the investigation should be pursued until the cause that determines the deficiency is detected. But in many cases a difficulty arises at the very outset of the inquiry, when it is necessary to distinguish between the original causes of the disordered menstruation and the general symptoms that have preceded or accompanied the arrest of functional action, often the direct results of the same untoward condition that caused the arrest of menstruation.

1. Systemic Amenorrhoea.-Scanty, delayed, or arrested menstruation depending on constitutional causes, includes a wide range of cases. It may be that the circulatory system is at fault, as in pale, anæmic, overgrown girls; or the nervous system, as in sluggish, inanimate patients. It may be that the nutrition of the body is depraved by bad food taken, by good food ill-digested, or by retention within the body of excrementitious matter, either in the loaded intestines, or by reason of insufficient depuration, whether by the liver, kidneys, or other excretive organ. There may be some hereditary constitutional taint, or some influence from without which modifies the general health. Cases occur in this country where menstruation ensues regularly during the summer months, and is partially or entirely absent during winter; removal to a warm climate being followed by a natural establishment of the function.

It very commonly happens that healthy country-girls, coming to reside in London, suffer from amenorrhoea. This is especially frequent with servants and work-girls, and constitutes a form of amenorrhoea which it would be eminently

injudicious to treat by any of those methods which exercise a direct stimulative influence on the generative organs. But the most illustrative cases of systemic amenorrhoea occur in women convalescent from diseases of an exhaustive kind. Very frequently several periods pass without fully restoring menstruation, though the recurrence of a distinct effort may be detected; at each time increasing, as the strength is regained, until the healthy relief is fully established. The meaning of this arrest is evident. Regular ovulation, and with the attendant menstrual changes, would possibly involve an urgent and immediate call for a nutritive supply to sustain the germ. The system, being itself under repair, cannot afford this; the demand could only be met at the risk of permanent injury, and so the primary and essential process of menstruation is deferred. Those exceptional cases in which pregnancy ensues before a woman's strength is restored after an illness, are almost invariably attended with unusual suffering, and often followed by very serious results.

A considerable number of the remedies successfully employed in amenorrhoea effect their purpose by improving the general health; they have, in fact, no direct influence whatever on the generative cycle in women, other than that which they exert over all the organs and functions of the body, equally in males and females; and as the majority of cases of amenorrhoea recognise a systemic origin, the comparatively great success of constitutional treatment is readily understood. The various preparations of iron and of strychnia, of iodine, of the mineral acids and vegetable bitters; the influence of pure air, good food, and

of bathing; the providing that due nutriment shall be supplied and excrementitious matter freely eliminated-all these are of acknowledged value in restoring healthy menstruation, but exercise no specific local influence.

Of the preparations of iron, the sesquioxide and compound iron pill, long favourite remedies in cases of amenorrhœa, are now banished from the pharmacopoeia, and the mistura ferri co., or Griffiths' mixture, another unstable preparation, might also be beneficially superseded by the more elegant and certain compounds which modern pharmacy has added to our resources. Among these may be especially mentioned the citrate and tartrate and acetate, the saccharated carbonate, the scaled pyrophosphate, syrup of the iodide and of the phosphate, and the sulphate, saccharated or granulated in order to prevent oxydation. The new tincture of perchloride of iron (P.B.) is, according to my experience, a less valuable preparation than the old muriated tincture, which contained a proportion of hydrochloric ether. It is in amenorrhoea with marked anæmia that iron is especially indicated. Where the want of vigour and of general tone is obviously traceable to the nervous system, the preparations of strychnia often prove very beneficial. This drug was first recommended as an emmenagogue by Sir T. Baddeley. It has undergone the usual fate, necessarily failing where employed in unsuitable cases. I have for some years almost exclusively employed in asthenic amenorrhoea (as well as in many other cases) the ignatia amara in place of the nux vomica. I believe it less liable to produce those excitant

influences occasionally occurring, even when the dose of strychnia has been very minute.

The vegetable bitters and the mineral acids often act as emmenagogues, in so far that they ensure a proper order of the food-changes; thus affording healthy nourishment, and inducing due fulfilment of functional action. But this series of processes would be of little avail were the blood itself already loaded with noxious elements. If the air breathed be deficient in oxygen or otherwise vitiated, this implies a partial arrest in the ultimate assimilation of the nutritive material prepared with such elaborate care. Just as retention of urea from inefficient renal action poisons the blood, so accumulated fæces may produce by resorption a toxæmic influence quite as marked as in cases where there is excess of bile in the blood from

hepatic obstruction. The injurious influence of defective sewerage external to the body, has deservedly attracted great attention of late years. But the poison is the same, whether generated within or breathed in foul air from without. In all such cases, many stages intervene between the state of health and the time when the resistant powers of the frame succumb to the noxious influence, give up the fight, and allow full sweep to the poison. For every one laid up with typhoid fever, there are hundreds exposed to the same influences who manage to hold their own, and, though notably reduced or constitutionally damaged and enfeebled, escape actual prostration by fever. In women exposed to such noxious influences, the amenorrhoea is only one of many evidences of toxæmia.

It is especially among the poor of large cities that such cases are met with, and they very constantly refer their general symptoms to the arrest of menstruation. In such cases, pure air and depurative remedies, especially combinations of chlorine, may act as emmenagogues.

There are certain cases of amenorrhoea of systemic origin, in which all ordinary remedies fail, but where arsenic exercises a marked beneficial effect, the menstruation recurring so soon as the system presents indications of the influence of the drug. There is neither a plethoric state, the sthenic amenorrhoea of some observers, nor is there an anæmic or asthenic condition. But the cases usually present some approach to that unhealthy state of the skin which in an extreme degree marks diseases where arsenic usually acts as a specific. In several such cases where the skin was dry and hard, or scurfy, arsenic has succeeded in my own practice, when a long succession of other remedies had previously failed to induce or re-establish menstruation.

2. Amenorrhoea due to some defective action in the ovaries or the uterus.-The evidence in such cases is both negative and positive. There is the absence of those general characteristics already mentioned, and the symptoms follow "certain periods more or less well marked in the regularity of their return, when a special disorder of the nervous and vascular systems, and various forms of local suffering referred more or less distinctly to the womb or to the parts imperfect menstrual effort.” 1

adjacent, announce a sort of Where the deficient menstrua

1 Dr. West: Diseases of Women, p. 37.