Observations on the disorder of the general health of females called chlorosis; shewing the true cause to be entirely independent of peculiarities of sex

Front matter

WORKS OF GENERAL INTEREST,

PUBLISHED BY

SAMUEL FI I GH LEA", 32, FLEET STREET.

Contents

Mammalia — continued.

Deer, Antelopes, &c.

Dogs, 2 vols.

Preface

In submitting the following little Work to the Public, the Author deems it not improper to premise that, the opinions contained in it, however much differing from most Medical Authorities, have not been hastily drawn from a general resemblance of symptoms amongst a few isolated cases ; but are purely the results of an extensive practical experience, extending over a period of upwards of thirty-six years, and during which, frequent opportunities wTere afforded him of observing the diseased subject under various circumstances of climate and CONSTITUTION.

His chief endeavour has been to direct the Reader’s attention to the fact that, the disorder called Chlorosis, is not peculiar to the Female Sex, and its occurrence limited to any particular period of life ; — but that it is solely a complication of affections (entirely independent of sexual formation) resulting from, and almost invariably attending a peculiar functional derangement of the liver and digestive economy : and further, that the Chlorotic appearance as it is termed, so often to be observed, not only in young females during the earlier years of growth and long before the period when puberty commences, but in those also of adult age, whether married or single, as well as in the young and delicate of the male sex, — may be thus easily accounted for.

IV

The Author sincerely hopes that, the simple mode of treatment he has pointed out, in accordance with his notions of the true cause of this disordered health (and from his long experience of its efficacy, he can confidently assert it to be by far the most successful),— will induce those of his Medical Brethren who may adopt it, to throw aside the use of most, or all of those disgusting and too often dangerous medicines, called emmenagogues— which not only are constantly proving ineffectual for the object of their administration, but even tend in a great degree, to increase the real and only disease of the Chlorotic female

In closing these few preliminary remarks, the Author may be allowed to state, that he has purposely avoided the introduction of numerous cases— in order, partly, to keep the Work within a convenient size, and partly, that the main object might not be overloaded with unnecessary illustrations, for it will be obvious, that the distinctive features of the disorder must be alike in almost every instance ; such additions, he therefore conceives, would have assisted but little in strengthening his position.

London, 1839.

ERRATA.

Page — Line.

6 — 18 — for the body is rather larger, read the body is largest at the umbilical region than otherwise.

11 — 17— for deficient, read deficient in the advanced state of pregnancy.

16 — 24 — for misterious, read mysterious.

19 — 1 — for seperately, read separately.

21 — 15 — for mucous, read mucus.

24 — 15 — for catemenia, read catamenia.

24 — Note — for Dr. Lococke’s Cyclop, of Med. read Dr. Lococke — Cyclop. Med.

29 — 4 in Note — for promonatory, read premonitory.

30 — 4 — for catemenial, read catamenial.

35 — 11 — after became pregnant, add the comma.

38 — 14 — for co-existant, read co-existent.

39 — 3 — for connot, read cannot.

41 — 2 — after congestion, add the full stop.

46 — 9— for whist, read whilst.

49 — 4 — reasonable, instead of a comma add a colon.

52 — 13 — for sluggish inactive state of liver, read sluggish state of

liver.

53 — 22 — obtain — instead of a semicolon, add full stop.

53 — 24 — operations — instead of semicolon, add the comma.

55 — 5—; for of a large metropolis or crowded towns, read of a large metropolis and of crowded towns.

55— 20— for the general appearance, read the general appearance of the individual should be carefully watched.

60 — 11 — for terminates, read terminate in the thoracic duct.

63— 23 — for gauglionic, read ganglionic system.

64 — 3— for callapses, read collapses, and instead of semicolon, add

the comma.

64 — 6 & 7—* vena por toe — instead of comma, add semicolon.

64 — 18 — for violen, read violent.

68—15 — for the nerves with the stomach are, read the nerves with the stomach is most important.

70 — 1 — for trasmitted, read transmitted.

70 — 19— for trisplanchnie nerves, read trisplanchnic nerves.

91 — 1 — for Prduce, read Produce.

108 — 16 — for menstration, read menstruation.

112 — 15 — for the remedy is dependent, read the remedy is to be dependant on the feelings of the patient.

1 13 — 4 — for any grade in society, read for any grade of society.

.

*

.

• .

.

' Pi

OBSERVATIONS

ON THE DISORDER OF

THE GENERAL HEALTH OF FEMALES,

CALLED

CHLOROSIS.

Chapter I

The complaint called Chlorosis, to which young females are supposed to he peculiarly liable, has ever been deemed by the medical practitioner, one of the most difficult and annoying maladies, with which he has to contend in general practice. This, however, does not arise from any paucity of opinions, or modes of treatment for its removal; for there are fewer diseases than those having a supposed dependence for their origin on that function of the uterus, termed menstruation, upon which medical men have expended more care, or written more largely.

The circumstance that chiefly induced me to consider this complaint more attentively was, an obser-

B vation I made many years since, that the disordered state of health in females, called Chlorosis, bore a very striking analogy to a state of ill-health, frequently to be met with in youths and delicate persons of the male sex ; and, on comparing the two more closely, I was induced to believe that they both arose from the same source, and were, in fact, the same complaint ; and consequently, entirely independent of sexual formation, and, per sequence, menstruation.

From practical observation, I conceived the immediate source of the complaint in either sex, to be an obstruction in the capillary extremities of the biliary vessels, giving rise to chronic functional derangement of the liver. Acting on this belief, I discarded the idea of Chlorosis being an idiopathic, or primary disease, — and I adopted a mode of treatment in accordance with my view of the case, which, for upwards of thirty years, has never deceived me.

At a certain period of life in the human subject, an important developement of the system and constitutional powers takes place ; in the male, this period is indicated by the secretion of fluids peculiar to his sex, — in the female, by the appearance of the menstrual discharge ; which, in a healthy woman, re-appears at pretty regular intervals of one month, until she reaches the age of about forty-five years, when it generally declines gradually, or ceases altogether. It is natural, therefore, provided she be in good sound bodily health, and there be no organic disability or malformation, for every woman to menstruate ; and it is found by experience, that, if the young female do not menstruate at the age when this discharge usually appears — that she, sooner or later, gives evidence of a disordered condition of the general health, — and until a healthy flow of the catamenia is established, the state of her constitution admits of but little improvement; and hence has arisen the question, which has led to so much error in the treatment of many complaints in females; namely. Is not the retention of the menses the cause of the general ill-health of the female 1 I contend that it is not — on the contrary, that the retention of this natural discharge is only one of many other symptoms and sympathetic affections, whose common origin is derangement of the biliary apparatus of the liver ; and I also contend, that, in by far the greater proportion of cases, this functional derangement of the liver is primary, or idiopathic ; and that the symptoms and affections called dyspepsia, are only the results of the sympathy existing between the liver and the other chylopoietic viscera. At the same time, I admit that there are also many instances to be met with, where an idiopathic dyspepsia was clearly the cause of the functional derangement of the liver. Yet, this, in no wise, alters or impairs my position of the liver being the immediate or proximate cause of the retention or suppression of the menses ; and I can confidently assert that, unless the remedies be such as possess a salutary influence over the liver, a healthy return or appearance of the catamenia can never be expected.

I, therefore, think it most proper to divide amenorrhoea, or non-appearance of the menses, under two heads that is, into functional, when the irregularities of the uterine system arise from a generally disordered condition of health ; and into organical, when actual disease of structure is a sufficiently assignable cause, for an irregular and disordered state of menstruation. At present, my purpose is, to confine my remarks to the first of these divisions. But, before I proceed to discuss the subject, it will be necessary to take a cursory review of the opinions of medical writers on menstruation; since it is from erroneous notions concerning the production and qualities of this discharge, that so many different modes of treatment, and dangerous, at the same time inefficient remedies have been recommended and resorted to, for the removal of this complaint. Although, were I to describe all the conflicting theories which have emanated from medical writers, I should be occupying the reader’s time and attention to little purpose. For, I shall show that, whenever a mode of treatment has been founded upon them, it has invariably been as inconsistent and uncertain as the theories themselves.

Chapter II

The usual time in our climate, at which females begin to menstruate, generally ranges between the ages of fourteen and sixteen, sometimes even later than eighteen ; and sometimes indeed much earlier than fourteen. In the northern countries, menstruation takes place at a more mature age ; and in the warmer climates, considerably earlier than in our own; but it is by no means possible to say at what precise age this function is established, since it is greatly dependent upon circumstances of climate, idiosyncrasy and on the influence of external occurrences. Still, however, the transition from childhood to puberty, is distinctly marked, although menstruation may not

BE PRESENT.

The trunk of the human female, during the earlier years of growth, is of a cylindrical shape, of a diameter of equal circumference ; or, perhaps, if there be any difference, the body is rather larger at the umbilical region than otherwise ; but, at about the age of puberty, the upper part of the trunk, the ribs, and clavicles, extend very rapidly, and the chest becomes suddenly and considerably enlarged; the scapulae, at this time, are separated some distance from each other in proportion to their former state, — the breasts are increased in volume, and the whole contour is much altered. Simultaneously with the enlargement of the thorax, there is also a corresponding expansion of the bones of the pelvis; and the body, which was previously largest at the umbilical region, is now considerably less there, than at any other part — it has no longer a cylindrical shape.

There is also an alteration in the mental powers proceeding at the same time, the mind becomes elevated, the eyes betoken increased intelligence, the blush of modesty suffuses the cheek, the gait and attitudes are much altered, — the female becomes thoughtful, and is no longer to be amused with the trifling considerations of childhood.

At the approach of puberty, similar evolution and developement takes place in the constitution of the male. The upper part of the trachea becomes enlarged, by which the voice is changed in sound, losing its femenine and soft tone, by becoming rough, strong, and maculine, hairs begin to make their appearance upon the chin, upper lip, and other parts of the body; and he now becomes subject to peculiar feelings and inclinations, to which, before this period he was a total stranger ; and (as with the appearance of the menstrual discharge in females) he also produces fluids peculiar to his sex ; for, until youth arrive at the age of puberty, neither the vessels of the uterus give forth the menstrual discharge, nor do the testes secrete the seminal fluids. The appearance of these fluids with either of the sexes, is an evidence of the completion of the evolution and expansion of the constitutional faculties, and is in harmony with the growth of the body at this particular period.

The generative organs of animals, are evolved in the same manner at their own proper age, and they undergo changes analogous to those in the human subject.

Many causes have been assigned for the appearance of the menstrual discharge in the human female. Some authors have ascribed it to the oblique position of the uterus, others to the influence of the moon over the female system, ( Richard Mead was of this opinion ) others again have endeavoured to account for it, upon the fact, that the female pelvis is larger in proportion to that of the male ; and on a somewhat similar notion to this, the upright position of the human body, was assigned as a cause of menstruation.

By some of the older authors, it was imagined that

the female gave out less perspiration than the male,

*

that, in consequence, humours collected in the system, which having accumulated to a certain quantity, were carried off by the vessels of the uterus, and they considered that these humours, if not thus disposed of, would from their supposed offensive nature, contaminate the whole system.

Some also thought this flux, to be a bad quality of the blood, which was required for the preservation of the health, to be thrown off periodically.

These ideas, however, like the others, cannot be supported with any plausibility, much less satisfactorily ; for it is well known, that women in hot climates perspire much more abundantly than those dwelling in colder regions ; and yet those women, provided they are in a good state of bodily health, have the menses regularly appear, and decidedly in greater

c quantity than otherwise ; and females who inhabit colder countries, where it is presumed perspiration is less copious, have also the menstrual discharge.

It is equally absurd to suppose that the menses are composed of noxious properties or bad qualities of the blood, for if this were the fact, it must follow that during the period of gestation, the health of the female would be greatly endangered, and the foetus would participate in whatever diseases accrued to the mother from their retention.

It has also been a very generally received opinion, that menstruation is provided to nourish and support the foetus in utero, from the circumstance of the discharge ceasing to appear when conception takes place. But this opinion like the rest is erroneous, for although the nourishment is supplied to the foetus through the umbilical vein, yet we have no proof of any red blood passing from the uterus to the foetus

through the placenta ; the blood contained in the body of the foetus is fabricated by its own powers, indeed, there are many facts to prove that its circulation is independent of that of the mother ; the increase and nourishment of the foetus is, however, dependent on the uterus, by means of the connection of the placenta with the organ.

The foetus receives from its mother aliments ready prepared ; thus the nutrimental fluids are diffused within the cells of the placenta, and absorbed by the radicles of the umbilical vein, which convey it to the proper sinus in the liver,* This will be more clearly seen on reference to the foetal circulation, when it will at once be evident that the stoppage of the menstrual discharge has nothing whatever to do in the nourishment of the foetus. Besides, as Dr. Denman very justly observes — “ If there were a gradual abatement of the menstrual discharge, in proportion to the growth of the foetus, its nourishment might have been presumed to be one of the final causes of menstruation. But as we know that there is an immediate suppression of the menstrual discharge, when a woman has conceived, it must be either superfluous in the early part, or diffident in the advanced state of pregnancy.”

* It is the opinion of some physiologists that the liver may be ' regarded as an organ of assimilation, as well as of secretion.

D. F. Lavagna, concludes that the blood in the umbilical arteries of the funis, contains little or no fibrin, whilst that in the umbilical vein forms a jelly ; hence he infers that the blood acquires fibrin in the circulation in the placenta, which it parts with in its passage through the feetus.f

f Annali di Medicina di Milano, No. 17.

If menstruation in its first appearance in the young female, is caused by a generally plethoric state of the sanguiferous system, (as some writers have supposed) occurring at this particular age, it must follow of course, that the same state of circulation should exist at every succeeding month, and that every woman must be in precisely the same condition; that is, that the slender girl of light complexion and delicate constitution must possess the same proportional quantity and force of circulation, as the strong, florid, hard-working country woman, and that each would menstruate in the same proportional quantity. But we know that such is not the fact, more especially in relation to the quantity of the discharge ; for it is found that the more delicate, fair-complexioned females, possessing the characteristics of the lymphatic temperament * — fair skin and soft flaccid flesh — in most instances, discharge a far greater quantity of fluid at each period, than those of the opposite temperament, And we also know that all females of whatever complexion, constitution, or temperament, provided they are in sound bodily health, have the discharge appear at about the same age of puberty. It is impossible, therefore, to admit of this theory for the cause of menstruation, unless we are prepared to argue upon speculation, in preference to observations founded on fact.

*Dr. Cullen remarks — “ That the growth of the body depends upon the increase of the quantity of fluids giving occasion to the distention of the vessels, and thus producing the gradual evolution and full growth of the whole system. This evolution does not happen equally in every part of the body at the same time ; but successively according to the different size and density of the several vessels determined by the original stamina. Thus, the upper parts of the body first acquire their natural size, and then the lower extremities. By the same constitution, it seems to he determined, that the uterus of the human species should not be considerably evolved, till the rest of the body is nearly arrived at its full bulk. But, as the vesssels of every part, by their distention and growth, at the same time by the same resistance they determine the blood in greater quantity, into the parts not yet equally evolved ; by this means the whole of the system must be successively evolved ; till every part is brought to that degree of distention, which is necessary to bring them to a balance, in respect of density and resistance with one another. Upon these principles, there will be a period in the growth of the human body, when the vessels in the

* Vide Dr. Hamilton’s Outlines, Theory, and Practice of Midwifery, published 1784.

uterus will be distended, till they arrive in a balance with the rest of the system; and their constitution may be such, that their distention may proceed so far as to open their extremities terminating in the cavity of the uterus, so far as to pour out blood there**— Or it may happen that a certain degree of distension may be sufficient to irritate and increase the action of the vessels, and thereby to produce an hermorraghic effort which may force the extremities of the vessels with the same effect of pouring out blood.” Thus he accounts for the first appearance of the discharge, by supposing a congestion of the vessels of the uterus occurring at the proper period for the evolution of that organ. — Dr. Hamilton, speaking of this theory of Dr. Cullen’s, says : “ In either way he accounts for the first appearance of a flow of blood from the uterus in women ; in order to this, he does not suppose any general plethora in the system, than what is constantly necessary to the successive evolution of the several parts of it ; and he proceeds upon the supposition that, — the evolution of each particular part must especially depend upon the plethora or increased congestion in its proper vessels. Thus he supposes it to happen to the uterus; but, as its plethoric state, he observes, produces an evacuation of blood from its vessels — this evacuation must empty these vessels more especially, and put them again into a relaxed state, with respect to the rest of the system. This emptied and relaxed state of the vessels of the uterus will give occasion to a new congestion of blood in them, till they are brought to that degree of distention that they may either force their extremities, or produce a new hermorraghic effort that may have the same effect. Thus an evacuation of blood from the uterus being once begun by the causes before mentioned, it must, by the operation of the same causes return after a certain period, and must continue to do so, — till particular circumstances occasion a considerable change in the constitution of the uterus,”

“ What determines the periods of these returns to be nearly in the space of a month, he cannot exactly explain ; but supposes it to depend on a certain balance between the vessels of the uterus and those of the other parts of the body. This must determine

the first periods, and, when it does so, it can be understood, that a considerable increase or diminution

of the quantity of the blood in the whole system, will have but little effect in increasing or diminishing the quantity distributed to the uterus. It may

also be further observed that, when the evacuation has been repeated for some time at regular periods,

it may be supposed, that the power of habit, which so readily takes place in the animal system, may have a great share in determining the periodical motions of the uterus with greater regularity ; though in the mean time, considerable changes may have happened with respect to the whole system.”

Up to this point, the argument of Dr. Cullen is by no means improbable, more especially when compared with the analogous works of nature, as shown in the organization aud functions of animals and plants. But when he alleges habit as possessing a controuling or regulating power over the function of menstruation, he then alleges that which is contrary to reason ; for it can never be induced, much less possess a controul over any member or function of the animal system, which is not under the power of the will, — it can never be established independently of volition.

But Dr. Hamilton, further adds — “This theory of Dr. Cullen’s, though still liable to objections, seems however as rational as any opinion that has yet been advanced, nor shall we ever perhaps be able clearly to investigate, the secret principle upon which this and many other phenomena of the animal economy equally intricate and misterious depend.”

It was the opinion of former writers,, and indeed it is the generally received opinion of most learned authorities of the present day, that the menstrual discharge is a secretion from the uterus. The chief arguments in favour of this doctrine are founded on the structure of the uterus, and the appearance and qualities of the evacuated fluids, which are said to he totally different to those of blood, and they have consequently erected modes of treatment for Chlorosis and other affections of the health of females, on the supposition of the menstrual discharge being a fluid possessed of peculiar properties, and differing materially from all other excretions of the body ; and that the cause of the general ill-health of the individual, is the retention or suppression of this discharge in the system.

*Sir Charles Clarke describes this discharge as of a red color possessing very little tenacity, which does not coagulate, poured out by the arteries of the uterus, once every lunar month in women, if they are neither pregnant nor suckling.” f Subsequently, he says, “ It is of consequence for practical purposes to observe that menstruation is a secretion, and not an effusion of

* Observations on those diseases of Females, which are attended by discharges — Part 1., page 11.

t Page 13.

D pure blood either from arteries or veins.” But why does he consider it, in common with most other

medical writers, as a secretion sui generis, and materially differing from pure blood 1 " Because, (he

says) all the blood from the sanguiferous vessels (with very few morbid exceptions) coagulates, whilst the fluid of the catamenia does not, whether it comes away in a stillatitious manner, or is retained in large quantity, as in the case of imperforate vagina.”

Speaking of the discharges from the uterus, he observes,*— “ That they all come away from the os externum: but that they spring from various sources and are of different kinds. The parts from which these secretions arise-— are

1. The internal surface of the uterus and of the fallopian tubes.

2. The inner membrane of the vagina.

3. The lacunse about the os externum.

4. The mucous membrane of the uterus.

* Observations on those diseases of Females, which are attended by discharges — Part I,, page 10,

**

These will be seperately considered — l. Secretions from the uterus : these are

«. The menstruous secretion.

(3. The secretion from the mucous membrane of the uterus, which extends to the cavities of the fallopian tubes.

y. The secretion of the glands, in the neighbourhood of the cervix of the uterus.”

From the foregoing arrangement, it does not very clearly appear in what part of the uterus the secerning apparatus for the menstrual fluid is placed. It cannot be considered the production of the mucous membrane — because, to this membrane Sir Charles assigns a discharge totally distinct in its character, — and yet he says the menstrual discharge arises from the internal surface of the uterus and of the fallopian tubes, — which surface, is in fact, the mucous membrane just mentioned — it being the only membrane which does line the cavity of the uterus. On the other hand, it cannot be a secretion from the uterus itself; that organ possessing no characters by which it can be associated with secreting glands : moreover, if the menstrual fluid, were a secretion properly so called, it would naturally be expected to be constantly in the course of production, but we have no gland in tbe animal economy, which secretes an abundant quantity of fluid, during only a few days, and its action then suspended for a month, and this occuring not for one month only, but for twelve times in each year, for about thirty years together.

May not the menstrual blood part with its fibrin during its transudation from the uterine vessels through the mucous membrane before mentioned 1 *

We understand by the term secretion, that function by which an organ separates from the blood, the materials of a substance which does not exist in that fluid, with its characteristic qualities. But we know that fibrin does exist as a characteristic quality of blood, and that it is one of its principle constituents; therefore, the mere separation of a fluid existing before the action of the organ by which it is prepared, is not on that account to be considered a secretion ; this observation is therefore applicable

* Professor D. F. Lavagna is of an opinion u that the only difference between the menstrual blood and common blood, is, that the former contains no fibrin.” — Annali cli Medicina di Milano, No. 17.

to the menstrual discharge, which is merely a separation of the fibrin from the blood, but not on that account a secretion.

I am inclined to think, under all these circumstances, that it is more reasonable to suppose that the menstrual discharge is essentially composed of pure blood, whilst it is contained in the uterine vessels, but in the process of its stillicidation from the vessels through the mucous membrane of the uterus, it becomes deprived of its fibrin, which reduces the discharge to albumen ; in which, however, the colouring matter of blood is held in combination, these being the only remaining constituents of that fluid. The discharge being thus separated from the fibrin of the blood, it becomes intimately mingled with mucous secreted by the membrane lining the cavity of the uterus, which at those periods of monthly congestion is secreted in a much greater quantity than usual.' *

* Whenever there is an unusual determination of blood to any of the mucous surfaces, the quantity of the secretions is increased,

provided inflammation be not present.

u Whatever is capable of increasing the determination of blood to the vessels of the uterus, may increase the quantity of their secretion,” —