Chlorosis.

The following differ considerably from the foregoing cases on account of the absence of any eruption or petechial mark, the only point of resemblance being that there is manifestly in all of them an unhealthy condition of the blood and consequently of the containing vessels. The patient J. B—, whose case I have to narrate to you now, is a rather tall, delicate. looking girl with very pale complexion, white lips, &c., suggesting at once the idea of chlorosis. The skin is white and clear looking, while the hair is dark. Has lived for some time in Bermuda, where she had a bad attack of yellow fever in 1856. Has never had jaundice. Has been resident in England for three years. Has been failing in health the last fourteen months, but has been really ill for about two months, during which time she has been rapidly losing strength, and her digestive powers have failed very much. She now suffers very frequently from pain in the stomach, with vomiting on moving suddenly or violently. The food only is ejected on these occasions.

She complains of very frequent, nearly constant pain in the chest and shoulders. The catamenia have been regular though very scanty, until the last six weeks, since when they have not recurred. Has never had jaundice. On admission she was markedly anæmic, with a yellowish tinge in the complexion; is very thin, has a worn and anxious expression. Suffers frequently from headache affecting the frontal and temporal regions. Frequently is troubled with vertigo, affecting her most when walking or standing for any length of time. Sleep is moderately good. The chest appears healthy. No cough. Heart's action rather irregular and decidedly excitable. On auscultation found slight murmur with the second sound, heard most at the base and along the large vessels, especially in right carotid, while there was a venous bruit to be heard in the neck on both sides. The abdomen I found moderately healthy, and more generally resonant than normal. The liver was within its

normal limits, nor could I find any evidence of enlargement of the spleen. These circumstances made me conclude that I had a simple case of chlorosis to deal with, and not of leucocythemia, as I was at first disposed to consider it, the patient having suffered formerly from yellow fever. The bowels had been constipated of late, but were generally quite regular.

Sulphur 6 was ordered to be taken three times a day. The first diet was ordered with four ounces of claret. She continued under this medicine for a week with little change except that the bowels acted rather more easily, but the stools were of very pale colour, as if wanting in bile, and the patient was complaining of pyrosis occurring very shortly after the principal meals. China 3x was ordered, a drop every four hours.

13th.—Is feeling decidedly better, with less pain, and less dyspnoea in moving rapidly. The stools are more regular, but still pale coloured. Tastes her food for a long time after eating it.

17th. Sore throat, but no evidence of inflammation in throat on inspection. The pain in the throat is relieved for Complains again of shooting pains Pulse 92. Belladonna 3 was given

a time by swallowing. through the shoulders. every four hours.

20th.- Reported better. Tongue and throat pale coloured and relaxed. Has some cough, which is, however, easy and rather loose. The appetite is very bad. The bowels are regular, and the stools of much better colour.

24th. Reported still better. Appetite better. The bowels regular. Cough much less. Complains much of tired, aching pains in the limbs, when they are hanging down. A great deal of thirst with dryness and soreness of the throat. Arsenicum 3 was ordered, a drop every four hours.

27th. The report is very much the same except that the colour of the lips is improving; the patient feels stronger, and the appetite is mending.

February 3rd.-Constant aching in the legs, which, however, do not swell. Dryness of the nares and throat continues.

17th. Still complaining of the aching of the lower extremities. Feet perspiring much at night, and the perspiration is of an unpleasant odour. There are no varicosities. Graphites 30 was ordered, a drop three times a day.

23rd. The report is "improving decidedly." aching of the limbs much better.

The

The feet are perspiring

much less. The dryness of the throat gone. The anæmic condition is greatly improved. The colour of the lips is much better, though the cheeks, &c., do not show much as yet. The catamenia appeared, though very scantily, on the 14th instant, being a mere show and lasting little over thirty-six hours, but it was a great relief to the patient, and she requested to be dismissed to be under treatment as an out-patient, but whether she has so continued I am not aware. She was manifestly in the way to improve, the symptoms breaking down one by one before the treatment adopted.

J. W, æt. 19, female servant, was admitted February 14th, 1871, giving the following history. Got wet and caught cold in the month of August last, since which time she has not menstruated. Catamenia had always occurred regularly before that time. Whether she has been subjected to treatment is not reported. The patient is moderately fat, but the complexion is very pale, the lips showing the pallor very much and the conjunctivæ being very blue. Complains of feeling the cold very much, and of a constant feeling of fatigue and general weakness. Continual headache and aching in the back. Palpitation of the heart and difficulty of breathing with the least exertion. The pulse was normal, except in being very compressible. The tongue was clean and the bowels regular. Pulsatilla 3, a drop three times a day.

22nd. Complaining much of severe pain in right side of the chest in taking a deep breath. There was, however, no cough, and auscultation showed that there was no derangement in the internal organs. There was severe pain on the same side from some decayed teeth. Temporal headache,

with severe shooting pain. Tongue pale and flabby. Ranunculus bulb. 3, a drop to be taken every four hours.

25th.-Is much improved as to the pleuro-dynic pain, which is nearly gone. The head also better. Appetite good. The bowels constipated, not having acted for five days. Nux vomica 3x, a drop to be taken every four hours.

March 1st.-Reported to have been improving in general condition until yesterday, when she was attacked with severe headache, with heat of the head, flushing, &c., aggravated by movement and light. Bowels still constipated. Belladonna 3, gtt. j every two hours.

5th. Much better. Still suffers from headache in the morning, but it does not last, nor is it of the same character. The flushing and heat of the head are gone. There is still some vertigo. The bowels are acting spontaneously. Appetite good. No signs of the catamenia occurring. Pulsatilla 3, a drop every four hours.

8th. The condition generally improving; takes her food better than she has done for months. Continue Pulsatilla. No other medicine was required, and on the 18th there was some appearance of the catamenia, very scanty, and lasting only a day or two, but the patient felt so much inspirited by the occurrence that she requested to be dismissed, and was allowed to depart, taking some Pulsatilla with her to continue under its influence.

M. L, æt. 24, nursemaid. Admitted February 7th, stating that she has suffered from weakness, palpitation of the heart, and general failure of strength for the last year. Has suffered from pain in the right flank for the last six weeks. Is complaining now of tenderness in the right side. Pain at the back of the head. Shooting pain through the temples. Dyspnoea with the least exertion. Anæmic bruit audible over the cervical vessels. Catamenia very irregular, and very scanty when they do occur. Leucorrhoea remaining after their cessation. Countenance very pale, the lips, especially inside, are very anæmic looking. The tongue pale and flabby. Appetite

very bad, eructations after food, and tasting of it. Pulsatilla 3, a drop three times a day; first diet.

11th.-Feels rather better in all respects.

14th.-Not so well.

Nausea after food. Severe head

ache, with shooting pains in occiput and temples.

17th.-Nausea gone. Appetite returning. Tongue clean. Pulse small and somewhat frequent. Complaining of pain and soreness in right flank, with tenderness to

pressure.

22nd. Improving. Pain in side less. Appetite continues to improve. Bowels acting.

ing pain in the dorsal region of back.

Complaining of shoot

25th.-Continuing to improve. Some pain in cardiac Continue Pulsatilla.

region.

March 1st.-Feeling much better. Some sharp catching pain occasionally in left hypochondrium. Complexion greatly improved. She was dismissed at her own request, wishing to go back to her situation.

Bronchitis and chronic metritis.

L. R-, servant, æt. 39, admitted January 18th, stating that for several winters she has been subject to a cough, recurring as soon as the cold weather sets in. Always appears to arise in an attack of cold from exposure, but remains behind, after the other symptoms disappear, until moderately warm weather sets in. Sputa generally yellow, sometimes rather frothy and copious; they have been occasionally streaked with blood; cough very frequent, most at night and morning, and aggravated by any change of temperature. Sharp pains at the upper part of the chest, especially the left side. In this spot there is some tenderness to pressure. The percussion sounds are clear, but

there are all sorts of moist râles to be heard over the whole upper part of the chest. The voice is at present very hoarse, and the larynx is tender to pressure. There is some pain in swallowing. Complaining of pains in head and in the