoric dysmenorrhcea there is not much de-
viation from  the symptoms now described;  but the
menstrual period will   be  preceded by headache,
flushing of the face, full and quick  pulse, a  sense of
weight in the pelvTs, rigors, and sometimes by de-
lirium.  These  precursory  symptoms are  followed
by the  catamenia,  which  are  sometimes  profuse
with  more or less of  coagula.  More frequently,
however, the discharge is  scanty,  and consists of
clots with portions of membrane, and the  difficulty
of emission is extreme.   The  pains  resemble those
of labor;  the patient bears down with considerable
effort, and after many abortive attempts, a paroxysm
of uterine suffering  is relieved, by the  expulsion of 
DYSMENORRHCEA.
155
a small concrete clot, or a detached portion of mem-
brane.   It must not be supposed  that  only the ple-
thoric women expel these false membranes ; women
of an opposite  temperament  may do  so, and for a
lengthened  period ;  an  ill-advised use of emmena-
gogues aiding such a result.
   Congestive  Dysmenorrhcea.—When  the  affection
of the mucous membrane is attended  with a partial
inability  to  secrete  the  full quantity  of menstrual
discharge, the large and repeated doses of aloes and
steel, so often given  with  the  intention of compel-
ling menstruation, augment the quantity of blood in
the uterus,  which remaining  stationary, every suc-
cessive period is accompanied  with an  increase of
congestion,  till at length this form of the  disease is
fully  established.  The  premonitory symptoms in
this variety  are comparatively slight.   A sense of
weight in the pelvis, with  the  bearing  down  pains
of prolapsus, lumbar pain, frequent micturition and
constipated  bowels, denote an enlarged uterus.  But
it is not till  the function  is about to commence, that
the very severe  symptoms arise.  There  is  then
intense  uterine pain,  with a  sensation as though
some foreign body  were  shut up in  the uterine
cavity ; and  in  the  attempts  at its expulsion,  the
uterus is aided by the voluntary, as well as involun-
tary efforts.   The paroxysms occur as in labor, but
in dysmenorrhcea there  is  no interval of ease.   In-
cessant restlessness  comes on ;  the  patient  looks
anxious and pale, and frequently attempts to mictu-
rate, and as the contraction of  the bladder is evacu- 
156             DYSMENORRHCEA.
ating the urine, she  uses all  her power in the vain
endeavor to expel  a  clot or  portions of membrane.
Sometimes there  is  spontaneous relief afforded by
the passage of a small  concrete mass; but  this is
temporary, and it is  only with the cessation of the
period,  that she  can be  said  to  be  relieved  from
her sufferings.   One  marked peculiarity of this form
is the absence  of inflammatory  symptoms.   The
pulse is rather weak, sometimes quick and irritable,
the skin is perspirable, and there is exhaustion, not
inflammation.   During  the intervals  of congestive
dysmenorrhoea,  where  false  membranes  are  con-
stantly expelled, there is generally abundant leucor-
rhoeal discharge, the health  becomes increasingly
disordered, the mammae shrivel, and the legs are
oedematous.   It is in this variety that  spurious abor-
tion most frequently  occurs.   A  mass  is ejected
from the uterus, which  is made up of a condensed
or laminated coagulum  with portions  of membrane,
or a membrane moulded to the cavity of the uterus,
inclosing  a large coagulum.   Illustrations of these
are  beautifully delineated  in  Dr. Granville's  work,
and hereafter I shall give  Dr. Montgomery's  dis-
tinctions  between this  form of membrane and the
true decidua.
   The late Dr. Mackintosh, of Edinburgh, pointed
attention  to dysmenorrhcea dependent on mechanical
obstruction, caused by contraction or stricture  of the
canal of  the  cervix, or by partial imperforation of
the os uteri.  Capuron  also alludes to it, and other
authors think  that  in  some  very rare  cases, the 
DYSMENORRHCEA.              157
malady may be attributed to such a cause.   There
is no doubt that dysmenorrhoea has occasionally co-
existed  with  such  malformation ; but it is  by no
means certain that it owed either its origin or its con-
tinuance to such a state of parts  as  its cause.   Dr.
Churchill, in one instance, distinctly ascertained the
presence of  a stricture half way up the canal of the
cervix;  but its dilatation  left the  dysmenorrhoea as
bad as before.  A few years ago I examined the cer-
vix after an extremely severe and protracted attack
of the disease, and I satisfied myself  and a  profes-
sional friend, that there was really narrowing of the
canal.   This  was entirely  cured by  bougies;  but
the catamenial  suffering was not at all  alleviated.
In  another  case I was more  successful, and  Dr.
Ryan entirely cured one of the  very bad forms of
dysmenorrhoea by metallic bougies.   In  Dr.  Mack-
intosh's examples there is  nothing  proved as to re-
tention of the menses, which might have  been look-
ed  for if the  mechanical  impediment had been so
complete as "scarcely to  admit a  bristle."   He
tried the treatment by bougies in twenty-seven in-
stances, and cured  twenty-four.   In eleven  of the
latter  number,  pregnancy  subsequently  occurred.
As the introduction of bougies must act  as a direct
and powerful uterine stimulus; the advantage,  even
where contraction  really  exists  is  not  necessarily
entirely attributable to dilatation.  In doubtful cases
an internal examination ought  to be made;  as dys-
menorrhcea  may depend  not only " on a small os,
but on inflammation of the lining membrane, and of 
158
DYSMENORRHCEA.
the neck of the womb, and on tumors  diminishing
the calibre of the passage through the cervix."  Still
I believe that the views of Dr. Mackintosh are more
correct than is  generally supposed, and  they should
not be disregarded in protracted and  obstinate dys-
menorrhoea.
   Causes.—It is not at all times easy to specify the
exciting cause.   The history usually brings to light
some symptoms of uterine irritation, more or less
acute ; some catamenial irregularity, some proof of
a temperament disposed to strong emotions.   Among
married women,  miscarriages,  premature confine-
ments, and  particularly the various effects of cold,
may  be  enumerated as preceding the  complaint.
Nor must uterine determination or congestion be for-
gotten, by some  pathologists regarded as the most
frequent  cause of all.
   Diagnosis.—But little need be said on the diag-
nosis of dysmenorrhoea ; as in the great majority of
cases, the functional disorder is  clearly  ascertained,
and the symptoms well defined.   It  is only in  the
cases of  spurious abortion, where  the characters of
individuals may be ignorantly aspersed, that  much
discrimination is required.   The  duration of  the
complaint, the nature of the menstrual  secretion in
former periods, the enlarged state of the  uterus from
congestion, as ascertained from examination by  the
vagina and rectum, independently of the physical
characters of the product, are quite sufficient to satis-
fy any observer.  Dr. Montgomery, in his elaborate
and accurate work, on " The Signs and  Symptoms 
DYSMENORRHCEA.
159
of Pregnancy," thus expresses  himself, in reference
to the peculiarities which distinguish the dysmenor-
rhoeal membrane.
   " The substance  expelled  in this disease will  be
found deficient in several of the properties of the true
decidua; for although produced by an action in the
uterus analogous to that by which it prepares the
decidual  nidamentum for the reception and support
of the ovum, it  differs  therefrom in two  essential
points;   first, that  it  is a  morbid product;  and
secondly, that not being intended, like  the true de-
cidua, to become an organ, or at  least a medium of
nutrition for the  ovum,  it  is not furnished with a
structure such  as would only  be required  for the
performance  of  such an office;  hence, it  is  thin,
flimsy, and  very unsubstantial  in its texture;  of a
dirty white or yellowish appearance when slightly
agitated  in water, devoid of the soft, rich, pulpy ap-
pearance, deep vascular color, and numerous forami-
na for the reception of the nutrient vessels from the
uterus, which are always so distinctly observable in
the true  decidua, which however  in one point it re-
sembles, having  its inner surface smooth, and  the
outer unequal, but of a ragged, shreddy appearance,
unlike that of the healthy uterine decidua, and  it is,
moreover, entirely destitute of the little cotyledonous
sacculi already described as an  essential character
in the  latter structure.  In texture, it  more nearly
resembles that of the reflexa than any other struc-
ture ; but no trace  of the transparent membranes of
the ovum can be discovered within  it, or attached 
160
DYSMENORRHCEA.
to it, and should  it happen to come  away entire, in
the form of a hollow triangular bag, we never find
within it a duplicate of itself forming an inner pouch
or reflex layer, as in the case of the natural decidual
envelopes of the ovum.   Morgagni has given a very
accurate account of this accidental product, as it
occurred in the case of a noble matron of his coun-
try, who expelled it almost every month with pains
like those of child-birth,  having its external surface
' unequal  and  not  without   many  filaments  that
seemed to have  been broken off  from the  parts  to
which they had  adhered  ; but internally hollow, on
which surface it was smooth and  moist, as if from
an aqueous humor which it had before contained.'"
  Pathology.—Some authors regard dysmenorrhoea
as a  neuralgic affection,  a disease  of enervation,
identical  with  hysteralgia  and  irritable  uterus.
Others take a different view of the malady, and con-
sider  it  as invariably dependent on a morbid condi-
tion of the mucous  lining of the  uterus.   The for-
mer attribute the pain, and all the other symptoms,
to acute irritation;  the latter, to  inflammatory ac-
tion.  These  conflicting opinions are  not irrecon-
cileable.   In a great number of cases,  particularly
in delicate single females, there is only acute ner-
vous irritation, affecting the muscular tissue as well
as the mucous lining, and producing pain.   In other
and aggravated examples of the malady, there exists
a low form of inflammation, modified by the pecu-
liar membrane which it affects, and inducing intense
pain.   There are facts strengthening the impression, 
DYSMENORRHCEA.
161
that dysmenorrhoea is often a disease  of  irritation.
Hysterical and susceptible females are more prone
to it than any other class.  The pain is mostly un-
accompanied by  symptoms of  inflammation ;  the
pulse  is quickened only  during  the paroxysm,  this
being over, it again subsides ; and the flushed face
and hot skin  are often  succeeded by a  cold  and
clammy surface.   Acute pain may exist without in-
flammation, and a layer of lymph may, as in dysen-
tery,  be thrown off from the  intestinal mucous sur-
face, without decided inflammatory action.  Neither
the pain of labor  nor the after-pains, occasionally so
protracted and agonizing, are  inflammatory ;  and
yet, if the degree of pain were to be the  criterion,
one might easily believe that inflammation really ex-
isted ; for certainly no suffering from dysmenorhoea
can be greater than the pain attendant on labor and
its subsequent contractions.   In other cases,  and
which are thought, (by the supporters  of the opinion
that inflammation is invariably present,) alone to
deserve the appellation of dysmenorrhoea, a modified
and low form of inflammation certainly exists, which
produces  a  false  membrane,  assuming, in some in-
stances,  the shape of  the uterine cavity,  and in
others, being expelled in detached portions.  I quote
the following remarks  from a  clear  and practical
paper on this  malady, read  before the Medical  So-
ciety  of  Guy's Hospital  in  1839,  by Mr. Henry
Oldham, one of the obstetric assistants of the insti-
tution.
   " There are so few instances in which minute in-
              21 
162             DYSMENORRHCEA.
  \
vestigations  of the  exact condition of the mucous
membrane and body of the uterus in dysmenorrhoea
are permitted, that we cannot  offer any remarks on
the visible changes  in  these  structures.   We are
consequently left to the  far less secure, but the only
admissible mode of  inferring the character of these
alterations, from the symptoms which  accompany
the affection and the analogous  productions  from
other mucous membranes.  There can be no doubt
that mucous membranes, though prone to  suppura-
tive inflammation, often  throw off from their surface
false membranes of  organized  lymph.   The trachea
in croup,  the intestines in some forms  of dysen-
tery,  the  urethra under inflammation, are familiar
examples of the kind;  and there is  but one com-
mon  explanation of this occurrence, viz. that the
products of  inflammation are  present, and that the
lining membranes of these several organs are the
seat of the diseased action.  The uterus presents a
precisely analogous instance  in dysmenorrhcea, and
we hence infer, that its  mucous lining is in a similar
state."
   A  paper  presented to the  Statistical  Society in
1839, by Mr. Lever, another of the obstetric assist-
antsof the Hospital, and displaying his usual research,
confirms these views, by showing that one of the oc-
casional ultimate results of dysmenorrhcea, is struc-
tural change of the uterus.  A protracted dysmenor-
rhoea, where the false membrane has been habitually
secreted, (and the fact will be  noticed  in the append-
ed cases,) is liable to induce thickening and indura- 
DYSMENORRHCEA,              163
 tion of the  os  and cervix.   This is the result  of
 chronic inflammation, and is only to be feared from
 the  probability  of  its assuming a malignant charac-
 ter in  women possessing a cancerous diathesis.  By
 such a structural change, whenever  it  affects the
 channel of the cervix, mechanical dysmenorrhcea may
 be induced.
   Prognosis.—This will  be more or less favorable,
 according  to the views entertained of its nature.  If,
Jjke irritable uterus, dysmenorrhcea be regarded as
 invariably  a neuralgic, not an inflammatory disease,
 it may be  severe and protracted, but it  will not be
 fatal.  In  fact, I know of no instance where a ter-
 mination so  serious has  been  its immediate result.
 But, if a scirrhous or  carcinomatous change of the
 uterus follow, even  very  rarely in  its train, then  a
 prolonged  dysmenorrhoea  is a great evil.   It must
 not, however, be forgotten, that in the majority of
 instances,  the affection is cured, either by medical
 treatment, marriage and  child-bearing,  or  by the
 natural permanent cessation of the catamenial func-
 tion.  From observation,  I am disposed to think,
 that marriage  and  connubial  intercourse are  fre-
 quently remedial; the probability or impossibility of
 such events must  therefore influence the prognosis.
 It is not meant to be affirmed, that they are invaria-
 bly curative, or that aggravated  examples of the af-
 fection are not to be found amongst married  women.
 I am  now attending  an  unmarried patient  in her
 forty-fifth  year,  who,  from  fifteen  to  forty-two,
(when the function entirely and suddenly ceased,) 
164
DYSMENORRHCEA.
invariably suffered from dysmenorrhoea.  Her sister
was  similarly affected  till her  marriage,  but that
event,  and frequent pregnancy,  entirely displaced
and cured  the dysmenorrhoea.   In the former case,
I have examined the uterus very carefully, but  I
cannot discover any structural change either in the
body, cervix, or os.   The utmost caution should be
used  in  the  investigation of suspected structural
change, supposed  to  be connected  with dysmenor-
rhcea, as, in the  opinion of the  sex, very little suf-
fering is sufficient to induce them to denominate any
case painful menstruation.  A few years  ago, it was
a matter of doubt whether the false  membranes of
dysmenorrhcea could  be  formed independently of
impregnation.   This  point is now laid at  rest, and
no suspicion can for a moment be entertained of the
purity  of any individual so circumstanced.   It  has
been thought, too, that conception was  entirely in-
compatible with this  disease.   I have known preg-
nancy occur in several instances, almost immediately
after the marriage of a dysmenorrhoeal patient;  but
it cannot be doubted, that an aggravated  form of the
malady must  be  unfavorable  to  such an event, and
that sterility  may often be fairly attributed  to such
a cause.
   Treatment.—This  is necessarily  different;  for,
while  inflammatory and congestive dysmenorrhoea
require depletion and  antiphlogistic  measures, the
neuralgic or irritable form calls only for narcotic and
slightly nauseating remedies.   There are,  however,
in the treatment of every variety, two principal in- 
DYSMENORRHCEA.
165
dications;  to alleviate the urgent  pain of the men-
strual period, and to employ, during the intervals of
the discharge, such remedies as shall restore to the
uterus its healthy secretory  power.  Both are occa-
sionally accomplished with difficulty ;  the first, how-
ever, is generally the most easy of fulfilment.
  I n the more ordinary variety of the  malady, the
neuralgic, the mustard hip-bath and some narcotics
are especially beneficial; if  the attack be aggravated
or of frequent recurrence, then  ipecacuanha or an-
timony ought to be employed.  But to be more pre-
cise : let  the  patient, on the  first  premonition of
pain, commence  the use of the hot bath at 96 or 98°,
and ordinarily remain in it for a half or three quar-
ters of an hour, repeating it three or four times in
the twenty-four  hours, and  always guarding against
the effects of cold, by keeping in a hot  bed, so long
at  least as to  allow  the skin to resume  its ordinary
temperature.  When the pain  is very  severe, the
bath may be continued  until faintness is induced ;
and if it be inadequate for this purpose, then half a
grain of  ipecacuanha, or fifteen or twenty drops of
antimonial wine may  be exhibited every hour.  It
will be found, that the general relaxation of the cu-
taneous surface, and the attendant  and  temporary
depression  of  the system,   greatly favor  menstrual
secretion.  In the milder cases, a hot hip-bath and
slight narcotics will suffice.   Camphor, ipecacuanha,
and hyoscyamus, the Dover's powder, the extract of
hop, lettuce, conium  and belladonna, variously com-
bined (vide  formulae), relieve the pain and  induce 
 166             DYSMENORRHCEA.

perspiration and sleep.  If perspiration is  with dif-
ficulty obtained, three, or four, or five grains of an-
timonial  powder may be given,  by which a diapho-
retic effect will be insured.   Sometimes, when the
pain is terribly severe, and the cerebral  excitement
goes on nearly to  delirium, one  quarter or half a
grain of the  acetate of morphia may be  given at
night; and smaller doses, either of it, the  muriate
or meconate  of morphia, or Battley's  Liquor opii
sedativus, at intervals during the day.  A supposito-
ry of opium, conium, hyoscyamus  or belladonna, is
often effectual in relieving the pain.  In some cases,
from the  forcing, bearing down efforts, we can  dis-
tinctly recognize the attempt on the part of the ute-
rus to expel a clot.   Here the  ergot, either in de-
coction or tincture, may be repeatedly given, and an
interval of marked  ease, however brief, will occa-
sionally follow its expulsion.   It would  be difficult
to speak  with precision  of  every  modification of
treatment; but enough  has been said to enable the
practitioner, while  he maintains the principle,  to
vary the mode of management.   In a French publi-
cation of the Society of Agriculture, Sciences,  and
Arts, Dr. Patin recommends the acetate of ammonia
for dysmenorrhoea;  enjoining, however this caution,
that  as it diminishes the discharge, it must  be used
with  reserve.   He says, that so far from  being  a
stimulant, it is really a sedative remedy ;  and he re-
gards it as applicable in any case, whether of  dys-
menorrhcea, profuse menstruation,  or menorrhagia,
if there be morbid excitement of the female genital 
DYSMENORRHCEA.
167
system.   This physician gives from forty to seventy
drops  three  or four  times daily ;  the only incon-
venience  being slight and transient  giddiness.   I
have no experience of this remedy.
   In the inflammatory and congestive forms of dys-
menorrhoea, in addition to the remedies already en-
joined, local  depletion is peremptorily required ; and
there are  cases, where  there is vascular fulness, in
which a small general bleeding will be advantageous.
Congestion  almost  invariably  prevents secretion;
the unloading of the vessels,  therefore, aids the flow
of the  discharge.  In the majority of instances, cup-
ping  on the  loins, to the extent  of eight, ten,  or
twelve ounces, or leeches will suffice,  and, rf neces-
sary, the bleeding may easily be repeated.   Leeches
to the os  uteri have been  already mentioned, and I
think, that when well  applied, they  are decidedly
more  beneficial  than any other   local  depletion.
Several times I have  witnessed their superior effica-
cy in  relieving the severe pain;  in one  instance,
where the patient had been in the habit, for several
years, of being occasionally cupped, the relief afford-
ed by  thus directly unloading the congested vessels
themselves, exceeded, to use her own expression,
any  idea  she  could  have formed.   The  speculum
tube  may be introduced into  the  vagina prior  to
their application ; and if the cervix be brought fully
into view, neither the vagina  nor any other part than
this portion of the congested viscus  will be fixed  on
by the leeches.   Their use should, as much as pos-
sible, be confined  to married women, and a clever 
168              DYSMENORRHCEA.
nurse should be  taught  to  apply them.  The hot-
bath, as  heretofore advised, sudorific, nauseating
and  anodyne medicines may all  be used.  Hot pop-
py fomentations to the abdomen generally, and par-
ticularly to the hypogastric region, injections, seve-
ral  times during  the  twenty-four hours, of poppy
and  conium  into  the  vagina,  so as  constantly to
bathe the lower part of  the uterus, will  encourage
the discharge and sooth  the pain.
  The second  part of  the treatment comprises the
management during the catamenial intervals.   In
the neuralgic and  irritable form of the disease, the
object is to improve the  general health, principally
by attention  to the disordered state of  the digestive
organs, and  by the avoidance of local  excitements.
I need not dwell on the  importance of mild and cor-
dial  aperients,  in preference to drastic and mercurial
purgatives.   An  occasional  alterative, such  as  the
grey powder, or a moderate dose  of blue pill, is re-
quired, but active and  repeated  purging must be in-
jurious.   Afterwards,  the  various  preparations  of
iron, combinations of  the mineral  and vegetable
tonics, omitting them when the  bowels are disposed
to be relaxed,  a  nutritious  and  unstimulating diet,
pure air, a temporary residence  at places celebrated
for their chalybeate waters, and  gentle but perse-
vering exercise, are the most  important indications.
Dr. Dewees, one of our ablest obstetric writers, re-
gards the neuralgic form  of dysmenorrhoea as analo-
gous  in  its  nature to  chronic  rheumatism;  and
strongly recommends, in the intervals of the disease, 
DYSMENORRHCEA.             169
the volatile  tincture of guaiacum ; adding, that  he
has relieved many dysmenorrhoeal patients by the
antiphlogistic plan, but cured none.  He begins with
drachm doses of  the tincture three times daily,  in-
creasing the quantity to  three drachms three times
daily, in a  glass of wine.   His  success  has  been
great;  mine, although I have often tried the guaia-
cum, has been inconsiderable.
   In the inflammatory, and especially in the more
frequent congestive form of dysmenorrhoea, local  de-
pletion, saline aperients, and spare diet, are particu-
larly necessary ;  nor should they be discontinued till
the  volume of the uterus is  satisfactorily lessened.
The hot hip-bath three times a-week, and warm in-
jections of the  fotus papaveris  twice a-day,  will
topically aid the former and  more important reme-
dies.   Afterwards,  mild tonics will  complete  the
restoration  of  the  patient.  Bearing  in mind what
has been already said, of structural  uterine change
following chronic dysmenorrhcea, mercury must not
be forgotten in  the inveterate  cases.   In  the  pre-
ceding chapter, when treating of its  deobstruent ef-
fects,  I pointed  out certain conditions  as unfavora-
ble to its use ; but, where  these  indications are ab-
sent, there  is no medicine so likely to  prove effica-
cious.   It may be employed in both  the varieties,  if
their continuance is  exceedingly prolonged, and the
false membrane is habitually expelled ;  but certainly
mercury is  most beneficial  where there is a thicken-
ed and  indurated  cervix, the  result  of chronic in-
flammation. 
170
DYSMENORRHCEA.
   The effect of the inunction of the iodine ointment
on the neck of the  uterus, where it is enlarged and
hardened, is most  satisfactory.   This  subject  will,
however, be more fully treated of in the chapter on
hard tumors of the  os and cervix.
                      Case 26.

  CHRONIC DYSMENORRHCEA--PREGNANCY  SUPERVENING
              AFTER FOURTEEN  MONTHS.

   OCCURRING IN THE  PRACTICE OF MR. HENRY OLDHAM.

  Oct. 20.  Mrs. H-------, a young lady of lively, active
habits, was married in  July, 1838.  For three or four  years
previous to her marriage, she appeared constitutionally deli-
cate,  and during this  time she  suffered  from  occasional
menorrhagia, followed  by menstrual suppression, the continu-
ance of which varied  between six weeks and two months.
This  condition  of the uterine function was attended with
great languor under exertion, imperfect nutrition from loss of
appetite, irregular action of the bowels, tympanitis, hysterical
emotions, and leucorrhoea more or less profuse.  During the
latter part of this time she had several  attacks of glandular
swellings, and the  right lobe of the thyroid remains perma-
nently enlarged.
  The first  three  months of marriage were attended with
marked  improvement in  her general health.  The appetite
became healthy, the features firm, the animal spirits buoyant,
and everything indicated confirmed health.   About the fourth 
DYSMENORRHCEA.
171
month after marriage the  first symptoms of dysmenorrhcea
appeared.   The menstrual period was preceded by intense
pain in the mamma?, lasting for days, which was relieved only
when  the  catamenia commenced to flow.  The discharge
itself was altered  in quality, being clotted, and in its expul-
sion occasioned much local  suffering.  The pains, however,
subsided with  the discharge, and the  first periods were  pass-
ed, leaving only a  temporary sense of exhaustion.   She came
under my care in March, 1839.   At this time she was labor-
ing under an attack of dysmenorrhcea,  which had been pre-
ceded by great irritability of the mammae, lasting eight days.
The local sufferings were very great,  and the discharges con-
sisted of occasional fibrous masses, with detached portions of
membrane and a brownish  colored fluid.  During the attack
she  complained  much of exhaustion,  her appetite left her,
and the least exertion aggravated the pain.   She was ordered
the hot hip-bath, with hot poppy fomentations, and  the fol-
lowing pills :—

     R. Ext. Hyoscy. gr. iv.
        Camphorae Rasae, gr. iij.
        Pulv. Ipecac, gr. i.  Ft. Pilul, ij.   Ter in die sumend.

   These had the desired effect of relieving the pain ; but the
symptoms after  the catamenial  period  did  not kindly pass
away.   There was continual  aching of  the  loins and groin,
as though the  uterine ligaments were strained; a  perpetual
sense of weariness; indifferent  appetite ;  and unrefreshing
sleep.   She also complained of pruritus of the external gen-
itals, and leucorrhoea was present.   The bowels were irregu-
lar, sometimes constipated, and at others relaxed.  Circula-
tion feeble.
   It would  be tedious to  recount  even a  monthly report,
although the symptoms were accurately noted.  They par- 
172
DYSMENORRHCEA.
took generally of those already enumerated.   At one time
the tonic treatment pursued  during  the  interval  seemed
almost to have  re-established  her  health ;  but the intense
agony of the succeeding  period  left the  same  exhaustion ;
and was  followed by the  same  constitutional effects.  The
sedative treatment, with slight variations, was enjoined during
the attacks, and  chalybeates variously combined—occasional
purgatives, with  good, but unstimulating diet, were the main
therapeutics in  the  intervals.   She  was ordered to the sea-
side, and marital  intercourse  was  suspended.   Temporary
alleviations were often procured;  but there still remained
delicacy, and continued ailment with the same functional dis-
order.   Her general health indeed  seemed  gradually to  get
worse ;  and some of her friends foreboded phthisis, without,
however, any physical  sign of thoracic disease being recog-
nised.   Iodine with the hydriodate  of potash in small  doses
was  given  with some  benefit; and the iodide of iron  had a
decidedly good effect.
   In September, 1839,  she menstruated naturally,  without  an-
tecedent pain ; and the discharge was  of  its proper consist-
ence, color, and  quantity,  and the appetite greatly improved.
In a fortnight after  this period she complained of more in-
tense suffering than she had  ever before experienced in  the
hypogastric region, with lumbar and bearing  down pains, ina-
bility to exert herself,  etc.  The mammae  also  became in-
tensely painful, so that  the least pressure on  them occasioned
shivering and  sudden pallor.   On examining the uterus, the
os and cervix were  found hardened  and painful, and the body
of the uterus fuller  than natural, its  weight being sufficient to
bear it  low down in the  vagina.   A previous examination,
about six weeks before this time, had  detected  the  os and
cervix larger than normal; but soft  and rather painful  when
even  gently  touched.   The  local  and  sympathetic  pains
seemed to be premonitory of the  menstrual  flow;  but this
period passed away, and  ten days afterwards  Dr. Ashwell 
DYSMENORRHCEA.
173
saw her with me.  On examination, the volume of the uterus
was found considerably augmented, and it was suspected that
this suspension of the catamenia had occasioned the conges-
tion.  Upon  more  careful examination, however, of  the
mammae, a well formed  areola was  visible, and  the  exist-
ence of  pregnancy became probable,  and  now, in Novem-
ber, the sympathetic affections have abundantly confirmed the
opinion.
                        Case  27.


    protracted  dysmenorrhcea cured by  mercury.

   In January, 1837,1 visited Mrs.------, aet.  24, residing a
few miles  from town.   She is  delicate  and  of  strumous
aspect, and has been married nearly two years.   She aborted
soon afterwards, and has  never  since  been pregnant.   The
present symptoms are intensely  painful menstruation, accom-
panied by the expulsion of clots and  portions of false mem-
brane.  Prior to marriage she suffered in a similar way, but
not to the same extent.  For a few months after this event,
the dysmenorrhcea  was materially alleviated;  but since the
abortion it has returned in aggravated  degree.  Now, pains
in the  hypogastrium, loins, and thighs, occur several  days
prior  to  menstruation,  inducing  fever and depriving her of
appetite and  sleep ;  the  dysmenorrhoea lasts  seven or eight
days, and from exhaustion she is generally on the sofa a week
afterwards; so that  the disease and its consequences  absorb
nearly the whole month, and leave but little opportunity for
curative treatment.   Leucorrhoea is always present when she
is not menstruating; the  bowels are irritable and uncertain;
sometimes constipated, and at  other  times, after  a gentle 
174
DYSMENORRHCEA.
aperient, or even  after trivial  mental excitement,  violently
purged.
  In  May, Mrs.-------  was  no  better, although she had
fully pursued the treatment laid  down in the previous pages.
She was emaciated, and as she complained  of constant heat
and pain at the neck of the bladder, and of pain also in coitu,
I was allowed to examine.   The lower  part of the  body of
the uterus was  enlarged, hard, and  slightly tender ;  the cer-
vix was thickened, generally increased in size, indurated and
uneven, but without the stony hardness of malignant disease ;
the os was patulous, and its edges not smooth.   The whole
viscus was increased in size, and on raising it  up on the fin-
ger, she was immediately relieved from pressure on  the neck
of the bladder, of  which at other times she complained.
  I now urged the importance  of  mercurial  treatment, the
recumbent posture, and the entire avoidance of sexual inter-
course.
  June  20.  Mrs.-------was ordered three  grains of blue
pill every night; and four ounces of the compound decoction
of sarsaparilla, with  two  grains of  quinine  twice a  day.
Meat diet and mild ale ; and she was also especially enjoined
to be  careful not to expose herself to cold.
  July 24.   The  mouth has been  affected, and  the flow of
saliva increased for the last fortnight;  but there has been
neither  premonitory  pain  nor  menstruation, although  more
than  a month has elapsed since the last period.   In  other re-
spects there is not much alteration; the  countenance is still
wan and anxious.
  August  10.  Menstruation  has occurred with much less
pain,  and without either narcotics or the warm bath.   Gums
are sore, and  the  salivation is  still  going on, although one
three-grain pill only is taken every third night.
  Sept.  25.   Has entirely  discontinued  the mercury for
several weeks, and the last  two periods  have been passed
with scarcely any pain, and without clots or membrane. 
DYSMENORRHCEA.               175
  I have twice examined the cervix uteri, and  although it is
still tender, the induration is gone, and the size of the uterus
and of the cervix also are again natural.   This patient after-
wards spent a considerable time in  the  country  and  by the
sea side, entirely recovering her health and strength.
                       Case 28.

 severe dysmenorrhcea dependent on  inflammatory
  congestion of the cervix and body of the uterus.

 occurring in the practice of mr. fenner of pentonville.

  MISS W------, aged  29, began to menstruate  so favora-
bly at seventeen  years of age, that  she was  unconscious of
the occurrence.   But after some months, she invariably suf-
fered, (and has continued to do so to the present year, 1839,)
a few days before the periods from acute pains in the loins,
and left hypochondrium, headache,  flatulence, retching and
violent palpitation of the heart.  The pain  in the left hypo-
chondrium and the palpitation  have since been almost con-
stantly present in greater or less  degree.   The  periodical
discharge  is always  dark, scanty, clotted, and membranous,
never lasting  more than a day and a half, and sometimes not
so long.   During the year  1838, there  were superadded a
shooting pain on the  inside of the left thigh, leucorrhoea, and
intense  pruritus, rendering the  condition of the  patient ex-
tremely distressing.
   Sept. 20, 1839.   A period  has just passed with such ag-
gravation of the above symptoms as led to my being consult-
ed.  On examining the uterus  by the speculum, 1 found its
cervix and body considerably congested, and very painful to 
176
DYSMENORRHCEA.
 the touch.  Moderate pressure with the finger instantly re-
 produced the palpitation of the heart, and the pain in the left
 hypochondrium,  causing  the  patient to  exclaim " Oh my
 heart!  how it beats !"  Then, " Oh my side ! you are bringing
 on the  pain in  my side!"  thus  demonstrating that  those
 sensations were merely sympathetic  of the condition of the
 uterus.
   Treatment.—She was bled to fifteen or sixteen ounces—
 a  pill of Pulv. Antimon. gr. iii.   Antimon. Pot. Tart.  Hydr.
 Chloridi. aa gr. £, was given every six hours until the mouth
 became  sore ;  afterwards it was  continued  once  or  twice
 daily, to maintain the derivative action, up to the time of the
 next  period.  A hip-bath, and an injection  of warm water
 into the vagina, were used twice every day while the  pains
 continued severe,—then every  night.  The patient  was en-
 joined to keep much in her bed, and to use the Hydrocyanic
 lotion (vide formulas)  for the  pruritus.   External  irritation
 was also kept up on the  left  hypochondrium  by the  Ung.
 Antimon. Pot. Tart.
   Sept. 29.   Much better;  pulse  90, and  less irritable;
 mouth sore;  pain in the left hypochondrium, and palpitation
 less.
   Oct.  1.   On examination by the finger, the uterus is found
 to be  much softer, and less sensitive; nor even the  pain and
 palpitation produced,-as before, by pressure.
   Oct.   17.  As the  period was  expected  to return  very
 shortly, the patient was again  moderately bled, complaining
 only of slight premonitory pain in the hip and head.  She
 has suffered less during the interval  than for  years;  her ap-
 petite and sleep being greatly improved.
   Oct.  23.   After passing a good  night, and getting up  well,
the catamenia appeared, as at first unconsciously, and  without
pain. 
DYSMENORRHCEA.             177
   It would  be easy to verify the  statements of the
text by a far greater number of cases ;  as examples
of the disease in its  different  forms, and of  every
degree of severity, are continually presenting  them-
selves in private and  in hospital  practice.   But the
instances cited may suffice to impress the importance
of a correct view of the precise pathological condi-
tion of the uterus before commencing any  active
treatment.  Nor can  it be too strongly urged that
as  pain is the accompaniment of so  many different
morbid conditions, it is in dysmenorrhcea absolutely
essential to know whether it be associated  with an
irritable  and neuralgic, or an inflamed and congested
uterus.   Palliatives and narcotics may suffice  in the
former varieties,  but in the  latter, till inflammation
and congestion be removed by depletion and  anti-
phlogistic  measures,  neither  narcotics,  tonics, nor
emmenagogues will avail.
   I  have already spoken of the advantages of leeches
directly applied  to the cervix  uteri,  when the dys-
menorrhcea can be traced to congestion ; and I have
lately seen several cases, one in particular, with Mr.
Fenner of Pentonville, who  devotes  much  time to
the  investigation and treatment of  female sexual
disease, where  by the aid of his speculum tubes,
scarification of the  neck  of the  uterus  was freely
practised.   There was not during the operation, nor
afterwards, any decided pain ;  and as three or four
ounces of blood  were quickly drawn,  it will prove a
far better,  quicker, and  less  troublesome  remedy
              23 
178
DYSMENORRHCEA.
than the application of leeches : the relief attendant
on this novel process, was superior to what had ever
resulted from the leeches.   I believe this method of
depletion  may  be  safely,  and often  most  advan-
tageously resorted to. 
CHAPTER  V.
            FORMULA OF REMEDIES.


   It may not  be without advantage that I  should
select, from the  various remedies used  in hospital
and private practice,  in the  diseases already de-
scribed,  ail of which are distinguished by paucity of
the catamenial discharge, those which, after repeat-
ed trials, I have found most efficient.


             APERIENTS AND PURGATIVES.

           Form.  1.—Pulv. Magnesia. Comp.

    R. Magnesias Sulphatis giss.  Magnes. Carb.  Sodae Ses-
      qui-Carb. aa 3iv.  Sodae Hydrochlorat. 3ii. Pulv. Zinzib.
      vel pulv. Aromatici 3j.  M. ft. Pulvis.

   Take one, two, or three teaspoonfuls at bed time, or occa-
sionally in the day, when the bowels are confined.   Usually
the powder may be mixed in warm water; but if a  more de-
cidedly aperient effect is desired, then half  a bottle of soda
water may be poured over the salt, and it may be swallowed
in a state of effervescence. 
180           FORMUL.E  OF  REMEDIES.
               Form. 2.—Pulvis Purgans.

    R. Pulv.  Rhei gr. vj.  Potassae Sulphatis vel Sodae Sulpha-
       tis  gr. x.   Pulv. Zinzib. gr. iii.  01. Cassias  gtt. ii.  M.
       ft. Pulvis Purgans.

  Take one powder in warm water night and  morning.


               Form. 3.—Pulvis Purgans.

    R. Hydr. Chloridi [Calomel] gr. ii.  Pulv. Jalapse, gr.  vj.
       Pulv. Cambogice gr.  iij.   Pulv. Zinzib.  gr.  iv.   Olei
       Cassiae  gtt. ii. M. ft. Pulv.

  Take one powder in gruel, or barley-water, once or twice
a week, at bed time.

      Form.  4.—Pulv. Scammonii cum Hydr. Chlorid.

    R. Scammon. Gum.  Resin. Pulv. gr.  viij.  Hydr. Chloridi
       [Calomel] gr. ii. vel iii.  Potassae Supertart. Sacch. Alb.
       aa  gr. x. M. ft. Pulv.

  Powders three and four will only occasionally be required ;
but where  the secretions of the intestinal canal are vitiated,
and the  hepatic functions  are  imperfectly performed, they,
or some of the more active  aperients (with  occasional altera-
tives), will be efficient remedies, if judiciously and sparingly
exhibited.

           Form. 5.—Pilula Colocynth. Comp.

    R. Extr. Colocynth. C.   Pil. Rhei Comp.   Pil. Cambogis
       C. aa Bl Olei Cassis gtt. vj.  M. ft. Pilulae xii.

  Take one or two  pills at bed time every night, or  every
other  night, or 
             FORMULAE  OF  REMEDIES.           181

  R.  Pil.  Colocynth. C.  Pil.  Galbani C. aa  3ss.  M. ft.
    Pilul. xij.

Take two pills twice a day.
            Form. 6.—Pilula Aperientes.

  R. Pil. Cambogiae C. gr. xxx. Soda? Carb. Quiniae Disulph.
    aa gr.  xv.   Ol.  Menth. Pip. gtt. vj.  Syr. q.  s.  M. ft.
    Pilulae xii.

Take two or three pills at bed time.
       Form. 7.—Pilula Aperientes Alterativa.

  R.  Pil. Hydr. Bi.   Hydr. Chlorid. [Calomel] gr. x.   Pulv.
    Antimonial.  gr. x. Antimon. Tartarizat. gr. iii. Pil. Rhei
    C. 9i.  Syr. q. s.  M. ft. Pilulae xii.

Take two pills every other night.
       Form. 8.—Pilula Aperientes Alterativa.

  R.  Pil.  Hydr. Chlorid. Comp. 9i. Pil. Aloes cum Myrrha
    9ii.  Extr. Sarsae. Extr. Taraxaci aa gr. x.  Syr. q. s.  M.
    ft. Pilulae xvj.

Take two or three twice a day.
          Form.  9.—Mist. Purgans Communis.

    R. Pu!v.  Rhei, Magnes. Carb.  aa 3ii.   Conf. Arom. 3iss.
       Infus. Rhei, Aquae Cinnamomi aa §iij.  M. ft. Mist.

  Take a wine-glass full  early in the morning, two or three
times a week. 
182          FORMUL/E  OF REMEDIES.
           Form.  10.—Mist. Rhei Comp.

             From Guy's Pharmacopoeia.

  R. Rhei pulv. 3j.  Sodae Carb.  3ii.  Pulv. Calumbae 3ii.
    Aquae Menth. Pip. Aquae fontis aa gvj.  M. ft. Mist.

Take two table spoonfuls three times a day.
               STOMACHICS AND TONICS.

   It has already  been  observed  that  the  various
preparations of iron, several of  which  I annex, are
by far  the  most  valuable  in these  affections, but
they cannot always be administered.  If the diges-
tive organs  are much  deranged,  or if there  be a
proneness to diarrhoea, they will probably still  more
irritate the  intestinal  mucous membrane.   Prelimi-
nary and cautious directions about the diet and the
alvine  secretions will be  required,  and when the
tone of these organs is  restored, and not till then,
iron in  some of its forms may be efficiently employ-
ed.   Occasionally,  when  the  general  health  has
been  long disordered and  tympanitis  has  ensued,
other remedial combinations will be required.

          Form. 11.—Pilulce, Ferri Ammon.
    R. Ferri Ammon. Bii.
      Extr. Gent. C. Extr. Papav. Alb. aa gr. x.
      Theriaci, q. s.   Ft. Pilulae xii.
Take two pills three times a day. 
FORMULAE  OF  REMEDIES.
183
       Form.  12.—Pilula Ferri cum Gentiand.

               From Guy's Pharmacopoeia.

  R. Ferri Sulphatis gr. i.  Extracti Gentianae Mollioris gr.
    iii. M. ft. Pilula.

Take one pill three  times daily.
  Form.  13.—Pilula Ferri cum Quinia Disulphate.

  R. Ferri Sesquioxydi Quiniae Disulphatis aa  9i.   Extr.
    Gentianae Mollioris, Extr.  Papav. Alb. aa gr. x. 01. Cassia?
     gtt. vj.   M. ft. Pilulae xii.

Take two pills twice or three times a day.
       Form.  14.—Pilula Ferri cum Galbano.

  R.  Ferri Sesquioxydi, Pilularum Galbani Compositarum, aa
    gr. xxv. Extr. Humuli. gr. x.   01. Cinnamon,  gtt. viij.
    Theriaci q. s. Ft. Pilulae xii.

Take two pills twice or three times a day.


       Form.  15.—Pilula Ferri cum Myrrha.

  R.  Ferri Sesquioxydi, gr. ii.
    Pulv. Gummi Myrrhae, gr. iii.
    Theriaci q. s. ut  fiat Pilula.
Take two pills three times a day. 
184           FORMULA  OF  REMEDIES. "
               TONICS WITH  PURGATIVES.

           Form. 16.—Pilula Aloes cum Ferro.

    R.  Ferri Sesquioxydi  gr.  i.  Extracti Aloes  Aquosi, Ex-
      tracti Gentianae Mollioris aa gr. ii.  Ol. Menthae Piperita^
      gtt. i. ut fiat Pilula.

  Take two pills twice or three times a day.


       Form. 17.—Pilula Colocynthidis cum Ferro.

    R. Ferri Sesquioxydi  gr. xviii.   Pilularum Galbani Com-
      positarum, Extracti Colocynthidis Compositi aa B'i.  The-
      riaci q. s. ut fiant Pilulae xii.

  Take two pills once, twice, or more frequently during the
day.

           Form. 18.—Pilula Rhei cum Ferro.

    R.  Pilularum Rhei Compositarum 9ii.
      Ferri Sesquioxydi 9i.
      Theriaci q. s.  ut fiant Pilulae xii.

  Take two pills once, twice, or more frequently during the
day.

           Form. 19.—Pilula Zinci Composita.

    R. Zinci Sulphatis gr. xii.  Extracti Gentianae 3j.   01.
      Anthemidis gtt. vj.   ut fiant Pilulae xii.

  Take two pills once, twice, or more frequently during  the
day. 
FORMULAE  OF  REMEDIES.           185
    Form. 20.—Mistura Ferri Aperiens.  No. 1.

  R. Ferri Sesquioxydi gr. x.  Magnesias Sulphatis.   Sodae
     Sulphatis aa 3iv.   Aquae destillatas §vj.  M. ft. Mistura.

 Take two tablespoonfuls twice or three times daily.


      Form. 21.—Mist. Ferri, Aperiens.  No. 2,

  R. Ferri Sulphatis gr. x.
     Magnes. Sulph. 5iii.
     Acid Sulph. dil. 3j.
     Infus. Gent. Comp. Infus. Rosae Comp. aa §iv. M. ft. Mist.

Take two tablespoonfuls twice or three times  daily.


          Form. 22.—Mist. Ferri Muriatis.

  R. Infus. Gentianae Compositi |vij.
     Syr. Aurantii §i.
     Tinct. Ferri Muriatis *t xl.  M. ft. Mistura.

 Take two tablespoonfuls twice or three times daily.


        Form.  23.—Mist.  Quinia Disulphatis.

  R. Infus. Rosae Compositi  gv.
     Tinct. Cardamomi Comp. §j.
     Quiniae Disulphatis 9i.
     Acid. Sulph.  dil. nx.  M. ft. Mistura.

 Take one or two tablespoonfuls twice or three times daily.
             24 
186           FORMULA  OF  REMEDIES.
              Form.  24.—Mist. Ferri Iodidi.

    R. Ferri Iodidi gr. xviii. Tinct. Calumbae §j.   Aquae destil-
       latae gvij.  M. ft.  Mistura.

  Take one  or two tablespoonfuls, two or three  times daily.
A piece of iron wire should be kept in the phial, to  prevent
decomposition of the  iodide of iron  and  precipitation of the
sesquioxyd of iron.


       CORDIALS, ANTISPASMODICS  AND  NARCOTICS.


         Form.  25.—Mist. Ammonia Composita.

     R. Ammoniae Carbonatis Biss. Tinct. Castorei, Sp. Lavan-
       dulae Comp.  aa 3vj.   Tinct. Hyoscyami 5i. vel Syrupi
       Papav. Alb. 3iv. vel Morphiae Acetatis gr. ^ vel. j.  Aquae
       Menthae Piperitae §vj.  M. ft. Mist.

  Take one  tablespoonful  three or four times daily.   It may
be unnecessary to add any of the narcotic  ingredients.


        Form. 26.—Mistura Castorei  Composita.

     R. Tinct. Castorei, §j. Sp. Lavandulae Comp. 3iv.  Tinct.
       Camph. C. 3iv.   M. ft. Mistura.

  Take half a teaspoonful every three  or  four hours in a
tablespoonful of water.


          Form. 27 —Mistura Morphia Acetatis.

     R. Morphiae Acetatis gr. i. vel. ii.
       Acid Acetici gtt.  x. 
FORMULAE  OF REMEDIES.            187
       Aquse destillatse 3iii.
       Tinct. Card. C.3i.  M. ft. Mistura.

   Take five or ten drops occasionally ; frequently, if pain or
 spasm be urgent.

                Form.  28.—Mistura Vini.

                  From Guy's Pharmacopoeia.
     R. Vini Albi, vel. Rubri, vel.  Spiritus Gallici §vj.  Ovo-
       rum  Duorum Vitellos.  Sacchari  grfs.  Olei Cinnamomi
       guttas iii.   M. ft. Mistura.

   Take two tablespoonfuls  frequently  during the  day, if
there be languor or faintness  from debility.


            Form. 29.—Mistura Creta Opiata.

                  From Guy's Pharmacopoeia.
     R. Pulveris Cretae Comp. cum.  Opio. 3iij.  Aquae Menth.
       Pip.  §ix.   M. ft. Mistura.

   Take two tablespoonfuls after every liquid motion.


        Form.  30.—Julepum Potassce  Carbonatis.

                  From Guy's Pharmacopoeia.
     R. Liquoris Potassae Carbonatis §j.  Aquae Menthae Viridis
       §xi.   M.  ft. Mistura.

   Take one or  two tablespoonfuls in  barley water or linseed
tea, twice or three times daily.

      Form. 31.—Infusum  Serpentarice  Compositum.

                  From Guy's Pharmacopoeia.
    R.  Serpentarise  Contusae, Contrajervae  Contusae  aa  3v. 
188           FORMULA  OF  REMEDIES.
      Aquae Ferventis gxvj.   Post Macerationem in vase leviter
      clauso per duas horas, liquorem  cola, et adde Tinct. Ser-
      pentarias §ij.  M. ft. Mistura.

  Take three tablespoonfuls every four or six hours, occa-
sionally adding to  each dose if it be required.

      Liquor. Ammon. Acet. 3iv. vel.
      Liq. Ammon. Sesquicarbonatis ""ixxx.

          Form. 32.—Pilula Moschi Composita.

     R. Moschi gr. xl.   Pulv. Zinzib.  Pulv. Valerianae aagr. vj.
      Camphorae   gr. xii.  Conservae Rosae q. s.  M.  ft.  pilu-
      lae xii.

  Take two  pills every three or four  hours.


               Form.  33.—Pilula Sedativa.

     R.  Pulv. Opii. gr. £.  Camphorae gr. iv.  Cons. Rosar. q. s.
      M. ft. pilula.

  Take one  pill every four or six hours.


       NARCOTIC  INJECTIONS AND  SUPPOSITORIES.

          Form.  34.—Enema Antispasmodicum.

     R.  Liq. Opii.  sedativ.rn.xxx.   Infus. Valerianae gi.  Mucil.
      Acaciae §ss.  M. ft. Enema.

  The injection to be passed  into  the bowel by a syringe
night and morning.


          Form.  35.—Enema  Contra Spasmas.

                     From Dr. Copland.
     R. Camphorae Rasas  gr. v.—x.  Potassae Nitratis 3ii. Olei 
FORMULA  OF REMEDIES.            189
Olivae gj.  Tere simul, et adde Infus.  Valerianae, Decocti
Malvae. C. aa gv.   M. ft. Enema.
         Form.  36.—Enema  Emolliens.

                 From Dr. Copland.

R. Flor. Anthemidis,  Semin. Lini. Contus. aa gss.   Aquae
  fervid, gvj. Macera  et  cola;  dein adde Opii. gr. ii.  iii.
  vel. vj.
Half this quantity to be used at a time.
             Form.  37.—Enema Belladonnce.

                     From Dr. Copland.
    R. Fol. Belladonnae Exsic. gr. xii.  Aquae Fervid, gvj.  M.
       ft. Enema.

  In severe dysmenorrhoea, in retention  of urine from spasm
of the sphincter vesicae, or spasm  of the rectum.
       Form. 38.—Enema Olei Terebinthince.

               From Guy's Pharmacopoeia.

  R. Olei Terebinth gss.  Ovi unius Vitellum.  Tere simul,
    et gradatim adde Decocti Hordei tepid, gx.

To be used once a  day or more frequently.


      Form. 39.—Enema Saponis Compositum.

  R. Saponis Mollis, gj.   Pulv. Opii. gr. iii. vel. vj.  Aquae
    Ferventis gvj.   M. ft.  Enerha. 
190           FORMULAE OF  REMEDIES.

   Half or the whole quatity to be used once, twice, or three
times daily.

                Form. 40.—Enema Tabaci.

                  From Guy's Pharmacopoeia.

    R. Tabaci 3j.   Aquae Ferventis gxvj.  Macera per sextam
       horoe partem et cola.

   One quarter or half the quantity may be used, and  if neces-
sary the injection may be repeated in an  hour.
           Form. 41.—Suppositorium Opii.

  R. Pulv. Opii gr.  | vel. i.  Sapon. Castiliensis gr. iii.   M.
    ft. Suppositorium.

The suppository to  be  used once, twice,  or thrice daily.
      Form. 42.—Suppositorium Belladonnce.

  R.  Extr. Belladonnae gr. i. vel. ii.  Saponis Castiliensis gr.
    iii. vel. iv. ft. Suppositorum.

To be used once or twice a day.
                 emmenagogues.

                   Form.  43.

R.  Liq. Ammon. fort. 3i.  vel. 3iss.
  Lactis tepid, gxvj.  M.  ft. injectio vaginalis.
A third part to be passed into the vagina three times daily. 
FORMULAE  OF REMEDIES.           191
Form. 44.
From Dr. Schonlein.
    R. Aloes Socotorin. gr. x.   Mucilaginis Acaciae gj.   M. ft.
       Injectio intestinalis.

  The injection to  be thrown  into the rectum  two or three
times a day.

                         Form. 45.

    R. Sinapis pulveris 3ii.
       Aquae Ferventis gxvj.  M. ft. Injectio.

  A third part to be passed into the  vagina three times daily. 
CHAPTER  VI.
              OF  MENORRHAGIA.

  Definition.—Inordinate  Menstruation, both  as
to the frequency of return, and the amount of the
secretion ;  in  the majority of instances  accompanied
by direct loss from the uterine arteries.

  There are two forms of  the disease.
  First, Profuse Menstruation, either as to frequency
of return,  or the amount of  the secretion, or both,
without uterine bleeding.
  Second,  Profuse  Menstruation  accompanied  by
direct loss of blood  from  the  uterine arteries, in-
cluding three varieties.
  a.  Acute or active menorrhagia;  occurring in the
plethoric and  robust.
  b.  Passive or chronic menorrhagia ;  the subjects
of this variety  being  the delicate,  hysterical, and
exhausted females ; and,
  c.  Congestive  menorrhagia;  generally met  with
at the middle  or more advanced periods of life. 
MENORRHAGIA.
193
   Profuse Menstruation,  either as to frequency of
return, or the amount of the secretion, or both, without
uterine bleeding.
   History and Symptoms.—I  may at once observe,
that the  hemorrhages  of abortion, pregnancy, and
parturition, and of  the various  organic  diseases of
the  uterus, do not  come  within  the scope of this
chapter;  and to avoid a perplexing multiplication of
names, I  include profuse secretion  of the catamenia,
as a form of menorrhagia,  as it is rarely a disease of
long continuance,  unaccompanied   by  bleeding di-
rectly from the uterine vessels.   If we  reflect on
the large  supply of blood constantly furnished to the
uterus during the greater part of life, and which is
every month, for a  functional  purpose, still further
augmented, it is not at all  surprising that the limits
of secretion are occasionally  exceeded,  and that,
instead of a fluid  only partially   sanguineous, its
usual  product,  pure  blood, should be  discharged
from its  vessels.   Thus, so  long  as the  discharge,
even  if  it be profuse, is not  blood,  menstruation
only exists ;  but, if the secretory  function is either
altogether or only partially superseded  from exces-
sive  determination  to  the  uterine  vessels,  their
orifices may give way, and, as then they will permit
blood to pass unchanged, menorrhagia is established.
   Profuse menstruation and  menorrhagia are neither
confined   to one  class of females  nor to one  age.
The young are less  liable than those more advanced
in life.   The  plethoric and robust less  frequently
than females of susceptible and feeble constitutions.
               25 
194
MENORRHAGIA.
Still, circumstances may induce these diseases in
every class, the periods of reproduction  and cata-
menial cessation being more obnoxious to them than
all others—climate and peculiarity of system being
criteria of importance.   In northern and cold coun-
tries, the amount  of menstrual secretion  which is
only natural  here, would be regarded as excessive;
and  in hotter  climates, what  we consider  profuse
menstruation, would be strictly  normal.  In  one
individual, or in the female  branches of a  whole
family, five,  six,  or seven ounces  may be  only a
healthy amount of discharge, while in others such a
quantity   would be morbidly  profuse.   It  follows
then, that in the one  case,  health  not  weakness
would accrue, while  in the  other,  weakness  not
health would  be the result.
   The question, therefore, whether menstruation be
healthy or inordinately  profuse, will  mainly  depend
on climate and idiosyncrasy, and especially on  its
constitutional effects.   If it occur during  pregnancy
and lactation, it is unnatural and in excess;  and  on
several  occasions,  in  married women more espe-
cially, I  have known it recur after long  periods of
suspension, so profusely, as to have  been mistaken
for abortion.   The way in which profuse  menstrua-
tion comes on is various.   I have now  a  patient in
whom, for some months, the discharge, without any
admixture of coagula, has every second week set in
suddenly  and with  a  large gush ; this  discharge,
with an interval of only a few hours, being repeated
for four, five,  or six days.   This individual is thirty- 
MENORRHAGIA.
195
one years old, and  unmarried ; and  so far as  I can
ascertain, is without the  slighest evidence of struc-
tural  disease; but  she  is anemiated  and feeble.
More frequently,  however,  the secretion is excessive
from its continuance, lasting  ten or twelve days, or
is too early in its  return.   Young and single women
are more prone to the latter;  while married females,
weakened by child-birth,  undue  lactation and leu-
corrhoea are obnoxious to the former variety.  Leu-
corrhoea,  indeed, has much  to   do with  profuse
menstruation, and is  generally present, either in the
catamenial intervals, or has  existed prior to  the
excessive  menstruation.   Dewees  states that  in
America  he  has scarcely ever  known  a  case of
genuine  profuse menstruation.    Such  examples
being  almost invariably accompanied by the dis-
charge of pure blood.  I do not doubt the accuracy
of this statement;  but a  similar  statement of  this
country, and of  my own experience, would not  be
correct,  as instances, and not  a few, have  come
under my own observation.
   The symptoms are precisely those induced  by a
drain on the  sanguineous system, varying  in degree,
according  to the amount, the continuance, and the
more or  less frequent recurrence  of  the  discharge.
At first languor,  inactivity, and sensations of weak-
ness, rather  than pain across the loins, are  com-
plained of; subsequently there is  severe and almost
constant  aching  in  the back and   lumbar region,
coming  round to the hips and front of the thighs,
and to the lowest  part of the abdomen.   The face 
196
MENORRHAGIA.
is pale, sometimes bleached and  cadaverous.   The
patient suffers  from nervous  headache, the  pain
being  often confined to  one spot, tinnitus aurium,
throbbing  of  the  temples,  frequent  vertigo, and
where the loss  has been  excessive, a sensation  as
though a  clock  were ticking in the head.   The
heart acts  feebly on small  quantities of blood, and
there is in  consequence chilliness of the surface and
coldness both of the hands and feet.   If  the malady
continue,  and particularly if there be much leucor-
rhoea, the whole series of symptoms now described
becomes more distressing.   The  disordered state of
the  brain from a diminished supply of blood, some-
times  closely resembles that arising  from repletion.
From  ignorance  or a disregard  of this  fact, giddi-
ness, confusion,  and a  sensation of falling  from
sudden movements, in turning  or lifting the  head,
have excited  a  fear of  apoplexy, and the  bleeding
and antiphlogistic treatment which have  been prac-
tised, have ensured a still further aggravation of the
original disease.   Nor will  the more serious indica-
tions dependent on excessive catamenial  discharge,
be confined to the brain alone.  The lumbar and
central pains become more decided, the  headaches
more agonizing,  the derangement of the  stomach
and  bowels is  permanently increased, and there is
almost constant pain, felt in some part of the course
of the colon, affecting either the sides or centre  of
the  abdomen.  There is palpitation,  and all the
symptoms so graphically  described by Dr. Addison.
Occasionally, in  some of the worst examples, there 
MENORRHAGIA.
197
is  confirmed diarrhoea.  I  have many times seen
oedema, and in one case, where the patient had long
resided in the East Indies, and was much exhausted
by frequent abortions, there was general  anasarca.
Nervousness almost to insanity, melancholy, and,
according to some authors, epilepsy  have resulted
from  the  disease.  So far  as my  observation  has
gone, a vaginal examination  has  revealed nothing
beyond a soft, flabby  condition of tbe vagina  and
uterus, leucorrhoea, and an os  slightly more patulous
than  natural, but  without tenderness  or induration.
The consequences of profuse  menstruation, if pro-
tracted, are  almost sufficiently  evident  from  the
detail of the symptoms.  Dr. Marshall Hall, in his
" Essay on  Blood Letting  and  its evils,"  has fully-
explained them.   I may, however, remark that they
are precisely of the same character as are produced
by hemorrhage from any other part.   Of course the
probability of early cure will  greatly  depend on the
severity  and  repetition of  the  attack.   In  the
slighter cases little treatment is required, and  the
disease often subsides  almost spontaneously;  and
even  in  the  more  aggravated  examples, suitable
and   persevering  treatment  generally  avails.   A
greater proneness  to abortion,  if the patient become
pregnant, and a disposition to  prolapse of  the uterus
and vagina, are results of the  malady.
   Causes.—Delicacy and debility of system and  un-
due  plethora conduce  to the  disease.  The former
frequently ; the  latter only in  few instances.   In all
classes these causes may be brought into activity by 
198
MENORRHAGIA.
 cold, inordinate physical effort, and mental excite-
 ment.  In  married  women,  repeated  labors  and
 abortions, and undue suckling, lay a foundation for
 the malady.   In all, excessive use of the genital or-
 gans  may lead  to  this or any other  form of  menor-
 rhagia, and the disease has  often had its  origin in
 hemorrhage occurring after labor.
   Diagnosis.—It  is by  no means difficult to distin-
 guish this from  the other forms of menorrhagia by
 the absence of coagula.   If the discharge does  not
 clot, it is still  menstrual  secretion ;  if on the  contra-
 ry, like blood  lost  from other parts  of the  body, it
 separates  into  serum  and  crassamentum,  it is  no
 longer a case  of  simple catamenial excess.  The
 freedom of the patient from organic uterine  disease
 will be satisfactorily ascertained by a vaginal exam-
 ination.
   Treatment.—This will vary in females of different
constitution, and in all there will  be a marked  dis-
 tinction between  the measures adopted  during  the
 discharge itself, and in the  menstrual intervals.   In
plethoric and  robust individuals, the larger amount
of secretion is often salutary, and may  be  allowed
 to continue in many instances till it naturally sub-
sides.   Where treatment is necessary, moderate  ve-
nesection  may,  a few  days before the  expected
period, be  practised;  more  frequently local  deple-
tion, by cupping on the  loins, or  leeches to the pu-
dendum or perineum, and in some instances to  the
cervix uteri.   When the  loss is really excessive,  the
patient should be confined to the sofa or a mattress, 
MENORRHAGIA.              199
strictly maintaining the recumbent posture, and the
diet should be unstimulating and cold.   Saline pur-
gatives, with dilute acid  and nitre, may always be
exhibited ; more rarely digitalis and superacetate of
lead  (vide  formulae).  The  apartment  should  be
cool,  the patient being lightly covered by bed clothes,
and  excitement  of  every kind  must  be carefully
avoided.  In some severe cases it may  be necessary
to apply cold  locally : iced  water,  and ice  itself,
wrapped in bladders, are used with this  view.   It has
been  thought right to inject cold stimulating  fluids
into the vagina, and,  in  a very few  examples, even
into the uterus, and to plug this canal as  far as the os.
I do not say that  such extreme measures are  never
demanded,  but happily,  if judicious  treatment be
early  adopted,  they will rarely be required.
   In  the interval of menstruation, a spare, unstimu-
lating, and only moderately nutritious diet, and fre-
quent saline aperients, should be enjoined.   Where
there  is decided plethora, shown by  a red and  flush-
ed countenance, swimming  in the head, and  a full,
hard  and quick pulse, small and repeated bleedings,
are beneficial.   Daily exercise by walking or riding,
although the former  is  to be  preferred, and the
avoidance of heated apartments and  luxurious indul-
gences, will contribute to  a  healthier  state of the
system generally, and particularly of the uterus.
   In  delicate, pallid,  and feeble patients, the disease
must  be treated differently.   Here the  excess  of se-
cretion, so far from being salutary, as it occasionally
is in the plethoric and robust,  is decidedly injurious; 
200
MENORRHAGIA.
every return,  by weakening the uterine capillaries,
aggravating the anemia.  Instead of  depletion and
antiphlogistic  means,  ammonia and small doses of
the acetate of  morphia, and the mistura vini of Guy's
Pharmacopoeia, are to be employed; and where the
loss is large, no remedy will generally be more effi-
cient  in checking it, and in  shortening the period of
the flow, than the ergot.  It may be given either in
powder or tincture; of the  former, five grains, and
of the tincture, thirty drops every six or eight hours.
Cold  applications,  and astringent injections, (vide
formulae,) into the vagina  have been  already men-
tioned.   Dewees recommends, for this purpose, su-
gar of lead and laudanum, and  speaks highly of
elixir  of vitriol and  laxatives.  Mackintosh  enjoins
the use of  an enema,  containing a scruple  of the
sugar of lead.   All the remedies are intended, either
by lessening the activity of the general  circulation,
or by  securing the contraction of the  uterus, to di-
minish the quantity of blood sent to it, and  thus to
curtail the amount of secretion.
  In the interval such measures must  be employed
as shall preclude the return of the  malady.   If it
can be attributed  to over lactation, excessive  leucor-
rhoea,  or frequent  abortion,  the  child  should be
weaned, the leucorrhoea cured,  and the risk of preg-
nancy for  a time prevented  by abstinence from in-
tercourse.   Chalybeate  water,  and mineral tonics, a
residence by the sea, or at some of the various spas
in this country or  abroad, salt-water baths,  of any
kind,  most  agreeable to the patient, vaginal injec- 
MENORRHAGIA.              201
tions, sponging with  cold  salt-water all over the
loins and hypogastric region, are well calculated to
relieve local  weakness and to aid the more  direct
and powerful measures.
  Second,  Profuse  Menstruation, accompanied by
discharges of blood directly from the uterine vessels,
including three varieties.
  a. Acute  or active menorrhagia; occurring prin-
cipally in the plethoric and robust.
  History and Symptoms.—This form of the disease
is much less  common than the passive and conges-
tive varieties.   It  occurs most frequently in pletho-
ric  married women  who  live generously, and in
whom the circulation is active.   In such individuals
exposure to cold or wet during menstruation, or any
circumstance  deranging their health, may induce
fever, inordinate action of the heart, congestion and
subsequent rupture of the  uterine capillaries,  and
menorrhagia.   I have also occasionally seen inflam-
matory and spasmodic menorrhagia, in young, florid,
and robust unmarried girls : although these varieties
are really more rare than the others,  I believe they
often exist   unnoticed.   The  undue plethora,  on
which they mainly depend, is relieved by this larger
periodical loss, and if it do not occur too often, this
morbid  state  may be altogether cured  by it.  In
healthy women also, a profuse catamenial discharge,
even when it is attended by pain, is often  long dis-
regarded, such an  event  being generally  viewed in
a favorable light.  It is not, therefore, till the loss is
really excessive and  somewhat  alarming,  or till  it
               26 
202
MENORRHAGIA.
has induced marked debility and a  pale, wan coun-
tenance, that medical aid is sought.  In active me-
norrhagia there  generally exist, immediately before
the expected period, and occasionally for a few days
prior to the flow, considerable  tension and  fulness
within the pelvis, accompanied by a feeling of weight
and throbbing in the uterus itself.   The mammae
often sympathize, becoming tumid, hot and tender
on pressure, and the external genitals are sometimes
slightly swollen  and painful.  The pulse is quicken-
ed, there is  oppression of the  head, and  often de-
cided head-ache, with sympathetic  fever.   In this
way the acute or active form of menorrhagia is ush-
ered in  and is throughout characterized  by a pre-
dominance of inflammatory or spasmodic symptoms,
or by a combination of  both.   Where inflammation
is present, there  will be  fixed   pain  in the uterine
region; a hot dry skin, and  a frequent hard and full
pulse.   Where spasm prevails,  the pain will not  be
constant; but having continued a longer or shorter
time, and often  most severely,  it will subside, and,
after an interval, again recur with throes resembling
the pains  of labor.   The discharge, too, is equally
variable, ceasing  for short periods, during the pain,
and returning when it subsides.  The pulse, during
the spasm, is contracted, irritable, and quick;  after-
wards it becomes softer and slower, giving proof  by
this rapid  change, of a state of system, neither  of
inflammation nor debility,  but  of irritation.  The
progress, duration, and severity of these attacks are
extremely variable.   Sometimes the discharge comes 
MENORRHAGIA.
203
on and continues by gushes, and numerous coagula
are expelled.  The patient,  in  many instances, is
thus relieved ;  the  head-ache, tension, and pain in
the uterine region are quickly diminished ;  the pulse
is softer and less quick; the skin cooler and moist;
and the remainder of the period is passed over with
tolerable comfort.  In the more  protracted and ag-
gravated  cases,  the  discharge  often continues for
three, four, five, or  six days, not without diminution,
but still  with such a  proneness to excessive return,
that the patient is  compelled to avoid exertion, and
to maintain,  almost constantly, the recumbent posi-
tion.   On the  subsidence  of  the flow, she is weak
and exhausted, and several  days elapse before she
regains  her  usual freshness of  countenance  and
strength of  pulse.  It is easy to mark the transition
from  this to  the  passive  form of menorrhagia ; for
although, at  first, the recurrence of  the events just
now described, may not seriously impair the health,
yet after a time,  the loss produces a  marked impres-
sion on the system ;  the flow lasting  longer, and the
number of days between  the  catamenial periods be-
ing so diminished, that scarcely is one attack over,
before another approaches.   Thus  the active and
acute variety is merged in the passive  form of the
disease.
,   Causes.—From the history already given, it  will
be inferred that menorrhagia is  generally dependent
on morbid conditions of the constitution; although
its causes may  be accidental or local.  Thus, while
the active form is mainly associated with a plethoric 
204
MENORRHAGIA.
 habit, and  does, under  such circumstances, afford
 relief, it may still  be frequently traced  to morbid
 uterine activity and excitement, arising  from local
 injuries, such as blows or falls,  sexual  excesses, re-
 peated abortions and leucorrhoea ; irritation  of  the
 bladder and of the  intestines generally, and espe-
 cially of the rectum, from hardened fceces, hemor-
 rhoids, worms, tenesmic purging,  constant and even
 occasional constipation.   Doubtless such causes will
 be rendered additionally injurious by too protracted
 and severe mental  and physical efforts, rich living,
 heated apartments  and soft beds, indolence and  too
 much sleep.
  Diagnosis.—The distinction  between the active
 and  inflammatory  or  spasmodic  menorrhagia,  and
 the passive form of the disease,  is not always easily
 made.  In the  beginning there is little difficulty ;
 but when, from  frequent repetition, debility exists,
 we may err.   Still the countenance, the  pulse, and
 the " tout ensemble" of the patient are such that we
 shall not remain long in doubt.  Nor must it be for-
 gotten, that on a correct discrimination of these dif-
 ferent conditions, the  success of the treatment will
 greatly depend.   It is true that active  menorrhagia
 may co-exist  with  debility, the uterine vascularity
 and  circulation  being, from  local  causes, morbidly
 increased;  but it would be a  great mistake to treat
 this latter condition as we should  that form of  the
 malady where the  discharge was dependent on gen-
 eral  fulness and activity.  If to  aid the diagnosis
the uterus be examined per vaginam, there will rare- 
MENORRHAGIA.
205
ly be discovered  any marked  change in its volume
or position, although I have  noticed  some fulness
and heat about the cervix and body of the organ.
   Treatment.—This is scarcely different from what
has been already enjoined in profuse menstruation,
occurring in plethoric individuals, vide page  198.
But  I  may remark, that  the  employment of  smart
drastic  purges, (vide formulas,)  often  does  great
good.  The  late  Dr. Cholmeley, of  Guy's,  relied
almost exclusively on  their exhibition ; and he has
frequently, as he passed through the wards, pointed
out cases entirely cured by these alone.
   In spasmodic menorrhagia, to which  I  have al-
ready referred, the pulse  is irritable and quick, not
hard and full.   The system is not plethoric, nor the
pain  constant,  (vide  cases ;)  but it subsides  and
again recurs.   Here bleeding,  nitre,  and digitalis,
fail  to  relieve ; and  recourse must be had to anti-
spasmodics, anodynes, and occasionally to alteratives.
It is not always easy at once  to distinguish this
form; but if  antiphlogistic means have  been tried
unsuccessfully, the  patient will often be cured by
remedies  of  a  different class.   Dr.  Gooch  says,
" that a lady laboring under spasmodic menorrhagia,
went through the whole routine of antiphlogistic
treatment without any benefit.   I then gave her, he
adds, one  grain of  ipecacuanha every  hour;  in
eight hours she became  nauseated and sick, and the
discharge immediately ceased.   This  state of  nau-
 sea was kept up for a day or two, and the discharge
did not recur.   When you  have a  case of menor- 
206
MENORRHAGIA.
rhagia, attended with  a quick  and irritable pulse,
the pain subsiding and  recurring, you may be cer-
tain that it arises from spasm or irritation, and that
it will be relieved by antispasmodic remedies.   The
two best are ipecacuanha taken  into the  stomach,
and assafcetida, with  opium  injected into the rec-
tum.  A grain of ipecacuanha is to be taken  every
hour till nausea is produced ; which  state must  be
maintained for  a day or two, by repeating the same
dose as frequently as may suffice for this  purpose ;
and quiet local  irritation in the uterus by injections
of assafcetida and opium,  by the  enema antispas-
modicum, form. 34, 35, 36, 37, or  39, to  be  found
at pages 188 and 189.   There  is a very marked
connection  between the pain and the discharge ;  for
if you can  relieve the one, the other will  cease."
  Nor must the  treatment in the interval be  disre-
garded ;  in  profuse  menstruation, unattended  by
real uterine hemorrhage, allusion has been pointedly
made to its extreme  importance.   If the bleeding
and the  antiphlogistic regimen, practised as a period
approaches, be exchanged,  after  the disease sub-
sides, for nutritious diet and wine, the malady will
not only continue, but  it will become aggravated,
and the loss, during  menstruation, may be so  large
as to  excite considerable apprehension.   Many pa-
tients protract  the menorrhagia by such error, and,
by  repeated discharges, the passive form  is induced.
A nice distinction is necessary here : thus, several
times when I have thought  that  the loss has de-
pended  on debility,  and I have unsuccessfully ex- 
MENORRHAGIA.
207
hibited  the ergot and  tonics, I have gone back to
the antiphlogistic plan, and  have cured the patient.
Nor let it be forgotten,  that local depletion is some-
times  most  beneficial;  especially  in  those  cases
where, in the absence of general  plethora, there is
local uterine fulness.
   b. Passive  or chronic  menorrhagia; the subjects
of this variety  being delicate,  hysterical, and ex-
hausted females.
   History and Symptoms.—This is  the most com-
mon form of menorrhagia,  and approaches in  fre-
quency to chlorosis  and  amenorrhoea.   A  partial
explanation may be  found  in the  want of attention
to early menstrual profusion, and  in the  too  indis-
criminate use of wine and  other  stimulants.   The
various degrees  in  which it exists,  deserves notice.
In some the excess may be so  slight, as  hardly to
produce  any  morbid effect;  and from this  stage
onward, to examples of marked hemorrhagic prostra-
tion,  every shade  of  the  complaint  may be wit-
nessed.   I have in  my recollection several instances
where a  fatal result seemed highly probable.  An
additional reason is thus supplied for careful investi-
gation, prior to and during  the treatment, by  tonics
and wine ; and where such measures are determined
on, their use  must be watched, modified,  and occa-
sionally suspended.   An attack of fever, or uterine
congestion, will  demonstrate  the  propriety of  this
admonition, and prove that  the  management should
rest on principle, and that it must  not be pursued
merely as a matter of routine. 
208
MENORRHAGIA.
   I need scarcely mention the class of women most
liable to passive menorrhagia—those originally deli-
cate, or who have become so from any of the causes
already enumerated at the commencement of this
chapter,  and not  the  robust  and plethoric, are its
subjects.
   The  symptoms are precisely  those  of morbidly
profuse menstruation, fully pointed out at page 195.
   Causes.—The same as in profuse menstruation.
   Diagnosis.—The presence  of clots in  the dis-
charge, or  the  stiffening  of the  linen by its  flow,
sufficiently explain the character of the disease.  If
the uterus be examined, it will rarely be found in-
creased in size ;  but its  cervix  and os, as well as
the vagina, are generally soft,  the former having
lost its close,  welted feel, and  the whole  being
bathed in leucorrhceal discharge.   Such  an inquiry
will also reveal any structural  lesion of  these  parts,
should it exist.
   Prognosis.—It may perhaps  be  unnecessary to
say much on this  point, as a fatal result is exceed-
ingly rare ;  but, as the long continuance of the mal-
ady may  induce  dropsies of various cavities, and
may call into play morbid tendencies  about other
organs, a too confident opinion should not be given.
Our anticipations of cure should  spring  not  only
from the tractable character of the malady, but from
a conviction that  the patient  will  strictly and per-
sevenngly carry out our measures of relief.
   Treatment.—Reference  must  be  made  to  page
198, where the means generally successful in arrest- 
MENORRHAGIA.               209
 ing excessive menstrual flow are enumerated.   Rest
 in the recumbent posture, during  and previously to
 the attack, either in bed on a mattress, or on the
 sofa, is indispensable.  Without it the best devised
 treatment will fail.   At first, patients  disregard the
 injunction ;  but  the continuance  of  the discharge,
 increasing debility,  and the  attendant evils, compel
 obedience.  Astringent injections should rarely be
 used during the  few first days of  the menstrual pe-
 riod, as they often produce uterine spasm ; but when
 coagula are passed,  either alone or mixed with the
 catamenial fluid, the secretory function is either par-
 tially  or  entirely  suspended, and injections  may
 then  be  highly  beneficial, (vide  formulae.)   Some
 patients derive little or no  advantage from them—
 others use them  so partially, as to  preclude any pro-
 bability of benefit—while not a few  ascribe pain,
 an  unusual  symptom  in passive  menorrhagia, and
 increased discharge  to their exhibition.   It is essen-
 tial that the patient lie, when the injection is thrown
 into the vagina, that the pelvis be  raised by placing
 a sofa-cushion under the hips, so that the fluid may
 easily reach  the  upper extremity  of this canal, and
 that whatever quantity be  injected, it shall be re-
 tained for ten or fifteen minutes in direct apposition
 with  the  parts.   To effect  this, the nurse should
 make firm pressure on the vaginal  orifice  by a nap-
 kin accurately applied.   Where these  conditions are
complied with, and  where occasionally, in suscepti-
ble  and irritable  women, the injections are slightly
warmed, so as to prevent the probability of the oc-
              27 
210
MENORRHAGIA.
curence of uterine  spasm  and pain, I know practi-
cally that great good will generally result from their
administration.
  But life is occasionally well nigh  destroyed  by
excessive menorrhagic  loss—the  patient being  re-
duced to the  same state as by uterine hemorrhage
after labor.   If the practitioner has reason, from its
previous occurrence, to  apprehend a renewed  visita-
tion of this kind, every preventive  measure must be
adopted.   Not only must  the treatment in the  in-
terval be carefully followed out, as directed at pages
200 and 201, but absolute  rest must be enjoined  for
several  days  prior to  the expected  catamenial  re-
turn ; sexual  excitement, physical exertion, stimuli
likely to affect the vascular system and  the  uterus,
and  intestinal constipation,  must  all  be  carefully
avoided.   During the flow, if alarming loss of blood
seem to be approaching, the  ergot and  opium, (vide
formulae) injections of cold water  and astringent
lotions  into  the  rectum,  and,  above all, plugging
the  vagina,  as far as the  os, must be practised.
Soft dry tow, slowly introduced in small quantities,
till the  passage is entirely  filled, forms the best
tampon or plug, and it may be  allowed to remain
unchanged for twenty-four  or thirty  hours.  The
patient  will  probably object  to such a remedy, and
suffer slightly from its use ;  but neither  of these
circumstances are sufficient to justify the practi-
tioner in giving it up.   A silk handkerchief, lint, or
linen, may be used, but they must be dry.   If wet
or saturated  with moisture, their introduction is 
MENORRHAGIA.
211
painful and difficult: dry soft tow, in  small  pieces,
is  certainly  far  better.   I  have  seen  two cases,
where if the  apparatus  for  transfusion had  been
within reach, I should have used it.   Both patients,
however, gradually recovered.  It  may be urged,
that injections of cold or medicated  water into the
uterine   cavity,  would  be  important.   I  confess,
without knowing that  the mucous lining was  heal-
thy, the  fear of subsequent inflammation  would,
with me, generally prevent  their employment.  I
am, however, convinced  that, in  excessive  menor-
rhagia, plugging is  not sufficiently often resorted to.
It need scarcely  be enjoined, that if the patient is
reduced to a very low ebb, or if there be prolonged
and profound syncope, she  must be moved with the
greatest  care.  In  the syncope following excessive
puerperal bleedings, such  precaution  is all impor-
tant, as asphyxia might  result  from its non-obser-
vance.   It is scarcely less  necessary in the  exhaus-
tion produced by excessive menorrhagia.
   c. Congestive  menorrhagia, generally met with at
the middle or more advanced periods of life.
   History and Symptoms.—On this  form  of  the
malady  enough  attention  has  not  been bestowed.
And yet, it differs so much from the others, that it
is a matter of surprise  that its peculiarities should
have been only slightly noticed.  It continues long,
occasionally for several years, (vide cases,) and fre-
quently  in  alarming  excess.  It  is often preceded
and followed by large watery and leucorrhoeal  dis-
charges  ; and pain in the uterine and lumbar regions 
212
MENORRHAGIA.
 is a common  accompaniment.   Its sympathetic  ef-
 fects on the brain, lungs, and heart, are occasionally
 severe ; and,  where the disease has continued long,
 there is generally coldness of hands and feet, a fee-
 ble  and  quick pulse,  and  an anxious  pallid and
 sunken countenance.   The  alterations in the  size
 and feel of the uter.us, which form  a part  of the
 disease, cannot, at this  period of life, be recognized,
 without some  alarm.   The  malady is  not confined
 to one class of women.  The  plethoric are  not, as
 far as I know, more prone to it than the debilitated
 and irritable.   I have rarely, if ever seen it,  before
 thirty-eight or forty years of age ; but  I  have sev-
 eral times met with modified attacks, independently
 of organic complications, after menstruation  might
 have been supposed to  have ceased.
   In the  milder instances,  the  symptoms already
 described, terminate after a  more or less  protracted
 continuance in the entire cessation of the function ;
 but  in  other  and  more protracted  examples, the
 symptoms are so extreme, as to excite real  appre-
 hension.  The recurrence of the bleedings is  uncer-
tain, although  in  general, a  catamenial period will
be  partially observed.    Occasionally the loss con-
tinues for many weeks or months, without any com-
plete cessation : the only appreciable change con-
sisting in a diminished flow, or  the discharge be-
comes  either  aqueous  or leucorrhoeal, and perhaps
slighly or offensively odorous.  In many cases there
will, at  the expiration of a fortnight, or midway in
the interval,  be  a  peculiar  bearing,  acute pain in 
MENORRHAGIA.
213
the lower  part of the uterus.  Several of my pa-
tients  have noted  this  pain  very accurately, and
have  correctly regarded it as indicative of a repeti-
tion of the menorrhagia.  This symptom has oc-
curred too often, to allow me to doubt, that it is in
some way connected with the  affection.  Dr. Chur-
chill mentions that in most, if not all  the  cases he
has seen, there was considerable dysuria, and that,
in  several, it  was  necessary for the patient to lie
down before the bladder could be completely evacu-
ated.  Irritation about  the  neck of this viscus, ex-
tending along the urethra to its orifice, is  common ;
but  the  dysuria, especially to  the extent related
above, I have  rarely met with.  Nor must it be for-
gotten that after these morbid occurrences  have  re-
peatedly taken place, and  when every thought  of
pregnancy  has been given  up,  conception  has  oc-
curred.  Such an  event, for a  time  at  least, and
perhaps  permanently, cures  the  affection.   It  is
therefore important  to  bear in  mind its possibility.
1  have known two examples  of healthy pregnancy
tinder these circumstances, after  an interval of five
or six years from the former accouchements.  Head-
ache, embarrassed  respiration,  bleeding  from  the
nose, sometimes excessive, dyspepsia,  impaired ap-
petite, and emaciation, are  frequent concomitants :
after all, these various mischiefs may  only be tem-
porary.  The function,  on whose  morbid condition
they all  depend, is  itself waning, and  a few  more
months may secure  its permanent suspension. Thus,
sometimes, even with only domestic care, and often 
214
MENORRHAGIA.
with  proper medical  treatment, the  affection  de-
clines,  and eventually the  patient  regains  more
health than she has  for a long time enjoyed.  But
this  is  not always so.  Unhappily there are cases
where the  hemorrhages, and their attendant evils,
continue for many months, even for several years,
inducing a strong  belief that organic  disease must
really  exist; nor  must  we  forget that  malignant
changes  do, although  rarely, develope themselves.
Even in their absence, life is, now and then, event-
ually destroyed  by exhaustion, arising from the re-
peated bleedings, by phthisis, or by dropsies of some
of the  great serous  cavities.   Anxious  inquiry  is
directed to the probable time of final cessation, and
it is  often asked,  how long these bleedings may
continue when they are not connected with structu-
ral disease ? In many instances, the function ceases
at forty-four or  five ; in more, at forty-seven, eight,
or fifty; in a few,  at a much more advanced period,
and  in fewer still, at thirty or between thirty and
forty years of  age.  I confess  my inability to  an-
swer the latter question ;  but I have met with more
than several instances, where hemorrhages, alarming
in  degree, have  continued for twelve, eighteen,
twenty-four, and forty-eight months, and have ulti-
mately declined, and the sufferer has regained good
health.
  It is right in  every protracted hemorrhage from
the uterus  to examine.  By this alone, and I allow
that  even then  we frequently fail, can we expect to
ascertain whether  there be  polypus,  a submucous 
MENORRHAGIA.              215
tumor, or so much increased bulk as to render the
existence of organic lesion highly probable.   In the
majority of the  examples of congestive menorrha-
gia, I believe that increased uterine bulk, fulness of
the cervix, and openness of the  os, constitute the
whole of the diseased change.
   Pathology.—Congestion of the uterine vessels is
the explanatory cause of these bleedings.   In some
instances, there is an unusual and excessive accu-
mulation of blood, and then it is not at all improba-
ble that  some of the  branches  of the  uterine arte-
ries, ramifying  on the mucous membrane,  give way.
In submucous tumor of the  womb, these vessels are
abnormally large, and are by their rupture  the source
of frequent hemorrhage.
   On the  whole, the symptoms  are  indicative of
slow  progress,  and lead  to  the conclusion that  the
disease  is  of  the passive kind.   The affection is
probably dependent  on the peculiarity of age—the
period having   arrived when  this most important
function is about to cease.  I  have  already  noticed
its supposed  frequent complication   with   organic
disease: nor is  it possible not  to feel anxiety on
this point, when we remember that vessels  and tis-
 sues  in a state of nearly  constant congestion, be-
 come hypertrophied, and liable  to the invasion of
 structural and  malignant  change.
   Diagnosis.—It must not be forgotten  that losses
 of blood occur  in connection with other states of
 the uterus than  the various forms of menorrhagia.
 Approaching abortion is often supposed to be menor- 
216
MENORRHAGIA.
rhagia;  nor is the mistake corrected, till the ovum
is  expelled, and the  hemorrhage  ceases.  I lately
saw a case, and  it is unnecessary to mention the
more common occurrences of this kind, where, from
the emaciation, bleached countenance, and exhaus-
tion, I had formed a most  unfavorable opinion, the
flooding having continued, although not excessively,
for nearly  six  months.   On examination, I found
the uterus large, and the lips of the uterine aperture
swollen, but not patulous.  The idea  of pregnancy,
as the patient  was forty-four, and had  not borne
children for several years, did not  occur  to me.  1
prescribed  some medicine  containing  ergot, and I
gave a doubtful opinion.  After taking three doses,
she expelled a blighted ovum, and in a few months en-
tirely, although with difficulty, recovered her health.
   " I was called," says  Dr. Gooch, " in the earliest
part of my practice, to  a lady who had for a con-
siderable time  a  dropping from the  uterus, which
had  produced  a bleached, cadaverous countenance,
cold hands and feet, and great debility.   On exami-
nation, I found at the  upper part of the  vagina a
little long projecting tumor, which  I thought might
possibly be a peculiar formation of the cervix uteri.
I was afterwards  called in great  haste  to see her,
and, on my entering the bed-room, she  said there
was something coming away ; and, on examination,
I found the leg of a foetus in the vagina.  I speedily
delivered  her  of  a  foetus  of about four  months
growth ; the placenta soon followed, and the hemor-
rhage ceased.  This  was  a blunder  of  mine ; for 
MENORRHAGIA.
217
that which I supposed to be  the cervix uteri, was
no  other than the foot of the  foetus, just beginning
to protrude through the os tincae."
   The diagnosis of menorrhagia from  pregnancy is
important: but not so important, nor so difficult, as
its  distinction from  some  of  the more concealed
organic diseases.  Corroding  ulcer,  cauliflower ex-
cresence of the  os, ulcerated  carcinoma of the cer-
vix and polypus,  descended  into  the vagina, are
easily  made  out  by  a common  examination ; but
whether protracted,  frequently recurring, and dan-
gerous hemorrhages arise from uterine congestion, or
from submucous tumor, a  polypus yet retained in the
uterine cavity, or from organic  disease of the mucous
lining itself,  it is  by no means easy to determine.
Often  in  the course of these  hemorrhages, there is
so much pain, such apparent traces of malignant dis-
ease about the face,  so much  emaciation, and such
very trivial and temporary benefit from every remedy
used,  that in  despair one believes, that it must be a
malignant affection, (vide case.)  After a time, how-
ever, and perhaps unexpectedly, the bleedings par-
tially  cease, the  pain diminishes, and  the patient's
health is improved.   A vaginal examination reveals
nothing beyond what has  been  already mentioned,
and hope is  again  encouraged.  Thus a favorable
diagnosis will mainly depend  on  the healthiness of
the uterus,  so far  as the finger  can  examine its
structure—on the absence of progressive and mark-
ed emaciation—on diminishing, at least not increas-
ing, hemorrhages;  on the  general  concurrence  of
             28 
218
MENORRHAGIA.
 the bleedings with  the  menstrual  periods;  and on
 the lessened  volume  of  the  uterus  during  the
 menstrual  intervals.   Other  circumstances, which
 cannot be accurately expressed, but which form a
 part of  that  unwritten and  incommunicable  tact,
 acquired by  all  observant men, will aid the judg-
 ment.   A  strumous constitution, glandular tumours
 in other  parts, hard tumours of  the fundus or body
 of  the uterus, broad ligaments or ovaries, increasing
 hemorrhages and uterine pain, a gradual giving way
 of  health,  and the absence of any beneficial effect
 from remedies, point to an  unfavorable termination,
 and lead to the  conviction that there is beyond the
 reach of an examination, by the finger or speculum,
 some malignant structural change.
   Prognosis.—Dr. Churchill  says,  " of all the cases
 I have seen, none have proved fatal, either directly
 or  indirectly."   This is more  than I  can affirm.
 Happily  the  malady is  generally cured, or perhaps
 it would be more correct to say, that as the catame-
 nial function  ceases  the  bleedings cease also.  If
 there be no latent tendency to malignant or pulmo-
 nary disease, it  is not likely that  such will occur.
 And it must  be  allowed, that  women  do  sustain
 excessive and long continued uterine hemorrhages,
 without a fatal result.  But let it  not  be supposed
that these formidable  losses do not seriously injure
the health.   They deprive  the  body of that blood
by which its solid structures are nourished, and thus
lay  the foundation of uterine  softening.  There is 
MENORRHAGIA.
219
also a probability of dropsy, and the patient may be
destroyed by phthisis.
   Treatment.—So much has been already said, that
it  is scarcely necessary to  enlarge  here.  In the
hemorrhagic intervals, if there  be  local  or general
plethora,  a  small bleeding,  cupping  on  the  loins,
leeches to the anus or vulva; and if there be fulness,
heat, and pain about  the cervix uteri, scarification,
as already recommended, may be practised.  Sexual
intercourse  and stimulants, mental  excitement and
physical effort, must  be avoided for  ten or twelve
days before the periodical  returns.  When there is
increasing pallor, oedema, threatened  dropsies, soft-
ening of  the cervix, and aggravated  debility,—sea
air, a mild  but nutritious diet,  consisting of animal
food and milk, or  malt liquor, must  be  enjoined.
Where  there is  universal coldness of surface, espe-
cially  of the extremities, frictions,  by  stimulating
embrocations, the flesh-brush, and horse-hair gloves,
the  wearing of flannel, and worsted  stockings, are
indicated.  The salt hip-bath, the local salt shower-
bath, applied  night and  morning,  by  a common
garden watering pot, over the hypogastric and lum-
bar  regions, are  often  advantageous.   Nor  is the
injection of cold  water, once  or twice  a day, into
the  rectum, to  be  forgotten.   Astringent vaginal
injections are deservedly  relied  on, especially  if
carefully administered, as already urged, (page 209,)
during  the  intervals.   Still  there are   cases, and
occasionally I meet with a  good many, where cold
injections cannot  be  borne.  Local fulness, excite- 
220
MENORRHAGIA.
 ment and  pain, follow their use, and  sometimes  I
 have attributed to their employment an earlier and
 larger  return of the hemorrhage.   They are most
 beneficial where  there is  copious  leucorrhoea, and
 from the cure of this morbid secretion, good may be
 invariably  anticipated.   It  is  to  be  remembered,
 that the  unmarried are liable to congestive menor-
 rhagia, and I have often thought that their cure was
 more difficult and protracted, and their hemorrhages
 larger, than where many children had  been borne ;
 but I am not  prepared to give a positive opinion.
 During  an attack, the  patient should  lie on a hard
 mattress, be  kept  perfectly quiet, covered lightly
 with bed clothes, and have warmth applied to the
 feet and legs; hot bottles, or mustard poultices may
 be  used for this  purpose.   Her  drink must be
 unstimulating   and  cold,  except   where there  is
 syncope, and then wine in small quantities may be
 given.
  I  have for several years tried the ergot in these
 cases, and  I think  highly of its efficacy ; but there
 are  more than a  few instances in which it has
 entirely failed, and  several in which it  has induced
 spasm, and increased bleeding.   I have two patients
 who, for  these reasons, always request that it may
 not  be used.   I prefer the  tincture to the powder,
and I give thirty drops for a dose.   Frequently lead
and opium, turpentine, muriated iron  and  opium,
 (vide formulae,) have proved serviceable.  Cold to
the  lower abdomen and genitals, and  particularly 
MENORRHAGIA,
221
plugging the vagina with soft tow, where the loss is
excessive, are effective remedies.
   Few cases will be introduced; very few  of every-
day occurrence.   But where the history and symp-
toms,  the  pathology  or treatment  of menorrhagia
require illustration, I shall  not scruple, as  briefly as
possible, to confirm the text by their insertion.
                       Case 29.

               spasmodic  menorrhagia.

  July 24, 1836.  I  visited Mrs.----, set.  37, a  widow,
residino- at Walworth, and under my care as an out-patient of
Guy's  Hospital.   She has never borne  children, and is of
spare habit, but neither weak nor emaciated.   She has been
menorrhagic for  several  years, and habitually suffers from
dyspepsia, earning  a  livelihood  by close application to her
needle.   Menstruation occurred two days since, and for the
last twenty-four  hours,  the  paroxysms of pain  and  spasm
about the uterus  have been very severe.  Much blood has
been lost  by  gushes, and many  large  clots  have been ex-
pelled.  The spasm still continues, and on my visit I found
the pulse quick (130)  and irritable, but neither full nor hard.
She is chill and  faint; the countenance pallid and anxious ;
has had  no sleep  since  the commencement of  the attack,
although  there have  been  rather long  intervals free from
pain.   At the commencement of the disease,  three  years
since, she was bled and purged, but without  any other than
an injurious effect.  Urine scanty and high colored.
   I ordered hot poppy fomentations to  the abdomen, and the
following mixture. 
222
MENORRHAGIA.
     R. Pulv. Ipecac, rad. 9i.  Tinct. Camph.  C. 3ii.  Mist.
       Camph. 3xiv.
     M. ft. Mistura.  Take  one  teaspoonful every  hour  till
       nausea is produced.

   In the evening she was considerably relieved ; had taken
six doses of the  ipecacuanha mixture, and  was completely
nauseated.  The pain occurred at more distant  intervals, and
the flooding  had  nearly ceased.  In a few days the menor-
rhagia  passed off, and she recovered  her accustomed health.
For several subsequent  periods she  pursued this plan;  and
when I saw her six  months afterwards, she informed me, that
the menstruation was  performed so  naturally, that  she had
entirely laid aside the use of the medicine.

   There   are   numerous  examples of   spasmodic
menorrhagia, especially  in crowded manufacturing
towns.  The treatment by bleeding and  purging is
too indiscriminately adopted;  nor is it, at least very
often,  till the patient's  health is decidedly injured,
that a  different  plan is  practised.   I  have jepeat-
edly cured this  form by nauseating  and anodyne
remedies.
                      Case 30.

       congestive  menorrhagia, nearly fatal.

   In 1833, I was asked  by  Mr.  Rendle of South-
wark, formerly a  clinical  clerk of Guy's  Hospital,
to see the following case :—

  Mrs- -----*t.  42, of spare  habit, the mother of several
children, and compelled to work  hard  as a washerwoman,
has long  suffered from menorrhagia,—dating its commence- 
MENORRHAGIA.
223
ment from the birth of her  last* child, now three years old.
At times the bleedings have been  less in  quantity, but they
have  never entirely  ceased.   Till  lately,  the menstrual
period  has  been nearly observed ;  but recently, the losses
have occurred  at very short  intervals,  and she has  been
weakened and emaciated by their excess.   Two days before
my visit, menstruation commenced, with sensations of fulness
and  weight in  the hypogastric  region.  For  twenty-four
hours there  was  no  hemorrhage ;  but soon afterwards,  large
coagula passed,  and an immense  quantity of blood was lost.
On our entrance, we feared she was  dying.  The pallor and
coldness of the face and extremities, the scarcely perceptible
pulse and  breathing, and the  clammy perspiration  of the
surface, betokened the  greatest  danger.  We stood over the
bed, doubtful whether she would  live or die.  We feared to
move her, least  fatal asphyxia should  ensue ;  nor was  it till
we had waited several minutes, and she had opened her eyes
and  breathed more  distinctly, that  we  dared  to give  some
ergot and  brandy.  At  this  moment,  I  wished to transfuse,
and  had the apparatus been at  hand, we should certainly
have injected  blood into her veins.   As this could  not be
done,  we repeated the  ergot  and  brandy  (vide formulae)
several  times, and  the  vagina  was  plugged.   No  further
bleeding occurred, but the recovery was very slow.
                       Case 31.

 protracted menorrhagia, terminating fatally,  by
                 phthisis  and  ascites.

  Mrs. T., set. 45, an out-patient of Guy's,—is the mother
of eight children, and of dark complexion.
  July  10, 1835.   Has suffered from menorrhagia for three
years, remedies having hitherto done little, if any good.  The 
224
MENORRHAGIA.
 bleedings  generally occur in connection with menstruation,
 although floodings in the  intervals have not been uncommon.
 Always and correctly prognosticates an  attack,  if  she has,
 about the middle of the period,  acute pain low down in the
 hypogastric  region,  with sensations of  weight  and  fulness
 about the uterus.   Pulse 110,  and compressible;  counte-
 nance pallid and sunken ; bowels easily and frequently purg-
 ed ; urine  scanty; perspiration frequent; marital intercourse,
 which rarely occurs, is often followed by bleeding.

     R. Secalis Cornuti 9ii.  Morphiae Acetat. gr. iss.  Ferri
       Sulph. gr. xii.  Cons. Rosae q. s.
     M. ft.  pilulae xxiv.  Take one pill three times daily.

   To use the tepid or cold hip-bath every evening.
   Two ounces of the compound alum injection  three times
 daily, and  to abstain from intercourse.
   July  30.  Has had one  excessive flooding since  the last
 report; stopped by cold, freely applied  over the  abdomen
 and loins, and  cold alum  wash injected  into the vagina.
 There  is  much leucorrhoea, and  frequent  cough ; counte-
 nance pale ; more emaciated and increasingly weak.   Cont.
 remedia.
   August  10.   No better;  leucorrhoea still continues ;  pulse
 120 ; feverish  at  night, with perspiration  in the morning ;
 complains  of some,  although slight  pain, about  the cervix
 uteri.  To  use  an injection of sulphate of  iron  (vide for-
 mulae.)

     R.  Tinct. Ferri Muriat.   Tinct.  Secalis Cornuti.   Tinct.
      Hyoscyami, aa 3iv.   M. ft.  Mistura.

   Take thirty drops  three times daily, in  a  teaspoonful  of
port wine.
   September 20.  To-day she  states that there is,  and has 
MENORRHAGIA.
225
been for the last few weeks, a constant sanguineous discharge,
not by gushes, but scarcely by more than a  few drops  at a
time.   Her  legs pit on  pressure, and they are  oedematous
and cold :  urine  scanty and high  colored ; breathing short,
and often  difficult; leucorrhoea scarcely diminished ; cough
short, hacking, and frequent, with a continuance of the morn-
ing perspirations.  Her  countenance has  the sallow leaden
hue, pointed out by Sir James Clark, in his invaluable practical
Work ,on  Consumption, as so characteristic of tuberculous
cachexia, acquired  in mature life.  Is to  go  into Wiltshire,
her native county, and to follow out the plan before pursued,
and so fully pointed out in the preceding page.
   On examination I  found the os uteri patulous and large,
the neck of the uterus soft, almost spongy, and entirely devoid
of its firm, glandular feeling.   I carried my  finger, without
difficulty, into the uterine cavity ; but 1 could detect no  hard
nor soft tumor.   The uterus is not  greatly increased in  size,
nor did any  bleeding follow this inquiry.
   November 15.  Her mother  informed me that  she had
died about  a month  previously, from dropsy  and consump-
tion, the bleedings continuing to the last.  She was exceed-
ingly  emaciated.   No examination was made after death.


   This case scarcely requires  any comment.   It  is
interesting,  because,  happily,  it is rare ; and the
fatal pulmonary  mischief  is  clearly attributable  to
the repeated bleedings.  It cannot be said that there
was  no  organic uterine change ; but it may, I think,
be fairly assumed, that  the structural  degeneration
of  the   reproductive  organs  was  not  malignant.
 Such softening is, I believe,  a frequent  accompani-
 ment of  very  protracted  congestive  menorrhagia,
                 29 
226                MENORRHAGIA.
and points to the propriety of improving the  health,
and of restraining  the hemorrhage, the former con-
dition being  mainly dependent on the latter.
                        Case  32.


       congestive  menorrhagia and pregnancy.

   I had frequent occasion to see Mrs.------, set. 42, dur-
 ing the years  1837,  1838,  1839, and  several times in  1840.
 This lady was thirty-eight years old in 1836, had been mar-
 ried eighteen  years, and was  the  mother of many children.
 Her health  had been good during  the  whole of her married
 life, with the exception of slight illnesses connected with her
 various confinements.   In  1837, she first suffered  from me-
 norrhagia, and in that, and the  following year, the discharge
 was often so excessive as to alarm her.  Once I happened to
 be present,  and certainly nearly two pints of bipod were lost
 by gush  in a few minutes.  These attacks induced syncope
 and  prostration at the  time, and in the menstrual intervals
 there was pallor,  weakness, and some emaciation.   Tow, for
 the purpose of plugging the vagina, has often been in readi-
 ness ; but her  unconquerable aversion to this valuable reme-
 dy, has  hitherto  most improperly  been allowed to prevent
 its use.   The  acute bearing pain, low down in the uterus, to
 which I  have  already alluded, invariably occurred  about the
 middle of the  interval, and was the certain  precursor of a
 coming hemorrhage.   Nor as a  premonitory condition, were
 there ever absent, feelings of weight, tension, and distressing
fulness in the lower part of the pelvis.   Several times I sat-
isfied myself by examination both by the rectum and vagina, 
MENORRHAGIA.
227
that the uterus was really larger, and congested prior to men-
struation.
  During  the  attacks,  astringent  vaginal injections, cold
sponging over the loins, and pudendum, were freely employ-
ed.   The  ergot, in its various forms, the acetate of lead and
acids, opium and turpentine, were  all given.  The recum-
bent position was long and strictly observed.
  In the intervals, tonics,  stomachics, sea air  and bathing,
local salt-water shower  baths,  good diet, rest, and as much
quiet as could  be obtained, were insisted on.
  I am often very anxious  about this case.  There  is ema-
ciation, a sallow, wan countenance, impaired appetite, and
great debility.   Leucorrhoea is always present during the me-
norrhagic intervals, and it is sometimes  slightly sanguineous
and offensive.   I have repeatedly examined during the last
two  years.  The os is constantly patulous, its lips swollen,
and, together with  the cervix, soft  and  flabby.   Still, there
has never  been either hardness, fissure, or abrasion.
  After the continuance of the menorrhagia for  more than
three years, and when all idea of pregnancy had  been aban-
doned, conception occurred.  Over  fatigue, the patient being
ignorant of her real state, produced  abortion at the end of the
third month (July 1840).  The ovum was quite healthy.


   This is one of the  large class of  cases.   I  need
not say that they are perplexing and difficult.   The
protraction and the debility induced by the repeated
hemorrhages,  fully justify  such a  conclusion.  But
additional  confirmation of the  opinion is afforded by
the possibility that  structural  malignant  change or
dropsies, or  exhaustion, may destroy the patient.
 Congestive  menorrhagia may, I  think, more fre-
 quently than is supposed, be attributed to the  avoid-
 ance  of  complete  sexual intercourse, and  to conse- 
228
MENORRHAGIA.
quent derangement and congestion of the ovaria and
uterus.   This  abstinence  is  dangerously practised
to avoid the risk of adding to the number of a fam-
ily, already thought to be too  numerous for the pe-
cuniary means  of its principal  supporter.  But this
is obviously a  subject  on  which one  cannot, with
propriety, enlarge.
                      Case 33.


   congestive menorrhagia--diagnosis difficult.

  Mrs. -------, aet. 52, has not  been  married, is tall, and
of large make.   Has always resided in or near London.   Up
to the  time  of her present  illness, has  enjoyed unbroken
health, and has been remarkable for muscular  strength and
activity.   In November, 1836, when she was 48 years old,
menstruation first became irregular, returning very profusely
after longer intervals.   Sometimes she  was alarmed by the
numerous  and large coagula which passed, and by syncope;
but she quickly rallied, and as she believed such occurrences,
if not natural, were very common, she  refused to adopt any
medical plan, or to take any particular care.   I frequently
saw her during  these hemorrhages ; she was chill, prostrate
and faint; but,  after their subsidence, management was at an
end.
   In August,  1838, almost two  years  after the commence-
ment of the malady, there was  emaciation,  frequent hot
flushes, and distress from heat in any form; a blanched skin,
a quick vibrating pulse, and slight uterine pain.   The patient
could not  walk so far, nor attend  so energetically to her do-
mestic duties. 
MENORRHAGIA.
229
  Prior to  the occurrence of the  menorrhagic attacks, Mrs.
-------always complained of weight, fulness and tension in
the uterine region, of pressure  on the bladder and dysuria,
and occasionally of pain about  the neck of the womb.   In
November, 1838, I was allowed to examine both by the  va-
gina and rectum.  The body of the uterus was heavier  and
larger than natural;  the os somewhat  patulous, and the cer-
vix swollen.   I did not use the speculum, as the hymen was
firm, and prevented even the easy passage of the finger;  but
I am confident there  was no abrasion.  All the parts were
unusually soft and flabby, but neither  pain nor  bleeding fol-
lowed the inquiry.
   From 1838 to August, 1840, the course of this disease has
been perplexing and unsatisfactory.
   In March and April, 1838, Sir James Clark was consulted
—at that time her  state was as follows : the general surface
is pale  and exsanguined; the least excitement quickens the
pulse,  and  produces  flushings of  heat.   The  emaciation
slowly  increases—there is  cedema  in various parts of the
body, but no  anasarca.  Only slight uterine pain is complain-
ed of;  but she has the appearance of a patient suffering from
malignant disease.   A continuation of the treatment was en-
joined.
   The remedies have been the ergot in every form and dose ;
turpentine ; the acetate of lead ;  acids and refrigerants ; ben-
zoin ; opium; the various astringent, stimulant, and anodyne
injections ; country  and sea air; spare and  nutritious diet;
leeches and small bleedings ; easy exercise  in a carriage, and
the recumbent position.  But only transient benefit has been
 derived.  Often, in the last two years, I have given it up as
 a lost case, as there has never been  a day during that time,
 without either sanguineous, sero-mucous  or muco-purulent
 discharge; but after I  have  arrived at this  conclusion, for a
 week, perhaps for several, the discharges decline, there is no
 uterine  pain,  there is  a rally of  the strength; she  becomes
 cheerful, walks about the garden, sleeps  better, enjoys her 
230
MENORRHAGIA.
 food, and gathers flesh; thus leading one to doubt, whether
 this may not be a very rare example of protracted, congestive
 menorrhagia, without any more than the usual non-malignant
 changes of structure.
   Several circumstances deserve attention in this case.  The
 patient is often  entirely free from  sanguineous loss for three
 or four weeks;  but its  place is always supplied by copious
 discharges of sero-mucous, not aqueous,  and occasionally of
 muco-purulent or purulent fluid ; generally as many as eight,
 nine,  and ten napkins are used daily, and  when the sanguine-
 ous discharge is  present, many more  are required, so that it
 is impossible not to wonder how these  large and constant
 drains are borne.
   The hemorrhages are invariably preceded by sensations of
 uterine congestion, and several times a clot has  been  passed
 entire, presenting an  accurate cast of the uterine  cavity.
 From its comparatively small size, and  unaltered form, an
 inference has been  drawn  that this viscus is still of nearly
 normal volume.
   There is scarcely any pain ; none of a severe or perma-
 nent kind : an anodyne has  never  been required for its alle-
 viation.   An  examination made  a few days since (August
 1840), both by the  rectum  and  vagina, reveals no traces of
 disorganization.  The os is  patulous, and its edges are large
and swollen ;  the cervix too is more bulky, but beyond these
changes I can discover nothing  anormal.

   I have dwelt  at  some  length  on  this case, be-
 cause I know it is but of rare occurrence.  A posi-
 tive opinion cannot be given.   My  own leans to its
malignant character.   The emaciation, the  repeated
bleedings,  the constancy of the serous, the muco-
serous, and  purulent discharges, the  gradual  dimi-
nution  of strength, and  the  trivial benefit derived 
MENORRHAGIA.
231
from  remedies,  all point to disease  of this  kind.
Still no care, no remedy at all likely to exert bene-
ficial  control, should  be  withheld.   The  patient
ought  to be encouraged,  and especially  on the
ground, that her long  struggle may terminate in a
stationary, inactive  condition  of  the disease, and
perhaps in recovery.
   I could add several  examples of protracted con-
gestive menorrhagia, where the congestion was con-
sequent on a  loaded condition of the bowels and lux-
urious living. To these, as causes, allusion has been
already made.  In one instance, where the  patient
was middle-aged, and the landlady of an inn, nearly
constant hepatic and intestinal derangement, as well
as increased  bulk of the liver, was  thus induced.
The menorrhagic attacks were most frightful, and
on not a few occasions, there was great difficulty in
rousing her from the consequent syncope.  The late
Dr. Cholmeley visited her, and stated  that she might
be cured by spare diet and purgatives.  The impor-
tance of these measures was enforced, and in a few
months the hemorrhages were prevented.   I mention
this case especially, to show the value of purgatives
prior to the anticipated return of the  menstrual pe-
riod.   I  often ordered  for this patient, after the dis-
ease had continued some time,  a full  dose of castor
oil, twenty-four hours before  the expected  com-
mencement of the  discharge, and with the best re-
sults.  Dr. Locock observes, " that in  examples of
this kind of menorrhagia, the  next return of men-
struation may be rendered comparatively trifling, by 
232
MENORRHAGIA.
the use of  a full  purgation about twenty-four hours
before the period, when  that  can be  ascertained,
avoiding  every medicine  of a drastic, stimulating
nature."   He also  adds,  thus  confirming what  I
have just advanced, "that chronic (congestive) me-
norrhagia is occasionally connected with organic or
functional disease of the hepatic system ; and when
it is recollected how notoriously inattentive women
are to the state of their bowels, and what enormous
masses of fcecal matter are allowed to take place, it
may easily be supposed to what degree the abdomi-
nal circulation  must  become obstructed, and how
powerfully such  obstruction must  act in producing
congestion of the pelvic viscera."
  In conclusion, I think it right  to observe, that  I
have twice witnessed, in  most extreme cases,  the
beneficial effects of injecting into the uterine cavity
a small quantity  of the spirit of turpentine.   It will
not be supposed, after  what I have heretofore said,
that I  advise this procedure  on slight grounds.   I
believe such injections to be very certain but highly
hazardous remedies, and they never ought to be em-
ployed except as derniers  ressorts.  The uterus  has
also been injected with a small quantity of lead and
alum  in solution; and the narrator of the treatment
says,  " the remedy is a dangerous  one, for in two
instances it was  followed  by vomiting, uterine  in-
flammation, and  death."  At page 243, vol.  II. of
Guy's Hospital  Reports,  and at  page  115  of  the
present work, additional cases and observations will
be found. 
MENORRHAGIA.
233
  I first employed the  turpentine in a menorrhagia
where every previous remedy had proved ineffectual.
The case is as follows :—Mrs. G., forty-five years
of age, and habitually intemperate, requested me to
give her some medicine to prevent hemorrhage from
the womb.   She was large, and rather bloated, but
still capable of  great exertion.  She was  married,
was the mother of  several  living children,  and  had
miscarried  a  few months previously.  I remonstrat-
ed with her  on  the excesses to which she  acknow-
ledged she was prone, and fully explained to  her,
that they were  the source of the  bleedings.  The
uterus was large and soft, and  the cervix was full
and flabby ; but although the os  was  sufficiently
patulous to permit the entrance of the finger, I could
not detect  further structural change.   An examina-
tion by  the rectum was also made.    She lived in my
immediate  neighborhood, and  as I  had frequent op-
portunities of seeing her, she adopted for a time the
prescribed plan  and diet.   By purging  during  the
intervals, and especially before the period, the losses
were for  a  few  months  greatly  diminished.  At
length she thought herself so well, as to be  no lon-
ger  under the  necessity to adopt  any plan which
curtailed her usual indulgences.   I lost sight of her
for some months, and  I  know during the interval,
that highly  seasoned food, and large  quantities of
ale  and wine were daily taken.   One evening,  I
was requested in haste to visit her, and I found her
almost dead from  uterine bleeding.   Her  husband
informed me, that since my last attendance, she had
               30 
234
MENORRHAGIA.
very frequently lost large quantities of blood, and he
had thought that on several occasions she must have
died, but that hitherto, she had always slowly rallied.
Brandy and ammonia and ergot, restored animation,
but she  had not said many words  before  a fresh
gush again induced alarming  syncope.   Cold water
was dashed over the face, ammonia was applied to
her nostrils by a camel-hair pencil, and after a very
lengthened fainting,  she again rallied.  On inquiry,
I found the attack had already lasted two days ; and
it  was  evident that  her  powers were exhausted.
Her voice was scarcely to be heard, the pulse  was
quick and feeble,  and her breathing was very short,
the countenance was livid and anxious; in fact, it
seemed as though another gush would destroy her.
Her medical attendant, Mr.  Burton, plugged with
sponge, but ineffectually.  On the  instant, I pro-
posed  to  inject a small quantity  of spirit of tur-
pentine ;  and  having procured a gum-elastic male
catheter, and cut off  its end, so  that there was an
open mouth, I  introduced  it through the  os, which
was very  patulous, into the uterine cavity, and by a
syringe I  injected about two or three drachms of the
spirit.   Soon afterwards I  plugged the vagina with
tow.   There was no further  bleeding, but the  pain
was indescribably great, as though there were  burn-
ing coals in the uterus and  bladder.   The  evidences
of hysteritis seemed  so clear, that I feared  we must
have  taken away blood.  Fomentations  of poppy
and conium applied very hot; camphor and lauda-
num, together with a purgative*'^nema, allayed the 
MENORRHAGIA.
235
intense suffering.  In twenty-four  hours I removed
the tow, and there was no further  bleeding.   Men-
struation never returned, and from the continued and
occasionally severe  pain which followed  the use of
the turpentine, I suspect that  adhesion of the sides
of the uterine cavity resulted from the inflammation.
Her former intemperate habits were soon resumed,
and in  less than a  year she  died.  No  inspection
could be obtained.
   I again witnessed the advantageous effect of this
remedy in July,  1838.  On that occasion I  was re-
quested to visit a lady under  the care of  Mr. Price,
of Margate.  On my  arrival, the following particu-
lars were  communicated  to  me :—Mrs.  M-------,
set. 45, is  the mother of several  children, and has
suffered from  menorrhagia for two or three  years :
of late, the losses had been large, and she had re-
paired  to  the sea-side for a  restoration of  health.
Two days before my  visit, July 17th, the period re-
 turned, and in a few  hours much blood was  pumped
 out of  the uterus  by gushes.   Mr. Price promptly,
 but without stopping  the hemorrhage,  gave large
doses of ergot,  acetate of lead, and sulphuric acid,
 at the same time applying cold externally, and in-
jecting astringents into the vagina.  It soon became
 evident that more must be done, and  Mr. P. boldly
 determined to throw a small quantity  of  turpentine
 into the uterine cavity.   On my arrival this had
 been effected some hours ;  the bleeding  had ceased,
 and she appeared to have all  the  symptoms of hys-
 teritis.   The agonising pain, described in the pre- 
236
MENORRHAGIA.
ceding case, was present, requiring aid  to  keep her
in bed.   The pulse was  140, irritable and  thrilling,
but  compressible, and without  hardness or power.
The abdomen was painful to the touch, but not in
the same way as in puerperal fever.  The pain had
aggravations  and  intervals  of  less severity,  and
it was not necessary,  as  it often is in puerperal pe-
ritonitis, to prevent the pressure of the bed-clothes
by placing a cradle over  the patient.  Still  the suf-
ferings   were described  as  almost  unendurable.
Opium, a purgative enema, and afterwards a sup-
pository, together with anodyne and mustard fomen-
tations, palliated the pain ; and, under the influence
of a full opiate,  she got some refreshing sleep.   The
vagina had been plugged prior to the injection of
the turpentine, and before we left her for the night,
I carefully filled  it  with  tow, wetting  it afterwards
by a syringe with decoction of ergot (vide formulae).
In the morning there had been no return of hemor-
rhage, and  I  was  subsequently  informed,  by   Mr.
Price, that she had recovered well but slowly.
  In cases of alarming  menorrhagia, it  is a matter
of moment that the practitioner remain with the pa-
tient and ascertain very frequently the extent of the
hemorrhage.   In puerperal bleedings, after the ex-
pulsion of the placenta,  life is  often dependent on
this precaution.   A crown princess of Austria,  who
had been attended by the celebrated Boer, of Vien-
na, (the case  is  related  by Dr. Rigby,)  and many
other women,  have  been  lost from the neglect of its
observance,  and in  the instances now under inquiry 
MENORRHAGIA.
237
it  is scarcely less necessary.  After excessive me-
norrhagic bleeding by gushes, or  in a stream, the
powers of life are often  reduced  to a very low ebb;
and  protracted  but  slight drainings may therefore
afterwards  insidiously and  unexpectedly sink the
patient. 
CHAPTER  VII.
OF LEUCORRHCEA.
  Definition.—An excessive and altered secretion
of the mucus, furnished by the membranes lining the
vagina and uterus, by the follicles of the interior of
the  cervix uteri, and by the lacunce of the vestibulum,
generally white or nearly colorless and transparent,
usually without much odor, glutinous, muco-purulent,
or purulent, sometimes yellow, green or slightly san-
guineous,  and of varying  degrees  of consistency.
The amount of constitutional derangement  depend-
ing on the severity of the affection and the suscepti-
bility of the patient.

  There are three forms of  the disease.
  First, The common leucorrhoea, often mild, some-
times acute.
  Second, The inveterate and chronic leucorrhoea.
  Third, The symptomatic  leucorrhoea.
  Acute and mild leucorrhoea.
  History and Symptoms.—I have adopted  this di-
vision, because it is both correct and comprehensive. 
LEUCORRHOEA.
239
It is proper  to distinguish  a recent,  common, and
inflammatory leucorrhoea, from one of the same or-
der, only of chronic inveteracy.   And it is certainly
not less correct to distinguish both  these from the
symptomatic form, when the discharge owes its ori-
gin  and  continuance  to  structural  or malignant
changes of the uterus or its appendages.  It is also
comprehensive,  not   only  including the  examples
where the  pathological condition is  inflammation or
simple  uterine catarrh, but also the symptomatic
cases,  where changes of a more serious or disorgan-
izing kind  are the source of  the mischief.  Of all
the diseases  peculiar to  the  sex, there is none so
common.   Few married women, particularly if they
are mothers,  escape its attacks.   The  young and
the robust  are less liable than those more  advanced
in  life, especially if  the  latter  possess susceptible
and delicate  constitutions.   If evidence  were re-
quired of its  almost universal prevalence,  it might
be  found  in the  number of its  synonymous names,
in the vast variety of real or supposed remedies, and
in the many treatises published  to elucidate its na-
ture.   In its milder forms, there  is so little pain and
constitutional disturbance, so little interference with
the uterine functions and the  comfort of the patient,
that we cannot wonder at  its neglect.   And  yet I
believe, if  care were  taken  at  this early stage,  if
ablution only was frequently practised, the tone  of
all  the parts, and more particularly  of the secretory
membrane, would be regained, and  further mischief
entirely prevented : so far as  my  observation has 
240
LEUCORRHOEA.
gone, there  is amongst female youth, and women
generally, in this  country, an  unfounded  dread  of
ablution of the external organs, either cold or tepid.
The vicissitudes of our climate in some measure ac-
count for and justify the  impression, but neverthe-
less  it is  too general, and  extensively  injurious.
The duration of the affectiou  has often  astonished
me; many individvals  stating that they have suffer-
ed from it for years, and some few during the whole
of their lives.  But it  is disease still;  for  in health
there is an accurate relation between the amount of
secretion and the purpose  which it serves, viz. lu-
brication of surface.   When,  from any cause, its
amount is increased beyond what is  necessary for
this important end, it is morbid ;  although, in many
instances, remedies are scarcely required for its cure.
It was stated, when treating of menorrhagia, that
climate and peculiarity of  constitution were  criteria
of importance in determining whether menstruation
was  morbidly profuse.   The observation is partially
true of leucorrhoea, as in hot climates and in  marshy
districts—in Holland for example—there is a larger
quantity of  mucous  naturally secreted than in drier
and more temperate regions.   I do  not wish to ex-
tend these general observations;  but  still, without
some clearing of the ground, it will be very difficult
to convey any correct ideas of the different degrees,
and of the   various seats of  this prevalent malady.
Thus,  although the vagina is the common  outlet for
all leucorrhoeal discharges, it must not be forgotten,
that  these   differ much from each other, being fur- 
LEUCORRHOEA.
241
nished by parts of different structure and vasculari-
ty, whose healthy secretions are far from identical.
A precise knowledge of these  differences will not
only assist us in the diagnosis, but will also  render
our treatment more efficient.
  The  mucus naturally secreted by  these  various
parts, although not entirely the same, does not differ
in any  of its essential  properties from  mucus  fur-
nished  by similar membranes  in other parts of the
body.   It  consists of  albumen and soda,  and in
transparency, color, and viscidity, it closely resem-
bles the white of an egg in its natural state.
   The  mucus secreted  by the  lining membranes of
the uterus and fallopian tubes, is correctly character-
ised by the above description.  Its  purpose  is such
a degree of lubrication  of the sides of the tubes, and
of the opposing surfaces of the uterine cavity, as shall
prevent their adhesion.   It need  scarcely be added,
that a very small quantity is sufficient, and that with
the exception of the period of pregnancy, when the
decidua covers the membrane,  its secretion must be
constant.
   The mucus furnished  by the lining membrane of
the vagina, is more abundant  in  quantity, and less
 viscid than the uterine  mucus.  This fact is readily
proved  by  examination  under procidentia.   If the
finger  be  merely  introduced  into  the  vagina and
 withdrawn,  it will be covered  by a  thin  mucus
 only ;  but if it be carried, as it often may,  through
 the os  into  the interior of the uterus, the adherent
 mucus will be found much more ropy and tenacious ;
               31 
242
LEUCORRHOEA.
 generally, indeed, it may be considerably drawn out
 without breaking.
   The mucus furnished by the lacunceofthe vestibu-
 lum, or that part of the vagina external to the hymen,
 is probably slightly more tenacious than  the  vagi-
 nal  secretion, and is said to exhale a peculiar odor.
 Whether it possesses this latter property independ-
 ently of pregnancy or morbid  action, or in higher
 degree than the mucus furnished by other parts, ad-
 mits, I think, of doubt.
   The secretion from the glands of the interior of
 the cervix uteri, is not often found in common leucor-
 rhoea.  I had  lately  an  opportunity of  examining
 these glands and their product, in a patient who had
 died  in early pregnancy.   The  glands themselves
 were numerous and clearly discernible,  and the mu-
 cus was easily drawn  out entire and unbroken.   Sir
 Charles Clarke, whose work on  Female diseases
 cannot be too highly esteemed, says, " that this mu-
 cus contains a smaller proportion of water than any
 other, approaching  nearer to the  nature of a  solid
 than  a fluid body.   These  glands,  in a state of
 health, perform the office of  secretion in pregnancy
 only ;  or if, at  any other time, the matter secreted
 is of  a very different  kind;  so  resembling common
 mucus as not to be distinguished from it."
  A remembrance of  these facts will aid us in form-
 ing a correct opinion of the nature and  precise seat
 of the  several forms of the disease.   If, then, these
 secretions differ from each other in health, doubtless
under various degrees of irritation and inflammatory 
LEUCORRHOEA.
243
action, a similar difference will be apparent.   The
simplest idea of leucorrhoea is obtained, by regard-
ing its mildest acute form as the result of mere hy-
peraemia or  vascular congestion,  whether it  affect
one only, or all  the  parts enumerated in its defini-
tion.   Under such an amount of  morbid influence,
the secretion furnished  by these various parts will
be more abundant than in health;  but it will  retain
its natural characters, it will still be a white,  trans-
parent, and glutinous mucus ;  there will be derange-
ment of system,  produced by febrile  excitement,
slight ardor  urinse, and some sensations of heat and
tenderness about the generative organs.   It is easy,
after this description, to understand the transition
to its more serious forms, where the healthy proper-
ties of the mucus are lost; where it has become not
only excessive  in quantity, but muco-purulent, en-
tirely purulent, or ichorous and watery, and of yel-
low, green,  or  sanguineous color;  and where the
constitutional  affection   is  acute  and  extensive.
Here we shall  have no hesitation in believing, that
congestion and  irritability have been succeeded  by
inflammation, and that whether several only, or  all
the parts  are affected, they have  lost their healthy
secretory action, and are pouring out pus, the pro-
per and usual product of an inflamed mucous mem-
brane.  Nor is  this  statement  less true of the third
or  symptomatic  form, where  the discharge  is the
consequence of any of the grave structural lesions,
of which it is soiconstant an accompaniment.
   Often, in  common leucorrhoea, I have examined
t 
244
LEUCORRHOEA.
by the vagina, but without  discovering more than
trifling increase of the body of the uterus, some ten-
derness of the cervix in the inflammatory form, but
none  in  the   protracted  or  chronic  variety.   The
state  of  the  cervix is occasionally soft, and the os
rather patulous.   Sometimes the orifice is not at all
open,  but generally the whole  of these parts are
supple, bathed in discharge, and much more relaxed
than in health.   In several instances where I have
used the speculum, the cervix has been pale, in more
acute cases slightly red, and  in two  severe attacks,
it was of a  deep crimson tinge.   In none where
there was  not suspicion  of  venereal taint, have I
seen erosion  or ulceration.  A few days since I  had
an opportunity of examination, and there were three
distinct and  large patches of superficial ulceration
on the cervix ; but the other  symptoms were too un-
equivocal  to  leave any doubt of  the  presence of
gonorrhoea.  I have  already  stated,  that  the  dis-
charge varies much in quantity; sometimes it is so
profuse as to oblige the  patient to change the nap-
kins several times daily ;  at other times it is less in
quantity, but acrimonious ; and in color and consist-
ency there is almost endless variety.
   Viewing the  different forms in this way, there
will be less  difficulty in assigning  to each, either a
mild,  aggravated, or symptomatic character.   Ex-
amples of the least severe kind, arising from excite-
ment, are  most frequent.  The  blood-vessels of one
or several of the secreting parts, from increased cir-
culation, become congested, and soon afterwards ex- 
LEUCORRHOEA.
245
cessive secretion, constituting the leucorrhoea, takes
place.   In many of these instances, the augmented
secretion is probably confined (and in this idea Dr.
Burne concurs) to the muciparous glands of  the os-
tium or entrance  of  the vagina,  scarcely affecting
the membrane  of  the  whole  canal, much less the
uterine secretory surfaces.   This opinion becomes
highly probable from the fact, that  recent and mild
leucorrhoea often yields to ablutions and lotions, ap-
plied, not as injections,  but as washes to the exter-
nal parts, the genital fissure  being  exposed by the
separation  of  the  labia.  Here the accompanying
symptoms will be so slight, as scarcely to secure the
attention of the  patient.   From this incipient and
mild  form, every  degree  and  variety will be  met
with, up to the most  aggravated  and symptomatic
examples of the affection.   In some,  the vascular
excitement and irritation will be more marked, and
the local  symptoms and constitutional derangement
more distressing.   The discharge may not only be
excessive,  but  highly irritating, and  there may be
ardor urinse, heat of the genital fissure, and dysuria.
But this assemblage of symptoms, constituting a
case of acute, inflammatory leucorrhoea, may quickly
yield to ablutions of tepid water or poppy fomenta-
tion,  aperients, abstinence  from intercourse, spare
diet,  and rest.  These,  therefore, are not the cases
in which medical aid is  anxiously sought.  But in a
still more  severe  attack,  where, from  any of the
 causes to be hereafter specified, inflammatory action
 has been followed  by excessive and acrimonious se- 
246
LEUCORRHttA.
 cretions,  the symptoms  will generally prompt  the
 patient to seek immediate relief.  In such, there will
 be rigors, from sympathy with the  uterus, heat of
 surface, a quick pulse, and white tongue, pain in the
 loins and hypogastric region, heat and pain about the
 cervix uteri and neck of  the bladder, affecting also
 the vagina, urethra, and external parts, distressing ar-
 dor urinae, and strangury.  These symptoms may con-
 tinue one or several  weeks, according  to the treat-
 ment and its success.  If, under the idea of its  be-
 ing a " weakness," tonics and  stimulant injections
 are early exhibited, the discharge will probably  be-
 come  more  excessive, purulent or muco-purulent,
 thin and watery, or ichorous, and  the constitutional
 effects more  aggravated.  If, on the contrary, anti-
 phlogistic and  soothing treatment  be adopted,  the
 morbid secretion will diminish in quantity,  and the
 general derangement will disappear.  In many  in-
 stances, the cure is quickly effected ; but in some,
even where proper treatment is early and fully pur-
 sued,  it lasts long, proves  very troublesome,  and
eventually  passes into a chronic  and inveterate state.
 It need scarcely be said that the  discharges in the  va-
 rieties now pointed  out, originate in increased action
of the  vessels  of   the  different  parts.  Females,
therefore, of plethoric habit, possessing more than
ordinary vigor  of constitution,  are  more liable to
such  attacks  than  those who  are  feeble  or less
 strong.  And as the  former is  not so numerous a
class as the latter, it may be affirmed  that leucor-
 rhoea,  attended  by  weakness, is the more common 
LEUCORRHtEA.
247
form.  Yet it must be remembered  that  some fe-
males  indulge in the pleasures of the table, and
drink  too  freely of malt  liquor,  wine, or  spirits.
In  many  affections  thus  produced, the  cares of  a
family or a business, or more frequently the  disin-
clination to   exercise,  or  eventually the want  of
strength sufficient to bear its inconveniences, almost
compel a sedentary life.   Hence  they become cor-
pulent, but not  strong ; a larger  quantity of blood
is generated, vessels scarcely to be seen before be-
come visible, the pulse is full, the  respiration is em-
barrassed  on  slight  exertion, and the functions  of
the  bowels and  the kidneys are badly performed.
In these examples, and they are  not very uncom-
mon, particularly about the  middle period of life,
menstruation often becomes profuse, and the  leucor-
rhoea excessive.    Great care is required in the treat-
ment ; for if  these undue secretions  are  suddenly
stopped, apoplexy, inflammation of the liver, of the
stomach or bowels may supervene and the  patient
be quickly destroyed : in  the section  on treatment
these circumstances will receive their full share of
attention.   In the various  degrees now pointed out,
leucorrhoea is  a common  sexual malady;  nor is  it
difficult to  believe, from  the  complication  of its
causes, the susceptibility  of women,  the  frequent
neglect of all treatment, and the  injudicious man-
agement so often adopted, that every variety of case
shall arise.
  Second,  Chronic and aggravated leucorrhoea.
  It is in this form,  not  in the  preceding, that the 
248
LEUCORRHCEA.
cure is difficult.   The history of these more serious
cases is  instructive ;  because  it generally reveals
early neglect or improper treatment.  Some females,
however, seem to be almost naturally the  subjects
of discharges,  unusual in amount  as  well  as  in
character.   In  many  instances,  amongst  the out-
patients of Guy's, these leucorrhoeal discharges are
so habitual, that  complaints of  congestion  in other
parts, about the  head  or chest,  pains in the limbs,
or neuralgic pains of  the abdomen, are  almost in-
variably complained  of for some weeks after the
excessive and morbid  secretion has been entirely or
even partially cured.   Nor  is it at all  uncommon,
when  many remedies  have  been  tried,  without
benefit, that the disease is allowed to take its course
uncontrolled.  The  frequent  results are  sterility,
from anemia of  the reproductive organs, especially
of the ovaria, prolapse and procidentia of the uterus,
and not unfrequently of the vagina and  bladder.
   It need  scarcely  be  added  that  pallor, partial
emaciation, or rather thinness of person, indigestion,
impaired  appetite, and  constipation, languor, and
weakness,  are  the constitutional accompaniments.
In some instances (vide cases), the continuance and
aggravation of the leucorrhoea  is the fault of the
practitioner.  Uterine or general plethora has  been
overlooked; the morbid state of  the cervix  or  body
of the uterus has been  disregarded;  abrasion  or
ulceration  affecting these  parts or the vagina, may
not have been discovered because an examination by
the speculum, or  the  fingew has not been made. 
LEUCORRHCEA.
249
Thus what  was  at first, and  for some time, a case
of aggravated and chronic leucorrhcea only, becomes,
in the progress of the morbid action, an example of
the  symptomatic form, and  requires for  its cure a
much more  local application of stimulant and alte-
rative  remedies.   I   have  known two examples
where severe and  primary attacks of leucorrhcea,
were rendered chronic and  aggravated by an  un-
natural  heat of  the  external  parts, produced  and
maintained  by the  constant  wearing of thick  nap-
kins, to secure the  patients against the  discomforts
of large discharges, which  were,  by  this  measure
alone, rendered still  more excessive and  constant,
(vide cases), a greater supply of blood  being  thus
induced.  Where the  leucorrhoea  is chronic  and
aggravated, there is  great variety in the  discharge.
Sometimes it is glutinous, transparent, and  colorless
—the natural secretion in excess—at  other times it
is decidedly purulent, muco-purulent, or watery, the
result of inflammation changing the  action of the
parts.   Nor  is the color  less  variable :  a  green or
brown tinge may indicate excessive irritation,  and
blood mingled with  the discharge  will  probably
result from  abrasion or rupture of  the capillaries of
the uterine surface, or it may announce the approach
of the catamenial period.
   After  these  observations,  it will be  understood
that the general  health may be fearfully and some-
times, although very rarely, fatally  broken down by
chronic  and inordinate leucorrhoea.  If it  exist in
the  young, or  in thosjt who  have scarcely passed
              32     ^ 
250
LEUCORRHCEA.
twenty years of age, amenorhoea and chlorosis, with
their  numerous evils, and  ultimately  phthisis, may
occur.  Nor would these results appear so astonish-
ing, if by accurate  inquiry the quantity of mucus,
constantly secreted, was  really known.   It would
then scarcely surprise us that a girl, delicate perhaps
from birth, or who,  at least, may never have enjoyed
good health, should eventually die from consumption
to which she may have  had a latent tendency, after
a  drain of blood  for months and years, sufficient to
furnish an ounce, or several ounces, of leucorrhoeal
secretion  daily.  Nor is it more to be wondered at
in married women,  that  menstruation should be long
suspended, and that conception should be prevented
during the exhaustion produced by these discharges.
It cannot,  I  think,  with truth  be affirmed, that
changes of structure never occur in connection with
protracted leucorrhcea, although it may probably be
satisfactorily proved,  that malignant lesions are not
within the scope of its  morbid powers.   Softening
of parts  and  partial  disorganization of the uterus
may, according to Andral, and my own observation,
take place.  I know that a  brain  may soften, and
purulent  deposit  be found in its substance, as the
effect  of undue lactation,  and there  is clearly  no
reason why some similar effect should not happen
to the uterus from excessive and  protracted leu-
corrhcea.
   Patients often  think  because the  pain and  heat,
and constitutional  disturbance continue, or are fre-
quently repeated, that  formidable   uterine disease 
LEUCORRHCEA.
251
must  exist.   This opinion is strengthened  by the
acrimony and odour, and the occasional sanguineous
tinge  of the  discharges.  Doubtless, under  such
circumstances,  examinations  by the speculum  and
finger ought to be made; but, even in their omission,
a hasty conclusion should  not  be formed, as these
symptoms often  occur  in  a functional but severe
and protracted case.
  There must be noticed also a form of the malady,
by some authors denominated the  passive,  but for
which a better appellation,  judging from its  perma-
nency, would  be habitual  leucorrhcea.   In many
instances it is the consequence of acute and  inflam-
matory attacks;  but  in still  more of constitutional
and   local  weakness.  The generative  organs of
most leucophlegmatic females, are habitually relaxed,
and there are not a few  where a very small quantity
of mucus seems naturally to exude  from the surface
of the genital fissure.   To  this condition  I  have
already alluded as one not generally deserving to be
regarded  as morbid, and  only requiring  for  its
control careful and  repeated ablutions.   But  this
habitual and trivial  discharge  dependent originally
on  constitution,  climate,  and   temperament,  may
become morbid by its  excess;  especially when it
co-exists with  amenorrhcea  and  chlorosis.  Nor
must  it be forgotten that it  has  been cured, when of
long standing, by marriage,  and by the re-occurrence
of menstruation.
  It is rare in the young,  and  common in married
women, to whom there  belong  the general condi- 
252
LEUCORRHCEA.
 tions already described,  and  whose  strength  has
 been weakened  by  sexual  excess,  menorrhagia,
 abortion,  or  over-lactation;  these having  perhaps
 induced  displacement and  prolapse of the  uterus.
 The symptoms are  slight, and  there is scarcely any
 local irritation.  The  discharge is generally white,
 stiffening the linen ;  and if there  be a  neglect of
 cleanliness, it may produce inflammatory abrasion
 of the upper part of the thighs and heat of the labia.
 The constitutional effects are trifling ;  and yet such
 a patient will  often by pallor of  face and  darkness
 round  the eye-lids,  languor  and  incapability  of
 exertion, afford sufficient indications of the existence
 of a weakening  malady.   Occasionally,  where the
 disease  has been  long unchecked, and  where the
 discharge is on the increase, there will be emacia-
 tion, constipated bowels, and depraved appetite and
 indigestion; and I  have often known such patients
 complain of pain in the stomach,  when empty, of a
 desire for food, without being able to  take any, at
 least with relish, and of dragging  and heavy feelings
 in the abdominal and lumbar  regions.   The com-
 plexion  is often  sallow and icterode, and several
 times I have had great difficulty in curing eruptions
 about the face and  forehead, which have long  ex-
isted in connection with this form of leucorrhcea.
  Third, The symptomatic leucorrhcea.
  To a certain extent  all  that has  been  heretofore
advanced  is applicable  to  the  symptomatic   form.
Most of the symptoms already pointed out  will exist
here; but  with great variety as to their causes and 
LEUCORRHCEA.
253
relief.   For  example,  a  transparent mucous dis-
charge is equally an attendant of prolapsus uteri, as
of inflammatory uterine catarrh : but the accompa-
nying symptoms are widely different; nor can the
cure be accomplished by  the same means.   Again
a muco-purulent, or  purulent secretion,  may result
not only from acute inflammation of the uterine mu-
cous lining, but from a cancerous or submucous tu-
mor.   The cure in  the one case may be effected
with comparative  ease :  in the  other  relief  only,
and  that not without  difficulty and delay,  can  be
expected.  The symptomatic form of the disease is
therefore deserving  of especial notice;  but,  as  in
subsequent parts of the work, it must be the subject
of remark, in connection with the structural lesions
of which it is so frequent an accompaniment, it  is
not necessary at present  to  make more than these
few observations.
   The importance of accurate examination  by the
finger  and speculum, where the leucorrhoea is sus-
pected to arise from lesions of  an organic kind, can
scarcely be too strongly urged.   Nor ought  it to  be
forgotten, that more than one such inquiry  may  be
required, as an affection at first confined within the
limits  of functional  disease, may in its progress ac-
quire a totally different character.
   There is a peculiur form of leucorrhcea somewhat
allied  to hydrometra, inasmuch as  the  contents  of
the uterus in  this  latter disease are  not  always se-
rous, but sometimes albuminous and  muco-purulent 
254
LEUCORRHCEA.
 secretions.  In this  variety the  discharge  does not
 consist of a limpid glairy fluid like  common mucus,
 nor does it come away gradually as  in common leu-
 corrhcea ; but the fluid is often entirely  purulent, or
 so closely resembles  pus, as to  be with  difficulty, if
 at all, distinguished  from it, either in color, viscidi-
 ty, or odor; and having accumulated in the uterine
 cavity to four, five, six, or  more ounces,  it  comes
 away by gush.   In these particulars  it differs widely
 from ordinary leucorrhoea, and  in  one example I
 thought from the suddenness of its escape,  and the
 similarity of the previous  symptoms, that  the  dis-
 charge must have been the result of abscess.   This
 opinion,  however, was not confirmed by subsequent
 events.   In all the instances falling under my obser-
 vation, and they are comparatively rare, muco-puru-
 lent leucorrhcea had long  existed previously,  and
 although it was suspended during an  accumulation
 going on  in the uterine cavity, it  returned  immedi-
 ately after the  escape of the purulent gush.  It is
 true, nevertheless,  that the  symptoms assume  a
 character distinct from any  other form of the mala-
 dy, as  the time for  the  eruption  approaches, (vide
 cases).   There is fulness about the hypogastrium, a
 sense of  constriction and weight about the  neck of
 the bladder and along the  course  of the  rectum,
dysuria,  heat,  general uneasiness, and  sometimes
acute pain with forcing about  the uterus.   In  one
instance the patient was so distressed by these, that
she was compelled  to keep her bed for several  days 
LEUCORRHCEA.
255
prior to the escape of the pus.   The general health
suffers from the repetition of this series of morbid
actions.
  Sometimes there is emaciation, and there is usu-
ally great difficulty in the  cure.   In two instances
where widows were its  subjects, the disease disap-
peared after marriage, pregnancy having soon occur-
red.   I have  several times  examined  prior to the
escape of the fluid;  the uterus has been generally
but  not greatly enlarged ; the  cervix swollen and
slightly tender, and the os partially closed.   In no
case has an examination revealed  subsequent struc-
tural mischief, and in none that I  have seen has the
uterus  been sufficiently voluminous to render it at
all probable that it should be mistaken for an ordi-
nary case of hydrometra.  I have never seen  this
affection  in young females.   Married  women, and
particularly widows, or  those in whom the reproduc-
tive organs having been employed are so no  longer,
seem to be its most frequent subjects.
   I  have thus attempted to elucidate the history and
symptoms of this prevalent  disease, without adopt-
ing the division into vaginal  and uterine leucorrhcea.
Independently of symptoms, it is allowed to be very
difficult to distinguish what portion  of two continu-
ous  membranes of identical  structure are morbidly
furnishing a nearly identical secretion ; it seems much
easier and more rational that the diagnosis  should
rest on the severity of  the symptoms, and the diffi-
culty of cure.   It is  known that the vagina is much
 more frequently the seat  of  disease  than the cavity 
256
LEUCORRHCEA.
of the uterus, and, in the majority of instances, it
yields more readily to remedies.  Thus where there
is marked aggravation of  symptoms and considera-
ble  constitutional derangement, the  uterine mem-
brane is probably  implicated ; but where, on  the
contrary, the whole of the symptoms  are locally and
constitutionally slight and easily cured, the vagina
will generally be  found to be the seat of the disease.
The frequent implication of both  the vaginal  and
uterine  secretory surfaces, and the  difficulty even
where one  only is morbidly affected, of distinguish-
ing which  it  is,  will often perplex  the diagnosis,
whatever divisional arrangement be adopted.
  Causes.—These are numerous, and, according to
their nature, have a distinct influence in the produc-
tion of  the different varieties of the disease.
  The  first form, which I have  denominated  the
common leucorrhcea, and  which is more  idiopathic
than the others, owes its origin, especially in deli-
cate and strumous females, to causes inducing  in-
creased action, and  sometimes inflammation in  the
secretory surfaces and  glandular  apparatus of  the
genital  organs.   These are, the application of cold
or moisture, frequent excitement resulting in debility
from  excessive  sexual  intercourse, abortions,  from
which  the  patient has only imperfectly recovered,
quickly recurring  labors, puerperal  hemorrhages,
menorrhagia,  profuse menstruation, and undue lac-
tation.   The  irritation of a pessary,  or of stimulant
injections on the vaginal surface and the cervix uteri
belong  also to this class.   There  are  other causes 
LEUCORRHCEA.
257
which act only indirectly, and these, with the agen-
cies already pointed  out, may lead, where the com-
mon, mild, and more idiopathic  disease is uncured,
to the chronic and aggravated form.  These operate
through the medium of the nervous system and  by
sympathy.  Thus in  amenorrhoea, where  the func-
tional or organic nerves of the uterus  are affected,
a  leucorrhoeal secretion  is  frequently  set up, not
only from the vaginal but likewise from the uterine
mucous surface.   Intemperance in eating and drink-
ing often induces derangement of the stomach, bow-
els, and  liver;  by  sympathy with  these, moibid ac-
tions  of the uterine  system may be  induced, and
leucorrhoea will often be the result.  Nor must irrita-
tion of the spinal marrow be omitted in this  enume-
ration.   I lately saw an example where leucorrhcea
might be traced to morbid affection of the chord in
the sacral region, as evidenced by tenderness when
these  parts were pressed.  Here  there was  an un-
usual degree of  lumbar and sacral pain, much more
than  could be fairly attributed to the quantity or
continuance of the discharge.  In  such, a cure is  ob-
tained  by rest,  leeches, and  stimulating embroca-
tions about the loins and  sacrum.  Still, I  do  not
wish  it to be  understood that dorsal,  lumbar, and
inguinal  pains, are the concomitants of leucorrhoea
of this kind alone.   For I am  quite aware  that
these symptoms are attendants  on cases of  leucor-
rhcea, where there is no such remote and  influential
sympathy.
   Symptomatic  leucorrhcea,  as  its  name  implies,
               33 
258
LEUCORRHCEA.
 being the consequence of other and distinct diseases,
 may be attributed to any causes which shall produce
 uterine or vaginal irritation.   Amongst these must
 be mentioned  relaxation, prolapsus,  and  the  other
 displacements of the womb, polypi of various kinds,
 affecting the uterus, vagina, or urethra, hard or soft
 tumors of the reproductive organs, ascarides, a pes-
 sary, and other bodies  intentionally introduced into
 the vagina.
   Pathology.—There can  be no doubt that leucor-
 rhcea owes  its origin to two distinct and  dissimilar
 conditions.   The first, a state of hyperoemia or  in-
 creased action of the vessels  of the secretory sur-
 faces,  and  the second, debility, either original or
 produced  by the continuance of the former state.   By
 some authors nearly all the cases are  supposed to
 depend on weakness, excepting such  only as are  ac-
 companied  by  symptoms of inflammatory  action.
 There  is truth in this opinion if the examples be  in-
 cluded where the leucorrhoea having been of the first
 kind originally, has, by its  continuance terminated
 in the opposite state.   Let it, however, be remem-
 bered,  that  it does  not necessarily follow because
 the system generally is  delicate, that  the uterus and
 vagina must of necessity be in  a state of anemia.
 Local  and  long  continued  inflammation often pro-
duces constitutional weakness,  and  certainly the
progress of the malady, the  irritation and  pain, and
the increased secretions, point to inflammation as
one of its essential  primary  conditions.  Nor must
we forget that delicacy often exists without leu-
corrhcea.  Still, original or  acquired feebleness of 
LEUCORRHCEA.
259
system  may  give increased  efficacy to the various
exciting causes of this prevalent malady.
  Probably in  all the instances where the uterine
lining membrane is implicated, particularly in  those
where leucorrhoea is vicarious of  menstruation, the
vessels  elimating the catamenial  fluid furnish  the
morbid  discharge.   In  the symptomatic forms, the
pathology  is  necessarily different, as  a displaced
uterus,  a prolapsed vagina, hard tumors, and various
other structural growths and deviations, produce the
disease.
  Diagnosis.—This  is frequently difficult, and  be-
tween  some  forms of the disease and gonorrhoea
nearly  impossible.   Still  in  numerous instances  a
correct  distinction may be drawn, and where  differ-
ence of treatment is involved, it ought to  be at-
tempted.
   In mild  leucorrhoea  it may be  assumed, that the
muciparous glands at the entrance of the vagina and
the lining  membrane of the canal are  alone affected.
Where  the symptoms are decidedly severe, the uter-
ine lining  membrane is often interested.   The diag-
nosis will  be aided  by an inquiry into the following
circumstances: If the  discharge was first observed
after abortion or delivery ; if it was prior to, or has
partially or entirely superseded menstruation; if there
be much pain in the hypogastric or lumbar regions,
with nausea and vomiting, or uncomfortable  sensa-
tions about  the stomach, liver, or head, these point
to an affection of the uterus,  rather than of the va-
gina.   With the latter, we know that  the constitu- 
260
LEUCORRHCEA.
tion  sympathizes  but  little, while with  the uterus,
by means of the organic  nervous system, its sym-
pathy is  most intimate.   It  has been proposed  to
use a piece of sponge as a  local test, which is to  be
introduced into  the vagina,  so as to plug  the  os
uteri, on going  to bed ;  and if, when it  is removed
in the morning, there be no more discharge adhering
to it than would  occur from  the natural  mucus of
the canal, the discharge which  takes place by day
must be regarded  as uterine.   If, on the  contrary,
the  sponge be  thoroughly  moistened,  the  vagina
must be considered as implicated in the  mischief.
But  it is evident that this test is  not  unexceptiona-
ble.   If  the  discharge be uterine  only, but exces-
sive, the sponge  will be much wetted with the  ab-
sorption, the  uterine cavity being so small  in  its
normal  state, that it cannot  contain more than a
few  drachms.   If the vaginal surface  be also  se-
creting  in excess, no satisfactory diagnosis can  be
thus  made.   Nor will an examination by the  finger
afford unerring  information ;  as  in merely vaginal
leucorrhcea, if it be profuse  and of long  standing,
there will be  a  similar relaxation and  softening of
the cervix, as is  found where  the uterine surface is
affected ;  and in most instances of either  form, the
os will  be open, or in at least a dilatable  state.
Thus we are compelled  to depend on the indica-
tions previously stated, except where we are per-
mitted to use the speculum, the only  certain  means
of diagnosis.  The following  account comprises the
result of M.  Marc d'Espine's researches  with this 
LEUCORRHCEA.               261
instrument  on  the subject of  leucorrhcea.  They
were extracted from  the Archiv. Gen. de Med. for
February, 1836.
  M.  d'Espine notices its  continuance during  the
menstrual  intervals, and also its occurrence just  be-
fore  or  just  after the  menstrual evacuation.   The
climate  of the middle  and  north of France appears
most favorable  to its  production, and  women with
very light or  very dark hair seem most liable  to it.
The character of the constitution exercises very lit-
tle influence.  Out of nineteen women  subject to
whites habitually, six were robust, nine were mode-
rately strong, and four weakly.
   An examination with the speculum gave the fol-
lowing result in 193 cases.  In  23 the uterine ori-
fice was found  dry—in 40 there was just a drop of
discharge in  the orifice—in 130 the discharge  was
 abundant.   The orifice may  be quite healthy—pale
 red—or bright red,  and occasionally it was granu-
 lated and  bloody.
   The  following  table will exhibit the character of
 the discharge and the state of the uterine orifice, in
 111 cases.
                                            Orif. deep red _
                         Orifice healthy.  Orif. reddish, and granulated'
 Aqueous  discharge,.....7        3         1
 Albuminous transp. discharge, . . 30         6         6
 Album, semi-transp.  discharge,
   streaked blue, grey or yellow, . 13       19        10
 Opaque discharge, streaked,  . .  3         7         6
                            53       35        23

    Doubtless where there  is pregnancy with a sealed
 os, the  leucorrhcea, however severe, must be vaginal. 
262
LEUCORRHCEA.
  From  leucorrhcea, the  consequence of structural
or malignant disease, the diagnosis will be made by
the accompanying  symptoms, and  by examination
of the vagina and  rectum, not  only by the  finger,
but by the speculum.
  From  inflammation of  the glands  in the interior
of the cervix; by the presence of the white creamy
discharge ; and  by  the peculiar tenderness  of the
cervix on  pressure, the adjacent parts being quite
sound.
  From  fluids,  which  very rarely  find  an outlet
through the vagina, after the bursting of an abscess
or cyst in the ovary, uterus^ or surrounding organs ;
by previous indications, such as local pain, swelling,
&c, which do not occur in leucorrhcea; by the sud-
denness of the  escape, and  often  by some marked
quality of the discharge,  as its  offensive odor and
its color, being often mixed  with blood, and its  ex-
treme viscidity or acrimonious tenuity.
  From gonorrhoea  the distinction is often difficult,
and  in some instances  impossible.   The character
of the individuals, and particularly of the husband,
and the previous and present habits of both, if they
be highly moral, will  go  far to  negative suspicion.
Even in doubtful cases, it must be remembered that
leucorrhcea is sometimes  purulent, and so far infec-
tious, as to produce from the male urethra a discharge
which, in its appearance  and  accompanying symp-
toms, is  not easily distinguished  from gonorrhoea.
Generally the secretion in  the male is mild, and there
is but little of that excitement, heat, and ardor urinae 
LEUCORRHtEA.
263
so constantly attendant on the real infectious gonor-
rhoea.   It is said, too, that  it is quickly cured, and
that it is rarely or never succeeded by gleet.  These
observations are  in the main correct, but still they
require some  qualification.  Where  by the specu-
lum, erosions  or  chancrous sores can be perceived
on  the os  and  cervix, the  syphilitic character  will
be  established.   If,  also, there be  tumefaction of
the inguinal glands, pain during coition, and  a dis-
charge from the urethra, with a burning pain along
its  course, and tenderness  and inflammation at its
orifice, gonorrhoea   is  probably present.  Lisfranc
says,  " that it is very difficult  to ascertain whether
these  white discharges are or are not contagious,
whether they are  or  are not venereal.   He  thinks
that a white discharge may communicate the vene-
real  disease,  especially  when the  former  is  con-
nected with small ulcerations of the  vagina or  ure-
thra, a case more common  than is usually thought,
but which may be  ascertained  by examining with  a
glass  those parts,  the  slightest erosions of which
easily escape  the naked eye."   (Vide Lectures pub-
lished in  the Lancet, Nov. 30, 1833.)  I presume
this  singular  statement is  not intended  to convey
the idea, that the venereal disease can be communi-
cated by common and unspecific ulcerations, merely
because they happen to exist  on the cervix uteri;
and  still, if less than this is  meant, there  is  little
if any point in the passage ; because the statement
is a mere truism, that syphilitic erosions or chancres
can produce the  syphilitic disease.  The perplexity, 
264
LEI C0RRHCEA.
therefore, of  these  cases, is fully admitted ;  and it
will often happen, that  where we are most  anxious
to arrive at a positive conclusion, we shall be least
able to do so.   At all  events, it behoves the practi-
tioner  to  be extremely tenacious of the  reputation
and happiness of parties thus circumstanced.   It is
always  his  duty to  cure  the disease, but rarely to
venture upon an exposition of its nature.  If he can
positively affirm that it is of simple origin, let  him
do so, if suspicion  has been aroused ;  if not, it is
better  to avoid any distinct allusion to the matter.
One thing is quite true, that  in  women of indispu-
table  purity, leucorrhoea is sometimes  so acrimoni-
ous, as  not  infrequently to produce discharge  and
abrasion in the husband ;  and on  one or two occa-
sions, after  abortion, I am almost confident,  that
eruptions and decided ulceration have been amongst
the results of intercourse.   In  these  examples  the
shadow of suspicion did not rest on the female.
   Prognosis or terminations of leucorrhcea.
   Acute leucorrhoea, if treated promptly, is usually
of short duration.   The  symptoms gradually sub-
side,  and the  tone  of the  parts  is  regained.   If,
therefore, there  is  a leucophlegmatic  habit, and  a
constant excess of moisture about the genital appa-
ratus, it is not improbable  that an  inflammatory at-
tack, under  such circumstances, may glide  into the
chronic form, and  may long continue.  Some fe-
males,  indeed,  except when  in  unusually good
health, seem never  to  be  fre.e from habitual  leucor-
rhcea; nor does  it appear seriously to affect them. 
LEUCORRHCEA.
265
But there  are  cases, where  the  discharge is  so
profuse and protracted,  that the same  results are
realized  as in excessive  menorrhagia.  There is a
quick  and  feeble pulse, a cadaverous countenance,
impaired  appetite, and emaciation.   If  the  patient
be married, (vide case,)  sterility is not an uncom-
mon  consequence;   and  if  single,  chlorosis  and
amenorrhcea,  and possibly dropsy or phthisis may
supervene.   I do not affirm these greater evils to be
the frequent sequel of the disease; but the practi-
tioner should be on  his  guard, more  particularly
where, in  the  unmarried, emaciation, amenorrhcea,
and  chlorosis  exist.   A  cough,  fever,  morning
perspiration,  and pulmonary  affection,  may soon
follow.
   Treatment.—-This must of necessity be different.
The  various forms of the malady differ so widely
from each other in degree, that while in the slighter
cases  scarcely any treatment  at all  is  required, in
the inveterate it is often most puzzling to find any
remedy.   Thus  the  mild  form easily yields,  the
inveterate is cured  with  great difficulty ;  and  the
symptomatic leucorrhoea  cannot be restrained till
the removal of  the  affection, if  that be possible, of
which  it forms a part.   But  to be more precise :
In ordinary cases, where  there is only  hyperseniia
or simple vascular  injection of  the  secretory mem-
brane, and where the discharge, although increased
in  quantity, still  retains  its transparent  mucous
character—rest, abstinence  from  intercourse, if
married, animal food  and wine, mild aperients, and
                34  •  • "■■ 
266
LEUCORRHCEA.
the employment, as a wash, of the Liq. Plumb. C,
or the Liq. Alumen.  C, or the  tepid  poppy water,
will usually, in the course of a few days or a week,
cure the disease.
   In the  inflammatory  form, which comparatively
we do not often see, where the secretion has become
purulent, wdiere  the  pulse is quick, full,  or hard;
where  there  is heat, increased  action, and inflam-
matory congestion of the secretory surfaces,  slight
swelling of the genitals, and  pains in the  loins and
hypogastric region, the antiphlogistic treatment  must
be at once commenced.   Blood  may be drawn  from
the arm in moderate  quantity, or from the  loins by
cupping.   Leeches to the hypogastrium, groins, or
perineum, must be promptly employed; and if, by a
vaginal  examination, the  cervix  shall  be found
swollen, shining,  red, and tender, leeches, or  what
are much better, scarifications, may be  used.  I
have now several times scarified, not punctured the
neck of the uterus by a common lancet, mounted on
a  piece of whalebone, with  marked benefit.   The
pain of  the  incision  is  most trifling ;  there  is no
ulceration nor suffering  afterwards, and  in twenty-
four hours, the cervix generally seems to be entirely
free from congestion.   In the  winter of  1839,  I
was asked by the late Mr. Fenner to visit a patient
of his at  Islington, suffering  from  inflammatory
leucorrhoea.   She had not been confined more than
two months;  her  own  reputation, and  that of her
husband, were above all  suspicion ; the severity of
the  pain in  micturition, and  the  profusion  and 
LEUCORRHCEA.
267
acrimony of  the discharge, would  have induced the
belief that it was  gonorrhoea.  An examination by
the speculum showed that the cervix was congested,
red, and extremely tender; but there was no dis-
charge  from  the urethra,  nor any swelling of the
inguinal glands ; aided by the speculum tube, the
cervix was scarified, and at least four or five ounces
of blood were  abstracted, the operation not  lasting
more than a  quarter of an hour.   The hip-bath,  as
advised  at page 165,  mild   aperients, spare diet,
salines,  and occasionally narcotics, will  be required.
Astringents are not included in  this  enumeration,
and if they are  used during the first few days of the
disease, while the  inflammatory stage continues,  or
before the  discharge has become thinner  and more
abundant, pain  and aggravation of  symptoms will
often ensue.  I  know there  are cases  easily cured
by the compound alum  injection, or some spirituous
lotion only.   In such, the affection  is probably the
common and  mild, not the inflammatory leucorrhcea;
or if it  be, and a cure is obtained, the patient and
the practitioner will not censure this empirical plan,
nor trouble themselves  about  the  precise nature of
the affection.   If there be swelling  of  the labia,  or
of the  parts  within, redness,  heat, tenderness, and
throbbing, and pain on examination, with a purulent
discharge, there is  inflammation, and the soothing,
not the astringent  plan  ought first  to  be  tried.
These acute  symptoms, however, soon  subside, but
the excessive discharge continues; and at this point
the use of injections,  regarded  by many  as the 
268
LEUCORRHCEA.
 specific  treatment for leucorrhcea,  must  be com-
 menced.  For  this  purpose the  various stimulants
 and astringents are employed, and often by  sponging
 the parts externally, and  within  the genital fissure,
 but more frequently by  throwing into the vagina,
 several times daily, two or three  ounces, (following
 the directions  given  at  page 209), aided  by sto-
 machics  or tonics, mild  aperients  and  rest, this
 unpleasant affection is cured.   Generally the  injec-
 tions  are cold,  but  occasionally the  discharge  is
 increased,  and  the   inflammatory   symptoms  are
 reproduced  by  cold  in any form.   I  have known
 many patients  cured  by tepid, and two by almost
 hot injections.   Dr.  Gooch  (at page 35 of  his
 Compendium) says, " that the treatment of leucor-
rhcea is  to a great extent empirical.   Cold astrin-
gents, among the rational practitioners, are in the
 most  general use; but tepid ones are often equally
beneficial.   Practitioners  have   exhausted  all  the
 cold astringent  remedies, and then, having recourse
to tepid  ones, the patient  has  been cured immedi-
 ately.   The liquor  plumb, acetat. is now used  at
 the Middlesex   Hospital, tepid,  and with  general
 success."  The various formulae  will  be hereafter
 mentioned.  In this way  examples of the inflam-
 matory form are cured; but thus  far it is presumed,
that they are not very  severe, nor that there is any-
 thing to prevent the  beneficial  operation of  medi-
cines, either in the  constitution or  in the  habits of
 the patient.  But we do not always possess these
advantages.  Sometimes,  where the  best  means 
LEUCORRHCEA.
269
have  been  long  and  judiciously  employed, the
leucorrhoea  continues, and the health  declines.   If
the discharge be only small in quantity, and if the
patient has  been originally robust, months and even
years may elapse without any serious results ; but
they come at  last.   I  have often wondered to find
the pallor, anemia, and other indications of  debility,
so extreme, where the  discharge was scarcely more
than by drops, although it had been  more excessive.
These examples remind us of passive menorrhagia,
where there  is  a  continual  sanguineous  draining
from the  uterus, attended by a cadaverous  counte-
nance, weak pulse, coldness of the extremities, and
excessive nervousness.   Indeed, these cases are not
only similar in their nature, but they  are almost
invariably benefited, and  sometimes cured, by one
peculiar  remedy, viz. the injection  of three or four
ounces of tepid, or  (after a time) cold  water, into
the  rectum, night   and  morning.   Sometimes  the
effects of chronic leucorrhoea  are so distressing, the
discharge so excessive, and the cure  apparently so
distant, that not only the patient,  but  the practi-
tioner also,  inquires, what further treatment can  be
adopted, and on what circumstances does this want
of benefit  depend ?   In some instances, there is  no
doubt, that the  delay  arises  from  the  difficulty of
restoring to the  secretory membranes their healthy
action.   Mr.  Hunter fixed  attention on this  point,
by the following remark, that  " a  gleet  seems to
take its rise from a habit  of action which the parts
have contracted; and as they have no disposition to 
270               LEUCORRHCEA.
 lay  aside  this action, it  is, of course,  continued."
 Thus a vaginal  discharge may be perpetuated  by a
 " habit of action," most  difficult to alter, but at the
 same time, satisfactorily explaining the pathology of
 passive or habitual  leucorrhcea.   Protraction  may
 also depend  on specific or organic disease, such  as
 gonorrhoea, hard  or  submucous  tumors,  ulcerated
 carcinoma,  polypi,   cauliflower   excrescence,  &c.
 The  reply, then,  to the  question,  what  further
 treatment  is to  be employed ? will depend on the
 results of examination by the finger or speculum, as
 these will  furnish the  best  answer to the  inquiry,
 what is it that prevents the cure ?   If the existence
 of structural maladies  be discovered, the attention
 will  be directed  to these as the source of the local
 symptoms, for leucorrhcea is then  only symptomatic
 of these graver diseases.  But if, so far as can be
 ascertained, the  individual is free  from any specific
 or organic affection,  recourse must then  be  had
 either  to fresh  remedies,  or  the  treatment already
 adopted must be differently and more  perseveringly
pursued.  English  practitioners do not frequently
examine per vaginam in leucorrhoea ;  and although
 in the  majority of  cases  such an  inquiry may  be
 dispensed with, in  dubious  instances it is certainly
requisite.   So long as the  discharge  is muciform,
even if  it be  excessive, without smell  and not san-
 guineous, it may be presumed to be functional ;  but
 where, having long retained these  properties,  it has
 become  acrimonious  and  offensive,  watery   and
 greenish,  or brown like  the  grounds of coffee, or 
LEUCORRHCEA.
271
decidedly streaked and mingled with  blood, there is
strong reason for a different opinion, and an exami-
nation is absolutely essential.   Injections of green
tea,  solutions of alum,  the sulphates  of zinc and
copper, iodine, sulphate or tartrate of iron, and the
carbonates of soda and ammonia, decoctions of bark,
logwood, the ergot  and catechu, and  others  (vide
formulae),  may all  be employed.  Nor must  it be
forgotten that each of these, good though it be, soon
loses its effect.  I have cured many cases of passive
leucorrhoea more  quickly  than  1 should otherwise
have done, by acting on this  suggestion : a  week
being often long enough to wear out the good effects
of one injection.   In the  employment of measures
acting  thus  locally  on the  secretory  organs, the
intention is to convert a morbid  into a  healthy
function, and of course constitutional   means, such
as good  air and diet, iron, quinine and chalybeate
waters,  with a regulated   system of aperients, are
not  to be excluded.   Both  classes of agents may be
in operation at the same time, without  determining,
what  is often difficult  to decide,  whether the
leucorrhoea  be  a  primary or  secondary  affection;
whether, in fact, it  has arisen from constitutional
delicacy, or  whether the constitutional  weakness is
the  sequel of the local disease.  Where the dis-
charge is habitual and inveterate, and  where, with-
out  disorganization  of  structure, the secreting sur-
faces have taken on a permanently unhealthy and
disordered action, the nitrate of silver surpasses all
other remedies in it's restorative  power.   Its benefi- 
272
LEUCORRHCEA.
cial influence has  been fully tested in affections of
the mucous tissues of the mouth and throat, and a
similar good effect will accrue from its use in chronic
and  inveterate  leucorrhoea.   Its  exhibition will  be
explained hereafter, (vide formulae.)   To Dr. Jewel
the profession  is indebted  for a succinct and com-
prehensive account of  its properties.   Through the
medium of the great sympathetic  nerve, and by con-
tinuity,  the  reproductive or sexual are  intimately
connected with the urinary organs, and hence have
been  suggested  copaiba, turpentine,  cubebs,  can-
tharides, and  the  tinct.  benzoin, comp.  (vide for-
mulae), for the treatment of  the chronic and invete-
rate  form.   Turpentine and  cantharides  I  have
given, often advantageously, and a good many times
with curative effect.  The latter is the great remedy
of Dr. Dewees; and, beginning with thirty drops in
sugared  water,  three times  daily,  he   does  not
hesitate  to mount up  to a  dose of  two hundred,
three times in the  twenty-four hours.  He is care-
ful, if there be  plethora, that  it shall be removed
prior to giving the tincture.
   " We cause the  patient,"  he informs us, " to be
well purged;  confine her to a milk  and vegetable
diet, and  sometimes order her to lose blood ;  when
the pulse  is sufficiently reduced by these means, or
if  the  pulse be in a proper condition  without them,
we  commence  the  cantharides, &c."    It  need
scarcely be added, by way of caution, that if stran-
gury appear, the tincture is to be left off.   " Should
the complaint withstand  the  first strangury, we are 
LEUCORRHOEA.
273
not discouraged, but re-commence the remedy at the
original dose of thirty drops, and  increase it as be-
fore until a difficulty in making water  is again ex-
perienced ; it rarely, however, withstands the second
irritation of the bladder."  In  hospital, and in pri-
vate practice,  I have secured these conditions ; but
I cannot report, as its  author  does, " that when
properly conducted, or sufficiently persevered  in, it
rarely fails to  effect a cure."   Still, my confidence
in this practitioner  is so great, that I  am anxious his
remedy should be extensively tried :—in other hands
it may be more successful than in  mine.
  Attention to the  general health cannot be neglect-
ed without detriment to the patient.   Lately I saw
a case  where the  discharge,  which had been  for
weeks excessive, was  restrained by  giving  five or
six doses of blue  pill, followed by  an aperient of
senna  and  salts;  the first  motions  were highly
offensive and   scybalous ;  afterwards they became
healthy, and with no other treatment than ablution,
and a removal into pure, dry, and mild air, and the
adoption of good diet and exercise, by which the
function of the skin was restored, the cure was com-
pleted.
  If the reader will  turn  to page 43 of  this work,
he will  find in that  and the succeeding  pages, direc-
tions relative  to the health of  anemiated patients,
which may be advantageously  followed  in  chronic
leucorrhcea.   It is  scarcely necessary to state,  that
menstrual irregularity is one of  the  frequent conse-
quences of the disease when protracted.   Leucor-
               35 
274
LEUCORRHCEA.
 rhcea may, indeed, become vicarious of menstruation
 altogether (vide page 144) ;  and certainly, although
 amenorrhoea induces leucorrhoea,  the converse  of
 this position is equally true.   Whenever, then, the
 general health  is  so far impaired by excessive dis-
 charge, as seriously to  have  deranged the  catame-
 nial function, constitutional as well  as local treat-
 ment must  be  pursued.  A  sea voyage, travelling
 abroad, the air of  the sea-coast, foreign and domes-
 tic chalybeate spas and iron,  constant exercise out
 of door, living in fact in the open air, are the meas-
 ures on which  we must principally rely.  The use
 of wine and spirituous liquors, strong tea and coffee,
 is recommended in habitual  or passive leucorrhcea.
 Doubtless such advice requires strict limitation, but
 still in certain  districts, and controlled  by medical
 authority, it is beneficial.  I recollect many years
 ago an old practitioner  in  the fenny and  damp part
 of  Lincolnshire,  who  said that  the disease was
 almost endemic in  his  neighborhood during certain
 parts of the year,  and  that he combated, and often
 cured it, by bark,  wine,  gin,  tea  and coffee.   In
 Belgium and  Holland,  and  round  Berlin,  the at-
 mosphere  is loaded with moisture, and it is common
 to attempt the cure of leucorrhoea,  which is  very
prevalent,  by  spirituous liquors,  tea,  and  flannel
 clothing.   Solid animal food  may be eaten twice in
the day, and if the digestive powers are  much im-
paired,  hot water, with a third or fourth  part of
brandy or  rum, may be  the dinner beverage.   But,
after what has been  said at page 43, 1  need only 
LEUCORRHCEA.              275
refer to the directions  there given.  A patient, suf-
fering  from  habitual leucorrhcea,  without organic
disease, should not sleep on a soft bed, nor frequent
heated rooms and crowded assemblies.  The excite-
ment of music, the theatre, and  late  hours, should
be exchanged for country air and exercise, moderate
riding  on  horseback,  and the simpler  habits and
scenes of rural life.   In  these cases,  almost every-
thing depends  on the improvement of the general
health,  and  this  cannot  be  accomplished  without
attention to  the  chylopoietic  organs.   Let healthy
digestion be restored, and  the leucorrhcea will gra-
dually  disappear.  It is  not always safe to cure  an
inveterate leucorrhea, without increasing for a time
the action of the liver and the intestines, or putting
the patient on a spare diet.  This is particularly im-
portant where  the discharge  first appeared on the
suppression of some customary  evacuation, as,  for
example, where  menstruation has become sparing
after  previous excess, or where  an eruption having
long existed, has at  once  or  gradually disappeared.
In  these  instances, some moderate  drain  is often
necessary.   Without it  plethora,  and its injurious
consequences, may occur.   An issue or seton ought
occasionally  to precede any  curative attempt.   In
the young  and middle-aged, spare diet, purging, and
exercise will mostly  suffice ; but in  women of full
habit,  addicted to the pleasures of the  table,  this
more decided  drain is often required.  At a more
advanced age, when  congestions in  the  different
organs  are probable,  and  where  the patients  are 
276
LEUCORRHCEA.
strumous and  feeble, peculiar watchfulness is requi-
site.  After the cure of habitual  leucorrhoea, ablu-
tions of cold water, at least, if not  injections  into
the vagina, should be daily practised ; avoiding their
use for a few days  before  and subsequent  to men-
struation.
   In Dr. Balbirnie's digest of the practice in  Female
Diseases, of several  eminent French physicians—a
book deserving  attentive  perusal,  the  fears I have
expressed of injecting the uterine cavity are said to
be, in the great majority of cases,  " totally unfound-
ed, and the mere  remnant of ancient prejudice."
M. Lisfranc first  injects  simply  fresh  water,  then
decoctions,  or astringent  injections or styptics, the
strength of  which is to be increased  by the addition
of a  few drops of concentrated  acid.  " A  gum-
elastic tube, introduced with circumspection, serves
as a means for conducting  the injected fluid,  and
we are thus enabled to cure white discharges which
obstinately  resist   every  other  method."—(Vide
Lectures in the Lancet,  Nov. 30, 1833.)   I  shall
append to this  chapter one or two cases, occurring
in the  practice of  M. Tealier, where injections of
soot and  water into the uterine cavity  were produc-
tive of benefit,  without  pain   or  any  apparent
evidences of hysteritis.  It is right  thus to contrast
the contradictory   results  of a  similar treatment.
Further  experiments,  which these  examples of
success may justify, may establish a correct deduc-
tion.   In the  French hospital cases, reported  by
Dr. Balbimie,  " narcotic injections"  were ordered 
LEUCORRHCEA.
277
by the  physician ;  and as immediately  afterwards
especial mention is made of " uterine injections" in
the private cases of M. Tealier, it is fair to  infer,
that the narcotic  injections referred  to above, were
merely  vaginal,  thus   establishing  the  fact,  that
throwing fluids into the cavity of the womb is by no
means a general  but a rare treatment.  Further on,
indeed, M. Lisfranc  says,  " that  sometimes these
uterine injections stop  the discharge suddenly, as in
the male,  or  they act more  slowly,  in  general
requiring  twenty  or  twenty-five days.   On  other
occasions " (and these, I fancy, are not infrequent)
" they convert the chronic  inflammation into  an
acute one," (an  event  replete  with  danger, where
the uterine mucous surface is its seat,) " hence the
treatment  must be modified to the case,  and usually
twenty-five to  thirty days are sufficient for a perfect
cure."  "  As  exceptions,  there are two cases in
which we should  proceed with more reserve, viz.,
when these  discharges  are  very  ancient,"   (the
examples  in which, by-the-bye in  England, such a
remedy is  generally thought of,) " then they become
habitual and  necessary to the  economy  : and  it is
frequently impossible to supply their place,"  (this is
a wise and extensive  interdiction of  uterine  injec-
tions) " and imprudent to attempt it—more espe-
cially if the woman be old, feeble, or have any ten-
dency  to  scrofula.   Intermittent  discharges  also
require the  same  precaution, with respect to their
 suppression, as uterine flooding."
   Inflammation of the cervix uteri.—As this affec- 
278
LEUCORRHCEA.
  tion is confined to the glandular part of the uterus,
  and as it  is attended by a peculiar discharge which
  rarely forms a part of the common leucorrhoeal secre-
  tion,  it is  entitled to  distinct consideration.  It is
  not always easy to distinguish it from inflammation
  of the surrounding parts, particularly when, having
  ceased to be  an acute, it has become a chronic mal-
  ady:  Here the white opaque secretion, its distinc-
  tive sign, will be  partially,  if not entirely, lost,  by
 its mixture with the thinner and more transparent
 secretions.   In addition also, the local pain and ten-
 derness on pressure, will  be  so  much  less than in
 the inflammatory stage, that the peculiar characters
 of the malady will be nearly destroyed.   In recent
 and marked cases,  its diagnosis is easy.  Sir Charles
 Clarke is entitled  to the praise of  having first de-
 scribed the symptoms and treatment.  Judging from
 the record of  cases amongst the in and out-patients
 at Guy's, as well as from private  practice,  I cannot
 regard  it as a very common disease.  Many times,
 from the pain which patients in the ward have com-
 plained of low down about the sacrum and coccyx,
 and deeply seated behind  the pubis, I have thought
 that there must have been  inflammation of  the cer-
 vix, and yet on examination, although the finger has
 been covered  by a white secretion, there has  been
 no acute suffering from  pressure on the neck of the
uterus.   Out of nearly one thousand cases of sexual
disease, treated at Guy's, I find inflammation of the
os and cervix has happened only twenty times.  It
rarely  occurs in single  females, or before  twenty, 
LEUCORRHCEA.              279
and is most common between this age and the period
of catamenial decline.   It is not dependent on pecu-
liarity of constitution—the plethoric and robust being
as frequently its subjects, as the delicate and irritable.
I have several times observed it soon after marriage.
Its pathognomic symptoms are the opaque white dis-
charge and pains behind the pubis, and at the lowest
part of the back and sacrum, aggravated by the muscu-
lar efforts necessary for the  evacuation of the bow-
els and the bladder ; in short, by any circumstance
which causes  pressure centrally in  the pelvis.  The
constitution is rarely affected, if judicious treatment
has been early adopted.   Where,  however, there
has been protracted  neglect, it will probably have
passed  into a chronic state, and, in connection with
inveterate  leucorrhcea, may have induced  excessive
anemia.  These symptoms—and,  if married, pain
during intercourse—first excite attention ; their con-
tinuance, and,  as  concomitants, irritability of the
bladder and rectum,  constitute  the disease.  Gene-
rally  menstruation is  not  deranged ; occasionally,
however, there is  dysmenorrhoea  or a scanty cata-
 menial flow.    Sometimes  recovery  takes place
 without any  treatment;  the symptoms  gradually
 disappear, and the glandular structure again becomes
 sound.  At other  times the  malady continues, not-
 withstanding  the treatment;  and some authors sup-
 pose,  that  from this  chronic inflammatory action,
 tubercular deposit  and cancerous  disease  may have
 their  origin;  but such serious  results,  probably,
 never occur, except where there  is  a latent tendency 
280
LEUCORRHCEA.
to structural and  malignant disease.   In that case it
is easy to understand  how  repeated inflammation
may induce morbid activity.
   Causes.—Circumstances either of a constitutional,
or local  kind, which augment  irritability, and pro-
duce  in  the  cervix increased  action.   Cold,  inor-
dinate exertion,  either  physical,  sexual,  or mental,
highly-seasoned  food, late hours, and  excitement,
and amenorrhoea  suddenly induced.
   Diagnosis.—The local  pain  (pressure on the cer-
vix producing it, while similar pressure on the im-
mediately contiguous vagina,  is borne without any
suffering),  and the white opaque discharge, enable
the practitioner  to  form  a correct  opinion of the
disease.   In  reference to the latter I may add, that
it differs widely from the transparent colorless mucus
of common leucorrhcea, and is not likely to be con-
founded with the watery,  or purulent  secretions, so
frequently occurring in mixed and  symptomatic cases.
   Sir  Charles  Clarke  characterizes the discharge
" as opaque, and  perfectly  white."   This  is  its
usual  color, but in undeniable examples I have seen
it of grey tint.  He further says,  " that it resembles,
in consistence, a mixture of starch and water made
without  heat, or  thin cream.  It is easily washed
from the finger after an examination ;  and it is capa-
ble of being diffused through water, rendering  it
turbid."   Of the  latter part of the statement  there
can be no  doubt,  and  the facility of mixture with
water,  certainly  constitutes   a   ready  and  true
diagnosis.  Let  it,  however,  be remembered, that 
LEUCORRHCEA.
281
 this creamy  discharge is rarely  copious  and free
 from admixture, except on rising  from bed  in  the
 morning, the  time which ought to be chosen for the
 vaginal examination.
   Treatment.—The  abstraction of  blood,  in  the
 more  serious attacks, is a primary measure.  And
 as the best methods of doing this  are  pointed  out
 at  page  167, the reader must refer to  this part
 of  the work, where  he  will  also find  directions
 for the  bath  and injections, which may  be bene-
 ficially followed  where the inflammation  is  not  so
 severe as to require the loss of  blood.  The poppy
 hip-bath used for an hour, twice a  day, soothes the
 pain and  irritation better  than  any other  remedy;
 and where this cannot be obtained, half  a  pint of
 warm  water,  or  gruel, starch water, or poppy tea,
 may be thrown into the  vagina  several times daily
 —the  prescribed precautions being taken to prevent
 its  immediate return.  As aperients,  castor oil, or
 any of the mild forms prescribed in chapter  5, may
 be employed.   Sometimes there is  so much irrita-
 tion about the bladder, that an opiate, or ten drops,
 two or  three times  daily, of  the  mist,  morphiae
 acetatis (vide  page 186,) may be administered, or an
 opium, or  a  belladonna  suppository may  be used.
 It is occasionally necessary to empty the bladder by
the catheter;   and  rest  in the  recumbent position
and spare and unirritating diet must be adopted.
36 
282
LEUCORRHCEA.
                       Case 34.

   It is unnecessary to  narrate any cases of common
leucorrhcea,  either  of  the  mild   or  acute  kind,  as
these are so numerous  as to be familiar to all.

                INVETERATE  LEUCORRHffiA.

  July  \0th, 1835.—Mrs. J.-----, aged  26, residing near
Guy's Hospital, has  been married six  years, and  has borne
three children.   Prior to her first confinement—immediately,
indeed, after  marriage—she had  leucorrhcea; but as it was
attributed to the excitement of pregnancy, and ceased soon
after  delivery, no treatment was adopted.  During both the
subsequent pregnancies the  discharge  returned, and  disap-
peared after recovery.   She imputes the present attack  to
over-nursing,  having  suckled  her last  infant nearly sixteen
months.  The weaning occurred in January,  1834, and since
this time, now a  year  and a  half, she  has  never been free
from excessive  discharge.   Prior  to the lengthened nursing
she was remarkably healthy, " en bon point," and active; but
for the last nine  months  her weakness has been extreme.
She  is aneiniated and pallid, emaciated, and incapable of any
exertion.  She has lost her former animation, and  sits or lies
nearly the whole day  on  the sofa.  Pulse  94, and  feeble,
skin  cool  and clammy ;  urine scanty, and of straw color;
appetite most capricious, and frequent  vomiting after  taking
food.  Sleeps well at night, and would  do so nearly all day,
if she were not frequently roused by her mother and children.
Cough, pain in the side, and morning perspiration are absent,
and none of  her family have died  of phthisis.  The legs are
oedematous, and the skin of the  face and eyelids is extended
and  flabby.   On the whole, there is  more exhaustion, more 
LEUCORRHCEA.
283
complete prostration, than  I  have ever before witnessed as
the consequence of leucorrhcea.   On inquiry about the treat-
ment,  I  found that many  remedies  had  been tried, and
although injections had  been carefully used she had frustrated
their  beneficial effects, by always  (day and night) wearing
two thick napkins.  Thus the  generative  organs were con-
stantly heated by the thickness of the covering, and increased
discharge was the result.   It was with difficulty she was per-
suaded  to use  any further means, she  was so  determinately
convinced that nothing could do her any  good.  She con-
sented,  however, to take the muriated  tincture of iron, good
diet, and  ale, to use nitrate of  silver  injection  three  times
daily, and, above all,  to leave off  the napkins.  The dis-
charge  was usually thin and watery ;  sometimes viscid, and
occasionally, for a few weeks together,  purulent.   It  had, on
several  occasions, been  streaked  with  blood;  but there had
never been any offensive odour.  She  had for many weeks
abstained from intercourse.   I   was curious to  ascertain its
quantity,  and as it was  quite necessary to use six napkins in
the twenty-four hours,  she  must, at least, have  lost several
ounces  daily.   It is not, therefore, at all surprising, after so
protracted a  drain, that her constitutional power was exceed-
ingly impaired.   Menstruation occurred every month, but so
scantily,  and so slightly sanguineous, that the leucorrhcea
might justly have been considered as vicarious of the function.
On examination, internally,  by  the  finger, the  vagina was
found to be capacious, and  so relaxed  that there were many
folds partially filling up its canal, and a thin secretion bathed
its entire surface.   The cervix was  large, but not tender,
the os patulous with thickened  edges, and  the whole of  the
parts exceedingly moist and  soft.  The body of the uterus,
examined by the rectum as well as by the vagina, appeared
more  voluminous than natural, and approached nearly to  the
os externum.  I could  not discover any ulceration, although 
284                 LEUCORRHCEA.
at the upper and posterior part of the vagina the surface was
rather rough, uneven and pulpy.
   It would  be tedious to narrate, day by  day, or even week
by week, the effects of the remedies.  The principal benefit
seemed to be  derived  from the various preparations of  iron,
and the frequent use of injections, particularly of the nitrate
of  silver.   These  had  been employed  by her  previous
attendant;  but as  he  had seen her only at distant  intervals,
their use was not steadily adhered to.  I was more fortunate,
as I visited her very frequently on my way to  Guy's, and
insisted, as  the condition of  my attendance, that the  treat-
ment  should be strictly pursued.   At one time we  were
compelled  to  give up  the injections for a few days, as they
produced  soreness, and she  was  tired  of  their use.  At
another,  the  iron  was  temporarily laid  aside, quinine  and
gentian, or  zinc and  hop, being substituted.  The local salt
shower-bath  over  the  abdomen and  hips  was extremely
beneficial, and she  expressed  great satisfaction on finding that
she was  gradually acquiring tone and strength from its  daily
use.   At first  it was employed tepid and subsequently  quite
cold; and she was rubbed  dry afterwards by towels impreg-
nated with  bay-salt.   The lower part of the body acquired
warmth by these frictions, and her whole appearance began
to improve.   The  injection was ultimately used, at 60 grains
of the nitrate to ixvi. of distilled water.   The napkins  were
entirely and most beneficially abandoned,—frequent  ablutions
and  clean  linen  being their substitutes.   In  chronic  and
inveterate leucorrhoea,  the wearing a protection of this kind,
and sometimes a pad, which  is still  worse, perpetuates the
disease.  And  now, in every case, I  am  particular  in my
inquiries on this point.  At the expiration of eight months
this patient had menstruated healthily three times, and she
had  regained  much  of her former  health.   She  visited
Brighton for several weeks, and in about twelve months from 
LEUCORRHCEA.                285
my first seeing  her, she had  perfectly recovered.  I hear
that she has since borne another child.

   This is an instructive, because it  is  not a  very
rare case of aggravated leucorrhoea.   Over-lactation
and  frequent  pregnancy are almost sure, sooner or
later, to  be succeeded by excessive mucous secretion.
Whether it  shall be  protracted to exhaustion, will
greatly depend on the attention and influence of the
practitioner.   If he regard  it  as a  matter of  little
moment, it will be allowed to persist, and eventually,
similar results to those pointed out, will occur ;  if,
on the contrary, he have  sufficient  weight to con-
vince  the   patient of her  situation and  its certain
consequences, if the discharge  continue, then  reme-
dies will be promptly and  efficaciously administered,
and  the  disease will be either cured or relieved.


                      Case 35.

  chronic leucorrhffia, attended by accumulations
                 of purulent fluid.

   August, 1835.—Mrs. ----, aet.  38, a  widow, and for-
merly  an out-patient  of  Guy's,  was sent to  me by Mr.
Morgan, one of the surgeons.  The history of the case is as
follows :  She has, up to the commencement of  the  disease
(nearly three years since), enjoyed  excellent  health.  As a
girl she was always vigorous, menstruated regularly, and was
capable of great exertion.  Subsequent to her marriage, in
her twenty-fourth year, she was robust and plethoric,  having
children  quickly, nursing  them  without difficulty, and  im-
proving in strength.  She  has now  (1835)  been  a  widow 
286
LEUCORRHCEA.
four years, and  for the last three, has suffered from leucor-
rhcea.   When first noticed, it  occurred a few  days  before
menstruation, and was not present again till the return of the
catamenia.  It  was  so slight,  that  no  means  were  used.
Subsequently, however, it continued throughout the month,
and  soon  became excessive and acrimonious.   Occasionally
it  has  been  purulent, often  muco-purulent,  and  slightly
odorous.  In July, 1834, the  discharge  began to  lessen in
quantity, and became thicker, to use  her own words,  " like
matter."  In a  few  days  more, the  leucorrhoea  seemed
entirely to have disappeared, but not satisfactorily, as  there
was  pain  and fulness about the  lower part of the belly, and
especially about the neck of the womb.   She  had  frequent
calls to  empty the  bladder, there was ardor urinae,  and feel-
ings  of  tension  and weight  within the  pelvic  cavity.   The
greater number of  these occurrences was entirely new; for,
although she  had frequently, when the  discharge was  puru-
lent, suffered from vaginal  irritation, heat, and  pain, yet the
symptoms just described were so different, that her  attention
was painfully excited.  The surgeon  then  in attendance gave
saline aperients, enjoined  rest  and  spare diet,  and recom-
mended the warm  hip-bath.  On one occasion, a few weeks
afterwards, when she was  getting out of bed,  she felt some-
thing suddenly give way within her, and there immediately
escaped from the vagina a quantity of offensive matter.  She
fainted,  but was quite relieved.  The  discharge continued
purulent for  a  week,  when  the usual  thin  and  mucuous
leucorrhcea  returned.   This  process   had  been  repeated
several times prior to my first visit, August  10, 1834.   She
was then  recovering from one of these escapes of  purulent
matter,  and  was  feeble and altogether ill.   Tonics,  good
diet, porter and wine were allowed ;  and in a few weeks the
secretion had again become muco-purulent, but more exces-
sive  than formerly.   At this  period  I  examined, but  there
was no  trace of  altered structure.   The  os was more than 
LEUCORRHCEA.
287
 usually patulous, and  the whole of the parts within reach of
 the finger were softened,  probably by the constant discharges.
 In a little more than three  months,  (Nov. 20, 1835.)  men-
 struation  having been suspended eight weeks, re-accumula-
 tion again took place, and on examination, I was struck with
 the increased bulk of the uterus.  The cervix was tender to
 the touch, and  the os was more closed than natural; still, at
 the lower, (whatever it might have been at the upper part of
 the channel of  the cervix,)  it was not completely occluded.
 There was, however, a firm, tense condition of the  neck, as
 well as of the body of the  womb, and the vagina was rather
 hot, although still moist and painful on pressure.   There was
 considerable  febrile excitement, and the patient  was in bed.
 A few days afterwards the gush occurred, and by measure, it
 was ascertained, that seven  ounces of fluid,  possessing all  the
 characters of  true pus, not  at all streaked  with  blood, had
 escaped.   Twice afterwards this series of morbid actions was
 gone through, and  on one occasion  I  was  present when  the
 matter escaped.  It amounted to half a pint, and  was cer-
 tainly  fetid.   Her  general   health  had improved,  and  the
 leucorrhcea in the intervals had slightly diminished.   Iron in
 various forms and  doses had been given, and once I pushed
 the  blue  pill  sufficiently far to  affect the  gums, gentle
 salivation  being  kept up  for several  weeks.  The nitrate of
 silver in solution had  appeared sometimes as though  it would
 entirely cure the affection, but the  discharge again and  fre-
 quently returned.   Under  these  circumstances,  I proposed
 the  injection  of the  uterus.   It  was  carefully done,  by
throwing  in some  portion of  an  ounce of  warm  water, with
three grains of the sulphate of zinc.  There were no imme-
diate effects ; but in  about  six  or  seven  hours, there was
agonizing  pain in the  uterine region and internally, tender-
ness on   pressure  nearly over  the whole  abdomen,  but
especially  at its lower part;  a quick, hard pulse ;  and in fact
all the  symptoms of  hysteritis.  The measures described at 
288
LEUCORRHCEA.
page 234 were pursued ;  but I was so fearful of an unfavora-
ble result,  that  fifteen  ounces  of blood were  abstracted,
calomel and colocynth purges, and subsequently a full opiate,
were  given.   After  these  measures  the  symptoms slowly
subsided, and  I  had the satisfaction to find, in two or three
weeks, that she  had  scarcely any  remnant of the  disease.
This apparent cure was  but of short duration.  The same
discharges again  returned, and  she left town  for the sea-side.
She resided there many  weeks, was considerably improved,
and married.   Pregnancy quickly occurred,  and when I  last
heard of her, she  had  not suffered  any return of this  dis-
tressing malady.


                        Case  36.

leucorrhcea, accompanied  with purulent discharge.

             REPORTED BV" DR. JOSEPH RIDGE.

   Marianne B----, aged 19, of florid complexion, ordinary
stature, and sanguineous temperament, was admitted in July,
1836,  into  Petersham Ward.   She had  been in service, and
had enjoyed good health, until eleven weeks since, when she
began  to complain of uneasiness in the hypogastric region,
with severe pain in the right groin, increased towards night.
This was  accompanied with a thick,  yellow, and very fetid
vaginal discharge, which has  continued up  to the  present
time.   The catamenia have  not been  arrested; and  they
appeared a fortnight  before admission.
   Her general  health  has suffered : she feels weak,  and
indisposed  to exertion.  There is a profuse purulent secretion,
which comes on at intervals, especially  after exertion.  On
getting out of  bed, or in  endeavoring to  evacuate the bladder
or rectum,  it passes per vaginam, by gushes, being preceded
by a  cessation for some  hours.  Occasionally, it  continues 
LEUCORRHCEA.
289
for two or three days together ;  and then ceases, until  its
accumulation is relieved  by a sudden flow.  She has lumbar
pain, and  occasionally  a  distressing  sense of  fulness and
bearing-down  in  the uterine  region.  Sometimes the pains
are severe and lancinating, extending to the pubes and groins:
bowels costive :  tongue slightly furred : pulse rather full, and
moderate.
   These  symptoms continued for several  weeks, with but
partial amelioration.  The  purulent secretion was, at  inter-
vals,  diminished;  but  soon  afterwards  recurred, in  equal
quantity.   She passed over two catamenial periods ;  and the
discharge appeared to be intimately mixed with  the sangui-
neous  flow.   Some shreds of membrane  were  discovered,
being preceded by  more than  usual pain.
   The  treatment  consisted  in the exhibition of laxatives,
with occasional  topical  bleeding, and  sedatives to allay con-
stitutional  irritation.  An opium suppository was  used, with
a belladonna plaster to the loins.   Injections of an astringent
kind, variously modified, with the hip-bath, were employed,
but with little advantage.
   The  obstinacy  of the disease, and the marked  debility
accompanying it, determined Dr. Ashwell to inject the cavity
of the uterus with tepid  water.  This was  effected by intro-
ducing a gum-elastic catheter with an open mouth, the edges
being smooth,  within the cervix, and propelling the fluid
through its tube.  Considerable pain over the pubes followed,
which was relieved by anodyne fomentations.  The discharge
greatly abated, and  a second injection was  ordered.   This
was  followed  by more  severe   symptoms,  and  marked
evidence of hysteritis; which  was  relieved  by bleeding, both
general  and local, purgatives, fomentations,  and  a  strict
antiphlogistic regimen.   The  discharge ceased with the cure
of the  hysteritis ;  and  in a few weeks she was  presented,
feeling quite well.
                 37 
290
LEUCORRHCEA.
   I was not prepared for so  alarming an attack of
inflammation, as  the  consequence of the injection
merely of warm water ;  although in several instan-
ces,  and  especially in the  somewhat  similar  one
already related,  hysteritis  of marked severity fol-
lowed the use of a weak solution of the sulphate of
zinc.   The remembrance of this induced me to em-
ploy tepid water only.  It is well known,  that in
extensive uterine hemorrhage, cold water, and water
variously medicated, may be safely employed.   But
in most of these cases, as already observed, there is
at least no evident and probably no real disease of
the lining membrane.
                     Case  37.

   This, and the following  case, are extracted from
Dr. Balbirnie's  work, page 129; and I present them
here to convey to  the reader an accurate idea  of the
way in  which  uterine injections  are  employed by
M. Tealier, and perhaps  in French practice  gene-
rally :  they are  described in the work of this physi-
cian on Cancer  of the Womb.

  Considerable tumefaction, without induration of the neck
of the womb—dilatation of its orifice—profuse leucorrhcea__
injections into the  cavity of the womb—cure.

  Madame  R----, aged thirty years, having had  two
children, of which the youngest is four years old, lively and
irritable, experienced since a  year that -she  had  quitted 
LEUCORRHCEA.
291
Geneva, her  native country, to  live in  Paris, all the symp-
toms of  uterine catarrh :  dull  pain in the hypogastrium, in
the loins, and in the groins,  where she experienced disagree-
able draggings when  she stood  for some time;  a weight on
the perinaeum, which  rendered long walks painful, and some-
times impossible—a continual and abundant  discharge from
the vagina  of a thick, yellowish  brown mucus, or of  a glairy
matter,  like  the white of  egg, on which were  remarked
sometimes  spots of blood.   Painful and habitual constipation
—loss of flesh—febrile pulse ; the menses having experienced
no  derangement.  To the touch the neck  appeared  soft  and
voluminous ;  and the uterine orifice, much dilated, admitted
easily the point of the index finger; all the surface of the os
tinea; was covered with a  thick mucus, which, when wiped
away, presented a greyish  white color, contrasting  with the
red tint of the uterine orifice ; slight lineary excoriations were
observed in the  direction of the cavity.   On pressure being
exercised with  the speculum on the body of the  womb, a
considerable  quantity of  thick  mucosities  issued  from  its
orifice—pressure with  the  finger and  the   speculum   was
painful—the  neck was an inch above the perinaeum.
  Bleeding from the  arm, to the extent of eight ounces,  was
practised;  and, during eight days, injections of the decoction
of the mallow-root, and poppy-heads, baths, a mild regimen,
and  rest, were  prescribed.   When  the  pains of the womb
were calmed, these emollients were replaced  by a decoction
of a handful of soot in a  pint of water, with  which, each
morning, three  or four injections were  made into the uterine
cavity, by  means of  a  gum-elastic  catheter,  introduced by
one of its ends  into the orifice.   These injections were  per-
formed  with facility, and without occasioning pain.  After
having withdrawn the catheter, a pledget of charpie,  imbibed
in the  same  decoction, was left upon the neck until next
day.
  This treatment was  continued  during fifteen days, after 
292                 LEUCORRHCEA.
which they were then stopped, in order to ascertain the state
of the discharge :  it had almost entirely ceased.   Injections,
nevertheless, were continued every two days during a month.
The patient then no longer experienced any of the symptoms
mentioned, and all treatment was suspended.   The health of
Madame R----has  not  been deranged  anew  for  a year
succeeding to this treatment.   She experiences some leucor-
rhoea from time to time, to which she  has been subject from
her infancy, and which does not constitute in  her a diseased
state.
                        Case 38.

   Soft  engorgement of the neck of the womb, bleeding on
the  slightest pressure—habitual leucorrhcea—orifice  of the
neck largely opened—superficial erosion on the posterior lip.
Infecundity, the consequence of this morbid state, removed
by its cure.

   Madame  L-----,  aged thirty, of good  constitution, and
having  had only one child, ten years  ago,  was tormented
with an habitual leucorrhcea, with a feeling of weight at the
womb, and some occasional  darting pains, which seemed to
pierce it.   Eighteen months ago, eight  days after the cessa-
tion  of  the menses, there commenced an oozing of  blood by
the  vagina, which was  very  inconvenient to the patient.
The discharge had continued  several months, when medical
aid was had recourse to, in the month of August, 1S34.
   This  lady had  been for some time the  prey of sadness,
from certain painful  circumstances, and under the  influence
of which  her indisposition had made sensible progress.   On
examination, the belly was found voluminous, and painful, on
pressure.  The pain was especially felt behind the  pubis, in
the groins and loins; it was  dull and  deep ;  at times it had 
LEUCORRHCEA.                293
the lancinating  character: the uterus was enlarged, sensible
beyond the vaginal  insertion, and descended  to within two
inches of  the os externum ;  the neck  to  the touch was soft
and spongy.  Seen by the speculum, and  compressed by the
instrument, it allowed to exude from all  its surface  a great
number of  drops of  blood;  the edges of  its orifice were
tumefied,  and of a lively red;  on  the  posterior lip there
existed a small ulceration,  somewhat  deep.   A yellowish
white  discharge, proceeding from the uterine cavity, impreg-
nated all  these  parts, and contributed to keep up  the soft
flaccid state of the tissus that was present.
   The patient being removed from the menstrual period, and
presenting all the appearances of a strong constitution, blood
was immediately drawn  from  the arm to the  extent of twelve
ounces.   This  bleeding, renewed three  days  after,  stopped
the discharge of blood ;  but the leucorrhosal  flux continued
in great abundance.   Injections with soot  water were carried,
as in the  last case, into the  uterine cavity ; they were con-
tinued during three  weeks,  at the  end of  which time the
leucorrhoeal discharge had almost entirely  ceased : the womb
was returned to its normal state.  During these three weeks
there had not appeared  a single drop of blood.   The menses
flowed then regularly ; and after their  cessation, the os tincae
was found firm, and  permitting  no  more the  exhalation of
blood; its  orifice was sensibly  contracted, and the leucorrhoeal
discharge  almost gone.

   M. Tealier has  informed us that  this lady,  who had been
barren from  this cause  for  nearly  ten  years,  immediately
afterwards became pregnant. 
294
LEUCORRHCEA.
                       Case 39.

 leucorrhcea, diagnosis  difficult  from  gonorrhcea.

occurring in the  practice of mr. tracy of cork street.

  May, 1840.—Mrs.----, aet. twenty-three, has been mar-
ried three years, and since  the birth of her first child, now
eighteen months ago, her health has always been  delicate,
and  six  months since  leucorrhcea  appeared.   She  visited
Cheltenham in February,  1840, and  after an absence  of
some weeks, during which her health was greatly improved,
she returned home.  The discharge was at this time watery
and thin, although  diminished  in quantity.  Intercourse was
resumed, and, as its consequence, the husband  had all the
symptoms of gonorrhoea.   In this case the reputation of both
parties was undoubted; but still the secretion from  the male
urethra continued for ten weeks, notwithstanding persevering
and active treatment.   Eventually he was cured by  steel and
a mixture of copaiba  mucilage and  liq.  potassae,  with the
oxymuriate injection. 
CHAPTER  VIII.
  OF THE DISORDERS ATTENDANT ON THE DECLINE OF
                  MENSTRUATION.

    It is impossible, within a reasonable space,  to
give a correct  definition  of  these important  affec-
tions ; although it is by no means difficult to furnish
in  detail an  accurate  and  condensed  account  of
them.  I shall therefore, after  a few  preliminary
observations, describe them in something  like the
order of their frequency,  beginning  with the more
common, and  concluding the  summary with  the
more dangerous deviations.   It has become too gen-
eral an  opinion, that the decline of this function
must be attended by  illness;  but this is surely  an
error ; for there are healthy women, who pass over
this time without any  inconvenience,  and  many
whose indisposition is  both  transient  and  slight.
That this does not more constantly happen, arises
from  the fact, that nature and health  are often sac-
rificed to  fashion and luxury.  I have already ex-
plained (at  page 42),  in  reference  to the physical
education of female j%uth, how  injuriously the na-
tional practices affect the  establishment of the func-
tion.   The almost entire  neglect of  out-of-door ex-
ercises and  sports, the substitution of prolonged in- 
 296        DECLINE  OF MENSTRUATION.

 door studies, by which both mind and body are pre-
 maturely exhausted; a  farinaceous  and vegetable,
 instead of an  easily digested  and  nutritious animal
 diet; clothing inappropriate  to  our changeable cli-
 mate; and  many other circumstances, too numerous
 to be recounted, are  productive of results  in  early
 life, conspicuously inauspicious  and hurtful.   Only
 let this  enumeration  be completed  by the subse-
 quent histories of  marriage and child-bearing, and
 we shall be convinced,  that  the  ills  attendant on
 catamenial decline, are attributable not to necessity,
 but mainly to habits,  unwisely begun, and still  more
 unwisely continued.
   Females themselves anticipate this period as ex-
 tremely  eventful,  denominating it  " the  critical or
 dodging time,"—" the turn of life,"  &c.  Nor can
 it be denied, that they often  have  sufficient reason
 for their anxiety.  With the  extinction  of this ex-
 traordinary secretion, the reproductive faculty dies—
 an event of itself of sufficient  magnitude in the life
 of a woman, to give to this  epoch  an emphatic in-
 terest.   The consequences may be injurious at any
 time of life, where even  a slight evacuation is  sud-
denly stopped ; for although it was originally exces-
sive and  morbid, such a  process eventually becomes
so habitual and necessary, that it  cannot be safely
done away,  without either preparatory antiphlogistic
treatment, or the institution §f some compensating
drain.   I have, in an appended  note, for which I
am indebted to Dr. Stroud, given  an extraordinary
analogous illustration occurring  in  the other   sex. 
DECLINE  OF  MENSTRUATION.        297
There  are few  practitioners  who could  not verify
the statement from their  own observation amongst
females.*
   We  cannot,  therefore,  be surprised,  especially
where luxury and  dissipation, or penury and  disease
have already injured the constitution, that  the cessa-
tion of two such prominent functions of the  female
economy,  as  menstruation and  reproduction, shall
be  sometimes accompanied  by  serious changes  in
the nervous,  vascular,  and  digestive systems.   Let
it  be  remembered, also, that these  are the distinc-
tive functions of the sex, exerting for many years a
marked influence over their health, and giving even
to their disorders  a peculiar character—not  lost till
after their final  decline.   And yet  it  must  not be
supposed,  that the effect of  these great changes is
always morbid.   Sometimes  it is  quite the reverse;
for there are women who  have never been vigorous
and well during the middle period of their lives, and
some who  have  suffered  from protracted  illness or

  * Case of Frederick P------. A young man subject to plethora,
and to large discharges of blood  from the nose every spring, having
for some time  labored under mental vexation and anxiety, missed,
during last spring (1840), his usual epistaxis.  He became somnolent,
morose, and dejected, and at length, after some bodily exertion, fell
into a sort of fainting  fit.  Under the direction of Mr. Symes of
Tavistock Square, he was largely bled, with apparent relief. Having
been placed in  bed, he lingered for some hours, with a  sense of
weight and oppression about the heart, which  gradually terminated
in  death.  On inspection of the body, about three pints of partially
coagulated blood were  found in the pericardial sac, having been
discharged from  a ruptured aperture  in the superior  cava, which
would admit the finger. With this exception* there was no other
disease, either in the heart or elsewhere.    "  .'
                38 
298        DECLINE  OF MENSTRUATION.

chronic uterine maladies, who after this time acquire
what they term,  " a settling of the constitution,"
and good health.
  If the affections accompanying catamenial decline
be classed  according to  their frequency, there can
probably be little if any doubt, that—
  Functional derangements of the brain and nervous
systeyn, are the most  numerous.
  Next in amount are the cases  of increased action
and  congestion of different organs.
  And, happily, among  the  least  common,  are
lesions of structure and malignant  disease.
  A  train of symptoms, fairly  to be denominated
nervous  or hysterical, so  often  accompanies  the
change, even when   most favorably  accomplished,
that  it excites  but  little attention, if some single
symptom  or the entire  affection  is  not of unusual
severity.   Timidity,  a dread  of serious disease,
irritability of temper, a disposition  to  seclusion,
impaired  appetite and broken sleep, with physical
weakness  and inquietude, are common indications.
Women are aware that such symptoms may be ex-
pected to  occur, and they are in consequence  alive
to their approach.  Of  course the  cessation  does
not always take place in the same way.   Occasion-
ally, but very rarely, it is sudden.  The  individual
having arrived  at the usual age, anticipated men-
struation  is prevented by «old, fright, or  by some
illness.  These circumstances, in earlier life, would
have been followed,  on their removal, by a return of
the discharge; but it is not so now.   Nature seizes 
DECLINE  OF MENSTRUATION.       299
this  opportunity to put  an  end  to  the  function
altogether, and  I  have known several  patients thus
dealt with, who  never had afterwards one  hour's
inconvenience.  But  a gradual extinction is much
more common.  One period being missed, there is
a return;  a longer time then  elapses,  and  there is
perhaps  an  excessive return ;  afterwards  some
months may  pass away  without any appearance,
then there is a sparing secretion ; and in this way
the  discharge, sometimes amounting  almost  to a
flooding, and  again  being so scanty and so slightly
sanguineous as scarcely to attract notice, altogether
disappears.  I have already, at page 214, mentioned
the different ages at which the cessation takes place;
and  as to the time occupied, it is nearly impossible
to afford  any precise information.  Some females
pass over  the period  in  a few  months, others are
irregular for a much longer time, and I have  known
instances  where several  years have intervened be-
tween the beginning and  completion of the change.
Hysteria,  of  marked  intensity, not   infrequently
exists, and in two patients formerly under  my  care,
a stranger, seeing the extent  of  mental  aberration,
might, without careful investigation, have concluded,
that they were really insane.  In  one  of these
instances,  a physician attending in  my  absence,
strongly  urged  restraint  and  removal.  Soothing,
temporising treatmentrhowever, must  be adopted in
these cases.   Irritability is their  prominent feature;
and  as the cessation  is  a  process of  nature,  it is
important  that  its  completion  should neither be 
300        DECLINE  OF MENSTRUATION.

hastened  nor  delayed by inappropriate  manage-
ment.
  The examples are not rare, where increased action
and  congestion  occur  as  the result  of catamenial
decline.  We do not expect to find delicate women
thus suffering, but those who  have  been  plethoric
and  healthy, who have indulged  in  good diet and
wine, or malt liquor, are exceedingly prone to such
affections.   Nor  must it be forgotten that the ten-
dency  often  continues for months, and sometimes
for   years  after  the  entire  disappearance of  the
secretion.  Every one at  all  observant of female
diseases, must know that  women  who have been
healthy prior to this  change, often  become  corpulent
after its completion, and are more than usually liable
to attacks of apoplexy, paralysis, pulmonary obstruc-
tion, and  cough.  Thus affording  an illustration of
the  remark, the correctness  of  which cannot  be
doubted, that while certain morbid conditions of the
cerebrum produce emaciation, there is another series,
amongst which  the  influences in  question must  be
placed, which induce repletion and obesity.  Head-
ache then, sensations of fulness about the cerebrum,
throbbings of the carotids, and visible  distension of
the superficial veins of the temples and neck,  ought
always to excite watchfulness if not apprehension.
Cases of  partial apoplexy and paralysis do occur as
the  result of  neglected amenorrhoea in earlier  life ;
and several times I have been struck with the relief
afforded to affections of the brain, at this period, by
an   excessive return  of the  catamenial  discharge.
Affections of the skin, too,  very difficult of cure, 
DECLINE  OF MENSTRUATION.        301
and  sometimes almost permanent, are by no means
rare.   Evanescent  eruptions  about  the  face  and
upper  part of the body are common.  But there is
scarcely  any organ  or  part  of  the  body, and  the
statement is  particularly true of the uterine system,
which may not suffer from acute or chronic inflam-
mation as the direct or remote consequence of this
great  change.   Hepatic  derangement,  and  even
disorganization, have been frequently attributed  to
this  cause.   I  cannot, from my own observation,
confirm the latter part of this statement, although I
have  known the  liver, in common with  the  other
chylopoietic  viscera, seriously disordered.
   A very few remarks will  suffice on the treatment
of these various sympathetic affections ;  and first, I
must be  allowed  to state, that no more serious mis-
take  can be committed, than to attribute any of
them, without  the most accurate  inquiry, to debility
rather than  to repletion.   Let  it  be remembered
that an accustomed  evacuation is about to cease, or
has finally disappeared ;  that the patients have been
previously healthy, and that the probability therefore
is, that the  weakness is apparent not real.  If, for
instance, because there is  languor and inactivity, a
slow  pulse,  torpid bowels, and depression of  mind,
stimulants and generous  diet  are  allowed,  some
important organ will become congested—the  brain
or the lungs—and either suddenly fatal or structural
disease  may occur.  I  know  not how often,  but
certainly very frequently, such errors happen;  and
it is,  therefore, the  more necessary to urge especial
caution. 
 302        DECLINE  OF MENSTRUATION.

   There  are instances  where  too large  bleedings
 have been  practised, and  where  the antiphlogistic
 treatment has been too long  pursued.   In  such, and
 in  others,  where  the active  symptoms have  been
 subdued,  or where from  the commencement the
 disease has been of  mixed character,  modified
 measures must be  adopted.   Further loss of blood
 and the continued exhibition of cathartics will in-
 duce anemia, and extreme irritability, while a sudden
 and injudicious alteration  of the treatment  may
 irretrievably injure some weakened organ or  part.
 Hence, it   will be  apparent that a  middle  and
 cautious course must  be chosen.   I have now under
 my care a  lady who  has ceased to  menstruate for
 three or four years, and  who, by the adoption of  a
 spare and vegetable diet, and the almost  daily use
 of purgatives throughout the whole  time,  has be-
 come gradually so  exhausted, irritable and neuralgic,
 that her life is a burden.   Many months of watchful
 treatment will  be required  ere she can return again
 to  animal  food, on which the restoration  of her
 health really depends.  More need not  be said on
 these important points.  Where symptoms of ple-
 thora continue—and  there are cases where on  even
 the poorest  diet patients will  fatten—purgatives or
 mild  aperients,  occasional small  general  or  local
 bleedings,  exercise,  and  abstinence  from  wine,
 spirits,  and  malt liquor, must be  strictly enjoined.
On setons and issues  great stress was formerly laid,
but they are not often necessary.   Where patients
cannot  be  induced to live appropriately,  but will 
           DECLINE OF  MENSTRUATION.       303

gratify the appetite, at whatever' risk, or where the
brain is  evidently the seat of  frequent  congestion,
and  serious symptoms are constantly  present, such
remedies are most  desirable.   Other measures of a
derivative kind will naturally suggest themselves, as
mustard  hip-baths,  and  pediluvia, frictions,  with
stimulating embrocations, and  the flesh brush, the
continuance of sexual intercourse, and  the encour-
agement,  by any gentle means, of the  catamenial
flow.
  At page 213, in the section  on congestive menor-
rhagia, the probability of pregnancy is mentioned.
Nor must it be forgotten that conception does occa-
sionally  occur  when the  process  of  catamenial
cessation  seems to be nearly complete.   The prac-
titioner will not, therefore, suppose, if the symptoms
of gestation arise, that they must of necessity be fal-
lacious.  I grant that spurious or mistaken pregnancy
is more likely;  and many men have exposed them-
selves to  ridicule by  erroneous   opinions on  this
difficult  matter.   More  than  this I need not say
here, as  in  the   " diagnosis  of  pregnancy  from
disease"  the distinguishing  marks  will  be fully
discussed.
   Lesions of structure   and   malignant disease.—
There is an almost universal impression that organic
maladies,  especially  of  the breast and uterus,  are
more likely to take  place at this than at  any other
time.   I  doubt whether  catamenial decline, as it is
a natural process, has  anything  to do with their
original  production; but I certainly think that the 
304       DECLINE OF  MENSTRUATION.
development of a latent tendency to disorganization
may accrue from the derangement, especially where
the uterus  becomes  congested, either as a  conse-
quence of  a superfluity of blood for which there is
no  adequate outlet, or  as the  result of a neglect of
its proper local abstraction.   Under such conditions,
I can easily understand that tubercular or cancerous
deposit, either in the uterine or mammary structures,
shall  receive a  stimulus of  growth,  which  may,
unchecked, lead to rapid development.
  It is  scarcely requisite to urge a frequent inquiry
as to the  state of  these organs ;  the breast may
easily,  if  any suspicion exist, be  examined;  and
although there  may  be  obstacles  in the way  of
vaginal investigations, they  will readily yield if the
necessity to the  patient's safety  be urged as their
justification. 
CHAPTER  IX.
             FORMULA OF  REMEDIES.

     The  following prescriptions are  selected  from
 many  which are generally used, and which I  have
 been long accustomed to employ in the diseases of
 menstruation,  characterized  by profusion or excess,
 and in leucorrhcea.
    [For the aperients and purgatives reference must
 be made to page  179.]

                STOMACHICS AND  TONICS.

   I shall add only two additional formulae :—

         Form.  46.—Mistura Tonka cum Acido.
                    Sir James Clark.
   R. Acid. Sulph. dil. 3iv.
      Syr. Aurant. §iss.
      Aquae Cinnamomi §j.  M. ft. Mist.

  Take one teaspoonful three times a day in  a wine-glass
full of water.  If it be advisable, a pill containing one or two
grains either of the sulphate of iron or quinine, with or with-
out a narcotic, may be given with  each dose.
                39 
306            FORMULAE  OF  REMEDIES.
            Form. 47.—Mist. Ferri Tartratis.

   R. Ferri Tartratis Ammoniat. 3j.
      Tinct. Aurant. |j.
      Tinct. Card. C. 3iv.
      Aquae destillatae gvjss.  M. ft. Mist.

  Take one tea, dessert, or tablespoonful three or four times
daily.

                SALINES  WITH PURGATIVES.

           Form. 48.—Mist. Salina cum Acido.
   R. Infus. Rosae C. §viij.
      Magnes. Sulph. 3iv. vel. 3viij.
      Pulv. Potassae Nitrat. B'i. vel. 9ii.
      Acid. Sulph. dil. 3ss. vel. 3j.
      Tinct. Digitalis 3iss.  M. ft. Mistura.

   Two tablespoonfuls three times daily.   If  it be necessary
to take  the following  pill frequently, the  menorrhagic  loss
being excessive, it should be  swallowed  half an hour or an
hour  before the mixture.  By this arrangement a considera-
ble quantity of the acetate of lead may be exhibited, without
the diminution of its  beneficial, and free from the risk of its
injurious properties.

                         Form. 49.

   R. Plumb. Acetatis gr. i. ad. ii. vel. iii.
       Micae Panis vel. Confect. Rosae Gallicae q. s.  Ft. pilula-

                       ASTRINGENTS.

            Form. 50.—Mistura Secalis Cornuiu

   R. Tinct. Secalis Cornut. 3iij.
       Pulv. Potass. Nitrat. 5j.
       Aquae Menth.  Pip. gvss.  M. ft. Mist. 
FORMULA  OF  REMEDIES.           307
   Take  one  tablespoonful,  one and  a half,  or  two table-
 spoonfuls, every two or three hours ; the dose being repeated
 more or less  frequently, according to  the  urgency  of  the
 .case.

                         Form. 51.
                         Dr. Dewees.
    R. Spir. JEther. Sulph. C.
       Tinct. Opii. aa gtt. xxx.
       Aquae Menth. Pip.  3vij.   M. ft. Haust.

   One draught to be taken every hour, (in cases of alarming
 ■menorrhagia or profuse menstruation) with the following pill:

    R. Pulv. Opii. gr. i.
       Plumb.  Acet. gr. ij.
       Cons. Rosae Gall. q. s.  Ft. pilula.


                         Form. 52.
                         Dr. Dewees.
    R. Infus. Rosae. C. |j.
       Elixir Vitrioli ^.xx.
       Magnes. Sulph. 3iss.  M. ft. Haust.

   One draught;  to be taken every six hours with  or without
 the lead.

            Form. 53.—Mist.  Terebinth. Comp.

   R. Spir. Terebinth. C. *i_xv,  xx, ad. xl.
       Mucil. Acaciae 3vij.
       Spir. Lavand. C. 3j.  M. ft. Haust.

   One draught every four, six, or eight hours.  I have given
this with  marked benefit  in  menorrhagia, where the loss is
not excessive,  but protracted, occurring in connection with
leucorrhcea ; a few drops of tincture of opium may be added. 
 308           FORMULA  OF  REMEDIES.


            Form. 54.—Mist. Copaibce  Comp.
   R.  Balsam. Copaibae gj.
       Mucil. Acaciae. §ij.
       Sp. Lavand. C. 3ij.
       Mist. Camph. §v.  M. ft. Mist.

   One or two tablespoonfuls to  be taken three or four times
 daily.   The efficacy of this mixture is increased, if it can be
 borne on the stomach, by the addition of one or two drachms
 of the powder of cubebs.  The tinctures  of cubebs, can-
 tharides, and capsicum, are frequently beneficial in protracted
 or dropping .menorrhagia;  and in chronic and inveterate
 leucorrhcea, fifteen or  twenty drops of each may be admin-
 istered three or four  times daily in water, or in an ounce of
 mucilage.  I have lately used the Extractum Haematoxyli,
 in doses of fifteen or twenty grains, three times a day ; con-
 tinued  for several weeks ; it must  be suspended  in water or
 mucilage, for if given in pills they become so  hard that they
 will pass through the body unchanged, and without effect.

   It is scarcely necessary to give the  more common
 astringent lotions and injections, although  I  do not
wish   it to  be inferred  from  the omission,  that  I
think  lightly of  their  efficacy.   The  compound
alum  wash, if well  used, is one of  the  most  valua-
ble remedies of the kind we possess ; but  there are
tedious  examples  of  leucorrhcea,  in  which   more
powerfully astringent and stimulant  means must be
employed.

            Form.  55.—Injectio Astringens.
   R.  Decoct. Secalis Cornut. gxiv.
      Argenti Nitrat. gr. xx.
      Tinct. Catechu gij.   M. ft. Injectio vaginalis. 
FORMULA  OF  REMEDIES.
309
  Four ounces to be used three times a day.   The decoction
of the secale is to be  prepared by boiling one ounce of the
bruised rye  in a pint and a half of water, down to a pint.

              Form.  56.—Injectio Astringens.
                       Dr. Copland.
   R.  Inf. Ouercus giv.  Pulv. Gallarum gr. xxx.
       Tinct. Catechu 3ij.   Ft. Injectio vaginalis.

  To be used once, twice, or three times daily.

              Form. 57.—Enema Astringens.
                       Dr. Mackintosh.
   R.  Plumb. Acetat. gr. xv, xx.
       Aquae purae giv.  Ft. Enema.
   To be  used by the rectum  once or twice daily.

            Form. 58.—Injectio Argenti Nitrat.

   R. Argenti Nitrat. gr. xv. ad. 3j.
       Aquae Rosae gxvj.  M. ft. Injectio vaginalis.

   Three  or four ounces to be used three or four times daily.
 In cases where an unhealthy condition of the vagina or cervix
 has  been ascertained to exist by the  speculum, or where, in-
 dependently of such state, the discharge is inveterate, a much
 stronger solution  is sometimes required, and with this by the
 aid of  the tube, the  diseased  parts may be directly touched,
 or washed  once or  twice  daily, a  camel-hair pencil being
 used for  the  purpose.  In a  protracted example of  leucor-
 rhcea  lately  under  my care, the nitrate of silver  was thus
 used, and with curative effect.  Of all the mineral astringents
 it is'the best.  Dr. Jewell  remarks,  "that by some it  is
 thought,  that the checking of a vaginal discharge  must  be
 prejudicial.   This opinion," he says,  " is at variance with my
\ 
310           FORMULA  OF  REMEDIES.

own experience ; but  I would employ the nitrate of silver,
not  merely with a  view of arresting the  discharge,  but  to
produce  a perfectly new  action, or  new excitement, in the
part from which  the secretion has its origin.   The  mode  I
have adopted in the application of this agent, has been either
to conceal it in a silver tube, as  it is employed  in cases of
stricture,  (except that  the  tube should be adapted to the size
of the ' argenti nitras,') or  in the form  of  a solution, in the
proportion, generally, of three grains to the  ounce of  distilled
water,  the strength  being  gradually  increased.   A piece of
soft  lint  may be moistened with  the solution, and introduced
into the vagina, for a short  period, several times in the day, or
a bit of sponge, firmly and neatly tied to the end of a slip of
whalebone, and  well  saturated  with the  solution, may be
passed into the vagina, up  to the os and  cervix uteri.  This
can easily be effected by the patient  herself.  It is necessary
that the  application should  be  frequently repeated, or no
permanent  benefit  can be  expected.   Should  it  become
requisite to employ a  strong solution, and  to  apply  it to  a
certain part, or  ulcerated surface, it can  be  accomplished
with a great  degree of nicety,  by means of a camel's  hair
brush introduced through the speculum or dilator."

            Form.  59.—Injectio Ferri Sulphat.
   R. Ferri Sulphatis  E)i, 3ii. vel 3j.
       Aquae distillatae  gxvj.  M. ft. Injectio vaginalis.
   Four ounces to be employed three or  four times daily.   I
have of  late  discontinued the  use of syringes, for  vaginal
injections ;  india-rubber bottles,  fitted with ivory tubes, are
far better: there is less  difficulty in their employment, and
they are not so apt  to  get  out of repair.*
 .__________.-------------------—-—.--------------------------------------------■----------------------------■—-—       ■ )
  * Patients should be told that the two last forms (58, 59) will spoil
any linen  which they may happen  to soil,  imprinting an indelible
stain.                                                     '' 
             FORMULAE OF  REMEDIES.          311

           Form. 60.—Injectio Soda Carbonat.
                  Dr. R. D. Thompson.
   R. Soda? Carbonat. 9i, 9ii. vel 5j.
      Aquae Purae gxvj.  M. ft. Injectio vaginalis.
  Four ounces three or four times daily.

   Dr. Thomson is said by Mr. Jones, in his " Prac-
tical  Observations on the  Diseases of Women," to
have ascertained,  by  repeated  experiments, that
inflammation of mucous  membranes  always engen-
ders a free acid on their surface, which acts there as
an irritant increasing  inflammation.   To neutralize
this,  he  makes use  of the alkali.   Mr.  Jones con-
firms this opinion by stating, that whenever litmus
paper has  demonstrated the presence of a free acid,
almost immediate relief  has been obtained by the
use  of  the alkali.  So far  as my exhibition of this
remedy  goes, it  supports these views;  certainly in
several examples of acrimonious leucorrhoea, it has
quickly relieved, and  several times cured the malady.

            Form. 61.—Injectio Succ. Limon.
   R. Succ. Limon. recent, gj. vel gij.
      Aquae Purae gxv. vel gxvj.  M. ft. Injectio vaginalis.
   To be used either warm or cold, as directed above.

   Acetic acid in the proportion of half an  ounce to a pint of
water; nitric, or muriatic acid, ten, twenty, or thirty minims
to a  pint of water, may be advantageously  used in protracted
leucorrhceal discharges.   Their effects will be either sedative
or stimulant  in proportion to their strength.   In  a diluted
-fh 
312           FORMULA OF  REMEDIES.
form, they will often soothe; whilst in greater intensity, they
will not only stimulate, but induce excessive  irritation.   The
sulphate of copper  9i. vel   3j.  to  a pint of  water, or  the
decoct, secalis, is often beneficial; nor must the injection of
the  black wash,  or  the oxymuriate  lotion  be  forgotten.
Electricity, and a  blister to the sacrum, are valuable reme-
dies ; and I  am anxious  to  give a  place to  the following
excellent combination of Sir Charles Clarke :—
   R.  Infus. Cascarillae gj.
       Aquae Pimentae gss.
       Tinct. Sabinae C. 3j. 3iss. vel 5ij.
       Syr. Zinzib 3j.   Ft. Haust.

  To be taken three times daily.
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