disease consequent upon functional difficulty at the rate of 32.30 per cent., a proportion far exceeding that of any of the classes already noticed.” Every medical man will recognise the soundness of the following remarks:

"The cause of this peculiar susceptibility to disease in the class of patients now under consideration, becomes a question of paramount importance; and is, without doubt, to be found in the faulty system of education pursued at boarding schools. The mental faculties are called into premature activity, and tasked to a degree beyond their power of endurance, and the mind is crowded with a mass of inatter under the fictitious denomination of accomplishments, which Nature never designed that it should entertain; while the proper training of the physical constitution is totally disregarded. Moreover, the indulgence of a propensity, irresistably active at this period of life, to the reading of novels, romances, and works of a similarly vicious character, has likewise a very injurious tendency. Witness for instance, the violent and often dangerous paroxysms of hysteric emotions occasionally consequent upon the mere perusal of an affecting narrative, having probably no foundation save in overstrained analogy, or in fiction. These are agencies to which the unlettered are entire strangers, or which they experience but seldom, and only to a very limited degree.

"It thus appears that an occupation of whatever kind, and wherever pursued, which requires no more than a moderate application of mere physical power for its performance, will bear a very favourable comparison in regard to its effect upon bodily health, with one in which the exercise of these faculties is neglected. The fact is, the muscles were designed for a purpose; and their due employment is no less necessary to the harmonious working of the economy of which they constitute an important portion, than for maintaining a healthy relationship with the objects of external nature. An employment requiring moderate and regular exercise, especially if pursued in an open untainted atmosphere, is of the first importance; while inactivity, whether the individual reside in town or country, is almost invariably followed by ill consequences. In no class of people is the menstrual function so healthily performed as in those necessitated to earn the means of subsistence by personal exertion; provided always that the employment be suitably adapted to the constitutional powers of the individual; while the converse of this is known to obtain with those in easy circumstances. Amongst farm servants and others, the period of puberty is seldom accompanied by any derangement of the general health; but in the higher grades of society, it forms an era of the greatest anxiety, and is often the commencement of serious and irreparable organic mischief." P. 90.

CHAP. III.-Diseases of Menstruation.

There is much in this chapter too, that might have been omitted without any detriment. A great portion of the details, connected with the subject of Amenorrhoea, serves only to swell the bulk of the volume. Witness, for example, the minute details of six or seven cases recorded to illustrate the effects of retarded mentruation in young girls, and of others to shew the ill consequences of the sudden stoppage of the discharge from exposure to wet and cold, or from some violent emotion of the mind, &c.

The account given of Dysmenorrhoea is exceedingly incomplete. Mr. W. alludes to the occasional presence of ulceration of the os uteri in this morbid state, but without attributing the one to the other as its producing cause. Dr. H. Bennett, however, has recently endeavoured to shew that, even in virgins, painful menstruation is occasionally connected with structural lesion of the uterine orifice, that a correct diagnosis cannot be formed

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without the aid of the speculum, and moreover, that the disease cannot be effectually cured without appropriate topical treatment. He does not hesitate even to propose that the hymen should be divided, when the speculum cannot be easily introduced. Surely such an extreme measure as this is scarcely warrantable under almost any circumstances; but, as Dr. B. has promised to publish the particulars of some cases in which he deemed its adoption necessary, we shall only, for the present, express our earnest hope that no medical man will ever have recourse to the step in question, save with the sanction and concurrence of another professional man, as experienced at least as himself.

We are uncertain whether Mr. Whitehead has used the speculum in virtuous unmarried females. No distinct mention is made of it in the body of his work; but there is a strange allusion to it in the introductory remarks, in these terms:-" Some are admitted (into the Manchester Lyingin Hospital) who are neither pregnant nor suckling, as well as a number of young unmarried females, labouring under retention or suppression of the menses, leucorrhoea, prolapsus, hysteria, chlorosis, and similar affections connected with disordered menstruation. In all such cases, I made it a point, whenever practicable, to examine the uterus with the speculum, and almost invariably found the existence of disease of this organ sufficient in extent to bring the other symptoms under the arrangement of sympathetic disturbances merely. This view was confirmed by the results of the treatment adopted. I have now examined upwards of two thousand such cases, and the result has almost invariably been the same." Are we to understand from this passage that there is organic or structural disease of the uterus in all cases of "retention or suppression of the menses, leucorrhoea, hysteria"? &c. Surely not; the very supposition would be

monstrous.

The section on Menorrhagia, or, as our author calls it, Metrorrhagic Menstruation, contains but little that calls for notice. Considerable confusion has been most gratuitously introduced into our author's remarks by his using the term metrorrhagia in a different sense from metrorrhagic menstruation; the former he employs to designate "uterine hæmorrhage, altogether unconnected with menstruation." It must be to this description of sanguineous evacuation that the following remarks on "metrorrhagic discharges" apply :—

"These are not unfrequently witnessed in young girls before the age of puberty; and they are by no means uncommon in those who have finally ceased to menstruate. In the former, such phenomena are usually associated with the hæmorrhagic diathesis; in the latter, with disease of the uterus, which, when not of a malignant character, consists in ulceration about the cervix, often the result of varicose inflammation; or of endo-uteritis." P. 141.

Whether the "abnormal discharges of blood," referred to in a subsequent paragraph, belong to metrorrhagia exclusively, or whether they apply in part to metrorrhagic menstruation, it is not quite easy to determine:

"Abnormal discharges of blood frequently come on during the early months of pregnancy; or supervene upon suspension or irregularity of the menstrual function, arising from other causes, and being accompani with abdominal en

largement and the general indications of pregnancy. When this state of things happens in the young unmarried female, the investigation is often fraught with peculiar difficulty: the employment of the only means by which a satisfactory knowledge of the case can be arrived at, being obstinately objected to. And even should every facility for the procedure be afforded, whether the existence of pregnancy be substantiated or disproved; it is still one of the most delicate positions in which either patient or practitioner can be placed, involving, on the one part, the discharge of a very disagreeable, difficult, and often thankless duty; on the other, sacrifice, to some extent, of character, and perhaps exclusion from society. For although the calumny which led to the investigation be proved to be unfounded, it is difficult to remove altogether the impression from the mind of the multitude: a woman's virtue cannot bear even to be suspected. Should an unfavourable opinion be pronounced and be found erroneous-for after the most rigid scrutiny, the ablest enquirer may fail to discover the truth-the mistake will never be forgotten, but will remain a blot upon his character ever afterwards. Under all circumstances, the practitioner cannot be too scrupulously guarded in delivering an opinion; and it should ever be his aim, however culpable his patient may be, to shield her fame, as far as is practicable, from the censorious taunts of an unfeeling public." P. 144.

Mr. Whitehead has omitted to inform his readers how this awkward blunder may be best avoided.

CHAP. IV.-Last Menstrual Crisis.

The particulars are given of a case, in which menstruation continued to be regularly and uninterruptedly performed from its first establishment in early life up to the 75th year. The woman was, at the beginning of the present year, an inmate of the Manchester Union Hospital. "It is remarkable that during every pregnancy (13 in all) she continued to menstruate until the last month of the full time, the discharge being similar in quantity and character to that of the non-gravid state; and that the discharge re-appeared, notwithstanding that she suckled her children, in two or three months after the birth of the child."

"With the exception of the pregnant periods just referred to, the menstrual discharge has suffered no interruption from its commencement until the present time, and there have been no particulars in which it has differed during the latter years of life from its state during her youth. At both times it continued for three days; and now, as then, it is preceded and accompanied by a sense of lassitude and pain in the back, which apprise her of its approach. The character, too, of the discharge as it occurs now, does not differ either in appearance or quantity from that to which she has been accustomed throughout life. She further states that her mother, who attained to a great age, was the subject of the same peculiarity; continuing to menstruate until the close of life; and that she had always heard a similar account of her maternal grandmother."

Mr. Whitehead mentions a still more curious case, in which a regular monthly discharge occurred in an old lady, 91 years of age, for upwards of a twelvemonth before her decease, although she had ceased to menstruate in her 54th year.

"In February, 1845, thirteen months before her decease, having suffered for several weeks previously from distension and general uneasiness of the abdomen, aching of the loins, and slight dyspeptic symptoms, a quantity of blood, bearing

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all the characters of ordinary menstrual fluid, was observed escaping from the vagina, and at first occasioned considerable alarm. It came on in the night-time, an hour or two after she had taken, with the view of promoting perspiration, a cup of hot beer-whey, and it continued uninterruptedly three or four days, then ceased; leaving the patient perfectly free, however, from the pain and uneasiness before complained of. About three weeks afterwards a similar train of symptoms appeared; the discharge, preceded by the lumbar and abdominal uneasiness as on the former occasion, continuing from three to four days, after which she expressed herself completely restored. In this manner the functional phenomena were periodically developed at intervals of twenty-three or twenty-four days, during the remaider of her life; the health being in a good state the whole time, with the exception of some slight sympathetic disturbance at the critical periods. She died at the thirteenth or fourteenth accession, while the organic product was still escaping. On each occasion the discharge, both as to quantity, appearance, and the period of its duration, together with the premonitory and accompanying symptoms, were everyway similar, so far as she was able to judge, to what they had formerly been during the activity of the catamenial function. An inspection of the body, after death, was not permitted." P. 148.

In another case, related by our author, menstruation has continued to recur regularly up to the 66th year; the lady is still alive.

From a tabular list of 69 cases, of whose history a brief abstract is given, it appears that the average age, at which menstruation ceases in this country, is between the 47th and 48th years of life. With respect to the diseases which more immediately appertain to this important change, our author remarks :

“ The forms of uterine disease commonly met with at the period of the last change of life, may, for practical convenience, be arranged under three heads, each distinguishable from the other by the character of the discharge with which, early or late, it is almost invariably accompanied; and also, by the kind and degree of suffering which it occasions in the organ immediately implicated, and the sympathetic disturbances simultaneously awakened in remote parts of the body. The first, and most common of these affections, is characterized by a muco-purulent discharge from the vagina, generally denominated leucorrhæa, or the whites; but which differs from simple leucorrhoea in several important particulars; the second, is often accompanied by vaginal hæmorrhage, the discharge differing, both as to its properties and in its source, from the menstrual product; the third form, is characterised by a watery, sanious, serous, or ichorous discharge, which is sometimes mixed with blood, sometimes with pus, mucus, or albumen-like shreds, and occasionally with small portions of fleshy matter, the product of the organic change upon which it depends. It generally emits an offensive odour." P. 155.

The first of these states is almost always associated with, and indeed dependent upon, the morbid state of the womb that is thus described:

"The lesion usually consists in hypertrophy of the cervix, or of the whole organ, with an ulcerated state of one or both labia. The most common form of ulceration is that of a simple granulating surface with a defined margin. Sometimes there is induration of the anterior labium, which, when considerably enlarged, projects downwards in a conical form, and is generally excoriated or superficially ulcerated, especially on its posterior surface; the abrasion extending in an upward direction towards the inner cervix. At other times both labia are indurated, with or without abrasion; and, accompanying this state of parts, there is often also an ulcerated fissure, more or less deep, occupying one or both com

missuræ labiorum. Occasionally, the labia appear but little, or even not at all enlarged, or in any way diseased, but the margin of the os presents a ring of intense redness. This is the sure indication of inflammation of the lining membrane of the uterus, or endo-uteritis; and is accompanied with enlargement of, and pain upon pressure being applied to, the body of the organ. That these morbid conditions of the uterus constitute the principal cause of all the disturbances before enumerated, is sufficiently clear, from the circumstance of their being most signally, often instantaneously relieved, by the mere use of local remedies, even without the assistance of constitutional treatment." P. 158.

For the cure of such cases, the general health must be improved by the use of alteratives and tonics; the local disease will require the occasional application of the nitrate of silver, either in the solid state or in that of a very strong solution-3j. to 3iij. of water.

When there is reason to believe that chronic Endo-uteritis is present, the treatment recommended by our author is thus explained:

"It consists in the application of leeches to the hypogastrium or over the upper part of the sacrum; and in the exhibition of remedies similar to those employed in Case XXI. In addition, when all febrile excitement has become completely subdued, a more decidedly tonic plan will probably be indicated; and considerable benefit may be derived from injecting within the uterus, a weak solution of nitrate of silver in combination with extractum conii; or by the introduction of an ointment of the same material. The latter form of the remedy is applied by means of a small piece of lint fixed upon the end of a long probe, and fastened to the handle of the instrument with a thread, with a view of securing its safe withdrawal. Not only does no disturbance or discomfort of any kind ensue upon the employment of these local measures; but, on the contrary, a beneficial change is often evident after the first application, and I have witnessed the suspension of pain to be instantaneous. The operation of injecting is done with the aid of the speculum, by means of a long syringe similar to Clarke's female syringe, having a nearly straight tube, with but one hole at its extremity. If carefully managed, from one to two drachms of the remedy, (which may be composed of different materials, varied in form and strength according to circumstances)-will pass within the organ at each operation, most of which returns almost immediately. The temperature of the fluid, previous to being used, should be raised to about ninety degrees, Fahr." P. 163.

The second condition alluded to is, in very many cases, connected with the existence of a varicose ulcer of the cervix of the uterus. "The hæmorrhage, which is sometimes alarmingly profuse, may cease after a few hours; but it often continues many days, or weeks, and sometimes several months. On subsiding, it is replaced by a light-coloured discharge which is observed, occasionally, to be more or less mixed with blood, but consisting essentially of a combination of mucus and pus in variable proportions; the vaginal mucous membrane participating, in greater or less degree, in the generally increased action of the surrounding parts, thus furnishing its peculiar secretion in unusual abundance. The affection under this form, familiarly known as the whites,' may harass the patient for years, or, by gradually undermining the constitutional powers, may keep her in a state of suffering and misery to the end of life. In some instances the congestion, which at the onset was confined to the lower part of the organ, does not terminate in varicose ulceration, but, becoming more generally diffused, assumes the form of uterine phlebitis, accompa