A young girl of sixteen consulted me on account of menstrual haemorrhage so excessive as to induce complete exhaustion, bordering upon syncope. She had menstruated for two years--during the first, in quite a normal manner--but during the second, had become subject to these menorrhagic accidents, since residence at boarding-school. It would have been easy to decide that the disturbance was directly due to the severity of the mental efforts exacted by the _regime_ of the school. But on further inquiry it appeared: first, that the mother of the girl had always been subject to menorrhagia, and it is well known that this often occurs exclusively as the result of hereditary predisposition. Second, that just before the entrance to school, and the disturbance of menstruation, the girl had been living in a malarial district, and had suffered from malarial infection, which is again a frequent cause of menorrhagia. Third, that the studies pursued at school were unusually rudimentary for a girl of sixteen, and indeed, below the natural capacity of her intelligence, had this been properly trained. But the hours of study were so ill-arranged, that the pupils were kept over their books, or at the piano, nearly all day, and even in the intervals allowed for recreation, no exercise was enforced. It was therefore frequently neglected, and the girl, with hereditary predisposition to menorrhagia, increased by malarial infection, and also by certain rheumatic tendencies, was allowed to expend upon elementary text-books an amount of time, attention, and nervous energy, that would have been deemed excessive for the most valuable intellectual pursuits. All physicians are aware of the frequent dependence of menorrhagia upon anemia, not only acquired, but congenital. The existence of anemia, or of an imperfect elaboration of the blood and vascular system, previous to the occurrence of the first menstruation, is a possible condition of menstrual disorder that must always be very carefully eliminated before any other cause be assigned. It is, moreover, extremely frequent. Others exist, but are more rare--as peculiar congenital predisposition to haemorrhages, with or without true hemophilia[45]. With such causes (anemia, rheumatism, malarial infection, hereditary predisposition), the observance of rest during the menstrual week would be quite ineffectual so long as the _regime_ of the other three weeks remain uselessly unhygienic. If the menstrual crisis finds the uterine blood-vessels already deprived of tonicity through nervous exhaustion or other cause, haemorrhage is as likely to occur as if that tonicity were only exhausted at the epoch of menstruation. In the cases described by Dr. Clarke, the cure was effected, when at all, not by an intermittence of study, which does not seem to have been tried, but by its complete cessation, together with that of all the conditions by which it was accompanied.