tion, which should be carefully diagnosticated when at all practicable.

We have seen that anemia is occasionally an efficient causing condition. When this condition is uncomplicated, it is almost always produced, more directly, by a failure on the part of the digestive apparatus. I do not think it would be proper here for me to do more than indicate a few general principles by which to be governed in the management of anemia. Almost always we need medicines and management, to give muscular tone to the stomach and bowels, a healthy state of the secretions in the whole of the alimentary canal, and more directly to add iron to the blood. We must effect perfect chymification, chylification, sanguification, and defecation; and if any of these processes is imperfectly performed, the result will not be attained. We cannot, in most cases, simply give iron with the hope of causing better sanguification. The first two steps of digestion must be well performed before good rich blood can be made, however much iron we may pass into the stomach or blood, were that possible. Then defecation, to keep separate the effete materials of the ingesta, is just as necessary to the formation of pure blood. We, to be sure, occasionally meet with cases that may be cured by any process that will correct one of these derangements, but this certainly is not common. By examining carefully each case as it comes up, we generally ascertain which one of these processes is most at fault. But we must not only furnish the vessels with well-digested material, but, to perfect sanguification, we must introduce oxygen in sufficient quantities, or we meet with failure still. In more special terms, our anemic patients will need the bitter tonics, and, generally, some stimulants given at meal-time, so as to stimulate the stomach at the time of digestion, get mixed with the chyme, and pass with it through the duodenum and jejunum, and not be absorbed wholly until taken up with the chyle. Iron may be superadded to these, more directly to enter the vessels; and probably two hours after eating is the best time to administer it. For the purpose of promoting proper secretions, a few grains of blue mass, administered every second or third night, to be followed in the morning after with a saline laxative, large enough merely to move the bowels gently, has seemed to me to suit very well generally. Then there are some substances that may be added,

if thought best, more directly to act upon the muscular portion of the alimentary canal; as strychnia and ergotine, both of which may be employed, in certain cases, to great advantage. Or, if we prefer, we may use five grains of pulverized nux vomica, or powdered ergot, in place of their alkaloid principles, three times a day. By keeping in view these leading ideas of the pathological causes of anemia, and the modes of relieving them, the treatment will be comparatively simple and efficacious. Healthful muscular exercise in the open air, at least one-fourth of the twenty-four hours, and proper diet, will be indispensable addenda to these. But we should not forget that, generally, underlying all these things, there may be a cause that it will be necessary to remove. In women, the uterus may be diseased, or the genital organs may be abused by masturbation. We should examine carefully, in order to ascertain the originating difficulty.

Uremic anemia, for I think this is the condition albuminuria usually indicates, is, happily, of more rare occurrence; and it is unfortunately, also, much more difficult to manage. Iron, ergot, and the terebinthinates,-the balsam copaiba particularly,—are the most useful means in such cases. The tincture of iron in pretty large doses, say forty drops three times a day after eating, is extremely useful. It should be administered during the intervals; and a few days before the attack, it may be omitted for five grains of the powdered ergot three times a day. One capsule of balsam copaiba, containing half a drachm, may be given in place of the iron, followed by the ergot. Such use of these remedies, although generally incapable of restoring the function of the kidneys, often improves the symptoms very much.

General plethora may accompany menorrhagia, but I think very seldom. Plethora, or rather congestion of the abdominal organs, is quite common; and the judicious management of it will afford great relief, if it does not cure the symptoms. I need not dwell at any great length on the subject in this place, as I have already spoken of it in the treatment of the paroxysm; but I must refer to the great benefit I have seen result, where this condition was prominent, in the use of minute doses of bichloride of mercury, and large doses of taraxacum, administered for a long time.

In one of the first cases I ever treated,—and one in which the most marked benefit resulted,-I put 3ii of the extract of tarax.

in 3xvi cinnamon-water, and then dissolved gr. i of corrosive chloride of mercury in it. The patient took a large table-spoonful of this mixture three times a day. Slight ptyalism occurred in three weeks from the time she began to take it; the paroxysm came on in three days after this occurrence; the discharge was very greatly reduced. The same process was repeated the next two months, when the patient was entirely cured. When the hemorrhage depends upon endometritis, which, I think, is very frequently the case, the disease is to be treated as directed in another part of this work. (See Endometritis.) When inflammation of the body or cervix uteri is present, our treatment will be ineffective, as a general thing, until it is removed. And we should look and expect their presence in a great many instances. Subinvolution and the congestive or hyperemic condition, which often accompany it, are not unfrequently the obstinate causes of menorrhagia. These conditions may be removed with a good deal of certainty by patient and persevering treatment. The treatment I have found most effectual is the application of nitrate of silver to the inner surface of the organ pretty thoroughly every seven or eight days. This stimulates the uterus to contraction and condensation, and in the course of four or six months the difficulty may be entirely removed. We should be sure to persevere long enough. On theoretic grounds, we might expect ergot and strychnia, administered for a length of time, to lead to the condensation of the uterus tissues; but I have so generally cured this class of cases by the local application of the nitrate of silver to the inner mucous membrane of the uterus, that I confess I have but little observation with any other treatment. These strong astringent applications to the inner surface of the uterus, made by the flexible caustic-holder, or the whalebone with cotton or lint upon the end of it, will generally cure those cases that are kept up by too great vascularity of the mucous membrane. We may thus introduce the nitrate of silver in substance, and apply it thoroughly to the inner surface, by freely moving the causticholder about in it, or if we fail in making a strong impression, a small piece of the nitrate may be left in the cavity to dissolve and diffuse itself. I have done this a number of times, and with the exception of trifling pain, lasting only for a few hours, and some sanguineous discharge for two or three days, have had no bad result.

The application of the nitrate to the inner surface may be done once a week with the caustic-holder, and in general will succeed well. The acid nitrate of mercury may be used with the whalebone probang once in two weeks, when the nitrate of silver is not used. Creasote, muriate tinct. of iron, and, in fact, all the remedies I have recommended for endometritis can be used in the way recommended under that head. But it sometimes happens that the menorrhagia continues in spite of this treatment, and I think generally on account of the imperfect applications to the inner surface of the uterus. It then becomes a question whether the os and cervix ought to be dilated. I think that when the bleeding resists all other judicious means for its arrest, this measure is justifiable, and, if the loss is great, demanded. We may have two objects in view in resorting to dilatation: 1st, to ascertain the precise condition of the cavity of the uterus when practicable in this way, and 2d, to be able to remove any small growths that may be found there, or to make a thorough application to the mucous membrane. In one instance, not long since, I cured the menorrhagia by dilating the os and cervix so that I could introduce my finger to the fundus, and then with a cotton swab cauterizing the membrane thoroughly with acid nitrate of mercury. I operated this way twice, at intervals of two months. There was but little inconvenience from its use, and the case was entirely cured. We should be careful to cure, if possible, all local complications of menorrhagia, as having a very important bearing upon our success. Hemorrhoids should be particularly attended to, as keeping up and aggravating the discharge. Chronic vaginitis, urethritis, cystitis, &c., or any disease in the pelvis that keeps up constant congestion of the parts, should be remembered as quite worthy of our notice in this connection. If ovaritis be complicating the case, it should be treated by the means which would be used were it an independent affection. Ovarian inflammation is supposed to have an important relation to this and other menstrual aberrations in two ways, 1st, by its directly stimulating the uterus by unusual manifestation of ovarian orgasm, and 2d, by acting, from proximity, thus keeping up a large flow of blood to the whole pelvic viscera.

CHAPTER VI.

DYSMENORRHEA.

DYSMENORRHOEA-DEFINITION-PAINFUL, BUT FREE-PAINFUL AND DIFFICULT OF FLOW-MEMBRANOUS-PAIN CAUSED BY SURROUNDING DISEASE -LOCATION OF PAIN-INFLAMMATORY-NEURALGIC AND MEMBRANOUSINFLAMMATION OF THE UTERUS-OF THE OVARIA-DEGREE OF SUFFERING -DESCRIPTION OF MEMBRANOUS

VARIETY-PROGNOSIS-TREATMENT

DIVISION INTO PALLIATIVE AND CURATIVE-GENERAL TREATMENT-OF PAROXYSM-BETWEEN THE PAROXYSMS-GENERAL-LOCAL TREATMENT.

DYSMENORRHEA means painful menstruation, or difficult menstruation with pain. Menstruation may be attended with severe suffering, when the flow is otherwise unattended with perceptible improprieties. It may be performed with difficulty, as when the flow is prevented by obstruction, or when a membrane is expelled with great pain. Whether there is a class of cases in which the flow is established slowly and imperfectly at first, or membranous productions are expelled without pain, I am not informed by authors; but I have certainly seen instances in which both these conditions were present with a very trifling amount of pain. To be dysmenorrhoea, the pain must occur at the time of the menstrual epoch, or immediately before or after it; and it must emanate from, if it is not confined to, the pelvic region. It is taken for granted, also, that it is necessarily connected with this process. The pain is not always seated in the uterus; it may be in the ovaria, in the plexus of nerves supplying the uterus, or the lower extremities; or it may be in the bladder, rectum, or urethra, one or more of them. And in some cases it seems to occupy all these organs and plexuses of nerves.

A question has often occurred to me in this connection, which I think of great interest to decide in each case. Is the pain always dependent upon a morbid condition of the uterus or ovaria, or is the pain dependent, in some instances, on the morbid condition of the organ in which it is located, the rectum or bladder, for