atresia of the passages, this form differing from the congenital only
etiologically, and in the fact that the flow has been once established.
The acquired atresiæ are mostly the result of violent inflammations or
traumatic influences. The vulva and vagina, or either, may be closed
from sloughing after difficult labors or gangrene following the septic
fevers. Occlusion of the cervix uteri may follow labor or amputation of
the part, but a far more frequent cause is the application of severe
caustics, happily less frequent now than formerly. Lawson Tait says he
has never met with atresia of this part from any other cause.
The mode of diagnosis has already been given, and in regard to
symptomatology there is only to be noted the statement of Bernutz, that
there is far greater intolerance of retention from acquired than from
congenital atresia.
Atrophy of the uterus is a normal process after the menopause, but it
sometimes occurs much earlier in life, and then causes scanty and
irregular menstruation or amenorrhoea. Attention was first called to
this condition by Simpson as a process sometimes following parturition
under the name of super-involution. Several labors in rapid succession
have been stated to be a cause, but Simpson and Courty both give a case
after a single birth. Uterine atrophy may also result from the pressure
of tumors, and it has been observed in paraplegias the result of
defective innervation.
The deranged menstruation is the one prominent symptom of this
condition, and a diagnosis is to be made by exploration. The cervix is
found small and the body light when lifted on the finger. Bimanual
examination and the introduction of the sound will reveal the true
condition of the organ. The latter process should be cautiously
conducted on account of a frequent change of texture in the uterine
walls which allows the instrument to pass through them with the use of
but very little force.
Amenorrhoea is physiological during nursing and pregnancy. The former
needs no attention, the latter only in regard to diagnosis. A sudden
cessation of menstruation, the patient presenting all the appearances
of good health, should immediately excite suspicion as to the nature of
the cause. It needs but little experience to distinguish and manage
these cases in the lower social ranks. The case is different, however,
in a family of good position, with an anxious mother urgent for active
measures, where no suspicions will be tolerated and the imputation of
possible pregnancy be warmly resented. Time is here the sure ally of
the physician, and an examination should be deferred until such a
period {187} has been reached that pregnancy can be positively
negatived or determined.
The influence of acute diseases in suppressing menstruation is not
marked. During convalescence from them the flow frequently ceases from
general debility. All chronic diseases depressing and exhausting in
nature cause suppression, as albuminuria, cirrhosis, and cancer.
Tuberculosis is as fruitful in interrupting the return as in preventing
the appearance of the flow, and suppression from this cause is very
frequent. Under impaired nutrition and depressed powers vital force is
engaged wholly in maintaining existence; there is none for any function
relating to the propagation of the species. In this class the
disappearance is gradual; the flow becomes scanty and irregular in
recurrence, and finally ceases. This form of amenorrhoea differs in no
material point from the similar class already considered; it is but a
symptom of disease of some vital organ or of some general abnormal
condition.
Suppression from psychical influences is not at all uncommon. Fright,
grief, bad news, sudden or prolonged anxiety, frequently cause this
disturbance of function. The mental impression need not be very
profound. Amenorrhoea is a common event with girls who go away from
home to boarding-school. In these cases it is not probable that there
is any pathological condition of the sexual organs; a change in their
innervation is a phrase which will best serve to explain the origin of
the derangement or to express our ignorance. The diagnosis of this form
may be a matter of deep interest when it occurs directly after
marriage, as it not infrequently does, and gives ground for the belief
that pregnancy has occurred. Still more important is it when the
suppression follows illicit intercourse, the fear of pregnancy then
exerting a powerful emotional influence. Some cases are on record, and
the writer has met with two: in both the function resumed its course
after a time without remedies.
Exposure to storm, getting the feet wet, and the sudden application of
cold to the genitals frequently cause suppression. All the conditions,
however, are not well understood. The bathing- and fishing-women of
Europe are said to ply their vocation without reference to
menstruation, and to suffer no inconvenience. In these cases the
increased flow of blood to the pelvic organs oversteps the narrow line
which separates physiological from pathological congestion, and may
even pass on to inflammation.
The SYMPTOMS are well marked--at first, local, as severe backache,
increased heat and pressure in the pelvic region, discomfort passing on
to pain, even uterine colic. If the impression be severe enough to
affect the general system, there will be febrile action more or less
intense, and various nervous symptoms, spasmodic or convulsive.
The therapeutics of amenorrhoea must be directed in accordance with the
conditions which cause it. But the strictly scientific method cannot be
followed at the outset. This method presupposes a direct examination of
the organs as the first step. For obvious reasons this must be deferred
until special symptoms show its necessity. For treatment the cases may
be classified, in some instances according to the schedule, but more
frequently according to the cause or leading features, and very
generally without reference to whether there is absence merely or
suppression of the function.
In amenorrhoea from atresia the measures of relief will be purely {188}
surgical; the treatment, therefore, does not fall within the scope of
this article.
The physician is frequently consulted in cases where menstruation has
occurred once or twice, perhaps at long intervals, and not appearing
regularly the fears of friends are excited. This is the normal course
of establishment in a large proportion of cases. Time and assurance and
regimen are alone needed, provided there is no evidence of deteriorated
health. Absence of the function alone does not demand treatment--a fact
which should be kept steadily in mind.
In a still larger class of cases the amenorrhoea depends upon, and is
the direct result of, some pronounced cachectic condition, as
chlorosis, scrofula, or a more or less active tubercular disease of the
lungs. The treatment of this class resolves itself into that of the
disease causing the derangement, and the reader is referred to the
articles on the corresponding subjects.
The cases requiring more direct consideration therapeutically are those
closely allied to the preceding, in which delay in appearance depends
upon want of development of the body or general feebleness of
constitution, or those in which absence follows and continues unduly
after some severe disease. In all these cases the treatment is to be
indirect rather than direct. The absent function is to be restored by
improving nutrition, by increasing bodily vigor, and by using every
means to establish the general health on a firm basis. Measures for
this purpose should be addressed to every particular of the habits,
occupation, and surroundings of the patient. They do not differ from
those of a general tonic course, but in some particulars a special
influence may be exerted upon the function at fault. The clothing
should be warm, especially about the pelvis and lower extremities, due
care of the feet being impressed in proportion to the universal neglect
shown by girls and women in regard to these important parts of the
person. The diet should be of plain, wholesome, substantial food, and
in many cases one of the lighter wines may be added to the principal
meal of the day with decided advantage. Gymnastics may be prescribed,
but outdoor life should be urged, with horseback riding as the very
best mode of exercise for promoting the flow. A change of air and scene
exerts a well-known and powerful influence in improving nutrition and
modifying vital actions. It should be rather from the city to the
country for these cases. Special advantages may be derived from a
residence at the seaside on account of the beneficial effects of
surf-bathing. A scientifically-conducted hydropathic establishment is
very desirable for its regular hours, well-ordered diet, and treatment
by baths and douches. Or a watering-place may be preferred where a
chalybeate water may exert a special influence in addition to those of
moderate indulgence in the gayety and amusement of such a place.
Inquiry as to school-life and educational work should never be omitted.
The general mode of education of girls is faulty in the extreme. No
attention is paid to the great change of puberty, which amounts to a
revolution in the economy, and instead of aiding the vital forces drawn
upon for effecting this change, they are still further depressed by
sedentary life in close rooms or strongly urged in another direction.
No two leading organs of the body can be pushed in development at the
same time with impunity. There is no exception here: either the brain
and nervous {189} system or the sexual organs will suffer. In this
direction is often found a potent cause of all the forms of uterine
derangement--a fact which cannot have escaped the observation of every
physician. The writer has always urged an entire break in the
school-life of girls of at least one year's duration at the time when
signs of puberty begin to manifest themselves; and this period is too
short rather than too long.
Tonics should supplement these regiminal measures. They may be hæmatic,
stomachic, and nervous--either or all. There is a chain of diseased
actions, and it may be attacked at any of its links. Iron stands at the
head of the list. It is not only an hæmatic tonic, and in proper
conditions a promoter of digestion, but decidedly promotes pelvic
congestion, and has therefore an emmenagogue action. The forms at
command are so numerous as to meet the requirements of any case or to
satisfy any fancy. The standard preparations, as a rule, deserve the
preference over more modern ones, in which efficacy is often sacrificed
to elegance. Among the best are those which contain the remedy in a
nascent state, as the compound mixture or the compound pills of iron of
the Pharmacopoeia. Dialyzed iron, the tincture of the chloride, and the
pyrophosphate are reliable, while the addition of manganese, as in the
syrup of the iodide of iron and manganese, is believed by some to
increase the efficacy. With iron may be combined nux vomica or
strychnia and quinia. In large sections of our country malaria is a
constantly-acting depressant of vital force, and the latter medicine
may be given for a time with a free hand, and may be followed by or
combined with arsenic to great advantage.
Constipation is almost universally present in women. It deserves
especial consideration in treating all disorders of the sexual organs.
When attention to habits and appropriate laxative food, as fruits,
oatmeal, Indian meal, cracked wheat, and salads, do not suffice, resort
must be had to enemata or drugs. Aloes has always had a reputation of
special virtue in amenorrhoea which is doubtless well founded. In pill
form it may be combined with any or all the other medicines. Pills of
aloin, one-fifth or one-third of a grain, have the advantage of very
small bulk.
Before considering more direct measures for establishing menstruation
it may be well to recall to mind the two elements of the
function--ovulation and the uterine flow. The first, the prime factor,
we can not influence by any medicines nor by any mode of treatment
except, perhaps, by electricity. Observation of animals shows that mere
proximity of the male influences it plainly, but this only indicates a
line along which we cannot prescribe. An opinion may, however, be asked
in regard to the propriety or advisability of marriage for a woman who
has never menstruated. In such case no advice should be given until
after a thorough local examination, and its tenor will then be in
accord with the condition of the organs. With such atresia or absence
of organs as not to permit sexual intercourse marriage should be
positively negatived. In such cases as those of partially-developed or
absent uterus the facts should be laid before the parties interested
and the decision referred to them. In the former class of cases some
hopes of improvement may be entertained.
The second factor of menstruation, the flow, we can influence by such
measures as cause a more or less intense pelvic congestion. The ovaries
sharing in this congestion, it is not impossible that ovulation is in
some {190} degree also promoted, but it can be only to a minor degree
and when the ovaries are in a favorable condition. The uterus is the
principal organ to be affected, and to it the most of these measures
are addressed.
Direct treatment for the establishment of menstruation should be first
of a character rather to solicit than to force the flow. These measures
act best where, the general health having been restored, the flow does
not appear, but the premonitory symptoms are present. Rest in bed,
warmth to the pelvic region by poultices or other means, and hot
drinks, are to be prescribed; among the latter infusions of pennyroyal,
some of the mints, tansy, and cotton-root have a high domestic
reputation and should be preferred. Hot pediluvia or hot sitz-baths,
prolonged to twenty or thirty minutes, may be taken at bedtime. These
may be rendered sufficiently stimulating to irritate the skin by the
addition of mustard. More active measures are stimulating enemata and
vaginal injections--for the former ten grains of aloes in mucilage, and
for the latter liquor ammonia in milk, fluidrachm j-pint j, gradually
increasing the strength to production of slight leucorrhoea. Both these
have the endorsement of high authority.
Such measures should be used or plied more assiduously about the
period, when that is known. During the interval a tonic course is
almost always required, and a powerful local influence can be exerted
by cold sitz-baths of brief duration, say one or two minutes, once
daily, followed by vigorous rubbing with a coarse towel or a
flesh-brush.
There are a few drugs known as emmenagogues from the reputation they
have of promoting the menstrual flow. They all are powerful stimulants
or irritants, and as they are also nearly all abortifacients, their
reputation is probably well founded. Modern physiology, by exploding
the doctrine of peccant humors to be carried off by menstruation, and
by establishing the doctrine of ovulation, has greatly diminished their
importance, while the varied conditions and causes of amenorrhoea
already given show at a glance how restricted is the field for their
administration. To give them when the anatomical conditions are unknown
is blind work; to force a function relating to reproduction when the
general system is struggling for existence is folly; and to goad
diseased organs with special stimulants is certain to do injury. Now
and then, however, special stimulants of this class and of the class
next to be considered are required. There are some cases which fail to
respond to the measures already detailed; there are others, generally
recognized by writers, when menstruation is absent without any
deterioration of health, known as cases of sexual atony or torpor; and
others in which the flow fails or disappears earlier than the usual
age. In these latter atrophy of the ovaries may be suspected, but
cannot be verified during life, and treatment should be faithfully
continued so long as there is reasonable probability of success. One
case occurred in the experience of the writer in which the menses
appeared occasionally during two years, each time apparently brought on
by special stimulants, but ceased at thirty-two, the general health
remaining excellent.
The principal emmenagogue drugs heretofore relied on, besides iron, are
saffron, apiol, rue, and savin. The first, from impurity and
costliness, is rarely prescribed, yet Trousseau says it is a fact of
public notoriety that women engaged in picking saffron suffer from
frequent attacks of uterine hemorrhage. Apiol may be given in capsules
in doses of five or six {191} drops twice daily for a week before the
expected flow, or fifteen drops may be administered in the course of
the few hours immediately preceding. The oils of savin and rue are
generally prescribed in doses of minim ij-v, three times daily. Ergot
and iodine figure sometimes as emmenagogues. The efficacy of the former
is denied by very high authority. The latter was esteemed very highly
by Trousseau. Its influence upon the scrofulous constitution may
possibly explain its action in promoting menstruation.
The permanganate of potassium is a recent addition to emmenagogues, and
the testimony in its favor is already sufficient to make it probable
that it is the most efficient of the list. The indications for its use
are want of action or atony of the organs. It should be administered
during a few days or a week preceding the time for menstruation, in
doses of from two to four grains three times daily; or two grains three
times daily may be administered during the whole month. The union of
its elements is but feeble, so that in pills as ordinarily made it
would be very likely to undergo decomposition, while in solution it is
unpleasant. Compressed tablets of the pure drug are now placed at
command of the profession, and are an unexceptionable form for
administration. The best time for taking the medicine is toward the
close of the digestive process, and each dose should be followed by
drinking at least a wineglassful of water. Pain in the stomach has been
sometimes observed even when every precaution has been taken. The
liability of the remedy to decomposition and its irritating powers are
objections to it, but the testimony in favor of its power to bring on
or promote the menstrual flow is at present very strong.
More decided measures of local stimulation than those already given may
be resorted to, and are far more reliable than drugs. They are--tents,
cupping the uterus, and electricity. A sea-tangle or tupelo tent may be
kept in the uterus over night just previous to the time of the flow. In
cases where stimulation rather than dilatation is needed a tent of
slippery-elm bark may be used. Thomas recommends a rubber exhauster for
cupping the cervix uteri. Simpson fashioned one for acting on the
lining membrane of the body. These measures are most likely to be
efficacious just before an expected period.
Electricity is the most reliable emmenagogue, and has such an amount of
testimony in its favor as not to permit a doubt as to its value. It is
the only direct uterine or menstrual stimulant except permanganate of
potassium. Statical electricity is now but little used, although
Golding-Bird published striking instances of its efficacy in
amenorrhoea at an early day in its therapeutic history. Faradization is
now most frequently resorted to. One pole is to be applied to the
sacrum and the other above the pubes or over either ovary. The internal
application of the current is much more powerful as well as less
painful. It is administered by applying a cup-shaped electrode to the
cervix, or by introducing an insulated sound into the uterus, the other
electrode being external as before. The séances should be repeated
every second or third day, and should be more frequent just before the
periods when their time is known. Beard and Rockwell insist that
general electrization should be administered at the same time, and Mann
passes the constant current through the organs during the intervals and
the faradic at the periods. Simpson originated {192} a galvanic
intra-uterine pessary, which Thomas has modified. It is doubtful
whether the feeble current generated by these instruments produces any
effect, or whether they act simply as mechanical irritants. When they
are used, it should be borne in mind that there is eminent and high
authority against the use of intra-uterine pessaries of any kind, and
that all agree that a patient to whom one is applied should be kept
under careful observation.
It must be stated that good results have been obtained with this class
of local remedies in cases which would seem extremely unpromising--even
in those in which amenorrhoea depends upon partially-developed organs.
There is most positive testimony of the highest character as to good
effects obtained in increasing development and promoting the flow.
Cases of acute suppression are to be treated by rest in bed, warmth
locally by baths and applications, and hot drinks, as already detailed.
Steaming the lower part of the body by placing the patient over the
vapor arising from aromatic herbs upon which boiling water has been
poured is a remedy which dates back to Hippocrates. Early in the case a
drink of spirituous liquor, taken hot, is often efficacious. If,
however, there is febrile action, diaphoretics should be administered,
such as the liquor ammonii acetatis with spirits of nitrous ether, and
aconite if required. Dry or wet cupping may be used if there is
evidence of intense uterine congestion. Should internal metritis or
inflammation of some pelvic organ result from acute suppression, the
treatment will be that for the disease thus caused. If efforts to
restore the suppressed flow do not prove speedily successful, special
measures should be postponed until the next period, the general health
meantime receiving due attention. At the return of the next period such
of the remedies for amenorrhoea should be administered as may seem best
adapted to the case, considered as to cause, condition of the organs,
or constitution of the patient.
Vicarious menstruation is so closely allied to amenorrhoea as to demand
some consideration here. The term is applied to a sanguineous flow,
recurring at regular intervals, from some organ or part of the body
other than the uterus. This flow has taken place from almost every
organ or part of the body; most frequently, however, it has been from
some mucous membrane, a wound, scar, or some part which by structure is
favorable to the exit of blood. Amenorrhoea is frequently present, and
is sometimes followed by acute suppression. Puech found 11 cases
attended by vaginal atresia congenital, and in 42 others the uterus was
absent or but partially developed. The treatment does not differ from
that of amenorrhoea. While measures are used to restore normal
menstruation, active repression of the abnormal flow should not be
attempted, unless the organ from which it proceeds is one likely to be
injured by its continuance.
Dysmenorrhoea.
Dysmenorrhoea, according to derivation, signifies a monthly flow with
labor or difficulty; its modern synonym is painful menstruation.
In but a very small proportion of women is menstruation painless. Not
only general and local distress attends it, but more or less pain.
{193} When the suffering reaches such a degree as to demand relief, the
case is one of dysmenorrhoea. In such cases the period generally
commences with a more pronounced molimen than ordinary; as it
progresses pain makes its appearance and gradually increases in
severity. Its seat is the pelvic region, the back and loins, and down
the thighs. It may be paroxysmal or continuous; in some cases the flow
is accompanied by expulsive efforts like those of labor. The pain may
last during the whole period, or relax very much, or even cease as soon
as the flow is freely established. In degree it may reach any height,
often causing the severest agony, taxing the powers of endurance to the
utmost, and requiring the most energetic measures for relief.