NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland AN INAUGURAL ESSAY ON CATAMBNIA. 3 AN [NAUGURAL ESSAY, SUBMITTED TO THE EXAMINATION OF CHARLES ALEXANDER WARFIELD, M. D. President, and the Medical Faculty OF THE COLLEGE OF MEDICINE OF MARYLAND. FOR THE DEGREE OF DOCTOR OF PHYSIC By Charles L. Snyder...of Virginia, MEMBER OF THE BALTIMORE MEDICAL SOCIETY. " Felix est qui potuit, rerum cojnoscere causas." 'Baltimore: PRINTED BY BENJAMIN EDE-S, Corner of South and Market-Streets. 1812. TO ELISHA DE BUTTS, M. D. PROFESSOR OF CHYMISTRY, IN THE COLLEGE OF MEDICINE OF MARYLAND. THIS dissertation is inscribed as a small Tribute of respect for his talents, And as a mark of Personal regard and esteem, By his sincere friend, The Author. THE laws of this institution require a publication of Thesis. ON MENSTRUATION. IVIenstruation, is a periodical discharge from the uterus of every healthy woman, who is not pregnant, or who does not suckle, from the age of puberty to that of an age considerably advanced. The early or late appearance of the discharge, de- pends upon all those causes which influence the growth and maturity of the girl, viz. climate, manner of living, education, associations and original stamina of constitu- tion. Climate assists nature in producing a more early or late discharge of this fluid, according to its temperature. Heat being an universal and powerful stimulus, gives tone and vigour to the system and tends to assist its early evolution with such rapidity, that girls in some of the warm climates menstruate, at the early age of eight, nine, or ten years. On the contrary, as we advance to- ward the north, we observe a gradual protraction of the B 10 discharge until we come to Lapland, where we are in- formed, they do not menstruate until the advanced peri- od of twenty years, or later, and then only in small quantities, and in some instances only in the summer ; animal life being too low in those cold situations, during winter. Certain associations and modes of education, by en- larging the mind and expanding the imagination, afford many sources of pleasure and amusement, which exert an astonishing influence in bringing about the early evolution and maturity of the female system, from the natural influence which the mind has in all instances upon the body, and which is demonstrable by observ- ing the difference in the first appearance of this dis- charge, in girls in affluent circumstances, and those dif- ferently situated. This difference, however, has been considered as attributable to the leisure, indolence, and relaxation attending girls in affluent situations. This opinion is refuted by the arguments of Professor Da- vidge, in an essay upon this subject; also Dr. Chap- man's notes on Burns; both of which amply prove, that the menstruous fluid, is a secretion, and depending as much upon the healthy tone and vigour of the system generally, as also the uterine vessels performing this of- fice, as that of the secretion of bile, gastric juice, urine or any other secretion, performed by the different func- tionaries of the system. 11 it is asserted and credited by Dr. Denman, (of whom we should not have expected such declarations) that Some women never menstruate, their constitutions not requiring or allowing this discharge ; using both terms, though differing in their true signification, as though he knew not which was most correct or definite, but for safety chooses both* In the first term, not requiring the discharge, I beg leave to differ with him, and observe for the present, that I believe it as essential to the health and life of the female, as the secretion of bile.—But am perfectly agreed to use the second, the system may not allow the discharge, which I shall shew is the conse- quence of some irregular action: Some women, of very robust habits, or such as gene- rally have a very abundant evacuation of the catamenia, do at times, menstruate, during pregnancy. In these cases, the office of secretion is performed by the arte- ries, of the os tincse. In the United States, there can be no specific time given, for the first appearance of the menses, as they appear, sooner or later, being influenced, by difference of latitudes, and our continent affording as many grada- tions of temperature, as perhaps the world besides, there is the same variety in the time of the first appearaiice of this evacuation, ilowt-ver, they appear in the states of Virginia and Maryland, from the twelfth to the x- teenth years, sooner or later, according to the health of 12 the girl, connectedly with the causes before mentioned as influencing the different periods. Denman, Burns and others, observe, that there are many changes taking place, after the first menstruous discharge, as consequences of, or produced by the men- struous flux; as expression and animation of counte- nance, gracefulness of attitude, intelligence of conversa- tion, expansion of the breasts, &c. These appearances however, are the results of, or criteria by which we de- termine the attainment of puberty, and are only conse- quences of that state, as is also the discharge itself. Healthy girls begin to menstruate without any previ- ous indisposition; and although asserted by all the writ- ers upon the subject, whom I have had an opportunity of consulting, that their first appearance is always ac- companied by some premonitory symptoms, as pain in the back, loins, inferior extremities, with various hys- terical affections; I believe those symptoms to be the consequences of disease and not the healthy concom- mitants of the discharge. For I have made enquiry of many healthy girls, who informed me, that they never had a pain in the back, loins or otherwise at those peri- ods, and are uniformly very cheerful and by no means disposed to hysteria. Nature being able at all times, when unmolested by disease, to execute her designs, it is absurd to admit the idea, that she should find it expe- dient to call in the aid of disease, to the accomplish- ment of any healthy process. 13 The quantity of fluid discharged at each evacuation, is regulated by the climate, constitution and manner of living; but from the great variety in the health of most young women, it varies in the same woman, at different periods. However, there is an usual quantity to which women, under similar circumstances, approach, which in Virgi- nia and Maryland is from six to ten ounces. The time required for the completion of each period of evacuation, differs considerably, being influenced by a variety of circumstances; generally from three to six or eight days. The cessation of the menses, appears to be governed very much by the early or late appearance of the same originally. But the common time of cessation in this country is from the forty-fourth to the fiftieth years: though I have known one instance of a woman, having a child, who was upwards of sixty years of age, and have no doubt but many such exceptions occur. It appears not to be known by many of those, who ad- mit the catamenia, to be a secretion, who gave the world the first publication on this subject. I will therefore, in this place observe, that Dr. Davidge made this the sub- ject of his inaugural essay, for the degree of doctor of phyic, in Edinburgh, in the year 1794. To which I refer those who may favour me by reading this essay, in justification of my opinion of the catamenia being a secretion. u IRREGULARITIES OF MENSTRUATION. SECTION FIRST. Amenorrhea.—This term is used to express both the retention and suppression of the menstrual flux. Bv the first term, we understand, that the menses, have not yet appeared. By the second, we mean the in- terruption of a function already established. I shall here differ from all the writers upon the cata- menia, who uniformly (I think I may venture to say) consider its irregularities idiopathic diseases. I should here experience much delicacy and diffidence in thus publicly advancing new doctrines, conscious of the un- welcome reception with which innovation is met, parti- cularly coming from the pens of young men, by persons of established reputation and who suppose their opi- nions correctly formed, by the experience of many years practice, did I stand alone; but am supported by Dr. Davidge, whose opinions are founded upon the sure base of sound sense, observation and logical reasoning, governed by experience, and unbiassed by fancy and enthusiasm—and upon whose decision, I am willing to risk the present subject. The catamenia being proved 15 to be a secretion, it must necessarily follow that the ir- regularities of the same are only symptomatic. For I presume no man will confess himself so unscientific as to call the offices of natural functionaries, disease. The catamenial evacuation may be interrupted, either by debility, fever, or malformation. Of which I shall treat seperately. First, the irregularity from debility, which includes both the retention and suppression. This state may be induced, by all the different causes noticed by writers, as tending to reduce the system, which are protracted or injudiciously treated; diseases of all kinds, both accute and chronic, as pulmonary con- sumption, rheumatism, autumnal fevers, &c. &c. Other causes, that tend to weaken the system, as scanty and bad diet, fatigue or a want of sufficiency of exercise, also certain affections of the mind, such as grief, fear, anxie- ty, disappointed love, and intense thinking, long con- tinued, upon all disagreeable subjects, or such as tend to depress the animal spirits; all of which operate pow- erfully in debilitating the system. The symptoms attending this state of debility, are such as are present in general debility, under all circum- stances, viz: a sense of languor and weariness, a pale and sallow complexion, (edematous swellings of the low- er limbs, complaints of the stomach, such as flatulency, acidity, loathing of food, but craving indigestible sub- 16 stances, as lime, chalk, &c. Pains in the head and differ- ent parts of the body, with various hysterical affections. In this state of the system, we see every organ perform- ing its office with difficulty, or the functions of many entirely suspended, and often we findthe uterus, among the last, resigning its healthy office. The catamenial flux, is interrupted or suppressed by fever, by whatever cause induced, as well as debility. When this occurs, there are all the diagnostics of the pre- sence of fever at any other time, as increased frequency, fullness and tension of the pulse, a dry skin, thirst, hur- ried respiration, constipation of the bowels, with pain in the head, back and uterus. Though all these symp- toms are not always present, yet there are a sufficient number of them attending to prove the real character of fever. Further, it may at all times be observed that the fever makes its appearance first; which circumstance is sufficient to prove that the fever is the original dis ■ ease. For, we frequently discover the inconveniences resulting from the interruption of the catamenia, such as pain in the back, head, &c. Among the last symptoms that we are advertised of, after the commencement of the original disease. We may account for its operation by referring to the general law of the animal economy, by which we know that a certain action of the arteries is necessary for the healthy performance of every func- tion in the system; so too high or too low action, will interrupt the processes necessary to health. 17 On the contrary it has been said, by authors that ttfc suppression of the catamenia, produced the fever and that inconsequence of the suppressions there have occur- red hemorrhages, from different parts of the body, as the nose, lungs, stomach, and hemorroidal vessels and that these hemorrhages, observe a periodical form. These hermorrhages we find, only appear in habits extremely debilitated, or such as labour under scorbu- tic affections. In which cases we find many of the other functionaries of the system impaired before the irregular- ities of the catamenia are manifested. Very few argu- ments, are necessary, to refute the idea that the suppres- sion of the catamenial flux produces fever. In the first place, if we relieve the system of the fever by the remedies suited thereto, viz: bloodletting, using the neutral salts, &c. Instead of anticipating the catamenial evacuations, we put the system in a condition, to perform this secre- tory office; and it would be as absurd to suppose that this secretion, would be obviated, as that any other secretion would be suspended, by the loss of a moderate quantity of blood. As long as the system, has blood enough to sup- port a healthy action, the catamenial secretion as well any other will go on in their proper order, though not to the same extent in a given time. For it does not neces- sarilv follow, that if blood be lost to a considerable ex- tent, that a healthy action of the system cannot exist; '.or a weak action, does not imply a diseased action- In 18 justification of the last position, I would observe that numberic: s cases have come within my own observation, in thecourse of my medical studies, in which young ladies have been attacked with fevers, a short time previous to the menstrual period and have been bled to the extent of several pounds in the course of twenty-four hours, and as soon as the febrile action was reduced, the menstrual secretion commenced. During the course of this winter I saw a patient who a few days previous to the catamenial period, was exposed to the influence of very cold and damp weather. A most alarming phrenitis ensued, at- tended with delirium, convulsions, and dilated pupils, with the most obstinate constipation, and the general ac- companying symptoms of this disease in its most formi- dable appearance. As I was present and the attending circumstances requiring immediate relief, at half past two o'clock P. M. I drew about sixteen ounces of blood, from the arm; which affording no apparent relief, I repeated the bleeding a second, a third and a fourth time, a in few hours and took at least fifty ounces of blood, in the sev- eral bleedings, which threw the patient into a state of syn- cope. From the alarming appearances that had preceed- ed, I made no effort to restore the patient, consequently she remained in a state approaching to syncope, during the night. By morning the arteries recovered their regu- lar action and the patient was able to get up; perfectly relieved of ^every disagreeable symptom and suffering 19 no other inconvenience, than what would result from temporary debility. In the course of the day the catam- enial discharge commenced and instead of being even di- minished, was more copious, than was customary. Many similar instances will occur, to every medical gentleman who will observe; though this I consider particularly worthy notice, being an instance, in which larger evac- cuations were made than usual in the course of a few hours, and from a young lady of a very delicate habit. I am aware, here, that I am coming into conflict, with the opinions, taught by Doctor Cullen and others, men, who have acquired the highest rank in the medi- cal world. But as I conceive it, by no means improper, for a man, who has a reputation to establish, to borrow from those, who have much to spare, when it can be tak- en from that portion, to which they are not entitled by merit; I may take the liberty of deriving a little from such sources. We are informed by the writings of Doctor Cullen, that there must necessarily exist a general plethora in the system, before the catamenial discharge, can occur. This idea, however, was consequent, to his unacquaint- ance with the real nature of catamenial discharge, for he considered it blood. We need not be surprised, at the absurdities, taught a few years ago, when we find that time makes very little change, as to the advancement of science. For at this time, we are taught by the Iec- 20 tures in a neighbouring university, that disease is neces- sary to constitute health.—If plethora were necessary, to the catamenial discharge it would, at all times be pre- vented, by the previous use of the lancet; but in no in- stance, do we see this occur, unless used to such an extent as to influence also, the other functionaries of the system. As a regular formation and reciprocal action of eve- ry part, of the female organs of generation, are neces- sary, to the healthy action and function of each indi- vidual part, the retention of the menses, may be conse- quent, to an absence or imperfection of the ovaria or any other natural part. There is much reason to believe, that some circumstances of this kind, frequently occur, and are among the many reasons, that may be assigned, to account for the permanent absence of the menses in many women, and their being incapable of impregna- tion, during life. It is certain, that several instances have occurred, of permanent suppression of the menses, in consequence of the loss of a part of these organs.—- If we may be allowed, to reason analogically, we may account, for most instances of original insusceptibility of impregnation, in the human female. For we are dailv evinced of the effects produced by the extirpation of the ovaria, of many of the inferior animals. Many consti- tutional diseases are daily presenting to physicians, pro- ceeding from these very occult causes: producing a va- riety of disagreeable spmptoms; as general debility, pains 21 in the back, hips and uterus, with various hysterical af- fections and irregularities of the menses. Which phy- sicians either from a want of science, or a knowledge of the laws of the economy of the genital organs, treat as common hysteria; and several instances I have known to be treated for rheumatism, supposing the pains, com- plained of in the back and hips, to be muscular, without giving themselves the trouble to discover the real cause. And as these last symptoms are most apt to occur in women, considerably advanced in years, and have borne children, many physicians are apt to consider them merely the natural consequences of the age of the wo- man, particularly if this state appear, about the period of the cessation of the menses; and leave them to cure themselves, which they suppose will happen after the ca- tamenial discharge, shall have terminated. The conse- quences of such neglect and ignorance, frequently are scirrhus, cancer and finally death. When the retention and suppression of the menses are consequent to constitutional debility, the objects to be kept in view, are to give tone and vigour, to the system generally, without attending particularly to the irregula- rities of the catamenia, as they are only symptomatic of the general affection. A variety of articles of the ma- teria medica, have been recommended, with much zeal and emphasis, under the term emenagogues, and still retain a place as a class in the materia medica. From 22 a firm conviction that there are no articles of medicine, that have the quality of bringing on and continuing the catamenial discharge regularly, but on the contrary, tend by their stimulant operation, very much to lay the foun- dation for future hemorrhages, from the uterus; I could wish that the term, were rejected. As those me- dicines when used for this purpose, are not only ex- ceedingly injurious, in their consequences, but the term itself, serves to give young men, incorrect views of the real nature of the catamenial secretion. The plan of treatment, best calculated to afford relief, is such as tends to alter the habit, by a general tonic and restorative operation. This object is to be attained first by curing the original disease, if any exist in the sys- tem. This will be done by the use of those remedies best calculated, to the removal of the particular disease. If debility alone, be present, the remedies are, exer- cise of all kinds in favourable weather, such as riding on horseback, in a carriage, swinging, dancing and walk- ing. These operate powerfully in restoring the system, when not used to such an extent, as to produce debility and fever. Travelling a distance from home, has a most happy effect in restoring the tone of the system, as there are in addition to the exercise, many sources of amuse- ment. When the circumstances and state of the patient's health, will justify these advantages, they should not be omitted as there are no articles of the materia medica, 23 perhaps more efficient than this plan, in the accomplish- ment of our object. The cold bath is a most salutary remedy in every case of debility, unaccompanied by fever, and may be ranked among the best. Before using this remedy however, the patient should have the advice of a physi- cian in every instance, as it is of the utmost importance that the state of the patient be particularly attended to before and during the use of the bath. The medicines that appear most effectual and best cal- culated to give tone to the system in this state, are the different preparations of iron, as the tine ferri. muriat. carbon, ferri. &c the Peruvian bark, gentian, quassia, and the nitric acid. The columbo is also an article of much importance, in this state of the system. These several remedies are to be used according to the condition of the patient, regulated by the good sense of the attend- ing physician. 24 MENORRHAGIA, OR IMMODERATE MENSTRUATIOiS SECTION S1XOND. Under this head the writers on the catamenia con- found this symptom with uterine hemorrhage. These two conditions of the system are as different and as dis- tinctly marked as any two variations of the system can be. The first being a diseased discharge of the cata- menial fluid, consequent to some irregular action in the system; therefore only symptomatic: while the second is an idiopathic disease, being a discharge of blood con- stituting a genuine hemorrhage. We are able, further to distinguish the two discharg- es by the coagulability or incoagulability of the fluid discharged. For the catamenial fluid comes away as secreted, in a fluid form, invariably. On the contrary, when there is a discharge of blood, coagula very fre- quently form, even in the uterus, and are discharged in clots. Again, different conditions of the system appear ne- cessary to these different evacuations. For excessive 25 menstruation occurs most frequently in girls, or those who have not borne children, and is excessive from long continuance, and is never attended with any immediate danger. On the contrary, hemorrhage, or the discharge of blood from the uterus, is very different and depends up- on the general causes that produce hemorrhages, from any other part of the system, and frequently the effusion of blood is very profuse, and proves fatal in a very short time. Further, married women, or those who have borne children, are more subject to uterine hemorrhage, than girls who have not had children. With these reasons, I shall leave the subject of he- morrhage, as improperly treated of under this head, and confine myself to the diseased state of menstruation* That excessive menstruation is a consequence of con- stitutional debility, we infer from the general debility, which exists invariably, in all instances in which this affection appears, as well as the peculiar symptoms that attend this state; as pains in the back, loins, and uterus, together with the swellings of the lower parts of the ab- domen during the period of the menstrual discharge; also from the remedies that relieve this painful opera- tion. All of which seem to be symptomatic of debility. As this state of the system, as well as the retention and suppression of the menses, depends upon constitutional debility, the same general remedies are to be used in this state of the system, that are used in those two dif- ferent states. During the period of the discharge, as there is consid- erable pain,* it is necessary to advise some gently stim- ulating medicines. Of these, opium and camphor, or 26 what is much better, proper proportions of opium and ipecacuanha in combination, which will in most instan- ces answer our purpose exceedingly well. The warm bath, in that form called semicupium will also afford relief in most instances, and I think should never be omitted. Before concluding this dissertation, permit me thus publickly to acknowledge, the many obligations, I feel myself under, to the professors of the different branches of medicine in this college: for the many advantages they have been pleased to afford me. Accept, gentle- men, my most sincere wishes, for your future prospe- rity. May your merit ever meet a just reward, and may your endeavours to improve the science of medi- cine, be crowned with honour to yourselves, equal to the blessings, they may afford mankind. Baltimore, Mayy 1812, ERRATA. Page 13 line 25, omit "in Edinburgh in the year 1794." page 15 line 7, for functionaries, read functions, page idem line 7, for seperately read separately, page 16 line 1st, the large P in pains should be a small p; page idem line 21, the large A in among should be a small a; page 18 line 1, for jus- tifiration read justification; page 20 line 6, for functionaries read functions; page idem, last line, for spmptomsread symp- toms; page 21 line 26, for emenagogucs read emraenagogues. 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