CHAPTER V.

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.