MISMENSTRUATION.
AMENORRHŒA.
The first variety of cases of amenorrhœa are those where no menstrual
fluid has ever been secreted. All girls, as we have seen, do not
menstruate at fifteen years, as all children do not cut their first
teeth at seven months, and in either case there may be no disease. But
when a female has reached adult life, when her frame has assumed the
character of womanhood, when she is not chlorotic, and when all her
organs (save the sexual) perform their functions naturally, then a cause
of the absence of the flux should be looked for. Menstruation may be
absent from congenital malformation. The ovaries may be wanting, or if
present may be atrophied or diseased; perhaps they present scarcely a
trace of a Graafian vesicle; or these glands can exist and the uterus be
absent or imperfect; or there may not be found a trace of a vagina. In
the second variety of amenorrhœa there has been a secretion of the
menses but no evacuation of them. This may be because there is an
occlusion of the vagina, or the os uteri may be imperforate. When the os
is closed by a membrane, the structure may be incised with the bistoury,
or perhaps be ruptured by the uterine sound.
The third variety is the most common form of amenorrhœa, viz: that in
which the flux having been properly established and appearing regularly
for a time, has been prematurely arrested. But it may be said of
amenorrhœa in its various forms, that it is not so much a disease as a
symptom of disease; a consequence of either individual organization,
disorder of the uterus or ovaries, or of some other organ or organs
sufficiently important to affect the constitution.
Hence all the means that restore the system to health, medicinal and
hygienic, may be recommended as tending to cure the complaint, and hence
we have to inquire whether there is serious disease in any of the organs
when the question of pregnancy arises, on account of the disappearance
of the menses.
It is always necessary in treating amenorrhœa to consider the cause of
it, and we should know that it may come from torpitude of the secernent
vessels of the uterus, produced by anxiety of mind, cold, or suddenly
suppressed perspiration; falls, especially when accompanied with terror;
or a general inertness and flaccidity of the system, and more
particularly of the ovaries. (F. 172, 173).
DYSMENORRHŒA.
There are few women who pass through the whole period of sexual vigor
without having more or less frequently to endure an attack of
dysmenorrhœa. Some few females experience great pain with each flow,
from puberty to the change of life, while in others pain is only an
exceptional accompaniment. With some women marriage effects a cure,
while in others it either aggravates or originates dysmenorrhœa. Three
distinct varieties of dysmenorrhœa have to be considered: the neuralgic,
the congestive, and the mechanical.
The variety which is called NEURALGIC DYSMENORRHŒA is more frequent in
unmarried females; and if married, in those that have not borne
children; and most frequently affects those of a nervous temperament,
and of a thin, delicate habit. The paroxysms present all the
characteristics of neuralgia. For a time before the catamenia appear
there is a sense of general uneasiness, a deep-seated feeling of cold
and headache, sometimes alternating with pain in the back and lower part
of the abdomen, perhaps extending down the thighs.
The flux comes on sometimes slowly and scantily, or in some cases in
slight gushes. The discharge may be paler than natural, and may be mixed
with slight clots. In some cases there is a membrane of plastic lymph
discharged either in shreds, or in the form of the uterine cavity that
it has lined. Conception is rare under such circumstances.
Though the disease seems to be of a simple neuralgic character, it is
supposed that there is a degree of inflammation of a peculiar kind in
the mucous membrane where the plastic lymph is thrown off.
In regard to the duration of the period, the constitutional injury
sustained, and as to the relief on the appearance of the menses, the
cases vary.
A peculiar irritability of the uterus is a common cause of this form of
the disease, but, like amenorrhœa, it may be caused by cold, mental
emotion, or local injury from a fall.
In the treatment of this class of cases, to reduce the pain, opium,
conium, hyoscyamus, etc., are given, often combined with camphor. (F.
161, 163, 166, 167.) These should be given in the form of an enema, or a
suppository, if the stomach is irritable. (F. 160.) The hot hip bath
should be employed, the patient remaining in it from thirty-five to
forty minutes; an ounce of carbonate of soda may be added to the water.
The good effects of the bath may be kept up by the use, immediately
afterwards, of a pessary of oxide of zinc and belladonna. (F. 163.) It
will be of benefit to take vaginal injections of tepid, or warm, or hot
water on the approach of the menses, and the patient should use a
pediluvium, or a hip bath, for two or three nights in succession
antecedent to the show of the menses. During the interval every effort
should be made to strengthen the patient, and to diminish the
irritability. Injections of tepid or cold water may be taken daily; the
diet should be nourishing, and plenty of exercise in the open air should
be taken by the patient. Some preparation of iron should be given, and I
have found F. 177 particularly useful.
CONGESTIVE DYSMENORRHŒA, sometimes described as _inflammatory_
dysmenorrhœa, generally comes on at a later time of life than the
neuralgic form. It occurs in females of a full habit and of a sanguine
temperament; in the married as well as the unmarried, and those that
have not borne children.
Restlessness and feverishness, rigors, flushing and headache generally
precede the severer symptoms. The sufferings commence, or are generally
aggravated four or five days before the period, and it may continue for
a week or more. Both before and after the catamenia appear, there is
great pain across the back, aching of the limbs, intolerance of light
and sound, weariness, the face is flushed, the skin hot, the pulse full
and bounding; when the flow gets abundant the pain is mitigated, though
there are paroxysms of pain, as small clots and shreds of membrane are
thrown off from the uterine cavity. Under the influence of inflammation,
the epithelial coat of the uterine cavity and of the vagina is sometimes
expelled. In the interim between the periods the cervix uteri is
congested and tender, and pain will be excited by pressing the ovaries;
usually there is a tenacious leucorrhœal discharge. Frequently the
breasts swell and become tender as the period approaches.
In treating this form of dysmenorrhœa, opiates must be used, as in the
former variety, to afford some alleviation. Give also saline purgatives,
febrifuge medicines, such as aconite, veratrium, and gelsemium; also
cooling drinks. During the interval the patient should live plainly,
avoid stimulants, and take moderate outdoor exercise. The suppositories
(F. 163) may be used steadily. If the disease be associated with a
rheumatic diathesis, the appropriate remedy for that should be used. It
is in such cases especially that chalybeate mineral water, warm sea
water, baths, colchicum, iodide of potassium, with friction and
electricity applied directly to the hypogastric region, succeed in
restoring health. (F. 103, 165).
MECHANICAL DYSMENORRHŒA is that form in which there is some mechanical
obstruction to the escape of the menstrual discharge. The causes of the
obstruction are various. There may be either a stricture of the internal
orifice of the uterus, or a narrowing of the whole canal of the cervix,
or the external os uteri may be small and contracted, or some tumor may
interfere with the patency of the cervical canal, and there may be
retroflexion or antiflexion of the uterus.
In these cases there is more or less violent expulsive pain coming on in
paroxysms, and there is usually a scanty flow. Often the discharge
escapes in gushes, each gush being preceded by a bearing down effort,
and accompanied by an expulsive pain. There are attacks of nausea,
restlessness and retching, with flatulence; there is always severe
headache and congestion, with tenderness of the ovaries; and if there is
endometritis, there are some other inflammatory symptoms.
Modern gynecology has various remedies for this class of cases, of which
it is not necessary to speak here.
MENORRHAGIA.
The term menorrhagia should be applied only to cases of menstrual flow,
although it is often employed to signify any considerable sanguineous
discharge from the uterus, other than normal monthly escape. But I will
say something here of cases where there is a more abundant or a more
prolonged flow than is natural to the subject of it, and of cases where
there is a recurrence of the discharge at short intervals, so as to seem
almost continuous.
In that variety in which the discharge is normal in quality but the
quantity is increased, there is undue uterine congestion, set up by
constitutional causes, or it is induced by slight disease of the uterus
or ovaries.
When menorrhagia takes place in plethoric habits, it is manifestly
remedial, and ought not to be restrained hastily. We may endeavor to
reduce the plethora, and a cooling diet, the recumbent position, and
saline cathartics may be enjoined. (F. 61).
If the flow continues five days or more, and especially if depressing
effects are manifested, such as general weakness, languor, mental
depression, with pain in the head, loins or back, the patient is
undoubtedly suffering from the loss of blood, and it is best to restrain
the flux by general and local means (F. 176.) At the time when the flow
is profuse or long continued, give strong cinnamon tea, a teacupful at a
time, or teaspoonful doses of tincture cinnamon every hour. Astringent
pessaries should sometimes be used. Formerly injections of cold water
were given; recently injections of hot water, as hot as can be borne in
the vagina, are considered more effectual. Fluid extract of ergot, in
half-teaspoonful doses, may be given every hour for two or three
successive hours. Other remedies are elixir vitriol and turpentine,
opium and acetate of lead during the attack; and counter irritation to
the sacrum, the douche to the loins, sponging, cold vaginal injections,
and the sitz bath during the interval. (F. 175).
If astringent or cold injections are used, the patient should lie upon
her back in bed, and the fluid should be thrown up gradually. Of course,
there are cases where only an experienced, well-educated physician can
do all that is required in removing the cause of the difficulty.