be by increased rate of discharge during the usual time, by lengthened
duration, or by too frequent returns of the periods.
There are wide physiological limits to the amount of discharge and the
duration of a menstrual period. While the average time is from three to
five days, and the average amount from three to five fluidounces, both
these terms may be doubled, or, on the other hand, they may be
diminished to a single day and a single ounce, without detriment to the
health. Menorrhagia may be said to exist when the flow is in excess as
compared with what is usual with the individual, or when the loss is so
great as to affect her general health.
The periodical return of the flow is of prime importance in
establishing the existence of menorrhagia. Repetition at periods
approximating the menstrual is the keynote of diagnosis. By this
menorrhagia is distinguished from the hemorrhage of a miscarriage and
from metrorrhagia. A profuse flow of blood after an absence of
menstruation for one or two months is held by patients, in perfect good
faith, to be the effect of taking cold: with almost absolute certainty
such a train of events indicates an abortion. Metrorrhagia is uterine
hemorrhage occurring independently of the menstrual periods. More
surely indicative of organic disease than menorrhagia, it is often most
closely allied to it; many cases which in the early stages present an
increased menstrual flow as a symptom are at a more advanced period
accompanied by metrorrhagia.
Thus far the diagnosis of menorrhagia is easy. Not so that differential
diagnosis upon which alone can therapeutic measures be based.
This derangement depends upon as many and as widely diverse causes as
the others. It is often one expression of affections of the general
system, is sometimes caused by disease of organs neither pelvic nor
generative, is a common symptom of a number of organic diseases of the
uterus, or it may be simply functional. The necessity for a thorough
physical examination is apparent. By touch, single and bimanual, by the
speculum, and by the uterine sound the condition of all the pelvic
organs should be investigated. These means failing to reveal the cause
of the menorrhagia, the examination should be pushed farther. The
cervix should be dilated by tents and the cavity of the uterus
explored. Very frequently this measure, and this alone, will reveal the
cause of the derangement. Such an examination is often as valuable for
its negative as for its positive results. No practitioner fulfils his
duty to his patient or is just to himself who treats a menorrhagia for
any length of time without making a physical examination. It may seem
unnecessary to emphasize so plain a duty, yet consultants very
frequently find cases in {201} which palpable causes of the disease
exist and where a direct examination has not even been proposed.
The following schedule will indicate the widely diverse conditions
which may give rise to menorrhagia, and will serve as a guide to the
study of the subject:
CAUSES OF MENORRHAGIA.--
I. Diseases of the General System:
Plethora;
Chlorosis and anæmia;
Debility, as from excessive lactation;
The exanthemata and typhoid fever;
Hæmophilia;
Scorbutic, uræmic, and malarial cachexiæ.
II. Local Affections, not Uterine:
Cerebral, as psychical influences;
Cardiac and pulmonary affections, as valvular disease,
emphysema, and phthisis;
Hepatic diseases, as cirrhosis and the changes produced by
residence in tropical climates;
Splenic and renal disease;
Abdominal tumors and loaded bowels;
Peri-uterine inflammations;
Ovarian influences.
III. Uterine Causes:
Subinvolution;
Areolar hyperplasia;
Endometritis, with fungous growths;
Laceration of the cervix, with eversion;
Ulceration of the cervix;
Displacement of the uterus;
Polypi and fibroid tumors;
Retention of products of conception;
Malignant disease;
Congestion.
I. Menorrhagia, the result of the first class of causes, but rarely
occupies more than a subordinate position. The acute affections, as the
exanthemata, do not afford time for more than a single flow, and this
has been well termed uterine epistaxis. The condition of plethora is
manifest. The cachexiæ are generally well marked and evident. An
exception may be made in this regard as to the effect of prolonged
residence in malarious locations. There can be no question that
menorrhagia is frequently of malarial origin, and even when the patient
does not present a cachectic appearance. The disease may be produced by
hepatic and splenic derangement, by deteriorated sanguinification, or
by depression of nervous force. Menorrhagia is not infrequently a
result of Bright's disease; an examination of the urine would determine
this point. That the opposite conditions of plethora and anæmia should
both cause menorrhagia is not difficult of explanation; in the one
there is excess of blood with increased vascular pressure; in the
other, a changed condition of the blood favoring transudation, with
loss of tone of the vessels.
II. That menorrhagia, as well as amenorrhoea, may have a purely {202}
emotional origin there can be no question, although this cause is not
generally recognized. The following case is an illustration: A healthy
young married woman, while menstruating, saw a neighbor's son thrown
from his horse; his foot became entangled in the stirrup, and he was
trampled to death before her eyes. She was immediately taken with
flooding, and profuse menstruation occurred for several succeeding
periods. Siredey expresses doubts as to cardiac and pulmonary diseases
so frequently causing menorrhagia as they are generally believed to do.
In a considerable experience during several years, and paying special
attention to this point, he found but one case thus caused. The
mechanical effect of disease of the abdominal organs in producing
passive congestion in distal parts is more direct and the influence in
producing menorrhagia more apparent. The same may be said of
accumulations in the bowels and the pressure of abdominal tumors.
Peri-uterine inflammations rank very high in the list of causes: their
presence and results, direct and indirect, as abscesses, displacements
of the uterus, etc., should never be overlooked. Ovarian influence is
naturally a potent etiological factor; menorrhagia is a frequent result
of sexual excesses, and is often seen in prostitutes and where there is
great disparity of age between the husband and wife.
III. Affections of the uterus itself are by far the most frequent cause
of menorrhagia. The necessity of investigating accurately the condition
of the great central organ of menstruation, and of ascertaining to what
particular disease the derangement of the flow is to be attributed,
will bear repetition. That an anatomical or pathological diagnosis can
always be made is not maintained, but when examination has failed to
reveal a basis for such a diagnosis, the practitioner should distrust
his position and consider his diagnosis provisional only, awaiting more
information from renewed examination or from further progress of the
case. The cases are few in which such a diagnosis cannot be made. They
are recognized by the term congestion as a cause in the schedule given
above. Congestion is of course the prominent factor in many cases of
menorrhagia, as in those from polypi and fibroids, those produced by
ovarian influences, and others which are evident. But the class here
recognized consists of those cases in which no anatomical or other
cause can be found, excess of the congestive element of menstruation
alone affording a rational explanation. Such cases occur most
frequently at the two extremes of life--at puberty and at the
menopause. During both these periods menorrhagia often occurs
unexpectedly and inexplicably.
The grosser forms of uterine growths, as malignant disease, polypi, and
fibroid tumors, are generally discovered without difficulty. The touch
reveals them, or the sound or bimanual examination indicates their
possible presence, which is confirmed by dilatation of the cervix and
exploration of the cavity of the uterus. This class of cases gives rise
more frequently to metrorrhagia; only exceptionally is the hemorrhage
confined to the menstrual periods.
A recent delivery in the history of the patient will indicate with some
probability one of several conditions which may give rise to
menorrhagia. Especially is this the case if the complete generative
cycle has been broken in any part of its course. If there has been a
miscarriage, there will be great probability of retained portions of
the placenta or membranes; {203} if from death of the child or other
cause nursing has not been performed, the conditions will be favorable
for subinvolution of the uterus; if labor has been instrumental or
precipitate, laceration of the cervix may be suspected. The first two
far exceed in frequency the last as causes of menorrhagia. Laceration
of the cervix exists often without producing this functional
disturbance, while subinvolution and retention of products of
conception are very often active agents.
Displacements of the uterus, either prolapsus or versions and flexions,
often have menorrhagia as a symptom.
The chronic inflammatory affections of the uterus are fruitful causes,
and menorrhagia is often found associated with, and sometimes dependent
on, the condition known as chronic corporeal metritis or areolar
hyperplasia, with consecutive erosions or ulcerations. Inflammation of
the lining membrane of the uterus accompanied by granulations or
fungous growths is one of the most frequent causes of menorrhagia.
Opinions differ as to the part inflammation plays in producing this
condition. Its entire absence in some cases is not improbable, the
fungosities springing from the seat of the placenta. By Winckel the
affection is termed adenoma diffusum et polyposum corporis uteri; by
Olshausen it is called endometritis fungosa. Under various names the
condition is well known and recognized as one of the most frequent of
all the uterine causes of menorrhagia; Siredey believes it to be the
origin of nearly one-half the cases. Due consideration of this cause is
especially important, because especial investigation is required for
its detection. The cervix must be dilated and the blunt curette passed
over the internal uterine surfaces. This will furnish ocular and
tangible evidence by detaching and bringing away some of the fungous
growths, and a diagnosis will thus be made impossible in any other way.
In considering the treatment of menorrhagia the management of the
patient during the intermenstrual periods must first engage attention.
The general health is to be promoted in every possible way and sound
hygienic regimen enforced. Two points demand especial attention--the
clothing and the bowels. All tight bandages around the abdomen should
be loosened, and all skirts and underclothing which hang upon the hips
be supported from the shoulders. The beneficial influence of free
action of the bowels cannot be overrated. Regular daily movement is
required in all cases, but much more is often of decided benefit. In
menorrhagia of the menopause in patients who have accumulated
considerable adipose tissue, especially about the abdomen, in those
where there is evident hepatic derangement, and in some others free
purgation with salines is one of the most efficient measures of
treatment.
During the menstrual intervals cachexiæ are to be treated according to
their nature. Chlorosis and anæmia will require iron, quinine, nux
vomica, and other tonics--the malarial cachexia the same, with the
addition of arsenic, which often renders especial service under these
circumstances. Then, too, the various uterine lesions giving rise to
menorrhagia must be corrected. Subinvolution is to be remedied, polypi
removed, the evil effect of fibroids combated by hypodermic injections
of ergot, displacements corrected by suitable pessaries, the tone of
the vessels and tissues of the pelvis increased by cold bathing, and
all indications fulfilled according to the nature of the case. For
details of treatment the reader {204} is referred to the articles upon
the various general, local, and uterine diseases which have been shown
to cause menorrhagia.
Especial attention should be given to girls whose menstrual life begins
with menorrhagia, lest a vicious habit become fixed. The evils of
school-life or those of sedentary indoor occupations should be
corrected, and rest in the recumbent position during menstruation
enforced. For the menorrhagia of puberty tonics, especially nux vomica
and brief applications of cold to the pelvic region, are particularly
indicated.
During an attack of menorrhagia the first remedy, and one without which
all others are useless, is rest in the recumbent position. If the
attack be severe recumbency should be absolute. Food should be light in
quality and moderate in amount, while all drinks are to be taken cold,
as ice-water, iced lemonade, or water acidulated with sulphuric acid
and sweetened to the taste, the beneficial effect of acids in addition
to cold being generally recognized. The bed should be hard and the
clothing light, and the foot of the bedstead may be raised some inches.
Many cases require no more active measures of repression. In subjects
about the menopause, in some cases of malignant tumor, and in some
others the hemorrhage seems to be a vent, and in moderate degree is
rather beneficial. Such cases are to be watched, but need not
necessarily be actively treated, certainly not with repressants and
astringent applications, until regimen and mild measures have been
tested.
In proceeding to medication the state of the general system first
demands consideration. If there be increased vascular action and
temperature, with evidences of active congestion of the pelvic region,
manifested by pain, distension, and tenderness of the hypogastric
region, with heat and throbbing of the passages, arterial sedatives and
relaxants will be demanded. Aconite or veratrum viride may be given
until an effect is produced on the pulse, and they may be combined to
advantage with salines, as the liquor ammonii acetatis. It is in these
conditions, of rare occurrence, that nauseants, such as ipecacuanha,
are of service.
Medicines having a more direct action in checking uterine hemorrhage
produce their effect by exciting contraction of the uterine walls and
blood-vessels, moderating congestion, and modifying the condition of
the nervous system. They are ergot, digitalis, bromide of potassium,
quinine, cannabis indica, and cinnamon.
Ergot stands at the head of the list from its well-known effect in
causing uterine contraction, and although reliable in proportion to the
increased size of the uterus and the distension of its cavity, it is
indicated in almost all cases for its hæmostatic action on the
capillaries, as well as for its specific action on the uterus.
Digitalis slows the action of the heart and excites the contractility
of the arterioles, while experience has proved it to be an efficient
remedy for menorrhagia. Bromide of potassium moderates vascular and
nervous excitement of the pelvic organs, and is especially indicated in
cases having an ovarian origin. Several of the French writers give very
strong testimony in favor of the efficacy of cinnamon as a remedy,
having tested it in a large number of cases without other medicines. It
may always be used as an adjuvant.
All these medicines may be combined in various proportions, and they
should be given in full doses. Infusion is the best form for the
administration of digitalis. Sulphate of quinia in doses of gr. vj-x is
often an {205} efficient remedy, and especially in cases where there
have been malarial influences. Cannabis indica is stated, by very high
authority, to be one of the best remedies, although its mode of action
is not clear. Iron should be administered as an hæmostatic tonic, and
not merely because there is some uterine disease or derangement.
The action of medicines may be supplemented by local applications.
Cloths wrung out of cold water or vinegar and water may be applied to
the hypogastric region or to the vulva. A bladder or rubber bag filled
with pounded ice may be laid on the abdomen above the pubes, or applied
to the lumbar region for its effect upon the spinal cord. One of the
most efficient means of applying cold is by an enema of cold water, or,
this failing, of ice-water. The rectum and uterus being contiguous, the
cold is applied almost directly. Siredey speaks highly of the cold
douche to the soles of the feet, the water being projected in jets from
a sprinkler. During the application uterine contractions are felt and
the flow stops. This is more especially adapted to debilitated and
anæmic patients with loss of vascular tone. Patients will often object
to the application of cold to check a flow of blood from the uterus,
knowing well the bad effects of suppression of menstruation which often
results from exposure to this agent. It is believed that evil results
never follow the application of cold when the flow is excessive;
perhaps because the system and the organs concerned have been relieved.
The application of heat is also an efficient remedy--hot-water bags to
the spine on Chapman's plan, or hot vaginal injections may be
administered, as recommended by Trousseau and Emmet, the water being at
a temperature as high as the patient can bear. To be properly
administered the aid of a nurse is required, as the flow should be kept
up for some time, at least a gallon of water being used.
There is only apparent contradiction in the use of both cold and heat
to check uterine hemorrhage. Various explanations of the action of both
have been given, and much argument presented why one should act better
than, or be preferred to, the other. The truth is, that both are
efficacious, and the value of both is based upon clinical experience.
The flow in menorrhagia is sometimes, if rarely, so excessive as to
demand mechanical means of restraint. A well-applied tampon gives
absolute control, and should never be omitted when the hemorrhage is
severe and the practitioner is not within easy reach of the patient.
Plugging the cervix with a sponge tent, supported by a vaginal tampon,
is to be preferred as most reliable, and also because upon its removal
the uterus can be explored for diagnosis or is prepared for direct
applications. Should a vaginal tampon alone be trusted, it must be
thoroughly applied to be reliable. This can only be done through a
speculum, preferably with Sims's duckbill. Pledgets or discs of cotton,
the first provided with strings to facilitate removal, squeezed out of
a carbolized saturated solution of alum, should be packed carefully and
firmly around and over the cervix, and the vagina filled. A folded
napkin to the vulva, supported by the usual T bandage, sustains the
whole. Such a tampon may remain, if necessary, thirty-six hours, the
catheter being used to relieve the bladder.
Direct applications to the interior of the uterus are sometimes
necessary both to check the flow and, in some cases, especially those
dependent {206} upon fungous growths of the endometrium, as a means of
cure. They may be either fluid by application or injection, or solid.
The former may be by swabbing the interior of the uterus by means of an
applicator armed with cotton dipped in the liquid, or by injection. The
drugs used for application are carbolic acid diluted with glycerin or
pure tincture of iodine, or the stronger tincture known as Churchill's,
Monsell's solution, or the liquor ferri perchloridi diluted or of full
strength. The preparations of iron are objectionable from the hard,
gritty, and disagreeable coagula formed, and the tincture of iodine is
generally quite as efficient as a hæmostatic and more active as an
alterative.
For efficient application the cervix should be dilated if not
sufficiently patulous, and a cervical speculum should be used, or the
solution will be squeezed out of the cotton before it reaches the seat
of the disease. For injection the same articles are used, beginning
with weaker solutions and gradually increasing the strength. They
should never be resorted to without the utmost caution. The os should
be patulous as a sine quâ non, and the injection carefully
administered. In case the os is open the instrument may be the common
extra long-pipe rubber syringe bent to a suitable curve by heating.
This having been charged with a drachm or so of the liquid, the end is
served with cotton like an applicator; over this several clove-hitch
turns with a string are taken, so that the cotton may be withdrawn if
pulled off in the uterus. The pipe is then carried to the fundus and
the piston very slowly depressed. Buttle's syringe is a more elegant
and a safer instrument in cases where the os is not thoroughly opened.
The terminal pipe of this instrument is very slender and perforated
with minute openings, and the piston is forced in by screw-action of
the handle, so that the fluid is expelled drop by drop.
Nitrate of silver is sometimes applied in solid form to the interior of
the uterus, both as a means of checking excessive hemorrhage and to
effect a cure by modifying the condition of the endometrium. It may be
done with a probe, the end of which has been coated with the substance,
passed in detail over the inner surface of the organ. A piece of the
solid caustic is also sometimes carried into the uterus and left there,
the application à demeure of the French, some of whom claim that in
their hands this measure has never failed to check the hemorrhage.
In those cases where positive evidence has been gained that the disease
depends upon fungous growths of the endometrium there is yet another
and a more reliable remedy. It is the curette. By this instrument the
growths which are the origin of the menorrhagia can be certainly and
safely removed, their return prevented by a thorough application of
iodine to the surface from which they spring, and a cure often effected
when all other means have failed.
Intra-uterine applications, injections, and surgical measures affecting
the interior of the uterus have been detailed, as they are advised and
used by authorities. It remains to give an opinion as to their merits,
and to state the precautions which should be taken when they are
resorted to.
First, it must be said that there is a very considerable difference of
opinion as to the safety of these measures. While some do not hesitate
to apply to the interior of the uterus fuming nitric acid, and
introduce pieces of nitrate of silver to dissolve there, others are
extremely careful {207} about making any applications to this part, and
reject intra-uterine injections altogether. Nor can it be denied that
very severe symptoms have frequently, and death sometimes, followed the
application of these remedies. In resorting to them, therefore, the
practitioner cannot be too minute in observing every precaution, and
they should never be resorted to if evidence of peri-uterine
inflammation exists. No intra-uterine injection should be given unless
the os be patulous, and the fluid should be thrown in with the utmost
gentleness. The milder articles should be tried first, and the severer
only as the temper of the uterus is tested. Always treat the patient
afterward as the subject of an operation, keep her in bed strictly, and
combat the first symptoms of trouble with opium.