suitable intervals, should the pain be severe, and an anodyne lotion to the suffering parts.

Nov. 24, 9 o'clock, A. M. Found my patient sitting up literally "clothed and in his right mind"-the pain had entirely left its former locality, and was now confined to back of head and neck, particularly the latter; but was not very severe-pulse precisely at 60, and of natural force. No febrile symptoms. The bowels had been freely moved by the cathartic-had slept well the latter half of the night. Ordered a blister to back of neck, the blistered surface to be sprinkled with morphia, the cuticle being removed; also continue the powders of morphia pro re nata. I left, engaging to see him again in two days. Business called me immediately from town, and on returning in season to fulfil my engagement, what was my surprise to meet friends returning from my patient's funeral! I learned that about two hours after I left him, he fell into a tranquil sleep, and soon after, in attempting to awaken him, he could not be roused, but muttered deliriously; soon became speechless and insensible, and died at 5 P. M. On hearing the sad news of his death, I feared that the morphia I had left had been injudiciously administered, and had contributed to the fatal result; but I learned afterward that none of it had been used. There was no post mortem examination.

I have thus recorded briefly the simple facts in this to me very interesting case, though the record contributes little to my credit in regard to my diagnosis of the disease, for I acknowledge that I did not suspect the nature or extent of the malady with which I was contending. I felt comforted, however, (I do not say gratified,) in finding that other physicians of greater eminence and more extended experience had been deceived in a similar manner. It is not probable that in the present instance any remedial measures would have averted the fatal issue, though the full extent of the disease had been known at the first.

I have called this a case of "Inflammation of the Dura Mater resulting from Otitis," though no post mortem examination revealed this to be the truth. I infer this from the fact that Dr. Watson has recorded several instances in his " Practice," presenting almost precisely the same symptoms, and where a sectio cadaveris showed that the dura mater was the chief seat of the morbid lesion. In these cases there was the same pain and otorrhea, with a pulse of natural force and frequency, and the same absence of fever and delirium, coma and convulsions, which symptoms continued till within a very short period of the fatal termination. In the present instance, it seems to me probable that the affection of the nasal passages extended to the fauces and along the eustachian tube to the ear, whence it was transferred to the dura mater and adjacent tissues.

Instances of otorrhea are frequent, and in ninety-nine cases out of a hundred, perhaps, they are attended with no danger, and readily yield to remedies; but an occasional fatal result like the one I have described, should

put the medical practitioner on his guard. We should apprehend serious consequences if the pain in the ear has been of long continuance, and especially if it is not relieved by a free discharge of matter.

Diseases of slow growth are apt to elude our search, even though extensive disorganization of an important organ may have resulted. Chronic tumors have gradually invaded the substance of the brain till one hemisphere has been almost entirely destroyed before alarming symptoms have been developed. A correct diagnosis is essential to a successful treatment, and every organ and sense that can aid us in our investigations into the nature of a malady, should be called upon for their testimony.

Physicians would confer a benefit on the profession by recording their mistakes. They would be eminently instructive, not to say numerous. The beacon light is necessary to the safety of the mariner in warning him of rocks and quicksands, as well as the heavenly bodies to show him his latitude, and the compass to guide him in the right course. X. Y. W.

Chlorotic Menorrhagia.

FROM THERAPEUTIQUE MEDICALE," BY TROUSSEAU AND PIDoux. [Translated for the N. H. Journal of Medicine.]

Many physicians, otherwise good observers, think that Chlorosis is necessarily characterized by a marked diminution, or by the entire suppression of the menstrual flux. They regard menorrhagia, that is to say, the immoderate flow of the menses, as an accident so unusual in this disease, that they explicitly exclude it. Yet it is impossible for them not to see frequently in their practice, women profoundly anæmic, in whom none of the general accompaniments of chlorosis are wanting, and who each month suffer large losses of blood. In this case they make a distinction, and call women who are in this latter situation anæmics, and those who are not entirely regular, chlorotics. And yet there is wanting in these anæmic women none of the symptoms of chlorosis; neither the extreme pallor, nor the decoloration of the blood, nor the bellows murmur of the principal arteries, nor the different neuralgias. So that if we examine in these patients all the functions, and all the organs except those of generation, we cannot fail to recognize chlorosis.

In our turn we will attempt to establish a distinction between anæmia and chlorosis. Anæmia is an accidental condition; it is produced at once, without transition, by large losses of blood. One becomes anæmic in a few days

in a few hours. Chlorosis is a permanent condition, usually slow to develop itself, and slow to leave the patient, and always ready to return under the influence of causes apparently the most trifling. Anæmia is a state essentially transitory; a few weeks suffice for the renewal of the blood, and for the complete restoration of the strength, no other help being needed than that afforded by good regimen and diet. A relapse is never to be feared, at least, unless another loss of blood again brings the patient to the same condition.

Thus far nothing appears more simple than the distinction between these two diseases, but it is far from being the case in practice that nature separates diseases so plainly.

Every day we see, sometimes in a woman, sometimes in a girl, a moral impression become the determining cause of chlorosis, but still more frequently the commencement of the disease dates at the time of a first application of leeches, by which in the whole but little blood was taken.

This being established, we can easily comprehend how a too copious bleeding from the nose, a large venesection, the repeated application of leeches, or a considerable menstrual flow may bring one into such a condition that chlorosis may manifest itself, that is to say, that in the place of anæmia, a disease transitory and easily cured by the powers of nature alone, there is developed a peculiar state of the system, by reason of which the decoloration and liquefaction of the blood goes on daily, although the losses of blood which at first caused it are not repeated. Here then, anæmia has its point of departure from chlorosis; it has disposed the system to chlorosis, and made this more easy and rapid in its development.

Let us now examine what part anæmia and chlorosis may have in hemorrhages.

Without troubling ourselves with classic distinctions between active and passive hemorrhage, it will be granted that uterine and other hemorrhages are sometimes connected with a state of the system in which reactions are energetic, and in which the phenomena, general as well as local, indicate a superabundance of life; sometimes occur in persons who are in a condition precisely the reverse. We would admit that in all hemorrhages, (except the traumatic and hypostatic) there is previously a local difficulty analagous to, if not identical with the first phenomena of inflammation, but we wish here to consider only the general organic condition, taking no account of the local. But the general condition of the system is here a matter of extreme importance. When, the hemorrhagic nisus being the same, the blood is in different states, it is impossible that the flux should not be, and in fact it is much modified by the degree of plasticity of the blood.

To take at first the most simple examples, let us notice what occurs in a recent wound, on the one hand in a vigorous, plethoric man, or, on the other, in a person completely anæmic. In the first case, a slight hemorrhage arrests itself; and if it is necessary to tie large arterial trunks, the use of any

hæmostatic means to stop the oozing of blood from the capillary vessels is superfluous; while in the second case, even after the ligature of small vascular trunks, there is still an oozing of a considerable quantity of blood, or at least of a reddish serosity, which deeply stains the clothes, and the abundance of which seriously threatens the life of the patient. That which is observed in man is also true of animals, considered in classes. Thus, while we can amputate the members of a dog and make enormous mutilations without destroying his life by the loss of blood, rabbits die exsanguine after a slight wound. The plasticity of the blood of dogs prevents the hemorrhage which on the other hand is favored by the fluid state of the blood of rabbits. But the proneness of anæmic individuals to hemorrhage, is evident from the commencement of a bleeding. Thus, if we apply leeches for the first time to an infant, the loss of blood, other things being equal, which will follow will be much less than that which will follow the second application; and this will be less than the hemorrhage which will follow a third application, so that one may see, unfortunately too often, the bite of a single leech cause a fatal hemorrhage in a child already exhausted by losses of blood.

If then anæmia, which we may consider as a transitory, and in some sort as an acute state, can have such an immense influence on hemorrhages, how much greater will that influence be if it remains for a long time; above all, if chlorosis is developed with all its accompaniments.

Now let us transfer to the mucous membrane of the uterus that which we have just stated in general. If a woman or a young girl has the menses too abundant, it will doubtless be true for some months that the interval which separates the menstrual periods will be sufficient for the re-constitution of the blood; but soon the repetition of the same accident will produce anæmia, and at length chlorosis. Thus, if the hemorrhagic nisus remains the same, the flux, in accordance with what we have said above, will become more and more abundant; and the chlorosis, the cause of the increase of the hemorrhage, will itself be aggravated by the hemorrhage, and the patient revolving continually in this circle, is soon brought into a critical state. Let us not loose sight of these principal facts; chlorosis is produced by the too abundant menses-chlorosis makes the menses yet more abundant. In other words, the too copious menses cause a thinning and liquefaction of the blood-the thinning and liquefaction of the blood are a cause of uterine hemorrhage. There is then a form of chlorosis which we may call menorrhagic. But is this form of chlorosis common in young girls? It is rare. After searching we can only find twelve cases. In adult women it is more common. ever, we ought to say that our observations in hospital as well as private practice, do not comprise a sufficiently large number of cases to enable us to make a complete statistical table. We have collected a dozen cases of menorrhagic chlorosis-three in young girls, nine in married women. None of these patients had any organic lesion of the uterus; we proved it positively

How

in all the married women, and as to the single, where an examination would have been difficult and hardly proper, we have judged by the rapidity of the cure, and by the good condition in which we have seen them for many years after, that the womb was exempt from serious lesion.

We now come to the therapeutics.

Two important circumstances present themselves to the physician-the `menorrhagia on the one hand, and on the other the chlorosis. The menorrhagia is combated by means which we are accustomed to consider injurious to chlorosis, of which the treatment, usually easy, is considered proper to excite the menses. The practitioner is thus placed between two shoals which it may be impossible for him to avoid.

Let us see if it is true that the chalybeate preparations so powerful in the treatment of chlorosis, are in fact emmenagogue medicines. There can be no doubt that in a chlorotic woman who has amenorrhea, iron reëstablishes the health and the uterine flow; but does it act as an emmenagogue, or as a re-constituent? Always when we give ferruginous preparations, in the case of chlorosis complicated with amenorrhea, the first phenomenon which we observe is the re-coloring of the tissues and at the same time the progressive diminution of the depraved appetites, of the disorders of the stomach, of the palpitations of the heart, of the difficulty of breathing, of the bellows murmur in the principal arteries, of thirst, &c.; so that after six weeks or two months of proper treatment, the appearance of the most vigorous health has returned, but still the menses are wanting; and it is not rarely the case that in continuing this treatment we notice symptoms of true sanguineous plethora, but still the menses do not appear. The health then is reëstablished—the chlorosis is cured, but the amenorrhea is not. Soon the menses appear and afterwards go on in their normal course. Now, here, the iron acted at first as a re-constituent, and when health was reëstablished, the functions of health, and menstruation among others, were in their turn reëstablished. The patient, then, has not recovered her health, because under the influence of iron the courses have returned; but, on the contrary, the courses have returned because the patient has recovered her health under the influence of iron. This is the highest evidence, for, if it were otherwise, we should see that the return of menstruation is the sign of the return of health; and it is the reverse which has taken place.

It is from not having observed the evolution and succession of these different phenomena, that practitioners have always imagined that iron was an emmenagogue; and this error, believed for centuries, will still prevail a long time in spite of the clearest facts, and in spite of the most careful observation; for, we are so made that we willingly cling to error, and obstinately resist truth.

Let us go a little farther. Not only is iron not an emmenagogue, but it is on the contrary, an hæmostatic. Thus, and we say it after experimenting on a large scale in our hospital, in women who are regular and not chlorotic,