Dyspepsia is a very frequent associate of dysmenorrhœa. Thus we meet with pain and tenderness in the gastric region, nausea, vomiting, and also cardialgia. Sometimes the liver becomes enlarged and tender on pressure; in many cases also jaundice is witnessed.
Gebhard refers to another phenomenon which may be classed under the head of dysmenorrhœa, from the character of the pain that is experienced, even though this pain is not felt at the menstrual periods, but in the intermenstrual epoch. This is the so-called intermediate dysmenorrhœa (intermenstrual pain, Ger. Mittelschmerz). In the character of the localized pain, intermediate dysmenorrhœa closely resembles ordinary dysmenorrhœa; it recurs often with precise regularity on certain days during the intermenstrual interval. Croom distinguishes three forms of intermediate dysmenorrhœa; that in which there is no discharge at all from the uterus, that in which there is a sanguineous discharge, and that in which there is a clear watery discharge. The first form he attributes to asynchronism in the processes of ovulation and menstruation; the second form, to endometritis with disintegration of the mucous membrane; the third, to a kind of hydrops tubæ profluens (profluent dropsy of the Fallopian tubes—hydrosalpinx in which the fluid accumulates in the tube, and at a certain stage of its accumulation flows into the uterus). Cases of intermediate dysmenorrhœa are somewhat rare, if we eliminate the cases in which pains occur in the intermenstrual epoch in consequence of disease of the uterine annexa. Inflammatory manifestations may be discovered in nearly all typical cases of intermediate dysmenorrhœa.
Long-continued dysmenorrhœa may give rise to numerous hysterical troubles, general convulsive seizures, local muscular spasm and paralysis, hiccough, spasm of the glottis, uterine cough, twitching and spasm of various groups of voluntary muscles. In some cases we see fully developed epileptic convulsions, with complete loss of consciousness and immobility of the pupils. Finally, psychoses may arise in association with dysmenorrhœa.
In cases of pathological changes in menstruation, a carefully arranged hygiene at the menstrual periods is of importance both for prophylactic and for therapeutic purposes, and in this connection I may refer to what I have written in the section on Hygiene during the Menarche. In cases of dysmenorrhœa a certain amount of repose and precaution are needed during the flow, with avoidance of chill, scrupulous cleanliness, and regulation of the bowels. In cases of amenorrhœa we must prescribe attention to the general nutrition by means of an easily digested roborant diet, as much fresh air as possible, and systematic bodily exercise. In these cases, bicycling, lawn tennis, and suitable gymnastics are often of value; also baths, in the form of warm general baths, hot sitz baths, and hot foot baths.
Vicarious Menstruation.
In cases in which, in consequence of morbid conditions of the uterus, the ovaries, or the organism as a whole, the menstrual flow has at the time of the menarche either failed entirely to appear or been exceedingly scanty, hæmorrhages from other organs have since ancient times been witnessed, and these hæmorrhages have been regarded as vicarious menstruation. The congestion that occurs during menstruation is not limited to the genital organs, and when the flow of blood from the uterus fails to occur, the organism seeks another outlet, in order to restore the disturbed equilibrium of blood distribution, and vicarious hæmorrhages take place from the mouth, the nose, the intestines, the anus, the gums, the mammæ, the ears, and the lungs; or hæmorrhages occur in the brain, the nerves, or the eyes.
Although it must be admitted that confusion has often occurred between vicarious menstruation and hæmorrhages dependent on pre-existing genuine organic disease, such as hæmoptysis due to pulmonary tuberculosis, or hæmatemesis due to gastric ulcer, still the existence of a true vicarious menstruation must be regarded as fully established.
Thus, Fricker, Fleischmann, Obermeier, Beigel, Withrow, Plyette, and Parsons observed vicarious epistaxis; Watson, Decaisne, Edebohls, Fischel, and Seeligmann, vicarious hæmatemesis; Franchi, Hotte, Ratgen, Voigt, and Windmüller, vicarious hæmoptysis; Dunlap, vicarious gingival hæmorrhage; Law and Petiteau, vicarious otorrhagia; Heusinger and le Fort, vicarious hæmorrhages, occurring variously from the anus, bladder, hand, ear, nipple, stomach, and nose; Baumgarten, vicarious hæmorrhage from the vocal cords and trachea; Hahn, from the bladder; Kerley, in the thyroid body; Gallemairts, in the eyes. Puech found, in the cases he collected, that vicarious menstrual hæmorrhage occurred from the stomach thirty-eight times, from the mammary glands twenty-five times, from the lungs twenty-four times, and from the nasal mucous membrane eighteen times. In all the cases menstruation had long been in abeyance.
Regarding vicarious epistaxis, especially exact observations have been published, showing the mutual relationship between the genital and the nasal mucous membrane. A series of cases has been recorded by Fliess. In one of these a remarkably well-developed girl of fourteen, who complained at three-weekly intervals of molimina, in the form of languor, headache, and sacrache, after an interval of four weeks epistaxis occurred instead of the expected menstruation; three weeks later came another attack of epistaxis; and finally, after an interval of seven weeks, came the first menstruation, which henceforward recurred every three weeks. In another case, that of a girl aged fifteen, menstruation appeared once; four weeks later came an attack of epistaxis instead of menstruation, and these attacks of epistaxis were continually repeated, at intervals of twenty-nine days, in place of menstruation, until finally pregnancy occurred. During pregnancy the epistaxis ceased, to recur however six weeks after parturition; the attacks continued for eight monthly periods, when they ceased finally at the commencement of the second pregnancy.
Other similar cases are known in which epistaxis recurred with all the regularity of the menstruation it replaced during pregnancy and ceased at parturition. Analogous cases occur in which epistaxis has persisted during pregnancy, during the puerperium, and at the climacteric period, replacing the physiologically suppressed menstrual flow. Similarly Liégois has observed vicarious hæmoptysis during pregnancy. According to Baumgarten, in vicarious epistaxis the bleeding almost always proceeds from the region of the cartilaginous septum, and may become very violent; vicarious hæmorrhage from the larynx proceeds from the true and false vocal cords. Tracheal hæmorrhage is a much rarer occurrence.