A system of practical medicine. By American authors. Vol. 4

by Unknown

DISORDERS OF THE UTERINE FUNCTIONS.

BY J. C. REEVE, M.D.

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Menstruation with its disorders is the only subject to be considered under this head. In its monthly recurrence it is most intimately connected with, and dependent upon, ovulation, each menstrual discharge being the sign and evidence of the maturation and expulsion of one ovum or more. This proposition is denied by some, but the evidence adduced against it, while sufficient to show that the two processes may be dissociated, and may sometimes occur independently, is not strong enough to invalidate the truth of the general statement.

Menstruation may be entirely absent, the flow may be excessive, or it may be accompanied by severe pain; and these derangements have been designated from time immemorial as amenorrhoea, menorrhagia, and dysmenorrhoea. The time is long past, however, when these affections could be treated as distinct diseases. Each of them may be caused by influences so various—and, above all, may depend upon pathological conditions so different, and even dissimilar—that the name applied to each is indefinite, and, like the term dropsy, only incites inquiry as to some abnormal condition of which the deranged flow is the symptom. A due appreciation of this fact is of prime importance, because treatment cannot be instituted with expectation of success until the particular form of each derangement has been distinguished.

The great majority of cases of uterine derangement depend upon changes of structure. Those considered purely functional are largely in the minority, and would be still less in number with a more intimate knowledge of pathology or with greater skill in examination. No argument is needed, therefore, to show that a direct and thorough examination of the organs concerned is essential to rational treatment of this class of affections. There are obvious difficulties in the way of such an investigation, different from and far greater than attend the investigation of the diseases of any other organ of the body. With tact and proper demeanor, however, these difficulties can be generally overcome, but in any other than trifling cases, and especially in those continuing for any considerable time, the practitioner will do injustice to himself as well as to his patient if he do not insist upon this indispensable investigation.

A due appreciation of the influence of uterine disorders and diseases upon other and remote parts of the body is necessary to a correct estimate of their importance, and often of great practical value in treatment. Through the sympathetic nervous system pathological conditions of the uterus modify the processes of organic life, and by direct or reflex action affect the cerebro-spinal system in its centre or at any point of its terminal ramifications. That the stomach responds readily to uterine excitations is shown in pregnancy, and uterine disease often causes disorders of the digestive organs the origin of which may not be suspected. Eructations, vomiting, and the various forms of indigestion are not uncommon. The bowels are irregular in action, constipation alternating with diarrhoea, and flatulent distension may occur even to a degree demanding special treatment. Failure of general nutrition and impoverished blood are the consequences of this disturbed digestion; without good blood there is no sound innervation, and the nervous system is soon in such a condition as to respond unduly to even insignificant impressions. Normal menstruation is marked by a nervous erethism which shows itself by irritability, fits of despondency, and exhibitions of temper. There are therefore abundant reasons why nervous diseases should be very frequently seen as a remote effect of uterine disorders.

A very large proportion of these reflex diseases first occur at the period of puberty, many present striking exacerbations at every menstrual period, and some are so closely associated with this function as to be cured only by remedies addressed to it. Headache, neuralgia, hysteria in its varied forms, chorea, catalepsy, epilepsy, and even mania, have been repeatedly shown to have their origin in the sexual organs. The reproach often directed at gynecologists, of a disposition to magnify their specialty, falls pointless before such important facts; and since it is not uncommon for diseases of organs in close proximity to the uterus, as those of the urethra, bladder, and rectum, to be mistaken for or confounded with diseases of the uterus itself, there is abundant warrant for urging the closest scrutiny as to a possible uterine origin of remote diseases, especially those of a nervous character.

Amenorrhoea.

The term amenorrhoea signifies the absence of menstruation. It occurs in two different forms: First, those cases in which menstruation has never occurred—emansio mensium; second, those in which it has disappeared after having been established—suppressio mensium.

The following pathological schedule may assist in the study of the subject. It need scarcely be said that it is not presented as correct in every particular, nor with the idea that the dividing-lines between physiological and pathological conditions can be always determined, but as a convenient guide to follow in the study of the subject:

A. Amenorrhoea (absent menstruation) from
	a,	anatomical conditions: want of development of organs, atresia of passages;
	b,	physiological influences: delayed puberty, idiopathic;
	c,	pathological causes: constitutional diseases, disease of the sexual organs, the cachexiæ.
B. Amenorrhoea (secondary or suppressed menstruation):
	a,	anatomo-pathological: atresia of passages, atrophy of organs;
	b,	physiological: pregnancy, nursing, premature change of life;
	c,	pathological: besides those given above—A-c—are psychical influences and exposure or taking cold during menstruation.

Absence or want of due development of some of the sexual organs is not of very infrequent occurrence. The ovaries are very rarely found wanting; they are more often checked in development and present the characteristics of early life. This condition may be the cause of delayed, irregular, or scanty menstruation, making a more or less near approach to amenorrhoea. Absence of the uterus is often combined with absence or with an undeveloped condition of the vagina, but this canal may be perfect and no change of the external organs be present to indicate that the uterus is wanting. It may also exist in a rudimentary form, and may be found corresponding in size and shape to the uterus of any period of early life.

Absence of the ovaries not only causes amenorrhoea, but checks the progress of the bodily development and prevents the sexual changes of puberty. When the ovaries are wanting there is almost always absence of the Fallopian tubes, uterus, and vagina. The symptomatology of absence of the uterus is not generally striking, the lack of menstruation being the principal sign; exceptionally, however, it is otherwise. In some cases where the ovaries are present and the uterus wanting, the most aggravated affections of the nervous system show themselves.

Congenital atresia of the genital canal may occur in any part of its course. Imperforate hymen is the most frequent as it is the least dangerous form, being more than twice as common as atresia of the vagina and three times as frequent as that of the cervix uteri. The vagina may be extremely small in calibre, closed in part or the whole of its course, or only a fibrous cord indicate where it should be. The uterus may be closed at the internal or external os; the latter is the more frequent. An occlusion at one point does not preclude the existence of other closures higher up. The effect of a closed canal with a recurring secretion above is evident, and gives rise to a well-marked class of cases. The organs above become distended, and the distension increases until an opening is made by art or the retained fluid bursts a passage for escape. This may occur outwardly with immediate relief and cure, or into the peritoneal cavity, causing speedy death. The time at which the uterus may be expected to give way under such distension cannot be stated, as the power of resistance of the organ differs and the amount of secretion each month may vary widely. Scanzoni in one case evacuated eight pounds of blood, the result of seven months' accumulation, and found the uterine wall as thin as paper. Bernutz states that the average time before interference is necessary is three or four years, and gives a case first operated upon in the tenth year of its course.

Menstrual retention is not at first indicated by pronounced symptoms. Suspicion of the nature of the case may be first excited by the severity of those symptoms which at every period announce the approach of menstruation and known as the menstrual molimen. As distension increases these become extreme, with rectal and vesical tenesmus and severe uterine colic. The nervous system sympathizes, as with all menstrual derangements, and there may be rigor, fainting, or even convulsions.

Whenever a patient presents such symptoms an examination should be insisted upon. It will generally reveal a smooth, soft, and fluctuating tumor, projecting externally if the case be one of imperforate hymen, or higher up if the vagina be occluded. If the uterus has become distended, there will be a round, smooth, elastic tumor above the pubes. Diagnosis will be more or less difficult according to the seat of the obstruction. Cases of imperforate hymen may be readily diagnosed by sight, if touch and the history are not sufficient. When the occlusion is deeper, the patient should be placed under the influence of an anæsthetic. By one finger in the rectum and the thumb in the vagina, and a sound in the bladder, the seat and extent of the obstruction may be determined. Should it be necessary, the urethra may be dilated and a finger passed into the bladder in order to make a diagnosis. Rectal exploration is of great assistance in discovering the uterine enlargement and its character. Scanzoni calls attention to the difference in the cervix when the atresia is at the internal or external os. In the latter case the cervix will be obliterated; in the former, it will be unchanged. With a perfect vagina and a cervix of this character retention may be taken for an early pregnancy, especially as it is not uncommon for sympathetic mammary symptoms and gastric troubles to be present. Time will demonstrate the nature of the case if a diagnosis cannot be made at once.

The age at which the menstrual flow is established varies greatly. The average age of puberty in this country, as appears from Emmet's tables made up of 2330 cases, is 14.23 years, and these are believed to be the only American statistics. A close correspondence may be noted between this and the statistics of the four largest cities of France, which give 14.26 as the average. But that it is not unusual for the appearance of menstruation to be delayed is shown by the fact that of the above 2330 cases, 288 only menstruated at sixteen years and 254 more between that age and twenty-three. The circumstances which may influence, within physiological limits, the appearance of menstruation should be considered in connection with cases of this kind. Climate and social position are the principal ones. The epoch of puberty descends in the scale of age in proportion to the average height of the temperature of various countries, and vice versâ. Social position and city life show a marked effect in hastening puberty as compared with the simpler manners and plainer life of rural populations. It amounts to an average of something over a year, and is explained by the influence of enervating and luxurious habits, of light reading and the drama, the chief subject of both being the grand passion, but especially of a freer intercourse between, and the co-education of, the sexes, and the greater extent to which music is cultivated and enjoyed.

Among pathological conditions giving rise to amenorrhoea it would seem that disease of the ovaries should occupy the first rank in frequency and importance. The reverse is the truth. The ovaries are rarely inflamed, and when so amenorrhoea is not always the result. They are frequently the seat of cystic degeneration, producing tumors of large size, yet so long as but a small portion of one of the organs remains unaffected Graäfian vesicles may still be furnished and menstruation continue. It is by the influence of remote pathological conditions that the menstrual flow is most frequently restrained, and especially by those general affections known as cachexiæ, all of which exhibit marked depression and low grade of vital power and activity, if not more pronounced pathological processes. Chlorosis, the relations of which to menstruation are intimate, and which seems to be sometimes the offspring of amenorrhoea, exerts a marked retarding influence, amounting to an average of one year and a half. The scrofulous cachexia is still more potent: Scanzoni states that of 31 well-marked cases, in 19 menstruation did not occur until the twenty-first year.

Amenorrhoea which is the result of pulmonary tubercular disease comes frequently under observation. It may occur at a very early period of the disease, before there is any great amount of deposit in the lungs, when it is rather the expression of want of vital force than of the exhausting effect of the disease. Under these circumstances it is only to the laity a subject of serious consideration; to the physician it is but a symptom.

The suppression as well as the absence of menstruation may be caused by 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 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 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 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 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 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 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. 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.

The organs in proximity to the uterus, partaking as they do of the menstrual congestion, are also markedly affected. There is rectal tenesmus, and on the part of the bladder frequent micturition and dysuria. Remote organs are influenced either directly or by sympathy. The breasts become tumefied and tender. There is flatulence, nausea, or even vomiting. The nervous system, during normal menstruation in a state of erethism, responds readily to the painful impressions, and presents symptoms of the most varied character and degree, amounting even to general convulsions.

Attacks of severe pain recurring at short intervals cannot but exert a powerful deleterious influence upon the general health. Digestion is interfered with, nutrition and sanguification are imperfectly performed, and there is a continuous chain of deranged function. The results to the nervous system, indirect and direct, and sometimes also from the measures of relief resorted to, are most deplorable. From every point of view this class of cases presents the strongest claims for relief.

The discharge in dysmenorrhoea varies very widely in amount and character. It may be so scanty as to border on amenorrhoea or so profuse as to be menorrhagic. It may be more or less fluid than usual. The expulsion of clots is a frequent feature, and the size and shape of these sometimes give indications of value. Like other uterine derangements, dysmenorrhoea is not a disease per se, but a symptom of some pathological condition the exact nature of which is to be ascertained whenever possible. Cases may be classified as follows: I., Obstructive or mechanical; II., congestive; III., neuralgic; IV., membranous. It cannot be too distinctly kept in view that this classification, like many others, cannot be rigidly followed. The dividing-lines are sometimes but faintly drawn by nature; some cases present the features of more than one class; some by natural progress pass from one class into another. Based upon leading clinical features, this classification will assist in the study of the subject, facilitate diagnosis, and aid in directing therapeutic measures.

Two classes given by some authorities are not included in the above classification. They are spasmodic and ovarian dysmenorrhoea. If by the former is implied painful contractions of the uterus during menstruation, the cases fall into the first class given above, the obstructive; and if irregular nervous action is implied, they belong to the third, the neuralgic. The term ovarian has been applied to those cases in which an abnormal condition of the ovaries exists, such as inflammation, enlargement, or dislocation. Such conditions are not easily ascertained during life; if ascertained, the fact throws light on the etiology of the case; but for treatment the case will range itself, according to the clinical features it presents, among those in which the vascular or the neurotic element predominates.

Obstructive or mechanical dysmenorrhoea is that form in which some impediment exists to the free escape of the menstrual discharge. The genital canal presents no exception to the general rule that when an excretory channel is obstructed violent and painful expulsive efforts are excited.

The causes which give rise to the obstruction are various. Among them are the following: fibroid tumors of the uterus distorting, and polypi obstructing, its cavity or neck; stenosis of the cervical canal, either congenital or acquired, the latter often the result of the injudicious use of strong caustics; a long and conical cervix; a contracted os, sometimes so small as to be justly termed the pinhole os; versions and flexions of the uterus.

The seat of obstruction is almost always uterine, but may be in the vagina or at its entrance. There is much difference of opinion as to the relative frequency of occurrence of obstruction at the internal or external orifice of the cervix.

The pain in this form of dysmenorrhoea generally does not precede the flow. In character it is sometimes like colic, but its leading feature is expulsive effort. It occasionally so nearly resembles abortion as to require care to distinguish between them. It is frequently intermittent, presenting intervals of complete relief. In severity it varies widely. In some cases the patient assumes and maintains a certain position which she has learned affords her some relief. This indicates with great probability uterine distortion from fibroid tumor. The writer has met with a marked instance of this kind.

The flow is more irregular in this than in other forms. It is sometimes extruded drop by drop; more often it appears in gushes, the fluid accumulating and distending the uterus until expulsive efforts are excited. Clots are often thrown off under these circumstances in shape and size corresponding to the cavity of the uterus.

Absence of prodromata, presence of the fluid being necessary to excite the pain, the intermittent and especially the expulsive character of the pain, and the kind of clots, indicate the nature of the case. A certain diagnosis, however, rests alone on physical examination. This should be by the touch, bimanual and rectal, and the sound. Sometimes additional aid will be derived from the speculum. By touch the form, size, shape, and direction of the cervix are ascertained, and its relations to the body of the uterus. The sound will give evidence as to the patency and direction of the cervical canal and uterine cavity.

A diagnosis of obstructive dysmenorrhoea should not be rejected because the patient occasionally passes a period without pain. In the male an enlarged prostate may for a long time interfere but little with micturition, and then all at once completely obstruct the flow of urine. A diagnosis cannot be based alone upon the condition of the cervical canal as found during the intermenstrual period. Two elements are to be considered, each of which may, and doubtless often does, play a part: tumefaction from the congestion attendant on the process, and spasm. The latter, caused by reflex action excited by irritation in the body of the uterus, assumes a leading position with those who claim that obstruction is the sole cause of dysmenorrhoea. That it plays an active part in many cases cannot be doubted; that it is a necessary condition of even spasmodic dysmenorrhoea is disproved by the positive statement of Matthews Duncan, that in some cases he could pass a sound freely into the uterus during the paroxysms.

A due estimate of the part which a uterine flexion plays in producing the dysmenorrhoea is important, but very difficult. Theoretically, the narrowing of the canal at the point of flexion should account for the symptoms, but experience does not accord with theory. All cases of flexion are not accompanied by dysmenorrhoea, and when so accompanied removal of the deformity does not always cure. Siredey in 52 observations found only 22 cases of dysmenorrhoea. Emmet's carefully-prepared tables show that in nearly 50 per cent. of anteflexions menstruation is painless. The conditions necessary seem to be extreme flexion, producing an acute angle. In less-pronounced cases it is maintained by many that the flexion is an unimportant factor, and that the dysmenorrhoea depends upon secondary conditions produced by it, as endometritis and congestion. The problem is difficult, and each individual case requires careful study. The facts indicate that there is much in the pathology of this form of disease not yet fully understood.

Congestive dysmenorrhoea depends upon an advance of the menstrual congestion beyond the physiological limits. In these cases the patient generally suffers for a few days before the period from a sense of fulness, weight, and heat in the back and pelvic region. Pain follows, is more or less severe, and varies somewhat in character, although generally dull and heavy. The hypogastric region usually becomes distended, and is sometimes very tender to the touch over the ovaries, "especially on the left side, without any reason for the difference being known." After a longer or shorter duration of these symptoms the flow appears, and this is often, especially if free, followed by an amelioration of the pain. In many cases, however, there is no remission of the suffering upon the discharge occurring. Not infrequently the general circulation is affected, the face is flushed, the skin hot, and there is more or less fever.

The flow may vary widely as to quantity. It is often at first and for a time more profuse than normal. Leucorrhoea frequently precedes and follows it, persisting during the entire interval. During that time also the patient suffers much from backache and bearing down, with difficulty of walking or of remaining on her feet.

Upon examination the vagina is found hot and tumefied, and increased arterial action is evident to the touch. The uterus is tender, enlarged, and heavier than usual. In cases associated with or dependent upon chronic inflammation or areolar hyperplasia the increase of size of the uterus during menstruation is marked. The sound may be used to determine the amount of enlargement and also the amount of tenderness. In cases dependent on endometritis touching the interior of the organ causes severe pain. Dyspareunia is frequently a symptom in this class of cases.

The conditions upon which congestive dysmenorrhoea depends are various, and may be either general or local or both combined. Plethora is rare in females, and local congestions are much more frequently dependent upon anæmia, the abnormal condition of the blood favoring them directly and also indirectly by its effect on the nervous system. In past times gout and rheumatism were considered to act frequently as the cause of dysmenorrhoea. They have almost disappeared from view since the era of direct examination began. Malaria, however, as a possible cause or a powerful factor should never be overlooked in regions where it prevails. The sexual instinct plays an important rôle; enforced abstinence, especially when suddenly brought about, and excess, being alike effective etiological factors. Young widows and prostitutes are both subject to this form of disease.

The local causes are numerous. Pelvic inflammations, as cellulitis or pelvic peritonitis, give rise to the disease. Affections of the uterus are frequent causes; displacements, as retroversion or prolapsus; and inflammation, either parenchymatous or of the endometrium. Quite a moderate grade of inflammation, as found during the interval, may, under the increased congestion of menstruation, become extreme. Many cases doubtless depend upon an ovarian influence even when no affection of these organs can be made out. Scanzoni hazards the theory that the maturation of Graäfian vesicles lying deeper than usual in the stroma of the ovary is one cause of this form of dysmenorrhoea.

In neuralgic dysmenorrhoea the neurotic element preponderates. The nerves play a part corresponding to that of the vessels in the congestive form. In some cases of this class no organic lesions can be discovered, and they are then termed idiopathic.

This form of dysmenorrhoea depends upon either a peculiar condition of the general nervous system or upon hyperæsthesia of the sexual system, or both combined. Either or both may have been inherited or acquired. It is frequent in subjects of the hysterical temperament, and in those presenting that preponderance of the nervous system so often seen as the result of over-refinement, luxury, habits of idleness, and other violations of hygienic law. Those subject to it often suffer from severe headaches, neuralgia, and other nervous affections. It is often caused by anæmia or chlorosis. Sexual influences, psychical or physical, and especially those that excite without satisfying, are sometimes efficient causes. Ovarian influence is often an important factor; some authorities designate all those cases in which no anatomical change can be found, ovarian. The prodromata of this form are very apt to be some of those nervous attacks to which such patients are liable, as headache or neuralgia, and they may be psychical, as aberration of temper, undue irritability, or tendency to melancholy. In character the pain is generally stated to be more acute than in the other forms. It is subject to great and sudden alternations. In acuteness and irregularity it often justifies the term spasmodic. From these characters and from the absence of anatomical change a differential diagnosis may be made. As in this form the most marked nervous symptoms are witnessed, so are also the most pronounced complications on the part of the general nervous system. They are often hysterical in character, but may be of every kind and degree, even to general convulsions, and mental aberration is sometimes a complication or result.

Membranous dysmenorrhoea is characterized by the expulsion at the menstrual periods of organized membrane, either as a whole or in pieces. In the former case it is like a cast of the interior surface of the uterus. The expulsion of this membrane is accompanied by pain, often of the most severe character. The pain presents well-marked features; it is markedly expulsive, identical with that of the obstructive form, closely resembling an abortion, to which the membrane adds an additional element of similarity. This pain and these expulsive efforts may continue twelve, eighteen, or twenty-four hours, and then cease, to be renewed only at the next period.

This form of disease is rare—so rare that observers having a large field of observation may never meet with over half a dozen cases. In regard to many points very diverse views are held, and the limits of a practical work do not permit even a statement of all of them. The nature of the membrane is one of these points too important to pass over. When thrown off entire, its internal surface is smooth and marked by the openings of the utricular glands; its external or uterine face is rough and villous. It presents the exact shape of the interior of the uterus, with openings corresponding to the Fallopian tubes and the os. It is impossible to escape the conviction that this membrane is the lining membrane of the uterus, thrown off as a whole, instead of by gradual melting down of its superficial layers, as in normal menstruation. The microscope sustains this view, and this is the generally received opinion; yet that the membrane is not always such is testified by competent observers from observations with the same instrument. It seems probable that this disputed point will be settled, as have been so many others in medicine, in favor of both parties. Siredey suggests the possibility of different kinds of membrane in these cases, while Barnes boldly states this as a fact.

Various theories have been advanced to account for the formation of the membrane. An abnormal course of conception, a changed ovarian influence, a peculiar endometritis, have been from time to time favorite terms in which to express our ignorance. Only in regard to the first has unanimity been obtained. That the membrane is always a product of conception is not now maintained by any respectable authority. It is a well-established fact of the utmost importance that such membranes may be expelled when there has never been sexual intercourse.

The membrane of dysmenorrhoea is to be distinguished from fibrinous masses, the remains of blood-clots from which the corpuscles have been squeezed; from mucus coagulated into shreds by astringent injections; and from the products of membranous vaginitis. Neither of these will present much difficulty with the aid of the microscope. The case is very different, however, when the membrane is to be distinguished from the decidua of an early pregnancy. From a single specimen or a single attack a diagnosis cannot be made. Thomas gives an instance of disagreement as to the nature of the same membrane by two of the highest microscopical authorities. The recurrence of the attacks at the regular menstrual periods will establish the diagnosis.

The prognosis of dysmenorrhoea varies in the different classes. In the obstructive form it will depend upon the curability of the lesion upon which it depends, and the same may be said of the congestive. The neuralgic cases do not yield readily to treatment, especially when dependent upon a peculiar and perhaps inherited nervous constitution. Caution should be exercised, however, in expressing an unfavorable prognosis. Like all nervous diseases in the female, it is subject to great mutations without apparent adequate cause, and will sometimes suddenly disappear in an inexplicable manner.

The membranous form affords still less promise of cure: the unsatisfactory results of treatment are generally acknowledged.

During an attack of dysmenorrhoea the patient should remain in bed for the benefit of rest and warmth. In those cases where the flow is not too free, and especially when relief follows its appearance, active measures to promote this end may be instituted by hot drinks and hot fomentations. In married patients a hot sitz-bath, during which the vaginal syringe is used to douche the uterus, is an efficient measure. Pain being the prominent symptom, and remedies for its relief being at hand and reliable, the indication is clear and the treatment can be briefly stated. In execution, however, it is not a simple problem: immediate relief is not alone to be considered. If opiates be resorted to for frequently-recurring pain, a habit will soon be formed that is no less a calamity than the disease itself. While, therefore, opium and its preparations are reliable remedies, and in many cases indispensable, they should be administered as seldom and as sparingly as possible, and always with an appreciation of possible injurious consequences. Many cases can be successfully managed with chloral hydrate, or belladonna, or Indian hemp. When opiates are resorted to, they should be combined as much as possible with other medicines by which their effects are modified, and relief afforded with the smallest possible dose. Thus in cases attended with vascular excitement these ends may be attained by the union of opium with tartar emetic or aconite; when there is marked disturbance of the nervous system, it may be combined with an antispasmodic, as the compound spirit of ether. Administration by the rectum will produce a local as well as a general effect, and injections of starch and laudanum or suppositories of opium and belladonna may be administered. The speediest and most certain relief is afforded by the hypodermic syringe. Resort to it should, however, be rigidly controlled; it should be used as a miser uses his gold, and it need scarcely be added that only very exceptional, if any, circumstances will ever justify placing the syringe in the hands of friends or attendants, no matter with what restrictions. Unfortunately, this is sometimes done, but very rarely without great injury resulting.

During the intervals general treatment should be instituted according to the indications. All functions at fault are to be regulated. Anæmia is to be corrected, the debilitating effects of malaria counteracted, good digestion promoted, and a weakened nervous system strengthened. These indications are met by tonics in various forms, notably iron and zinc; by antiperiodics, as quinia and arsenic; by stomachics; and by the judicious use of wine. There are other remedies quite as useful as drugs—cold sponging and shower-baths, followed by vigorous rubbing, general electrization, and, when the patient cannot or will not take outdoor exercise, massage. Change of scene and air is sometimes beneficial or even necessary. In many cases of pronounced neuralgic form, or in which the nervous system has been shattered by the severity or long duration of the attacks, there can be but little hope of amelioration without a thorough change of habits and mode of life in every respect.

The local treatment will be according to the conditions present. In the obstructive form, polypi are to be removed if present, and in stenosis the patency of the canal restored. Dilatation may be accomplished by tents. Should these fail, resort may be had to surgical measures, as the frequent passage of bougies gradually increasing in size, forcible dilatation with steel dilators under an anæsthetic, or by incision. Each of these measures has its advocates, and with all cures have been effected. Flexions should be corrected as far as possible by a vaginal pessary. Intra-uterine pessaries more certainly correct the deformity, but great care should be exercised in their use. If inflammation be present, uterine or pelvic, they will not be tolerated or will do positive injury; nor should a patient with any instrument of this kind ever be allowed to pass out of reach of the physician unless she can herself remove it.

The treatment of many cases of congestive dysmenorrhoea is very similar to that of suppressed menstruation from cold—warm drinks, hot foot- and sitz-baths, fomentations, and douches.

Particular attention should be paid to the bowels, not alone to correct constipation, but to give full relief to a clogged portal system by saline purgatives. If there be prolapsus, a pessary should be adapted so as to keep the uterus up in its place; by this means passive congestion is much relieved. Bromide of potassium is a reliable remedy as a corrector of pelvic congestion. In the congestive cases of anæmic subjects iron will act beneficially; in inflammatory congestion it does injury. Dysmenorrhoea dependent upon hyperplasia or endometritis should receive the treatment appropriate to those affections.

In neuralgic dysmenorrhoea the general treatment is far more important than the local. All those hygienic and therapeutic measures already detailed should be faithfully persevered with. For the relief of pain and control of the nervous symptoms enemata of asafoetida are useful. Chloral may also be administered in the same way or by the stomach, with camphor, valerian, and the æthers as required. In this form apiol has been successfully used; the evidence as to its value is clearer than the explanations of its mode of action. It may be given in capsules, each containing five grains, one, two, or three daily.

Some local measures often render good service: among them is the passage of bougies, which sometimes modify the sensitiveness of the cervical canal, as they do that of the male urethra. The galvanic current, both continuous and Faradic, has effected cures, but the cases to which it is best adapted or in which it is most likely to be good cannot be clearly indicated. A galvanic stem-pessary may be used, observing due caution. This instrument has been modified and much improved by Thomas: being made like a string of metallic beads, it is extremely flexible, and many of its former objectionable features are removed.

A successful treatment of membranous dysmenorrhoea has not yet been promulgated. The great difficulty of its cure is admitted by the highest authorities. Some cases associated with stenosis of the cervix have been cured by dilatation—a fact which but strengthens the general principle of correcting all anatomical changes whenever possible. Strong caustics have been applied to the interior of the uterus with a view of exerting an alterative influence upon the seat of the disease. The course seems correct in theory, but in practice it has not proved fruitful of good results, and treatment in the majority of cases is limited to palliation.

In regard to marriage in females afflicted with dysmenorrhoea, it may be stated to be advisable in many cases of the neuralgic form and in anæmic subjects where the flow is so scanty as to border on amenorrhoea. In cases of the congestive form, if dependent on inflammation or on organic lesions, as fibroids, there is very great probability that the symptoms will be aggravated by this radical change of mode of life.

Menorrhagia.

The term menorrhagia signifies excessive menstrual flow. The excess may 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 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 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; 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 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 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 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 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.

While the writer would not be just to the reader if he did not state that some very high authorities are strongly opposed to intra-uterine injections and applications, he would not be just to himself did he not state that his own experience has been favorable to them. While he once saw severe and dangerous symptoms follow syringing the cervix with water to cleanse it of mucus, he never in a single instance saw any evil effects from intra-uterine injections properly administered, nor from nitrate of silver à demeure or the application of nitric acid. But while these measures have often ameliorated cases of menorrhagia where the endometrium was affected, they have seldom cured, as compared with the curette. Indeed, the general statement may be made that as of late years the value of the curette has become more and more recognized, resort to severe intra-uterine applications has proportionally diminished. From his experience he is fully prepared to believe with Courty, that "there are cases of uterine hemorrhage which cannot be mastered in any other way," and with Siredey, that "the operation cures in the great majority of cases." It should be noted, in this connection, that some of the warmest advocates of the instrument explain its beneficial effects otherwise than by the removal of fungosities. Thus, Thomas attributes them to "the fracture of tortuous and distended blood-vessels," and Siredey to "the irritation and excitation produced by its introduction and action during reflex contractions."