No.852.

LONDON, SATURDAY, DECEMBER 28, 1839.

LECTURES

ON THE

FUNCTION AND DISEASES OF THE WOMB,

BY CHARLES WALLER, M.D.Delivered at his Class Room,

BARTHOLOMEW-CLOSE, BARTHOLOMEW’S HOSPITAL,

In a Course of Lectures on Midwifery and theDiseases of Women and Children.

LECTURE III.

Obstruction of the Menstrual Flow accompa-nied with Plethora symptoms and treat-ment. - Emmenagogues improper. - Sup-pression; its varieties.—Sudden Suppres-sion symptoms and treatment.—Vicariousdischarges of Blood.—Suppression frequentlythe result of ill health, and treatment re-

quired.—Suppression natural under certaincircumstances. - Menorrhagia ; varieties—Active and Passive Menonrhagia.

DISORDERS OF THE MENSTRUAL FUNCTION. 1( Continued.) IIII

ALTHOUGH obstruction of the menstrualdischarge (emansio mensium) is very gene-rally dependant upon a chlorotic state ofconstitution, as described in our last lec-ture, yet you will now and then find, thoughthese instances are rare, that the interruptionis occasioned by the opposite state, thesystem being in a plethoric condition, thevessels being over full. The symptomsdiffer so essentially, that it is impossiblefor you to commit an error in this respect,as they are just the opposite to those whichhave already passed under our notice. The

general appearance of your patient will at

once indicate this condition ; her face isflushed instead of being pale and sallow,the pulse beats with force, and is not inor-dinately accelerated ; there is frequentlyintense headache, thirst, dryness and heatof skin, a furred state of the tongue, dimi-nution of the secretions generally ; in short,you will perceive all the marks of febriledisturbance, and these are liable to perio-dical exacerbations occurring, perhaps,

once in every three or four weeks. Youscarcely need be told that the treatment

required for the cure of this kind of obstruc.tion differs greatly from that which is re-quired in ordinary cases of chlorosis. Yourplan is, indeed, exceedingly simple ; yoursingle indication being to reduce vascularaction, and this is done, 1st, by venesection:blood should be removed from the arm insmall quantities, say from four to eightounces, and this operation must be repeatedevery four weeks. If, upon careful exami-nation, you find that there is determinationof blood to any particular organ, cupping-glasses may be applied in the neighbour-hood of the part, or, in some instances,leeches may be preferred. 2ndly, by pur-gation: your object here is not simply toempty the bowels, but to lower the system ;you will select, therefore, those remedieswhich, by acting upon the mucous mem-brane, produce a very copious watery se-

cretion. A sufficient quantity of sulphate ofmagnesia dissolved in the infusion of roses,and administered three times daily, will beas serviceable as any ; a grain or two ofthe chloride of mercury may also be givenevery night. 3rdly, by spare diet: it isquite clear that no benefit would be derivedfrom the method of treatment under consi-deration, if we were, at the same time, toallow full nourishment ; the plan, therefore,must be carried out by allowing food insmall quantity, and not of very nutritiousquality. Animal food, for the most part, isto be abstained from, and all stimulatingdrinks avoided. By these three methods,then, viz., by venesection, by purgation, andby spare diet, the plethora is to be over-

come, sometimes in a longer, sometimes ina shorter period of time; and the naturaland healthy balance of the circulationhaving been restored, we may reasonablyexpect the appearance of the catamenialsecretion. On no account should you haverecourse to stimulating emmenagogues, [asthe cause of the non-appearance of the flowis the result of an action of the menstrualvesselsalmost amounting to inflammation.

After the use of the antiphlogistic reme-dies recommended to you, the hip-bath willbe of service.’

2K

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Suppression of the Ilenstrual Flow.—The ing saline purgatives freely. Anothermodecatamenial discharge is sometimes suddenly of giving relief is by the use of medicines,stopped during its flow ; Lit other times which determine to the skin, such as the fcl.causes which operate during the intervals lowing:—Solution of acetate of ammoniaprevent its occurrence ; or, thirdly, it may 3 iij ; syrup of poppies, 3 ss; solution oi tar.be arrested in consequence of a debilitated tar emetic, M. xxv. One ounce every fourstate of system similar to that already de- hours. The warm bath is also serviceable.scribed as the cause of emansio mensium, Great care should be taken, on the one hand,and to these cases the term adult chlorosis to avoid exposure to cold; whilst we shouldhas been not improperly applied. The recollect, on the other hand, that excessivemenses may be suddenly suppressed by any heat tends to increase vascular action, andpowerful mental emotion, such as excessive is, therefore, positively injurious; a meanjoy, grief, terror, &c. In the greater num- temperature is, therefore, to be preferred;ber of cases, however, the interruption of but little nutriment, and no stimulating be-the secretion is referrible to external causes, verage, should be allowed. Should theespecially exposure to cold in combination obstruction occur at the commencement of awith moisture ; it is well known that if a monthly period, and the treatment describedfemale get wet in the feet during her be promptly put into practice, the dischargemonthly periods, suppression is a very may be reproduced. lflore frequently itcommon occurrence, and hence the reason does not re-appear until the next month, andwhy servant girls, whose avocations subject where the case has been neglected, severalthem to such exposure, are the most fre- periods will pass over before the constitu-quent sufferers from this affection. From tion is restored to that healthy conditionwhatever cause it may have been produced, which will enable the uterus to perform itsits attendant symptoms are usually of an functions with regularity.active or inflammatory character ; sharp Where menstruation is in this way sup.pains are felt in the hips, loins, and region pressed, you occasionally have a vicariousof the uterus; you will observe symptoms discharge of blood from other organs of theof vascular activity, marked by increased body, this may occur in the form of epis-frequency and force of the pulse ; determi- taxis, hemoptysis, hasmatemesis, or therenation of blood to the head is also indicated may be blood effused by the rectum. Theby throbbing pains, attended with powerful danger under these circumstances will ne-

pulsations of the carotid and temporal cessarily depend upon the degree of thearteries. There is heat and dryness of skin, haemorrhage. If it be but trifling, thethe tongue is dry and coated, the urine general plan of treatment is to be persistedsmall in quantity and high coloured ; in in, without reference to this particularshort, the secretions generally are dimi- symptom.nished. There is palpitation of the heart, Should month after month pass awaya sensation of choaking in the throat (globus without the restoration of the secrete, youhystericus), with other symptoms of an will most probably find that other organshysterical nature. The cerebral symptoms besides the uterus are in fault, and these,occasionally run so high as to produce therefore, will require your chief consi.temporary derangement; these instances, derationhowever, are not often met with. Nausea deration and vomiting sometimes attend this variety The menstrual discharge may oe sup’of suppressed catamenial secretion. pressed, not during its flow, in the sudden

.

manner just described; but as the result of

Treatment of sudden Suppression.—From some cause operating during the inferva!.

the symptoms attendant upon this disorder, During pregnancy, you know, for example,

which have been enumerated, you will be the flow is naturally suppressed Thishave been enumerated, vou will be conditian will be known by its attendant

prepared in some degree for its treatment: symptoms, will not being a state of disease,this must be of the antiphlogistic kind. will not be further noticed at this time.Venesection is the first remedy required. further noticed at this time.

The quantity of blood drawn away to be When the general health is suffering fromregulated by the violence of the febrile any debilitating cause, the evacuation is

symptoms on the one hand, and by the ge- frequently absent; and here I would useneral constitution of the patient on the other. the words of the justly celebrated Burns,If she be of full habit, and rigid muscular in his work on the principles of midwifery.fibre, from 12 to 16 ounces of blood may be He observes, " the effect is often mistakentaken from the arm: this operation to be for the cause, the bad health being attri,repeated or not according to circumstances. buted to the absence of the menses; andIf the action of the heart and arteries be much harm is frequently done by the admi.somewhat reduced, but not to a sufficient nistration of stimulating medicines. In

degree, a smaller bleeding will be neces- them the irregularity of the menses is symp-sary, either from the arm, or by the appli- tomatic, and generallv indicates considerablecation of cupping-glasses to the loins. The debility, induced perhaps by great fatigue,circulation must also be lowered by exhibit- bad diet, loss of blood or long continued

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serous discharge, hectic fever, or dys- period of lactation. Still we occasionallypepsia." find women of plethoric habits who men-Do not, however, imagine that I am strnate whilst nursing: others, again, are

claiming for the menstruating membrane of said to continue « regular" whilst pregnant.the womb a total exemption from disease. It If the discharge in these latter cases beis doubtless sometimes the original seat of particularly noticed, you will find it com-the disorder which interferes with its func- monly consists of blood, often passing awaytion. Debility of this part is occasionally in clots (a certain proof that it is not theinduced by too frequent sexual intercourse, menstrual secretion), the times of its appear-Again, it is liable to a peculiar action of its ance are irregular, and by no means corre-vessels, similar to that which takes place in sponding to the menstrual periods. I do notthe vagina in leucorrhea, and then, instead go the length of affirming that pregnantof the regular monthly flow, a white mucous women have never menstruated, although,discharge is constantly exuding, or there from the changes which the uterus then un-may be chronic inflammation of the mem- dergoes, it is difficult to explain the fact.brane itself. In all these cases suppressio Dr. Blundell, in his lectures, relates a casemensium is very obviously the direct effect in which he noticed this occurrence. Iproduced, and to the uterus itself the reme- stated to you, in a former lecture, that iron,dies must be applied, in various forms, was to be administered inThe primary indication in the cure of this cases of amenorrhoea. Whenever you pre-

form of the disorder is, however, still the scribe this metal, your patient should besame, viz., not so much to force the evacua- apprised of its effect upon the colour of thetion, as to alter that morbid action of vessels alvine evacuations, or she would probablyto which suppression owes its origin. Great be alarmed at finding them perfectly black, ancare is required in investigating the state of effect, you are aware, which is alwayshealth in general, as well as the particular sooner or later produced.condition of the uterus. Having determined iu.the seat of the disorder, your next inquiry Menorrhaghia.will be to ascertain whether there be ge- The literal meaning of the word menor-neral or local plethora, or general or local rhagia is, a bursting forth of the menstrualdebility, and according to the existence of discharge ; in other words, an immoderatethe one or the other of these states, your se- flow of the menses; but in the general ac-lection of remedies will depend whether, for ceptation of the term it is used much more

instance, you treat your patient upon the extensively, for it is applied to almost everytonic or the antiphlogistic plan. I enter- coloured discharge from the womb. It istain a very decided opinion that those especially to be noticed, that this appella-medicines called emmenagogues would tion is made use of to designate those disor-scarcely, perhaps never, be employed, if the ders in which there is no menstrual secre-

symptoms of the disorder were more gene- tion at all, but where the discharge consistsrally traced to their cause. I must not dis- cf blood solely : in fact, all sauguineousmiss this subject without saying a few effusions from the unimpregnated uterus havewords regarding the use of mercury, a re- been described under the name of menor-medy so frequently noticed, and so highly rhagia. Profuse menstruation, in its strictestextolled as an emmenagogue. To the use sense, very rarely occurs, and when present,of mercurials, under proper restrictions, and it is hardly to be considered a disease, butin certain cases, that is to say, when they is rather the effect of repletion, and may,are required for the relief of the disordered therefore, be regarded as Nature’s own re-condition, either of the uterus or any other medy for the relief of this condition.organ, there can be no objection. It some- There are two distinct forms which thistimes produces a beneficial effect, but it disorder assumes; first, a simply increaseddoes so indirectly; in other words, it does quantity of the secretion at its natural andnot act as a direct stimulus to the womb, stated periods; or, secondly, there may bebut it alters the morbid action of its vessels, no material alteration in the quantity, butand thus accomplishes the grand primary the periods of recurrence more frequent, twoindication before mentioned. A great variety or three weeks only intervening, instead ofof remedies have been from time to time re- the lunar month. This state is exceedinglycommended as local stimulants ; but I shall inconvenient to the female; means, there.not detain you by a consideration of these fore, must be had recourse to for the pur-separately, as a long and tolerably extensive pose of lessening the quantity of blood, andpractice in these cases fully warrants me in this is easily effected by small venesections,expressing my disapprobation of this me- to be repeated, if necessary, and by an in-thod of treatment. nutritious and spare diet.The absence of the catamenia is not al- The atmosphere in which the patient re.

ways the result of disordered action ; it has sides should not be over-heated, althoughbeen before noticed as one of the common care is, on the other hand, required to avoidconsequences of pregnancy. The flow is exposure to cold during the flow, as a sud-also very generally suspended during the den check might be induced which would

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inevitably be followed by unpleasnt symp-toms. It is proper, also, to advise the pa-tient to place herself in the recumbent posi-tion when the time is approaching, and thisposture is to be continued throughout thewhole period. In forming your judgmentin these cases, the natural quantity of thesecretion, in each individual case, must betaken into the account, or you will be verylikely to fall into error. In addition tobleeding and spare diet, moderate purgationshould be employed.

In the more common cases of what iscalled menorrhagia, you will find not onlyan alteration in the quantity, but in the

quality also of the fluid effused, for the dis-charge consists of pure blood, instead of themenstrual secretion, and hence might withgreater propriety be called haemorrhage fromthe unimpregnated womb. These irruptionsof blood take place in the two oppositeconditions of system, viz., of plethora andinanition, from which the division intoactive and passive menorrhagia, the formerconnected with, if not depending upon, anincrease in the force, as well as the fre-quency of the arterial circulation, the latterresulting from extreme weakness of vessels,appearing indeed to depend upon conges-tion, and a retarded motion of the blood.Before entering at large upon the subject, Imust remind you of the diagnostic markbetween blood and the proper menstrual

flow, and this you will recollect is a verysimple one. If it be the former (blood), itwill coagulate, either passing away in clots,or stiffening the napkins, which imbibe it.In all cases of doubt, carefully examinewhat has passed away, and you will find nodiflictilty in distinguishing the one from theother, as the proper menstruous secretionnever coagulates.

ATTACHMENT OF THE PLACENTATO THE

CERVIX UTERI.

WILLIAM SIMPSON.

To the Editor of THE LANCET.SiR :-Seeral medical gentlemen, to whom

ltlr. Wilson and myself have related the fol-lowing case, are of opinion that it containssome critical points of practice, and that itmight be worthy of insertion in your valu-able publication. The case was one ofadhesion of the placenta to the cervix uteri,to a greater extent than Mr. Wilson or my-self had ever experienced, attended withalteration of its structure, and great dangerarose from its obstructing the descent of thefoetus into the pelvis, combined withhæmorrhage to a frightful extent. I am,Sir, yours most obediently,

110, Guildford-street,Nov. 25, 1839.

On Wednesday, the 13th instant, I wassent for to see a patient in the neighbour.hood of Finsbury-square, being engaged toattend at her confinement, which she ex.pected about Christmas. I learned, on myarrival, that she had lost a great deal ofblood from the uterus during the previoustwenty-four hours. On examination, I foundthe os uteri sufficiently open to admit onefinger, but there had been no pains or ute.rine contractions. By the application ofcloths dipped in cold water over the uterusand pubis, combined with absolute rest in arecumbent position, I was able to arrest thehaemorrhage, and, during the following fewdays, every thing appeared to be going onwell. On the fifth night (Sunday) at about12 o’clock, the haemorrhage returned withincreased violence. Before morning thebed and bed-clothes were completely satu.rated with blood, and she was scarcely ableto move from exhaustion. From a foolishfeeling of not wishing to disturb me duringthe night, I did not see her until the fore.noon of Monday. On examination, I foundthe os uteri dilated to the size of half-a.crown, but completely blocked up by theplacenta ; there were also frequent andre.gular pains in the back. Having waitedabout an hour, during which time I tried toirritate the uterus with my finger, so as toinduce vigorous action, the only result,however, being increased haemorrhage, Ifound myself obliged to have recourse tomore energetic measures to hasten delivery.During the next hour and a half I gave herabout four scruples of ergot, in four doses;this had the desired effect of increasing thepains, and dilating the os uteri to its fullestextent, but also increased the hæmorrhagewithout altering the position of the placentaor foetus. I now determined to introducemy hand, and, if able to touch the mem-branes with my finger, to rupture them andbring down the feet. I found the placentacompletely grown to the whole circumfe-rence of the cervix, with the exception ofone spot only, large enough to admit myforefinger ; it was so adherent, and so highlyorganised, as to convey the sensation ofthere being an uterus within the uterus, theedge of the placenta feeling precisely thesame as the edge of an os uteri, dilated tothe size of the spot alluded to above.

Having succeeded in enlarging the openingto double or treble its size, and the painscontinuing strong and frequent, at the ur-

gent solicitation of the patient, I withdrewmy hand, in hopes that the membraneswould become protruded and the foetusfollow in the usual way. In this I «aa

disappointed, and fearing she would sinkfrom loss of blood, I determined to call onmy friend Mr. Wilson, sen., of Charlotte-street, and ask his opinion whether I shouldat once rupture the membranes and bringaway the foetus. He kindly offered to ac.