for a few minutes. The cervical canal must be patulous for subsequent drainage, and it should, if possible, be excluded from the action of the copper. This treatment has proved very valuable in uterine hemorrhage and endometritis. A much stronger current, 80 to 100 M., has been used for ten minutes in the cervix for gonorrhea. After three applications all gonococci had disappeared. In a similar way zinc has been used. It forms an oxychloride, which has the property of softening the tissue, and has been used successfully in cases of sclerosis and fibroid. After having been used, these corrodable electrodes are polished with emery cloth.1

1A. H. Goelet, The Times and Register, 1893, pt. 2, p. 743.

PART VII.

ABNORMAL MENSTRUATION AND METRORRHAGIA.

THE normal process of menstruation has been considered in Part III. (pp. 115-120). This process is subject to disturbances which may occur in very different gynecological diseases or without any affection of the genitals. It may be absent (amenorrhea) or scanty; the bleeding may take place from another part (vicarious menstruation); it may be painful (dysmenorrhea); it may begin too early in life (precocious menstruation); or it may be profuse (menorrhagia).

Finally, there may be hemorrhage from the uterus at other times than the menstrual period (metrorrhagia).

CHAPTER I.

AMENORRHEA.

AMENORRHEA is the absence of the menstrual flow. This may either be so that the flow had begun and suddenly stopped, which is called suppression of menses, or so that it does not come on at allamenorrhea proper.

1. Suppression of Menses. Etiology.-The suppression of menses may be due to exposure during menstruation, by which the feet or the skin becomes wet and cold (compare p. 129); to emotions, especially a fright; or to the appearance of an acute inflammation, such as pneumonia or erysipelas.

Symptoms. The symptoms are sometimes slight or none, and the courses reappear at the next period; but sometimes the sudden suppression of the menstrual flow gives rise to acute congestion or inflammation of the womb or the appendages, to extravasation of blood into the peritoneal cavity or the pelvic connective tissue, and the amenorrhea may last long or be final.

Treatment. It is proper to try to bring the flow back by hot applications to the abdomen, hot hip-baths, hot vaginal and rectal injec

tions; but, as a rule, this medication succeeds only in so far as it relieves pain. The same is accomplished by opiates.

2. Amenorrhea, in the proper sense of the word, is the condition in which the menstrual flow fails to appear, although the patient has reached the proper age and feels as if she would be relieved by its coming, or where it does not reappear at the usual period in persons who have already menstruated.

Etiology.-We have seen above that menstruation, as a rule, is absent during pregnancy and lactation. In persons who have never menstruated the cause may be congenital faulty development: absence of the ovaries and tubes; absence or imperfect development of the uterus, such as a rudimentary or infantile uterus; absence or atresia of the vagina. Often, especially in young servants, the cause is overwork, sometimes combined with insufficient food. The causes may also be the same that are at work in making menstruation stop in those who have already menstruated. A common cause is a change of climate and habits. Thus amenorrhea is often found in women who move from the country to large cities, and in those who have recently immigrated from Europe. It is often a sequel of debilitating diseases, such as anemia, phthisis, malaria, typhoid fever, diabetes, or chronic mercurial poisoning. It is not rare in insane women and morphiomaniacs. It is sometimes found in the late stage of chronic metritis, in inflammation of the uterine appendages, in cases of malignant disease of both ovaries, or in women afflicted with a vesico-vaginal fistula. It is a frequent accompaniment of the development of obesity.

About the effect of the removal of the uterine appendages see p. 119. Symptoms.-The symptoms of amenorrhea, besides the absence of the flow, may be insignificant, but it is quite common that the patient complains of headache, flashing heat, heaviness in the abdomen, nervousness, nausea or vomiting, and sometimes she may even suffer from convulsions of the hysterical or epileptic type. If the lack of flow is due to atresia of the genital canal, the fluid accumulates behind the partition, considerable pain is experienced at each recurrence of the menstrual period, and a tumor is felt in the pelvis corresponding to the distended vagina, uterus, or both. The abnormal sensations occurring at the time of the menstrual period are called the menstrual molimen.

Diagnosis. The most important diagnostic question is if the amenorrhea might not be physiological and due to pregnancy, normal or ectopic-i. e. outside the uterine cavity. In this respect every sign of pregnancy as taught in works on obstetrics must be thought of, especially the early signs, such as the softening of the lower uterine segment, the increased diameter of the uterus in the antero-posterior direction, morning sickness, and small tongues of brown pigmentation

shooting out from the superior external circumference of the areola, the first beginning of what is known as the secondary areola.

In ectopic gestation we may, besides the signs of pregnancy, find a tumor outside of the uterus corresponding in size to the duration of the amenorrhea.

Treatment.-Idiopathic amenorrhea should not be regarded or treated as a disease. In the beginning of menstrual life it is quite common that a period or two are skipped. If the girl is otherwise well no treatment is called for. If the cause of the amenorrhea is anemia, be it from loss of blood, from defective assimilation, or from wasting diseases, the only aim should be to ameliorate the general condition by proper alimentation, tonics (p. 226), moderate exercise in the open air, horseback riding, mild gymnastics, or massage. Aperients have some influence in bringing on the flow, and the one most credited with emmenagogue power is aloes. In malaria quinine and arsenic are the chief remedies. If the nervous system is upset, bromides, antipyrin, or phenacetin is very useful. Hot vaginal and rectal injections, warm hip-baths, warm foot-baths with or without mustard, and long, warm general baths will sometimes bring back the courses. The mere introduction of the sound works as a stimulus to the uterus, and may have the same effect. Electricity in all its forms (p. 229) is a powerful remedy, especially bipolar intra-uterine faradization, with secondary current, and, best of all, galvanism, with the negative pole in the uterus.

Besides iron, quinine, strychnine, and aloes, the following drugs have more or less well-founded reputation as emmenagogues: Manganese in the form of the permanganate of potassium or the binoxide (gr. ij to iv, t. i. d.); chlorate of potassium (gr. v to xx, t. i. d.) in combination with iron; santonin (gr. ij or iij, t. i. d.); oleum sabina (mij to vj, t. i. d.); oleum rutæ (miij to vj, t. i. d.); oleum tanaceti (Miij to vj, t. i. d.); oleum hedeomæ (mij to x, t. i. d.) or a warm infusion made of the herb; ergot (p. 227); radix gossypii (p. 227); tinet. cantharidis (mx, xx, up to f5j, t. i. d.); tinct. hellebori nigri (mxx to xl, t. i. d.). As their effect is very uncertain, it is wise to combine several in one prescription—e. g. ;

R. Strychnine sulph.,

gr. j;

Aloes Socotr.,

Эј;

Quinine sulph.,

3ij;

Ferri sulphat. exsiccat.,

Dij;

Ol. sabina,

3j;

Ft. pill. No. Ix.

Sig. Three pills three times a day.

It is also well to combine the use of drugs with the other remedial

agents recommended.

If in cases of rudimentary uterus the development is so insufficient that there is no hope of help from electricity and the other remedies, and if the nervous symptoms are very distressing, the removal of the uterine appendages is indicated. If the apparent amenorrhea is in reality retention of the menstrual blood behind an obstruction in the genital canal, the removal of the obstruction by operations that will be described in treating of the diseases of the special organs, is the only means of saving the patient's life.

Scanty menstruation is a lower degree of amenorrhea, and is treated on the same principles especially with tonics and electricity.

CHAPTER II.

VICARIOUS MENSTRUATION.

VICARIOUS menstruation, or xenomenia, consists in the occurrence, at the time of menstruation, of bleeding from another part of the body than the uterus, or the appearance of another secretion. The vicarious bleeding may sometimes take place alone, instead of the normal uterine monthly discharge, or it may be combined with it so as to be supplementary. In the latter case the flow from the normal source is generally scanty. Vicarious menstruation has been found to appear on nearly every mucous membrane and every part of the skin, the most common places being the stomach, the breasts, and the lungs. As to other secretions, serous diarrhea and increase of leucorrheal discharge have been observed to accompany or replace menstruation. I have myself seen colostrum in the breasts and profuse perspiration appear at the menopause.1

Vicarious menstruation is a rather rare condition. It is mostly found in weak, nervous, hysterical women. Wounds, ulcers, and varicose veins predispose to it.

Symptoms.-Generally the patient has both menstrual molimen in the pelvis and congestion, swelling, and pain in the place where the vicarious bleeding is to occur.

Prognosis.-The importance of the affection depends on the nature of the locality affected. A bleeding from the skin or the nose is far less serious than that from the stomach and the lungs. In general the chances of stopping the abnormal loss of blood are good if we succeed in bringing back or increasing the normal flow.

Treatment. The treatment is chiefly directed to the relief of the amenorrhea or scanty menstruation (p. 240). The ectopic bleeding calls only for treatment if it becomes excessive, and is then treated according to the general rules of medical and surgical practice.

1 Garrigues, Amer. Jour. Obst., 1884, vol. xvii. p. 524.