twice or thrice; whether this combination produces its salutary effects, by acting on the skin, or by improving the secretions of the alimentary canal, the author cannot determine; but he has invariably found it a useful medicine.. In cases, however, of abdominal irritation, it seems inapplicable, and ought to be withheld." 68.

We need not dwell on the stage of exhaustion in typhoid fever. Dr. O'Brien's practice is one rather of vigilant observation than of active treatment. Generally speaking, however, "it is tonic and moderately stimulant,” Gentle laxatives, blisters, &c. are employed; but wine and opium have not answered his expectations, and on them he places little or no reliance.

We must now close our analysis of Dr. O'Brien's report. It is valuable, as proceeding from an institution where experience, on a large scale, forms the basis and affords the data.

XII.

PRACTICAL OBSERVATIONS ON LEUCORRHOEA, FLUOR ALBUS, OR WEAKNESS, WITH CASES ILLUSTRATIVE OF A new Mode of TREATMENT. By George Jewel, Member of the Royal College of Surgeons, one of the Accoucheurs to the St. George's and St. James's Dispensary, &c. 8vo. 1830.

OUR readers are aware that, in our 24th Number, page 517, et seq. we gave an account of Mr. Jewel's paper on the use of nitrate of silver in leucorrhoea, as published in the Medical and Physical Journal, for October, 1829. The present essay is an amplification of that paper, including some additional experience, and a more systematic investigation of the subject.

The first and second chapters of the present work are dedicated to the pathology of leucorrhoea. The popular opinion, no doubt, is, that leucorrhoea proceeds from debility, whether local or constitutional. This opinion is countenanced at least, if not supported, by medical authorities. Dr. Clark, when speaking of the transparent mucous discharges, unaccompanied by change of structure, classes such affections under two heads-namely, those which originate from, or are accompanied by, increased action in the vessels of the part, and others which arise from debility. Mr. Burns has given an opinion somewhat the same, and so have many other authors.

"A minute pathological inquiry must, I think, lead to the conclusion, that local irritation, determination, or inflammation, is the immediate exciting cause. Whilst some writers have insisted on leucorrhoea being always a local disease, having its seat, for the most part, in the uterus or vagina; others have maintained it to be symptomatic, having its origin in general functional disturbance of the system. To this not by any means unimportant part of the subject, I have directed my attention, in order to discover which opinion was entitled to credit; and I have been led to the belief, that the vaginal discharge is commonly the result of some direct local stimulus. That cases do occur, which seem to depend upon a disordered state of the digestive organs, or disturbance of the general health, is obvious; but this altered or relaxed state of fibre, is one which particularly predisposes to local inflammation, or congestion. BATTIN,

however, who has written upon this subject, makes his eighth species of the disease, leucorrhoea from indigestion;' whilst PINEL commences his classification with the constitutional' variety. It is not unusual for a female to have excessive leucorrhoeal discharge accompanied by great disturbance of the system. Vertigo, a preternatural heat of the surface, a coated tongue, thirst, and a full pulse, are the symptoms which often accompany, and sometimes precede, the vaginal discharge; when, after a few days of active purgation, and a strictly vegetable diet, all the symptoms, together with the discharge, entirely disappear. Here it must be evident that the uterine vessels partake of the general plethoric state, or disturbance of the system." 4.

Dr. Dewees has divided vaginal discharges into three classes-one (the leucorrhoea of direct irritation) following inflammation of the mucous membrane of the uterus or vagina, produced by some local cause, as laborious parturition, irritating substances applied to the surface of the vagina, &c. Secondly, the "leucorrhoea of remote irritation," in which are ranged all those instances in which the vagina sympathises with some other organs or structures of the body, as with the uterus during pregnancy, or with the same in long-obstructed menses-with the rectum when irritated by hæmorrhoids, &c. Under the third head (the leucorrhoea of habit) he includes those instances of the discharge, which continue after the active or inflammatory condition of the parts has ceased; as after syphilis or gonorrhoea has been cured, a prolapsed uterus restored, &c. It is evident that Dr. Dewees considers the disease as almost invariably of local origin.

"Every protracted or severe case of leucorrhoea, will be attended by great functional disturbance, an interrupted digestion,* a pallid and leucophlegmatic countenance, scanty and irregular menstrual evacuations, a morbid sensibility of the nervous system, oppressed respiration, and exhaustion of the vital powers. It will produce, in short, a variety of anomalous complaints; not unfrequently a remarkable coldness of the feet and legs, and prolapsus, or falling down of the womb, and sometimes prevents conception from taking place. Such are the common effects of profuse vaginal discharges; and hence will appear the difficulty, in the more advanced period of the disease, of distinguishing between cause and effect. The various dyspeptic and other symptoms, which sometimes prove so distressing to the patient, I conceive are, for the most part, secondary or sympathetic, and consequently, if we succeed in removing the local disease, these will gradually disappear. It would, however, be injudicious to direct the attention wholly to the one, to the neglect of the other. It has been well observed by an able writer, that an idiopathic and organic affection of some part may co-exist with disorder of the general health, and that which was a mere functional complication in the beginning, may become organic disease in the sequel." 7.

As to the actual seat of the disease, much diversity of opinion has, as usual, obtained. Cullen, Leake, Hamilton, Sylvius, Astruc, &c. seem to think the leucorrheal discharge issues from the same vessels that furnish the menstrual secretion. Mr. Jewel believes that this discharge seldom issues from the uterine cavity. The uterus is no doubt lined by a mucous membrane, and, like all other tissues of that kind, may occasionally throw out a superabundant quantity of mucus, or even pus.

"Le derangement des digestions accompagne constamment leucorrhée constitutionelle."-GARDIEN.

No. XXVI. FASCIC. III.

E E

"By attending to the following circumstances, we shall, in some cases, be able to ascertain whether the discharge issues from the uterine cavity, or not. When the seat of the disease is in the vagina, or cervix of the uterus, the discharge commonly appears during the night, notwithstanding the patient is confined to the horizontal position, but if in the cavity of the womb, it is generally suspended a piece of sponge, therefore, being introduced into the vagina at bed-time, will occasionally determine the question; for if the discharge issues from the surface of the vagina, it will become saturated with it. This test, it must be admitted, is not implicitly to be relied on; although, by being often repeated, it may throw considerable light upon the pathology of the disease. The discharge issuing from the cavity of the womb, so completely deranges the functions of this organ, that in almost all cases it renders the female incapable of conception. A purulent discharge, the result of active inflammation in the mucous lining of the uterus unconnected with parturition, is not common in its

occurrence.

Some writers, who seem to have devoted a good deal of attention to female diseases, state that most leucorrhoeal discharges arise from the mucous surface of the vagina. Dr. DEWEES has declared his belief that it consists in an altered action of the vaginal lacunæ, or glands, which furnish, in a state of health, the moisture so important to the part; and Mr. BURNS imagines that the most ample and most frequent source is from the vagina.

It must be admitted, that a great pathological difficulty sometimes arises, in deciding upon the tissue or part which has been morbidly excited but it is fortunate, that in the majority of cases, the local habitation of the disease is of limited extent; and I may add with confidence, that we possess a remedy which, if judiciously employed, will generally effect a cure, even under most unfavourable circumstances." 11.

Three states or conditions, Mr. J. observes, are requisite for the production of leucorrhoea-irritation, congestion, inflammation of the subacute or chronic kind. NAUCHE in France, and GooсH in this country, have sepa rated irritation of the uterine system from inflammation of the same. Mr. Jewel does not quite accord with Dr. Gooch, in his definition of IRRITABLE UTERUS-namely, a painful state of that organ, neither attended by, “nor tending to produce a change in its structure." This, he thinks, is a bold assertion, since unhealthy action, if long kept up in a part, may eventually produce" a decisive morbid change." When we consider how long the most painful affections, for example, neuralgia, will go on without any appreciable alteration of texture, we cannot question Dr. Gooch's definition. Besides, although it is probable that leucorrhoea may be attended with chronic inflammation of the parts, it does not follow that a painful or irritable uterus should be attended by the same. Pain may and does exist, quite independent of inflammation. Mr. Jewel introduces a long extract from Dr. Gooch, on irritable uterus, for the purpose of making a pathological distinction between irritable uterus and leucorrhoea.

"First in reference to the pain experienced by the patient, when pressure is applied over the pelvic region, and the absence of leucorrhoea, as indicative of the body of the uterus being the seat of the disease; and secondly, the presence of a copious vaginal discharge, at first thin and transparent, then becoming thick and opaque, as indicative, either that the morbid action is limited, or has extended, to the cervix uteri.

The sequelae of this irritable state of the uterus, and its contiguous parts, are great depression of spirits, languor, palpitation of the heart, hysterical and other nervous sensations, in all their Proteian shapes." 18.

We shall now introduce a case to shew Mr. Jewel's practice in this troublesome complaint.

"Case 1.-S. J. ætat. 49, residing in Bridle Lane, admitted a patient under my care at the St. George's and St. James's Dispensary, on the 10th of June. She is the mother of fourteen children, exclusive of two abortions, and has, during the last twelve months, been subject to profuse catamenia, and excessive leucorrhoeal discharge of a yellowish colour. She has pain in the loins, shooting in paroxysms through the region of the uterus, in which there is also a sense of fulness and throbbing. She complains of great languor, with loss of appetite and uneasiness at the pit of the stomach. She is frequently attacked with the globus hystericus, and disturbance about the head, and says that a flow of tears affords her much relief. Pulse 85. Bowels confined.

Ten ounces of blood to be abstracted from over the sacrum by cupping.

B. Magnes. Sulph. Zvj.

Infus. Rosæ.. Zvijss.

Acid Sulph. dil. 3j.-M. ft. Mist. cujus sumantur

Cochlearia duo vel tria ampla, mane, quotidie.

B. Argent. Nitrat. gr. xij.

Aq. distill..... 3vj.-M. ft. Injectio.

14th. During a period of twenty-four hours after the cupping, she felt extremely faint and sick, and now complains of increased languor. Says she has used the injection regularly, notwithstanding the presence of the catamenia, and that it occasioned no degree of pain, except a little smarting, the parts having been for some time in an irritable state.

To omit the aperient medicine.

The strength of the injection to be increased from grs. ij. to grs. iv. to the ounce of water; and to take a pill, containing five grains of the extract of hyosciamus and half a grain of opium, at bed time.

18th. The sanguineous discharge has ceased, having continued only a week, its usual period being from ten days to a fortnight. The leucorrhoeal fluid has become white and thinner than it has been for several months.' The local pains are greatly relieved, but she still complains of occasional heat and throbbing about the womb.

To continue the injection.

22d. The leucorrhoea has ceased, and the local heat and pains have almost left her. There is still great languor and loss of appetite.

....

Zvijss.

B. Infus. Rosæ
Sulph. Quinin. .. ǝj.

Tinct. Card. comp. 3ss.-M. ft. Mist. cujus su

mantur Cochlearia duo ampla ter die.

To continue the injection.

26th. The vaginal discharge has not re-appeared. Her spirits are better, and the appetite improves.

Continuentur remedia.

30th. There is no leucorrhoea. Her general health continues to improve, and she intends to go into the country in the course of a few days. Discharged cured." 21.

This discharge often appears immediately before and after the menstrual period and only at such times. This, he thinks, may be accounted for on the principle of congestion. A congestive state of the utero-vaginal vessels, however, he generally attributes to irregularities of diet and to sedentary habits. Mr. Jewel confidently avers that, whether the disease under consideration proceed from morbid sensibility, congestion, or irritation of the parts, the nitrate of silver will be equally efficacious in remedying the malady.

"From a strict pathological investigation into the numerous cases of leucorrhoea which have fallen under my observation, I have been induced to believe, that when the morbid secretion is abundant, and the local symptoms severe, one uterine affection gives rise to the disease more frequently than any other, namely, a sub-acute or chronic inflammation of the cervix uteri. Even when the vaginal surface appears to have been the tissue primarily affected, we shall find, in almost all protracted cases, the cervix uteri also seriously involved in the mischief. Mr. Burns, an authority which cannot be quoted without respect, alludes to this part of the subject by observing, that when the discharge is very opaque, and attended by considerable pain in the back and loins, there is reason to think that the cervix uteri is in a state of irritation; and by examination may be found tender to the touch, and the mouth soft and enlarged a little. This state does not constitute disease of structure, though it may lead to it, but it consists merely in an affection of the glands. After the tender state is nearly subdued, and the discharge has become more chronic, the cold bath, tonics, and astringent injections are proper.' Here it is evidently meant that, as long as the tender state of the cervix uteri continues, we ought not to employ those means which are usually had recourse to, with a view of giving tone and vigour to the system, which, in fact, is an admission of the inflammatory character of the disease. I have scarcely ever seen an instance of profuse leucorrhoea, without more or less tenderness of the cervix uteri. I have also reason to know that very many of such cases are mistaken for carcinoma uteri, and that, in consequence, no remedies are prescribed, or a very inefficient mode of practice is adopted. It may be difficult, it is true, in some cases, to discriminate between a chronic inflammatory affection of the cervix uteri, and incipient scirrhous disorganization. The following remarks will, probably, assist the young practitioner in his diagnosis :-This inflammation of the cervix uteri, like scirrhus, or any organic disease of the uterine system, attacks occasionally at the period of life when the catamenia are about to cease, but I have more frequently found it to exist in married females, from the age of twenty-six or twenty-seven to that of forty, and I have recently seen several cases occurring in young married females, within three months after the birth of the first child. The local symptoms in both diseases, are very nearly allied. There will be occasional lancinatting pains through the region of the uterus, with a constant dull kind of pain about the inferior portion of the sacrum, the hip or groin, attended by an irritable bladder, or frequent desire to void the urine, and, in some severe instances, by tenesmus, and pain within the vagina when in the sitting posture. The vaginal discharge is commonly of a milky or cream-like colour, now and then having a glutinous consistence; and is often, in the more acute cases, mixed with a dark-coloured or grumous secretion. Menstruation, if not interrupted by lactation, may be resumed with its usual regularity, although, after a time, some deviation takes place generally, in the first instance, by its continuing several days beyond the accustomed period. I have remarked that, although the local pains are not unfrequently increased in severity at the commencement of menstruation, a great relief is afforded as soon as the catamenial secretion becomes more abundant. Upon making an examination per vaginam in this disease, the os uteri will not be found opened to the same extent as in scirrhus, (an exception may be made in the case of a woman who has had a numerous family); nor will its margin present the same cartilaginous hardness to the touch. The pain does not appear to be situated in the edges of the os uteri, as described by some authors, but in the cervix, as pressure upon this part alone occasions the patient to complain. The uterus will be found projecting lower in the vagina than natural, but this will depend upon the nature of the disease; the more acute, the further it will have descended. It should be recollected, that prolapsus uteri is a very common effect of protracted leucorrhoea, when, in addition to the symptoms already enumerated, there will be fulness about the pudendum, or weight on the perinæum, and a dragging sensation about the loins, with difficulty in