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In addition to the adoption of a more rational course of habits for the patient, much may be done by the judicious use of medicines. Almost invariably the tonics must be preceded by, or accompanied with, alteratives and laxatives. The stomach will no more recognize and respond properly to a tonic that is introduced into it until prepared by correcting the secretions, quickening the gastric circulation, and unloading the bowels, than it will digest food under similar circumstances. The alteratives suitable, generally, are mercury in some form, taraxacum, and turpentine. When the bowels are torpid, the stools dry and of unnatural color, particularly if the color is light, from three to six grains of blue mass given every third night, and followed next morning by a seidlitz powder, or sufficient sulphate of magnesia to cause one or two evacuations, is an admirable alterative. Ten grains of good extract of taraxacum, with a minute quantity, say the twentieth of a grain, of bichloride or biniodide of mercury, three times a day for two or three days, generally does very well. The mercury should not be given with the taraxacum longer than three days, and then intermitted for a week, but the taraxacum may be given. steadily for weeks. An excellent alterative for the stomach is Venice turpentine. Ten grains three times a day after eating, on sugar, alternated or given with some of the mercurial preparations, proves often of great service. I cannot but mention the compound confection of black pepper, made in imitation of Ward's paste, as having frequently an excellent laxative and corrective effect on a weak state of the stomach accompanied with constipation. I have known it to cure some of the most obstinate cases of constipation attended with anæmia.

If there is not scantiness of secretions, but slowness of peristaltic movement, we ought to depend on rhubarb and aloes. The compound aloetic pill is a good preparation. In the selection of tonics we should bear in mind the difference between the stomachic and blood tonics. Iron is, perhaps, the only direct blood tonic, while there are a great many articles that act as stomachics. Almost all the bitter vegetables ranged under that head in the books are useful under certain circumstances. The stomach tonics, by improving digestion, are indirectly blood tonics, so that they are sometimes all that are necessary. In many instances, too, the stomach must be prompted by the bitters, or other stomachics, before it will absorb or assimilate iron. The bitter may precede the iron, or be administered simultaneously with it. It is sometimes convenient and profitable to combine the alterative and stomach tonic. A mixture of this kind, often used, is the compound tincture of cinchona, with bichloride of mercury dissolved in it. The tincture of gentian, or colomba, answers very well compounded with mercury. Extract of gentian and Quevenne's iron compounded in a pill produce good results on the anæmic patient. If we understand the principle that governs the treatment in such cases, we may

readily find the means to accomplish our ends, by alteratives, stomach tonics, and blood tonics.

The cachexiæ, several of which interfere with the regularity of the function of menstruation, must be treated as if the menses were present in their normal quantity, and in these cases the amenorrhoeal complication is of no importance, hence special efforts to restore the flow are injudicious, and in most cases injurious.

In cases of defective nervous energy we may expect benefit from the direct application of electricity to the uterus, or to the nerves that supply it. In a paper read before the New York State Medical Society, by A. D. Rockwell, M. D.,* I find the following statement:

"Amenorrhoea is a symptom that yields, perhaps, more readily to some one of the many forms of electrization than to any or all other methods of treatment. In cases dependent on, or associated with, general debility, general electrization is of course indicated; but where all external efforts have been fruitless, internal electrization is not infrequently followed by an immediate and satisfactory flow."

He gives a case as illustrative of the efficacy of his method of performing local electrization:

"I introduced a cup-shaped metallic electrode to the uterus, so that the os was com pletely surrounded, and applied the positive pole firmly against the abdomen immediately above the pubes. The current, which was of considerable strength, I reversed rapidly a number of times during the seance, and on the following day repeated the application. In less than six hours after making the second attempt, slight signs of returning menstruation were manifest, and steadily increased until, as regards quantity, the flow was quite natural. The patient was immediately relieved of all her distressing spasmodic symptoms, and at the present time (three weeks having elapsed since the treatment) still remains free from them."

Query. Was this menstruation or metrorrhagia ?
Dr. Parvin, in the same journal, says:

"The positive electrode passed into the uterine cavity, the negative applied to the hypogastrium, gives oftentimes a very prompt success in inducing a sanguineous discharge from the uterus; but in order that such result should follow, this means should be used only at a time when the other phenomena of menstruation manifest themselves, the flow only wanting."

The faradic is the form of electrization recommended by both these gentlemen.

In patients well developed in most respects, whose genital system is deficient, the menses cannot be produced unless these organs grow and become more active. Anything that will stimulate these organs will occasionally bring this result about. Wedlock is a remedy sometimes. The indulgence in society, and the recreations of it, in company with men, sometimes, through the moral faculties, stimulate the

* American Practitioner, May, 1872.

genital organs towards development. The stimulus thus afforded by society is one of the beneficial effects resulting from the change of habits in young girls who go to boarding-schools until sexually dwarfed by confinement to the uninteresting society of their own sex.

Sir James Y. Simpson has recommended an instrument, which he calls an "intrauterine pessary," to bring about this development. It is equally applicable to cases of atrophy of the uterus arising after the menses have been established. I have had occasion to use it, and am now employing it in the interesting case to which I have alluded above. It is theoretically better, I am afraid, than it will be found practically; yet no doubt much good may be done by it. The object of the intrauterine pessary is that it may be the medium, or generator, rather, of galvanism, to stimulate the nerves of the uterus.

Both of these effects are promotive of uterine hemorrhage, if not of correct menstruation. They are necessary to the development of an atrophied uterus, whether congenital or acquired. But this instrument is recommended and used in obstinate cases of amenorrhoea, where there is no apparent deficiency in the size and development of the organs concerned. It is in this class of cases that most may be effected by it, and yet it sometimes entirely fails to produce any effect. To do good in the cases of atrophy and want of development it should be used continuously. Where the development is good, I am inclined to think that the pessary will do more good by using it intermittingly. In these cases we may introduce the instrument one week before the time of the expected period, and allow it to remain, and then, after the time is passed, remove it, and again introduce it at the proper time. We should remember that we cannot use an instrument of the same size in all cases. In the uterus that is much atrophied it would be violence to use an instrument that is applicable to a fully developed organ. In the former we must have an instrument that will pass into it easily, and in a couple of months use one larger; and after the lapse of a similar time make another one still larger, etc., until development is complete. The instrument is made of copper and zinc, and consists of a stem and bulb. The bulb is hollow, in order to be light as possible, flattened, and oval in shape, one inch long, three-quarters of an inch wide, and half an inch thick. It should be perforated through its thinnest diameter by a hole two-twelfths of an inch in diameter. Into this perforation the stem is to be inserted. The stem should be two inches long for a uterus not atrophied, and as much less as is necessary, in the judgment of the attendant, when atrophy has taken place. It should be hollow and light like the bulb. The bulb, and one inch of the stem next the bulb, is made of copper, the extremity of the stem of zinc. This completes the instrument as made and used by Professor Simpson. I find, in some instances, great difficulty, if not an entire impracticability, in wearing it, on account of its tendency

to fall out. Sometimes, too, the galvanic stimulus is not sufficient. On these accounts I have made an addition to it, which, I think, adds to its efficiency as well as to security of position. This consists of a zinc ball, about an inch in diameter, attached to a copper rod four inches long. The ball is introduced into the vagina after the intrauterine pessary has been introduced, while the stem is attached to a framework outside the pelvis to keep the whole in position. As will be seen by a study of this apparatus we have quite a galvanic battery, the copper rod reaching from the framework of zinc outside to the zinc. ball inside, this last lying in contact with the copper bulb of the pessary, etc. If we do not desire any galvanism the whole apparatus can be made of copper. Made in this way the instrument is quite efficient. The young physician or student may be embarrassed in his attempts to introduce the pessary without a little consideration. The plan I have found most convenient is, to expose the os uteri by means of the bivalve speculum; secondly, to secure the pessary by inserting a piece of whalebone, properly shaped, in the perforation in the bulb; thirdly, thus mounted, to insert the stem, and with great gentleness urge it forward to its full length, or until it is arrested by the contracted internal os uteri or the end touching the fundus. If this arrest occurs the instrument is either too large or too long, and must be replaced by one more suitable in this respect. After the pessary is inserted we may withdraw the speculum, and, if necessary, apply the ball and external framework above described to keep it in position. All this direction does not include a fact which should ever be borne in mind by the student, viz., that sometimes the instrument is utterly intolerable; and, at others, a good deal of address and patience is required to habituate the parts to it. The patient should be forewarned that pain and inflammation are the possible effects, and that she must inform us should they be considerable. There is always some pain, sometimes a great deal. When the irritation is too severe the instrument must be removed, quietude observed, and, if necessary, anodynes, and even antiphlogistic treatment must be resorted to, to remove the symptoms. After all these have subsided it may be again introduced. A little perseverance and care will render most cases tolerant of its presence. During the time the instrument is used the vagina must be thoroughly cleansed, at least twice a day, with tepid, warm, or cold water, and fine soap, used as injections.

For the treatment of Amenorrhoea by retention the reader is referred to the Treatment of Atresia and Absence of the Vagina.

CHAPTER XI.

MENORRHAGIA AND METRORRHAGIA.

HEMORRHAGE occurring at the time of menstruation beyond the usual quantity is menorrhagia. Hemorrhages occurring at other times. do not belong to this denomination, but are called metrorrhagia. Often both metrorrhagia and menorrhagia occur in the same individual, which depend upon the same conditions of the system or reproductive organs, and are alike symptomatic of some local or general dis

ease.

It is not difficult to understand that an exaggeration of the hyperæmia, or an unusually rapid disintegration of the uterine mucous membrane, would cause more than a normal amount of flow, nor that a want of accordance in time might be followed by the same result. Indeed most cases of uterine hemorrhage are traceable to conditions which disturb the equilibrium of these phenomena. The causes which thus act are varied and numerous.

Morbid nervous influences, which increase the discharge of blood from the uterus, sometimes emanate from the nervous centres, and hence may be properly termed centric; much more frequently, however, they are reflected through the nervous centres from other and sometimes distant organs, and these last are entitled to the denomination of reflex or eccentric nervous influences.

Mental and emotional excitement emanating directly from the brain, and cerebral and spinal excitement originating in inflammation or functional exhaustion of the brain or spinal cord, are examples of centric etiological influences. Many years ago I witnessed the ravages of an epidemic of cerebro-spinal inflammation, in which uterine hemorrhage was of almost universal occurrence among those adult females who fell under its influences.

Morbid reflex nervous influences afford a more numerous class of causes. First among them, both in frequency and importance, are those arising from abnormal conditions of the ovaries, such as congestion, inflammation, displacement, and erotic excitement. Next to the influence of these bodies is that exerted by the mammary glands. Menstruation is generally more profuse when it occurs during lactation. The effect of mammary irritation in causing congestion of the uterus, and thus promoting hemorrhage from it, is well illustrated by the familiar fact that sinapisms or blisters applied to the breast will often cause metrorrhagia. Vesical irritation, or inflammation, which gives rise to tenesmus, rectal irritation, as from the presence of hemorrhoids

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