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.