ON OBSTINATE MENORRHAGIA.

that the change would complete the cure. However, in about four months she made her appearance " as bad as ever," so I determined on the following plan:A careful examination- was again gone through. The uterus. felt fuller and softer, and the os more open than natural. Thefinger could be introduced a little way into the os, but nopeculiar soft, pulpy, or vegetating unevenness could be distinguished. The uterine sound showed that the cavity waslarger than natural; in fact, the instrument could be easily turned on its curve without much displacement of the uterus. No hitch or obstruction whatever indicated a polypoid exThe sound, when withdrawn, was crescence of any magnitude. covered with blood, which seemed to flow more abundantly in consequence of the disturbance caused by the uterine sound; but this increase lasted only half an hour after the examination was concluded. Not the least pain was caused by any part of

ON

OBSTINATE MENORRHAGIA. H NRY

SAVAGE, M.D. LOND., F.R.C.S. ENG.,

SENIOR PHYSICIAN TO THE SAMARITAN

HOSPITAL

FOR WOMEN.

haemorrhage, unconnected with pregnancy or parturition, occasionally assumes a rebellious form not to be understood by the ordinary doctrinal explanations of its pathology. Menorrhagias (or rather metrorhagias) are said to be active, passive, functional, or symptomatic, according as they are considered to depend on general vascular derangement, on UTKRIE

diathesis,

or on

morbid states of the womb itself.

The

reme-

useful, are such as correspond with these views. the examination. A large sponge-tent, two inches and a half long, was introThus cooling purgatives, drastics, antimonials, bleeding, astrin- duced to its whole length. A still larger was employed the same be said may gents, have each had their advocates. The On the third day the os uteri would easily day following. of the series of special anti-menorrhagics-bitartrate of potash, admit two fingers. The patient was then laid upon her back, oxide of silver, Indian hemp, digitalis, Cayenne pepper, cinna- the legs raised, the hips well supported; in short, placed as iit mon, &c., and of the removal from the womb itself of some the operation of lithotomy. With Recamier’s curette (the end of which passed into the cavity of the womb with, tangible exciting cause, as polypus in-one or other of its innu- larger the utmost facility) I proceeded to scrape with force enough to. merable varieties. remove any possible vegetation or fungosity, which I considered The majority of menorrhagias yield to one or other of the it a fair presumption to regard as a very probable cause of above remedies; but some do not. The two following cases, hoemorrhage so inveterate. The operation lasted about six In that time (the curette being of the largest size) I selected from a large number which have come under my minutes. I had believe completely gone over the entire internal surface of notice at the Samaritan Hospital during the last four years, the uterus and its neck. Wherever I felt, through the instruof this intractable in my opinion, are instructive examples ment, a sensation as if it was passing over a velvety surface, class:— there I continued scraping until the surface gave the impression CASE I.-A woman, aged thirty-six, married, came to the of being comparatively smooth and hard. The patient was, hospital two years and a half ago, having the ordinary appear- asked, frequently, if the operation gave her pain; but she said She was extremely she felt none whatever. I constantly withdrew and examined ance of females subject to loss of blood. pale, she said she was weak, felt low-spirited, and had at the curette, expecting to see a large collection of vegetations or last become quite unequal to her domestic duties, which were accumulations of the soft surface I seemed to be scraping off, far from laborious; she had but two children, and had expe- but the amount altogether did not, by a third, cover the cavity rienced no privation; she never noticed any irregularity in the of its spoon shaped end; much more, however, of a jelly-like,. catamenial function till six months after her last confinement, white, tough, transparent mucous came away. The patient having always felt well till then. On the reappearance of the was put to bed. The haemorrhage for the first half-hour ,c,at-amenia at that period, she lost a great deal of blood. This slightly increased. It then began decidedly so to diminish discharge lasted for three weeks. After a week’s interval, it that it was not considered necessary to resort to any of the again appeared, increasing until about the right catamenial means provided for the opposite contingency. The next day period, according to her calculation, and subsiding gradually the haemorrhage was still less, and I thought I could feel that to the interval of a week as before, and so continuing ever the uterus was smaller. She had passed a good night, and said since, reversing, as it were, the ordinary rule, she having but she felt better and was in no pain. With the view of more one week’s interval instead of three. A letter from her medi- effectually destroying the polypoid vegetations, the idea of cal attendant states, that this has been going on for eight which the result of the operation seemed to me to confirm, I months. He had tried all the usual remedies without success. injected three drachms of the tincture of iodine, of the London A polypus was suspected, but not found. I examined her Pharmacopoeia, into the uterine cavity. The effect was almost carefully several times, failing also to find anything more than magical; the hemorrhage seemed to stop at once. The day -slight enlargement of the uterus, which had a soft feel, with following it was almost gone. Two injections of three drachms the os perhaps slightly more open than common. Cold hip- of the same tincture were used at intervals of three days. -I)aths, oxide of silver, -Indian hemp, &c., were tried for a Beyond a sensation of warmth, the patient declared she felt month. They made but a temporary impression. The interval nothing; and on this occasion she left the hospital six weeks ’of cessation extended to a fortnight; but the total amount of after her admission. All discharge had ceased for three weeks loss was still far too great. The uterus was now injected daily previously. The womb was clearly much less in size, and the with a strong solution of tannin and alum; from four to eight os had closed to its natural dimensions. I met this patient accidentally in the street a few days ago, ounces of this was thrown into the cavity of the womb in a continuous and rather forcible stream through a full-sized male nine months after she last left the hospital. She assured me. catheter, cut off at the end-the os having been previously that, ever since the operation, her catamenial periods had been well dilated by a sponge-tent to ensure free retrogression of perfectly natural. She was walking briskly, and looked in dies

most

’

the fluid.

excellent health. CASE 2.-A woman, thirty-four years of age, thin, spare, pallid, nervous, and debilitated, came to the hospital a year ago, complaining of excessive loss of blood at the catamenial periods, which had lasted at least a fortnight at a time during the past two years. The complaint had come on after a miscarriage a year previously. The uterus could be felt soft, larger than natural, and the os open, but not sufficiently so to admit the finger. The os uteri was dilated by a succession of spongetents, but I thought in this case I would try the iodine injection alone. Accordingly, four ounces of a mixture of tincture left it. She said’she was about the same as at first, and her look of iodine and water (equal parts) was injected with some force, corresponded with the statement. Another selection of anti- in the usual way, into the uterus. The nervous and excitable menorrhagics was tried; they failed as before. Recourse was temperament of this patient, as I anticipated, betrayed some again had to the tannin and alum injection (tannin, two intolerance of such a proceeding. She complained of pain in drachms; alum, four drachms; water, six ounces). The cata- both groins for some hours afterwards. The next day the menial interval again quickly extended to a fortnight, and once hemorrhage was greatly diminished. The same injection was to three weeks. She remained in the hospital three months. repeated every third day for a fortnight. The uterus now The decrease in quantity seemed to justify my yielding once began evidently to return to its right size, and the os to close. more to her wish to go home, and agreeing in her supposition She left the hospital two months after her admission. Her Internal remedies

were

discontinued.

The hagmor-

rapidly subsided. At the end of a fortnight, it had nearly disappeared. At the end of another month, I yielded to her anxiety to return home, and she left the hospital much improved in health and appearance, but the discharge was not quite gone. The injection from first to last had caused her no pain whatShe mentioned occasionally only aslight sensation of ever. drawing and coldness," but not by way of complaint. In about four months she again came to the hospital. The haemorrhage had begun to increase about two months after she

!age ,

.

now

570

’

health improved tion.

rapidly from the first use of

the iodine

jnjec-

In this case, most of the anti-menorrhagics best esteemed had been administered without any advantage. The above two cases are types of a vast number of menorrhagias I have treated on a principle involving more or less the supposition that some unnatural condition of the lining membrane of the uterus existed. Injections as mere astringents Dr. were used, by Blundell amongst others, years ago.

Locock’s gouge, Becamier’s curette, Jobert’s uterine speculum, Simpson’s looped scraper, recognise the same thing-viz., the possible existence of wonderfully small polypi as the real cause of dangerous uterine hasmorrhage; but I am not aware that iodine has ever yet been employed for the same object. Injections of the uterine cavity are regarded by the profession in general as full of danger, and I am not prepared to say they not so, unless

care be taken to secure an unobstructed fluid by previous ample artificial dilatation of the os and cervix uteri. With this proviso, I have never seen any ill effects from uterine injections ; and of all the various solutions I have used and seen used for years past, I have never met with one so satisfactory and so free from objection as the tincture of iodine. It is also worth while, I think, to direct attention to a point in the rational. of uterine haemorrhage exemplified by the use .of any means tending to empty the uterine cavity, or otherwise lead to a return to its healthy size and tone. In both the above cases, as well as in all the rest I have met with, the .slow contraction of the uterus seemed to keep pace with the diminution of the discharge. I have often seen brought on unintentionally a smart metrorhagia by the introduction of a spongetent of the smallest size, which only ceased on the removal of ,the tent. Gloucester-place, Portman-square, Nov, 1857. are

escape for the

REMARKS

MARKHAM, M.D., F.R.C.P., MABY’S

day place idiopathic pneumonia

in

our

nosological systems

in the same class rheumatic fever ? Acute rheumatism is no longer called arthritis, however prominent and severe the arthritic symptoms attending it may be ; we do not consider them the essence of the disease, but only as certain of its consequences. Neither do we treat the arthritis; we direct our attention mainly to that disordered condition of the system which has, we know, provoked the arthritis. We find a fever also raging and we call the disease rheumatic fever. Why, coincidentally, in like manner, may we not be led to call idiopathic inflammation of the lungs pneumonic fever. Now, if this view of the pneumonia be correct, it is evident that the nature of ordinary inflammation, as regards its treatment, must be considered under the head of those diseases which, for want of a more par-

of diseases

as

knowledge of their intimate nature, we designate as blood-diseases; it is a disease in which constitutional disturb-

INFLAMMATION AND BLOODLETTING CONTROVERSY. PHYSICIAN TO ST.

one

amongst the fevers, ranking it, for example,

ticular

ON THE

BY W. O.

local inflammation, varying doubtless much in extent, would probably have been excited. In the first case, I think it must be admitted that there ex ists a peculiar, an abnormal, condition of the system which predisposes the individual to the inflammation. It cannot be imagined, that the mere local application of the cold air* or of any other of the exciting causes, to which he had been subjected, excited the pneumonia, for then assuredly the other ninety-nine of his companions could not all have escaped the potent influence. Now, if we admit the fact of this predisposing condition of the system, we admit, I imagine, that the system is diseased anteriorly to the moment that the local inflammation arises; and therefore that the pneumonia is not, strictly speaking, idiopathic, but falls under the class of those constitutional disorders in which the local inflammation is merely of secondary consideration. In the idiopathic inflammation, there is some obscure influence to which the fluids or solids of the body, or both of them, have been subjected before the pneumonic symptoms arise ; but in the traumatic inflammation, on the contrary, whatever constitutional disturbances appear, are consequences, not antecedents, of the local inflammation. Is it, indeed, unreasonable to believe, that we shall

HOSPITAL.

(Continued from page 517.) THE above facts, then, seem to suggest to us reasons, why bleeding should not in many cases be the proper remedy, and is frequently found inefficacious in internal inflammations. With regard, indeed, to all those internal inflammations which manifestly arise as secondary to some other disorder, the pleurisy and pneumonia attending phlebitis, for example; the pneumonia incidental to typhus; the pneumonia associated with pericarditis and rheumatic fever, &c.-with regard to these, it is admitted that the treatment of the local pneumonia is a matter of quite secondary consideration to the treatment of the general disorder. But the so-called idiopathic pneumonia-the pneumonia which has no such relations to any primary disorder -is placed in quite another category of diseases. It is, if I mistake not, generally regarded as an acute inflammation, arising from a local source of irritation, much in the same way that inflammation is seen to arise, consequent to a local injury on the external surface of the body ; but a little consideration may perhaps show us, that such a view of its nature is not

altogether satisfactory. Idiopathic pneumonia arises obscurely-that is to say, without any distinct and manifest cause to which it ’can with certainty be ascribed. It cannot be looked upon as a purely local inflammation in the sense in which we should regard pneumonia arising from, say, a gunshot wound. Every one must admit, on the face of it, that there is a distinction somewhere in the two cases. Of a hundred persons who are exposed to the selfsame external conditions, atmospheric, hygienic, and dietetic, one only is attacked with so-called idiopathic pneumonia. But this is clearly a very different result from what would have happened had they been all subjected to a similar traumatic injury of the lungs; then, in the whole of them some degree of

exists anterior to the manifestation of local inflammation. may be said by way of illustration of ordinary catarrhs, cynanche tonsillaris, pleurisy, herpetic and other eruptions, erysipelas, and, in fact, perhaps, of almost all inflammations, whether internal or external, which do not take their origin from direct local injury. Now it cannot be denied, that since the days when modern pathology took its rise, the treatment of these disorders has undergone a complete change, and that our views concerning the nature of diseased processes have become clearer and juster. We have learnt-a most important lesson-the extent of our ignorance concerning them, and can measure pretty accurately what is positive and what is hypothetical in our knowledge of them. Amongst other things, we have learnt this---viz., that in disorders of the kind here spoken of, bleeding is not an appropriate remedy. We see distinctly enough the fallacy upon which was chiefly, if not entirely, based the theory of bleeding in former days-viz., "that the morbific matter should be evacuated at the orifice made by the lancet"-the corrupted blood removed from the system. And we find, nowadays, at all events, that in such diseases, loss of blood is not well borne, and is sometimes at certain periods of their progress little less than loss of life. If, then, we regard idiopathic pneumonia, not as a local inflammation, but as a general disorder, manifesting itself in a particular organ, we shall at once havereason, by analogy, to believe that bleeding is not a suitable remedy.for it, and that it never has been so, and is only to be practised for the purposes defined elsewhere. And the proposition gains strength from the fact, that traumatic inflammations of the lungs do seem to demand large bleedings for their cure; at least, this much is certain, despite all theory of change of type, that the extremely vigorous treatment by venesection practised by Mr. Guthrie fifty years ago, in such injuries of the lungs, is exactly the same treatment as was practised and found successful, for

ance

The

same

* Cold has been from the earliest ages, and’still is, regarded as a most powerful exciting cause of disease. Admitting it to be so, it is surely evident, in the instance of pheumonia, for example, that the cold acts in some manner The lungs do not feel the effects of on the system, not directly on the lungs. the cold directly; we must rather suppose that some change is brought about in the body, anterior to the manifestation of the local inflammation. The disease falls on the lungs, it might have fallen on the kidneys, on the joints, on the heart, on the membranes of the brain; or, to put the matter in another form, can we believe that cold would excite pneumonia in the lungs of a person perfectly healthy, unless there were pre-existing in that person a predisposition to the disease-i. e., an abnormal state of some of the parts of the body-its muds or its soUds ?r ...

.

-

-

571